Presentation on theme: "Oncology Understanding Medical Surgical Nursing 4th ed., Ch 11 OBJECTIVES: 1. Explain the differences between benign & malignant tumors. 2. List risk factors."— Presentation transcript:
Oncology Understanding Medical Surgical Nursing 4th ed., Ch 11 OBJECTIVES: 1. Explain the differences between benign & malignant tumors. 2. List risk factors for the development of cancer. 3. State 7 warning signs of CA. 4. Define terms used to name & classify CA. 5. List the most common sites of CA in men & women. 6. List nursing responsibilities in the care of patients having diagnostic tests to detect possible CA. 7. Explain the nursing care of clients undergoing each type of CA therapy: surgery, radiation, chemotherapy, biologic response modifiers.
Health Statistics American Cancer Society: Males: over ½ Prostate, lung, & colorectal Women: ~½ breast, lung, & colorectal Children (0-14yrs) Colorectal CA is the 3 rd most common CA in both men & women.
U.S Deaths CA is the 2 nd leading cause of death in the US, exceeded only by heart disease. Breast, Prostate, Lung, & Colorectal CA’s account for ½ of all deaths, men & women. Health Statistics
Older Adult Considerations More cases of CA CA î with aging S&S of CA may be misdiagnosed
Cancer (CA) Large group of diseases characterized by uncontrolled growth & spread of abnormal cells. (American Cancer Society) Neoplasms or Tumors Cells that reproduce abnormally & in an uncontrolled manner.
Normal Cell Growth Uniform shape Cell cohesiveness Controlled growth Well differentiated Programmed cell death (apoptosis)
CA cells divide & multiply, in an abnormal manner. Mutation of Cellular Genes Abnormal Cell Growth No Cell Division Limit Lack of Contact Inhibition Cancer Pathophysiology
Cancer Cell Growth Abnormal appearance Lack of cohesiveness Rapid, disorderly division Poorly differentiated No apoptosis
Benign Tumors Slow, steady growth Remains localized Usually contained within a capsule Smooth, well-defined; movable when palpated Resembles parent tissue Crowds normal tissue Rarely recurs after removal Rarely fatal
Malignant Tumors Rate of growth varies – usually rapid Metastasizes Rarely contained within a capsule Irregular; more immobile when palpated Little resemblance to parent tissue May recur after removal Fatal without treatment
Metastasis Process by which tumor cells are spread to distant parts of body; used to describe movement of CA cells from primary to secondary site. Invade Blood or Lymph Vessels Move by Mechanical Means Lodge & Grow in New Location
The process by which normal cells are transformed into CA cells. Etiology: Carcinogen Exposure Initiation Promotion Carcinogenesis
Initiation Carcinogens: CA causing agents 1.Repair itself 2.Permanently ∆’ed, don’t cause CA 3.Transformed & produce new line of CA cells
Promotion Process by which CA promoters aid in alternation or injury to DNA.
Progression The expression of malignant mutation acquiring more aggressive characteristics over time.
Carcinoma Sarcoma Melanoma Leukemia Lymphoma Cancer Types
Most Common Cancers Men –Prostate –Lung –Colon Women –Breast –Lung –Colon
Skin Cancer Malignant lesion of skin; may or may not metastasize – Types: basal cell, squamous cell, malignant melanoma – Assessment: change in color, size, shape of preexisting lesion; pruritus; local soreness – Interventions Instruct in preventive measures (limiting exposure to sun, use of sunscreens) Instruct to monitor lesions for changes, nonhealing lesions; report to primary health care provider immediately Assist with surgical excision of lesion as prescribed
Leukemia Malignant exacerbation in number of leukocytes, usually at immature stage, in bone marrow – Data collection Normal, elevated, or reduced white blood cell count; decreased H/H; thrombocytopenia; positive bone marrow biopsy; anorexia; fatigue; bleeding; fever; lymphadenopathy; splenomegaly; bone pain, swelling
Lymphoma: Hodgkin’s Disease Malignancy of lymph nodes; originates in single lymph node or single chain of nodes – Data collection Presence of Reed-Sternberg cells in nodes Fever; malaise; night sweats; anorexia; anemia & thrombocytopenia; enlarged lymph glands, including nodes, spleen, liver
Hodgin’s disease cont’d characterized by painless, progressive enlargement of lymphoid tissue Interventions Provide care before & after external radiation as prescribed Provide care before & after chemotherapy as prescribed Monitor for signs of infection, bleeding Follow bleeding precautions
Non-Hodgkin’s lymphoma (NHL) Any of a heterogeneous group of malignant tumors involving lymphoid tissue.
Lung Cancer Malignant tumor of lung; may be primary or metastatic – Causes Cigarette smoking; exposure to environmental pollutants; exposure to occupational pollutants – Data collection Cough; dyspnea; hoarseness; hemoptysis; chest pain; anorexia; wt loss; weakness – Interventions Place in Fowler’s position Administer oxygen as prescribed
Lung CA Small-cell lung CA: hormonal cells Non-small lung CA: -squamous-cell: larger airways -adenocarcinomas: (large-cell carcinomas), in secretory portion -bronchoalveolar carcinomas: small air sacs, or alveoli
Multiple Myeloma Malignant proliferation of plasma cells, tumors within bone Data collection Bone, skeletal pain, especially in ribs, spine, pelvis Osteoporosis Recurrent infections; fatigue; anemia; thrombocytopenia; granulocytopenia; elevated uric acid & calcium serum levels
Risk factors Smoking Exposure to radiation Exposure to environmental & chemical carcinogens Smokeless tobacco Frequent heavy consumption of alcohol
Risk factors Dietary habits Pickled, smoked, charbroiled High-fat, low-fiber diets High-fat diets Diet low in vitamins A, C, & E
Hereditary Cancers ~ 90% of cancers are not inherited Genetic Susceptibility: Postmenopausal breast CA Lung CA – Smokers Leukemia – identical twin Neuroblastoma – siblings Colon CA – breast CA
American Cancer Society Cancer’s 7 Warning Signals: CAUTION 1. Change in bowel or bladder habits 2. A sore that does not heal 3. Unusual bleeding or discharge 4. Thickening lump in breast or elsewhere 5. Indigestion or swallowing difficulties 6. Obvious ∆ in warts or moles 7. Nagging cough or hoarseness
Prevention Early Detection Regular Screening Genetic Testing Healthy Lifestyle
Breast Self-Examination (BSE) – Performing BSE 7 to 10 days after menses If postmenopausal or posthysterectomy, select specific day of month, perform regularly – Client instructions In shower or bath, examine breasts Use pads of second, third, and fourth fingers to press firmly on every part of breasts, using right hand to examine left breast and vice versa Use small circular motions in a spiral or up and down motion so that entire breast is examined, checking for any lump, knot, thickening of tissue
Breast Self-Examination (BSE) (continued) Look at breasts in mirror, raising arms over head to determine any changes in size, dimpling of skin, changes in nipple, asymmetry; repeat with hands on hips Lying down, feel breasts as when in shower or bath; when examining right breast, place right hand behind your head and vice versa for left breast Any changes noted should be reported immediately to health care provider
Testicular Self-Examination (TSE) – Performing testicular self-examination Select day of month; perform on that day every month – Client instructions In shower, gently lift each testicle; each one should feel like an egg: firm but not hard, smooth with no lumps Using both hands, place middle fingers on underside of each testicle, thumbs on top; gently roll testicle between thumb and fingers to feel for swelling, lumps, or mass Any changes noted should be reported immediately to health care provider
Diagnosis of CA Biopsy: sample of tissue for pathological examination. Incisional bx: removal of a portion of tissue for examination. Excisional bx: removal of complete lesion, with little or no margin of surrounding normal tissue removed.
Diagnosis of Cancer Needle aspiration bx: aspiration of fluid or tissue by means of needle. Endoscopy: directly visualize an internal structure through a body cavity or through a small incision; can also obtain cells or tissue.
Tumor Nodes Metastasis Indicate tumor size, spread to lymph nodes, & extent of metastasis. Direct tx, predict prognosis, & contribute to CA research. Staging
T* Subclasses T×: tumor can’t be adequately assessed To: no evidence of primary tumor Tis: carcinoma in situ T1, T2, T3, T4: progressive î in tumor size & involvement regional lymph
Nt Subclasses N×: regional lymph nodes cannot be assessed No: no regional lymph nodes cannot be assessed N1, N2, N3: î involvement regional lymph nodes
M‡ Subclasses M×: not assessed Mo: no (known) distant metastasis M1: distant metastasis present, specify site(s)
Grading Histopathology G1: well differentiated G2: mod well-differentiated G3: poorly differentiated G4: undifferentiated
Staging Classification for CA Stage 1: malignant cell confined Stage 2: limited spread, local area, nearby lymph nodes. Stage 3: larger or spread to nearby tissues or both; regional lymph node likely involved. Stage 4: metastasized to distant parts of body.
Surgery Radiation Therapy Chemotherapy Therapeutic Interventions
Cancer Therapies Surgery removal of all malignant cells; may include removal of tumor, surrounding tissue & regional lymph nodes. Preventive, Diagnostic, Curative Palliative: relieve or reduce intensity of uncomfortable symptoms. [not a cure] Reconstructive
Laser Surgery Laser beam vaporizes tissue with little bleeding & low risk of infection. ophthalmology gynecology urology neurosurgery otolaryngology
Nursing Interventions Monitor VSs Monitor labs Monitor client’s wt. Monitor I&O Monitor for bleeding, S&S of infection Psychosocial issue
Nursing Interventions When surgery may result in a Δ of body image, client may benefit from support groups: The American Cancer Society Reach to Recovery The Lost Chord Club I Can Cope Look Good, Feel Good The Ostomy Club
Radiation Therapy Cure or control CA that has spread to local lymph nodes or to tx tumors that can’t be removed. Preop to ↓ size of tumor Postop to destroy malignant cells not removed by surgery.
External Radiation tx’s based on radiologist’s recommendations. ~ 5x/wk for 2 to 8 wks. Directed toward superficial lesions or targeted to deeper structures within body. Body marked, not washed off
Marking areas to be radiated Explain procedure & instruct pt on how to protect markings Skin care & protection from sunlight Avoid applications of heat or cold External Radiation Nursing Interventions
External Radiation Nursing Interventions Cont’d Diet- high protein & calories Fluid intake: 2 or 3 quarts/day Assess for lethargy & fatigue Provide frequent periods of rest
External Radiation Nursing Interventions Cont’d Mucositis Frequent oral care Advise use of neutral mouthwash (diphenhydramine (Benadryl) & water Discourage use of alcohol & tobacco. Avoid very cold foods & drinks.
1.Private room 2. Sign on door – radiation area 3.Time - film badges. (30 mins./shift) 4. The pt. Must be as self-sufficient as possible. 5. The radioactive material may leave the pt. Accidentally; immediately notify physician & radiation safety personnel. Internal radiation safety measures (Sealed)
Pts will receive the following instructions Restricted to your room. Use disposable eating utensils. These utensils should be placed in special waste container after use. Wear gloves when handling items that are not protected by coverings, such as personal items the pt. may wish to take home. Flush toilet 2 or 3 times after each use. This will insure that all radioactive urine is washed from toilet bowl. Avoid physical contact with visitors.
Visitors have the following restrictions Visits should be limited to 30 hour/day. No pregnant women or persons under age 18 should visit the patient without special permission. Remain at least 6 ft. from the pt. Must be protected with gowns, shoe covers, & gloves. Should not handle any items in the room. Must not smoke, eat, or drink while in the client's room.
Radioactive implant (brachytherapy) Usually combined with a course of external radiation therapy to ↑ dosage to a specific site. Visitors limited to 60 mins. Standing away from area. Liquid Radiation Tx (Zevalin therapy) Non-Hodgkins’s lymphoma
Internal radiation safety measures Unsealed Additional considerations: 1.Gloves 2. Contaminated materials may require special care. (lead-lined container & long-handled forceps); Follow hospital policy for radioactive waste cleanup
Radiation Safety Time Distance Shielding
Radiation Side Effects Normal cell sensitivity: Alopecia (hair follicle), Bone marrow suppression Lining of the digestive & urinary tracts, ovaries, testes, & lymph tissue
Chemotherapy Medications Different Antineoplastic Classes Are Given Different classes affect different stages of the CA’s life cycle Allows lower dosages of each agent Reducing toxicity Slowing development of resistance
Alkylating Agents Most widely used antineoplastic drug Form bonds or linkages with DNA Called alkylation Changes the shape of DNA Prevents normal DNA function Kill or slow down replication of tumor cells Adverse effect Bone marrow suppression Damage epithelial cells lining GI tract Cyclophosphamide (Cytoxan), nitrogen mustard
Antimetabolites Chemically similar to essential building blocks of the cell Resemble purines or pyrimidines Building blocks of DNA & RNA CA cells use this drug to construct proteins or DNA Block DNA synthesis Kill CA cells or slow growth Methotrexate (Mexate)
Antitumor Antibiotics Not widely prescribed Interact with DNA in a manner similar to alkylating agents Doxorubicin (Adriamycin)
Plant Alkaloids/Natural Products Structurally very different Common ability to arrest cell division Sometimes called mitotic inhibitors Vincristine (Oncovin)
Hormones & Hormone Blockers Used to slow growth of hormone-dependant tumors Certain tumors stimulated by natural hormones Specific hormones or hormone blockers can block receptor sites Hormones used in CA chemotherapy Use of testosterone or antiestrogen to slow breast cancer (Tamoxifen) Estrogen to slow growth of prostate CA Other major class is corticosteroids
Biologic Response Modifiers & Miscellaneous Antineoplastics Biologic response modifiers stimulate the body’s immune system Limit the severe immunosuppressive effects of other anticancer drugs Immunotherapy Some used to minimize the toxic effects of other antineoplastics
Miscellaneous Anticancer Drugs Have Different Mechanisms of Actions Asparaginase deprives CA cells of an essential amino acid Mitotane (Lysodren) - similar to the insecticide DDT Poisons CA cells by forming links to proteins
Miscellaneous Anticancer Drugs Others given to counteract the toxicity of antineoplastics Colony Stimulating Factors: G-CSF, GM-CSF Oprelvekin (Neumega) - stimulates platelet production Epoetin alfa; Erythropoientin EPO (Epogen) - stimulates RBC production Interleukin-2 – stimulates T-cells
Next Generation Drugs tyrosin kinase inhibitors: a chemical that helps govern growth of CA cells. Targets a specific “receptor” site found on surface of CA cell. Iressa -bowel, breast, head, ovary, prostate, bladder & kidney Herceptin (trastuzumab) –breast CA Gleevec –chronic myelogenous leukemia
Chemotherapy Side Effects Antineoplastic drugs: doxorubicin (Adriamycin): red urine Bone marrow suppression Leukopenia Thrombocytopenia Anemia N/V & diarrhea
Chemotherapy Side Effects Alopecia Stomatitis Reproductive Alterations Neurotoxicity
Non-traditional approaches Alternative Therapies: Biofeedback Reflexology Herbal supplements Enzyme therapy Reiki Cultural factors Spiritual factors
Bone Marrow Transplantation (BMT) Tx leukemia -though high-dose chemotherapy, total body irradiation Types of donor stem cells Allogeneic, syngeneic, autologous Procedure Harvest: marrow harvested through multiple aspirations from iliac crest to retrieve sufficient bone marrow for transplantation Conditioning: refers to immunosuppressive therapy regimen to eradicate all malignant cells
Bone Marrow Transplantation Replacing diseased or damaged bone marrow with normally functioning bone marrow. Stem Cell Transplants Used in some solid tumor CA’s
Bone Marrow Transplantation Nursing interventions Reinforce info., explained by physicians regarding expectations of specific tx’s. Allow pt express their feelings & enc. them to follow guidelines of conventional medical practice.
Nursing Intervention Bone Marrow Suppression Monitor CBC, & WBC Allow for periods of rest Prevent overtiring Protect from infection Protective isolation
Hematopoietic System Leukopenia ( low WBC’s d/t depression of bone marrow) Life-threatening infections Normal WBC: 4,500 – 11,000/mm ³
Neutropenia: a low absolute neutrophil count ANC measured is in the setting of chemotherapy for CA. A normal absolute neutrophil count (ANC) is above 1,500. An ANC less than 500 is defined as neutropenia & significantly ↑’ s the risk of infection.
Neutropenia ↓ pneumonia, septicemia, infections. Tx: colony-stimulating factors (CSFs) Granulocyte colony-stimulating factors (G-CSF) Granulocyte CSF (filgrastim [Neupogen]), Granulocyte-macrohage CSF (GM-CSF) (sargramostim[leukine or Prokine]) SQ or IV.
Nursing Interventions Neutropenic precautions: protective isolation Monitor VS Report î temp Assess for signs of infection
Anemia: ↓ RBCs Fatigue Tx: recombinant human erythropoietin, or epoetin alfa (Epogen, Procrit) SQ or IV. (side effect: ↑ BP) Transfusions Normal hemoglobin: g/dL female; g/dL male Normal hematocrit: 35-47% female; 42-52% males
Thrombocytopenia low platelets, d/t depression of bone marrow. Potential for bleeding 50,000 mm³ Less than 20,000 mm³ spontaneous bleeding Tx: Transfusion Normal Platelet Count: 150, ,000 mm³
Thrombocytopenia Nursing Interventions Monitor for bleeding Venous punctures or injections – apply pressure for 5 mins Instruct use of soft tooth brush, & electric razor.
Integumentary System Alopecia loss of hair d/t destruction of hair follicles, never permanent.
GI System Stomatitis Tx: Viscous Xylocaine Candida infection of mouth & esophagus Tx: nystatin p.o. Nausea, Vomiting & Diarrhea d/t breakdown of normal GI cells. Metoclopramide (Reglan) Check serum protein level for nutritional status
Nursing Intervention - GI Antiemetics prochlorperazine (Compazine); promethazine (Phenergan) Serum albumin less than 3 g/dL indicates poor nutrition & possible need for support Dehydration, Anorexia, Constipation Cardiac Pulm
GI System Physiological Symptoms or Psychological Responses Depression Withdrawal
Pain Management Pain - a late symptom of CA Tx: Opioids – MS, hydromorphone (Dilaudid), fentanyl, methadone. Sustained-release MS p.o. – MS Contin or Roxanol SR for terminally ill pts with pain Cocktails
Pain Control Causes of pain Bone destruction; obstruction of an organ; compression of peripheral nerves; infiltration or distention of tissue; inflammation or necrosis; psychological causes, such as fear Interventions Assess pain as fifth VS Collaborate with pain management team Administer salicylates, acetaminophen (Tylenol), anti-inflammatories, opioid analgesics orally or parenterally as prescribed Provide nonpharmacological techniques of pain control
Relationships of Food & CA Thought to be carcinogenic: Nitrates in cured & smoked foods High-fat diets Excessive caloric intake Alcohol & cigarettes
Relationships of Food & CA Certain diets seem to have health benefits – Diets high in fiber – Diets rich in vitamin C – Diets high in vitamin A
Relationships of Food & CA Health benefits – Phytochemicals - anticarcinogenic. – Legumes contain vitamins, minerals, protein, & fiber – High intake of soy foods
The Effects of CA May cause unexplained wt. loss, weakness, early satiety, & anorexia May lead to loss of muscle tissue, hypoalbuminemia, & anemia Effect of CA on the pt. depends on the location of the tumor
Nutritional Care Calorie needs of the pt with CA are greater than before the illness. Pts who can eat normally tolerate the side effects of therapy better. Pts can form aversions to food, making anorexia worse.
Nutritional Care Soft diet Low-residue diet High-protein, high-calorie diets and plenty of fluids for pts undergoing radiation or chemotherapy 45 to 50 calories per kg of body weight per day
Nutritional Care Carbohydrates & fat needed to provide energy & spare protein for tissue building & the immune system 1.0 to 1.2 g of protein per kg of body wt. a day Malnourished pts may need from 1.3 to 2.0 g of protein per kg of body wt. a day. Vitamins & minerals are essential.
Nutritional Care Encourage foods that will ↑ appetite Salad dressings, gravies, sauces, & syrups Several small meals Drugs to control nausea & pain. Nutritional supplements
A pt. with CA may feel that comments to encourage eating are depressing reminders of the CA & the situation. How can the health care professional be helpful to the pt?
Oncological Emergencies - Sepsis, disseminated intravascular coagulation (DIC) Maintain strict aseptic technique; administer antibiotics, anticoagulants, cryoprecipitated clotting factors as prescribed – Syndrome of inappropriate antidiuretic hormone (SIADH) Tumors can produce, secrete, stimulate brain to synthesize ADH Initiate fluid restriction, increased sodium intake as prescribed; administer demeclocycline (Declomycin) as prescribed – Spinal cord compression Occurs when tumor directly enters spinal cord Assess for back pain, neurological deficits; prepare client for radiation, chemotherapy as prescribed
Oncological Emergencies (cont’d). Hypercalcemia Late manifestation of extensive malignancy, often in clients with bone cancer Monitor serum calcium level; administer oral or parenteral fluids as prescribed; administer medications to lower calcium levels as prescribed – Superior vena cava syndrome Occurs when vein compressed, obstructed by tumor growth Prepare client for radiation therapy as prescribed – Tumor lysis syndrome Occurs when large numbers of tumor cells are destroyed rapidly, indicating CA tx is effective Encourage oral hydration; administer diuretics as prescribed