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The Patient with Cancer

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1 The Patient with Cancer
Chapter 25 The Patient with Cancer 1

2 Learning Objectives Explain the differences between benign and malignant tumors. List the most common sites of cancer in men and women. Describe measures to reduce the risk of cancer. Define terms used to name and classify cancer. List nursing responsibilities in the care of patients having diagnostic tests to detect possible cancer. Explain the nursing care of patients undergoing each type of cancer therapy: surgery, radiation, chemotherapy, and biotherapy. Assist in developing a nursing care plan for the terminally ill patient with cancer and the patient’s family.

3 What Is Cancer? 3

4 Normal Body Cells A normal cell has the following characteristics
Distinct, recognizable appearance typical of all cells from a particular tissue (“tissue of origin”); has a single small nucleus The ability to perform a specific function when mature The production of substances that hold cells from the same type of tissue closely together Ability to recognize other cells and identify their tissue of origin Reproduce in a controlled manner to produce additional identical cells only as needed for growth and replacement Cell division inhibited by inadequate space or insufficient nutrients Remain in their tissue of origin (except for blood cells, which migrate) What is a neoplasm? Tumors may be benign or malignant. 4

5 Benign Tumors Relatively harmless, primarily because they do not spread to other parts of the body Problems, however, if they create pressure on or obstruct body organs Surgical removal of benign tumors often recommended 5

6 Malignant Tumors Characteristics of cancer cells are
Change in appearance from normal cells Inability to properly perform function of tissue of origin; may assume functions of other cells Not readily recognized by other cells Abnormal proteins (tumor markers) on cell surface Random, disorganized, uncontrolled growth pattern Continue dividing even when no need for additional cells, inadequate space, or inadequate nutrients Ability to migrate from one tissue or organ to another What is the basis for a diagnosis of cancer? Malignant tumors may press on normal tissues and compete with normal cells for nutrients. 6

7 Malignant Tumors Can invade nearby tissues or disperse cells to colonize distant parts of the body Regional invasion The movement of cancer cells into adjoining tissue Metastasis Process by which cancer spreads to distant sites Most common sites of metastasis: liver, brain, bone, lungs Once metastasis has occurred, cancer treatment is more difficult and less likely to be curative What are tumors found away from the original site of malignant cells called? 7

8 Malignant Transformation
Factors that promote the transformation of normal cells to malignant cells are increasing age, diet, hormones, and chronic irritation Carcinogens Substances that damage cell DNA, causing normal cells to become malignant A person’s general emotional and physical health also may be factors in promoting or slowing the growth of cancer cells. What are the four steps of malignant transformation? 8

9 Classification of Tumors
Anatomic site Type of tissue from which they developed Staging system for cancer TNM system T refers to the tumor N to regional lymph nodes M to distant metastases What does the term differentiation mean? When it is difficult to recognize the original type of tissue from which tumor cells came, they are described as poorly differentiated cells. When cells are well-differentiated, the tissue of origin is recognizable. Staging is done at the time of diagnosis and at intervals during and after treatment. Such staging is helpful in planning treatments and in predicting long-term survival. 9

10 Risk Factors Genetic and environmental
Changes in genetic information of a normal cell can cause alterations that lead to malignancies Carcinogens Cigarette smoke, asbestos, and nitrites Drugs Diethylstilbestrol, androgenic steroids, and high-dose unopposed synthetic estrogens Familial cancers Appear at a higher rate than expected in one family Hereditary cancers Predictable patterns of inheritance based on a single gene A single, specific cause of cancer has not been identified. Other factors thought to be associated with cancer development are increasing age, heredity, and hormones. What is genetic counseling? 10

11 Seven Warning Signs The American Cancer Society has identified seven warning signs associated with many common types of cancer Guide the nurse and the public in identifying signs and symptoms that require medical evaluation The first letters of the warning signs spell out CAUTION, making it easier to remember them What are the warning signs of cancer? 11

12 Prevention and Early Detection
Health promotion Diet low in fat, calories, and preservatives, and high in fiber with at least five servings of various fruits and vegetables daily Appropriate calorie intake to maintain or attain normal body weight important because obesity is a risk factor for some cancers A balanced program of activity and rest with stress management may enable the body to resist diseases, including cancer Many behaviors associated with good health may reduce the risk of some cancers. What beverages and foods should be taken in limited quantities to help decrease the risk of cancers? 12

13 Prevention and Early Detection
Avoidance of carcinogens Cigarette smoke Alcohol Intercourse with multiple partners A variety of chemicals and drugs Excessive sun exposure Identification of high-risk people High-risk people can be monitored closely to detect cancer early Screening for cancer The value of early detection and treatment The seven warning signs of cancer How to do self-examinations (breast, skin, testicular) The importance of periodic examinations for common cancers Public education has focused attention on carcinogens, and people are becoming more aware of the need to avoid them. How many people quit smoking each year? On a broader scale, legal restrictions on public smoking are reducing the exposure of nonsmokers to so-called second-hand smoke. 13

14 Diagnosis of Cancer Health history Physical examination
Diagnostic procedures When cancer is suspected, when high-risk people are screened, or when determining the extent of known disease Tissue examinations, imaging studies, endoscopic procedures, and laboratory tests The health history and physical examination often provide the first clues to the presence of cancer. Combinations of procedures may be indicated for cancers that are difficult to locate or to determine whether there is more than one site. Are laboratory tests specific for cancer? 14

15 Medical Treatment of Cancer
15

16 Surgery To diagnose and stage the cancer, relieve symptoms, maintain function, effect a cure, or reconstruct affected structures May be extensive or simple Treatment based on type of cancer, location, staging, and extent of metastasis Surgeon often consults with a radiologist and an oncologist to determine the best therapy Surgery is most likely to be curative when tumors are detected early, are slow growing, confined to one area, and do not invade vital body structures. What is a radical procedure? Adjuvant and neoadjuvant therapies are relatively recent approaches to cancer treatment. Adjuvant therapy may be used when a patient has had surgery or radiotherapy and is free of signs of disease but has a high likelihood of recurrence. Neoadjuvant therapy uses chemotherapy to reduce the extent of the tumor before surgery or radiotherapy. 16

17 Radiotherapy Ionizing radiation used in treatment of disease
Treat cancer because malignant cells are more sensitive than are normal cells to radiation Immediate and delayed effects on cells Immediate: cell death due to damage to cell membrane The delayed effect is alteration of DNA, which impairs the cell’s ability to reproduce Radiotherapy: given internally or externally What is the unit of measure for radiation doses? A tumor is considered radiosensitive if it can be destroyed by radiation at a dose that is tolerated by surrounding normal tissue. Internal radiation requires the introduction of the radioactive substance into the body. External radiation is given by way of a beam directed at the tumor. 17

18 Radiotherapy Caregiver safety
The amount of radiation received by those who come in contact with the patient depends on the time of exposure, distance from radiation source, and amount of shielding between the caregiver and the source Unless direct care is being given, remain at least 6 feet away from the source Effective shielding depends on type of rays emitted The denser the material composing the shield, the better protection it provides The less time spent near the source, the less exposure is incurred. How does distance from the source affect radiation exposure? 18

19 Figure 25-3 19

20 Radiotherapy External radiation Procedure Patient preparation
Special x-ray machine delivers radiation to area Patient preparation Patient goes through a treatment simulation; includes CT scanning, to determine the exact location to be treated Radiation therapist marks the skin over area to be treated Instruct patient not to remove the markings until given permission by physician The source of the radioactivity is located outside the body. Who determines the number of radiation treatments given? A variation of this therapy is intraoperative radiation therapy (IORT), a technique in which the tumor or tumor bed is radiated directly during surgery. 20

21 Radiotherapy Internal radiation
Introduction of radiation source into the body Patients emit radiation and do pose a threat to others until the source is removed or excreted Sealed-source radiation Radiation inserted into body in a sealed container Unsealed-source radiation What are some sources of internal radiation therapy? When sealed-source radiation is used the patient’s body fluids are not radioactive. One example of sealed-source radiation is cesium, which is contained in a sealed applicator that is inserted into body cavities to treat cancer of the mouth, tongue, vagina, and cervix. Sealed-source radiation also may be placed in threads, beads, needles, or seeds and implanted into body tissues, or enclosed in a mold and applied externally. When unsealed sources are used, there are some additional considerations because body fluids may be contaminated. 21

22 Radiotherapy Side effects Bone marrow suppression Alopecia Anorexia
Dry mouth Effects on reproduction What is the goal of the ideal radiation treatment? Normal cells that are most sensitive to radiation include those of the hair follicle, bone marrow, lining of the digestive and urinary tracts, ovaries, testes, and lymph tissue. Radiation damage to these cells account for many of the side effects of the therapy. Side effects are usually not evident until at least a week after treatments are started. 22

23 Chemotherapy Chemical agents to treat disease Antineoplastic
Destroy rapidly dividing cells; may be used alone or in combination with other forms of treatment Types of antineoplastic drugs Cytotoxic agents Hormones and hormone antagonists Biologic response modifiers Radioimmunotherapy Administered by physician or nurse who has had specialized education Route: oral, intramuscular, intravenous, intracavity, intrathecal In some cases, chemotherapy is curative. In other circumstances, it may reduce the number of cancer cells, causing symptoms to decrease and often prolonging life. Why would a combination of chemotherapy drugs be used? Chemoembolization is a technique in which the drug is injected directly into an artery supplying the tumor. 23

24 Chemotherapy Side effects Bone marrow suppression Nausea and vomiting
Alopecia Extravasation Antineoplastic drugs act on both normal cells and malignant cells. What organs may be at risk for toxic effects during chemotherapy? Although bone marrow suppression is the most dangerous side effect, nausea and vomiting are likely to be the most distressing. Antineoplastic agents also can cause very serious tissue injury to the vein during administration. 24

25 Biotherapy Hematopoietic growth factors
Colony-stimulating factors: stimulate the bone marrow to produce platelets, red, and white blood cells Biologic response modifiers (BRMs) Intended to boost the body’s existing defenses Act directly on malignant cells or stimulate the immune system to act against them Monoclonal antibodies Specific for proteins on surface of certain cancer cells How do hematopoietic growth factors reduce the risk of infection? The most common side effects of BRMs are extreme fatigue, headache, muscle aches, chills, and fever. 25

26 Bone Marrow and Stem Cell Transplantation
Bone marrow transplantation: used after treatment of leukemia and lymphoma with chemotherapy and/or radiation that destroys bone marrow Stem cell transplantation: treats the destruction of the bone marrow caused by the chemotherapy and radiotherapy Transplantation of bone marrow or peripheral blood stem cells: restores the blood manufacturing cells If a patient donates his or her own stem cells or bone marrow before therapy, it is classified as an autologous transplant. What is an allogenic stem cell transplant? 26

27 Hormone Therapy Various treatments to suppress natural hormone secretion, block hormone actions, or provide supplemental hormones Hormones may be used to block the male sex hormones in the treatment of prostate cancer and female hormones in the treatment of breast cancer. 27

28 Complementary and Alternative Therapies
Nontraditional treatments Relaxation techniques, guided imagery, music, meditation, herbal remedies, and acupuncture Complementary therapy Nontraditional therapy used with conventional treatment Alternative therapy The patient uses nontraditional therapy in place of traditional treatment Research is being conducted by the National Center for Complementary and Alternative Medicine in the National Institutes of Health to determine the therapeutic value of nontraditional therapies. Why should patients be encouraged to report the use of all herbal products to their physician? 28

29 Unproven Methods of Cancer Treatment
American Cancer Society discourages treatments that have not been studied Alternative therapies can be harmful and may delay treatment with potentially effective conventional therapies See Box 25-2, p. 383 Studies have found that 6% to 9% of patients with cancer admit to using some questionable method of cancer treatment. What are some examples of unproven treatments? 29

30 Nursing Care: Diagnostic Phase
30

31 Assessment: Health History
Chief complaint Pain, lesions, lumps, or changes in body function Complete description of problem and signs and symptoms Past medical history Document chronic illnesses, serious injuries, surgeries, and hospitalizations Family history Inquire about the incidence of cancer and other serious diseases in the patient’s immediate family People who develop one of the common signs of cancer are often aware of how serious the condition might be. Why do some people ignore the signs of cancer? 31

32 Assessment: Health History
Review of systems Record any of the following signs and symptoms: pain, lumps, fatigue, activity intolerance, lesions of the skin or mucous membranes, easy bruising or bleeding, headache, vision or hearing disturbances, hoarseness, cough, dyspnea, hemoptysis, loss of appetite, difficulty swallowing, digestive disturbances, blood in the urine or stool, and change in bowel pattern 32

33 Assessment: Health History
Functional assessment Describe the patient’s diet, use of alcohol and tobacco, safe sex practices, activity, sleep routines Document the occupation and describe a usual day Assess health practices, including frequency of breast self-examination, testicular examination, and medical checkups Identify concerns about living conditions and/or location Note sources of stress; support and coping strategies 33

34 Assessment: Physical Examination
Vital signs, height, and weight Inspect face, scalp, and oral mucosa for lesions Palpate the neck for enlarged lymph nodes Inspect skin for color, lesions, edema, and bruising Auscultate breath sounds and observe respiratory effort Inspect breasts for symmetry, dimpling, and abnormal skin color, and palpate for lumps or thickened areas Inspect abdomen for distention, auscultate for bowel sounds, and palpate for masses Inspect genitalia for lesions Palpate scrotum for descended testicles/testicular lumps 34

35 Interventions 35

36 Ineffective Denial Deny the seriousness of the situation and do not seek medical care Encourage people to learn the warning signs of cancer and to report them promptly Emphasize that these signs may be caused by conditions other than cancer, but medical evaluation is needed for a correct diagnosis. What may happen when people delay treatment? 36

37 Anxiety Patient needs encouragement, support, and honest information
Remain hopeful but don’t give false reassurance May show this stress through anger, irritability, fear, or depression When coping is not effective, refer to a psychiatric clinical nurse specialist or a mental health counselor 37

38 Deficient Knowledge Tell patient about diagnostic procedures, including preparation, what the procedure is like, and any specific postprocedure care 38

39 Nursing Care: Treatment Phase
39

40 Assessment: Health History
Note patient’s diagnosis and treatment plan Complete drug profile; record allergies prominently Review the systems to detect significant symptoms related to cancer or treatment: fatigue, weakness, headache, sore or dry mouth, dyspnea, palpitations, altered taste sensations, nausea, diarrhea, constipation, blood in stools, change in urinary frequency, hematuria or dysuria, sexual dysfunction, numbness, and tingling sensations What psychological assessment should be done? 40

41 Assessment: Health History
Determine the effects of the illness and therapy on the patient’s daily functioning Explore patient’s knowledge, fears, concerns, and coping strategies 41

42 Assessment: Physical Examination
Note general appearance, level of consciousness, posture, and gait Assess mental and emotional state Measure weight and vital signs and compare with previous measurements Assess skin for lesions/bruises; scalp for hair loss Inspect the oral mucous membranes for lesions and inflammation 42

43 Assessment: Physical Examination
Observe patient’s respiratory effort and auscultate the lungs Inspect the abdomen for distention, and auscultate bowel sounds Inspect and palpate the extremities for color, edema, and peripheral pulses Test extremity reflexes and sensation 43

44 Interventions 44

45 Anxiety Encourage patient to express feelings and identify the source of the anxiety Listening and touch can be very effective in reducing anxiety Recognize need for patient teaching or referrals The thought of having surgery or of receiving cancer therapy may be very frightening to the patient. What symptoms of anxiety may be displayed by the patient? 45

46 Ineffective Coping Strategies to promote coping include teaching, encouraging self-care within the patient’s limitations, treating physical signs and symptoms, emphasizing abilities, coaching in relaxation strategies, and encouraging the use of coping strategies that have been effective in the past The patient may need help in setting priorities and in coping with the side effects of therapy. How can support groups help the patient cope? 46

47 Risk for Injury Pneumonitis and pulmonary fibrosis Cardiac toxicity
Encourage coughing and deep breathing exercises Protect patient from exposure to people who have upper respiratory infections Cardiac toxicity Monitor for dyspnea, increasing pulse pressure, edema Neurotoxicity Protect extremities that lack normal sensation Patients receiving doxorubicin (Adriamycin) may show signs of heart failure. What should you do if you assess signs of heart failure? 47

48 Risk for Injury Thrombocytopenia Avoid trauma and bruising
Minimal invasive procedures: rectal temperatures After venipunctures or injections, apply pressure for 5 minutes to control oozing Instruct patient to use soft toothbrush and an electric razor to prevent trauma to the oral tissues or the skin Assess for signs and symptoms of internal bleeding: increased pulse and respirations, restlessness, pallor, decreased urine output, and falling blood pressure Both radiation and chemotherapy can suppress the production of platelets. How does a low platelet count affect the blood? 48

49 Risk for Injury Anemia Reproductive cells
Monitor hemoglobin and hematocrit Encourage a diet high in iron Patient should report palpitations, pallor, and excessive fatigue to the physician Reproductive cells Women are usually advised not to become pregnant within 2 years of chemotherapy or while receiving radiotherapy When should anemia be anticipated? Anemia is treated with packed red blood cells and erythropoietin (epoetin alfa). Female patients of childbearing age should discuss specific reproductive guidelines with their physicians. Why are male patients counseled about the advisability of banking sperm before beginning therapy with certain drugs. 49

50 Risk for Infection Avoid crowds and close contact with others who have infectious diseases Promptly report any signs of infection Compromised host precautions Private room Strict hand washing by all who enter the room Fresh flowers, fruits, and vegetables not allowed What signs of infection should be reported? The venous access device presents a potential portal for infection. 50

51 Imbalanced Nutrition: Less Than Body Requirements
High-protein, high-calorie diet Small, frequent feedings Light exercise before meals may stimulate the appetite Nutritional supplements (such as Carnation Instant Breakfast, Ensure, or Sustacal), enteral feedings, or both may be ordered if the patient has excessive weight loss Be familiar with the specific antineoplastic agents so that the patient can be advised of any specific food restrictions Various combinations of antiemetics and sedatives can be tried as ordered to obtain relief from nausea Anorexia is common with cancer therapy, but maintaining good nutrition is essential. If patients have specific food preferences and aversions, they should be respected. What foods may taste bitter when on chemotherapy? Contrary to common belief, not all patients with cancer have problems with weight loss. 51

52 Impaired Oral Mucous Membranes
Frequent, gentle mouth care Artificial saliva Encourage increased fluid intake, chew sugarless gum or candies, suck on ice chips, and moisten dry food before eating Eat soft foods, and avoid foods that are acidic, salty, or spicy Use soft-bristled or foam toothbrush What is mucositis? Lemon and glycerin swabs are no longer recommended because lemon juice dehydrates oral tissues and glycerin provides a medium for bacterial growth. 52

53 Constipation Monitor patient’s bowel movements
The physician may prescribe a high-fiber diet, stool softeners, laxatives, and phosphate or bisphosphate enemas to prevent or treat constipation What may cause a patient on chemotherapy to be constipated? 53

54 Fatigue Assess the patient’s need for assistance and schedule activities to conserve energy Encourage patient to prioritize activities and ask others to assume less important ones Daily naps and mild exercise helpful Fatigue is a common symptom in the patient with cancer. Side effects of therapy may cause the patient to tire easily. 54

55 Disturbed Body Image Be sensitive to patient’s concern about hair loss
Use wigs, scarves, or hats The American Cancer Society lends wigs to patients free of charge The society also sponsors the “Look Good-Feel Better” program to help patients look their best during therapy The effects of cancer and cancer treatments can alter physical appearance and function. What are some examples of disturbed body image? 55

56 Dysfunctional Grieving
Listen in an accepting way that lets the patient know the feelings are understood Support patient and provide practical information about adapting to the loss Participation in a support group may help the patient learn new coping strategies and begin to resolve the grief process Changes in body appearance often trigger a grief response. What are some behaviors that suggest that the patient is beginning to accept the loss or change? 56

57 Impaired Family Processes
Encourage family to remain involved Family members may need help to handle their responses to the patient’s illness Obtain a social work consultation if necessary to assist them with insurance and disability claims and financial assistance referrals While undergoing treatment for cancer, the patient may be concerned with meeting responsibilities at home and at work. How can family members help the patient cope? 57

58 Ineffective Therapeutic Regimen Management
Pretreatment teaching plan informs patient of what the prescribed therapy involves Chemotherapy Teaching plan includes drugs administered, potential side effects, related precautions Provide written information to supplement the verbal teaching Explore what patient has heard about chemotherapy; correct any misconceptions What are some sources of information on cancer you can give to the patient? Inform the patient of measures that can be taken that usually make the side effects more tolerable. 58

59 Recovery and Rehabilitation
If the outcome of treatment appears to be a cure, the patient and family are usually overjoyed Some patients become excessively concerned with their bodies, constantly looking for new evidence of cancer Periodic checkups essential but may be dreaded because the patient realizes that complete or permanent recovery cannot be guaranteed If signs of possible recurrence, patients are concerned As patients recover from the effects of cancer and cancer therapy, rehabilitation may be needed to restore them to the highest possible level of functioning 59

60 Terminal Illness Although increasing numbers of people are surviving cancer, it is still the second leading cause of death If treatment is unsuccessful, patient begins to decline For patients who wish to die at home, hospice provides support and teaching Focus: keep patient’s symptoms, especially pain, under control during the final period of the illness Provides bereavement care after the patient’s death Provide information about home health care, hospice, and voluntary and charitable organizations whose services might be needed. What must you be aware of to work effectively with terminally ill patients? 60

61 Terminal Illness Be attentive and accepting
Listening carefully is more important than talking Guide patients to claim their accomplishments and find peace Terminally ill patients should remember that although they are going to die eventually, they are living now and can still have some pleasure 61

62 Oncologic Emergencies
Conditions sometimes develop that require emergency intervention as a result of the disease process or therapy Examples: hypercalcemia, syndrome of inappropriate antidiuretic hormone, disseminated intravascular coagulation, superior vena cava syndrome, and spinal cord compression See Table 25-11, p. 393 62


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