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1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 25 The Patient with Cancer
2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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 patients family.
3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. What Is Cancer?
4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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)
5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment of Cancer
16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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 cells ability to reproduce Radiotherapy: given internally or externally
18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 25-3
20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Radiotherapy External radiation Procedure 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
21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Radiotherapy Side effects Bone marrow suppression Alopecia Anorexia Dry mouth Effects on reproduction
23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chemotherapy Side effects Bone marrow suppression Nausea and vomiting Alopecia Extravasation
25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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 bodys 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
26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Hormone Therapy Various treatments to suppress natural hormone secretion, block hormone actions, or provide supplemental hormones
28Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
29Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
30Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care: Diagnostic Phase
31Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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 patients immediate family
32Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
33Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment: Health History Functional assessment Describe the patients 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
34Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
35Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Interventions
36Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
37Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anxiety Patient needs encouragement, support, and honest information Remain hopeful but dont 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
38Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Deficient Knowledge Tell patient about diagnostic procedures, including preparation, what the procedure is like, and any specific postprocedure care
39Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care: Treatment Phase
40Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment: Health History Note patients 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
41Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment: Health History Determine the effects of the illness and therapy on the patients daily functioning Explore patients knowledge, fears, concerns, and coping strategies
42Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
43Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment: Physical Examination Observe patients 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
44Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Interventions
45Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
46Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Ineffective Coping Strategies to promote coping include teaching, encouraging self-care within the patients 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
47Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Risk for Injury Pneumonitis and pulmonary fibrosis 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
48Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
49Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Risk for Injury Anemia 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
50Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
51Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
52Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
53Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Constipation Monitor patients bowel movements The physician may prescribe a high-fiber diet, stool softeners, laxatives, and phosphate or bisphosphate enemas to prevent or treat constipation
54Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Fatigue Assess the patients 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
55Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Disturbed Body Image Be sensitive to patients 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
56Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
57Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Impaired Family Processes Encourage family to remain involved Family members may need help to handle their responses to the patients illness Obtain a social work consultation if necessary to assist them with insurance and disability claims and financial assistance referrals
58Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
59Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
60Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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 patients symptoms, especially pain, under control during the final period of the illness Provides bereavement care after the patients death
61Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
62Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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
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