1. Chapter 16 Oncology: Nursing Management in Cancer Care

2. Cancer
Disease process that begins when abnormal cell is transformed by genetic mutation of cellular DNA
Metastasis: abnormal cells have invasive characteristics, infiltrate other tissues
Malignant cancer cells: demonstrate uncontrolled growth that does not follow physiologic demand

3. Malignant Process
Cell proliferation: uncontrolled growth with ability to metastasize and destroy tissue, and cause death
Cell characteristics: presence of tumor-specific antigens, altered of shape, structure, metabolism
Metastasis:
Lymphatic spread
Hematogenous spread
Angiogenesis
Carcinogenesis

4. Characteristics of Benign and Malignant Neoplasms
Cell characteristics
Mode of growth
Rate of growth
Metastasis
General effects
Tissue destruction
Ability to cause disease

5. Question Tell whether the following statement is true or false:
Malignant tumors spread by way of blood and lymph channels to other areas of the body.

6. Answer
True.
Rationale: Malignant tumors spread by way of blood and lymph channels to other areas of the body. Cells bear little resemblance to the normal cells of the tissue from which they arose.

7. Carcinogenic Agents and Factors
Viruses, bacteria
Physical factors: sunlight, radiation, chronic irritation
Chemical agents: tobacco, asbestos
Genetic, familial factors
Diet
Hormones

8. Question
Which specific agents or factors are associated with the etiology of cancer?
Dietary and genetic factors
Hormonal and chemical agents
Viruses
All of the above

9. Answer D. All of the Above
Rationale: Specific agents or factors associated with the etiology of cancer include viruses and bacteria, physical factors; sunlight, radiation, chronic irritation, chemical agents; tobacco, asbestos, genetic and familial factors, diet, hormones.

10. Primary and Secondary Prevention
Primary prevention: concerned with reducing cancer risk in healthy people
Secondary prevention: involves detection, screening to achieve early diagnosis, intervention
Now great emphasis on primary, secondary prevention of cancer

11. Primary Prevention Avoid known carcinogens
Lifestyle, dietary changes to reduce cancer risk
Public, patient education

12. Secondary Prevention Identification of patients at high cancer risk
Cancer screening
Self-breast exam
Self-testicular exam
Screening colonoscopy
PAP test
Public, patient education

13. Diagnosis of Cancer Determine presence, extent of tumor
Identify possible spread (metastasis) of disease or invasion of other body tissues
Evaluate function of involved, uninvolved body systems, organs
Obtain tissue, cells for analysis, including evaluation of tumor stage, grade

14. Tumor Staging and Grading
Staging: determines size of tumor, existence of metastasis
Grading: classification of tumor cells
Tissue of origin
Degree to which cell retain structure and function of tissue of origin
TNM
T: extent of primary tumor
N: lymph node involvement
M: extent of metastasis

15. Cancer Management
Cure
Control
Palliation

16. Surgical Treatment Diagnostic surgery
Biopsy: excisional, needle, incisional
Tumor removal: wide excision, local excision
Prophylactic surgery
Reconstructive surgery

17. Question
Which type of surgery is being done when lesions that are removed are likely to develop into cancer?
Diagnostic
Palliative
Prophylactic
Reconstructive

18. Answer
C. Prophylactic
Rationale: The type of surgery being done when lesions that are removed are likely to develop into cancer is called prophylactic surgery. Diagnostic surgery such as a biopsy is usually performed to obtain a tissue sample for analysis of cells suspected to be malignant. Palliative surgery is performed in an attempt to relieve complications of surgery. Reconstructive surgery is carried out in an attempt to improve function or obtain a more desirable cosmetic effect.

19. Radiation Therapy Curative, control, or palliative External radiation
Internal radiation
Radiation reactions
Effect on GI system
Effect on bone marrow
Systemic effects
Long-term effects, tissue changes

20. Nursing Care of the Patient Undergoing Radiation Therapy
Patient, family education
Restrictions, precautions
Skin care
Oral care
Protection of care providers

21. Chemotherapy
Agents used to destroy tumor cells by interfering with cellar function, replication
Curative, control, or palliative
Cell kill, cell cycle

22. Chemotherapeutic Agents
Classification
Administration
Dosage
Extravasation
Hypersensitivity reactions

23. Chemotherapy Toxicity
Gastrointestinal
Hematopoietic
Renal
Cardiopulmonary
Reproductive
Neurologic
Fatigue

24. Nursing Management in Chemotherapy
Assessing fluid, electrolyte status
Modifying risks for infection, bleeding
Administering chemotherapy
Protecting caregivers

25. Bone Marrow Transplantation (BMT)
Used for hematological cancers that effect marrow or solid tumors treated with chemotherapy dosage that ablates bone marrow
Types of BMT
Allogenic
Autologous
(Syngeneic)
Graft vs. host disease
Venous occlusive disease

26. Nursing Management in Bone Marrow Transplantation
Implementing pretransplantation care
Providing care during treatment
Providing posttransplantation care
Caring for recipients
Caring for donors

27. Impaired Skin Integrity: Erythematous Areas
Avoid use of soaps, cosmetics, perfumes, powders, lotions and ointments, deodorants
Use only lukewarm water to bathe area
Avoid rubbing or scratching area
Avoid shaving area with straight-edged razor
Avoid applying hot-water bottles, heating pads, ice, adhesive tape to area
Avoid exposing area to sunlight or cold weather
Avoid tight clothing in area; use cotton clothing
Apply vitamin A & D ointment to area

28. Impaired Skin Integrity: Wet Desquamation
Do not disrupt any blisters that have formed
Avoid frequent washing of area
Report any blistering
Use prescribed creams or ointments
If area weeps, apply nonadhesive absorbent dressing
If area is without drainage, use moisture-, vapor- permeable dressings such as hydrocolloids, hydro gels on noninfected areas (Swearingen, 2008)
Consult with enterostomal therapist (ET), physician if eschar forms

29. Alopecia Discuss potential hair loss, regrowth with patient, family
Explore potential impact of hair loss on self-image, interpersonal relationships, sexuality
Prevent or minimize hair loss
Prevent trauma to scalp
Suggest ways to assist in coping with hair loss:
Encourage patient to wear own clothes, retain social contacts
Explain that hair growth usually begins again once therapy is completed

30. Altered Nutrition: Nausea and Vomiting
Assess patient’s previous experiences, expectations of nausea and vomiting, including causes, interventions used
Adjust diet before, after drug administration according to patient preference, tolerance
Prevent unpleasant sights, odors, sounds in environment
Use distraction, music therapy, biofeedback, self- hypnosis, relaxation techniques, guided imagery before, during, after chemotherapy

31. Altered Nutrition: Nausea and Vomiting (cont’d)
Administer prescribed antiemetic, sedatives, corticosteroids before chemotherapy, afterward as needed
Ensure adequate fluid hydration before, during, after drug administration; assess intake, output
Encourage frequent oral hygiene
Provide pain relief measures if necessary
Consult with dietician as needed
Assess, address other contributing factors to nausea, vomiting

32. Nutritional Problems
Anorexia
Malabsoprtion
Cachexia

33. Nutritional Problems: Expected Outcomes
Exhibits weight loss no greater than 10% of pretreatment weight
Reports decreasing anorexia, increased interest in eating
Demonstrates normal skin turgor
Identifies rationale for dietary modifications
Patient, family verbalize strategies to address, minimize nutritional deficits
Participates in calorie counts, diet histories

34. Nutritional Problems: Expected Outcomes (cont’d)
Uses appropriate relaxation, imagery before meals
Exhibits laboratory, clinical findings indicative of adequate nutritional intake
Consumes diet high in required nutrients
Carries out oral hygiene before meals
Reports that pain does not interfere with meals

35. Nutritional Problems: Expected Outcomes (cont’d)
Reports decreasing episodes of nausea, vomiting
Participates in increasing levels of activity
States rationale for use of tube feedings or parenteral nutrition
Participates in management of tube feedings or parenteral nutrition if prescribed

36. Altered Body Image
Assess patient’s feelings about body image, level of self- esteem
Identify potential threats to patient’s self-esteem
Validate concerns with patient
Encourage continued participation in activities, decision making
Encourage patient to verbalize concerns
Individualize care for patient

37. Altered Body Image (cont’d)
Assist patient in self-care when fatigue, lethargy, nausea, vomiting, other symptoms prevent independence
Assist patient in selecting and using cosmetics, scarves, hair pieces, clothing that increase his or her sense of attractiveness
Encourage patient, partner to share concerns about altered sexuality and sexual function, to explore alternatives to usual sexual expression
Refer to collaborating specialists as needed

38. Question
Which measure should the RN not teach a client about protecting the skin between radiation treatments?
Handle the area gently.
Avoid irritation with soap and water.
Use a heating pad every day on the area.
Wear loose fitting clothes.

39. Answer C. Use a heating pad every day on the area.
Rationale: Measures to protect a client’s skin between radiation treatments include handling the area gently, avoiding irritation with soap and water, and wearing loose-fitting clothing. The client should not use a heating pad every day on the area because it will not promote tissue repair.

40. Monitoring and Managing Potential Complications
Infection
Septic shock
Bleeding, hemorrhage

41. Factors Contributing to Infection
Impaired skin, mucous membrane integrity
Chemotherapy
Radiation therapy
Biologic response modifiers 
Malignancy
Malnutrition
Medications 
Urinary catheter
Intravenous catheter

42. Factors Contributing to Infection (cont.)
Other invasive procedures
Contaminated equipment
Age
Chronic illness
Prior infections
Recent travel
Pet excreta
Prolonged hospitalization

43. Septic Shock
Septicemia, septic shock life-threatening complications that must be prevented or detected, treated promptly
Patients who are neutropenic and/or who have hematologic malignancies are at greatest risk
Signs, symptoms include altered mental status, either subnormal or elevated temperature, cool and clammy skin, decreased urine output, hypotension, tachycardia, other dysrhythmias, electrolyte imbalances, tachypnea, abnormal arterial blood gas values

44. Bleeding and Hemorrhage
Thrombocytopenia (decrease in circulating platelet count): most common cause of bleeding in patients with cancer, usually defined as platelet count of less than 100,000/mm3 (0.1 × 1012/L)
Plan of nursing care addresses nursing assessment parameters, interventions for patients at risk for bleeding

45. Question Tell whether the following statement is true or false:
Rationale: The most common cause of bleeding in cancer patients is thrombocytopenia.

46. Answer
True.
Rationale: The most common cause of bleeding in cancer patients is thrombocytopenia.

47. Hospice
Comprehensive, multidisciplinary approach to care of patients with terminal illness, their families
Focuses on
Quality of life
Palliation of symptoms
Psychosocial, spiritual care

48. Oncologic Emergencies
Superior vena cave syndrome
Spinal cord compression
Pericardial effusion, cardiac tamponade
Disseminated intravascular coagulation (DIC)
Syndrome of inappropriate secretion of antidiuretic hormone
Tumor lysis syndrome