CARE OF THE PATIENT WITH CANCER

- Nursing Implications

NUR 133

Lecture # 8/9

K. BurgerMSEd, MSN, RN, CNE

3/05kb

Incidence & Prevalence

2nd leading cause of death 1 out of 3 persons will be affected by cancer

sometime in their lifetime Cancer of lung = leading cause of cancer

deaths in both men and women Cancer of colon = 2nd largest incidence Breast and Prostate = highest gender

incidence

Pathophysiology

Carcinogenesis / Oncogenesis Tumor development slow and insidious Initiator – Promotor Theory Loss of cellular control mechanisms

(ie: apoptosis) Loss of differentiation

WHAT ARE CARCINOGENS?

Environmental/Lifestyle risk factors:tobacco, alcohol, diet, sexual/reproductive behavior, ultraviolet radiation, other pollutants and irritants

Hormones:estrogen

Oncogenic viruses:HBV, HPV, HIV, HSV

Normal Versus MalignantCell Characteristics

NORMAL

Limited cell division

Undergo apoptosis

Controlled growth

Well differentiated

Adhere tightly together

Contact inhibited

Euploid

MALIGNANT

Rapidly dividing/multiplying

Do not undergo apoptosis

Uncontrolled growth

Anaplastic morphology

Adhere loosely together

Able to move / metastasize

Aneuploid

HOLISTIC NURSING CONSIDERATIONS

Primary level care: Prevention and Screening/ client education Secondary level care: Diagnostic Testing Treatment and side-effects of Surgery,Radiotherapy,Chemotherapy Tertiary level care: End of life and psychosocial issues

PREVENTION AND SCREENING Patient Education

Health promotion: Diet hi in whole grains, Vit C,A, & cruciferous fruits & vegetables.

Limit fat, alcohol, kcal, salt-cured, smoked, charbroiled meats. Maintain healthy immune system.

Avoidance of carcinogens:

Limit exposure to sun, tobacco smoke/chew, radiation, viruses,chronic irritants, immunosuppressants, hormonal agents.

Regular cancer screening: ACS Cancer Detection Guidelines C A U T I O N

Annual physical exam, BSE, TSE

Primary Intervention

DIAGNOSTIC TESTINGPatient Education and Support

• Common laboratory tests: CBC, bilirubin, alkaline and acid phosphatase, tumor markers (PSA, CA, CEA)+ others

Radiological procedures: CT, PET, MRI, ultrasound, mammography, BE, UGI, CXR

Endoscopic procedures: bronchoscopy, esophagoscopy, colonoscopy, cystoscopy

Biopsy / incisional, needle aspiration, stereotactic

Secondary Intervention

Tumor StagingTNM Classification

T = primary tumor size

N = lymph node involvement

M = metastasis

T4 N3 M1

What does this indicate?

Tumor Grading

CLASSI Normal cell

Well differentiatedII Abnormal cell; moderately differentiatedIII Suspiciously malignant; poorly differentiatedIV Probably malignant

very poorly differentiatedV Malignant; undifferentiated

Classification byTissue of Origin

FOR EXAMPLE: Sarcoma Lymphoma Glioma Osteoma Lipoma Adeno Melano

CANCER TREATMENT - SURGERYNursing Care

Pre-op teaching Nutritional promotion pre and post op Pain control Monitor for post-op complications C & DB, incentive spirometry, antiembolitic

rx, leg exercises, ambulation etc. Body image disturbance= potential nsg dx

Secondary Intervention

CANCER TREATMENT – CHEMOTHERAPYNursing Care

Prior to administration: hydration and anti-emetics During administration: vesicant precautions: gloves,

monitor IV site closely Post administration: utilize interventions for common side effects: Myelosuppression – infection, bleeding, fatigue

GI complications - anorexia, N/V, xerostomia, Alopecia

Secondary Intervention

Chemotherapeutic Agents/Anti Neoplastic Drugs

Classification Examples

Alkylating Agents CytoxanCisplatin (Platinol)

Antimetabolites Methotrexate5-FU

Plant Alkaloids(Anti-mitotics)

Vincristine (Oncovin)Taxol

Antibiotics BleomycinAdriamycin

HormonesHormone Antagonists

Megace (Progesterone)Tamoxifen

Immunotherapy/Targeted TherapyBiological Response Modifiers (BRM)

Interferon Monoclonal Antibodies - Herceptin Interleukin Colony Stimulating Factor (CSF)- Neupogen

Epogen Gene Therapy HLA Side Effects: stimulation of inflammatory

process, flu-like symptoms

CANCER TREATMENTEXTERNAL RADIATION -Nursing Care

Teletherapy Promote nutrition and rest Do not remove simulation markings Utilize interventions for common side effects:

Myelosuppression – infection, bleeding, fatigue

GI complications – anorexia, N/V, taste alterations,

mucositis, xerostomia, diarrhea

Skin reactions – dry/wet desquamation

Secondary Intervention

CANCER TREATMENTINTERNAL RADIATION – Nursing Care

Brachytherapy – Sealed vs Unsealed Safety considerations:

Private room. Radioactive caution sign

Limit visitors to ½ hr; no under 18, no pregnant

Rotate nurse assignments/ wear dosimeter

Time - Distance - Shielding

Bodily excretions radioactive if unsealed

Secondary Intervention

New Developments in Radiation Therapy

3D-CRT Three dimensional conformal radiation therapy

-Uses CT images to map location of Ca in 3 dimensions. Client fitted with mold ( to keep area still during rx).-Beams are matched to precise shape of tumor-Reduces radiation damage to surrounding normal tissue

IMRT Intensity modulated radiation therapy

-Uses same technology as 3D-CRT but intensity can also be precisely adjusted (modulated)-This increased control, also reduces damage to normal tissue

THE PATIENT WITH CANCER A NURSING PROCESS APPROACH

The following common problems should be considered:

Infection Bleeding Pain Malnutrition Fatigue Psychosocial Issues Maslow's Hierarchy of Needs

FOCUSED ASSESSMENT of the Patient with Cancer

S/S of bleeding: Platelets, CBC, H&H, gums, stools, urine, skin, LOC

S/S of infection: Temp, WBC, resp, urinary, skin, invasive sites

Pain: W H A T S U P or S L I D A Nutritional Status: Weight, serum albumin &

transferrin, appetite, N&V, diarrhea, food aversions/preferences

Coping skills of patient and S.O. Patient knowledge: disease, treatment, outcomes

DIAGNOSIS

Risk for injury r/t bleeding tendencies Risk for infection r/t diminished immunity Chronic pain r/t disease process and therapy Nutrition, imbalanced; less than body requirements

r/t anorexia, N/V, pain, disease process Fatigue r/t myelosuppression Risk for ineffective coping r/t diagnosis of cancer Anticipatory grieving r/t potential disease outcome Body image disturbance r/t surgical rx / alopecia

PLANNING

Patient will demonstrate: Platelet, CBC, H&H, albumin, transferrin levels in normal range No evidence of bleeding No evidence of infection Pain relieved and/or controlled Progressive weight gain toward goal Performance of ADLs within level of ability Verbalized awareness of own coping abilities Ability to identify and express feelings freely/effectively Verbalized acceptance of self in situation Verbalized understanding of disease process & treatment

IMPLEMENTATION

RISK FOR INJURY R/T BLEEDING TENDENCIES

Monitor platelet, CBC, H&H levels Observe for S/S bleeding and or hypoxia Bleeding precautions: gentle handling, fall

precautions, electric razor, soft toothbrush, gentle nose blowing, avoid invasive procedures, no rectal temps, no intercourse

Administer stool softeners as per MD orders Administer transfusion therapy as per MD orders

IMPLEMENTATION

RISK FOR INFECTION R/T DIMINISHED IMMUNITY

Monitor WBC and ANC daily Observe closely for S/S infection Neutropenic precautions: limit invasive procedures,

private room, no exposure to communicable illness strict handwashing, no fresh flower, fruits, vegetables, no standing water, C&DB

Administer hematopoietic growth factors per MD orders

MyelosuppressionAnemia – Leukopenia- Thrombocytopenia

ANEMIA = 10% lower than normals

LEUKOPENIA = 2500/mm or lower

THROMBOCYTOPENIA = 50,000/mm or lower

IMPLEMENTATION

CHRONIC PAIN R/T DISEASE PROCESS & THERAPY

Acknowledge and accept patient report Determine patient’s acceptable pain level Administer analgesics per MD orders Eliminate aggravating factors Enlist known alleviating factors Utilize cognitive-behavioral strategies: guided imagery,

distraction, relaxation etc.

IMPLEMENTATION

NUTRITION, IMBALANCED; LESS THAN BODY REQUIREMENTS R/T ANOREXIA,N&V,PAIN…

Monitor serum albumin, transferrin, body weight, intake & output

Identify patient food likes and dislikes Offer small frequent nutrient dense meals/snacks See National Cancer Institute - Nutrition in Cancer Care Administer anti-emetics & analgesics ac per MD orders ANTI-EMETIC Examples: Zofran, TIgan, Ativan, Compazine

IMPLEMENTATION

FATIGUE R/T MYELOSUPPRESSION

Monitor RBC, H&H Structure daily routines/activities to conserve patient

energy Encourage nutritionally balanced diet Administer biologic response modifiers (ie: Epogen)

per MD orders Administer blood transfusion per MD orders

IMPLEMENTATION

RISK FOR INEFFECTIVE COPING ANTICIPATORY GRIEVING BODY IMAGE DISTURBANCE Utilize effective communication techniques and

attentive listening skills Encourage patient verbalizations of fears and concerns Explore and utilize existing patient coping mechanisms Provide information on support groups, hospice care Encourage expression of feelings regarding body image Provide information regarding plastic surgery, prosthetic

optionsTertiary Intervention

EVALUATION

PATIENT WILL:

Be free from bleeding, infection Verbalize relief, reduction and/or control of pain Maintain optimal nutritional status free of N&V Perform ADLs to desired level Express feelings about disease, prognosis, body

image, etc. Demonstrate healthy coping mechanisms

ADDITIONAL CONSIDERATIONS

Hospice care Oncological emergencies Multicultural approaches Complementary therapies Community-based care Evidence-based practice Clinical trials and research

Oncologic Emergencies

Disseminated Intravascular Coagulation (DIC) Sepsis Syndrome of Inappropriate Antidiuretic

Hormone ( SIADH ) Hypercalcemia Spinal Cord Compression Superior Vena Cava Syndrome Tumor Lysis Syndrome

Laryngeal Cancer

Combined alcohol/tobacco use = primary risk factor

Incidence increasing / Men higher / Over 60 Most = squamous cell carcinoma Hoarseness = earliest sign Other signs???

Laryngeal CancerASSESSMENT

History of smoking, alcohol use, environmental and/or occupational exposures

Physical assessment for s/s Diagnostic assessments: CBC, Albumin,BUN,

Creatinine, Liver function studies, CT, MRI, PET, Tumor mapping, Panendoscopy

Laryngeal CancerNURSING DIAGNOSES

Potential for respiratory obstruction Impaired swallowing Imbalanced Nutrition Impaired verbal communication Risk for situational low self esteem r/t

disturbed body image +++++++++++++

Laryngeal CancerPLANNING OUTCOMES

Maintain positive oxygenation status Prevent aspiration Promote nutritional balance Facilitate alternate communication Promote positive self-image Promote coping mechanisms and anxiety

reduction

Laryngeal CancerINTERVENTIONS

NON SURGICAL

Chemotherapy

Radiation Therapy– Voice rest– Mouth/Throat care: sprays,fluids,artificial saliva– Skin care:mild soap,no sun,cold,heat,lotions,powder

Laryngeal CancerINTERVENTIONS

SURGICAL

Dependent on size, node involvement and metastasis (TNM staging)

Ranges from resection of tumor alone to total laryngectomy and possibly radical neck dissection

Total LaryngectomyNursing Considerations

Airway maintenance– Mechanical ventilation– Humidification– C & DB, Oxygen Rx, Positioning

Laryngectomy stoma & tube care– Suture line care– Suctioning prn

Communication facilitation– Paper/pencil or table slate– Speech therapy– Electrolarynges– TEF

Total LaryngectomyNursing Considerations (Continued)

Monitor for hemorrhage Prevention of infection Wound care; Graft care Pain management Nutritional support Psychosocial support Health teaching

Breast CancerVersus Benign Breast Disorders

MATCHING EXERCISE

A.Fibroadenoma

B.Fibrocystic breast disease

C.Ductal ectasia

D.Intraductal ectasia

Perimenopausal woman with green/brown nipple discharge, erythema & edema over mass

50 y.o. woman with serous nipple discharge/ no mass

22 y.o. woman with round,firm,non-tender, movable mass

35 y.o. woman with multiple,tender nodular areas and feeling of generalized breast fullness

Breast Cancer

Leading cause of cancer deaths in woman Incidence higher in Caucasian women Early dx is key to prognosis & survival Also affects men ( over 60 more common ) Risk Factors: age, estrogen exposure, genetics,

family history,diet,weight,exercise

Types of Breast Cancer

Lobular carcinoma in situ (LCIS) Ductal carcinoma in situ (DCIS) Invasive ductal carcinoma (IDC) 80%cases Invasive lobular carcinoma (ILC) Medullary carcinoma Colloid carcinoma Tubular carcinoma Inflammatory breast cancer

Breast CancerPrimary Level Care

SCREENING

THREE PRONGED APPROACH

BREAST SELF EXAM

CLINICAL BREAST

EXAMMAMMOGRAPHY

Breast CancerASSESSMENT

Assess risk factor historyNational Cancer Institute Breast Cancer Risk Assessmenthttp://www.cancer.gov/bcrisktool/

Physical assessment: location of breast mass, fixed vs movable, consistency, dimpling, peau d’orange, nipple retraction, lymph nodes

Additional imaging: ultrasound,MRI Breast biopsy: needle vs surgical Staging and grading

Comparison of Breast Lumps

Benign Breast Disease Multiple or single Rubbery texture Mobile / slippery Regular borders Tenderness (cyclic) No retraction May increase/decrease

in size rapidly

Cancer Unilateral Firm texture Fixed firmly Irregular border Usually painless Usually w/retraction Grows constantly

Breast CancerASSESSMENT (continued)

CXR Bone scan CT PET Blood tests/ CBC,Liver Enzymes,Ca,Alkaline Phosphatase

Tumor tests/ Estrogen and Progesterone Receptors, HER2

Breast CancerNURSING DIAGNOSES

Anxiety r/t to diagnosis of cancer Anticipatory grieving Disturbed body image Acute pain Ineffective protection r/t therapies ++++++++++++++++++

Breast CancerPLANNING OUTCOMES

Anxiety reduction Promotion of coping strategies Pain relief Body image enhancement Free from infection, fatigue, bleeding

Breast CancerINTERVENTIONS

SURGICAL RX Lumpectomy Partial mastectomy ( wide excision) Modified radical mastectomy Lymph node dissection / sentinel biopsy Oophorectomy / Ovarian ablation Breast re-construction

Post MastectomyNursing Considerations

Lymphedema precautions Positioning and mobility Arm exercises Drains and wound care Pain management Short stay is common; health teaching ! Adjuvant therapy complications Support group referrals

Lymphedema Interventions

Place sign above bed No BP, BW, Injections

on operative side Support arm on pillow Progressive exercises Compression sleeve Patient teaching re:

avoidance of injury

Breast CancerAdjuvant Therapy

Radiation ( teletherapy – brachytherapy)SE = skin changes, swelling&heaviness, lymphedema

ChemotherapySE = see previous slides + heart damage, ?infertility

Monoclonal antibody therapy (Herceptin)SE = see previous slide + heart damage

Hormone therapy ( Blockers or Inhibitors)SE = menopausal symptoms, uterine CA, thrombus

Breast CancerPsychosocial Support

Encourage verbalization Listen, listen, listen…. Involve significant others Arrange for support group contact Reach for Recovery Local Chapter-Hauppauge American Cancer Society website

Skin Cancer

Incidence and prevalence increasing Highest in light-skinned, over age 60, hx of

frequent sun-exposure Prevention,screening,early intervention Actinic Keratosis

Squamous CellBasal CellMelanoma

Skin CancerINTERVENTIONS

Drug Therapy Radiation Therapy Immunotherapy Cryosurgery Curettage / Electrodesiccation Excision