nursing care of client with cancer

7/27/2019 Nursing Care of Client With Cancer

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Nursing Care of the Client with Cancer

Cancer Background

A. Definition

1. Family of complex diseases

2. Affect different organs and organ systems

3. Normal cells mutate into abnormal cells that takeover tissue

4. Eventually harm and destroy host

5. Historically, cancer is a dreaded disease

B. Oncology

1. Study of cancers

2. Oncology nurses specialize in the care,treatment of clients with cancer


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Incidence and Prevalence

1. Cancer accounts for about 25% of

death on yearly basis

2. Males: 3 most common types of cancer

are prostate, lung and bronchial, colorectal

3. Females: 3 most common types ofcancer are breast, lung and bronchial, and

colorectal


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Risk factors for cancer: (some are controllable; some are not)

1. Heredity: 5 10% of cancers; documented with some breast andcolon cancers

2. Age: 70% of all cancers occur in persons > 65

3. Lower socio-economic status

4. Stress a. Leads to greater wear and tear on body in general

5 Diet: certain preservatives in pickled, salted foods; fried foods;high-fat, low fiber foods; charred foods, high fat foods, diet high inred meat

6. Occupational risk: exposure to know carcinogens, radiation,high stress

7. Infections, especially specific organisms and organ (e.g.papillomavirus causing genital warts and leading to cervical cancer)

8. Tobacco Use: Lung, oral and laryngeal, esophageal, gastric,pancreatic, bladder cancers

9. Alcohol Use: also tied with smoking

10. Sun Exposure (radiation) e.g. skin cancer


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Nursing role includes health promotion to lower thecontrollable risks

1. Routine medical check up and screenings

2. Client awareness to act if symptoms of cancer occur

3. Screening examination recommendations by AmericanCancer Society; specifics are made according to age andfrequencies

a. Breast Cancer: self-breast exam, breast examinationby health care professionals, screening mammogram

b. Colon and Rectal Cancer: fecal occult blood, flexiblesigmoidoscopy, colonoscopy

c. Cervical, Uterine Cancer: Papanicolaou (Pap) test

d. Prostate Cancer: digital rectal exam, Prostate-specific

antigen (PSA) test


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Physiology of Cancer

A. Background

1. Normal Cell Growth includes twoevents

a. Replication of cellular DNA

b. Mitosis (cell division)


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Theories of Carcinogenesis (what causes cancer tooccur)

1. Cellular Mutation

a. Cells begin to mutate (change the DNA to unnatural

cell reproduction)2. Oncogenes/Tumor Suppressor Genes Abnormalities

a. Oncogenes are genes that promote cell proliferationand can trigger cancer

b. Tumor suppressor genes normally suppress

oncogenes but are damaged3. Exposure to Known Carcinogens

a. Act by directly altering the cellular DNA (genotoxic)

b. Act by affecting the immune system (promotional)


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4. Viruses

viruses break the DNA chain and mutates thenormal cells DNA

Epstein-Barr virus

Human papilloma virusHepatitis virus

5. Drugs and Hormones

a. Sex hormones often affect cancers of thereproductive systems (estrogen in some breast

cancers; testosterone in prostate cancer) b. Glucocorticoids and steroids alter immune

system


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6. Chemical Agents

a. Industrial and chemical

b. Can initiate and promote cancer

b. Examples: hydrocarbons in soot ; arsenic in

pesticides; chemicals in tobacco7. Physical Agents

a. Exposure to radiation Ionizing radiation found in x-rays, radium, uranium

UV radiation

Sun, tanning beds8. Immune function

1. Protects the body from cancerous cells

2. Increased rate of cancer in immunocompromised pts


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Neoplasms: also called tumors (mass of new tissue that growsindependently of surrounding organs

1. Types of neoplasms

a. Benign

1. Localized growths respond to bodys homeostatic controls

2. Encapsulated 3. Stop growing when they meet a boundary of another

tissue

4. Can be destructive

b. Malignant

1. Have aggressive growth, rapid cell division outside thenormal cell cycle

2. Not under bodys homeostatic controls

3. Cut through surrounding tissues causing bleeding,inflammation, necrosis (death) of tissue


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Malignant tumors can metastasize

a. Tumor cells travel through blood or lymphcirculation to other body areas and invade tissuesand organs there.

1. Primary tumor: the original site of themalignancy

2. Secondary tumor (sites): areas wheremalignancy has spread i.e. metastasis (metastatictumor)

3. Common sites of metastasis are lymph nodes,liver, lungs, bones, brain

4. 50 60 % of tumors have metastasized by timeprimary tumor identified

b. Cancerous cells must avoid detection by immune

system


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C. Malignant neoplasms can recur after surgical removal of primary

and secondary tumors and other treatmentsD. Malignant neoplasms vary in differentiation.

a. Highly differentiated are more like the originatingtissue

b. Undifferentiated neoplasms consist of immaturecells with no resemblance to parent tissue and have nouseful function

E. Malignant cells progress in deviation with eachgeneration and do no stop growing and die, as donormal cells

F. Malignant cells are irreversible, i.e. do not revert tonormal

G. Malignant cells promote their own survival by hormoneproduction, cause vascular permeability; angiogenesis;divert nutrition from host cells


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The steps of metastasis


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Effects of Cancer

1. Disturbed or loss of physiologic functioning, from pressure orobstruction

a. Anoxia and necrosis of organs

b. Loss of function: bowel or bladder obstruction

c. Increased intracranial pressure d. Interrupted vascular/venous blockage

e. Ascites

f. Disturbed liver functioning

G. Motor and sensory deficits

Cancer invades bone, brain or compresses nervesh. Respiratory difficultiesa. Airway obstruction

b. Decreased lung capacity


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2. Hematologic Alterations: Impaired function of blood cells

1. Secondary to any cancer that invades the bone marrow (leukemia)2. May also be caused by the treatment

a. Abnormal wbcs: impaired immunity

b. Diminished rbcs and platelets: anemia and clottingdisorders

3. Infections: fistula development and tumors may becomenecrotic; erode skin surface

4. Hemorrhage: tumor erosion, bleeding, severe anemia

5. Anorexia-Cachexia Syndrome: wasting away of client

a. Unexplained rapid weight loss, anorexia with altered smelland taste

b. Catabolic state: use of bodys tissues and muscle proteinsto support cancer cell growth


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6. Paraneoplastic Syndromes: ectopic sites with excess hormone

production a. Parathyroid hormone (hypercalcemia)

b. Ectopic secretion of insulin (hypoglycemia)

c. Antidiuretic hormone (ADH: fluid retention)

d. Adrenocorticotropic hormone (ACTH)

7. Pain: major concern of clients and familiesa. Types of cancer pain

1. Acute: symptom that led to diagnosis

2. Chronic: may be related to treatment or to progression ofdisease

b. Causes of pain

1. Direct tumor involvement including metastatic pain 2. Nerve compression

3. Involvement of visceral organs


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8. Physical Stress: body tries to respond and destroyneoplasm

a. Fatigue

b. Weight loss

c. Anemia

d. Dehydration

e. Electrolyte imbalances

9. Psychological Stress

a. Cancer equals death sentence

b. Guilt from poor health habits

c. Fear of pain, suffering, death

d. Stigmatized


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Collaborative Care

A. Diagnostic Tests: used to diagnose cancer

1. Determine location of cancer

a. Xrays

b. Computed tomography

c. Ultrasounds d. Magnetic resonance imaging

e. Nuclear imaging

f. Angiography

2. Diagnosis of cellular type of can be done through tissue

samples from biopsies, shedded cells (e.g. Papanicolaousmear) washings

a. Cytologic Examination: tissue examined undermicroscope

b. Identification System of Tumors: Classification Grading -- Staging


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1. Classification: according to the tissue or cellof origin, e.g. sarcoma, from supportive

2. Grading:

a. Evaluates degree of differentiation andrate of growth

b. Grade 1 (least aggressive) to Grade 4(most aggressive)

3. Staging

a. Relative tumor size and extent of disease b. TNM (Tumor size; Nodes: lymph node

involvement; Metastases)


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3. Tumor markers: specific proteins which indicatemalignancy

a. PSA (Prostatic-specific antigen): prostate cancer

b. CEA (Carcinoembryonic antigen): colon cancer

c. Alkaline Phosphatase: bone metastasis4 Direct Visualization

a. Sigmoidoscopy

b. Cystoscopy

c. Endoscopy

d. Bronchoscopy

e. Exploratory surgery; lymph node biopsies todetermine metastases


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Other non-specific tests

a. CBC, Differential

b. Electrolytes

c. Blood Chemistries: (liver enzymes:

alanine aminotransferase (ALT); aspartate

aminotransferase (AST) lacticdehydrogenase (LDH)


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Treatment Goals: depending on type and stage of cancer

A. Cure

1. Recover from specific cancer with treatment

2. Alert for reoccurrence

3. May involve rehabilitation with physical and

occupational therapyB. Control: of symptoms and progression of cancer

1. Continued surveillance

2. Treatment when indicated (e.g. some bladder

cancer, prostate cancer)C. Palliation of symptoms: may involve terminal care if

clients cancer is not responding to treatment


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Treatment Options (depend on type of cancer)alone or with combination

A. Chemotherapy

1. Effects are systemic and kills themetastatic cells

2. Often combinations of drugs in specificprotocols over varying time periodsMuch more effective then a single agent

Consider the timing of the nadir of each drug The time when the bone marrow activity and WBC counts

are at their lowest levels after chemo

Different times for different drugs


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3. Cell-kill hypothesis: with each cell

cycle a percentage of cancerous cells

are killed but some remain; repeating

chemo kills more cells until those leftcan be handled by bodys immune

system


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B. Classes of Chemotherapy Drugs

1. Alkylating agents

1. Action: create defects in tumor DNA

2. Examples: Nitrogen Mustard, Cisplatin

2. Antimetabolites

1. Action: similar to metabolites needed for vital cellprocesses Counterfeit metabolites interfere with cell division

2. Examples: Methotrexate; 5 fluorouracil

3. Toxic Effects: nausea, vomiting, stomatitis, diarrhea,alopecia, leukopenia

3. Antitumor Antibiotics 1. Action: interfere with DNA

2. Examples: Actinomycin D, Bleomycin

3. Toxic Effect: damage to cardiac muscle


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4. Antimiotic agents

1. Action: Prevent cell division

2. Examples: Vincristine, Vinblastine

3. Toxic Effects: affects neurotransmission,

alopecia, bone marrow depression

5. Hormone agonist

1. Action: large amounts of hormones upset thebalance and alter the uptake of other hormones

necessary for cell division

2. Example: estrogen, progestin, androgen


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6. Hormone Antagonist

1. Action: block hormones on hormone-binding tumors (breast, prostate,

endometrium; cause tumor regressionDecreasing the amount of hormones can decreasethe cancer growth rate

Does not cure, but increases survival rates

2. Examples: Tamoxifen (breast); Flutamide(prostate)

3. Toxic Effects: altered secondary sexcharacteristics


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7. Hormone inhibitors

Aromatase inhibitors (Arimidex, Aromasin)

Prevents production of aromatase which is

needed for estrogen productionUsed in post menopausal women

Side effects

Masculinizing effects in women

Fluid retention


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Effects of Chemotherapy a. Tissues (fast growing) frequently affected

b. Examples: mucous membranes, hair cells, bone marrow,specific organs with specific agents, reproductive organs (allfetal toxic, impair ability to reproduce).

Administration of chemotherapeutic agents

a. Trained and certified personnel, according to establishedguidelines

b. Preparation

1. Protect personnel from toxic effects

Drugs absorbed through skin and mucous membranes Protective clothing and extreme care

2. Extreme care for correct dosage; double check withphysician orders, pharmacists preparation

c. Proper management clients excrement


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d. Routes

1. Oral

2. Body cavity (intraperitoneal or

intrapleural) 3. Intravenous

a. Use of vascular access devices because of

threat of extravasation (leakage intotissues) and long-term therapya. If the drug is a vessicant it may result in pain,

infection and tissue loss


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e. Types of vascular access devices

1. PICC lines (peripherally inserted

central catheters)

2. Tunnelled catheters (Hickman,

Groshong)

3. Surgically implanted ports

(accessed with 90o angle needle


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Hickman Catheter


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Portacath


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PICC Line


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Managing side effects of chemotherapy

A. Nausea and vomiting

80% of patients will develop it

Antiemetics such as Zofran, Tigan,

Compazine as well as Ativan to control the

symptoms

Monitor for dehydration and need for IVfluids


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B. Bone marrow suppression

Decreased number of RBC

Leads to hypoxia, fatigue

Hgb 9.5-10 gm/dl require oral iron supplementsHgb below 8 gm/dl require transfusion

May use Epogen to stimulate RBC production


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Decrease number of WBC (normal 4,500-11,000mm3) especially neutrophils (normal 3,000-7,000cells/cc) Neutropenia-count below 2000

Pt at extreme risk for infection

May order granulocyte colony stimulating factor (leukine) tostimulate bone marrow to increase WBC count

Neutropenic precautions Private room

Good handwashing

Monitor temp q 4 hours, monitor for chills, UTI, pneumonia

Limit visitors to healthy adults

No flowers or plants

Monitor neutrophil count


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ThrombocytopeniaDrop in platlet count (normal 150,000-400,000/mm3)

below 100,000

Test pt for bleeding in stool and urine

Avoid punctures for IV or IM

Handle pt gently

Use electric razor

Avoid placing foley or rectal thermometers

Avoid oral trauma with soft bristle brushes, avoid

flossing, avoid hard candyWatch for ALOC, pupil changes that might indicate

intracranial bleeds

Stool softeners to avoid straining


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C. Mucocitis

Inflammation and ulceration of mucous

membranes and entire GI tract

Rinse mouth with normal saline and peroxide every 12 hours

Topical analgesic medication

Avoid mouthwashes with alcohol

Avoid spicy or hard food

Watch nutritional status


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D. Alopecia

Hair loss

2-3 weeks after treatment is started

Affects all the hair, including eyebrows,

eyelashes

Within 4-8 weeks after treatment hair begins

to grow backBefore hair loss, have the pt pick out a wig

that is similar to hair color


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E. Peripheral neuropathy

Numbness and tingling to fingers and toes

in a glove and sock pattern

May cause gait and possible fall problems

F. Provide emotional and spiritual

support to patient and families


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Surgery 1. Diagnosis, staging, and sometimes treatment of cancer

2. May be prophylaxis or removal of at risk tissue or organprior to development of cancer (breast cancer)

3. Involves removal of body part, organ, sometimes withaltered functioning (e.g. colostomy)

4. Debulking (decrease size of) tumors in advanced cases

5. Reconstruction and rehabilitation (e.g. breast implant postmastectomy)

6. Palliative surgery to improve the quality of life Removal of tumor tissue that is causing pain or obstruction

5. Psychological support to deal with surgery as well ascancer diagnosis


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Radiation Therapy

1. Treatment of choice for some tumors to kill orreduce tumor, relieve pain or obstruction Destroy cancer cells with minimal exposure to normal cells

Cells die or are unable to divide

2. Delivery

a. Teletherapy (external): radiation delivered inuniform dose to tumor Beam radiation

b. Brachytherapy: delivers high dose to tumor andless to other tissues; radiation source is placed in

tumor or next to it in the form of seeds Radiation source within the patient so pt emits radiation for

a period of time and is a hazard to others

c. Combination


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3. Goals a. Maximum tumor control with minimal

damage to normal tissues

b. Caregivers must protect selves by using

shields, distancing and limiting time withclient, following safety protocolsPrivate room

Caution sign on the door for radioactive material

Dosimeter film badge by staffNo pregnant staff

Limit visitors to hour per day and keep them atleast 6 ft from the source


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4. Treatment Schedules a. Planned according to radiosensitivity of tumor,

tolerance of client

b. Monitor blood cell counts

5. Side Effects a. Skin (external radiation): blanching, erythema,sloughing, breakdownUse mild soak

Dry skin with a patting motion, not rubbing

Dont use powders or lotions unless prescribed byradiologist

Wear soft clothing over the site

Avoid the sun and heat


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b. Ulcerated mucous membranes: pain, lack

of saliva (xerostoma)

c. Gastrointestinal: nausea and vomiting,

diarrhea, bleeding, sometimes fistulaformation

d. Radiation pneumonitis

1-3 months after treatment

Cough, SOB, fever

Treated with steroids to decrease inflammation


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Monoclonal antibodies (inoculate

animal with tumor antigen and retrieve

antibodies against tumor for human)

Antibodies target specific substancesneeded by the cancer cell for growth

(Herceptin for breast cancer)


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Gene therapy

experimental

May insert gene into the tumor cells to

make them more susceptible to being

killed by antiviral agents

May insert genes for cytokines that

increase their effectiveness in killing

cancer cells


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Angiogenesis inhibitor drugs

prevent new blood vessels from

forming and delivering blood to the

tissue


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F. Bone Marrow Transplantation and Peripheral Blood Stem CellTransplantation

1. Stimulation of nonfunctioning marrow or replace bone marrow

2. Common treatment for leukemias

G. Pain Control

1. Includes pain directly from cancer, treatment, or unrelated

2. Necessary for continuing function or comfort in terminally illclients

3. Goal is maximum relief with minimal side effects

4. Multiple combinations of analgesics (narcotic and non-narcotic) and adjuvants such as steroids or antidepressants;

includes around the clock (ATC) schedule with additionalmedications for break-through pain

5. Multiple routes of medications

6. May involve injections of anesthetics into nerve, surgicalsevering of nerves radiation

7. May need to progress to stronger pain medications as pain

increases and client develops tolerance to pain medication


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Nursing Diagnoses for Clients with Cancer

A. Anxiety

1. Therapeutic interactions with client and family; communityresources such as American Cancer Society, I Can Cope

2. Availability of community resources for terminally ill (Hospicecare in-patient, home care)

B. Disturbed Body Image 1. Includes loss of body parts (e.g. amputations); appearance

changes (skin, hair); altered functions (e.g. colostomy); cachexicappearance, loss of energy, ability to be productive

2. Fear of rejection, stigma

C. Anticipatory Grieving

1. Facing death and making preparations for death: will beconsideration

2. Offer realistic hope that cancer treatment may be successful


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D. Risk for InfectionE. Risk for Injury

1. Organ obstruction

2. Pathological fractures

F. Altered Nutrition: less than body requirements

1. Consultation with dietician, lab evaluation of nutritionalstatus

2. Managing problems with eating: anorexia, nausea andvomiting

3. May involve use of parenteral nutrition

G. Impaired Tissue Integrity

1. Oral, pharyngeal, esophageal tissues (due to chemotherapy,bleeding due to low platelet counts, fungal infections such asthrush)

2. Teach inspection, frequent oral hygiene, specific non-irritating products, thrush control


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Oncologic Emergencies

A. Pericaridal Effusion and Neoplastic

Cardiac Tamponade

1. Concern: compression of heart by fluid

in pericardial sac, compromised cardiac

output

2. Treatment: pericardiocentesis


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B. Superior Vena Cava Syndrome

1. obstruction of venous system with

increased venous pressure and stasis; facial

and neck edema with slow progression torespiration distress

Late signs are cyanosis, decreased cardiac output

and hypotension

2. Treatment: respiratory support; decreasetumor size with radiation or chemotherapy


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Compression of the superior vena cava in SVC

syndrome


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C. Sepsis and Septic Shock

1. Early recognition of infection

Patients at risk secondary to low WBC and

impaired immune system

2. Treatment: prompt intervention with

antibiotics and vasopressors


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D. DIC disseminated intravascular

coagulation

Triggered by severe illness, usually sepsis

in cancer patientsAbnormal clotting uses up existing clotting

factors and platelets quickly then the pt

hemorrhages

Mortality rate is 70%

Prevention of sepsis is key


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E. Spinal Cord Compression

1. Pressure from expanding tumor or

vertebral collapse can cause irreversible

paraplegia 2. Back pain initial symptom with

progressive paresthesia and paralysis

Paralysis is usually permanent

3. Treatment: early detectionHigh dose corticosteroid to decrease the swelling

radiation or surgical decompression


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F. Obstructive Uropathy

1. Concern: blockage of urine flow;

undiagnosed can result in renal failure

2. Treatment: restore urine flow


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G. Hypercalcemia 1. High calcium (normal 9-10.5) usually from bone metastases

2. May also come from cancer of the lung, head, neck, kidneyand lymph nodes that secrete parathyroid hormone that causesthe bone to release calcium

2. Symptoms include fatigue, muscle weakness, polyuria,constipation, progressing to coma, seizures

3. Treatment restore fluids with intravenous saline which also increases the

excretion of calcium

loop diuretics increase calcium excretion

Calcium chelators such as mithracin

Inhibit calcium resorption from the bone with calcitonin,diphosphonate


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H. Tumor Lysis Syndrome

1. Occurs with rapid necrosis of tumor cellswith chemotherapyWhen tumor cells die they release potassium and

purines

Potassium (norm 3.5-5.5) elevation causes cardiacarrhthymias, muscle weakness, twitching, cramps

Purines convert to uric acid which causes renal

failure, flank pain, gout when elevated above 10mg/dl

Hyperphosphatemia with secondary tohypocalcemia causes heart block, HTN, renal failure


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Treatment

Hydration

Instruct pt to increase fluid intake before

and after chemoMay need IV hydration

Diuretics to increase urine flow

Allopurinol to increase uric acid excretion

May need dialysis


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I. SIADH (Syndrome of Inappropriate Antidiuretic HormoneSecretion)

1. Ectopic ADH production from tumor leads to excessivehyponatremia

2. holds onto too much fluid which decreases sodium level(normal 135-145)

3. Symptoms Weakness, muscle cramps, fatigue, ALOC, headache, seizures

2. Treatment: restore sodium level Fluid restriction

Increase sodium

Antibiotic demeclocycline works in opposition to ADH Limits ADH effect on distal renal tubules so they can excrete water

nursing care of client with cancer

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