The Client with Cancer

Cancer

Smeltzer & Bare:

Chapter 16, 17

Not a single disease, but a group of

distinct diseases with different
causes, manifestations, treatments &
prognoses. It is characterized by a
process that begins when an
abnormal cell is transformed by the
genetic mutation of the cellular DNA.
1

Learning Objectives:

Incidence of Cancer

1. Describe the role of the nurse in health

education & preventive care in decreasing the
incidence of cancer.
2. Perform a focused assessment appropriate for
determining the status of a client with cancer.
3. Describe common nursing diagnoses and
collaborative problems of patients with cancer.
2

most common is prostate, but highest death

rate is lung cancer.

Deaths due to Lung Cancer

Learning Objectives:
4. Apply the nursing process to a client with
cancer.
5. Apply the nursing process to a client receiving
chemotherapy.
6. Apply the nursing process to the client
receiving radiation therapy.
7. Describe the role of the nurse in assessment
and management of common oncologic
emergencies.
8. Apply the nursing process to a terminally ill
client.
3

takes approx. 30 years to lung cancer to develop

External Factors that Increase Risk of

Developing Cancer

Characteristics of Cancer Cells

Malignant Cells

Chemical Carcinogens
Tobacco
Asbestos
Ionizing radiation
Environmental factors
Viruses
Chronic Irritation
Dietary Factors

Rapid or continuous growth

Anaplastic
Loose adherence
Migratory
Invasive
Once you have a cancer cell it continues to divide until the
organism it lives within dies.
Anaplastic: the organ cell loses its distinction due to the
cancer and begins to lose its function. No longer appears7
its own but, still identifiable.
Loose adherence: the cells begin to fall apart from each
other to different parts of the body
Migratory: cells can attach somewhere else - metastasis.

carcinogenic: can cause

cells to change into
cancerous cells.

Excessive use of ETOH

10

Normal and Cancerous

Lung Cells

Internal Factors that Increase

Risk of Developing Cancer
Immune Function
Age as you age your immune function declines
Genetic Predisposition

relative had colonoscopy cancer you get checked 10

years before the age they were diagnosed

* women >40 are encouraged to get mamograms

11

elderly: cancer develops more slowly bc cells divide more

slowly.

Cancer Development
Oncogenesis/ Carcinogenesis

1. Which of the
following statements
by a client would
indicate to the nurses
that further teaching is
needed concerning
cancer?

Once initiation has occurred it starts to

Initiation divide.
Promotion when they multiply
when cells are detectable - there has to be
Progression 1 billion cells to be detectable
Metastasis Cells break off and spread else where.
9

c.

a. Anything that can alter the

RNA or DNA in a cell can
produce mutant cells.
b. Everyone has some mutant
cells in their body at any
given time.
c. Cancer cells follow an
orderly progression in
reproduction.
d. Anything that will suppress
the immune system will
make an individual more
susceptible to cancer.

12

Cancer Prevention

Secondary Prevention

Primary Prevention- Activities to prevent

cancer from developing in the cells.

Screening
B.S.E. & mammography
Colonoscopy
Papanicolaou smear
Testicular self exam
Prostate specific antigen levels
prostate/ stony feeling
Digital Rectal Exam ovarian/ feel ovaries are

Secondary Prevention- Also known as

early detection
Primary: you are doing something to prevent your self from
getting cancer (i.e hpv vaccine, good diet, healthy lifestyle)

big and hard

Secondary: youre not preventing cancer you are detecting it

13
early. (i.e mamogram, colonoscopy)

http://cancernet.nci,nih,gov/wyntk_pubs

16

an example maybe put on exam*

Primary Prevention

2. The client tells

you that she has
heard that the
origin of most
cancers is
genetic. What is
your best
response?

Factors that Reduce Risk

Fresh vegetables
Increased fiber
Vitamins A, C, E

Risk Factors
Obesity
Diet high in dietary fat
Nitrate cured foods- Avoid cold cuts, hot dogs
Smoking
Alcohol
Overexposure to sun
Sedentary lifestyle

bacon, cold cuts, hot dogs

14

nicotine is excreted
through your kidney to
your bladder

Liver, mouth, esophagus,

colon & rectum
Lung

17

3. A client asks what

part of the body the cell
sample is taken for her
yearly Pap smear. The
nurse replies that the
cells are scraped from
the:

Known Environmental Carcinogens

Alcohol

Asbestos
Chemotherapy
drugs
Pesticides
Sunlight
Tobacco

A. The development of
most cancers is
predetermined and not
affected by
environmental factors.
B. Cancers arise in cells
that have alterations in
the genes.
C. The majority of cancers
are inherited.
D. Cancer is more
common among males
than females.

Leukemias
Lung
Skin
Lung, esophagus, pancreas,
bladder, kidney, stomach,
colon, & leukemias

a. Cervix
b. Uterus
c. Ovaries
d. Fallopian tube

15

18

4. What is the
major cause of
cancer deaths
among men?

6. A female client is
diagnosed with ovarian
cancer. She is likely to
have which
manifestation?

A. Skin cancer
B. Prostate cancer

c. Dyspnea

D. Lung cancer

d. Night sweats

As tumor gets bigger it presses on your bowels.

Seven Warning Signs of Cancer

C
A
U
T
I
O
N

b. Postcoital bleeding

C. Colorectal cancer

19

a. Changes in bowel
elimination

Diagnosis: TNM Staging System

Primary Tumor (T)
TO
No evidence of primary tumor
TIS Carcinoma in Situ
T1,T2,T3, T4
Increasing size of primary tumor

Changes in bowel or bladder habits

A sore that does not heal
Unusual bleeding or discharge
Thickening or lump
Indigestion or difficulty swallowing
Obvious change in a wart or mole
Nagging cough or hoarseness

some cancers dont give any indication of cancer at all

22

Regional Lymph Nodes

(N)
NO
No lymph node involvement
N1,N2, N3 Increasing lymph nodes involvement
Distant Metastasis (M)
MO
No distant metastasis
M1
Distant metastasis
20

check on cat scan if there is cancer for metastasis

23

sometimes cancer is too small so CAT scan cant detect

In Situ: tumor is growing, but noninvasive/ not
invaded the organ it is in. (common in breast
cancer) it is incapsulated
5. A 67 year old man
is admitted with a
tentative diagnosis of
bronchogenic
carcinoma. His chief
complaint is dyspnea
and chronic cough.
He has a sputum
sample for cytologic
testing ordered.
Important nursing
implications involved
with this test include
which of the
following?

Treatment Modalities

a. Obtain the sample before

bed.
b. Collect the specimen in the
morning before the client
eats or drinks.

c. Have the client brush his

teeth for collecting specimen.
d. Keep the client NPO for 8 hrs
before collecting specimen.

21

Surgery lung, colon respond well to surgery

Radiation used for most types of cancer before and after surgery
Hormonal Manipulation prostate, urterine, breasts
Immunotherapy bone marrow transplant
Chemotherapy same as radiation
Bone Marrow Transplantation

used with leukemia, etc

24

Surgery

External Radiation Therapy

remove tumor and

Removal of diseased tissue part of organ

breasts removed if genetically
Prophylaxis get
predisposed. (i.e ovaries removed)
Diagnosis biopsy
bowel obstuc. bc of tumor even if its not
Treatment i.e
malignant yet/
Palliative cancer most likely cant be Tx, but removing
tumor for increased comfort
Reconstructive Breast reconstruction, bc its
tramatic

25

diagnostic test: CT (can tell what organ looks like- see

extent of malignancy),
PET scan: looks at function of organs
MRI: looks at area of increased activity (u can get a false
positive) can pick up smaller tumors
7. How does
surgery for cure
differ from
surgery for
palliation?

A. Palliative surgery may

not extend the client's
survival time.
B. Palliative surgery is less
painful than surgery for
cure.
C. Curative surgery
increases physical
function.
D. Curative surgery
prevents cancer.

Several different delivery methods

depending on the depth of the tumor.
most common.
Pin pointing exactly where they want the radiation.
Marks your body to know where.
cancer of rectum; they point laser at your rectum
usually give smaller doses within weeks to increase
success

28

Internal Radiation Therapy

Brachytherapy
Radiation implanted within the body
Used frequently for GYN cancers
Implanted in needles, seeds, or
catheters within body cavities
Vagina, abdomen, pleura or breasts

26

Radiation Therapy
Goals of radiation therapy
small enough tumor for lumpectomy
Prophylactic and radiation (i.e breast cancer)
To control cancer
To cure cancer
Palliative increase comfort, not cure cancer

**radiation is more specific than chemo, which means

symptoms are related to the area you get treated.
Usually get diarrhea, not constipation

TeletherapyTeletherapy- the actual radiation

source is outside the patient.

27

not as common. take a radioactive seed and put it in your

body for a period of time. A lot of nursing care involved.
done w/i the hospital
If you are pregnant you cannot take care of this kind of pt.
29
if you have contact w. person you have a radiation badge,
that monitors how much radiation you are receiving to check
if youve reached limit of over exposure. As a nurse you limit
contact to 30 min a day. Placed in a private room w. sign on
the door. Placed on bed rest bc the radiation marbles can fall
out. NEVER TOUCH THEM with hands; use tongs.

Nursing Diagnosis: Impaired skin integrity r/t

erythematous & desquamation reactions to
radiation
Interventions:
Meticulous skin care

Avoid soap, cosmetics, perfumes, powders, deodorants

Do not remove marking
Avoid shaving area
Wash with warm water only
Avoid sun exposure
Report any blisters; Do not disrupt any blisters
Use prescribed creams and lotions only
If area weeps, apply thin gauze dressing

You dont use any product on the sites of radiation

unless doctor orders it.

30

Side effects of Radiation

Skin reaction *
Altered taste & sensations * everything tastes bad so
Freeze your
sperm/eggs

they dont eat as much

Fatigue * regardless of radiation placement

Inflammatory responses
Infertility radiation anywhere near your reproductive
organs youwill be perfanantly infertile
Alopecia

10. When
teaching the
client about
upcoming
external
radiation
treatments,
the nurse
should stress
the
importance
of

* Most common side effects

a. Massaging the area daily.

b. Exposing the area to
sunlight for 30 minutes
each day.
c. Not using soap on the
treatment area & ink
markings
d. Applying cosmetic creams
over the reddened areas to
conceal reddened areas.

31

8. For which types

of cancer is
radiation therapy
most effective?

11. A client receives a

cervical intracavity
radium implant as part
of her therapy. A
common side effect of
cervical implant is:

A. Cancers of the blood,

such as leukemia
B. Superficial cancers on
the outside of the body
C. Cancers that are
localized to one tissue
or body area
D. Cancers that are large
or widespread with
evidence of distant
metastasis

systemic: skin is localized

a. Creamy, pink-tinged
vaginal discharge.
b. Stomatitis
c. Constipation
d. Xerostomia

32

9. A client is
scheduled for
external radiation
treatment for
laryngeal cancer. Of
the following, which
is not a common
systemic side effect
of this treatment?

34

12. A clients care

plan during the
time that she has
a cervical
radiation implant
in place would
include which
intervention?

a. Nausea
b. Fatigue
c. Malaise
d. Dry desquamation of
the skin

33

diarrhea not constipation

xerostomia: dry mouth; stomatitis: mouth sores

35

a. Frequent ambulation
b. Unlimited visitors
c. Low residue diet
d. Vaginal irrigations
every day

bc they are getting diarrhea+dont want them to strain (bare

down) white rice, bread

36

Goals of Chemotherapy

Antimetabolites

Cure
May be combined with surgery &
radiation therapy
Preoperatively to reduce tumor size
Postoperatively to destroy remaining
cancer cells
Increase survival time
Decrease life threatening complications
Effects are systemic
give chemo before surgery; will help shrink the tumor.
Affects your whole body for the most part

37

CellCell-cycle specific
5-fluorouracil (5-FU)
Methotrexate
6-thioguanine
Hydroxyurea (Hydrea)
Cytarabine (ara-C)
6-Mercaptopurine (6-MP)

dont memorize drugs on module. Understand what it

means and teaching is invovled.

40

Nadir: the lowest point that an individuals blood cell count will
reach as a side effect of chemo/radiation (usually 10-14 days). avoid crowds
blood cells, hair cells, lining of GI tract quick cell reproduction so
in chemo it gets attacked first i think. Hair loss etc.

Alkylating Agents

Principles of Chemotherapy
10,000,000,000 cells
start
X
99%
100,000,000
1st round
X
99%
1,000,000
2nd round
X
99%
10,000 after 3rd round
in order for chemo to work it has to kill every single cell.
38
Chemo attacks in a specific moment in the cell cycle. You have
to get multiple rounds of chemo because of this. Usually given
3,4 other drugs at the same time to attack the other cells that
arent in that specific moment in the cell cycle. But killing
100% of the cells is impossible.

Classification of
Chemotherapeutic agents

Look at module. Those will be on the exam.

41

Antitumor Antibiotics
Cell cyclecycle-nonspecific
Doxorubicin (Adriamycin) *
vesicant
Daunorubicin
vesicant
Bleomycin
Datinomycin
Mitomycin *
vesicant

Antimetabolites
Alkylating Agents
Antitumor Antibiotics
Plant Alkaloids/Antimitotics
Nitrosureas
Topoisomerase 1 Inhibitors
Hormonal Agents

dont need to memorize. but they will give more than

one med.

Cell Cycle nonnon-specific

Cyclophosphamide (Cytoxan)
Cisplatin (CDDP) *
Busulfan
Carboplatin,
Chlorambucil (Leukeran)
Nitrogen mustard *
* Strongly emetogenic

* Strongly emetogenic
39

emetogenic- causes vomiting.

42

Immunotherapy:
Biologic Response Modifiers
(BRMs)

Plant Alkaloids
Cell cyclecycle-specific

Vincristine (Oncovin)
vesicant

Vinblastine *

Herceptin
Interleukins (1,2, 3)
Interferons

vesicant

Vindesine
vesicant

* Strongly emetogenic
43

Topoisomerase I Inhibitors

46

Colony Stimulating Factors (CSF)

Epoetin Alpha-(erythropoetin)
stimulates red blood cell production

Prevent cells from dividing

Cell cyclecycle-specific

Filgrastim (Neupogen)-stimulates
neutrophil production

Irinotecan (Camtosar)
Topotecan

Oprelvekin (Neumega)- stimulates

platelet production
44

47

help body replace all the cells you killed with chemo

Chemotherapeutic Regimens
Used in Breast Cancer

Hormonal Manipulation
Hormones
Androgens
Estrogens
Progestins
Lutenizing hormone

CMF
AC
FAC
AMFVP
ACMF

Hormone Antagonists
Tamoxifen Decreases estrogen levels

A=doxorubicin, V=vincristine, P=prednisone, F=5fluoroucil, M=methotrexate, C=cyclophosphamide

45

48

13. Following a
lumpectomy for
breast cancer, the
methotrexate,
cyclophosphamide,
5-FU protocol was
prescribed. Which
of the following
statements should
be included in the
teaching plan of
the client receiving
these medications?

a. Have the client see a

cardiologist prior to therapy.
b. Encourage the client to
increase fluid intake to
approximately 3 liters per day.
c. See that the client protects
herself from sun during
chemotherapy.
d. Recommend that the client eat
only foods she likes because of
potential nausea.

You want to push fluids to get drug moving

14. Which of the

following statement
is true regarding
chemotherapyrelated alopecia?

16. For which type

of cancer is
chemotherapy
most beneficial?

49

15. The normal

pattern for the
administration of
antineoplastic
medications is
usually:

17. The most

important nursing
measure when
administering
vincristine
(Oncovin) is to:

a. Monitor the clients

blood pressure every 15
minutes.
b. Keep the client in a
recumbent position.

d. Give it with food, milk or

an antacid.
A

b. Massive doses given

only once

d. IV medications
alternating with PO
medications
C

53

Vesicant

18. A client has

been receiving
chemotherapy for
liver cancer is
making holiday
plans. The clients
WBC count today
is 2000/cm3. Which
of the following is
the most
appropriate advise
to give to this client
regarding holiday
plans?

a. Low doses given

continuously over a long
period of time

51

c. Monitor the IV site

closely for infiltration.

c. Relatively high doses

on a cyclic schedule

Too toxic for continuous

52

a. Hair loss is temporary; growth

will occur soon after
chemotherapy is
discontinued.
b. Hair loss is transient & is one
of the minor side efforts of
chemotherapy.
c. Hair loss can be minimized by
adjusting the dosage of the
causative medication.
d. Hair loss is permanent so
clients need to prepare for
alternatives such as wigs.

50

A. Brain tumors
B. Superficial cancers on
the outside of the body
C. Cancers that are
localized to one tissue
or body area
D. Cancers that are large
or widespread with
evidence of distant
metastasis

a. You should avoid being with

your family because you may
be contagious.
b. There is little point in
celebrating this year, is
there?
c. Try not to eat foods that are
high in carbohydrates over
the holidays.
d. You should try to avoid being
in crowded public situations.

54

Nursing Diagnosis: Risk for injury r/t

vesicant chemotherapy: Extravasation

Routes of Administration

Central venous catheter

PICC line
Vesicants are those agents that, if
mostdont cross blood brain barrier, but if you want
Intrathecal (IT) catheter it to put it in the IT
deposited into the subcutaneous tissue
can
put
it
whereever
there
is
a
cavity.
(i.e
can cause tissue necrosis & damage
Intracavitary (IC) catheter
plueral space, bladder)
to underlying tendons, nerves & blood
Orally
vessels.
Injection
IM, SC, Intralesionally (IL)

Monitor for extravasation

Topically skin cancers

pain, redness, no blood return

55

port a cath?

check IV site for these signs

58

You stop the IV. Call the doctor. Give ice or heat - not sure

Safe Preparation, Handling, &

Disposal
Exposure to antineoplastic drugs:
Inhalation of aerosols
Absorption through skin

OSHA Guidelines include:

Wear gowns & gloves during preparation &
administration
Wear gowns & gloves when handling body
secretions i.e vomit, stool, blood of clients
who received chemotherapy within previous
48 hours
Drugs themselves can lead to cancer. Dispose of it safely - special
56
biohazzard bags, etc.

Portacath

Extravasation

causes an ulcer

59

Management of Extravasation
Stop drug administration.
Leave needle in place & attempt to aspirate any
residual drug from tubing.
Administer antidote, if indicated. Then remove
the needle.
Do not apply manual pressure to the site.
Apply ice or hot compress for 24-48 hours, as
indicated.
Observe the site.
Document the appearance of the site.

central line under then skin. implanted in day surgery outside the
57
skin

60

10

19. An anticancer
medication is
classified as a
vesicant. The
nurse knows that
this medication:

Common side effects of

Chemotherapy

a. Is capable of causing
irritation to the skin

Bone marrow suppression

b. Is capable of causing
blisters on the skin

Decreased production of RBCs, WBCs, &

platelets

Lowered Absolute neutrophil count

(ANC)

c. Can be only given PO

ANC= (Total WBC count x % segmented

neutrophils + % bands
100

d. Must be given in a
deep IM injection

Normal range: 1,500 to 8,000/mm3

61

Nursing Process: The patient with

Cancer

under 1000 is increase risk of infection

64

Nursing Diagnoses for the Client receiving

chemotherapy: Risk for infection r/t
decreased immune response

Assessment:
Anemia
in order tumor to grow it has to establish blood
Bleeding supply. So it causes bleeding.
Fatigue
Infection
Cachexia muscle wasting
Pain
Body image disturbance
Psychosocial status

Neutropenic Precautions
Monitor absolute neutrophil count

Assess temperature q4h (no rectal temps)

CBC daily
ANC: Call MD if ANC <1,000 or significantly
less than last count
Thorough hand hygiene every time you enter
the room
Private room if ANC <1000

62

65

Do a head to toe inspection. No rectal temps (bc potential to break

skin). Hand hygiene, private room, no enemas, no suppositories.

Nursing Diagnosis: Risk for Injury

related to the side effects of the
chemotherapy

Nursing Diagnosis: Risk for infection r/t

decreased immune response
Neutropenic Precautions
Allow no one in room with cold or sore throat
No fresh flowers
Provide low microbial diet no raw fruit, vegs, undercooked meat or fish
Avoid suppositories, rectal temps, enemas
Incentive spirometer q4h
Total body hygiene q day with antimicrobial
solution Try to get them in the shower.

Expected Outcome: Client will experience

minimal side effects of chemotherapy, will
demonstrate knowledge of rationale for
chemotherapy and will demonstrate
knowledge of potential side effects of
drugs and related self-management
strategies.
63

66

11

Nursing Diagnosis: Risk for infection r/t

decreased immune response

Nursing Diagnosis: Impaired oral mucous

membranes: Stomatitis

Neutropenic Precautions

Remove dentures, except for meals

Mouthwash: baking soda & saline or H2O2
& saline.
Avoid commercial mouthwashes.
Magic mouthwash, as prescribed. lidocane in mouth wash
Avoid irritating foods i.e citrus juices
Ice chips

Ambulate using high-efficiency particulate air

(HEPA) mask.
Prevent skin dryness in high risk areas (lips,
feet, bony prominences).
Oral hygiene after meals & q4h W/A with salt
and soda solution; Avoid commercial
mouthwashes
Central venous access is preferred.
Change IV tubing daily
avoid anything that might break the skin, monitor for skin
abrasions, breakdown

67

70

Nursing Diagnosis:
Diagnosis:
Risk for deficient fluid volume
2 nausea & vomiting

Nursing Diagnosis: Risk for bleeding

r/t bone marrow depression
Assess platelet count for thrombocytopenia:
Mild risk50,000-100,000/mm3
Moderate risk20,000-50,000/mm3
Severe risk
less than 20,000/mm3

Give antiemetics30 minutes prior to

chemotherapy and continue taking for 1-2
days following chemo.
Zofran drug of choice
Reglan
Compazine
Droperidol

Interventions:
Use soft toothbrush
Use electric razor
Avoid rectal temps, IM injections
Stool softeners
Avoid forceful blowing of nose
No Aspirin
68

Nursing Diagnosis: Impaired oral mucous

membranes: Stomatitis mouth sores
Assess oral cavity q shift.
Monitor for dehydration.
Brush with soft toothbrush or toothette
sponge.
Floss unless platelet count falls below
40,000/mm3.
Administer analgesics as prescribed.

Excessive vomiting: hypokalemia, metabolic alkalosis.

Pt education: take zofran 30 mins before chemo

71

Nursing Diagnosis:
Diagnosis: Imbalanced Nutrition:
Less than body requirements
2 nausea & vomiting
May persist for 24hrs after administration
Frequent mouth care
Adjust diet according to client preferences
Push fluids
Small, frequent, high calorie, high
potassium, high protein meals, low
residue
push fluids to get chemo out of body!

mouth wash that will numb the mouth

69

72

12

20. A client
receiving
chemotherapy
asks the nurse
why she has
developed sores
in her mouth.
What is the most
appropriate
response?

Nursing Diagnosis: Imbalanced Nutrition:

Less than body requirements
2 Side effects of Chemotherapy

Anorexia & changes in taste

Bland soft foods
Moderate temperature foods
Foods without strong odors
Avoid greasy, spicy foods
Eat food that is craved
Foods high in calories & protein
Adequate fluid intake

a. Dont worry; it always happens

with chemotherapy.
b. You need to use the special
mouth wash more often.
c. It is a sign that the chemo is
working.
d. The sores result because the
cells in the mouth are sensitive
to the chemotherapy.

Food tastes different. Bland soft foods are tolerated the best, foods
73
without strong odors.
Sometimes cut down on the dose of chemo if effects are that bad,
but it prolongs with chemo tx and makes it less effective.

Nursing Diagnosis : Anticipatory grieving

related to loss: altered role functioning

Nursing Diagnosis: Fatigue &

activity intolerance r/t Side
effects of Chemotherapy
Plan activities
Take short walks
Light exercise
Budget energy
Complementary methods aroma therapy, etc.
Promote sleep and rest
Administer erythropoietin and
blood transfusions as ordered
fights anemia and fatigue

76

Develop rapport: Use active listening

Assess coping by asking the client directly
how s/he is coping with the diagnosis
Support the clients expression of feelings
Guide the client to community resources
Refer client to qualified professionals, as
needed

74

Nursing Diagnosis : Ineffective coping

related to Alopecia

77

Nursing Diagnosis : Pain

Expected Outcome: The client with
pain will experience pain relief as
measured by a pain intensity scale
for self-report.

Temporary; Hair will start to regrow about 6

weeks after treatment stops.
Lightly brush hair
Wigs, scarves, hats
Cut hair before therapy begins
Daunorubicin
Doxorubicin
5-FU
Methotrexate
Vincristine

Caused by cancer or cancer therapy

Increased pain increases anxiety,
hopelessness and depression

Hair will grow back but it may be a

different color & texture
75

78

13

Barriers to pain management

Cancer Pain Management

Analgesics

Drug tolerance
Physical dependence
Addiction
Societal barriers
Knowledge deficit: healthcare provider
Client barriers

Tylenol, aspirin, NSAIDS

Morphine, hydromorphone, fentanyl

Surgical interventions
Peripheral neurectomy
Ablation of sensory nerve root fibers
Sympathectomy

Nonpharmalogical interventions

Reluctance
Fear
Not wanting to be a burden

TENS unit
Physical therapy
79

82

morphine can be given IV pca pump, or an oral form of morphine

(pretty high doses).

Risk factors for pain

Morphine Sulfate

Disease related:

Drug of choice for severe pain associated

with terminal cancer
Can be administered IV, Im, sc P.O.,
rectally, sublingually
In adults with severe pain, maintenance
IV infusions may be as high as 80
mg/hr. Higher doses may be needed.
Side Effect: Constipation
Toxicity: Respiratory Depression

Bone metastasis
Nerve compression
Visceral pain

Treatment related:
Chemotherapy-related pain
Radiation therapy-related
Surgical pain
tumor compresses on bone, nerves, and organs causing pain.
80

Principles of Pain Management

World Health Organization Analgesic Ladder

81

83

21. A 60-year old

has terminal lung
cancer. On
admission, a
morphine drip was
prescribed to
intractable pain.
Which of the
following would the
nurse recognize as
a side effect of this
medication?

a. Client is awake and alert and

requires minimal rescue doses
of medication for medication for
pain.
b. Client requires rescue doses of
pain medication every 4 hours.
c. Client has not had a bowel
movement for 5 days.
d. Clients pulse rate is 60 beats
per minute.

84

diludid morphine are commonly used.

14

22. The client asks the

nurse why there are
so many side effects
from the
chemotherapy he is
taking for his cancer.
The best response by
the nurse is:

a. These medications have

systemic effects.

Metastatic Disease

b. Chemotherapy works
against disseminated
diseases.

Cancer can spread to any other organ.

The most common mechanism is through
the lymphatic circulation but can also
spread trough the bloodstream.

c. The medication kills both

normal body cells and
cancer cells.

The treatment of metastatic disease is

often (not always) palliative depending
upon the organ that is affected.

d. Chemotherapy attacks
malignant cells during their
vulnerable period of
growth.
85

23. High uric

acid levels
may develop
in clients who
are receiving
chemotherapy
. This is
caused by:

88

a. The inability of the kidneys to

excrete the drug metabolites.

Complementary Modalities

b. Rapid cell catabolism.

c. Toxic effects of the
prophylactic antibiotics that
are given concurrently.
d. The altered blood pH from
the acid medium of the
drugs.

chemo is killing cells. The cells starts to break down to be

excreted in your urine. The breakdown of cells upon death,
youll have uric acid build up. So high uric acid is a good
thing, its doing its job

24. The drug of choice

to decrease uric acid
levels is:

86

INTEGRATIVE MEDICINE
Complementary, Alternative
Mind/body control
Visualization or relaxation
Manual healing
Acupressure
Massage
Homeopathy
Herbal products
Acupuncture
http://cis.nci.nih.gov/fact/9_14.htm
89

Oncologic Emergencies

a. Prednisone

b. Allopurinol
c. Indomethacin
(Indocin)
d. Hydrochlorothiazide

87

Hypercalcemia
Superior Vena Cava Syndrome
Spinal Cord Compression
Tumor Lysis Syndrome
Sepsis
DIC
SIADH

90

15

Hypercalcemia
Serum calcium > 11mg/dL

Spinal Cord Compression

Early Symptoms
Fatigue, lethargy,
Anorexia, nausea, vomiting
Decreased peristalsis; Constipation
Polyuria
Late Symptoms
Dehydratioin, prolonged p-r interval,
paralytic ileus, severe muscle weakness,
hyporeflexia,

occurs when someone has bone metastasis. caleium

is being released in your blood not in your bone
can cause asystole.
Tx can be dialysis

* Early symptom

91

94

Nursing Care of Spinal Cord

Compression

Nursing Care

Vigorous hydration with normal saline

Administration of Lasix, once hydrated
Monitor I & O
Monitor cardiovascular status
Administration of bisphosphonates,
calcitonin, glucocorticoids
For life threatening hypercalcemia,
prepare patient for dialysis
92

Superior Vena Cava Syndrome

Symptoms:

Administration of high dose

steroids: Decadron
Support through radiation therapy
Meticulous skin care
tumor on your spinal cord or area thats pressing on your
spincal cord.

95

Tumor Lysis Syndrome

Characterized by:
Hyperkalemia
Hyperphosphatemia
high phosphate = low calcium
Hypocalcemia absorption
Hyperuricemia

Upper body swelling: face, neck, trunk,

arms & fingers
Periorbital edema
Dyspnea, cough, hoarseness
Dysphagia
Nausea
Chest pain
tumor is pressing in your lungs, which compresses your vena
cava

Symptoms
Back pain *
Motor sensory symptoms of
numbness and tingling
Autonomic dysfunction with bowel
and bladder incontinence

93

tumor is sensitive to drugs and the chemo is really working. occurs

when you have a more than expected killing of cells and more 96
breakdown of what the tumor is made off (AEB S/S above)
However, if left untreated you can die from hyperkalemia, etc.
Push fluids!!

16

Nursing Care in
Tumor Lysis Syndrome

Treatment of DIC
Antibiotics

Prevention is essential
Vigorous hydration before and
during chemotherapy
Strict I&O
Allopurinol
Monitor electrolytes q 3-4 hours

Anticoagulants (Heparin) in early

phase
Cryoprecipitated clotting factors in
later phase

as long as someone has good kidneys theyll be peeing it out.

97

100

Syndrome of Inappropriate
Antidiuretic Hormone (SIADH)

Sepsis/Septic shock

Excessive H2O reabsorbed by kidney and put

into systemic circulation

Symptoms:
Fever >100.4 orally
Tachycardia>90 bpm
Hypotension SBP<90
Tachypnea> 20 bpm
WBC>12,000 or <4,000
Left shift of neutrophils
Bands :: Segs more bands than segs

Hyponatremia (Normal Na level: 135135-145 mmol/L)

mmol/L)
Fluid retention
Weight gain

Late Signs

anyone of 2 of these symptoms at the same time you likely have

98
sepsis.

Disseminated Intravascular
Coagulation (DIC)

when you have clotting factors released then its gone and you
start bleeding.

101

Nursing care in SIADH

Assessment: Prolonged PT, PTT,

Platelets
Extensive clotting in small blood
vessels followed by Extensive
bleeding
70% mortality rate
T
Tx it with heparin and clotting factors.

Extreme muscle weakness

Personality changes
Coma & death

99

Fluid restriction
Administer Hypertonic saline solution (3% NaCl)
Administer Lasix
Monitor diagnostic tests
Serum sodium, serum osmolality, urine sodium,
urine osmolality, water loading test
Identify clients at risk
Lung Ca, pancreas, duodenum, prostate, brain or
Hodgkins disease
Monitor and report signs and symptoms
102
Monitor I&O
Tumor stimulates the brain to secrete the antidiuretic hormone. Too
much water is put into your system causing hyponatremia, fluid
retention, weight gain. Give lasix. Monitor serum osmolarity, and
urine osmolarity and I&O.

17

Psychosocial Aspects of Cancer

EMOTIONAL DISTRESS
ANXIETY
DEPRESSION
SPIRITUAL DISTRESS
LOSS OF PERSONAL CONTROL
LOSS AND GRIEF
SOCIAL DYSFUNCTION
103

Psychosocial aspects
of Cancer Care

Rehabilitation
CANCER EDUCATION
Disease, treatment, nutrition, community
resources, care level
PHYSICAL FUNCTIONAL STATUS
PSYCHOLOGICAL SUPPORT
SPIRITUAL SUPPORT
ECONOMIC ISSUES
LEGAL & ETHICAL ISSUES
SCHOOL-RELATED ISSUES
HOUSING
PERSONAL CARE

106

Terminal Care
HOSPICE CARE
The National Hospice and Palliative Care
Organization www.nhpco.org
Finding Our Way: Living with Dying in
America
www.findingourway.net
Growth House
www.growthhouse.org
Partnership for Caring: Americas voices
for the Dying: Advance directives
www.partnershipshipforcaring.org

Providing emotional support

Stories of survivorship
Providing support for the family

104

Promoting Coping throughout the

Cancer Continuum
Diagnosis and treatment
Survivorship
Recurrent Disease and
Progression
Terminal Illness
if you pass the five year mark of remission its a good sign. But
cancer can still come back after five years
105

107

25. A client with

cancer of the lung
is receiving the
colony stimulating
factor Filgrastim
and is complaining
of bone pain. What
should you
administer to
relieve the pain?

a. ASA 10 gr po
b. Tylenol 650 mg po
c. Demerol 50 mg Im
d. Morphine sulfate 30mg
po

108

18

26. A client is to
receive epoetin
(Epogen)
injections. What
laboratory value
should the nurse
assess before
giving the
injection?

b. Partial Prothrombin
Time (PTT)
c. Hemoglobin
d. Prothrombin Time

hemoglobin bc hematocrit can be changed by hydration.

27. Which of the

following is an
appropriate nursing
measure for the
nurse to teach a
client who is
receiving
anticancer
medications?

29. The client who has

just had a mastectomy
for breast cancer is
crying as you enter the
room. When you ask
why she is crying the
client responds, I
know I shouldn't cry
because this surgery
may well save my life,
but I was so pleased
with my figure before,
and I know that things
will not be the same.
What is your best
response?

a. Hematocrit

109

28. Why is the

transplantation of
bone marrow cells
separated from the
preconditioning
chemotherapy
regimen by at least 2
days?

A. To prevent a more profound

neutropenic response
B. To give the client a rest period
before the vigorous
therapeutic regimen begins
C. To ensure all chemotherapy is
cleared and cannot exert
killing effects on the
transplanted cells
D. To allow the client to recover
from the severe nausea and
vomiting caused by the
chemotherapy

111

112

30. A client is
scheduled for a
mastectomy with
lymph node
dissection. The
client says, This
surgery will make
me look like half a
woman. What is
the most
appropriate
nursing
response?

a. Avoid brushing your

teeth to avoid gum
bleeding.
b. Stay in the sun as much
as possible to increase
production of vitamin D.
c. Avoid eating for 6 hours
after medication to
avoid nausea.
d. Increase fluid intake to
2-3 liters per day.
110

A. It is alright to be sad.
Mourning this loss is
important in getting past this
point.
B. You're right. It is silly to carry
on like this when a
prosthesis is available.
C. Would you like to talk to
someone who also has had
a mastectomy?
D. How have you coped with
difficult situations in the
past?

a. Im sure no one will know

youve had a mastectomy.
b. Todays prosthetics are very
realistic.
c. Youre concerned about how
youll look after surgery?
d. Everything will be alright. Your
husband will still love you.

113

The end. See you next time!

114

19