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 take over 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

Nursing Care of the Client with Cancer

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 of cancer are breast, lung and bronchial, and colorectal

Nursing Care of the Client with Cancer

Risk factors for cancer: (some are controllable; some are not) 1. Heredity: 5 10% of cancers; documented with some breast and colon 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 in red 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

Nursing Care of the Client with Cancer

Nursing role includes health promotion to lower the controllable risks 1. Routine medical check up and screenings 2. Client awareness to act if symptoms of cancer occur 3. Screening examination recommendations by American Cancer Society; specifics are made according to age and frequencies a. Breast Cancer: self-breast exam, breast examination by health care professionals, screening mammogram b. Colon and Rectal Cancer: fecal occult blood, flexible sigmoidoscopy, colonoscopy c. Cervical, Uterine Cancer: Papanicolaou (Pap) test d. Prostate Cancer: digital rectal exam, Prostate-specific antigen (PSA) test

Nursing Care of the Client with Cancer

Physiology of Cancer A. Background 1. Normal Cell Growth includes two events a. Replication of cellular DNA b. Mitosis (cell division)

Nursing Care of the Client with Cancer

2. Cell cycle is under control of cyclins, and suppresor gene products which control process by working with enzymes; cyclins promote cell division suppresor gene products limit cell division 3. Forms the basis of how some chemotherapeutic agents work against cancers

Nursing Care of the Client with Cancer

Theories of Carcinogenesis (what causes cancer to occur) 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 proliferation and can trigger cancer b. Tumor suppressor genes normally suppress oncogenes but are damaged 3. Exposure to Known Carcinogens a. Act by directly altering the cellular DNA (genotoxic) b. Act by affecting the immune system (promotional)

Nursing Care of the Client with Cancer

4. Viruses viruses break the DNA chain and mutates the normal cells DNA Epstein-Barr virus Human papilloma virus Hepatitis virus Drugs and Hormones a. Sex hormones often affect cancers of the reproductive systems (estrogen in some breast cancers; testosterone in prostate cancer) b. Glucocorticoids and steroids alter immune system

5.

6.

Chemical Agents a. Industrial and chemical b. Can initiate and promote cancer b. Examples: hydrocarbons in soot ; arsenic in pesticides; chemicals in tobacco 7. Physical Agents a. Exposure to radiation
Ionizing radiation found in x-rays, radium, uranium UV radiation
Sun, tanning beds

8. Immune function
1. Protects the body from cancerous cells 2. Increased rate of cancer in immunocompromised pts

Nursing Care of the Client with Cancer

Neoplasms: also called tumors (mass of new tissue that grows independently 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 the normal cell cycle 2. Not under bodys homeostatic controls 3. Cut through surrounding tissues causing bleeding, inflammation, necrosis (death) of tissue

Nursing Care of the Client with Cancer

Malignant tumors can metastasize a. Tumor cells travel through blood or lymph circulation to other body areas and invade tissues and organs there. 1. Primary tumor: the original site of the malignancy 2. Secondary tumor (sites): areas where malignancy has spread i.e. metastasis (metastatic tumor) 3. Common sites of metastasis are lymph nodes, liver, lungs, bones, brain 4. 50 60 % of tumors have metastasized by time primary tumor identified b. Cancerous cells must avoid detection by immune system

Nursing Care of the Client with Cancer

C. Malignant neoplasms can recur after surgical removal of primary

and secondary tumors and other treatments D. Malignant neoplasms vary in differentiation. a. Highly differentiated are more like the originating tissue b. Undifferentiated neoplasms consist of immature cells with no resemblance to parent tissue and have no useful function E. Malignant cells progress in deviation with each generation and do no stop growing and die, as do normal cells F. Malignant cells are irreversible, i.e. do not revert to normal G. Malignant cells promote their own survival by hormone production, cause vascular permeability; angiogenesis; divert nutrition from host cells

The steps of metastasis

Nursing Care of the Client with Cancer

Effects of Cancer 1. Disturbed or loss of physiologic functioning, from pressure or obstruction 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 nerves h. Respiratory difficulties
a. Airway obstruction b. Decreased lung capacity

Nursing Care of the Client with Cancer

2. Hematologic Alterations: Impaired function of blood cells
1. 2. Secondary to any cancer that invades the bone marrow (leukemia) May also be caused by the treatment

3.

4. 5.

a. Abnormal wbcs: impaired immunity b. Diminished rbcs and platelets: anemia and clotting disorders Infections: fistula development and tumors may become necrotic; erode skin surface Hemorrhage: tumor erosion, bleeding, severe anemia Anorexia-Cachexia Syndrome: wasting away of client a. Unexplained rapid weight loss, anorexia with altered smell and taste b. Catabolic state: use of bodys tissues and muscle proteins to support cancer cell growth

Nursing Care of the Client with Cancer

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 families a. Types of cancer pain 1. Acute: symptom that led to diagnosis 2. Chronic: may be related to treatment or to progression of disease b. Causes of pain 1. Direct tumor involvement including metastatic pain 2. Nerve compression 3. Involvement of visceral organs

Nursing Care of the Client with Cancer

8. Physical Stress: body tries to respond and destroy neoplasm 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

Nursing Care of the Client with Cancer

A. 1. 2. Collaborative Care Diagnostic Tests: used to diagnose cancer Determine location of cancer a. Xrays b. Computed tomography c. Ultrasounds d. Magnetic resonance imaging e. Nuclear imaging f. Angiography Diagnosis of cellular type of can be done through tissue samples from biopsies, shedded cells (e.g. Papanicolaou smear) washings a. Cytologic Examination: tissue examined under microscope b. Identification System of Tumors: Classification Grading - Staging

Nursing Care of the Client with Cancer

1. Classification: according to the tissue or cell of origin, e.g. sarcoma, from supportive 2. Grading: a. Evaluates degree of differentiation and rate 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)

Nursing Care of the Client with Cancer

3. Tumor markers: specific proteins which indicate malignancy a. PSA (Prostatic-specific antigen): prostate cancer b. CEA (Carcinoembryonic antigen): colon cancer c. Alkaline Phosphatase: bone metastasis 4 Direct Visualization a. Sigmoidoscopy b. Cystoscopy c. Endoscopy d. Bronchoscopy e. Exploratory surgery; lymph node biopsies to determine metastases

Nursing Care of the Client with Cancer

Other non-specific tests a. CBC, Differential b. Electrolytes c. Blood Chemistries: (liver enzymes: alanine aminotransferase (ALT); aspartate aminotransferase (AST) lactic dehydrogenase (LDH)

Nursing Care of the Client with Cancer

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 therapy B. 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

Nursing Care of the Client with Cancer

Treatment Options (depend on type of cancer) alone or with combination A. Chemotherapy 1. Effects are systemic and kills the metastatic cells 2. Often combinations of drugs in specific protocols over varying time periods
Much 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

 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 left can be handled by bodys immune system

Nursing Care of the Client with Cancer

B. 1. 2. Classes of Chemotherapy Drugs Alkylating agents 1. Action: create defects in tumor DNA 2. Examples: Nitrogen Mustard, Cisplatin Antimetabolites 1. Action: similar to metabolites needed for vital cell processes
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

Nursing Care of the Client with Cancer

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 the balance and alter the uptake of other hormones necessary for cell division 2. Example: estrogen, progestin, androgen

6. Hormone Antagonist 1. Action: block hormones on hormonebinding tumors (breast, prostate, endometrium; cause tumor regression
Decreasing the amount of hormones can decrease the cancer growth rate Does not cure, but increases survival rates

2. Examples: Tamoxifen (breast); Flutamide (prostate) 3. Toxic Effects: altered secondary sex characteristics

 7. Hormone inhibitors
Aromatase inhibitors (Arimidex, Aromasin)
Prevents production of aromatase which is needed for estrogen production Used in post menopausal women Side effects
Masculinizing effects in women Fluid retention

Nursing Care of the Client with Cancer

Effects of Chemotherapy a. Tissues (fast growing) frequently affected b. Examples: mucous membranes, hair cells, bone marrow, specific organs with specific agents, reproductive organs (all fetal toxic, impair ability to reproduce). Administration of chemotherapeutic agents a. Trained and certified personnel, according to established guidelines 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 with physician orders, pharmacists preparation c. Proper management clients excrement

Nursing Care of the Client with Cancer

d. Routes 1. Oral 2. Body cavity (intraperitoneal or intrapleural) 3. Intravenous
a. Use of vascular access devices because of threat of extravasation (leakage into tissues) and long-term therapy
a. If the drug is a vessicant it may result in pain, infection and tissue loss

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

Hickman Catheter

Portacath

PICC Line

Nursing Care of the Client with Cancer

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 IV fluids

 B. Bone marrow suppression

Decreased number of RBC
Leads to hypoxia, fatigue Hgb 9.5-10 gm/dl require oral iron supplements Hgb below 8 gm/dl require transfusion May use Epogen to stimulate RBC production

 Decrease number of WBC (normal 4,500-11,000 mm3) especially neutrophils (normal 3,000-7,000 cells/cc)
Neutropenia-count below 2000 Pt at extreme risk for infection May order granulocyte colony stimulating factor (leukine) to stimulate 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

 Thrombocytopenia
Drop 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 candy Watch for ALOC, pupil changes that might indicate intracranial bleeds Stool softeners to avoid straining

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

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 back Before hair loss, have the pt pick out a wig that is similar to hair color

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

Nursing Care of the Client with Cancer

Surgery 1. Diagnosis, staging, and sometimes treatment of cancer 2. May be prophylaxis or removal of at risk tissue or organ prior to development of cancer (breast cancer) 3. Involves removal of body part, organ, sometimes with altered functioning (e.g. colostomy) 4. Debulking (decrease size of) tumors in advanced cases 5. Reconstruction and rehabilitation (e.g. breast implant post mastectomy) 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 as cancer diagnosis

Nursing Care of the Client with Cancer

Radiation Therapy 1. Treatment of choice for some tumors to kill or reduce 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 in uniform dose to tumor

Beam radiation

b. Brachytherapy: delivers high dose to tumor and less 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

3. Goals a. Maximum tumor control with minimal damage to normal tissues b. Caregivers must protect selves by using shields, distancing and limiting time with client, following safety protocols
Private room Caution sign on the door for radioactive material Dosimeter film badge by staff No pregnant staff Limit visitors to hour per day and keep them at least 6 ft from the source

Nursing Care of the Client with Cancer

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, breakdown
Use mild soak Dry skin with a patting motion, not rubbing Dont use powders or lotions unless prescribed by radiologist Wear soft clothing over the site Avoid the sun and heat

 b. Ulcerated mucous membranes: pain, lack of saliva (xerostoma) c. Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation d. Radiation pneumonitis
1-3 months after treatment Cough, SOB, fever Treated with steroids to decrease inflammation

Nursing Care of the Client with Cancer

Monoclonal antibodies (inoculate animal with tumor antigen and retrieve antibodies against tumor for human)
Antibodies target specific substances needed by the cancer cell for growth (Herceptin for breast cancer)

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

Angiogenesis inhibitor drugs prevent new blood vessels from forming and delivering blood to the tissue

Nursing Care of the Client with Cancer

F. Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation 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 ill clients 3. Goal is maximum relief with minimal side effects 4. Multiple combinations of analgesics (narcotic and nonnarcotic) and adjuvants such as steroids or antidepressants; includes around the clock (ATC) schedule with additional medications for break-through pain 5. Multiple routes of medications 6. May involve injections of anesthetics into nerve, surgical severing of nerves radiation 7. May need to progress to stronger pain medications as pain increases and client develops tolerance to pain medication

Nursing Care of the Client with Cancer

Nursing Diagnoses for Clients with Cancer A. Anxiety 1. Therapeutic interactions with client and family; community resources such as American Cancer Society, I Can Cope 2. Availability of community resources for terminally ill (Hospice care 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); cachexic appearance, loss of energy, ability to be productive 2. Fear of rejection, stigma C. Anticipatory Grieving 1. Facing death and making preparations for death: will be consideration 2. Offer realistic hope that cancer treatment may be successful

Nursing Care of the Client with Cancer

D. Risk for Infection E. Risk for Injury 1. Organ obstruction 2. Pathological fractures F. Altered Nutrition: less than body requirements 1. Consultation with dietician, lab evaluation of nutritional status 2. Managing problems with eating: anorexia, nausea and vomiting 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 as thrush) 2. Teach inspection, frequent oral hygiene, specific nonirritating products, thrush control

Nursing Care of the Client with Cancer

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

B. Superior Vena Cava Syndrome 1. obstruction of venous system with increased venous pressure and stasis; facial and neck edema with slow progression to respiration distress
Late signs are cyanosis, decreased cardiac output and hypotension

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

Compression of the superior vena cava in SVC syndrome

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

 D. DIC disseminated intravascular coagulation

Triggered by severe illness, usually sepsis in cancer patients Abnormal clotting uses up existing clotting factors and platelets quickly then the pt hemorrhages Mortality rate is 70% Prevention of sepsis is key

Nursing Care of the Client with Cancer

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 detection

High dose corticosteroid to decrease the swelling radiation or surgical decompression

F. Obstructive Uropathy 1. Concern: blockage of urine flow; undiagnosed can result in renal failure 2. Treatment: restore urine flow

G. Hypercalcemia 1. High calcium (normal 9-10.5) usually from bone metastases 2. May also come from cancer of the lung, head, neck, kidney and lymph nodes that secrete parathyroid hormone that causes the 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

H. Tumor Lysis Syndrome 1. Occurs with rapid necrosis of tumor cells with chemotherapy
When tumor cells die they release potassium and purines Potassium (norm 3.5-5.5) elevation causes cardiac arrhthymias, muscle weakness, twitching, cramps Purines convert to uric acid which causes renal failure, flank pain, gout when elevated above 10 mg/dl Hyperphosphatemia with secondary to hypocalcemia causes heart block, HTN, renal failure

 Treatment
Hydration Instruct pt to increase fluid intake before and after chemo May need IV hydration Diuretics to increase urine flow Allopurinol to increase uric acid excretion May need dialysis

Nursing Care of the Client with Cancer

I. SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) 1. Ectopic ADH production from tumor leads to excessive hyponatremia 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