Terminologies

Tumor 6. lumps, mass, swelling Neoplasm-7 abnormal growth of mass tissue that has no purpose; benign or malignant Benign neoplasm 10 does not invade other tissues Malignant neoplasm metastasizes to other tissues and organs Neoplasia 9. Any new or continued cell growth not needed for normal development or replacement of dea and damaged tissue Cancer malignant neoplasm Extravasation leakage of medication from the vein into the subcutaneous tissue Dysplasia 8bizarre cell growth resulting in cells that differ in size, shape or arrangement form other cells of the same type of tissue. Alteration in size, shape and organization of cells

Adenocarcinoma arises from glandular tissues Anaplasia 5.cells that lack normal cell characteristic and differ in shape and organization with respect to their cells of origin Carcinoma composed of epithelial cells Carcinogenesis process of transforming normal cells into malignant cells Carcinoma in situ 4.confined to the local areas; 1st stage of cancer Sarcoma cancer that arises from the connective tissues Differentiation the process of maturation of a cell line of cancer cell Tumor markers chemicals found in the blood that are produced by certain cancer Apoptosis 3.program cell death Staging process of determining the size and spread or metastasis of a tumor Tumor-specific antigen(TSA) -2 protein on the membrane of cancer cells that distinguishes the malignant cell from a benign cell of the same
tissue type

Essential Concepts of Cancer

Terminologies What is Cancer Theory of cancer Normal Cell Growth vs. Cancer Cell Growth - Etiology and Causative Factors Pathophysiology Classification of Tumors Effects of Cancer
-

Nursing Process Assessment Laboratory & Diagnostic Tests -Tumor Staging and Grading Nursing Diagnoses & --Planning Implementation and Management -Treatment Modalities Chemotherapy -

1CELLS
- Are complex units that dramatically respond to the

changing demand and stress of daily life - Growth of cells and tissues start during Infancy, childhood and continue to grow by cell division (Mitosis) till maturity. - Cells of skin, hair, mucous membrane, stomach, intestine, bladder and uterus have the ability to divide throughout lifespan, provided only the right number of cell is always present in any tissue or organ - Tissues and organs stop growing by cell division after development is complete. Ex: heart muscle,

Characteristic of Normal Cells:

1. Have limited cell division (mitosis) Reason for cell Division:  To develop normal tissue  To replace lost or damaged normal tissue 2. Undergo Apoptosis normal cell have finite life span. With each round of cell division, the telomeric DNA at the ends of the chromosomes shorten  When this DNA is gone, the cell responds to signals for programmed cell death apoptosis  The purpose of apoptosis is to ensure each organ has adequate number of cells at their functional peak

3. Show specific morphology - Each normal cell has a distinct and recognizable appearance, size, and shape 4. Have a small Nuclear-cytoplasmic ratio - The size of normal cell nucleus is small compared with the size of the rest of the cell 5. Perform specific differentiated Functions - Every normal cell has at least one special function: Ex. Skincells makes keratin; liver cells makes bile; cardiac muscle to contract; nerve cell conduct impulses; RBC make Hb to carry O2 6. Adhere tightly together - - normal cells make proteins (Fibronectin) that protrude from the cell surface, allowing cells to binds closely and tightly together except RBC and WBC no fibronectin 7. Are non migratory - Since they bound together, they do not wander from one tissue into the next 8. Grow in an orderly manner and well regulated - Normal cell wont divide unless body condition are optimal for cell division 9. Are contact are inhibited 10. Are Euploid have 23 pairs of chromosomes

What Is Cancer Cells?

CANCER - is a complex of diseases which occurs when normal cells mutate into abnormal cells that take over normal tissue, eventually harming and destroying the host

What Is Cancer?
A large group of diseases characterized by: Uncontrolled growth and spread of abnormal cells Proliferation (rapid reproduction by cell division) Metastasis (spread or transfer of cancer cells from one organ or part to another not directly connected)

WHAT IS CANCER
Normal cell division

Loss of Normal Growth Control - metastasis

First mutation

Cancer cell division

Cell damage no repair

Cell Suicide or Apoptosis

Second Third mutation mutation Fourth or later mutation

Uncontrolled growth

Oncogenes
Normal cell
Normal genes regulate cell growth

Cancer cell

Oncogenes accelerate cell growth and division

Mutated/damaged oncogene

CARCINOGENESIS - THREE STEPS:

INITIATION Initiators(carcinogen)such as chemical, physical factors and biologic agent, escape normal enzymatic mechanism and alter the genetic structure of the cellular DNA. Changes initiate programmed cellular death(apoptosis) 2. PROMOTION repeated exposure to promoting agents(cocarcinogens) causes the expression of abnormal or mutant genetics information even after long latency periods 3. PROGRESSION The cellular changes formed during initiation and promotion exhibit increased malignant behavior. These cells invade adjacent tissues and to metastasize
1.

Example of Normal Growth

Dead cells shed from outer surface

Epidermis Cell migration Dividing cells in basal layer

Dermis

The Beginning of Cancerous Growth

Underlying tissue

Angiogenesis
- The metastatic cascade begins and ends with angiogenesis - is the ability of cancer cells to secretes substances that stimulate blood vessel growth 1. Inability of the immune system to recognize cancer cell Two critical components of the Immune Response: 1. The ability to recognize a pathogen as foreign 2. The ability to mount a response to eliminate the pathogens 2. Failure of immune Defense Apoptosis- falling off Two pathways to Cell death: 1. Necrosis cell death resulting from injury 2. Apoptosis cellular suicide results in cells rapidly shrinking with loss of their intercellular contents

Tumors (Neoplasms)

Underlying tissue

Invasion and Metastasis

1. CANCER CELL INVADE SURROUNDING TIssues and blood vessels

2. CANCER cells are transported by the circulatory system to distant sites Cancer cells reinvade and grow at new location

Theory of Pathogenesis of Cancer

- Cellular transformation and Derangement theory conceptualizes that normal cells may be
transformed into cancer cells due to exposure to some etiologic agents

- Failure of the Immune Response Theory

advocates that all individuals possess cancer cells. However, the cancer cells are recognized by the immune response system. So, the cancer cells undergo destruction. Failure to the immune response system leads to inability to destroy the cancer cells

Etiology/CAUSATIVE FACTORS
1. 2.

3. 4. 5.

6. 7.

Radiation X-rays/radioactive isotopes, from sunlight, ultraviolet rays Chemicals Tobacco, dyes, polycyclic hydrocarbons(truck emissions. Oil refineries), air pollution; fertilizers, weed killers; dyes; drugs - tobacco, cytotoxic drugs, hormones; food preservative Physical agent: radiation; Physical irritation/trauma Hormonal Agents: estrogens, Diethystilbestrol(DES) Genetics and familial factors oncogene(hidden/repressed genetic code for cancer that exist in all individual) -when exposed to carcinogens-----.changes cell structure-become malignant; associated with familial patterns Virus- Helicobacter pylori and Bacteria Dietary factors

Predisposing Factors
1. 2. 3. 4. 5. 6. 7.

8. 9.

Age older individual prone to cancer expose to carcinogen longer Sex: women- breast cancer, uterus, cervix; men prostate, lung cancer Urban vs Rural residence; common in urban due to greater exposure to carcinogens Geographic distribution e.g in Japan Ca in stomach, US breast Occupation chemical factory worker, radiology Heredity: +family Hx Stress: depression, grief, anger, aggression, despair = dec. immunocompetence(affect hypothalamus and pituitary gland). Immunodeficiency may spur the growth and proliferation of Ca cells Precancerous lesion Obesity: studies linked obesity to breast and colorectal Ca

What Causes Cancer?

Some viruses or bacteria
Some chemical Heredity Diet Hormon es

Radiation

Population-Based Studies
Regions of Highest Incidence U.K.: Lung cancer CANADA: Leukemia U.S.: Colon cancer

CHINA: Liver cancer

JAPAN: Stomach cancer

AUSTRALIA: Skin cancer

BRAZIL : Cervical cancer

Genes and Cancer

Viruses Chemicals Radiation

Heredity

Chromosomes are DNA molecule

Viruses

Cancer-linked virus

Virus inserts and changes genes for cell growth

Examples of Human Cancer Viruses

Some Viruses Associated with Human Cancer
Virus Epstein -Barr virus Human Papillomavirus Hepatitis B virus Type of Cancer Burkitt s Lymphoma Cervical cancer Liver cancer

Human T -cell Adult t-cell leukemia Lymphotrophic virus Kaposi s sarcoma associated Kaposi s sarcoma herpes Virus

Bacteria and Stomach Cancer

Patient s tissue sample

H. pylori

Tobacco Use and Cancer

Some Cancer-Causing Chemicals in Tobacco Smoke

High-Strength Radiation

High

Leukemia Incidence
Low Least X-ray Dose (atomic radiation

Most

AIDS and Kaposi s Sarcoma

Without disease HIV infection Depressed immune system KSHV infection Kaposi s sarcoma

Heredity and Cancer

All Breast Cancer Patient

Heredity Can Affect Many Types of Cancer

Inherited Conditions That Increase Risk for Cancer

Name of Condition Type of Cancer Hereditary Retinoblastoma Retinoblastoma Xeroderma Pigmentosum Wilm s Tumor Li-Fraumeni syndrome Familial Adenomatous Polypus Fanconi s Aplastic Anemia Skin Kidney Sarcoma, brain, breast , leukemia Colon, Rectum Leukemia, liver, skin

PATHOPHYSIOLOGICAL BASIS OF MALIGNANT NEOPLASIA

Predisposing Factors/ Etiological Factors y Cellular Ca Cell proliferation >Disrupt normal cell growth and interfere with tissue function *Pressure *obstruction *pain *effusion(extravasation) *ulceration *Vascular, thrombosis, embolus, thrombophlebitis

y Malignant cells produce

enzymes, hormones and other substances (paraneoplastic syndrome) *anemia *hypercalcemia *edema *DIC y Anorexia and cachexia syndrome *tissue wasting *severe weight loss *severe debilitation

Pathophysiology
ABNORMAL CELL FORMED BY MUTATION OF DNA

CELL GROWS AND PROLIFERATES

METASTASIS OCCURS WHEN ABN. CELLS INVADE OTHER TISSUE,THROUGH LYMPH AND BLOOD Cancer development linked to immune system failure Example of clients susceptible to developing cancer

Classificationof Cancer
According to Behavior of Tumor
Benign - tumors that cannot spread by invasion or metastasis; hence, they only grow locally Malignant - tumors that are capable of spreading by invasion and metastasis. By definition, the term cancer applies only to malignant tumors

Staging and Grading of Neoplasm

- This method determining the extent of a confirmed neoplastic

disease Grading measures the degree of tumor malignancy Staging measures the extent of spread of tumor - TNM System: y T- Tumor y N- Node y M Metastasis

TNM(TUMOR) STAGING SYSTEM

STAGE TX TO TIS TI T2 T3 T4 CHARACTERISTICS PRIMARY TUMOR (T) No primary Tumor can be assessed No evidence of primary tumor Carcinoma in Situ stage 1 Increasing size and extent of the primary tumor REGIONAL LYMPH (N) Nodes (N) NX NO N1, N2, N3 MX MO MI Can not be assessed No regional lymph No distant metastasis Increasing involvement of regional lymph nodes Distant Metastasis Presence of metastasis No distant Metastasis Distant metastasis

Stage 1:
Progressive alteration of malignant cells with additional genetic changes results in a heterogeneous population of malignant cells with varying degrees of metastatic potential - Increasing tumor size, leading to tissue pressure and mechanical expansion, may cause neoplastic invasion - As the malignant tumor grows, the cells at the center become hypoxic, and it begins to seek its own blood supply - Neoplastic cells from the primary tumor invade surrounding tissue and penetrate blood or lymph vessels - Vascularization(Angiogenesis) of the tumor dramatically increases its metastatic potential

Stage 2:
cancer cell migrate via the lymph or blood circulation or by direct extension. -The lymphatic system provides the most common pathways for the initial spread of malignant cancer cells. - Spread to the lymphatic nodes draining the region of the primary tumor site. - The blood vessels (both veins and arteries) carry cancer cells from the primary tumor to the capillary beds of the lungs, liver and bones - Metastasis spread to distant organs and tissues is almost always the result of cells moving through its blood stream - to have fallen onto and seeded the entire peritoneal cavity with metastatic site of the tumor. - To complete this stage in the metastatic cascade, tumor cells must survive a variety of hemodynamic and immunologic challenges
-

Stage 3:
- Cancer cells are established at the secondary site,

result from the entrapment caused by the size of the tumor clump, from adherence to cells at the new site through specific instruction, or by binding to exposed basement membrane - Continued growth and proliferation at the metastatic site depends on the: y Development of its own blood supply(angiogenesis) y Ability to evade eradication by immune responses

Malignant versus Benign Tumor

Benign (not cancer) tumor cells grow only locally and cannot spread by invasion or metastasis

Malignant (cancer) cells invade neighboring tissues, enter blood vessels, and metastasize to different sites

Why Cancer Is Potentially Dangerous

Brain
Melanoma cells travel through bloodstream

Liver Melanoma (initial tumor)

Patterns of cell Proliferation

Hyperplasia Dysplasia Metaplasia Anaplasia Neoplasia

Hyperplasia
y Tissue growth based on
Hyperplasia Normal

an excessive rate of cell division, leading to a larger than usual number of cells; the process of hyperplasia is potentially reversible; can be a normal tissue response to an irritating stimulus. An example is a callus

Dysplasia
Bizarre cell growth differing in size, shape and cell arrangement
Hyperplasia
Normal

Mild dysplasia

Carcinoma in Situ
Hyperplasia Carcinoma in Mild situ dysplasia (severe dysplasia) Cancer (invasive

Normal

Patterns of cell Proliferation

Metastasis: 3 stages
1.

Invasion neoplastic cells from primary tumor Metaplasia invade into surrounding conversion of one type of cell in a tissue with penetration Patterns of cell Proliferation tissue to another type not normal of blood or lymph. for that tissue 2. Spread tumor cells Anaplasia spread through lymph or change in the DNA cell structure and circulation or by direct orientation to one another, expansion characterized by loss of 3. Establishment and differentiation and a return to a growth tumor cells are more primitive form. established and grow in Neoplasia secondary site: lymph nodes or in uncontrolled cell growth, either organs from benign or malignant Metastasis venous circulation y

Cancer Tends to Involve Multiple Mutation

Benign tumor cells grow only locally and cannot spread by invasion or metastasis Malignant cells invade neighboring tissues, enter blood vessels, and metastasize to different sites

Mutation cells inactivates proliferate suppressor gene

Mutations inactivate DNA repair genes

Protooncogenes mutate to oncogenes

More mutations, more genetic instability, metastatic disease

Mutations and Cancer

Genes Implicated in Cancer

Growth factors = proliferation

Invasive

Matrix
Proteases Fibroblasts, adipocytes Cytokin es

lood vessel

Cytokines, proteases = migration & invasion

Comparison of The Characteristics of Benign and Malignant Neoplasm

Characteristics Mode of Growth Capsule Cell characteristic Benign Grows slowly Encapsulated Malignant Grows rapidly Not capsulated

Well differentiated Poorly mature cells; cell function differentiated(anaplastic poorly type) Extremely unusual when surgical removed Never occur Not harmful to host Very good prognosis Common following surgery Very common Always harmful Poor prognosis

Recurrence Metastasis Effect of neoplasm Prognosis

Classification of Tumors
CARCINOMAS: EPITHELIAL TISSUE BODY SURFACES, LINING OF BODY CAVITIES ETC: (ADENOCARCINOMA) SARCOMAS: CONNECTIVE TISSUE STRIATED MUSCLE, BONE, ETC (OSTEOSARCOMA) LYMPHOMAS AND LEUKEMIAS HEMATOPOIETIC SYSTEM NERVOUS TISSUE TUMORS EX. NERVE CELLS-NEUROBLASTOMA MYELOMA Develops in the plasma cells of bone marrow

CLASSIFICATION OF CANCER BY TISSUE OF ORIGIN

Tissue of Origin

Connective tissues
Fibrous tissue Adipose Cartilage Bone

Benign Fibroma Lipoma Chondroma Osteoma

Malignant Sarcoma Fibrosarcoma Liposarcoma Chondrosarcoma Osteogenic sarcoma Carcinoma Squamos cell carcinoma Basal cell carcinoma Adenocarcinoma Malignant carcinoma Endothelioma Hemangioendothelioma Hemangiosarcoma Kaposi s sarcoma Lymphangiosarcoma Multiple myeloma Leukemia Malignant Lymphoma Lymphosarcoma

Epithelium
Skin and mucousmembrane Glands Pigmented cells Papilloma Adenoma Nevus Hemangioma

Endothelium:
Blood vessels Lymph vessel Bone marrow Lymphoid Tissue

Lymphangioma

CLASSIFICATION OF CANCER BY TISSUE OF ORIGIN

Tissue of Origin
Muscle Tissue Smooth muscle Striated muscle Nerve Tissue: Nerve Fibers and shealths Ganglion Cells: Glial cells Meninges Gonads:

Benign
Leimyoma Rhabdomyoma

Malignant
Leiomyosarcoma Rhabdomyosarcoma

Neuroma Neurofibroma Ganglioneuroma Glioma

Neurogenic sarcoma Neurofibrosarcoma Neuroblastoma Glioblastoma Malignant meningioma Embryonal carcinoma Embryonal sarcoma Teratocarcinoma

Dermoid cyst

Different Kinds of Cancer

Some common carcinomas
Leukemia Bloodstream Lung Breast (women) Lymphomas: Lymph nodes Some common Colon Bladder Prostate (men) Sarcomas: Fat Bone Muscle

Naming Cancers
Cancer Prefixes Point to Location
Prefix
adeno chondro erythro hemangi ohepatolipolymphomelano myelomyo osteo-

Meaning
gland cartilage Red blood cell blood vessel liver fat lymphocyt e pigment cell bone marrow muscle bone

Women who smoke like men, die like men.

Women, Tobacco & Lung Cancer

Effects of Cancer:
Disruption of Function- can be due to obstruction or pressure Hematologic Alterations: can impair function of blood cells Hemorrhage: tumor erosion, bleeding, severe anemia Anorexia-Cachexia Syndrome: wasted appearance of client Effects of Cancer

Paraneoplastic Syndromes: ectopic sites with excess hormone production Parathyroid hormone hypercalcemia secretion of insulinhypoglycemia Antidiuretic hormone (ADH)fluid retention, HTN & peripheral edema Adrenocorticotropic hormone (ACTH): cause excessive secretion of cortisone (ie: fluid retention,glucose levels)

Effects of Cancer
y Pain: major concern of clients and y families associated with cancer y Physical Stress: body tries to respond y and destroy neoplasm y Psychological Stress

ASSESSMENT
Nursing History Health History chief complaint and history y of present illness (onset, course, duration, location, precipitating and alleviating factors) Warning Signal of Cancer Cancer signs:CAUTION US! C change in bowel or bladder habits A sore that does not heal U unusual bleeding or discharge U unexplained sudden weight loss U unexplained anemia T- thickening or lumps in the breast or elsewhere I indigestion or difficulty in swallowing O obvious change in wart or mole N nagging cough or hoarseness of voice

The Cancer Detection Examination

1. Cytologic Examinatiomn or Papanicolaou test( Pap smear)  Class 1 Normal  Class 11 inflammation  Class 111 mild to moderate dysplasia  class1V probably malignant  ClassV malignant 2. Biopsy 5. radiodiagnostic techniques(radioisotopes) 3. UTZ 6. CT scan 4. MRI 7. Antigen skin test 5. X-rays 8. Lab test

Diagnostic Surgery Cytologic specimen Needle Biopsy Excisional and IncisionalBiopsy Surgery as treatment Surgery for recurrence and metastasis Palliative surgery Reconstructive surgery Preventive surgery

Laboratory test:
y Alpha-feto-protein y Human Chorionic Gonadotropin(HCG) y Prostatic Acid phosphatase y Prostatic specific Antigen(PSA) y Carcinoembryonic Antigen(CEA)

Endoscopic examination Monoclonal Antibodies

DIAGNOSTIC EXAMINATION
CT SCAN
Purpose: provides photograph of tissue densities with use of radiation Nursing Responsibilities: y If dye will be used, keep the patient NPO for 4 HR before the test and check for allergies Contraindication y Pregnant women y Obesity(more than 300 lbs) y Claustrophobic patients y Allergy to dye y Client with unstable VS

(E C ) Endoscopic R trograde
Cholangiopancreatography
- Provide radiographic visualization of the bile and -

pancreatic duct Contraindicated in Pnacreatitis Keep the client NPO before and after the procedure Keep Narcan at bedside Inform the client that he or she may havehoarse and sore throat several days after the procedure

Endoscopy
y Assessment of the esophagus and stomach y Obtain consent y Remove denture y NPO 6- 8 hr before the procedure y Resume feeding after gag reflex return

Hysterosalphingography
y To determine patency of the fallopian tube and to detect pathology in the uterine cavity y Involve X-ray examination and administration of a radiopaque dye into the uterine cavity

IVP
Visualization of the urinary tract Obtain consent NPO for8- 10 hr before the procedure Administer Laxative t clear bowels before the procedure Check for allergy to iodine, seafoods or shellfish before the procedure y Keep Epinephrine at bedside to counteract possible allergy y Increase fluid intake after the procedure to facilitate excretion of the dye
y y y y y

Liver Biopsy
y Rule out liver disorder y Obtain consent y Obtain the result of homeostasis tests before the biopsy since bleeding is a common complication y Position the patient on the left side or supine during Biopsy y Instruct client to inhale, exhale and hold position of the liver and to prevent accidental puncture to the diaphragm y Position the client on the right side after biopsy for two hrs. to prevent hemorrhage y Maintain bed rest for 24 hr after the procedure

Lung Scan
y Determine lung perfusion when pulmonary emboli y y y y y

and infarction are suspected Obtain consent Remove jewelry from the chest area Administer sedative as prescribed Wear gloves within 24 hr after the procedure when urine is being discarded Involved injection of radioactive isotope into the body

Mammography
y To determine the presence of breast tumor y Instruct the client to avoid the use of deodorant, talcum

y y y y

powder, lotion, perfume and any ointment on the day of the exam as these contain Calcium oxalate which may crystallize and may give a False positive result Instruct the client that the breast will be placed between two x-ray plates Provide health teaching related to a self breast exam Best done a week after menstruation Position: lying down with pillow under the shoulder of the breast being examined

Papanicolaou test
- A smear method of examining stained exfoliative cells also called pap smear - It evaluate the cellular maturity, metabolic activity and morphological variations of cervical tissue

CAUTION US!
Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickenings or lumps Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging or persistent cough or hoarseness Unexplained anemia Sudden unexplained weight loss

Warning Signs of Cancer

y Change in bowel or bladder habits

A person with colon cancer may have diarrhea or constipation, or he may notice that the stool has become smaller in diameter A person with bladder or kidney cancer may have urinary frequency and urgency

A sore that does not heal

Small, scaly patches on the skin that bleed or do not heal may be a sign of skin cancer A sore in the mouth that does not heal can indicate oral cancer

Unusual bleeding or discharge

Blood in the stool is often the first sign of colon cancer Similarly, blood in the urine is usually the first sign of bladder or kidney cancer Postmenopausal bleeding (bleeding after menopause) may be a sign of uterine cancer

Thickenings or lumpsor glands (such as the Enlargement of the lymph nodes

thyroid gland) can be an early sign of cancer Breast and testicular cancers may also present as a lump

I ig sti r iffic lty i s ll i g

Cancers of the digestive system, including those of the esophagus, stomach, and pancreas, may cause indigestion, heartburn, or difficulty swallowing

Obvious change in a wart or mole

Moles or other skin lesions that change in shape, size, or color should be reported

Nagging or persistent cough or hoarseness

Cancers of the respiratory tract, including lung cancer and laryngeal cancer, may cause a cough that does not go away or a hoarse (rough) voice

Unexplained anemia
Sudden unexplained weight loss

A Late signs of Ca:

y Effusion when lymphatic flow is obstructed, there may be effusion in serous cavities - E.g. effusion into the pleural cavity: pleural effusion; effusion into the abdominal cavity: ascites y Ulceration and Necrosis - Result as the tumor erodes blood vessels and pressure on tissue causes ischemia----> tissue damage and bleeding----->infection Vascular thrombosis, Embolus, Trombophlebitis - Tumors tend to produce abnormal coagulation factors that cause increased clotting(pulmonary emboli----->lifethreatening)

Paraneoplastic Syndrome
- Malignant cells produce enzymes, hormones and other substances - Anemia o Ca cells produce chemicals that interfere with RBC production o Iron uptake is greater in the tumor than that deposited in the liver o Blood loss my result from bleeding - Hypercalcemia o Tumor of the bone, squamous cells lung Ca, Ca of the breast produce a parathyroid like hormone that increases or accelerates bone breakdown and release of calcium o Also results from metastasis to the bones o Enhanced by immobilization and dehydration

DIC (Dessiminated Intravascular Coagulation)

o More likely to occur in Ca of the lungs, pancreas,

stomach, prostate o Precipitated by the release of tissue thromboplastin or endothelial injury

ANOREXIA CACHEXIA SYNDROME

o The final outcome of unrestrained Ca cell growth o Malignant neoplasm deprive normal cells of nutrition o Tumors produce alteration in enzyme system necessary for normal metabolism--- stored fat is lost, tissues lose nitrogen(negative Nitrogen balance) o Tumors revert to anaerobic metabolism--- consume glucose; deplete glycogen stores in the liver and convert glucose to lactate o Protein depletion, serum albumin levels decrease o Tumors take up Na. Water retention masks malnutrition and is not immediately reflected as weight loss o Ca. cells produce anorexigenic substances that act in the satiety center of the hypothalamus, causing anorexia o Taste sensation diminishes or becomes altered and the individual may have aversion to eating, particularly meat

Characteristic of Malignant Cells

 Contain protein called Tumor Specific Antigen(TSA)

e.g. a. carcinoembryonic Antigen( CEA) b. Prostate Specific Antigen (PSA)  Contain less fibronectin, a cellular cement  Nuclei cell are large and irregular shape(pleomorphism) due to inc. RNA synthesis  Chromosomal abnormalities, fragile chromosome  Mitosis occurs frequently  Invade and metastasized rapidly

Mechanism of Metastasis
1. Lymphatic spread transport of tumor cells
through lymphatic circulation by way of interstitial fluid  Breast tumor metastasized rapidly through: axillary,clavicular, thoracic lymph channel 2. Hematogenous spread is the dissemination of malignant cells via blood stream 3. Angiogenesis is the growth of new capillaries from the host tissue by the release of growth factors and enzymes such as vascular endothelial growth(VEGF)

Physical Assessment
Inspection skin and mucus membranes for lesions, bleeding, petechiae, and irritation Assess stools, urine, sputum, vomitus for acute or occult bleeding Scalp noting hair texture and hair loss Palpation Abdomen for any masses, bulges or abnormalities Lymph nodes for enlargement Auscultation of lung sounds, heart sounds and bowel sound

Laboratory & Diagnostic Tests

Tests Cancer detection examination Laboratory tests Complete blood cell count (CBC) Tumor markers identify substance (specific proteins) in the blood that are made by the tumor PSA (Prostatic-specific antigen): prostate cancer CEA (Carcinoembryonic antigen): colon cancer Alkaline Phosphatase: bone metastasis Biopsy

Diagnostic Tests
Determine location of cancer: X-rays Computed tomography Ultrasounds Magnetic resonance imaging Nuclear imaging Angiography

Diagnosis of cell type

Tissue samples: y from biopsies, shedded cells (e.g. Papanicolaou (PAP) smear), & washings y Cytologic Examination: tissue examined under microscope

Direct Visualization:
Sigmoidoscopy Cystoscopy Endoscopy Bronchoscopy Exploratory surgery; lymph node biopsies to
y determine metastases

Cancer Detection and Diagnosis

Early Cancer May Not Have Any Symptoms

Cervical Cancer Screening

Normal Pap smear

Abnormal Pap smear

Breast Cancer Screening

Prostate and Ovarian Cancer Screening

Colon Cancer Screening

Biopsy

Pathology

Proteomic profile
Patient s tissue sample or blood sample

Genomic profile

Microscopic Appearance of Cancer Cells

Tumor Staging and Grading

y Staging determines size of tumor and existence of

metastasis y Grading classifies tumor cells by type of y tissue y The TNM system is based on the extent of the tumor(T), the extent of spread to the lymph nodes(N), and the presence of metastasis(M).

NURSING DIAGNOSES

Acute or chronic pain Impaired skin integrity Impaired oral mucous membrane Risk for injury Risk for infection Fatigue Imbalanced nutrition: less than body requirements y Risk for imbalanced fluid volume Anxiety Disturbed body image Deficient knowledge Ineffective coping Social isolation

OUTCOME IDENTIFICATION
1.Pain relief 2.Integrity of skin and oral mucosa 3.Absence of injury and infection 4.Fatigue relief 5.Maintenance of nutritional intake and fluid and electrolyte balance 6.Improved body image 7.Absence of complications

1. Knowledge of prevention and cancer treatment 2.Effective coping through recovery and grieving process 3.Optimal social interaction

Prevention and detection Primary Prevention Reducing modifiable risk factors in the external and internal environment Secondary Prevention Recognizing early signs and symptoms and seeking prompt treatment Prompt intervention to halt cancerous process

Cancer Prevention:
Skin avoid overexposure to sunlight Oral - annual oral examination. Breast monthly BSE from age 20. TSE for male Lungs avoid cigarette smoking; annual chest X-ray Colon Digital rectal examination for persons over age 40. Rectal biopsy, proctoscopic examination, Guaiac stool examination for persons age 50 and bove Uterus Annual Pap s smear from age 40 Basic annual physical examination and blood examination

Dietary Recommendations Against Ca

y Avoid obesity y Cut down on total fat intake y Eat more high fiber foods raw fruits and vegetable, y y y y

whole grain cereals Include foods rich in Vit A and C in daily diet Include cruciferous vegetables in the diet- broccoli, cabbage, cauliflower, brussel sprouts Be moderate in the consumption of alcohol beverages Be moderate in the consumption of salt cured, smoked-cured nitrate-cured foods

Cancer Prevention
Carcinogen ic chemicals

Carcinogenic radiation Cancer viruses or bacteria

Avoid Tobacco
Lung Cancer Risk Increases with Cigarette Consumption
15x Lung Cancer Risk

10x

5x

0
Nonsmoke

15 Cigarettes Smoked per Day

30

Protect Yourself From Excessive Sunlight

Limit Alcohol and Tobacco

Combination of Alcohol and Cigarettes Increases Risk for Cancer of the Esophagus

40x 30x Risk Increase 20 x 10x

Alcoholic Consumed per Day Drinks Packs of Cigarettes Consumed per Day AND

Diet: Limit Fats and Calorie

Correlation Between Meat Consumption and

Colon Cancer Rates in Different Countries

40 30 Number of Cases 100,000 (per people)

20

80

100

20 00

300

Diet: Consume Fruits and Vegetables

Avoid Cancer Viruses

HPV Infection Increases High

Risk for Cervical Cancer

Cervicall Cancer risk

Low

Noninfecte d Women

Women Infected with HPV

Avoid Carcinogens at Work

y Some Carcinogens in the Workplace
Carcinogen Arsenic Asbestos Benzene Chromium Leather dust Naphthylamine Radon Soots, tats, oil Vinyl chloride Wood dust Occupation Mining, pesticide workers Construction workers Type of Cancer Lung, skin, liver Lung , mesothelioma

Petroleum, rubber, chemical worker leukemia Metal workers, electroplaters Shoe manufacturing Chemical, dye ,rubber workers Underground mining Coal, gas petroleum workers Rubbers workers, polyvinyl chloride manufacturing Furniture manufacturing lung Nasal, bladder bladder lungs Lung, skin, liver liver nasal

Industrial Pollution

Goals of Treatment
y To slow the disease progression y To alleviate clinical manifestation y To maintain high quality of life y y y y y

Determining Treatment Modalities: Types of tumor Extent of the Disease Client s co-morbid conditions performance status Client s wish

Treatment Modalities
major role in - is performed: diagnosing, staging and treatment of cancer. Used less a. when a client has frequently. Indicated for Ca that either an existing are confined to the organ of premalignant origin and regional lymph nodes condition Purpose: b. Known family hx that 1. Prophylaxis/preventive strongly predisposes 2. Diagnostic the person to the 3. Curative development of 4. Preventive cancer 5. Control (Cytoreductive surgery) c. At-risk tissue or 6. Palliative organ is removed to prevent Ca 7. Reconstructive/rehabilitative

1. Surgery

1. Prophylaxis

development EX: Benign Mole

2. Diagnostic Biopsy
- Provide proof of Ca - All or part of a suspected lesion is removed for examination or testing
Biopsy type Needle Description Aspirating cells in a fluid or in very soft tissue Boring a core of solid tissue or making a punch, scrape or bite Removing a wedge of suspected tissue from a larger tissue mass Completely removing an entire lesion without removing any adjacent normal tissue Problem/limitations Sample error, sample size may not be adequate for accurate testing. May spread for Ca by seeding it to surrounding tissue. May damage healthy tissue Sample error; tumor seeding; damage to healthy tissue Tumor seeding; leaving micrometastasis; damage to healthy tissue

Incisional Excisional

Staging

Performing multiple needle or Tumor seeding; sample error; damage to incisional biopsies in tissues healthy tissue where metastasis is suspected or likely

3. Curative surgery
- Surgery alone can result in a cure rate of 27 % to 30 % when all visible and microscopic tumor is removed or destroyed
Surgery type Local excision description Removal of all identifiable tumor along with a small margin of normal tissues Removal of all identifiable tumor plus immediate tissue or adjacent tissue Removal of tumor, surrounding tissue, adjacent structures, and usual lymph channels draining the area Removal of tumor, lymphatic, adjacent organ, and all tissue in the regions Purpose/Use Small localized tumors

Wide local excision(radical) Wide excision

Small tumors with only local tissue invasion Small to moderate-size tumors with known local invasion Tumor infiltrate in a wide area but with no known distant metastasis

Extended radical excision

4. Control (Cytoreductive Surgery)

- Debulks by removing part of the tumor and leaving

a known amount of gross tumor - This type of surgery alone can not result in a cure, but decreases the number of cancer cells and increases the chances that other therapies can be successful

5. Palliative
- To improve quality of life during the survival time - Tumor tissue that causes pain, obstruction, difficulty

of swallowing is removed

6. Determination of therapy effectiveness ( second look )

- is a rediagnosis after treatment - To assessmt the disease status in clients who have been treated and have no symptoms of remaining tumor - The result of this surgery are used to determine whether a specific therapy should be continued or discontinued

7. Reconstructive or rehabilitative Surgery

- Increases function, enhance appearance, or both. - Ex: breast reconstruction after mastectomy; replacement of

the esophagus after radiation damage; bowel reconstruction, revision of scars; release of contractures; placement of penile implants

Side effect of Surgical Therapy

y Loss of specific parts or its function y Sometime whole organ s are removed y Result in major scarring or disfigurement y Result to grieving about the loss of body or change in life

style Nursing care: y Similar to those related to surgery y Consider the client s ability and the ability of the family to cope with the uncertainty of cancer and its treatment and the changes of body image and role

2. RADIATION THERAPY
- Is to destroy cancer cells with minimal exposure of the

normal cells to the damaging actions of radiation - The effect are seen only in the tissue in the path of radiation beam - Can be apparent within days or weeks, others after months to years after radiation is completed Mechanism of action:  Cells are exposed to ionizing radiation-- atoms within the cells are kicked out of orbit-- tremendous release of intracellular energy-- cell damaged--- die outright or unable to divide - Ionizing radiation is given off naturally(Gamma radiation) by: Radium, and Cobalt -also be generated by linear accelerators (Roentgen radiation)

Types of Energy/Rays Produced by Gamma Radiation:

1. Gamma rays Very light and have low energy-transfer potential Travel at the speed of light, allowing them to be concentrated and penetrate deeply into tissue Most common type used to treat Ca 2. Beta rays Heavier and travel at a moderate to high speed High linear energy-transfer potential and do not penetrate tissue Used in some diagnostic test 3. Alpha rays Very Heavy and slow Easily transfer energy to their surrounding and quickly lose their ability to penetrate tissue Use in laboratory test rather Tx of Ca Hamful to human if it is ingested chonically

TYPES OF RADIATION THERAPY

y External-bean radiation therapy(Teletherapy).

Administered through an X-ray machine y Internal radiation therapy. Administered within or near the tumor Types: y Sealed-source radiation therapy(Brachytherapy) y Unsealed-source radiation therapy(oral, IV)

Side Effect of Radiation Therapy

Skin Reactions: o Erythema, dry/moist desquamation o Atrophy, telangiectasia, depigmentation, necrotic/ulcerative lesions Nursing Responsibilities:  Observe for early signs of skin reaction and report  Keep area dry  Wash area with water, no soap and pat dry(do not rub)  Do not apply ointment, powder or lotion on the area  Do not apply heat, avoid direct sunshine or cold  Use soft cotton fabrics for clothing  Don not erase markings on the skin. These serve as guide for areas or irradiation

Bone Marrow Dysfunction

- Ca Tx kills both malignant and non-malignant cells in bone marrow - Blood count should be monitored carefully during an after Tx - Monitored for bleeding. If bleeding occur pressurized for 5 minutes if doesn t stop report to the physician - Shaving should be done with electric razor to prevent cutting of skin - Use soft tooth brush - Handwashing - Personnel should maintain strict aseptic technique in doing any procedures - ASA should be avoided - Stool and urine should be monitored for occult(Guiaiac stool)

Side Effect of Radiation Therapy

2. Infection due to bone marrow suppression Ng responsibilities:  Monitor blood count weekly  Good personal hygiene, nutrition, adequate rest  Teach signs of infection to report to physician 3. Hemorrhage  Platelets are vulnerable to radiation Ng responsibilities:  Monitor platelets count  Avoid physical trauma or use of Aspirin  Teach sign of hemorrhage  Use direct pressure over injection sites until bleeding stops

Side Effect of Radiation Therapy

4. Fatigue  Result of high metabolic demands for tissue repair and toxic waste removal  Plenty of rest and good nutrition 5. Weight Loss, muscle wasting(Cachexia)  Anorexia, pain and effect of Ca Stomatitis  Ulceration of oral mucous membrane  Nursing Intervention:  Administer analgesic before meals  Bland diet, no smoking//alcohol  Good oral hygiene/saline rinses q2h  Avoid flossing  Avoid tobacco product  Use soft bristle toothbrush  Sugarless lemon drops or mints to increase salivation

Side Effect of Radiation Therapy

7. Diarrhea 8. Nausea and vomiting 9. Headache 10. Hair loss/Alopecia 11. Cystitis 12. Social Isolation

Principles of Radiation protection - DTS

1. Distance. Maintain a distance of at least 3 feet when not performing procedures 2. Time. Limit contact for 5 minutes each time, a total of 30 minutes per shift 3. Shielding. Use lead shield during contact with client

Teaching Guidelines about Radiation therapy

1. 2.

3.

4. 5. 6.

It is painless Lie very still on a special table while the intervention is being given and you may be placed in a special position to maximize tumor irradiation Each Tx usually last for a few minutes. You may hear sound of the machine being operated, and the machine may move during the therapy As a safety precaution for the therapy personnel, you will remain alone in the treatment room while the machine is in operation The technologist will be right outside your room observing you through a window or by a closed-circuit TV. You may communicate There is no residual radioactivity after radiation therapy. safety precautions are necessary only during the time you are actually receiving. You may resume normal activities of daily living

3. Chemotherapy
- The use of antineoplastic drugs to treat cancer; cell kill and the cell

cycle Objectives: y To destroy all malignant tumor cells without excessive destruction of normal cells y To control normal growth if cure is no longer possible y Used as Adjuvant therapy Indication: y Disease is widespread y Risk of undetectable disease is high y The tumor is resistant to radiation therapy and cannot be resected ADJUVANT CHEMOTHERAPY - Done after initial treatment with radiation therapy or surgery to eradicate remaining cancer cells that are suspected to be still present

Contraindications
y Infection. The anti-tumor drugs are immunosuppressive y Recent surgery. The drugs may retard healing process y Impaired Renal or Hepatic function. The drugs are

nephrotoxic and hepatoxic y Recent radiation therapy. Also immunosuppressive y Pregnancy. The drugs may cause congenital defects y Bone marrow depression. The drugs may aggravate the condition. The WBC levels must be within normal limits

Routes of Administration
y Intravenous y Regional y Topical y Intra-arterial y Intracavitary y Intraperitoneal y Intrathecal

CHEMOTHERAPEUTIC AGENTS:
y Antimetabolites y Taxanes y Vinca Alkaloids y Camptothecins y Alkylating agents y Hormonal therapy y Antitumor antibiotics y Miscellaneous

Antiemetics drugs R/T Chemotherapy

y Dronabinol(Marinol) y Ondansetron(Zofran) y Graniserton(Kytril) y Alprazolan(Zanax) y Lorazepam(Ativan) y Haloperidol(Haldol) y Prochlorperazine(Compazine)

Safe Handling of Chemotherapeutic Agents

Wear mask, gloves and back close gown Skin contact with drugs must be washed immediately with soap and water. Eyes must be flushed immediately with copious amount of water 3. Sterile/alcohol wet cotton pledgets should be used wrapped around the neck of the ampule or vial when breaking an withdrawing the drugs 4. Expels air bubbles on wet cotton 5. Vent vials to reduce internal pressure after mixing 6. Wipe external surface of syringes and IV bottles 7. Avoid self inoculation by needle stab 8. Clearly label the hanging IV bottle with ANTINEOPLASTIC CHEMOTHERAPY 9. Contaminated needles and syringes must be disposed in a clearly marked special container. "leak-proof , puncture-proof 10. Dispose half-empty ampoules, vials, IV bottles by putting into plastic bag, seal and then into another plastic bag or box, clearly marked before placing for removal. Label as Hazardous waste 11. Hand washing should be done before and after removal of gloves 12. Trained personnel only should be involved in use of drugs 13. Ideally preparation of drugs should be in laminar flow conditions with filtered air
1. 2.

Nursing Management:
y Monitor for side effects of chemotherapy y Provide good hand washing techniques in caring for y y y y y y

the client Check vital signs Instruct client to avoid persons with URTI Monitor laboratory studies Monitor for signs of infection Monitor nutritional status Promote sleep and rest

4. BIOTHERAPY
- Which are agents that stimulate the body s natural immune system to control and destroy malignant cells - The use of a person s immune system to fight Ca or to lessen the side effects caused by some cancer treatment PURPOSE: y Control cancer growth y Make cancer cells more recognizable to the immune system y Boost the killing power of immune y Alter cancer cells growth pattern y Prevent cancer cells from spreading to other parts of the body y Enhance the body s ability to repair damaged cells from radiation and chemotherapy

Classification of Biologic Agents

y Hematopoietic growth factors y Biologic response Modifiers y Interferon's y Interleukins y Monoclonal antibodies y Vaccines y Anti-angiogenesis agents

TREATMENT MODALITIES
Aimed towards: CURE - free of disease after treatment normal life Control -Goal for chronic cancers Palliative Care: Quality of life maintained at highest level for the longest possible time

TREATMENT MODALITIES y Surgery surgical removal of tumors; most commonly

used treatment Preventive or prophylactic Diagnostic surgery Curative surgery Reconstructive surgery Palliative surgery y Chemotherapy use of antineoplastic drugs to promote tumor cell death, by interfering with cellular functions and reproduction

TREATMENT MODALITIES y Radiotherapy directing high-energy

y ionizing radiation to destroy malignant

tumor cells without harming surrounding tissues Teletherapy (external): radiation delivered in uniform dose to tumor Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it

TREATMENT MODALITIES
y Immunotherapy use of chemical or microbial agents

to induce mobilization of immune defenses. y Biologic response modifiers (BRMs) use of agents that alters immunologic relationship between tumor and host in a beneficial way

TREATMENT MODALITIES
y Bone marrow peripheral stem cell y transplantation aspirating bone marrowcells from

compatible donor and infusing them into the recipient y Gene therapy transfer of genetic materials into the client s DNA

NURSING MANAGEMENT
1.Promote measures that relieve pain and discomfort. y Pharmacologic and non-pharmacologic interventions 2.Promote measures to maintain intact skin integrity 3.Promote measures that maintain oral mucosa 4.Promote measures to prevent injury from abnormal bleeding y Monitor platelet count; avoid aspiring products,etc

NURSING MANAGEMENT
1.Promote measures that identify and prevent infection y Monitor WBC count; encourage frequent handwashing and overall cleanliness 2.Help decrease the client s fatigue and increase his activity level 3.Promote measures that ensure adequate nutritional intake y High protein, high calorie diet 4.Ensure adequate fluid and electrolyte balance

NURSING MANAGEMENT
1.Promote measures to enhance body image. y Take an honest gentle, caring approach; encourage client to express and verbalize feelings 2.Promote measures that address preventing complications of cancer therapy 3.Instruct client and family about the disease process and treatments; provide necessary information for self-care. 4.Help client and family cope effectively 5.Promote measures to reduce social isolation

Care of Clients Receiving Chemotherapy

Classes of Chemotherapy Drugs: Alkylating agents: Action: create defects in tumor DNA Ex: Nitrogen Mustard, Cisplatin Toxic Effects: reversible renal tubular necrosis y Antimetabolites: Action: phase specific Ex: Methotrexate; 5 fluorouracil Toxic Effects: nausea, vomiting, stomatitis, y diarrhea, alopecia, leukopenia

Classes of Chemotherapy Drugs:

y Antitumor Antibiotics:

Action: non- phase specific; interfere with y DNA Ex: Actinomycin D, Bleomycin, adriamycin (doxorubicin) Toxic Effect: damage to cardiac muscle y Miotic inhibitors: Action: Prevent cell division during M phase of cell division Ex: Vincristine, Vinblastine Toxic Effects: affects neurotransmission, alopecia, bone marrow depression

Classes of Chemotherapy Drugs:

y Hormones:

Action: stage specific G1 Ex: Corticosteroids Hormone Antagonist: Action: block hormones on hormone- binding tumors ie: breast, prostate, endometrium; cause tumor regression Ex: Tamoxifen (breast); Flutamide (prostate) Toxic Effects: altered secondary sex characteristics

Phases of cell Cycles

G1 phase RNA and protein synthesis occur.post mitotic phase during which ribonucleic acid(RNA) and protein synthesis are increased and cell growth occur 2. S phase DNA synthesis occur. Nucleic acid are synthesized and chromosomes are replicated in preparation for cell mitosis 3. G2 phase premitotic phase: DNA synthesis is complete, mitotic spindle forms. During G2RNA and protein synthesis occur as in G1. P-prophase; M-metaphase; Aanaphase; T- telophase 4. Mitosis cell division occurs G0 phase the resting phase, can occur after mitosis and during G1 phase. - In Go phase are those dangerous cells that are not actively dividing but have the potential for replicating
1.

Effects of Chemotherapy
y Tissues: (fast growing) frequently affected

Examples: mucous membranes, hair cells, bone marrow, specific organs with specific agents, reproductive organs (all are fetal toxic; impair ability to reproduce)

Evaluation of Treatment Response/NG. Intervention for Chemotherapeutic side effect

Myelosuppression:
a.

Neutropenia

depleted production of WBCs Infection control measures. Protect from infection Avoid people with infection b. Thrombocytopenia - Decreased platelets:  less than 20,000/m  Predisposes the client to bleeding  Bleeding precautions  Avoid ASA  Protect trauma c. Anemia due to abnormal destruction of RBCs due to nephrotoxic therapies  Fatigue, headaches, dizziness, fainting, pallor, dyspnea, palpitation and tachycardia  Provide frequent rest period

Gastrointestinal effects: y Nausea and vomiting, Anorexia, Stomatitis, Diarrhea and constipation  Administer antiemetic to relieve nausea and vomiting  Replace fluid electrolytes losses, low-fiber diet to relieve diarrhea  Increase fluid intake and fibers in diet to prevent/relieve constipation Integumentary effect: y Alopecia y Skin reactions  Extravasations at rejection sites  Hyper pigmentation in the nail within 2-3weeks after administration and continues for 10- 12weeks after the end of the therapy  Photosensitivity

Nursing Intervention: Integumentary system

y Pruritus, urticaria and systemic signs  Provide good skin care y Stomatitis  Provide good oral care  Avoid hot and spicy food y Alopecia  Reassure that is temporary  Encourage to wear wigs, hats or head scarf y Skin pigmentation  Inform that is temporary y Nail changes  Reassure that nails may grow normally after chemotherapy

Genito-urinary system
y Hemorrhagic cystitis  Provide 2

3 L of fluid per day y Urine color changes  Reassure that it is harmless

Reproductive Health:
y Sexual health may also affected y Chemotherapeutic agents should not be administered

during 1st trimester, 2nd, 3rd trimester predisposes the infant to low birth weight y Premature menopause or amenorrhea  Reassure that menstruation resumes after chemotherapy

Chemotherapy Administration
Administration Routes of administration: Oral Body cavity (intraperitoneal or intrapleural) Intravenous Use of vascular access devices because of threat of extravasation (leakage into tissues) & long- term therapy

Types of vascular access devices:

PICC lines: (peripherally inserted central catheters) Tunneled catheters: (Hickman, Groshong) Surgically implanted ports: (accessed with 90o angle needle- Huber needles)

Nursing care of clients receiving chemotherapy

receiving chemotherapy Assess and manage: Toxic effects of drugs (report to physician) Side effects of drugs: manage nausea and vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions

Nursing Care of Clients Receiving Chemotherapy

y Monitor lab results (drugs withheld if blood counts

seriously low); blood and blood product administration y Assess for dehydration, oncologic emergencies y Teach regarding fatigue, immunosuppression precautions y Provide emotional and spiritual support to clients and families

Indications: y Leukemias Aplastic anemia y Lymphomas Immunodeficiency y Myeloma Thalassemia y Sickle cell disease COMMON COMPLICATION: Graft-versus-host disease Nursing Management: implement infection

Care of Client with Specific Neoplasm Disorder

1. Integumentary System: Skin cancer Epidemiology: most common type: basal cell carcinoma, Squamous cell carcinoma, an malignant melanoma Risk Factors: y Prolonged exposure to UV radiation y Light complexions y Family history of melanoma Diagnostic test: Skin Biopsy Medical Management: y Surgery(removal of the lesion) y Chemotherapy y Radiatio therapy

Nursing Management:
y Teach client about preventive measure y Instruct client to monitor a lesion that does not heal

and its characteristics y Instruct removed that may lead to chronic irritation of the skin y Instruct client to wear layered clothing and use sunscreen to protect the skin y Instruct the client to avoid exposure fro the sun between 11am -3pm

Musculoskeletal System: Bone cancer

Epidemiology: Most common form: Osteogenic Sarcoma Peak of incidence: 10 to 25 years old Usually found in the metaphysis of long bones especially in the lower extremities Risk Factors: Radiation exposure Diagnostic Tests:  MRI, CT scan, Biopsy, Bone scan, Medical Management: y Surgery(amputation or limb resection) y Chemotherapy y Radiation therapy

Nursing management:
y Prepare the client and family for the treatment which

may include amputation and chemotherapy y Provide support for the client y Prepare for prosthetic fitting as necessary y Assist the client in dealing with problems regarding self-image

Gastrointestinal System
A. Gastric Cancer
Epidemiology: Most common type: adenocarcinoma; frequent in clients with pernicious anemia; more common in males Risk Factors: y Diet high in complex carbohydrates, grains and salts y Diet low in fresh, green vegetables and fresh fruits y Smoking y Alcohol ingestion y History of gastric cancer Diagnostic test: o Biopsy o GI X-ray o Gastroscopy

Medical MGT:
y Surgery(gastrectomy) y Chemotherapy y Radiation therapy

Nursing management: y Monitor VS y Monitor weight y Assess nutritional status y Encourage small, bland, and easy to digest foods with supplemental vitamins and minerals y Prepare the client for chemotherapy and radiation therapy y Prepare the client for surgical resection

B. Colon Cancer
Epidemiology - most common type: y Adenocarcinoma y Usually located in the ascending and descending colon Risk Factors: y Family history of bowel inflammatory disease y High fat, high protein, low fibers diet y Older than 40 years old Diagnostic test: y Fecal Occult blood testing y Barium enema y Colonoscopy y Biopsy

Medical MGT:
y Blood tranfusion y Surgery(Colectomy, colon resection, end to end

anastomosis) y Chemotherapy y Radiation therapy Nursing MGT: y Watch out for signs and symptoms of intestinal obstruction y Provide emotional and support and comfort y Administer IV fluid and electrolytes as prescribed y Prepare the client for surgery

C. Rectal cancer
Epidemiology - most common form: Adenocarcinoma Risk factors: y Older than 40 years old y Family Hx of rectal polyps and cancer y History of bowel inflammatory disease y High fats, high protein, low fiber diet Diagnostic test: y Proctosigmoidoscopy y Barium enema y Fecal occult blood testing y Biopsy

Medical MGT:
y Surgery( colon resection, end to end anastomosis) y Chemotherapy y Radiation therapy Nursing GT: y Watch out for signs of intestinal obstruction y Provide emotional support and comfort y Monitor I&O y Monitor hydration status y Monitor serum electrolytes levels y Prepare the client for surgery

D. Liver cancer
Epidemiology y Most common type: Hepatocellular carcinoma, y Nonresectable because of rapid metastasis Risk factors: y Hepatitis y Chronic infection y Hepatitis B and C y Exposure to chemical toxins y Smoking alcohol intake Diagnostic test y X-rays, liver scan, laparoscopy, UTZ, MRI, Biopsy, CT scan

Medical Mgt:
y y y y

Radiation therapy Hemotherapy Surgical removal of the lesion Liver transplantation

Nursing MG: y Relieve symptoms brought about by radiation and chemotherapy y Teach client and the family to report complication of chemotherapy y Provide support

E. Pancreatic Cancer
y Epidemiology- most common site: head of the

pancreas y Responsible for the development of Hyperinsulinism Risks factors: DM, Alcohol use, History of previous pancreatitis, smoking, high fat diet, exposure to environmental chemicals Diagnostic test: y ERCP UTZ y C TSCAN BIOPSY

Medical Mgt:
Medical Mgt: y Radiation y Chemotherapy y Whipple s procedure Nursing Mgt: y Pain management y Improve nutritional status of the client y Improve client s comfort y Relieve discomfort of the skin y Administer opioid analgesic as prescribed y Protect bony prominences from pressure

Gall Bladder Cancer

y Epidemiology Most common form: adenocarcinoma;

common in woman Risk Factors: y Hx of gallstone y Older than 50 years old y High fat diet Diagnostic test: y UTZ, oral Cholecystography y Biopsy

Medical Mgt:
Medical MGT: y Cholecystectomy y Radiation therapy y Chemotherapy Nursing MGT: y Prepare the client for surgery y instruct the client to report complications o radiation and chemotherapy y Provide emotional support

4. RESPIRATORY SYSTEM
Lung cancer Epidemiology most common form: Bronchogenic Carcinoma Four Major Type: o Small cell carcinoma o Squamous cell carcinoma o Adenocarcinoma o Large cell carcinoma Risk Factors: y Cigarette smoking y Exposure to environmental pollutants y Exposure to occupational pollutants y Tuberculosis y Radiation Diagnostic test: y Sputum exam, CX-ray, Biopsy, Bronchoscopy, MRI, CT scan
A.

Medical Mgt:
Medical MGT: y Bronchodilators y Corticosteroids y Radiation therapy y Chemotherapy y Surgery(Pneumonectomy, lobectomy, Segmentectomy) Nursing Mgt: y Monitor VS y Monitor respiratory status y assess for tracheal deviation y Administer pain reliever as prescribed y Administer supplemental O2 as prescribed y Monitor pulse oximetry y Encourage rest periods between activities y Provide a high-calorie, high protein. High Vitamin diet

B. Laryngeal Cancer
Risk factors: y Voice strain y Cigarette smoking y Exposure to environmentalpollutants y Exposure to radiation y Chronic laryngitis Diagnostic Test:laryngoscopy, CT scan, MRI, Biopsy Medical Mgt: y Chemotherapy y Radiation therapy y Surgical removal of the tumor y tracheostomy

Nursing Mgt:
y Place client in high Fowler s position y Monitor respiratory status y Monitor for signs of aspiration of food and fluid y Administer supplemental O2 as prescribed y Provide a high-calorie, high protein, high-vitamin

diet y Administer analgesic as prescribed

REPRODUCTIVE SYSTEM
A. Cervical Cancer Epidemiology: most common cause Risk factors: y Multiple sexual partnet y High parity y Poor hygiene y Early age of first intercourse y Smoking tobacco y STDs y Chronic cervicitis y Lowsocio-economic group Diagnostic Test: y Pap Smear, Cold conization

Human papilloma virus

Medical Mgt:
Medical MGT:

y Chemotherapy y Cryosurgery y Externa radiation y Internal radiation

implants y Laser therapy y Conization y Hysterectomy

Nursing Mgt after Surgery: y Monitor VS y Assist with deep breathing and coughing exercise y Encourage early ambulation y Monitor I&O y Apply antiembolic stockings y Monitor vaginal bleeding y Assess incision site y Monitor bowel sound y Avoid strenuous activities y Instruct client to avoid sexual intercourse for 3 to 6 weeks

B. Ovarian Cancer
Epidemiology: leading cause of death among reproductive malignancies Risk Factors: y Above 40 years old y Amily history of ovarian and breast cancer y Family history of colorectal cancer y Nulliparity y History of infertility y History of dysmenorrhea y Use of ovulation-stimulation drugs Diagnostic test: y CT scan y Intravenous Pyelogram y UTZ y Biopsy y Explor Lap

Medical Mgt:
Medical MGT: y TAH-BSO y Chemotherapy y Radiation therapy y Immunosuppressive therapy Nursing MGT: y Prepare client for surgery y Provide support y Promote client s comfort y Teach client to report complications of chemotherapy, immunotherapy, and radiation therapy y Prevent infection

C. Endometrial Cancer
Epidemiology: most common malignancy in female genital reproductive system Risk factors: y History of pelvic radiation y Presence of other reproductive cancer y Family history of DM, HTN, Obesity and hyperestrogenism y Early menarche y Late menopause y Delayed onset of ovulation y Dysfunctional uterine bleeding Diagnostic test: y Pelvic exam, Hysteroscopy, Biopsy, Endovaginal ultrasound Medical MGT: y Internal and external radiation therapy y Chemotherapy y Tamoxifen(Nolvadex) y Progestational therapy with the use of metroxyprogesterone(DepoPr overa) or megestrol acetate(megace) y TAH-BSO

Nursing MGT for clients with Internal Radiation Implants:

y y y y

y o o o

Instruct the client to remain on bed Provide low residue diet increased fluid intake Aminister antiemetics, broadspectrum antibiotic, analgesis, sedative, and anti-diarrheal medication as prescribed In case of dislodgement of the radiation implant: Use long handled forcep to get the Implant Put the implant in a lead lined container Organized care so that the time spent in the client s bedside is minimal

D. Vaginal Cancer
Risk Factors: y Ingestion of Diethyl-stilbestrol(DES) y Exposure to DES in utero in girls y Repeated pregnancies y History of STD, HPV, Herpes Virus y Immunosuppressive therapy prior irradiation Diagnostic test: y Pelvic exam y Cytologic exam of any questionable area in the vagina y Colposcopy y Biopsy

Medical Mgt:
Medical MGT: y External and internal radiation therapy y Hysterectomy y Lymphadenectomy y Vaginectomy Nursing MGT: y Provide emotional support y Promote rest y Discuss potential impact of the disease y Promote a therapeutic environment that will allow the client to feel comfortable discussing her sexual concern

E. Vulvar Cancer
Risk factors: y History of STDs y Vulvar disorder(leukoplakia and diabetic vulvitis Diagnostic test: BIOPSY Medical MGT: y Topical Antibiotic y Steroid creams y Hormone cream y Chemotherapy y Irradiation therapy y Simple and radical vulvectomy

Nursing MGT: y Administer antipruritic creams for itching y Instruct client to report signs of complication from chemotherapy and irraditaion therapy y Prepare client for surgery

6. BREAST CANCER
Epidemiology: most common malignancy in women in the USA Risk factors: y Age, Ethnicity, Ocarian and hormonal dysfunction, benign breast cancer, Family Hx of breast Ca, Mantle radiation for treatment of Hodgkin s disease, Alcohol intake, High fat and high caloric diet, obesity, Nulliparity, High dose exposure to radiation, early menarche and late menopause Diagnostic Test: y Mammography, Biopsy

Medical Mgt:
Medical MGT: y Chemotherapy y Radiation therapy y Hormonal manipulation through the use of medication like Tamoxifen(Novaldex) for estrogen receptor tumor y Lumpectomy y Simple, modified, and radical mastectomy y Oophorectomy y Ablative therapy with adrenalectomy or chemical ablation

Nursing Mgt:
y Prepare client for surgery y Relieve client s discomfort resulting from

chemotherapy and radiation therapy y Assist client in coping with body images changes

Nursing Mgt. After Mastectomy:

y Monitor VS y Position client on the unaffected side y Elevate affected side above the heart level y Encourage deep breathing and coughing exercise y Assess operative site for infection y Administerr diuretics and provide low-salt diet for

severe lymphedema y Assist client with the exercise prescribed by the physician to decrease muscle weakness and lymphedema

7. Urinary System
A. Renal Cancer
Epidemiology: most common type: Adenocarcinoma Risks factors: y Smoking y Exposure to lead, phosphate and cadmium y Infection y Hypertension y Traumatic injuries to the kidneys

Diagnostic Test:
Diagnostic test: y Intravenous pyelography y CT scan y UTZ. y Nephrotomography y Renal Biopsy Medical MGT: y Chemotherapy y Immunotherapy y Radiation therapy y Nephrectomy

Nursing MGT:
y Monitor VS esp.BP y Monitor I&O y Instruct the client to

report complication of radiation, chemotherapy, and immunotherapy y Prevent infection

B. Bladder Cancer
Epidemiology:
y Very high rate of recurrence following the treatment y Good prognosis Risk Factors: y Cigarette smoking y Cystitis y Contrast medium y Chronic infection an instrumentation y Catheterization and cystoscopy

Diagnostic test:
y Intravenous

pyelogram y Cystoscopy y Biopsy y CT scan y MRI

Medical Mgt:
Medical MGT:
y y y y

Radiation therapy Chemotherapy Cystectomy Urinary diversion creation

Nursing MGT: y Monitor urine for hematuria y Monitor I& y Prepare the client for surgery y Instruct client about side effects and complication of chemotherapy and radiation therapy y Assist client in coping with changes in body image after surgery

C. Prostate Cancer
Risk factors:
y y y y y y y y y y

Family hx. Of prostate Ca Age above 65 years old Obesity STDs Smoking Digital rectal exam Biopsy Transrectal ultrasound CT scan MRI

Medical MGT:
y Hormonal

Diagnostic tests:

manipulation(Orchiect omy) y Radiation therapy Chemotherapy y Stilphostrol y Prostatectomy y TURP

Nursing Mgt:
Nursing MGT:

y Assess the urine for hrmaturia y Monitor urine output y Provide support y Prepare client for surgery y Teach client about the side effects and

complication of hemotherapy anf radiation therapy y Provide comfort

8. BRAIN CANCER
Epidemiology: y Common in children between the ages of 3 12 and in adults aged 55 65 y Metastasizes to the central nervous system Risk Factors: y Neplasm from other organs y Heredity y HIV infection y Exposure to radiation Diagnostic Test: y CT scan, MRI, EEG, Biopsy, PET scan

Medical Mgt:
y Chemotherapy y Radiation therapy y Surgery (craniotomy) Nursing MGT: y Assess neurologic status y Institute safety measure y Assess weight loss and nutritional status y Initiate seizure precautions y *repare the client for surgery y Provide support y Educate client about effects of radiation and chemotherapy

9. Endocrine System
A. Leukemia
Epidemiology: most common malignancy in children Risk factors: y Genetic factors y Exposure to radiation Congenital abnormalities(Down syndrome) y Alkylating agents Diagnostic test: y Lumbar tap, Ct scan, Gallium scan Medical MGT: y Chemotherapy y Radiation therapy y Bone marrow transplantation y Antibiotic, antibacterial, antiviral, antifungal medications, blood transfusion

Nursing Mgt:
Nursing Management: y Provide high-calorie, high protein, high-Carbohydrate diet y Provide adequate rest periods y Provide activities that will conserve the client s energy y Avoid injections and trauma y Instruct client to avoid NSAID and Aspirin y Assist client in self-care and mobility y Prepare client for transplantation y Instruct client and family about the effects and complications of radiation and chemotherapy

B. Lymphoma(Hodgkin s Disease)
Epidemiology y Progresses slowly; usually begins with a lymph nodes and spreads via the lymphatic vessels into adjacent lymph nodes y Most common type: Nodular sclerosis Risks Factors: y Immune system deficiencies y Exposure to environmental pollutants y Genetic factors y History of infectious mononucleosis

Diagnostic Test:
and abdomen y CT scan y MRI y PET scan y Gallium Scan Medical MGT: y Radiation therapy y Chemotherapy y Splenectomy
y Biopsy y X-ray of the chest, pelvis,

Nursing MGT:
y Monitor side effects R/T chemotherapy and radiation therapy y Monitor for signs of infection and bleeding y Maintain bleeding precaution y Prevent infection

Four Complication of Ca which Need Medical Emergencies:

1. Hypercalcemia
-

Occur commonly , found in malignant tumor Calcium level higher than 10.5 mg/dL Signal the final stage of cancer Early S&S: nausea, vomiting, constipation and weakness Later S&S: renal failure, coma, cardiac arrest Treated aggressively with IV Normal Saline, Lasix

2. Spinal Cord Compression

- Cancer of the lung, breast, and prostate carry the greatest risk of metastasizing to the spinal cord - The chief symptom of metastasis to spinal cord is back pain - Radiation, surgery, and steroid therapy is initiated - Pain medication should be given frequently

3. Superior Vena Cava Syndrome

y Caused by an obstruction of the superior vena cava y Occur in conjunction with lung cancer and

lymphomas y Typically the client experience: DOB, swelling of the face and neck, edema in the upper extremities, chest pain and cough, headache, visual disturbances and alteration of LOC y O2 inhalation, Radiation with diuretics y Fowlers position, monitor VS esp. the RR y Elevate lower extremities y Provide restful environment

4. Cardiac Tamponade
y Caused by the formation of pericardial fluid,

which reduces cardiac output by compressing the heart y Tumor metastasis to the pericardium is associated with lung cancer, breast cancer, Hodgkin s disease, lymphoma, melanoma, GIT tumors and sarcoma y S&S: rapid, weak pulse, distended neck vein during inspiration, ankle or sacral edema, pleural effusion, ascites, enlarged spleen, lethargy and altered LOC y Tx: aspiration of fluid; administer pain medication

Promoting Coping Throughout the Ca Continuum

y Assess client s coping mechanisms y Listen for verbal and observe no-verbal cues that client is trying to air his/her emotional stress y Deal with client s emotional distress regarding diagnosis of cancer y Encourage social support from client s family and friends y Emphasize importance of routine physical checkup y Teach client bout the possible side-effects of therapies that patient is undertaking y Teach measures to counteract the effects

1. Providing support for clients y Nurse should be emphatic, active listener, y Good oral communicator and a caring person y Patient value storytelling from cancer survivors y Encourage the client to join support groups

Psychosocial Aspects of Cancer Care

2.Providing support for the Family

y y

Assess the family s functioning patterns coping strategies and stressors Assumes the role as the family caregiver for the patient and the family Nurses must be aware that Ca patients are overly aware of their body image Enhance client s self-esteem by letting him accept any possibilities of physical change and deterioration Provide palliative nursing interventions for these changes

3. Promoting Positive Self-Concept

y y y