Nursing Management of clients with cancer

Oncology nursing

1. Oncology Medical surgical nursing I E. CHAULUKA

2. Cancer Disease process that begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA. Abnormal cell builds clone and begins to proliferate abnormally, ignoring growth regulating signals Metastasis: cells infiltrate tissues, gain access to lymph & blood vessels, carry cells to other parts of the body.

3. Benign vs. Malignant Tumors Benign (noncancerous) Well differentiated cells; resemble normal D oes not infiltrate surrounding tissues; encapsulated Slow growth rate No metastasis Localized No tissue damage Does not cause death Malignant (cancerous) Undifferentiated cells; little resemblance to normal cells Infiltrates and destroys surrounding tissue. Variable/ fast growth + Metastasis Causes anemia, weakness, wt loss. Extensive tissue damage Causes death without tx

4. Four Main Classifications of Cancer Lymphomas (cancers occurring in infection-fighting organs, such as lymphatic tissue). Leukemias (cancers occurring in blood-forming organs, such as the spleen, and in bone marrow). Sarcomas (cancers occurring in connective tissue, such as bone). Carcinomas (cancers occurring in epithelial tissue, such as the skin).

5. Pathophysiology of Malignant Cells Invasion Proteinases: destructive enzyme; destroys surrounding tissue Mechanical pressure: force from rapidly proliferating cells. Metastasis: spread of malignant cells from primary tumor to distant sites (lymph, blood).

6. Development, Prevention, and Detection of Cancer Carcinogenesis and the primary prevention of cancer Carcinogenesis The process by which normal cells are transformed into cancer cells Various factors are possible origins of cancer Carcinogens Substances known to increase the risk for the development of cancer

7. Carcinogenesis Initiation: chemicals, physical factors and biologic agents alter genetic structure of DNA Promotion: repeated exposure to carcinogens cause expression of abnormal genetic information over a long latency period. Progression: altered cells exhibit increased malignant behavior

8. Agents/ factors leading to carcinogenesis Viruses/ bacterias (suspected) thought to incorporate themselves into genetic structure of cell. Epstein-Barr virus  Burkitt lymphoma H. pylori  gastritis  gastric cancer Physical agents Sunlight Radiation Chronic inflammation/irritation Tobacco use Chemical agents (75% of cancers) Tobacco Work place exposure (arsenic, soot, tars, wood dust)

9. Agents/ factors leading to carcinogenesis Genetics & Familial Factors Genetics Shared environments Shared cultural/lifestyle factors Dietary factors Fats Alcohol Salt cured/smoked meats Red meat Processed meats Hormonal agents Endogenous (bodies own hormone production): breast, prostate, utuerus

10. Immune System Early stages: immune system can detect and destroy malignant cells (sometimes) Immunocompromised patients: increased chance of cancer Organ transplant  Karposi’s sarcoma, lymphoma, skin, cervical, anogenital cancers AIDS  Karposi’s sarcoma Immune system failure: Tumor antigens hide them from normal immune function

11. Primary Prevention Primary Prevention: Reducing risks. One-third of cancers worldwide could be prevented. Avoid carcinogens Dietary/lifestyle changes

12. Secondary Prevention Promote screening & early detection.

13. Diagnosis Determine the presence and extent of tumor Identify possible spread (metastasis) Evaluate function of involved body systems/organs Obtain tissue and cell for analysis

14. Diagnosis Labs FBC Tumor markers (monitor response to cancer treatments) Mammography – breast cancer CXR – lung cancer, bone forming tumors US, CT, MRI - evaluation of suspected tumors Bone marrow aspirate Cervical biopsy/ PAP smear – suspected cervical cancer or HIV+ women PSA – suspected prostate cancer HIV test – HIV related cancers (KS, cervical cancer, lymphoma) Barium swallow, endoscopic tissue biobsy – suspected esophagus cancer

15. Tumor Staging & Grading Staging: size of tumor & metastasis Staging Tumor, nodes, metastasis (TNM) staging system for cancer is used to indicate tumor size (T), degree of regional spread to lymph nodes (N), and extent of metastasis (M) Clinical Staging Stage 0: Cancer in situ Stage I: Tumor limited to the tissue of origin Stage II: Limited local spread Stage III: Extensive local and regional spread Stage IV: Metastasis Grading: classification of the tumor cell (I-IV) Tumors are classified as grade 1 to grade 4 Grade 1: Mild dysplasia—cells only slightly different from normal cells Grade 2: Moderate dysplasia—moderately well differentiated Grade 3: Severe dysplasia—poorly differentiated Grade 4: Anaplasia —cells difficult to determine

16. Primary tumor (T) TX: Main tumor cannot be measured. T0: Main tumor cannot be found. T(is), or T in situ: The tumor is still within the confines of the normal glands and cannot metastasize. T1, T2, T3, T4: Refers to the size and/or extent of the main tumor . The higher the number after the T, the larger the tumor or the more it has grown into nearby tissues. T's may be further divided to provide more detail, such as T3a and T3b.

17. Regional lymph nodes (N) Lymphatic fluid transports immune system cells throughout the body. Lymph nodes are small bean-shaped structures that help move this fluid. Cancer often first spreads to and through nearby lymph nodes. NX: Cancer in nearby lymph nodes cannot be measured. N0: There is no cancer in nearby lymph nodes. N1, N2, N3: Refers to the number and location of lymph nodes that contain cancer. The higher the number after the N, the more lymph nodes that contain cancer.

18. Distant metastasis (M) Metastasis is the spread of cancer to other parts of the body. MX: Metastasis cannot be measured. M0: Cancer has not spread to other parts of the body. M1: Cancer has spread to other parts of the body.

19. Management of Cancer (Goals) Cure: complete eradication of malignant disease Control: prolonged survival and containment of cancer cell growth Palliation: Relief of symptoms associated with disease

20. Management of Cancer Surgery Radiation Chemotherapy Bone Marrow Transplantation

21. Management of Cancer: Considerations Patient preferences Cost of treatment Stage of disease Grade/ type of cancer Co-morbid conditions (HTN, DM, COPD) General condition of patient Age of patient Organ function

22. Management of Cancer (Surgery) Surgical removal of entire cancer remains the ideal and most frequently used treatment. Biopsy: Obtain a tissue sample. Excisional: easily accessible tumors (skin, breast); removal of entire tumor and surrounding tissue to be tested. Incisional: Large tumor mass; wedge of tissue tested Needle: Not easily accessible tumors; (lung, liver); fast, easy; aspirating tissue fragments through a needle. Surgery as Treatment Remove tissue and surrounding tissue Local excisions: outpatient; small easily accessible tumor Wide excision: Removal of tumor, lymph nodes, adjacent structures; may result in disfigurement.

23. Management of Cancer (Surgery) Prophylactic surgery: removing non vital tissues or organs that are at increased risk to develop cancer. (mastectomy) Palliative surgery: make patient comfortable; remove tumor to provide pain relief, obstruction, etc. Reconstructive surgery: Breast, head, neck, skin Nursing Management General pre/post op care Address patient pain, anxiety, fears

24. Management of Cancer (Radiation) Used to cure, control, prophylactically treat, palliative treatment Ionizing radiation: breaks strands of DNA helix leading to cell death; not all tumors are radiosensitive. External radiation: invisible beam of highly charged electrons penetrate body and target a tumor Internal radiation: implantation/ brachytherapy, delivers high dose of radiation to localized area. Implanted by needle, beads, catheters into body cavities.

25. Management of Cancer (Radiation) Toxicity Alopecia Dry skin Oozing skin Stomatitis: (inflammation of oral tissues) Dry mouth Thrombocytopenia (decreased platelets) Anemia Nursing management Skin/ oral care & education Nutritional status Protect against radioactive implants (away from other patients, prohibit children, limit time with patient to 30 minutes, shielding equipment)

26. Management of Cancer (Chemotherapy) Antineoplastic agents used to destroy tumor cells by interfering with cellular function. Used to treat systematic disease rather than localized tumors Adjuvant: destroy remaining cells post op Neoadjuvant : reduce size of tumor pre-op Primary: leukemia, lymphoma tx

27. Management of Cancer (Chemotherapy) Administration Inpatient or outpatient Extravasation: damage to soft tissue if they inadvertently leak from a vein Vesicants: if deposited into subcutaneous tissue, cause necrosis Watch for absence of blood return from IV catheter, resistance to flow of IV fluid, burning, pain, redness at site. Hypersensitivity reactions: itching, chest tightness, agitation, N/V, dyspnea, feeling of impending doom, anaphylaxis (severe).

28. Management of Cancer (Chemotherapy) Toxicity GI system: N/V 24-48 hours after administration, stomatitis, diarrhea Myelosuppression (depression of bone marrow function): decreased WBC, RBC, platelets Renal: possibility of renal failure, monitor BUN, creatinine , adequate hydration Reproductive system impairment Neuro : tingling, pain, burning extremities, (neuropathy) Nursing management Assess fluid and electrolyte status Modify risk for infection and bleeding Administer chemo

29. Management of Cancer (Bone Marrow Transplant) Hematologic cancers Donor cell harvested under general anesthesia Allogeneic: from donor other than the patient (family, unrelated donor) Autologous: from the patient Syngeneic: from an identical twin Graft-versus-tumor effect: donor cells recognize the malignant cells and act to elimininate them. Graft-versus-host disease: Immune response against new cells Give immunosuppresents to avoid GVHD Sx:rash , blistering, mucosal shedding, diarrhea, abd pain, hepatomegaly, jaundice

30. Management of Cancer (Bone Marrow Transplant) Nursing Management Pretransplant care: nutritional assessment, blood work, HIV testing Providing care during treatment: manage symptoms (nausea, diarrhea, mucositis ) Monitor VS, oxygen saturation Assess adverse affects (fever, chills, SOB, chest pain )

31. Most Common Types of Cancer in Malawi Kaposi’s Sarcoma #1 men, #2 women Presentation: Red, purple, brown papules on skin & mucous membranes Treatment Early: ART Radiation, Surgery, Chemotherapy Head & Neck Cancers Oral cavity, oropharynx, nasopharynx , larynx Presentation: Non healing ulcers in mouth, easily bleed, dysphagia, cough, hoarseness Surgury , Chemotherapy

32. Most Common Types of Cancer in Malawi Breast Cancer Women of reproductive age- clinical breast exams every 6 months Surgery, chemo, hormonal treatment, radiation Esophagus Cancer Risk factors: alcohol/ smoking Unexplained dysphagia Esophagectomy Radio-chemotherapy Endoscopic stenting, bypass surgery

33. Most Common Types of Cancer in Malawi Cervical Cancer Screening for woman reproductive age Vaccinate girls 9-14 for HPV Total radical hysterectomy with lymph nodes Radiation, chemotherapy, palliative care Prostate Cancer Prostatectomy Radiotherapy Hematological Malignancies Lymphoma, leukemia, multiple myeloma Peripheral blood film examination for abnormal FBC Bone marrow examination Chemotherapy

34. Nursing Care of Patients with Cancer Maintain Tissue Integrity Stomatitis (damage/ulceration to oral tissues from chemo/radiation) Normal saline mouth rinse q 2 hours while awake Soft toothbrush Remove dentures Moisturize lips Avoid spicy/hard foods Assess gag relfex Radiation associated skin impairment Avoid soaps, cosmetics, lotions Prevent trauma, rubbing, scratching Pain relief Alopecia Address anxiety Avoid excessive combing or brushing

35. Nursing Care of Patients with Cancer Promote nutrition Hydration Small/ frequent meals Oral hygiene Prevent unpleasant odors, sights, sounds Feeding schedules, using simple diets, relieving GI sx Percutaneous endoscopic gastrostomy (PEG) tubes NGT feedings Relieving pain Pain scale & pain characteristics Analgesics Distraction, imagery, etc.

36. Nursing Care of Patients with Cancer Decrease fatigue Encourage rest Promote normal sleep habits Encourage adequate protein and calorie intake Strategies to promote mobility Improving body image and self esteem Encourage patient verbalize concerns Assist patient in self care Assisting in the grieving process Encourage verbalization of fears Explore coping strategies Encourage participation of family in treatment Pastoral care

37. Nursing Care of Patients with Cancer Infection Prevention(patients are often neutropenic ) Neutropenic precautions (see Leukemia lecture) Prevention of bleeding (see Leukemia lecture)

38. Hospice Cure and control of patient is no longer an option Quality of life Palliation of symptoms Provision of psychosocial and spiritual support for patients and families