ONCOLOGY NURSING CANCER BACKGROUND • Introduction
o Cancer nursing practice covers all age groups, and nursing specialties and is carried out in a variety of health care settings, including the home, community acute care institutions, and rehabilitation centers. Nurse need to identify their own reactions to cancer because of its association with pain and death and to set realistic goals to meet the challenges inherent in caring for patients with cancer. In addition, the cancer nurse must be prepared to support the patient and family through a wide range of physical, emotional , social, cultural and spiritual crises.
o Study of Cancer
o Oncologic Nursing specializes in the care and treatment of clients with cancer.
• Incidence and Prevalence
o Males: 4 most common types of cancer are prostate; lung and bronchus; and colorectal
o Females: 4 most common types of cancer are breast; lung and bronchus; and colorectal
• Risk factors for cancer: ( some are controllable; some are not)
o Viruses and Bacteria
Epstein-Barr virus is highly suspected as a cause in
Burkitt’s lymphoma,
nasopharyngeal cancer, and some types of non-Hodgkin’s lymphoma and Hodgkin’s disease.
Herpes simplex virus type II, cytomegalovirus, and human papillomavirus types 16, 18, 31 and 33 are associated with dysplasia and cancer of the cervix.
Hepatitis B virus is implicated in the cancer of the liver; the human T-cell lymphotropic virus may be a cause of some lymphocytic leukemias and lymphomas.
Human immunodeficiency virus(HIV) is associated with
Kaposi’s sarcoma. The
bacterium Helicobacter pylorus has been associated with an increased incidence of gastric malignancy, secondary to inflammation and injury of gastric cells.
Exposure to sunlight or radiation, chronic irritation or inflammation.
Tobacco use
Diagnostic x-ray procedures or with radiation therapy used to treat disease.
o Chemical Agents
Smoking is strongly associated with cancers of the lung, head and neck, esophagus, pancreas, cervix, and bladder.
Asbestos, uranium, and viruses acts synergistically with tobacco
to promote cancer
development.
Chewing tobacco is associated with cancers of the oral cavity and primarily occurs in men younger than 40 years of age.
Aromatic amines and aniline
dyes; pesticides and
and tars; asbestos; benzene; betel nut and lime; cadmium; chromium compounds; nickel and zinc ores; wood dust; beryllium compounds; and polyvinyl chloride
o Genetic and Familial Factors o Dietary Factors
Dietary substances associated with an increased cancer risk include fats, alcohol, salt-cured or smoked meats, foods containing nitrates and nitrites, and a high caloric dietary intake.
Obesity is associated with endometrial cancer and possible postmenopausal breast cancers. o Hormonal Agents
Cancers of the reproductive tract depends on endogenous
hormonal levels for growth. Diethylstilbesterol (DES) has long been recognized as a cause of vaginal carcinomas.
• Role of the Immune System
Patients who are
immunocompetent have been shown to have an increased incidence of cancer.
Organ transplant recipients who receive immunosuppressive therapy to prevent rejection of the transplanted organ have an
increased incidence of
lymphoma. Kaposi’s sarcoma, squamous cell cancer of the skin and cervical and anogenetical cancers.
Patients with immunodefiency diseases, such as AIDS, have an increased incidence of Kaposi’s sarcoma; lymphoma, rectal and
head and neck cancers. Some patients who have received alkylating agents to treat Hogkin’s disease have an
increased incidence of
secondary malignancies. Autoimmune diseases, such as rheumatoid arthritis and Sjogren’s syndrome, are associated with increased cancer development.
o Nursing Role
Includes health promotion to lower the controllable risks
Increase consumption of fresh vegetables (especially those of cabbage family) because studies indicate that roughage and vitamin-rich foods help to prevent certain kinds of cancer. Increase fiber intake because
risk for certain cancers ( eg. Breast, prostate, and colon).
Increase intake of vitamin A, which reduces the risk of esophageal, laryngeal, and lung cancers.
Increase intake of foods rich in vitamin C, such as citrus fruits and broccoli, which are thought to protect against stomach and esophageal cancers.
Practice weight control because obesity is linked to cancers of the uterus, gallbladder, breast and colon.
Reduce intake of dietary fat because a high-fat diet increase the risk of breast, colon, and prostate cancers.
Practice moderation in consumption of salt-cured, smoked, and nitrate-cured foods; these have been linked
to esophageal and gastric cancers.
Stop smoking cigarettes and cigars, which are carcinogens. Reduce alcohol intake because
drinking large amounts of alcohol increases the risks of liver cancer. ( Note: people who drink heavily and smoke are at greater risk for cancers of the mouth, throat, larynx, and esophagus)
Avoid overexposure to the sun, wear protective clothing, and use a sunscreen to prevent skin damage from ultraviolet rays that increase the risk of skin cancer.
PHYSIOLOGY OF CANCER
a. Normal cell growth includes two events
- Replication of cellular DNA - Mitosis (cell division)
b. Four phases of Cell Cycle
- G1 phase – RNA and protein synthesis occur
- S phase – DNA synthesis occurs
- G2 phase – premitotic phase; DNA synthesis is complete mitotic spindle forms
- Mitosis – cell division occurs The G0 phase, the resting or
dormant phase of cells, can occur after mitosis and during the G1 phase. In G0 phase are those dangerous cells that are not actively dividing but have the potential for replicating. The administration of certain chemotherapeutic agent (as well as administration of some
other forms of therapy) is coordinated with the cell cycle.
Some unproductive
differentiations occurs ( seen on biopsy report)
- Anaplasia: cells that lack
normal cellular
characteristics and differ in shape and organization with respect to their cells of origin; usually, anaplastic cells are malignant.
- Dysplasia: bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same type of tissue.
- Metaplasia: conversion of one type of mature cell into another type of cell.
Neoplasms: also called tumors – mass of new tissue that grows independently of surrounding organs.
CHARACTERI STICS
BENIGN MALIGNANT Cell
characteristics Well-differentiat ed cells that resemble normal cells of the Cells are undifferentia ted and often bear little resemblance to the normal cells of the
tissue from which the tumor originated. tissue from which they arose.
Mode of Action Tumor
grows by expansion and does not infiltrate the surroundin g tissues; usually encapsulat ed. Grows at the periphery and sends out processes that infiltrate and destroy the surrounding tissues. Rate of
Growth Rategrowth is of usually slow Rate of growth is variable and depends on level of differentiatio n; the more anaplastic the tumor
faster it grows
Metastasis Does not spread by metastasis Gains access to the blood and lymphatic channels and metastasizes to other areas of the body. General
Effects Is usually a localized phenomeno n that does not cause generalized effects unless its location interferes with vital functions Often causes generalized effects, such as anemia, weakness, and weight loss. Tissue Destruction Does not usually Often causes extensive
cause tissue damage unless its location interferes with blood flow tissue damage as the tumor outgrows its blood supply or encroaches on blood floe to the area; may also produce substances that cause cell damage. Ability to Cause Death Does not usually cause death unless its location interferes with vital functions Usually causes death unless growth can be controlled. • Effects of Cancer
A. Disturbed or loss of physiologic functioning from pressure or obstruction
- Anoxia and necrosis of organs
- Loss of function: Bowel or bladder obstruction - Increased intracranial pressure - Interrupted vascular/venous blockage - Ascites
- Disturbed liver functioning
B. Hematologic Alterations: Impaired function of blood cells
- Leukopenia - Anemia
- Clotting disorders
C. Infections: fistula development and tumor may become necrotic; erode skin surface
D. Hemorrhage: tumor erosion, bleeding, severe anemia
E. Anorexia-Cachexia Syndrome: wasting away of client
- Unexplained rapid weight loss, anorexia with altered smell and taste
- Catabolic state: use of body’s tissue and muscle proteins to support cancer cell growth
F. Paraneoplastic Syndromes: ectopic sites with excess hormone production
- Parathyroid hormone
(Hypercalcemia)
- Ectopic secretion of insulin (hypoglycemia)
- Antidiuretic hormone (ADH: fluid retention)
- Adrenocorticotropic hormone (ACTH)
G. Pain: major concern of clients and families associated with cancer.
Sources Descriptio n
Underlyin g Cancer Bone
Metastasis Throbbing, aching Breast, Prostate, myeloma Nerve Compressi on Burning, Sharp, Tingling Breast, Prostate, Lymphoma Lymphatic or Venous Obstructio n Dull, Aching, Tightness Breast, Kaposi, Lymphoma Ischemia Sharp, Throbbing Kaposi Organ Obstructio n Dull, Crampy, gnawing Colon, Gastric Organ
Infiltration Distention, Crampy Liver, Pancreas Skin inflammati on, infection, necrosis Burning, sharp Breast, head, neck Kaposi
H. Physical Stress: body tries to respond and destroy neoplasm
- Fatigue - Weight loss - Anemia - Dehydration - Electrolyte imbalance I. Psychological Stress
- Cancer equals death sentence
- Guilt from poor health habits - Fear of pain, suffering, and
death
- Stigmatized COLLABORATIVE CARE
• Diagnostic Tests:
a. Determine location of cancer - X-rays
- Computed tomography - Ultrasound
- Magnetic resonance imaging - Nuclear imaging
- Angiography
b. Diagnosis of cellular type of cancer – can be done through tissue samples from biopsies, shedded cells, ( e.g. Papanicolaou smear) washings - Cytologic examination:
tissue examined under microscope
- Identification System of Tumors: Classification – Grading – Staging
- Classification: according to the tissue or cell of origin,
e.g. sarcoma, from
supportive tissue - Grading:
o Evaluates degree of differentiation and rate of growth
o Grade 1 (least
aggressive) to Grade IV ( most aggressive)
o Relative tumor size and extent of disease
o TNM (Tumor size, Nodes: Lymph node involvement: metastases)
c. Tumor markers: specific proteins which indicate malignancy
- PSA ( Prostatic-specific antigen): prostate cancer
- CEA ( Carcinoembryonic antigen): colon cancer
- Alkaline Phosphatase: bone metastasis
- CA 125: cancer of the breast and endometrium d. Direct Visualization - Sigmoidoscopy - Cystoscopy - Endoscopy - Bronchoscopy
- Exploratory surgery: lymph node biopsies to determine metastases
e. Other non-specific tests - CBC, Differential
- Electrolytes
- Blood Chemistries
- Liver enzymes: alanine aminotransferase
(ALT);aspartate
aminotransferase (AST) lactic dehydrogenase(LDH) • Treatment Goals: depending on type
and stage of cancer a. Cure
- Recover from specific cancer with treatment
- Alert for recurrence
- May involve rehabilitation
with physical and
occupational therapy
- Three seasons of survival o Diagnosis/treatment
o Extended survival: treatment completed and watchful waiting
o Permanent survival: risk of recurrence is small
b. Control: control of symptoms and progression of cancer
- Continued surveillance
- Treatment when indicated ( e.g some bladder cancer, prostate cancer)
c. Palliation of symptoms: may involve terminal care if client’s cancer is not responding to treatment
(depend on type of cancer) alone or with combination Drug Class and Examples Mechanis m of Action Common Side Effects Alkylating Agents Busulfan, carboplastin, chlorambucil, cisplatin, cyclophospham ide, dacarbazine, hexamethyl melamine, ifosfamide , melphalan, nitrogen mustard, thiotepa Alter DNA structure by misreading DNA code, initiating breaks in the DNA molecule, cross-linking DNA strands Bone marrow suppressions, nausea, vomiting, cystitis(cyclopho sphamide, ifosfamide), stomatitis, alopecia, gonadal suppression, renal toxicity (cisplatin)
Carmustine (BCNU), lomustine (CCNU), semustine (methyl CCNU, streptozocin the alkylating agents: cross the blood – brain barrier cumulative myelosupressi on, especially thrombocutope nia: nausea, vomiting Topoisomer ase 1 Inhibitors Irinotecan, topotecan Induce breaks in the DNA strands by binding to enzyme topoisome rase 1, preventin g cells from dividing Bone marrow suppression, diarrhea, nausea, vomiting, hepato-toxicity Antimetabol ites 5-azacytadine, cytarabine, Interferen ce with the biosynthe sis of Nausea, vomiting, diarrhea, bone marrow suppression,
edatrexate fludarabine, 5-fluoroucil (5-FU), FUDR, gencitabine,h ydroxyurea, 6-mercaptopuri ne, methotrexate , pentostatin, 6-thioguanine metabolite s or nucleic acids necessary for RNA and DNA synthesis proctitis, stomatitis, renal toxicity ( methotrexate ), hepatotoxicity Antitumor Antibiotics Bleomycin, dactinomycin, daunorubicin, doxorubicin (Andriamycin) , idarubicin, mitomycin, mitoxantrone, plicamycin Interfere with DNA synthesis by binding DNA; prevent RNA synthesis Bone marrow suppression, nausea, vomiting, alopecia, anorexia, cardiac toxicity (daunorubicin, doxorubicin)
Spindle Poisons Plant alkaloids: etoposide, teniposide, vinblastine, vincristine ( VCR), vindesine, vinorelbine taxanes: paclitaxel, docetax metaphas e by inhibiting mitotic tubular formation (spindle): inhibit DNA and protein synthesis Arrest metaphas e by inhibiting tubulin depolymer ization suppression (mild with VCR), neuropathis (VCR), stomatitis Hormonal Agents Androgens and antiandrogen s, estrogens and Bind to hormone receptor sites that alter cellular growth: Hypercalcemia , jaundice, increase appetite, masculinizatio n, feminization,
antiestrogen, progestins and antiprogestin s, aromatase inhibitors, lutenizing hormone – releasing hormone analogs, steroid block binding of estrogens to receptor sites ( antiestro gens): inhibit RNA synthesis; suppress aromatase of cytochrom e P450 system, which decrease estrogen level sodium and fluid retention, nausea, vomiting, hot flashes, vaginal dryness CHEMOTHERAPY - Administration of chemotherapeutic agents
a. Trained and certified personnel, according to established guidelines b. Preparation
- Protect personnel from toxic effects
- Extreme care for correct dosage; double check with
physician orders,
pharmacist’s preparation c. Proper disposal of clients’ excreta d. Routes
- Oral
- Body cavity intraperitoneal or intrapleural
- Intravenous
o Use of vascular access devices because of threat
of extravasation
( leakage into tissues) and for long-term therapy o Types of vascular access
devices
- PICC lines (peripherally inserted central catheters)
- Tunnelled catheters (Hickman, Groshong)
- Surgically implanted ports ( accessed with 90 degrees angle needle)
e. Nursing care of clients receiving chemotherapy
• Assess and manage
o Toxic effects of drugs ( report to physician)
o Side effects of drugs: manage inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions
• Monitor lab results ( drugs withheld if blood counts seriously low); blood and blood product administration
• Assess for dehydration, oncologic emergencies
• Teach regarding fatigue,
• Provide emotional and spiritual support to clients and families
SURGERY
a. Diagnosis, staging, and sometimes treatment of cancer
b. Involves removal of body part, organ, sometimes with altered functioning ( e.g. colostomy)
c. Debulking (decrease size) of tumors in advances cases
d. Reconstruction and rehabilitation (e.g breast implant post mastectomy)
e. Psychological support to deal with surgery as well as cancer diagnosis RADIATION THERAPY
a. Treatment of choice for some tumors to kill or reduce tumor, relieve pain or obstruction
- 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
- Combination c. Goals
- Maximum tumor control with minimal damage to normal tissues
- Caregivers must protect selves by using shields, distancing and limiting time with the client, following safety protocols
d. Treatment schedules
- Planned according to radiosensitivity of tumor, tolerance of client
- Monitor blood cell counts e. Side Effects
- Skin ( external radiation):
blanching, erythema,
sloughing
- Ulcerated mucous
membranes: pain, lack of saliva
- Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation - Radiation pneumonia
BIOTHERAPY
a. Modification of biologic processes that result in malignancies; based on immune surveillance hypothesis
b. Used for hematological
malignancies, renal and melanoma c. Monoclonal antibodies ( inoculate
animal with tumor antigen and retrieve against tumor for human)
a. Client giving photosensitizing compound which concentrates in malignant tissue
b. Later given laser treatment to destroy tumor
BONE MARROW TRANSPLANTATION AND PERIPHERAL BLOOD STEM CELL TRANSPALANTATION
a. Stimulation of nonfunctioning marrow or replace bone marrow
b. Common treatment for leukemia PAIN CONTROL
a. Includes pain directly from cancer, treatment or unrelated
b. Necessary for continuing function or comfort in terminally ill client
c. Goal is maximum relief with minimal side effects
d. Multiple combinations of analgesics (narcotic and non-narcotic) and
adjuvants such as steroids or antidepressants; includes around the clock (ATC) schedule with additional medications for break-through pain e. Multiple routes of medications
f. May involve injections of anesthetics into nerve, surgical severing of nerves radiation
g. May need to progress to stronger pain medications as pain increases and client develops tolerance to pain medication
NURSING DIAGNOSES FOR CLIENTS WITH CANCER
• Anxiety
a. Therapeutic interactions with client and family; community resources such as American Cancer Society, “ I Can Cope”
b. Availability of community resources for terminally (Hospice care in-patient, home care)
a. Includes loss of body parts ( e.g. amputations): appearance changes (skin, hair); altered functions ( eg colostomy): cachexic appearance, loss of energy, ability to be productive
b. Fear of rejection, stigma • Anticipatory Grieving
a. Facing death and making preparations for death; will be consideration
b. Offer realistic hope that cancer treatment may be successful
• Risk for Infection • Risk for Injury
a. Organ obstruction
b. Pathological fractures
• Altered Nutrition: less than body requirements
a. Consultation with dietician, lab evaluation of nutritional status
b. Managing problems with eating: anorexia, nausea and vomiting
c. May involve use of parenteral nutrition
• Impaired Tissue Integrity
a. Oral, pharyngeal, esophageal tissues ( due to chemotherapy, bleeding due to low platelet counts, fungal infections such as thrush)
b. Teach inspection, frequent oral hygiene, specific non-irritating products, thrush control
ONCOLOGIC EMERGENCIES
• Pericardial effusion and Neoplastic Cardiac Tamponade
a. Concern: compression of heart by fluid in the pericardial sac, compromised cardiac output
b. Treatment: pericardiocentesis • Superior Vena Cava Syndrome
a. Concern: obstruction of venous system with increases venous pressure and stasis; facial and neck
edema with slow progression to respiratory distress
b. Treatment: respiratory support: decrease tumor size with radiation or chemotherapy
• Sepsis and Septic Shock
a. Concern: early recognition of infection
b. Treatment: prompt
• Spinal Cord Compression
a. Concern: pressure from expanding tumor can cause irreversible paraplegia; back pain initial
symptom with progressive
paresthesias; leg pain weakness
b. Treatment : early detection and radiation or surgical decompression • Obstructive Uropathy
a. Concern: blockage of urine flow; undiagnosed can result in real failure b. Treatment: restore urine flow
• Hypercalcemia
a. Concern: high calcium from ectopic parathyroid hormone or metastases
b. Behaviors: fatigue, muscle weakness, polyuria, constipation progressing to coma, seizures
c. Treatment: restore fluids with intravenous saline; loop diuretics; more definitive treatments
• Hyperuricemia
a. Concern: occurs with rapid necrosis of tumor cells as with chemotherapy; can result in renal damage and failure
b. Prevention and treatment with fluids and allopurinol (Zyloprim)
• SAIDH (SYNDROME OF
INAPPROPRIATE ANTIDIURETIC HORMONE SECRETION)
a. Concern: ectopic ADH production from tumor leads to excessive hyponatremia