Nursing Care of Clients Experiencing Oncological Stressors BREAST CANCER
PATHOPHYSIOLOGY
Unregulated growth of abnormal cells, takes 5-10 years before clinically palpable Irregular, poorly defined mass
Hormone dependent
Infiltrating ductal carcinoma>80%
Growth causes fibrosis, blocks lymphatics, causes edema - leads to skin dimpling, Peau d’orange skin, seen in advanced disease
RISK FACTORS
Advancing age
Mother, sister, daughter with breast cancer, 90% have no familial history Previous breast cancer
Fibrocystic disease
>30 at first pregnancy, nulliparity early menarche, late menopause exogenous estrogen
cancer of uterus, ovary, colon
LOWERING THE RISK
Weight control Diet low in fat Cruciferous foods
Vitamin A: orange, dark green veggies Soybeans
Restrict alcohol consumption
SCREENING
BSE, monthly beginning at age 20
Clinical Breast exam (CBE) by health professional
• 20-40: every 3 years
• 40 : annually
Mammography
• 35-40: screening
• 40 +: annually
• High risk clients, tighter parameters
High Risk
Start BSE/ CBE sooner
Annual mammography 25 – 35
Prophylactic mastectomy
RISK PROFILE ANALYSIS
Prognosis is worse in these patterns:
Estrogen or Progesterone negative Cancer cells are irregular in shape Grade 3 or 4:
• poorly differentiated
HER - 2 neu:
• protein in cancers with high rate of recurrence - younger women
STAGING
Stage I: tumor <2cm & confined to breast Stage II: tumor up to 5 cm or
• axillary nodes involved
Stage III: tumor >5cm or extends to chest wall, skin or
• supraclavicular or infraclavicular nodes
Stage IV: metastasis
OCCURRENCE/FREQUENCY
CLINICAL MANIFESTATIONS
Skin changes Increased vascularity
Nipple retraction or ulceration Pain or soreness
MANAGEMENT
Local:
• Mastectomy or
• Lumpectomy with radiation: Stage 1 & 2
Hormonal Therapy:
• Estrogen or progesterone + tumors
ADJUVANT CHEMOTHERAPY
Positive lymph nodes
NIH Panel: negative nodes as well
SURGICAL MANAGEMENT
Axillary node dissection: stage disease
• Sentinal Node
Lumpectomy Quadrantectomy
Modified Radical Mastectomy Standard Radical Mastectomy
• bilateral oophorectomy
• bilateral adrenalectomy
Figure 74-4
Surgical management of breast cancer
RADIATION THERAPY
Eligibility
• tumor <5cm
• no large or fixed nodes
Survival Rate
Side Effects:
• temporary skin changes - dry, itchy, red
• permanent skin changes - fibrosis, pigment
• fatigue
• pneumonitis & arm edema rare
PHARMACOLOGIC MANAGEMENT
Chemotherapy
• Alkylating Agent: Cytoxan
• Anti-metabolites:
• Methotrexate
• 5 Fluoruracil
Autologous Bone Marrow Transplant
HORMONAL THERAPY
Estrogen receptor positive tumors
• Tamoxifin - antiestrogen
• hot flashes, vaginal dryness, flare response
Androgens
Aminoglutethimide
BREAST RECONSTRUCTION
Immediate vs. delayed
Saline Implants
• TRAM flap - transverse rectus abdominis muscle
• Latissimus dorsi muscle
Criteria for client selection
COLLABORATIVE MANAGEMENT
The client undergoing breast biopsy
Nursing care of the client having a mastectomy Nursing care of the client having breast reconstruction
NURSING PROCESS
Psychosocial - Coping Skin Integrity
hematoma - pressure dressing, drain
Injury to arm - infection, lymphedema
sign on bed, pink armband, no IV/punctures no heavy lifting, prevent cuts & burns
Knowledge Deficit
postop arm exercises breast prosthesis
POSTOPERATIVE CARE
Altered comfort – Acute Pain/Chronic Pain Risk for ineffective breathing pattern Imbalanced Nutrition < body requirements Risk for infection
Anticipatory Grieving Disturbed sleep pattern Impaired Skin Integrity Ineffective Coping Impaired Social Interaction Impaired Adjustment Sexual Dysfunction
Anxiety R/T diagnosis of cancer Disturbed body image Deficient Knowledge Potential for metastases
What interventions are appropriate for each nursing Dx or collaborative problem?
Review these:
LARYNGEAL CANCER
Accounts for 2-3% of all malignancies Predominantly in men
Potentially curable if diagnosed early
ETIOLOGY AND RISK FACTORS
Primary etiological factor is cigarette smoking or other tobacco products-mutation of p53 gene Alcohol combined with cigarettes increases the risk
Occupational exposure to asbestos, wood dust, mustard gas, petroleum products, inhalation of noxious fumes
Chronic laryngitis & voice abuse
PATHOPHYSIOLOGY
Squamous cell is most common malignant tumor of larynx(80%) Metastatic disease often palpated as neck mass
Distant metastasis found in the lungs, liver
Diagnosed on basis of white, patchy mucosal lesions (leukoplakia) or Red patches (erythroplasia)
CLINICAL WARNING SIGNS OF LARYNGEAL CANCER
Change in voice quality, hoarseness Lump in mouth, throat or neck Persistent cough, earache, sore throat Hemoptysis
Sores within the throat that do not heal in 2 weeks Dysphagia or dyspnea
Burning sensation when drinking citrus juices or hot liquids
COLLABORATIVE MANAGEMENT
Assessment
History - What questions would you ask?
Physical assessment/clinical manifestations
• Hoarseness R/T tumor bulk separating vocal cords
• Inspection with laryngeal mirror or fiberoptic laryngoscope (laryngoscope is more accurate)
COLLABORATIVE MANAGEMENT
Palpate neck for tumor nodal involvement
Look for clinical warning signs of laryngeal cancer – outlined previously Psychosocial assessment
• What will you focus on?
Laboratory assessment
• Nonspecific: Chemistries, protein & albumin assay, renal & liver function studies
COLLABORATIVE MANAGEMENT Radiographic & other studies
X-rays to determine metastasis
Nuclear imaging–PET and SPECT scans
Endoscopy to define tumor extent and take definitive biopsies for TNM staging and grading
CT, MRI
LARGE GRANULAR CELL TUMOR OF THE TRUE VOCAL CORD
MANAGEMENT APPROACHES
Tumor ablation-(when tumor confined) with radiation therapy, cure rates 85%-95%
Laryngectomy with or without radical neck dissection Chemotherapy
• Preoperatively to shrink tumor size, postoperatively to reduce risk of metastasis
• Palliation
• Induction chemotherapy followed by radiation may preserve the larynx
MANAGEMENT- NONSURGICAL APPROACH
Balanced nutrition pre-treatment Teaching about the treatment Regional and systemic s/s of RT
Oropharyngeal & dysphagia changes to RT – management Skin care over irradiated areas
Hoarseness may intensify- treatment effect. Voice rest and reassurance that voice will at least return to pretreatment quality.
MANAGEMENT - NONSURGICAL APPROACH
Hoarseness may intensify- treatment effect. Voice rest and reassurance that voice will at least return to pretreatment quality 4-6 wks after RT completed
Xerostomia- if salivary glands in path of RT. Gum chewing, hard candy, salivart may help
SURGICAL MANAGEMENT
Laryngectomy
• Total
• Partial Tracheostomy
Oropharyngeal cancer resections
Laser surgery for small tumors, sometimes combined with RT-preserving most of the glottis, leaving client with usable voice
OPERATIVE PROCEDURES NOTE
During a hemilaryngectomy, a tracheostomy is performed to protect the airway- may be temporary or permanent
With a total laryngectomy, the trachea is separated from the pharynx & esophagus, brought out onto the neck surface and sutured in place, thus creating a permanent laryngectomy stoma with placement of a laryngectomy tube (shorter & wider in diameter than s trach tube). There is no risk for aspiration with a total laryngectomy
Because no air enters the nose, sense of smell is lost
OPERATIVE PROCEDURES- NOTE
Neck dissection includes removal of lymph chains, sternocleidomastoid muscle, jugular vein, 11
thcranial nerve (spinal accessory) and surrounding soft tissue. Shoulder drop will be present after surgery
Major body image and self concept issues accompany this 8 hour operation
POSTOPERATIVE CARE
Laryngectomy
Altered comfort – Acute Pain/Chronic Pain Risk for aspiration (with partial, not total) Ineffective airway clearance
Risk for impaired gas exchange Impaired Verbal Communication Imbalanced Nutrition < body requirements Risk for infection
Risk for hemorrhage Impaired Skin Integrity Ineffective Coping Impaired Social Interaction Impaired Adjustment Anxiety R/T fear of the unknown Disturbed body image Deficient Knowledge
What interventions are appropriate for each nursing Dx or collaborative problem?
POSTOP CARE-ADDITIONAL DIAGNOSES
Impaired verbal communication Impaired skin integrity
Ineffective coping-individual/family Impaired social interaction
Deficient knowledge
What interventions are appropriate for each nursing Dx or collaborative problem?
POSTOPERATIVE CARE
Total laryngectomy
Same care as for partial laryngectomy plus some additions
• Nutrition-NG tube feedings, proceeding to clears, then regular food
• Communication-magic slate, note pad
• Artificial larynx
• Esophageal speech
• Tracheoesophageal puncture
