Title: Care of the Oncology Patient Part 1: Pathophysiology and Treatment Options
1Care of the Oncology PatientPart 1
Pathophysiology and Treatment Options
Janie Best, RN, MSN, APRN, BC
2Objectives
- Integrate and relate the pathophysiologic changes
of normal and cancer cells to common clinical
assessments in the adult patient - Determine and apply a nursing plan of care to
address the needs of the adult patient with
cancer - Integrate restorative principles into a plan of
care for the adult with cancer - Develop nursing interventions to assist the adult
with alterations in oncological function - Discuss IOM comptencies in the care of the
patient with oncological conditions
3What is cancer?
- Reactions
- patient, family, nurse
- Resources of the patient
- Collaborative team approach
- Student nurse scope of practice
- Support of the patient / family
- DO NOT tell the diagnosis ask what have you
been told? - MD develops the plan of care and treatment plan
4What is cancer?
- Definition
- Complex group of diseases
- Various manifestations based on body system
tumor cells involved - A chronic illness with acute exacerbations rather
than one that is synonymous with death and
suffering.
5What is cancer?
- Can affect anyone
- One of the most feared diagnoses
- Psychologic support needed during the diagnostic
process
6Incidence / Mortality
- USA 2007 estimates
- 1,444,920 new cases
- 1 million basal and squamous cell skin cancers
- 559,650 deaths
- 1,550 deaths each day
- Mortality rates vary among types of cancer
Source American Cancer Society 2007 statistics
7Cancer in the USACultural disparity
- Lack of health insurance
- Lower incomes
- Unequal access to health care
- Knowledge deficit
- Cultural beliefs and attitudes
8Cancer in the USACultural Diversity
- Most frequently diagnosed
- Female Breast cancer
- Male Prostate cancer (African Americans 50
higher incidence) - Melanoma
- Caucasian 10 x African Americans
- Bladder Cancer
- Male 4x female
- Caucasians 2x African Americans
Source American Cancer Society (2006)
9Cancer in the USACultural Diversity
- Hispanics
- 2x more cervical, stomach, liver cancer
- African Americans
- Highest overall mortality
- More colorectal, lung cancer
- African American women- Breast cancer - lower
incidence but 28 higher mortality - Native Americans
- lowest incidence and mortality
Source American Cancer Society (2006)
10Cancer Risk Factors
- Internal
- Age
- Gender
- Race
- Genetics
- Immunological
- Hormonal
- Psychosocial
- External
- Chemicals
- Radiation
- Viruses
- Diet
- Tobacco
- Alcohol
- Chemotherapy
11Intrinsic factors (genetic predisposition)
Cancer
- Promoters
- Viruses
- Unhealthy lifestyle
- Smoking
- Poor diet
- Physical agents
- Chemical agents
- Environmental factors
- Stress
- Chronic disease
- Depressed immune system
From LeMone Medical Surgical Nursing Critical
Thinking in Client Care p. 373
12Seven Warning Signs of Cancer
- C - Change in bowel or bladder habits
- A - A sore that does not heal
- U - Unusual bleeding or discharge
- T - Thickening or lump in breast or elsewhere
- I - Indigestion or difficulty swallowing
- O - Obvious change in wart or mole
- N - Nagging cough or hoarseness
13Detection and Prevention
Detection and Prevention
- Primary prevention
- Before it happens screenings
- Educational programs that identify / teach
methods of reducing cancer risks - Secondary prevention
- After diagnosis follow up care
14Healthy People 2010
- Objective 17.1
- to reduce cancer deaths to a rate of no more
than 103 / 100,000 people - Methods
- Assessment / screening / self-screening
- Education
- Smoking cessation
- Dietary habits
15Detection and Prevention
- Breast
- Clinical every 3 yrs
- Self (SBE) monthly
- Premenopausal at the end of menses
- Postmenopausal the same day every month
- Testicular
- Monthly
- Prostate
- Yearly PSE, digital rectal exam
16Detection and Prevention
- RN role
- Education
- Know risk factors
- Use resources
- Care provider, teacher, advocate, emotional
supporter, role model - Gift of presence
17Normal Cell Characteristics
- Have limited cell division
- Have distinct and recognizable appearance, size,
and shape - Nuclear space is small in proportion to rest of
cell - Perform specific differentiated functions
- Adhere tightly together
- Nonmigratory
- Grow in an orderly and well-regulated manner
- Are contact inhibited
18Characteristics of Benign Cells
- Continuous or inappropriate cell growth
- Strongly resemble parent tissues
- Small nucleus compared with rest of cell
- Perform differentiated functions
- Adhere tightly together
- Nonmigratory
- Grow in orderly manner by expansion
19Characteristics of Malignant Cells
- Rapid or continuous cell division
- Lose appearance of parent cells (anaplastic)
- Large nucleus compared to rest of cell
- Lose some or all differentiated functions
- Adhere loosely together
- Able to migrate
- Grow in a disorderly manner by invasion
- Not contact inhibited
20FIGURE 16-2. Phases of the cell cycle
21Terms
- Angiogenesis
- Ability of cells to grow new capillaries to meet
nutritional needs- tumor emboli travel to distant
sites - Carcinogenesis
- chemicals, physical factors, and biologic agents,
escape normal enzymatic mechanisms and alter the
genetic structure of the cellular DNA
22Carcinogenesis - Stages
- Initiation
- DNA is damaged
- Promotion
- Initiates cell growth
- Progression
- Tumor establishes its own blood supply
- Metastasis
- Cancer cells migrate to other locations
23Metastasis
- Invasion spread of primary tumor into
surrounding tissues - Mechanical pressure
- Cells break off of primary tumor
- Enzyme destruction of basement membrane
- Metastasis spread of malignant cells to distant
sites - Body cavity
- Lymphatic
- Blood circulation
24Metastasis
- Lymphatic
- Cells enter by interstitial fluid or by invasion
- Hematogenous
- Travel through the bloodstream
- Related to vascularity of the tumor
- Arterial blood turbulent, but rich in oxygen
25Common Sites for Metastasis
26Common Sites for Metastasis
27Normal Immune Response
- Tumor associated antigens
- Macrophages
- T lymphocytes
- Lymphokines
- Natural killer cells (lymphocytes)
28Immune Response
- Immune system
- Detects developing cancer cells and destroys them
before cell growth becomes uncontrolled - Immune compromise
- Increases incidence
- Immunoincompetent (organ transplant, AIDS,
Chemotherapy (alkylating agents), Rheumatoid
Arthritis, Sjogren syndrome, age-related changes
29Immune System Failure
- Failure to recognize malignant cells
- Lack of tumor-associated antigens within the
malignant tumor - Failure to respond promptly to malignant cells
- Abnormal concentrations of T lymphocytes
30Diagnostic Tests
Diagnostic Tests
- Laboratory tests
- CBC
- Chemistries
- Protein tumor markers (PSA, CEA)
- X-Ray
- MRI
- CT
- Laboratory tests
- CBC
- Chemistries
- Protein tumor markers (PSA, CEA)
- X-Ray
- MRI
- CT
- Ultrasound
- Nuclear Imaging
- Biopsy
- Fine needle
- Incisional
- Excisional
- Endoscopy
- Laparoscopy
- Ultrasound
- Nuclear Imaging
- Biopsy
- Fine needle
- Incisional
- Excisional
- Endoscopy
- Laparoscopy
31Cancer Classification
32Cancer Classification
33Tumor Staging Grading
- Example
- T2 Increasing size and /or local extent of the
primary tumor - N0 No regional lymph node metastasis
- M0 NO distant metastasis
- Staging size of tumor and existence of
metastasis - TNM
- T primary tumor
- N node involvement
- M metastasis
34Tumor Staging Grading
- Grading classification of tumor cells
- Numeric value
- I well differentiated tumor closely resemble
the normal cells of origin slow growing - II Moderately differentiated have some more
malignant characteristics - III poorly differentiated, can establish the
tissue of origin few normal characteristics - IV- poorly differentiated or undifferentiated
35Treatment Options
- Based on realistic / achievable goals
- Cure
- Control
- Palliation
- Reassessment plan
36Radiation therapy
- Goal tumor control
- External / Internal
- Damages DNA
- Destroys rapidly multiplying cancer cells
rapidly dividing normal cells - Varying tumor sensitivity
- Side effects
- Skin changes
- Altered tastes
- Nausea / vomiting
- Fatigue
- Damage to normal tissue
37Radiation therapy
- Internal (Brachytherapy)
- Needles, seeds, beads, catheters into body
cavities, oral
- External
- Various energy levels based on tumor
38Radiation Therapy ExternalNursing Care
- Education
- Use only plain water and do not wash the markings
- Do not rub, scratch, or scrub treated skin areas
- No lotions or ointments
- NO heat or cold therapy
- Protect skin from sun for 1 year
- Rest and eat balanced diet
- Monitor for adverse effects
- Skin
- GI
- Pulmonary
- Lab values
39Radiation Therapy InternalNursing Care
- Education
- Private room
- May be on bedrest while temporary implant is in
place - Limit visits to 10 30 min
- Visitors remain 6 feet from patient
- Rest
- Balanced diet
- Monitor for adverse effects
- Skin
- N V
- Diarrhea
- Chills / fever
- Fistulas or necrosis of adjacent tissues
40Chemotherapy
- Uses
- Cure, ? survival time, ? risk for specific
life-threatening complications - Actions
- Disruption of cell cycle in various phases
- Interfers with ability of cell to synthesize
enzymes and chemicals - Usually a combination of drugs over varying
periods of time
41Classes of Chemotherapy Drugs
- Alkylating agents
- Antimetabolites
- Antitumor Antibiotics
- Mitotic inhibitors
- Hormones Hormone antagonists
42(No Transcript)
43Nursing Care During Chemotherapy
- Assessment for s/s toxicity
- Management of Side Effects
- Patient Education
- Central line catheter care
- Management of side / toxic effects
- Presence
44Impaired oral mucous membranes r/t
Chemotherapy Immunosuppression Lack of /
decreased salivation Infection Decreased
nutrition Decreased oral intake
Activity Intolerance r/t Effects of
chemotherapy Increased metabolic demand from
cancer Imbalance between oxygen supply /
demand Decreased healthy RBCs Anxiety
Nausea r/t chemotherpy
Chemotherapy Nursing Diagnoses
Disturbed body image r/t Alopecia
Deficient knowledge r/t Lack of information
about Chemotherapy Misinformation
Ineffective protection r/t Chemotherapy Immunosup
pression Bone marrow suppression Inadequate
secondary defenses Leukopenia,
neutropenia Invasive procedures central
line Thrombocytopenia
Patient / Family Education Medication
regime Safety precautions
45(No Transcript)
46Treatment Options - Surgery
- Diagnostic
- Primary treatment
- Prophylactic
- Palliative
- Reconstructive
47Nursing Role in Cancer Surgery
- Education -
- General perioperative care
- Assessment for postoperative complications
related to other treatment methods (radiation /
chemotherapy)
- Infection
- Impaired wound healing
48Nursing Care
- Based on Nursing Process
- Cancer type
- Quality of life
- Quantity of life
- Characteristics of the patient
- Treatment goals
- Combination therapies
49Assessment
- Infection
- Bleeding
- Skin problems
- Pain
- Fatigue
- Psychosocial status
- Body image
50Nursing Diagnoses
- Impaired oral mucous membrane
- Impaired tissue integrity
- Impaired tissue integrity alopecia
- Impaired tissue integrity malignant skin lesions
51Nursing Diagnoses
- Imbalanced Nutrition Less than body
requirements r/t anorexia and fatigue - Disturbed body image
- Chronic pain r/t disease process
- Impaired physical mobility r/t pain fatigue
- Risk for Caregiver role strain
52Plan
- Management of secondary problems
- Multidisciplinary team approach
53Implementation
- Evidence Based Practice
- Pt / family education
- Counseling / referrals
54Evaluation
- Expected Patient Outcomes
- Based on the identified plan of care
- Quality improvement / research
- Legal / ethical considerations
- Patient confidentiality
- Do Not Resuscitate status
55Implanted Port
Tunneled Right atrial catheter
PICC
56Managing Complications/Emergencies
- Superior Vena cava syndrome
- Sepsis
- Spinal cord compression
- Hypercalcemia
- Hyperuricemia
- Tumor Lysis Syndrome
57Superior Vena Cava Syndrome
- S/S Late
- Edema of arms hands
- Respiratory distress
- Dyspnea
- Cyanosis
- Tachypnea
- Epistaxis
- Altered consciousness
- Neurologic deficits
- Compression by mediastinal or adjacent thoracic
tumors - S/S Early
- Morning facial, periorbital, edema
- Tightness of shirt or collar (Stokes sign)
58Superior Vena Cava Syndrome Nursing Care
- Respiratory support
- Monitor vital signs
- Corticosteroids to ? edema
- Safe environment (seizure precautions)
- Anti-fibrinolytics / anticoagulants (if due to
clot) - High dose Radiation therapy
59Sepsis
- Life-threatening
- Early identification is critical to survival
- Usually gram negative bacteria
60Factors Predisposing Cancer patients to infection
- Impaired skin and mucous membrane integrity
- Chemotherapy
- Radiation therapy
- Biologic response modifiers
- Malignancy
- Malnutrition
- Medications
61Factors Predisposing Cancer patients to infection
- Urinary catheter
- IV catheter
- Invasive procedures
- Contaminated equipment
- Age
- Chronic illness
- Prolonged hospitalization
62Sepsis- Early Signs / Symptoms
- Vasodilation
- Vascular dehydration,
- High fever
- Peripheral edema
- Hypotension
- Tachycardia
- Tachypnea
- Hot flushed skin with creeping mottling
- Anxiety or restlessness
63Sepsis- Late Signs / Symptoms
- Hypotension
- Rapid thready pulse
- Respiratory distress
- Cyanosis
- Subnormal temperature
- Cold clammy skin
- Decreased urinary output
- Altered mentation
64Spinal Cord Compression
- Emergency
- Initial symptom Back pain
- Leg pain, numbness, paresthesias, coldness
- Bowel / bladder dysfunction
- Neurologic dysfunction progressing from weakness
? paralysis
65Spinal Cord Compression Nursing Considerations
- Assess for neurologic changes
- Patient education s/s cord compression
- Treatment
- high dose radiation or surgical decompression
- Back or neck braces
66Hypercalcemia
- Late manifestation of extensive malignancy
- Bone metastasis bone releases calcium
- Lung, Breast, esophagus, thyroid, head, neck,
multiple myeloma excessive parathyroid hormone
release
67Hypercalcemia
- Early Nonspecific sx
- Fatigue
- Anorexia
- Nausea
- Constipation
- Polyuria
- Neurologic sx
- Muscle weakness
- Lethargy
- Apathy
- Diminished reflexes
- Untreated leads to
- Altered mental status
- Psychotic behavior
- Cardiac arrhythmias
- Seizures
- Coma
- Death
68Hypercalcemia - Treatment
- Medications
- Glucocorticoids, calcitonin, diphosphonate,
gallium nitrate - Dialysis (if renal function impaired)
69Hyperuricemia
- Causes
- Rapid necrosis of tumor cells after vigorous
chemotherapy for lymphomas and leukemias - Tumor lysis syndrome
- Increased uric acid production
- S/S nausea, vomiting, lethargy, oliguria
- Treatment Allopurinol (Zyloprim)
- Probenecid (Benemid)
- Sulfinpyrazone (Anturane)
70Tumor Lysis Syndrome
- Emergency
- Positive sign that cancer treatment is effective
- Commonly seen with radiation or chemotherapy of
acute leukemia, lymphoma, small cell lung cancer,
multiple myeloma - HyperKalemia
- Hyperuricemia
- Hyperphosphatemia with 2 hypocalcemia
71TUMOR LYSIS SYNDROME
Rapidly growing cancer
High dose chemotherapy / radiation
Rapid release of intracellular contents
Kidneys unable to excete large volumes of
released electrolytes
hyperKalemia
hyperphosphatemia
hyperuricemia
Tingling, numbness Muscle spasms Renal
failure (eventually lowers Serum calcium)
Oliguria Nausea Tall, peaked T waves Ventricular
arrythmias
? serum uric acid Oliguria azotemia
72Tumor Lysis Syndrome
- S/S
- Nausea, vomiting
- Lethargy
- Edema
- Fluid overload
- Heart failure
- Cardiac dysrythmias
- Seizures
- Muscle cramps
- Tetany
- Syncope
- Possible sudden death
73Tumor Lysis Syndrome
- Identification of at risk patients
- Prevention through hydration
- 3,000 5,000 ml day before, day of, and for 3
days after treatment - Keep fluid intake consistent throughout the 24 hr
period - Follow antiemetic regimen
- Call MD if unable to maintain oral intake
74Putting it together-
- 28 yr old patient to receive radiation to left
breast and axillary area following lumpectomy for
breast cancer. She is avid golfer and wonders
how radiation therapy will affect her appearance
and golf game.
75NCLEX Questions
- Mr. Lawrence has a history of colon cancer.
Cells from the colon tumor have traveled to his
liver. This process is called - Carcinogenesis
- Dysplasia
- Metastasis
- Mutation
76NCLEX Questions
- You are taking care of a client who just received
the first cycle of chemotherapy for acute
leukemia 2 days ago. As an oncology nurse you
are closely monitoring the clients laboratory
tests of uric acid, potassium, phosphorus, and
calcium based on the knowledge that the client is
at risk for - Spinal cord compression
- Tumor lysis syndrome
- Septic shock
- Superior vena cava syndrome
77NCLEX Questions
- Ms. Hernandez complains of nausea and vomiting
following her daily chemotherapy treatment. The
MOST appropriate nursing intervention would be
to - Keep Ms. Hernandez NPO until her daily
chemotherapy is completed - Provide antiemetic medication 30 -40 minutes
prior to each treatment - Provide clear liquids until the chemotherapy is
completed. - Schedule chemotherapy administration for bedtime
78NCLEX Questions
- Which of the following cancer patients could
potentially be placed together as roommates? A
patient - With a neutrophil count of 1000.mm3
- Who underwent debulking of a tumor to relieve
pressure - Receiving high-dose chemotherapy after a bone
marrow harvest - who has a platelet count of 180,000µl
79NCLEX Questions
- Which of the following cancer patients could
potentially be placed together as roommates? A
patient - With a neutrophil count of 1000.mm3
- Who underwent debulking of a tumor to relieve
pressure - Receiving high-dose chemotherapy after a bone
marrow harvest - who has a platelet count of 180,000µl
80Case Study Mastectomy Patient
81References
References
- LeMone, P., Burke, K. (2008). Nursing Care of
Clients with Cancer. In Medical-Surgical Nursing
Critical Thinking in Client Care, 4th Ed., pp.
368-417. - Smeltzer, S.C., Bare, B.G. (2004). Oncology
Nursing management in cancer care. In Brunner
Suddarths Textbook of Medical Surgical
Nursing, 10th ed. Pp. 315-367. - Smeltzer, S.C., Bare, B.G. (2004). End of Life
Care. In Brunner Suddarths Textbook of
Medical Surgical Nursing, 10th ed. Pp.
369-393. - Videbeck, S.L. (2006). Grief and Loss. In
Psychiatric Mental Health Nursing, 3rd Ed. pp
221-245. - Workman, M.L. (2002). Altered cell growth and
cancer development. In Ignatavicius,D., Workman,
M.L. Medical-Surgical Nursing Critical thinking
for collaborative care, 4th Ed. pp. 407-422. - Workman, M.L. (2002). Interventions for clients
with cancer. In Ignatavicius,D., Workman, M.L.
Medical-Surgical Nursing Critical thinking for
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