CARE OF THE PATIENT WITH CANCER - Nursing Implications

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CARE OF THE PATIENT WITH CANCER- Nursing
Implications

• NUR 133
• Lecture 8/9
• K. BurgerMSEd, MSN, RN, CNE
• 3/05kb

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Incidence Prevalence

• 2nd leading cause of death
• 1 out of 3 persons will be affected by cancer
  sometime in their lifetime
• Cancer of lung leading cause of cancer deaths
  in both men and women
• Cancer of colon 2nd largest incidence
• Breast and Prostate highest gender incidence

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Pathophysiology

• Carcinogenesis / Oncogenesis
• Tumor development slow and insidious
• Initiator Promotor Theory
• Loss of cellular control mechanisms(ie
  apoptosis)
• Loss of differentiation

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WHAT ARE CARCINOGENS?

• Environmental/Lifestyle risk factorstobacco,
  alcohol, diet, sexual/reproductive behavior,
  ultraviolet radiation, other pollutants and
  irritants
• Hormonesestrogen
• Oncogenic virusesHBV, HPV, HIV, HSV

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Normal Versus MalignantCell Characteristics

• NORMAL
• Limited cell division
• Undergo apoptosis
• Controlled growth
• Well differentiated
• Adhere tightly together
• Contact inhibited
• Euploid

• MALIGNANT
• Rapidly dividing/multiplying
• Do not undergo apoptosis
• Uncontrolled growth
• Anaplastic morphology
• Adhere loosely together
• Able to move / metastasize
• Aneuploid

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HOLISTIC NURSING CONSIDERATIONS

• Primary level care
• Prevention and Screening/ client education
• Secondary level care
• Diagnostic Testing
• Treatment and side-effects of
• Surgery,Radiotherapy,Chemotherapy
• Tertiary level care
• End of life and psychosocial issues

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PREVENTION AND SCREENING Patient Education

• Health promotion
• Diet hi in whole grains, Vit C,A,
  cruciferous fruits vegetables.
• Limit fat, alcohol, kcal, salt-cured,
  smoked, charbroiled meats.
  
• Maintain healthy immune system.
  
  
• Avoidance of carcinogens
• Limit exposure to sun, tobacco smoke/chew,
  radiation, viruses,chronic irritants,
  immunosuppressants, hormonal agents.
• Regular cancer screening
• ACS Cancer Detection Guidelines
• C A U T I O N
  
  Annual physical
  exam, BSE, TSE
  
  

Primary Intervention
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DIAGNOSTIC TESTINGPatient Education and Support

• Common laboratory tests CBC, bilirubin, alkaline
  and acid phosphatase, tumor markers (PSA, CA,
  CEA) others
• Radiological procedures CT, PET, MRI,
  ultrasound, mammography, BE, UGI, CXR
• Endoscopic procedures bronchoscopy,
  esophagoscopy, colonoscopy, cystoscopy
• Biopsy / incisional, needle aspiration,
  stereotactic

Secondary Intervention
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Tumor StagingTNM Classification

• T primary tumor size
• N lymph node involvement
• M metastasis
• T4 N3 M1
• What does this indicate?

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Tumor Grading

• CLASS
• I Normal cell Well differentiated
• II Abnormal cell moderately differentiated
• III Suspiciously malignant poorly
  differentiated
• IV Probably malignant very poorly differentiated
• V Malignant undifferentiated

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Classification byTissue of Origin

• FOR EXAMPLE
• Sarcoma
• Lymphoma
• Glioma
• Osteoma
• Lipoma
• Adeno
• Melano

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CANCER TREATMENT - SURGERYNursing Care

• Pre-op teaching
• Nutritional promotion pre and post op
• Pain control
• Monitor for post-op complications
• C DB, incentive spirometry, antiembolitic rx,
  leg exercises, ambulation etc.
• Body image disturbance potential nsg dx

Secondary Intervention
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CANCER TREATMENT CHEMOTHERAPYNursing Care

• Prior to administration hydration and
  anti-emetics
• During administration vesicant precautions
  gloves, monitor IV site closely
• Post administration utilize interventions for
• common side effects
• Myelosuppression infection, bleeding,
  fatigue
• GI complications - anorexia, N/V, xerostomia,
  
• Alopecia

Secondary Intervention
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Chemotherapeutic Agents/Anti Neoplastic Drugs
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Immunotherapy/Targeted TherapyBiological
Response Modifiers (BRM)

• Interferon
• Monoclonal Antibodies - Herceptin
• Interleukin
• Colony Stimulating Factor (CSF)- Neupogen
  
  Epogen
• Gene Therapy HLA
• Side Effects stimulation of inflammatory
  process, flu-like symptoms

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CANCER TREATMENTEXTERNAL RADIATION -Nursing Care

• Teletherapy
• Promote nutrition and rest
• Do not remove simulation markings
• Utilize interventions for common side effects
• Myelosuppression infection, bleeding,
  fatigue
• GI complications anorexia, N/V, taste
  alterations,
• mucositis, xerostomia, diarrhea
• Skin reactions dry/wet desquamation

Secondary Intervention
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CANCER TREATMENTINTERNAL RADIATION Nursing Care

• Brachytherapy Sealed vs Unsealed
• Safety considerations
• Private room. Radioactive caution sign
• Limit visitors to ½ hr no under 18, no pregnant
• Rotate nurse assignments/ wear dosimeter
• Time - Distance - Shielding
• Bodily excretions radioactive if unsealed

Secondary Intervention
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New Developments in Radiation Therapy

• 3D-CRT Three dimensional conformal radiation
  therapy-Uses CT images to map location of Ca in
  3 dimensions. Client fitted with mold ( to keep
  area still during rx).-Beams are matched to
  precise shape of tumor-Reduces radiation damage
  to surrounding normal tissue
• IMRT Intensity modulated radiation therapy-Uses
  same technology as 3D-CRT but intensity can also
  be precisely adjusted (modulated)-This increased
  control, also reduces damage to normal tissue

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THE PATIENT WITH CANCER A NURSING PROCESS
APPROACH

• The following common problems should be
  considered
• Infection
• Bleeding
• Pain
• Malnutrition
• Fatigue
• Psychosocial Issues
• 
  
• 
  
  Maslow's Hierarchy of Needs

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FOCUSED ASSESSMENT of the Patient with Cancer

• S/S of bleeding Platelets, CBC, HH, gums,
  stools, urine, skin, LOC
• S/S of infection Temp, WBC, resp, urinary, skin,
  invasive sites
• Pain W H A T S U P or S L I D A
• Nutritional Status Weight, serum albumin
  transferrin, appetite, NV, diarrhea, food
  aversions/preferences
• Coping skills of patient and S.O.
• Patient knowledge disease, treatment, outcomes

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DIAGNOSIS

• Risk for injury r/t bleeding tendencies
• Risk for infection r/t diminished immunity
• Chronic pain r/t disease process and therapy
• Nutrition, imbalanced less than body
  requirements r/t anorexia, N/V, pain, disease
  process
• Fatigue r/t myelosuppression
• Risk for ineffective coping r/t diagnosis of
  cancer
• Anticipatory grieving r/t potential disease
  outcome
• Body image disturbance r/t surgical rx / alopecia

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PLANNING

• Patient will demonstrate
• Platelet, CBC, HH, albumin, transferrin levels
  in normal range
• No evidence of bleeding
• No evidence of infection
• Pain relieved and/or controlled
• Progressive weight gain toward goal
• Performance of ADLs within level of ability
• Verbalized awareness of own coping abilities
• Ability to identify and express feelings
  freely/effectively
• Verbalized acceptance of self in situation
• Verbalized understanding of disease process
  treatment

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IMPLEMENTATION

• RISK FOR INJURY R/T BLEEDING TENDENCIES
• Monitor platelet, CBC, HH levels
• Observe for S/S bleeding and or hypoxia
• Bleeding precautions gentle handling, fall
  precautions, electric razor, soft toothbrush,
  gentle nose blowing, avoid invasive procedures,
  no rectal temps, no intercourse
• Administer stool softeners as per MD orders
• Administer transfusion therapy as per MD orders

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IMPLEMENTATION

• RISK FOR INFECTION R/T DIMINISHED IMMUNITY
• Monitor WBC and ANC daily
• Observe closely for S/S infection
• Neutropenic precautions limit invasive
  procedures, private room, no exposure to
  communicable illness strict handwashing, no
  fresh flower, fruits, vegetables, no standing
  water, CDB
• Administer hematopoietic growth factors per MD
  orders

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MyelosuppressionAnemia Leukopenia-
Thrombocytopenia

• ANEMIA 10 lower than normals
• LEUKOPENIA 2500/mm or lower
• THROMBOCYTOPENIA 50,000/mm or lower

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IMPLEMENTATION

• CHRONIC PAIN R/T DISEASE PROCESS THERAPY
• Acknowledge and accept patient report
• Determine patients acceptable pain level
• Administer analgesics per MD orders
• Eliminate aggravating factors
• Enlist known alleviating factors
• Utilize cognitive-behavioral strategies guided
  imagery, distraction, relaxation etc.

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IMPLEMENTATION

• NUTRITION, IMBALANCED LESS THAN BODY
  REQUIREMENTS R/T ANOREXIA,NV,PAIN
• Monitor serum albumin, transferrin, body weight,
  intake output
• Identify patient food likes and dislikes
• Offer small frequent nutrient dense meals/snacks
• See National Cancer Institute - Nutrition in
  Cancer Care
• Administer anti-emetics analgesics ac per MD
  orders
• ANTI-EMETIC Examples
• Zofran, TIgan,
  Ativan, Compazine

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IMPLEMENTATION

• FATIGUE R/T MYELOSUPPRESSION
• Monitor RBC, HH
• Structure daily routines/activities to conserve
  patient energy
• Encourage nutritionally balanced diet
• Administer biologic response modifiers (ie
  Epogen) per MD orders
• Administer blood transfusion per MD orders

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IMPLEMENTATION

• RISK FOR INEFFECTIVE COPING
• ANTICIPATORY GRIEVING
• BODY IMAGE DISTURBANCE
• Utilize effective communication techniques and
  attentive listening skills
• Encourage patient verbalizations of fears and
  concerns
• Explore and utilize existing patient coping
  mechanisms
• Provide information on support groups, hospice
  care
• Encourage expression of feelings regarding body
  image
• Provide information regarding plastic surgery,
  prosthetic options

Tertiary Intervention
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EVALUATION

• PATIENT WILL
• Be free from bleeding, infection
• Verbalize relief, reduction and/or control of
  pain
• Maintain optimal nutritional status free of NV
• Perform ADLs to desired level
• Express feelings about disease, prognosis, body
  image, etc.
• Demonstrate healthy coping mechanisms

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ADDITIONAL CONSIDERATIONS

• Hospice care
• Oncological emergencies
• Multicultural approaches
• Complementary therapies
• Community-based care
• Evidence-based practice
• Clinical trials and research

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Oncologic Emergencies

• Disseminated Intravascular Coagulation (DIC)
• Sepsis
• Syndrome of Inappropriate Antidiuretic Hormone (
  SIADH )
• Hypercalcemia
• Spinal Cord Compression
• Superior Vena Cava Syndrome
• Tumor Lysis Syndrome

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Laryngeal Cancer

• Combined alcohol/tobacco use primary risk
  factor
• Incidence increasing / Men higher / Over 60
• Most squamous cell carcinoma
• Hoarseness earliest sign
• Other signs???

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Laryngeal CancerASSESSMENT

• History of smoking, alcohol use, environmental
  and/or occupational exposures
• Physical assessment for s/s
• Diagnostic assessments CBC, Albumin,BUN,
  Creatinine, Liver function studies, CT, MRI, PET,
  Tumor mapping, Panendoscopy

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Laryngeal CancerNURSING DIAGNOSES

• Potential for respiratory obstruction
• Impaired swallowing
• Imbalanced Nutrition
• Impaired verbal communication
• Risk for situational low self esteem r/t
  disturbed body image

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Laryngeal CancerPLANNING OUTCOMES

• Maintain positive oxygenation status
• Prevent aspiration
• Promote nutritional balance
• Facilitate alternate communication
• Promote positive self-image
• Promote coping mechanisms and anxiety reduction

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Laryngeal CancerINTERVENTIONS

• NON SURGICAL
• Chemotherapy
• Radiation Therapy
• Voice rest
• Mouth/Throat care sprays,fluids,artificial
  saliva
• Skin caremild soap,no sun,cold,heat,lotions,powde
  r

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Laryngeal CancerINTERVENTIONS

• SURGICAL
• Dependent on size, node involvement and
  metastasis (TNM staging)
• Ranges from resection of tumor alone to total
  laryngectomy and possibly radical neck dissection

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Total LaryngectomyNursing Considerations

• Airway maintenance
• Mechanical ventilation
• Humidification
• C DB, Oxygen Rx, Positioning
• Laryngectomy stoma tube care
• Suture line care
• Suctioning prn
• Communication facilitation
• Paper/pencil or table slate
• Speech therapy
• Electrolarynges
• TEF

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Total LaryngectomyNursing Considerations
(Continued)

• Monitor for hemorrhage
• Prevention of infection
• Wound care Graft care
• Pain management
• Nutritional support
• Psychosocial support
• Health teaching

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Breast CancerVersus Benign Breast Disorders
Perimenopausal woman with green/brown nipple
discharge, erythema edema over mass 50 y.o.
woman with serous nipple discharge/ no mass 22
y.o. woman with round,firm,non-tender, movable
mass 35 y.o. woman with multiple,tender nodular
areas and feeling of generalized breast fullness

MATCHING EXERCISE A.Fibroadenoma B.Fibrocystic
breast disease C.Ductal ectasia D.Intraducta
l ectasia
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Breast Cancer

• Leading cause of cancer deaths in woman
• Incidence higher in Caucasian women
• Early dx is key to prognosis survival
• Also affects men ( over 60 more common )
• Risk Factors age, estrogen exposure, genetics,
  family history,diet,weight,exe
  rcise

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Types of Breast Cancer

• Lobular carcinoma in situ (LCIS)
• Ductal carcinoma in situ (DCIS)
• Invasive ductal carcinoma (IDC) 80cases
• Invasive lobular carcinoma (ILC)
• Medullary carcinoma
• Colloid carcinoma
• Tubular carcinoma
• Inflammatory breast cancer

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Breast CancerPrimary Level CareSCREENING
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Breast CancerASSESSMENT

• Assess risk factor historyNational Cancer
  Institute Breast Cancer Risk Assessmenthttp//www
  .cancer.gov/bcrisktool/
• Physical assessment location of breast mass,
  fixed vs movable, consistency, dimpling, peau
  dorange, nipple retraction, lymph nodes
• Additional imaging ultrasound,MRI
• Breast biopsy needle vs surgical
• Staging and grading

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Comparison of Breast Lumps

• Cancer
• Unilateral
• Firm texture
• Fixed firmly
• Irregular border
• Usually painless
• Usually w/retraction
• Grows constantly

• Benign Breast Disease
• Multiple or single
• Rubbery texture
• Mobile / slippery
• Regular borders
• Tenderness (cyclic)
• No retraction
• May increase/decrease in size rapidly

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Breast CancerASSESSMENT (continued)

• CXR
• Bone scan
• CT
• PET
• Blood tests/ CBC,Liver Enzymes,Ca,Alkaline
  Phosphatase
• Tumor tests/ Estrogen and Progesterone Receptors,
  HER2

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Breast CancerNURSING DIAGNOSES

• Anxiety r/t to diagnosis of cancer
• Anticipatory grieving
• Disturbed body image
• Acute pain
• Ineffective protection r/t therapies

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Breast CancerPLANNING OUTCOMES

• Anxiety reduction
• Promotion of coping strategies
• Pain relief
• Body image enhancement
• Free from infection, fatigue, bleeding

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Breast CancerINTERVENTIONS

• SURGICAL RX
• Lumpectomy
• Partial mastectomy ( wide excision)
• Modified radical mastectomy
• Lymph node dissection / sentinel biopsy
• Oophorectomy / Ovarian ablation
• Breast re-construction

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Post MastectomyNursing Considerations

• Lymphedema precautions
• Positioning and mobility
• Arm exercises
• Drains and wound care
• Pain management
• Short stay is common health teaching !
• Adjuvant therapy complications
• Support group referrals

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Lymphedema Interventions

• Place sign above bed
• No BP, BW, Injectionson operative side
• Support arm on pillow
• Progressive exercises
• Compression sleeve
• Patient teaching reavoidance of injury

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Breast CancerAdjuvant Therapy

• Radiation ( teletherapy brachytherapy)
• SE skin changes, swellingheaviness, lymphedema
• Chemotherapy
• SE see previous slides heart damage,
  ?infertility
• Monoclonal antibody therapy (Herceptin)
• SE see previous slide heart damage
• Hormone therapy ( Blockers or Inhibitors)
• SE menopausal symptoms, uterine CA, thrombus

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Breast CancerPsychosocial Support

• Encourage verbalization
• Listen, listen, listen.
• Involve significant others
• Arrange for support group contact
• Reach for Recovery Local Chapter-Hauppauge
• American Cancer Society website

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Skin Cancer

• Incidence and prevalence increasing
• Highest in light-skinned, over age 60, hx of
  frequent sun-exposure
• Prevention,screening,early intervention
• Actinic KeratosisSquamous CellBasal
  CellMelanoma

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Skin CancerINTERVENTIONS

• Drug Therapy
• Radiation Therapy
• Immunotherapy
• Cryosurgery
• Curettage / Electrodesiccation
• Excision