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Care of the Oncology Patient Part 1: Pathophysiology and Treatment Options

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Title: Care of the Oncology Patient Part 1: Pathophysiology and Treatment Options


1
Care of the Oncology Patient Part 1
Pathophysiology and Treatment Options
Janie Best, RN, MSN, APRN, BC
2
Objectives
  • 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

3
What 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

4
What 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.

5
What is cancer?
  • Can affect anyone
  • One of the most feared diagnoses
  • Psychologic support needed during the diagnostic
    process

6
Incidence / 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
7
Cancer in the USA Cultural disparity
  • Lack of health insurance
  • Lower incomes
  • Unequal access to health care
  • Knowledge deficit
  • Cultural beliefs and attitudes

8
Cancer in the USA Cultural 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)
9
Cancer in the USA Cultural 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)
10
Cancer Risk Factors
  • Internal
  • Age
  • Gender
  • Race
  • Genetics
  • Immunological
  • Hormonal
  • Psychosocial
  • External
  • Chemicals
  • Radiation
  • Viruses
  • Diet
  • Tobacco
  • Alcohol
  • Chemotherapy

11
Intrinsic 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
12
Seven 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

13
Detection 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

14
Healthy 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

15
Detection 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

16
Detection and Prevention
  • RN role
  • Education
  • Know risk factors
  • Use resources
  • Care provider, teacher, advocate, emotional
    supporter, role model
  • Gift of presence

17
Normal 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

18
Characteristics 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

19
Characteristics 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

20
FIGURE 16-2. Phases of the cell cycle
21
Terms
  • 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

22
Carcinogenesis - Stages
  • Initiation
  • DNA is damaged
  • Promotion
  • Initiates cell growth
  • Progression
  • Tumor establishes its own blood supply
  • Metastasis
  • Cancer cells migrate to other locations

23
Metastasis
  • 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

24
Metastasis
  • 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

25
Common Sites for Metastasis
26
Common Sites for Metastasis
27
Normal Immune Response
  • Tumor associated antigens
  • Macrophages
  • T lymphocytes
  • Lymphokines
  • Natural killer cells (lymphocytes)

28
Immune 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

29
Immune 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

30
Diagnostic 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

31
Cancer Classification
32
Cancer Classification
33
Tumor 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

34
Tumor 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

35
Treatment Options
  • Based on realistic / achievable goals
  • Cure
  • Control
  • Palliation
  • Reassessment plan

36
Radiation 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

37
Radiation therapy
  • Internal (Brachytherapy)
  • Needles, seeds, beads, catheters into body
    cavities, oral
  • External
  • Various energy levels based on tumor

38
Radiation Therapy External Nursing 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

39
Radiation Therapy Internal Nursing 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

40
Chemotherapy
  • 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

41
Classes of Chemotherapy Drugs
  • Alkylating agents
  • Antimetabolites
  • Antitumor Antibiotics
  • Mitotic inhibitors
  • Hormones Hormone antagonists

42
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43
Nursing Care During Chemotherapy
  • Assessment for s/s toxicity
  • Management of Side Effects
  • Patient Education
  • Central line catheter care
  • Management of side / toxic effects
  • Presence

44
Impaired 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
Treatment Options - Surgery
  • Diagnostic
  • Primary treatment
  • Prophylactic
  • Palliative
  • Reconstructive

46
Nursing Role in Cancer Surgery
  • Education -
  • General perioperative care
  • Assessment for postoperative complications
    related to other treatment methods (radiation /
    chemotherapy)




  • Infection
  • Impaired wound healing

47
Nursing Care
  • Based on Nursing Process
  • Cancer type
  • Quality of life
  • Quantity of life
  • Characteristics of the patient
  • Treatment goals
  • Combination therapies

48
Assessment
  • Infection
  • Bleeding
  • Skin problems
  • Pain
  • Fatigue
  • Psychosocial status
  • Body image

49
Nursing Diagnoses
  • Impaired oral mucous membrane
  • Impaired tissue integrity
  • Impaired tissue integrity alopecia
  • Impaired tissue integrity malignant skin lesions

50
Nursing 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

51
Plan
  • Management of secondary problems
  • Multidisciplinary team approach

52
Implementation
  • Evidence Based Practice
  • Pt / family education
  • Counseling / referrals

53
Evaluation
  • Expected Patient Outcomes
  • Based on the identified plan of care
  • Quality improvement / research
  • Legal / ethical considerations
  • Patient confidentiality
  • Do Not Resuscitate status

54
Implanted Port
Tunneled Right atrial catheter
PICC
55
Managing Complications/Emergencies
  • Superior Vena cava syndrome
  • Sepsis
  • Spinal cord compression
  • Hypercalcemia
  • Hyperuricemia
  • Tumor Lysis Syndrome

56
Superior 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)

57
Superior 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

58
Sepsis
  • Life-threatening
  • Early identification is critical to survival
  • Usually gram negative bacteria

59
Factors Predisposing Cancer patients to infection
  • Impaired skin and mucous membrane integrity
  • Chemotherapy
  • Radiation therapy
  • Biologic response modifiers
  • Malignancy
  • Malnutrition
  • Medications

60
Factors Predisposing Cancer patients to infection
  • Urinary catheter
  • IV catheter
  • Invasive procedures
  • Contaminated equipment
  • Age
  • Chronic illness
  • Prolonged hospitalization

61
Sepsis- Early Signs / Symptoms
  • Vasodilation
  • Vascular dehydration,
  • High fever
  • Peripheral edema
  • Hypotension
  • Tachycardia
  • Tachypnea
  • Hot flushed skin with creeping mottling
  • Anxiety or restlessness

62
Sepsis- Late Signs / Symptoms
  • Hypotension
  • Rapid thready pulse
  • Respiratory distress
  • Cyanosis
  • Subnormal temperature
  • Cold clammy skin
  • Decreased urinary output
  • Altered mentation

63
Spinal Cord Compression
  • Emergency
  • Initial symptom Back pain
  • Leg pain, numbness, paresthesias, coldness
  • Bowel / bladder dysfunction
  • Neurologic dysfunction progressing from weakness
    ? paralysis

64
Spinal 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

65
Hypercalcemia
  • Late manifestation of extensive malignancy
  • Bone metastasis bone releases calcium
  • Lung, Breast, esophagus, thyroid, head, neck,
    multiple myeloma excessive parathyroid hormone
    release

66
Hypercalcemia
  • 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

67
Hypercalcemia - Treatment
  • Medications
  • Glucocorticoids, calcitonin, diphosphonate,
    gallium nitrate
  • Dialysis (if renal function impaired)

68
Hyperuricemia
  • 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)

69
Tumor 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

70
TUMOR 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
71
Tumor Lysis Syndrome
  • S/S
  • Nausea, vomiting
  • Lethargy
  • Edema
  • Fluid overload
  • Heart failure
  • Cardiac dysrythmias
  • Seizures
  • Muscle cramps
  • Tetany
  • Syncope
  • Possible sudden death

72
Tumor 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

73
Putting 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.

74
NCLEX 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

75
NCLEX 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

76
NCLEX 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

77
NCLEX 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

78
Case Study Mastectomy Patient

79
References
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
    collaborative care, 4th Ed. pp. 423-444.
  • http//www.cancer.org/downloads/STT/CAFF2007PWSecu
    red.pdf. Accessed 5/14/08
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