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ONCOLOGICAL DISORDERS
TREATMENT MODALITIES
PYRAMID POINTS
• Assessment of the client for pain
• Interventions for the client in pain
• Handling hazardous and infectious materials
related to radiation or chemotherapy
• Care of the client receiving external or internal
radiation or chemotherapy
• Monitoring for expected and unexpected effects
of radiation and chemotherapy
PYRAMID POINTS
• Interventions if an anaphylactic reaction occurs
from the administration of chemotherapy
• Safety related to caring for a client with an
internal radiation implant
• Interventions in the event of a dislodged radiation
source
• Monitoring for complications associated with
bone marrow transplantation
PAIN CONTROL
• CAUSES OF PAIN
– Bone destruction
– Obstruction of an organ
– Compression of peripheral nerves
– Infiltration or distention of tissue
– Inflammation or necrosis
– Psychological, such as fear or anxiety
PAIN CONTROL
Reproduced by permission of WHO, from Cancer pain relief, 2nd edition. Geneva: World Health
Organization, 1996.
PAIN CONTROL
• IMPLEMENTATION
– Collaborate with other members of the health
care team to develop a pain management
program
– Administer oral preparations if possible and if
they provide adequate relief of pain
– Mild and moderate pain may be treated with
salicylates, acetaminophen (Tylenol), and
nonsteroidal antiinflammatory drugs (NSAIDs)
PAIN CONTROL
• IMPLEMENTATION
– Severe pain is treated with narcotics such as
codeine sulfate, meperidine (Demerol),
morphine sulfate, and hydromorphone
hydrochloride (Dilaudid)
– Subcutaneous injections and continuous IV
infusions of narcotics provide superior pain
control
PAIN CONTROL
• IMPLEMENTATION
– Monitor for side effects of medications
– Monitor for effectiveness of medications
– Provide nonpharmacological techniques of
pain control, such as relaxation, guided
imagery, biofeedback, and diversion
– Do not undermedicate the cancer client who is
in pain
SURGERY
• DESCRIPTION
– Used to diagnose, stage, and treat cancer
• TYPES
– Prophylactic surgery
– Curative surgery
– Control (cytoreductive) surgery
– Palliative surgery
– Reconstructive or rehabilitative surgery
PROPHYLACTIC SURGERY
• Performed in clients with an existing
premalignant condition or a known family history
that strongly predisposes the person to the
development of cancer
• An attempt is made to remove the tissue or organ
at risk and thus prevent the development of
cancer
CURATIVE SURGERY
• All gross and microscopic tumor is either
removed or destroyed
CONTROL (CYTOREDUCTIVE) SURGERY
• A “debulking” procedure that consists of
removing part of the tumor
• It decreases the number of cancer cells and
increases the chance that other therapies will be
successful
PALLIATIVE SURGERY
• Performed to improve quality of life during the
survival time
• Performed to reduce pain, relieve airway
obstruction, relieve obstructions in the
gastrointestinal (GI) and urinary tract, relieve
pressure on the brain and spinal cord, prevent
hemorrhage, remove infected and ulcerated
tumors, and drain abscesses
RECONSTRUCTIVE OR
REHABILITATIVE SURGERY
• Performed to improve quality of life by restoring
maximal function and appearance
SIDE EFFECTS OF SURGERY
•
•
•
•
Loss or loss of function of a specific body part
Reduced function as a result of organ loss
Scarring or disfigurement
Grieving about altered body image or imposed
change in lifestyle
CHEMOTHERAPY
• DESCRIPTION
– Kills or inhibits the reproduction of neoplastic
cells
– The effects are systemic and affect both
healthy cells and cancerous cells
– Normal cells most profoundly affected include
the skin, hair, lining of the GI tract,
spermatocytes, and hematopoietic cells
CHEMOTHERAPY
• DESCRIPTION
– Cell cycle phase-specific medications affect
cells only during a certain phase of the
reproductive cycle and cell cycle phasenonspecific medications affect cells in any
phase of the reproductive cycle
– Usually several medications are used in
combination (combination therapy) to increase
the therapeutic response
CHEMOTHERAPY
• DESCRIPTION
– Combination chemotherapy is planned to
avoid prescribing medications with nadirs (the
time during which bone marrow activity and
white blood cell counts are at their lowest) at
or near the same time, to minimize
immunosuppression
– Antineoplastic therapy may be combined with
other treatments such as surgery and radiation
CHEMOTHERAPY
• DESCRIPTION
– The preferred route of administration is by IV
– Side effects include alopecia, nausea and
vomiting, mucositis, skin changes,
immunosuppression, anemia, and
thrombocytopenia
– Refer to the Module entitled Antineoplastic
Medications for additional information related
to chemotherapy
RADIATION THERAPY
• DESCRIPTION
– Destroys cancer cells with minimal exposure of
normal cells to the damaging effects of radiation;
the cells damaged either die or become unable to
divide
– Effective on tissues directly within the path of
the radiation beam
RADIATION THERAPY
• DESCRIPTION
– Side effects include skin changes and
irritation, alopecia, fatigue, and altered taste
sensation; also, the effects vary according to
the site of treatment
– Teletherapy and brachytherapy are the most
commonly used types of radiation therapy to
treat cancer
TELETHERAPY
• DESCRIPTION
– Also called beam radiation and the actual
radiation source is external to the client
– The client does not emit radiation and does not
pose a hazard to anyone else
TELETHERAPY: EXTERNAL BEAM RADIATION
From Monahan, F. & Neighbors, M. (1998). Medical surgical nursing: Foundations for clinical
practice, ed 2, Philadelphia: W.B. Saunders. Courtesy of Varian Medical Systems, Inc., Palo Alto,
CA.
TELETHERAPY: CLIENT EDUCATION
• Wash area with water or mild soap and water
using the hand rather than a washcloth; rinse the
soap thoroughly, and pat dry using a soft towel or
cloth
• Do not remove the radiation markings from the
skin
• Use no powders, ointments, lotions, or creams on
the area unless prescribed
TELETHERAPY: CLIENT EDUCATION
• Wear soft clothing over the area avoiding belts,
buckles, straps, or any clothing that binds or rubs
the skin
• Avoid sun and heat exposure
• Monitor for moist desquamation (weeping of the
skin)
• If moist desquamation occurs, cleanse the area
with warm water and pat dry, apply antibiotic
ointment or corticosteroid cream as prescribed,
and expose the site to air
BRACHYTHERAPY
• DESCRIPTION
– Radiation source comes into direct,
continuous contact with tumor tissues for a
specific time
– The radiation source is within the client; for a
period of time, the client emits radiation and
can pose a hazard to others
– Includes either an unsealed or sealed source
of radiation
BRACHYTHERAPY
• UNSEALED RADIATION SOURCES
– Administered via the oral or IV routes, or as an
instillation into body cavities
– The source is not completely confined to one
body area, and it enters body fluids and is
eventually eliminated via various excreta,
which is radioactive and harmful to others
– Most of the source is eliminated from the body
within 48 hours; then the client nor the excreta
are radioactive or harmful
BRACHYTHERAPY
• SEALED RADIATION SOURCES
– A sealed, temporary or permanent radiation
source (solid implant) placed within the tumor
target tissues
– The client emits radiation while the implant is
in place, but the excreta is not radioactive
SEALED RADIATION SOURCE
• NURSING CARE
– Place the client in a private room with a private
bath
– Place a radiation caution sign on the client’s
door
– Organize nursing tasks to minimize exposure
to the radiation source
– Nursing assignments to a client with a
radiation implant should be rotated
SEALED RADIATION SOURCE
• NURSING CARE
– Limit time to one-half hour per care provider
per shift
– Wear a dosimeter film badge to measure
radiation exposure
– Wear a lead shield to reduce the transmission
of radiation
– A nurse should never care for more than one
client with a radiation implant at one time
SEALED RADIATION SOURCE
• NURSING CARE
– Do not allow a pregnant nurse to care for the
client
– Do not allow children under the age of 16 or a
pregnant woman to visit the client
– Limit visitors to one-half hour per day; visitors
should be at least six feet from the source
– Save bed linens and dressings until the source
is removed, then dispose in the usual manner
– Other equipment can be removed from the
room at any time
EXPOSURE TO RADIOACTIVITY
AND DISTANCE
From Monahan, F. & Neighbors, M. (1998). Medical surgical nursing: Foundations for clinical
practice, ed 2, Philadelphia: W.B. Saunders.
A DISLODGED RADIATION SOURCE
• Do not touch a dislodged radiation source with
bare hands
• If the radiation source dislodges, use a longhandled forcep and place in the lead container
kept in the client’s room, and call the physician
• If unable to locate the radiation source, bar
visitors and notify the physician
REMOVAL OF SEALED RADIATION SOURCES
• The client is no longer radioactive
• Inform the client that sexual partners cannot
“catch” cancer
• Inform the female client that she may resume
sexual intercourse after 7 to 10 days, if the
implant was cervical or vaginal
• Provide a betadine douche if prescribed, if the
implant was placed in the cervix
• Administer a Fleets enema if prescribed
REMOVAL OF SEALED RADIATION SOURCES
• Advise the client who had a cervical or vaginal
implant to notify the physician if nausea,
vomiting, diarrhea, frequent urination, vaginal or
rectal bleeding, hematuria, foul-smelling vaginal
discharge, abdominal pain or distention, or a
fever occurs
BONE MARROW TRANSPLANTATION
• Used in the treatment of leukemia for clients who
have closely matched donors and who are
experiencing temporary remission with
chemotherapy
• The goal of treatment is to rid the client of all
leukemic or other malignant cells through
treatment with high doses of chemotherapy and
whole body irradiation
• Since these treatments are lethal to bone marrow,
without the replacement of bone marrow function
through transplantation, the client would die of
infection or hemorrhage
BONE MARROW
Copyright © Ed Reschke, used with permission.
TYPES OF DONOR MARROW
• ALLOGENEIC
– Marrow donor is usually a sibling or parent
with a similar tissue type
• SYNGENEIC
– Uses bone marrow from an identical twin
• AUTOLOGOUS
– Most common type
– The marrow donor is also the recipient
– Marrow is harvested during disease remission
and is stored frozen to be reinfused later
BONE MARROW TRANSPLANTATION HARVEST
• Marrow is harvested through multiple aspirations
from the iliac crest to retrieve sufficient bone
marrow for the transplant
• Approximately 500 to 1000 ml of marrow is
aspirated
• Marrow is filtered for any residual cancer cells and
to deplete cells that may cause graft versus host
disease
• Allogeneic marrow is transfused immediately;
autologous marrow is frozen for later use
• Harvest is obtained before the initiation of the
conditioning regimen
BONE MARROW TRANSPLANTATION
CONDITIONING
• Refers to an immunosuppression therapy
regimen used to eradicate all malignant cells,
provide a state of immunosuppression, and
create space in the bone marrow for the
engraftment of the new marrow
BONE MARROW TRANSPLANTATION
TRANSPLANT
• Bone marrow is administered through the client’s
central line in a manner similar to a blood
transfusion
• Marrow is infused over a 30-minute period or may
be administered by IV push directly into the
central line
BONE MARROW TRANSPLANTATION
ENGRAFTMENT
• The transfused bone marrow cells move to the
marrow-forming sites of the recipient’s bones
• Engraftment occurs when the white blood cells,
erythrocyte, and platelet counts begin to rise
• When successful, the engraftment process takes
2 to 5 weeks
ALLOGENEIC BONE MARROW
TRANSPLANTATION
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative
care, ed 4, Philadelphia: W.B. Saunders.
BONE MARROW TRANSPLANTATION
• POST-TRANSPLANTATION PERIOD
– The client remains without any natural
immunity until the donor marrow begins to
proliferate and engraftment occurs
– Infection and severe thrombocytopenia are
major concerns until engraftment occurs
BONE MARROW TRANSPLANTATION
COMPLICATIONS
• FAILURE TO ENGRAFT
– If the transplanted bone marrow fails to
engraft, the client will die unless another
transplantation is attempted and is successful
BONE MARROW TRANSPLANTATION
COMPLICATIONS
• GRAFT VERSUS HOST DISEASE (GVHD)
– Although the recipient cannot recognize the
donated bone marrow cells as foreign or nonself because of the total immunosuppression,
the immune-competent cells of the donated
marrow recognize the client’s cells as foreign
and mount an immune offense against them
– The graft is actually trying to attack the host
BONE MARROW TRANSPLANTATION
COMPLICATIONS
• GRAFT VERSUS HOST DISEASE (GVHD)
– GVHD is managed with immunosuppressive
agents, with caution to avoid suppressing the
new immune system to the extent that the
client becomes more susceptible to infection,
or the transplanted cells stop engrafting
BONE MARROW TRANSPLANTATION
COMPLICATIONS
• VENO-OCCLUSIVE DISEASE
– Involves occlusion of the hepatic venules by
thrombosis or phlebitis
– Signs include right upper quadrant abdominal
pain, jaundice, ascites, weight gain, and
hepatomegaly
– Early detection is critical because there is no
known way to open the hepatic vessels
– The client will be treated with fluids and
supportive therapy