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Download Chapter 10 Nursing Care of Patients with Cancer
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Nursing Care of Patients with Cancer Review of Normal Anatomy and Physiology What is Cancer? By definition: Excessive growth of cells that lack capabilities of normal cellular function. Cancer is a name for a large group of diseases characterized by cells that multiply rapidly, are uncontrolled, and invade normal tissue. Cell Cycle Normal cells- When cells reach life expectancy, they reproduce to form new cells as the body needs them. Cells of the same type reproduce until the correct number have been replenished. Cell division stops when normal cells surround other normal cells. Cancer cells- new cells form when the body don’t need them and the cells don’t die when they should. These extra cells form a mass of tissue called a tumor. They ignore the growth regulating signals around them. They continue to grow in a disorderly , unrestricted manner. Predisposing factors are to blame. Cell Cycle Cancer Oncology is the specialty area that deals with cancer patients. AKA: the study of tumors. Cancer is the second leading cause of death in the U.S. Early detection and treatment is vital in the successful treatment of cancer. Cancer Concepts Neoplasm- new growths of abnormal tissue. Not all neoplasms contain cancer cells. 2 types of neoplasms exist: Benign- non-cancerous cells, non recurrent. Malignant- cancer cells that are unlimited in growth. Growth continues until cells start to break off, which leads to metastasis. Benign Tumors Slower rate of growth Localized Generally remain encapsulated Movable and well defined Cells resemble those of origin Recurrence is rare Usually not life threatening Malignant Tumors Rapid rate of growth Invades surrounding tissue or metastasizes Rarely encapsulated Irregular borders and immovable Cells can’t be readily identified as to tissue of origin Recurrence is common Fatal if not treated FACTS An organ containing a benign tumor can usually go on and function as usual without complications- unless size interferes with function. Breast lump or ovarian cyst An organ containing a malignant tumor will eventually be affected and it’s function will be altered. Lung CA- SOB, coughing, hemoptysis Metastasis The spread of a tumor from the primary site to a different area or distant part of the body. “In situ” simply means that a tumor is contained within one area. AKA: localized In situ tumors are usually surgically removed and may or may not require treatment. If a tumor metastasizes, there are more general effects on the body. Metastasis Mets can occur by three means Invade blood or lymph vessels Move by mechanical means Lodge and grow in a new location by direct extension into surrounding tissues Etiology Cancer cell growth involves a 2-step process Initiation- normal cells become altered or damaged due to carcinogen exposure. Define carcinogens/carcinogenesis. Promotion- repeated exposure to carcinogens that causes cells to mutate. Risk Factors Viruses Radiation Chemicals Irritants Genetics Diet Hormones Altered Immunity Cancer Types/Tumor Classifications 4 types of malignant tumors: Carcinoma- originate from epithelial cells and tend to metastasize Sarcoma- originate from connective tissue Leukemia- originate from organs that form blood Lymphoma- originate from organs that fight infection Viruses Retrovirus- often found in leukemic cells Epstein-Barr virus- associated with lymphoma HSV 2- associated with cervical and penile cancers HPV- associated with cervical and penile cancers Hepatitis B- associated with liver cancer Radiation Sunlight- leading cause of skin cancer and leukemias. U/V rays. Radiation leaks X-rays Prolonged exposure to power lines, electromagnetic waves such as cell phones and microwaves Chemicals and Irritants Length of exposure and degree of exposure play a role. Tobacco- leading cause of mouth and throat cancers. Also contributes to lung CA. Chemicals used in factories Alcohol intensifies toxicity of tobacco Asbestos Genetics Accounts for only 10% of cancers! Cancers associated with genetics Breast CA Skin CA Colon CA Leukemia Genetic screening and counseling is available Ex: BRCA 1 and 2 Diet What a person does not consume is as important as what he or she consumes! High-fat, low-fiber diets predispose to CANCER Diets low in vitamins C,A, and E predispose to cancer Hormones Estrogen is associated with cancer of the breast, uterus, ovaries, cervix and vagina. The estrogen/progesterone sensitivity plays a big role in the treatment of breast cancer. (ER/PR) If this test is positive, the patient will have to do Herceptin long-term or for remainder of life. Adenocarcinoma of the Caecum Lung Cancer Metastasis to Skin Most Common Cancers Men Prostate Lung Colon Women Breast Lung Colon Cancer Death Rates 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/other tissue I-indigestion or swallowing difficulties O-obvious change in wart or mole N-nagging cough or hoarseness Prevention Early Detection Regular Screening Genetic Testing Healthy Lifestyle Prevention (cont’d) Protectant Foods Folic Acid Omega-3 Fatty Acids Fruits and Vegetables Vaccines Incidence The exact cause of cancer is unknown Highest incidence in ages 60-69 Followed by 70-79 Men have a higher incidence of cancer that women Mortality rates have decreased Remission Partial Complete Diagnosis Biopsy Lab/tumor markers Cytology Radiological tests Nuclear imaging Ultrasound MRI Endoscopic procedures Fine Needle Biopsy Stereotactic Biopsy Mammogram Staging of Cancer Treatment of cancer is based on staging of disease. Tumor, Node, Metastasis system (pg. 178) ◦ T is for tumor size ◦ N is for node involvement ◦ M is for metastasis or extent thereof ◦ Ex: T2, N1, M0 Staging system ◦ Stage I Stage III ◦ Stage II Stage IV Cancer Treatment Options Surgery Curative Palliative Other-Prophylactic Other-Reconstruction Radiation Therapy Chemotherapy Side Effects of Radiation Fatigue Nausea, Vomiting, Diarrhea, and Anorexia Mucositis Xerostomia Skin Reactions Bone Marrow Depression Radiation Radiation can be one of two types Internal- allows for higher doses without destroying surrounding tissues. Radiation is actually emitted from pt during therapy. Safety principles apply. External- external beam radiation to destroy cancer cells with minimal damage to normal, healthy cells. Internal Radiation Therapy Unsealed- administered IV or oral Distributed throughout pt’s body Use safety precautions when in direct contact with patient and or any body tissue or Sealed- administered into hollow cavity Delivers specific rad. dose continuously over hours or days Radiologist inserts and removes Can be used for cervical cancer, uterine cancer, prostate cancer Radiation Safety: Internal Time- Plan ahead by having everything needed when entering pt room Distance- Stand at the greatest distance away from site of internal radiation Shielding- Wear lead apron if close contact and prolonged care are needed Radiation Safety: Internal Visitors are limited to 10 min. standing as far away from radiation as possible Prevent dislodgement of sealed implant from cavity through strict bed rest with minimal turning from side to side Radiation in Use sign on door If vaginal radiation implant, keep legs closed together and straight Do not bathe patient below the waist Low residue diet to minimize BM which could cause dislodgement Radiation Safety: Internal Cont. Force fluids Check position of Foley cath will be in place to keep bladder from being exposed to radiation and b/c of bedrest Do not raise HOB more than 30 – 45 degrees TED hose Keep long handled forceps and a lead container in pt’s room applicator every 4 hours by checking threads that are brought out and fastened to the skin Implants are inserted by Radiologist – if implant fall out, CALL RADIOLOGIST TO PUT BACK IN!!! NEVER TOUCH IMPLANT Radiation Safety: Internal – After implant Removal Perform good peri-care – often times a douch and enema are ordered Pt is no longer radioactive It is normal for patient to have odorous, discolored vaginal discharge Anti-Neoplastic Drugs Anti-neoplastic drugs are drugs used in the treatment of cancer. They have 3 uses: Cure Control Palliation Nursing Assessment Things to look for in the assessment of the cancer patient Side effects of chemo and/or radiation Sepsis, bone marrow suppression or depression, and infection Signs of bleeding due to low platelet count Pain VS and weight How Chemo Works Chemotherapy affects cells that rapidly divide and reproduce. Cancer cells are not the only cells that are rapidly-dividing cells. ALL malignant cells must be destroyed in order for the cancer to be cured. Repeated cycles of chemo are needed in order to obtain total destruction. Can be given alone or in combination regimens. Chemo is given in a series of cycles to allow for recovery of the normal cells and to destroy more of the malignant cells. Each cycle gets some cancer cells, but not all. That’s why repeated cycles are needed: in hopes that eventually all cells will be killed. Most regimens are every 3 weeks. Some treatments can go on indefinitely until remission or progression occurs. Most regimens call for 6-8 week cycles or treatments with scans ordered half way through to check response. Cycles are utilized to give blood counts a chance to build back up Nadir is a term used when patients are undergoing chemo. Nadir means low point. This is the point where RBC, WBC, and PLT counts start dropping. Usually 7-10 days after start of chemo round Better results are usually achieved with combination therapy vs. single agent Classes of Anti-neoplastic Drugs Alkylating agents Antibiotics Antimetabolites Hormones Vinca alkaloids The common goal of all classes is to attack and kill cancer cells!!! Nursing Management of the Pt Receiving Chemo Relevant factors Drug or drugs to be given The dose of the drugs Patient’s physical condition Response of the tumor to treatment Type and severity of side effects Pretreatment labs Anti-neoplastic Preparation Strict guidelines for mixing these agents Must wear disposable, plastic gloves, and gown Prevent accidental spills Must wash hands before and after mixing or handling Double or triple check accuracy Anti-neoplastic Administration Chemo can be given PO IV (drip, push, or infusion) SQ IM Intracavity or Intrathecal Side Effects of Chemotherapy Bone marrow depression- neutropenia, anemia, thrombocytopenia Nausea, vomiting, anorexia, diarrhea, constipation Stomatitis Alopecia Possible sterility Neuropathy Chemo Side Effects Alopecia Usually occurs 10-21 days after initiation of chemotherapy Always inform patient of this SE Hair loss is a personal problem that is dealt with in varying degrees Be supportive Hair loss is temporary Hair follicles are rapidly dividing cells. Antineoplastic medications may or may not cause hair loss. Always let pt know alopecia is temporary and it will grow back. Usually the hair grows back a different color or texture. Warn the pt. that hair loss can be gradual or come on suddenly in large amounts. Advise pt to get a wig before hair falls out to match the color and style. Some people have compromised tx before due to hair loss issues. Ice caps may help prevent loss due to freezing hair follicles Chemo Side Effects Anorexia Helpful hints to lessen loss of appetite Small, frequent meals Diet high in nutritive value Medications can be given to stimulate appetite Advise supplements (Ensure, Boost) Chemo Side Effects Bone Marrow Depression When production of blood cells is decreased. Manifested by abnormal lab results and clinical evidence often times Neutropenia Thrombocytopenia Anemia Chemo Side Effects Nausea and vomiting The most dreaded side effect Anti-emetics have come a long way Teaching should include: Small, frequent meals Fluids between meals Avoid greasy or spicy foods and odorous foods Bland diet better tolerated Carbonated drinks may help relieve nausea Chemo Side Effects Stomatitis Inflammation of the mouth Distinguish inflammation from thrush Teaching should include: Avoid cold or hot liquids Avoid citrus or acidic juices Avoid alcohol or smoking Avoid spicy foods Avoid commercial mouthwash Encourage soft bristle toothbrush Swish with baking soda, salt, and water soln Medication for pain Chemo Side Effects Sepsis Always a potential with significant BM depression A temp of 101 or greater should always be reported Antibiotics are prescribed if counts too low along with drugs to raise WBC Possible hospitalization Patient Teaching Patient and family teaching when oral therapy is prescribed Do not take OTC’s without prior approval Never increase, decrease, or omit dose without speaking to physician. Take as directed. Contact physician for any problems Assess mouth daily and report problems Drink plenty of fluids Keep all appointments Alcohol only in moderation No invasive procedures without prior approval Have blood checked as ordered, on time Chemotherapy Extravasation Cancer Related Pain Pain is a major concern for cancer pts Chronic pain can lead to depression and even suicide Obstacles to proper pain management Fear of addiction Lack of knowledge regarding pain management (breakthrough pain) Respiratory depression or over-sedation Hospice Care For Advanced CA Most patients with advanced cancer know they are dying. Honesty and openness are the best approaches. Prognosis of <than 6 Months Goal is to keep patient comfortable All curative treatment ceases Promotes comfort and quality of life Don’t forget stages of grieving/death and dying Other Treatment Options Bone Marrow transplant- process of replacing diseased BM with normally functioning BM Graft vs. host Biotherapy Also known as immunotherapy Peripheral Stem Cell transplant-based on the theory that circulating stem cells are capable of repopulating the BM Bone Marrow Transplant Pt is given high doses of chemo to kill the pt’s bone marrow. That is then replaced with healthy marrow from a compatible donor. Bone marrow is taken from the donor, then transfused into the pt’s blood stream. Until the marrow takes hold (2-4 weeks), the pt has no immune system. High mortality rate with transfusions and if rejection occurs, it’s a very painful death. The first 3 months are critical Oncological Emergencies Superior Vena Cava Syndrome- most common in lung cancer patients. Tumor enlarges and blocks blood flow thru the vena cava. S/S- very high pitched voice, edema of head and neck, possible seizures Hospitalization is required with radiation therapy and drug therapy to shrink tumor Oncological Emergencies Spinal Cord Compression- seen most in patients with bone metastasis to the spine. S/S- severe low back pain and most often the loss of the use of their legs. MRI often ordered to rule out compression Radiation required to relieve the compression of the spinal cord Oncological Emergencies Hypercalcemia- most often seen in patients with bone metastasis S/S- calcium level is over 11, confused, disoriented Calcium leaves the bone due to bone disease and deterioration and enters the circulation. Treatment involves drugs Aredia or Zometa which help decrease Calcium levels in the blood. Calcium levels are checked daily. Calcitonin injections can also be used and given by home care If calcium level gets too high, pt can go into a coma Oncological Emergencies Pericardial effusion- fluid around the heart Usually seen when the cancer invades the pericardial sac S/S- SOB, edema Treatment is a pericardialcentesis Oncological Emergencies Disseminated intravascular coagulation (DIC)abnormal coagulation- very critical situation All clotting factors are used up S/S- bleeding, clots, infarctions Treatment- Fresh frozen plasma
