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CANCER/TRANSPLANT/End OF LIFE BY: Diana Blum MSN Metropolitan Community College NURS 2150 This ppt created with the help of material from Osborne, K. et al (2010) Medical Surgical Nursing Preparation for Practice. Pearson: Boston. GOAL OF CANCER CARE Combination of treatments effective in controlling most cancers http://www.youtube.com/watch?v=j_wRpa2b5XI CARCINOGEN Any chemical, physical, or genetic agent that can irreversibly alter cellular DNA Abnormal cells produced Tobacco smoke – can both initiate & promote cancer growth ROLE OF IMMUNE SYSTEM Surveillance of tumor-associated antigens 2nd leading cause of death in USA Metastasizing cancer Cell 1 out of 4 Americans will have CA at some time in their life Definition According to the American Cancer Society: A large group of diseases characterized by uncontrolled growth and spread of abnormal cells Top 3 Cancers that cause Deaths figure 64-1 Men Women Lung Lung Prostate Breast Colorectal Colorectal Neoplasm (aka TUMOR) Cells that reproduce abnormally and in an uncontrolled manner 4 types of Malignancies Carcinoma: skin, glands, lining of digestive urinary and reproductive tracts Sarcoma: bone, muscle, other connective tissues Melanomas: pigment cells in the skin Leukemias and lymphomas: blood forming tissues: lymphoid tissue, plasma cells, and bone marrow Early Diagnosis Is Key for survival 7 Warning Signs 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 other I – indigestion or difficulty swallowing O – obvious change in wart or mole N - nagging cough or hoarseness Staging Stage 1 The malignant cells are confined to the tissue of origin. Not invasive with other tissues Stage 2 Limited spread of the cancer in the local area usually near lymph nodes Stage 3 The tumor is larger or has spread from the local site of origin into nearby tissues regional lymph nodes are likely to be involved Stage 4 The cancer has metastasized to distant parts of the body THE TNM Staging System Specifies the status of the primary tumor, regional lymph nodes, and distant mets T: tumor N: regional nodes M: distant mets Malignant Transformation 4 steps Initiation: DNA exposed to carcinogen Promotion: sufficient exposure to agent to encourage/enhance cell growth Progression: accelerated growth, enhanced invasion, altered appearance and activity Metastasis: tumor develops blood vessels Penetrates capillaries and form fibrin network (undetectable by immune system) Dissolve lining of blood vessels to invade surrounding tissue Set up their own blood supply Treatments Surgery: Done for: diagnosis Symptom relief maintain function Reconstruction Possible cure Surgery continued Preop/postop care varies The recommended treatment is based on the cancers: type, location, and mets Radiotherapy Uses ionizing radiation Dose: 1 gray equals 100 rads Used to treat malignant cells Has delayed and immediate effects Delayed: altered DNA which impairs the cells ability to reproduce Immediate: cell death due to damage of cell membrane Figure 64.4 Immobilizers for radiation therapy. From Osborne Book Caregiver Safety with radiation The less time spent near the source the less exposure Unless direct care being given stay 6 ft away from the source Effective shielding depends on type of rays (the denser the material the more protection) External radiation PROCEDURE Source is outside the body Special xray machine provides treatment # of treatments depends on the doctor Example: 5 times a week for 2-8 weeks PATIENT PREP Treatment simulation to determine exact dosage needed and schedule The skin is marked with permanent, waterproof ink, by the radiologist for the exact site Instruct client not to remove markings without permission Internal Radiation (Brachytherapy) PROCEDURE Sources Iodine, phosphorus, radium, iridium, radon, cesium Instruct client that they pose a threat until the source is removed unless permanently implanted small beads used 2 TYPES Sealed Unsealed Sealed Source is sealed in a container and inserted into the body (CESIUM) Sources may be placed in threads, beads, needles, seeds, or molds To protect visitors from exposure the client needs: To be placed in isolation Have a sign on the door indicating radiation No pregnant women or kids under 18 allowed in room Limit time with visitors Have organized schedule for cares Figure 64.5 Brachytherapy applicator. From Osborne Book Staff to wear film badges to monitor exposure Recognize that Sealed sources can become dislodged Portable lead shields provides minimal protection Immediately notify MD if source becomes dislodged. Do not touch source with bare hands Unsealed Body fluids may be contaminated Must wear gloves when working with patient Contaminated fluids, dressings, etc may require additional precautions depending on the agency. Disposable utensils are recommended Equipment being removed from room must be checked for radiation level first Radiation side effects Normal cells may be harmed (hair follicles, bone marrow, lining of gi tractand urinary tract) Anemia-deficiency of RBC Low WBCs Take 2-6 wks to recover Bruising/Bleeding( low platelets) Takes 2-6 wks to recover Alopecia (hair loss) Anorexia Dry mouth Harms reproductive cells Chemotherapy Use of chemical agents to treat (Antineoplastics) Destroy rapidly dividing cells Curative in some cases Decreases symptoms in others Chemotherapy and the Cell Cycle Stages of cancer: Initiation (alteration of cell’s genetic structure) Promotion (reversible proliferation of altered initiated cells) Progression (increase in growth rate and possible metastasis) Chemo kills at a constant % of cancer cells Can be cell cycle specific (G(1), S, G(2), or M) or Cell Cycle non-specific - G(0) or dividing phase Chemotherapy Categories Alkylating agents Nitrosourea ses Plant Alkaloids Antitumor Antibiotics Antimetabolit es Hormonal agents Miscellaneous agents such as : L-asparaginase Procarbazine Chemotherapy Use of chemical agents to treat cancer (Antineoplastics) Destroy rapidly dividing cells Can be done with or without radiation Complication: Extravasation – STOP DRUG IMMEDIATELY!! Chemotherapy Other Complications: Nadir Lowest point in cell count after chemo/radiation – highest risk for infection Neutropenia Bone marrow suppression 7-14 days after chemo Absolute Neutrophil Count (ANC) Limitations of chemotherapy: Few agents cross the blood-brain barrier The phenomenon of resistant tumor Most agents are most effective on dividing cells, but… As a tumor grows, more cells become inactive From Osborne Book From Osborne Book Chart 64-21 (continued) Routes of Administration From Osborne Book From Osborne Book Chart 64-21 (continued) Routes of Administration From Osborne Book From Osborne Book Cancer Drug Examples 5FU Megace Side effects and toxicities The result of the destruction of normal cells Fast-growing cells most susceptible to damage Cell destruction → fatigue, anorexia, and taste alterations Gastrointestinal system effects Genitourinary system effects Nursing management related to side effects and toxicities From Osborne Book Side Effect Management Drink 8-12 cups of clear liquid a day Small frequent meals Bland foods Rest Encourage wig Be gentle with hair washing No styling products Check mouth for sores No sugar Drinks room temp Do not rub/scratch skin MANAGEMENT Continue dexamethasone Begin radiation to affected area Opioid medications to manage pain Analgesics ATC & additional doses for breakthrough pain Laxative to prevent & manage constipation Physical therapy NUTRITION The nutritional status of cancer patients can be altered in a variety of ways Anorexia, or loss of appetite, usually peaks 4 weeks into treatment and subsides shortly after treatment ends Cancer cachexia Nutritional screening Nutritional support: oral nutrition, enteral feedings, parenteral nutritional support Artificial nutrition and hydration can raise ethical questions for patients who have cancer, particularly those at end of life From Osborne Book Figure 64.7 Cancer cachexia. Source: © Welcome Trust Images/Custom Medical Stock Photo From Osborne Book Biotherapy Treatment with agents whose origin is from biological sources and/or affects biological responses monoclonal antibodies and cytokines hematopoietic growth factors interferons (INF) interleukins From Osborne Book Uses of Biologic Response Modifiers Definition- natural substances produced in small amts. by body’s immune system; reproduced by recombinant DNA technology How does this differ from chemotherapy? Goal – enhance pts. Immunologic response to tumor cells Three categories based on Activity of BRM Modulation or induce a host’s recognition to a tumor: Intron A (alpha interferon) anti viral Interleukin-2 : T/B lymphocytes cause flu-like S&S premedicate, labs, VS, check I & O & monitor for arrhythmias Tumoricidal action TNF, monoclonal antibodies, LAK, TIL (activated by interleukin-2) Colony stimulating factors: G-CSF (Neupogen), GM-CSF (Leukine), EPO (Procrit) Transplants and hormone therapy Bone marrow- used with leukemia/lymphoma Stem cell- bone marrow depression Umbilical cord blood These 3 are done to restore blood manufacturing cells Hormone therapy-used to supress natural hormone secretion, block hormone actions, or provide supplemental hormones From Osborne Book Complications of transplantation Primarily due to the conditioning regime Can include bleeding, infection, nausea and vomiting, diarrhea, mucositis, and graftversus-host disease (GVHD) May also have late effects Nurses must be aware of the signs of graft failure and GVHD Graft failure rare, but nurse must expertly assess patient Requires another transplant or death will result From Osborne Book Oncological emergencies Hypercalcemia Syndrome of inappropriate antidiuretic hormone (fluid does not come off) Disseminated intravascular coagulation (DIC) Superior Vena Cava Syndrome (redness/edema of face, tachycardia, distended neck veins) Teach client not to bend forward Spinal cord compression secondary to tumor From Osborne Book Nurse’s Role in early detection/ prevention for Septic Shock Check vital signs, shaking, chills, hypotension Report temperature of 100.4 or above Check skin for rash Check peripheral or central IV sites Avoid injections Assess pulmonary function Check urine changes Avoid catheterization Control environment Give CSF & antibiotics Three phases of Septic Shock Phase I -warm stage, caused by gram negative organisms increase heart rate, skin warm, increased temp. antibiotics need to be started immediately Phase II - warm to cold stage shift of fluid, cold, clammy, decreased bp, increased pulse, decreased urine output give IV fluids, lasix, dopamine Phase III of Septic Shock Full cold stage Alteration of cardiac output Monitor hemodynamics Give dopamine, dobutamine, IV fluid to maintain PAWP bet. 12-18, ventilate Chart 64-24 (continued) Oncologic Emergencies From Osborne Book From Osborne Book Other possible Oncologic Emergencies What cause them? would Tumor Lysis Syndrome DIC Pericardial effusion/ca rdiac tamponade SIADH tumor destroys cells and releases cellular components that form imbalances : increased K, P, uric acid; decreased calcium Rx: allopurinal, Ca, dialysis Quality of Life The oncology nurse can positively affect QOL by prioritizing symptoms and implementing appropriate relief measures For patients at end of life, nurses should be familiar with the concepts of hospice and palliative care From Osborne Book Survivorship What does the 5 year survival rate mean? Extended survival has certain considerations: teaching needs resocialization employment insurance coverage American Cancer End of Life and Transplantation By Diana Blum RN MSN Metropolitan Community College Nurs 2150 End of Life Death: lungs and heart cease to function Causes: illness or trauma that overwhelms the body Direct causes are: respiratory failure or shock Multi-organ failure Inadequate blood flow to body tissues deprive cells of oxygen which leads to acidosis, hyperkalemia, and tissue ischemia First organs hit: kidneys, liver, heart, brain › May also be in lung with septicemia Vfib, asystole, or PEA can occur at any point of shock or hypoxemia After cardiac arrest, respiratory arrest occurs within minutes Clinical death refers to cessation of heartbeat and breathing with no evidence of brain function present Incidence of death Dying is a part of life cycle 2.5 or more people die each year in the USA from CAD and cancer Natural process Stages of death › Pallor mortis: body becomes pale. 15-120 minutes post death › Algor mortis: body temp falls › Rigor mortis: muscle stiffness. Relaxation occurs after about 72 hours post onset of rigor › Liver mortis: blood begins to pool on lowest part example: to back if lying on back. 20 minutes to 3 hours after death › Decomposition: we start to decompose http://www.youtube.com/watch?v=BuF5qxIDa3c http://www.youtube.com/watch?v=Qo5mCB9gbfY&feature=PlayList&p= C477E57325CB86CC&index=0 care Palliative: philosophy that provides compassion and supportive approach to the dying Helps to relieve symptoms Provides emotional and spiritual support Hospice as a Consideration Symptom control and pain management Comfort and dignity is a philosophy First hospice in USA in 1974 in New Haven, Conn. Eligibility: life expectancy of 6 months or less 24 hour, 7 day /week coverage HOSPICE Hospice is not a building – it is a model of care Distress symptoms Pain Dyspnea n/v Fatigue Weakness Constipation Anorexia delirium Assessments Past medical hx Assess emotions (see next slide) Assess LOC Teach family signs of distress (pain, restlessness, moaning) Assess skin for temp, color, mottling, cyanosis Assess vs: they will drop as death nears Assess culture for customs/rituals Assess lungs for cheyne stokes Provide a comfortable environment (music, massage, no restraints, family near, lights dim, etc) Emotions with impending death Withdrawl is 1st Vision like appearances › Talk/mumble to people that are not present › Picking at air › Affirm their experience Letting go › May be agitated or perform repetitive tasks Saying goodbye › Saying goodbye is important › Touching, hugging, saying I love you, crying is okay › Acknowledge these expressions as natural end Tx Pain management Fatigue management Dyspnea management Oxygen n/v management Agitation management Grief management for pt and family Offer support Be realistic Encourage reminiscence Promote spirituality Foster hope Post mortem care Pronouncement of death Call PCP and other care providers Call NORS Allow family to view body At Alegent, security or pastoral care will go over funeral arraignments like mortuary At Alegent, a silk rose is placed on the door and given to family when they leave as well as the belongings of the deceased Euthanasia Passive: involves withdrawing or withholding tx that might prolong the life of a person who cannot be cured This is accepted by all Active : involves a healthcare provider taking action that purposefully and directly causes the client’s death This is not allowed Advance Directives Written document that specifies the client’s wishes should something happen to them. DPOA-HC: appoints someone to make decisions in the event the client is unable Living will: instructs doctors and family what life sustaining or lack of they wish to have done. Why Transplant? Transplantations http://www.youtube.com/watch?v=SvxpyfZ9Rsk The Road to Transplant Treatment Evaluation by a major transplant center Listed or Not Listed Waiting Evaluation for Transplant 3-4 day process Many tests: extensive lab work (40+ labs), ultrasounds, doppler studies, x-rays, bone scan, echocardiogram, upper GI, SBS Consultations my many disciplines including surgeon, transplant coordinator, psychology, psychiatry, social work, child life, child development, specialist MD Criteria for Transplant End stage disease Failure to treat Benefits> Risk absence of malignancy & infection Able to survive surgery Sepsis Loss of line sites MELD/PELD (liver) NORS score/rating What is the testing for histocompatability? ABO and Rh HLA - Human leukocyte or lymphocyte antigen Contraindication – positive tissue typing for crossmatch with HLA antibodies PRA - panel of reactive antibodies Complications of Transplant Rejection Infection Death Multi-system involvement/ failure What are the types of graft rejection? Hyperacute minutes to hours Chronic months or years preformed B cell antibodies to donor antigens T and B cell not always treatable Acute 4 days to 4months treatment not usually successful Graft-versus- Host with bone marrow transplants cell mediated Treatable donor T cells react Reversible – OKT3 S&S: skin, liver, GI HYPERACUTE REJECTION Can be avoided with crossmatching prior to transplant What are the medications for immunosuppression? Imuran inhibits DNA/RNA blocks antibodies cellcept or cytoxan could be substitute ATG alters T cell function serum sickness ALG as a substitute Thymoglobulin Muromonab-CD3 or OKT3 monoclonal antibody blocks T cell function premedicate prevention/treatment of rejection cytokine release syndrome Basiliximab-chimeric antibody (mouse/human) Medications continued... Tacrolimus (fk-506)/ Sirolimus (renal dysf) -100 times more potent than CSA -Many drug interactionsNephrotoxic with NSAIDS -Blocks interleukin 2 production Cyclosporine -nephrotoxic, hepatotoxic Corticosteroids-drug interactions! What are the types of donor bone marrow? Autologous - donor is recipient, How is this possible? Allogenic - human with similar HLA type Syngeneic - identical twin Peripheral blood stem cell harvest apheresis BM Transplantation process Harvesting marrow is obtained from the posterior and anterior iliac crests and filtered Bone marrow infusion Post transplant nadir period thaw bone marrow and infuse through an IV with a filter day 0 is day of transplant and nadir point of pancytopenia care directed to neutropenia, thrombocytopenia, and anemia (protective isolation) pre-engraftment Transplantation process if allogenic Conditioning goals: remove malignant cells inactivate the immune system empty the marrow cavities Nursing care related to conditioning ( the side effects of chemo such as cytoxan): alopecia anorexia, nausea stomatitis SIADH hemorrhagic cystitis Post-engraftment period New blood cells are circulating in peripheral blood 2-4 weeks after transplant Continue on Cyclosporine A and steroids Continued protection for patient for 2-3 months Nursing Care of the Bone Marrow Transplant Patient Conditions that require BMT: leukemia, aplastic anemia, immune deficiency diseases, tumors of the breast, ovarian, testicular Why is bone marrow transplant important as a treatment for malignant disease? Allows the client to receive high doses of chemotherapy without concerns of myelosuppression Nursing Diagnoses related to BMT Risk for infection PC: Bleeding Alteration in fluid volume Ineffective breathing pattern Altered Sensory-perception Altered skin integrity R/T GVHD Impaired family/individual coping Recipient Concerns Pre-transplant concerns Maintain physical health/ current labs Dental screening Treat chronic conditions Psychological preparation Prepared every minute Fear/ Cost Post-transplant concerns Potential for infection Alteration in elimination Knowledge deficit of health maintenance Increased demand of care partner Fatigue Donor Concerns Quality of Life Criteria for being a donor Responsibility Support Major Types of Transplants and resultant nursing care Kidney Heart Pancreas Corneal Other: orthotopic approach Stem cell heterotopic approach Bone Skin Small Bowel Heart valves Liver/Small Bowel Heart-lung, lung check urine output & electrolytes mechanical ventilation Liver Corneal transplant Surgical removal of diseased cornea and replaced with donor Use a calm approach Assess for signs of infection prior to surgery Regional anesthesia is used Antibiotics injected after Dressing in place and removed the next day by the surgeon Pt to lie on non operative side A shield is to be worn at nite for the 1st month Graft rejection is possible Liver transplant Not candidate if: severe cardiovascular instability, severe respiratory disease, active alcohol or substance abuser, metastatic malignant disease, inable to follow directions regarding meds and self care Donor livers are primarily from trauma victims Living donors can also be used The liver is the only organ that can grow back Renal transplant Not a cure 2-70 yrs is age range to get transplant Thorough assessment before Cardiac disease excludes candidate Monitor urinary status closely Cancer clients get dialysis Diabetes clients need very close monitoring donors Kidney donors may be living or dead Matching is difficult Kidneys donors must be : free of disease and infection, no history of cancer, no htn or renal disease, adequate renal function Post op Urological management is key Monitor for rejection Monitor urine color Pink and bloody right after Normal after several days-weeks Daily specimens obtained and cultured Instruct about meds and rejection Heart transplant 2300 transplants each year Criteria to get: life expectancy less than 1 year, age less than 65, normal pulmonary vascular resistance, no active infections, stable psychosocial status, no drug or etoh abuse Post op: monitor for bleeding, similar recovery to cabg, monitor for tamponade, instruct client to change position slowly b/c of orthostatic hypotension 2nd to denervation, instruct to follow medication schedule religiously to prevent rejection which usually happens in first 3 months, instruct client to follow recommended diet, allow 10 minutes warm up and cool down with exercise Role of the Nurse in Transplantation Issues The nurse needs to express caring/empathy to client issues: The assessment/ physical exam The psychosocial evaluation 6 coping mechanisms cost 6 support systems ethical concerns anxiety 6 legal regulations 6 depression 6 loss of control uniform anatomical gift act National Organ Transplant Act UNOS Success of Transplant Liver- 83% at 1 year/ 71% 5 year(cad) Liver- 85% 1 year/ 81% 5 year (living) Small bowel/ Liver-Small bowelapproximately 65% one year/ 46% 5 year Heart- 83% at one year/ 69% 5 year Heart/Lung- 65% at one year/41% 5 year Kidney- 94% one year/ 82% 5 year (cad) Kidney- 97% one year/91% 5 year (living) Living Donation Usually between 18-60 years of age May give single kidney, lobe of lung, segment of the liver, or portion of the pancreas Tissue typing, crossmatching, and antibody screen are performed, as well as urine tests, CXR, EKG, arteriogram, and psychologic/psychiatric evaluation Positive Aspects of Living Donation Eliminates waiting list-surgery may be scheduled(decreases stress of Tx) Recipient may begin taking immunosup. Drugs 2 days before transplant Higher rate of compatibility...between blood related living donor Psychological benefit Websites to Visit United Network for Organ Sharing (UNOS) www.unos.org American Society of Transplantation (AST) www.asts.org Nebraska Medical Center www.unmc.edu www.nebraskatransplant.org Transplant Recipients International Organization www.trioweb.org http://www.youtube.com/watch?v=IFSNDqjOS_8&f eature=related
