CARE OF PATIENTS WITH CANCER Characteristics of Normal Cells The Biology of Normal
Cells 1) Have limited cell division 2)          Undergo Apoptosis 3)        Show specific morphology
4) Perform specific differentiated functions 5)          Adhere tightly together 6)      Non migratory
7) Grow in orderly and well regulated manner 8)             Are euploid               * Normal cell
growth (cell cycle) consists of 5 intervals or phases * Differentiation – refers to the process
whereby cells develop specific                           structures and functions in order to
specialize in certain                        tasks             * Cellular adaptation a.
Hypertrophy – refers to an increase in size of normal cells b.       Atrophy – refers to the shrinkage
of cell size c.    Hyperplasia – refers to an increase in the number of normal cells d.
Metaplasia – refers to a conversion from the normal patters of differentiation of one type of cell
into another type of cell not normal for that tissue e.     Dysplasia – refers to an alteration in the
shape, size, appearance and distribution of cells f.       Anaplasia – refers to disorganized,
irregular cells that have nor structure and have loss of differentiation; the result is always
malignant Evolution of Cancer Cells Cancer – refers to a disease whereby cells mutate into
abnormal cells that proliferate abnormally Neoplasia – refers to an abnormal cell growth or
tumor -         a mass of new tissue functioning independently and         serving no useful purpose
Invasion – occurs when cancer cells infiltrate adjacent tissues                     surrounding the
neoplasm Metastasis – occurs when malignant cells travel through the blood or
lymph system and invade other tissues and organs to form                         a secondary tumor C.
Characteristics of malignant cells           1. Rapid cell division and growth: regulation of the rate
of mitosis is lost         2. No contact inhibition: cells do not respect boundaries of other cells
and             invade their tissue areas         3. Loss of differentiation: cells lose specialized
characteristics of function for            that cell type and revert back to an earlier, more
primitive cell type          4. Ability to migrate (metastasize): cells move to distant areas of the
body and              establish new site malignant lesions (tumors)            5. Alteration in cell
structure: differences are evident between normal and                malignant cells with respect to
cell membrane, cytoplasm and overall cell                shape          6. Self-survival
a. may develop ectopic sites to produce hormones needed for own                            growth
                 b. can develop a connective tissue stroma to support growth                     c. May
develop own blood supply by secreting angiotensin growth                           factor to stimulate
local blood vessels to grow into tumor D. Epidemiology of Cancer                  1. Incidence of
cancer                  a. Cancer affects every age group though most cancer and cancer
                    deaths occur in people older than 65 years of age                    b. Cancer
ranks 3rd as the cause of morbidity in the Philippines                    c. Highest incidence of all
cancer is prostate cancer                  d. Highest cancer incidence in males in order of
frequency: prostate                      cancer, lung cancer and colorectal cancer                    e.
Highest cancer incidence in females in order of frequency: breast                          cancer, lung
cancer and colorectal cancer              2. Common sites of cancer and their sites of metastasis
                 Cancer Type Sites of Metastasis 1. Brain Cancer Central Nervous System 2.
Breast cancer Brain Liver Regional lymph nodes Vertebrae 3. Colon cancer Brain Liver Lung
Lymph nodes Ovaries 4. Lung cancer Bone Brain Liver Lymph nodes Pancreas Spinal cord 5.
Prostate cancer Bladder Bone Liver External factors causing CANCER 1. Chemical
Carcinogens- over 1,000 chemicals are known to be carcinogenic •                 Alcoholic beverages
(Liver, esophagus, mouth, breast colon)                      -- serves as a promoter in cancers of the
liver and esophagus             - when combined with tobacco, the risks for other cancers are
even               higher •        Anabolic Steroid (Liver) •         Arsenic (Lung; Skin) •
Asbestos (Lung; peritoneum) •             Benzene (Leukemia ·         Diesel exhaust (Lung) ·
Hair dyes (bladder) ·         Pesticides (Lungs) ·       Sunlight (Skin; eyes) ·        Tobacco (Lungs;
esophagus; mouth; pharynx; larynx n           smokeless tobacco (snuff and chewing tobacco)
increases the risk of       oral and esophageal cancers * long-term exposure to secondhand
smoke increases the risk for lung and              bladder cancers 2. Physical Carcinogens –
 Radiation –        Chronic Irritation- GERD 3. Viral Carcinogens               - some viral infections
tend to increase risk of cancer            Ex: Epstein Barr              Genital herpes
Papillomavirus                  Hepatitis B               Human cytomegalovirus 4. Dietary Factors
        - diets in high fat, low in fiber and those containing nitrosamines found in
preserved meats and pickled foods promote certain cancers such as colon,                   breast,
esophageal and gastric Personal factors causing CANCER 1. Immune Functions 2. Age                     a.
Increased risk for people over age of 65          b. Factors attributed to cancer in elderly include
hormonal changes, altered              immune responses and the accumulation of free radicals
c. Age has been identified as the single most important factor related to the             development
of cancer 3. Gender           a. certain cancers are more commonly seen in specific genders
                 ex: breast cancer –more common in female                           colon cancer –
more common in males 4. Genetic Risk                  - 15% of cancers may be attributed to a
hereditary component                 Ex: Breast, colon, lung, ovarian and prostate cancers 5. Race –
can affect any population             - African-Americans experience a higher rate of cancer than
any other racial             or ethnic group CARCINOGENESIS: Transformation of Normal
Cells into Cancer Cells 1. Initiation – occurs when carcinogen damages DNA                         -
carcinogenesis cause changes in the structure and function of the cell at                     the genetic
or molecular level. This damage may be reversible or may                        lead to genetic
mutations if not repaired; however the mutations may                      not lead immediately to
cancer 2. Promotion – occurs with additional assaults to the cell, resulting in further genetic
                  damage 3. These genetic events result in a malignant conversion 4. Progression –
the cells are increasingly malignant in appearance and behaviour                         and develop
into an invasive cancer with metastases to distant body                        parts Comparison of
the Characteristics of Normal and Cancer Cells Characteristic Normal Cells Cancer Cells Mitotic
cell division Mitotic division lead to 2 daughter cells Mitosis leads to multiple daughter cells that
may or may not resemble the parent. Multiple mitotic spindles Appearance 1. Cells of same type
homogeneous in size, shape, and growth 2. Cells cohesive, form regular pattern of expansion 3.
Uniform size to nucleus 4. Have characteristic pattern of organization 5. Mixture of stem cells
(precursors) and well-differentiated cells 1. cells larger and grow more rapidly than normal;
pleomorphic 2. Cells not as cohesive; irregular patterns of expansion 3. Larger, more prominent
nucleus 4. Lack characteristic pattern of organization of host cell 5. Anaplastic, lack of
differentiated cell characteristics, specific functions Growth pattern 1. do not invade adjacent
tissue 2. Proliferate in response to specific stimuli 3. Grow in ideal conditions (ex: nutrients,
oxygen, space, correct biochemical environment) 4. Exhibit contact inhibition 5. Cell birth
equals or is less than cell death 6. Stable cell membrane 7. Constant or predictable growth rate 8.
Cannot grow outside specific environment (ex: breast cells grow only in breast) 1. invade
adjacent tissues 2. Proliferation in response to abnormal stimuli 3. Grow in adverse conditions
such as a lack of nutrients 4. Do not exhibit contact inhibition 5. Cell birth exceeds cell death 6.
Loss of cell control a result of cell membrane changes 7. Growth rate erratic 8. Able to break off
cells that migrate through bloodstream or lymphatics or seed to distant sites and grow in other
sites Function 1. have specific, designated purpose 2. Contribute to the overall well-being of the
host 3. Function in specific, predetermined manners (ex: cells in the thyroid secrete thyroid
hormone) 1. serve no useful purpose 2. do not contribute to the well-being of the host; parasitic,
actually feed off host without contributing anything 3. If cells function at all, they do not
function normally or they may actually cause damage (ex: lung cancer cells secrete ACTH and
cause excessive stimulation of adrenal cortex) Other 1. develop specific antigens, characteristic
of the particular cell formed 2. Chromosomes remain constant throughout cell division 3.
Complex metabolic and enzyme pattern 4. Cannot invade, erode, or spread 5. cannot grow in
present of necrosis or inflammation 1. develop antigens completely different from a normal cell
2. chromosomal aberrations 3. have more primitive and simplified metabolic and enzyme pattern
4. invade, erode and spread 5. grow in presence of necrosis and inflammatory cells such as
lymphocytes and macrophages 6. exhibit periods of latency that vary from tumor to tumor 7.
have own blood supply and supporting stroma                           Metastasis - ability of cancer
cells to spread from the original site of the tumor to distant organs Stages: 1. Detachment
         * tumor cell loses cohesiveness and it has increasing motility           * tumor cell
detaches from the primary tumor and create defects in the                basemement membranes with
resulting stromal invasion and spread into the              circulation 2. Migration              *
Cancer cells migrate via the lymph or blood circulation or by direct               extension         *
the lymphatic system provides the most common pathway for the initial                   spread of
malignant cancer cells            * The blood vessels carry cancer cells from the primary tumor to
the capillary            beds of the lungs, liver and bones          * Direct tumor extension of
tumors to adjacent tissues also occurs 3. Dissemination                * Cancer cells are established
at the secondary site which may result from               entrapment due to the size of the tumor
clump, adherence to cells at the new              site through specific interactions, or by binding to
exposed basement               membrane 4. Angiogenesis                * Vascularization of the tumor
  The Immune System and Cancer Two critical components of the immune response 1. the
ability to recognize a pathogen as foreign 2. the ability to mount a response to eliminate the
pathogen           * T-cell lymphocyte, macrophages, and antigens recognize cancers cells as
           non-self and destroy them ·        Immune Surveillance Theory –          proposes that
immune responses, particularly cell-mediated           responses, provide a defense against cancer
cells by recognizing the                   antigens on the surface of some neoplastic cells as
foreign                - they are killed by cytotoxic T cells that have receptors for specific tumor
              antigens and by interferon-activated natural killer (NK) lymphocytes
and macrophages                 - macrophages phagocytize the pathogen and present it as antigen
to T and                B lymphocytes ·          Failure of Immune Defenses - the immune system
may be unable to recognize cancer cells as foreign or to mount an immune response due to the
following: a. it’s immature, old or weak b. malnutrition or chronic ailment c. cancer cells
escape detection because they resemble normal cells.          Others produce substances that shield
them from recognition or they        may be coated with fibrin d. use of immunosuppressive
drugs which can suppress immune system                Classification of Neoplasms 1. Benign – from
latin word “benigunus”- kind 2. Malignant Comparision of the characteristics of Benign and
Malignant neoplasm Characteristic Benign Neoplasm Malignant Neoplasm Speed Growth
Grows slowly Usually continues to grow throughout life unless surgically removed May have
periods of remission Usually grows rapidly Tends to grow relentlessly throughout life Rarely,
neoplasm may regress spontaneously Mode of Growth Grows by enlarging and expanding
Always remains localized; never infiltrates surrounding tissues Grows by infiltrating
surrounding tissues May remain localized (in situ) but usually infiltrates other tissues Capsule
Almost always contained within a fibrous capsule Capsule does not prevent expansion of
neoplasm but does prevent growth by nfiltrations Capsule advantageous because encapsulated
tumor can be removed surgically Never contained within a capsule Absence of capsule allows
neoplastic cells to invade surrounding tissues Surgical removal of tumor difficult Cell
characteristics Usually well differentiated Mitotic figures absent or scanty Anaplastic cells
absent Cells function poorly in comparison with normal cells from which they arise If neoplasm
arises in glandular tissue, cells may secrete hormones Usually poorly differentiated Large
numbers of normal and abnormal mitotic figures present Cells tend to be anaplastic Cells too
abnormal to perform any physiologic functions Occasionally a malignant tumor arising in
glandular tissue secretes hormnes Recurrence Unusual when surgically removed Common
following surgery because tumor cells spread into surrounding tissues Metastasis Never occur
Very common Effect of Neoplasm Not harmful to host unless located in area where it
compresses tissue or obstructs vital organs Does not produce cachexia (weight loss, debilitation,
anemia, weakness, wasting) Always harmful to host Causes death unless removed surgically or
destroyed by radiation or chemotherapy Causes disfigurement, disrupted organ function,
nutritional imbalances May result in ulcerations, sepsis, perforations, hemorrhage, tissue slough
Almost always produces cachexia, which leaves person prone to pneumonia, anemia, and other
conditions Prognosis Very good Tumor generally removed surgically Depends on cell type and
speed of diagnosis Poor prognosis if cells are poorly differentiated and evidence of metastatic
spread exists Good prognosis indicated if cells still resemble normal cells and there is no
evidence of metastasis        Classification of cancer according to tissue of origin           1.
Carcinoma - refers to a tumor that arises from epithelial tissue; the name of
                         the cancer identifies the location                  example: basal cell
carcinoma          2. Sarcoma - refers to a tumor arising from supportive tissues; the name of the
                       cancer identifies the specific tissue affected                   example:
osteosarcoma Tissue of Origin Benign Neoplasms Malignant Neoplasms Connective Tissue
Bone Fibrous tissue Adipose tissue Osteoma Fibroma Lipoma Osteosarcoma Fibrosarcoma
Liposarcoma Epithelial Tissue Glandular Surface Adenoma Papilloma Adenocarcinoma
Squamous cell carcinoma Hematopoietic Erythrocytes Granulocytes Lymphatic tissue
Erythroleukemia Leukemia Hodgkin’s disease, malignant lymphoma Lymphocytes Plasma cells
  Lymphocytic leukaemia Multiple myeloma Cancer Prevention and Control 1. Prevention –
involves measures to avoid or reduce exposure to carcinogens                     - activities are aimed
at interventions before pathologic change has                    begun 2. Screening – helps to
identify high-risk populations and individuals 3. Early Detection – involves finding a
precancerous lesion or a cancer at its earliest,                      most treatable stage
                   - also called secondary prevention                      - methods
                         a. inspection                          b. palpation                           c.
use of tests or procedures Approaches to Cancer prevention 1. Education 2. regulation –
prohibit the sale of tobacco and alcohol to minors, limiting smoking in                       public
places, imposing excise taxes, regulating the use of                    manufactured carcinogens such
as asbestos, and prohibiting carcinogens                    in foods 3. host modification               -
aims to alter the body’s internal environment to decrease the risk of or to                reverse a
carcinogenic process Cancer Prevention 1. Skin: Avoid exposure to sunlight 2. Oral: Annual
oral examination 3. Breast: Monthly BSE from age 20 4. Lungs: Avoid cigarette smoking;
annual chest x-ray 5. Colon: DRE for person over age 40. Rectal biopsy, proctosigmoidoscopic
examination, Guiac stool examination for persons age 50 and above 6. Uterus: annual Pap’s
smear from age 40 7. Basic: annual physical examination and blood examination Dietary
Recommendations against cancer 1. Avoid obesity 2. Cut down on total fat intake 3. Eat more
high fiber foods – raw fruits and vegetables, whole grain cereal 4. Include food rich in vitamin A
and C in daily diet 5. Include cruciferous vegetables in the diet-brocolli, cabbage, cauliflower,
brussel sprouts 6. Be moderate in the consumption of alcoholic beverages 7. Be moderate in the
consumption of salt-cured, smoked-cured and nitrate-cured foods Recommendations of the
American Cancer Society for Early Cancer Detection             1. For detection of breast cancer
a. Beginning at age 20, routinely perform monthly breast self-examination                  b. Women
ages 20-39 should have breast examination by a healthcare provider                     every 3 years
         c. Women age 40 and older should have a yearly mammogram and breast                          self-
examination by a healthcare provider          2. For detection of colon and rectal cancer            a. all
persons age 50 and older should have a yearly fecal occult blood test               b. digital rectal
examination and flexible sigmoidoscopy should be done every                     5 years          c.
Colonoscopy with barium enema should be done every 10 years               3. For detection of uterine
cancer          a. yearly papanicolao (Pap) smear for sexually active females and any female
            over age 18          b. At menopause, high-risk women should have an endometrial
tissue sample 4. For detection of prostate cancer                a. beginning at age 50, have a yearly
digital rectal examination            b. beginning at age 50, have a yearly prostate-specific antigen
(PSA) test American Cancer Society’s seven warning signs of cancer (uses acronym
CAUTION):          1. Change in bowel or bladder habits         2. A sore that does not heal       3.
Unusual bleeding or discharge          4. Thickening or lump in breast or elsewhere          5.
Indigestions or difficulty in swallowing         6. Obvious change in wart or mole         7. Nagging
cough or hoarseness Diagnostic tests of Cancer 1. Biopsy/cytology               a. Histologic and
cytologic examination of specimens are performed by the                pathologist on tissues collected
by needle aspiration of solid tumors, exfoliation           from epithelial surface, and aspiration of
fluid from blood or body cavities         b. Tissues may be obtained by excisional biopsy, incisional
biopsy, and needle            biopsy      c. By examination of these tissues, the name, grade, and
stage of the tumor can be           identified        2. Papanicolao Test (Pap Smear)              Class
I: Normal           Class II: Inflammation           Class III: Mild to moderate dysplasia
Class IV: Probably malignant              Class V: Malignant 3. Ultrasound 4. MRI 5. X-rays 6. CT
scan 7. Radiographic techniques 8. Antigen Skin test 9. Laboratory tests                a. Alpha-feto-
protein          b. HCG            c. Prostatic Acid Phosphatase (PSA)             d.
Carcinoembroyenic antigens (CEA) 10. Endoscopic examination 11. Monoclonal antibodies C.
Tumor markers         1. Tumor markers are protein substances found in the blood or blody fluids
2. Are released either by the tumor itself, or by the body as a defense in response to           the
tumor (called host response) 3. Tumor markers are derived from the tumor itself. And include
the ff:                 a. Oncofetal antigens, present normally in fetal tissue, may indicate an
                   anaplastic process in tumor cells; carcinoembyonic antigen (CEA)
                   and alpha-fetoprotein (AFP) are examples of oncofetal antigens.
b. Hormones are present in large quantities in the human body;                             however, high
levels of hormones may indicate a hormone-secreting                             malignancy; hormones
that may be utilized as tumor markers include                          the antidiuretic hormone (ADH),
calcitonin, catecholamines, human                          chorionic gonadotropin (HCG), and
parathyroid hormone (PTH)                         c. Isoenzymes that are normally present in a
particular tissue may be                        released into bloodstream if the tissue is experiencing
rapid,                     excessive growth as the result of tumor; are examples include
                   neuron-specific enolase (NSE) and prostatic acid phosphatase (PAP)
                d. Tissue-specific proteins identify the type of tissue affected by
malignancy; an example of a tissue-specific protein is the protastic-                            specific
antigen (PSA) utilized to identify prostate cancer 4.Host-response tumor makers include the
following:                    a. C-reactive protein                   b. Interleukin-2                     c.
Lactic dehydrogenase                      d. Serum Ferritin                             e. Tumor necrosis
factor Staging 1. The TNM tumor system is utilized for classifying tumors                     a. T indicates
the tumor size                     1) T0 indicates no evidence of tumor               2) Tis indicates
tumor in situ          3) T1,T2,T3,T4 indicate progressive degrees of tumor size and involvement
       b. N indicates lymph node involvement                   1) N0 indicates no abnormal lymph
nodes detected            2) N1a, N2a indicate regional nodes involved with increasing degree
from               N1a to N2a, no metastases detected                3) N1b, N2b, N3b indicate regional
lymph nodes involvement with increasing                                   Degree from N1b to N3b,
metastasis suspected              4) Nx indicates inability to assess regional nodes            c. M
indicates distant metastases             1) M0 indicates no evidence of distant metastasis                  2)
M1, M2,M3 indicate ascending degrees of distant metastasis and includes                       distant lymph
nodes Different Modalities for Cancer 1. Surgical interventions 2. Chemotherapy 3. Radiation
therapy 4. Immunotherapy 6. Bone Marrow transplantation Surgical Intervention 1. Preventive
surgery- removal of precancerous lesions or benign tumors 2. Diagnostic surgery- biopsy 3.
Curative surgery- removal of an entire tumor 4. Reconstructive surgery – improvement of
structures and function of an organ 5. Palliative surgery – relief of distressin signs and
symptoms; retardations of metastasis Common Nursing Techniques and Procedures A.
Radiation therapy        1. Is used to kill a tumor, reduce the tumor size, relieve obstruction, or
decrease         pain      2. Causes lethal injury to DNA, so it can destroy rapidly multiplying
cancer cells,        as well as normal cells         3. Can be classified as internal radiation therapy
(bachytherapy) or external            radiation therapy (teletherapy) B. The client undergoing
brachytheraphy ( internal radiation)         1. Sources of internal radiation            a. Implanted into
affected tissue or body cavity            b. Ingested as a solution                 c. Injected as a
solution into the bloodstream or body cavity               d. Introduced through a catheter into the
tumor      2. Side effects of internal radiation            a. Fatigue          b. Anorexia            c.
Immunosuppression                d. Other side effects similar to external radiation        3. Priority
nursing diagnoses: Impaired tissue integrity; fatigue; anxiety; risk for             infection; Social
isolation; Imbalanced nutrition: less than body requirements             4. Client education            a.
Avoid close contact with others until treatment is completed                 b. Maintain daily activities
unless contraindicated, allowing for extra rest                 periods as needed            c. Maintain
balanced diet; may tolerate food better if consumes small,                    frequent meals            d.
Maintain fluid intake ensure adequate hydration (2-3 liters/day)                   e. If implant is
temporary, maintain bedrest to avoid dislodging the implant.                   f. Excreted body fluids may
be radioactive; double-flush toilets after use              g. Radiation therapy may lead to bone
marrow suppression           5. Nursing management of client receiving internal radiation                  a.
Exposure to small amounts of radiation is possible during close contact with                      persons
receiving internal radiation: understand the principles of protection                  from exposure to
radiation: time, distance, and shielding              1) Time: minimize time spent in close proximity
to the radiation              source; a common standard is to limit contact time to 30 minutes
            total per 8-hour shift; minimum distance of 6 feet used when                       possible
         2) Distance: maintain the maximum distance possible from the                         radiation source
         3) Shielding: use lead shields and other precautions to reduce exposure                       to
radiation          b. Place client in private room           c. Instruct visitors to maintain at least a
distance of 6 feet from the client and               limit visitors to 10-30 minutes             d. Ensure
proper handling and disposal of body fluids, assuring the containers                     are marked
appropriately           e. Ensure proper handling of bed linens and clothing                f. In the event of
a dislodged implant, use long-handled forceps and place the                    implant into a lead
container; never directly touch the implant              g. Do not allow pregnant woman to come into
any contact with radiation              sources; screen visitors and staff for pregnancy               h. If
working routinely near radiation sources, wear a monitoring device to                      measure exposure
        i. Educate client in all safety measures          6. Evaluation: client demonstrates measures to
protect others from exposure to              radiation, identifies interventions to reduce risk of
infection, remains free from             infection, achieves adequate fluid and nutritional intake, and
participates in          activities of daily living (ADLs) at level of ability C. The client undergoing
external radiation therapy (teletheraphy)             1. The radiation oncologist marks specific
locations for radiation treatment using                a semipermanent type of ink                a. Treatment
is usually given 15-30 minutes per day, 5 day per week, for 2-7                       weeks           b. The
client does not pose a risk for radiation exposure to other people               2. side effects of external
radiation therapy            a. Tissue damage to target area (erythema, sloughing, hemorrhage)
         b. Ulcerations of oral mucous membranes                  c. Gastrointestinal effects such as
nausea, vomiting, and diarrhea               d. Radiation pneumonia               e. Fatigue           f.
Alopecia            g. Immunosuppression             3.Priority nursing diagnoses: risk for infection;
impaired skin integrity; social             isolation; disturbed body image; anxiety; fatigue              4.
Client education exam for external radiation a.           Wash the marked area of the skin with plain
water only and pat skin dry; do not use soaps, deodorants, lotions, perfumes, powders or
medications on the site during the duration of the treatment; do not wash off the treatment site
marks b.       Avoid rubbing, scratching, or scrubbing the treatment site; do not apply extreme
temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor c.
Wear soft, loose-fitting over the treatment area d.          Protect skin from sun exposure during the
treatment and for at least 1 year after the treatment is completed; when going outdoors, use sun-
blocking agents with sun protector factor (SPF) of at least 15 e.             Maintain proper rest, diet,
and fluid intake as essential to promoting health and repair of normal tissues f.                Hair loss may
occur; choose a wig, hat, or scarf to cover and protect head (refer to care of client with alopecia
later in chapter)         5. Nursing management of the client receiving external radiation                    a.
Monitor for adverse side effects of radiation               b. Monitor for significant decreases in white
blood cell counts and platelet             counts           c. Client teaching (refer to later sections for
management of                 immunosuppression, thrombocytopenia                 6. Evaluation; client
identifies interventions to reduce risk of infection, remains                free from infection, achieves
adequate fluid and nutritional intake, participates               in activities of daily living (ADLs) at
level of ability, and maintains intact             skin. The Client Undergoing a Bone Marrow
Transplant (BMT) 1. BMT – used in the treatment of leukemias, usually in conjunction with
radiation or chemotherapy            a. Autologous BMT – the client is infused with own bone
marrow harvested                  during remission of disease             b. Allogenic BMT – the client is
infused with donor bone marrow harvested                        from a healthy individual 2. The bone
marrow is usually harvested from the iliac crest, then frozen and stored until transfusion 3.
Before receiving the BMT, the client must first undergo a phase of immunosuppressive therapy
to destroy the immune system, infection, bleeding, and death are major complications that can
occur during this conditioning phase 4. After immunosuppression, the bone marrow is transfused
intravenously through a central line 5. Side of BMT                a. malnutrition         b. infection
related to immunosuppression              c. bleeding related to thrombocytopenia 6. Priority Nursing
Diagnoses          a. Risk for infection          b. Risk for hemorrhage           c. Risk for imbalanced
nutrition        d. Social isolation         e. Anxiety 7. Nursing Management of client undergoing a
bone marrow transplant            a. Monitor for graft-versus-host disease             b. Provide private
room for the hospitalized client; client will be hospitalized for                 6-8 weeks          c.
Encourage contact with significant others by using telephone, computer, and                      other means
of communication to reduce feelings of isolation               d. Refer to management for imbalanced
nutrition, immunosuppression and                  thrombocytopenia 8. Evaluation: client evaluates
understanding of risks and participates in activities that reduce risk of infection, hemorrhage,
and malnutrition; client demonstrates effective coping mechanisms The Client Undergoing
other therapeutic interventions 1. Immunotherapy/biologic response modifiers (BMR)                        a.
Enhances the person’s own immune responses in order to modify the biologic                         processes
resulting in malignant cells          b. Currently considered experimental in use               c.
Monoclonal antibodies: antibodies are recovered from an inoculated animal                        with a
specific tumor antigen, then given to the person with that particular                  cancer type; the goal
is: destruction of the tumor          d. Cytokines: normal growth-regulating molecules possessing
antitumor abilities                   1) Interleukin-2(IL-2) increases immune response effective and
                    destroys abnormal cells                       2) Interferons are substances produced
by cells to protect them from                         viral infection and replication; interferon-alpha 2b
is most                     commonly used                         3) Hematopoietic growth factors such as
granulocyte colony-                          stimulating factor (G-CSF) and erythropoietin, balance the
                     suppression of granulocytes and erythrocytes resulting from
chemotherapy           e. natural killer cells (NK cells) : exert a spontaneous cytotoxic effect on
         specific cancer cells; they also secrete cytokines and provide a resistance to
metastasis 2. Gene therapy             a. Current use in investigational           b. Increases
susceptibility of cancer cells to the destruction by other treatments;                 insertion of specific
genes enhances ability of client’s own immune system to                    recognize and destroy cancer
cells 3. Photodynamic theory            a. Used to treat specific superficial tumors such as those of
the surface of           bladder, bronchus, chest wall, head, neck and peritoneal cavity                 b.
Photofirin, a photosensitizing compound, is administered intravenously where                       it is
retained by malignant tissue           c. Three days after injection, the drug is activated by a laser
treatment which             continues for 3 more days             d. The drug produces a cytotoxic
oxygen molecule (singlet oxygen)               e. During intravenous administration, monitor for chills,
nausea, rash, local skin            reactions, and temporary photosensitivity              f. Drug remains
in tissues 4-6 weeks after injection; direct or indirect exposure                 to sun activates drug,
resulting in chemical sunburn; educate client to protect                 skin from exposure to sun
Oncologic Emergencies: Diagnosis and Management 1. Spinal Cord Compression                            a.
Occurs secondary to pressure from expanding tumors                   b. Early symptoms include back and
leg pain, coldness, numbness, tingling,                paresthesias, progression leads to bowel and
bladder dysfunction, weakness,               and paralysis           c. Early detection is essential:
investigate all complaints of back pain or               neurological changes            d. Treatment is
aimed at reducing tumor size by radiation and/or surgery to                    relieve compression and
prevent irreversible paraplegia; may receive                 corticosteroids to reduce cord edema
e. Nursing interventions include early recognition of symptoms, neurological                       checks and
medication administration 2. Superior vena cava syndrome                    a. Compression or obstruction
of the superior vena cava (SVC)            b. Usually associated with cancer of the lungs and
lymphomas            c. signs and symptoms are the result of blockage of venous circulations of
head,           neck, and upper trunk           d. Early signs and symptoms are periorbital edema and
facial edema          e. Symptoms progress to edema of neck, arms, and hands, difficulty
swallowing,              shortness of breath         f. Late signs and symptoms are cyanosis, altered
mental status, headache, and             hypotension           g. Death may occur if compression is not
relieved        h. Treatment included high-dose radiation to shrink tumor and relieve symptoms
       i.Nursing interventions include:             a. Monitoring vital signs             b. providing
oxygen support             c. preparing tracheostomy if necessary                d. initiating seizure
precautions            e. administering corticosteroids to reduce edema 3. Disseminated
intravascular coagulopathy (DIC)             a. Severe disorder of coagulation, often triggered by
sepsis, whereby abnormal               clot formation occurs in the microvasculature; this process
depletes the            clotting factors and platelets, allowing extensive bleeding to occur tissue
          hypoxia occurs as a result of the blockage of blood vessels from the clots                 b. Signs
and symptoms are related to decreased blood flow to major organs                       (tachycardia, oliguria,
dyspnea) and depleted clotting factors (abnormal                  bleeding and hemorrhage)               c.
Treatment includes anticoagulants to decrease stimulations of coagulation and
transfusion of one or more of the following:                         1) fresh frozen plasma (FFP)
                 2) cryoprecipitate                     3) platelets                   4) packed RBC
d. Nursing interventions include assessing client, monitoring for bleeding,                     applying
pressure dressings to venipuncture sites, and preventing risk of                   sepsis        e. Mortality
for clients experiencing DIC is greater than 70% despite aggressive                     treatment 4. Cardiac
tamponade           a. Pericardial effusion secondary to metastases or esophageal cancer can lead to
          compression of heart, restricting heart movement and resulting in cardiac
tamponade           b. Signs and symptoms are related to cardiogenic shock or circulatory collapse:
          anxiety, cyanosis, dyspnea,hypotension, tachycardia,tachypnea,impaired                       levels
of consciousness, and increased central venous pressure                 c. Pericardiocentesis is performed
to remove fluid from pericardial sac            d. Nursing interventions                       1)
administering oxygen                      2) maintaining intravenous line                         3)
Monitoring vital signs                    4) hemodynamic monitoring                            5)
administration of vasopressor agents COMMON CANCER DISORDERS I. BREAST
CANCER             - unregulated growth of abnormal cells in breast tissue Etiology and
pathophysiology          A. cause is unknown but many risk factors influence development                    1.
Female gender and white Caucasian race                2. family history of mother or sister with breast
cancer        3. medical history of cancer of other breast, endometrial cancer or atypical
Hyperplasia          4. Menarche before age 12 (early) or menopause after age 50(Late)                5.
First birth after 30 years of age, oral contraceptive use (early or prolonged),                prolonged
use of estrogen replacement therapy             6. Lifestyle factors: high-fat diet, obesity, high
socioeconomic status, breast               trauma, smoking, ingesting more than 2 alcoholic drinks
daily        7. Exposure to radiation through chest x-ray, fluoroscopy B. Begins as a single
transformed cells and is hormones-dependent; does not                 develop in women without
functioning ovaries who never received hormones                 replacement therapy         C. Most often
occurs in ductal areas of breast D. Noninvasive: does not penetrate surrounding tissues; may
be ductal or lobular;         usually diagnosed through mammogram or nipple discharge E.
Invasive: penetration of tumor into surrounding tissue            Manifestations 1. Lump in upper outer
quadrant of breast, usually nontender but may be tender 2. dimpling of breast tissue surrounding
nipple, or bleeding from the nipple 3. Asymmetry with affected breast being higher 4. Regional
lymph nodes swollen and tender Management 1. Radiation therapy 2. Mastectomy                        a)
Segmental mastectomy – or lumpectomy; removes the tumor and margin of                            breast
tissue surrounding the tumor            b) simple mastectomy – removal of the complete breast but no
other structures          c) Modified radical mastectomy – removal of the breast and axillary lymph
         nodes but chest wall muscles are not resected              d) Radical mastectomy – removal of
the breast, axillary lymph nodes and                underlying chest wall muscles          e) Breast
reconstruction – may be performed at the time of mastectomy or may                      be done at a later
time; can be accomplished through submuscular breast                    implant, placing an implant after
using a tissue expander, using muscles with                 intact blood supply from the back or
abdomen, or creating a free muscle flap                with the gluteus maximus muscle 3. Medication
therapy         a. Tamoxifen (Novadex) interferes with estrogen activity for treating advanced
          breast cancer          b. Chemotherapy – when axillary nodes are involved Care of
patient undergoing mastectomy 1. Maintain usual postoperative assessment 2. Begin emotional
support before surgery and continue in postoperative period 3. Turn, cough and deep breathe to
prevent respiratory complications; restrictive surgical dressing may decrease chest expansion 4.
Position client on back or unaffected side 5. Jackson-Pratt drain or Hemovac may be in place to
drain fluids that accumulate when lymph nodes are removed 6. Note signs of bleeding on
dressing and reinforce pressure dressing as needed 7. Encourage early range of motion exercise
to prevent contractures are lymphedema 8. Use unaffected arm only to provide IV fluids and take
blood pressure 9. Discharge instructions             a) Use caution when lifting heavy objects with
arms on affected side           b) Avoid injury and infection on affected side; wear rubber gloves
when            washing dishes and garden gloves when working outside                  c) Don’t allow
procedures, such as blood pressure or venipunctures on the                  affected side        d) Refer
client to support group for psychosocial support B. PROSTATE CANCER                         - unregulated
growth of abnormal cells in the prostate gland           Etiology/pathophysiology           1.
Adenocarcinoma is most common type; high levels of testosterone may play a                       Role
2. Usually begins in peripheral tissue on back and sides of the gland              3. Metastasis via
lymph and venous changes is common; bony tissue is major                     site of distant metastasis-
especially pelvic bones and spine            4. Is seen predominantly over 40 years of age Clinical
Manifestations           1. Clients in early stages often show no symptoms; tumor may be found
during             digital prostate exam         2. Genitourinary: dysuria, frequency, reduced force of
stream, hematuria,              nocturia,abnormal prostate found on DRE              3. Musculoskeletal:
back pain, migratory bone pain, bone or joint pain              4. Neurologic: nerve pain, muscle
spasms, bowel or bladder dysfunction,                 bilateral weakness of lower extremities            5.
Systemic: fatique and weight loss       Diagnostic and Laboratory tests           1. Prostate-specific
antigen (PSA) levels         2. Transurectal ultrasound (obtained if PSA results are abnormal)
      3. tissue biopsy        4. bone scan       5. MRI          6. CT scans to detect metastasis
Therapeutic Management             1. Hormone therapy          2. Radiation therapy          3. Brachy
therapy (Radioactive seeds implanted in the prostate)            4. Prostatic cryosurgery         5.
Surgery                   a) Orchiectomy – decreases androgen production                         b)
Radical procedures include removal of gland, capsule,ampulla,vas
deferens,seminal vesicles, adjacent lymph nodes, and cuff of bladder                            neck
                 c) Suprapubic prostatectomy – abdominal and bladder incisions to
                    remove prostate tissue                  d) Retropubic prostatectomy – low
abdominal incision without opening                         bladder                   e) Perineal
prostatectomy – incision between scrotum and anus                           (perineal area)
                 f) Homium laser – laser treatment; less bleeding, fewer complications
                    and shorted hospital day       6. Medication therapy                      a. estrogen
therapy of luteinizing hormone antagonist (Lupron) given                           to slow rate of
growth and extension of tumor                     Nursing Management of Patient Undergoing
Prostate Surgery 1. Maintain usual postoperative assessment 2. If dressings are present, monitor
for drainage and change as needed 3. Monitor vital signs closely for 24 hours, observing for
signs of hemorrhage (frank blood in urine, large blood clots, decreased haemoglobin and
hematocrit, tachycardia, and hypotension) 4. IN clients who have a urinary catheter following
surgery, traction may be applied against the prostatic fossa to prevent bleeding; the balloon at the
tip of the catheter exerts pressure to prevent hemorrhage; the surgeon positions the external end
of the catheter by anchoring it tightly to the client’s inner thigh to maintain traction; the catheter
should not be repositioned 5. A client who has a large indwelling catheter may feel the urge to
void, which results from stimulation of the micturition center, explain to the client that this is a
normal sensations; efforts by the client to void or strain will increase the risk of bleeding and
aggravate pain 6. Continuous bladder irrigation (CBI) may be ordered on a client postoperatively
      a. The purpose of the CBI is to prevent the formation of blood clots             b. If blood clots
do form, the urinary catheter will become plugged and prevent                 outflow of urine; the
obstruction will also cause bladder spasms and pain            c. A key nursing intervention for the
client in CBI is to keep the outflow from the            catheter light pink or clear; the rate of
administration of the irrigating solution is          therefore titrated to keep the color of the
outflow this color and prevent blood            clots from forming; it is essential to calculate intake
and output to determine true            urine output        d. Indications that the rate of the
irrigations is inadequate include: decreased            outflow from the catheter; bladder spasms;
and dark-colored or frankly            bloody drainage 7. Monitor client for signs of
hemorrhage;bladder spasms and frank bloody output may indicate bleeding 8. The irrigating
solution used during and after surgery may be absorbed causing fluid shifts and dilutional
hyponatremia, referred to as TURP syndrome; monitor the client for signs of hyponatremia and
bradycardia, nausea and vomiting, monitor serum sodium levels and haemoglobin and
hematocrit; in addition, other signs of volume excess will also be evident, including hypertension
and confusion 9. If manual irrigations are ordered, maintain sterile technique 10. Medicate as
needed for pain          DOWNLOAD

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