CARE OF PATIENT WITH CELLULAR PROLIFERATION

CARE OF PATIENT WITH CELLULAR PROLIFERATION Professor Joan Glasheen Lecturer OVERVIEW • Progress in prevention, treatment, & survival - Early detection - Sophisticated diagnostic tests - Aggressive chemotherapy, radiation, surgery - Effective management of side effects - Bone marrow transplants - Genetic research - Biological response therapy Epidemiology • Variables/Risk Factors - Sex - Site - Age - Race - Heredity/genetics - Obesity - Socio-economic status - Geographic's - Environmental exposure Health Promotion • Primary Prevention – control of risk factors • Secondary Prevention – early detection - CAUTION 7 WARNING SIGNS - ACS Guidelines • Tertiary Prevention – monitoring for complications, symptom management, support groups Guidelines for early detection of cancer GENERAL Cancer related Checkup: 18-40 years - every 3 years 40 years & older - every year BREAST 20 - 40 Years: Breast exam by MD every 3 years Breast self-exam every month Baseline mammogram between ages of 35 and 39. Every yr. >40 UTERINE/CERVIX Sexually active people or 18 yr. > Papanicolaou (Pap) smear & yearly pelvic examination Health Counseling: Smoking cessation, avoiding sun Exam for cancer of thyroid, testes, prostate, ovaries, skin, and lymph nodes. GUIDELINES FOR EARLY DETECTION OF CANCER PROSTATE 50yr. > Prostate Specific antigen <4mg/ml Combined with rectal examination, nearly 90% of clinically significant cancers can be detected. TESTICULAR 15 - 45 yr.: Testicular selfexam COLON & RECTUM Ages 40 years and older Digital rectal exam every year Ages 50 years and older Digital rectal exam every year Stool for occult blood year Protoscopic exam or flexible sigmoidoscopy every 5 yrs Anatomy & Physiology • Cell cycle (Go, resting, G2, S, G2, mitosis) • Normal Cell Characteristics - Appearance - Growth pattern - Differentiated functions - Non-migratory Characteristics of Early Embryonic Cells • • • • • • Rapid & continuous cell division Large nucleus Perform no differentiated functions Adhere loosely together Able to migrate Not contact inhibited Commitment Phase of Early Embryonic Cells • Turn off proto-oncogenes • Expression of specfic genes Biology of Abnormal Cells • Benign Neoplasm - Grow slowly - Show specific morphology - Small nucleus - Differentiated functions - Adhere tightly together - Grow orderly manner - Non-migratory • Malignant Neoplasm - Grows rapidly - Anaplastic morphology - Large nucleus - Undifferentiated - Adhere loosely together - Grow by invasion - Able to migrate Carcinogenesis/Oncogenesis • Steps of Malignant Formation - Initiation (pure carcinogens) - Latency Period - Promotion - Progression Metastasis • Malignant transformation - Extension into surrounding tissue • Tumor vascularization - Penetration into blood vessels • Blood vessel penetration - Release of tumor cells into blood • Arrest and invasion - Invasion of tissue at site of arrest Routes of Metastasis • Local Seeding • Bloodborne • Lymphatic Secondary Tumors Breast: Bone & lung Prostate: Bone (spine & legs); Pelvic nodes Lung Cancer: Brain, bone, liver, lymph nodes, pancreas Melanoma: GI tract, lymph nodes, lung, brain Colorectal: Liver, lymph nodes, adjacent structures Cancer Classification • Neoplasm - Benign: suffix - oma - Malignant: root sarco- or carcino• Tissue of origin - Epithelial: glands, ducts, mucous membrane - Connective tissue: bone, muscle, fat - Hematopoietic: blood vessels, bone marrow, lymph tissue - Pigmented: pigmented producing skin - Neural: Nerve Tissue • Name of scientist describing tumor – Hodgkins, Wilms Tumor Classification • Grading – Histological make-up (cellular aspects of tumor) Gx – G4 • Staging – exact location & extent of spread @ diagnosis – – – – Clinical Surgical Pathological TNM Classification: Tx, To, T1,2,3,4 ; Nx, No, N123 Mx, M0, M1 Phases of Cancer • • • • • • • Pre-diagnosis Initial Diagnosis Treatment Phase Readmission Phase Reoccurrence Terminal Survival Assessment • History – depends on phase of cancer - Focus on system of body - Height, weight, vital signs - Focus on effects of treatment - Review medications - Determine knowledge level • Subjective Data • Objective Data Collaborative Assessment • Laboratory blood tests – – – – – – CBC Platelet count WBC with differential Blood chemistry (ca ++; alkaline phosphatase Coagulation studies (PT,Ptt) Tumor markers (specific for types of cancer) Collaborative Assessment • • • • • • • Cytology Studies Biopsy Body Imaging – MRI, CT Scan Radiological Studies Ultrasound Endoscopies Immune Studies – antigen skin testing Nursing Diagnoses • Physiological Imbalanced nutrition Fatigue Altered comfort Altered oral mucosa Impaired skin integrity Disturbed sensory perceptions Nursing Diagnoses • Psycho-social Altered coping, individual/family Knowledge deficit Decisional conflict Grieving Powerlessness Hopelessness Altered body image Surgical Interventions • Purposes - Diagnosis - Cure - Control - Palliation - Reconstruction Surgical Interventions • Biopsies – Needle, incisional, excisional,staging • Local Incision • Wide Local Incision • Wide Excision • Extended Radical Excision Radiation Therapy • Treatment of disease with ionizing radiation - damage to DNA leads to cell death • Underlying Principles: - Dose Determination - Fractionalization • Purposes - Cure - Control - Palliation Radiation Therapy • Tele “distant” therapy – beam radiation (Cobolt 60) • Patient Preparation Side Effects – Site Specific • Skin Changes Local - skin changes - erythema, dryness, moist desquamation, hyperpigmentation • Head and Neck - mucous membrane • Breast - erythema, swelling, discomfort • Head/Brain - alopecia, CNS edema, motor & neuro deficits • Pelvis & long bones - diarrhea, bone marrow suppression • Lung & chest wall – pneumonitis, esophagitis • Radiation Syndrome – effects not related to site Brachytherapy • Use of high energy radioactive materials within body tissues • Rationale: A very limited dose, directly absorbed into malignant tissue for specific period of time • Types - Sealed isotopes (Molds, Plaques, Needles) - Unsealed (orally or IV for dx. or Rx. Of hyperthyroidism i.e.. iodine 131) Brachytherapy – Safety Principles • • • • • • “Caution: Radioactive Material” sign Know type & place of implant Time, Distance, Shielding Body fluids precautions Wear dosimeter badge Never touch radiation source with bare hands (Lead container & forceps in room) Chemotherapy • Goals - Cure - Control - Palliation Pathophysiological Principles of Chemotherapy • Cell Kill Hypothesis – Any dose of Chemo. Will destroy only a fraction of malignant cells (Overhead) • Cell Cycle Specific • Cell Cycle Non-specific • Combination Therapy (Tumor sensitivity, side effects, variation in timing of drug induced immunosuppression) • Hormones and Steroids Classification of Chemotherapeutic Agents • Alkylating Agents - Interferes with DNA Replications • Antimetabolites - Inhibits DNA Synthesis • Nitrosoureas - Interfere with DNA replication and repair. • Antitumor antibiotics - Interfere with nucleic acid synthesis and function, inhibits RNA synthesis and DNA synthesis • Plant Alkaloids) arrest or inhibits mitosis • Hormonal Therapy Dosage Calculation • Remember the Five Rights: medication, time, route, dose, patient • Calculate body surface area (BSA) • Recalculate drug and dosage against order • Check current labs • Review drugs and potential side effects • Verify informed consent • Pre-medicate if ordered Preparation • OSHA Standards - Reconstitute under Class II laminar flow biological safety cabinet - Wear protective clothing, latex gloves, gown, mask, goggles - Change protective clothing when contaminated - Careful disposal of drug contaminated items Routes of Chemo Therapy Administration (overhead) • • • • • Oral Intravenous Intra-arterial Isolated limb perfusion Intracavity – Intra-peritoneal – Intraventricular – Intrathecal – Intravesical • Intraperitoneal • Intraventricular • intrapleural Side Effects of Chemotherapy • Gastrointestinal - Nausea & Vomiting - Mucositis/stomatitis - Diarrhea & Constipation • Fatigue • Alopecia • Infection Side Effects of Chemotherapy • Bone Marrow Suppression - Anemia - Neutropenia - Granulocytopenia - Leukopenia - Thrombocytopenia NIC – Nutrition/Nausea & Vomiting • • • • • • Explore food preferences Avoid spicy foods Monitor weight Assess for Sx. Of dehydration Small frequent meals Administer antiemetics NIC – Mucositis/Stomatitis • Assess oral mucosa • Oral hygiene before & after meals - Rinse mouth with ½ strength peroxide/saline - Avoid alcohol or glycerine mouth washes Antimicrobal therapy Topical Anesthetics Soft diet, popsicles Artificial saliva NIC - Alopecia • Reassure that hair loss temporary • Use mild shampoos, avoid dyes & permanents • Cut hair short & purchase hair piece before loss • Ice caps, pressure caps NIC - Anemia • • • • Assess hemaglobin, hematocrit Encourage frequent rest periods Monitor packed red cell infusions Administer procrit if ordered NIC – Risk for infection • Monitor WBC – Handout on neutrapenia (Absolute Neutraphil Count (ANC) • Private room (CHIPS precautions) WBC > 1,000 mm3 • Avoid crowds • Strict handwashing • Low bacteria diet • Monitor IV sites, arm pits, genitalia, anal areas • Report temperature 100о F (38o C) NIC - Thrombocytopenia • Assess platelet counts <50,000 risk for bleeding; < 20,000 very high risk for hemorrhage • Assess for bleeding any orifice, petechiae, ecchymosis, hematomas • Avoid intramuscular injections, venopunctures • Avoid trauma to anal area Immunotherapy Biological Response Modifiers • Agents that restore, augment, or modulate the host’s normal immune system - Interleukins - Interferons • Agents that have direct antitumor effect • Agents that block access to cancer cells