Med Surg – Oncology :Nursing management in Cancer Care – Flashcards
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Prevalence of cancer in US
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Affects more than 1.5 million Second only to cardiovascular disease as a cause of death Leading causes of cancer death include: Lung, prostate and colorectal CA in men Lung, breast and colorectal CA in women Worldwide, cancer affects men more than women and is higher in industrialized nations
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Cancer - terms
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1. Disease process that begins when abnormal cell is transformed by genetic mutation of cellular DNA 2. Metastasis: abnormal cells have invasive characteristics, infiltrate other tissues 3. Malignant cancer cells: demonstrate uncontrolled growth that does not follow physiologic demand (neoplasia) 4. Anaplasia: pattern of growth in which cells lack normal characteristics/shape/organization in relation to their cells of origin. These cells have increased malignant potential.
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Malignant Process
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1. Cell proliferation: uncontrolled growth with ability to metastasize and destroy tissue, and cause death. 2. Cell characteristics: presence of tumor-specific antigens, altered of shape, structure, metabolism 3. Metastasis: -Lymphatic spread -Hematogenous spread -Angiogenesis (growth of new blood vessels that allow cancer cells to grow) 4. Carcinogenesis (process of transforming nl into CA cells)
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Cancer - Effects on the body
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1. Change in bowel or bladder habits 2. A sore that does not heal 3. Unusual bleeding or discharge 4. Thickening or lump 5. Indigestion or difficulty swallowing 6. Obvious change in wart or mole 7. Nagging cough or hoarseness
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Is the following statement true or false? Malignant tumors spread by way of blood and lymph channels to other areas of the body.
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True Rationale: Malignant tumors spread by way of blood and lymph channels to other areas of the body. Cells bear little resemblance to the normal cells of the tissue from which they arose.
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Carcinogenic Agents and Factors
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1. Viruses, bacteria (20% of all CA) 2. Physical factors: sunlight, radiation, chronic irritation 3. Chemical agents: Tobacco, Asbestos -Tobacco smoke, thought to be the single most lethal chemical carcinogen, accounts for at least 30% of CA deaths. Associated with CA of lung, head/neck, esophagus, stomach, pancreas, cervix, kidney and bladder and with acute myeloblastic leukemia 4. Genetic, familial factors ( lifestyle, culture, genetic, shared environments) 5. Diet: ETOH, fats, cured meats, nitrates, red & processed meats 6. Hormones
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Hormonal Agents
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1. Combo of estrogen and progesterone alone vs estrogen alone may decrease risk of endometrial CA but may increase risk of breast CA, CAD, Stoke and blood clots 2. Oral contraceptives and prolonged estrogen Rx are assoc. with an increase in hepatocellular, endometrial, and breast CA, but may decrease the risk of ovarian CA.
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Which specific agents or factors are associated with the etiology of cancer? Dietary and genetic factors Hormonal and chemical agents Viruses All of the above
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All of the above Rationale: Specific agents or factors associated with the etiology of cancer include viruses and bacteria, physical factors; sunlight, radiation, chronic irritation, chemical agents; tobacco, asbestos, genetic and familial factors, diet, hormones.
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Primary and Secondary Prevention
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1.Primary prevention: concerned with reducing cancer risk in healthy people. 2.Secondary prevention: involves detection, screening to achieve early diagnosis, intervention 3.Now great emphasis on primary, secondary prevention of cancer
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Primary Prevention
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Avoid known carcinogens Lifestyle, dietary changes to reduce cancer risk Public, patient education Vaccinations/Immunizations
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Secondary Prevention
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Identification of patients at high cancer risk Cancer screening Self-breast exam Self-testicular exam Screening colonoscopy PAP test Public, patient education
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Tumor Staging and Grading
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1. Staging: determines size of tumor, existence of metastasis TNM T: extent of primary tumor N: lymph node involvement M: extent of metastasis 2. Grading: classification of tumor cells
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Cancer Management
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1. Cure 2. Control 3. Palliation E.g Comfort, Pain Management, Relieves Symptoms.
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Surgical Treatment
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1. Diagnostic surgery 2. Biopsy: excisional, needle, incisional -Excisional for small, easily accessible tumors -Incisional for large tumor masses -Needle, most often as outpatient: fast, inexpensive 3 Tumor removal: wide excision, local excision 4 Prophylactic surgery e.g. colectomy,mastectomy and oophorectomy 5. Palliative surgery 6. Reconstructive surgery
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Which type of surgery is being done when lesions that are removed are likely to develop into cancer? Diagnostic Palliative Prophylactic Reconstructive
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Prophylactic Rationale: The type of surgery being done when lesions that are removed are likely to develop into cancer is called prophylactic surgery. Diagnostic surgery such as a biopsy is usually performed to obtain a tissue sample for analysis of cells suspected to be malignant. Palliative surgery is performed in an attempt to relieve complications of surgery. Reconstructive surgery is carried out in an attempt to improve function or obtain a more desirable cosmetic effect
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Nursing Care of the Patient Undergoing Radiation Therapy
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1. Patient, family education 2. Restrictions, precautions 3. Skin care 4. Oral care: mucositis/stomatitis (irritated and bleeding gums/mucous membranes) 5. Protection of care providers: -Posting of safety precautions -Staff wear dosimeter badges -No pregnant RN allowed as care giver or visitor -Limit visitors to 30 min. No children allowed -Keep 6 foot distance from radiation source - Plan care so the nurse is not in the room for more than 30mins at a time
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Dosimeter
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The personal ionising radiation dosimeter is of fundamental importance in the disciplines of radiation dosimetry and radiation health physics and is primarily used to estimate the radiation dose deposited in an individual wearing the device. Ionising radiation damage to the human body is cumulative, and is related to the total dose received, for which the SI unit is the sievert. Workers exposed to radiation, such as radiographers, nuclear power plant workers, doctors using radiotherapy, those in laboratories using radionuclides, and HAZMAT teams are required to wear dosimeters so a record of occupational exposure can be made. Such devices are known as "legal dosimeters" if they have been approved for use in recording personnel dose for regulatory purposes. Dosimeters can be worn to obtain a whole body dose and there are also specialist types that can be worn on the fingers or clipped to headgear, to measure the localised body irradiation for specific activities.
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Oral Care - Radiation Therapy
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1. Mucositis: inflammation of mucous membranes of oral cavity and GI tract. 2. Stomatitis: a form of mucositis, resulting in redness of of gums and tissues surrounding teeth > may lead to painful ulcerations, bleeding and secondary infection 3. Meticulous oral care is needed Assess pt for pain, dehydration, impaired nutrition
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Chemotherapy
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-Agents used to destroy tumor cells by interfering with cellar function, replication -Classification: Curative, control, or palliative
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Chemotherapy Toxicity
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1. Gastrointestinal: n/v = most common side effect. Initiating antiemetic drugs prior to chemo session helps. 2. Hematopoietic: bone marrow depression (neutropenia) 3. Renal: SIADH, decreased perfusion, interstitial nephritis 4. Cardiopulmonary: monitor EF and signs of CHF 5. Reproductive: possible sterility. Many agents are teratogenic...use reliable methods of birth control 6. Neurologic: encephalopathy, neuropathies in hands/feet 7. Cognitive: decline in information handling/speed of processing, visual-spatial, learning, memory 8. Fatigue: subjective and distressing
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Syndrome of Inappropriate Antidireutic Hormone( SIADH)
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-A condition in which high levels of a hormone cause the body to retain water. -In this condition, the body retains water instead of excreting it normally in urine. This process upsets the body's balance of minerals called electrolytes, especially sodium. -Treatments include fluid restriction and, possibly, medications to adjust electrolyte balance. Underlying conditions also need treatment
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Nursing Management in Chemotherapy
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1. Assessing fluid, electrolyte status 2. Assessing cognitive status 3. Modifying risks for infection, bleeding 4. Administering chemotherapy -Extravasation kit readily available (used if IV infiltrates and chemo drugs gets into the tissue this treats this because chemo drugs are corrosive(vesicants) and eat tissue. -Evidence based data on effective antidotes is limited -NEVER infuse vesicants into peripheral veins in hands/wrist. -Vesicants cause tissue damage and possibly necrosis -Hypersensitivity reactions: usually an allergic type reaction. DC infusion and initiate emergency measures 5. Protecting caregivers -When administering chemo treatment, nurses wear masks, googles, gloves due to aerosolization of the chemo drugs.
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Bone Marrow Transplantation
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-Used for hematological cancers that effect marrow or solid tumors treated with chemotherapy dosage that ablates(destroys) bone marrow - Types of BMT Allogenic (compatible donor) Autologous (from the patient) Syngeneic ( from identical twin) -Graft-versus-host disease: major cause of morbidity/mortality in 30-50% of allogenic transplants -Venous occlusive disease Nursing Care: Until engraftment of the new marrow occurs, the patient is at high risk for death from sepsis and bleeding
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Complimentary and Alternative Therapies for Cancer
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Accupuncture Massage Relaxation Guided Imagery Herbs, vitamins
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Impaired Skin Integrity: Erythematous Areas
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1. Avoid use of soaps, cosmetics, perfumes, powders, lotions and ointments, deodorants 2. Use only lukewarm water to bathe area 3. Avoid rubbing or scratching area (put mittens on patient) 4. Avoid shaving area with straight-edged razor 5. Avoid applying hot-water bottles, heating pads, ice, adhesive tape to area 6. Avoid exposing area to sunlight or cold weather (avoid temperature extremes). 7. Avoid tight clothing in area; use cotton clothing 8. Apply vitamin A and D ointment to area
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Impaired Skin Integrity: Wet Desquamation
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-Wet Desquamation = clinical pattern seen as a consequence of radiation exposure where the skin thins and then begins to weep(leaks fluid) because of loss of integrity of the epithelial barrier and decreased oncotic pressure -Sloughing of the epidermis and exposure of the dermal layer clinically characterize moist desquamation.
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Nursing Care: Wet Desquamation
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1. Do not disrupt any blisters that have formed 2. Avoid frequent washing of area 3. Report any blistering 4. Use prescribed creams or ointments 5. If area weeps, apply nonadhesive absorbent dressing 6. If area is without drainage, use moisture-, vapor-permeable dressings such as hydrocolloids, hydro gels on noninfected areas (Swearingen, 2008) 7. Consult with enterostomal therapist (ET), physician if eschar forms
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Alopecia: mainly a side effect of chemo
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-Discuss potential hair loss, regrowth with patient, family -Explore potential impact of hair loss on self-image, interpersonal relationships, sexuality -Prevent or minimize hair loss -Prevent trauma to scalp -Suggest ways to assist in coping with hair loss: -Encourage patient to wear own clothes, retain social contacts -Explain that hair growth usually begins again once therapy is completed - Consider wigs.
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Altered Nutrition: Nausea and Vomiting
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Assess patient's previous experiences, expectations of nausea and vomiting, including causes, interventions used Adjust diet before, after drug administration according to patient preference, tolerance Prevent unpleasant sights, odors, sounds in environment Give Frequent, small meals. Use distraction, music therapy, biofeedback, self-hypnosis, relaxation techniques, guided imagery before, during, after chemotherapy Administer prescribed antiemetic, sedatives, corticosteroids before chemotherapy, afterward as needed Ensure adequate fluid hydration before, during, after drug administration; assess intake, output Encourage frequent oral hygiene Provide pain relief measures if necessary Consult with dietician as needed Assess, address other contributing factors to nausea, vomiting
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Nutritional Problems - Chemo
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- Anorexia (No appetite) -Malabsoprtion -Cachexia ( extreme weight loss, body wasting away)
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Altered Body image
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-Assess patient's feelings about body image, level of self- esteem -Identify potential threats to patient's self-esteem Validate concerns with patient -Encourage continued participation in activities, decision making -Encourage patient to verbalize concerns -Individualize care for patient -Assist patient in self-care when fatigue, lethargy, nausea, vomiting, other symptoms prevent independence -Assist patient in selecting and using cosmetics, scarves, hair pieces, clothing that increase his or her sense of attractiveness -Encourage patient, partner to share concerns about altered sexuality and sexual function, to explore alternatives to usual sexual expression -Refer to collaborating specialists as needed
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Nursing care for Patient with cancer
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Meticulous care to prevent infection, e.g. 1. Avoid IM injections 2. Avoid insertion of foleys 3. Vital signs every 4 hrs 4. Monitor WBC 5. Avoid contact with sick personnel/visitors 6. Avoid rectal or vaginal procedures including use of tampons or suppositories (these are potential sources of infection 7. Keep room super clean, changing fluids and equipment daily
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Hospice
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1 .Comprehensive, multidisciplinary approach to care for patients with terminal illness, their families 2. Focuses on: - Quality of life - Palliation of symptoms - Psychosocial, spiritual care
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Which measure should the RN not teach a client about protecting the skin between radiation treatments? Handle the area gently. Avoid irritation with soap and water. Use a heating pad every day on the area. Wear loose fitting clothes.
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Use a heating pad every day on the area. Rationale: Measures to protect a client's skin between radiation treatments include handling the area gently, avoiding irritation with soap and water, and wearing loose-fitting clothing. The client should not use a heating pad every day on the area because it will not promote tissue repair.
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Monitoring and Managing Potential Complications
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Infection Septic shock Bleeding, hemorrhage
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Factors Contributing to Infection
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Impaired skin, mucous membrane integrity Chemotherapy Radiation therapy Biologic response modifiers Malignancy Malnutrition Medications Urinary catheter Intravenous catheterOther invasive procedures Contaminated equipment Age Chronic illness Prior infections Recent travel Pet excreta Prolonged hospitalization
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Septic Shock
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1. Septicemia, septic shock life-threatening complications that must be prevented or detected, treated promptly 2. Patients who are neutropenic and/or who have hematologic malignancies are at greatest risk 3. Signs, symptoms include altered mental status, either subnormal or elevated temperature, cool and clammy skin, decreased urine output, hypotension, tachycardia, other dysrhythmias, electrolyte imbalances, tachypnea, abnormal arterial blood gas values 4. Sepsis causes massive vasodilation which decreases BP( hypotension)
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Bleeding, hemorrhage
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1. Thrombocytopenia (decrease in circulating platelet count) 2. Most common cause of bleeding in patients with cancer, usually defined as platelet count of less than 100,000/mm3 (0.1 × 1012/L) 3. Plan of nursing care addresses nursing assessment parameters, interventions for patients at risk for bleeding 4. Minimize anything that pokes the patient E.g Needles.
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Is the following statement true or false? The most common cause of bleeding in cancer patients is thrombocytopenia.
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True Rationale: The most common cause of bleeding in cancer patients is thrombocytopenia.
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Breast Cancer
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1. Over a lifetime, risk is about 12%, or 1 in 8 women. 2. Risk increases with age: 2/3 are found in women 55+ 3. 5-10% breast CA is thought to be hereditary Multiple first degree relatives with early onset breast CA, breast and ovarian CA in same family, male breast CA, Ashkenazi Jewish background, BRCA1 and BRCA2 BRCA positive women have a 56-84% chance of CA Male BRCA2 mutation carries have a 6-7% chance of CA 4. 80%+ cases have no known family hx of disease
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Breast CA Prevention Strategies in High Risk Patient
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1. Long term surveillance with breast exams 2x/year 2. Chemoprevention / Prophylactic drugs with tamoxifen and raloxifene (Evista) 3. Prophyactic Mastectomy can reduce chance by 90% 4. Consultation with a genetic counselor, plastic surgeon and psychiatrist can be invaluable
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Breast cancer prophylactic drugs
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1. Tamoxifen 2. Raloxifene (Evista)
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Clinical s/sx of Breast CA
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-Most are found in upper, outer quadrant of breast (tail of sphinx) -Generally, lesions are non-tender, fixed and hard with irregular borders -Advanced signs and symptoms: 1. dimpling 2. nipple retraction or 3. skin ulceration -Generally, the smaller the tumor the better prognosis -5 year survival rate for stage I breast CA is 88% and for stage 4 is 15% -Distant metatasis commonly occur in bone, lung, liver, adrenals, skin and brain
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Recent changes in CA law re: mammograms
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1. Recently, CA law requires that women whose mammograms show dense breast tissue receive that information in writing. 2. "Your mammograms shows that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer." 3. From Kaiser org....."this information and the results of your mammogram is given to you to raise your awareness and to inform your conversations with your doctor."
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PostOp - Breast cancer surgery
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1. Most pts are discharged 1-2 days after axillary lymph node dissection with surgical drains in place. Some are same day surgery. Drains are usually removed 7-10 days post-op 2. Most can shower on second post-op day, but if reconstructive surgery was done, showering is postponed until drain is removed. 3. Arm exercises 3X/day to restore ROM 4. Heavy lifting >5-10 lb is avoided for 4-6 weeks 5. Chemotherapy is most commonly initiated after breast surgery and before radiation. It is recommended for those with positive lymph nodes or invasive tumors greater than 1 cm in size regardless of node status
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Colorectal cancer
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1. Cancers of the colon and rectum is now the THIRD most common CA in USA and third leading cause of cancer death in both men and women 2. Lifetime risk of CA is 1 in 20 3. Risk increases with age and with a family hx of colon CA and those with IBD or polyps 4. If detected early, survival rate is 90%; however most are detected late and their survival rate is low 5. Most patients are asymptomatic for long periods and only seek health care if a change in bowel habits or rectal bleeding 6. Prevention and early screening are key
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Risk factors for Colorectal Cancer
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Increasing age Family hx Previous colon CA or adenomatous polyps High consumption of ETOH Smoking Obesity Hx of gastrectomy Hx of IBD High fat, high protein esp beef and low fiber diets Genital or breast CA in women
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Assessment and Diagnosis - Colorectal cancer
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1. Abd and rectal exams 2. Fecal occult blood testing 3. Double contrast barium enema 4. Proctosigmoidoscopy and colonoscopy 5. The majority of cases are ID'ed with colonoscopy 6. Positive CEA ( carcinoembryonic antigen) is a tumor marker useful in assessing progression or recurrence of cancers, esp. of the GI tract
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Complications of colorectal CA
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Bowel obstruction Perforation Abscess formation Peritonitis Sepsis shock
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Colorectal CA -Treament
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1. Surgery is the main Rx, curative or palliative. -Segmental resection with anastomosis 2. May have adjuvant chemo or radiation Rx.
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Anastomosis
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A connection made surgically between adjacent blood vessels, parts of the intestine, or other channels of the body, or the operation in which this is constructed.
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Ostomy
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An ostomy is surgery to create an opening (stoma) from an area inside the body to the outside
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Locations of Ostomies and consistency of feces
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1. Ileostomy : fluid feces and the most irritating to skin 2. Ascending colon: fluid 3. Transverse colon: mushy and uniform 4. Sigmoid: Formed and least irritating to skin
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Nursing care of Stomas
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- Stoma should be pink to rosy - Meticulous skin care - The ONLY ostomy that can be irrigated is descending or sigmoid - Stoma should pouch out like a large nipple otherwise it can retract into peritoneal cavity and leak leading to peritonisis.
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Lung cancer
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The #1 cause of cancer deaths in men and women in the USA 15% of new cancers involve the lung or bronchus In approximately 70% of lung cancers the disease has spread to regional lymphatics and other sites by the time of diagnosis As a result, the long term survival rate is low Overall, the 5 year survival rate is only 16% The most common cause is cigarette smoke (90%)
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Lung cancer - Risk factors
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1. Cigarette smoke ( causes 1 of every 6 deaths in the USA due to lung or cardiovascular disease). 2. Exposure to second hand smoke 3. Environmental and occupational exposure, e.g. asbestos, pollution from refineries, motor vehicle emissions 4. Genetics: rate is 2-3X higher in close relatives of patients with lung cancer, regardless of smoking status
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Lung cancer- Signs and symptoms
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1. Asymptomatic until late in its course 2. Cough is present in 65-75% of patients 9often ignored because smoker's think it is a normal smoker's cough) 3. Airway obstruction 4. Dyspnea 5. Blood tinged sputum 6. Chest or shoulder pain could be r/t chest wall or pleural involvement 7. Chest tightness, hoarseness, head & neck edema if mets to lymphatics 8. Common sites of mets: lymph nodes, bone, brain, contralateral lung, adrenal glands and liver
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Lung Cancer - treatment
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Surgery Radiation chemotherapy
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Lung Cancer - Diagnostics
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CXR- Chest Xray Fiberoptic bronchoscopy Fine needle aspiration A variety of scans PFT's -Pulmonary Function Tests V/Q scans - ventilation/perfusion tests
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Research on cancer
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1. Antioxidants speed up lung cancer progression 2. Smoking doubles mortality risk in colorectal cancer survivors 3. Supplemental O2, FIO2 of .4 to .6 is able to "reprogram" the metabolism of cancerous tissues away from being hostile to anti-tumor killer cells 4. Green tea alters metabolism of cancer cells, slowing the spread of the disease as well as reducing overall cancer risk. 5. Diet rich in tomatoes may lower breast CA risk 6. A significant # of patients who will develop pancreatic CA manifest hyperglycemia or DM type II sometimes up to 3 years prior to diagnosis of pancreatic CA 7. Caramel colors in colas is carcinogenic: Worst is all types of Pepsi, Best is coca-cola. Super best is stop drinking so much soda.
