Cancer and Oncological Emergencies

3. Cancer and Oncological Emergencies Cancer and Oncological Emergencies

4. Introduction • Cancer ranks 2nd to cardiovascular disease as the leading cause of death in the Gaza Strip. • Death rate increased from 10.3% in 2007 to 13.6 in 2012, 2016 (6.9-11.3%) • Some related factors : nutrition, physical inactivity, stress, obesity, and other lifestyle factors (preventable). • Some other factors may be genetic, or associated with chemical weapons used in wars by Israeli soldiers.

5. Key Points • Cancer is a neoplastic disease process that involves abnormal cell growth and differentiation. • Cancer is the growth of abnormal cells that tend to invade neighboring tissue and spread to distant body sites. • Condition of uncontrolled cellular proliferation ; no limits; no purpose. • The exact cause of cancer is unknown, but : • viruses, • physical and chemical agents, • hormones, • genetics, and • diet are thought to be factors that trigger abnormal cell growth.

6. Key Points • Cancer cells may invade surrounding tissues and/or spread to other areas of the body through lymph and blood vessels (metastasis). For a cell to become cancerous, the following genetic alterations must occur : • spur cell growth; • inactivate genes that normally slow growth; • allow cells to keep dividing, • allow cells to live on with abnormalities ( Lack of apoptosis); • recruit normal cells to support and nourish them, and to • develop strategies that prevent the immune system from destroying them

7. The Cell Clock • The cells possess some counting system that tells them when to stop dividing. • Uncontrolled growth • Cancer cells first develop from a mutation in a single cell • go through the cell cycle more often than normal, • overabundance of abnormal cells. • Uncontrolled cellular reproduction occurs when cells become independent of normal growth control signals (autonomous). • At a certain stage of development, the cancer cell fails to mature into the type of normal cell from which it originated, cancer cells can spread from the site of origin, a process called metastasis.

8. Abnormal cell growth • Cancers may arise from the skin, bone, organs, or blood. • Cancer is classified by the tissues or blood cells in which it originates. Most cancers derive from epithelial tissues and are called carcinomas. • Epithelial tissue; Carcinomas. • Glandular organs; Adenocarcinomas. • Mesenchymal (CT) tissue; Sarcomas. • Blood-forming cells; Leukemias. • Lymph tissue; Lymphomas. • Plasma cells; Multiple myeloma. • Pigment cells (melanomas) • Tissue of the brain and spinal cord (gliomas) • Erythrocytes (erythroleukemia).

9. Major tips: • Screening and early diagnosis are the most important aspects of care. The importance of early detection: Hx, risk factors

10. Risk Factors Age Genetic predisposition Exposures to chemicals, viruses, tobacco, and alcohol Diet high in fat and red meat, low in fiber Sun, ultraviolet light, or radiation exposure Sexual lifestyles: Multiple sexual partners, STD, HIV/AIDS Other risk factors include poverty, obesity, and chronic GERD

11. Diagnostic Procedures and Nursing Interventions Tissue biopsy – the definitive diagnosis of abnormal cancer cells. CBC and differential – screenings for leukemias. Chest x-ray, CT, MRI, PET are used to visualize tumors, metastasis, or progression of cancer. Tumor marker assays (CEA: carcinoembryonic antigen, CA 125: cancer antigen detected in ovarian ca , alpha fetoprotein: elevated in ca, liver ca, cirrhosis) – screenings that screen for cancers of the colon, pancreas, liver, prostate, uterus, and ovaries. Elevatedvalues are suggestive of cancer.

12. Therapeutic Procedures and Nursing Interventions • Radiation therapy - resulting in the death of cells. Side effects include skin changes, hair loss, and debilitating fatigue. • Internal radiation therapy • Client should be placed in a private room and bath. • Appropriate signage should be placed on the door • Health care personnel should wear a dosimeter film badge that records the amount of radiation exposure. • Visitors should be limited to 30-min visits and maintain a distance of 6 ft. • Visitors and health care personnel who are pregnant or under the age of 16 should not come in contact with the client. • A lead container should be kept in the client’s room • Precautions listed above should be carried out at home if the client is discharged during therapy.

13. Therapeutic Procedures and Nursing Interventions External radiation therapy Wash skin over irradiated area gently, with mild soap and water, and dry thoroughly using patting motions. Do not remove radiation “tattoos” that are used to guide therapy. Do not apply powders, ointments, lotions, or perfumes to irradiated skin. Wear soft clothing over irradiated skin and avoid tight or constricting clothes. Do not expose irradiated skin to sun or a heat source.

14. Therapeutic Procedures and Nursing Interventions Surgical excision – diagnostic, curative, or palliative. Risk of “seeding.” Chemotherapy – a certified provider administers systemic or local cytoxicmedications to destroy rapid dividing cells. Often, combinations of anticancer medications are used. The most significant adverse effect is immunosuppression (bone marrow suppression). Measures must be employed to reduce risk, especially at the medications’ nadir. Nausea and vomiting, alopecia, and mucositisare common side effects. Take measures to prevent extravasation of vesicants.

15. Assessment • Signs and Symptoms (clinical findings depend on the type and location of cancer) • Seven warning signs (CAUTION) • Change in bowel or bladder habits • A sore that doesn’t heal • Unusual bleeding or discharge • Thickening or lump in the breast or elsewhere • Indigestion or difficulty swallowing • Obvious change in warts or moles • Nagging cough or hoarseness • Weight loss • Fatigue/weakness • Pain (may not occur until late in the disease process) • Nausea/anorexia

16. Assess/Monitor For pain – evaluate PQRST (provokes, quality, radiates, severity, time) of pain Sleep/rest patterns to determine the need for intervention Oral cavity for ulcer/myositis related to immune suppression secondary to cancer treatment Fatigue/SOB VS, especially temperature to detect fever related to infection WBC and platelet count I&O Serum electrolytes Weight loss, cachexia, and wasting Diarrhea Skin alterations Agitation and restlessness Presence of support systems

17. NANDA Nursing Diagnoses Anticipatory grieving Risk for infection Fear/anxiety Imbalanced nutrition: Less than body requirements Ineffective tissue perfusion

18. Nursing Interventions Encourage screenings (Pap smear, mammogram, colonoscopy, stool for occult blood). Implement pain control measures as prescribed. Provide pain medication before pain becomes severe. Serve small amounts of cool food if mouth pain is present. Provide frequent oral care, soft toothbrush or swab, local anesthetic mouth rinse . Use distraction when appropriate (Quran, prayers, and imagery). Encourage/maintain nutrient intake. Perform calorie counts to determine intake. Provide liquid supplements as needed. Perform mouth care prior to serving meals to enhance appetite. Premedicate with antiemetics. Administer megestrol (Megace) to increase appetite. Add protein powders to food or tube feedings.

19. Nursing Interventions Reduce risks of neutropenia. Protect the client from sources of possible infection. Use hand hygiene. Encourage the client/significant others to use hand hygiene. Encourage the client to avoid crowds while undergoing chemotherapy. Administer colony-stimulating factors as prescribed to stimulate white blood cell production. Reduce risks of anemia. Administer oxygen as needed for fatigue. Encourage rest periods between periods of activity. Administer recombinant erythropoietin alpha as prescribed.

20. Nursing Interventions • Reduce risks of thrombocytopenia. • Avoid ASA/NSAIDs and IM injections if platelet count is decreased. • Administer antiemetics before treatments and meals. • Maintain IV fluids as prescribed. • Implement post-radiation care, if applicable: • Interventions are based on site of radiation: • Antidiarrheals for GI tract. • Mouth care for head and neck. • Octreotide (Sandostatin) if prescribed. • Encourage female clients to wear a hat or wig if undergoing radiation or chemotherapy that produces alopecia (hair loss).

21. Nursing Interventions • Listen to the client’s concerns, avoid false reassurance. • Provide prescribed anxiolytics if necessary. • Allow time for the client to discuss feelings regarding loss and to grieve (mastectomy, hysterectomy, limb, lack of options for further treatment).

22. Complications and Nursing Implications Oncologic Emergencies Syndrome of inappropriate antidiuretic hormone (SIADH) – due to excessive intravascular volume to increased ADH (common in bronchogenic cancers). Monitor the client for hyponatremia and low serum osmolality. Administer furosemide (Lasix), IV normal saline, and/or hypertonic saline as prescribed for severe hyponatremia. Spinal cord compression – related to metastases. Assess the client’s neurological status, including motor and/or sensory deficits. Administer corticosteroids as prescribed. Support the client during radiation therapy.

23. Descriptions of Tumor Growth and Spread • Tumor treatment often depends on the grade and stage of the cancer. • Grading: An assessment of the tumor based on the degree of anaplasia it demonstrates; poorly differentiated (highly anaplastic) cells are assigned a high grade. • Staging: A clinical decision about the size of a tumor, the degree of local invasion, and the degree to which it has metastisised. • Local Growth of a Tumor • compressing the cells and blocking off their blood supply • release chemicals or enzymes to kill neighboring cells. • To grow beyond a certain size, tumors must stimulate the development of their own blood supply ( angiogenesis) to meet high metabolic demands.

24. Metastasis • Movement of cancer cells from one part of the body to another; spread of cancer cells from the original (primary) site in the blood or lymph to a new, secondary site. • The term malignancy refers to the ability of a tumor to metastasize. • Cancer cells metastasize three ways: • by circulation through the blood and lymphatic system • by accidental transplantation during surgery • by spreading to adjacent organs and tissues.

25. Process of Metastasis • 1-Detachment • 2- Invasion • 3-Dissemination and Seeding • When the secondary site has reached a critical size, the tumor cells will again begin to produce tumor angiogenesis factor and new blood vessel formation will be initiated to support growth of this secondary site.

27. Female cancer

28. Breast cancer

30. Key Points Breast cancer is the most common cancer in women, 70% of cases occur after age 50. It ranks 2nd cause of death. A combination of BSE, CBE, and mammography is effective in detecting early breast cancer. An annual CBE and mammogram should be performed earlier for women at risk for breast cancer.

31. Risk Factors • High genetic risk: • First-degree relative with breast cancer (parent, sibling, or child) • Early age at diagnosis • Female sex (less than 1% of males develop breast cancer) • Age over 40 (premenopausal woman older than age 45) • Early menarche • Late menopause • First pregnancy after age 30 or nullparity • Endometrial or ovarian cancer • Early or prolonged use of oral contraceptives

32. Risk Factors premenopausal woman older than age 45 High-fat diet (possible risk) Low-fiber diet (possible risk) Excessive alcohol intake (possibly related to folic acid depletion) Cigarette smoking Exposure to low level radiation Hormone replacement therapy (HRT) Obesity History of endometrial or ovarian cancer

33. Diagnostic procedures and Nursing interventions • Mammogram • Prepare the client for mammogram; • No talcum powder or deodorant before the procedure. Mammograms are best done in the first 2 weeks of the menstrual cycle. • Biopsy: Definitive Diagnosis • Incisional biopsy is the surgical removal of tissue from a breast mass. • Excisional biopsy removes the mass itself for histologic exam. • Aspiration therapy is the removal of tissue or fluid from the breast mass through a large-bore needle. • The choice of treatment depends on the stage and size of the tumor, as well as nodal involvement.

34. Therapeutic Procedures andNursing Interventions • Surgical: • lumpectomy (breast-conserving), • wide excision or partial mastectomy, • total mastectomy, • modified radical mastectomy, • radical mastectomy, and • reconstructive surgery. • Adjuvant therapy • Radiation therapy, • Chemotherapy, or • Hormonal therapy)

35. Assessments • Monitor for signs and symptoms. • Skin changes (for example, peaud’orange) • Dimpling • Increased vascularity • Nipple retraction or ulceration • Enlarged lymph nodes • Breast pain or soreness

36. Assess/Monitor Risk factors for breast cancer Family Hxof breast cancer Hxof SBE and mammography Client’s understanding and expectations of treatment Dressings, drains for indications of postop. bleeding Circulatory status of affected arm I &O VS Postoperative drainage Fluid collection or swelling at operative site Signs of infection Pain Signs of disturbed body image

37. NANDA Nursing Diagnoses Anxiety Anticipatory grieving Acute pain Disturbed body image Impaired skin integrity Risk for infection

38. Nursing Interventions • Screening • All women • > age 20: Monthly BSE and annual CBE • Age 40: Baseline screening mammogram • Age 40 to 50: Yearly screening mammograms • Chemoprevention: Administration of selective estrogen receptor modifiers (SERMs) to women at high risk for breast cancer. • Prepare the client for surgery, radiation, or chemotherapy, as indicated.

39. Postoperative nursing interventions Administer pain medications as prescribed. Maintain surgical asepsis of dressings, incision, and drains. Support arm on operative side with sling while ambulating. Encourage the client to lie on the unaffected side postoperatively to relieve pain. Advise the client to avoid a dependent arm position. Encourage early arm exercises to prevent lymphedema and to regain full ROM. Avoid administering injections, taking BPs, or drawing blood from the affected arm.

40. Postoperative nursing interventions Teach the client to avoid constrictive clothing Emphasize SBE Refer the client to home health care services for care of drains and dressings Instruct the client to report numbness, pain, heaviness, or impaired motor function of the affected arm to the surgeon. Provide emotional support to the client and family. Refer the client to a community support group as appropriate.

41. Complications and Nursing Interventions Tumor invasion of lymphatic channels and seeding of cancer cells into the blood and lymphatic systems. The most common areas of metastases are the nearby bone, lungs, brain, and liver.

42. Cervical cancer

43. Key Points The incidence of cervical cancer in situ is increasing and affecting a younger population than in the past. Early cervical cancer is generally asymptomatic. Symptoms do not develop until the cancer has become invasive. Papanicolaou (Pap) tests are an effective screening tool for detecting the earliest changes associated with cervical cancer.

44. Risk Factors Early sexual activity (before 18 years old) Low economic status Chronic inflammation Infection with human papilloma virus (HPV), associated in 90% of cases History of sexually transmitted diseases (STDs) Infection with HIV Cigarette smoking Immunosuppression Intrauterine exposure to diethylstilbestrol (DES) during pregnancy

45. Diagnostic Procedures and Nursing Interventions Pap Smear – microscopic examination of cervical cells Cervical biopsy (definitive) is performed for cytologic studies when a cervical lesion is identified. Biopsy is usually performed during colposcopy as a follow-up to an abnormal Pap smear.

46. Therapeutic Procedures and Nursing Interventions Removal of the lesion by conization (conebiopsy), cryotherapy, laser ablation, or loop electrosurgical excision procedure (LEEP). Clients with more extensive cancer may require a total abdominal hysterectomy or a more extensive pelvic surgery called exenteration(UT, GI, & Gyne; colostomy & urostomy)

47. Assessments • Monitor for signs and symptoms: • Painless vaginal bleeding • Watery blood-tinged vaginal discharge • Leg pain (sciatic) or leg swelling • Flank pain (hydronephrosis) • Unexplained weight loss • Pelvic pain

48. Assess/Monitor Pain level Vital signs Signs of infection Signs of disturbed body image The client’s understanding and expectations of treatment

49. NANDA Nursing Diagnoses Acute pain Ineffective peripheral tissue perfusion

50. Nursing Interventions Treat and reverse anemia as indicated. Treat any pelvic, vaginal, or UT infections. Administer analgesic as prescribed. Provide emotional support to the client and family. Prepare the client for biopsy, cryosurgery, conization, laser therapy, LEEP, radiation, or surgery as indicated.