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CARE OF THE PATIENT WITH CANCER - Nursing Implications

CARE OF THE PATIENT WITH CANCER - Nursing Implications. NUR 133 Lecture # 8/9 K. BurgerMSEd, MSN, RN, CNE 3/05kb. Incidence & Prevalence. 2 nd leading cause of death 1 out of 3 persons will be affected by cancer sometime in their lifetime

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CARE OF THE PATIENT WITH CANCER - Nursing Implications

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  1. CARE OF THE PATIENT WITH CANCER- Nursing Implications NUR 133 Lecture # 8/9 K. BurgerMSEd, MSN, RN, CNE 3/05kb

  2. Incidence & Prevalence • 2nd leading cause of death • 1 out of 3 persons will be affected by cancer sometime in their lifetime • Cancer of lung = leading cause of cancer deaths in both men and women • Cancer of colon = 2nd largest incidence • Breast and Prostate = highest gender incidence

  3. Pathophysiology • Carcinogenesis / Oncogenesis • Tumor development slow and insidious • Initiator – Promotor Theory • Loss of cellular control mechanisms(ie: apoptosis) • Loss of differentiation

  4. WHAT ARE CARCINOGENS? • Environmental/Lifestyle risk factors:tobacco, alcohol, diet, sexual/reproductive behavior, ultraviolet radiation, other pollutants and irritants • Hormones:estrogen • Oncogenic viruses:HBV, HPV, HIV, HSV

  5. NORMAL Limited cell division Undergo apoptosis Controlled growth Well differentiated Adhere tightly together Contact inhibited Euploid MALIGNANT Rapidly dividing/multiplying Do not undergo apoptosis Uncontrolled growth Anaplastic morphology Adhere loosely together Able to move / metastasize Aneuploid Normal Versus MalignantCell Characteristics

  6. HOLISTIC NURSING CONSIDERATIONS • Primary level care: Prevention and Screening/ client education • Secondary level care: Diagnostic Testing Treatment and side-effects of Surgery,Radiotherapy,Chemotherapy • Tertiary level care: End of life and psychosocial issues

  7. Health promotion: Diet hi in whole grains, Vit C,A, & cruciferous fruits & vegetables. Limit fat, alcohol, kcal, salt-cured, smoked, charbroiled meats. Maintain healthy immune system. Avoidance of carcinogens: Limit exposure to sun, tobacco smoke/chew, radiation, viruses,chronic irritants, immunosuppressants, hormonal agents. Regular cancer screening: ACS Cancer Detection Guidelines C A U T I O N Annual physical exam, BSE, TSE PREVENTION AND SCREENING Patient Education Primary Intervention

  8. DIAGNOSTIC TESTINGPatient Education and Support • Common laboratory tests: CBC, bilirubin, alkaline and acid phosphatase, tumor markers (PSA, CA, CEA)+ others • Radiological procedures: CT, PET, MRI, ultrasound, mammography, BE, UGI, CXR • Endoscopic procedures: bronchoscopy, esophagoscopy, colonoscopy, cystoscopy • Biopsy / incisional, needle aspiration, stereotactic Secondary Intervention

  9. Tumor StagingTNM Classification T = primary tumor size N = lymph node involvement M = metastasis T4 N3 M1 What does this indicate?

  10. Tumor Grading CLASS I Normal cell Well differentiated II Abnormal cell; moderately differentiated III Suspiciously malignant; poorly differentiated IV Probably malignant very poorly differentiated V Malignant; undifferentiated

  11. Classification byTissue of Origin FOR EXAMPLE: • Sarcoma • Lymphoma • Glioma • Osteoma • Lipoma • Adeno • Melano

  12. CANCER TREATMENT - SURGERYNursing Care • Pre-op teaching • Nutritional promotion pre and post op • Pain control • Monitor for post-op complications • C & DB, incentive spirometry, antiembolitic rx, leg exercises, ambulation etc. • Body image disturbance= potential nsg dx Secondary Intervention

  13. CANCER TREATMENT – CHEMOTHERAPYNursing Care • Prior to administration: hydration and anti-emetics • During administration: vesicant precautions: gloves, monitor IV site closely • Post administration: utilize interventions for common side effects: Myelosuppression – infection, bleeding, fatigue GI complications - anorexia, N/V, xerostomia, Alopecia Secondary Intervention

  14. Chemotherapeutic Agents/Anti Neoplastic Drugs

  15. Immunotherapy/Targeted TherapyBiological Response Modifiers (BRM) • Interferon • Monoclonal Antibodies - Herceptin • Interleukin • Colony Stimulating Factor (CSF)- Neupogen Epogen • Gene Therapy HLA • Side Effects: stimulation of inflammatory process, flu-like symptoms

  16. CANCER TREATMENTEXTERNAL RADIATION -Nursing Care • Teletherapy • Promote nutrition and rest • Do not remove simulation markings • Utilize interventions for common side effects: Myelosuppression – infection, bleeding, fatigue GI complications – anorexia, N/V, taste alterations, mucositis, xerostomia, diarrhea Skin reactions – dry/wet desquamation Secondary Intervention

  17. CANCER TREATMENTINTERNAL RADIATION – Nursing Care Brachytherapy – Sealed vs Unsealed • Safety considerations: Private room. Radioactive caution sign Limit visitors to ½ hr; no under 18, no pregnant Rotate nurse assignments/ wear dosimeter Time - Distance - Shielding Bodily excretions radioactive if unsealed Secondary Intervention

  18. New Developments in Radiation Therapy • 3D-CRTThree dimensional conformal radiation therapy-Uses CT images to map location of Ca in 3 dimensions. Client fitted with mold ( to keep area still during rx).-Beams are matched to precise shape of tumor-Reduces radiation damage to surrounding normal tissue • IMRTIntensity modulated radiation therapy-Uses same technology as 3D-CRT but intensity can also be precisely adjusted (modulated)-This increased control, also reduces damage to normal tissue

  19. THE PATIENT WITH CANCER A NURSING PROCESS APPROACH The following common problems should be considered: • Infection • Bleeding • Pain • Malnutrition • Fatigue • Psychosocial Issues Maslow's Hierarchy of Needs

  20. FOCUSED ASSESSMENTof the Patient with Cancer • S/S of bleeding: Platelets, CBC, H&H, gums, stools, urine, skin, LOC • S/S of infection: Temp, WBC, resp, urinary, skin, invasive sites • Pain: W H A T S U P or S L I D A • Nutritional Status: Weight, serum albumin & transferrin, appetite, N&V, diarrhea, food aversions/preferences • Coping skills of patient and S.O. • Patient knowledge: disease, treatment, outcomes

  21. DIAGNOSIS • Risk for injury r/t bleeding tendencies • Risk for infection r/t diminished immunity • Chronic pain r/t disease process and therapy • Nutrition, imbalanced; less than body requirements r/t anorexia, N/V, pain, disease process • Fatigue r/t myelosuppression • Risk for ineffective coping r/t diagnosis of cancer • Anticipatory grieving r/t potential disease outcome • Body image disturbance r/t surgical rx / alopecia

  22. PLANNING Patient will demonstrate: • Platelet, CBC, H&H, albumin, transferrin levels in normal range • No evidence of bleeding • No evidence of infection • Pain relieved and/or controlled • Progressive weight gain toward goal • Performance of ADLs within level of ability • Verbalized awareness of own coping abilities • Ability to identify and express feelings freely/effectively • Verbalized acceptance of self in situation • Verbalized understanding of disease process & treatment

  23. IMPLEMENTATION • RISK FOR INJURY R/T BLEEDING TENDENCIES • Monitor platelet, CBC, H&H levels • Observe for S/S bleeding and or hypoxia • Bleeding precautions: gentle handling, fall precautions, electric razor, soft toothbrush, gentle nose blowing, avoid invasive procedures, no rectal temps, no intercourse • Administer stool softeners as per MD orders • Administer transfusion therapy as per MD orders

  24. IMPLEMENTATION • RISK FOR INFECTION R/T DIMINISHED IMMUNITY • Monitor WBC and ANC daily • Observe closely for S/S infection • Neutropenic precautions: limit invasive procedures, private room, no exposure to communicable illness strict handwashing, no fresh flower, fruits, vegetables, no standing water, C&DB • Administer hematopoietic growth factors per MD orders

  25. MyelosuppressionAnemia – Leukopenia- Thrombocytopenia ANEMIA = 10% lower than normals LEUKOPENIA = 2500/mm or lower THROMBOCYTOPENIA = 50,000/mm or lower

  26. IMPLEMENTATION • CHRONIC PAIN R/T DISEASE PROCESS & THERAPY • Acknowledge and accept patient report • Determine patient’s acceptable pain level • Administer analgesics per MD orders • Eliminate aggravating factors • Enlist known alleviating factors • Utilize cognitive-behavioral strategies: guided imagery, distraction, relaxation etc.

  27. IMPLEMENTATION • NUTRITION, IMBALANCED; LESS THAN BODY REQUIREMENTS R/T ANOREXIA,N&V,PAIN… • Monitor serum albumin, transferrin, body weight, intake & output • Identify patient food likes and dislikes • Offer small frequent nutrient dense meals/snacks • See National Cancer Institute - Nutrition in Cancer Care • Administer anti-emetics & analgesics ac per MD orders • ANTI-EMETIC Examples: Zofran, TIgan, Ativan, Compazine

  28. IMPLEMENTATION • FATIGUE R/T MYELOSUPPRESSION • Monitor RBC, H&H • Structure daily routines/activities to conserve patient energy • Encourage nutritionally balanced diet • Administer biologic response modifiers (ie: Epogen) per MD orders • Administer blood transfusion per MD orders

  29. IMPLEMENTATION • RISK FOR INEFFECTIVE COPING • ANTICIPATORY GRIEVING • BODY IMAGE DISTURBANCE • Utilize effective communication techniques and attentive listening skills • Encourage patient verbalizations of fears and concerns • Explore and utilize existing patient coping mechanisms • Provide information on support groups, hospice care • Encourage expression of feelings regarding body image • Provide information regarding plastic surgery, prosthetic options Tertiary Intervention

  30. EVALUATION PATIENT WILL: • Be free from bleeding, infection • Verbalize relief, reduction and/or control of pain • Maintain optimal nutritional status free of N&V • Perform ADLs to desired level • Express feelings about disease, prognosis, body image, etc. • Demonstrate healthy coping mechanisms

  31. ADDITIONAL CONSIDERATIONS • Hospice care • Oncological emergencies • Multicultural approaches • Complementary therapies • Community-based care • Evidence-based practice • Clinical trials and research

  32. Oncologic Emergencies • Disseminated Intravascular Coagulation (DIC) • Sepsis • Syndrome of Inappropriate Antidiuretic Hormone ( SIADH ) • Hypercalcemia • Spinal Cord Compression • Superior Vena Cava Syndrome • Tumor Lysis Syndrome

  33. Laryngeal Cancer • Combined alcohol/tobacco use = primary risk factor • Incidence increasing / Men higher / Over 60 • Most = squamous cell carcinoma • Hoarseness = earliest sign • Other signs???

  34. Laryngeal CancerASSESSMENT • History of smoking, alcohol use, environmental and/or occupational exposures • Physical assessment for s/s • Diagnostic assessments: CBC, Albumin,BUN, Creatinine, Liver function studies, CT, MRI, PET, Tumor mapping, Panendoscopy

  35. Laryngeal CancerNURSING DIAGNOSES • Potential for respiratory obstruction • Impaired swallowing • Imbalanced Nutrition • Impaired verbal communication • Risk for situational low self esteem r/t disturbed body image • +++++++++++++

  36. Laryngeal CancerPLANNING OUTCOMES • Maintain positive oxygenation status • Prevent aspiration • Promote nutritional balance • Facilitate alternate communication • Promote positive self-image • Promote coping mechanisms and anxiety reduction

  37. Laryngeal CancerINTERVENTIONS NON SURGICAL • Chemotherapy • Radiation Therapy • Voice rest • Mouth/Throat care: sprays,fluids,artificial saliva • Skin care:mild soap,no sun,cold,heat,lotions,powder

  38. Laryngeal CancerINTERVENTIONS SURGICAL • Dependent on size, node involvement and metastasis (TNM staging) • Ranges from resection of tumor alone to total laryngectomy and possibly radical neck dissection

  39. Total LaryngectomyNursing Considerations • Airway maintenance • Mechanical ventilation • Humidification • C & DB, Oxygen Rx, Positioning • Laryngectomy stoma & tube care • Suture line care • Suctioning prn • Communication facilitation • Paper/pencil or table slate • Speech therapy • Electrolarynges • TEF

  40. Total LaryngectomyNursing Considerations (Continued) • Monitor for hemorrhage • Prevention of infection • Wound care; Graft care • Pain management • Nutritional support • Psychosocial support • Health teaching

  41. Breast CancerVersus Benign Breast Disorders Perimenopausal woman with green/brown nipple discharge, erythema & edema over mass 50 y.o. woman with serous nipple discharge/ no mass 22 y.o. woman with round,firm,non-tender, movable mass 35 y.o. woman with multiple,tender nodular areas and feeling of generalized breast fullness MATCHING EXERCISE A.Fibroadenoma B.Fibrocystic breast disease C.Ductal ectasia D.Intraductal ectasia

  42. Breast Cancer • Leading cause of cancer deaths in woman • Incidence higher in Caucasian women • Early dx is key to prognosis & survival • Also affects men ( over 60 more common ) • Risk Factors: age, estrogen exposure, genetics, family history,diet,weight,exercise

  43. Types of Breast Cancer • Lobular carcinoma in situ (LCIS) • Ductal carcinoma in situ (DCIS) • Invasive ductal carcinoma (IDC) 80%cases • Invasive lobular carcinoma (ILC) • Medullary carcinoma • Colloid carcinoma • Tubular carcinoma • Inflammatory breast cancer

  44. Breast CancerPrimary Level CareSCREENING

  45. Breast CancerASSESSMENT • Assess risk factor historyNational Cancer Institute Breast Cancer Risk Assessmenthttp://www.cancer.gov/bcrisktool/ • Physical assessment: location of breast mass, fixed vs movable, consistency, dimpling, peau d’orange, nipple retraction, lymph nodes • Additional imaging: ultrasound,MRI • Breast biopsy: needle vs surgical • Staging and grading

  46. Benign Breast Disease Multiple or single Rubbery texture Mobile / slippery Regular borders Tenderness (cyclic) No retraction May increase/decrease in size rapidly Cancer Unilateral Firm texture Fixed firmly Irregular border Usually painless Usually w/retraction Grows constantly Comparison of Breast Lumps

  47. Breast CancerASSESSMENT (continued) • CXR • Bone scan • CT • PET • Blood tests/ CBC,Liver Enzymes,Ca,Alkaline Phosphatase • Tumor tests/ Estrogen and Progesterone Receptors, HER2

  48. Breast CancerNURSING DIAGNOSES • Anxiety r/t to diagnosis of cancer • Anticipatory grieving • Disturbed body image • Acute pain • Ineffective protection r/t therapies • ++++++++++++++++++

  49. Breast CancerPLANNING OUTCOMES • Anxiety reduction • Promotion of coping strategies • Pain relief • Body image enhancement • Free from infection, fatigue, bleeding

  50. Breast CancerINTERVENTIONS SURGICAL RX • Lumpectomy • Partial mastectomy ( wide excision) • Modified radical mastectomy • Lymph node dissection / sentinel biopsy • Oophorectomy / Ovarian ablation • Breast re-construction

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