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Nursing Care & Interventions in Managing Those with Cancer

Keith Rischer RN, MA, CEN. Nursing Care & Interventions in Managing Those with Cancer. Today’s Objectives…. Identify the goals of cancer therapy. Distinguish between cancer surgery for cure and cancer surgery for palliative care.

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Nursing Care & Interventions in Managing Those with Cancer

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  1. Keith Rischer RN, MA, CEN Nursing Care & Interventions in Managing Those with Cancer

  2. Today’s Objectives… Identify the goals of cancer therapy. Distinguish between cancer surgery for cure and cancer surgery for palliative care. Discuss the nursing care needs for clients undergoing therapy for cancer. Discuss radiation therapy. Identify nursing interventions for patients undergoing chemotherapy. Discuss care of patients with neutropenia Discuss care of patients with thrombocytopenia Explain the rationale for hormonal manipulation therapy. Explain the basis of targeted therapy for cancer.

  3. Impaired immune and hematopoietic function Bone marrow Anemia and thrombocytopenia Altered gastrointestinal structure and function Tumors obstruct structures Tumors increase metabolic rate Tumors in liver reduce liver function Diet high in protein and carbohydrates supplement when 5% weight loss Monitor albumin Consequences of Cancer

  4. Consequences of Cancer • Motor and sensory deficits • Bone metastases • Spinal cord compression • Pain • Decreased respiratory function • Airway obstruction • Tumor compression • Pleural effusions

  5. Surgery as Cancer Treatment • Oldest form of cancer treatment used for: • Prophylaxis • Remove at risk tissue • Diagnosis (biopsy) • Cure • Control (debulks) • Palliation • Determining efficacy of therapy (second look) • Reconstruction • Side effects of surgical therapy

  6. Radiation Therapy • Purpose • Mechanism of action • Ionizing radiation • Cells die or unable to divide • Exposure • amount delivered • Dose • amount absorbed • Killing effects of radiation • Given in a series of divided doses • Fractionation…180-280 rads qd typical • Some organs can tolerate more radiation • YouTube - Radiation Therapy to Treat Cancer

  7. Radiation Therapy • Teletherapy (Beam) • Distant-external treatment • Brachytherapy • Unsealed • Body fluids potential hazard • Isotopes given IV or instilled in body cavities • Iodine ingestion for thyroid cancer • Sealed • Body fluids NOT hazard, but pt. may be • Implanted in proximity to tumor

  8. Nursing Care w/Sealed Implants • Private room with private bath • “Caution: Radioactive Material” note • Nurse wears dosimeter film badge • No pregnant women or children under 16 not to visit • Limit visitors 30 min/day • Stay 6 ft away • Never touch radioactive source with hands • Save all dressings and bed linens until radioactive source is removed.

  9. Side Effects of Radiation Therapy • Local skin changes • Hair loss • Altered taste sensations • Fatigue • Debilitating • Can last for months • Tissue fibrosis and scarring of healthy tissue

  10. Nursing Care w/Radiation Therapy • Education • Skin care • Dry skin in path of radiation • Do not use lotions or ointments. • Avoid direct exposure of the skin to the sun. • Care for xerostomia (dry mouth). • Bone exposed to radiation is more vulnerable to fracture. • Reproductive effects • Depends on site • Harvest sperm or ova

  11. Chemotherapy • Mechanism • Cytotoxic • Some selectivity • Damages cell DNA • cell division • Rapidly dividing cells more sensitive to chemo • Skin, hair • Intestinal tissues • Spermatocytes • Blood-forming cells

  12. Chemotherapy Drug Categories Table 28-6 p.492 • Antimetabolites • Act as counterfeit metabolites so cells can’t divide • Cell cycle specific • Antitumor antibodies • Interrupt DNA and RNA • Cell cycle nonspecific • Alkylating agents • Cross link DNA-prevents DNA/RNA synthesis • Cell cycle nonspecific • Antimitotic agents • Interfere with mitosis-prevent division • Cell cycle specific

  13. 5-Fluorouracil (5-FU) • Anti-metabolite • IV • SE • Decr. WBC & platelets • Stomatitis • Anorexia • Darkening of skin…sun sensitivity • Nursing responsibilities • Use sunscreen when outside • Menstrual changes…decreased sperm counts

  14. Cytoxan (Cyclophosphamide) • Alkylating agent • po or IV • SE • N&V 2-4 hours after tx • Pancytopenia 14 days after tx • Alopecia 2-3 weeks after tx • Loss of appetite • Nursing Considerations • Can cause hemorrhagic cystitis…incr. po and stop if hematuria • Mesna (Mesnex) often given to protect • po or IV

  15. Vincristine (Oncovin) • Anti-mitotic • IV • SE • Constipation/abd. Cramping • Stomatitis • Alopecia 2-3 weeks after tx • Nursing considerations • Increase fiber

  16. Chemotherapy Treatment Issues • Combination chemotherapy • More effective-possible more toxic • Drug dosage • Dependant on type of cancer & client size • Drug schedule – • Usually every 3 to 4 weeks for 6-12x • Drug administration • IV route most common • Use central lines or ports to avoid vessel irritation • Extravasation • YouTube - P9290001 Getting her port accessed www.freehelpforcancer.com

  17. Side Effects of Chemotherapy • Fatigue • Alopecia or hair loss • Nausea and vomiting • Antiemetics • Zofran • Ativan • Compazine • Mucositis-open sores • mouth (stomatitis) see Mouth care chart 28-6 p.496 • Skin changes • Bone marrow suppression • Anemia • Immunosuppression • Thrombocytopenia

  18. Neutropenia • Highest risk • Chemo/radiation • Liver/kidney disease • Tumors bone marrow, sm. Cell lung CA, lymphoma, breast cancer, elderly >70 yrs • Treatment • Filgrastim: granulocyte colony stimulating factor • Red Flag • T>100.4 and ANC <500 • Medical management • Cultures • IV abx • Nursing assessments/priorities

  19. Neutropenic Precautions chart 28-7 p.497 • Good handwashing!!! • Private room – cleaned daily • Do not use supplies from common areas – straws, etc. • No water pitchers • Limit # of health care providers, visitors • VS q 4 hrs • Watch for sepsis • Inspect mouth, skin, mucous membranes q 8 hrs • Inspect any open areas for sx infection • No flowers and potted plants • Fungi

  20. Absolute Neutrophil Count (ANC) • Normal Range • > 2,500/mm3 • 1000-2500…safe to continue chemotherapy • 1000-1500 minimal risk • 500-1000 moderate risk • <500 SEVERE risk • WBC x(%neutrophils + % bands) • Example: breast CA after chemo • WBC 2000, neutrophils 14.8%, bands 5% • 2000 x (0.148 +.05)= 2000 x 0.198=396

  21. Thrombocytopenia • Reduction of platelets below normal range • Normal = 150,000-400,000 mm3 • Etiology: • Bone marrow suppression • Critical values • 50,000 or less- risk of bleeding • <20,000 spontaneous life threatening hemorrhages (brain bleed) • Consider platelet transfusion if febrile or bleeding • <10,000 transfusions recommended

  22. Nursing Priorities w/Thrombocytopenia chart 28-9 p.497 • Handle gently • Avoid punctures • Apply ice to trauma • No rectal temps, lubricate suppositories • Electric razor • Mouth care – • no flossing, avoid dental work, avoid hard foods, check denture fit • Avoid contact sports • Shoes with firm soles

  23. Hormone Therapy • Patho • Types of CA • Breast, prostate, endometrium • Treatment • Surgical (remove the hormone producing organ) • Pharmocologic suppression • Steroids or estrogen

  24. Stem Cell/Bone Marrow Transplant • Goal • Give higher than usual dose of chemo to prepare way for engraftment of stem cell transfusion • Bone marrow wiped out WBC>0.1 • Bone marrow/stem cells harvested from pelvis/iliac crest of matched donor or self (autologous) • Strained-administered as IV infusion • NHL, multiple myeloma, some breast/testicular CA • Takes 2-4 weeks before stem cells will take • very high risk of infection

  25. Oncology Case Study • 70yr male • PMH: • metastatic GB CA-dx 2006 w/hepatic resection, radiation therapy completed, currently on weekly chemo • Malignant pleural effusions • CAD, HTN • HPI: Progressive worsening of SOB since last thoracentesis 2 weeks ago. Sudden onset of severe SOB early am. Incr. weakness w/nausea. No c/o CP • VS: T-98.2 P-123 (ST) R-22 BP 101/68 sats 90% RA • Assessment: • Resp: severely diminished right side • Other systems WNL

  26. Oncology Case Study • Medical/Nursing Priorities… • Nursing Assessments… • Nursing Interventions…

  27. Oncology Case Study: Oncology Floor • 83 yr. female new admission • PMH: rectal CA 1987 w/surgical resection/colostomy and radiation • Chief c/o: Persistent low abd. crampy pain w/nausea • CT: large poorly differentiated carcinoma in pelvis w/migration to lymph nodes • Small bowel obstruction: ? tumor

  28. Oncology Case Study: Priorities • Medical… • NG to LIS • NPO • IVF: NS @ 100cc/hr • Nursing… • Pain control • Nausea control • Volume status

  29. Breast Cancer • Article • YouTube - Breast cancer real story

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