Nursing Care of the Client with Cancer

1. Nursing Care of the Client with Cancer • Cancer Background A. Definition • 1. Family of complex diseases • 2. Affect different organs and organ systems • 3. Normal cells mutate into abnormal cells that take over tissue • 4. Eventually harm and destroy host • 5. Historically, cancer is a dreaded disease B. Oncology • 1. Study of cancers • 2. Oncology nurses specialize in the care, treatment of clients with cancer

2. Nursing Care of the Client with Cancer • Incidence and Prevalence • 1. Cancer accounts for about 25% of death on yearly basis • 2. Males: 3 most common types of cancer are prostate, lung and bronchial, colorectal • 3. Females: 3 most common types of cancer are breast, lung and bronchial, and colorectal

3. Nursing Care of the Client with Cancer • Risk factors for cancer: (some are controllable; some are not) • 1. Heredity: 5 – 10% of cancers; documented with some breast and colon cancers • 2. Age: 70% of all cancers occur in persons > 65 • 3. Lower socio-economic status • 4. Stress • a. Leads to greater wear and tear on body in general 5 Diet: certain preservatives in pickled, salted foods; fried foods; high-fat, low fiber foods; charred foods, high fat foods, diet high in red meat • 6. Occupational risk: exposure to know carcinogens, radiation, high stress • 7. Infections, especially specific organisms and organ (e.g. papillomavirus causing genital warts and leading to cervical cancer) • 8. Tobacco Use: Lung, oral and laryngeal, esophageal, gastric, pancreatic, bladder cancers • 9. Alcohol Use: also tied with smoking • 10. Sun Exposure (radiation) e.g. skin cancer

4. Nursing Care of the Client with Cancer • Nursing role includes health promotion to lower the controllable risks 1. Routine medical check up and screenings 2. Client awareness to act if symptoms of cancer occur 3. Screening examination recommendations by American Cancer Society; specifics are made according to age and frequencies • a. Breast Cancer: self-breast exam, breast examination by health care professionals, screening mammogram • b. Colon and Rectal Cancer: fecal occult blood, flexible sigmoidoscopy, colonoscopy • c. Cervical, Uterine Cancer: Papanicolaou (Pap) test • d. Prostate Cancer: digital rectal exam, Prostate-specific antigen (PSA) test

5. Nursing Care of the Client with Cancer • Physiology of Cancer A. Background 1. Normal Cell Growth includes two events • a. Replication of cellular DNA • b. Mitosis (cell division)

6. Nursing Care of the Client with Cancer • 2. Cell cycle is under control of cyclins, and suppresor gene products which control process by working with enzymes; • cyclins promote cell division • suppresor gene products limit cell division • 3. Forms the basis of how some chemotherapeutic agents work against cancers

7. Nursing Care of the Client with Cancer • Theories of Carcinogenesis (what causes cancer to occur) 1. Cellular Mutation • a. Cells begin to mutate (change the DNA to unnatural cell reproduction) 2. Oncogenes/Tumor Suppressor Genes Abnormalities • a. Oncogenes are genes that promote cell proliferation and can trigger cancer • b. Tumor suppressor genes normally suppress oncogenes but are damaged 3. Exposure to Known Carcinogens • a. Act by directly altering the cellular DNA (genotoxic) • b. Act by affecting the immune system (promotional)

8. Nursing Care of the Client with Cancer 4. Viruses • viruses break the DNA chain and mutates the normal cells DNA Epstein-Barr virus Human papilloma virus Hepatitis virus 5. Drugs and Hormones • a. Sex hormones often affect cancers of the reproductive systems (estrogen in some breast cancers; testosterone in prostate cancer) • b. Glucocorticoids and steroids alter immune system

9. 6. Chemical Agents • a. Industrial and chemical • b. Can initiate and promote cancer • b. Examples: hydrocarbons in soot ; arsenic in pesticides; chemicals in tobacco 7. Physical Agents • a. Exposure to radiation • Ionizing radiation found in x-rays, radium, uranium • UV radiation • Sun, tanning beds • Immune function • Protects the body from cancerous cells • Increased rate of cancer in immunocompromised pts

10. Nursing Care of the Client with Cancer • Neoplasms: also called tumors (mass of new tissue that grows independently of surrounding organs 1. Types of neoplasms a. Benign • 1. Localized growths respond to body’s homeostatic controls • 2. Encapsulated • 3. Stop growing when they meet a boundary of another tissue • 4. Can be destructive b. Malignant • 1. Have aggressive growth, rapid cell division outside the normal cell cycle • 2. Not under body’s homeostatic controls • 3. Cut through surrounding tissues causing bleeding, inflammation, necrosis (death) of tissue

11. Nursing Care of the Client with Cancer • Malignant tumors can metastasize a. Tumor cells travel through blood or lymph circulation to other body areas and invade tissues and organs there. • 1. Primary tumor: the original site of the malignancy • 2. Secondary tumor (sites): areas where malignancy has spread i.e. metastasis (metastatic tumor) • 3. Common sites of metastasis are lymph nodes, liver, lungs, bones, brain • 4. 50 – 60 % of tumors have metastasized by time primary tumor identified b. Cancerous cells must avoid detection by immune system

12. Nursing Care of the Client with Cancer C. Malignant neoplasms can recur after surgical removal of primary and secondary tumors and other treatments D. Malignant neoplasms vary in differentiation. • a. Highly differentiated are more like the originating tissue • b. Undifferentiated neoplasms consist of immature cells with no resemblance to parent tissue and have no useful function E. Malignant cells progress in deviation with each generation and do no stop growing and die, as do normal cells F. Malignant cells are irreversible, i.e. do not revert to normal G. Malignant cells promote their own survival by hormone production, cause vascular permeability; angiogenesis; divert nutrition from host cells

13. The steps of metastasis

14. Nursing Care of the Client with Cancer • Effects of Cancer 1. Disturbed or loss of physiologic functioning, from pressure or obstruction • a. Anoxia and necrosis of organs • b. Loss of function: bowel or bladder obstruction • c. Increased intracranial pressure • d. Interrupted vascular/venous blockage • e. Ascites • f. Disturbed liver functioning • G. Motor and sensory deficits • Cancer invades bone, brain or compresses nerves • Respiratory difficulties • Airway obstruction • Decreased lung capacity

15. Nursing Care of the Client with Cancer 2. Hematologic Alterations: Impaired function of blood cells • Secondary to any cancer that invades the bone marrow (leukemia) • May also be caused by the treatment • a. Abnormal wbc’s: impaired immunity • b. Diminished rbc’s and platelets: anemia and clotting disorders 3. Infections: fistula development and tumors may become necrotic; erode skin surface 4. Hemorrhage: tumor erosion, bleeding, severe anemia 5. Anorexia-Cachexia Syndrome: wasting away of client • a. Unexplained rapid weight loss, anorexia with altered smell and taste • b. Catabolic state: use of body’s tissues and muscle proteins to support cancer cell growth

16. Nursing Care of the Client with Cancer 6. Paraneoplastic Syndromes: ectopic sites with excess hormone production • a. Parathyroid hormone (hypercalcemia) • b. Ectopic secretion of insulin (hypoglycemia) • c. Antidiuretic hormone (ADH: fluid retention) • d. Adrenocorticotropic hormone (ACTH) 7. Pain: major concern of clients and families a. Types of cancer pain • 1. Acute: symptom that led to diagnosis • 2. Chronic: may be related to treatment or to progression of disease b. Causes of pain • 1. Direct tumor involvement including metastatic pain • 2. Nerve compression • 3. Involvement of visceral organs

17. Nursing Care of the Client with Cancer 8. Physical Stress: body tries to respond and destroy neoplasm • a. Fatigue • b. Weight loss • c. Anemia • d. Dehydration • e. Electrolyte imbalances 9. Psychological Stress • a. Cancer equals death sentence • b. Guilt from poor health habits • c. Fear of pain, suffering, death • d. Stigmatized

18. Nursing Care of the Client with Cancer • Collaborative Care A. Diagnostic Tests: used to diagnose cancer 1. Determine location of cancer • a. Xrays • b. Computed tomography • c. Ultrasounds • d. Magnetic resonance imaging • e. Nuclear imaging • f. Angiography 2. Diagnosis of cellular type of can be done through tissue samples from biopsies, shedded cells (e.g. Papanicolaou smear) washings • a. Cytologic Examination: tissue examined under microscope • b. Identification System of Tumors: Classification – Grading -- Staging

19. Nursing Care of the Client with Cancer 1. Classification: according to the tissue or cell of origin, e.g. sarcoma, from supportive 2. Grading: • a. Evaluates degree of differentiation and rate of growth • b. Grade 1 (least aggressive) to Grade 4 (most aggressive) 3. Staging • a. Relative tumor size and extent of disease • b. TNM (Tumor size; Nodes: lymph node involvement; Metastases)

20. Nursing Care of the Client with Cancer 3. Tumor markers: specific proteins which indicate malignancy • a. PSA (Prostatic-specific antigen): prostate cancer • b. CEA (Carcinoembryonic antigen): colon cancer • c. Alkaline Phosphatase: bone metastasis 4 Direct Visualization • a. Sigmoidoscopy • b. Cystoscopy • c. Endoscopy • d. Bronchoscopy • e. Exploratory surgery; lymph node biopsies to determine metastases

21. Nursing Care of the Client with Cancer Other non-specific tests • a. CBC, Differential • b. Electrolytes • c. Blood Chemistries: (liver enzymes: alanine aminotransferase (ALT); aspartate aminotransferase (AST) lactic dehydrogenase (LDH)

22. Nursing Care of the Client with Cancer Treatment Goals: depending on type and stage of cancer A. Cure • 1. Recover from specific cancer with treatment • 2. Alert for reoccurrence • 3. May involve rehabilitation with physical and occupational therapy B. Control: of symptoms and progression of cancer • 1. Continued surveillance • 2. Treatment when indicated (e.g. some bladder cancer, prostate cancer) C. Palliation of symptoms: may involve terminal care if client’s cancer is not responding to treatment

23. Nursing Care of the Client with Cancer Treatment Options (depend on type of cancer) alone or with combination A. Chemotherapy • 1. Effects are systemic and kills the metastatic cells • 2. Often combinations of drugs in specific protocols over varying time periods • Much more effective then a single agent • Consider the timing of the nadir of each drug • The time when the bone marrow activity and WBC counts are at their lowest levels after chemo • Different times for different drugs

24. 3. Cell-kill hypothesis: with each cell cycle a percentage of cancerous cells are killed but some remain; repeating chemo kills more cells until those left can be handled by body’s immune system

25. Nursing Care of the Client with Cancer B. Classes of Chemotherapy Drugs 1. Alkylating agents • 1. Action: create defects in tumor DNA • 2. Examples: Nitrogen Mustard, Cisplatin 2. Antimetabolites • 1. Action: similar to metabolites needed for vital cell processes • Counterfeit metabolites interfere with cell division • 2. Examples: Methotrexate; 5 fluorouracil • 3. Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia 3. Antitumor Antibiotics • 1. Action: interfere with DNA • 2. Examples: Actinomycin D, Bleomycin • 3. Toxic Effect: damage to cardiac muscle

26. Nursing Care of the Client with Cancer 4. Antimiotic agents • 1. Action: Prevent cell division • 2. Examples: Vincristine, Vinblastine • 3. Toxic Effects: affects neurotransmission, alopecia, bone marrow depression 5. Hormone agonist • 1. Action: large amounts of hormones upset the balance and alter the uptake of other hormones necessary for cell division • 2. Example: estrogen, progestin, androgen

27. 6. Hormone Antagonist • 1. Action: block hormones on hormone-binding tumors (breast, prostate, endometrium; cause tumor regression • Decreasing the amount of hormones can decrease the cancer growth rate • Does not cure, but increases survival rates • 2. Examples: Tamoxifen (breast); Flutamide (prostate) • 3. Toxic Effects: altered secondary sex characteristics

28. 7. Hormone inhibitors • Aromatase inhibitors (Arimidex, Aromasin) • Prevents production of aromatase which is needed for estrogen production • Used in post menopausal women • Side effects • Masculinizing effects in women • Fluid retention

29. Nursing Care of the Client with Cancer Effects of Chemotherapy • a. Tissues (fast growing) frequently affected • b. Examples: mucous membranes, hair cells, bone marrow, specific organs with specific agents, reproductive organs (all fetal toxic, impair ability to reproduce). Administration of chemotherapeutic agents a. Trained and certified personnel, according to established guidelines b. Preparation • 1. Protect personnel from toxic effects • Drugs absorbed through skin and mucous membranes • Protective clothing and extreme care • 2. Extreme care for correct dosage; double check with physician orders, pharmacist’s preparation c. Proper management clients’ excrement

30. Nursing Care of the Client with Cancer d. Routes • 1. Oral • 2. Body cavity (intraperitoneal or intrapleural) • 3. Intravenous • Use of vascular access devices because of threat of extravasation (leakage into tissues) and long-term therapy • If the drug is a vessicant it may result in pain, infection and tissue loss

31. e. Types of vascular access devices • 1. PICC lines (peripherally inserted central catheters) • 2. Tunnelled catheters (Hickman, Groshong) • 3. Surgically implanted ports (accessed with 90o angle needle

32. Hickman Catheter

33. Portacath

34. PICC Line

35. Nursing Care of the Client with Cancer Managing side effects of chemotherapy • A. Nausea and vomiting • 80% of patients will develop it • Antiemetics such as Zofran, Tigan, Compazine as well as Ativan to control the symptoms • Monitor for dehydration and need for IV fluids

36. B. Bone marrow suppression • Decreased number of RBC • Leads to hypoxia, fatigue • Hgb 9.5-10 gm/dl require oral iron supplements • Hgb below 8 gm/dl require transfusion • May use Epogen to stimulate RBC production

37. Decrease number of WBC (normal 4,500-11,000 mm3) especially neutrophils (normal 3,000-7,000 cells/cc) • Neutropenia-count below 2000 • Pt at extreme risk for infection • May order granulocyte colony stimulating factor (leukine) to stimulate bone marrow to increase WBC count • Neutropenic precautions • Private room • Good handwashing • Monitor temp q 4 hours, monitor for chills, UTI, pneumonia • Limit visitors to healthy adults • No flowers or plants • Monitor neutrophil count

38. Thrombocytopenia • Drop in platlet count (normal 150,000-400,000/mm3) below 100,000 • Test pt for bleeding in stool and urine • Avoid punctures for IV or IM • Handle pt gently • Use electric razor • Avoid placing foley or rectal thermometers • Avoid oral trauma with soft bristle brushes, avoid flossing, avoid hard candy • Watch for ALOC, pupil changes that might indicate intracranial bleeds • Stool softeners to avoid straining

39. C. Mucocitis • Inflammation and ulceration of mucous membranes and entire GI tract • Rinse mouth with ½ normal saline and ½ peroxide every 12 hours • Topical analgesic medication • Avoid mouthwashes with alcohol • Avoid spicy or hard food • Watch nutritional status

40. D. Alopecia • Hair loss • 2-3 weeks after treatment is started • Affects all the hair, including eyebrows, eyelashes • Within 4-8 weeks after treatment hair begins to grow back • Before hair loss, have the pt pick out a wig that is similar to hair color

41. E. Peripheral neuropathy • Numbness and tingling to fingers and toes in a glove and sock pattern • May cause gait and possible fall problems F. Provide emotional and spiritual support to patient and families

42. Nursing Care of the Client with Cancer Surgery • 1. Diagnosis, staging, and sometimes treatment of cancer • 2. May be prophylaxis or removal of at risk tissue or organ prior to development of cancer (breast cancer) • 3. Involves removal of body part, organ, sometimes with altered functioning (e.g. colostomy) • 4. Debulking (decrease size of) tumors in advanced cases • 5. Reconstruction and rehabilitation (e.g. breast implant post mastectomy) • 6. Palliative surgery to improve the quality of life • Removal of tumor tissue that is causing pain or obstruction • 5. Psychological support to deal with surgery as well as cancer diagnosis

43. Nursing Care of the Client with Cancer Radiation Therapy 1. Treatment of choice for some tumors to kill or reduce tumor, relieve pain or obstruction • Destroy cancer cells with minimal exposure to normal cells • Cells die or are unable to divide 2. Delivery • a. Teletherapy (external): radiation delivered in uniform dose to tumor • Beam radiation • b. Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it in the form of seeds • Radiation source within the patient so pt emits radiation for a period of time and is a hazard to others • c. Combination

44. 3. Goals • a. Maximum tumor control with minimal damage to normal tissues • b. Caregivers must protect selves by using shields, distancing and limiting time with client, following safety protocols • Private room • Caution sign on the door for radioactive material • Dosimeter film badge by staff • No pregnant staff • Limit visitors to ½ hour per day and keep them at least 6 ft from the source

45. Nursing Care of the Client with Cancer 4. Treatment Schedules • a. Planned according to radiosensitivity of tumor, tolerance of client • b. Monitor blood cell counts 5. Side Effects • a. Skin (external radiation): blanching, erythema, sloughing, breakdown • Use mild soak • Dry skin with a patting motion, not rubbing • Don’t use powders or lotions unless prescribed by radiologist • Wear soft clothing over the site • Avoid the sun and heat

46. b. Ulcerated mucous membranes: pain, lack of saliva (xerostoma) • c. Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation • d. Radiation pneumonitis • 1-3 months after treatment • Cough, SOB, fever • Treated with steroids to decrease inflammation

47. Nursing Care of the Client with Cancer Monoclonal antibodies (inoculate animal with tumor antigen and retrieve antibodies against tumor for human) • Antibodies target specific substances needed by the cancer cell for growth (Herceptin for breast cancer)

48. Gene therapy • experimental • May insert gene into the tumor cells to make them more susceptible to being killed by antiviral agents • May insert genes for cytokines that increase their effectiveness in killing cancer cells

49. Angiogenesis inhibitor drugs • prevent new blood vessels from forming and delivering blood to the tissue

50. Nursing Care of the Client with Cancer F. Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation • 1. Stimulation of nonfunctioning marrow or replace bone marrow • 2. Common treatment for leukemias G. Pain Control • 1. Includes pain directly from cancer, treatment, or unrelated • 2. Necessary for continuing function or comfort in terminally ill clients • 3. Goal is maximum relief with minimal side effects • 4. Multiple combinations of analgesics (narcotic and non-narcotic) and adjuvants such as steroids or antidepressants; includes around the clock (ATC) schedule with additional medications for break-through pain • 5. Multiple routes of medications • 6. May involve injections of anesthetics into nerve, surgical severing of nerves radiation • 7. May need to progress to stronger pain medications as pain increases and client develops tolerance to pain medication