Cancer- Related Disorders and Hematologic Disorders - Cancer is a neoplastic disease process that involves abnormal cell growth and differentiation. TEXTBOOK: a complex disease characterized by uncontrollable growth and spread of abnormal cells NB: cancer can affect all body tissue. Normal body cell grows, divide and die in an orderly fashion. Effect cells randomly at any point of the cell cycle Great for treatment of slow growing cancer that have many cells in the resting phase Cancer cell: dying cells grow and form new abnormal cells and can form new blood vessels to provide nourishment for continued growth. Normal: Large cytoplasm, single nucleus, single nucleolus, fine chromatin. Cancer: Small cytoplasm, multiple nuclei, multiple and large nucleoli, coarse chromatin. Genetic mutations are responsible for abnormal cancerous growth. These mutations are either inherited, or caused by something external. Factors that trigger abnormal cell growth: - Viruses ( Hep B and C- liver) Physical and chemical agents Hormones Familial history lifestyle Metastasis: cancer cells can invade surrounding tissues and spread to other areas of the body through lymph and blood vessels. - No matter where cancer spreads, it always is named based on the origin in which it started. For example, colon cancer that spreads to the liver is called metastatic colon cancer. Typical sites of metastasis of lung cancer include the brain, bone, lymph nodes, liver, and pancreas. Kidneys are not a typical site of lung cancer metastasis. Metastasis is usually diagnosed when there is onset of new findings (bone pain indicative of bone metastasis; change in bowel or bladder tone indicative of nervous system involvement). Invasion refers to the direct extension and penetration by cancer cells into neighboring tissues. The proliferation of transformed cells and the progressive increase in tumor size eventually leads to a breach in the barriers between tissues, leading to tumor extension into adjacent tissue. For cancer, invasion is the direct extension and penetration by cancer cells into neighboring tissues. It is generally distinguished from metastasis, which is the spread of cancer cells through the circulatory system or the lymphatic system to more distant locations. Screening and early diagnosis are the most important aspects of health education and care. The nurse should prevent, recognize, and treat complications associated with carcinoma. Clients of African, Hispanic, or Native American descent have an increased risk of death from cancer than white Americans, despite a lower risk for developing many cancer types. Minority population tend to have a worse prognosis for cancer related to several factors (low socioeconomic status, lack of access to health care, or reluctance to seek treatment, poverty) A tumor is an abnormal collection of cells, but not all tumors are cancers. - - Noncancerous tumors are benign. They do have the potential of pressing on healthy organs and tissues as they grow, but they do not invade other tissues and they do not metastasize. Cancerous tumors are malignant. Can metastasize- rupture the cell walls BODY TISSUES: Cancers can arise from almost any tissue in the body. Cancerous cells decrease the functional ability of the tissue in which they are located. - Epithelial tissue: carcinomas Glandular organs: adenocarcinomas Mesenchymal tissue (connective tissue, blood vessels, and lymphatic tissue): sarcomas Blood‑forming cells: leukemias Lymph tissue: lymphomas Plasma cells: myelomas HEALTH PROMOTION AND DISEASE PREVENTION: - Consume a healthy diet (low‑fat with increased consumption of fruits, vegetables, and lean protein). Limit intake of sugar, salt, nitrates, nitrites, and processed and red meats. Maintain a healthy body weight/body mass index. Avoid use of tobacco products. Limit alcohol consumption to one drink per day for females and two drinks per day for males. Avoid risky lifestyle choices (recreational drug use, needle sharing, unprotected sexual intercourse). Avoid exposure to environmental hazards (radiation, chemicals). Use personal protective equipment when available. Breast feed infants exclusively for the first 6 months of life. Engage in physical activity or exercise routinely. Protect skin and eyes from UVA and UVB rays. Remove at‑risk tissue such as moles to prevent conversion to skin cancer. Chemoprevention is the use of medications or other substances to disrupt cancer development. Aspirin and celecoxib to reduce the risk of colon cancer Vitamin D and tamoxifen to reduce the risk of breast cancer. Immunization to prevent human papilloma virus (HPV), which is associated with cervical, head, and neck cancers. Immunization for Hepatitis B to prevent liver disease which can progress to liver cancer. WARNING SIGNS: - Change in bowel habits, a sore that does not heal, and a lump or thickening in the breast or elsewhere are all potential warning signs of cancer. RISK FACTORS IN PPT: - Hepatitis B and C are risk factors for primary liver cancer. Alcohol abuse is also a risk factor for the development of liver cancer. Consuming a diet high in animal fat may predispose a person to colon or breast cancer. Exposure to radon is a risk factor for lung cancer. - Familial polyposis is a risk factor for colorectal cancer. BREAST CANCER PPT: - A strong family history of breast cancer indicates a risk for breast cancer. Annual rather than biannual screening may be indicated for a strong family history. An annual mammogram is performed after age 40 or in younger clients with a strong family history. The client may perform a self-breast examination monthly, but a clinical examination by a health care provider is indicated annually. Annual CT breast scans after age 50 are not a current recommendation. NUTRITION PPT: - - - Avoiding red meat and processed foods such as lunchmeats, and consuming bran and whole grains can reduce cancer risk and should be included in health education classes on diet and cancer risk reduction. Consuming foods high in vitamin A, including apricots, carrots, and leafy green and yellow vegetables, can also reduce cancer risk. (YELLOW-ORANGE) Reducing sodium is helpful in the treatment of hypertension and heart and kidney failure, but no evidence suggests that lowering of sodium intake decreases the incidence of cancer. Eating cruciferous vegetables such as broccoli, cauliflower, Brussels sprouts, and cabbage may actually reduce cancer risk. CYTOLOGICAL: Cytology is the exam of a single cell type, as often found in fluid specimens. It's mainly used to diagnose or screen for cancer. It's also used to screen for fetal abnormalities, for pap smears, to diagnose infectious organisms, and in other screening and diagnostic areas. - Nursing Action: Monitor patients' lab results and make sure they understand what they mean. Screening Recommendations: Instruct clients to discuss benefits and risks for each screening exam with their provider to determine if and when screening should take place. Clients at increased risk for specific cancer types might need to start screenings earlier or have them more frequently. - - Mammogram: Annually for female clients 45-54 years. At 55 years, clients can transition to every two years. Clients in good health should continue screening as long as there is at least 10 years continued life expectancy. Clinical breast exam: Every 3 years for clients 20 to 39 years. Annually for clients older than 40 years. Colonoscopy: At age 50 and then every 10 years Fecal testing: Guaiac-based fecal occult blood test or fecal immunochemical test annually; or stool DNA test every 3 years. - - Prostate screening: Prostate-specific antigen testing annually for males 70 years and older. Clients younger than 70 years should make an individual decision with the provider when to initiate screening. Screening for gene mutations: For clients who have a strong family history of breast or colon cancer Pap test: Clients age 21 to 29, every 3 years. Clients age 30 to 65, every 5 years with an HPV DNA test, or every 3 years with Pap test alone. Low-dose helical CT: For healthy adults who are current or former smokers aged 55 to 74 years with a 30-year pack history, either currently smoking or abstained within the last 15 years. ASSESSMENT: AGE: highest incidence of cancer occurs in older adults. - Female older adults most commonly develop colorectal, breast, lung, pancreatic and ovarian cancer. Male older adults most commonly develop lung, colorectal, prostate, pancreatic and gastric cancers. Immune function: Cancer incidence increases among clients who are immunosuppressed. Chronic irritation and tissue trauma: Incidence of skin cancer is higher in people who have burn scars or other types of severe skin injury. Race - Non-Hispanic white American females are more likely to develop breast cancer than any other group. Non-Hispanic white American males are at an increased risk for testicular cancer than any other group. African American males are at an increased risk for colorectal and pancreatic cancers. Hispanic American and African American clients have increased risk of higher occurrence rate of liver cancers Native American and African American clients have a higher occurrence of rate of renal pelvis cancer. Genetic Predisposition Exposure to chemical, tobacco and alcohol Exposure to some viruses and bacteria - Liver cancer can develop after many years of infection with hepatitis B or hepatitis C. Infection with human T‑cell leukemia virus increases the risk of lymphoma and leukemia. Infection with Epstein‑Barr virus has been linked to an increased risk of lymphoma. HPV infection is the main cause of cervical cancer. - HIV increases the risk of lymphoma and Kaposi’s sarcoma. Helicobacter pylori can increase the risk of stomach cancer and lymphoma of the stomach lining. Diet: a diet high in fat, red meat, processed meat, preservative and additives and low in fiber Sun, ultraviolet light, or radiation exposure: ionizing (radon, xray) and UV (sun, tanning beds) Sexual lifestyle: multiple sexual partners or STIs Poverty, obesity, and chronic GERD: Chronic disease Air pollution EXPECTED FINDINGS: - - Benign tumors are often slower growing have cells that closely resemble the surrounding area, and primarily have localized effects unless they compress blood vessels or nerves Malignant tumors have cells that are different from the cells around them, and can grow very rapidly if they are more abnormal. These cells continually proliferate toward the outer edges of the tumor, so that they can take over other tissue and access vasculature and lymphatics. The findings associated with the presence of a tumor are dependent on the tissue in which they are located; clients will report pain and possible physiological changes if organ or tissue function has been disrupted. Laboratory Tests: - Can help identify cancerous tumors. Tests include tumor markers and tests used for screening such as PSA> prostate Diagnostic Procedures: - Diagnostic procedures help determine the size and location of tumors, and can include imaging tests used for screening in addition to biopsy and other types of imaging (MRI, CT scan, fluoroscopy, PET scan, nuclear imaging). Staging of Cancer: - The tumor-node-metastasis (TNM) system is used to stage cancer. Tumor (T): - TX: Unable to evaluate the primary tumor TØ: No evidence of primary tumor Tis: Tumor in situ (IN ORIGINAL PLACE- LOCALIZED) T1, T2, T3, and T4: Size and extent of tumor NODE (N) - NX: Unable to evaluate regional lymph nodes NØ: No evidence of regional node involvement N1, N2, and N3: Number of nodes that are involved and/or extent of spread METASTASIS (M) - MX: Unable to evaluate distant metastasis MØ: No evidence of distant metastasis Grading: is needed because some cancer cells are more malignant than others. Well differentiated: means the cells look much like normal cells and tend to grow slowly. Undifferentiated (poorly differentiated): means the cells do not look like normal cells and tend to grow quickly and spread. - GX: grade cannot be determined G1: Tumor cells are well differentiated G2: Tumor cells are moderately differentiated G3: Tumor cells are poorly differentiated but the tissue of origin can be established. **Tumor cells are poorly differentiated and determination of the tissue of origin is difficult Prognosis: - Early diagnosis usually results in a better prognosis. Many cancers spread or metastasize before any manifestations are noted. Minority populations tend to have a worse prognosis for cancers related to several factors (low sociocultural status, lack of access to health care, or reluctance to seek treatment). Nurse care includes helping to coordinate care among various providers and also may include helping patients to create a survivorship plan. The client will need to continue prevention and screening for new cancer or recurrence of the original cancer, as well as watch for manifestations of metastasis. The client might require ongoing therapy for the effects of cancer and cancer treatment, such as pain management or fertility treatments. The nurse should assist with management and help the client coordinate care among various providers. COMPLICATIONS: Malnutrition: Clients who have cancer are at increased risk for weight loss and anorexia. - The presence of carcinoma in the body increases the amount of energy required for metabolic function. Cancer can impair the body’s ability to ingest, digest, and absorb nutrients Adverse effects of cancer treatment can affect the desire for food or ability to eat. Findings include: nausea, vomiting, changes in taste, anorexia, pain, diarrhea, early satiety, dry mouth, thickened saliva, and irritation of the GI tract. NURSING ACTIONS: - Administer antiemetics and antacids as prescribed Monitor relevant laboratory data (albumin, ferritin, and transferrin). Encourage frequent oral hygiene. ● Incorporate client preferences into meal planning when possible. ● Avoid early satiety by limiting liquids during meals. ● Teach the client to collaborate with dietary services. CLIENT EDUCATION ● Understand how to manage the expected effects of treatment. ● Consume adequate protein, carbohydrates, and calories. Constipation/gastric stasis/intestinal obstruction NURSING ACTIONS - Can be related to cancer or cancer treatment. Opioids can cause delayed emptying, slowed bowel motility. Administer stool softener or laxative as needed. Encourage fluids, fiber, and activity as tolerated. Paraneoplastic syndromes: Paraneoplastic syndromes result when T cells in the body attack normal cells rather than cancerous ones. They result in changes in neurologic function (movement, sensation, mental function). - Management includes minimizing the immune system response by administration of steroids, immune factors, plasmapheresis, or irradiation. NURSING ACTIONS - Recognize manifestations of paraneoplastic syndrome. Administer medications as prescribed. Provide a safe environment until the client returns to baseline mental status. Use aids for vision or hearing deficits, as indicated ONCOLOGICAL EMERGENCIES: Syndrome of inappropriate antidiuretic hormone (SIADH): SIADH occurs when excessive levels of antidiuretic hormones are produced. Because antidiuretic hormones help the kidneys and body to conserve the correct amount of water, SIADH causes the body to retain water. This results in a dilution of electrolytes (such as sodium) in the blood. - It is most commonly associated with lung and brain cancers. Key findings include nausea and vomiting (early); lethargy, hostility, seizures, and coma. NURSING ACTIONS - Monitor for hyponatremia and low blood osmolality. Administer furosemide, 0.9% sodium chloride IV, and hypertonic sodium chloride solution as prescribed for severe hyponatremia. - Monitor vital signs and blood sodium level because furosemide promotes sodium excretion and hypertonic sodium chloride can cause fluid overload Hypercalcemia: A common complication of breast, lung, head, and neck cancers; leukemias and lymphomas; multiple myelomas; and bony metastases of any cancer MANIFESTATIONS: Anorexia, nausea, vomiting, shortened QT interval, kidney stones, bone pain, and changes in mental status NURSING ACTIONS: Administer 0.9% sodium chloride IV, furosemide, pamidronate, and phosphates as prescribed Superior vena cava syndrome: Results from obstruction (metastases from breast or lung cancers) of venous return and engorgement of the vessels from the head and upper body MANIFESTATIONS: Periorbital and facial edema, erythema of the upper body, dyspnea, and epistaxis NURSING ACTIONS - Position the client in a high‑Fowler’s position initially to facilitate lung expansion. Use high‑dose radiation therapy for emergency temporary relief. Hematologic disorders: Hematologic problems can be caused by the cancer itself or chemotherapy. - Anemia: When cancer invades the bone marrow, it decreases the number of red blood cells, platelets (thrombocytopenia) and white blood cells (neutropenia). Disseminated intravascular coagulation: Secondary to leukemia or adenocarcinomas NURSING ACTIONS - Observe for bleeding, and apply pressure as needed. Be prepared to administer blood clotting factors that have been lost through bleeding and need to be replaced with plasma transfusions. Heparin also can be used to slow the cascade of events that makes the body overuse its blood clotting factors. Sepsis: Pathogens in the body can lead to septicemia and septic shock, which are life-threatening. - Clients who are neutropenic are at an increased risk. NURSING ACTIONS: - Institute resuscitation measures, including obtaining blood cultures, measuring blood lactate, and administering antibiotics and crystalloid fluids. Vasopressors can be required if fluid administration is insufficient. Spinal cord compression: Occurs when vertebrae degrade secondary to cancer, or tumors invade the spinal column. Without immediate intervention, permanent neurologic damage can occur. MANIFESTATIONS: Changes in sensation, muscle strength, reduced deep tendon reflexes, worsening back pain, and bowel or bladder retention NURSING ACTIONS - Plan to administer high-dose IV corticosteroids to reduce inflammation around the spinal cord. Prepare the client for possible radiation therapy or surgery to relieve cord compression. CLIENT EDUCATION: An MRI usually confirms diagnosis Tumor lysis syndrome (TLS): TLS occurs when tumors are rapidly destroyed, releasing intracellular content into the bloodstream faster than the body can process them. This rapid release causes hyperkalemia, hyperphosphatemia, and hyperuricemia. Without correction, TLS leads to kidney injury and changes in cardiac function that can lead to death. - Older age increases risk, as well as certain chemotherapy agents and types of cancer. MANIFESTATIONS: Gastrointestinal distress, flank pain muscle cramps and weakness, seizures, and mental status changes NURSING ACTIONS - Administer IV fluids and encourage fluid intake of 3 L daily, including consumption of alkaline fluids to lower uric acid levels. Administer medications (diuretics, allopurinol, sodium polystyrene) to reduce potassium, uric acid, and phosphorus levels. CLIENT EDUCATION: Hemodialysis and intensive care might be required.
