GERONTOLOGY AND
CANCER
NURS 201
NURSING
QUOTE OF
THE DAY
CHRONIC ILLNESS
Trajectory of Chronic Illness
• Most chronic illnesses have the potential of an acute exacerbation of symptoms.
• Preventing and managing a crisis
• Carrying out prescribed treatment regimen
• Controlling symptoms
• Onset, duration, severity
• Reordering time
• Usual schedules may need to be adjusted
• Adjusting to changes in course of disease
• Preventing social isolation
• Attempting to normalize interactions with others
• Prevention of Chronic Illness
• Preventive health behaviors —voluntary actions taken
by an individual or group to decrease the potential
threat of illness
• Primary
• Secondary
CHRONIC
ILLNESS
• Tertiary
• Primary prevention refers to measures that prevent
the occurrence of a specific disease.
• Secondary prevention refers to actions aimed at
early detection of disease that can lead to
interventions to prevent disease progression.
• Tertiary prevention refers to activities (e.g.,
rehabilitation) that limit disease progression or return
the patient to optimal functioning.
NURSING MANAGEMENT
• Nurses play a critical role in management of chronic conditions.
• Planning care
• Teaching patient and family
• Implementing strategies
• Assessing patient and family outcomes
OLDER ADULTS
Aging population
•
Surviving acute illness
•
Living with chronic illness
•
Becoming more educated and resourceful
•
More ethnically diverse
Increasing life expectancy anticipated to continue
•
77.8 for men
•
80.8 for women
•
Young old are 65-74.
•
Old old are 85 and older.
•
Frail old have some dysfunction.
ATTITUDES TOWARD AGING
• Aging is normal.
• Older adults have diverse characteristics.
• Care should not be based on age alone.
• Myths and stereotypes can lead to poor care.
• Ageism leads to discrimination and disparate care.
BIOLOGIC
AGING
SPECIAL OLDER ADULT POPULATIONS
•
Chronically Ill Older Adults
•
•
Older Adult Women
•
•
Incidence of chronic illness triples after age 45.
Double jeopardy
•
An aging body
•
Being a woman
Homeless Older Adults
•
Numbers are increasing.
•
Mortality rates are 3 times higher than for those with housing.
•
Have more health problems and appear older
•
Require an interdisciplinary services approach
SPECIAL
OLDER ADULT
POPULATIONS
SPECIAL
OLDER ADULT
POPULATIONS
CULTURALLY COMPETENT CARE
• The term ethnogeriatric describes the specialty area of
providing culturally competent care to older adults.
• Loss of ethnic ties occurs as neighborhoods change,
including loss of friends of the same culture and
language, loss of religious institutions that support ethnic
activities, and loss of stores that carry ethnic foods.
• Loss of ethnic support can occur when children or others
deny or ignore cultural practices.
• Support is most often found within the family, religious
practices, and isolated geographic or community clusters.
SOCIAL SUPPORT AND OLDER ADULTS
• Family caregivers
• Primary and preferred
• Semiformal levels of support
• Clubs, faith-based organizations, neighborhoods, senior centers
• Formal systems of support
• Social welfare agencies, health facilities, government agencies
• Area Agency on Aging
• Elder Mistreatment/Abuse
• From 2-10% of community-dwelling older adults in the United States are abused, neglected, or
exploited by trusted others.
• Mortality risk is 3 times higher.
• Mandated to report to a supervisor if abuse is suspected
• Self-Neglect
MEDICARE AND MEDICAID
• Medicare is federally funded insurance for people >65. (Something you get when your
worked a lot of years)
• Also covers those < 65 with disabilities or end-stage kidney disease
• Medicaid is a state-administered, needs-based program to assist eligible low-income
people with medical expenses.
CARE ALTERNATIVES FOR OLDER ADULTS
• Special care needs
• Need assistance with ADLs
• Cognitively impaired
• Homebound
• No longer able to live at home
• Homeless
• Home Health Care
• Homebound
• Intermittent or acute health needs
• Supportive caregiver involvement
• Long-Term Care
• Transition may be difficult for patients and families
• Relocation stress syndrome
LEGAL AND ETHICAL ISSUES
Many complex and emotional situations may arise for older adults.
Decisions may be difficult.
You can help.
Stay informed about concerns.
Be knowledgeable about resources.
Advocate for patients and resolution.
NURSING MANAGEMENT
Specialty of Gerontological Nursing
•
Complex, skilled, creative care
•
Older adult disease symptoms are often atypical and underreported.
•
Patients may be fearful and anxious about both health problems and institutions of care.
Nursing Assessment
•
Attends to primary needs first
•
Focuses on functional abilities
•
Comprehensive
•
Involves an interdisciplinary team and approach
•
End of Life Care assessment for those elderly patients dying from a terminal illness ( observing for Cheynes Stokes
Planning
NURSING
MANAGEMENT
• Identify strengths and
abilities.
• Gain a sense of control.
• Feel safe.
• Reduce stress.
NURSING
MANAGEMENT
• Nursing Implementation
• Acute Care
NURSING
MANAGEMENT
• Nursing Implementation
• Acute Care
• Assistive devices can decrease disability
when used properly.
• Older adults are at higher risk for safety
from problems related to illness, disability,
and normal aging processes.
• Medication use
1. Use of a marked pill box to
distinguish medications
NURSING
MANAGEMENT
NURSING MANAGEMENT
•
Nursing Implementation
•
Acute Care — Depression
•
Not a normal part of aging
•
20% of suicides
•
Co-occurs with medical conditions
•
Geriatric Depression Scale
•
Physical restraints
•
Chemical restraints
•
Used to ensure safety ONLY
•
Least restrictive approach
•
Highly regulated
•
Sleep
PATIENT EDUCATION
• Need for certain vaccinations if elderly:
 Shingles vaccine at age 60
 Pneumococcal vaccine at age 65, and every 10 years after
 Visual Acuity Testing every year
 Having pills marked in case to increase medication compliance
EVALUATION
NCLEX QUESTION
• A nurse is admitting an older adult client who fell at home and was unable to
get up. The client was not discovered until 3 days later by a family member.The
client is admitted with a fractured hip, malnutrition, and dehydration. Which of
the following lab values, noted on admission, should indicate to the nurse that
the malnutrition is a long standing problem?
A. Increased Sodium
B. Decreased Albumin
C. Increased BUN
D. Decreased blood sugar
RATIONALE
• B. Decreased Albumin
• This is an example of a complete protein which shows nutritional status
NCLEX QUESTION
• A nurse in a post-surgical unit is admitting an older adult client from the
recovery department following abdominal surgery for a bowel obstruction. Of
which of the following information regarding pain management should the
nurse be aware? Older adult clients
A. have a diminished capacity to perceive pain.
B. are sensitive to the analgesic effect of opiates.
C. require higher doses of opiates for analgesia.
D. possess an increased tolerance for pain.
NURSING
MANAGEMENT
RATIONALE
• B. are sensitive to the analgesic effect of opiates.
• Require less amount, due to decreased abilities of the liver to metabolize and the kidneys
to excrete wastes
WHAT IS CANCER
• Cancer is defined as a group of diseases characterized by uncontrolled and unregulated growth of cells
• An estimated 1,658, 370 people in the United States are diagnosed annually with cancer
• Overall both the incidence and mortality rate of cancer have been declining as a result of prevention
• Overall cancer is higher in men than women
• Although mortality rates from all types of cancer combined have decreased, cancer is the second most
cause of death in the U.S. (heart disease being the first)
• People 40-79 yrs old, cancer is the leading cause of death
• Breast Cancer is the number one type for women, while Prostate Cancer is more prevalent in men
INCIDENCE
OF CANCER
BIOLOGY OF CANCER
• There are two major dysfunctions that produce cancer, defect cell proliferation and defective cell
differentiation.
• Defect in cell proliferation involves cancer cells that have grown in tissue culture that are characterized
by a loss of contact inhibitions, meaning these cells have no regard of boundaries and grow on top of each
other and in between normal cells
• The pyramid effect in cancer growth accelerates the production by multiples, therefore there is
continuous growth of a tumor mass.
• Defect in cell differentiation involves altering the otherwise orderly process that progresses from a
state of immaturity to a state of maturity.
BIOLOGY OF
CANCER
NORMAL CELL
DIFFERENTIATION
BIOLOGY OF
CANCER
PROTOONCOGENES
• Protooncogenes are normal cell genes that are important regulators of
normal cell processes
• Promote growth, whereas tumor suppressor genes suppress growth
• The protooncogene has been described as the genetic lock that keeps the cell in its
mature functioning state, when unlocked cancer mutations can occur
• Oncogenes can change a normal cell into a malignant one
NCLEX QUESTIONS
• True or False
• Both the incidence and mortality rates of cancer have overall decreased due to the
advancements in technology
TUMOR SUPPRESSOR GENES
• Tumor suppressor genes function to regulate cell growth
• They prevent cells from going through the cell cycle
• Examples of alterations in tumor suppressor genes of BRCA 1 AND BRCA 2, which
increase risk for breast cancer
• Another example is the APC gene, which can increase risk for colorectal cancer and the
PSA which is indicative of prostate cancer
TUMOR
SUPPRESSION
GENES
DEVELOPMENT
OF C ANCER
INITIATION
• Initiation, the first stage of cancer, involves in the usual DNA sequence cell cycle
• Gene mutations can occur in two situations: inherited or acquired in a person’s lifetime
• 5-10% are inherited
• Carcinogens (cancer-causing agents) can enter the cell’s nucleus and alter DNA, can be chemical, radiation, or viral
• The three most common psychosocial factors that influence the patient are anxiety, fear, and hope
PROMOTION
• A single alteration of the genetic structure is sufficient enough to cause cancer
• The risk for cancer is increased with the presence of promoting agents
•
Promotion, the second stage in the development of cancer, is characterized by the reversible
proliferation of the altered cells.
• Promoting factors include dietary fat, obesity, cigarette, smoking, and alcohol consumption
• Completed Carcinogens are capable of initiating and promoting cancer, Smoking is an example
• The latent period includes the time for the initiation and promotion stages
• For the disease process to become clinically evident, the cells must reach a critical mass
PROGRESSION
•
Progression is the final stage in cancer
•
This stage is characterized by increased growth rate of the tumor, increased invasiveness, and metastasis
•
Metastasis is a multistep process beginning with rapid growth of the primary tumor
•
The process of the formation of blood vessels within the tumor itself is termed tumor angiogenesis
•
Tumor cells are able to detach from the primary tumor, invade tissue, and penetrate the walls of the lymph vessels
•
Tumor cells can travel to distant organ sites via hematogenous or lymphatic routes.
•
Main sites of metastasis include brain and cerebrospinal fluid, lungs, liver, adrenals, and bone
ROLE OF THE IMMUNE SYSTEM
• The immune system has the potential to distinguish cells that are normal from abnormal
• Cancer cells can be perceived as non-self and elicit an immune response resulting in the rejection and destruction
• Cancer cells may display altered cell-surface antigens as a result of malignant transformation
• The immune system’s response to antigens if the malignant cells is termed immunologic surveillance
• This surveillance involves Cytotoxic T Cells, Natural Killer Cells, Macrophages, and B Cells
ROLE OF THE IMMUNE SYSTEM
•
The process by which cancer cells evade the immune system is termed immunologic escape.
•
Cancer cells can evade and escape the immune system due to secretions of substances that can suppress the
immune system response
•
Oncofetal Antigens are a type of tumor antigen
•
These antigens are an expression of the shift of cancerous cells to a more immature metabolic pathway
•
Examples of oncofetal antigens are carcinoembyronic antigen (CEA Colon Cancer) and A-fetoprotein (AFP Lung Cancer)
•
These onconfetal antigens can be used as tumor markers that can be used to monitor the effect of therapy and indicated tumor
recurrence
NCLEX QUESTION
• When caring for the patient with cancer, what does the nurse understand as
the response of the immune system to antigens of the malignant cells?
A. Metastasis
B. Tumor angiogenesis
C. Immunologic escape
D. Immunologic surveillance
RATIONALE
• D. Immunologic surveillance
Immunologic surveillance is the process where lymphocytes check cell surface antigens
and detect and destroy cells with abnormal or altered antigenic determinants to prevent
these cells from developing into clinically detectable tumors. Metastasis is increased
growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site
in the progression stage of cancer development. Tumor angiogenesis is the process of
blood vessels forming within the tumor itself. Immunologic escape is the cancer cells'
evasion of immunologic surveillance that allows the cancer cells to reproduce.
BENIGN VERSUS MALIGNANT
NEOPLASMS
• Tumors can be classified as benign(Stagnant) or malignant (Ability to metaseries)
• Malignant neoplasms range from well differentiated to undifferentiated
• The ability of the malignant tumor cells to invade and metastasize is the major difference
between benign and malignant neoplasms (Look at text book box)
BENIGN VERSUS
MALIGNANT
NEOPLASMS
TYPICAL FEATURES OF CANCER TISSUE
• Increases in cell number
• Large variations in cell appearance and size
• Loss of normal arrangement of cells
• Distorted shape
• Increase in mitotic activity
NCLEX QUESTION
• Which of the following does not apply to benign tumor cells?
a. A slow, progressive rate of growth that may come to a standstill or regress
b. Non-invasive manner of growth
c. Liberation of enzymes and toxins that destroy tumor tissue and normal tissue
d. Composed of well-differentiated cells that resemble the cells of the tissue of origin
RATIONALE
• C. Liberate enzymes and toxins that destroy tumor tissue and normal tissue
(Liberating enzymes and toxins that destroy tumor tissue and normal tissue is an ability
that characterizes metastatic tumor cells)
CLASSIFICATION OF CANCER
• Anatomic Site Classification: the tumor is identified by the tissue of origin, anatomic site, and behavior of the
tumor
• Histological Classification: also called grading of tumors, the appearance of cells and degree of
differentiation are evaluated pathologically by biopsy by needle aspiration
• Grade I includes cells that slightly differ from normal cells
• Grade II include cells that are more abnormal and moderately differentiated
• Grade III include cells that are very abnormal
• Grade IV include cells that are immature and primitive
• Grade X cells cannot be assessed
• Biopsy Staging: uses a needle, identifies the appearance of the cells and degree of differentiation
CLASSIFICATION OF CANCER
•
Classifying the extent and spread of disease is termed staging
•
Clinical Staging
•
Stage 0: cancer in situ
•
Stage 1: tumor limited to the tissue of origin
•
Stage 2: limited local spread
•
Stage 3: extensive local and regional spread
•
Stage 4: Metastasis (Stage 4 and beyond has poor prognosis for treatment and life expectancy)
•
TNM Classification System used to determine the anatomic extent of the disease involvement according to three parameters
tumor size and invasiveness (T), presence or absence of regional spread to the lymph node how many node involved (N), and
metastasis to distant sites (M) where did it metastasis
•
Surgical Staging refers to the extent of the disease as determined by surgical excision, exploration, and/or lymph
node sampling.
CLASSIFICATION OF
CANCER
PREVENTION AND EARLY DETECTION
OF CANCER
• Early detection and prompt treatment are responsible for increased survival rates in patients with cancer
• Reduce and avoid exposure to known or suspected carcinogens
• Have a regular physical
• Eat a balanced diet that includes fruit and vegetables, whole grains, and amounts of fiber
• Those who are 50 years old should have screening for colon cancer (colonoscopy and fecal occult blood
test) every 10 years from this age on
• A patient that is a smoker should notify their healthcare provider if they develop hoarseness or a nagging
cough
• Know the Seven Warning Signs!!!
PREVENTION AND EARLY
DETECTION OF C ANCER
• These can be very non-specific signs that a
patient is developing Ca.
• Very important that patients are aware of
these and to report them immediately to
their primary healthcare physician
PREVENTION AND EARLY DETECTION
OF CANCER
• A diagnostic plan for the person suspected of having cancer includes the health history
(including history of present illness), identification of risk factors, the physical examination,
and specific diagnostic tests
• Tests may include: Chest X-Ray, Tissue Biopsy, CBC, Cytology Studies
• Biopsy is the removal of a tissue sample for pathologic analysis
TREATMENT GOAL
• The goals of cancer treatment are cure, control, and palliation
• Curative cancer therapy differs according to the particular cancer being treated and may involve
local therapies such as surgery and radiation.
• The risk for recurrent disease is highest after treatment completion and gradually decreases the
longer the patient remains disease free
• Control is the goal of the treatment plan for many cancers that cannot be completely eradicated
but are responsive to anticancer therapies
• Palliation is the treatment goal when relief or control of symptoms and the maintenance of a
satisfactory quality of life are the primary objectives
PERSONALIZED CANCER MEDICINE
• In this tx the patient’s personalized genetic information is used to guide decisions made
about prevention, diagnosis, and treatment of cancer.
• Targeted therapy is a tx in which a person’s cancer genes or proteins are targeted that
contribute to cancer growth and survival
• In order to formulate a targeted therapy, a sample of tumor obtained through a biopsy
must be tested
SURGICAL THERAPY
• Surgical intervention can be used to eliminate or reduce the risk of cancer development
• Prophylactic removal of non-vital organs can help to alleviate or reduce the incidence of some cancers
• An example of prevention of cancer would be a person positive for BRCA 1& BRCA 2, getting a
prophylactic mastectomy
• When the goal is cure or control, the objective is to remove all or much resectable tumor as possible while sparing
normal tissue. Debulking may be used if the organ or tumor cannot be fully removed
• Debulking will decrease tumor size and help to improve the effects of other therapies
• When cure or control is not possible, surgical procedures may be used to maximize bodily function
The goal of this treatment is to eliminate or to reduce the number of
cancer cells in the primary tumor and metastatic tumor site.
Chemotherapy mostly affects cells with high growth rate fraction due the
multiplying nature of cancer
Chemotherapy can be administrated through multiple routes, IV
administration is the most common
When administrating IV chemo, be aware of extravasation because of
most chemotherapies are either vesicants or irritants
CHEMOTHERAPY
Other routes can be through a PICC, Tunneled Central Line, or Port-acath through a huber needle access
Irritants can damage the intima of the vein, causing phlebitis and
sclerosis
Vesicants may cause tissue breakdown and necrosis
The PICC line is the most secure way to administer a drug that may be
a vesicant
If you suspect that that the infusion may be causing extravasation (leakage),
stop the drug immediately!!!!
PICC LINE
PLACEMENT
TUNNELED
CENTRAL
LINE
PORT-A-CATH
NCLEX QUESTION
• What is the most effective way to administer a chemotherapeutic agent that
is a vesicant
• a. orally
• b. through a Central Line
• c. through a peripheral IV
• d. through an IM injection
RATIONALE
• B. through a Central Line
• Less likely to have extravasation occur
NCLEX QUESTION
• The patient is receiving an IV vesicant chemotherapy drug. The nurse notices
swelling and redness at the site. What should the nurse do first?
A. Ask the patient if the site hurts.
B. Turn off the chemotherapy infusion.
C. Call the ordering health care provider.
D. Administer sterile saline to the reddened area.
RATIONALE
• B. Turn off the chemotherapy infusion.
Because extravasation of vesicants may cause severe local tissue breakdown and necrosis,
with any sign of extravasation the infusion should first be stopped. Then the protocol for
the drug-specific extravasation procedures should be followed to minimize further tissue
damage. The site of extravasation usually hurts, but it may not. It is more important to
stop the infusion immediately. The health care provider may be notified by another nurse
while the patient's nurse starts the drug-specific extravasation procedures, which may or
may not include sterile saline.
GOALS OF
CHEMOTHERAPY
CHEMOTHERAPY
• Regional Treatment is a form of chemotherapy which involves delivery of drug directly to the tumor site
• There are several forms of regional tx such as intraarterial chemotherapy (via the arteries to the tumor), intraperitoneal
chemotherapy (via the peritoneal cavity), & intrathecal or intraventricular (via lumber puncture), and lastly intravesical (via the
bladder).
• Effects of Chemotherapy on Normal Tissues
1. Acute Toxicity: during and immediately after therapy, includes anaphylactic and hypersensitivity reactions, N&V, cardiac dysrhythmias
2. Delayed Effects: delayed N&V, mucositis, alopecia, skin rashes, altered bowel functions
3. Chronic Toxicities: involves damage to vital organs
Explore patient concerns about chemotherapy, if there is hesitation
CHEMOTHERAPY
RADIATION THERAPY
• Radiation is energy that is emitted from a source and travels through
space or some material
• To avoid serious toxicity and long-term complications of treatment,
radiation to surrounding healthy tissue must be limited to the maximum
tolerated for that specific tissue.
• Stimulation is a process by which the radiation treatment fields are
defined, filmed, and marked out on the skin
• Target Volumes Include:
1. Gross Target Volume (GTV), the gross extent of the tumor identified by imaging
2. Clinical Target Volume (CTV), the GTV plus additional margin to encompass any subclinical disease
3. Planning Target Volume (PTV), the GTV.CTV plus additional margin to allow organ motion.
• Radiation may be used by itself, in combination with chemotherapy, or surgery to treat primary tumors, of for palliation of
metastatic lesions.
• Radiation is usually not an appropriate primary treatment, because of its deadly effect on surrounding tissues
RADIATION THERAPY
External Radiation
• Also known as teletherapy or external beam radiation
• The most common form of radiation therapy
• With this technique the patient is exposed to radiation from a megavolt tx machine
• Patients receiving external radiation, should thoroughly dry and clean their skin to avoid irritation
Internal Radiation
• Also known as brachytherapy, which means “close” or internal radiation treatment.
• Allows for direct delivery of radiation to the target with minimal exposure to surrounding healthy tissues
• Implants are used to complete this type of radiation
• Patients with temporary implants are radioactive while the implant is inside
• Permanent implants have short half lives and do not emit much radiation
RADIATION
THERAPY
NCLEX QUESTION
• The nurse counsels the patient receiving radiation therapy or chemotherapy
that
• a. effective birth control methods should be used for the rest of the patients’ life
• b. if nausea and vomiting occur during treatment, the treatment plan will be modified
• c. after successful treatment, a return to the persons’ previous functional level can be
expected
• d. the cycle of fatigue-depression-fatigue that may occur during therapy may be reduced by
restricting activity
RATIONALE
• C. after successful treatment, a return to the persons’ previous functional level can be
expected
• Most Individuals should be able to get back to a functional way of life after chemotherapy
takes place
BONE MARROW SUPPRESSION
• Myelosuppression is one of the most common and serious side effects of chemotherapy and can also occur
because of radiation
• The major difference in manifestations between chemotherapy and radiation is with radiation only bone marrow
within the area is affected. Damage to bone marrow is more systemic with chemotherapy
• Checks CBC frequently , especially 7 to 10 days following initiation of tx.
• Neutropenia is more common in patients receiving chemotherapy, temperature must be monitored in these patients
to help prevent infection, can be the first serious side effect to appear ( Ex:WBC below normal range
• Thrombocytopenia can result in spontaneous bleeding or major hemorrhage, below 50,000
• Anemia is common in both patients undergoing chemotherapy and radiation, and may be the cause of excessive
fatigue
NCLEX QUESTION
• Which nursing diagnosis is most appropriate for a patient experiencing
myelosuppression secondary to chemotherapy for cancer treatment?
A. Acute pain
B. Hypothermia
C. Powerlessness
D. Risk for infection
RATIONALE
• D. Risk for infection
Myelosuppression is accompanied by a high risk of infection and sepsis. Hypothermia,
powerlessness, and acute pain are also possible nursing diagnoses for patients undergoing
chemotherapy, but the threat of infection is paramount.
GASTROINTESTINAL EFFECTS
•
The intestinal mucosa is one of the most sensitive tissues to radiation and chemotherapy
•
The damage is caused by the release of serotonin from the GI tract which triggers the chemoreceptor zone and the the vomiting center in the
brain
•
The various side effects include N&V, Diarrhea, Mucositis, & Anorexia
•
Have the patient limit high fiber foods that may increase diarrhea
•
Oral care should be performed frequently (ex: rinsing the mouth after each meal and at bedtime with a saline solution to help with possible
ulceration formation)
•
Small frequent meals of high-protein, high-calorie foods should be encouraged
•
Anti-nausea medication should be administered one hour before chemotherapy starts to help decrease risk of vomiting
•
Look out for potential S/S of anti-nausea medication (Zofran (odansetron) headache and QT extending on the cardiac monitor
•
Eating foods served at room temperature
SKIN CHANGES
• With radiation therapy, skin effects are local, occurring only in the treatment field
• Erythema may develop 1 to 24hrs after a single tx but generally occurs progressively as the tx dose accumulates
• This is an acute response followed by dry desquamation
• Wet Desquamation can produce pain, drainage, and increased risk of infection
• With chemotherapy, the skin effects vary including mild erythema and erythrodysesthesia syndrome (aka hand foot
syndrome) tingling of soles and palms with accompanied blistering, ulceration, and pain
• Patient may also c/o peripheral neuropathy secondary to chemotherapy
• Alopecia is also a skin effect of chemotherapy
DRY
DESQUAMATION
WET
DESQUAMATION
PULMONARY EFFECTS
• Both Chemotherapy and Radiation have the potential to produce pulmonary tissue
damage that is irreversible and progressive
• Pneumonitis is a delayed acute inflammatory reaction that may occur within 1 to 3
months after completion od thoracic radiation
• Pulmonary edema and fibrosis can also occur with chemotherapy as well
CARDIOVASCULAR EFFECTS
• Radiation to the thorax can cause damage to the pericardium, myocardium, valves, and
coronary blood vessels.
• Pericarditis or Pericardial effusion is also very common
• ECG abnormalities can occur as well
• Left ventricular dysfunction and HF may be the end result
COGNITIVE EFFECTS
• Cognitive effects can occur anytime during the cancer treatment
• The alteration in cognitive status can be seen as brain fog or mental cloudiness called
chemo brain
• Memory problems can become an issue
• Daily activities and social gathering may be difficult to attend
REPRODUCTIVE EFFECTS
• The patient and her or his partner require information about the expected effects of
treatment relative to reproductive and sexual issues
• Fertility preservation should be addressed prior to the start of any cancer treatment
• Potential infertility can be a significant consequence for the individual, and counseling may
be indicated
• Encourage discussion of issue related to reproduction and sexuality
IMMUNOTHERAPY & TARGETED
THERAPY
Immunotherapy uses the immune system, the body’s main defense against infection and disease, to fight cancer
• Boosts immune system and create an environment that is not conducive for cancer cells to grow
• Attack cancer cells directly
• Side effects include inflammatory responses such as flu-like S/S
• Patients are usually pre-medicated with tylenol and fluids to decrease S/S
Targeted Therapy interferes with cancer growth by targeting specific cell receptors and pathways that are
important in tumor growth
• A major advantage of targeted therapy is that is does less damage to normal cells
• A major class example is tyrosine kinase inhibitors
• Common side effects include skin rashes, others may include liver toxicity, bone marrow suppression, CNS effects
Nursing monitoring includes monitoring vital signs, temperature, planning for periods of rest, assisting with
activities of daily living, and monitoring for oral intake
I MMUNOT H E R AP Y
& TAR G E T E D
T H E R APY
HORMONE THERAPY
• The hormones estrogen and progesterone can
enhance the growth of some breast cancers, and
androgen (Testosterone) can enhance the growth of
prostate cancers.
• When given as a cancer treatment, it can block the
effects of the hormone and stop the growth of
cancer cells
STEM CELL TRANSPLANTATION
• Bone marrow transplantation (BMT) & Peripheral Stem Cell Transplantation (PSCT) are
effective life-saving treatment for a number of malignant and nonmalignant diseases
• The approach is to eradicate diseases tumor cells and/or clear the bone marrow of its
components to make way for engraftment of the healthy stem cells
• After chemotherapy and radiation therapy are completed, healthy stem cells are infused
• Stem cells transplantation is extremely risky, some people die from tx-related
complications
TYPES OF STEM CELL TRANSPLANTS
Allogeneic Transplantation donor
• Stem cells are acquired from a donor (graft) who, through human leukocyte antigen (HLA) tissue typing is
determined to be a match to the recipient
• The donor is often a family member, but may be an unrelated donor found through national or international
bone marrow registry
Syngeneic Transplantation twins
• A type of allogeneic transplantation that involves obtaining stem cells from one identical twin and infusing them into the other
• Identical twins have identical HLA and are perfect matches
Autologous Transplantation
• Patients receive their own stem cells back after myeoblative (destroying bone marrow) chemotherapy
• This method enables patients to use their previously harvested stem cells while enduring intensive chemotherapy
HARVEST PROCEDURES
• In one type of procedure, used for harvesting stem cells residing in bone marrow, the
procedure is done in the OR where the bone marrow is aspirated, can take up to 1-2hrs,
and the patient can go home the same day
• In another type of collection, peripheral stem cell transplants are obtained from the
peripheral blood in an outpatient procedure, it is done using cell separator that
automatically separates the stem cells from the blood
• Cord blood is also rich in hematopoietic stem cells
MALNUTRITION
• The patient with cancer may experience protein and calorie
malnutrition characterized by fat and muscle depletion
• Soft-non-irritating high-protein and high-calorie foods should be
eaten throughout the day (whole milk, eggs, nuts, chicken)
• Teach the patient to avoid extremes of temperatures, tobacco, alcohol,
spicy or rough foods, an other irritants
• The family should be involved as well, because of the increasingly lack of
of appetite and encouragement to eat
• Expect low albumin levels for these patients
• Know foods that are high in complete protein
ALTERED TASTE SENSATION
• Also called dyguesia
• Cancer cells may release substances that stimulate the bitter taste buds
• Teach patients to avoid foods that they dislike
• Tell the patient to experiment with spices and other seasoning agents in an attempt to
mask taste alterations
CANCER CACHEXIA
• Also called wasting syndrome
• A complex, multifactorial syndrome characterized by anorexia and/or unintended loss of
weight and appetite
• Is accompanied by tissue wasting, skeletal atrophy, immune dysfunction, and metabolic
abnormalities
• This type of weight loss cannot be reversed nutritionally
• 3 options are available to help alleviate this: treat the cancer, increase nutritional intake, or
use megestrol acetate (Megace) an appetite stimulant
NCLEX QUESTION
• The nurse is caring for a patient suffering from anorexia secondary to
chemotherapy. Which strategy would be most appropriate for the nurse to use
to increase the patient's nutritional intake?
A. Increase intake of liquids at mealtime to stimulate the appetite.
B. Serve three large meals per day plus snacks between each meal.
C. Avoid the use of liquid protein supplements to encourage eating at mealtime.
D. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.
RATIONALE
• D. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.
The nurse can increase the nutritional density of foods by adding items high in protein
and/or calories (such as peanut butter, skim milk powder, cheese, honey, or brown sugar)
to foods the patient will eat. Increasing fluid intake at mealtime fills the stomach with fluid
and decreases the desire to eat. Small frequent meals are best tolerated. Supplements can
be helpful.
INFECTION
• Primary cause of death in the patients with cancer
• The usual sites of infection include the lungs, GU system, mouth,
rectum, peritoneal cavity, and blood which is called (septicemia)
• Instruct patients at risk for neutropenia to call their doctor if they have
a temp of 100.4 (38) or higher
• Infection for these patients can quickly lead to death if not treated
quickly
• Avoiding processes that expose patients to infection and bleeding( ex:
flossing, having fresh flower/fruit, those that possible have URI)
• Avoiding large crowds, Cooking food all the way through, and
consulting with a physician before dental appointments
ONCOLOGIC EMERGENCIES
• Life-threatening emergencies that can occur as a result of cancer or cancer treatment
• Within this group there are several sub groups of emergencies that include obstructive
emergencies, metabolic emergencies, infiltrative emergencies
• Obstructive emergencies are caused by tumor obstruction of an organ or blood vessel
• Metabolic emergencies are caused by the production of ectopic hormones directly from
the tumor or are secondary to metabolic alterations caused by the tumor or cancer
treatment
• Infiltrative emergencies occur when malignant tumors infiltrate major organs or
secondary to cancer therapy
OBSTRUCTIVE EMERGENCIES
Superior Vena Cava Syndrome
• Caused by lung CA, Breast CA
• S/S include facial edema, jugular distension, headache, sz’s
• Considered a medical emergency
• Tx: Radiation therapy to site of obstruction
Spinal Cord Compression
• Neurological emergency caused by cancer in the epidural space or spinal cord
• Caused by Breast, Lung, Prostate CA
• S/S include intense localized persistent back pain
• Tx: radiation to site and possible laminectomy
Third Space Syndrome
• Shifting of fluid from vascular space to interstitial space
• S/S hypovolemia, hypotension, tachycardia, decreased urine output
• Tx: Fluid, electrolyte, and plasma protein replacement
METABOLIC EMERGENCIES
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
• Sustained production of antidiuretic hormone (ADH)
• S/S include weight gain without edema, weakness, N&V, oliguria, coma
• Tx: take measures to correct sodium-water imbalance,give lasix
Hypercalcemia
• Occurs in metastatic disease or multiple myeloma
• S/S include apathy, depression, fatigue, muscle weakness
• Tx: hydration, diuretics, biophosphonates
Tumor Lysis Syndrome
• Metabolic complications characterized by rapid release of intracellular components in response to chemotherapy
• S/S include hyperuricemia, hyperkaelmia, hypocalcemia, weakness, cramps
• Tx: Increase urine production using hydration therapy, intake of allopurinol to decrease uric acid production
INFILTRATIVE EMERGENCIES
Cardiac Tamponade
• Fluid accumulation in pericardium
• S/S include heavy feeling in chest, SOB, tachycardia, cough, dysphagia, hoarseness
• Tx: administer O2 therapy, IV hydration
Carotid Artery Rupture
• Invasion of arterial wall by tumor or erosion following surgery
• Occurs most frequently with patients with head and neck cancer
• S/S include bleeding both minor and major
• Tx: Administer IV fluids and blood products
INFILTRATIVE
EMERGENCIES
CANCER PAIN
• Moderate to severe pain occurs in approximately 50% of patients receiving active tx
• 80% to 90% in patients with advanced cancer
• A thorough pain assessment is necessary for these patients includes location, intensity, quality, quality, patterns, and
relief measures
• Pain management should address chronic and acute issues
• A combination of non-steroidal anti-inflammatory drugs, opioids, adjuvant pain medications, should be used to
control pain
• Non-pharmacological methods should be considered as well (urban zen, massage therapy)
• Understand that when the patient says that the pain medication is no longer effective, suspect a possible tolerance
to pain medication
COPING & SURVIVORSHIP
• Nurses play a key role in assisting patients in coping with the psychosocial issues associated with cancer treatment
• Anxiety and fear may be experienced throughout the cancer continuum, including at diagnosis, during or after
treatment, and in association with long-term follow-up
• Be available, Listen actively, help provide relief from distressing symptoms, Use caring touch, Assist the patient in
maintaining normal lifestyle patterns, and maintain hope
• Arrange for support groups and include family and caregivers
• The increase in survivorship is attributed to the aging and growth of the population as well as improvements in
early detection and treatment
• The impact of a cancer diagnosis can affect many aspects of a patient’s life, with cancer survivors commonly
reporting financial, vocational, marital, and spiritual concerns long after treatment is over
GERONTOLOGIC CONSIDERATIONS
• Cancer is usually a disease of aging of 78% of cancers occurring in people 55yrs or older
• Cancer manifestations in older adults may be mistakenly attributed to age-related changes and ignored by the
person
• Older adults are especially vulnerable to complications of both cancer and cancer therapy because of overall decline
in functioning
• Issues to assess include projected life expectancy, co-morbidities that would affect treatment, and patient decisionmaking capacity and wishes
• Advanced age has been identified as one of the highest risk factors for cancer development
• Realizing when a patient wants to transition to hospice
• Respecting the patient’s autonomy when they want to stop treatments
CULTURALLY COMPETENT CARE
• Difference in survival rates from cancer are attributed primarily to a combination of
factors, including poverty, difficult access to health care, differences in tumor biology
• Culturally competent care in oncology is needed to meet the need of diverse groups
• Nurses have to actively seek to understand cultural differences to the individualized needs
of their patients