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MAIN CATEGORIES OF CANCER
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Interphase - 90% growth, DNA replication, cell func.
G0 - resting stage. Cell leaves to carry out function
Carcinoma: cancer that begins in the skin or in tissues
that line or cover internal organs
Sarcoma: begins in bone, cartilage, fat, muscle, blood
vessels, or connective/supportive tissues.
Leukemia: begins in blood forming tissue, such as
bone marrow, and causes large numbers of abnormal
blood cells to be produced and enter the blood.
Lymphoma and myeloma: begins in cells of the
immune system, bone marrow
CNS cancers: begin in tissues of the brain and spinal
cord; ex: nerve cells: neuroblastoma
Classification of Cancer
According to behavior of tumor
• Benign:
• tumors that cannot spread by invasion or
metastasis; hence they only grow locally
• Malignant:
• capable of spreading by invasion/metastasis.
• Metastases share name of the primary tumor
• Spread to vital organs (liver, brain) — life
threatening
•
•
•
•
Healthy cells
Large cytoplasm
Single nucleus
Single nucleolus
Fine chromatin
•
•
•
•
Cancerous cells
Small cytoplasm
Multiple nuclei
Multiple and large
nucleoli
Coarse chromatin
CELL PARTS & CYCLE
Nucleus- control center; controls genetic info
Mitochondria- powerhouse; converts sugar to energy
via cellular respiration.
Ribosomes- site of protein synthesis
Golgi apparatus- packaging center of cell; packages
& secretes proteins
Centrioles- organizes microtubules (spindle fibers) for
mitosis
Chromosomes- condensed DNA and proteins, codes
for genetic traits
Endoplasmic Reticulum- Transports intracellular
materials.
Cell cycle
G1- growth and prep of chromosomes for replication
S phase- DNA replication occurs
G2- prepare for mitosis
M phase- mitosis occurs 10%
• Prophase: chromosomes condensing; nucleus
present
• Metaphase- chromosomes line up in middle of cell;
nucleus dissembled
• Anaphase- chromosomes move away to opposite
sides via spindles
• Telophase - new nuclei forms on both sides to form
new cells.
• Cytokinesis- splits cells into 2.
Cell cycle quality control:
• Checkpoints in G1 & G2
• Apoptosis: self destruction of cell
• Mitosis checkpoints: detect failure of spindle fibers
& arrest cell in metaphase.
• Gene mutations = checkpoint failure = cancer
CANCER
Gene mutations:
1. Tumor suppressor gene mutations: Cancer cells
avoid apoptosis and keep growing and dividing,
resulting in a tumor. This is a recessive mutation
so both alleles in the gene need to be mutated to
cause the cancer.
“brakes of a car”
2. Proto-oncogene mutations: dominant genes, only
one allele needs to be stated to cause cancer.—
proto-onco gene mutates into an oncogene, a cell
will keep diving even when there are no messages
to divide.
“gas of a car”
Abnormal cell growth —> Tumor/neoplasm formation
—> apoptosis fails —> Invasion & Metastasis
Invasion: direct migration and penetration by cancer
cells into neighboring tissues
Metastasis: ability of cancer cells to penetrate into
lymphatic and blood vessels, circulate through the
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bloodstream, and then invade normal tissues elsewhere
in the body.
Establishment and growth: tumor cells established
and grow in secondary site: lymph nodes or in organs
from venous circulation
Carcinogenesis Stages:
1.
Initiation: carcinogens cause mutations in the
cellular DNA.
• Spontaneous
• Carcinogens: chemicals, physical factors,
biologic agents
2. Promotion: allow a cell that has undergone
initiation to become cancerous. (Doesn’t affect cells
that haven’t undergone initiation). Leads to the
formation of pre-neoplastic or benign lesion.
• Drugs
• Sex hormones
3. Spread/Progression: cancer grows into
surrounding tissue or organs (stimulate angiogenesis) ,
nearby or distant. Spread via lymphatic system or
blood stream.
• Proliferation— rapid reproduction by cell
division: hyperplasia, dysplasia, and
metaplasia, neoplasia
• Metastasis — spread or transfer of cancer
cells
ETIOLOGY
•
•
•
•
•
•
Viruses and bacteria
Physical agents
Chemicals
Genetics
Lifestyle factors
Hormones
Viruses:
• Human papilloma virus (HPV)
• Cervical, head, and neck cancers
• Hepatitis B Virus (HBV)
• Liver cancer
• Epstein-Barr virus (EBV)
• Burkitt lymphoma, & nasopharyngeal cancer
Bacteria:
• Chronic inflammatory reactions to bacteria &
production of carcinogenic metabolites
• H. Pylori — gastric cancer
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Physical Agents:
• Exposure to sunlight
• UV rays— skin cancer
• Clothing styles
• Use of sunscreen
• Occupation
• Recreational habits
• humidity, altitude, latitude.
• Radiation
• Repeat x-ray procedures
• Radiation therapy
• Nuclear weapon manufacturing sites/nuclear
power plants — inc. incidence of: leukemia,
multiple myeloma, cancers of lung, bone,
breast, thyroid, and other tissues.
• Radon — lung cancer. // ventilation in homes
• Chronic irritation or inflammation
• Tobacco carcinogens
• Industrial chemicals and asbestos
Chemical Agents
• Tobacco/smoking
• Cancer of head, neck, lungs, esophagus,
stomach, pancreas, cervix, kidney, bladder,
myeloblastic leukemia.
• Passive smoke
• Lung cancer, childhood leukemia, larynx,
pharynx, brain, bladder, rectum, breast
• Cigars
• Pipes
• Roll your own products
• Water pipes (hookah)
• E-cigs
• Chewing tobacco
• oral, pancreatic, and esophageal cancer
• Vinyl chloride (used for plastic manufacture,
asbestos factories, construction works)
• Polycyclic hydrocarbons (from refuse burning, auto
and truck emissions, oil refineries, air pollution)
• Arsenic, soot, and tars
• Fertilizers
• Pesticides
• Formaldehydes
• Dyes (aniline dyes used in beauty shops, hair bleach)
• Betel nut and lime (chewed as stimulants in some
cultures)
Genetics
• Extra, too few, or translocated chromosomes
• Chronic myelogenous leukemia,
meningiomas, acute leukemia,
retinoblastomas, Wilms tumor.
• Cancer in two or more first degree relatives
• Onset of cancer in family member <50 y/o
• Same type of cancer in several family members
• Individual fam members with >1 type of cancer
• Rare cancer in 1 or > family members
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Lifestyle factors
• Diet
• Ingestion of carcinogens & absence of
protective substances in diet
• Fats
• Alcohol: cancers of mouth, pharynx, larynx,
esophagus, liver, rectum and breast
• Salt cured/smoked meats
• Nitrate / nitrite containing foods
• Red and processed meats
• Obesity
• breast, colon, endometrium, esophagus,
kidney
• pancreas, thyroid, gallbladder, ovary, cervix,
multiple myeloma, Hodgkin lymphoma,
prostate.
• Insufficient physical activity
Hormonal Agents
• Disturbances in endogenous hormonal production
• breast, prostate, uterus
• Diethylstilbestrol (synthetic estrogen)
• Menstruation before 12
• Menopause after 55
• Null parity
• Delayed childbirth (After 30 y/o)
• Estrogen & progesterone therapy
• hepatocellular, endometrial, and breast cancer
• Decreases risk of ovarian cancer
PREDISPOSING FACTORS
• Age — older individuals
• Longer exposure to carcinogens
• Alterations in the immune system
• Sex
• Male: prostate cancer
• Female: breast cancer
• Urban residence
• Greater exposure to carcinogens
• Stressful lifestyle
• Greater consumption of preservatives & cured
foods
• Geographic distribution
• Japan: gastric cancer / may be RT national diet
(raw foods), ethnic customs, and pollution.
• US: breast cancer
• Occupation — > risk of exposure to carcinogens
• Chemical factory workers
• Farmers
• Radiology
• Department personnel
• Heredity
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• Positive family history inc, risk to develop
dse.
• ovarian, colorectal, prostate, melanoma,
leukemia, sarcomas, and primary brain
tumors.
• Stress — affects hypothalamus and pituitary gland
• Depression
• Grief
• Anger
• Aggression
• Despair
• < immunocompetence; immunodeficiency =
growth and proliferation of cancer cells
• Precancerous lesions
• Pigmented moles
• Burn scars
• Senile keratosis
• Leukoplakia
• Benign polyps or adenoma of colon/stomach
• Fibrocystic dse. Of breast
• Obesity
PATHOPHYSIOLOGY
Abnormal cell formed by mutated DNA
↓
Cells grow and proliferate
↓
Metastasis occurs when abnormal cells invade other
tissue through lymph and blood
(cancer dev linked to immune system failure)
Ways the tumor cells evade the immune system:
• Don’t present with Tumor assoc. antigen(TAA)
• Altered cell membranes (genetic mutations)
• Induce T-lymph anergy/tolerance
• Block killing of tumor
• Induce cell death of the lymphocyte
• Release cytokines
• inhibit antigen presenting cells (APCs)
• Over expression of suppressor T lymphocytes
permits uncontrolled cell growth
• Low levels of antibodies
• Impairs proliferation of helper T-cells
• Combine with antibodies to hide from the normal
immune defense mechanism
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PROLIFERATION PATTERNS
•
•
•
•
•
Hyperplasia
Dysplasia
Metaplasia
Anaplasia
Neoplasia
Hyperplasia
• Excessive rate of cell division — > # of cells
• Cell structure and arrangement normal
• Reversible
• Normal tissue response to something irritating
• Ex: callus
Dysplasia
• Bizarre cell growth differing in size, shape, and
cell arrangement
• Potentially malignant
• “Carcinoma in situ” — uncontrolled growth
of cells that remain in same location — may
be metastatic malignancy — removed asap
Metaplasia
• Conversion of one type of cell in a tissue to
another type not normal for that tissue
Anaplasia
• change in DNA cell structure and orientation
to one another, characterized by a loss of
differentiation and a return to a more primitive
form
Neoplasia
• Uncontrolled cell growth, either benign or
malignant that follows no physiological
demand.
Creating a cancer cell:
Brakes on cell growth (tumor suppressor genes) be
released at the same time, accelerators for cell growth
(oncogenes) are being activated.
• Tumors amplify their own supply of growth signals.
• Cytokines and proteases released.
• Destroys basement membrane and surrounding
matrix — leads to metastasis: BV or lymphatic sys.
Carcinomas
• Most common
• Arise from cells that cover external and internal body
surfaces
• lung, breast, and colon
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Sarcomas
• Cells found in supporting tissue of the body such as
bone, cartilage, fat, connective tissue, and muscle
Lymphomas
• Arise in the lymph nodes and tissues of the body’s
immune system
Leukemias
• Cancer of immature blood cell that grow in the bone
marrow and tend to accumulate in large numbers in
the blood stream.
COMMON CAUSES OF CANCER
Breast cancer
• Early menarche
• Late menopause
• nulliparous/older than 30 at the birth of first
child.
Lung cancer
• Tobacco use
• Asbestos
• Radiation exposure
• Air pollution
Colorectal cancer
• Men
• Familial polyposis
• Ulcerative colitis
• High fat low fiber diet
Prostate cancer
• ≥ 50 y.o men
• Highest incidence in African Americans
• Positive fam hx
• Exposure to cadmium
Cervical cancer
• Sexual behavior
• First intercouse at an early age
• Multiple sex partners
• Sexual partner who has had multiple sexual
partners
• HPV and AIDS
• Low socioeconomic status
• Cigarette smoking
Head and neck cancer
• Males
• Alcohol and tobacco use
• Poor oral hygiene
• Long term sun exposure
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EFFECTS OF CANCER
• Occupational exposures — asbestos, tar, nickel,
textile, wood, leather work, machine tool
experience.
Skin cancer
• Fair complexion
• Positive fam hx
• Moles
• Exposure to coal, car, creosote, arsenic, radium
• Sun exposure between 11am to 3pm
• Disruption of function: D/T obstruction or
pressure
• Hematologic alterations: can impair function
of blood cells
• Hemorrhage: tumor erosion, bleeding, severe
anemia
• Anorexia-Cachexia syndrome: wasted
appearance of client.
Paraneoplastic Syndromes: ectopic sites with excess
hormone production
↑ Parathyroid hormone→ hypercalcemia
↑ secretion of insulin→ hypoglycemia
↑ Antidiuretic hormone (ADH) → fluid
retention, HTN & peripheral edema
↑ Adrenocorticotropic hormone (ACTH):
cause excessive secretion of cortisone (ie:
fluid retention, ↑ glucose levels)
Pain: major concern of clients and families associated
with cancer
Physical Stress: body tries to respond and destroy
neoplasm
Psychological Stress
C: Change in bowel/bladder habits
• color, consistency
• size/shape of stools
• Blood present
• Alternating constipation and diarrhea (most common
characteristic of colon cancer)
A: A sore that does not heal
• Doesn’t seem to be getting better over time
• Getting buffer
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• More painful
• Starts to bleed
• Tumor causes impaired circulation and oxygenation.
U: Unusual bleeding or discharge
• Blood in stool or urine
• Discharge from any parts of body
T: Thickening or lump in breast or elsewhere
• Any lump found in the breast doing SBE
• Scrotum during self exam
• Other lumps found in body
I: Indigestion or difficulty swallowing
• Feeling pressure in throat or chest which makes
swallowing uncomfy
• Feeling full without food or with small amount
Obvious changes in wart or mole
• A: asymmetry
• B: border
• C: color
• D: Diameter
N: Nagging cough or hoarseness
• Change in voice
• Hoarseness
• Sputum with blood
U: Unexplained anemia
• Cancer slows down erythropoietin production
• RBCs wear out faster than normal and not replaced
as quickly.
S: Sudden weight loss
• Tumor uses your blood and nutrients and releases
waste products inside the body
PHYSICAL ASSESSMENT
• Tumors can release chemicals that increase the
body’s metabolism.
Inspection
• Skin & mucous membranes: lesions, bleeding,
petechiae, irritation
• Stool, urine, vomitus: acute or occult blood
• Scalp: noting hair texture and hair loss
Palpation
• Abdomen for any masses, bulges, abnormalities
• Lymph node enlargement
Auscultation
• Lung sounds
• Heart sounds
• Bowel sounds
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LABORATORY AND DIAGNOSTIC TEST
Laboratory tests
• CBC
• hemoglobin
• Hematocrit (low in anemia, may indicate
malignancy)
• Leukocytes
• Platelets
• Tumor markers: identify substance (specific
proteins) in the blood that are made by the tumor)
• PSA (prostatic-specific antigen): prostate
cancer
• CEA (carcinoembryonic antigen): colon
cancer
• AFP (alpha-feto-protein)
• HCG (human chorionic gonadotropin
• Alkaline phosphatase: bone metastasis
• Biopsy
• Needle aspiration
• Incisional- remove part of tumor
• Excisional- remove whole tumor.
Determine location of cancer:
• X-rays
• Computed tomography
• Ultrasounds
• Magnetic resonance imaging
• Nuclear imaging
• Angiography
• Endoscopic exams
Diagnosis of cell type:
• Tissue samples: from biopsies, shedded cells
(papanicolau (PAP) smear) & washings
• Cytologic examination: tissue examined under
microscope
Direct Visualization:
• Sigmoidoscopy
• Cystoscopy
• Endoscopy
• Bronchoscopy
• Exploratory surgery: lymph node biopsies to
determine metastases.
CANCER SCREENING
Papanicolau (PAP) smear
• Early detection of cancer in the cervix
• Doctor uses small brush or wooden scraper to
remove a sample of cells from the cervix and upper
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vagina. Cells are placed on a slide and sent to
laboratory.
• Early detection form pap test has helped lower the
death rate from cervical cancer more than 75%
• Additional test may be necessary
Mammography:
• Most beneficial during menopause
• Not sufficient enough as definitive proof for
presence or absence of breast cancer. Additional tests
may be necessary.
PSA test & Digital Rectal Exam
• Men ≥ 50 y.o
• Biopsy to confirm
• Experts are trying to develop blood tests that might
alert people to malignancies while cancers are still in
their early stages.
Fecal Occult Blood Test (FOBT)
• Detects invisible amount of blood in the feces
• Screening test for colon cancer
• Stool sample is smeared on a chemically treated card
• If blood is confirmed in the stool, more tests will be
DIAGNOSIS OF CANCER
conducted to find source of bleeding
• Sigmoidoscopy: rectum, lower colon
• colonoscopy: colon and upper part
Biopsy:
• Surgical removal of a small piece of tissue for
microscopic examination. For leukemias, a small
blood sample serves the same purpose.
• Microarrays can be used to determine which genes
are turned on or off in the sample
• Proteomic profiles: analysis of protein activity
Appearance under microscope:
• Irregularly shaped dividing cells
• Variation in nuclear size and shape
• Variation in cell size and shape
• Loss of specialized cell features
• Loss of normal tissues organization
• Poorly defined tumor boundary
• Determine the presence and extent of cancer
• Identify possible disease metastasis
• Evaluate function of involved and uninvolved organ
systems
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TUMOR STAGING AND GRADING
• Obtain tissues and cells for analysis, including
evaluation of tumor stage and grade.
Staging
• Determines size of tumor
• Existence of local invasion
• Lymph node involvement
• Distant metastasis
• TNM systems
• T - tumor
• Tx - primary tumor cannot be assessed
• T0 - No evidence of primary tumor
• Tis - carcinoma in situ
• T1-4 - increasing size and or local extent
of the primary tumor
• N - node
• Nx regional lymph nodes cannot be
assessed
• N0 - no regional lymph node metas.
• N1-3 - inc. involvement
• M - metastasis
• Mx - distant metas. Cannot be assist
• M0 no distant metas.
• M1 distant metastasis
• Stage 0-IV
• Stage 0: abno. Cells haven’t spread. “in
situ”
• Stage I-III: cancers havn’t spread
beyond primary site or have only
spread to nearby tissue.
• Stage IV: metas. To distant areas of
body.
• Categories of cancer
• In situ: abnormal cells are present but
have not spread to nearby tissue
• Localized: cancer is limited to the
place where it started, with no sign that
it has spread
• Regional: cancer has spread to nearby
lymph nodes, tissues or organs
• Distant: cancer has spread to distant
parts of body
• Unknown: there is not enough
information to figure out this stage
Grading
• Pathologic classification of tumor cells
• Type of tissue
• Degree of differentiation
• Grade I-IV
• Grade I- well differentiated, less aggressive,
better prognosis
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NURSING PROCESS
• Grade II - cells look somewhat abno.
Moderately differentiated, intermediate grade
tumors.
• Grade III - very abno. Considered high
grade.
• Grade IV- poorly differentiated/
undifferentiated: more aggressive, less
responsive to treatment
NURSING Dx
• Acute or chronic pain
• Impaired skin integrity
• Impaired oral mucous membrane
• Risk for injury
• Risk for infection
• Fatigue
• Imbalance nutrition: less than body requirements
• Risk for imbalanced fluid volume
• Anxiety
• Disturbed body image
• Ineffective coping
• Social isolation
OUTCOMES
• Pain relief
• Integrity of skin and oral mucosa
• Absense of injury and infection
• Fatigue relief
• Maintenance of nutritional intake
• Maintenance of F&E balance
• Improved body image
• Absence of complications
• Knowledge of prevention and cancer treatment
• Effective coping through recovery and grieving
process
• Optimal social interaction
IMPLEMENTATION/MANAGEMENT
• Prevention and detection
• Primary prevention
• Reducing modifiable risk factors in
external and internal environment
• Secondary prevention
• Recognizing early signs and symptoms
and seeking prompt treatment
• Prompt intervention to halt cancerous
process
• Tertiary prevention
• Focus on monitoring and preventing
recurrence of the primary cancer as
well as screening for development of
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second malignancies in cancer
survivors
• Chemo, radiation
CANCER PREVENTION
• Avoid tobacco
• Protect yourself from excessive sunlight
• Wear protective clothing
• Sun screen lotions
• Sun is brightest from 11am-4pm
• Limit alcohol intake
• Limit fats and calories: lessen meat consumption
• Consume fruits and vegetables: 5-9 servings/ day
• Avoid cancer viruses
• Avoid carcinogens at work
• Avoid industrial pollution
TREATMENTS
Primary goal: cure the patient
• Render him clinically and pathologically free of
disease and return their life expectancy to that of
healthy individuals of the same age and sex.
Alternative goal:
• Prolong survival while maintaining the pt’s
functional status and QOL
Third goal:
• Relieve symptoms such as pain for patients in whom
the likelihood of cure or prolonged survival is very
low.
Major modalities:
• Surgery
• Radiation
• Chemotherapy
• immunotherapy/biologic therapy
• Molecularly targeted therapy
• Monoclonal antibody therapy
• Hormonal manipulation
• Photodynamic therapy.
Treatment is determined by: type and extent of tumor
involvement, Tx goals, performance status, age, and
client’s co-morbid conditions.
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SURGERY
Surgery:
Removal of diseased tissue
• Diagnostic
• Prophylactic
• Palliative
• Reconstructive
• Cure
• Control
Surgery as Primary Treatment (Curative)
• Debulking: removal of entire tumor or as much as
feasible + surrounding tissue and regional lymph
nodes. Cytoreduction
• Local excisions
• Outpatient basis
• Small margin
• Normal tissue easily accessible
• Wide/radical (enbloc dissections)
• Primary tumor
• Lymph nodes
• Adjacent involved structures
• Surrounding tissues
• May result in disfigurement, altered
functioning, needing rehabilitation or
reconstructive proc.
• Robotics— precision and dexterity
• Prostate
• Gynecologic cancers
• Salvage surgery — performed in addition to
treatment of local recurrence
• Mastectomy after primary lumpectomy
Prophylactic Surgery:
• Removal of precancerous lesions or benign tumor
• Family hx/genetic predisposition
• Presence of abno s/s/x
• Alt options of managing risk
• colectomy, mastectomy, oophorectomy
Palliative Surgery:
• Cure is not an option
• Relieve symptoms
• Make patient as comfortable as possible
• Ulceration
• Obstruction
• Hemorrhage
• Pain
• Malignant effusions
Reconstructive/rehabilitative Surgery:
• Improve function or obtain a more desirable
cosmetic effect.
• Breast
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• Head and neck
• Skin cancers
Nursing Management
• General preoperative nursing care
• Radiation and chemotherapy may contribute to post
op complications
• Infection
• Impaired wound healing
• Altered pulo/renal function
• VTE
• F+E imbalance
• Organ dysfunction
• Pre op:
• Provide verbal + written information about
surgical procedure
• Prophylactic antibiotics
• Diet
• Bowel preparation
• Serve as a patient advocate and liaison— encourage
family to take an active role in decision making
when possible
• Provide consistent information
RADIATION
•
•
•
•
Reduce tumor size
Prevent local recurrence
Relieve symptoms of metastatic disease
Treat oncologic emergencies
• Superior vena cava syndrome
• Bronchial airway obstruction
• Spinal cord compression
Electromagnetic radiation
X-rays
Gamma rays
Particulate radiation
Electrons
Beta particles
Protons
Neutrons
Alpha particles
Functions of ionizing radiation
• Alters DNA molecules of cells, leading to cell death
• Damage DNA through formation of free radicals
• Replicating cells most vulnerable
• Bone marrow
• Lymphatic tissue
• GI epithelium
• Hair follicles
• Gonads
• Localized treatment
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Mostly effective in
• Small tumors
• Rapidly dividing
• Poorly differentiated (no longer resembling the tissue
of origin)
Radiation dosage
• Sensitivity of target tissues
• Size of tumor
• Radiation tolerance of surrounding normal tissues
• Critical structures adjacent to tumor target
External Radiation
• EBRT- external beam radiation therapy
• Beam of highly charged protons or gamma
rays to penetrate the body and target the tumor
with pinpoint accuracy.
• Volumetric images
• CT
• MRI
• PET scans
• Allows for more precision to target the tumor
— less toxicity
• IMRT- intensity modulated radiation therapy
• Intensity/energy levels can be controlled at the
different angles aimed at the tumor.
• Higher doses delivered to tumor while sparing
healthy surrounding tissues
• Daily fractions or hyperfractionated— shorten
pt duration of treatment sched.
• IGRT- image guided radiation therapy
• Continuous monitoring of tumor c
• Ultrasound
• X-ray
• CT scans
• Allows for automatic adjustment of beams as
tumor changes in shape or position
• Respiratory gating
• Tx synchronizes with pt’s respiratory cycle
• Beam adjusts as tumor moves
• SBRT- stereotactic body radiotherapy
• High doses of radiation penetrate very deeply
into the body to control deep-seated tumors
• 1-5 tx days
• Proton therapy
• Deliver high energy dose to a deep tumor with
decrease doses of radiation to tissues in front
and virtually no radiation exits to pts healthy
tissue behind tumor
• Close proximity to critical structures (heart,
BV)
Internal Radiation
• Local or systemic
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• Higher dose and intensity of radiation provided than
EBRT
Brachytherapy
• Temporary (HDR) or permanent implant (LDR)
• Placement of radioactive sources within or
immediately next to cancer site.
• Rods
• Seeds
• Beads
• Ribbons
• Catheters
• Lumens w/in organs
• Interstitial tissue compartments
• UTZ, CT, and MRI guide placement
HDR- High dose radiation
• Tx time is shorter
• Red. Exposure to personnel
• Outpatient basis over several days
Local Internal Radiation
• Intraluminal HDR
• Insertion of catheters into lumens of organs
• Lesions in
• Bronchus
• Esophagus
• Rectum
• Bile duct
• Surface
• Tx for tumors of eye
• Retinoblastoma
• Ocular melanoma
• Interstitial HDR
• Catheter placed into perineum closest to
affected organ
• Prostate
• Pancreatic
• Breast cancer
• Intracavitary radioisotopes
• Gynecologic cancers
• Radioisotopes are inserted into specifically
positioned applicators within the vagina.
• LDR requires hospitalization
Systemic Internal Radiation
• IV administration of a therapeutic radioactive isotope
• Iodine (I-131) — thyroid cancer
• Radium- 223 dichloride — prostate cancer
bone metastases
Toxicity
• Localized in region being treated
• Risk inc. with assoc. chemo
• Acute/early — 2 weeks within initiation
• Late effects — 6 months to 1 yr post tx
• Chronic
• Fibrosis
• Atrophy
• Ulceration
• Necrosis
• Dysphagia
• Incontinence
• Cognitive impairment
• Sexual dysfunction
• Altered Skin Integrity
• Alopecia
• Hyperpigmentation
• Radiation dermatitis
• Erythema and dry desquamation
• Moist or wet desquamation (dermis
exposed, skin oozing serous fluid)
• Ulceration
• Risk factors:
• Dose and form of radiation
• Inclusion of skin folds
• Increased age
• Medical comorbidities
• Tx interruption, delays, or cessation of
therapy.
• Alterations in oral mucosa
• Stomatitis (inflam. Oral tissues)
• dec. Salivation
• Xerostomia
• Change or loss in taste
• Mucositis (inflam. Of lining of mouth, throat,
and GI tract)
Stomach/colon involvement
• Anorexia
• Vomiting
• Diarrhea
Bone marrow involvement
• Anemia
• Leukopenia
• Thrombocytopenia
• Risk for infection & hemorrhage
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Systemic S/E- secondary to substances released
when tumor cells are destroyed.
• Fatigue
• malaise
• Anorexia
Late Effects (6 months+)
• Fibrosis
• Atrophy
• Ulceration
• Necrosis
• May affect:
• Lungs
• Heart
• CNS
• Bladder
• Dysphagia
• Incontinence
• Cognitive impairment
• Sexual dysfunction
Nursing Management:
• Promote healing, patient comfort, and quality of life.
• ERBT: assess the patient’s skin
• Assess nutritional status
• General feelings of well being
• Explain that weakness and fatigue are symptoms that
result from treatment and do not represent
deterioration or progression of the disease.
Protecting Caregivers:
• Pts receiving internal radiation emit radiation while
the implant is in place, therefore contact with the HC
team is guided nu principles of time, distance, and
shielding to minimize exposure of personnel to
radiation.
• Assign pt to a [private room
• Post appropriate notices about radiation safety
precautions
• Dosimeter badges
• Pregnant women shouldn’t be assigned to the
patient’s care
• Limit visitors to 30 mins daily
• 6 foot distance from radiation source.
• Explain precautions to keep the patient from feeling
isolated.
PAGE 11 OF 22
CHEMOTHERAPY
• The use of antineopalstic drugs in an attempt to
destroy cancer cells by interfering with cellular
functions including replication and DNA repair.
• Systemic dse.
• May be combined with surgery, radiation, or both
• Reduce tumor size preoperatively (neoadjuvant)
• Destroy any remaining tumor cells post op (adjuvant)
• Treat some forms of leukemia (primary)
Classification:
MOA:
• Cycle-specific agents: agents destroy cells that are
actively reproducing (S phase)
• M phase (plant alkaloids) half mitotic spindle
formation.
• Cell cycle nonspecific agents: prolonged effect on
cells.
Chemical Group:
• Alkylating agents:
• Nitrosoureas
• Antimetabolites
• Antitumor antibiotics
• Topoisomerase inhibitors
• Plant alkaloids (mitotic inhibitors)
• Hormonal agents
• Misc. agents
Adjunct chemotherapeutic agents: additional meds
given with chemo to enhance activity/protect normal
cells.
• leucovorin is often given with 5-FU.
• Enhances ability of fluorouuacil to remain in the
intracellular environment.
• Rescues normal cells from high doses of
methotrexate
• Reduces/lessens toxicity: severe bone marrow
depression, mucositis, diarrhea, lover and lung
and kidney damage.
Dosage:
Determined by:
• Pt’s total body surface area
• Weight
• Previous exposure & response to radiation
therapy
• Organ function
• Modification required if
• Critical lab values
• Dangerous toxicities
• Maximum lifetime dose limits must be adhered to
because of the danger or long term irreversible organ
complications.
• Ex: doxorubicin lifetime limit = 550mg/m2
(Risk of cardiomyopathy)
DANE DELION
Extravasion: occurs when IV agents escape the vein
and leak into surrounding tissues
Nonvesicant, irritant, vesicant
Vesicant: causes inflammation, tissue damage, and
potential necrosis of tendons, muscles, nerves, and
BVs.
Severe sloughing and ulceration may require skin
grafting.
Chemo classified as vesicants:
• dactinomycin (Cosmegen)
• daunorubicin (DaunoXome)
• doxorubicin (Adriamycin)
• nitrogen mustard (Mustargen)
• mitomycin (Mutamycin)
• vinblastine (Velban)
• vincristine (Oncovin)
*Antidotes must be available where vesicant
chemotherapy agents are administered.
*Should never be given in peripheral veins in hands or
wrist
• Short duration: forearm
• Prolonged admin: right atrial silastic catheters,
implanted venous access devices, peripherally
inserted central catheters (PICCs)
HSRs - IgE mediated
• Associated with life threatening outcomes
• Rash
• Urticaria
• Fever
• Hypotension
• Cardiac instability
• Dyspnea
• Wheezing
• Throat tightness
• Syncope
Ex: carboplatin, oxaliplatin (Eloxatin), L-asparaginase
Anaphylactoid reactions (nonallergic)
• Cytokine release syndrome
Ex: rituximab and cetuximab
BSN 3
PAGE 12 OF 22
TOXICITY
• GI system - antitumor & antimetabolites
• CINV
• Triggered by activation of vomiting centers in
medulla, chemoreceptor trigger zone, GI tract,
pharynx, cerebral cortex.
• Peripheral, autonomic, vestibular, or cognitive
pathways
• Pharmacologic: corticosteroids, phenothiazines,
sedatives, histamines, serotonin blockers
• Non-pharmacologic: relaxation technique,
imagery, acupressure, acupuncture, small
frequent meals, bland foods, comfort foods.
• Stomatitis/mucositis: inflammation of mouth,
throat, and GI tract
• Diarrhea
• Hematopoietic System
• Myelosupression (depressed BM function) Tx with
G-CSF or GM-CSF stimulate production of WBCs
esp neutrophils.
• Leukopenia
• Neutropenia
• Anemia — EPO
• Thrombocytopenia — inc risk for bleeding &
infection — Il-11 stir. Production of
megakaryocytes. Toxic effects: HSR, capillary
leak syndrome, PE, atrial dysrhythmias, N/V,
diarrhea
• Nursing responsibilities: frequent monitoring of
blood cell counts, Educate pt about how to prevent
infection, injury, blood loss
• Renal System — methotrexate & mitomycin
• Impaired water secretion
• SIADH
• Decreased renal perfusion
• Precipitate cell products after cell lysis
• Interstitial nephritis
• Excretion of uric acid — kidney damage
• Intracellular contents released into circulation:
hyperphosphatemia, hyperkalemia, hypocalcemia,
obstructive neuropathy.
• Nursing responsibilities: monitor BUN, serum
creatinine, creatinine clearance, adequate
hydration, diuresis, alkalization of urine,
allopurinol to prevent renal toxicity.
• Hemorrhagic cystitis — cyclophosphamide and
ifosfamide therapy.
• Hematuria, dysuria, suprapubic pain, life
threatening hemorrhage
• Tx: aggressive IV hydration, freuen voiding,
diuresis. MEsna binds to metabolites to prevent
HC.
DANE DELION
BSN 3
• Cardiopulmonary system - Anthracyclines
• (Daunorubicin 300 mg/m2, doxorubicin 550 mg/
m2)
• RF: >70 y.o, preexisting cardiac dse, HTN,
tobacco use, renal/hepatic function.
• Dextrazoxane (Zinecard) — cardioprotectant
• Monitor cardiac ejection fraction & other signs of
HF.
• Pulmonary function - bleomycin, carmustine,
busulfan, mitomycin, paclitaxel
• Alveolar damage
• Bronchospasm
• Pneumonitis
• Pulmonary fibrosis
• Monitor closely for changes in pulmo function.
• Capillary leak syndrome with resultant PE —
cytarabine, mitomycin, cyclophosphamide,
carmustine.
• Dyspnea & cough —> ARD —> Respi failure
•
•
•
•
Reproductive system
Sterility
Ovulation problems, early menopause
Temp or perm. Azoospermia (absence of
spermatozoa)
• Sperm banking
• Cryopreservation of oocytes, embryos, or ovarian
tissue
• Reliable methods of birth control; not to assume
sterility has resulted.
• Neurologic system
• Metabolic encephalopathy — ifosfamide,
methotrexate, cytarabine
• Sensory alterations in hands and feet — taxanes and
plant alkaloids
• Tingling, prickling, numbing sensations
• Freezing or burning pain, sharp, stabbing, electric
shock pain
• Loss of deep tendon reflexes, muscle weakness, loss
of balance and coordination
• Paralytic ileus
• Oxaliplatin— lip parenthesis, discomfort or
tightness in back of throat, inability to breathe, jaw
pain
• Instruct pts to avoid drinking cold fluids or being
exposed to cold temps. Cisplatin may cause
peripheral neuropathies and hearing loss.
•
•
•
•
•
•
•
•
•
•
PAGE 13 OF 22
Cognitive impairment “chemo brain”
Difficulty remembering dates
Multitasking
Managing numbers and finances
Organization
Face/object recognition
Inability to follow directions
Feeling easily distracted
Motor & behavioral changes
RF: comorbidities, age, medications, impaired
nutrition, organ dysfunction, anemia, fatigue, F&E
imbalances.
• NURSING MANAGEMENT
• Monitor laboratory and physical assessments of
metabolic indices and the dermatologic, hematologic,
hepatic, renal, cardiovascular, renal, neurologic and
pulmonary systems.
• Monitor toxicity
• Assess F&E status
• Anorexia, N/V, altered taste, mucositis, diarrhea
• Assess cognitive status
• Modifying risks for infection and bleeding
• Administering chemotherapy
• Be familiar with agents that are mostly
associated with HSRs, signs and symptoms, time
sensitive HSR interventions.
• Monitor for extravasion (swelling, redness,
burning pain @ site, absence of blood return
from IV, resistance to flow of IVF)
• Monitor central lines (risk for infection,
thrombosis)
• Prevent N/A
• Administer antiemetics 30 mins before
chemotherapy
• Managing cognitive changes
• Nonpharma: exercise, natural restorative
environmental intervention, cognitive training
programs
• Maintain F&E balances, nutrition deficits,
fatigue, pain, and infection to minimize their
contribution to cognitive impairment.
• Managing fatigue
• Address factors contributing to fatigue
• Encourage balanced rest and exercise
• Rearrange daily schedule to conserve energy
expenditure, encourage pt to ask for help from
family and significant others
• Promote patient’s normal sleeping habits
• Relaxation techniques and guided imagery.
• Protecting Caregivers
• Emergency spill kits
• Take precautions when handling bodily fluids or
excreta from the pt
• Follow institutional policies regarding the prep,
handling, and disposing of chemotherapeutic
agents and supplies.
DANE DELION
BSN 3
HEMATOPOIETIC STEM CELL TRANSPLANTATION
(HSCT)
• Standard to treat hematologic malignancies
• Malignant myeloma
• Acute leukemia
• Non-hodgkin lymphoma
• Allogenic: from a donor other than the patient.
(Family member or match from National Bone
Marrow Registry or Cord Blood registry)
• Autologous: from the patient
• Syngenetic: from an identical twin
• Myeloablative: high dose chemo and total body
irradiation
• Nonmyeloablative: mini-transplants, does not
completely destroy bone marrow cells.
Ablative alloHSCT
• High dose chemotherapy and radiation completely
eradicates the bone marrow to help prevent rejection
of donor stem cells.
• HSCs infused via IV, beings engraftment. 2-4+
weeks later, new bone marrow becomes functional,
proceeds new RBCs, WBC, and platelets.
• ADVANTAGE: Graft-vs-tumor effect— donor
cells recognize malignant cells and act to eliminate
them.
• Acute S/E:
• Alopecia
• Hemorrhagic cystitis
• N/V/D
• Encephalopathy
• PE
• Acute kidney injury
• F&E imbalances
• Severe mucositis
• Chronic S/E:
• Sterility
• Pulmonary, cardiac, renal, hepatic, neurologic
dysfunction
• Osteoporosis
• Avascular bone necrosis
• Diabetes
• Secondary malignancy
Nonablative alloHSCT
• Lower chemo doses; aimed at destroying malignant
cells
• Suppresses immune system to allow engraftment of
donor stem cells.
• Less organ toxicity and infection
• Indications: older patients, pts c underlying organ
dysfunction.
Before engraftment pts are at risk for:
• Infection
• Sepsis
• Bleeding
PAGE 14 OF 22
Hepatic Sinusoidal Obstructive Syndrome (HSOS)
• (Veno-oclusive disease)
• High risk of development during the first 30 days of
HSCT
• Capillary that receives blood from the terminal
branches of the hepatic artery and portal vein and
deliver it into central veins.
• Inflammation of the epithelium that lines these
capillaries.
• Embolization of RBCs
• Destruction, fibrosis, and occlusion of sinusoids.
S/Sx:
• Weight gain
• Hepatomegaly
• inc. bilirubin
• Ascites
• Jaundice
• Encephalopathy
Dec incidence:
• Peripheral stem cells
• Specific chemotherapy dosing
• Nonmyeloablative regimens.
Graft Vs. Host Disease (GVHD)
• Donated stem cells attack recipient’s tissues during
the start of engraftment.
• Acute: < 100 days
• Chronic > 100 days
S/sx:
• Rash —> blistering —> desquamation (similar to
2nd degree burns)
• Mucosal inflammation: eyes & GI tract
• Diarrhea: 2L/day
• Biliary stasis c/ abdominal pain
• Hepatomegaly
• Inc. liver enzymes
• Obstructive jaundice
Prevention:
• Immunosuppressant drugs
• Cyclosporine
• Methotrexate
• Tacrolimus
• Mycophenolate mofetil
Other complications:
• Encephalopathy
• Hemolytic uremeia syndrome
• Hemolytic anemia
• Thrombotic thrombocytopenia purpura
Autologous HSCT (AuHSCT)
• Do not have a suitable donor
DANE DELION
BSN 3
• Pts c healthy bone marrow but require bone ablative
doses of chemotherapy to cure an aggressive
malignancy.
Indications: lymphoma, multiple myeloma,
neuroblastoma, Ewing sarcoma, germ cell tumors.
Process:
1) stem cells collected from patient
2) Preserved for re-infusion
3) Purged (treated to kill any malignant cells)
4) Pt treated with high dose chemo & radiation
5) Stem cells re-infused
Advantage: no need for immunosuppressants
Disadvantage: tumor cells may remain in the bone
marrow despite conditioning regimens.
Syngenetic transplants:
• Less incidence of GVHD & rejection
• Less graft vs tumor effect
• Genetic defects may still be transmitted
• Another matched sibling or an unrelated donor may
be a more suitable donor to combat an aggressive
malignancy.
Nursing Management:
Pre-treatment:
• Nutritional assessments
• Extensive physical exams
• Organ function tests
• Psych evals
• Blood work (past infectious antigen exposure:
hepatitis, CMV, herpes simplex, HIV, syphilis)
• Social support systems
• Financial and insurance resources
• Informed consent
• Patient education
During treatment:
• Close monitoring and symptom management
• Monitor V/S, O2 sat.
• Neutropenic diet
• Asses for adverse effects: fever, chills, SOB, chest
pain, cutaneous reax, N/V, hypo/hypertension,
tachycardia, taste changes
• Reactions to DMSO: N/A, chills, dyspnea,
dysrhythmias, hypotension, cardiac or respi arrest.
• Engraftment syndrome: noninfectious fever, skin
rash, weight gain, diarrhea, pulmonary infiltrates.
Tx: corticosteroid therapy
• Support with blood products and hemopoietic growth
factors
• Monitor for potential infections: herpes simplex,
CMV, EBV, Candida infections, varicella zoster,
• Pulmonary comp: PE, pneumonia
• Monitor for renal comp.
PAGE 15 OF 22
After therapy
Recipient:
• Ongoing nursing assessments during follow up
exams
• Psych evals
• Assess fam and caregivers needs
• Provide education, support, and information about
other resources
Donor:
• May experience mood alterations, low self esteem,
guilt during transplantation failure.
• Educate and support
• Reduce anxiety
• Promote coping
• Encourage to maintain realistic expectations.
HYPERTHERMIA
•
•
•
•
•
•
•
T > 41.5ºC
Radio waves
UTZ
Microwaves
Magnetic waves
Hot water baths
Hot wax immersions
Hyperthermia + Radiation
• Cells during the S-phase are more sensitive to heat
than radiation
• Additional heat damages tumor blood vessels to
prevent them from repairing themselves after
radiation
Hyperthermia + Chemotherapy
• Alters cell membrane permeability
• Increased uptake of chemotherapeutic agent
• Enhances function of immune T cells and
macrophages to combat malignant cells
Delivery: local/regional
• Into tumor
• On the skin
• In a body orifice
• Regional perfusion
S/E:
• Burns
• Fatigue
• Hypotension
• Peripheral neuropathies
• Thrombophlebitis
• N/V
• Diarrhea
• Electrolyte imbalance
• Cardiovascular stress
DANE DELION
BSN 3
TARGETED THERAPIES
• Work against cancer cell capabilities:
• Malignant transformation
• Uncontrolled reproduction
• Growth and metastasis
• Blocking apoptosis
• Altered genetic coding
• Like a lock and key mechanism
• Biologic response modifiers (monoclonal antibodies,
growth factors, cytokines)
• Gene therapy
BRM
• Uses naturally occurring or recombinant agents to
alter the immunologic relationship between the
tumor and the host.
• Goal: destroy/stop malignant growth
• Basis: restoration, modification, stimulation,
augmentation of body’s natural immune defenses to
cancer.
Nonspecific BRMs
• bacille Calmette-Guérin
• Corynebacterium parvum
• These agents stimulate an immune response that will
eradicate malignant cells
• Localized malignant melanoma and localized bladder
cancer.
Monoclonal Antibodies (MoAbs)
• Targeted antibodies for specific malignant cells
• Can be combined with:
• Radioactive materials
• Chemo
• Toxins
• Hormones
• Other BRMs
• Destroy cancer cells and spare normal cells
• Identify key antigen proteins on tumors that aren’t
present on normal tissue, blocks pathway of
communication btwn malignant cell and extracellular
environment, resulting in an inability to initiate
apoptosis, reproduce, or invade surrounding tissue.
• Assists in DX ovarian, colorectal, breast, prostate
cancers, leukemias, lymphoma.
• Used in purging residual tumor cells from stem cells
collections for pts undergoing HSCT.
• Trastuzumab (Herceptin): HER2 receptors over
expressed in breast & other cancers
• Rituxumab (Rituxin): CD20 antigen — non
hodgkin lymphoma, B-cell chronic lymphocytic
leukemia.
PAGE 16 OF 22
Cytokines:
• Produced by cells of the immune system in order to
modulate immune responses
• IFNs
• ILs
• CSFs
IFNs:
• Antiviral
• Antitumor
• Immunomodulatory properties
• Effects:
• Antiangiogenesis
• Direct destruction of tumor cells
• Inhibition of growth factors
• Disruption of cell cycle
• Hematologic cancers
• Severe toxicities
ILs:
• Produced by T-cells, NK cells, and dendritic cells
• IL-2: approved to treat renal cell cancer and
metastatic melanoma
• Toxicities may be severe; Il treatments limited
Cancer Vaccines
• Mobilize body’s immune responses to prevent or
treat cancer
• Autologous vaccines: cancer cells are taken from
patient’s own tissue (biopsy), killed, and prepared to
be reinjected into the patient.
• Allogeneic vaccines: cancer cells taken from another
person
• Prophylactic vaccines: prevent disease
• HPV2 (Ceravix): rec for female only. Protects
against HPV 16 & 18; responsible for 70% of all
cervical cancers
• HPV4 (Gardasil): male & female. (HPV 6,11,16
& 18)
• HPV9 (Gardasil-9): male and female. 9 HPV
types, cervical, anal, vaginal, and vulval cancers.
• Therapeutic vaccines: kill existing cancer cells and
inhibit further cancer growth
• Sipuleucel T (Provenge, Dendreon Corp)
metastatic prostate cancer no longer responding
to hormone therapy.
Gene therapy
• Correct genetic defects, manipulate genes to induce
tumor cell destruction, assist the body’s immune
defenses
• No FDA approved gene therapies.
• Developmental approaches:
• Tumor directed therapy: introduction of a
suicide gene into tumor cells
• Active immunotherapy: invoke anti tumor
responses
• Adoptive immunotherapy: altered lymphocytes
programmed to cause tumor destruction.
DANE DELION
BSN 3
PAGE 17 OF 22
Nursing Management— Targeted therapies
• Monitoring therapeutic and adverse effects
• ADVERSE EFFECTS: fever, myalgia, N/V,
capillary leak syndrome, PE, hypotension.
• Severe HSRs seen with MoAb infusions.
• Promoting Home, Community based, and
transitional care
• Educate pts and caregivers about continuity of
care
• Teach administration technique and proper
disposal
• Teach how to manage common symptoms
• Collaborate with physicians, social workers,
third party payers, and pharmaceutical
companies to help patient support cost of oral
medications.
• Encourage compliance with follow up
appointments
may invade ulcerated areas and cause a
secondary infection.
• Side effects: severe oral pain, affect swallowing,
nutritional intake, speech, QOL, coping abilities,
and willingness to adhere to treatment regimens.
• Management:
• Oral cavity assessment
• Assess for dehydration, pain, and nutritional
impairment
• Maintain good oral hygiene: brushing,
flossing, rinsing & dental care
• Cryotherapy (oral ice during infusion)
• Low level laser therapy
• Sodium bicarbonate mouth rinses
• Palifermin (Kepivance) — promotes
epithelial cell repair and accelerated
replacement of cells in the mouth and GI
tract.
NURSING CARE OF PATIENTS WITH CANCER
• Radiation dermatitis: radiation associated
impairment of skin integrity
• S/sx:
• Pain
• Irritation
• Pruritus
• Burning
• Skin sloughing
• With drainage (wet desquamation)
• W/o drainage (dry desquamation)
• Management:
• Maintenance of skin integrity
• Cleansing
• Promotion of comfort
• Pain reduction
• Prevention of additional trauma
• Prevention and management of infection
• Promotion of a moist wound healing
environment
• Use moisturizer on skin
• Avoid sun exposure to area of treatment
• Avoid tape or bandages (source of irritation)
•
•
•
•
•
•
•
•
•
Maintaining tissue integrity
Promoting nutrition
Relieving pain
Improving body image and self esteem
Addressing sexuality
Assisting in grieving process
Management of psychosocial distress
Monitoring and managing potential complications
Promoting home, community based, and transitional
care
I. MAINTAINING TISSUE INTEGRITY
• Stomatitis: inflammatory process of the mouth
including music and tissues surrounding teeth.
• Risk factors:
• medications (doxorubicin, 5 FU, IL-2, IFN,
molecular temsirolimus, everolimus)
• Poor oral hygiene
• General debilitation
• Existing dental dse
• Impaired salivary gland function
• Myelosupression
• Tobacco use
• Diminished renal function
• Impaired nutritional status
• S/sx:
• changes in sensation
• erythema
• edema
• painful ulcerations.
• Onset: 5-14 days after chemotherapeutic agents
• Pathophysiology: injury and apoptosis of basal
epithelial cells, leading to loss of epithelial
renewal, atrophy, and ulceration. Organisms
• Alopecia: temporary or permanent thinning or
complete loss of hair.
• Risk factors:
• Whole brain radiation
• Chemotherapy
• Targeted agents
• Onset:
• 2-3 weeks after initiation of chemo/rad.
Regrowth usually happens 8 weeks after
last Tx.
• 1-3 months after targeted therapy: patchy,
frontal or temporal hair loss. May cause
change in hair growth rate, texture,
curliness, and pigment.
DANE DELION
BSN 3
• Management:
• Cryotherapy during admin of chemo (seldom
used) — risk for scalp metastasis
• Provide information about hair loss and
support the patient and family in coping
• Assist pts to identify proactive choices that
may improve their responses to cancer and
perceived lack of control.
• Malignant Skin Lesions: local metastasis of the
tumor into the epithelium and its surrounding lymph
and blood vessels.
• Risk factors: most commonly assoc. with breast
cancer.
• S/sx:
• Erythema
• Discolored nodules
• Wounds involving edema
• Exudates
• Tissue necrosis
• Fun gating lesions — overgrowth of malodorous
organisms
• Pain
• Discomfort
• Embarrassment
• Complications:
• Hemorrhage
• Vessel compression/obstruction
• Airway obstruction (esp in head neck cancer)
• Management:
• Assess for size, appearance, condition of
surrounding tissue, odor, bleeding, drainage, and
associated pain/symptoms
• Monitor for signs of infection
• Wound cleansing
• Reduction of superficial bacteria
• Control of bleeding
• Odor reduction
• Protection from further skin trauma
• Pain management
• Emotional support of pt and family
II. PROMOTING NUTRITION
• Nutritional impairment: may contribute to physical
and psychosocial consequences
• Decreased protein and caloric intake
• Metabolic or mechanical effects of cancer
• Systemic dse
• S/E of treatment
• Pt’s emotional status
PAGE 18 OF 22
Anorexia
• Causes:
• Alterations in taste (inc. salty, sour, metallic
tastes. Altered responses to sweet and bitter
flavors)
• Early satiety after eating only a small amount of
food.
• Decrease in digestive enzymes
• Abnormalities in the metabolism of glucose
and triglycerides
• Prolonged stimulation of gastric volume
receptors
• Psychological distress (fear, pain, depression,
isolation)
• Food aversion r/t N/V
Malabsorption: patients unable to absorb nutrients
from the GI system
• Tumor activity (impaired enzyme production,
interference with protein & fat digestion)
• Cancer treatment (chemo & radiation cause
damage to mucosal cells of the bowel,
sclerosis of intestinal BV, fibrotic changes in
GI tissue).
• Management: surgical intervention to
• Change peristaltic patterns
• Alter gastrointestinal sections
• Reduce absorptive surfaces of GI mucosa
Cancer Related Anorexia-Cachexia Syndrome
(CACS): increased energy expenditure, decreased
intake. May occur during curative or palliative stages.
• Pathophysiology:
• Immunologic + neuroendocrine + metabolic
processes = anorexia, unintentional weight
loss, inc. metabolic demand c impaired
metabolism of glucose and lipids.
• Altered metabolism + tumor responses =
cytokine release & generalized systemic
inflammation.
• S/Sx:
• Weightless
• Malnutrition (loss of adipose tissue, visceral
protein, and skeletal muscle mass)
• Loss of appetite
• Early satiety
• Fatigue
• Complications:
• Anemia
• Peripheral edema
• Progressive debilitation
• Decreased QOL
• Psychological distress
• Anxiety
• Management:
• Assess and address factors that interfere with
oral intake or associated with increased risk of
decreased nutritional status
DANE DELION
• Initiate appropriate referrals for
interdisciplinary collaboration to manage
factors that interfere with oral intake
• Educate pt to avoid unpleasant sights, odors,
and sounds during mealtimes
• Suggest foods that are well tolerated by pt.
• Respect ethnic and cultural food preferences
III. RELIEVING PAIN
• Assess patient for the source and site of pain
• Factors that influence patient’s perception and
experience of pain
• Fear
• Apprehension
• Fatigue
• Anger
• Social isolation
• Pharmacologic & nonpharma approaches
• Surgical interventions may relieve pain
IV. DECREASING FATIGUE
• Acute fatigue: serves a protective function, occurs
after an energy demanding experience
• Cancer related fatigue: a distressing, persistent,
subjective sense of physical, emotional, and
cognitive tiredness related to cancer or cancer
treatment that is not proportional to recent activity
and interferes with usual functioning.
• Exercise
• Physical activity
• Cognitive behavioral therapy to address sleep
• Progressives uncle relaxation
• Yoga
• Mindfulness medication
• Antidepressants
• Anxiolytics
• Hypnotics
• Psychostimulants
V. IMPROVING BODY IMAGE AND SELF
ESTEEM
• Nurse serves as a listener and counselor to both
patient and family
• Consider patients culture and age when discussing
concerns and potential interventions
• Encourage continued participation in activities and
decision making
• Encourage pt to verbalize concerns
• Assist in selecting and using cosmetics, scarves, hair
pieces, hats, and clothing that increase their sense of
attractiveness
VI. ADDRESSING SEXUALITY
• Discuss fertility plans prior to initiation of any
therapy
• Make referrals for specialized evaluation beyond
scope of nursing intervention
BSN 3
PAGE 19 OF 22
• Clients at greatest risk of sexual dysfunction: tumors
that involve sexual/pelvic organs, tx that affect
hormonal systems mediating sexual function.
VII. MANAGEMENT OF PSYCHOSOCIAL
DISTRESS
• Actual/potential losses
• Fear of the unknown
• Symptoms due to cancer/cancer tx
• Changes in family and social roles
• Financial concerns
• Sense of loss of control
• S/sx: vulnerability, sadness, fears, depression,
anxiety, panic, social isolation, existential and
spiritual crisis
• Referral to mental health providers may be helpful to
address specific concerns
VIII. MONITORING AND MANAGING
POTENTIAL COMPLICATIONS
Infection:
• Leukopenia- decrease in circulating WBCs
• Granulocytopenia- decrease in neutrophils
• Monitor lab studies (WBC counts. ANC <1,500
cells/mm3 risk for infection. <500 cells/mm3 severe
risk for infection)
• Assess common sites of infection:
• Pharynx
• Skin
• Perineal area
• Urinary
• Respiratory tracts
• Invasive catheters
• Long term IV cath.
• Typical s/sx of infection may not be present in
myelosuppressed patients bc the dec number of
circulating WBCs + diminished inflamm. response
• Report fever immediately
• Collect cultures from wound drainage, exudates,
sputum, urine, stool, or blood
• Provide education to patient and family about
infection prevention, s/sx to report, and importance
of adherence to microbial therapy.
Septic Shock:
• Life threatening complication
• S/sx must be identified early and aggressive
intervention must be made
• Pts at highest risk: neutropenic, hematologic
malignancies.
Bleeding and Thrombocytopenia: < 100,000/mm3
• Risk factors
• Infiltration of bone marrow
• Abno. antibody function (leukemia, lymphoma)
• Bacterial + viral infections
• Medications (heparin, vancomycin)
DANE DELION
BSN 3
• Posttransfusion antibody destruction
• Coagulopathies associated with infection or
malignancies (gastric & pancreatic cancer)
• Risk for VTE
• Provide pt and family teaching about s/sx of
VTE to report to provider
• Early s/sx:
• Petechiae
• Ecchymosis
• Dec in HCT or HGB
• Management:
• Bleeding precautions
• Use soft toothbrush for mouth care
• Use electric razor for shaving
• Emery board for nail care
• Avoid IM injections, use smallest needle
possible
• Apply pressure to venipuncture site for at
least 5 minutes
• Avoid bladder catheterizations
• Avoid medications that interfere with
clotting
IX. PROMOTING HOME, COMMUNITY
BASED, AND TRANSITIONAL CARE
• Educating patients about self care
• Vascular access devices
• Infusion pumps
• Drainage catheters
• Wounds
• Administration of medication
• Share strategies about how to manage side
effects
• Which side effects should be reported
promptly to physician
• Stress importance of patient safety and
infection prevention
• Outcomes: provide a sense of comfy, decrease
distress, improve coping, foster self management,
promote adherence, and enhance QOL.
• Continuing and transitional care
• Assess the home environment
• Suggest modifications to address pt’s
physical and safety needs
• Ongoing nursing visits or phone contact
from home
• Referrals and coordinate available
community resources.
CANCER SURVIVORSHIP CARE
• Prevention & detection of new and recurrent cancer
• Mammography
• Pap smear
• Smoking cessation programs
• Nutrition counseling
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• Surveillance for cancer spread, recurrence, or second
cancers
• Colonoscopy post colon cancer
• Mammography post breast cancer
• Liver function tests
• PSA test post prostate cancer
• Intervention for consequences of cancer and its
treatments
• Lymphedema therapy
• Pain management
• Enterostomal therapy
• Fertility care
• Psychosocial support or care
• Reconstructive surgery
• Coordination between specialists and primary
providers to meet health needs
• Care for comorbidities
• Influenza vax
• Bone densitometry
• Monitor for chemo induced cardiotoxicity
GERONTOLOGIC CONSIDERATIONS
• Impaired immune system
• Special precautions to prevent infection
• Monitor for atypical s/sx of infection
• Altered drug absorption, distribution,
metabolism, and elimination
• Careful chemo calculations
• Frequently assess for drug response
• Dose adjustments
• Increased prevalence of comorbidities
• Monitor how cancer affects pt’s other diseases
• Monitor pts tolerance to Tx
• Monitor for drug interactions
• Diminished renal, respiratory, and cardiac
reserve
• Prevent decreases in renal function, atelectasis,
pneumonia, cardiovascular compromise
• Dec. skin and tissue integrity; reduction of body
mass; delayed healing
• Prevent pressure ulcers
• Monitor for dermatologic changes resulting
from Tx
• Monitor nutritional status
• Dec. musculoskeletal strength
• Prevent falls, Assess supports for ADLs at home,
teach use of assistive mobility devices
• Dec. neurosensory functioning: loss of vision,
hearing, and distal extremity tactile senses
• Provide instruction modified for pt’s vision and
hearing changes
• Provide instruction regarding safety and skin
care for distal extremities
• Assess home for safety
• Altered social and economic resources
DANE DELION
BSN 3
• Assess for financial concerns, living conditions,
and resources for support
• Potential changes in emotional and cognitive
capacity
• Provide education and support modified for
patients level of functioning and safety.
ONCOLOGIC EMERGENCIES
• Superior Vena Cava Syndrome (SVCS): the
superior vena cava becomes blocked by a tumor,
enlarged lymph node, thrombus, or drainage from
head, neck, arms, and thorax.
• Advance staged cancer — therapy shifts from
curative to palliative
• Lung cancer & lymphomas
• S/Sx:
• Dyspnea
• Facial swelling
• Enlarged neck and chest veins
• ICP: visual disturbances, headache, altered
mental status
• Dx:
• CXR
• CT scan
• MRI
• Histology
• Venogram
• Tx:
• Emergency: stent and radiation therapy
• Non-emergency: histology diagnosis &
appropriate treatment (chemotherapy, other
medications: thrombolytics, anticoagulants)
• Supportive measures O2 therapy,
corticosteroids, diuretics
• Nursing Management:
• Identify pt at risk for SVCS: non-small cell lung
cancers, lymphomas, mediastinal metastases
from breast cancer.
• Provide pt education regarding s/sx to report
• Monitor cardiopulmonary and neurologic status
• Semi fowler position
• Monitor pt’s fluid volume status
• Avoid upper extremity venipuncture and BP
measurement; instruct pt to avoid tight or
restrictive clothing
• Spinal Cord Compression: spinal cord becomes
compressed at the thoracic, cervical, or sacral level
by a tumor.
• Often associated by cancers that metastasize to the
bone: breast, lung, prostate, lymphoma,
nasopharyngeal, and multiple myeloma.
• S/sx:
• Inflammation
PAGE 21 OF 22
• Back/neck pain
• Worsened by: movement, supine recumbent
position, coughing, sneezing, or valsalva
maneuver.
• Numbness, tingling
• Motor loss
• Bowel/bladder dysfunction
• Dx:
• Percussion at level of compression
• Abnormal reflexes
• Sensory and motor abnormalities
• MRI, bone scan, CT scan
• Tx:
• Radiation
• surgery— debulk the tumor
• Vertebral augmentation
• Vertebroplasty
• Kyphoplasty
• Chemotherapy
• Nursing Management:
• Asses neurologic function
• Control pain with pharmacologic and non
Pharma methods
• Prevent complications from immobility
• ROM exercise
• Urinary catheterization
• Provide encouragement and support
• Hypercalcemia: excess calcium in the blood,
kidneys cannot excrete it fast enough, bones can’t
reabsorb it.
• Results from cytokine release, hormonal
substances, and growth factors released by
cancer cells.
• Breast, lung, renal cancer, myeloma, and
leukemias.
• S/sx:
• Fatigue
• Weakness
• Confusion
• Hyporeflexia
• Polydipsia
• Dehydration
• Dysrhythmias
• Dx: serum calcium test > 10.5 mg/dL
• Ionized serum calcium > 1.29 mmol/L
• Tx:
• Identify patients at risk for hypercalcemia
• Educate pts and family
• Need to consume 2-4L fluid daily unless CI
• Promotion of mobility and importance of
preventing demineralization and breaking down
of bones.
DANE DELION
• Tumor lysis syndrome: the release of intra-tumor
cellular contents into the blood stream that lead to
electrolyte imbalances (hyperkalemia,
hyperphosphatemia, hypocalcemia) which have end
organ effects on heart, kidneys, and CNS.
• Lung cancer, leukemia, lymphoma
• S/sx:
• Acute kidney injury (creatinine > 1.5 times
upper limit of normal)
• Dysrhythmias
• Seizures
• Neuro: fatigue, weakness, memory loss, altered
mental state, muscle cramps, tetany
• Cardiac: HTN, dysrhythmias, cardiac arrest
• GI: anorexia, N/V, abdominal cramps, increased
bowel sounds
• Renal: flank pain, oliguria, anuria, acidic urine
pH
• Other: gout, malaise, pruritis
• Dx:
• Serum electrolyte levels
• Urinalysis
• ECG to detect cardiac changes
• Tx:
• Aggressive fluid hydration
• Diuretics (loop diuretics)
• Allopurinol
• IV sodium bicarb.
• Hemodialysis
• Nursing management:
• Identify at risk patients
• Assess for s/sx of electrolyte imbalances
• Assess urine pH to confirm alkalization
• Monitor serum electrolyte and uric acid levels
BSN 3
PAGE 22 OF 22