NURS 201 Medical Surgical Nursing Week 1 Professor Rivera MSN-Ed, RN ● Overview ○ Definition ○ Pathophysiology and Etiology ■ Benign vs Malignant ○ Risk Factors ○ General Effects, S/S’s ○ Diagnostic Tests and Staging Cancer Outline ● Treatments ○ Surgery ○ Chemotherapy ○ Radiotherapy ● Managing Side Effects ● Nursing Process Pathophysiology and Etiology ● Neoplasm ○ Mass of new tissue that grows independently of its surrounding structures ○ AKA Tumor ○ Has no physiological purpose ● Benign 🡪 ○ Well differentiated ○ Growth does not endanger life or health ■ Depends on the location ● Malignant 🡪 ○ Ranges from well-differentiated to undifferentiated ○ If not treated, a growth will recur, continue to grow, and spread ○ Invades and metastasizes Who is at risk? People exposed to carcinogens People exposed to Radiation Elderly Immunocompromised Individuals with history of frequent trauma Caucasian woman-> 40yo (breast cancer) Caucasian Men-> testicular cancer African american men->Prostate cancer Family history (these individuals are usually diagnosed 15-20 yrs earlier than those without family history) Smokers, drinkers,individuals who work with chemicals Some viruses and bacterias like Mono, HPV, hepatitis B or C, HIV Low socioeconomic status Those who live in an area with poor air quality Stress Prevention and Early Detection ● Making healthy lifestyle choices: ○ Avoid smoking/tobacco products ○ Limited alcohol consumption ○ Exercise regularly and maintain a health weight ○ Wear sunscreen and avoid prolonged sun exposure ○ Follow occupational safety protocols ○ Eat foods that are high in antioxidants such as Vitamin C, coffee and blueberries, low fat. Avoid processed meats ● Regular screenings / Immunization ○ colorectal, mammography screenings, pap smear Classifying Cancer ● Classification ○ Naming of tumor ○ Named for tissue or cell of origin, anatomic site, and tumor behavior ● Grading - how FAST it spreads ○ Evaluates the appearance and amount of differentiation of the cell ○ Estimates rate of growth, aggressiveness of the tumor ○ 4 Grades ■ Grade I cells differ slightly, well differentiated → Grade IV cells are immature, undifferentiated ● Staging - how FAR it spreads ○ The extent and spread of the disease ○ Stage 0: cancer in situ → Stage IV: Metastasis http://www.patientresource.com/userfiles/image/StagesOfCancer(1).jpg SCREENING PREVENTION Breast CA: ● Mammogram : Annually for women older than 40 ● Clinical breast exam: Annually for women older than 40. Every 3 years for women 20-39 years old. Colorectal CA: ● Fecal Occult Blood: Annually for adult of all ages ● Colonoscopy: At age 50 and then every 10 years ● Digital rectal exam: For men older than 50 years old ○ Also for Prostate CA Cervical CA ● Pap Smear: Every 3 years between 21 to 29 years old; every 5 years between 30 and 65 years old Screening for gene mutations: for clients who have a strong family history of breast or colon cancer Breast or Testicular Self Examination: Monthly Diagnostic Tests ● Several procedures to diagnose cancer ○ Depends on the suspected primary or metastatic sites of the cancer ○ Microscopic histological examination of tissue reveals type of cell and structural differences ○ Various diagnostic tests. ○ Biopsy is the definitive means of diagnosing cancer and provides histological proof of malignancy Diagnostic Tests, continued ● Oncological imaging- detects mass ○ X-ray, CT, MRI, PET scan ○ Mammography ○ Ultrasound ○ Nuclear imaging ○ Angiography ● Direct visualization ○ Sigmoidoscopy, cystoscopy, endoscopy - direct visualization of areas involved ● Laboratory tests ○ Blood - detects pancytopenia as the patient is responding to treatment ○ CBC, Chemistry profil ○ Liver function studies ○ Tumor or Genetic Markers ○ Urine, other body fluids Treatment Goal Cure, Control, and Palliative care Cancer Therapies at a Glance ● Chemotherapy: Uses anticancer drugs ● Radiation ○ Brachytherapy: radiation delivered inside body ○ External Beam Radiation Therapy : uses radiation from an outside source ○ Intensity-modulated radiation ● Surgery: is indicated to diagnose, stage, and treat certain types of cancer. ● Ablation Procedures: used to destroy cancer cells ○ Radiofrequency Ablation : delivers electric current ○ Cryotherapy : Uses liquid nitrogen ○ Microwave Thermotherapy : Uses microwaves to heat and destroy tissue ● Targeted Therapy: molecular based medication therapy ● Immunotherapy : uses biologic response modifiers ● Photodynamic Therapy : Uses photosensitizing agents that is absorbed by all the cells Surgery ● Often primary treatment ○ Indicated to diagnose, stage and treat certain types of cancer ○ Removal of cancerous lesion and portion of normal surrounding tissue ○ Debulking ○ Prophylactic, Curative, Control, Palliative, Reconstructive ● Depends on location and metastases ● May also be used: ○ For diagnostic purposes ○ To relieve secondary effects ● Assess for bleeding and infection! Pharmacologic Therapy: Chemotherapy ● Systemic chemical therapy ● aka Anti-Neoplastic Therapy ● Used for solid tumors and hematologic malignancies ■ Goals: Cure, Control, Palliation ● Administered by numerous routes ● Goal is to kill most possible cancer cells, allow client’s immune system to complete process ● Effects are systemic because chemotherapy is usually administered intravenously ■ Affects, skin, GI tract and lining, spermatocytes, and hematopoiesis ■ Specific side effects: fatigue, alopecia, n/v, mucositis, skin changes, and myelosuppression (CBC) CHEMOTHERAPY AGENTS CLASSIFICATION AND MEDICATION SIDE EFFECT ADVERSE EFFECT FOLIC ACID ANALOGUE Methotrexate ● Stops cells reproduction needed for synthesis of DNA by inhibiting folic acid conversion ● S Phase specific ● Used for solid tumors like breast and lung ● Also used in RA, Crohn's and psoriasis REPRODUCTIVE TOXICITY. Client must avoid pregnancy while on these medications and 6 months after RENAL DAMAGE: due to hyperuricemia or elevated levels of uric acid. Monitor BUN, Crea, I&O Encourage Fluid intake of 2-3 L per day Administer allopurinol METHOTREXATE DOSING IS ONCE A WEEK SE: Mucositis, nausea and vomiting Contraindicated in liver, kidney dysfunction, bone marrow suppression, leukopenia, thrombocytopenia, anemia or gastric ulcer and in older adults Aspirin, NSAIDS, sulfonamides, PCN, and tetracycline cause methotrexate toxicity . Avoid folic acid supplements or vitamins containing folic acid since folic acid changes the body’s response to methotrexate decreasing its effect. Administer with leucovorin rescue to reduce toxicity to healthy cells. This med is a folic acid derivative. It enters healthy cells and blocks methotrexate. PYRIMIDINE ANALOGUE Cytarabine ● Used for acute myelogenous leukemia, non Hodgkins lymphomas and acute lymphocytic leukemia ● Fluorouracil ● Employed extensively to treat solid tumors ● Destroys cells mainly in the S phase FOR CYTARABINE Other toxicities include stomatitis and conjunctivitis Can cause liver disease, watch for jaundice. Monitor liver enzyme PURINE ANALOGUES Mercaptopurine, thioguanine ● Used for chronic lymphocytic leukemic and acute nonlymphocytic leukemia Pregnancy category D Contraindicated in px who are resistant to the medications Contraindicated in clients who have liver disease Can increase or decrease anticoagulant effects of warfarin Monitor PT and INR Can cause pulmonary edema. Monitor breathe sounds. Report rales. Notify MD of SOB Cytarabine Syndrome: Can happen within 6-12 hours after administration. Findings include fever, myalgia, malaise and conjunctivitis. Administer corticosteroids. Can cause arachnoidism (nausea, headache, fever). Tx manifestations with dexamethasone. Notify the provider of nausea, vomiting, headache or fever OVERVIEW OF CHEMOTHERAPY SIDE EFFECTS ● Anorexia ● Nausea/Vomiting ● Diarrhea ● Alopecia ● BONE MARROW SUPPRESSION – Myelosuppression ○ Neutropenia ○ Thrombocytopenia ○ Anemia Memorize all the lab values for myelosuppression. Platelets, WBC, ANC and RBC and Hgb Managing the side effects: Anorexia Loss of appetite due to both the cancer and the tx, and be secondary to: ● ● ● inflamed mouth or esophagus: difficulty chewing or swallowing → pain management anxiety or depression → therapy N/V → fluids and antiemetics Nursing Interventions ● ● ● ● ● ● ● Provide high calorie, high protein diet Sneak in calories Use topical anesthetics gel for oral lesions to improve oral intake before meals Perform calorie count to determine intake Provide liquid nutritional supplement as needed. Add protein powders to food or tube feedings Administer megestrol to increase appetite if prescribed MUCOSITIS AND STOMATITIS ● MUCOSITIS : Refers to inflammation in the mucus lining of the upper GI tract from the mouth to the stomach ● STOMATITIS: refers to inflammation of oral cavity tissues ● Interventions: ○ Examine the client’s mouth several times a day and inquire about the presence of oral lesions ○ Document the location and size of lesions, obtain a specimen for culture and report them to the provider ○ Avoid using glycerin-based mouthwash or mouth swabs for client care. Nonalcoholic, anesthetic mouthwashes are recommended. ○ Discourage consumptions of salty, acidic or spicy foods Offer oral hygiene before and after each meal. Use lubricating or moisturizing agents to counteract dry mouth. ○ Patients can be given topical anesthetic gels for painful oral lesions before meals to improve oral intake MUCOSITIS AND STOMATITIS INTERVENTIONS ● Rinse the mouth with a solution of 0.9 NaCl, room temp ● Perform gentle flossing and brushing using soft bristled toothbrush or foam swab to avoid traumatizing the oral mucosa. ● Rinse the mouth before and after meals. ● Avoid mouthwash that contains alcohol ● Take meds to control infection such as nystatin or acyclovir ● Choose soft bland foods and supplements that are high in calories (mashed potatoes, scrambled eggs, cooked cereal, milk shakes, ice cream, frozen yogurt, bananas and breakfast mixes) Avoid spicy, salty, acidic rough or hard food. ● Avoid drinking alcohol and the use of tobacco ● Drink at least 2 L of water per day (If no restrictions) NAUSEA and VOMITING from CHEMOTHERAPY ● Many meds used in chemo are emetogenic (induces vomiting) or cause anorexia and an altered taste in mouth ● NURSING ACTIONS ○ Ensure antiemetic are given before chemotherapy based on response & duration of CINV (Chemotherapy induced nausea & vomiting) ■ ondansetron ■ metoclopramide ○ Administer antiemetic 30-60min before administration of chemo and several days after each treatment ■ Even when CINV appears to be controlled ○ Implement non-pharmacological methods to reduce nausea ■ visual imagery ■ relaxation ■ acupuncture ■ distraction ■ Reduce vomiting cues such as odors (provide emesis basin) ○ Assess for findings of dehydration or fluid and electrolyte imbalance ○ Perform mouth care before meals to enhance appetite Managing the Side Effects: continued Diarrhea: ● Dietary Modifications: ○ Avoid hot food ○ Avoid fried, fatty, or highly seasoned foods ○ Avoid foods that are gas producing ● Medications ○ Antidiarrheals - Loperamide ○ Antimotility agents ○ Antispasmodics ● Monitor for electrolyte imbalance for diarrhea ○ Hydration and electrolyte supplementation depending on severity of diarrhea ● Skin Care ○ Lukewarm sitz baths may help discomfort and cleanse rectal area if significant rectal irritation develops ○ The rectal area must be kept clean and dry to maintain skin integrity ○ Visually inspect the perianal area for evidence of skin breakdown ○ Systemic analgesia may be used for the painful skin irritations that may develop. Managing the Side Effects: continued Constipation: ● Dietary Modifications: ○ High fiber food intake ○ Encourage fluid intake if not contraindicated ● Medications ○ Stool softeners ● Encourage activity as tolerated For both diarrhea or constipation: ● Note the number, volume, consistency, and character of stools per day. Teach patients to maintain a diary or log to record episodes and aggravating and alleviating factors. Managing the Side Effects: continued Leukopenia ● Infection Precautions ○ Major cause of mortality through auto contamination or cross contamination ● Protective isolation, private room with HEPA filtered or laminar airflow system ● Frequent and thorough handwashing and Strict aseptic technique for all procedures ● Limit visitors, should have masks and appropriate PPE ● Avoid risky environments (i.e. swimming whether in a swimming pool or in the ocean) ● Talk to the oncologist before any dental procedure Managing the Side Effects: continued Leukopenia continued ● Monitor for signs of infection ○ Monitor VS, temperature, s/s (fever, sore throat) ○ Monitor urine color & consistency ○ Monitor WBC (especially which one?) ○ Immediately notify MD if s/s of infection are present ● Food safety precaution: ○ Avoid raw/fresh meat, fish, egg (including homemade desserts with egg as an ingredient) or raw fruits and vegetables - preference is canned vegetables ○ Avoid dinner buffets, left-over food, restaurant food ○ Avoid drinking tap water or water that has stood for more than 15 minutes Managing the Side Effects: continued Leukopenia continued ● Avoid fresh flowers and standing water in the room ● Make sure client’s room is cleaned daily. Linen is changed daily. ● Daily bathing using antimicrobial soap ● Oral hygiene frequently ● Antibiotic, antifungal, antiviral meds as ordered ● Instruct client to avoid crowds and those with infection ● Avoid activities that requires exposure to contaminants; i.e. changing pet’s litter box, gardening ● Instruct patients that neither they nor their household contacts should receive vaccination with live virus Managing the Side Effects: continued Thrombocytopenia ● Institute bleeding precautions ○ Avoid IVs, injections, invasive procedures. When necessary, use the smallest gauge needle possible and apply pressure for approximately 10 min after blood is obtained ○ Handle patient gently and avoid trauma or excessive straining ○ Administer thrombopoietic medication such as oprelvekin to stimulate platelet production ○ Handle patient gently, even when taking BP or removing tape ● Monitor platelet count. Risk for bleeding when platelet count falls below 50,000/mm3 ; spontaneous bleeding frequently occurs when platelet count falls below 20,000/mm3 – a platelet transfusion may be needed ● Monitor for s/s of bleeding (bleeding gums, petechiae, ecchymosis, nose bleeds, occult or frank blood in stools, urine or vomitus) Preparation and Handling of Chemotherapy Agents ● There are specific guidelines for administration of chemotherapy drugs. ○ May pose an occupational hazard to health care professionals who do not follow safe handling guidelines ● A person preparing, transporting, or administering chemotherapy may absorb the drug through inhalation of particles when reconstituting a powder and through skin contact from exposure to droplets or powder from oral agents. ● Risk in handling the body fluids and excretions of people receiving chemotherapy immediately after administration for 48 hours. ● Only those personnel specifically trained in chemotherapy handling techniques should be involved with the preparation and administration of cancer drugs. Radiation Therapy ● Application of external beams or high-energy protons to kill cancer cells ● Used for ~50% of clients with cancer ● Localized treatment ● May precede surgery to shrink tumor ● May follow surgery to kill cancer cells left behind ● May be used as palliation for inoperable cancers ● Side effects include local skin changes and irritation, alopecia, nausea and vomiting, fatigue (most common side effect of radiation) and altered taste sensation, the effects vary according to the site of the treatment. Managing Radiation side effects ●Radiation side effects include local skin changes and irritation, alopecia (hair loss), fatigue (most common side effect of radiation), and altered taste sensation; the effects vary according to the site of treatment ●Alopecia: ○Inform pt hair loss is temporary (for chemotherapy) ○Occurs throughout the body ○The hair that comes back maybe different ○Do not use a tourniquet ○Discuss purchase of wig before starting chemotherapy ○Advise mothers to bring their child’s favorite hat ●Rash and dryness, photosensitivity reactions ○Skin care; avoid alcohol and harsh soap ○Avoid exposure to sun, heat ○Use sun-block lotions ○Wear long sleeve shirts, big hats, umbrellas Client Education Guide: Radiation Therapy for Cancer ● Wash the irradiated agent gently each day with warm/tepid water alone or with mild soap and water ● Use the hand rather than a washcloth to wash the area. Dry the irradiated area with patting motions rather than rubbing motions. ● Take care not to remove the markings that indicate exactly where the beam of radiation is to be focused. ● No powders, ointments, lotions or creams on the skin at the radiation site unless they are prescribed by the radiologist ● Avoid wearing belts, buckles, straps or any type of clothing that binds or rubs the skin at the radiation site ● Avoid exposure of the irradiated area to the sun ● Avoid heat exposure. Care of the Client with a Sealed Radiation Implant ● Place the client in a private room with a private bath ○ Place a radiation precaution sign on the client’s door ● ALARA: Time, Distance, Shielding ○ Organize nursing tasks to minimize exposure to the radiation source ○ Limit time to 30 minutes per care provider per shift. ○ Wear a dosimeter film badge to measure radiation exposure ○ Lead shielding may be used to reduce exposure to radiation ○ A nurse should never care for more than 1 client with a radiation implant at a time ● A client with a radiation implant should be discussed during huddle ● Do not allow a pregnant visitors; or pregnant nurse to care for client ● Do not allow children younger than 16 years PRIORITY NURSING ACTIONS FOR: DISLODGED IMPLANT 1. Encourage the client to lie still 2. Use a long-handled forceps to retrieve the radioactive source 3. Never touch the radiation source. 4. Deposit the radioactive source in a lead container 5. Contact the oncologist. 6. Place all contaminated equipment and linens in designated containers. 7. Prohibit visitors from entering. Radiation Therapy Limit visitors to 30 minutes per day. Visitors should be at least 6 feet from the source Save bed linens and dressing until the source is removed. Then place the linens and dressings in the designated containers. Other equipment can be removed from the room at any time. Planning ●Nursing goals may include that client will: ○Demonstrate no signs of infection ○Sustain no injuries ○Consistently rate pain at a level of 3 or less ○ Maintain weight within normal range ○Remain hydrated ○Vocalize feelings related to cancer ○Relate potential side effects of chosen therapies ○List strategies for coping Implementation Nursing interventions may include: ● To prevent infection ○ Monitor vital signs, especially temperature ○ Monitor WBC counts frequently ○ Teach client to avoid crowds, small children, people with infections ○ Protect skin and mucous membranes ○ Encourage client to consume diet high in protein, minerals, vitamins ○ filgrastim (Neupogen) if ordered Implementation ●Prevent injury ○ Assess frequently for signs, symptoms indicating problem with organ obstruction ■ specific to known sites of cancer and metastasis ○ Teach client to differentiate minor problems from serious ones ○ Monitor lab values: CBC Questions? Chronic Illness and Older Adults What is chronic illness? ● Illness can be categorized as either acute or chronic. ● Chronic illnesses are those that are prolonged, do not resolve spontaneously, and are rarely cured completely. ● Chronic diseases account for 70% of all deaths in the United States. ● As the population ages, more older adults are living with more than one chronic illness (frequently up to 6 or more). ○ experience limitations in physical functioning, work productivity, and quality of life. ● Patients with chronic illness may require long-term nursing care while patients with acute issues (surgery and subsequent recovery, sepsis/infection, flu) will need shorter-term nursing care (assuming there are no complications) ● An acutely ill patient should be assessed prior to interview to confirm they are stable Acute Care vs. Chronic Illness Care • Some societal changes contributing to the increase in chronic illnesses include • Insufficient physical activity • Lack of access to fresh fruits and vegetables • Tobacco use • Alcohol consumption. Chronic Illness Older Adults Frail older adults Clinical manifestations of frailty include 3 or more of the following criteria: 1. Unintentional weight loss (greater or equal to 10 pounds in a year) 2. Self-reported exhaustion 3. Weakness 4. Slow walking speed 5. Low level of physical activity When determining if an older adult is malnourished, the nurse should: Assess Assess mood, depression (when depressed, may eat less), mobility Review Review labs to determine protein and fat intake (albumin and cholesterol) Inspect Inspect teeth, ears, eyes Ask about how they get food (transportation, meals on Ask about wheels, etc) Nursing Management ○Identify strengths and abilities ○Include caregivers in planning ○Priority goals ■Gain a sense of control ■Feel safe ■Reduce stress Nursing Management: Implementation When carrying out a plan: ○Modify approach based on the older adult’s physical, functional, and mental status ○Assess the environment, Assess the patient ○Remember health promotion and disease prevention ○Inactivity and immobility lead rapidly to loss of function ○Assess for depression Questions? Key Points CANCER TREATMENT The goal of cancer treatment is cure, control, or palliation. Several factors determine the therapeutic approach taken. • When cure is the goal, treatment is offered that is expected to have the greatest chance of disease eradication. It may involve local therapy (e.g., surgery or radiation) alone or in combination with or without periods of adjunctive systemic therapy (e.g., chemotherapy, targeted therapy, immunotherapy). • Control is the goal of treatment for many cancers that cannot be completely eradicated but are responsive to anticancer therapies and can be maintained for long periods with therapy. • Palliation is the goal of treatment when the goals are the relief or control of symptoms and maintaining a satisfactory quality of life. Palliative care and treatment are not mutually exclusive and can take place concurrently. Modalities for cancer treatment include surgery, chemotherapy, radiation therapy, immunotherapy, targeted therapy, and hormone therapy. Surgery • The goal of surgery is to remove all or as much resectable tumor as possible while sparing normal tissue. Chemotherapy • The goal of chemotherapy is to eliminate or reduce the number of cancer cells present in the primary tumor and metastatic tumor site(s). ● Chemotherapy can be given by multiple routes, including oral or IV. The most common is IV administration through a central vascular access device. This reduces the risk of extravasation. • Increasingly chemotherapy is self-administered orally by patients. Providing teaching about proper medication handling and ensuring accurate dosing are important nursing considerations. • Chemotherapy-induced side effects are the result of the destruction of normal cells, especially those that are rapidly proliferating. These include those in the bone marrow, lining of the gastrointestinal system, and the integument (skin, hair, nails). Radiation • Radiation is used to treat a carefully defined area of the body either by itself or in combination with surgery or chemotherapy. It can be used as palliative treatment for symptom control in those with metastatic disease. • The intestinal mucosa is one of the most sensitive tissues to radiation and chemotherapy. ● Injuries result in diarrhea, mucositis, anorexia, nausea, and vomiting. • Nausea and vomiting are common with chemotherapy agents. Some patients have anticipatory or delayed nausea and vomiting. COMPLICATIONS RESULTING FROM CANCER • Infection is the leading cause of death. • The patient with cancer may have malnutrition, including protein and nutrient deficiencies, electrolyte depletion, dehydration, weight loss, and impaired wound healing. • Oncologic emergencies can result from the cancer or cancer treatment. They are classified as obstructive, metabolic, or infiltrative. These include superior vena cava syndrome, spinal cord compression, syndrome of inappropriate antidiuretic hormone secretion, hypercalcemia, tumor lysis syndrome, disseminated intravascular coagulopathy, and cardiac tamponade.
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