Oncology Older individuals are more prone

 Branch of medicine that deals to Ca

with the study, detection, b. Sex
treatment and management of women – breast, uterus, cervix
cancer and neoplasia cancer
Men – prostate, lung Ca
 In the Philippines, cancer ranks c. Urban Vs Rural
third in leading causes of d. Geographic Distribution
morbidity and mortality after e. Occupation
communicable diseases and f. Hereditary
cardiovascular diseases g. Stress
h. Precancerous lesions
 In the Philippines, 75% of all Pigmented moles, burn scars,
cancers occur after age 50 benign polyps, adenoma,
years, and only about 3% occur fibrocystic disease of the
at age 14 years and below breast
i. Obesity
 If the current low cancer - Breast and colorectal Ca
prevention consciousness persists,
it is estimated that for every 1800 Cancer Incidence
Filipinos, one will develop cancer Carcinogenesis
annually a. Initiation
- first step, chemicals, physical
 most Filipino cancer patients
factors and biologic agents, escape
seek medical advice only when
the normal enzymatic mechanisms
symptomatic or at advanced
and alter the genetic structure of
stages: for every two new
the cellular DNA
cancer cases diagnosed
- normally these alterations are
annually, one will die within the
reversed by DNA repair mechanism
year
or programmed cellular suicide
 The top cancer sites in the
(apoptosis)
Philippines include those
cancers whose major causes
2. Promotion
are known (where action can
- Repeated exposure
therefore be taken for primary
Causes expression of abnormal or
prevention), such as cancers of
mutant genetic information
the lung/larynx (anti-smoking
campaign), liver (vaccination
- Proto-oncogenes, “on switch”
against hepatitis B virus),
Ca suppressor genes, “turn off”
cervix (safe sex) and
P53 gene, a tumor suppressor gene
colon/rectum/stomach (healthy
regulates whether cells repair or
diet). Except for the liver, the
die after DNA is damaged
top Philippine cancer sites are
also the top cancers worldwide
3. Progression
-Third step of cellular
Terms to Define
carcinogenesis
a. Hyperplasia – increase in the
The cellular changes formed during
number of cells
initiation and promotion now
b. Metaplasia – conversion of
exhibit increased malignant
one cell to another cell
behavior
c. Dysplasia – bizarre cell
growth resulting in difference
Etiologic Factors
in size, shape and
1. Viruses
arrangement
Oncogenic viruses
d. Anaplasia – cells that lack
a. Epstein Bar virus, burkitt’s
normal cellular characteristic
lymphoma, nasopharyngeal Ca,
e. Neoplasia – uncontrolled cell
non-Hodgkin and hodgkin’s
growth
lymphoma
Predisposing Factors
a. Age
b. Herpes simplex Type II,
cytomegalovirus and HPV type
16,18,31,33, Cervix Ca
c. HIV, kaposi sarcoma
d. H. pylori, gastric Ca
2. Physical Agents
- Ultraviolent rays, especially in fair
skinned blue or green eyed people,
skin Ca
- Radiation from x-ray or nuclear,
leukemia, multiple myeloma, Ca of
lung, bone, breast and thyroid
3. Hormones
- Oral contraception or HRT, Inc.
incidence of hepatocellular,
endometrial and breast Ca
4. Chemical Agents
- 75% related to environment
Tobacco smoking, single most
lethal carcinogen, 30% of Ca
deaths, lung, head and neck
esophagus, bladder panceas,
cervix ca
chewing tobacco, ca of the oral
cavity in men younger than 40
years old
5. Industrial compounds
- Vinyl chloride (plastics, asbestos)
Polycyclic aromatic hydrocarbons
(burning, auto and truck emission)
Fertilizers and weed killers
Dyes, (analine dyes, hair dyes)
6. Dietary Factors
Carcinogenic
- fats, alcohol, salt cured or
smoked meats, high caloric content
Proactive
- high fiber, Cruciferous
vegetables ( cabbage, broccoli,
cauliflower, brussels, sprouts)
Carotenoids (carrots, tomatoes,
spinach, apricots, peaches, dark
green and yellow vegetables), vit
E, C, zinc and selenium
7. Genetics
- Oncogenes ( hidden/repressed
genetic code for Ca that exist in all
individual
8. Age: Advancing age is a
significant risk factors
9. Immunologic Factors
a. Immunosuppressed individuals
more susceptible to cancer
Characteristics of Ca
a. Metastasis
1. Lymphatics
- the most common mechanism
breast tumors, axillary, clavicular,
and thoracic LN
2. Hematogenous
- disseminated through the blood
stream
related to the vascularity of the
tumor
Angiogenesis – ability to induce
the growth of new capillaries from
the host tissue to meet the
nutrients and oxygen
Classification and staging
Tissue of Origin
Carcinoma:
a. Squamous cell Ca – surface
epithelium
b. Adenocarcinoma – glandular or
parenchymal
c. Sarcoma – connective tissue
d. Leukemia, Lymphoma
B. Staging – determines the size of
the tumor and the existence of
metastasis
TNM Classification
T – extent of primary tumor
N – absence or presence and
extent of regional lymph node
metastasis
M – absence or presence of
distance metastasis
Primary Tumor (T)
TX – primary tumor cannot be
assessed
TO – no evidence of primary tumor
Tis – carcinoma in situ
T1,2,3,4 – increasing size or local
extent of primary tumor
Regional lymph nodes (N)
NX – regional LN cannot be
assessed
NO – no regional LN metastasis
N1,2,3 – increasing involvement of
LN
Distant Metastasis
MX – Distance metastasis cannot
be assessed
MO – No distant metastasis
M1 – distant metastasis

Grading
Classification of tumor cells
Grade I – IV, define the type of
tissue which the tumor originated
Normal T0, N0, M0
Stage I T1, N0, M0
Stage II T2, N1, M0
Stage III T3, N2, M0
Stage IV with metastasis
2. Histologic
Grade 1 - well differentiated
Grade 2 - Moderately
differentiated more abnormal
Grade 3 - Poorly differentiated,
Very abnormal
Grade 4 - Very immature,
anaplastic hard to even determine
the tissue of origin
Nomenclature of Neoplasia
Tumor is named according to:
1. Parenchyma, Organ or Cell
Hepatoma- liver
Osteoma- bone
Myoma- muscle
Nomenclature of Neoplasia
Tumor is named according to:
2. Pattern and Structure, either
GROSS or MICROSCOPIC
Fluid-filled CYST
Glandular ADENO
Finger-like PAPILLO
Stalk POLYP
Nomenclature of Neoplasia
Tumor is named according to:
3. Embryonic origin
Ectoderm ( usually gives rise to
epithelium)
Endoderm (usually gives rise to
glands)
Mesoderm (usually gives rise to
Connective tissues)
BENIGN TUMORS
Suffix- “OMA” is used
Adipose tissue- LipOMA
Bone- osteOMA
Muscle- myOMA
Blood vessels- angiOMA
Fibrous tissue- fibrOMA
MALIGNANT TUMOR
Named according to embryonic cell
origin
1. Ectodermal, Endodermal,
Glandular, Epithelial
Use the suffix- “CARCINOMA”
Pancreatic AdenoCarcinoma
Squamos cell Carcinoma
Named according to embryonic cell
origin
2. Mesodermal, connective tissue
origin
Use the suffix “SARCOMA
FibroSarcoma
Myosarcoma
AngioSarcoma
“PASAWAY”
1. “OMA” but Malignant
HepatOMA, lymphOMA, gliOMA,
melanOMA
2. THREE germ layers
“TERATOMA”
3. Non-neoplastic but “OMA”
Choristoma
Hamatoma
Warning signs of Ca
C – change in bowel or bladder
habits
A – sore that does not heal
U – unusual bleeding or
discharge
U – unexplain sudden weight
loss
U – unexplained anemia
T – thickening or lump
I – indigestion or difficulty in
swallowing
O – obvious change in wart or
mole
N – nagging cough or
hoarseness of voice
Screening
a. Early detection and
treatment are the
cornerstones of cancer
survival
b. Educating the public about a
healthy lifestyle and early
detection
c. Health education
d. Reduce and avoid exposure
to known carcinogens
e. Eat a balanced diet of
vegetables, fruits and whole
grains, reducing fat and red
smoked and cured meat.
f. Limit alcohol beverages
g. Exercise regularly
h. Reduce stress and
encourage adequate rest and
relaxation
 i. Follow screening a. Most client fear of death
recommendations upon confirmation of
j. Know the seven warning Cancer
signs b. Clients usually ignored
k. Seek medical attention cardinal signs of Cancer
c. Most often cancer is
Diagnostic test detected during routine
1. Biopsy exam
- removal of tissue for histologic d. Questions that need to be
examination answered: Example (Is the
- essential for choosing treatment disease curable or not?)
Types
a. FNAB Nursing Diagnosis
b. Incision a. Ineffective coping
c. Excision b. Anticipatory grieving
d. Punch c. Disturbed body image
d. Fatigue
Preprocedure e. Impaired elimination
a. Depends on the location and f. Hopelessness
type of biopsy g. Impaired oral mucous
b. May need to be NPO if membrane
sedation or contrast is used
c. Inform the client about the Common Cancer complaint
procedure a. Nausea
 Impaired nutrition less than
Postprocedure body requirements
a. Control bleeding  acute pain
b. Monitor for infection  Impaired skin integrity
c. Manage pain  Signs and symptoms of
d. Inform the client how to malignant neoplasia
obtain the results  Proliferation of Ca cells
 Pressure
B. Imaging
- X-ray, ultrasound, MRI, Ct
 Obstruction
scan
- Methods of obtaining 2. Pain ( late sign of Ca )
information about the  Pressure on nerve endings
presence, location and  Distention of organs/vessels
extend of tumor  Lack of O2 to tissue and
Method chosen is based on organ
1. ability to visualize tumor  Release of pain mediators
2. Risk  Pleural effusion and ascites
3. Client comfort
4. Cost 3. Ulceration and necrosis
 As tumor erodes BV and
Preprocedure pressure on tissue causes
a. Assess for allergy if contrast is ischemia, tissue damage,
to be used bleeding and infection
b. NPO depending on the area  Vascular throbosis, Embolus,
being imaged, use of sedation Thrombophlebitis
or contrast  Tumors tends to produce
c. Prepare patient for length of abnormal coagulation factors
imaging, possible noise of
machinery, need to remain
still.
d. Monitor the client for flushing, Paraneoplastic Syndrome
itching or nausea, indicating 1. Anemia
allergy to contrast.  Ca cells produces chemicals
that interfere with rbc
production
Points to Remember
  Iron uptake is greater in the
tumor than that deposited in
the liver
 Blood loss from bleeding
2. Hypercalcemia
 Increases and acce;erates
bone breakdown and release
of Calcium
3. Anorexia – Cachexia Syndrome
 Final outcome of
unrestrained Ca growth
 Ca deprived normal cells
nutrition
 Protein depletion, serum
albumin decreases
 Tumors take up Na
 Act in the satiety center
causing anorexia
 Taste sensation diminishes
Pain: Cancer and End of Life
a. 30% of clients experience
pain at the time of diagnosis.
b. 30% to 50% experience pain
while undergoing therapy.
c. 70% to 90% experience pain
as cancer advances and
overcomes their defenses
d. Cancer pain is complex,
interactive, and ever-
changing. It comes from two
general sources: the cancer
itself, and its various
treatments
e. Cancer pain is more than a
physical symptom. It is a
reminder of ones mortality
and a harbinger of death.
f. It interferes with normal
routines, degrades the
quality of life, and robs one
of rest, creativity, joy, and
peace.
g. Cancer pain adds stress and
worry to its sufferers and
friends and family. For this
reason, healthcare
professionals
h. Take pain seriously,
recognizing that only the
person in pain knows how it
feels.
i. Provide information and
resources for pain control.
j. Communicate with
genuineness, accurate
empathy, and nonpossessive
warmth.
k. Encourage sufferers to share
their feelings and network
with other survivors.
l. Respect culture norms and
wishes of sufferers,
maximizing their control
m. Encourage release of energy
through joy-producing
activities.
n. Monitor pain medications,
effectiveness, and adverse
effects
Management of Cancer
1. Cure
 eradication of malignant
diseases
2. Control
 prolonged survival and
containment of cancer cell
growth
3, Palliation
 relief of symptoms
associated with the disease
Therapeutic Modalities for Cancer
a. Surgery
b. Chemotherapy
c. Radiation therapy
d. Immunotherapy
e. Bone Marrow Transplantation
Surgery
 The ideal and most
frequently used
Goals
a. Primary
b. Prophylactic
c. Palliative
d. reconstructive
 Removal of tissue for
diagnosis, staging, palliation
or treatment of cancer.
 Most frequently used cancer
therapy
 Most successful single
therapy if cancer has not
spread
 Very often performed on an
OPD or brief stay basis
Diagnostic Surgery
Biopsy
Excisional biopsy
- most frequently used for easily
accessible tumors of the skin,
breast, ULGIT,URTI
- provides the pathologist the cells
and the entire tissue
 - decreases the chance of seeding
the tumor
Incisional Biopsy
- used if the tumor mass is too
large to be removed
- a wedge of tissue from the tumor
is taken
Needle Biopsy
- done on suspicious masses that
are easily accessible
- fast, inexpensive and easily
performed
Surgery as primary treatment
- Remove the entire tumor or
as much as is feasible
1. Local excision
- if the mass is small
2. Wide or Radical Excision
- removal of the primary tumor,
LN, adjacent and surrounding
tissue
- results in disfigurement and
altered function
3. Salvage surgery
Prophylactic Surgery
- Removal of non-vital structures
that are likely to develop Ca
Palliative Surgery
- when cure is not possible, the
goal of treatment is to make the
patient as comfortable as possible
and to promote a satisfying and
productive life for as long as
possible
Radiation Therapy
 Used to control malignant
disease when a tumor cannot
be removed surgically
 To relieve the symptoms of
metastatic disease,
especially when the Ca
spread to the brain, bone.
 A radiosensitive tumor is one
that can be destroyed by a
dose of radiation that still
allows for cell regeneration in
the normal tissue
Radiation Therapy
 Uses ionizing radiation to kill
or limit the growth of cancer
cells. May be internal or
external
 Effect cannot be limited to
cancer cells only
 is a cancer treatment that
uses high doses of radiation
to kill cancer cells and stop
them from spreading. At low
doses, radiation is used as an
x-ray to see inside your body
and take pictures, such as x-
rays of your teeth or broken
bones.
 Radiation use in cancer
treatment works in much the
same way, except that it is
given at higher doses.
Radiation therapy is used to:
a. Treat cancer. Radiation can be
used to cure, stop, or slow the
growth of cancer.
b. Reduce symptoms. When a
cure is not possible, radiation may
be used to shrink cancer tumors in
order to reduce pressure.
 Radiation therapy used in
this way can treat problems
such as pain, or it can
prevent problems such as
blindness or loss of bowel
and bladder control.
 Cells are most vulnerable to
radiation during DNA
synthesis and mitosis
 Most sensitive are those body
tissue that undergo frequent
cell division. (BM, Lymphatic,
GIT, gonads)
 Tumors that are well
oxygenated are more
sensitive to radiation
 Cells most sensitive during M
and G2 phase
Radiosensitivity
Highly sensitive
- ovaries, testes, bone marrow,
blood, intestines
Low sensitivity
- muscle, brain, spinal cord
Types
Teletherapy (External Beam)
a. x-rays are used to destroy
cancerous cells at the skin
surface or deeper
b. b. Used more commonly
c. Client is not radioactive
during treatment
d. Simulation – X-ray or Ct
planning session to identify
the field which delivers
 maximum radiation to the
tumor and minimal to normal
tissue. Involves skin
markings
e. Administered in fractions of
the full dose, 5 days a week
for 4-6 weeks
b. Brachytherapy (Internal)
a. used primarily in the head
and neck, gynecologic,
prostate cancer
b. delivers a high dose of
radiation in a local area
using implants
c. Client is radioactive only
when implaint is in placed
d. plan cares efficiently to
minimize nurses, exposure to
implant, use shielding, wear
a film badge and maintain
safe distance.
e. Pregnant nurses should not
care for clients with
implanted radiation
f. Pickup dislodge implants with
long forceps placed in a
special container.
g. Body fluids of clients treated
with systemic radioactive
iodine are radioactive; fluids
of client with implants are
not
Radiation Dosage
 The lethal tumor dose is
defined as the dose that will
eradicate 95% of the tumor
yet preserve normal tissue
Adverse Reaction
a. Seen only in the organs in
the radiation field, except for
systemic effects of nausea,
anorexia and fatigue
b. Skin reactions are common
and expected with external
beam
c. Toxicity
d. Localized to the area being
irradiated
e. Alteration in oral mucosa,
stomatitis, xerostomia,
change and loss of taste,
decreased salivation
f. Altered skin integrity,
alopecia, erythema,
shedding, desquamation
g. Thrombocytopenia
h. Anemia
Radiation Safety
 Distance - the greater the
distance the lesser the
exposure
 Time - the less time spent
close to radiation the less
exposure (max of 30 min
per shift)
 Shielding - use lead
aprons and gloves
 Standards - kept as low as
reasonably achievable
 Monitoring device - film
badge (measure the
whole exposure of the
nurse)
Side Effects
a. Skin: Itching, redness, burning,
sloughing
 Keep skin free of foreign
substance
 Avoid use of medicated
solutions
 Avoid pressure, trauma,
infection
 Avoid exposure to heat, cold
or sunlight
b. Anorexia, vomitting, nausea
 Provide small, attractive
feedings
 Avoid extremes of
temperatures
 Administer antiemetics
before meals
c. Diarrhea
 Encourage low residue,
bland, high protein foods
 Provide good perineal hygine
 Monitor electrolytes, Na,K,Cl
d. Anemia. Leukopenia,
thrombocytopenia
 Isolate patient
 provide frequent rest period
 Encourage high protein diet
 Assess for bleeding
 Monitor lab results CBC,
WBC, Plt
Chemotherapy
Systemic treatment with chemicals
which destroy rapidly proliferating
cells
Used for cure in testicular, Hodgkin
disease, ALL, neuroblastoma,
Wilms and Burkitt’s lymphoma
Used to control breast, nod-
Hodgkin, small cell lung and
ovarian cancer
Used palliative for relief of pain,
obstruction and to improve comfort
What does chemotherapy do?
Cure cancer - when
chemotherapy destroys cancer
cells to the point that your doctor
can no longer detect them in your
body and they will not grow back.
Control cancer - when
chemotherapy keeps cancer from
spreading, slows its growth, or
destroys cancer cells that have
spread to other parts of your body.
Ease cancer symptoms (also
called palliative care) - when
chemotherapy shrinks tumors that
are causing pain or pressure.
Chemotherapy
a. Chemotherapy works by
stopping or slowing the
growth of cancer cells, which
grow and divide quickly. But
it can also harm healthy cells
that divide quickly, such as
those that line your mouth
and intestines or cause your
hair to grow. Damage to
healthy cells may cause side
effects. Often, side effects
get better or go away after
chemotherapy is over.
b. Sometimes, chemotherapy is
used as the only cancer
treatment. But more often,
you will get chemotherapy
along with surgery, radiation
therapy, or biological
therapy. Chemotherapy can:
c. Make a tumor smaller before
surgery or radiation therapy.
This is called neo-adjuvant
chemotherapy.
Destroy cancer cells that may
remain after surgery or radiation
therapy. This is called adjuvant
chemotherapy.
Help radiation therapy and
biological therapy work better.
Destroy cancer cells that have
come back (recurrent cancer) or
spread to other parts of your body
(metastatic cancer).
Cell Cycle
Time required for one tissue cell to
divide and reproduce two identical
daughter cells
Go – resting phase
G1 – RNA and protein synthesis
occurs
S – DNA synthesis occurs
G2 – Premitotic phase
M – cell division occurs
Chemotherapy may be given in
many ways.
Injection. The chemotherapy is
given by a shot in a muscle in your
arm, thigh, or hip or right under the
skin in the fatty part of your arm,
leg, or belly.
Intra-arterial (IA). The
chemotherapy goes directly into
the artery that is feeding the
cancer.
Intraperitoneal (IP). The
chemotherapy goes directly into
the peritoneal cavity (the area that
contains organs such as your
intestines, stomach, liver, and
ovaries).
Intravenous (IV). The
chemotherapy goes directly into a
vein.
Topically. The chemotherapy
comes in a cream that you rub onto
your skin.
Orally. The chemotherapy comes
in pills, capsules, or liquids that you
swallow.
Antineolplastic agent
Cell Cycle non-specific
1. Alkylating agents
- acts with DNA to hinder cell
growth and division
- cisplatin, cyclophosphamide
2. Steroids and sex hormones
- alter the endocrine environment
to make it less conducive to growth
of cancer cells.
3. Antitumor antibiotics
- interfere with DNA synthesis by
binding DNA. Prevent RNA
synthesis
- Bleomycin, dactinomycin,
doxorubicin, mitomycin
- cardiac toxicity (daunorubicin,
doxorubicin)
Cell Cycle Specific (S phase)
1. Antimetabolites
- foster cancer cell death by
interfering with cellular metabolic
process
-5-flouroracil, methotrexate,
cytarabine
- renal toxicity (methotrexate)
Cell cycle specific (M phase)
1. Plant alkaloids
- makes the host body a less
favorable environment for the
growth of cancer cells
- arrest metaphase by inhibiting
mitotic tubular formation. Inhibit
DNA and RNA synthesis
-vincristine, vinblastine
- Taxanes: Paclitaxel (bradycardia)
Chemotherapy
a. Used to treat systemic
diseases rather than
localized lesions that are
amenable to surgery and
radiation
b. Used in an attempt to
destroy tumor cells by
interfering with cellular
function and reproduction
c. Use of chemicals to destroy
cancer cells
d. Interferes DNA & RNA
activities associated with cell
division
e. Often used in combination
with radiation therapy
f. Cytotoxic - is an agent
capable of destroying cells
g. Cytotoxic drug - alkylating
and antimetabolites
h. Can be combined with
surgery or radiation therapy
i. Used to reduce the tumor
size preoperatively and to
destroy the remaining tumor
cells preoperatively
j. Eradication of 100% of tumor
is nearly impossible
k. Goal is to eradicate enough
of the tumor so that the
remaining tumor cells can be
destroyed by the immune
system
Contraindication
a. Infection
b. Recent surgery
c. Impaired renal or hepatic
function
d. Recent radiation therapy
e. Pregnancy
f. Bone marrow depression
Extravasation – cause tissue
necrosis and damage to tendons,
nerves and blood vessels
Major side effects
GI System
1. Nausea and vomitting
- administer anti-emetics
- NPO 4-6 hrs before
chemotherapy
- bland diet foods in small
amounts after treatment
2. Diarrhea
3. Stomatitis
- Good oral hygiene
- rinse with viscous lidocaine
before meals
- rinse with plain water or
hydrogen peroxide after meals
- apply water soluble lubricants
- Suck popsicle to provide
moisture
Hematologic (Myelosuppression)
1. Thrombocytopenia
- Avoid bumps or bruishing
- protect client from physical
injury
- Avoid aspirin
- Avoid IM injections
- Assess for bleeding tendencies
b. Leukopenia
- use careful handwashing
- reverse isolation if WBC <1000
- assess for signs of respiratory
infection
- Avoid crowds
c. Anemia
- Provide adequate rest periods
- monitor CBC
- Administer o2 PRM
Integumentary System – Alopecia
- Explain hair loss is not
permanent
- Support and encouragement
- Scalp tournique or scalp
hypothermia to minimize hairloss
- Advise client to obtain wig
Renal system ↓ bone marrow activity
- may cause direct damage to anemia, prone to infection
kidneys by excreting metabolites. and bleeding tendency
- encourage fluids and frequent Metabolic
voiding TLS and Hyperkalemia
- increased excretion of uric acid
may damage kidneys Perceived Change in Body Image
- Administer allopurinol, Inc. OFI a. Obvious reminder of
disability
Reproductive System b. need for prosthesis
1. Infertility and mutagenic (breast, leg and eye)
damage to chromosomes c. need for hardware (wheel
2. Banking sperm chair, crutches)
3. Use contraception d. need for medication (CR
therapy)
Side Effects from Radiation and e. extent of disability or
Chemo Therapy limitation
a. Neurologic/Sensory/Perceptu
al Type of loss
a. Meningeal irritation a. symbols of sexuality
b. CN and peripheral b. social acceptability
neuropathy (colostomy)
c. Cerebellar toxicity c. ability to communicate
d. Ototoxicity (laryngectomy, aphasia)
b. Cardiac d. anatomic changes
a. Pericardial Effusion (amputation)
b. Arrhythmias
c. CHF Terminally Ill
c. Pulmonary • 50% die from the disease
a. Pleural Effusion • time from diagnosis to death
b. Pneumonitis ranges from weeks- years
d. GIT • not all clients become
a. Stomatitis terminally ill
b. Esophagitis • others die during initial
c. Pharyngitis treatment; others die from
d. Taste alteration complications of treatment
e. Anorexia
• Endpoint: no response to
f. Nausea and vomiting
treatment and progressions
g. Constipation and diarrhea
cannot be controlled
h. Weight loss
GUT
Nephrotoxicity
Hemorrhagic cystitis
HOSPICE CARE
Hyperuricemia
• standard of care for
Urine color changes
terminally ill cancer clients
Reproductive
• symptom control
• Loss of libido
• pain management
• Impotence
• providing comfort and dignity
• Amenorrhea
• 24 hour – 7 day coverage
• Irregular menses
• services given are based on
• Menopausal symptoms
client’s need not on its ability
• Azoospermia
to pay
• Sterility
• One can suffer without
• Gynecomastia physical pain and one can
Hepatic have physical pain and not
Hepatotoxicity necessarily suffer.
Integumentary
• The founder of the modern
Alopecia
hospice movement described
Dermatitis and ulcers
suffering as “total pain,” an
Hematopoietic
experience of changing self-
 perception, fear of physical
distress and dying, concerns
about relationships, changing
self-perception, and memory
of other person’s suffering (
Ethical Issues
• caring can be just
successful as curing;
when curing is not an
option
• care is exercised during
the final stage of life
• Goals of Intervention
• to care without functional
and structural impairment
• if cure is not possible
goals must
= prevent further
metastasis
= relieve symptoms
= maintain high
quality of life
Bone Marrow Transplant
• Used in the treatment of
leukemia for clients who
have closely matched donors
• and experiencing temporary
remission with chemotherapy
• Severe aplastic anemia,
breast Ca, brain Ca
Types
Autologous
- own bone marrow, most common
type
Allogenic
- transplant from a genetically
non-identical donor
- sibbling most common type
procedure
1. Harvest – through multiple
aspiration from the iliac crest to
retrieve sufficient bone marrow for
the transplant
- 500ml- 1000ml
2. Conditioning
- immunosuppressant therapy is
given to eradicate all malignant
cells
3. Transplantation
a. administered through central
line like BT
b. infused 30 min
4. Engraftment
a. transfused BM move to marrow
forming sites
b. occurs when WBC, erythrocytes,
plt ct begin to rise
c. takes 2-5 weeks
Complications:
a. Failure of engraftment.
b. Infection: higher risk 3-4
weeks
c. Pneumonia: principal cause
of death during first three
months
d. Graft vs host disease –
principal complication
a. Acute – 1st 100 days post
transplant
b. Chronic – 100-400 days
Nursing Care: Pretransplant
1. Provide protected environment
- strict reverse isolation
2. Monitor central lines frequency
3. Provide care receiving
chemotherapy
Post transplant
• Prevent infection
• Maintain protective
environment
• Administer antibiotics
• Check IV set ups q12hrs
2. Provide mouth care for
stomatitis and mucositis
3. Monitor carefully for bleeding
a. check for occult blood in
emesis, stools
b. observe for easy bruising
c. Check platelet ct daily
d. replaced blood component
4. Maintain fluid and electrolyte
balance
5. Provide client health teaching
Nursing Assessment
a. Weight loss
b. Frequent infection
c. Skin problems
d. Pain
e. Hair Loss
f. Fatigue
g. Disturbance in body image/
depression
h. Managing effects of Cancer
and treatment
Pain
1. Description
 a. Whatever the client says it is,
whenever the client says it exists.
b. may be caused by treatment,
cancer destruction of tissue or
pressure or pressure on nearby
structures and cancer progression
c. Bone metastasis are very
common cause
Nursing Interventions
a.. Assess all clients for pain even if
they do not appear to be
experiencing it.
b. Educate clients and families
about narcotic use
1. Correct use of narcotics results
in addiction in <1% of client
2. Narcotic dose may be
increased with increasing dose not
have be reserved for last resort
use.
c. Instruct clients on
nonpharmacologic methods of pain
management.
d. Administer pain medication as
ordered, utilizing a combination of
non-narcotic and narcotic
analgesics
e. Oral route is preferred if possible
f. Meperidine (demerol) is seldom
used to treat cancer pain because
it metabolizes and accumulates
during extended use.
Myelosuppression
- reduced numbers of white and
red blood cells and platelets
associated with cancer or
treatment
- Neutropenia <1000
- Thrombocytopenia < 100,000
- results in infection and bleeding
- the oral cavity is the primary site
of infection
Assessment
Monitor for clinical manifestations
of infection
• Erythema, warmth, swelling
at incision site
• Fever
• Shaking chills
• Pain
• Foul smelling duscharge
• White oral plaque
• Change in sensorium
• Monitor for clinical
manifestation of bleeding
• Bruising and petechiae
• Blood in the urine, stool and
vomitus
• Changes in mentation
• Pain
• Weak, rapid pulse, low blood
pressure, pale cool skin
Nursing intervention
a. Instruct practice of careful
washing
b. Perform oral and perineum
care
c. Place client in protective
isolation
d. Administer antibiotics and
antipyretics
e. Avoid unnecessary invasive
procedures to prevent
bleeding or infection
f. Avoid shaving
g. Administer iced gastric
lavage
MAINTAIN TISSUE INTEGRITY
a. Handle skin gently
b. Do NOT rub affected area
c. Lotion may be applied
d. Wash skin only with SOAP
and Water
MANAGEMENT OF STOMATITIS
a. Use soft-bristled toothbrush
b. Oral rinses with saline
gargles/ tap water
c. Avoid ALCOHOL-based rinses
MANAGEMENT OF ALOPECIA
Alopecia begins within 2 weeks of
therapy
a. Regrowth within 8 weeks of
termination
b. Encourage to acquire wig
before hair loss occurs
c. Encourage use of attractive
scarves and hats
d. Provide information that hair
loss is temporary BUT
anticipate change in texture
and color
PROMOTE NUTRITION
a. Serve food in ways to make it
appealing
b. Consider patient’s
preferences
c. Provide small frequent meals
d. Avoids giving fluids while
eating
e. Oral hygiene PRIOR to
mealtime
f. Vitamin supplements

RELIEVE PAIN
a. Mild pain- NSAIDS
Moderate pain- Weak opiods
b. Severe pain- Morphine
c. Administer analgesics round
the clock with additional dose
for breakthrough pain
DECREASE FATIGUE
a. Plan daily activities to allow
alternating rest periods
b. Light exercise is encouraged
c. Small frequent meals
IMPROVE BODY IMAGE
a. Therapeutic communication
is essential
b. Encourage independence in
self-care and decision making
c. Offer cosmetic material like
make-up and wigs
ASSIST IN THE GRIEVING PROCESS
a. Some cancers are curable
b. Grieving can be due to loss of
health, income, sexuality,
and body image
c. Answer and clarify
information about cancer and
treatment options
d. Identify resource people
e. Refer to support groups
MANAGE COMPLICATION:
INFECTION
a. Fever is the most important
sign (38.3)
b. Administer prescribed
antibiotics X 2weeks
c. Maintain aseptic technique
d. Avoid exposure to crowds
e. Avoid giving fresh fruits and
veggie
f. Handwashing
g. Avoid frequent invasive
procedures
MANAGE COMPLICATION: Septic
shock
a. Monitor VS, BP, temp
b. Administer IV antibiotics
c. Administer supplemental O2
d. Nursing Intervention
MANAGE COMPLICATION: Bleeding
• Thrombocytopenia
(<100,000) is the most
common cause
• <20, 000 spontaneous
bleeding
• Use soft toothbrush
• Use electric razor
• Avoid frequent IM, IV, rectal
and catheterization
• Soft foods and stool softeners
Colon cancer
• Adenocarcinoma is the most
common type
• Metastasis is common to the
liver
• 2nd most common site for
cancer in men and women
• Ages >50-60
• May be caused by
diverticulitis, chronic
ulcerative colitis, familial
polyposis
Cancer sites
a. Sigmoid colon – 33%
b. Rectum – 27%
c. Ascending Colon – 22%
d. Transverse colon – 11%
e. Descending colon 6%
Metastatic sites
Liver the most common site
Peritoneal surface
Spread via lymphatics to lung,
bone and brain
COLON CANCER
Risk factors
1. Increasing age
2. Family history
3. Previous colon CA or polyps
4. History of IBD
5. High fat, High protein, LOW fiber
6. Breast Ca and Genital Ca
COLON CANCER
Sigmoid colon is the most common
site
Predominantly adenocarcinoma
If early 90% survival
34 % diagnosed early
66% late diagnosis
COLON CANCER
PATHOPHYSIOLOGY
Benign neoplasm DNA
alteration malignant
transformation malignant
neoplasm  cancer growth and
invasion  metastasis (liver)
COLON CANCER
ASSESSMENT FINDINGS
1. Change in bowel habits-
Most common
2. Blood in the stool
3. Anemia
4. Anorexia and weight loss
5. Fatigue
6. Rectal lesions- tenesmus,
alternating D and C
Right sided lesions
- dull abdominal pain, melena
Left sided lesions
- signs of obstruction and bright
red stool
Rectal lesion
- tenesmus, rectal pain.
Incomplete BM., bloody stool,
constipation
Colon cancer
Diagnostic findings
1. Fecal occult blood
2. Sigmoidoscopy and colonoscopy
3. BIOPSY
4. CEA- carcino-embryonic antigen
Colon cancer
Complications of colorectal CA
1. Obstruction
2. Hemorrhage
3. Peritonitis
4. Sepsis
Colon cancer
MEDICAL MANAGEMENT
1. Chemotherapy- 5-FU
2. Radiation therapy
Colon cancer
a. SURGICAL MANAGEMENT
Surgery is the primary treatment
Based on location and tumor size
Resection, anastomosis, and
colostomy (temporary or
permanent)
Right hemicolectomy – primary
surgery for cancer of the ascending
colon
- removal of the terminal ileum,
cecum, right transverse colon
Left hemicolectomy – primary
surgery for cancer of descending
and sigmoid colon
- removal of the distal transverse,
descending and sigmoid colon
Colostomy
Single barrel – proximal colon is
brought to the surface forming one
stoma’
Double barrel – two stomas,
proximal excretes stool, distal
secretes mucus
Stool formation depends on
1. Ascending – loose, liquid
2. Transverse – semisolid
3. descending – soft, formed stool
Sexual dysfunction affects 15 –
1005 depending on the client age,
surgical technique
Colon cancer
NURSING INTERVENTION
Pre-Operative care
1. Provide HIGH protein, HIGH
calorie and LOW residue diet
2.Provide information about post-
op care and stoma care
3. Administer antibiotics 3-5 day
prior
Colon cancer
NURSING INTERVENTION
Pre-Operative care
4. Enema or colonic irrigation the
evening and the morning of
surgery
5. NGT is inserted to prevent
distention
6. Monitor UO, F and E, Abdomen
PE
Colon cancer
NURSING INTERVENTION
Post-Operative care
1. Monitor for complications
a. Leakage from the site
b. prolapse of stoma
c. Infection
d. Bowel obstruction
2. Assess the abdomen for return
of peristalsis
Colostomy Care
Prevent skin breakdown
- cleans skin around stoma with
mild soap, water and padding
motion
- assess skin regularly for irritation
- avoid use of adhesive on irritated
skin
Control odor
- change pouch
- empty bag frequently and
provide ventilation, use deodorizer
- Avoid gas producing foods
Promote adequate stomal drainage
 - assess stoma for color and NURSING INTERVENTION:
intactness COLOSTOMY CARE
- mucoid/serosanguinous drainage Empty the pouch or change the
1st 24hrs pouch when
- assess for flatus 1/3 to ¼ full (Brunner)
Irrigate colostomy as needed ½ to 1/3 full (Kozier)
- position client on toilet or high
fowlers Breast Cancer
- fill irrigation bag with water (500- The most common cancer in
1000ml) FEMALES
- Remove old pouch and clean skin Numerous etiologies implicated
- lubricate catheter and insert to
stoma RISK FACTORS
- allow fecal contents to drain 1. Genetics- BRCA1 And BRCA 2
Provide adequate nutrition 2. Increasing age ( > 50yo)
2500ml liquids/day 3. Family History of breast cancer
4. Early menarche and late
Health teaching when discharge menopause
a. change in odor, consistency and 5. Nulliparity
color of stool 6. Late age at pregnancy
b. bleeding from stoma Breast Cancer
c. persistent constipation and 7. Obesity
diarrhea 8. Hormonal replacement
d. persistent leakage around the 9. Alcohol
stoma 10. Exposure to radiation
e. skin irritation
PROTECTIVE FACTORS
Colon cancer 1. Exercise
NURSING INTERVENTION: 2. Breast feeding
COLOSTOMY CARE 3. Pregnancy before 30 yo
Colostomy begins to function 3-6
days after surgery
The drainage maybe soft/mushy or Stages I and 2 are 70-90% curable
semi-solid depending on the site Invasive or infiltrating, capable of
Colon cancer metastasis
a. Ductal – 70%
NURSING INTERVENTION: b. Lobular – 10 % higher incidence
COLOSTOMY CARE of contralateral breast cancer
• BEST time to do skin care is
after shower Breast Cancer
• Apply tape to the sides of the ASSESSMENT FINDINGS
pouch before shower 1. MASS- the most common
• Assume a sitting or standing location is the upper outer
position in changing the quadrant
pouch 2. Mass is NON-tender. Fixed, hard
NURSING INTERVENTION: with irregular borders
COLOSTOMY CARE 3. Skin dimpling
• Instruct to GENTLY push the 4. Nipple retraction
skin down and the pouch 5. Peau d’ orange
pulling UP Breast Cancer
LABORATORY FINDINGS
• Wash the peri-stomal area
1. Biopsy procedures
with soap and water
2. Mammography
• Cover the stoma while
3. Tumor marker CA 2729
washing the peri-stomal area
• Lightly pat dry the area and Breast Cancer
NEVER rub Breast cancer Staging
• Lightly dust the peri-stomal TNM staging
area with nystatin powder I - < 2cm
• Colon cancer II - 2 to 5 cm, (+) LN
III - > 5 cm, (+) LN
IV- metastasis
Metastatic sites
a. Bone
b. Liver
c. Lung
d. Brain
Treatment
Surgical management is the
primary treatment for breast
cancer
Breast conservation (lumpectomy,
segmental resection)
- removal of the cancer with
margin of healthy tissue
- If followed by radiation therapy
has equivalent 5 year survival to
mastectomy
Simple – removal of all breast,
nipple and skin
Modified radical – axillary
lymphnodes are removed
Radical mastectomy – pectoral
muscles are removed
Medical therapy
External beam radiation therapy 3
weeks after surgery. Most
commonly used
Chemotherapy
Tamoxifen therapy
Breast Cancer
NURSING INTERVENTION : PRE-OP
1. Explain breast cancer and
treatment options
2. Reduce fear and anxiety and
improve coping abilities
3. Promote decision making
abilities
4. Provide routine pre-op care:
Consent, NPO, Meds, Teaching
about breathing exercise
Breast Cancer
NURSING INTERVENTION : Post-OP
1. Position patient:
Supine
Affected extremity elevated to
reduce edema
Breast Cancer
2. Relieve pain and discomfort
Moderate elevation of extremity
IM/IV injection of pain meds
Warm shower on 2nd day post-op
Breast Cancer
3. Maintain skin integrity
Immediate post-op: snug dressing
with drainage
Maintain patency of drain (JP)
Monitor for hematoma w/in 12H
and apply bandage and ice, refer to
surgeon
3. Maintain skin integrity
Drainage is removed when the
discharge is less than 30 ml in 24 H
Lotions, Creams are applied ONLY
when the incision is healed in 4-6
weeks
Promote activity
Support operative site when
moving
Hand, shoulder exercise done on
2ndday
Post-op mastectomy exercise 20
mins TID
NO BP or IV procedure on operative
site
Promote activity
Heavy lifting is avoided
Elevate the arm at the level of the
heart
On a pillow for 45 minutes TID to
relieve transient edema
NURSING INTERVENTION : Post-OP
MANAGE COMPLICATIONS
Breast Cancer
Lymphedema
10-20% of patients
Elevate arms, elbow above
shoulder and hand above elbow
Hand exercise while elevated
Refer to surgeon and physical
therapist
Breast Cancer
NURSING INTERVENTION : Post-OP
MANAGE COMPLICATIONS
Hematoma
Notify the surgeon
Apply bandage wrap (Ace wrap)
and ICE pack
Breast Cancer
NURSING INTERVENTION : Post-OP
TEACH FOLLOW-UP care
Regular check-up
Monthly BSE on the other breast
Annual mammography
Lung Ca
The number 1 cancer killer in men
and women
 • 6th to 7th decade of life
• 70% involvement of
lymphnodes
• 85% caused by inhalation of
carcinogenic chemicals
Pathophysiology
Arise from a single transformed
epithelial cell in the
tracheobronchial airways.
Adenocarcinoma - most prevalent
carcinoma of the lung for men and
women, peripherally located and
often metastasized
Squamous cell Ca – centrally
located and arises in the segmental
and subsegmental bronchi
Large cell Ca – fast growing tumor
that arise peripherally
Bronchioalveolar – slower growing
and arises at the alveoli
Classification and staging
Non small cell Ca – 70-75%
a. Adenocarcinoma
- most common (40%)
- slowest growing,
metastasize early
b. Squamous cell – 30%
c. Large cell – rarest
- has the worst prognosis
Small cell (25%)
a. Oat cell (90%)
- very aggressive and
metastasize at diagnosis.
5 year survival rate is 48% if
detected early and localize (rare)
Overall 5 year survival rate is 15%
Risk factors
Tobacco smoking
- single most important
preventable cause of death
- 10x more common than in non-
smoker
- passive smoke exposure
increases the risk to 35%
Environmental and occupational
exposure
- arsenic, asbestos, mustard gas,
oil, radiation
.genetics
Diet
Clinical manifestation
Develops insidiously and is
assymptomatic until late in the
course
s/sx depends on the location and
size of the tumor, degree of
obstruction and metastasis
Cough or chronic cough
- dry, persistent without sputum
production
Wheezing
Hemoptysis or blood tinged sputum
Chest and shoulder pain
Common sites of metastasis
• LN
• Bone
• Brain
• Contralateral lung
• Adrenal glands
• liver
Screening test: No screening
program currently exist.
Assessment:
• Clients are very rarely
symptomatic at the time of
diagnosis.
• Persistent cough and
dyspnea
• Recurrent bronchitis and
pneumonia
• Blood streaked sputum
• Chest pain
Diagnostics
a. Chest xray (solitary
peripheral nodule, coin
lesion)
b. Ct scan of the chest
c. Fiberoptic bronchoscopy
d. Fine needle biopsy under ct
scan
Surgical Management
Dependent on whether the tumor is
resectable
May be cure for non small cell if no
metastasis occurred and lung
function is sufficient on removal of
all or part of the lungs (50%)
Lobectomy – removal of lobe
(common)
Pneumonectomy – removal of the
lung
Segmentectomy – partial removal
of the lung lobe
Adjuvant therapy
a. Chemotherapy is the primary
treatment for small cell
b. Radiation is standard post op for
advanced non-small cell
Radiation therapy – for localized
intrathoracic lung ca and palliation
for hemprtysis, obstruction
dysphagia and pain
Nursing Intervention
Assess for signs of superior vena
cava syndrome
Postlobectomy, manage chest tube
Assess respiration and for presence
of pneumothorax or atelectasis
Position properly post-op
1. Lobectomy – avoid prolonged
lying on the operative site
2. Pneumonectomy – position on
the back or operative side only
Instruct the client on deep
breathing, coughing and
ambulation
Pain management to promote deep
breathing
Refer client to smoking cessation
Prostate Cancer
• a slow growing malignancy of
the prostate gland
• Usually an adenocarcinoma
• This usualy spread via blood
stream to the vertebrae
• 2nd most common cause of
cancer deaths
• 190000 new cases each year
and 30,000 deaths annually
• Over 80% are diagnosed in
early stages. Allowing an
almost 100% 5 year survival
rate.
• Overall for all stages survival
is 96%
Prostate Cancer
• Predisposing factor
• Age
• Strong family history
• High fat diet may play a role
• Having a vasectomy may
play a role
Prostate Cancer
Assessment Findings
• DRE: hard, pea-sized nodules
on the anterior rectum
• Hematuria
• Urinary obstruction
• Pain on the perineum
radiating to the leg
Prostate Cancer
Diagnostic tests
1. DRE
2. Prostatic specific antigen (PSA)
3. Elevated SERUM ACID
PHOSPHATASE indicates SPREAD or
Metastasis
Surgical Management
Radical prostatectomy – removal of
prostate, capsule, ejaculatory
ducts, seminal vesicles plus
lymphnodes
Watchful waiting without
intervention may be appropriate in
men over 70 years of age with
small, early stage cancers
Prostate Cancer
Medical and surgical management
Prostatectomy
TURP
Chemotherapy: hormonal therapy
to slow the rate of tumor growth
Nursing Interventions
Prepare patient for chemotherapy
Prepare for surgery
Nursing Interventions: Post-
prostatectomy
1. Maintain continuous bladder
irrigation. Note that drainage
is pink tinged w/in 24 hours
2. Monitor urine for the
presence of blood clots and
hemorrhage
3. Ambulate the patient as soon
as urine begins to clear in
color
4. Provide for bladder retraining
after foley catheter removal
a. Perineal exercises
b. restrict caffeine
c. limit fluid intake at nigth
5. Education
a. Avoid lifting, straining, and
prolonged travel
b. possible impotence
Bladder Cancer
Transitional cell carcinoma – most
common (90-95%)
Approximately 54300 new cases
and 12400 deaths
No screening for early detection
Risk factors
• Smoking
• Occupational exposures
• Caucasian males >50 years
old
Asessment
• Gross, painless hematuria
• Dysuria
• Urinary frequency
 • Urgency
• Urinary hesitancy
• Suprapubic, rectum, back
pain
Diagnostic
1. Urinary cytology – late
morning or early afternoon
2. Bladder washing more
reliable
3. Flow cytometry – exdamine
DNA content of urine cells
4. IVP – evaluate upper urinary
tracts
5. Cystoscopy – tumor
visualization and biopsy
6. CT scan, transurethral
ultrasound, MRI
7. Tumor marker – p53 and
epidermal growth factor in
late stage
Surgical management
1. Transurethral resection and
fulguration (Destruction of
surrounding tissue with
electricity) most common for
low grade Ca
2. Radical cystectomy (bladder,
prostate, seminal vesicles,
urethra, overy, FT are
removed) for high grade
tumors
3. Adjuvant therapy
4. Radiation therapy – used in
invasive cancer
5. Chemotherapy – cisplatin,
methotrexate, vincristine
Nursing interventions
• Instruct on preop low residue
and clear liquid diet
• Assess for urinary stoma and
teach maintainance of ileal
conduit and appliance
• Assess urinary output (should
produce urine immediately)
for infection and signs of
peritonitis
• Discuss possible sexual
dysfunction
Skin cancer
Malignant lesion of the skin, which
may or may not metastasized
Types
a. Basal cell – most common type
arising from the basal cells
contained in the epidermis
b. Squamous Cell – 2nd most
common type in whites.tumor of
the keratinocytes Metastasized to
the LN and fatal
c. Malignant melanoma – can
metastasized to the brain, lung,
bone, skin. Fatal
SKIN CANCER
Causes: UV light exposure, chronic
irritation and friction
Dx: skin biopsy
S/sx: change in color, size, shape of
lesion
• Monitor lesions that do not
heal
• Removed moles or lesions
that are subject to chronic
irritations
• Avoid contact with chemical
irritants
• Use sun screen lotions and
clothing
• Avoid sun exposure between
11am-3pm
• Contact Dermatitis
• Inflammatory response after
contact with a specific
antigen
• Assessment:
• Pruritus and burning
• Edema
• Erythema at the point of
contact
Signs of infection
Vesicles with drainage
Gastric Cancer
Approximately 22000 cancers and
13,000 deaths per year
African americans, japanese,
chinese and US have higher
incidence
95% are adenocarcinomas
Prognosis is poor, 5 year survival
rate is 5-15 %
Risk factors
• Male > 40 years of age
• Low socioeconomic status
• Poor nutritional health habits
and vitamin A deficiency
• Family history
• Previous gastric resection
• Pernicious anemia
• H. pylori infection
• Gastric atrophy and chronic
gastritis
 • Rubber workers and coal - small frequent feeding low
miners carbohydrate, high fat, high
protein.
Metastatic sites - restrict fluids 30 minutes
Direct extension to the pancreas, after meals reducing risk of
liver, esophagus. dumping syndrome
Intraperitoneal dissemination to
ovary Postoperative
Nodal spread to the neck - Respiratory status: reflux
Bloodstream metastasis to the aspiration
lung, adrenal, liver, bone and - Infection
peritoneal cavity - Pain – potential anastomotic
leak obstruction
Screening - Bezoar (food clumping)
Among high risk person’s only formation causing gastric
Barrium x-ray or endoscopy outlet obstruction
- Bleeding
Assessment - Dumping syndrome
Early manifestations are non- - anemia
specific
Upper epigastrium, retrosternal Cervical Cancer
pain 13,000 new cancers and 4000
Uneasy sense of fullness after deaths
meals Very treatable and curable
Loss of appetite 80-90% are squamous carcinoma
Nausea and vomiting
Weakness Risk factors
Fatigue Sexual intercourse before age 17,
anemia multiple partners
Sexual partner who has multiple
Diagnostic procedure partners
EGD Cigarette smoking
Biopsy Human papilloma virus
Endoscopic ultrasound Lower socioeconomic status
Double contrast upper GI series
CT scan Metastatic sites
Abdomen and pelvis
Lung
Liver
Surgical management Bone
Only treatment that is potentially
curative
a. Total gastrectomy
Radical subtotal gastrectomy Screening
a. Billroth I Pap’s smear beginning at age 18 or
b. Billroth II sexually active
b. Proximal subtotal gastrectomy
assessment
Paliation of symptoms - Assymptomatic in the early
Adjuvant therapy stage
External beam radiation for control - Watery vaginal discharge
of unresectable tumors, palliation - Late manifestation,
and increased survival. postcoital, heavy or
Chemotherapy has little impact – 5 intermenstrual bleeding.
FU, doxorubicin, mitomycin
diagnostics
Nursing Intervention Colposcopy – application of acetic
• Goal is control of clinical acid followed by magnified
manifestation and supporting examination of the pelvis
optimal functioning Biopsy
• Assess the nutritional status Endocervical curettage
Cone biopsy
Management
Total abdominal hysterectomy and
lymphadenectomy
Depends on the stage and desire
for child bearing
Radiation therapy
Chemotherapy for advanced
disease
Laser therapy
- used when all boundaries of the
lesion are visible during
colposcopic examination.
- minimal bleeding is associated
with the procedure.
- slight vaginal discharge is
expected following the procedure
and healing occurs in 6 to 12
weeks.
Conization
- a cone shaped area of the cervix
is removed
- performed in women who desire
further childbearing.
- long term follow up care is
needed, as new lesions can
develop
- the risk of procedure includes
hemorrhage, uterine perforation,
incompetent cervix and preterm
labor in future pregnancies.
Hysterectomy
For microinvasive cancer if
childbearing is not desired.
A vaginal approach is most
commonly performed.
A radical hysterectomy and
bilateral lymphnode dissection may
be performed for cancer that has
spread beyond the cervix but not
to the pelvic wall.
Nursing intervention
Assess for changes in bowel and
bladder pattern
Bladder training
If laser surgery for early diseases is
used, instruct to avoid douching,
tampoons and sexual activity for 2-
4 weeks
Assess for sexual dysfunction,
surgical shortening of vagina,
vaginal dryness
 Leukemia
 “white blood” neoplastic
proliferation of one particular
cell type.
 Unregulated proliferation of
WBCs in the bone marrow
 Classified into lymphoid or
myeloid, acute and chronic
 Acute Myeloid leukemia
 Defect in hematopoetic stem
cells that differentiate into all
myeloid cells.
 All age group are affected
and incidence increases with
age with peak at age 60
 With treatment patients
survive an average of 1 year
with death usually due to
infection or hemorrhage.
 Clinical manifestation
 Most of signs and symptoms
evolve from insufficient
production of normal blood
cells.
 Fever, infection, weakness,
fatigue, bleeding tendencies.
 Pain from enlarged liver and
spleen
 Hyperplasia of gums
 Diagnostics
 CBC, decrease erythrocytes
and platelets
 Bone marrow aspiration,
excess of immature blast
cells (>30%)
 Medical management
 The objective is to achieve
complete remission by
aggressive chemotherapy
called induction therapy.
 High doses of cytarabine and
daunorubicin
 The aim is eradication of
leukemic cells but it is often
accompanied by eradication
of normal type of myeloid
cells.
 Consolidation therapy
(postremission therapy)
eliminate any residual
leukemia cells that are not
clinically detectable,
diminishing the chance of
remission.
 70% experience relapse
 Consolidation therapy
(postremission therapy)
eliminate any residual
leukemia cells that are not
clinically detectable,
diminishing the chance of
remission.
 70% experience relapse
 Chronic Myeloid Leukemia
 Arises from mutation in the
myeloid stem cell. Normal
myeloid cells continue to
produced, but there is
preference for immature
(blast) forms.
 Uncontrolled proliferation
results in marrow expansion
of long bones, liver and
spleen resulting in pain.
 Chromosome 22
(philadelphia chromosome)
and chromosome 9 (BCR-ABL
gene) producing an abnormal
protein (tyrosine kinase)
causing WBC to divide
rapidly.
 Common in 40 – 50 years old
 Median life expectancy of 3
to 5 years
 Patient is usually
assymptomatic
 WBC exceeds to
100000/mm3.
 Shortness of breath or
confused due to decrease
capillary perfusion of brain
and lungs from leukostasis.
 Treatment
 Imatinib mesylate (Gleevec)
tyrosine kinase inhibitor –
blocking BCR-ABL protein
preventing cells to divide.
 Avoid antacid, grape juice
and acetaminophen
 Treatment
 Imatinib mesylate (Gleevec)
tyrosine kinase inhibitor –
blocking BCR-ABL protein
preventing cells to divide.
 Avoid antacid, grape juice
and acetaminophen
 Correction of chromosome
abnormality
 Interferon alfa and cytosine
administered subcutaneously
daily.
 Many patient cannot tolerate
profound fatigue, depression,
anorexia, mucositis and
inability to concentrate.
 Leukopheresis – blood of
patient is removed and
seperated, leukocytes
removed and remaining
blood returned. Causing
temporary decrease in WBC.
 Acute Lymphocytic Leukemia
 Uncontrolled proliferation of
immature cells (lymphoblast)
 Common in young children,
with boys affected more than
girls
 >80% of children survive at
least 5 years
 Clinical manifestation
 Immature lymphocytes
proliferate in bone marrow
 Decrease WBC, RBC and
platelets
 Leukemic cell infiltration
causing pain from enlarged
liver, spleen, bone pain,
headache and vomiting
 Treatment
 Very sensitive to
corticosteroids and vinca
alkaloids
 Prophylaxis of intrathecal
chemotherapy
(methotrexate)
 Chronic Lymphocytic
Leukemia
 Common malignancy in older
adults >60 years old.
 Average survival time ranges
from 14 years to 2.5 years
 Most of cells are fully mature
 Clinical Manifestation
 Enlargement of lymphnodes,
painful
 Splenomegally
 “B” symptoms – constellation
of symptoms including fever,
drenching sweating, and
unintentional weight loss.
 Absent reaction to skin test
(Anergy)
 Treatment
 Chemotherapy with
corticosteroid and
chlorambucil (leukeran)
 Fludarabine (fludara)
frontline therapy – major side
effect is prolonged bone
marrow supression
 Treatment
 Chemotherapy with
corticosteroid and
chlorambucil (leukeran)
 Fludarabine (fludara)
frontline therapy – major side
effect is prolonged bone
marrow supression
 Lymphomas
 Neoplasms of cells of
lymphoid origin
 Usually starts in lymph
nodes
 Hodgkin’s Lymphoma
 Rare malignancy that has
impressive cure rate.
 Common in men than women
peaks at early 20’s and after
50 years
 Malignant is Reed-Sternberg
cells (hallmark of the
disease)
 Clinical Manifestation
 Painless enlargement of one
or more lymphnodes on one
side of the neck. (cervical,
supraclavicular and
mediatinal)
 Mediatinal mass on chest x-
ray
 Pain after drinking alcohol
 “B” symptoms
 Diagnosis
 Excisional lymphnode biopsy
finding Reed-Sternberg cells
 Elevated ESR and serum
copper level assess disease
activity.
 Treatment
 The intent in treating is cure
regardless of the stage of the
tumor.
 Shortcourse chemotherapy
followed by radiation therapy
 ABVD standard of treatment,
Adriamycin, Bleomycin,
Vinblastine, Decarbazine
 Non Hodgkin’s Lymphoma
 Involved malignant B
lymphocytes
 Incidence increases with age
at diagnosis of 50 to 60 years
old.
 Common in
immunodeficiencies or
autoimmune disorders
 Clinical manifestation
 At early stage symptoms are
virtually absent until late in
the course
 Lymphadenopathy in the
later stage and B symptoms
 management
 Radiation alone in early non
aggressive tumor.
 Oncologic Emergencies
 Superior Vena Cava
Syndrome (SVCS
 Compression or invasion of
the superior vena cava by
tumor, enlarged lymph
nodes, intraluminal thrombus
that obstructs venous
circulation, or drainage of the
head, neck, arms, and
thorax.
 Typically associated with
lung cancer,SVCS can also
occur with lymphoma and
metastases.
 If untreated, SVCS may lead
to cerebral anoxia (because
not enough oxygen reaches
the brain),laryngeal edema,
bronchial obstruction,and
death.
 Gradually or suddenly
impaired venous drainage
giving rise to
• Progressive shortness of breath
(dyspnea),cough, and facial
swelling
• Edema of the neck, arms, hands,
and thorax and reported sensation
of skin tightness and difficulty
swallowing
• Possibly engorged and distended
jugular,temporal, and arm veins
• Dilated thoracic vessels causing
prominent venous patterns on the
chest wall
• Increased intracranial pressure,
associated visual disturbances,
headache, and altered
mental status
Diagnostic
 Diagnosis is confirmed by
• Clinical findings
• Chest x-ray
• Thoracic CT scan
• MRI
.
 Treatment
• Radiation therapy to shrink tumor
size and relieve symptoms
• Chemotherapy for radiation-
resistant tumor (eg, lymphoma or
small cell lung cancer) or when the
mediastinum has been irradiated to
maximum tolerance
• Anticoagulant or thrombolytic
therapy for intraluminal
thrombosis
• Surgery (less common), eg, vena
cava bypass graft (synthetic or
autologous) to redirect blood flow
around the obstruction
• Supportive measures such as
oxygen therapy,corticosteroids,
and diuretics
 Treatment
• Radiation therapy to shrink tumor
size and relieve symptoms
• Chemotherapy for radiation-
resistant tumor (eg, lymphoma or
small cell lung cancer) or when the
mediastinum has been irradiated to
maximum tolerance
• Anticoagulant or thrombolytic
therapy for intraluminal
thrombosis
• Surgery (less common), eg, vena
cava bypass graft (synthetic or
autologous) to redirect blood flow
around the obstruction
• Supportive measures such as
oxygen therapy,corticosteroids,
and diuretics
 Nursing Intervention
• Monitor and report clinical
manifestations of SVCS.
• Monitor cardiopulmonary and
neurologic status.
• Facilitate breathing by
positioning the patient properly.
This helps to promote comfort and
reduce anxiety produced by
difficulty breathing resulting from
progressive edema.
• Promote energy conservation to
minimize shortness of breath.
• Monitor the patient’s fluid volume
status and administer fluids
cautiously to minimize edema
 Spinal Cord Compression
 Potentially leading to
permanent neurologic
impairment and associated
morbidity and mortality,
compression of the cord and
its nerve roots may result
from tumor, lymphomas, or
intervertebral collapse.
 The prognosis depends on
the severity and rapidity of
onset.
 About 70% of compressions
occur at the thoracic level,
20% in the lumbosacral level,
and 10% in the cervical
region.
 Metastatic cancers (breast,
lung, kidney, prostate,
myeloma, lymphoma) and
related bone erosion are
associated with spinal cord
compression.
 Clinical manifestation
 Local inflammation, edema,
venous stasis,and impaired
blood supply to nervous
tissues
 Local or radicular pain along
the dermatomal areas
innervated by the affected
nerve root
 Pain exacerbated by
movement, coughing,
sneezing, or the Valsalva
maneuver
 Neurologic dysfunction, and
related motor and sensory
deficits (numbness, tingling,
feelings of coldness in the
affected area, inability to
detect vibration,loss of
positional sense)
 Motor loss ranging from
subtle weakness to flaccid
paralysis
 Treatment
 Radiation therapy to reduce
tumor size to halt
progression and
corticosteroid therapy to
decrease
inflammation and swelling at the
compression site
 Surgery only if symptoms
progress despite radiation
therapy or if vertebral fracture
leads to additional nerve damage
 Chemotherapy as adjuvant
to radiation therapy
for patients with lymphoma or
small cell lung cancer
 Nursing Intervention
 Perform ongoing assessment
of neurologic function to
identify existing and
progressing dysfunction.
 Control pain with
pharmacologic and
nonpharmacologic
measures.
 Prevent complications of
immobility resulting from
pain and decreased function
 Maintain muscle tone by
assisting with range-ofmotion
exercises in collaboration with
physical and occupational
therapists.
 Institute intermittent urinary
catheterization and bowel
training programs for
patients with bladder or
bowel dysfunction.
 Nursing Intervention
 Perform ongoing assessment
of neurologic function to
 identify existing and
progressing dysfunction.
 Control pain with
pharmacologic and
nonpharmacologic
measures.
 Prevent complications of
immobility resulting from
pain and decreased function
 Maintain muscle tone by
assisting with range-ofmotion
exercises in collaboration with
physical and occupational
therapists.
 Institute intermittent urinary
catheterization and bowel
training programs for
patients with bladder or
bowel dysfunction.
 Hypercalcemia
 In patients with cancer,
hypercalcemia is
a potentially life-threatening
metabolic abnormality resulting
when the calcium released from
the bones is more than the kidneys
can excrete or the bones can
reabsorb.
 Clinical manifestation
 Fatigue, weakness,
confusion,
 Decreased level of
responsiveness, hyporeflexia,
 nausea, vomiting,
constipation, polyuria
 (excessive urination),
polydipsia (excessiv
 Nursing Intervention
 Identify patients at risk for
hypercalcemia and assess for
signs and symptoms of
hypercalcemia.
 Teach at-risk patients to
recognize and report signs
and symptoms of
hypercalcemia.
 Encourage patients to
consume 2 to 3 L of fluid
daily unless contraindicated
by existing renal or cardiac
disease.
 Explain the use of dietary
and pharmacologic
interventions such as stool
softeners and laxatives for
constipation.
 Nursing Intervention
 Identify patients at risk for
hypercalcemia and assess for
signs and symptoms of
hypercalcemia.
 Teach at-risk patients to
recognize and report signs
and symptoms of
hypercalcemia.
 Encourage patients to
consume 2 to 3 L of fluid
daily unless contraindicated
by existing renal or cardiac
disease.
 Explain the use of dietary
and pharmacologic
interventions such as stool
softeners and laxatives for
constipation.
 Cardiac Tamponade
 Cardiac tamponade is an
accumulation
of fluid in the pericardial space.
 The accumulation
compresses the heart and
thereby impedes expansion
of the ventricles and cardiac
filling during diastole.
 As ventricular volume and
cardiac output fall, the heart
pump fails, and circulatory
collapse develops.
 CARDIAC TAMPONADE
ASSESSMENT FINDINGS
 1. BECK’s Triad- Jugular
vein distention,
hypotension and
distant/muffled heart
sound
 2. Pulsus paradoxus
 3. Increased CVP
 4. decreased cardiac
output
 Treatment
 Pericardiocentesis (the
aspiration or withdrawal
 of the pericardial fluid by a
large-bore needle inserted
 into the pericardial space).
 CARDIAC TAMPONADE
NURSING INTERVENTIONS
 1. Assist in
PERICARDIOCENTESIS
 2. Administer IVF
 3. Monitor ECG, urine
output and BP
 4. Monitor for recurrence
of tamponade
 Pericardiocentesis
 Patient is monitored by
ECG
 Maintain emergency
equipments
 Elevate head of bed 45-60
degrees
 Monitor for complications-
coronary artery rupture,
dysrhythmias, pleural
laceration and myocardial
trauma