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Resources Nursing Care of the Patient with Cancer

Ju-An Broyles, RN, MSN, FNP N200 CancerSourceRN.com http://www.cancer.org (American Cancer Society) http://www.nci.nih.gov/

Cancer Pathophysiology
Abnormal cells DNA Oncogenes Abnormal growth Cells become invasive Metastasis

Breast Cancer Cell

Cancer is classified by tissues or blood cells in which it originates: Glandular tissues (adenocarcinoma) Connective, muscle, bone tissue (sarcoma) Tissue of the brain and spinal cord (gliomas) Pigment cell (Melanoma) Plasma cell (myeloma) Lymphatic tissue (lymphomas) Leukocytes (leukemia)

Cancer Risk Factors

Environmental Genetic susceptibility Host susceptibility Lifestyle

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Environmental
Viruses Chemicals Sunlight Radiation Tobacco use

Environmental
Lung cancer Aspirin and other NSAIDs Tamoxifen SERMs Finasteride

Genetic Susceptibility
About 5-10% of cancers have familial tendency Examples of cancers that show familial inheritance are: retinoblastomas, breast, ovarian, endometrial, colorectal, stomach, prostate, and lung cancer BRCA-1 (and 2) gene

Dietary Factors (Lifestyle)

Dietary factors related to 35% of all environmental cancers Diet-

Host Susceptibility
Immune system Carcinogens

Host Susceptibility
New, additional cause of cancer is prior treatment with chemo or radiation therapy for a prior malignancy Can cause leukemias (latency period 2-5 yrs) or solid tumors (10-20 years) Prognosis for these are usually poor

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Seven Warning Signs and Health Seeking Behaviors

Nurses Role Primary prevention Secondary prevention (early detection)

Seven Signs of Cancer

Change in bowel or bladder habits could be a sign of colorectal cancer. A sore that does not heal on the skin or in the mouth could be a malignancy and should be checked by a doctor. Unusual bleeding or discharge from the rectum, bladder or vagina could mean colorectal, prostate, bladder or cervical cancer. Thickening of breast tissue or a new lump in the breast is a warning sign of breast cancer. A lump in the testes could mean testicular cancer. Indigestion or trouble swallowing could be cancer of the mouth, throat, esophagus or stomach. Obvious changes to moles or warts could mean skin cancer. Nagging cough or hoarseness that persists for four to six weeks could be a sign of lung or throat cancer.

Benign vs Malignant Tumors

Benign Tumors

Staging Cancer
TNM
T: extent primary tumor N: Lymph node involvement M: Metastasis

Malignant Tumors

Breast Cancer
70% occur in women over age of 70 BRCA1 & 2 gene Other risks

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Breast assessment

Breast Cancer Locations

Symptoms that may indicate breast cancer Breast lump * Breast pain * Change in the size or shape of the breast * Swelling of the arm (lymphoedema) * Dimpling of the breast skin * Involution or inversion of the nipple * Axillary lymphadenopathy * Nipple discharge or bleeding * Ulceration of the breast skin * Bone or abdominal pain / jaundice Symptoms requiring specialist referral Lumps * All new discrete breast lumps * A new lump in pre-existing nodularity Asymmetrical nodularity persisting after menstruation * Breast abscess * Persistently refilling or recurrent cysts * Axillary lymphadenopathy * Breast pain * Pain associated with a lump * Persistent unilateral pain in a postmenopausal woman Nipple discharge * All women aged over 50 years * Women aged below 50 years with: * Bilateral discharge sufficient to stain clothes * Blood-stained nipple discharge * Persistent discharge from a single duct Family history

1:7 women will develop in lifetime in OC If already had breast cancer, 3-4x more likely to develop it again Detection
Mammogram (5-17% missed cancers) Digital mammogram MRI (finds 2x cancers vs mammo+ US) Positron Emission Tomography scanradioactive sugar injected. Self Breast Exam (SBE)

Breast Cancer

Breast Cancer-New treatments

Monoclonal Antibody therapy- Herceptin Antiangiogenesis - Avastin

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Breast Cancer-New treatments

Chemotherapy-new version of Taxol, Abraxane, better tolerated tumors shrunk better. Aromatase Inhibitors-drugs prevent estrogen from forming, used after 2 years of tamoxifen in clinical trials

Breast Cancer
Breast cancer in men-approximately 1690 new cases will be diagnosed in men this year. 100x more common in women than men

Malignant Melanoma
Melanoma is a malignancy of pigment-producing cells (melanocytes) Melanoma accounts for only 4% of all skin cancers
*

70% arise from pre-existing mole Risks: excessive sunlight exposure, increased nevi (moles), tendency to freckle from the sun, family history, red hair, fair skin, blue eyes, susceptibility to sunburn, celtic or scandinavian ancestry (Melanoma rare in african-americans)

Malignant Melanoma

Malignant Melanoma

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Colon Cancer
Colonoscopy versus Virtual Colonoscopy 1:20 will have colon cancer in lifetime Approximately 150,000 new cases each yr in USA Early detection critical; 5 yr survival rate is 92%.

Colon Cancer
Higher risk in smokers Diets high in vegetables & fruits lower risk Right-sided (ascending colon) tumors present with anemia, fatigue. Lesions can grow large without obstructive symptoms as stool liquid in ascending colon Left sided (descending colon) tumors present with obstructive symptoms Aspirin and Calcium (1500 mg) may lower risk

Growth of polyp: takes approximately 5 yrs to grow 1/2 inch, takes approximately 5-10 years for these to become malignant

Tests to Diagnose Colorectal Cancer

Digital rectal exam (detects 15%) Fecal occult bloood Sigmoidoscopy (2/3 of cancers detected) Colonoscopy-visualize, photograph, & biopsy up to the ileocecal valve Barium enema (detects lesions not visible or palpable) CT scan-detects cancer spread

Lab Tests Used in Cancer Detection

Tumor Markers-

Lab Tests Used in Cancer Detection

Ultrasound: Mammogram:

MRI PET scans, CT scans

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Diagnosis
Self exam Stool guaiac Rectal exam & sigmoidoscopy Blood studies Tissue Biopsy Pap smear Digital exam PSA

Nursing Diagnosis
Anxiety r/t lack of knowledge Dx & Tx Disturbed self concept r/t Ineffective individual coping Sexual dysfunction r/t Knowledge deficit Altered Nutrition r/t intake, N & V, anorexia Potential for injury r/t susceptibility At risk for infection

Nursing Diagnosis
Pain r/t dx and tx
Impaired physical mobility r/t Activity intolerance r/t malnutrition & tx

Nursing Care of Patient with Cancer

Assessment for infection Bleeding Skin Problems Hair loss, body image Nutrition Pain Fatigue

Noncompliance Collaborative: hemorrhage, infection, bladder neck obstruction, many of the above Etc.. Etc. Etc.

Therapies
Surgery & lymph node staging chemotherapy radiation hormonal palliative treatment

Nurses role with Surgery patient

monitor VS good assessment
I & O wound complications

teaching
pre-op post-op

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Management of Cancer-Surgery
Diagnostic-Biopsy Primary Treatment Prophylactic surgery Pallative-

Nurses role with Radiation

Safety
distance length of time shielding

Teaching Prevent complications Expected side effects

Radiation Therapy
Goal: palliative, cure, or control of cancer. Types: electromagnetic, particulate (alpha, beta, electron neutrons) External (beam) or internal delivery (implant) Safety interventions: Time, Distance, Shielding

Radiation Therapy
Cells that undergo frequent cell division are most effected by radiation Slower growing tissues are nearly resistant

Types of Radiation
External-amount of energy determine how deep radiation can treat externally Internal-high dose to a localized area; Implant (needles, seeds, beads into vagina, abdomen, pleura, breast)

Radiation Therapy
Ionizing radiation used to interrupt cell growth. High-energy particles Normal cells can tolerate a specified dose of radiation before complications occur. Cancers are most radiosensitive because they divide rapidly, are well-oxygenated, and poorly differentiated.

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Radiation Therapy
Ionizing radiation Pallative radiation can relieve symptoms

Radiation Safety-Implant
Teach patient:
Stay 3 feet minimum away from others for 1-3 days after discharge Minimize time with other individuals Wash hands with plenty of soap and water after void. Rinse bathroom sink and tub thoroughly after each use

Radiation Safety-Implant
Absorbent pads cover floor around toilet. Cover telephone, overbed table with plastic, hampers marked radioactive No pregnant staff member may care for patient Film badges worn by all staff entering room (at chest level) Verbal contact every 2 hours via telephone or call system (or per hospital policy) Double glove for handling urinals, bedpans, emesis basins or any contact body fluids. Instruct flush toilet 3 times with each use. Disposable food trays. Lead shield to be used if implants

Nursing Care of Patient with Radiation Therapy

Protect skin and oral mucosa- assessment frequently, avoid ointments, lotions, or powders to treated area. Teach weakness, fatigue, etc is from therapy, not worsening of cancer. Use lukewarm water, avoid rubbing/scratching area, avoid sun, report blistering. Apply vitamin A&D ointment to irritated areas, avoid tight clothes

Radiation Therapy
If implant, protect caregivers Encourage rest periods throughout day Encourage adequate protein and calorie intake

Chemotherapy
Destroys tumor cells by interrupting cellular functions and reproduction. Each time tumor exposed to chemo, percentage of tumor cells (20-90%) are destroyed.

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Chemotherapy
Chemo attacks rapidly dividing cells, cancer cells are rapidly dividing cells Other cells that divide rapidly Chemotherapy drugs remain in urine, stool, saliva, blood, emesis up to 48 hours after administration completed

Nursing Care for Patient Receiving Chemo

Monitor for extravasation Nausea and vomiting Oral care Teach to flush toilet 2 x after each use Double latex gloves for 2 days after chemo for any body secretions

Nursing Care for Patients Receiving Chemo

Patients on bleeding precautions Incontinent patients Chemo spill kit Pathogen-free diet: no raw fruits, vegetables, tea, pepper, avoid most spices except salt and sugar

Nurses role with Hormonal therapy

Teaching
side effects Tamoxifen, Lupron, Zoladex, etc

Therapeutic communication
sexuality impotence

Nursing Care of Cancer Patient

Problem: Fatigue
Most common and most distressing symptom, No single cause

Ways to Manage Fatigue

Encourage exercise. Encourage rest periods throughout day, space activities Identify anxiety/depression, refer or treat Avoid patient chilling

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Mucositis/Stomatitis
cancersourceRN.com the chemotherapy made my mouth and throat so raw I could not talk or swallow my own saliva. The constant pain in my throat was like being stuck with a fiery hot poker. Thank goodness for Morphine-a cancer patient suffering from stomatitis

Mucositis/Stomatitis
Signs & symptoms include taste changes, oral pain, ulceration, edema, bleeding, dry mouth, infection,altered nutritional status 40% of people with cancer will develop oral complications Can occur 2-14 days from the time of chemo administration, varies with type of chemo

Nursing Care-Mucositis
Nursing care includes: assessment-normal mucosa is pink, moist, clean, intact (Use flashlight if needed), assess for erythema, edema, signs of candidiasis (white patches), ulcers, exudate, discolored lesions, pallor. Check for altered texture and shininess, amount of saliva, coating, bad odors, cracks, fissures, blisters

Nursing Care-Mucositis
Teach to avoid spicy food, alcohol based OTC mouthwashes, good oral hygiene including flossing, brushing, rinsing, moisturizing.Toothpastes with sodium bicarb aid in dissolving mucus, reduce acidity of inflammation. Rinse agents: water, saline, salt&soda, 1/2 strength H2O2 or Peridex mouthwash. At risk for dental caries as can have 95% decline in salivation

Nursing Care of Mucositis

Topical anesthetics (20% Benzocaine, viscous lidocaine, Orabase) oral capsaicin in form of candy is being studied Gels that congeal to form an occlusive covering: Zilactin, Oratect, Gelclair Mycelex troches, Mycostatin, Bacitracin

Nurses role with Palliative Care

We cant save everyone We can care for all. DNR does not = no care Although you cant save their life, be their lifesaver.
Improve pain control & quality of life Reduce side effects

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