Oncology Nursing Management PDF

ONCOLOGY NURSING M A N A G E M E N T O F PAT I E N T S W I T H O N C O L O G I C D I S O R D E R S DORA ISABEL SALORIA MIRASOL EPIDEMIOLO GY  ONCOLOGY NURSING ONCOLOGY NURSING - provision of specialized treatment and care to people with cancer ONCOLO...

ONCOLOGY NURSING M A N A G E M E N T O F PAT I E N T S W I T H O N C O L O G I C D I S O R D E R S DORA ISABEL SALORIA MIRASOL EPIDEMIOLO GY  ONCOLOGY NURSING ONCOLOGY NURSING - provision of specialized treatment and care to people with cancer ONCOLOGY - a branch of medicine that specializes in the diagnosis and treatment of cancer  ONCOLOGY CANCER - a disease process that begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA BENIGN - a growth that is encapsulated, slow growing, does not metastasize MALIGNANT - a growth that is not self limiting, can invade adjacent tissues, able to metastasize METASTASIS - spreading of disease from primary tumor to an anatomically distant DIAGNOSIS OF CANCER PURPOSE:  Determine the presence of tumour and its extent  Identify possible spread (metastasis) of disease or invasion of other body tissues  Evaluate the function of involved and uninvolved body systems and organs  Obtain tissue and cells for analysis, including evaluation of tumour stage and grade  DIAGNOSIS OF CANCER NURSING RESPONSIBILITIES: Explain the procedure or tests to be done Communicate and encourage the patient and family to voice or communicate their fears and concerns Supports the patient and family throughout the test or procedure  DIAGNOSIS OF CANCER HEALTH DIAGNOSTIC HISTORY STUDIES - Biopsy - Endoscopic Examination - MRI, CT scan, PET scan - Blood Tests (CBC, Liver Function Studies, Tumor ASSESSMENT Markers) OF HEALTH PHYSICAL FACTORS ASSESSMENT - Family History - Lifestyle - Exposure to  DIAGNOSIS OF CANCER DIAGNOSTIC TEST DESCRIPTION Biopsy Definitive method for diagnosing cancer MRI (Magnetic Resonance The contrast used can make Imaging), tumors show up brighter in CT (Computed Tomography) pictures PET scan Radioactive glucose tracer is used (Positron Emission to locate cancer in the body Tomography) Endoscopy Thin, lighted tube used to examine (colonoscopy, bronchoscopy) or remove some or all abnormal tissue  DIAGNOSIS OF CANCER COMMON TUMOR MARKERS Cancer Types AFP (Alpha-fetoprotein) Liver, Testicular BRCA1, BRCA2 Breast, Ovarian CA 19-9 Pancreas, Gall bladder, Bile duct, stomach CEA (Carcinoembryonic Colon Antigen) PSA (Prostate-specific Prostate Antigen) CA-125 Ovarian  DIAGNOSIS OF CANCER BIOPSY - obtain a tissue sample for analysis of cells suspected to be malignant Excisional biopsy - used for easily accessible tumors of the skin, breast, upper and lower gastrointestinal tract, and upper respiratory tract Incisional biopsy - performed if the tumor mass is too large to be removed Needle biopsies are performed to sample suspicious masses that are easily  DIAGNOSIS OF CANCER TUMOR STAGING AND GRADING Grading - refers to the classification of the tumor cells Staging Grade I - well-differentiated tumors, closely - determines the size of the tumor and the resemble the tissue of origin in structure and existence of metastasis function TNM system Grade II – moderately differentiated, cell have - T refers to the extent of the primary tumor some immaturity - N refers to lymph node involvement, Grade III – poorly differentiated, immature - M refers to the extent of metastasis cell Grade IV - do not clearly resemble the tissue of origin in structure or function,  DIAGNOSIS OF CANCER TNM TX: Main tumor cannot be measured. NX: Cancer in nearby lymph nodes cannot be T0: Main tumor cannot be found. measured. T1, T2, T3, T4: The higher the number after N0: There is no cancer in nearby lymph the T, the larger the tumor or the more it has nodes. grown into nearby tissues. T's may be further N1, N2, N3: The higher the number after the divided to provide more detail, such as T3a N, the more lymph nodes that contain cancer. and T3b. MX: Metastasis cannot be measured. M0: Cancer has not spread to other parts of the body. M1: Cancer has spread to other parts of the INTERVENTIONS/TREATMENT CUR CONTRO PALLIATIO E complete L prolonged N relief of eradication of survival and symptoms malignant containment of associated with disease cancer cell the disease growth INTERVENTIONS/TREATMENT SURGERY CHEMOTHERAPY removal of the entire antineoplastic cancer remains the ideal agents are used in and most an attempt to frequently used treatment destroy tumor cells method RADIATION BONE MARROW THERAPY TRANSPLANTATIO use of ionizing radiation N to interrupt cellular use of ionizing growth radiation to interrupt INTERVENTIONS/TREATMENT SURGERY AS A PRIMARY TREATMENT  Local excision - warranted when the mass is small - it includes removal of the mass and a small margin of normal tissue that is easily accessible  Wide or radical excision - includes removal of the primary tumor, lymph nodes, adjacent involved structures, and surrounding tissues that may be at high risk for tumor spread - this surgical method can result in disfigurement and altered functioning  Video-assisted endoscopic surgery - replacing surgeries associated with long incisions and extended recovery periods - an endoscope with intense lighting and an attached multichip minicamera is INTERVENTIONS/TREATMENT SURGERY  Salvage surgery - an additional treatment option that uses an extensive surgical approach to treat the local recurrence of the cancer after a less extensive primary approach is used - a mastectomy to treat recurrent breast cancer after primary lumpectomy and radiation is an example of salvage  Electrosurgery - makes use of electrical current to destroy the tumor cells  Cryosurgery - uses liquid nitrogen to freeze tissue to cause cell destruction  Chemosurgery - uses combined topical chemotherapy and layer-by-layer surgical removal of abnormal tissue INTERVENTIONS/TREATMENT SURGERY  Laser surgery - (light amplification by stimulated emission of radiation) makes use of light and energy aimed at an exact tissue location and depth to vaporize cancer cells  Stereotactic radiosurgery (SRS) - a single and highly precise administration of high-dose radiation therapy used in some types of brain and head and neck cancers - this type of radiation has such a dramatic effect on the target area that the changes are considered to be comparable to more traditional surgical approaches  INTERVENTIONS/TREATMENT PROPHYLACTIC SURGERY - involves removing nonvital tissues or organs that are likely to develop cancer - The following factors are considered when electing prophylactic surgery: Family history and genetic predisposition Presence or absence of symptoms Potential risks and benefits Ability to detect cancer at an early stage Patient’s acceptance of the postoperative outcome - examples are colectomy, mastectomy, oophorectomy  INTERVENTIONS/TREATMENT PALLIATIVE SURGERY - performed in an attempt to relieve complications of cancer, such as ulcerations, obstructions, hemorrhage, pain, and malignant effusion RECONSTRUCTIVE SURGERY - may follow curative or radical surgery and is carried out in an attempt to improve function or obtain a more desirable cosmetic effect - it may be performed in one operation or in stages  INTERVENTIONS/TREATMENT NURSING MANAGEMENT IN CANCER SURGERY - completes a thorough preoperative assessment for all factors that may affect patients undergoing surgical procedures - provides education and emotional support by assessing patient and family needs and exploring with the patient and family their fears and coping mechanisms, encouraging them to take an active role in decision making when possible - recognize the patient’s needs and the impact that altered functioning and altered body image may have on quality of life - provide the patient and family with opportunities to discuss concerns  INTERVENTIONS/TREATMENT NURSING MANAGEMENT IN CANCER SURGERY - communicate frequently with the physician and other health care team members to be certain that the information provided is consistent - assesses the patient’s responses to the surgery and monitors for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction - provides for patient comfort, postoperative teaching, wound care, activity, nutrition, and medication - plans for discharge, follow-up and home care, and treatment are initiated as early as possible to ensure continuity of care from hospital to home INTERVENTIONS/TREATMENT RADIATION THERAPY - may be used to cure the cancer, as in Hodgkin’s disease, testicular seminomas, thyroid carcinomas, localized cancers of the head and neck, and cancers of the uterine cervix - may also be used to control malignant disease - can be used prophylactically  EXTERNAL RADIATION - depending on the amount of energy they contain, x-rays can be used to destroy cancerous cells at the skin surface or deeper in the body - the higher the energy, the deeper the penetration into the body  INTERVENTIONS/TREATMENT RADIATION THERAPY  INTERNAL RADIATION - also known as brachytherapy - delivers a high dose of radiation to a localized area - this internal radiation can be implanted by means of needles, seeds, beads, or catheters into body cavities (vagina, abdomen, pleura) or interstitial compartments (breast) - Brachytherapy may also be administered orally Palliative radiation therapy - used to relieve the symptoms of metastatic disease INTERVENTIONS/TREATMENT NURSING MANAGEMENT IN RADIATION THERAPY - answer questions and allay fears - If a radioactive implant is used, the nurse informs the patient and family about the restrictions placed on visitors and health care personnel and other radiation precautions. - ensure that patients understand their own role before, during, and after the procedure - Protecting the skin and oral mucosa assess the skin and oral mucosa frequently for changes (particularly if radiation therapy is directed to these areas) ensure skin is protected from irritation, and the patient is instructed to avoid using ointments, lotions, or powders on the area Instruct patient that gentle oral hygiene is essential to remove debris, prevent  INTERVENTIONS/TREATMENT NURSING MANAGEMENT IN RADIATION THERAPY assist patient with activities of daily living and personal hygiene offers reassurance by explaining that these symptoms are a result of the treatment and do not represent deterioration or progression of the disease - Protecting the caregivers the nursing staff must minimize radiation exposure to themselves as much as possible by applying the principles of time, distance, and shielding, as follows: - Minimize amount of time near a radioactive source. - Maximize distance from radioactive source. - Use required shielding to minimize exposure. Nurses who are or may be pregnant should not be involved in the immediate care of such patients  INTERVENTIONS/TREATMENT NURSING MANAGEMENT IN RADIATION THERAPY Nursing visits to the patient should be planned in advance to minimize the amount of time the nurse is in contact with the patient to minimize radiation exposure, the nurse remains as far away (ie, at the entrance to the room) from the radiation source as possible but makes special efforts to provide some time to discuss the patient’s anxieties and fears Wear film badges or pocket ion chambers to monitor exposure. Wear rubber gloves to dispose of any soiled matter that may be contaminated. (These gloves, however, do not provide protection from sealed radiation sources.) Provide specific laundry and housekeeping directions Keep the patient restricted to her room and allow no visitors who are or may be pregnant or who are younger than 18 years of age  INTERVENTIONS/TREATMENT CHEMOTHERAPY - antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions and reproduction - is used primarily to treat systemic disease rather than lesions that are localized and amenable to surgery or radiation - may be combined with surgery or radiation therapy, or both, to reduce tumor size preoperatively, to destroy any remaining tumor cells postoperatively - the goals of chemotherapy (cure, control, palliation) must be realistic because they will define the medications to be used and the aggressiveness of the treatment plan.  INTERVENTIONS/TREATMENT CHEMOTHERAPY - Repeated cycles of chemotherapy are used to kill more tumor cells by destroying these nondividing cells as they begin active cell division. - Reproduction of both healthy and malignant cells follows the cell cycle pattern - The cell cycle time is the time required for one tissue cell to divide and reproduce two identical daughter cells - The cell cycle of any cell has four distinct phases, each with a vital underlying function: 1. G1 phase—RNA and protein synthesis occur 2. S phase—DNA synthesis occurs 3. G2 phase—premitotic phase; DNA synthesis is complete, mitotic spindle forms  INTERVENTIONS/TREATMENT CHEMOTHERAPY: SPECIAL PROBLEMS - EXTRAVASATION - leakage of medication from the veins into the subcutaneous tissues - vesicants cause tissue necrosis and damage to underlying tendons, nerves, and blood vessels - sloughing and ulceration of the tissue may be so severe that skin grafting may be necessary - Medications classified as vesicants include dactinomycin, daunorubicin, doxorubicin (Adriamycin), nitrogen mustard, mitomycin, vinblastine, vincristine, and vindesine - Only specially trained physicians and nurses should administer vesicants - Careful selection of peripheral veins, skilled venipuncture, and careful  INTERVENTIONS/TREATMENT CHEMOTHERAPY: SPECIAL PROBLEMS - EXTRAVASATION - Indications of extravasation during administration of vesicant agents include the following: Absence of blood return from the intravenous catheter Resistance to flow of intravenous fluid Swelling, pain, or redness at the site - What will you do as a nurse?  INTERVENTIONS/TREATMENT - EXTRAVASATION order from the doctor: name of antidote or - Stop the chemotherapy immediately treatment plan. - Obtain Drug Extravasation Kit - Perform hand hygiene. Don double gloves (under- - perform hand hygiene and don double gloves guard nitrile gloves and followed by nitrile gloves) (underguard nitrile gloves and followed by nitrile - Aspirate the extravasated (residual) drug from the gloves), cannula, as much as possible using a 10ml syringe - assess the intravenous site and observe for signs as per instruction from the doctor. and symptoms of extravasation - Obtain the antidote and refer to the Recommended - Do not remove cannula. Estimate the - Treatment Regimens for Cytotoxic Drug extravasated drug’s volume and assess the Extravasations as ordered by the doctor severity of tissue damage a) Assist doctor in administering the antidote - Discard the nitrile gloves and followed by the b) Remove cannula and apply gauze over the underguard nitrile gloves into the zip lock bag. site when ordered by the physician Perform hand hygiene c) Avoid applying pressure to the site  INTERVENTIONS/TREATMENT d) Discard all used requisites into the zip lock bag and follow by disposing the zip lock bag into a cytotoxic waste bin e) Perform hand hygiene. - Apply cool/warm compress according to the extravasated cytotoxic drug as per Doctor’s order - Documentation and Follow up - Document the appearance of extravasated site - Raise an Electronic Hospital Occurrence Report (eHOR)  INTERVENTIONS/TREATMENT - Renal System: damage the kidneys because of CHEMOTHERAPY: SPECIAL PROBLEM their direct effects during excretion and the TOXICITY accumulation of end products after cell lysis - toxicity associated with chemotherapy can be - Cardiopulmonary System: cause irreversible acute or chronic cumulative cardiac toxicities - cells with rapid growth rates (eg, epithelium, bone - Reproductive System: Testicular and ovarian marrow, hair follicles, sperm) are very susceptible function can be affected by chemotherapeutic to damage, and various body systems may be agents, resulting in possible sterility affected as well - Peripheral neuropathies, loss of deep tendon - Gastrointestinal System: nausea and vomiting reflexes, and paralytic ileus may occur - Hematopoietic System: myelosuppression - Miscellaneous: Fatigue is a distressing side effect (depression of bone marrow function), resulting in for most patients that greatly affects quality of life. decreased production of blood cells Fatigue can be debilitating and last for months after treatment.  INTERVENTIONS/TREATMENT NURSING MANAGEMENT  PREVENTION OF INFECTION  MAINTENANCE OF SKIN INTEGRITY  Assess patient for evidence of infection  In erythematous areas:  Report fever a. Avoid the use of soaps, cosmetics,  Obtain cultures and sensitivities perfumes, powders, lotions and  Initiate measures to minimize infection ointments, deodorants - Place patient in private room b. Use only lukewarm water to bathe the - Avoid contact with people who have area recent infections c. Avoid rubbing or scratching the area - Personal and hand hygiene d. Avoid shaving the area with a - Encourage ambulation straightedged razor - Avoid raw foods, fresh fruits, flowers e. Avoid applying hot-water bottles, heating  Assess and change intravenous sites and pads, ice, dressing as per protocol and adhesive tape to the area  INTERVENTIONS/TREATMENT NURSING MANAGEMENT MAINTENANCE OF SKIN INTEGRITY  Encourage and assist in oral hygiene  If wet desquamation occurs:  Preventive a. Do not disrupt any blisters that have a. Avoid commercial mouthwashes formed b. Brush with soft toothbrush; use b. Avoid frequent washing of the area nonabrasive c. Report any blistering toothpaste d. Use prescribed creams or ointments MAINTENANCE OF TISSUE INTEGRITY; e. If area weeps, apply a thin layer of gauze COPING WITH HAIR LOSS dressing  Discuss potential hair loss and regrowth  MAINTENANCE OF INTACT ORAL MUCOUS with patient and family. MEMBRANES  Explore potential impact of hair loss on self-  Assess oral cavity daily image, interpersonal relationships, and  Instruct patient to report oral burning, pain, areas sexuality.  INTERVENTIONS/TREATMENT NURSING MANAGEMENT  Prevent or minimize hair loss through the following: a. Use scalp hypothermia and scalp tourniquets b. Cut long hair before treatment. c. Use mild shampoo and conditioner, gently pat dry, and avoid excessive shampooing d. Avoid electric curlers, curling irons, dryers, clips, barrettes, hair sprays, hair dyes, and permanent waves. e. Avoid excessive combing or brushing; use wide- b. If hair loss has occurred, take photograph to toothed comb wig shop to assist in selection.  Prevent trauma to scalp c. Begin to wear wig before hair loss. a. Lubricate scalp with vitamin A&D ointment to  INTERVENTIONS/TREATMENT NURSING MANAGEMENT FEWER EPISODES OF NAUSEA AND VOMITING MAINTENANCE OF NUTRITIONAL STATUS BEFORE, DURING, AND AFTER CHEMOTHERAPY AND OF WEIGHT WITHIN 10% OF  Adjust diet before and after drug administration PRETREATMENT WEIGHT according to patient preference and tolerance  Teach patient to avoid unpleasant sights,  Prevent unpleasant sights, odors, and sounds in the odors, sounds in the environment during environment mealtime.  Use distraction, music therapy, biofeedback, self-  Suggest foods that are preferred and well hypnosis, relaxation techniques, and guided imagery tolerated by the patient, preferably high-calorie before, during, and after chemotherapy and high-protein foods  Administer prescribed antiemetics, sedatives, and  Respect ethnic and cultural food preferences corticosteroids before chemotherapy and afterward as  Encourage adequate fluid intake, but limit needed fluids at mealtime  Ensure adequate fluid hydration before, during, and  Suggest smaller, more frequent meals  INTERVENTIONS/TREATMENT NURSING MANAGEMENT  Collaborate with patient, physician, and other RELIEF OF PAIN AND DISCOMFORT health care team members when changes in  Use pain scale to assess pain and discomfort pain management are necessary. characteristics: location, quality, frequency, INCREASED ACTIVITY TOLERANCE AND duration DECREASED FATIGUE LEVEL  Assure patient that you know that pain Is real and  Encourage several rest periods during the day, will assist him or her in reducing it especially before and after physical exertion  Assess other factors contributing to patient’s pain:  Increase total hours of nighttime sleep fear, fatigue, anger  Rearrange daily schedule and organize activities to  Administer analgesics to promote optimum pain conserve energy expenditure relief within limits of physician’s prescription  Encourage patient to ask for others’ assistance  Assess patient’s behavioral responses to pain and pain experience  INTERVENTIONS/TREATMENT BONE MARROW TRANSPLANTATION Types of BMT based on the source of donor cells NURSING MANAGEMENT  Implementing pretransplantation care: Nutritional include: assessments, extensive physical examinations and 1. Allogeneic (from a donor other than the patient): organ function tests, and psychological evaluations either are conducted. Blood work includes assessing past a related donor (ie, family member) or a matched antigen exposure unrelated donor (national bone marrow registry, cord  Providing care during the treatment: monitoring the blood registry) patient’s vital signs and blood oxygen saturation; 2. Autologous (from patient) assessing for adverse effects, such as fever, chills, 3. Syngeneic (from an identical twin) shortness of breath, chest pain  Providing Posttransplantation Care: Ongoing nursing assessment in follow-up visits is essential to detect late effects of therapy in BMT patients. Late  ONCOLOGY EMERGENCIES SUPERIOR VENA CAVA SYNDROME SPINAL CORD COMPRESSION (SVCS) - Potentially leading to permanent neurologic - Compression or invasion of the superior impairment and associated morbidity and mortality, vena cava by tumor, enlarged lymph compression of the cord and its nerve roots may nodes, intraluminal thrombus that result from tumor, lymphomas obstructs venous circulation, or drainage - Pain exacerbated by movement, coughing, - Progressive shortness of breath (dyspnea), sneezing, or the Valsalva maneuver cough, and facial swelling, edema of the - Neurologic dysfunction, and related motor and neck, arms, hands, and thorax sensory deficits, motor loss ranging from subtle - Treatment: Radiation therapy to shrink weakness to flaccid paralysis, bladder and/or bowel tumor size and relieve symptoms dysfunction - Treatment: Radiation or decompressive laminectomy  ONCOLOGY EMERGENCIES SYNDROME OF INAPPROPRIATE SECRETION HYPERCALCEMIA OF ANTIDIURETIC HORMONE (SIADH) - a potentially life-threatening metabolic - The continuous, uncontrolled release of antidiuretic abnormality resulting when the calcium hormone (ADH), produced by tumor cells or by the released from the bones is more Than the abnormal stimulation of the hypothalmic–pituitary kidneys can excrete or the bones can network, leads to increased extracellular fluid volume, reabsorb water intoxication, hyponatremia, and increased - Fatigue, weakness, confusion, decreased excretion of urinary level of responsiveness, hyporeflexia, - Serum sodium levels below 120 mEq/L, symptoms of nausea, vomiting, constipation, polyuria hyponatremia including personality changes, irritability, (excessive urination), polydipsia (excessive nausea, anorexia, vomiting, weight gain, fatigue, thirst), dehydration, and dysrhythmias muscular pain (myalgia), headache, lethargy, and - Treatment: Hydration, biphosphonates confusion. - Treatment: Fluid restriction, parenteral sodium  ONCOLOGY EMERGENCIES TUMOR LYSIS SYNDROME Potentially fatal complication associated with radiation- or chemotherapy induced cell destruction of large or rapidly growing cancers such as leukemia, lymphoma, and small cell lung cancer Neurologic: Fatigue, weakness, memory loss, altered mental status, muscle cramps, tetany, paresthesias (numbness and tingling), seizures Cardiac: Elevated blood pressure, shortened QT complexes, widened QRS waves, dysrhythmias, cardiac arrest GI: Anorexia, nausea, vomiting, abdominal cramps, diarrhea Renal: Flank pain, oliguria, anuria, renal failure, acidic  WHAT IS YOUR ROLE AS A STUDENT NURSE? RAISE AWARENESS FOR CANCER PREVENTION STRATEGIES: 1. Increase consumption of fresh vegetables (especially those of the cabbage family) because studies indicate that roughage and vitamin-rich foods help to prevent certain kinds of cancer. 2. Increase fiber intake because high-fiber diets may reduce the risk for certain cancers (eg, breast, prostate, and colon) 3. Increase intake of vitamin A, which reduces the risk for esophageal, laryngeal, and lung cancers 4. Increase intake of foods rich in vitamin C, such as citrus fruits and broccoli, which are thought to protect against stomach and esophageal cancers 5. Practice weight control because obesity is linked to cancers of the uterus, gallbladder, breast, and colon  WHAT IS YOUR ROLE AS A STUDENT NURSE? RAISE AWARENESS FOR CANCER PREVENTION STRATEGIES: 6. Reduce intake of dietary fat because a high-fat diet increases the risk for breast, colon, and prostate cancers 7. Practice moderation in consumption of salt-cured, smoked, and nitrate-cured foods; these have been linked to esophageal and gastric cancers. 8. Stop smoking cigarettes and cigars, which are carcinogens. 9. Reduce alcohol intake because drinking large amounts of alcohol increases the risk of liver cancer (Note: People who drink heavily and smoke are at greater risk for cancers of the mouth, throat, larynx, and esophagus.) 10. Avoid overexposure to the sun, wear protective clothing, and use a sunscreen to prevent skin damage from