ONCOLOGY-NURSING (1).pptx PDF

NCM 112 – Cellular Aberration ONCOLOGY NURSING  DEFINITION OF TERMS  Cancer- a disease process whereby the cells proliferate abnormally, ignoring growth regulating signals in the environment surrounding the cells.  Malignant- having cells or processes that ar...

NCM 112 – Cellular Aberration ONCOLOGY NURSING  DEFINITION OF TERMS  Cancer- a disease process whereby the cells proliferate abnormally, ignoring growth regulating signals in the environment surrounding the cells.  Malignant- having cells or processes that are characteristic of cancer.  Metastasis- spread of cancer cells from the primary tumor to distant sites.  Carcinogenesis- process of transforming normal cells into malignant cells.  Oncology- field or study of cancer.  Staging- process of determining the size and spread, or metastasis, of a tumor.  DEFINITION OF TERMS  Grading- identification of the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and structural characteristic of the tissue of origin.  Chemotherapy- use of drugs to kill tumor cells by interfering with cellular functions and reproduction  Radiation therapy- use of ionizing radiation to interrupt the growth of malignant cells.  Biologic response modifier (BRM) therapy- use of agents or treatment methods that can alter the immunologic relationship between the tumor and the host to provide a therapeutic benefit.  Biopsy- a diagnostic procedure to remove a small sample of tissue to be examined microscopically to detect malignant cells. DEFINITION OF TERMS  Brachytherapy- delivery of radiation therapy through internal implants.  Teletherapy -is radiation delivered from a distant source, from outside the body and directed at the patient’s cancer site.  Tumor-specific antigen (TSA)- protein on the membrane of cancer cells that distinguishes the malignant cell from a benign cell of the same tissue type. DEFINITION OF TERMS  Control- containment of the growth of the cancer cells.  Extravasation- leakage of medication from the veins into the subcutaneous tissues. DEFINITION OF TERMS  Anaplasia- cells that lack normal cellular characteristics and differ in shape and organization with respect to their cells of origin; usually, anaplastic cells are malignant. Ex. Leiomyosarcoma (malignant smooth muscle tumor  Hyperplasia- increase in the number of cells of a tissue; most often associated with period of rapid body growth.  Metaplasia- conversion of one type of mature cell into another type of cell.  Dysplasia- bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same type of tissues.  Neoplasia- uncontrolled cell growth that follows no physiologic demand. DEFINITION OF TERMS  Cytokines- substances produced by cells of the immune system to enhance production and the functioning of components of the immune system.  Myelosuppression- suppression of the blood cell-producing function of the bone marrow.  Nadir- lowest point of white blood cell depression after therapy that has toxic effects on the bone marrow. DEFINITION OF TERMS  Neutropenia- abnormally low absolute neutrophil count.  Palliation- relief of symptoms associated with cancer.  Stomatitis- inflammation of the oral tissues. Often associated with some chemotherapeutic agents.  Thrombocytopenia- decrease in the number of circulating platelets; associated with the potential for bleeding. DEFINITION OF TERMS  Vesicant- substance that can cause tissue necrosis and damage, particularly when extravasated.  Xerostomia- dry oral cavity resulting from decreased function of salivary glands.  Alopecia- hair loss.  Cure- prolonged survival and disappearance of all evidence of disease so that the patient has the same life expectancy as anyone else in his or her age group.  Proliferative Patterns  Several patterns of cell growth exist:  Hyperplasia  Metaplasia  Dysplasia  Anaplasia  Neoplasia The growth of cancerous cells are described as MALIGNANT neoplasms An uncontrolled cell growth that follows no physiologic demand The degree of ANAPLASIA (lack of differentiation of cells) ultimately determines the malignant potential Normal Cell VS Cancer Cell Normal Cell VS Cancer Cell Normal Cells VS Cancer Cells  Oncology Nursing  an incredibly broad field that encompasses everything from cancer prevention to end-of-life care.  An oncology nurse is a registered nurse who cares for and educates patients who have cancer.  Oncology nurses work in a multi-disciplinary team, in a variety of settings, from the in- patient ward, to the bone marrow transplant unit.  Epidemiology  Cancers can occur at any age, but 75% of cancer patients in the Philippines are 50 years old and above while 3.2% belong to the pediatric age bracket (0 to 14 years).  It is the 3rd leading cause of death (After Heart Disease and Stroke)  In 2010, breast cancer became the most common cancer in the country with 16 percent of a total of 50,000 cases resulting in death  Lung cancer is the leading cause of cancer for Filipino men. It was the leading cause of cancer deaths in the country before it was replaced by breast cancer  Pathophysiology of the Malignant Process  Cancer is a disease process that begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA  The abnormal cell forms a clone and proliferates abnormally  The abnormal cell ignores growth-regulating signals in the environment surrounding the cell  These cells acquire invasive characteristics, and changes occur in the surrounding tissues  These cells infiltrate the tissues and gain access to lymph and blood vessels, which carry the abnormal cells to other areas of the body (Metastasis)  Pathophysiology of the Malignant Process  Cancer is NOT a single disease with a single cause  It is a group of distinct diseases with different causes, manifestations, treatments, and prognoses  Tumors and Tissue Types Tissue Type BENIGN TUMORS MALIGNANT EPITHELIAL (2) Surface Papilloma Squamous Cell Carcinoma Glandular Adenoma Adenocarcinoma CONNECTIVE (7) Fibrous Fibroma Fibrosarcoma Adipose Lipoma Liposarcoma Cartilage Chondroma Chondrosarcoma Bone Osteoma Osteosarcoma Blood Vessels Hemangioma Hemangiosarcoma Lymph Vessels Lymphangioma Lymphangiosarcoma Lymph Tissue Lymphosarcoma MUSCLE (2) Smooth Leiomyoma Leiomyosarcoma Striated Rhabdomyoma Rhabdomyosarcoma  Tumors and Tissue Types Tissue Type BENIGN TUMORS MALIGNANT NEURAL TISSUE (4) Nerve Cell Neuroma Neuroblastoma Glial Cell Glioma (benign) Glioblastoma, astrocytoma, medullablastoma, oligodendrioglioa Nerve Sheaths Neurilemmoma Meninges Meningioma Neurilemmal sarcoma Meningeal sarcoma HEMATOLOGIC (5) Granulocytic Myclocytic leukemia Erythrocytic Ertythrocytic leukemia Plasma Cells Multiple myeloma Lymphocytic Lymphocytic leukemia of lymphoma Monocytic Monocytic Leukemia ENDOTHELIAL TISSUE (3) Hemangioma Hemangiosarcoma Blood Vessels Lymphangioma Lymphangiosarcoma Lymph Vessels Ewing’s Sarcoma  Characteristics of Benign VS Malignant Neoplasms Characteristics Benign Malignant Cell Characteristics Well-differentiated Cells are cells that resemble undifferentiated and normal cells of the often bear little tissue from which the resemblance to the tumor originated normal cells of the tissue from which they arose Mode of Growth Tumor grows by Grows at the periphery expansion and does not and sends out processes infiltrate the that infiltrate and surrounding tissues; destroy the usually encapsulated surrounding tissues Rate of Growth Usually slow Variable and depends on level of differentiation; more anaplastic, faster growth Metastasis Does not spread by Yes; Gains access to the metastasis blood and lymphatic channels and  Characteristics of Benign VS Malignant Neoplasms Characteristics Benign Malignant General Effects Usually localized, does Generalized effects not cause generalized such as anemia, effects unless location weakness, weight loss interferes with vital function Tissue Destruction Does not cause tissue Causes extensive damage unless location tissue damage as the interferes with blood tumor outgrows its flow blood supply or encroaches or blood flow to the area; may also produce substances that cause cell damage Ability to cause death Does not usually cause Yes; Usually causes death unless its location death unless growth can interferes with vital be controlled functions  Characteristics of Malignant Cells (7)  Cell membranes are altered, which affects fluid movement in or out of the cell  Cell membrane contains proteins called tumor specific antigens which develop s, they become less differentiated (mature) over time  Cell membranes contains less fibronectin, making them less cohesive thus making them not adhere to adjacent cells readily  Nuclei typically are large and irregularly shaped (pleimorphism)  Nucleoli (structures within nucleus that contains RNA) are larger, perhaps due to increased RNA synthesis  Chromosomal abnormalities (translications, deletions, additions) are usually found  Mitosis is more frequent Invasion and Metastasis  Invasion and Metastasis  Invasion: growth of the primary tumor into the surrounding host tissues  Mechanical pressure exerted by rapidly proliferating neoplasms may force fingerlike projections of tumor cells into surrounding tissue ad interstitial spaces  Since malignant cells are less adherent, they may break off from the primary tumor and invade adjacent structures Invasion and Metastasis  Metastasis: spread of malignant cells from the primary tumor to distant sites by (1)direct spread of tumor cells to body cavities (2) lymphatic and blood circulation (1) Direct spread: Cells or emboli can be shed that can travel within the body cavity and “seed” the surfaces of other organs  Invasion and Metastasis (2)Lymphatic and Blood Circulation  Lymphatic- most common; tumor emboli enters the lymph channels by way of interstitial fluid that communicates with lymphatic fluid.  After entering the lymphatic circulation, malignant cells either lodge in lymph nodes or pass between lymphatic and venous circulation  Invasion and Metastasis  Lymphatic and Blood Circulation  Blood Circulation (Hematogenous Spread)  Malignant cells are disseminated via bloodstream  Directly related to vascularity of tumor  Few malignant cells can survive the turbulence of arterial circulation, insufficient oxygenation, or destruction by the body’s immune system  Most arteries and arterioles are far too secure to permit malignant invasion  The malignant cells that survive are able to attach to endothelium and seal themselves from immune system surveillance  Invasion and Metastasis  Angiogenesis  Induction of growth of new capillaries from host tissue to meet the needs of the malignant cells for nutrients and oxygen  It is through this vascular network that tumor emboli can enter the systemic circulation and travel to distant sites.  Large tumor emboli that become trapped in the microcirculation of distant sites may further metastasize to other sites Carcinogenesis Carcinogenesis  Initiation  Promotion  Progression  Carcinogenesis  Initiation – initiators (Carcinogens) such as chemicals, physical factors, and biologic agents, escape normal enzymatic mechanisms and alter the genetic structure of the cellular DNA  Normally, the alteration are reversed by DNA repair or cell suicide (apoptosis)  Occasionally, cells escape these mechanisms, and permanent cellular mutations occur Carcinogenesis  Promotion – repeated exposure to promoting agents (co-carcinogens) causes the expression of abnormal or mutant genetic information even after long latency periods  Cellular oncogenes are present in cells to act as “on switch” for cellular growth  Cancer suppressor genes are “off switch” or regular unneeded cellular proliferation  When the supressor genes are mutated, malignant cells are allowed to reproduce  Carcinogenesis  Promotion – The p53 gene is a tumor supressor gene  This gene regulates whether cells will repair or die after their DNA is damaged  This gene is frequently mutated in human cancer  A mutated p53 gene is associated with poor prognosis and may determine treatment response  Once this genetic expression occurs in cells, the cells begin to produce mutant cell population that are different from the original  Carcinogenesis  Progression – the cellular changes formed during initiation and promotion now exhibit increased malignant behavior.  The cells now show a propensity to invade adjacent tissues and to metastasize *Agents that initiate or promote cellular transformation are referred to as carcinogens  Etiology (6)  Viruses and Bacteria  Physical Agents  Chemical Agents  Genetic and Familial Factors  Dietary Factors  Hormonal Agents  Etiology  Viruses and Bacteria  Viruses are thought t o incorporate themselves in genetic structure of cells, thus altering future generations of that cell population *Epstein-Barr virus is highly associated with Burkitt’s Lymphoma, Hodgkin’s disease *Herpes Simplex virus is associated with dysplasia and cancer of cervix *Hepatitis B is implicated in cancer of liver *HIV is associated with Kaposi’s Sarcoma  Etiology  Physical Agents  Exposure to ultraviolet sun rays, especially to fair skinned people, can increase risk for skin cancer  Exposure to ionizing radiation with repeated diagnostic x-ray procedures or with radiation therapy or exposure to radioactive materials at nuclear weapons manufacturing sites  Etiolog y  Chemical Agents  Tobacco smoke is thought to be the single most lethal chemical carcinogen, which accounts for at least 30% of cancer deaths  Others include: aromatic anilines, pesticides, formaldehydes, arsenic, soot, tars, asbestos, lime, betel nut, cadmiun, chromium compounds, nickel and zinc ores, beryllium compounds, polyvinyl chloride  Etiology  Genetic and Familial Factors  Most cancers appear to run in families  May be due to genetics, shared environment, or cultural/lifestyle factors  Etiology  Dietary Factors  Related to 35% of all environmental cancers  Could be proactive, carcinogenic or co- carcinogenic  Risk for cancer increases with long term ingestion of carcinogens or co-carcinogens OR chronic absence of proactive substances in diet  Obesity is also associated with various cancers (endometrial, breast, colon, kidney, gallbladder)  Etiology  Dietary Factors  Increased cancer risk: fats, alcohol, salt-cured or smoked meats, foods with nitrates/nitrites, high caloric dietary intake  Decreased cancer risk: high-fiber foods, cruciferous vegetables (cabbage, brocolli, cauliflower,) carotenoids (carrots, tomatoes, spinach, dark green and leafy vegetable)  Etiology  Hormonal Agents  Tumor growth may be promoted by disturbances in hormonal balance  DES  OCP especially estrogen  Immune System  The human immune system can detect the development of malignant cells and destroy them before cell growth becomes uncontrolled  When the immune system fails to identify and stop the growth of malignant cells, clinical cancer develops  If a patient is immunoincompetent (patients who receive immunosuppressive therapy, patients with immunodeficiency diseases like AIDS) can have increased risk for cancer  Immune System  Normal Immune Response  Usually the immune system recognizes as foreign certain antigens on the cell membranes of many cancer cells.  These foreign antigens are known as tumor cell antigens, and are capable of stimulating both cellular and humoral immune response  T-lymphocytes are responsible for recognizing tumor associated antigens. When T- lymphocytes recognize tumor antigens, other T-lymphocytes that are toxic to the tumor cells are released into the circulation.  Immune  System Normal Immune Response  Certain lymphocytes can produce lymphokines which can kill or damage malignant cells.  Macrophages and Interferons (IFNs) can disrupt cancer cells.  B-Lymphocytes can also defend the body against malignant cells  Natural Killer (NK) cells, a subpopulation of lymphocytes, act by directly destroying cancer cells or producing lymphokines that assist in cell destruction  Immune System  Immune System Failure  If the body fails to recognize the malignant cell as different from “self”, the immune response may not be stimulated  When tumors do not possess tumor-associated antigens that label them as foreign, the immune response is not alerted  The failure of immune system to respond promptly to the malignant cells allow the tumor to grow too large to be managed by normal immune mechanisms  Immune System  Immune System Failure  Tumor antigens may combine with the antibodies produced by the immune system and hide or disguise themselves from normal immune defense mechanism.  These Tumor Antigen - Antibody complexes can further suppress the production of antibodies  Tumors are also capable of changing their appearances of producing substances that impair usual immune responses  These substances not only promote tumor growth but also increase the patient’s susceptibility to infection by various pathogenic organisms Detection and Prevention of Cancer Detection and Prevention of Cancer  Primary Prevention  Secondary Prevention  Detection and Prevention of Cancer  Primary Prevention  Education for the community through knowledge and skills  Patients should be assisted to avoid known carcinogens  Dietary and various lifestyle changes  Detection and Prevention of Cancer  Secondary Prevention  Genetic screening  Cancer risk evaluation  Public Awareness about health promoting behaviors (Papanicolaou / Pap smear tests, breast and testicular examinations, digital rectal examinations)  Diagnosis and related Nursing Considerations  Patients with suspected cancer undergo extensive testing to:  Determine the presence of tumor 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 tumor stage and grade  Diagnosis and related Nursing Considerations  Patients are usually fearful when undergoing extensive testing and anxious about the test results  The nurse can relieve fear and anxiety by(3) Explaining the tests to be performed,  The sensations likely to be experienced  The patient’s role in the test procedures  Diagnosis and related Nursing Considerations  Tumor Staging and Grading  Staging determines the size of the tumor and existence of metastasis  The TNM system is frequently used  T: Primary tumor extent  N: lymph node involvement  M extent of metastasis  Diagnosis and related Nursing Considerations  TUMOR- size  T1 = 4cm  T4 = invades the adjacent and deep subjacent area  NODES- lymph node involvement  N0 = none  N1 = ipsilateral (same side)  N2 = contralateral/ bilateral  N3 = fixed palpable  METASTASIS- the extent of distant metastasis  M0 = none  M1 = distant M  Diagnosis and related Nursing Considerations  Kung walang N at * Stage 1 * Stage 4 M, depende sa T  T1 N0  T1 N2 M0 ang stage  Lahat ng may N1 M0  T2 N2 M0 pero walang M ay * Stage 2  T3 N2 M0 stage 3  T2 N0  T1 N3 M0  Stage 4 kapag N2 and beyond, kahit M0  T2 N3 M0 na anong T * Stage 3  T3 N3 M0  T3  T4 N0 M0 N0M0  Diagnosis and related Nursing Considerations Grading:  Classification of tumor cells  More undifferentiated, more malignant  Grade 1- 75-100% well differentiated, closer to normal cells (best prognosis)  Grade 2- 50-75%  Grade 3- 25-50%  Grade 4- 0-25% (more malignant), poorly differentiated  Management of Cancer  CURE: complete eradication of malignant disease  CONTROL: prolonged survival and containment of cancer cell growth  PALLIATION: Relief of symptoms associated with the disease  Management of Cancer (7)  Surgery  Radiation therapy  Chemotherapy  Bone Marrow Transplant  Biologic Response Modifier therapy  Photodynamic therapy  Gene therapy SURGERY  Surgery  Surgical removal of the entire cancer is the ideal and most frequently used method  Two Types:  Diagnostic Surgery  Surgery as Primary Treatment  Surgery  Diagnostic Surgery  BIOPSY  Usually performed to obtain a tissue sample for analysis of cells suspected to be malignant  Surgery  Three types of Biopsy  Excisional: removal of the entire tumor and surrounding marginal tissues as well (to decrease the possibility that residual disease cells remain on the periphery of the tumor that may lead to recurrence)  Incisional: if the tumor mass is too large to be removed entirely, a wedge of tissue from the tumor is removed for analysis  Needle: a specially designed needle is used to obtain a small amount of tissue, by aspirating tissue fragments through a needle guided into an area suspected of bearing disease  Surgery  Surgery as Primary Treatment  The goal is to remove the entire tumor or as much as is feasible and any involved surrounding tissues, including regional lymph nodes  Local Excision: used when mass is small, includes removal of mass and a small margin of small tissue that is easily accessible  Radical Excision: (en bloc) removal of the primary tumor, lymph nodes, adjacent involved structures, and surrounding tissues that may be at high risk for tumor spread  Salvage Surgery: uses extensive surgical approach to treat the local recurrence of the cancer after a less extensive primary approach is used eg mastectomy to treat recurrent breast cancer after primary surgery  Surgery  In addition to surgical blades or scalpels, other types of surgical interventions are available  Electrosurgery – uses electrical current to destroy tumor cells  Cryosurgery – uses liquid nitrogen to freeze tissue to cause cell destruction  Chemosurgery – combined chemotherapy and layer-by-layer surgical removal of abnormal tissue  Laser surgery (light amplification by stimulated emission of radiation) – uses 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 Laparoscopic Electrosurgery Monopolar laparoscopic electrosurgery involves the insertion of optical and surgical instruments into the abdomen through small incisions, providing the surgeon access to the peritoneal cavity and a view of the surgical site. Due to a limited field of vision during minimally invasive surgery, surgeons can see only approximately 10% of the live electrode (the area inside the square), thus any burns outside the surgeon's field of view can go undetected until days after surgery by which time serious burns may have caused severe infection.  What is cryosurgery (also called cryoablation)?  Cryoablation is a treatment for prostate cancer that uses small probes, called cryoprobes, inserted into the prostate gland in order to destroy the prostate cancer.  The probes are placed precisely into the prostate using ultrasound guidance, and temperature sensors placed into and around the prostate are used to be certain that proper freezing of the tissue is obtained.  The entire prostate is frozen to -40°C, while the urethra is protected by a special warming catheter.  The procedure is performed under spinal anesthesia, so the patient has no pain during the procedure. CRYOSURGERY FOR PROSTATE CANCER Cryoablation therapy offers: a minimally invasive procedure favorable success rate and complication rates a short recuperation period procedure can be repeated if the first cryoablation has failed radiation therapy or radical prostatectomy is still an option if the procedure fails less than half the cost of the traditional treatment The disadvantages are: men will have a suprapubic urinary catheter for 2-3 weeks after the procedure, similar to prostate surgery most patients treated with cryosurgery on both sides of the prostate will have impotence initially after the procedure, but it can be treated and may improve over time CHEMOSURGERY  Also called chemical peels  Chemical peels (often called chemosurgery) use a chemical solution, applied by a trained healthcare professional to remove the top layers of damaged skin. New cells formed during healing produce a tighter, more youthful-looking skin.  Chemical peels have proven successful in restoring wrinkled, sun-damaged and blemished skin, and may be applied to the entire face, or specific areas such as the mouth or forehead. WHAT IS STEREOTACTIC RADIOSURGERY? Stereotactic radiosurgery is a non-surgical treatment using very focused beams of radiation on small and previously inaccessible tumors or lesions deep within the body. Because the radiation beams enter the body from many different angles and all focus directly on the tumor or lesion, the surrounding healthy cells and important structures (blood vessels, nerves, etc.) are spared.  How Stereotactic Radiosurgery is Performed A stereotactic frame is temporarily affixed to the patient's head for the treatment, using only local anesthesia. The patient then undergoes the appropriate imaging studies necessary to define the exact location and shape of the lesion. Depending on the type of lesion, these studies may include digital angiography, CT, MRI, or PET (positron emission tomography) scanning.  Surgery  Prophylactic  Palliative  Reconstructive  Surgery  Prophylactic – involves removing nonvital tissues or organs that are likely to develop cancer.  Offered selectively to patients and discussed thoroughly with the patient and family  Factors to be considered  Family history or 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 Common Prophylactic Surgery  Colectomy – excision of the colon  Mastectomy – removal of the breast  Oophorectomy – excision of one or two ovaries  Surgery  Palliative – When cure is not possible, the goals of treatment are to make the patient as comfortable as possible, and to promote a satisfying and productive life for as long as possible  Major goal is a high quality of life – with quality defined by the patient and family  This is an attempt to relieve complications of cancer, such as ulcerations, obstructions, hemorrhage, pain, and malignant effusions  Surgery  Reconstructive – may follow curative and radical surgery and is carried out in an attempt to improve function or obtain a more desirable cosmetic effect  Patients are instructed about possible reconstructive surgical options before the primary surgery by the surgeon who will perform the reconstruction  May be indicated for breast, head, neck, and skin cancers WARNING SIGNALS OF CANCER  C- Changes in bowel and bladder habits  A- A sore that does not heal  U- Unusual bleeding or discharge  T- Thickening or a lump in the breast or elsewhere  I- Indigestion or difficult swallowing  O- Obvious changes in a wart or mole  N- Nagging cough or hoarseness  U- Unexplained anemia  S- Sudden unexplained weight loss  usually follows radical or curative surgery  Attempts to improve function  Obtain a more desirable cosmetic effect  Indicated for breast, head & neck, skin cancers  Nursing Management in Cancer Surgery  The patient undergoing surgery is often anxious about the surgical procedure, possible findings, postoperative limitations, changes in normal body functions, and prognosis.  The nurse provides education and emotional support by assessing the patient and family needs and exploring with the patient and family their fears and coping mechanisms, encouraging them to take an active rile in decision making when possible  Nursing Management in Cancer Surgery  When the patient or family asks about the results of diagnostic testing, the nurse’s response is guided by the information the physician previously conveyed to them  The patient/family may also ask the nurse to explain and clarify information that the physician initially provided but that they did not grasp because they were anxious at the time  Nursing Management in Cancer Surgery  After surgery, the nurse assesses the patient’s responses to the surgery and monitor for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction.  The nurse also provides for patient comfort  Postoperative teaching addresses wound care, activity, nutrition, and medication information  Plans for discharge, follow-up and home care, and treatment are initialed as early as possible to ensure continuity of care from hospital to home Radiation Therapy  Radiation Therapy  Ionizing radiation is used to interrupt cellular growth  May also be used to control malignant disease when a tumor cannot be removed surgically or when local nodal metastasis is present  It can be used prophylactically to prevent leukemic infiltration to the brain or spinal cord  Radiation Therapy  Cells are most vulnerable to the disruptive effects of radiation during DNA synthesis and mitosis (Early S, G2, and M phases of the cell cycle)  Therefore those body tissues that undergo frequent cell division are most sensitive to radiation therapy  These include bone marrow, lymphatic tissue, epithelium of GI tract, hair cells, and gonads  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  External Radiation – X-rays are used to destroy cancerous cells at the skin surface or deeper in the body.  Higher energy, deeper penetration into the body  Internal Radiation – a radioisotope is inserted into specially positioned applicators after the position is verified by x-ray  The radioisotopes remain in place for a prescribed period and then are removed  Radiation Therapy  Toxicity  May be increased when concomitant chemotherapy is administered  Altered skin integrity is a common effect  Alopecia, erythema, desquamation  Xerostomia  Loss of taste  Dysphagia  Thrombocytopenia  Leukopenia  Fatigue, malaise, anorexia  Nursing Management in Radiation Therapy  The nurse can explain the procedure for delivering radiation and describe the equipment, the duration of the procedure (often minutes only) the possible need for immobilizing the patient during the procedure, and the absence of new sensations, including pain, during the procedure  If radioactive implant is used, the nurse informs the patient and family about the restrictions placed on visitors and health care personnel and other radiation procedures  Nursing Management in Radiation Therapy  Protecting the skin and oral mucosa  The nurse assess the patient’s skin, nutritional status, and general feeling of well-being  The skin and oral mucosa are assessed frequently for changes  The skin is protected from irritation, and the patient is instructed to avoid using ointments, lotions, or powders on the area  Gentle oral hygiene is essential to remove debris, prevent irritation, and promote healing  The nurse offers reassurance by explaining that these symptoms are a result of the treatment and do not represent deterioration or progression of the disease Safety Precautions TO MINIMIZE EXPOSURE OF PERSONNEL TO RADIATION  The pt should be in a private room.  Posting of appropriate notices about radiation safety  Wearing dosimeter badges  No pregnant staff member assigned  Prohibiting visits from children & pregnant women  Limit visits to 30’ daily  Visitors maintain 6 ft distance from radiation source  Administered orally – thyroid carcinomas Chemotherapy  Chemotherapy  Antineoplastic agents are used in an attempt to destroy the tumor cells by interfering with cellular functions and reproduction  Used primarily to treat systemic disease vs lesions that are localized (amenable to surgery or radiation)  Chemotherapy  Each time a tumor is exposed to a chemotherapeutic agent, a percentage of tumor cells depending on dosage is destroyed  Repeated dosages of chemotherapy are necessary over a prolonged period to achieve regression of tumor, but a goal of the treatment is to eradicate enough of the tumor so that the remaining tumor cells can be destroyed by the body’s immune system  Classification of Chemotherapeutic Agents Drug Class Mechanism of Action Common Side Effects Alkylating Agents Alter DNA structure by Bone marrow misreading DNA code, suppression, nausea, initiating breaks in DNA vomiting, stomatitis, molecule, x-linking DNA alopecia, gonadal strands suppression, renal toxicity Nitrosureas Similar to alkylating Myelosupression, agents, crosses blood- nausea, vomiting brain barrier Topoisomerase I Induce breaks in DNA by BM suppression, Inhibitors binding to enzyme diarrhea, ausea, topoisomerase I, vomitng, hepatotoxicity preventing cells from dividing Antimetabolites Interfere with Nausea, vomiting, biosyntheis of diarrhea, BM metabolites or nucleic suppression, proctitis, acids necessary for stomatitis, renal toxicity,  Use of medicines or antineoplastic agents to attack cancer cells.  Chemotherapeutic drugs work by impairing mitosis effectively targeting fast-dividing cells.  Scientists have yet to identify specific features of malignant and immune cells that would make them uniquely targetable.  Hair growth and intestinal epithelium are severely affected  Causes fear because the side effects can be severe.  Used when the cancer has metastasized – treats systemic disease rather than localized lesions  Used in combination treatments  ADMINISTRATION OF CHEMO AGENTS May be administered in the  Hospital  Clinic  Home setting ROUTES can be  Topical, Oral  IV, IM, SQ  Arterial, intracavitary, intrathecal  Depend on the type of agent to be used SPECIAL PROBLEMS  Extravasation  Toxicity Classification of Chemotherapeutic Agents Drug Class Mechanism of Action Common Side Effects Antitumor Antibiotics Interfere with DNA BM suppression, nausea, synthesis by binding vomiting, alopecia, DNA; Prevent RNA anorexia, cardiac synthesis toxicity Mitotic Spindle Poisons *Plant Alkaloids Arrest Metaphase by BM suppression, inhibiting mitotic tubular neuropathies, stomatitis formation *Taxanes Arrest Metaphase by Bradycardia, inhibiting tubulin hypersensitivity, BM depolymerization suppression alopecia, neuropathies Hormonal Agents Bind to hormone Hypercalcemia, receptor sites that alter jaundice, up appetite, cellular growth, block masculinization, binding of estrogens to feminization, receptor, inhibit RNA sodium/fluid retention, synthesis nausea, vomiting, vaginal dryness, hot  Chemotherapy  Special Problems: Extravasation  Special care must be done if Vesicants are to be deposited intravenously  Vesicants: agents that if deposited into the subcutaneous tissue (extravasation), cause tissue necrosis and damage to undelying tendons, nerves and blood vessels  Only specially trained physicians and nurses should administer vesicants  If extravasation is suspected, administration is stopped, and ice is applied to site (unless vesicant is a vinca alkaloid)  Vesicant is aspirated and a neutralizing solution is injected. The solution depends on the extravasated agent  Chemotherapy  Toxicity  GI System – nausea and vomiting, mucositis, stomatitis, anorexia  Hematopoietic – myelosuppression  Renal – accumulation of end products after cell lysis,  Cardiopulmonary – irreversible cumulative cardiac toxicities, CHF,  Chemotherapy  Toxicity  Reproductive – sterility  Neurologic – neurologic damage, peripheral neuropathies, loss of deep tendon reflexes, paralytic ileus  Miscellanous - fatigue  Nursing Management in Chemotherapy  Assessing Fluid and Electrolyte Status  Anorexia, nausea, vomiting, altered taste and diarrhea put the patient at risk for nutritional and fluid and electrolyte imbalances  Changes in the mucosa of the GI tract may lead to irritation of oral cavity and intestinal tract, further threatening patient’s nutritional status  It is important for the nurse to assess the patient’s nutritional and fluid and electrolyte stats frequently Toxic Effects of Chemotherapy 1. Gastrointestinal System 1. Nausea and Vomiting: 24 hrs after due to stimulation of the vomiting centers of the brain Mgt: 1. Use of phenothiazines, sedatives, steroids and histamines 2. Relaxation technique 3. Alterations in patient’s diet 2. Stomatitis, anorexia, diarrhea: inflammation of mucosal lining of entire GIT 2. Hematopoietic System: chemotherapeutic agents depress bone marrow function resulting in decreased production of blood cells (myelosuppression) and increase the risk of infection and bleeding a. Leukopenia (WBC) b. Thrombocytopenia (platelets) c. Anemia (RBC) Mgt: frequent monitoring of blood cell count, patient must be protected from infection and injury 3. Renal System:chemotherapeutic agents can be harmful to the kidneys because of direct effect of the drugs during their excretion and the accumulation of end products after cell lysis. : rapid lysis after chemotherapy results in increased urinary excretion of uric acid, which can lead to renal damage. 4. Cardiopulmonary System - antitumor antibiotics (daunorubicin and doxorubicin) causes cardiac toxicities - ECG and signs of CHF must be monitored closely - Bleomycin and Busukfan cause toxic effects on lung function = Monitor patient closely for changes in pulmonary function 4. Reproductive System: testicular and ovarian function can be affected by chemotherapeutic agents resulting in possible sterility 5. Neurologic System: the plant alkaloids, esp. Vincristine cause neurologic damage with repeated doses  MANAGEMENT OF STOMATITIS  Use soft-bristled toothbrush  Oral rinses with saline gargles/ tap water  Avoid ALCOHOL-based rinses  MANAGEMENT OF ALOPECIA Alopecia begins within 2 weeks of therapy  Regrowth within 8 weeks of termination  Encourage to acquire wig before hair loss occurs  Encourage use of attractive scarves and hats  Provide information that hair loss is temporary BUT anticipate change in texture and color Bone Marrow Transplant  Bone Marrow Transplant  Procedure to replace damaged or destroyed bone marrow with healthy bone marrow stem cells.  Done when healthy bone marrow has been destroyed (ablated) by chemotherapy or radiation.  Types of BMT (based on donor)  Allogeneic (from donor other than the patient): either a related donor (family member), or a matched unrelated donor  Autologous (from patient, eg other parts of their body)  Syngeneic (from idenical twin) Nursing Management in Bone Marrow Transplantation  Implementing Pretransplantation care  All patient’s must undergo extensive pretransplantation evaluations to assess the current clinical status of the disease  Nutritional assessments, exensive physical examinations and organ function tests, and psychological evaluations are conducted  Blood work includes assessing past antigen exposure Nursing Management in Bone Marrow Transplantation  Providing Care during Treatment  Monitoring the patient’s vital signs and blood oxygen saturation: assessing for adverse effects, such as fever, chills, shortness of breath, chest pain, cutaneous reactions, nausea, vomiting, hypo/hypertenson, tachycardia, anxiety, taste changes Nursing Management in Bone Marrow Transplantation  Providing Posttransplantation Care  Late complications could occur 100 days or more after BMT  Includes infections, restrictive pulmonary abnormalities, recurrent pneumonias  Sterility  Chronic “Graft-versus-host Disease (bone marrow graft is rejected Biologic Response Modifiers Biologic Response Modifiers (BRM)  Use of a naturally occurring or recombinant (reproduced through genetic engineering) agents or treatment methods that can alter the immunologic relationship between the tumor and the cancer patient to provide a therapeutic benefit  Goal is to destroy or stop malignant growth Biologic Response Modifiers (BRM)  Nonspecific BRM  Bacille Calmette Guerin (BCG), Corynebacterium parvum  When injected into a patient, the agents serve as antigens that stimulate an immune response  The hope is that the stimulated immune system will then eradicate the malignant cells Monoclonal antibodies – grow and produce specific antibodies for specific malignant cells, to allow for destruction of cancer cells and spare normal cells  Biologic Response Modifiers (BRM)  Cytokines – substances produced by immune system cells to enhance the production and functioning of components of the immune system  Interferons (IFN)– antiviral and antitumor  Interleukins (IL) – signals and coordinates other cells of immune system  Hematopoietic Growth Factors – regulate production of cells in blood (neutrophils, macrophages, monocytes)  Tumor Necrosis Factor (TNF) – stimulate other cells of the immune response Retinoids – vitamin A derivatives that are used for treating acute promyelocytic leukemia Nursing Management in BRM Therapy  BRM therapies usually are still investigational and considered a last- chance effort by many patients who have not responded to standard treatments  Nurses have to be familiar with each agent given, and the potential side effects to assess and manage potential toxicities  Accurate observations and careful documentation are essential components of patient assessment and data collection, as the agents given are usually investigational in nature Photodynamic Therapy Photodynamic Therapy  An investigational cancer treatment that uses photo sensitizing agents  When administered intravenously, these agents are retained in higher concentrations in malignant tissue than in normal tissue  They are then activated by a light source, usually laser light, which penetrates body tissue.  The light-activated agent then creates activated single oxygen molecules that are cytotoxic or harmful to body tissue cells  Selective cytotoxicity is then achieved with minimal destruction to normal tissues ene Therapy  Gene Therapy  Includes approaches that correct genetic defects or manipulate genes to induce tumor cell destruction in the hope of preventing or combating disease  This is considered by many to be controversial and a potential source of bioethical concerns  An example of one such trial involves inserting the p53 tumor suppressor gene into cancer cells  Normally this gene is responsible for repairing damaged cells or causing cell death when the cell cannot be repaired  Cancer cells have mutated p53 genes that lead to uncontrolled cell growth  Insertion of normal p53 genes can lead to either cancer cell death or slowing of tumor growth Plan of Nursing Care  Plan of Nursing Care  Risk for infection related to altered immunologic response  Impaired skin integrity: erythematous and wet desquamation reactions to radiation therapy  Impaired oral mucous membrane: stomatitis  Impaired tissue integrity: alopecia  Imbalanced nutrition, less than body requirements, related to nausea and vomiting  Fatigue  Chronic Pain  Potential complication: Risk for bleeding problems  Plan of Nursing Care Nursing Diagnosis: Risk for infection related to altered immunologic response Goal: Prevention of Infection Nursing Interventions Rationale Expected Outcomes 1. Assess px for evidence Signs and symptoms of Demonstrates normal of infection infection may be temperature and vital signs a. Check vital signs q 4 diminished in the Exhibits absence of signs hours immunocompromised host. of inflammation: local b. Monitor WBC count and Prompt recognition of edema, erythema, pain, differential each day infecion and subsequent and warmth c. Inspect all sites tat may initiation of therapy will Takes deep breaths and serve as entry ports for reduce morbidity and coughs every 2 hours to pathogens (IV sites, mortality associated with prevent respiratory wounds, skin folds,) infection dysfunction and infection 2. Report fever > 38.3 oC, Early detection of infection Exhibits absence of chills, diaphoresis, swelling, facilitates early intervention pathologic bacteria on heat, pain, erythema, cultures exudate. Also report Avoids contact with others change in respiratory or with infections mental status, urinary Avoids crowds frequency or burning, malaise, myalgias, arthralgias, rash, diarrhea  Plan of Nursing Nursing Diagnosis: Risk for infection related to Care altered immunologic response Goal: Prevention of Infection Nursing Interventions Rationale Expected Outcomes 3. Obtain cultures and These tests identify the All personnel carry out sensitivities as indicated organism and indicate the most hand hygiene after each before initiation of appropriate antimicrobial voiding and bowel therapy. Use of inappropriate antimicrobial treatment movement antibiotics enhances (wound exudate, sputum, Excoriation and trauma of proliferation of additional flora urine, stool, blood) and encourages growth of skin are avoided antibiotic-resistant organisms 4. Initiate measures to Exposure to infection is Trauma to mucous minimize infection: reduced membranes is a. Discuss with patient and a. Preventing contact with avoided(avoidance of rectal family pathogens help prevent thermometers, (1) Placing patient in private infection suppositories, vaginal room if absolute WBC count