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Module (3) Module Title: Nursing Management for patient with Cancer Unit Title: Oncological Nursing Allotted Time: 3 Hours' theory Objectives:  Implements standardized protocol and guidelines when providing nursing care for adult patients with cancer.  Utilize critical thinking skills and clinical...

Module (3) Module Title: Nursing Management for patient with Cancer Unit Title: Oncological Nursing Allotted Time: 3 Hours' theory Objectives:  Implements standardized protocol and guidelines when providing nursing care for adult patients with cancer.  Utilize critical thinking skills and clinical competences needed when providing nursing care to adult individuals with cancer.  Describe the responsibilities of the nurse in meeting the psychological needs of adult patients with cancer.  Synthesize clinical evidence in order to solve problems related to the management of patient care and the organization.  Conducts appropriate nursing activities skillfully and in accordance with best evidence based practice.  Manage time effectively and set priorities.  Apply communication skills effectively with surgical, nursing andmedical staff in inter-professional, social and therapeutic context.  Measure critically the outcomes of nursing activities.  Use problem-solving skills.  Works effectively with a team  Communicate effectively with all staff members in inter-professional context to improve patient's outcomes.  Use information technology.  Convey a positive attitude toward other team members while working with patients with cancer. Teaching Methods and Training materials:  Lecture  Discussion Content 75  Case study  Problem solving Outlines:  Introduction  Definition  Risk factors (carcinogens)  Characteristics of Benign and Malignant Neoplasms  Diagnosis of Cancer  Management of cancer  Surgical management  Radiation Therapy  Chemotherapy  Nursing Process for Patient with Cancer Content 76 Oncology: Nursing Management for patient with Cancer Introduction: Cancer is a major health problem. It exhibits a striking geographic variation related to difference in the age structure of populations, as well as environmental factors. Incidence of cancer reaches a maximum in developed countries and is higher in men than in women. Cancer is a global cause for death, being ranked the third in developing countries after infectious and parasitic diseases. However, it ranks second in developed countries after diseases of the circulatory system. Definition: Cancer is a disease process that begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA. This abnormal cell forms a clone and begins to proliferate abnormally, ignoring growth regulating signals in the environment surrounding the cell. Risk factors (carcinogens): There are certain factors that linked to the carcinogenic process. 1. Chemical agents: such as  Smoking (active or passive).  Air pollution (car exhaust),  Industrial exposure such as asbestos, and uranium. 2. Physical agents: such as  Excessive exposure to the ultraviolet rays of the sun  Exposure to ionizing radiation. 3. Some genetic disorders: such as  Individuals with Down's syndrome having high incidence of acute leukemia due to chromosomal abnormalities. Content 77 4. Genetic transmission as breast cancer 5. Hormonal Agents:  Excessive production of endogenous hormones as (early menarche, late menopause, and nulliparous women).  Administration of exogenous hormones as (use of oral contraceptives, prolonged estrogen therapy). 6. Dietary factors:  High proteins and fats in diet,  Foods are considered genotoxic as nitrosamines that are found in preserved meats and pickled, salted food. 7. Alcohol: that acts as a promoter by modifying the metabolism of carcinogens in the liver and esophagus, thus increasing the effectiveness of carcinogens in some tissues. 8. Viral and bacterial infections For example:  The Epstein-Barr virus  The hepatitis B virus is implicated in cancer of the liver.  The bacterium Helicobacter pylori has been associated with an increased incidence of gastric malignancy, perhaps secondary to inflammation and injury of gastric cells. Content 78 Characteristics of Benign and Malignant Neoplasms CHARACTERISTICS Cell characteristics Mode of growth Rate of growth Metastasis General effects Tissue destruction Ability to cause death Recurrence Palpation Content BENIGN Well-differentiated cells that resemble normal cells of the tissue from which the tumor originated Tumor grows by expansion and does not infiltrate the surrounding tissues; usually encapsulated Rate of growth is usually slow MALIGNANT Cells are undifferentiated and often bear little resemblance to the normal cells of the tissue from which they arose Grows at the periphery and sends out processes that infiltrate and destroy the surrounding tissues Rate of growth is variable and depends on level of differentiation; the more anaplastic the tumor, the faster its growth Does not spread by metastasis Gains access to the blood and lymphatic channels and metastasizes to other areas of the body Is usually a localized phenomenon Often causes generalized effects, that does not cause generalized such as anemia,, weakness, and effects unless its location weight loss interferes with vital functions Does not usually cause tissue Often causes extensive tissue damage unless its location damage as the tumor outgrows its interferes with blood flow blood supply or encroaches on blood flow to the area; may also produce substances that cause cell damage Does not usually cause death Usually causes death unless unless its location interferes with growth can be controlled vital functions Rare Recurrent Movable Fixed or immobile 79 Diagnosis of Cancer: The diagnosis of cancer is a multi-phasic process that includes: 1. Obtaining a careful history:regarding host and environmental risk factors. Taking into consideration that the signs and symptoms of the cancer usually vague due to slow cancer growing so it indicates the importance of education about self-examination to diagnose cancer as early as possible. 2. Seven warning signs of cancer:     Change in bowel or bladder habits. A sore that does not heal. Obvious change in a wart or a mole. Nagging cough or hoarseness.    Unusual bleeding or discharge. Thickening or lump in the breast. In digestion or difficulty swallowing. 3. Physical examination: Conducting an in-depth physical examination focused on changes indicative of malignancy or pre-malignant state and performing selected diagnostic procedures. 4. Diagnostic tests:  Plain and contrast radiographs.  Ultrasound  CTscan  Endoscopic procedures  MRI  Biopsy. Staging and grading of tumors:Staging determines the size of the tumor and the existence of local invasion and distant metastasis. Several systems exist for classifying extent of disease the most common system is TNM system. TNM Classification System  T means the extent of the primary tumor.  N means the absence or presence and extent of regional lymph node metastasis Content 80  M means the absence or presence of distant metastasis. Management of cancer: Cancer can be treated by either local or systemic modalitiessuch as surgery,radiation therapy, chemotherapy, immunotherapy, or other methods. The choice of therapy depends upon the location and grade of the tumor and the stage of the disease, as well as the general state of the patient. 1. Surgical management Surgical removal of the entire cancer remains the ideal and most frequently used treatment method. Surgery may be used as:  Diagnostic Surgery:such as a biopsy that performed to obtain a tissue sample for analysis of cells suspected to be malignant.  Surgery as primary treatment:when surgery is the primary approach in treating cancer, the goal is to remove the entire tumor 2. Radiation Therapy Radiation therapy is a localized treatment that is used alone or in conjunction with other treatments such as surgery or chemotherapy, or both. Radiation therapy may be administered: Before surgery: to treat undisturbed tissues and to reduce the tumor's size to make resection feasible. After surgery to treat cancer cells that may have been disseminated beyond the surgical margins or that may have remained in the tumor bed. Side effects of radiotherapy: 1- General side effects of radiation therapy: Radiation nausea  Fatigue / Malaise  Low Blood Count  Anorexia Content 81  Acute local reactions  Altered skin integrity  Alterations in oral mucosa  Esophageal irritation with chest pain and dysphagia  Bone marrow cells proliferate rapidly,  Increased risk for infection 3. Chemotherapy Chemotherapy is a systemic therapy; this means that it affects the whole body by going through the bloodstream. Chemotherapy may be used in five ways. 1. Adjuvant therapy, which is a course of chemotherapy used in conjunction with another treatment modality and aimed to treating micro-metastases. 2. Neo-adjuvant chemotherapy by administration of chemotherapy to shrink a tumor before it is removed surgically. 3. Primary therapy, for treatment of patients who have localized cancer for which an alternative but less than completely effective treatment is available. 4. Induction chemotherapy, drug therapy is given as the primary treatment for patients who have cancer for which no alternative treatment exists. 5. Combination chemotherapy, administration of two or more chemotherapeutic agents to treat cancer to allow each medication to enhance the action of other or to act synergistically with it. Side effects of chemotherapy:  Nausea and vomiting:  Hepatomegaly, Jaundice and abdominal pain.  Depression of bone marrow function resulting in decreased production of blood cells. Decreases the number of WBCs (leukopenia), red blood cells (anemia), and platelets (thrombocytopenia) and increases the risk for infection and bleeding.  Congestive heart failure. Content 82  Pneumonitis.  Hypoxemia  Hand and feet paresthesia. Muscle weakness and loss of deep tendon reflex.  Dysuria, hematuria.  Irreversible damage of the kidney  Gonadal failure, infertility and premature menopause  Skin problems: petechiae, ecchymosis , skin dryness, desquamation, shrinking , wrinkles and thinning, poorly healing wounds  Alopecia (Hair loss)  Fatigue: Nursing Interventions: Managing Stomatitis;  Clinicians agree that good oral hygiene that includes brushing, flossing, and rinsing is necessary to minimize the risk for oral complications associated with cancer therapies.  Soft-bristled toothbrushes prevent or reduce trauma to the oral mucosa.  Oral swabs with sponge like applicators may be used in place of a toothbrush for painful oral tissues.  Oral rinses with saline solution or tap water may be necessary for patients who cannot tolerate a toothbrush.  Products that irritate oral tissues or impair healing, such as alcohol-based mouth rinses, are avoided.  Foods that are difficult to chew or are hot or spicy are avoided to minimize further trauma.  The patient's lips are lubricated to prevent becoming dry and cracked.  Adequate fluid and food intake is encouraged. Content 83 Maintaining Tissue Integrity:  The patient who is experiencing skin and tissue reactions to radiation therapy requires careful skin care to prevent further skin irritation, drying, and damage.  The skin over the affected area is handled gently; rubbing and use of hot or cold water, soaps, powders, lotions, and cosmetics are avoided.  The patient may avoid tissue injury by wearing loose-fitting clothes and avoiding clothes that constrict, irritate, or rub the affected area.  If blistering occurs, care is taken not to disrupt the blisters, thus reducing the risk of introducing bacteria. Assisting Patients to Cope With Alopecia:  The nurse's role is to provide information about alopecia and to support the patient and family in coping with disturbing effects of therapy, such as hair loss and changes in body image.  Patients are encouraged to acquire a wig or hairpiece before hair loss occurs so that the replacement matches their own hair.  Use of attractive scarves and hats  Knowledge that hair usually begins to re-grow after completing therapy Promoting Nutrition: General Nutritional Considerations  Whenever possible, every effort is used to maintain adequate nutrition through the oral route.  Food should be prepared in ways that make it appealing. Unpleasant smells and unappetizing-looking foods are avoided.  Family members are included in the plan of care to encourage adequate food intake. Small, frequent meals are provided, with supplements between meals. Content 84  Patients should avoid drinking fluids while eating, to avoid earl)' satiety. Oral hygiene before mealtime often makes meals more pleasant.  Pain, nausea, and other symptoms that may interfere with nutrition are assessed and managed.  Nutritional support via the enteral route may be necessary..  Parenteral nutrition (PN) may be necessary. Relieving Pain:  Analgesics are administered based on the patient's level of pain  non-pharmacologic approaches offer the best methods of managing cancer pain. Decreasing Fatigue:  Alternating periods of rest and activity are beneficial. Regular, light exercise may decrease fatigue and facilitate coping  Nutrition counseling is provided to patients who are not eating enough calories or protein. Improving Body Image and Self-Esteem:  Any negative feelings that the patient has or directs to body image should be identified and discussed. Assisting In the Grieving Process:  An important role of the nurse is to answer any questions the patient and family have and clarify information provided by the physician.  The nurse encourages the patient and family to verbalize their feelings in an atmosphere of trust and support. Content 85