NCM 112 Complete Finals PDF

CELLULAR ABERRATION PART I – NCM 112  A disease process whereby cells proliferate abnormally, ignoring growth-regulating Parts of the Cell signals in...

CELLULAR ABERRATION PART I – NCM 112  A disease process whereby cells proliferate abnormally, ignoring growth-regulating Parts of the Cell signals in the environment surrounding the cells. Nursing Role in Cancer Care  Multifaceted and overlaps with many other nursing specialties  Occurs in: hospitals, clinics, rehabilitation centers, home care, and long-term facilities  Diagnosis to end-of-life care. Precision Medicine Cell Cycle  Advances in technology and biological Interphase research (like genome sequencing)  G0, Normal Human Cells  Identification of unique patient  G1, Cell start to grow but some DNA, cell characteristics (genomics and cellular growth. profiles)  S, Replication of DNA occurs  Development of personalized, precise, and targeted treatment for cancer. Mitosis  Modern approach to understanding health  Prophase – chromosomes are condensed  Connecting, Collecting, and Analyzing many  Metaphase – Chromosomes align at the kinds of information based on the disease center that presented on the certain, specific client.  Anaphase – The duplicated DNA  Stop focusing on the general disease itself segregates but the client’s specific disease symptom  Telophase – Chromosomes are Cancer Health Disparities decondensed  Socioeconomic status Cytokinesis  Race/Ethnicity  Cell splits into two daughter cells  Diet  Stress Resting Phase (G0)  Geography  Cells may leave interphase and enter into a Pathophysiology non-dividing quiescent phase.  Anaplasia. The pattern of growth in which cells lack normal characteristics and differ in shape and organization from their cell of origin.  Genetic mutation of DNA  Formation of the abnormal clone  Proliferation of the abnormal clone  Abnormal clone requires invasive characteristics. Metastasis Disruption of Cell Cycle = Abnormal Cell Growth  Ability of cancer cells to penetrate lymphatic CANCER and blood vessels, circulate through the amlap  bloodstream, and then invade normal  Usually to the bone, brain, liver, and lung (to tissues elsewhere in the body. the highly vascular organs)  Often causes generalized effects such as anemia, weakness, systemic inflammation, Tumor Angiogenesis weight loss, anorexia, and CAS.  Often causes extensive tissue damage as  Growth of new blood vessels from the the tumor outgrows its blood supply or vasculature encroaches on blood flow to the area, may  Tumor releases vascular endothelial growth also produce substances that cause cell factor (VEGF) to stimulate blood vessel damage. formation.  Causes death unless growth can be Neoplasm controlled.  Recurs when excised surgically and the size  An abnormal growth of tissue that does not is double than the former size. have any physiological purpose or function.  Prognosis. If the client is diagnosed early,  Used interchangeably with the mass, tumor, good prognosis. If the client is diagnosed cyst or lump late, then bad prognosis.  Two types: benign and malignant. Carcinogenesis Benign. Well-differentiated cells resemble normal cells of the tissue from which the tumor  Process of transforming normal cells into originated. cancerous ones and has significant clinical implications.  Growth. Grows by expansion and does not  Initiation – Promotion – Progression infiltrate the surrounding tissues, usually  Initiation. Exposure to carcinogens that encapsulated. Grows slowly but causes DNA mutation. continuously throughout life unless excise  Promotion. Proliferation and expansion of surgically. mutated cells.  Does not spread by metastasis.  Progression. Angiogenesis, invasion and  General effects. Localized phenomenon and metastasis. does not cause generalized effects unless location interferes with vital functions. Carcinogens  Does not cause cell damage unless its  Agents that initiate and promote the location interferes with the vital function. formation of cancer. Does not cause death.  Recurrence. Does not recur when excised Invasion surgically.  Refers to the growth of the primary tumor  Prognosis. Good into the surrounding host tissues. Malignant. Poorly-differentiated or  It occurs by forcing finger-like projections of undifferentiated and may bear little the tumor into the surrounding tissues, resemblance to the normal cells of the tissue breaking away from the primary tumor and which they arose (anaplasia). invading adjacent structures, or producing enzymes that destroy surrounding tissues.  Grows at the periphery and infiltrates. Rate of growth is variable and depends on level Proliferative Patterns of differentiation, the more anaplastic, the faster its growth.  Can access to the blood and lymphatic channels and metastasizes to other areas of the body. amlap  fewer signs of plasma cells and proteins in the blood.  Smoldering Multiple Myeloma (SMM). No symptoms and more signs of plasma cells and proteins in the blood.  Multiple Myeloma (MM). Symptoms throughout the body. Blood is full of cancerous plasma cells and proteins. Etiology of Cancer  Viruses and Bacteria CLASSIFICATION OF CANCER BY TISSUE OF  Physical Agents ORIGIN  Chemical Agents Adenocarcinoma  Genetics  Thickened, plaque-like white mucous Viruses membranes.  Human papilloma virus: linked to cervical,  Originate from the epithelial tissues in our head, and neck cancer (epithelial tissues) body.  Hepatitis B virus: associated with liver Squamous Cell Carcinoma cancer  Epstein Barr Virus: connected to Burkett  Large with abundant eosinophilic cytoplasm lymphoma and NPCA, EBV infects B cells. and a large, often vesicular nucleus.  Cancer that begins in the squamous cells, Bacteria thin, and look like fish scales.  Helicobacter pylori: associated with gastric Sarcoma cancer. Chronic H pylori infection leads to prolonged inflammation in the stomach  Low grade, mid-grade, and high grade are lining, causing DNA damage and increasing used to describe soft tissue sarcoma. risk for cancer.  Originates in supportive and connective tissues such as bones, tendons, cartilage, Physical Agents muscle, and fat.  Sunlight – UV rays cause skin cancer  Low Grade. Look more like normal cells (melanoma, BCCA, SCCA) under a microscope and grow and spread  Clothing styles – inadequate clothing more slowly than in mid-grade and high- coverage increases UV exposure grade soft tissue sarcoma.  Sunscreen – help protect against UV-  Mid-Grade. Abnormal under a microscope, induced skin damage and skin cancer. spread more quickly than low grade.  Occupation and recreational habits –  High-Grade – look more abnormal, quickest outdoor work of activities increase UV among the three. exposure, particularly in high-risk conditions Myeloma (high altitudes, low altitudes, high humidity)  Medical procedures – repeat exposure to  Large nuclei that make the cell look like X-rays and radiation therapy pimento stuffed olives.  Occupational exposure – workers at  Cancer that arises in plasma cells, a type of nuclear weapon manufacturing sites or white blood cell. nuclear power plants are at increased risk Types of Myeloma due to ionizing radiation.  Radon – a radioactive gas that can  Monoclonal Gammopathy of Undeclared accumulate in poorly ventilated homes, Significance (MGUS). Few symptoms and especially in basements. amlap   Tobacco Carcinogens – persistent  Extra, too few, or translocated exposure to tobacco smoke irritates chromosomes can disrupt normal cell respiratory tissues, leading to lung and function, leading to cancer other cancers.  Chronic Myelogenous Leukemia (CML).  Industrial Chemicals and Asbestos – Chromosomes 9 and 22 (aka Philadelphia prolonged exposure to industrial chemicals Chromosome) or asbestos can cause chronic inflammation  Meningiomas in the lungs and other tissues, raising the  Acute Leukemia risk of cancers such as mesothelioma  Retinoblastomas (linked to asbestos) and other industrial-  Wilms Tumor (Cancerous tumors from the related cancers. cells of the kidneys)  Mutations can be inherited (germline – present at birth) or acquired (somatic – Chemical Agents parent has mutated gene 50% chance that the child will inherit it)  Tobacco/Smoking – cancer of head, neck,  Family history of cancer in two or more 1st- lungs, esophagus, stomach, pancreas, degree relatives (parents, siblings, children) cervix, kidney, bladder, myeloblastic  Early onset of cancer (diagnosis before age leukemia. 50)  Passive Smoke (Secondhand Smoke) –  Same type of cancer in multiple family lung cancer, childhood leukemia, larynx, members pharynx, brain, bladder, rectum, breast.  Individual family members with more than  Other Tobacco Products one type of cancer o Cigars, pipes o Roll-your-own products  Rare cancers in one or more family o Water pipes (hookah) members o Electronic Nicotine Delivery Systems  Hereditary Cancer Syndromes o Chewing tobacco – oral, pancreatic, o BRCA1 / BRCA2 – Breast and esophageal cancer. ovarian  Vinyl chloride (Plastic) – liver cancer and o MEN1/MEN2 – Multiple endocrine other cancer among workers in plastic, neoplasia syndromes asbestos, and construction industries. Lifestyle Factors  Polycyclic Hydrocarbons – produced by refuse burning, vehicle emissions, oil  Diet – ingestion of carcinogens, absence of refineries, and air pollution. protective substances (antioxidants, fiber,  Betel Nut and Lime – Chewed as and phytochemicals), high in saturated trans stimulants in some cultures, they are linked fat. to oral cancers.  Alcohol Consumption – can damage  Arsenic, soot, and tars – found in certain cellular DNA which can lead to cancers of industrial environments. the mouth, pharynx, larynx, esophagus,  Fertilizers and Pesticide – chemicals in liver, rectum, and breast. these products can increase cancer risk,  Salt-cured and Smoked Foods – contain particularly among agricultural workers. carcinogenic compounds like nitrosamines,  Formaldehyde – linked to cancers of the which increase the risk of cancers, respiratory system and other organs. particularly in the stomach and digestive  Dyes (Aniline Dyes) – often used in beauty tract. products like hair bleach, they are  Nitrate and Nitrite-Containing Foods – associated with bladder cancer. processed meats (e.g. bacon, bologna, canned meat, corned beef, deli meat) Genetics contain nitrates and nitrites, which can form  Chromosomal Abnormalities amlap  carcinogenic compounds during cooking or Role of Immune System digestion.  Immune system regularly identifies and  Red and Processed Meats – consuming destroys cancer cells through immune large amounts has been linked to an surveillance increased risk of colon, stomach, and other cancers. Cooking at high temperatures  Immune surveillance fails – (grilling, frying) can also produce Immunocompromised patients (e.g.post- carcinogenic compounds. transplant patients, AIDS, patients treated  Obesity – major risk factor for cancers of with previous cancer) have increased incidence of cancer the breast, colon, endometrium, esophagus, kidney, pancreas, thyroid, gallbladder,  Tumor growth and progression ovary, cervix, multiple myeloma, Hodgkin Predisposing Factors lymphoma (lymph node cancer), and prostate; promotes chronic inflammation  Age – older individuals and hormonal imbalances. o Longer exposure to carcinogens  Sedentary Lifestyle – physical activity o Alterations in the immune system helps regulate weight, hormone levels, and  Sex immune function, all of which play a role in o Male: prostate cancer cancer prevention. o Female: breast cancer  Disturbance in Endogenous Hormonal  Geographic Distribution Production - High or imbalanced levels of o Japan: gastric cancer, maybe natural hormones (like estrogen, related to national diet (raw foods), progesterone, and testosterone) can ethnic customs, and pollution stimulate cell growth in hormone-sensitive o US: Breast cancer tissues, increasing the risk of cancers in the  Occupation – risk of exposure to breast, prostate, and uterus. carcinogens  Diethylstilbestrol (DES) – synthetic o Chemical factory workers estrogen has been linked to an increased o Farmers risk of breast cancer in women who took it o Radiology Department personnel and clear cell adenocarcinoma of the vagina  Precancerous Lesions and cervix in their daughters. o Pigmented moles  Early Menstruation (Before Age 12) and o Burn scars Late Menopause (After Age 55) – o Senile keratosis prolonged estrogen exposure increasing the o Leukoplakia risk of breast and endometrial cancers. o Benign polyps or adenoma of  Nulliparity (No childbirth) – higher lifetime colon/stomach exposure to estrogen and progesterone, o Fibrocystic disease of the breast which increases the risk of breast, o Obesity endometrial, and ovarian cancers.  Breast Cancer Common Causes  Delayed Childbirth (After Age 30) – longer o Early menarche period of uninterrupted estrogen exposure o Late menopause before the pregnancy-related hormonal o Nulliparous / older than 30 at birth changes increases breast cancer risk.  Lung Cancer Common Causes  Estrogen and Progesterone Therapy – o Tobacco use hormone replacement therapy (HRT) is o Asbestos used for managing menopausal symptoms o Radiation exposure but is associated with an increased risk of o Air pollution breast, endometrial, and hepatocellular  Colorectal Common Causes cancers but decreases risk of ovarian o Men cancer. o Familial polyposis o Ulcerative colitis amlap  o High fat low fiber diet fluid retention and increased glucose  Prostate levels. o >50 yo men  Pain – major concern of clients and families o Highest incidence in African associated with cancer Americans  Physical stress – body tries to respond o Positive fam history and destroy neoplasm o Exposure to cadmium  Psychological and Financial Stress  Cervical Cancer o Sexual behavior Effects of Cancer o First intercourse at an early age  C – Change of bowel/bladder habits o Multiple sex partners o Color, consistency o Sexual partner who has had multiple o Size/shape of stools sexual partners o Blood present o Human Papillomavirus and o Alternating constipation and diarrhea Autoimmune Disease Syndrome (most common characteristic of o Low socioeconomic status colon cancer) o Cigarette smoking  A – A sore that does not heal  Head and Neck Cancers o Doesn’t seem to be getting better o Male over time o Alcohol and tobacco use o Getting buffier o Poor oral hygiene o More painful o Long-term sun exposure o Starts to bleed o Occupational exposure – asbestos, o Tumor causes impaired circulation tar, nickel, textile, wood, leather, and oxygenation work, machine tool experience  U – unusual bleeding or discharge  Skin o Blood in stool or urine o Fair complexions o Discharge from any parts of body o Positive family history  T – thickening or lump in breast or o Moles elsewhere o Exposure to coal, car, creosote, o Any lump found in the breast doing arsenic, radium SBE o Sun exposure between 11am to 3pm o Scrotum during self-exam  Effects of Cancer o Other lumps found in body o Disruption of function – due to  I – indigestion or difficulty swallowing obstruction or pressure o Feeling pressure in throat or chest o Hematologic alterations – can which makes swallowing impair the function of blood cells uncomfortable o Hemorrhage – tumor erosion, o Feeling full without food or with a bleeding, severe anemia small amount o Anorexia-Cachexia syndrome –  O – Obvious changes in wart or mole wasted appearance of the patient o A: asymmetry  Paraneoplastic Syndromes – ectopic sites o B: border with excess hormone production o C: color o Increased parathyroid hormone – o D: diameter hypercalcemia  N – Nagging cough or hoarseness o Increased secretion of insulin – o Change in voice hypoglycemia o Hoarseness o Increased ADH – fluid retention, o Sputum with blood hypertension, and peripheral edema  U – Unexplained anemia o Increased ACTH – causes excessive o Cancer slows down EPO production secretion of cortisone which causes amlap  o RBCs wear out faster than normal o Ultrasounds and not replaced as quickly o Magnetic resonance imaging  S – Sudden weight loss o Nuclear imaging o Tumor uses your blood and nutrients o Angiography and releases waste products inside o Endoscopy exams the body.  Diagnosis of Cell Type o Tissue samples: from biopsies, Physical Assessment shedded cells (papanicolau PAP  Inspection smear) and washings o Skin and mucous membranes, o Cytologic examination: tissue lesions, bleeding, petechiae, examined under microscope irritation  Direct Visualization o Stool, urine, vomitus; acute or occult o Sigmoidoscopy – rectum, lower blood colon o Scalp: noting hair texture and hair o Cystoscopy loss o Endoscopy  Palpation o Bronchoscopy o Abdomen for any masses, bulges, o Exploratory Surgery: Lymph node abnormalities, and tenderness biopsies to determine metastases o Lymph node enlargement Cancer Screening  Auscultation o Heart sounds  PAP Smear o Lung sounds o Early detection of cancer in the o Bowel Sounds cervix  Laboratory Tests o Doctor uses a small brush or o Hemoglobin wooden scraper to remove a sample o Hematocrit (low in anemia, may of cells from the cervix and upper indicate malignancy) vagina. Cells are placed on a slide o Leukocytes and sent to the laboratory. o Platelets o Early detection from pap tests has  Tumor markers – a substance made by helped lower the death rate from tumor in the blood. cervical cancer by more than 75% o PSA (prostatic-specific antigen): o Additional tests may be necessary. prostate cancer  Mammography o CEA (carcinoembryonic antigen): o Most beneficial during menopause colon cancer o Not sufficient enough as definitive o AFP (alpha-fetoprotein): liver, proof for presence or absence of ovaries, testicles breast cancer. Additional tests may o HCG (human chorionic be necessary. gonadotropin) o If light colored, cancer o Alkaline phosphatase: bone o If dark colored, tissue or fat metastasis  PSA test and Digital Rectal Exam o Leukocytes o Men 50 and above o Platelets o Biopsy to confirm  Biopsy o Experts are trying to develop blood o Needle aspiration tests that might alert people to o Incisional – remove part of tumor malignancies while cancers are still o Excisional – remove whole tumor in their early stages.  Determine the location of the cancer  Fecal Occult Blood Test (FOBT) o X-rays o Detects the invisible amount of blood o Computed tomography in the feces amlap  o Screening for colon cancer o N0 – no regional lymph node o Stool sample Is smeared on a metastasis chemically treated card o N1 – the doctor can feel the lymph o If blood is confirmed, more tests will node/s be conducted to find the source of o N2 – nodes feel swollen and lumpy bleeding. o N3 – swollen distant lymph nodes  M – Metastasis Cancer Staging o Mx – distant metastasis. Cannot be  Determines the size of tumor assessed.  Existence of local invasion o M0 – no distant metastasis  Lymph node involvement o M1 – distant metastasis  Distant metastasis Tumor 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 characteristics of the tissue of origin. TNM STAGING  Grade X o Grade cannot be assessed  T – Tumor (undetermined grade) o Tx- primary tumor cannot be  Grade I assessed o Well-differentiated o T0 – no evidence of primary tumor o less aggressive o Tis – carcinoma in site o better prognosis o T1 – tumor penetrates mucosa and  Grade II submucosa o Cells look somewhat abnormal o T2 – tumor invades but fails to o Moderately differentiated penetrate muscle layer. o Intermediate grade tumors o T3 – tumor penetrates the  Grade III subserosa o Very abnormal o T4 – tumor directly invades other o Considered as high grade organs and structures.  Grade IV  N – Node o Poorly differentiated/undifferentiated o Nx – regional lymph nodes cannot o More aggressive be assessed o Less responsive to treatment amlap  o Recognizing early signs and symptoms and seeking prompt treatment and intervention to halt cancerous process by using screening tools. o Mammogram o PAP smears o DRE o Colonoscopy Nursing Diagnosis  Tertiary Prevention o Focus on monitoring and preventing  Acute or chronic pain recurrence of the primary cancer as  Impaired skin integrity well as screening  Impaired oral mucous membrane o Chemotherapy  Risk for injury o Radiotherapy  Risk for infection  Fatigue  Imbalance nutrition: less than body Cancer Prevention requirements  Risk for imbalanced fluid volume  Avoid tobacco  Anxiety  Protect yourself from excessive sunlight  Disturbed body image o Wear protective clothing  Ineffective coping o Sun screen lotions  Social isolation o Sun is brightest from 11am-4pm  Limit alcohol intake Outcomes  Limit fats and calories: lessen meat consumption  Pain relief  Consume fruits and vegetables: 5-9  Integrity of skin and oral mucosa servings/day  Absence of injury and infection  Avoid cancer viruses  Fatigue relief  Avoid carcinogens at work  Maintenance of nutritional intake  Avoid industrial pollution  Maintenance of F and E balance  Improved body image THANK YOU!!!!  Absence of complications  Knowledge of prevention and cancer treatment  Effective coping through recovery and grieving process  Optimal social interaction Implementation and Management  Primary Prevention o Reducing modifiable risk factors through health promotion o Reducing smoking and alcohol consumption o Healthy lifestyle o Vaccinations  Secondary Prevention amlap  CELLULAR ABERRATION PART II Treatment  NO DEFINITE CURE FOR CANCER  Approaches are not initiated until the diagnosis of cancer has been confirmed and staging and grading has been completed.  Determined by: type and extent of tumor involvement, treatment goals, performance status, age, and client’s co-morbid conditions. Definitive goals  Cure: complete eradication of the disease  Control: Prolong survival, containment of cancer growth, functional status and maintaining quality of life.  Palliation: Relief of symptoms (pain) associated with the disease and improvement of the quality of life. American Cancer Society  Breast o Breast self-examination o Clinical breast examination o Mammography  Colorectal o Sigmoidoscopy o Barium enema o CT colonography / virtual colonoscopy o FOBT  Prostate o PSA (Prostate self-exam)  Cervix o Pap test/smear o Co-testing with HPV and pap test Triad Management amlap  o Use of an electric current to destroy tumor cells  Laser surgery/ Photocoagulation/ Photoablation o Use of light and energy aimed at an exact tissue location and depth to vaporize cancer cells.  Photodynamic Surgery o IV administration of a light sensitizing agent  Radiofrequency ablation Treatment Modalities o Used localized application of thermal energy that destroys cancer cells.  Surgery DIAGNOSTIC SURGERY  Radiation  Chemotherapy Excisional Biopsy  Immunotherapy / Biologic Therapy  Most frequently used for small easily  Molecularly targeted therapy accessible tumors of the skin, breast, GIT, Surgery and upper respiratory tracts.  Removal of diseased tissues. If cancer is Incisional Biopsy confined to the removed tissue, surgery  Wedge of tissue from the tumor to remove alone can be a cure to cancer for analysis. Performed if the tumor is too  Indicated to diagnose, stage, and treat, large to be removed. certain type of cancer.  May be used as a combination with other Needle Biopsy treatments  The ideal form of treatment  Performed to sample suspicious masses that are easily and safely accessible. Usage of Surgery  Removal of the diseased tissue Prophylactic surgery  Diagnostic  Prophylactic  Removal of precancerous lesions or benign  Palliative tumor to prevent cancer  Reconstructive  Colectomy, mastectomy, oophorectomy  Cure  Performed in clients with an existing  Control premalignant condition or a known family history or genetic mutation. Surgical Techniques used for Localized Destruction of Tumor Tissue Curative Surgery  Chemosurgery  All gross and microscopic tumor is removed o Use of chemicals or chemotherapy or destroyed applied directly to tissue to cause  May include surrounding tissue and regional destruction. lymph nodes.  Cryoablation  May result in disfigurement, altered o Use of liquid nitrogen or a very cold functioning, needing rehabilitation or probe to freeze tissue and cause cell reconstructive procedure. destruction Control Surgery  Electrosurgery amlap   Aka debulking Preventive Measures  Increases the chance for other therapies to  Administration prophylactic antibiotics to be successful reduce infection risk  Removing a large portion of locally invasive  Provide specific instructions regarding diet tumor. and bowl preparation if needed Palliative Surgery Patient support  Performed to improve quality of life during  Act as a patient advocate and liaison, the survival time for symptom relief and encouraging family involvement in decision- comfort making.  Cure is not an option  Ensure patients and families receive o Reduce pain consistent information to reduce anxiety and o Relieve destruction improve collaboration. o Relieve pressure o Prevent hemorrhage Reconstructive Surgery  Improve quality of life by restoring maximal Radiation Therapy function  More desirable cosmetic effect  Uses ionizing radiation to interrupt cellular  Example: growth of tumor cells o Breast reconstruction after  Causes cellular destruction but affects both mastectomy normal and abnormal cells o Head and neck  Used as supportive therapy in conjunction o Skin cancers with surgery and chemotherapy  Reduce tumor size, prevent local Adverse Effects of Surgery recurrence, relieve symptoms of metastatic disease.  Loss of function of a specific body part  Treat oncologic emergencies  Reduced function as a result of organ lost o Superior vena cava syndrome  Scarring or disfigurement o Bronchial airway obstruction  Grieving about altered body image or o Spinal cord compression imposed change in lifestyle o Bleeding  Pain, infection, bleeding, and  Localized treatment, targeting specific areas thromboembolism. to minimize damage to surrounding healthy Nursing Responsibilities tissues.  Mostly effective in Preparation of surgery o Small tumors  Provide both verbal and written information o Rapidly dividing about the surgical procedure to ensure o Poorly differentiated patient understanding.  Dosage  Educate about potential post-op o Sensitivity of target tissues complications due to prior radiation or o Size of tumor chemotherapy such as: o Radiation tolerance of surrounding o Infection normal tissues o Impaired wound healing o Critical structures adjacent to tumor o Altered pulmonary or renal function target. o Venous thromboembolism Principles of Radiation o Fluid and electrolyte imbalance o Organ dysfunction. amlap   Time – exposure time is 15-30 minutes per Types of Radiotherapy shift uninterrupted External Radiation  Distance – stay 3-5 feet distance from the source  Teletherapy/ Beam radiation  Shielding – wear lead apron  Administered by x-ray Types of Radiation  Sources: betatron, linear accelerator, cobalt 60 teletherapy machine  Non-ionizing  Client is not radioactive o Infrared  Skin changes known as radiodermatitis o Radio waves occur due to skin penetrated by radiation o Visible light rays (occurs 3-6 weeks after the start of the o Radiofrequency from cellphones treatment.  Ionizing  Superficial injury from radiation can o Gamma rays manifest as erythema, hyperpigmentation, o X-rays and dry/moist desquamation o UV rays  Less toxic Types of External Radiation  External Beam RT (EBRT) Functions of Ionizing Radiation o Beam of highly charged protons or gamma rays to penetrate the body  Alters DNA molecules of cells, leading to and target the tumor with pinpoint cell death accuracy.  Damage DNA through formation of free o Allows for more precision to target radicals by replicating cells most vulnerable the tumor o Bone marrow: affects blood cell o Less toxicity production  Intensity modulated RT o Lymphatic tissue: impairs immune o Intensity / energy levels can be response controlled at the different angles o GI epithelium: Causes GI side aimed at the tumor effects such as nausea or diarrhea o Higher doses delivered to tumor o Hair follicles: lead to hair loss while sparing healthy surrounding o Gonads: may result in infertility or tissues hormonal changes o Daily fractions or hyperfractionated shorten patient duration of treatment Particulate Radiation schedule  Electrons  Image guided RT  Beta particles o Repeated imaging to account for  Protons tumor movement e.g. due to  Neutrons breathing or organ shift and changes in size, shape, or position  Alpha particles o Ensures the radiation beam remains Uses Radiotherapy focused on the tumor, minimizing exposure to surrounding healthy  Before surgery (Neo-adjuvant) – decrease tissues. the tumor size)  Stereotactic Body RT  After surgery (Adjuvant) – eradicate the o High doses of radiation penetrate possible residual disease very deeply into the body to control  Concurrent – in conjunction with deep seated tumors, 1-5 tx days. chemotherapy o Proton therapy amlap  o Delivery high energy dose to a deep  It is enclosed in a metal container in the for tumor with increased doses of of seed, bead, needle, plaque or mold radiation to tissues in front and  The client will be placed on strict bed rest to virtually no radiation exists to prevent dislodgement of the radiation patient’s healthy tissues behind source. tumor.  Must be at the bedside long forceps and o Close proximity to a critical lead-lined container destruction.  In case of accidental dislodgement, the Nursing Responsibilities nurse should retrieve the radioisotope with long forceps. Pick it up at arm’s length and  Inform the client that this is a short and place it in its lead-lined container (lead pig). painless procedure that will last for 20-30 Notify the radiologist for reinsertion. minutes High Dose Radiation  Instruct the client not to wear constricting clothing during the procedure to prevent  Treatment time is shorter further skin breakdown.  Reduced exposure to personnel  Inform the client that the radiologist / RTT  Outpatient basis over several days will place a skin mark/port. It delineates the part of the body where radiation rays pass. Local Internal Radiation  Advice the client not to remove the skin  Intraluminal HDR: insertion of catherters mark. It can only be removed once the into lumens of organs treatment has been completed.  Surface: treatment for tumors of the eye  Focus on skin care  Interstitial HDR: catherter placed into o Use only water and avoid soap in perineum closes to affected organ (prostate, cleaning the affected area, although pancreatic, breast, gyne) soap can change the angle and  Intracavitary intensity of radiation o Pat the area dry, do not rub Systemic Internal Radiation (Unsealed) o Avoid o Promote healing patient comfort and  IV administration of a therapeutic quality of life radioactive isoptope o ERBT – assess patient’s skin  Iodine (1-131) thyroid cancer o Assess nutritional status  Radium – 223 dichloride – prostate cancer bone metastases  The isolation time will depend on the half- Internal Radiation life of the radioisotope used.  Local or systemic Nursing Responsibilities  Higher dose and intensity of radiation provided than external  Provide specific care for clients receiving  Introduced into the patient’s body radiation via unsealed source (IV, orally, or  The client is radioactive, therefore the direct instillation into the body cavity.) principles of radiation are observed. o Isotope maybe excreted in body waste: instruct client to flush the Brachytherapy toilet several times after each use for several days  Indicated for radioisotope with long half-life o Color of trash bin for toxic  Implanted in the body cavity (intracavitary) substances red or orange or directly to the tumor o Remove trash when client is  Implantation takes about 2-3 days where discharged the client is isolated o Use paper plates and disposable utensils. amlap Effects of Radiotherapy o Necrosis  Occur within 2 weeks of treatment initiation Nursing Responsibilities  Symptoms depend on the treatment site  Nurses must wear a film badge which and may include measures the rad per number of exposure o Skin reactions to radiation o Fatigue  The maximum permissible exposure is 400 o Gastrointestinal upset milliards per month  Develop 6 months to 1 year post-treatment  A nurse should never care for more than  Can progress to chronic tissues including one client with a radiation implant at one o Fibrosis: scarring of tissues time o Atrophy: tissue shrinkage or loss of  The nurse must maximize her nursing care function within 30 minutes. Over exposure may lead o Ulceration or necrosis: tissue to leukemia, leucopenia breakdown or death.  No pregnant, nurses, or visitors are  Altered skin integrity permitted near radiation o Alopecia o Hyperpigmentation  Visitors younger than 18 years are not o Radiation dermatitis allowed. o Erythema and dry desquamation  Contact with the HC team is guided by o Moist or wet desquamation principles of time, distance, and shielding to  Skin factors minimize exposure of personnel to radiation o Dose and form of radiation  Assign pt to an isolated provate room o Inclusion of skin folds  Limit visitors to 90 mins daily o Increased age  6 feet distance from radiation source o Medical comorbidities Chemotherapy o Tx interruption, delays, or cessation of therapy.  Use of antineoplastic drugs in an attempt to  Alterations in oral mucosa destroy cancer cells by interfering with o Stomatitis cellular functions, including replication and o Decreased salivation DNA repair. o Xerostomia  Systemic delivery o Change or loss in taste  May be combined with surgery, radiation, or o Mucositis both.  Organ involvement  Reduce tumor size preoperatively (neo  Stomach/colon involvement adjuvant) o Anorexia  Destroy any remaining tumor cells post-op o Vomiting (adjuvant) o Diarrhea  Treat some forms of leukemia (primary)  Bone marrow involvement  Chemical Group: o Anemia o Alkylating agents o Leukepenia o Nitrosources o Thrombocytopenia o Antimetabolites  Systemic side effects o Antitumor antibiotics o Fatigue o Topoisomerase inhibitors o Malaise o Plant alkaloids o Anorexia o Hormonal agents  Late Effects  Adjunct chemotherapeutic agents additional o Fibrosis meds given with chemo to enhance activity / o Atrophy protect normal cells o Ulceration  Reduces/lessens toxicity amlap Cell Division (Refer to page 1)  Organ function  Laboratory results Drugs for Chemotherapy  Previous exposure and response to RT Drug Class and Cell- Common side  Dangerous toxicities Example cycle effects o Maximum lifetime dose limits must Alkylating Agent Cell-cycle Bone marrow be adhered (Cyclophosphamide) non-specific suppression, nausea and vomiting, cystitis, Routes alopecia Nitrosources Cell-cycle Thrombocytopenia, (Carmustine) non-specific nausea and vomiting,  Oral pulmonary and  IV hepatic and renal  Intrathecal damage Topoisomerase Cell-cycle Bone marrow  Implanted vascular port Inhibitors specific (S- suppression, n and v,  Intravesicular (topotecan) phase) diarrhea, flu like  Regional perfusion symptoms Antimetabolites Cell-cycle Bone marrow (Methotrexate, S- specific (S- suppression, n and v, Nursing Considerations for IV Flourouracil) phase) diarrhea, stomatitis, renal toxicity  The appropriate IV site for chemotherapy Antitumor antibiotics Cell-cycle Bone marrow administration is between the antecubital (Doxorubicin) non-specific suppression, n and v, space and wrist. diarrhea, flu-like symptoms  Vesicant and chemotherapy agents should Cell-cycle Bone marrow be administered before non-vesicant drugs specific (S- suppression, n and v, if two such drugs are ordered in phase) alopecia, anorexia, cardiac toxicity combination Plant alkaloids Cell-cycle Bone marrow  Client’s arm should be in a natural, relaxed specific (M- suppression, position during administration. phase) peripheral neuropathies  The IV line should be flushed with 10ml of Hormonal Agents Cell-cycle Menstrual normal saline specific irregularities, n and v,  If painful IV site, stop the infusion (growth hot flushes, jaundice, inhibitory masculinization, Types of Chemotherapy that Cause Local agent) feminization Damage Vesicants – have the ability to cause blistering, skin Chemo-tox man sloughing and damage to the surrounding tissue  Cisplatin / Carboplastin – acoustic nerve including necrosis. damage  Severe sloughing and ulceration may  Vincristine – peripheral neuropathy require skin grafting.  Steomycin – pulmonary fibrosis  Doxorubicin – cardiotoxicity Types of Vesicants  Trastuzumab – cardiotoxicity  DNA Binding  Cyclophosphamide 0 hemorrhagic cystitis  Non-DNA binding  5-FU – myelosuppression  Others  6-MP – myelosuppression  Methotrexate – myelosuppression Key Administration Guidelines Dosage  Antidotes must be readily available  Avoid peripheral veins in the hands or wrists  Patient’s total body surface area o {Sq root [(Weight (kg) x Height (cm)) Antidotes and Treatments / 3600]} x doctors order  Weight Extravasated Antidote Tx Vesicants amlap  Anthracyclines Dimethylsulfoxide Topical cooling o Promote hydration of at least 3 liters dexrazoxane per day Cisplatin Sodium Topical cooling chiosulfate  Methotrexate - Antineoplastic agent used for Dactinomycin Topical cooling treatment of a wide variety of cancers as Docetaxel Hyaluronidase Topical cooling well as autoimmune diseases. Mytomicin Dimethylsulfoxide Topical cooling Oxaliplatin Sodium Topical warming  Leucovorin – folic acid which is given Thiosulfate together with methotrexate to decrease its Paclitaxel Topical cooling toxic effects to normal cells. Vinca alkaloids Hyaluronidase Topical cooling  Doxorubicin – cytotoxic anthracycline antibiotic used to treat various cancers, Non-Vesicants including AIDS-associated Kaposi’s sarcoma Irritant Drugs o Common sx: Diarrhea, alopecia,  Alkalyting agents reddish urine, ventricular  Topoisomerase II inhibitors dysrhythmias and cardiotoxicity  Plastin salts  Vincristine – a vinca alkaloid used to treat acute leukemia, malignant lymphoma,  Topoisomerase I inhibitors Hodgkin’s disease. Only 2 mg or 2 mL  Antimetabolites o Side effects: peripheral neuropathy Extravasation (tusok2), depression of achilles tendon  Refers to unintended injury caused by  Tamoxifen – breast cancer patients chemotherapy drug leaking from the blood o Competes with estradiol for binding vessel during infusion therapy to estrogen in tissues containing  Occurs as a result of medical intervention high concentrations of receptors Managing Extravasation o Side fx: Nausea, vomiting, hypercalcemia, hot flushes,  Stop the infusion confusion, edema, bone pain, may  Leave the needle also increase cholesterol and triglyceride effects. Safe Handling of Chemotherapeutic Agents Toxic Effects of Chemo  Level 3 gowns  Nitrile gloves  Bone marrow depression  KN-95 mask  Alopecia  Avoid self-inoculation if needle puncture  GI disturbances (n and v, diarrhea)  Discard contaminated syringes and needles Care of Clients under Chemotherapy in puncture-proof and leak-proof containers  Anemia Common Drugs and Management o Rest periods are important to  Cyclophosphamide – a nitrogen mustard prevent over-exhaustion. used to treat lymphomas, myelomas, o Give them food rich in iron such as leukemia, mycosis fungoides, lean meat, liver, egg yolk, green neuroblastoma. Administered IV. Tea leafy vegetables colored urine. o Other sources that are rich in iron o BUN and creatinine prior to are shellfish, nuts, dried fruits, whole administration grain, enriched bread, cereals, citrus o Monitor I and O and voiding pattern. fruits o Encourage patient to empty bladder o Iron sulfate (FeSO4) should be given every 2-3 hours in an empty stomach to prevent diarrhea amlap  o Increase intake of high-protein foods o Consider cutting hair if long to and red meats minimize pulling and tangling. o Give iron preparation as ordered Shorter hair is less susceptible to such as Ferrous SO4 administered trauma and resulting hair loss. orally. o Protein-based shampoo should be  Neutropenia used to nourish hair cells. o Institute reverse isolation and o Use satin pillows to minimize friction protective isolation rubbing of the hair. Minimizing o Avoid people with upper respiratory friction will help to protect the hair. tract infection o Although ice caps on the head and o Limit the number of visitors rubber bands around the scalp have o The client is placed on a low- been used to try to limit alopecia, bacteria diet that excludes raw fruits they have not been particularly and vegetables effective. o And the damp, moist soil in potted  GI distrubances plants are good media for bacterial o Nausea and vomiting growth o Antiemetic agents: metoclopramide, o Use sterile techniques when ondansetron, offer ice chips or hot performing invasive procedures and cold beverages as long as it is  Thrombocytopenia not highly irritating. o Observe for bleeding tendencies o Constipation – laxative as ordered, o Avoid situations that could increase OFI potentially cause injury or bleeding o Diarrhea – fluid and electrolyte such as IM injection (avouidance replacement, avoid fatty foods, helps prevent hematomas and BRAT diet. abnormal bleeding) o Stomatitis – risk for altered nutrition o Venipuncture less than body requirements, offer o Rectal temperature fluids that are soothing to the mouth. o Flossing teeth Care for Patients With Cancer o Straight razor usage o Contact sports Assessment o Aspirin and aspiri-containing products Possible problems in cancer paitents: o Straining at bowel movements.  Infection: o Use of soft toothbrush or swab, blow o immune system compromised prone the nose gently to infection o Use an electric shaver, electric razor  Bleeding and shavers provide safely and o Local bleeding, fragile blood vessels prevent cuts due to angiogenesis o Padding the side rails and removing o Systemic bleeding: Nutritional all hazardous and sharp objects deficiencies leading to low vitamin from the environment levels. o Decrease the chance of  Skin Problems spontaneous bleeding, person o Vitamin E and C deficiencies should be handled gently.  Hair loss  Alopecia (reversible) o Related to nutritional deficiencies o Hair dyer, sprays, eyes, clips of  Nutritional concerns elastic bands, frequent shampooing, o Increased metabolic demand of and has perms all cause trauma to cancer cells the hair which might promote hair  Pain damage. amlap  o Damage to tissues activates  Relieving pain nociceptors o Implement both pharmacologic  Fatigue  Assisting in the grieving process o Often linked to nutritional o Help frame questions and connect deficiencies with resources  Psychosocial status  Monitoring and managing potential o Emotional and mental challenges o Complications: w/o for infection  Body Image septic shock, bleeding, or o Physical changes impact self- hemorrhage. esteem Evaluation Diagnosis  Expected outcomes  Impaired oral mucous membrane  Maintains oral mucous membrane integrity  Impaired tissue integrity  Maintains tissue integrity  Imbalanced nutrition  Maintains nutritional status  Anorexia  Achieves pain relief  Chronic pain  Increases activity tolerance and reduces  Fatigue fatigue  Disturbed body image  Improves body image and self-esteem  Anticipatory grieving  Progresses through grieving process  Experiences no complications Planning SPECIFIC CANCER DISEASES  Major goals of cancer management  Management of stomatitis (hygiene) Brain cancer  Maintenance of tissue integrity (proper  S/sx – headache, altered mental status, nutrition and hygiene ataxia, seizures, visual and speech deficits  Maintenance of nutrition  Evaluation – CBC imaging studies (MRI,  Relief of pain CT), electrolyte levels o Pharmacologic and non-  Management – Corticosteroids, surgery, pharmacologic measures radiation, chemotherapy  Relief of fatigue o Balanced rest and physical activity Breast Cancer  Improved body image  Effective progression through the grieving  S/sx – change in breast size/shape, process dimpling, nipple discharge, axillary lump o Support patient and family through  Evaluation – biopsy (definitive) DABDA stages mammography, imaging  Absence of complications  Management – surgery: radiation hormone therapy, chemotherapy Intervention Cervical Cancer  Managing stomatitis o Good oral hygiene, soft-bristled  S/sx – abnormal bleeding, malodorous toothbrush discharge, dysuria  Maintaining Tissue Integrity  Evaluation - pap smear colposcopy biopsy o Gentle skin care, avoid harsh  Management – HPV vaccination, surgery, substances, wear loose clothing radiation, chemotherapy  Promoting Nutrition Colorectal Cancer o Provide appealing meals, consider alternative feeding methods, vitamin  S/sx – anemia, rectal bleeding, bowel habit supplementation changes, obstruction amlap   Evaluation – CBC, imaging, endoscopy (colonoscopy gold standard)  Management – cryotherapy surgery, radiation, chemotherapy Lung Cancer  S/Sx – cough, chest pain, weight loss, fatigue  Evaluation – chest x-ray, CT scan, bronchoscopy  Management – surgery, radiation, chemotherapy amlap CELLULAR ABERRATION PART II Treatment Modalities Treatment  Surgery  Radiation  NO DEFINITE CURE FOR CANCER  Chemotherapy  Approaches are not initiated until the  Immunotherapy / Biologic Therapy diagnosis of cancer has been confirmed and  Molecularly targeted therapy staging and grading has been completed.  Determined by: type and extent of tumor Surgery involvement, treatment goals, performance status, age, and client’s co-morbid  Removal of diseased tissues. If cancer is conditions. confined to the removed tissue, surgery alone can be a cure to cancer Definitive goals  Indicated to diagnose, stage, and treat, certain type of cancer.  Cure: complete eradication of the disease  May be used as a combination with other  Control: Prolong survival, containment of treatments cancer growth, functional status and maintaining quality of life.  The ideal form of treatment  Palliation: Relief of symptoms (pain) Usage of Surgery associated with the disease and improvement of the quality of life.  Removal of the diseased tissue  Diagnostic American Cancer Society  Prophylactic  Breast  Palliative o Breast self-examination  Reconstructive o Clinical breast examination  Cure o Mammography  Control  Colorectal Surgical Techniques used for Localized o Sigmoidoscopy Destruction of Tumor Tissue o Barium enema o CT colonography / virtual  Chemosurgery colonoscopy o Use of chemicals or chemotherapy o FOBT applied directly to tissue to cause  Prostate destruction. o PSA (Prostate self-exam)  Cryoablation  Cervix o Use of liquid nitrogen or a very cold o Pap test/smear probe to freeze tissue and cause cell o Co-testing with HPV and pap test destruction  Electrosurgery Triad Management o Use of an electric current to destroy tumor cells  Laser surgery/ Photocoagulation/ Photoablation o Use of light and energy aimed at an exact tissue location and depth to vaporize cancer cells.  Photodynamic Surgery o IV administration of a light sensitizing agent  Radiofrequency ablation amlap  o Used localized application of thermal o Reduce pain energy that destroys cancer cells. o Relieve destruction o Relieve pressure DIAGNOSTIC SURGERY o Prevent hemorrhage Excisional Biopsy Reconstructive Surgery  Most frequently used for small easily  Improve quality of life by restoring maximal accessible tumors of the skin, breast, GIT, function and upper respiratory tracts.  More desirable cosmetic effect Incisional Biopsy  Example: o Breast reconstruction after  Wedge of tissue from the tumor to remove mastectomy for analysis. Performed if the tumor is too o Head and neck large to be removed. o Skin cancers Needle Biopsy Adverse Effects of Surgery  Performed to sample suspicious masses  Loss of function of a specific body part that are easily and safely accessible.  Reduced function as a result of organ lost  Scarring or disfigurement  Grieving about altered body image or Prophylactic surgery imposed change in lifestyle  Removal of precancerous lesions or benign  Pain, infection, bleeding, and tumor to prevent cancer thromboembolism.  Colectomy, mastectomy, oophorectomy Nursing Responsibilities  Performed in clients with an existing premalignant condition or a known family Preparation of surgery history or genetic mutation.  Provide both verbal and written information Curative Surgery about the surgical procedure to ensure patient understanding.  All gross and microscopic tumor is removed  Educate about potential post-op or destroyed complications due to prior radiation or  May include surrounding tissue and regional chemotherapy such as: lymph nodes. o Infection  May result in disfigurement, altered o Impaired wound healing functioning, needing rehabilitation or o Altered pulmonary or renal function reconstructive procedure. o Venous thromboembolism o Fluid and electrolyte imbalance Control Surgery o Organ dysfunction.  Aka debulking Preventive Measures  Increases the chance for other therapies to be successful  Administration prophylactic antibiotics to  Removing a large portion of locally invasive reduce infection risk tumor.  Provide specific instructions regarding diet and bowl preparation if needed Palliative Surgery Patient support  Performed to improve quality of life during the survival time for symptom relief and  Act as a patient advocate and liaison, comfort encouraging family involvement in decision-  Cure is not an option making. amlap   Ensure patients and families receive  Ionizing consistent information to reduce anxiety and o Gamma rays improve collaboration. o X-rays o UV rays Radiation Therapy Functions of Ionizing Radiation  Uses ionizing radiation to interrupt cellular growth of tumor cells  Alters DNA molecules of cells, leading to  Causes cellular destruction but affects both cell death normal and abnormal cells  Damage DNA through formation of free  Used as supportive therapy in conjunction radicals by replicating cells most vulnerable with surgery and chemotherapy o Bone marrow: affects blood cell  Reduce tumor size, prevent local production recurrence, relieve symptoms of metastatic o Lymphatic tissue: impairs immune disease. response  Treat oncologic emergencies o GI epithelium: Causes GI side o Superior vena cava syndrome effects such as nausea or diarrhea o Bronchial airway obstruction o Hair follicles: lead to hair loss o Spinal cord compression o Gonads: may result in infertility or o Bleeding hormonal changes  Localized treatment, targeting specific areas Particulate Radiation to minimize damage to surrounding healthy tissues.  Electrons  Mostly effective in  Beta particles o Small tumors  Protons o Rapidly dividing  Neutrons o Poorly differentiated  Alpha particles  Dosage o Sensitivity of target tissues Uses Radiotherapy o Size of tumor  Before surgery (Neo-adjuvant) – decrease o Radiation tolerance of surrounding the tumor size) normal tissues  After surgery (Adjuvant) – eradicate the o Critical structures adjacent to tumor possible residual disease target.  Concurrent – in conjunction with Principles of Radiation chemotherapy  Time – exposure time is 15-30 minutes per Types of Radiotherapy shift uninterrupted External Radiation  Distance – stay 3-5 feet distance from the source  Teletherapy/ Beam radiation  Shielding – wear lead apron  Administered by x-ray  Sources: betatron, linear accelerator, cobalt Types of Radiation 60 teletherapy machine  Non-ionizing  Client is not radioactive o Infrared  Skin changes known as radiodermatitis o Radio waves occur due to skin penetrated by radiation o Visible light rays (occurs 3-6 weeks after the start of the o Radiofrequency from cellphones treatment. amlap   Superficial injury from radiation can  Instruct the client not to wear constricting manifest as erythema, hyperpigmentation, clothing during the procedure to prevent and dry/moist desquamation further skin breakdown.  Less toxic  Inform the client that the radiologist / RTT will place a skin mark/port. It delineates the Types of External Radiation part of the body where radiation rays pass.  External Beam RT (EBRT)  Advice the client not to remove the skin o Beam of highly charged protons or mark. It can only be removed once the gamma rays to penetrate the body treatment has been completed. and target the tumor with pinpoint  Focus on skin care accuracy. o Use only water and avoid soap in o Allows for more precision to target cleaning the affected area, although the tumor soap can change the angle and o Less toxicity intensity of radiation  Intensity modulated RT o Pat the area dry, do not rub o Intensity / energy levels can be o Avoid controlled at the different angles o Promote healing patient comfort and aimed at the tumor quality of life o Higher doses delivered to tumor o ERBT – assess patient’s skin while sparing healthy surrounding o Assess nutritional status tissues o Daily fractions or hyperfractionated Internal Radiation shorten patient duration of treatment