NUPC-113-Module-3.pdf

MODULE III CARE OF CLIENTS WITH PROBLEM IN CELLULAR ABERRATIONS Lesson 1 Overview of Cancer Lesson 2 The Nursing Process Lesson 3 Oncologic Emergencies Lesson 4 Responses to Alterations JIMA J. MAMUNGAY, RN, MAN ...

MODULE III CARE OF CLIENTS WITH PROBLEM IN CELLULAR ABERRATIONS Lesson 1 Overview of Cancer Lesson 2 The Nursing Process Lesson 3 Oncologic Emergencies Lesson 4 Responses to Alterations JIMA J. MAMUNGAY, RN, MAN  2 TABLE OF CONTENTS 3 Introduction 74 Learning Activity 3 Learning Outcomes 75 Module Summary 3 Module Organizer 82 References 4 Module Guide 84 Appendix 6 Lesson 1 37 Lesson 4 5 Pretest 36 Pretest 6 Overview 37 Breast Cancer 6 Biology of Normal Cells 43 Cervical Cancer 7 Biology of Abnormal Cells 45 Colorectal Cancer 9 Cancer Development: 49 Endometrial Cancer Carcinogenesis/Oncogenesis 51 Head and Neck Cancer 13 Cancer Etiology/Genetic Risk 58 Lung Cancer 14 Genetic/Genomic Considerations 63 Ovarian Cancer 14 Cultural Considerations 65 Pancreatic Cancer 67 Prostate Cancer 16 Lesson 2 71 Urothelial Cancer 15 Pretest 16 Nursing Assessment 19 Planning and Implementation 20 Cancer Surgery 21 Radiation Therapy 23 Cytotoxic Systemic Agent Therapy 28 Immunotherapy: Biological Response Modifiers 28 Molecularly Targeted Therapy 29 Monoclonal Antibody Therapy 29 Hormonal Manipulation 30 Photodynamic Therapy 32 Lesson 3 31 Pretest Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  3 MODULE III CARE OF CLIENTS WITH PROBLEM IN CELLULAR ABERRATIONS INTRODUCTION This module introduces care of clients with problems in cellular aberrations. It is expected that you will learn to understand how cancer develops and apply the appropriate interventions utilizing the nursing process. This module will help you deliver and prioritize appropriate, safe and correct interventions or patient’s care that have problem in cellular aberrations that will enhance your capabilities to become a good and responsible nurse in the future. LEARNING OUTCOMES After studying the module, you should be able to: 1. apply appropriate nursing concepts and actions holistically and comprehensively. 2. utilize the nursing process in the care and health education of patients with problems in cellular aberrations. 3. ensure a well-organized and accurate documentation system of patient with cellular aberrations. 4. demonstrate relevant legal, moral, and ethical standards with proper inter-professional collaboration in rendering care to patients with problems in cellular aberrations. 5. show safe and appropriate care to patients based on their culture and practices. 6. integrate relevant legal, moral, and ethical standards of care in performing the roles and responsibilities of a nurse. 7. apply evidence-based practices in caring patients with problems in cellular aberrations. 8. plan an effective care to promote, maintain, or restore functional health patterns to client with cellular aberrations. MODULE ORGANIZER Hi! My name is Jima Jose Mamungay. I will be your Instructor for this course. In case you encounter difficulty, discuss this with me during the scheduled face-to-face meeting at the CCHAMS Faculty Office. If not, contact me to this following contact details: Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  4 [email protected] Jima Querrer Jose Mamungay 09178417848 MODULE GUIDE There are four lessons in the module. Read each lesson carefully. Lesson 1 to 4 starts with the brief overview of the topic and followed by steps in the nursing process then the response of an individual with these alterations. After reading each lesson, you are required to answer the exercises/activities to find out how much you have benefited from it. Work on these exercises carefully because they are graded and submit your output to my email given to you. Rubrics will be used to evaluate your outputs that are seen in the appendices section of this module. As you go along, there are important aspects of care that are highlighted. These aspects include the following: NURSING SAFETY PRIORITY Boxes which highlight important information you can use to avoid patient harm. These are further categorized as Action Alert and Critical Rescue. Good luck and happy reading!!! Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  5 PRETEST Before you start our first lesson, let us check if you are ready to begin our course by answering this pretest. It is all about Cancer. Write your answer in a piece of paper. Good luck. Be honest to yourself. Modified TRUE or FALSE. Read each statement below carefully. Place a T on the line if you think a statement is TRUE. Place an F on the line if you think the statement is FALSE and beside your answer, write the word/s that makes it wrong then write the correct word/s that will make it correct. Good luck. __________1. Chromosomes are the coded instructions for the making of all the different proteins the human body produces. __________2. Specific morphology: each normal cell type has a distinct and recognizable appearance, size, and shape. __________3. Differentiated function; a normal cell has at least one function it performs to contribute to whole-body function like skin cells make keratin and liver cells make bile. __________4. Cancer is normal cell regulation; the processes of normal cell growth and function are lost and become unpredictable. __________5. An allele is an opposite form (or variation) of a gene. __________6. Carcinogens may be chemicals, physical agents, or viruses. __________7. Tight adherence: normal cells make proteins that protrude from the membranes, allowing cells to bind closely and tightly together. __________8. Migratory; normal cells do not wander throughout the body (except for blood cells). __________9. Meiosis occurs when one cell divides into two new cells that are identical to each other. __________10. Cancer can develop in any tissue or organ but tends to occur more commonly in tissues that continue to grow by cell division (mitosis) throughout the life span. “Believe you can and you’re halfway there.” -Theodore Roosevelt “Your attitude determines your direction” -Unknown Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  6 Lesson 1 Overview of the Cancer BIOLOGY OF NORMAL CELLS Cellular regulation refers to all aspects of cell growth and function. Many different normal cells work together to make the whole person function at an optimal level. For optimal function, each cell must perform in a predictable manner. Genes are the coded instructions for the making of all the different proteins the human body produces. An allele (pronounced "ah-lee-el") is an alternate form (or variation) of a gene. Protein synthesis is the process by which genes are used to make the proteins needed for physiologic function. Some genetic variations (also called mutations) can reduce the function of the protein produced, some can eliminate the function of the protein produced, and a few variations enhance the function of the produced protein compared with the function of the normal or typical genetic sequence. Gene mutations that increase the risk for a disorder are known as susceptibility genes. Gene mutations that decrease the risk for a disorder are known as protective or resistance genes. For optimal function, each cell must perform in a predictable manner: v Specific morphology: each normal cell type has a distinct and recognizable appearance, size, and shape. v A smaller nuclear-to-cytoplasmic ratio; the size of the normal cell nucleus is relatively small compared with the size of the rest of the cell, including the cytoplasm. v Differentiated function; a normal cell has at least one function it performs to contribute to whole-body function. For example, skin cells make keratin and liver cells make bile. v Tight adherence: normal cells make proteins that protrude from the membranes, allowing cells to bind closely and tightly together. An example is fibronectin to keep most normal tissues bound tightly to each other. Exceptions are blood cells. v Nonmigratory; normal cells do not wander throughout the body (except for blood cells). v Orderly and well-regulated growth is a very important feature of normal cells. They divide (undergo mitosis) for only two reasons: a. to develop normal tissue, or b. to replace lost or damaged normal tissue. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  7 Cell division or MITOSIS occurs in a well-recognized pattern. Mitosis makes one cell divide into two new cells that are identical to each other and to the cell that began mitosis. Whether a cell enters and completes the cell cycle to form two new cells depends on the presence and absence of specific CELLULAR REGULATION proteins. Proteins that promote cells to enter and complete cell division are produced by oncogenes and are known as cyclins. When cyclins are activated by external or internal signaling, they allow a cell to leave G0 and enter the cycle. These activated cyclins then drive the cell to progress through the different phases of the cell cycle and undergo cell division. Proteins produced by suppressor genes control the amount of cyclins present and ensure that cell division occurs only when it is needed. Thus, cellular regulation of division is a balance between the oncogene protein products that promote cell division (cyclins) and the proteins that limit cell division (suppressor gene products). v Contact inhibition is CELLULAR REGULATION that stops further rounds of cell division when the dividing cell is completely surrounded and touched (contacted) by other cells. Of the normal cells that can divide, each cell divides only when some of its surface is not in direct contact with another cell. Once a normal cell is in direct contact on all surface areas with other cells, it no longer undergoes mitosis. Thus normal cell division is contact inhibited. v Apoptosis is programmed cell death. Not only do normal cells have to divide only when needed and have to perform their specific differentiated functions, some cells also have to die at the appropriate time to ensure optimum body function. Thus normal cells have a finite life span. With each cell division the telomeric DNA at the ends of the cell's chromosomes shortens. When this DNA is gone, the cell responds to CELLULAR REGULATION signals for apoptosis. This ensures that each organ has an adequate number of cells at their functional peak. v Euploidy, having a complete set of chromosomes, is a feature of most normal human cells. These cells have 23 pairs of chromosomes, the correct number for humans. BIOLOGY OF ABNORMAL CELLS Cancer is abnormal cell regulation; the processes of normal cell growth and function are lost and become unpredictable. Cancer is a life-threatening disease and without intervention leads to death. Neoplasia is any new or continued cell growth not needed for normal development or replacement of dead and damaged tissues. This new growth may be benign or malignant. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  8 Benign tumor cells are normal cells growing in the wrong place or at the wrong time. They are not needed for normal growth and development. Although benign tumors do not invade other tissues, depending on their location, they can damage normal tissue and may need to be removed. Cancer cells, also called malignant cells, are abnormal, serve no useful function, and invade and destroy normal body tissues. Without treatment, cancer leads to death of tissues, organs, and, ultimately, the person with a cancer diagnosis. Cancer can develop in any tissue or organ but tends to occur more commonly in tissues that continue to grow by cell division (mitosis) throughout the life span. All cancers start from normal cells that undergo changes at the gene level. These changes result in a loss of control over cell growth. Carcinogenesis and oncogenesis are additional names for cancer cell growth and development. Malignant transformation is the process of changing a normal cell into a cancer cell. Carcinogens are substances that can damage normal cell DNA and change the activity of genes. Carcinogens may be chemicals, physical agents, or viruses. Cellular dysregulations present in cancer cells and malignant tumors is: v Anaplasia or loss of the specific appearance (morphology) of the parent cells v A large nuclear-cytoplasmic ratio or a larger-than-normal cell nucleus v Loss of specific cell function v Loose adherence resulting in the ability of malignant cells to migrate v Rapid, persistent cell division with loss of contact inhibition v Aneuploidy or abnormal chromosomes v No response to normal cellular signals for programmed cell death (i.e., apoptosis) A primary tumor is the original tumor, identified by the normal tissue from which it arose. When primary tumors are located in vital organs, such as the brain or lungs, they can grow excessively and lethally damage the vital organ or crowd out healthy organ tissue and interfere with that organ's ability to perform its vital function. A metastatic tumor is one that has spread from the original site, usually through the blood or lymph, into other tissues and organs, where it can establish metastatic or secondary tumors that grow and cause more damage and dysfunction. v When a metastatic tumor is in another organ, it is still a cancer from the original altered tissue. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  9 v For example, when breast cancer spreads to the lung and the bone, it is breast cancer in the lung and bone, not lung cancer and not bone cancer. CANCER DEVELOPMENT CARCINOGENESIS/ONCOGENESIS The process of carcinogenesis or oncogenesis occurs through the steps of initiation, promotion, progression, and metastasis. 1. Initiation begins the change of a normal cell into a cancer cell. Initiation is the result of the expression of oncogenes (genes that cause normal cells to transform into cancerous cells) or reduced expression of suppressor genes (genes that prevent cancerous transformation of normal cells), altering cell division. If growth conditions are right, widespread metastatic disease can develop from just one cancer cell. 2. Promotion is the enhancement of growth of an initiated cell. Many normal hormones and body proteins, such as insulin and estrogen, act as promoters and make initiated cells divide more often. 3. Progression is the continued change of a cancer, making cells more malignant. One change is the development of a separate blood supply. Over time, changes in cell growth and function provide advantages that allow cancer cells to live and divide, no matter how the conditions around them change. 4. Metastasis is the spread of a tumor or cancer cells from the original site. For example, cancer cells can migrate through the lymph or vascular system to other organs. Common sites of metastasis are lymph nodes, lungs, bones, and the brain. See Figure 1 for the steps of Metastasis. Table 1 shows the common sites of metastasis for different cancer types. Table 1. Common Sites of Metastasis for Different Cancer Types Type of Cancer Common Site/s 1. Breast Cancer Bone, Lung, Liver, Brain 2. Lung Cancer Brain, Bone, Liver, Lymph nodes, Pancreas 3. Colorectal Cancer Liver, Lymph nodes, Adjacent structures 4. Prostate Cancer Bone (especially spine and legs), Pelvic nodes 5. Melanoma GI tract, Lymph nodes, Lung, Brain 6. Primary Brain Cancer Central Nervous System Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  10 Figure 1. Steps of Metastasis Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  11 Cancers are classified by the type of tissue from which they arise. For example, glandular cancers are carcinomas and connective tissue cancers are sarcomas. See table 2 for the classifications of tumors by tissue of origin. Table 2. Common Sites of Metastasis for Different Cancer Types PREFIX TISSUE OF BENIGN TUMOR MALIGNANT TUMOR ORIGIN Adeno Epithelial glands Adenoma Adenocarcinoma Chondro Cartilage Chondroma Chondrosarcoma Fibro Fibrous Fibroma Fibrosarcoma connective Glio Glial cells (brain) Glioma Glioblastoma Hemangio Blood vessel Hemangioma Hemangiosarcoma Hepato Liver Hepatoma Hepatocarcinoma Hepatoblastoma Leiomyo Smooth muscle Leiomyoma Leiomyosarcoma Lipo Fat/Adipose Lipoma Liposarcoma Lympho Lymphoid tissues Malignant lymphomas Hodgkin's lymphoma Non-Hodgkin's lymphoma Burkitt's lymphoma Cutaneous T-cell Melano Pigment- Melanoma producing skin Meningio Meninges Meningioma Malignant ma meningioma Meningioblastoma Neuro Nerve tissue Neuroma Neurosarcoma Neurofibro Neuroblastoma ma Osteo Bone Osteoma Osteosarcoma Renal Kidney Renal cell carcinoma Rhabdo Skeletal muscle Rhabdomyoma Rhabdomyosarcoma Squamous Epithelial layer of Papilloma Squamous cell carcinoma skin, mucous of skin, bladder, lungs, membranes, and cervix organ linings * Carcinomas are tumors of glandular tissue; sarcomas are tumors of connective tissue; blastomas are tumors of less differentiated, embryonal tissues. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  12 Solid tumors develop from specific tissues (e.g., breast cancer and lung cancer). Hematologic cancers (e.g., leukemias and lymphomas) arise from blood cell-forming tissues and lymphatic tissues. Systems of cancer grading, and staging are used to standardize cancer diagnosis, prognosis, and treatment. Grading of a tumor classifies cellular aspects of the cancer and ranks cancers for the degree of malignancy based on cancer cell appearance, growth rates, and aggressiveness compared with the normal tissues from which they arose. Low-grade cancers have fewer malignant features and are well differentiated; high-grade cancers have more malignant features, such as anaplasia. See table 3 for the summary of grading of malignant tumors. Table 3. Grading of Malignant Tumors GRADE CELLULAR CHARACTERISTICS G0 Grade cannot be determined G1 Tumor cells are well differentiated and closely resemble the normal cells from which they arose. This grade is considered a low grade of malignant change. These tumors are malignant but are relatively slow growing G2 Tumor cells are moderately differentiated; they still retain some of the characteristics of normal cells, but also have more malignant characteristics than do G1 tumor cells. G3 Tumor cells are poorly differentiated, but the tissue of origin can usually be established. The cells have few normal cell characteristics. G4 Tumor cells are poorly differentiated and retain no normal cell characteristics. Determination of the tissue of origin is difficult and perhaps impossible. Tumor ploidy classifies tumor chromosomes as normal or abnormal. When cancer cell chromosomes are abnormal, they are called aneuploidy. The degree of aneuploidy usually increases with the degree of malignancy. Staging describes the extent or severity of a person's cancer. The TNM staging system is based on the size of the primary tumor (T), whether cancer cells have spread to nearby lymph nodes (N), and whether metastasis (M) or spread of cancer to other parts of the body has occurred (see table 4 for the staging of cancer-TNM classification). Staging is important because for most cancers the smaller the cancer is at diagnosis, the fewer the lymph nodes that are involved; and the less it has spread, the greater the chances are that treatment will result in a cure. Staging also influences selection of therapy. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  13 1. Clinical staging assesses the patient's clinical manifestations and evaluates clinical signs for tumor size and possible spread. 2. Surgical staging assesses the tumor size, number, sites, and spread by inspection at surgery. 3. Pathologic staging is the most definitive type, determining the tumor size, number, sites, and spread by pathologic examination of tissues obtained at surgery. Table 4. Staging of Cancer- TNM Classification PRIMARY TUMOR (T) Tx Primary tumor cannot be assessed T0 No evidence of primary tumor TIS Carcinoma in situ T1, T2, T3, Increasing size and/or local extent of the primary tumor T4 REGIONAL LYMPH NODES (N) Nx Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1, N2, N3 Increasing involvement of regional lymph nodes DISTANT METASTASIS (M) Mx Presence of distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis CANCER ETIOLOGY AND GENETIC RISK Carcinogenesis may take years and depends on several tumor and patient factors. Three interacting factors influence cancer development: exposure to carcinogens, genetic predisposition, and immune function. Oncogene activation with overexpression is the main mechanism of carcinogenesis regardless of the specific cause. Oncogenes cause normal cells to transform into cancerous cells. The normal cell's suppressor genes (which control cell growth and prevent oncogene overexpression) can be damaged or mutated. As a result, the oncogenes are overexpressed. Both external and personal factors can activate oncogenes, damage suppressor genes, or both, leading to cancer development. External factors that cause cancer include: 1. Exposure to chemical carcinogens, including many known chemicals, tobacco, drugs, and other exposures that occur in everyday life, such as air pollution and sun exposure. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  14 2. Exposure to physical carcinogens, such as radiation and chronic irritation. 3. Infection with a carcinogenic virus, such as certain strains of the human papillomavirus (HPV) or hepatitis C (HVC). 4. Possible dietary factors, such as low fiber intake, high intake of red meat, and high animal fat intake; preservatives, contaminants, preparation methods, and additives (e.g., dyes, flavorings, and sweeteners) also may have cancer-promoting effects. Personal factors in cancer development include: 1. Immune function, with decreased immune function increasing cancer risk. 2. Advancing age, the single most important risk factor for cancer. 3. Genetic predisposition, resulting from the inheritance of specific gene mutation(s). Genetic/Genomic Considerations Genetic risk for cancer occurs only in a small percent of the population; however, people who have a genetic predisposition are at very high risk for cancer development. Mutations in suppressor genes or oncogenes can be inherited when they occur in germline cells (sperm and ova) and are then passed on to one's children, in whom all cells contain the inherited mutations. Thus for some people tight cellular regulation is compromised by a mutation in a suppressor gene, which reduces or halts its function and allows oncogene overexpression. In other people, the suppressor genes are normal and the oncogene is mutated and does not respond to suppressor gene signals, thus reducing cellular regulation and increasing the risk for cancer development. Inherited predisposition for specific cancers, inherited conditions associated with cancer, familial clustering, and chromosomal aberrations demonstrate a pattern of genetic risk for cancer. Cultural Considerations The incidence of cancer varies among ethnicities. Black Americans have a higher incidence of cancer than white Americans do, and the death rate is higher for African Americans. One explanation for this difference is that individuals in an ethnic minority have less access to health care. Black individuals are more often diagnosed with later stage cancer that is more difficult to cure or control. However, this disparity in health care access does not explain all differences. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  15 PRETEST Before you start our first lesson, let us check if you are ready to begin our course by answering this pretest. It is all about Cancer. Write your answer in a piece of paper. Good luck. Be honest to yourself. There are seven warning signs of Cancer. Use the acronym CAUTION US. If you have any of these symptoms, you may consider consulting a doctor for further evaluation. Give the meaning of the acronym CAUTION US. 1. C 2. A 3. U 4. T 5. I 6. O 7. N 8. U 9. S “It is okay to not know, but it is not okay to not try” -Unknown “Do the right thing……. Even when no one is looking” -Unknown Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  16 Lesson 2 The Nursing Process Cancer can develop in any organ or tissue, reducing the function of that tissue or organ. Cancers that occur in nonvital tissues (such as the breast) can cause death by metastasizing (spreading) into vital organs (e.g., brain, liver, bone marrow) and disrupting critical physiologic processes. Nursing Assessment Assess for impaired immunity and blood-producing functions: 1. Presence of infection due to altered or decreased production and function of White Blood Cells (WBC). 2. Presence of anemia due to decreasing number of Red Blood Cells § Fatigue, shortness of breath and tachycardia are present to patient with anemia. 3. Presence of impaired clotting due to thrombocytopenia or decreased number of platelets. Assess for altered Gastrointestinal (GI) Function: 1. Weight loss because of increased metabolic rate, loss of appetite, and alterations in taste. 2. Cachexia or extreme body wasting and malnutrition due to an imbalance between food intake and energy use. 3. Early satiety or sense of fullness even when only small volumes are ingested. 4. Bowel obstruction due to decreased ability to absorb nutrients and eliminate wastes. 5. Malnutrition and may lead to death due to damaged liver (if tumors invade the liver). Assess for altered Peripheral Nerve Function: 1. Peripheral neuropathy with reduced sensory perception § Loss of sensation in the lower extremities like numbness, tingling, neuropathic pain, and changes in gait and balance. Assess for Motor and Sensory Deficits: 1. Bones are thinner that increases the risk for fractures. 2. Pain 3. Spinal cord compression 4. Hypercalcemia Assess for Cancer Pain: 1. Acute pain Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  17 2. Chronic pain Assess for altered Respiratory and Cardiac Function: 1. Dyspnea and hypoxemia can occur due to airway obstruction caused by the tumors. 2. Thicken an alveolar membrane and damage lung blood vessel that leads to impaired gas exchange. 3. Hypoxia due to impaired gas exchange. 4. Superior vena cava (SVC) syndrome due to compression of the blood and lymph vessels in the chest. § Most common presenting symptoms of SVC syndrome are: a. Face/neck swelling b. Distended neck veins c. Cough d. Dyspnea e. Orthopnea f. Upper extremity swelling g. Distended chest vein collaterals h. Conjunctival suffusion- it is characterized by redness of the conjunctiva that resembles conjunctivitis but that does not involve inflammatory exudates § Less common symptoms are: a. Stridor b. Hoarseness c. Dysphagia d. Pleural effusion e. Head plethora f. Headache g. Nausea h. Lightheadedness i. Syncope j. Change in vision k. Altered mental status l. Upper body edema m. Cyanosis n. Papilledema o. Stupor p. Coma 5. Cardiac conditions from radiation include pericarditis, coronary artery disease, myocardial dysfunction, and valvular heart disease. Assess for the Seven Warning signs of Cancer. Use the acronym CAUTION US. If you have any of these symptoms, you may consider consulting a doctor for further evaluation. 1. C– Changes in bowel or bladder habits 2. A– A sore that does not heal 3. U– Unusual bleeding or discharge Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  18 4. T– Thickening or lump in the breast or elsewhere 5. I– Indigestion or difficulty swallowing 6. O– Obvious change in a wart or mole 7. N– Nagging cough or hoarseness 8. U– Unexplained anemia 9. S– sudden weight loss Table 5 presents the cancer assessment or questions that you could use to evaluate the cancer type of the patient. Table 5. Cancer Assessment CANCER TYPE ASSESSMENT CONSIDERATION Colorectal Ask the patient whether bowel habits have changed cancer over the past year (e.g., in consistency, frequency, color). Is there any obvious blood in the stool? Test at least one stool specimen for occult blood during the patient's hospitalization. Encourage the patient to have a baseline colonoscopy. Encourage the patient to reduce dietary intake of animal fats, red meat, and smoked meats. Encourage the patient to increase dietary intake of bran, vegetables, and fruit. Bladder cancer Ask the patient about the presence of: Pain on urination Blood in the urine Cloudy urine Increased frequency or urgency Prostate cancer Ask the patient about: Hesitancy Change in the size of the urine stream Pain in the back or legs History of urinary tract infections Skin cancer Examine skin areas for moles or warts. Ask the patient about changes in moles (e.g., color, edges, sensation). Leukemia Observe the skin for color, petechiae, or ecchymosis. Ask the patient about: o Fatigue o Bruising o Bleeding tendency o History of infections and illnesses o Night sweats o Unexplained fevers Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  19 Lung cancer Observe the skin and mucous membranes for color. How many words can the patient say between breaths? Ask the patient about: o Cough o Hoarseness o Smoking history o Exposure to inhalation irritants o Exposure to asbestos o Shortness of breath o Activity tolerance o Frothy or bloody sputum o Pain in the arms or chest o Difficulty swallowing Planning and Implementation Primary prevention of cancer involves avoiding exposure to known causes of cancer. Secondary prevention of cancer involves screening for early detection. Tertiary treatment occurs after a cancer diagnosis and the purpose is to prolong survival time or improve quality of life. Therapies for cancer include surgery, radiation therapy, cytotoxic agents, biological and immunomodulation drugs, hormonal therapy, and photodynamic therapy. Therapies may be used separately or, more commonly, in combination to kill cancer cells. The types and amount of therapy used depend on the specific type of cancer, whether the cancer has spread, and the health of the patient. Chart 1 discusses the dietary habits to reduce cancer risk. Chart 1. Dietary Habits to Reduce Cancer Risk R Avoid excessive intake of animal fat. R Avoid nitrites (prepared lunch meats, sausage, bacon). R Minimize your intake of red meat. R Keep your alcohol consumption to no more than one or two drinks per day. R Eat more bran. R Eat more cruciferous vegetables such as broccoli, cauliflower, Brussels sprouts, and cabbage. R Eat foods high in vitamin A (e.g., apricots, carrots, leafy green and yellow vegetables) and vitamin C (e.g., fresh fruits and vegetables, especially citrus fruits). Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  20 CANCER SURGERY OVERVIEW Surgery for cancer involves the removal of diseased tissue and may be used for prophylaxis, diagnosis, cure, control, palliation, determination of therapy effectiveness, and reconstruction. 1. Prophylactic surgery is the removal of at-risk tissue to prevent cancer development and is performed when a patient has an existing premalignant condition or a known family history that strongly predisposes the person to the development of a specific cancer. 2. Diagnostic surgery (biopsy) is the removal of all or part of a suspected lesion for examination and testing. It provides proof of the presence of cancer. 3. Curative surgery is focused on removal of all cancer tissue and alone can result in a cure rate of 27% to 30% when all visible and microscopic tumors are removed or destroyed. 4. Cancer control, or cytoreductive surgery, is the removal of part of the tumor and leaving a known amount of gross tumor. It is also known as debulking surgery, and it does not alone result in a cure. 5. Palliative surgery is focused on improving the quality of life during the survival time and is not focused on cure. 6. Second-look surgery is used for a rediagnosis after treatment. The results of this surgery are used to determine whether a specific therapy should be continued or discontinued. 7. Reconstructive or rehabilitative surgery increases function, enhances appearance, or both. PATIENT-CENTERED COLLABORATIVE CARE The nursing care needs of the patient having surgery for cancer are similar to those related to surgery for other reasons. Surgery usually involves the loss of a specific body part or its function. The amount of function lost and how much the loss affects patients depend on the location and extent of the cancer and surgical intervention. Some cancer surgery results in major scarring or disfigurement. Two additional priority care needs are psychosocial support and assisting the patient to achieve or maintain maximum function. 1. Assess the patient's and family's ability to cope with the uncertainty of cancer and its treatment and with the changes in body image and role. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  21 2. Coordinate with the health care team to provide support for the patient and family. 3. Encourage the patient and family to express their feelings and concerns. 4. Encourage the patient to look at the surgical site, touch it, and participate in any dressing changes or incisional care required. 5. Provide information about support groups, such as those sponsored by the American Cancer Society or specialty cancer organizations. 6. Discuss with the patient the idea of having a person who has coped with the same issues come for a visit. 7. Teach the patient about the importance of performing and progressing the intensity of any prescribed exercises to regain as much function as possible and prevent complications. 8. Coordinate with the physical therapist, occupational therapist, and family members to plan strategies individualized to each patient to regain or maintain optimal function. RADIATION THERAPY OVERVIEW The purpose of radiation therapy for cancer is to destroy cancer cells with minimal exposure of the normal cells to the damaging actions of radiation. Because the effects of radiation are seen only in the tissues in the path of the radiation beam, this type of therapy is a local treatment. Radiation doses vary according to the size, location, and radiation sensitivity of the tumor and the surrounding normal tissues. Figure 2 shows the penetrating capacity of different types of radiation. Figure 2. Penetrating Capacity Of Different Types Of Radiation Radiation therapy is delivered in one of two categories: 1. Teletherapy: The radiation source is external to the patient and remote from the tumor site. It is also called external Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  22 beam radiation. Because the source is external, the patient is not radioactive and is not a hazard to others. This type of therapy usually is given as a series of divided doses. 2. Brachytherapy: The radiation source comes into direct, continuous contact with the tumor tissues for a specific period of time. It is delivered in a solid, sealed form or unsealed within body fluids. With all types of brachvtherapy, the patient emits radiation for a period of time and is a hazard to others. Side effects of radiation therapy are limited to the tissues exposed to the radiation and vary according to the site. Skin changes and hair loss are local but are likely to be permanent. Other common side effects include altered taste sensations and severe fatigue. Radiation damage to normal tissues during cancer therapy can start the inflammatory responses that cause tissue fibrosis and scarring. These effects may not be apparent for many years after radiation treatment. PATIENT-CENTERED COLLABORATIVE CARE For teletherapy, teach patients to: 1. Wash the irradiated area gently each day with water or with a mild soap and water and rinse thoroughly. 2. Not remove any ink or dye markings that indicate exactly where the beam of radiation is to be focused. 3. Dry the irradiated area with patting motions rather than rubbing motions; use a clean, soft towel or cloth. 4. Powders, ointments, lotions, or creams on the skin should not be used at the radiation site unless they are prescribed by the radiologist or the radiation therapy advanced practice nurse. 5. Wear soft clothing over the skin at the radiation site. 6. Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at the radiation site. 7. Avoid exposure of the irradiated area to the sun. a. Protect this area by wearing clothing over it but not by applying sunscreen agents. b. Avoid going outdoors between 10:00 AM and 4:00 PM to avoid the more intense sunrays. 8. Avoid heat exposure. For patients receiving brachytherapy: 1. Assign the patient to a private room with a private bath. 2. Place a "Caution: Radioactive Material" sign on the door of the patient's room. 3. If portable lead shields are used, place them between the patient and the door. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  23 4. Keep the door to the patient's room closed as much as possible. 5. Wear a dosimeter film badge at all times while caring for patients with radioactive implants. Each badge should be used only by one individual. 6. Wear a lead apron while providing care. Always keep the front of the apron facing the source of radiation ( do not turn your back toward the patient). 7. Pregnant nurses should not care for these patients; do not allow pregnant women or children younger than 16 years old to visit. 8. Limit each visitor to 30 minutes per day. Be sure visitors are at least 6 feet from the source. 9. Never touch the radioactive source with bare hands. In the rare instance that it is dislodged, use long-handled forceps to retrieve it. Deposit the radioactive source in the lead container kept in the patient's room. 10. Save all dressings and bed linens until after the radioactive source is removed. CYTOTOXIC SYSTEMIC AGENT THERAPY OVERVIEW Anti-neoplastic agents (commonly called chemotherapy) are used to cure cancer and to increase survival time. These drugs have some selectivity for killing cancer cells over normal cells. The tumors most sensitive to chemotherapy are those that have rapid growth. The effects of cytotoxic therapy are systemic, providing the opportunity to kill metastatic cancer cells that may have escaped local treatment. The normal cells most affected by chemotherapy are those that divide rapidly, including skin, hair, intestinal tissues, spermatocytes, and blood-forming cells. Cytoxic drugs are classified by the specific types of action they exert in the cancer cell and include antimetabolites, antitumor antibiotics, antimitotics, alkylating agents, topoisomerase inhibitors, and miscellaneous agents. Successful cancer chemotherapy most often involves giving more than one anticancer drug in a timed manner, known as combination chemotherapy. Drugs are selected based on known tumor sensitivity to the drugs and the degree of side effects expected. Dosages for most chemotherapy drugs are calculated according to the type of cancer and the patient's size, usually based on Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  24 milligrams per square meter of total body surface area or on weight in kilograms. Although most chemotherapy drugs are given IV, they may also be given by the oral, intra-arterial, isolated limb perfusion, intracavitary, and intrathecal routes. Administration of IV chemotherapy is usually performed by a registered nurse who has completed an approved chemotherapy course. Extravasation, or infiltration, is a serious complication of IV chemotherapy administration that can lead to pain, tissue loss, and in worst-case scenarios, loss of the limb. 1. The most important nursing intervention for extravasation is prevention by close monitoring of the access site during chemotherapy administration. 2. Immediate treatment of extravasation depends on the specific drug. Coordinate with the oncologist and pharmacist to determine the type of compress and specific antidote needed for the extravasated drug. 3. Perform and document the following activities for an extravasation event: a. Date and time when extravasation was suspected or identified b. Date and time when the infusion was started c. Time when the infusion was stopped d. The exact contents of the infusion fluid and the volume of fluid infused e. The estimated amount of fluid extravasated f. A diagram of the exact insertion site, and indication of whether this is a venous access device, implanted port, or a tunneled catheter g. The method of administration (e.g., pump, controller, rate of infusion) h. The needle type and size i. Indication on the diagram of the location and number of venipuncture attempts j. The time between the extravasation and the last fully documented blood return k. All agents administered in the previous 24 hours through this site (list agent administered, dosage and volume, and order of administration) l. Patient's vital signs m. Patient's subjective sensations and symptoms n. All observations of the site, including size, color, and texture o. A photograph of the site p. Administration of neutralizing or antidote agents Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  25 q. Application of compresses and their temperature r. Other nursing interventions s. Patient's responses to nursing interventions t. Notification of the prescribing physician (including the time) u. Written and oral instructions given to the patient about follow-up care v. Any consultation request Nurses and other health care workers who prepare or give these drugs or who handle the patient's excreta within 48 hours of the patient receiving IV chemotherapy must use extreme caution and wear personal protective equipment (PPE), including eye protection, masks, double gloves, and gown. Side effects of chemotherapy often include bone marrow suppression (e.g., neutropenia, anemia, and thrombocytopenia), nausea and vomiting, mucositis (inflammation of the lining of the digestive system), alopecia, changes in cognitive function, and peripheral neuropathy. PATIENT-CENTERED COLLABORATIVE CARE For patients with neutropenia: 1. Administer medications that enhance the immune system (e.g., biological response modifiers [BRMs]) as prescribed such as filgrastim (Neupogen, Imu-Max, etc.) to promote the production and release of white blood cells. Considerations for Older Adults Older adults are at even greater risk for chemotherapy-induced neutropenia because of age-related changes in bone marrow function. Using growth factors, such as filgrastim (Neupogen) and pegfilgrastim (Neulasta) before neutropenia occurs can reduce the severity of neutropenia and the risk for infectious complications. 2. Assess the skin and mucous membranes, lung sounds, mouth, and insertion sites for venous access device(s) every 8 hours. 3. Urge the patient to report any indicator of infection, such as a change in skin and mucous membranes ( e.g., pimple, sore, rash, open area), presence of a cough, burning on urination, pain around the venous access site, or new drainage from any location. 4. Use good handwashing before contact with the patient. 5. Modify the environment to protect patients who have neutropenia or thrombocytopenia. 6. Ensure that mouth care and washing of the axillary and perianal regions are performed at least every 12 hours to Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  26 reduce bioburden. Some institutions use daily chlorhexidine cloths. 7. Monitor for manifestations of infection. CRITICAL RESCUE NURSING SAFETY PRIORITY The patient with neutropenia often does not develop a high fever or have purulent drainage, even when a severe infection is present. Consider any temperature elevation in a patient with neutropenia to be an indication of infection. Report it to the provider immediately and anticipate immediate intervention such as implementation of a sepsis protocol. 8. Teach patients and family members precautions to reduce the risk for infection. For patients with anemia: 1. Administer BRMs as prescribed. 2. Assess for tachycardia and increased respiratory rate. 3. Encourage the patient to rest. 4. In collaboration with other members of the health care team, postpone or cancel activities that do not have a direct impact on the health of the patient. For patients with thrombocytopenia, provide a safe hospital environment: 1. Handle the patient gently, such as using a lift sheet when moving and positioning the patient in bed. 2. Avoid IM injections and venipunctures. 3. Apply firm pressure to needle stick sites for 10 minutes. 4. Test all urine and stool for the presence of occult blood. 5. Observe IV sites every 4 hours for bleeding. 6. Avoid rectal temperatures, even on unconscious patients. 7. Administer prescribed suppositories carefully with liberal lubrication. 8. Instruct the patient and unlicensed assistive personnel to use an electric shaver rather than a razor. 9. When providing mouth care or supervising others in providing mouth care, instruct about: a. Using a soft-bristled toothbrush or tooth sponges b. Checking to ensure that dentures fit and do not rub For patients with chemotherapy-induced nausea and vomiting (CINV): 1. Administer prescribed antiemetics on a scheduled, rather than PRN, basis. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  27 2. Ensure that premedication with antiemetics occurs before each session of IV chemotherapy. 3. Assess patients for dehydration and electrolyte imbalances. 4. Teach patients to continue the therapy as prescribed, even when the nausea and vomiting appear controlled. For patients with mucositis: 1. Examine the patient's mouth, including the roof, under the tongue, and between the teeth and cheek, every 4 hours. 2. Document the location, size, and character of fissures, blisters, sores, or drainage. 3. Provide or encourage self-managed, frequent oral hygiene: a. Use a soft-bristled brush or sponges after meals and before sleeping. b. Rinse the mouth with plain water or saline every 2 hours while awake and as often as the patient desires. c. Avoid the use of alcohol or glycerin-based mouthwashes. 4. Administer antimicrobial agents, topical analgesic drugs, and artificial saliva as prescribed. For patients with alopecia: 1. Reassure patients that hair loss is temporary, and that hair regrowth usually begins about 1 month after completion of chemotherapy. 2. Inform the patient that the new hair may differ from the original hair in color, texture, and thickness. 3. Teach the patient to avoid scalp injury by: a. Using head covering to avoid direct sunlight on the scalp b. Wearing some head covering underneath helmets, headphones, headsets, and other items that rub For patients with changes in cognitive function ("chemo brain"): 1. Support the patient who reports this side effect. Listen to the patient's concerns and tell him or her that other patients have also reported such problems. 2. Warn patients against participating in other behaviors that exacerbate cognitive impairment, such as excessive alcohol intake, recreational drug use, and taking part in activities that increase the risk for head injury. For patients with chemotherapy-induced peripheral neuropathy, teach patients to prevent injury by: 1. Wearing well-fitting shoes with a protective sole 2. Inspecting feet daily (with a mirror) for open areas or redness 3. Avoiding extremes of temperature; wearing warm clothing in the winter, especially over hands, feet, and ears Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  28 4. Protecting hands with potholders when cooking and gloves to wash dishes or garden 5. Moving slowly and scanning the ground when changing positions IMMUNOTHERAPY: BIOLOGICAL RESPONSE MODIFIERS OVERVIEW BRMs modify the patient's biological responses to tumor cells. Some have direct antitumor activity; others interfere with cancer cell differentiation, transformation, or metastasis. BRMs also can improve immune function and enhance the body's ability to repair or replace cells damaged by cancer treatment. Two common types of BRMs used as cancer therapy are: 1. Interleukins (ILs), which help different immune system cells recognize and destroy abnormal body cells; in particular, IL- 1, -2, and -6 appear to "charge up" the immune system and enhance attacks on cancer cells by macrophages, natural killer (NK) cells, and tumor-infiltrating lymphocytes. Side effects of ILs include generalized inflammatory reactions that can be severe: a. Widespread edema from "capillary leak" b. Chills or rigors (severe shaking with chills}; rigors is managed with meperidine (Demerol) c. Fever with flu-like general malaise, often managed with acetaminophen 2. Interferons (IFNs), which can slow tumor cell division, stimulate the growth and activation of NK cells, induce cancer cells to resume a more normal appearance and function, and inhibit the expression of oncogenes. MOLECULARLY TARGETED THERAPY OVERVIEW Technically biological agents, these drugs take advantage of one or more differences in cancer cell growth or metabolism that are not present or are only slightly present in normal cells. Agents used as targeted therapies disrupt pathways that lead to excessive cancer cell division/reproduction by: 1. Targeting and blocking epithelial growth factor receptors (EGFRs) or the vascular endothelial growth factor {VEGF) and receptors (VEGFRs); when a cancer cell's growth depends on having the growth factors bind to their specific receptors, blocking the receptor slows or eliminates the cancer cell's growth. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  29 NOTE: For therapies that bind to the EGFR and VEGFR receptors, normal cells in the skin, GI tract, and mucous membranes also express these receptors and may develop open sores, rashes, and acne-type lesions. 2. Blocking signals for cell division and function. These drugs include tyrosine kinase inhibitors (TKis), multikinase inhibitors (MKis), and proteasome inhibitors. 3. Blocking many enzymes essential to cancer cell and tumor blood vessel growth; these agents are categorized as multikinase inhibitors. 4. Blocking the growth of blood vessels so that nutrients cannot be delivered to tumors (angiogenesis inhibitors) 5. Inhibiting the formation of proteins in cells, a drug class called proteasome inhibitors Targeted therapies work only on cancer cells that overexpress the actual target substance. Each person's cancer cells are evaluated to determine whether the cells have enough of a target to be affected by targeted therapy. MONOCLONAL ANTIBODY THERAPY Monoclonal antibodies bind to specific cell surface membrane proteins, preventing the protein from performing its function, typically promoting cell division. By binding cancer cell proteins, monoclonal antibodies prevent cell division. The monoclonal antibodies to the EGFR bind to those specific receptors when the receptors are on normal tissue. Thus side effects occur in those tissues that normally express EGFR, such as the skin, mucous membranes, and lining of the GI tract. HORMONAL MANIPULATION Hormonal manipulation can help control some types of cancer by decreasing the amount of hormones reaching hormonesensitive tumors. Some drugs are hormone antagonists that compete with natural hormones at the tumor's receptor sites, preventing a needed hormone from binding to the receptor. Hormone inhibitors suppress the production of specific hormones in the normal hormone-producing organs. Androgens and the antiestrogen receptor drugs cause masculinizing effects in women, with increased chest and facial hair, interruption of the menstrual period, and shrinkage of breast tissue. Feminine manifestations often appear in men who take estrogens, progestins, or antiandrogen receptor drugs, including thinning Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  30 facial hair, smoother skin, and gynecomastia. Testicular and penile atrophy also occur to some degree. PHOTODYNAMIC THERAPY OVERVIEW Photodynamic therapy (PDT) is the selective destruction of cancer cells through a chemical reaction triggered by different types of laser light. It is most commonly used for non-melanoma skin cancers, ocular tumors, GI tumors, and lung cancers located in the airways. An agent that sensitizes cells to light is injected IV along with a dye. These drugs enter all cells but leave normal cells more rapidly than cancer cells. Usually within 48 to 72 hours, most of the drug has collected in high concentrations in cancer cells. At this time, a laser light is focused on the tumor. The light activates a chemical reaction within those cells, retaining the sensitizing drug that induces irreversible cell damage. PATIENT-CENTERED COLLABORATIVE CARE The patient has increased sensitivity to light for up to 12 weeks after the photosensitizing drug is injected, with the most sensitivity in the 48 hours immediately after a treatment. The most intense period of light sensitivity is after injection and before the laser treatment. During this time, the patient is at high risk for sunburn and eye pain for 1 to 3 months after therapy. Teach the patient to: 1. Reduce exposure to light with protective clothing, window shades, and UV-protective sunglasses. 2. Refrain from taking any newly prescribed or over-the- counter ( OTC) drugs without contacting the physician who performed the PDT. Some drugs make the light sensitivity even worse; other drugs interact with the photosensitizing drug. 3. Start re-exposure to sunlight and other bright lights slowly. Start by exposing only about 1 inch of skin to sunlight at a time. Start with 10 minutes, and increase the time by about 5 minutes each day. 4. Remember that sunscreen cannot prevent severe sunburn during this time. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  31 PRETEST Before you start our first lesson, let us check if you are ready to begin our course by answering this pretest. It is all about Cancer. Write your answer in a piece of paper. Good luck. Be honest to yourself. Matching Type: Match Column A to Column B Column A Column B Microorganisms enter the bloodstream and Disseminated Intravascular grow unchecked due to low a white blood cell Coagulation (DIC) count and impaired immune function. A clotting problem triggered by sepsis. Stokes' sign Certain cancers secrete or stimulate the Tumor lysis syndrome (TLS) secretion of antidiuretic hormone (ADH) when it is not needed by the body for fluid and electrolyte balance resulting to retention of pure water and dilution of electrolytes. Symptoms includes back pain, numbness or Syndrome of Inappropriate tingling, and paralysis (which may be Antidiuretic Hormone (SIADH) permanent) High serum calcium level Nose bleeds It occurs when large numbers of tumor cells Superior vena cava (SVC) are destroyed rapidly, and their intracellular syndrome contents are released into the bloodstream faster than the body can eliminate them. It is most common in patients with lymphomas, Spinal cord compression (SCC) lung cancer, and cancers of the breast, esophagus, colon, and testes. Tightness of the shirt or blouse collar Septic Shock Epistaxis Hypercalcemia “Why fit in when you were born to stand out?” -Dr. Seuss “Learning is never done without errors and defeat” -Vladimir Lenin Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  32 Lesson 3 Oncologic Emergencies Oncologic emergencies are acute complications associated with cancer and its treatment that often require immediate intervention to avoid life-threatening situations. These complications include sepsis and disseminated intravascular coagulation (DIC), syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, tumor lysis syndrome, and superior vena cava syndrome. Sepsis and disseminated intravascular coagulation 1. Microorganisms enter the bloodstream and grow unchecked, because the patient often has low a white blood cell count and impaired immune function. This problem can lead to septic shock and death. 2. Disseminated intravascular coagulation (DIC) is a clotting problem triggered by sepsis, the release of clotting factors from cancer cells, or blood transfusions. Extensive abnormal clotting occurs throughout the small blood vessels, using up the existing clotting factors and platelets. This process is then followed by extensive bleeding that can range from minimal to fatal hemorrhage. 3. Management focuses on prevention, early detection, and prompt aggressive treatment. 4. For prevention: a. Identify those patients at greatest risk for sepsis and DIC. b. Use aseptic technique during care for open skin areas, nonintact mucosa, or any invasive procedure. c. Teach patients and family members the early manifestations of infection and sepsis and when to seek medical assistance. 5. For treatment: a. Administer timely IV antibiotic therapy. b. With DIC, anticipate IV administration heparin or clotting factors. Syndrome of inappropriate antidiuretic hormone 1. Certain cancers secrete or stimulate the secretion of antidiuretic hormone (ADH) when it is not needed by the body for fluid and electrolyte balance. The result is retention of pure water and dilution of electrolytes. In addition to lung and other cancers, Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  33 syndrome of inappropriate antidiuretic hormone (SIADH) can be caused by morphine and cyclophosphamide. 2. Assess for: a. Weight gain daily b. Decreased urine output c. Weakness and fatigue d. Muscle cramps e. Low serum sodium levels of 115 to 120 mEq/L (normal range is 135 to 145 mEq/L) f. Decreased and altered mentation and seizures when sodium levels are less than 110 mEq/L; this is a medical emergency 3. Management includes: a. Free water restriction b. Increased sodium intake c. Drug therapy, most often with demeclocycline d. Immediate cancer therapy to cause tumor regression 4. Monitor for fluid overload, including peripheral edema and pulmonary edema (dyspnea, presence of crackles in lungs). Spinal cord compression 1. Spinal cord compression (SCC) and damage occur when a tumor directly enters the spinal cord or when the vertebrae collapse from tumor degradation of the bone. It most commonly occurs with lung, prostate, breast, and colon cancers. 2. Manifestations include: a. Back pain b. Numbness or tingling c. Paralysis (which may be permanent) ACTION ALERT NURSING SAFETY PRIORITY Early recognition and treatment of spinal cord compression are essential to a good outcome. Assess any cancer patient with new-onset back pain, muscle weakness or a sensation of "heaviness" in the arms or legs, numbness or tingling in the hands or feet, loss of ability to distinguish hot and cold, or an unsteady gait, and report these findings to the oncologist immediately. 3. Teach patients and families the manifestations of early SCC and instruct them to seek help as soon as problems are apparent. 4. Management is often palliative and may include: a. High-dose corticosteroids to reduce swelling around the spinal cord Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  34 b. High-dose radiation to the site c. Intense chemotherapy to reduce tumor size d. Surgery to remove the tumor from the area (less common) e. External back or neck braces to reduce pressure on the spinal cord or spinal nerves Hypercalcemia 1. Hypercalcemia (high serum calcium level) occurs most often in patients with bone metastasis. Tumors can also secrete parathyroid hormone, causing bone to release calcium. 2. Management includes: a. Oral hydration b. Parenteral hydration with normal saline c. Drug therapy to reduce calcium levels temporarily: 1. Oral glucocorticoids 2. Bisphosphonates d. Dialysis (if renal impairment is present) Tumor lysis syndrome 1. Tumor lysis syndrome (TLS) occurs when large numbers of tumor cells are destroyed rapidly and their intracellular contents, including potassium and purines (DNA components), are released into the bloodstream faster than the body can eliminate them. The purines are converted to uric acid. Untreated TLS can cause renal failure and death by hyperkalemia and cardiac arrest. \ 2. TLS is most often seen in patients receiving radiation or chemotherapy for cancers that are very sensitive to these therapies, including leukemia, lymphoma, small cell lung cancer, and multiple myeloma. 3. Prevention through hydration is the best management for TLS. a. Instruct at-risk patients to drink at least 3000 mL {5000 mL is more desirable) of fluid the day before, the day of, and for 3 days after treatment. b. Stress the importance of adhering to the antiemetic regimen so that oral hydration can be accomplished. c. Instruct patients to contact the cancer clinic immediately if nausea and vomiting prevent adequate fluid intake, so that IV fluids can be started. d. Management of actual TLS includes: 1. Aggressive fluid resuscitation 2. Osmotic diuretics 3. Drug therapy to increase the excretion of purines such as allopurinol (Aloprim, Zyloprim); rasburicase (Elitek), or febuxostat (Uloric) 4. Drug therapy to reduce serum potassium levels i. Sodium polystyrene sulfonate Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  35 ii. IV infusions of glucose and insulin 5. Dialysis (for severe hyperkalemia and hyperuricemia) Superior vena cava syndrome 1. Superior vena cava (SVC) syndrome occurs when the SVC is compressed or obstructed by tumor growth or by the formation of clots in the vessel. It is most common in patients with lymphomas, lung cancer, and cancers of the breast, esophagus, colon, and testes. 2. Manifestations result from blockage of blood flow from the head, neck, and upper trunk. Early manifestations include: a. Facial edema, especially around the eyes, on arising b. Tightness of the shirt or blouse collar (Stokes' sign) 3. Later manifestations include: a. Edema in the arms and hands b. Dyspnea c. Erythema of the upper body d. Epistaxis (nosebleeds) 4. Late manifestations include: a. Hemorrhage b. Cyanosis c. Mental status changes d. Decreased cardiac output and hypotension 5. Management includes: a. High-dose radiation therapy to the mediastinal area b. Stenting of the vena cava c. Surgery (rarely). Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  36 PRETEST Before you start our first lesson, let us check if you are ready to begin our course by answering this pretest. It is all about Cancer. Write your answer in a piece of paper. Good luck. Be honest to yourself. Matching Type: Match the picture in Column A to the disease in Column B Column A Column B Breast Cancer Cervical Cancer Lung Cancer Prostate Cancer Colorectal Cancer “Always believe in yourself” -Unknown “Every accomplishment starts with the decision to try” -Unknown Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  37 Lesson 4 Responses to Alteration BREAST CANCER OVERVIEW Breast cancer is second only to lung cancer as a cause of cancer death in women. Men account for less than I% of breast cancers. Early detection through the regular screening methods of clinical breast examination and mammography can improve survival. Breast cancer has many different forms with different clinical presentations and responses to therapy. Breast cancer is divided into two broad categories, noninvasive and invasive: 1. Noninvasive cancers remain within the breast ducts and make up 20% of breast cancers. Ductal carcinoma in situ (DCIS) is a common, early, noninvasive breast cancer. Another type is lobular carcinoma in situ (LCIS). 2. Invasive cancers penetrate the tissue surrounding the ducts and make up 80% of all breast cancers. The most common type of invasive breast cancer is infiltrating ductal carcinoma. Another type is inflammatory carcinoma. a. When the breast tumor invades lymphatic channels, skin drainage is blocked, causing skin edema, redness, warmth, and an orange peel appearance of the skin ("peau d'orange"). b. Invasion of the lymphatic channels carries cancer cells to the axillary lymph nodes. Pathologic examination of these nodes helps determine the stage of the disease. c. Invasive breast cancer can spread through the blood and lymph systems to distant sites, most commonly the bone, lungs, brain, and liver. There is no single cause of breast cancer, but many risk factors are associated with its development: 1. Female gender 2. Advancing age 3. Family history, especially first-degree relatives of individual with breast cancer 4. Previous exposure to high-dose ionizing radiation to the chest 5. Early menarche (before 12 years of age) and late menopause (after 50 years of age) Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  38 6. History of previous breast cancer 7. Nulliparity (no pregnancies) or first birth after 30 years of age Genetic/Genomic Considerations Mutations in several genes, such as BRCA 1 and BRCA2, are related to hereditary breast cancer. People who have specific mutations in either one of these genes are at a high risk for developing breast cancer and ovarian cancer. However, only 5% to 10% of all breast cancers are hereditary. Only women with a strong family history and a reasonable suspicion that a mutation is present have genetic testing for BRCA mutations. Encourage women to talk with a genetics counselor to carefully consider the benefits and potential harmful consequences of genetic testing before these tests are done. Cultural Considerations One of every eight U.S. women will develop invasive breast cancer by age 70. Euro-American women older than 40 years are at a greater risk than other racial/ethnic groups. Black American women younger than 40 years have breast cancer more often than others in that age-group. Black American women have a higher death rate at any age when compared with other women with the disease. Cultural disparities with regard to breast cancer stage and mortality are persistent: 1. Non-Hispanic white women are more likely to present with an earlier stage breast cancer than American Indian/Alaska Native, Asian Indian/Pakistani, black, Filipino, Hawaiian, Mexican, Puerto Rican, and Samoan women. 2. Black American and Puerto Rican women have the highest risk for triple negative breast cancer. In this type of breast cancer, cells lack receptors for estrogen, progesterone, and the protein HER2. Cultural disparities should be addressed with targeted interventions that are appropriate for specific cultural and ethnic groups. NURSING ASSESSMENT Obtain patient information about: 1. Age, race, ethnicity 2. Personal and family history of cancer 3. Age at menarche and menopause 4. Number of children and age at first child's birth 5. Health behaviors, including practice of breast self-exam (BSE), clinical breast examination, and mammography 6. How the mass was discovered and how long ago Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY  39 7. Whether other body changes have been noticed recently, especially bone or joint pain 8. Brief nutritional history, including intake of fat and alcohol Assess for: 1. Specific information about the mass: a. Location of the mass, described using the face-of-the-clock method b. Shape, size, and consistency c. Assess benign lumps as mobile and round or oval; assess possible malignant lumps as fixed and irregularly shaped, often in the upper outer breast quadrant d. Skin changes, such as dimpling, orange peel appearance, redness and warmth, nipple retraction, or ulceration 2. Presence of enlarged axillary or supraclavicular lymph nodes 3. Pain or soreness in the affected breast 4. Psychosocial adjustment: a. Patient's current knowledge and need for information b. Patient's self-image, sexuality, and current intimate relationships c. How the patient has successfully handled stress in the past d. Patient's feelings about the disease and expectations of treatment e. Myths or misconceptions the patient may have (and how to dispel them) f. Need for additional resources 5. Imaging assessment for diagnosis and staging: a. Mammography or digital mammography b. Ultrasonography c. Breast-specific gamma imaging (BSGI) d. Chest x- ray e. Bone, liver, and brain scans f. Computed tomography ( CT) scan of the chest and abdomen g. Magnetic resonance imaging (MRI) 6. Pathologic examination of tissue for diagnosis and prognosis: a. Biopsy, which is the definitive test that proves presence or absence of cancer b. Presence of tumor hormone receptors ( cancers that express receptors have a better treatment response) and protein expression profiling of tumor cell c. Lymph node involvement or other sites of metastasis PLANNING AND IMPLEMENTATION Teach women ways to minimize surgical area deformity and enhance body image, such as the use of a breast prosthesis or the option of breast reconstruction. Module III- NUPC 113: Care of Clients with Problem in Cellular Aberrations DMMMSU-CCHAMS Prepared by: JIMA J. MAMUNGAY