Oncological Disorders Management PDF

**Chapter 12, pg. 951: Management of Patient with Oncological Disorders** **Cancer:** disease process that begins when a cell is transformed by genetic mutations of the cells DNA - Epidemiology: men vs women, race/ethnicity (higher in african american men and women), and geography (ex: tobac...

**Chapter 12, pg. 951: Management of Patient with Oncological Disorders** **Cancer:** disease process that begins when a cell is transformed by genetic mutations of the cells DNA - Epidemiology: men vs women, race/ethnicity (higher in african american men and women), and geography (ex: tobacco exposure) **Tablet 12-1, pg. 956** -------------------- ------------------------------------------------------------------------- ------------------------------------------------------------------------------- **Normal Cells** **Cancer Cells** **Structure** Cells divide in an orderly way; Normal DNA Cells created without control; Abnormal DNA **Energy** Most derived from O2, using a normal cycle, very little from glycolysis Most energy without O2, does not use normal cycle, almost all from glycolysis **Blood vessels** Have built-in blood vessel system Do not have built-in blood vessel system **Growth Factors** Normal amount, produce normal activity Overproduced and more active **Functions** Normal balanced manner Overactive or underactive -------------------- ------------------------------------------------------------------------- ------------------------------------------------------------------------------- **Benign vs. Malignant** ----------------------------------- ----------------------------------------------- -------------------------------------- **[Characteristics]** **[Benign]** **[Malignant]** **Cell characteristics** Well-differentiated cells Undifferentiated cells **Mode of growth** Encapsulated tumor, grows by expansion Grows, infiltrates, destroys tissues **Rate of growth** Slow Variable, depends on differentiation **Metastasis** Does not Does **General effects** Localized, doesn\'t cause generalized effects Often causes generalized effects **Tissue destruction** Usually doesn\'t cause tissue damage\*\* Often causes extensive tissue damage **Ability to cause death** Usually does not cause death Eventually causes death ----------------------------------- ----------------------------------------------- -------------------------------------- **Pathophysiology of the Malignant Process** - Carcinogenesis/oncogenesis, pg. 957 - 1\. **Initiation**: Carcinogens such as chemicals, physical factors cause mutations in the cellular DNA i. Leads to excessive cell division through DNA damage ii. Carcinogens can come into play here iii. So it's normally reversible due to apoptosis but the mutations make it not reversible - 2\. **Promotion**: Repeated exposure to promoting agents causes proliferation and expansion of initiated cells iv. Growth of an initiated cell/dividing of cells v. **They enhanced the growth by substances known as "promoters"** vi. Normal hormones & proteins can act as promoters & make cells divide more frequently - 3\. **Progression**: Altered cells exhibit malignant behaviors vii. Continued change of cancer and angiogenesis occurs viii. Angiogenesis: new blood vessels from existing blood vessels, tumor develops own blood supply. ix. Tumors developed in this stage continue to divide 1. **Oncogenes (proteins that promote cell division)** - Cyclins: proteins produced by oncogenes that promote cells to enter and complete cell division - Once activated they drive the cell to progress through phases of the cell cycle 2. **Suppressor genes (proteins that limit cell division)** - Control the amount of cyclins present - They ensure that cell division occurs only when it is needed x. This stage identifies where the original tumor came from. - Malignant transformation: the process of changing a normal cell into a cancer cell - **Carcinogenic Agents and factors** - Viruses, bacteria - Physical agents: sunlight, radiation, chronic irritation (IBS, H. pylori) xi. H. Pylori can cause stomach ulcers (stomach cancer or esophageal cancer) - Chemical agents: Tobacco, asbestos - Genetic, familial factors **\[chart 12-1 pg. 960\]** - Lifestyle behaviors (obesity, poor diet, ETOH, intake of red and processed meat, smoking meat) - Hormonal agents: estrogen **Cancer Detection and Prevention, pg 968** - Primary prevention: Health promotion (vaccines; Ex = Gardasil) - Secondary prevention: Screening and early detection - Tertiary prevention: Monitor and prevent reoccurrence - **Chart 12-2 pg.969:** Cancer prevention guidelines **Dx of cancer, table 12-4:** - Determine presence, extent of tumor - Identify possible disease metastasis - Evaluate functions of involved and uninvolved body systems and organs - Obtain tissue and cells for analysis, including evaluation of tumor stage and grade **Tumor staging and grading, Chart 12-3**: TNM Classification system - Staging: determines the size of the tumor, the existence of local invasion, lymph node involvement, and distant metastasis - Tumor, nodes, metastasis (TNM) - Grading: pathologic classification of tumor cells: I--IV **Cancer Management** - Treatment goals: Cure, Control, Palliation - Types of treatment: Surgery, Radiation, Chemotherapy, hematopoietic stem cell transplantation, hyperthermia, targeted therapies - **Best way to monitor nutritional status of a pt with cancer: Weigh the patient daily (study lab question)** **Surgical Treatment, pg. 982; table 12-5 & 12-6pg. 984** - Diagnostic surgery: Biopsy: excisional, incisional, needle - Primary treatment: Local excision, Wide or radical excision, Minimally invasive techniques, Salvage surgery - Prophylactic surgery - **Palliative surgery, table 12-6:** relieves symptoms - Reconstructive surgery: breast after mastectomy - Nursing Management **Radiation Therapy pg. 987** - Radiations purpose is to destroy cancer cells with minimal exposure of the normal cells to radiation - Cells undergoing division are more affected - Curative, Control, Neoadjuvant, Prophylactically or Palliative - Dosage \[QD, 5QW, etc\] - **External radiation: Teletherapy** - **Must be in exact same position for all treatment** - Most commonly used form - Penetrate the body and target the tumor with pinpoint accuracy - Beams are conformed concisely around the tumor with higher doses delivered to the tumor - Effects to surrounding tissue is reduced - Pt is not radioactive & not hazardous to others - Pt marked for therapy, beams concisely around tumor - **Internal radiation: Brachytherapy, pg. 991** - High dose radiation for short period of time OR Low dose over extended period - **Source of radiation is placed within pt** xii. Soluble isotopes -- ingested or injected xiii. Implanted sources of RT 3. Seeds/beads -- prostate, cheek, cervical - Stay in place but eventually loses its radioactivity 4. Needles -- tongue 5. Rods -- brain 6. Cervical implant 7. **Since the pt is radioactive, visitors are limited** - **Education: no children can visit, no prepregnant people, nurse can only come in so many times a day + limit visitors = 30 min time limit, stay 6 feet away from patient** xiv. **Nurses should be wearing dosimeter badges** - Patient is radioactive so group nursing tasks - Radiation Toxicity - Local reactions: red and inflamed skin; dry to wet desquamation of skin to potentially ulceration - Altered skin integrity: have erythematous area, tell them to not be in the sun, try not to rub it or scratch it - Alterations in oral/GI mucosa: stomatitis, change/loss of taste, decreases saliva (xerostomia) w/ neck radiation, mucositis xv. Stomatitis: Inflammation of the mouth and surrounding tissues - Bone marrow: toxic to bone marrow - Systemic effects: fatigue, malaise, anorexia - Late effects: permanent damage to tissues, loss of elasticity, fibrosis, atrophy, local tissue changes; heart lung & CNS can alter quality of life **Nursing Management during Radiation Therapy** - Skin: no scented lotions, soaps, & powder, no hot water, keep area clean - Avoid heating pads, ice packs, adhesive tape, tight clothing - Aquaphor can be used or HCP may prescribe a specific topical for irritation - Avoid rubbing & scratching the area - Avoid temperature extremes - Nutrition: protein, but need to eat whatever they can eat - At risk for developing ulcers if not eating - Protection of healthcare providers: Time, Distance, Shielding, implant dislodgement **Chemotherapy** - Systemic treatment which works for the metastasis - MOA: Kills good and bad cells which makes them weak - Low platelets: worried about falls and bleeding - **Normal cells most commonly affected \[b/c these cells rapidly divide\]:** skin, hair, intestinal tissues, spermatocytes, and blood-forming cells - Administration - Route: PO, IV (central line), Intra-arterial, Intracavitary, Intrathecal xvi. **Intrathecal**: delivers drugs into spinal xvii. **Intra-arterial**: chemo given directly into an artery (most often for liver cancer) xviii. **Intracavitary:** Intracavitary radioisotopes are used to treat gynecologic cancers. In these malignancies, the radioisotopes are inserted into specially positioned applicators within the vagina - Dosage: total body surface area xix. Scheduled to maximize cancer cell death & minimize damage to normal cells. - **Extravasation (vesicant):** xx. Extravasation: is the leakage caused by intravenously administered chemotherapy agents which are additionally classified by their potential to damage tissue if they inadvertently leak from a vein into surrounding tissue xxi. Damage to tissue around IV xxii. **Indicates of extravasation during administration:** 8. Absence of blood return from the IV catheter, resistance to flow of IV fluids, or burning/pain, swelling, or redness at the site xxiii. **If extravasation is suspected the medication must be stopped immediately** - Prevention is key xxiv. Carefully monitor the access site changes, inflammation, etc. xxv. Advocate for implanted port if client is eligible xxvi. Be aware of the antidote xxvii. Monitor for blood return of access site - Hypersensitivity reactions - Premedicate with Benadryl & Phenergan - Drug administration: extravasation/infiltration vesicants are drugs that damage tissue - **PREVENTION IS KEY** - Careful monitoring of access site - Advocate for implanted port if client is eligible - Be aware of the antidote - Monitor for blood return of access site **Chemotherapy Toxicity** - Gastrointestinal, pg.1005 - Nausea/vomiting, stomatitis, mucositis, diarrhea - **Meds: Corticosteroids, phenothiazines, sedatives, and histamines (benadryl)** - Hematopoietic - Myelosuppression: depression of bone marrow function xxviii. Nadir which leads to leukopenia, neutropenia, anemia, & thrombocytopenia (low platelets) 9. **Nadir**: most often used to describe the lowest absolute neutrophil count following chemotherapy xxix. At risk for infection & bleeding - **KNOW Meds: Erythropoietin to stimulate RBCs & Filgrastim \[Neupogen\] for WBC stimulation** - Renal, pg 1006 - Rapid tumor cell lysis: damages blood vessels or filtering structures (can't excrete waste) xxx. Hydration, diuresis, alkalinization of urine xxxi. Clinical signs range from changes in lab values to AKI xxxii. Monitor lab values during therapy: BUN, Cr, electrolytes - Hemorrhagic cystitis xxxiii. Aggressive IV fluids, frequent voiding, diuresis - Meds: Allopurinol, Amifostine (protects tissues from cancer tx), Mesna - Cardiopulmonary - Monitor EF and s/sx of HF xxxiv. EF = amount of blood pushed out of heart w/ each beat xxxv. HF = difficulty breathing, lung sounds, edema, etc. - Monitor pulmonary function tests and s/sx of resp failure - May have issues w/ ovulation or early menopause; men lack sperm production - Reproductive: Testicular and ovarian function - Chemo before kids = will likely have fertility issues for men & women - Neurologic: Chemo induced neurotoxicity to CNS, PNS, & cranial nerves - Neuropathy, if unreported or undetected, can lead to motor neuron damage, muscle weakness, loss of coordination - Cognitive impairment - Fatigue: Biggest complaint - Long-term effects: osteoporosis, hand tremors, inhibits fertility **Nursing Management with Chemotherapy, chart 12-4** - Assessing fluid & electrolyte status. Assessing cognitive status. Managing cognitive changes - Modifying risks for infection & bleeding - Avoid crowds - Administering chemotherapy - Monitor for hypersensitivity rxn, extravasation, communicate w/ prescriber - Preventing nausea/vomiting: premedicate & educate on home med regimen - Managing fatigue: help pt plan - Protecting caregivers: education, don't let them handle pills, or adjust chemo pumps - Nurses may be exposed to low dose chemo agent so be familiar w/ spill procedures, handling procedures, educate family procedures handling - Chart 12-4 pg. 1011, chart 12-5 pg. 1016 **Hematopoietic Stem Cell Transplantation (HSCT), pg. 1014** - **Types**: Allogenic \[from a donor; ex. Graft-vs-host dz\], autologous (from the pt), syngeneic (from identical twin), myeloablative, and nonmyeloablative - Most commonly used to tx malignant myeloma, acute leukemia, and non-hodgkin\'s lymphoma - Most susceptible for getting sick: day 14 after transplant - Biggest concern is their risk of infection b/c they don't have enough WBCs to fight it off - Complications - **Infection** and bleeding - Failure to graft: donated cells fail to grow in BM - **KNOW Graft-versus-host disease (GVHD)**: donated cells attack host tissue, use in immunosuppressive meds to avoid xxxvi. Major cause of morbidity & mortality in the allogeneic transplant population xxxvii. Occurs when the donor lymphocytes initiate an immune response against the recipient's tissues \[skin, GI, liver during the beginning of engraftment\]. May be acute \[w/in first 1-00 days\] or chronic \[after 100 days\] xxxviii. **To prevent GVHD, patients receive immunosuppressant drugs, such as cyclosporine, methotrexate, tacrolimus, or mycophenolate mofetil.** - Veno-occlusive disease (VOD): blockage of liver blood vessels - Nursing Management for HSCT - Implementing care before/after tx: infection prevention xxxix. Avoid large crowds (ex: church, grocery stores) and no family events/potlucks due to immunosuppression - Providing care during treatment: manage the large amount of ADRs - Providing care after tx: psychological treatment for both recipients and donors - **Until engraftment of the new marrow occurs, the patient undergoing HSCT is at high risk for death from sepsis and bleeding (book)** **Immunotherapy pg. 1021** - The use of medications or biochemical mediators to stimulate or suppress components of the immune system to kill cancer cells - Nonspecific immunotherapy boosts the immune system to enhance cancer cell destruction (bacilli Calmette-Guérin, cytokines) - Monoclonal antibodies: rituximab \[Rituxan\], Checkpoint inhibitors, Cancer vaccines, CAR T-cell immunotherapy **Nursing Care for Patients with Cancer, pg. 1037** - Maintaining Tissue Integrity - Stomatitis: assess oral cavity and good oral hygiene xl. Help pt with oral care (rinse with NS every 1-4 hr) xli. Don't brush with hard bristle brush (bring from home) xlii. Avoid heat, ice, or causing further trauma to skin - Stomatitis: Inflammation of the mouth and surrounding tissues - Radiation-Associated Impairment - Alopecia: scarves, wigs - Scalp pulling to save their hair - Malignant Skin Lesions: monitor - **Promoting Nutrition** - Anorexia: Megestrol helps w/ appetite and weight gain xliii. Older female pt admitted for failure to thrive gets megestrol acetate - Malabsorption - Cancer related anorexia-cachexia syndrome - **Nutritional considerations**: Small frequent meals, Educate patient to avoid unpleasant sights, odors, and sounds in the environment during mealtime, eat preferred foods, If patient desires, serve alcoholic beverages at mealtime with foods \[not on empty stomach\] xliv. **KNOW Chart 12-6:, pg. 1054-1058 QUESTIONS FROM THIS** - Relieving Pain, chart 12-9 - Assessment, education, collaboration xlv. Rest at night, maintain good nutrition - Dexamethasone and analgesics are used for pain relief in brain & bone cancer - Decreasing Fatigue: assessment, interventions - Exercise and nutrition - Improving Body Image and Self-esteem - Assess, encourage, assist - Addressing sexuality, grieving process, psychosocial distress - **Managing Potential Complications: KNOW chart 12-6** - Infection: monitor total & neutrophil count xlvi. Promote hand hygiene - Septic shock: monitor VS - Bleeding and thrombocytopenia (platelets \ 10.4** lv. Normal is 8.5-10.5 - **Tumor lysis syndrome: breaks off & metastasizes** - ​​The release of tumor intracellular contents (nuclei acids, electrolytes, and debris) leads to rapidly induced electrolyte imbalances (book) - **Labs: potential increase in K level (so monitor this lab)** **Hospice and Advanced Cancer** - The needs of patients with end-stage illness are best met by a **comprehensive interdisciplinary** specialty program that focuses on quality of life - Focuses on quality of life, palliation of symptoms, provision of psychosocial and spiritual support for patients and families - Focus of care is on family as well as patient -