Oncology Nursing Points PDF

Oncology Nursing Points Outline Overview Warning signs of cancer (CAUTION US) Change in bowel pattern A sore that does not heal Unusual bleeding Thickening of breast, testicle, skin Indigestion Obvious change...

Oncology Nursing Points Outline Overview Warning signs of cancer (CAUTION US) Change in bowel pattern A sore that does not heal Unusual bleeding Thickening of breast, testicle, skin Indigestion Obvious change in mole Nagging cough Unexplained anemia Sudden unexplained weight loss Nursing Points General All cancer diagnoses must be confirmed with a biopsy and/or histologic examination (gold standard) , excision biopsy may produce scars unlike with fine needle Cancer Staging / TNM Scoring Stage 0: carcinoma in situ (is) Stage I: local tumor growth Stage II: limited spreading Stage III: regional spreading Stage IV: metastasis to other organ E.g. Tis, N0, M0 = cancer is localized Mitosis is a normal cell division for growth and repair. It is when DNA replicates and each of the 2 new daughter cells produced has a genetically identical copy of parents' cell's DNA Apoptosis Cellular activity includes a programmed death of cells that is is also known as Malignant versus benign differences: Rate of growth, ability to cause death, ability to spread Benign tumor: does not spread to other tissues or organs Assessment Testicular Cancer Instruct client to perform monthly self examination  Best performed after warm shower Cervical Cancer Women should have regular gynecological examinations with Pap smear testing Every 3 years routine Annually if abnormal Breast Cancer Metastasis can easily occur via the lymph nodes Risk Factors Early menarche Late menopause BSE (Breast Self Examination) Perform monthly 7-10 days after menses, same day every month, or once a month Mammogram Once a year for ages 40 and above Do not perform blood pressure checks or invasive procedures on an arm that has had a mastectomy Risk for Lymphedema Prostate Cancer Men after 50 should have regular prostate examinations Removal of the prostate gland can be achieved via Transurethral Resection of the Prostate (TURP) Therapeutic Management Chemotherapy Precautions Nadir: It is a term that represents the period of time when blood levels are at their lowest point. Administered by nurse with specialty training Considered a toxic biohazardous material – handle only with special ‘chemo’ gloves (thicker) Will cause decreased immune system Neutropenia (Low WBC-Neutrophils) Leukepenia (Low WBC-Granulocytes) Anemia Thrombocytopenia: Low platelet count Initiate neutropenic and bleeding precautions Patient may require antiemetics or antihistamines during chemotherapy to manage symptoms Radiation Can cause burns to skin → keep skin hydrated after radiation Nursing Concepts Cellular Regulation Comfort Infection Control Health Promotion Patient Education  Monthly self-exams (breast, testicle) Trust your instinct – if something doesn’t seem right, tell your provider Changes to normal appearance or pattern usually indicate a problem Chemotherapy Outline Overview Antineoplastic Chemotherapy Anti-: Against -neoplastic: abnormal cells or growth Chemo-: chemical, drug -therapy: given for therapeutic benefit Drugs given to kill cancer cells and/or stop their growth Administration of Chemo Patient Safety Staff Safety Infection Prevention Immunocompromise Central Line Associated Blood Stream Infections (CLABSIs) Patient Education Drug Specific Chemotherapy Precautions Nursing Points General Place in therapy Cure Single-Treatment (rare) Combined-treatment (common) Control Extend life Improve quality of life Not for cure Palliative Relieve tumor-related symptoms Improve comfort Cure or control not possible “Liquid” Tumors Lymphoma Leukemia Bone Marrow Transplant (BMT) Only cure for Leukemia Completed once achieve remission High dose chemotherapy given to wipe out bone marrow New bone marrow cells transfused  Myeloma Solid Tumors Adjuvant Chemotherapy After surgery/radiation Neoadjuvant Chemotherapy Before surgery/radiation Hyperthermic intraperitoneal chemotherapy (HIPEC) “hot chemo” washing of abdomen Common for pelvic and abdominal cancers Effective in contacting microscopic cells missed with surgery Chemotherapy precautions apply Common Toxicities Cardiac Pulmonary Neurologic Gastrointestinal Assessment Functional status – every encounter with patient Fatigue Are you experiencing fatigue? If so, how severe has it been, on average, in the past week? 0-10 How does fatigue interfere with your regular activities? Rundown of symptoms Constipation/diarrhea Nausea/vomiting Mucositis Toxicities Cardiac Pulmonary Neurologic Skin/Mucous membranes GI Accurate weights at every treatment Monitor for weight loss Many drugs weight-based or BSA-based Absolute Neutrophil Count Used to determine level of myelosuppression Most common treatment-limiting factor for patients Life-threatening MD will not clear for chemo until ANC >1000 Leads to delay in care Nadir Lowest point of ANC Most vulnerable state 50-75% of patients with cancer die from infection while neutropenic  Febrile neutropenia Modified immune response No WBCs to sound alarm of infection Oncologic emergency Leads to sepsis, shock, MODS Prevention Pharmacologic Colony stimulating factors Give 24 hours after chemotherapy Helps to stimulate growth Infection No live vaccinations Limit exposure to pets and children Wear mask in highly populated areas Limit indwelling medical devices, tampons, rectal suppositories Therapeutic Management Infection prevention Low WBC precautions Patient to wear mask in populated areas Staff and family wear mask while in hospital Hand washing No fresh fruit or uncooked vegetables orfresh meats (e.g. sushi, sashimi etc) Symptom management Nausea/vomiting Fatigue Constipation/diarrhea Mucositis Anorexia Safety Chemotherapy precautions 48 hours post-chemo Double flush toilet Caregivers wear 2 sets gloves Wash soiled linens immediately Seal diapers and sanitary napkins in 2 bags before disposing Administration Independent double check In pharmacy while preparing drug (Pharmacists) At bed/chairside immediately before administering (RNs) Special tubing/devices Monitor for reactions Extravasations Most chemo drugs are vesicants Oncologic Emergencies Febrile Neutropenia  Tumor Lysis Syndrome Graft vs. Host Disease Bone Marrow Transplant Body rejects engraftment with new bone marrow cells Nursing Concepts Cellular Regulation Cancer begins as a single abnormal cell Chemotherapy targets abnormal cells to kill, control, and regulate them Coping Isolating Socioeconomic impact Stigma Symptom management Patient Education Paramount to success Separate appointments for teaching new patients are common Patient Education Infection prevention Important to teach when to expect nadir Foods to eat Influenza, Pneumococcal vaccinations as appropriate Wash hands Continue to see Primary Care Provider Maintain established medication regimen notify PCP and oncologist of ED and hospital stays Adherence to care plan Pre-infusion labs ANC Kidney function Determine eligibility for infusion Post-infusion medications Often for symptom management Radiation Therapy Outline Overview What is radiation therapy? Treatment with radiation to destroy cancer cells Given to 60% of all patients with cancer Review: Electrical charge of atoms → neutral with balance of protons (+), electrons (-), and neutrons (neutral) Nursing Points General Radiation treatment destroys cancer cells by delivering high-energy particles, beams, or waves These disrupt the balance of protons and electrons and cause atoms to be unbalanced → free radical formation → breaks down DNA stand → keeps cancer cells from growing and dividing Cancer and healthy cells are susceptible but healthy cells are better at repairing damage In high doses causes cell apoptosis in endothelial lining of blood vessels → microvascular dysfunction → cell death Rapidly dividing cells are more susceptible (radio-sensitive) Amount to destroy cancer cells without destroying healthy cells ordered in Gy (Gray) or Centigray Fractionation: Total dose divided into daily treatments over a period of time to allow for healthy cell recovery between treatments Hypofractionation: Larger doses given over a short time Hyperfractionation: Doses further divided, can be delivered multiple times/day Assessment Side effects of treatment Acute- occur about two weeks after initiation of treatment and typically resolve in less than 6 months General Fatigue- Energy conservation technique Skin irritation- teach skincare → mild moisturizing products, avoid sun exposure, mild soaps, loose clothing Site-specific- depending on tissues surrounding treatment areas Brain- Hair loss- can be permanent, cognitive changes Head and Neck- Dry mouth, mouth sores, difficulty swallowing, see dentist 2xa year Chest- Cough, heavy, swollen breasts Abdomen- Nausea and vomiting, diarrhea, GERD Late- >6 months after treatment Can be permanent damage from fibrosis, necrosis, or atrophy Organ damage Connective tissue damage Radiation-induced tumor- rare but can occur Therapeutic Management Goals of radiation therapy Cure- alone or with a combination of chemo and surgery Control- stop the spread of disease Prophylaxis- to prevent the anticipated microscopic spread Palliation- Control pain, bleeding, improve quality of life Types of radiation therapy External Beam Radiation Therapy (EBRT)- uses a machine to deliver a beam that passes through the body Patient evaluated to determine eligibility → simulation completed to determine the position of patient and apply permanent tattoo markings for guides → treatment planned by physicist and radiation oncologist → treatment by a radiation therapist Patients must be in same position each time for treatment Patients might hear the machine and will see machine moving but will not feel the treatment Patients are not radioactive after treatment Special types of EBRT Image-guided radiotherapy (IGRT)- uses imaging to visualize area with each treatment Intensity-modulated radiation therapy- More targeted treatment adjusts size and intensity of beams TBI- total body irradiation for hematologic malignancies prior to a stem cell transplant Stereotactic radiosurgery- delivered directly to brain tumors using special head ring Stereotactic body radiotherapy- high dose to small area guided by internal or external markers and body frame to immobilize patients Intraoperative radiotherapy- single high dose delivered to the exposed tumor in OR Internal Radiation Therapy Delivers radioactive isotopes that release energy to destroy atoms as they decay Brachytherapy Sealed sources of radioactive isotopes placed in or close to the tumor Low dose radiation- delivers radiation over days/ weeks Radioactive precautions during treatment ALARA- As low as reasonably achievable exposure to others Dosimeter to monitor exposure High dose radiation- delivers dose when activated for 10-20 min Precautions only during the short treatment Radioisotope or radiopharmaceutical therapy Ingested, injected, or instilled into body cavity  Directed toward the target area Bound to monoclonal antibodies ® to be delivered directly to tumors Bound to Iodine to be delivered to thyroid (Iodine- 131) Precautions to avoid exposure to others Time, Distance, and Hygiene to reduce exposure Nursing Concepts Cellular Regulation Radiation causes disruption of cell cycle mitosis, apoptosis Patient Education Specific side effects Safety of radiation therapy Tissue/ Skin Integrity Local skin irritation common with certain radiation treatments Patient Education Safety of radiation therapy Explain what to expect before, during and after treatment Reducing exposure to others Site-specific education about anticipated side effects This is very important for people getting short duration of treatment because side effects might appear weeks after treatment Available resources Support groups for cancer patients and families Education material specific to their treatment Leukemia Outline Overview Proliferation of abnormal, undeveloped WBCs Unable to function in infection control / immunity Diagnosed by blood tests and bone marrow biopsy Nursing Points General Characterized by type of WBC affected Acute Lymphocytic Leukemia (ALL) 2-4 years of age Chronic Lymphocytic Leukemia (CLL) 50-70 years of age Acute Myelogenous Leukemia (AML) Peak at 60 years of age Chronic Myelogenous Leukemia (CML) Incidence increases with age Assessment Weight loss Fever Infections Pain in bones and joints Night sweats Aplastic Anemia Pallor Fatigue Easy bleeding and bruising ↑ WBC in CLL and CML ↓ WBC in ALL and AML Philadelphia chromosome in majority of CML clients Mouth sores from chemo Therapeutic Management Chemotherapy and radiation Bone Marrow Biopsy Apply pressure to biopsy site Provide analgesia Initiate neutropenic precautions Strict hand washing Limit visitation No fresh fruits or flowers Initiate bleeding precautions Avoid fatigue Plan activities to provide time for rest Instruct client on oral hygiene Rinse mouth with saline Avoid lemon, alcohol based mouthwash Nursing Concepts Cellular Regulation Infection Control Comfort Clotting Patient Education Bleeding Precautions Infection Precautions Oral Hygiene Lymphoma Outline Overview Cancer of the lymphatic system affecting lymphocytes Impairs immune response Nursing Points General Classified by Type Hodgkin’s Lymphoma Presence of Reed-Sternberg cells Non-Hodgkin’s Lymphoma Absence of Reed-Sternberg cells 90% of Lymphomas Tumors may form in/around the lymph nodes Lymphocytes affected – can travel/metastasize through lymphatic system Assessment Painless swelling of lymph nodes Persistent fatigue Fever Night sweats Shortness of breath Unexplained weight loss Enlarged liver or spleen Risk for Infection Therapeutic Management  Official diagnosis with lymph node biopsy Hold pressure over biopsy site Chemotherapy Radiation Lymph node removal Monitor for s/s metastasis (high risk) Nursing Concepts Infection Control Neutropenic Precautions Monitor for s/s Infection Clotting May have risk for bleeding, especially after surgery or biopsy Cellular Regulation Chemotherapy Precautions Patient Education Bleeding Precautions Infection Precautions Oral Hygiene Lung Cancer Outline Overview  Two Types Small Cell (Oat Cell) Non-Small Cell (NSCLC) Multiple Treatment Modalities Radiation Surgery Chemotherapy Symptom Management Survivorship Nursing Points General NSCLC Vast majority of Lung Cancers Staging of disease drives treatment options Small Cell/Oat Cell Aggressive growth Spreads early on Incurable at late-stage Symptom management/palliative care a priority Smoking Cessation Largest modifiable risk factor Quitting exponentially decreases risk of lung cancer Screening High Risk: Spiral CT Low Risk: No routine screening Treatment Radiation Local, focused treatment As frequently as 5x/week Chemotherapy Systemic treatment Indicated in metastatic disease Side Effects Dependent on treatment regimen Regimens change frequently NCCN guidelines are excellent resource Surgery Wedge Partial lobe removed Smaller tumor burden Lobectomy Total lobe removed Moderate tumor burden Pneumonectomy Removal of total lung  Largest tumor burden Immediate Rehabilitation Early ambulation Cough and deep breathing Treated similarly to an open heart patient Multiple chest tubes Splinting with cough Cardiac monitoring Depending on stage of disease, any treatment may be palliative or curative Patient education key Conversation between MD and patient Causes Tobacco use Second hand smoke exposure Asbestos exposure Genetics Assessment Initial presentation can be non-specific Symptoms Shortness of breath Productive Cough Bloody or pink-tinged sputum Activity intolerance Anxiety Rule out other cardiac/respiratory issues Chest x-ray Chest CT if concerning for cancer Lab work Functional capacity Ability to perform ADLs Appetite Activity tolerance All predictors of how patient will tolerate treatments Smoking cessation Obtain honest history from patient More pack years = higher risk The sooner they stop, the lower the risk of cancer they will see Ongoing treatment Monitor for chemotherapy drug-specific symptoms Cardiac & respiratory toxicities Decreased appetite Weight loss Monitor respiratory status Decline common Patient may need supplemental oxygen  Serious cases of activity intolerance may require home health or other assistance to complete ADLs Advanced Care Planning Discussion and decision point between patient and provider regarding patient’s end of life wishes Can be prompted by RN to MD Risk vs. benefit analysis Symptom management Air hunger / shortness of breath Pain Nausea / vomiting Chemotherapy side effects Therapeutic Management Driven by type of lung cancer – often multimodal NSCLC: Stage I & II – Surgical, Medical NSCLC: Stage III & IV – Medical, Palliative (which may include palliative surgery) Oat Cell / Small Cell: Medical & Palliative Not all interventions are curative Chemotherapy Determined by: Disease progression Patient presentation ADLs Chronic conditions Nutrition status Genetic mutations NCCN guidelines Length of chemotherapy plan driven by patient tolerance and disease response to treatment Radiation Target therapy 5 days/week Monitor for signs of skin irritation or infection Ensure patient has transportation to appointments Nursing Concepts Coping Any cancer diagnosis will affect patient’s ability to cope Has profound impact on family/support system Health promotion Smoking is a modifiable risk factor Oxygenation Impacted by disease process Can impair patient comfort Patient Education Smoking cessation  Imperative at time of diagnosis Life threatening if on home oxygen Chemotherapy precautions Protect family members from body fluids Avoid sick individuals Palliative medicine Different from hospice care Goal-directed quality of life and symptom management driven care Contact oncologist If admitted to hospital for any reason If primary care provider suggests any medication changes Prostate Cancer Outline Overview 2nd most common cancer in males Behind only skin cancer 1 in 9 men Treatment modalities Surgery Chemotherapy/Immunotherapy Radiation Hormonal Nursing Points General Treatment dependent on tumor stage and grade  Stage = amount of disease spread; grade = speed of disease growth Distant metastases will require chemo for cure Radiation often recommended in multi-modal approaches Surgery common in lower stages Can affect sexuality/reproduction Onco-fertility is up and coming Hormonal therapy can be prescribed long-term Risk factors Age > 50 African-American descent Family history BRCA-1, BRCA-2 Diet Link unclear We know North Americans are at higher risk than their peers in Asia Prevention Biggest risk factors not modifiable Age Race Genetics Modifiable Weight Physical activity Diet high in vegetables Life expectancy Dependent on staging at diagnosis Local/regional mets: 99% at 5 years Distant: 30% at 5 years Lower grades in older men may not be treated aggressively Manage symptoms in cancers we do not treat for cure Urinary symptoms Pain Metastasis – each changes life expectancy in its own way Bone Lungs Lymph nodes Brain Liver Assessment Screening Done on patient-specific basis Symptoms Genetic history Age Provider discretion  PSA level Suggested to start between ages 50-60 Blood test for prostate-specific antigen Also used post-treatment to monitor for recurrence Patient history Difficulty urinating Frequent urination Blood in urine/ejaculate Erectile dysfunction Hip and/or lower back pain Side effects Dependent on treatment modality Changes in fertility Weight loss Disease process Impotence Change in sex drive Pain with urination Sexuality Often guides decision making process for patient Decreases with disease process and treatment Younger patients should be referred to fertility Therapeutic Management Hormonal – 1st line for metastatic Suppresses androgens (testosterone) Surgical: orchiectomy Pharmacological Impotence Absent sex drive Fatigue Chemotherapy Hair loss Nausea Weight loss Fatigue Infection Radiation Skin rash Blood in urine Pain Surgery Can be nerve-sparing Impotence Many require urinary catheters post-surgery May require hospital say Nursing Concepts Coping Cancer diagnosis Stress survivorship Sexuality Can cause ED Can alter sex drive Refer to onco-fertility Elimination Symptoms can prompt diagnosis Needs may change over time Patient Education Dependent on treatment Surgery: signs of infection, difficulty urinating Radiation: skin rash, hematuria Chemotherapy: weight loss, infection prevention Hormonal: sexual changes Fertility Sexual dysfunction Sperm banking Treatment modalities Aggressive care may not be best choice Long-term monitoring is common Testicular Cancer Outline Overview Young to middle-aged men 50% are 20-34 years old Less than 10% older than 55 Prime family building ages Highly treatable Detect early though Testicular Self-Exam (TSE) > 99% lifetime survival rate Nursing Points General Affects younger men Most common cancer in young men  Incidence increasing Risk factors Young age Personal history of testicular cancer Chance of recurrence high in first 15 years Family history History of undescended testicle Myths: Horseback riding Motorcycle riding Trauma Fertility impact Orchiectomy is common Chemotherapy impact As many as 50% of patients are infertile after treatment Assessment Presenting symptoms Painless lump most common Non-movable Typically uni-lateral Aching in pelvis Metastatic symptoms GI: Anorexia Lung: Cough, chest pain, shortness of breath Diagnostics Testicular ultrasound CT abdomen and pelvis Chest xray – common site of metastasis Serum Human chorionic gonadotropin (beta-HCG) Therapeutic Management Dependent on presentation Patient age Stage of disease Curable even when metastatic With each stage of metastatic disease, intensity of treatment increases Often will be a multimodal approach Surgery Orchiectomy: surgical removal of testicle In early disease, possible to cure with surgery alone Radiation Decreases failure rate by 15% Chemotherapy In early stages, single dose of Chemo may work Increase in total cycles of chemotherapy increases with each stage of disease Surveillance  Key to lifelong survival Recurrence common in first 10-15 years Monitor beta-HCG levels Nursing Concepts Coping Treatment affects physical and emotional well-being Survivorship begins at diagnosis Positive coping key to outcomes Reproduction Encourage sperm banking prior to treatment Orchiectomy, Radiation, and Chemotherapy impact fertility No impact on malformations of future children Sexuality Body image Fertility impact Patient Education Testicular self-exam Hard, non-movable lumps or masses Fullness in pelvis or testicle Fertility Sperm banking prior to treatment Up to 50% of patients are infertile 2 years after treatment Increased risk of testicular cancer in descendents No abnormal risk of birth defects Colorectal Cancer Outline Overview  Cancer of colon and rectum share: Causes Screening Incidence Symptoms Surgery is the definitive treatment Can vastly alter the flow of GI tract Subsequent surgeries common Nursing Points General Colon Cancer Cancer of large intestine Surgery is the only cure 5-year survival 64% Rectal Cancer Cancer of connector between intestine and anus Treatment will include surgery and chemotherapy Radiation also possible 5-year survival 67% Other Colorectal Cancers Anal HPV related Appendiceal High mortality Risk Factors Modifiable Sedentary lifestyle Waist circumference Smoking Alcohol use Diet Non-modifiable Age Family history Sex Assessment Colonoscopy Screening Average risk Begin age 45 Every 10 years until age 75 Increased risk Abdominal cancer history History of IBS or other GI syndromes History of abdominal radiation Begin age 45, or earlier as determined by MD  Frequency of subsequent exams patient-specific Consider risk factors and personal history Screening alternatives Stool tests Sigmoidoscopy Virtual Colonoscopy Any abnormal results require follow-up colonoscopy Symptoms Colon Cancer Asymptomatic in early stages Colonoscopy helps to catch early Late stage Abdominal tenderness Rectal bleeding Ascites Rectal Cancer Bleeding in 60% of patients Change in bowel movements diarrhea malformed stool fullness in rectum/anus feeling of incomplete BM Diagnostics Colon Cancer Colonoscopy Abdominal CT CEA level perform baseline at diagnosis use to monitor disease progression Liver and kidney function Rectal Cancer Digital Rectal Exam (DRE) Rigid Proctoscopy Assess sphincter involvement Helps determine level of continence expected after surgery CT Stool Testing Occult stool Stool DNA CEA level perform baseline at diagnosis use to monitor disease progression Liver and kidney function Therapeutic Management Surgery is First Line  No cure without surgical removal Depends on tumor location Recovery differs depending on area of resection Many require colostomy or ileostomy Sometimes reversible Chemotherapy Some breakthrough treatments in last decade Needed for any patient with metastatic disease Radiation Not indicated for colon cancer Some benefit for rectal cancer Conservative resections to preserve continence Supplement surgical removal of tumor Radiate remaining cancer cells to prevent growth Bladder irritation common Nutrition Alteration in GI tract Changes absorption of nutrients Dumping syndrome Short gut syndrome Recurrent bowel obstructions Surgical adhesions Scar tissue Tumor burden Supplemental nutrition as needed Protein supplements Vitamin supplements Tube feeding Total Parenteral Nutrition (TPN) Nursing Concepts Elimination Some require colostomy, ileostomy as a result Rectal cancer surgery may reduce continence Changes in stool character common Gastrointestinal/Liver Metabolism Surgery alters the route of GI tract Absorption of nutrients and fluids often changes Nutrition Diet is a risk factor Altered nutrition during surgery and chemotherapy is common Patient Education Screening recommendations Understand personal risk Understand familial risk Colonoscopy  Most MD prefer Uncomfortable preparation So important for detecting early Early detection = more survival Dietary changes Prevention Less red meat More vegetables Decrease alcohol usage During Treatment Optimize protein intake Watch intake/output closely Prevent dehydration Family history Genetic component is strong Abnormal Coloscopy may change screening recommendations for immediate family Breast Cancer Overview Breast Anatomy- men and women Lobules- where milk is made Ducts- takes milk to nipple Cancer Anatomy Abnormal Cells Loss of Apoptosis= Overgrowth Breast Cancer An overgrowth of abnormal cells in, or from, the breast Second most common cancer in women behind skin cancer 1% of diagnoses are in men, survival rate similar to women, but usually later diagnosis Nursing Points General  3 Main Types of Breast Cancer Lobular Carcinoma- From the Lobules Ductal Carcinoma- From the Ducts Inflammatory rare, only 1-5%, aggressive Location Invasive Spread to surrounding tissues Noninvasive Only in duct or lobule In Situ Other name for Noninvasive meaning ‘in place’ (i.e. DCIS) Grading How differentiated (abnormal) the cells are GX (unknown) to G3 (very abnormal) Staging How far the cancer cells have spread 0- in situ or noninvasive to IV- distant metastasis Recurrent- cancer that has come back after treatment Cellular Testing Estrogen Receptors (ER) Progesterone Receptors (PR) HER2/NEU Protein involved in normal cell growth, may be overproduced in cancer cells Assessment Breast exam (no evidence for self-breast exams, clinical with routine care) Lump in breast or armpit Asymmetry Breast or Skin that is inflamed (red/itchy), dimpled, scaly or puckered Nipple changes or discharge (inverted) Peau d’orange (orange peel skin) Trademark sign of Inflammatory BC Imaging Mammogram Ultrasound MRI Metastasis (most common sites) Bone Mets Bone pain Hypercalcemia Liver Mets Ascites Jaundice RUQ pain  Brain Mets Altered Mental Status Headache Lung Mets Dyspnea Risk Factors Non-modifiable Older age Family History Genetic mutations BRCA 1/2 Prophylactic mastectomy History of benign or malignant breast conditions XRT to breast can increase risk Dense Breasts Estrogen Exposure Early menarche / Late menopause Older at first birth or nulliparous Estrogen HRT Modifiable Obesity / Sedentary lifestyle Alcohol consumption Estrogen based HRT and OCP Protective Factors Early Pregnancy Breast Feeding Certain HRT and OCP- unclear cause Therapeutic Management Treatment modalities Surgery Lumpectomy Mastectomy (unilateral or bilateral) Lymph node dissection Reconstruction Implants Autologous Tissue (Flaps) Prosthesis Radiation Chemotherapy Targeted Therapy Immunomodulating Therapy Hormone therapy Symptom Management Chemotherapy-related Peripheral neuropathy  Pancytopenia Hair loss Nausea Weight Loss/Gain Surgery-related Lymphedema – lymph node dissection Body image disruption Pain control Radiation-related Skin rash, breakdown and infection Pain at site Targeted and Immunomodulating Depends on drugs- different side effects Hormone-related Hair loss Mood swings Hot flashes Pseudomenopause Nursing Concepts Evidence-Based Practice Research is ongoing and we need to stay current on best practice Hormone Regulation Link to ERT Cellular Regulation Loss of cellular differentiation Patient Education Know Your Risk Factors Genetics Modifiable Non-Modifiable Know your Cancer Location- ductal vs lobular Local Spread- invasive vs noninvasive/in situ Grade- how different are my cells Staging- how far has it spread in my body Testing- what tests were done and what are the results Know your Treatment and Side Effects What Treatments will I get and in what order What are the specific side effects to my treatments? Ovarian Cancer Overview Cancer of ovaries and/or Fallopian tubes Non-specific symptoms Abdominal metastases common Hormone-related Affects older women Treatment modalities Current research and clinical trials are promising Often requires surgery No routine screening exists Nursing Points General Three main types Epithelial – majority Germ cell – egg production Stromal – hormone producing Genetic Risk BRCA-1, BRCA-2 Same genes linked to breast cancer risk Genetic counseling Assessment Non-specific symptoms Abdominal pain  Fatigue Difficulty urinating Bloating Constipation Reflux Early fullness Diagnosis Radiology Pelvic ultrasound Abdominal CT Chest CT Mammogram Remember: hormonal component Breast Ca to Ovarian Mets Ovarian biopsy Often requires oophorectomy Fertility concerns Advanced stage Malignant ascites Malignant pleural effusion No specific tumor marker CA-125 “recognizes” most female reproductive cancers Does not differentiate between cancers Therapeutic Management Initial Treatment Surgery Early stage: radical hysterectomy & oophorectomy Later stage: pelvic exoneration, HIPEC May require colostomy, ileostomy, and/or urostomy May require ureteral stents Chemotherapy Required for all patients except low-risk stage I Radiation uncommon Goals of care Not always treating for cure Abdominal metastases are difficult to treat Often palliative focus Relieve GI symptoms Decrease pain Crucial conversations Encourage questions from patient Advocate to team Nursing Concepts Coping Cancer diagnosis  Family history Genetic counseling Hormone Regulation Some tumors fed by hormones Risk/benefits of hormone therapy post-treatment Reproduction Occurs within female reproductive system Fertility impact Patient Education Genetic component Family history Familial risk Counseling recommended Symptom management Treatment related Chemotherapy Post-surgical Disease-related Pain GI symptoms Survivorship Survivor at time of diagnosis Support groups Fertility impact Cervical Cancer Overview Direct link to Human Papillomavirus (HPV) Preventable, sexually transmitted infection Vaccination available Suggested for all women and men 26 and younger Incidence much higher worldwide than in US Treatable, cure dependent on extent of disease spread 60-80% 5-year survival rate if caught stage 1 or 2 Less than 50% stage 3 or 4 Nursing Points General  Higher incidence worldwide vs. US due to well-known screening guidelines Screening every 3 years starting with onset of sexual activity or at age 21, whichever comes first Gardasil vaccination available to prevent HPV Both men and women eligible for vaccination Risk factors Known HPV infection Obesity HIV infection Multiple sexual partners Smoking Using birth control pills for a long time (five or more years). Having given birth to three or more children. Prevention Gardasil-9 vaccination Protects against 9 strains of HPV known to cause cervical cancer 3 shot series available to men and women up to age 26 Assessment Signs & symptoms Vaginal bleeding Not related to period Abnormal in amount or substance Post-menopausal Vaginal pain Foul smelling discharge Pain with urination Pain with intercourse Routine monitoring Pap smear every 3 years at onset of sexual activity until age 30 HPV screening every 3-5 years until age 65 Recommendations constantly changing Therapeutic Management Dependent on staging at time of diagnosis Early phase may only require surgery Cryosurgery Ablation Conical excision of affected area Otherwise, combination of surgery, chemotherapy, and radiation Surgery: Partial or Radical Hysterectomy Advanced Stage: Pelvic Exoneration Radiation Internal Radiation (Brachytherapy) – radioactive device inserted into vaginal canal to directly radiate the cervix Traditional Radiation Chemotherapy  May not be treating for cure Any therapy can be palliative Fertility Encourage referral to oncofertility prior to intervention Hysterectomy is common Nursing Concepts Health Promotion Preventing HPV infection is key to preventing cervical cancer Encourage adherence to routine screening Infection Prevention Prevent HPV infection Encourage vaccination Reproduction Encourage oncofertility consult for women of childbearing age Hysterectomy is common even in early-stage disease Patient Education HPV Prevention Gardasil vaccine Safe sex practice Routine screening Fertility Impact Hysterectomy and pelvic radiation are common Encourage consult to oncofertility Treatment specific education Chemotherapy precautions Post-surgical recovery expectations Radiation side effects Liver Cancer Overview Liver cancer impedes the function of the liver and can block the flow of blood and bile Nursing Points General In order to understand liver cancer it is important to understand the functions of the liver Synthesizes clotting factors Metabolizes fats, carbohydrates, and many medications Synthesizes proteins including albumin Cancer in the liver usually spreads from a different cancer Hepatocellular carcinoma (HCC) is the most common cancer that does form in the liver Cirrhosis from any cause is a HUGE risk factor for liver cancer Chronic inflammation and damage to liver cells leads to fibrosis and cellular changes that can cause HCC Very poor prognosis with advanced disease and cirrhosis HCC has a 5-year survival rate of 18.4% Involve palliative care early in treatment to promote quality of life Assessment Pain- In the right upper quadrant or referred to right shoulder from enlarged liver Caution with medications →Impaired metabolism of opioids, but pain management is SO important Jaundice/ itching- from biliary obstruction/ bilirubin build up Treatment Percutaneous drain or stent to brain bilirubin Skin care- fragrance free soaps and lotions to reduce itching Fluid retention- ↑ pressure in portal vein, Na+ and water retention, ↓ albumin synthesis Treatment Diuretics- potassium sparing ↓ Na+ intake Elevate extremities to reduce dependent edema Ascites- fluid retention in the peritoneal cavity Treatment Paracentesis if symptomatic shortness of breath from increased pressure on lungs Encephalopathy- Altered LOC- ­↑ toxins traveling to the brain Nursing considerations Can be exacerbated with medications (opioids, benzos) Speed up the passage of food through the body to reduce toxin build-up Prevent opioid-induced constipation Treatment Lactulose- titrate to 2-3 soft bowel movements per day  Bleeding- varices from ↑ portal vein pressure, ↓ liver synthesis of coagulation factors, ↓ platelets from splenomegaly Nursing Considerations Bleeding precautions, education Treatments Cauterization Blood product infusions Therapeutic Management Liver resection/ transplantation- ideal but many are not eligible due to advanced disease at diagnosis Direct therapy to cancer- kills cancer cells and/or cuts off blood supply to tumor TACE- transcatheter arterial chemoembolization Brachytherapy Radioembolization Systemic treatment Chemotherapy/ biotherapy Palliative care Nursing Concepts GI/Liver Metabolism Cirrhosis review- exacerbated with liver cancer Fluid & Electrolyte Diet- ↓ Na+ Fluid restriction if ordered Coping Patient and family Patient Education Pain management Bleeding precautions Palliative care education No alcohol/ avoid Tylenol Stomach Cancer Outline Overview Stomach Anatomy Proximal stomach (top) Cardia fundus body Makes gastric juices to digest food and intrinsic factor (B-12) Pepsinogen –> Pepsin HCL-hydrochloric acid Distal stomach (bottom) Antrum Pylorus Holds broken down food and releases to the small intestine Layers of stomach Mucosa (innermost) Submucosa Muscle Serosa (outermost) Close to other organs Colon Liver Spleen Pancreas Small intestine Nursing Points General  Treatment varies Stage (TNM) Tumor size Lymph node involvement Metastasis Location of disease Type of cell involved Adenocarcinomas- 90-95% Stomach (gastric) cancer is 4th most common cancer worldwide Usually diagnosed between ages 55-80, rare WBCs -> B Lymphocytes -> Plasma Cells  WBCs- fight infection, fuel immunity, arise from stem cells in the Bone Marrow B Lymphocyte (antibody driven immunity) -> Plasma Cell Plasma Cells- secrete antibodies (proteins that kill invaders) in response to antigens (unique molecules on invaders) Malignant Plasma Cells (Multiple Myeloma) secrete abnormal antibodies called monoclonal antibodies or M proteins that do not fight infection Monoclonal Gammopathy of Undetermined Significance (MGUS) vs Smoldering Multiple Myeloma (SMM) vs Multiple Myeloma (MM) MGUS- low levels of M proteins and therefore abnormal plasma cells, no damage SMM- intermediate levels of M proteins and abnormal plasma cells, no damage MM- active disease with damage 20% of pts with MGUS develop MM, risk is 1% per year Assessment Signs/Symptoms Decreased Immunity/ Increased Infections- fewer functioning antibodies to fight Anemia/Pancytopenia- malignant cells crowd bone marrow decreasing functional/normal cells Bone Pain/Lytic Lesions (damaged spots), 2-fold- Crowd out normal bone cells Secrete osteoclast activators Impaired Kidney Function- M proteins build up and cause damage Neuro, 2-fold Bone destruction leading to spinal cord damage M proteins are toxic to nerves (PN) Hypercalcemia- multifactorial but mostly from bone destruction Diagnosis Blood Tests & Bone marrow biopsy and aspiration–> look for abnormal cells and M proteins, altered CBCDs (CBC with differential) Urine- can detect M proteins and kidney damage (glomerular damage causes leakage of large cells due to big sieve holes) Imaging- looking for bony abnormalities and lytic lesions CRAB Criteria- C- Hypercalcemia, R- Renal Insufficiency, A- Anemia, B- Bone Disease Risk Factors Older Age- 65+  Male- slightly more than women Black- 2x more than whites Obesity- the only modifiable risk factor Family history- can sometimes run in families Therapeutic Management Treatments MGUS and SMM- watch and wait, no treatment Targeted treatments- target specific abnormalities on malignant cells Biological or immunomodulating treatments- use the body’s immune system Chemotherapy- kills all rapidly dividing cells Radiation treatment- damages all rapidly dividing cells so that they die Corticosteroids- boost immune system, can directly act against abnormal plasma cells Watch for bone and renal damage with long term steroids Bone marrow transplant (BMT)- kill all Bone Marrow and replace with new cells Symptomatic treatment Bisphosphonates to preventbone loss Bone marrow stimulators Blood transfusions for pancytopenia Nursing Concepts Cellular Regulation Immunity Lab Values Patient Education Nursing Care and Pt Ed- SAFETY!! Protect from infections Protect from mechanical bone damage (falls) Protect from foot/hand/limb damage- Peripheral Neuropathy similar to diabetes or paralysis Additional nursing care for side effects of treatments Melanoma Overview The skin is made of three layers Hypodermis Dermis Epidermis (most superficial) The epidermis has 3 cell types Squamous cells Basal cells Melanocytes Make melanin which pigments the skin Protects from harmful effects from the sun Basement membrane Separates the epidermis from deeper layers of the skin Nursing Points General Classifications of melanoma In-situ Has not crossed the basement membrane Good prognosis Invasive Has spread beyond the basement membrane Poorer prognosis especially with distant spread Several types of melanomas Superficial spreading Most common type Often arises from long-standing nevi (mole) Nodular Dark brown or black- extra melanin Vertical growth Lentigo maligna Appear in sun-exposed areas Might have hypopigmentation- loss of melanin Acral lentiginous Occurs on palms, soles, and nails Mucosal lentiginous Occurs on a mucosal surface Conjunctiva Respiratory tract Oral cavity GI Esophagus Anus GU  Urethra Vagina Penis Risk factors Fair complexion and light eyes Multiple nevi (moles) Unprotected or excessive sun exposure Teach sun safety Severe sunburns as a child Genetic mutation BRAF Gene that can cause normal cells to become cancerous Assessment Changes to the skin- ANY of these is suspicious in a mole (doesn’t have to have ALL these characteristics) -ABCD- Asymmetry One side looks different than the other Border Irregular border Color Black, blue, variation in color in the same mole Diameter >6 mm is concerning ANY suspicious lesion should be checked by a dermatologist- blistering, draining, etc. No other symptoms unless it has spread to other sites With lymph node involvement Palpable lymph node Also commonly spreads to the brain, lungs, and liver Therapeutic Management Removal of the suspicious lesion (mole/ suspected cancer) Punch biopsy- an instrument “punched” into the skin to remove the lesion Shave biopsy- sterile razor used to remove the lesion Incisional biopsy- scalpel used to cut out part of the lesion Excisional biopsy- scalpel used to cut out entire lesion The goal is to have clear margins when removed 1cm tissue around lesion without cancer Diagnostics Pathology Biopsy sample sent to review for cancer cells MRI/ CT/ PET Scan To assess for metastasis Lymph node biopsy To assess for micro-spread Antineoplastics  Chemotherapy Side effects Pancytopenia- ↓WBC, ↓ Plts, ↓ RBC Fatigue Nausea and vomiting Immunotherapy Enhances immune system response Targeted therapies Radiation therapy Used for brain metastasis Nursing Concepts Cellular regulation Abnormal growth of cells Patient education Know A, B, C, D Skin integrity Disruption in skin integrity Skincare after removal Patient Education Skin self-assessments Know your skin and recognize changes Annual skin checks by a dermatologist for high-risk patients Treatment specific education Chemotherapy Care of excision site Sun Safety Slip on a shirt Slop on sunscreen Slap on a hat Wrap on sunglasses Bladder Cancer Overview Bladder Anatomy- men and women Hollow organ with muscular walls to allow for expansion and contraction Connected to kidney by ureters Urine forced out urethra when bladder contracts Layers of the bladder wall Transitional epithelium- urothelium/ innermost layer Connective tissue- blood vessels and nerves Muscle Fatty layer Nursing Points General What is bladder cancer? An overgrowth of abnormal cells in the bladder Staged with TNM- Tumor size, lymph node involvement, and metastasis Has the highest rate of recurrence of any cancer Is treatable but often returns- some treat it like a chronic condition Incidence More common in men Mainly occurs in the older population- the average age at diagnosis is 73 Types of Bladder Cancer Urothelial Carcinomas- starts in cells that line the bladder, most common Other Types (1-2%): Squamous Cell Carcinoma- formed from chronic bladder irritation (foleys, infections) Adenocarcinomas- gland forming Small Cell- neuroendocrine cells Sarcoma- start in the muscle of the bladder Location Invasive Growth into deeper layers of the bladder More difficult to treat Noninvasive Only in the inner layer of the bladder- transitional epithelium Risk Factors and causes Chemical exposure Arsenic in water Aromatic amines- used in dye industry Diesel fumes  Genetic mutations Inherited- not thought to be a major cause Acquired- more common, can be from exposure to toxin or random Chronic bladder irritation and inflammation Infections UTIs Schistosomiasis- parasitic worm- common in Africa and Middle East Chronic foley catheters SMOKING- causes half of bladder cancers, A direct link with bladder cancer Assessment Hematuria- Blood in the urine is the first sign Is often intermittent- bleeding not always constant Changes to urination from an irritated bladder Frequency Pain Urgency Difficulty/ weak stream Signs of spread to other areas Lower back pain or flank pain Bone pain Lower extremity edema Palpable mass- rare Diagnostics Urinalysis Hematuria Urine cytology and tumor marker Look for cancer cells or common proteins released by tumors in the urine Cystoscopy Camera inserted through the urethra Biopsies can be taken (TURBT- transurethral resection of bladder tumor) Pyelogram- X-ray of urinary system after dye injected to assess the function Intravenous- dye injected to vein Retrograde- dye injected through a catheter Therapeutic Management  Treatment modalities depend on the stage at diagnosis and are often a combination of treatments Surgery TURBT- can lead to bladder scarring and urinary changes Cystectomy- Removal of the bladder Partial- a portion of bladder removed Radical- removed bladder and lymph nodes In men- removes the prostate and seminal vesicles In women- removes ovaries, Fallopian tubes, uterus, cervix, and part of the vagina Reconstructive surgery Incontinent diversion Ileal conduit/ urostomy Stoma on abdomen constant urine release Continent diversion- stoma attached to pocket that holds urine until ready to empty Neobladder- new bladder made with intestines- urine passed through urethra but no urge to pass so it must be done on schedule Intravesical Therapy- Therapy delivered directly to the bladder via a catheter Bacillus Calmette-Guerin (BCG)- immunotherapy that activates the immune system to fight cancer cells Causes flu-like symptoms Causes burning/ bleeding with urination Chemotherapy- several treatment options to kill cancer cells directly Some claim more effective if chemo is heated Causes irritation and burning in bladder Radiation External beam Causes skin irritation, fatigue, nausea Systemic Chemotherapy Given before or after surgery Given with or without radiation Side effects: Nausea, vomiting, fatigue, hair loss from destruction of rapidly dividing cells in the body Targeted Therapy Directed at specific cellular mutations causing cancer Often oral agents Nursing Concepts  Cellular Regulation Apoptosis failure leads to cancer growth Elimination Changes d/t cancer and surgical changes Patient Education- Consistent follow-up because bladder cancer often comes back Patient Education Smoking cessation- HUGE- smoking has a direct link to bladder cancer Sexual- change in body image with urostomy, removal of organs and nerves with surgery might prevent orgasm in men and women Treatment specific- ensure they understand what to expect following treatments and reasons to return to the clinic or hospital Brain Tumor Overview Tumors in the brain disrupt normal brain functioning Area of the brain Frontal Controls Motor movement, thought, reasoning, bowel and bladder Called the “silent area of the brain” Tumors growing here show less symptoms initially Temporal  Controls memory, hearing, and speech Parietal Controls memory, reasoning, and spacial recognition Occipital Controls vision and reading Cerebellum Controls coordination and balance Brainstem/ Pons/ Medulla Controls breathing, heart rate, consciousness Ventricles Allows for movement of cerebral spinal fluid (CSF) which nourishes and protects the brain Meninges Membranes covering the brain and spinal cord Blood-brain barrier Restricts passage of substances to the brain Also limits what medications will reach the brain Tumors in the brain lead to an increase in intracranial pressure Normal ICP 5-15 mmHg, impacted by brain tissue, blood, and CSF The pressure inside the skull increases as a tumor grows and can also increase if a tumor blocks the flow of CSF An increase in ICP can cause brain tissue death Brain tumors grow from different cells of the brain tissue Neurons- Nerve cells A tumor from these cells is called neuronal Glial cells- supporting cells of the brain A tumor from glial cells is called a glioma and further classified by the type of supporting cell it comes from Astrocytes- transport nutrients A tumor from these cells is called astrocytoma A fast-growing, grade 4 astrocytoma is called glioblastoma Oligodendrocytes- insulates nerve fibers A tumor from these cells is called oligodendroglioma Ependymal cells- lines the ventricles and secrete CSF Cancer in these cells is called ependymoma Tumors in the meninges are called meningioma Lymphoma can also form in the brain called CNS lymphoma Nursing Points General Brain tumors are most commonly from metastasis or spread from cancers of another origin Tumors that originate in the brain are called primary brain tumors Primary brain tumors usually don’t spread to other parts of the body but can spread across the brain Benign- slow-growing, clear margins  Malignant- fast-growing, grow into surrounding tissue Incidence Can occur at any age Commonage of onset depends on tumor type Risk Factors Radiation treatment to the head Weakened immune system HIV linked to CNS lymphoma Genetic disorders Neurofibromatosis Li-Fraumeni syndrome Turcot syndrome Assessment General symptoms from ↑ ICP Headache Nausea Vomiting Altered level of consciousness Seizures Focal symptoms related to tumor location in the brain Sensory changes Hearing Vision Personality changes Weakness Ataxia = impaired balance and coordination Therapeutic Management Decrease ICP Steroids work quickly Dexamethasone IVP drug of choice Ventricular Shunt A surgical procedure to drain CSF Rarely given Mannitol Risk of rebound increase ICP Remove or shrink the tumor Craniotomy- the goal is to remove the entire tumor Tumor excised in surgery Sometimes due to location, tumors cannot be surgically removed Radiation treatment External Beam radiation Radioactive implants Chemotherapy Must cross the blood-brain barrier or be delivered directly to CNS Ommaya reservoir is a port inserted in the ventricles to give chemo directly  Intrathecal chemo is given by oncologists via lumbar puncture Chemotherapy wafers can be placed in OR after tumor removed- this delivers chemo directly to the area Targeted therapy Prevents angiogenesis so tumors cannot get blood supply Nursing Concepts Cellular regulation Tumors formed from masses of abnormal cells that grow out of control Cognition AMS/ impaired memory from tumors Intracranial regulation Alterations in ICP Coping Terrifying diagnosis because it can lead to severe disability or death Patient Education Treatment specific Side effects of chemo and radiation Immunosuppression Risk of bleeding Hair loss Fatigue Nausea Post-op instructions In hospital for 5-6 days after craniotomy Recognize symptoms of recurrence Headaches Change in headache characteristics New persistent headache Vision changes Bone Cancer Overview Cancer in the bone in adults is most often the result of metastasis from another cancer. Primary bone cancers are rare but can occur at any age. Bone cancers can spread to other parts of the body with the most common site of metastasis being the lungs. Nursing Points General Sarcomas are tumors that develop in bone and connective tissue.  The three most common types of bone cancer are: Osteosarcoma Develops in osteoblasts in growing bones Most often found in children and young adults Chondrosarcoma Develops in cartilage Most often in adults Ewing sarcoma Develops in bone or soft tissue and often spreads Most often in teenagers Risk factors: Radiation treatment in the past Large doses of prior radiation can lead to cellular changes History of bone growth disorder such as Paget’s disease Excessive bone growth leads to increased osteoblast activity and potential of mutation Assessment Pain From damaged tissue Can be a dull ache or localized sharp pain that is worse at night Swelling and tenderness to touch From increased vascularity to area Decreased ROM If tumor is in joint Pathologic fractures From weakened bones Diagnostics X-ray CT and MRI Precise imaging Assess for metastasis Biopsy To confirm diagnosis Lab values ↑ALP- Alkaline phosphatase Byproduct of osteoblast activity Released during bone formation- in this case tumor formation CBC- Complete blood count Assess for bone marrow metastasis often found in Ewing Sarcoma ↓RBC, ↓WBC, ↓platelets Others labs to assess organ function prior to initiating treatment LFTs- Liver function tests CMP- Kidney function and electrolytes Therapeutic Management  Combination treatments have led to huge advances in treatment of bone cancers. Surgery to remove tumor Most common and definitive treatment for bone cancer Limb sparing surgery is done most often but occasionally amputations are necessary Bone grafts replace the lost bone Rotationplasty sometimes used if lower leg amputated Heel from amputated leg is used as knee to improve mobility Chemotherapy Neoadjuvant Prior to surgery to reduce tumor burden Ewings sarcoma treated first with chemo Adjuvant- After surgery to prevent recurrence Eliminate micro-metastasis not detected with imaging Adverse effects Nausea and vomiting Pancytopenia- ↓RBC, ↓platelets, ↓WBC Secondary cancers- a known complication of Etoposide is secondary leukemia later in life Radiation Targeted therapy directed at tumors May be done preoperatively or post-operatively Usually used for Ewing sarcoma but can be used with all sarcomas Nursing Concepts Cellular Regulation- A mutation in genes leads to the failure of cellular regulation and tumor growth Comfort- Pain is a common symptom Human development- Often occurs in children and impacts their growth and development Mobility- Surgery will often spare limbs but can lead to long term impacts to mobility. Patient Education Monitor for surgical site infection Monitor for neutropenic fever while undergoing chemotherapy Follow up care Followed closely for 5 years after treatment to monitor for recurrence or secondary cancer Pituitary Adenoma Overview Pituitary gland = master gland Located at the base of the brain It balances hormones made by most glands Link between the brain and the endocrine system Anterior 80% of gland produces hormone Somatotropin or GH- Growth hormone Thyrotropin or TSH- Thyroid stimulating hormone Corticotrophin or ACTH- Adrenocorticotropic hormone Gonadotropins or FHS, LH- Follicle stimulating and luteinizing hormone Prolactin Posterior Nerve endings from hypothalamus Stores hormones made in hypothalamus Vasopressin Oxytocin Rare to have tumors form in posterior pituitary Nursing Points General Pituitary adenomas are benign tumors Non-cancerous Stay confined to the pituitary gland 1cm =Macroadenoma 2x as common as micro Can grow and put pressure on nearby structures Pressure changes called mass effect Can crush pituitary cells Leads to decreased hormone production Can lead to many health problems Close to brain = nerve damage Changes in hormone production= systemic effects Functional pituitary adenomas Produce too much of a hormone Can produce more than one hormone Non-functional pituitary adenomas Also called null pituitary adenomas Doesn’t affect hormone regulation  Often not removed unless they grow too large Etiology No environmental risk factors Family history Can be inherited but usually occurs independently Occurs more commonly in women Common in people 30-40 but can occur in any age Thought to occur in up to 20% of people Often unknown that a pituitary adenoma is present Incidentalomas- found on accident, usually on an MRI Assessment Local effect of mass Pressure on nearby structures Nerve damage Vision changes Headache Nausea/ vomiting Change in behavior Change in smell Hypopituitary effects from crushing pituitary cells Low Growth hormone- decrease muscle/ bone growth Reduced muscle strength Increased obesity Decreased height and growth in children Low Gonadotropin- decreased sex hormone Men- low sex drive, impotence Women- low sex drive, breast atrophy Low Thyrotropin- slow down metabolism Fatigue Cold intolerance Weight gain Excess stimulating hormones from functional pituitary adenoma Producing excess hormone Prolactinoma- ↑ prolactin= decreased sex hormones Most common Same effects of low gonadotrophin ↑ GH- increased bone and muscle growth Acromegaly Increased size of hands and feet Bulky appearance but actually weak Glucose intolerance Giantism in children  D. Cushing disease- ↑ Corticotropin- excess cortisol 1. Central obesity 2. Moon face 3. DM 4. Acne Therapeutic Management Diagnosis A. Physical exam B. MRI/CT II. Treatment A. Monitor for clinical manifestations B. Hypophysectomy- Surgery to remove tumor 1. Transsphenoidal- Endoscopy a. Through nose b. Hole drilled beneath upper lip to access 2. Open craniotomy a. Removed through small opening in skull C. Stereotactic Radiosurgery 1. Destroyed from high doses radiation from multiple angles D. Medication management 1. Some medications available that can actually ↓ the tumor size a. Dopamine receptor agonists- slows down prolactin b. Somatostatin analogue- slows down production of GH Nursing Concepts Hormone regulation A. That’s what this is all about! II. Human development A. Growth can be accelerated or delayed. III. Cellular regulation A. Alteration in cellular production leads to tumor formation Patient Education Hormone replacement therapy Sometimes required after surgery Followed closely by endocrinologist Dietary changes Specific diet recommendations with hormone imbalances  Recommend dietitian