Medical Surgical Nursing - Oncologic Care

Cancer Done ● Abnormal cell proliferation ● Cells ignore growth-regulating signals in the cell and cell surrounding environment (cell does not follow any normal structure) ● Transformed by genetic mutation is the DNA (During initiation, carcinogens (substances that can cause cancer), such as chemicals, physical factors, or biologic agents, cause mutations in the cellular DNA). ● Not a single disease with a single cause ● 2nd leading cause of cancer. ● Cancer is a large group of disorders with different causes, manifestations, treatments, and prognoses. Because cancer can involve any organ system and treatment approaches have the potential for multisystem effects, cancer nursing practice overlaps with numerous nursing specialties. Malignant Process: Pathophysiology: ● Characteristics of Cells ○ Benign versus malignant cells (see Table 15-1) ○ Benign are defined and do not cause death unless compressing a certain area. ● Malignant Cell Characteristics ○ Undifferentiated (little resemblance to anything) ○ Grows at periphery and overcomes contact inhibition to invade and infiltrate (grow uncontrollably and travel to other areas) ○ Rate of growth dependent on degree of anaplasia ● Invasion and Metastasis ○ Lymphatic and hematogenous spread ○ Work by angiogenesis (During progression, the altered cells exhibit increasingly malignant behavior. These cells acquire the ability to stimulate angiogenesis (growth of new blood vessels that allow cancer cells to grow), to invade adjacent tissues, and to metastasize). ● Carcinogenesis → process of malignant transformation ○ Initiation, promotion, progression ○ Initiation: During initiation, carcinogens (substances that can cause cancer), such as chemicals, physical factors, or biologic agents, cause mutations in the cellular DNA. Normally, these alterations are reversed by DNA repair (apoptosis) ○ Promotion: During promotion, repeated exposure to promoting agents (co carcinogens) causes proliferation and expansion of initiated cells with increased expression or manifestations of abnormal genetic information, even after long latency periods. ○ Progression: cells already altered and exhibit malignant behavior. During progression, the altered cells exhibit increasingly malignant behavior. These cells acquire the ability to stimulate angiogenesis (growth of new blood vessels that allow cancer cells to grow), to invade adjacent tissues, and to metastasize ● Nomenclature for malignant disease (Table 15-2) ● Etiology ○ Viruses and bacteria: Ex. HPV can cause cervix cancer, helicobacter pylori is one bacterium identified as a significant cause of gastric cancer, hepatitis B virus (HBV) (liver cancer), and Epstein-Barr virus (EBV) (Burkitt lymphoma and nasopharyngeal cancer). ○ Physical agents: Ex. sunlight, radiation, chronic irritation or inflammation, tobacco carcinogens, industrial chemicals and asbestos. ○ Chemical agents: Ex. Tobacco, Hookah, cigarettes, Many chemical substances found in the workplace are carcinogens or co-carcinogens. suspected chemical substances continues to grow and includes aromatic amines and aniline dyes; pesticides and formaldehydes; arsenic, soot, and tars; asbestos; benzene; cadmium; chromium compounds; nickel and zinc ores; wood dust; beryllium compounds; and polyvinyl chloride. Betel nuts and lime, which are chewed as stimulants in some cultures, are also included. ○ Genetics and familial factors: Ex. cancer in 2 or more 1st degree relatives, parents, siblings, or children. Almost every cancer type has been shown to run in families. This may be due to genetics, shared environments, cultural or lifestyle factors. Genetic factors play a fundamental role in cancer cell development. ○ Lifestyle factors: Ex. diet, obesity, & insufficient activity. Dietary substances that appear to increase the risk of cancer include fats, alcohol, salt-cured or smoked meats, nitrate- and nitrite-containing foods, and red and processed meats. Heavy alcohol use increases the risk of cancers of the mouth, pharyn ○ Hormonal agents: Ex. Estrogen medication can cause cancer. Tumor growth may be promoted by disturbances in hormonal balance, either by the body’s own (endogenous) hormone production or by 1009 administration of exogenous hormones. ○ Factors implicated or known to induce carcinogenesis include viruses and bacteria, physical agents, chemicals, genetic or familial factors, lifestyle factors, and hormones. ● Immune System Role Detection and Prevention: ● Primary Prevention (reduces the risk of the disease through health promotion and risk reduction strategies). Ex. HPV vaccine, smoking cessation. ○ Avoid known carcinogens ○ Lifestyle, dietary changes ○ Public, patient education ● Secondary Prevention (early detection activity trying to identify high risk individuals to try and detect early enough to be able to implement treatment ) ○ Identify high risk individuals ○ Cancer screening (American Cancer Society Screening Guidelines, Table 15-3) ○ Public, patient education ● Tertiary Prevention (patients who have entered into remission) ○ Cancer free ○ Prevent relapse and secondary malignancies Cancer Diagnosis: ● Determine presence, extent of cancer ● Identify possible spread (metastasis) of disease or invasion of other body tissues ● Evaluate function of involved, uninvolved body systems and organs ● Obtain tissue and cells for analysis ● The diagnostic evaluation includes a review of systems; physical examination; imaging studies; laboratory tests of blood, urine, and other body fluids; procedures; and pathologic analysis. ● Staging determines the size of the tumor, the existence of local invasion, lymph node involvement, and distant metastasis. ● Grading is the pathologic classification of tumor cells. Grading systems seek to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and histologic characteristics of the tissue of origin (differentiation). ● Diagnostic test chart: ○ Tumor staging and grading (TNM Classification – Chart 15-3) M1 - Distant metastisis Cancer Management: The range of possible treatment goals includes complete eradication of malignant disease (cure), prolonged survival and containment of cancer cell growth (control), or relief of symptoms associated with the disease and 1019 improvement of quality of life (palliation). ● ● ● ● Cure Control Palliation Surgery: Surgical removal of the entire cancer remains the ideal and most frequently used treatment method. ○ Diagnostic ■ Biopsy ○ Prophylactic- Prophylactic or risk reduction surgery involves removing non-vital tissues or organs that are at increased risk of developing cancer. ○ Palliative: When surgical cure is not possible, the goals of surgical interventions are to relieve symptoms, make the patient as comfortable as possible, and promote quality of life as defined by the patient and family. ○ Reconstructive: May follow curative or extensive surgery in an attempt to improve function or obtain a more desirable cosmetic effect ● Radiation - local ● Chemotherapy - systemic Radiation Therapy ● Neoadjuvant (prior to local definitive treatment) radiation therapy, with or without chemotherapy, is used to reduce tumor size in order to facilitate surgical resection. ● Radiation therapy may be given prophylactically to prevent local recurrence or spread of microscopic cells from the primary tumor to a distant area (e.g., irradiating the breast and axilla following lumpectomy or mastectomy for breast cancer). ● Treat localized lesions Uses: ○ ○ ○ ○ ○ Cure Control Reduce tumor size Prevent metastasis Palliative therapy: Is used to relieve the symptoms of locally advanced or metastatic disease, especially when the cancer has spread to the brain, bone, or soft tissue, or to treat oncologic emergencies, such as superior vena cava syndrome, bronchial airway obstruction, or spinal cord compression ● Dosage/Administration ○ Depends on target tissue sensitivity ○ External beam (EBRT): The primary radiotherapy modalities include EBRT, brachytherapy (a form of internal radiation), systemic (radioisotopes), and contact or surface molds ○ Internal (Brachytherapy): Brachytherapy delivers the dose of radiation to a localized area while systemic radiotherapy relies on strategies for getting the radionuclides closer to the tumor. ○ Brachytherapy is the placement of radioactive sources within or immediately next to the cancer site in order to provide a highly targeted, intense dose of radiation beyond a dose that is usually provided by EBRT. ○ Systemic (radioisotopes): y (radiopharmaceutical therapy) involves the intravenous (IV) administration of a therapeutic radioactive isotope targeted to a specific tumor. ○ Contact/surface molds ○ The radiation dosage depends on the sensitivity of the target tissues to radiation, the size of the tumor, radiation tolerance of the surrounding normal tissues, and critical structures adjacent to the tumor target. Radiation Therapy Toxicity: ● Localized in irradiated region ● Increased with concomitant chemotherapy ● Affected body tissues: those that proliferate rapidly: skin, epithelial lining of GI tract, and bone marrow ● Altered skin integrity ● Altered oral mucosa ● Risk for infection and bleeding ● Systemic side effects: fatigue, malaise, and anorexia ● Late effects (long term): fibrosis, atrophy, ulceration, and necrosis ● Acute or early toxicities most often begin within 2 weeks of the initiation of treatment occur when normal cells within the treatment area are damaged and cellular death exceeds regeneration. ● Body tissues most affected are those that normally proliferate rapidly, such as the skin, the epithelial lining of the gastrointestinal tract, and the bone marrow. ● Altered skin integrity is common and can include alopecia (hair loss) associated with whole brain radiation. ● Systemic side effects are commonly experienced by patients receiving radiation therapy. These include fatigue, malaise, and anorexia that may be secondary to substances released when tumor cells are destroyed. Early effects tend to be temporary and most often subside within 6 months of the cessation of treatment. ● Late effects (approximately 6 months to years after treatment) of radiation therapy may occur in body tissues that were in the field of radiation. These effects are chronic, usually a result of permanent damage to tissues, loss of elasticity, and changes secondary to a decreased vascular supply. Nursing Management: ● Goal: Safe delivery and prevention of complications ● Assessments: guided by irradiated area, skin, nutritional status, and feelings of well-being ● Ideally, nurses consider factors that may be predictive of radiation toxicities or radiosensitivity of tissues. In particular, diminished body mass index (BMI) and elevated radiation doses have been associated with greater toxicity and symptoms. ● In patients receiving EBRT, the nurse assesses the patient’s skin regularly throughout the course of treatment. In addition, nutritional status and general feelings of well-being are assessed throughout the course of treatment. ● If systemic symptoms, such as weakness and fatigue, occur, the nurse explains that these symptoms are a result of the treatment and do not represent deterioration or progression of the disease. Safety Precautions: ● ● ● ● ● Based on principles of time, distance, & shielding from exposure Dosimeter badges Prohibit children and pregnant women visits Limit visitors to 30 minutes daily & to remain 6 feet from radiation source making sure that pregnant staff members are not assigned to the patient’s care, prohibiting visits by children or pregnant visitors, limiting visits from others ● When the patient has a radioactive implant in place, the nurse and other health care providers need to protect themselves, as well as the patient, from the effects of radiation. Chemotherapy ● Antineoplastic drugs used to destroy cancer cells by interfering with cellular function, including replication & DNA repair ● Treat systemic disease ● Goal: Cure, control, or palliation ● Agents (Table 15-7) ● Dosage ○ Body surface area, weight ○ Previous responses to chemo/radiation ○ Organ functioning ○ Maximize kill cycle while minimizing impact on healthy tissue and subsequent toxicities ○ Modification of dosage required if lab values or patient’s symptoms indicate toxicities ● Extravasation ○ Mild discomfort to severe tissue destruction ■ Nonvesicant ■ Vesicants are those agents that, if deposited into the subcutaneous or surrounding tissues (extravasation), cause inflammation; tissue damage; and possibly necrosis of tendons, muscles, nerves, and blood vessels. . Vesicant chemotherapy should never be given in peripheral veins involving the hand or wrist. Peripheral administration is permitted for short-duration infusions only, and placement of the venipuncture site should be on the forearm area using a soft, plastic catheter. ■ ■ Irritant – inflammatory reaction ● Prevention is essential ○ Vesicant chemotherapy NEVER given peripherally in hands and wrists ○ For frequent or prolonged administration PICCs and ports. For any frequent or prolonged administration of antineoplastic vesicants, right atrial silastic catheters, implanted venous access devices, or peripherally inserted central catheters (PICCs) should be inserted to promote safety during medication administration and reduce problems with access to the circulatory system PICC Lines Port Implant: Hypersensitivity Reactions (HSRs): ● Signs/symptoms occur: ● rash, urticaria, fever, hypotension, cardiac instability, dyspnea, wheezing, throat tightness, and syncope (Braskett & Cohen, 2014). ● Immediate HSRs appear within 1 hour of an infusion, while delayed HSRs may occur hours afterward. ● Although patients may or may not react to the first infusion of a chemotherapy agent, repeated exposure increases the likelihood of a reaction. ○ Stop medication ○ Start emergency procedures or specific protocols ● Prevent ○ Desensitization procedures may be possible, and the patient is retreated with the agent at reduced dosages or slower infusion rates. ○ Premedication regimens are used for certain chemotherapy agents to prevent or minimize reactions. Chemotherapy Toxicity: Cells with rapid growth rates (e.g., epithelium, bone marrow, hair follicles, sperm) are very susceptible to damage, and the effects may manifest in virtually any body system. ● Gastrointestinal- nausea and vomiting ● Hematopoietic- myelosuppression (depression of bone marrow function), resulting in decreased WBCs (leukopenia), granulocytes (neutropenia), red blood cells (RBCs) (anemia), and platelets (thrombocytopenia) and increased risk of infection and bleeding. ● Renal- renal system may shut down, renal failure and dialysis. Some chemotherapy agents damage the kidneys because they impair water secretion, leading to syndrome of inappropriate secretion of antidiuretic hormone (SIADH), decreased renal perfusion, precipitate end products after cell lysis, and cause interstitial nephritis. Rapid tumor cell lysis after chemotherapy results in increased urinary excretion of uric acid, which can cause renal damage. In addition, intracellular contents are released into the circulation, resulting in hyperkalemia, hyperphosphatemia, and hypocalcemia and obstructive nephropathy. (See later discussion of tumor lysis syndrome.) ● Cardiopulmonary- issues such as tachycardia, congestive heart failure, murmurs, high or low BP. ● Reproductive- sterility. Women may develop problems with ovulation or early menopause, whereas men may develop temporary or permanent azoospermia (absence of spermatozoa). Because treatment may damage reproductive cells, banking of sperm is often recommended for men before treatment is initiated. ● Neurologic-affects CNS, peripheral nervous system, cranial nerves. Chemotherapyinduced neurotoxicity, a potentially dose limiting toxicity, can affect the central nervous system, peripheral nervous system, and/or the cranial nerves. Neurotoxicity characterized by metabolic encephalopathy can occur with ifosfamide, high-dose methotrexate, and cytarabine ● Chemotherapy-induced neurotoxicity, a potentially dose limiting toxicity, can affect the central nervous system, peripheral nervous system, and/or the cranial nerves. Neurotoxicity characterized by metabolic encephalopathy can occur with ifosfamide ● Cognitive impairment- memory lapses. Many patients with cancer experience difficulty with remembering dates, multitasking, managing numbers and finances, organization, face or object recognition, inability to follow directions, feeling easily distracted, and motor and behavioral changes. ● Fatigue Nursing Management: ● Assessments ○ Fluid & Electrolytes ○ Cognitive status (AOx3) ○ Managing fatigue & cognitive status ● Modifying risks for infection & bleeding (CBC) ● Administering chemotherapy ● Preventing nausea & vomiting (by giving antiemetics) ● Managing cognitive changes & fatigue ● Laboratory and physical assessments of metabolic indices and the 1052 dermatologic, hematologic, hepatic, renal, cardiovascular, neurologic, and pulmonary systems are critical in evaluating the body’s response to chemotherapy. These assessments are