NURSING MANAGEMENT OF CLIENTS WITH DISTURBANCES IN CELLULAR FUNCTIONING LEARNING OBJECTIVES: At the end of the discussion, the studentswill be able to: 1. Summarize the nursing roles and opportunities in cancer prevention, detection, diagnosis and treatment of cancer 2. Enumerates the case finding and early detection methods of cancer. 3. Explains the major health problems of client with cancer and its specific nursing diagnosis with interventions. 4. Identify the psychosocial implications of cancer. 5. Differentiate the modes of treatment for cancer and its specific nursing responsibilities. 6. Discuss the nursing management for oncologic emergencies. CANCER y CANCER affects every age group. y The incidence of cancer is higher in men than in women and higher in industrialized sectors and nations y Refers to class of diseases or disorders characterized by the development of abnormal cells that divide uncontrollably and have the ability to infiltrate and destroy normal body tissue WARNING SIGNS OF CANCER C - Change in bowel or bladder habits A - Sore that does not heal U - Unusual bleeding T - Thickening or lump I - Persistent indigestion O - Obvious change in warts or mole N - Nagging cough or persistenthoarseness A - Anemia L - Loss of appetite DETECTION AND PREVENTION OF CANCER y PRIMARY PREVENTION Acquisition of knowledge and skills necessary to educate client, community about cancer risk. y SECONDARY PREVENTION Cancer screening programs for individuals who are found to be at high risk for cancer NURSING RESPONSIBILITIES IN EARLY DETECTION OF CANCER STEPS TO REDUCE CANCER RISK When teaching individual patients or groups, nurses can recommend the following cancer prevention strategies: 1. Increase consumption of fresh vegetables (especially those of the cabbage family.) 2. Increase fiber intake. 3. Increase intake of Vitamin A. 4. Increase intake of foods rich in Vitamin C. 5. Practice weight control. 6. Reduce intake of dietary fat. 7. Practice moderation in consumption of salt-cured, smoked and nitrate-cured foods. 8. Stop smoking cigarettes and cigars. 9. Reduce alcohol intake. 10. Avoid overexposure to sun. RECOMMENDATION FOR EARLY DETECTION OF CANCER BREAST CANCER Risk Factors Menarche before age 11 Menopause after age 50 Family history of breast cancer especially mother or sister History of uterine cancer Nulliparity or birth of first child after age 30 History of uterine cancer Link with obesity, diabetes and hypertension Presence of benign breast cyst. Screening Breast Self-Examination Regular mammograms (screen all middle aged woman) COLORECTAL CANCER COLORECTAL means colon and rectum combined Highest for people older than 85 years of age High for people with family history of colon cancer, polyps adenomatous, of inflammatory bowel disease, high fat, high protein (with high intake of beef), low fiber diet, genital or breast cancer in women 1 Infection A. abdominal mass. Signs: Early sign firm painless. underlying respiratory diseases. hard. An important role of the oncology nurse is to assess the patient for these problems and complications 1.is performed to search for pulmonary density. suggest malignancy. shortness of breath Screening: Testicular Self-Examination(TSE) CERVICAL CANCER Refers to the cancer of the neck of the uterus. TB most common symptom is a cough or change in cough Repeated unresolved URTI Diagnostic Examination: Chest x ray . smooth testicular mass varying in size Late sign ureteral obstruction. Digital Rectal Examination PROSTATE CANCER Risk Factors Increasing age. it becomes stony hard and fixed DIAGNOSTIC PROCEDURE Digital Rectal Examination Prostate Specific Antigen TESTICULAR CANCER Primarily affect young to middle-aged men (20 to 35 years old) Most testicular tumors originate in gonadal cells. SCREENING: Use of fine or large bore needle biopsy. CT Scan & Thyroid Scan LUNG CANCER Most common from cigarette smoking. MRI. Genetic. Colonoscopy an insertion of fiber optic scope through the rectum for direct visualization of the colon. leg or groin pain Diagnostic Procedure 1. Pap s Smear THYROID CANCER .Lesions that are single. COPD. decreased size and force of the urinary stream Every man older than 40 should have DRE ( Digital rectal exam ) as part of regular check up The more advanced lesion. NURSING PROCESS: THE PATIENT WITH CANCER I. & fixed on palpation or associated with cervical lymphadenopathy. a solitary peripheral nodule (coin lesion). Assessment: Painless vaginal bleeding post-menstrual and post-coital Foul-smelling or serosanguinous vaginal discharge Pelvic. ASSESSMENT Regardless of type of cancer treatment or prognosis many patients with cancer are susceptible to the following problems and complications. Monitoring laboratory studies to detect early changes in WBC count ± Leukopenia ± Granulocytopenia ± Neutropenia 2 . atelectasis and infection. lower back. urinary retention. Intravenous Catheter · Other Invasive Procedures · Contaminated Equipment · Age · Chronic Illness · Prolonged Hospitalization B. after age 50 Having father or brother with prostate cancer doubles the risk of relatives A diet high in red meat increase risk Difficulty and frequent urination. Ultrasound.Diagnostic Procedure 1. 2. Assess factors that promotes infection: · Impaired skin & mucus membrane integrity · Chemotherapy · Radiation Therapy · Biologic Response Modifiers · Malignancy · Malnutrition · Urinary Catheter. Psychosocial Status 9. pain perception. Related factors causing pain: Underlying disease Pressure exerted by tumor Diagnostic procedures Cancer treatment B. situation and foods that aggravate or relieve anorexia and medication history D. Chest x.Physical signs of weight loss and cachexia are secondary to decreased protein and caloric intake. Skin Problems Assess predisposing factors and other risk factors 4. Body Image and Self-Esteem II. nausea. 3 C. Cachexia A. Assess for feelings of weariness. Give emphasis not only to physical pain but psychosocial as well. side effects of the treatment or emotional status of the patient. Fatigue Fatigue has been recognized as one of the significant and frequent symptoms experienced by patients receiving cancer therapy. lack of energy. lack of motivation. Impaired nutritional status may contribute to: Disease progression Immune incompetence Increased incidence of infection Delayed tissue repair Diminished functional ability Decreased capacity to continue chemotherapy B. Pain A. altered taste. (pain. Impaired oral mucous membranes related to stomatitis. Common bleeding sites: ± Skin and mucous membranes ± Intestinal ± Genito-Urinary Tract ± Respiratory tract ± Brain C. pain scales C. Anthropometrical measurements Serum protein levels Serum electrolytes Skin response to intradermal injection Hemoglobin and hematocrit levels Serum Iron Levels . Signs of bleeding ± Gross hemorrhage ± Blood in the stools. Nursing Diagnosis Risk for infection related to altered immunologic response Impaired skin integrity: erythematous and wet desquamation reaction to radiation therapy. anxiety) 8. nausea. Bleeding A. Hair Loss Assess also the psychological impact of this side effect on the patient and the family 5. Assess site of pain. Mal-absorption 3. Determine diet history. sputum. any episodes of anorexia. Anorexia 2. weakness. urine. Imbalanced nutrition: less than body requirements related to nausea and vomiting. Assess factors that contribute to bleeding ± Bone marrow suppression from radiation ± Chemotherapy ± Medications that interfere with coagulation and platelet functioning B.ray 2. Nutritional Concerns COMMON NUTRITIONAL PROBLEMS 1. diarrhea. 7. fear.C. inability to carry out ADL. Clinical and laboratory data useful in assessing Patient s nutritional status o o o o o o 6. or vomitus ± Oozing at injection sites ± Bruising (ecchymosis) ± Petechiae ± Changes in mental status 3. constipation. and inability to concentrate Assess for physiologic and psychological stressors that contribute to fatigue. metabolic. mechanical effects of cancer and systemic disease. changes in appetite. o Inform patient the advantage of receiving alternative methods of feeding by parenteral or enteral route. o Avoid rubbing or use of hot or cold water. Fluid and electrolyte imbalance related to anorexia. o Help patient identify sources of fatigue o Plan activities to conserve energy as well as alternate periods of rest. powder. Relieving Pain: o Provide adequate rest and sleep o Promote diversional activities o Provide adequate rest and sleep o Offer Empathy o Give pain reliever medications as ordered Decreasing Fatigue o Help the patient and the family to understand that is an expected and temporary side effect of cancer process and of many treatments used. o Identify any negative feeling that that the patient has or threats to body image. o Reducing odor. o Aseptic technique should be observed during dressing and wound care. Planning o Maintenance of tissue integrity o Maintenance of nutrition o Relief of pain o Relief of fatigue o Improve body image o Effective progression through grieving process o Absence of complications Nursing Interventions Managing Stomatitis o Provide good oral hygiene. o Instruct to acquire a wig or hairpiece before hair loss. nausea & vomiting. o Encourage use of attractive scarves and hats. o Avoid alcohol based mouth rinses. o Referral to support groups Assisting in the Grieving process III. Managing Malignant Skin Lesion: o Carefully assessing and cleansing the skin. o Regular. soaps. o Protecting the skin from pain and further trauma. o Encouraged small frequent feedings. lotion and cosmetics avoided o Avoid tissue injury by wearing loose-fitting clothing. altered taste. o Controlling the bleeding. o Use soft bristled toothbrushes and nonabrasive toothpaste. treatment. function and roles Self care deficit due to fatigue. function and roles Grieving r/t anticipatory loss and altered role functioning Potential for spiritual distress Deficient knowledge about disease process. Promoting Nutrition: o Prepare foods that are appealing. and selfcare measures Assisting Patients to cope with Alopecia: o Provide information about hair loss. diarrhea Anticipatory grieving related to loss of body parts and altered role functioning Disturbed body image and situational low selfesteem related to changes in appearance. malaise. light exercise is recommended Body Image and Self-Esteem o Positive approach is necessary o Encourage independence and continued participation in self-care decision making o Patient should be assisted to assume tasks and participate in those activities that are personally of most value. o Reducing superficial bacteria. o Lubricate cracked and dry lips o Adequate food and fluid intake is encouraged Maintaining Tissue Integrity o Handle affected area gently. complication management. o Oral swabs with sponge like applicators maybe use in place of toothbrush. 4 . o Patient s preferences as well as physiologic and metabolic requirements are considered when selecting foods. support patient and family in coping with disturbing effects of therapy. and protective isolation Anxiety due to knowledge deficit and uncertain future Disturbed body image r/t changes in appearance. o Neurologic assessment o Fluids and electrolyte status monitoring o Administration of intravenous fluids. PROMOTING HOME AND COMMUNITY BASED CARE 1. Teaching Patients Self-Care 2. vasopressors. 3. loss of heath. infiltration to the brain and spinal cord. disease of coagulation and altered immunity that may increase the risk. oxygen and broad spectrum antibiotic as ordered. o Assist patient and family acquire knowledge to cope with the disease process o Assist patient and family members to acknowledge and cope with their reactions and feelings.distance . Continuing Care NURSING MANAGEMENT DIFFERENT MODALITIES OF TREATMENT 1. RADIATION THERAPY Ionizing radiation that is used to: Interrupt cellular growth Cure cancer Used to control malignant disease when tumor cannot be removed surgically used when local metastasis is present Used prophylactically to prevent leukemia. sealed source radiotherapy. social interaction. Peri-operatively. the nurses asses the patient response to the surgery. Septic Shock o Assess signs and symptoms of septic shock. curietherapyorendocurietherapy is a form of radiotherapy where a radiation source is a place inside or next to the area requiring treatment. body image.From the greek word bradys means. o Administration of antibiotics as ordered 2. o Assess response of patient and family about the diagnosis and planned treatment. Bleeding and Hemorrhage o Monitor laboratory values especially platelet count o Assess the patient for bleeding o Taking steps to prevent trauma and minimize the risk for bleeding The patient undergoing surgery for cancer requires general peri-operative nursing care with specific care related to the patient s age. Managing and Monitoring Potential Complications 1. normal sensations. 2. organ impairment. o Monitoring laboratory data. sexuality and intimacy. o Assist in answering inquiries and questions. identifying resources and support people. nutritional deficits.Also known as internal radiotherapy. SURGERY Types: y y y y 5 Diagnostic Prophylactic Palliative Reconstructive . activity nutrition and medications information is given. SOURCE OF RADITAION THERAPY External Radiation therapy (Teletherapy) -administer through an x-ray machine Internal Radiation Therapy -administer near or within the tumor Types: Sealed Source (Brachytherapy ) Unsealed BRACHYTHERAPY .o Grieving is a normal response to fears and anticipated losses that include. Infection o Strict asepsis technique o Health teaching on how to recognize signs and symptoms of infection o Maintain skin integrity. blood products. short . Monitor possible complication: Post-Operative teaching about wound care. Use lead shield during contact with client 6 . lotion on the area Do not apply heat. Special Problem:Extravasation Contraindication: 1. CHEMOTHEPEUTIC AGENT 1. and Intrathecal. Shielding . 12.Busulfan. chlorambucilm. 8. hexamathyl. asplatin. theothecin.Maintain a distance of at least 3 feet when not performing nursing procedure 2.Alter DNA structure by misreading DNA code initiating breaks in DNA molecule.BRACHYTHERAPY . Oval. 5. no soap and pat to dry and do not rub Do not apply ointment. PRINCIPLES OF RADIATION PROTECTION 1. Palliation o Nursing Responsibility: Observe for early signs of skin reaction and report immediately Keep area dry Was area with water. 5. . IV.Cytaraine 5-flourfacil (5-FU) Pentatastine . breast and skin cancer and can also be used to treat tumors in many other body sites. 11. Infection Hemorrhage Fatigue (radiation cause exhaustion) Weight loss Stomatitis Diarrhea Nausea and Vomiting Headache Alopecia Cystitis Social Isolation Route:Topical. Time . Goal:Cure. Antimetablikes .Limit contact with the patient for 5 minutes each time. Alkylating . 2. avoid sunshine or cold Use soft fabric for clothing DO NOT ERASE MARKING ON THE SKIN 2. Distance . 4. cross linking DNA strands. depigmentation . powders. decabazine. Subcutaneous. a total of 30 minutes per shift 3.Interfere with biosynthesis of metabolic or nucleic acid necessary for RNA and DNA synthesis. Skin Reaction . 7. 6. . 4. 9. Intra-cavity. Arterial.Is commonly used as an effective treatment for cervical.Erythema. CHEMOTHERAPY Anti-neoplastic agents that are used in an attempt to destroy tumor cells by interfering with cellular function and reproduction. Control. fosfamde nitrogen mustard.Can be used alone or in combination with other therapy such as surgery EBRT and chemotherapy SIDE EFFECT OF RADIATION THERAPY AND IT S RESPONSE 1.Atrophy telangiectasia. cyclophosphamide. 6. Infection Recent Surgery Impaired Renal or hepatic functions Recent Rad. dry/moist desquamation . 3. IM. cabopatin. prostate. 3. melamine. Therapy Pregnancy Bone Marrow Depression 2.Necrotic or ulcerative lesion SAFETY PRECAUTION IN RADIATION THERAPY Assigning to a private room Posting notices Dosi meter badge must be worn Not assigning pregnant staff Prohibit children Limit visits 30 minutes daily Maintain 3 feet distance - 3. 10. 2. *Dispose of all chemotherapeutic waste as hazardous material. Reproductive System a. and Sodium Bicarbonate SIDE EFFECT OF CHEMOTHERAPY 1. Constipation 2. INDICATION OF EXTRAVASATION DURING ADMINISTRATON OF VESICANTS Absence of blood return from the intravenous catheter Resistance to flow of the intravenous fluid Swelling. Using radio waves can produce heat. Nyaluronidase. Anemia b. and systemic signs b.Arrest metaphase by inhibiting mitotic tubular formation (spindle) inhibit DNA and protein synthesis. 4. leak proof. teniposide. Alopecia d.Interfere with DNA synthesis by binding to DNA. Nausea and Vomiting 7 . doxorubicin. THERMAL THERAPY or HYPERTHERMIA The generation of temperatures greater than physiologic fever range ( above 41. Pruritus. vinblastine. prevent RNA synthesis Vesicant are those agent if deposited into the subcutaneous tissues can cause extravasation y y y y y y y Dactoinomycin Paunorubicin Doxorubicin Nitrogen mustard Mitomycin Vinblastine Vincristine b. Urine color changes 5. Integumentary System a. Thrombocytopenia 4.etoposide. pain. Hemorrhagic changes b. hot wax immersions. Plant alkaloids .mitomycin . Anti-tumor Antibiotic .3. puncture proof container. and hot water baths. Diarrhea c. ultrasound. Hematopoetic System a. magnetic waves. Neutropenia c.Bleomian. Nail Changes 3. Stomatitis c. vineristine . and redness at the site Of the extravasation is suspected: Medication administration must be stopped immediately Ice applied on the site (expect for vesicant) vinca alkaloid Physician may aspirate any infiltrate medication from the tissue and infect neutralizing solution onto the area reduce to reduce tissue damage Example of neutralizing solution: Sodium thiosulfate. Genito Urinary System a. 4. Premature menopause or amenorrhea SAFETY PRECAUTIONS IN ADMINISTERING CHEMOTHERAPY *Use of biologic safety cabinet for the preparation of all chemotherapeutic agents *Wear surgical gloves when handling antineoplastic agent and the excretions of patients who received chemotherapy *Wear disposable long sleeved gown when prepares and administering chemotherapeutic agents *Use Leur lock fitting in all intravenous tubing used to deliver chemotherapy *Disposable of all equipment used in chemotherapy preparation and administration in appropriate.5 C ) has been used for many years to destroy tumors in human cancer. microwaves. Skin Pigmentation e. Urticaria. Gastrointestinal System a. liver. Syngeneic . BCG treat bladder cancer BRM (Biological Response Modifiers) Nursing Management: Patients receiving BRM therapy have many of the same needs as cancer patients undergoing treatment approaches BRM therapies are still investigational a considered a last-chance effort by many patients. Infection: highest risk in 3 to 4 weeks 3. .herpes simplex virus. BIOLOGIC RESPONSE MODIFIERS . . disease causing gene. 8 Liver and renal function should be monitor Offer emotional support and educate the client and family regarding the therapy 8. 2. Essential that the nurse assess the need for education. GENE THERAPY A technique for correcting defective genes responsible for disease development. Pneumonia: non-bacterial or intestinal pneumonia are principal causes of death on the first 3 months post-transplant 4. . Donor bone marrow is aspirated from multiple sites along iliac crest under general anesthesia 3. Late complications such as cataracts. Malignant cells lack repair mechanisms necessary to repair cell damage by elevated temperature.Use as a treatment for basal cell carcinoma.from a donor other than a patient.Substances that are able to trigger the immune system to indirectly affect tumors. A gene is inserted into the genome to replace an abnormal. Donor suitability is determined through tissue antigen typing of human leukocyte antigen (HLA) and mixed leukocyte culture (MLC) 2. 6.A photosensitizer is a chemical compound (Porfimer) that can be excited by a light of a specific wavelength. Nursing Management: o Local skin care 5. stimulation. and endocrine abnormalities .A ternary treatment for cancer involving 3 key components: a photosensitizer. Autologous from patient 2. marrow. MAJOR SIDE EFFECT: PHOTOSENSITIVITY FOR 4 TO 6 WEEKS AFTER TREATMENT NURSING MANAGEMENT: Instruct client to protect themselves from direct and indirect sunlight to prevent skin burns.The basis of BRM is restoration. (GVHD) Graft vs.These include cytokines such as interferons and interleukins. BONE MARROW TRANSPLANTATION Types 1. Failure of engraftment 2.(bone marrow registry) 3. Most tumor cells lack an adequate blood supply during periods if increased cellular demand such as during Hyperthermia. Viruses are used as a gene therapy vectors such as retrovirus. Eg. support and guidance for the patient and family in planning and evaluating patient care. 3.family member.E.Principles: 1. modification and augmentation of the body s natural defense against cancer . 9. host disease: principal complication caused by an immunologic reaction of engrafted lymphoid cells against the tissue of the recipient . . Allogenic . light and tissue oxygen. Malignant cells are sensitive to harmful effects of high temperatures. Donor marrow is infused IV into the recipient COMPLICATIONS: 1.Acute GHVD develops within first 100 days post-transplant and affects GUT..g. PHOTODYNAMIC THERAPY . and lymphoid tissue -Chronic GVHD Develops 100 400 days post-transplant manifested by multiorgan involvement 5. matched unrelated donor.from an identical twin Procedure: 1.is also called IMMNUNOTHERAPY . adenovirus. Recurrent malignancy 6. Prevent Infection. 2. 4. Communicable disease and immunizations Daily hygiene and skin care Fever Activity 9. practices & products that are not presently considered to be effective by the standards of medicine. effects. Instruct the client in the use of neck or back braces if they are prescribed. Surgery may be needed to remove the tumor and relieve the pressure to spinal cord. 2. and promotion of hope with the patient and family. Administer oral or parenteral Normal Saline fluids as prescribed. When working with children. Provide protective environment. A. pets. but outside child s room so they can see what they look like without isolation garb. HYPERCALCEMIA INTERVENTIONS: Monitor calcium level. Prepare the patient for radiation therapy to the mediastinal area. Check patency and observe signs of infection such as fever. B. Client should be in laminar airflow room or strict reverse isolation. Promote energy conservation to minimize shortness of breath. side effects. supportive care. The nurse should encourage any patient who uses unconventional therapies to inform the physician about such use.NURSING CARE PRETRANSPLANT 1. Provide skin care. 3. SUPERIOR VENA CAVA SYNDROME (SVCS) 3. CAM treatments are the diverse group of medical and health care systems. Recipient immunosuppression attained with total body irradiation (TBI) and chemotherapy to eradicate existing disease and create space in host marrow to allow transplanted cells to grow. INTERVENTIONS: Assess for signs and symptoms of SVCS. 3. Monitor central lines frequently. Provide care for client receiving chemotherapy and radiation therapy that induce immunosuppression. Objects must be sterilized before being brought to the room. redness around sight. 2. 5. Administer medications to lower the calcium level as prescribed. NURSING MANAGEMENT FOR ONCOLOGIC EMERGENCIES: 1. Prepare the client for radiation and/or chemotherapy. Monitor cardiopulmonary and neurologic status. 4.Maintain fluid and electrolyte balance and promote nutrition. introduce new people were they can be seen. visitors) Diet modifications Medication regimen schedule. Truthful responses should be given in nonjudgmental manner to questions and inquiries about unproven methods. dosage. UNPROVEN & UNCONVENTIONAL THERAPIES Also called Complementary and Alternative Medicine. 6. Provide mouth care for stomatitis and mucositis. SPINAL CORD COMPRESSION INTERVENTIONS: Assess for back pain and neurological deficits. Nursing Management Trusting relationship. C. NURSING CARE POST TRANSPLANT 1. 9 . Prepare the client for dialysis if the condition becomes life threatening or is accompanied by renal impairment. Provide client teaching and discharge planning concerning: Home environment (cleaning. Monitor carefully for bleeding. Prepare to administer IV infusion of glucose and insulin to treat hyperkalemia. Encourage oral/IV hydration. Prepare the client for dialysis if hyperkalemia and hyperuricemia persist despite treatment. reorient the patient. Administer antidiuretic hormone antagonist as prescribed. 6. Monitor ECG tracings Assess heart and lung sounds. It is the irreplaceable gift. Survivorship (client who entered successful treatment enter an indeterminate period of long term survivorship) C. compassion is the only thing that brings beauty and meaning to our lives. 5. Diagnosis and treatment (clients received diagnosis and treatment in different ways) B. Initiate fluid restriction and increased sodium intake as prescribed. and provide supportive measures and appropriate patient instruction. SIADH INTERVENTIONS: Monitor accurate recording of intake and output. maintain patient IV access. Terminal illness. Assess for pulsusparadoxus. Provide frequent oral hygiene. Monitor serum sodium levels. TUMOR LYSIS SYNDROME INTERVENTIONS: Monitor Intake and Output. when everything is done that can be done. Administer diuretics as prescribed. 10 .4. 7. PERICARDIAL EFFUSION & CARDIAC TAMPONADE INTERVENTIONS: Monitor vital signs and oxygen saturation frequently. Monitor and record intake and output Elevate the head of patient s bed. Administer cryoprecipitated clotting factors if DIC progress and hemorrhage is the primary problem. Recurrent disease and progression (most clients live with the threat or reality of recurrent disease) D. INTERVENTIONS: Measure and document Intake & output Inspect all body orifices & tubes for bleeding Prevent bleeding Administer anticoagulant as prescribed. Reposition and encourage the patient to cough. y Providing support for client (your presence as a caring person) y Providing support for the family y Promoting positive self-concept y Promoting coping throughout the cancer continuum A. DIC/CONSUMPTION COAGULOPATHY PSYCHOSOCIAL ASPECTS OF CANCER CARE When cancer becomes a part of life s journey it is hardwork. As needed. Administer medications that increase the excretion of purine as prescribed. Minimize patient s physical activity.