1elsevier items and derived items © 2007 by saunders, an imprint of elsevier, inc. chapter 25 the...

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Chapter 25

The Patient with Cancer


Learning Objectives

• Explain the differences between benign and malignanttumors.

• List the most common sites of cancer in men andwomen.

• Describe measures to reduce the risk of cancer.• Define terms used to name and classify cancer.• List nursing responsibilities in the care of patients having

diagnostic tests to detect possible cancer.• Explain the nursing care of patients undergoing each

type of cancer therapy: surgery, radiation, chemotherapy,and biotherapy.

• Assist in developing a nursing care plan for the terminallyill patient with cancer and the patient’s family.


What Is Cancer?


Normal Body Cells

• A normal cell has the following characteristics • Distinct, recognizable appearance typical of all cells from a

particular tissue (“tissue of origin”); has a single small nucleus • The ability to perform a specific function when mature • The production of substances that hold cells from the same

type of tissue closely together• Ability to recognize other cells and identify their tissue of origin • Reproduce in a controlled manner to produce additional

identical cells only as needed for growth and replacement • Cell division inhibited by inadequate space or insufficient

nutrients • Remain in their tissue of origin (except for blood cells, which

migrate)


Benign Tumors

• Relatively harmless, primarily because they do not spread to other parts of the body

• Problems, however, if they create pressure on or obstruct body organs • Surgical removal of benign tumors often

recommended


Malignant Tumors

• Characteristics of cancer cells are• Change in appearance from normal cells • Inability to properly perform function of tissue of

origin; may assume functions of other cells • Not readily recognized by other cells • Abnormal proteins (tumor markers) on cell surface• Random, disorganized, uncontrolled growth pattern • Continue dividing even when no need for additional

cells, inadequate space, or inadequate nutrients • Ability to migrate from one tissue or organ to

another


Malignant Tumors

• Can invade nearby tissues or disperse cells to colonize distant parts of the body • Regional invasion

• The movement of cancer cells into adjoining tissue

• Metastasis • Process by which cancer spreads to distant sites

• Most common sites of metastasis: liver, brain, bone, lungs

• Once metastasis has occurred, cancer treatment is more difficult and less likely to be curative


Malignant Transformation

• Factors that promote the transformation of normal cells to malignant cells are increasing age, diet, hormones, and chronic irritation

• Carcinogens • Substances that damage cell DNA, causing normal

cells to become malignant


Classification of Tumors

• Anatomic site • Type of tissue from which they developed

• Staging system for cancer • TNM system

• T refers to the tumor• N to regional lymph nodes• M to distant metastases


Risk Factors

• Genetic and environmental • Changes in genetic information of a normal cell can

cause alterations that lead to malignancies • Carcinogens

• Cigarette smoke, asbestos, and nitrites

• Drugs • Diethylstilbestrol, androgenic steroids, and high-dose

unopposed synthetic estrogens

• Familial cancers• Appear at a higher rate than expected in one family

• Hereditary cancers• Predictable patterns of inheritance based on a single gene


Seven Warning Signs

• The American Cancer Society has identified seven warning signs associated with many common types of cancer

• Guide the nurse and the public in identifying signs and symptoms that require medical evaluation

• The first letters of the warning signs spell out CAUTION, making it easier to remember them


Prevention and Early Detection

• Health promotion • Diet low in fat, calories, and preservatives, and high

in fiber with at least five servings of various fruits and vegetables daily

• Appropriate calorie intake to maintain or attain normal body weight important because obesity is a risk factor for some cancers

• A balanced program of activity and rest with stress management may enable the body to resist diseases, including cancer


Prevention and Early Detection

• Avoidance of carcinogens • Cigarette smoke• Alcohol• Intercourse with multiple partners• A variety of chemicals and drugs• Excessive sun exposure

• Identification of high-risk people • High-risk people can be monitored closely to detect cancer

early

• Screening for cancer • The value of early detection and treatment • The seven warning signs of cancer • How to do self-examinations (breast, skin, testicular) • The importance of periodic examinations for common cancers


Diagnosis of Cancer

• Health history • Physical examination • Diagnostic procedures

• When cancer is suspected, when high-risk people are screened, or when determining the extent of known disease

• Tissue examinations, imaging studies, endoscopic procedures, and laboratory tests


Medical Treatment of Cancer


Surgery

• To diagnose and stage the cancer, relieve symptoms, maintain function, effect a cure, or reconstruct affected structures

• May be extensive or simple• Treatment based on type of cancer, location,

staging, and extent of metastasis • Surgeon often consults with a radiologist and

an oncologist to determine the best therapy


Radiotherapy

• Ionizing radiation used in treatment of disease• Treat cancer because malignant cells are more

sensitive than are normal cells to radiation • Immediate and delayed effects on cells

• Immediate: cell death due to damage to cell membrane

• The delayed effect is alteration of DNA, which impairs the cell’s ability to reproduce

• Radiotherapy: given internally or externally


Radiotherapy

• Caregiver safety • The amount of radiation received by those who

come in contact with the patient depends on the time of exposure, distance from radiation source, and amount of shielding between the caregiver and the source

• Unless direct care is being given, remain at least

6 feet away from the source • Effective shielding depends on type of rays emitted

• The denser the material composing the shield, the better protection it provides


Figure 25-3


Radiotherapy

• External radiation• Procedure

• Special x-ray machine delivers radiation to area

• Patient preparation • Patient goes through a treatment simulation; includes CT

scanning, to determine the exact location to be treated• Radiation therapist marks the skin over area to be treated

• Instruct patient not to remove the markings until given permission by physician


Radiotherapy

• Internal radiation • Introduction of radiation source into the body• Patients emit radiation and do pose a threat to

others until the source is removed or excreted • Sealed-source radiation

• Radiation inserted into body in a sealed container

• Unsealed-source radiation


Radiotherapy

• Side effects• Bone marrow suppression • Alopecia• Anorexia • Dry mouth• Effects on reproduction


Chemotherapy

• Chemical agents to treat disease• Antineoplastic

• Destroy rapidly dividing cells; may be used alone or in combination with other forms of treatment

• Types of antineoplastic drugs • Cytotoxic agents• Hormones and hormone antagonists• Biologic response modifiers• Radioimmunotherapy

• Administered by physician or nurse who has had specialized education

• Route: oral, intramuscular, intravenous, intracavity, intrathecal


Chemotherapy

• Side effects • Bone marrow suppression • Nausea and vomiting• Alopecia • Extravasation


Biotherapy

• Hematopoietic growth factors • Colony-stimulating factors: stimulate the bone

marrow to produce platelets, red, and white blood cells

• Biologic response modifiers (BRMs)• Intended to boost the body’s existing defenses • Act directly on malignant cells or stimulate the

immune system to act against them

• Monoclonal antibodies• Specific for proteins on surface of certain cancer

cells


Bone Marrow and Stem Cell Transplantation

• Bone marrow transplantation: used after treatment of leukemia and lymphoma with chemotherapy and/or radiation that destroys bone marrow

• Stem cell transplantation: treats the destruction of the bone marrow caused by the chemotherapy and radiotherapy

• Transplantation of bone marrow or peripheral blood stem cells: restores the blood manufacturing cells


Hormone Therapy

• Various treatments to suppress natural hormone secretion, block hormone actions, or provide supplemental hormones


Complementary and Alternative Therapies

• Nontraditional treatments • Relaxation techniques, guided imagery, music,

meditation, herbal remedies, and acupuncture

• Complementary therapy • Nontraditional therapy used with conventional

treatment

• Alternative therapy • The patient uses nontraditional therapy in place of

traditional treatment


Unproven Methods of Cancer Treatment

• American Cancer Society discourages treatments that have not been studied

• Alternative therapies can be harmful and may delay treatment with potentially effective conventional therapies

• See Box 25-2, p. 383


Nursing Care: Diagnostic Phase


Assessment: Health History

• Chief complaint • Pain, lesions, lumps, or changes in body function • Complete description of problem and signs and

symptoms

• Past medical history • Document chronic illnesses, serious injuries,

surgeries, and hospitalizations

• Family history• Inquire about the incidence of cancer and other

serious diseases in the patient’s immediate family



• Review of systems • Record any of the following signs and symptoms:

pain, lumps, fatigue, activity intolerance, lesions of the skin or mucous membranes, easy bruising or bleeding, headache, vision or hearing disturbances, hoarseness, cough, dyspnea, hemoptysis, loss of appetite, difficulty swallowing, digestive disturbances, blood in the urine or stool, and change in bowel pattern



• Functional assessment• Describe the patient’s diet, use of alcohol and

tobacco, safe sex practices, activity, sleep routines • Document the occupation and describe a usual day • Assess health practices, including frequency of

breast self-examination, testicular examination, and medical checkups

• Identify concerns about living conditions and/or location

• Note sources of stress; support and coping strategies


Assessment: Physical Examination

• Vital signs, height, and weight • Inspect face, scalp, and oral mucosa for lesions • Palpate the neck for enlarged lymph nodes • Inspect skin for color, lesions, edema, and bruising • Auscultate breath sounds and observe respiratory effort • Inspect breasts for symmetry, dimpling, and abnormal skin color,

and palpate for lumps or thickened areas • Inspect abdomen for distention, auscultate for bowel sounds, and

palpate for masses • Inspect genitalia for lesions• Palpate scrotum for descended testicles/testicular lumps


Interventions


Ineffective Denial

• Deny the seriousness of the situation and do not seek medical care

• Encourage people to learn the warning signs of cancer and to report them promptly


Anxiety

• Patient needs encouragement, support, and honest information

• Remain hopeful but don’t give false reassurance

• May show this stress through anger, irritability, fear, or depression

• When coping is not effective, refer to a psychiatric clinical nurse specialist or a mental health counselor


Deficient Knowledge

• Tell patient about diagnostic procedures, including preparation, what the procedure is like, and any specific postprocedure care


Nursing Care: Treatment Phase



• Note patient’s diagnosis and treatment plan• Complete drug profile; record allergies prominently • Review the systems to detect significant symptoms

related to cancer or treatment: fatigue, weakness, headache, sore or dry mouth, dyspnea, palpitations, altered taste sensations, nausea, diarrhea, constipation, blood in stools, change in urinary frequency, hematuria or dysuria, sexual dysfunction, numbness, and tingling sensations



• Determine the effects of the illness and therapy on the patient’s daily functioning

• Explore patient’s knowledge, fears, concerns, and coping strategies



• Note general appearance, level of consciousness, posture, and gait

• Assess mental and emotional state• Measure weight and vital signs and compare

with previous measurements• Assess skin for lesions/bruises; scalp for hair

loss • Inspect the oral mucous membranes for

lesions and inflammation



• Observe patient’s respiratory effort and auscultate the lungs

• Inspect the abdomen for distention, and auscultate bowel sounds

• Inspect and palpate the extremities for color, edema, and peripheral pulses

• Test extremity reflexes and sensation


Interventions


Anxiety

• Encourage patient to express feelings and identify the source of the anxiety

• Listening and touch can be very effective in reducing anxiety

• Recognize need for patient teaching or referrals


Ineffective Coping

• Strategies to promote coping include teaching, encouraging self-care within the patient’s limitations, treating physical signs and symptoms, emphasizing abilities, coaching in relaxation strategies, and encouraging the use of coping strategies that have been effective in the past


Risk for Injury

• Pneumonitis and pulmonary fibrosis • Encourage coughing and deep breathing exercises • Protect patient from exposure to people who have

upper respiratory infections

• Cardiac toxicity • Monitor for dyspnea, increasing pulse pressure,

edema

• Neurotoxicity• Protect extremities that lack normal sensation


Risk for Injury

• Thrombocytopenia • Avoid trauma and bruising• Minimal invasive procedures: rectal temperatures • After venipunctures or injections, apply pressure for

5 minutes to control oozing • Instruct patient to use soft toothbrush and an

electric razor to prevent trauma to the oral tissues or the skin

• Assess for signs and symptoms of internal bleeding: increased pulse and respirations, restlessness, pallor, decreased urine output, and falling blood pressure


Risk for Injury

• Anemia • Monitor hemoglobin and hematocrit• Encourage a diet high in iron• Patient should report palpitations, pallor, and

excessive fatigue to the physician

• Reproductive cells • Women are usually advised not to become pregnant

within 2 years of chemotherapy or while receiving radiotherapy


Risk for Infection

• Avoid crowds and close contact with others who have infectious diseases

• Promptly report any signs of infection• Compromised host precautions

• Private room• Strict hand washing by all who enter the room • Fresh flowers, fruits, and vegetables not allowed


Imbalanced Nutrition: Less Than Body Requirements

• High-protein, high-calorie diet • Small, frequent feedings • Light exercise before meals may stimulate the appetite• Nutritional supplements (such as Carnation Instant

Breakfast, Ensure, or Sustacal), enteral feedings, or both may be ordered if the patient has excessive weight loss

• Be familiar with the specific antineoplastic agents so that the patient can be advised of any specific food restrictions

• Various combinations of antiemetics and sedatives can be tried as ordered to obtain relief from nausea


Impaired Oral Mucous Membranes

• Frequent, gentle mouth care• Artificial saliva• Encourage increased fluid intake, chew

sugarless gum or candies, suck on ice chips, and moisten dry food before eating

• Eat soft foods, and avoid foods that are acidic, salty, or spicy

• Use soft-bristled or foam toothbrush


Constipation

• Monitor patient’s bowel movements • The physician may prescribe a high-fiber diet,

stool softeners, laxatives, and phosphate or bisphosphate enemas to prevent or treat constipation


Fatigue

• Assess the patient’s need for assistance and schedule activities to conserve energy

• Encourage patient to prioritize activities and ask others to assume less important ones

• Daily naps and mild exercise helpful


Disturbed Body Image

• Be sensitive to patient’s concern about hair loss

• Use wigs, scarves, or hats • The American Cancer Society lends wigs to

patients free of charge • The society also sponsors the “Look Good-

Feel Better” program to help patients look their best during therapy


Dysfunctional Grieving

• Listen in an accepting way that lets the patient know the feelings are understood

• Support patient and provide practical information about adapting to the loss

• Participation in a support group may help the patient learn new coping strategies and begin to resolve the grief process


Impaired Family Processes

• Encourage family to remain involved • Family members may need help to handle their

responses to the patient’s illness • Obtain a social work consultation if necessary

to assist them with insurance and disability claims and financial assistance referrals


Ineffective Therapeutic Regimen Management

• Pretreatment teaching plan informs patient of what the prescribed therapy involves

• Chemotherapy • Teaching plan includes drugs administered,

potential side effects, related precautions • Provide written information to supplement the verbal

teaching • Explore what patient has heard about

chemotherapy; correct any misconceptions


Recovery and Rehabilitation

• If the outcome of treatment appears to be a cure, the patient and family are usually overjoyed

• Some patients become excessively concerned with their bodies, constantly looking for new evidence of cancer

• Periodic checkups essential but may be dreaded because the patient realizes that complete or permanent recovery cannot be guaranteed

• If signs of possible recurrence, patients are concerned• As patients recover from the effects of cancer and

cancer therapy, rehabilitation may be needed to restore them to the highest possible level of functioning


Terminal Illness

• Although increasing numbers of people are surviving cancer, it is still the second leading cause of death

• If treatment is unsuccessful, patient begins to decline

• For patients who wish to die at home, hospice provides support and teaching • Focus: keep patient’s symptoms, especially pain,

under control during the final period of the illness • Provides bereavement care after the patient’s death


Terminal Illness

• Be attentive and accepting• Listening carefully is more important than

talking • Guide patients to claim their accomplishments

and find peace• Terminally ill patients should remember that

although they are going to die eventually, they are living now and can still have some pleasure


Oncologic Emergencies

• Conditions sometimes develop that require emergency intervention as a result of the disease process or therapy

• Examples: hypercalcemia, syndrome of inappropriate antidiuretic hormone, disseminated intravascular coagulation, superior vena cava syndrome, and spinal cord compression

• See Table 25-11, p. 393

1elsevier items and derived items © 2007 by saunders, an imprint of elsevier, inc. chapter 25 the...

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cancer slide

malignant cells

movement of cancer cells

normal body cells

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