cancer/transplant/end of lifecancer/transplant/end of life by: diana blum msn metropolitan community...
TRANSCRIPT
This ppt created with the help of material from Osborne, K. et al (2010) Medical Surgical Nursing Preparation for Practice. Pearson: Boston.
GOAL OF CANCER CAREGOAL OF CANCER CARE
Combination of treatments effective in controlling most cancers
http://www.youtube.com/watch?v=j_wRpa2b5XI
CARCINOGENCARCINOGEN
Any chemical, physical, or genetic agent that can irreversibly alter cellular DNA
Abnormal cells produced
Tobacco smoke – can both initiate & promote cancer growth
ROLE OF IMMUNE SYSTEMROLE OF IMMUNE SYSTEM
Surveillance of tumor-associated antigens
22ndnd leading cause of death in leading cause of death in USAUSA
Metastasizing cancer Cell
1 out of 4 Americans will have CA at some time in their life
DefinitionDefinition
According to the American Cancer Society:
A large group of diseases characterized by uncontrolled growth and spread of abnormal cells
Top 3 Cancers that cause Top 3 Cancers that cause DeathsDeathsfigure 64-1figure 64-1
Men Lung Prostate Colorectal
Women Lung Breast Colorectal
Neoplasm (aka TUMOR)Neoplasm (aka TUMOR)
Cells that reproduce abnormally and in an uncontrolled manner
4 types of Malignancies4 types of Malignancies
Carcinoma: skin, glands, lining of digestive urinary and reproductive tracts
Sarcoma: bone, muscle, other connective tissues
Melanomas: pigment cells in the skin
Leukemias and lymphomas: blood forming tissues: lymphoid tissue, plasma cells, and bone marrow
Early Diagnosis Is Key for survival
7 Warning Signs7 Warning Signs
C – change in bowel or bladder habits
A – a sore that does not heal
U – unusual bleeding or discharge
T - thickening or lump in breast or other
I – indigestion or difficulty swallowing
O – obvious change in wart or mole
N - nagging cough or hoarseness
Stage 1Stage 1
The malignant cells are confined to the tissue of origin. Not invasive with other tissues
Stage 2Stage 2
Limited spread of the cancer in the local area usually near lymph nodes
Stage 3Stage 3
The tumor is larger or has spread from the local site of origin into nearby tissues
regional lymph nodes are likely to be involved
Stage 4Stage 4
The cancer has metastasized to distant parts of the body
THE TNM Staging SystemTHE TNM Staging System
Specifies the status of the primary tumor, regional lymph nodes, and distant mets
T: tumor
N: regional nodes
M: distant mets
Malignant TransformationMalignant Transformation
4 steps Initiation: DNA exposed to carcinogen
Promotion: sufficient exposure to agent to encourage/enhance cell growth
Progression: accelerated growth, enhanced invasion, altered appearance and activity
Metastasis: tumor develops blood vessels
Penetrates capillaries and form fibrin network (undetectable by immune system)
Dissolve lining of blood vessels to invade surrounding tissue
Set up their own blood supply
TreatmentsTreatments
Surgery:
Done for:
diagnosis Symptom relief maintain function Reconstruction Possible cure
Surgery continuedSurgery continued
Preop/postop care varies
The recommended treatment is based on the cancers: type, location, and mets
RadiotherapyRadiotherapy
Uses ionizing radiation
Dose: 1 gray equals 100 rads
Used to treat malignant cells
Has delayed and immediate effects
Delayed: altered DNA which impairs the cells ability to reproduce
Immediate: cell death due to damage of cell membrane
Figure 64.4 Figure 64.4 Immobilizers for radiation Immobilizers for radiation therapy. therapy.
From Osborne Book
Caregiver Safety with radiationCaregiver Safety with radiation
The less time spent near the source the less exposure
Unless direct care being given stay 6 ft away from the source
Effective shielding depends on type of rays (the denser the material the more protection)
External radiationExternal radiation
PROCEDURE Source is outside the body Special xray machine provides treatment # of treatments depends on the doctor
Example: 5 times a week for 2-8 weeks
PATIENT PREP Treatment simulation to determine exact
dosage needed and schedule The skin is marked with permanent,
waterproof ink, by the radiologist for the exact site
Instruct client not to remove markings without permission
Internal Radiation Internal Radiation (Brachytherapy)(Brachytherapy)
PROCEDURE Sources
Iodine, phosphorus, radium, iridium, radon, cesium
Instruct client that they pose a threat until the source is removed unless permanently implanted small beads used
2 TYPES Sealed
Unsealed
Sealed Sealed Source is sealed in a container and inserted
into the body (CESIUM) Sources may be placed in threads, beads,
needles, seeds, or molds To protect visitors from exposure the client
needs: To be placed in isolation Have a sign on the door indicating radiation No pregnant women or kids under 18 allowed in
room Limit time with visitors Have organized schedule for cares
Figure 64.5Figure 64.5 Brachytherapy applicator. Brachytherapy applicator.
From Osborne Book
Staff to wear film badges to monitor exposure
Recognize that Sealed sources can become dislodged
Portable lead shields provides minimal protection Immediately notify MD if source becomes dislodged.
Do not touch source with bare hands
Unsealed Unsealed Body fluids may be contaminated
Must wear gloves when working with patient
Contaminated fluids, dressings, etc may require additional precautions depending on the agency.
Disposable utensils are recommended
Equipment being removed from room must be checked for radiation level first
Radiation side effectsRadiation side effects
Normal cells may be harmed (hair follicles, bone marrow, lining of gi tractand urinary tract)
Anemia-deficiency of RBC Low WBCs
Take 2-6 wks to recover Bruising/Bleeding( low platelets)
Takes 2-6 wks to recover Alopecia (hair loss) Anorexia Dry mouth Harms reproductive cells
ChemotherapyChemotherapy
Use of chemical agents to treat (Antineoplastics)
Destroy rapidly dividing cells
Curative in some cases
Decreases symptoms in others
Chemotherapy and the Cell Chemotherapy and the Cell CycleCycle Stages of cancer:
Initiation (alteration of cell’s genetic structure)
Promotion (reversible proliferation of altered initiated cells)
Progression (increase in growth rate and possible metastasis)
Chemo kills at a constant % of cancer cells
Can be cell cycle specific (G(1), S, G(2), or M) or
Cell Cycle non-specific - G(0) or dividing phase
Chemotherapy CategoriesChemotherapy Categories
Alkylating agents
Nitrosoureases
Plant Alkaloids
Antitumor Antibiotics
Antimetabolites
Hormonal agents
Miscellaneous agents such as : L-
asparaginase Procarbazine
ChemotherapyChemotherapyUse of chemical agents to treat
cancer (Antineoplastics) Destroy rapidly dividing cells
Can be done with or without radiationComplication:
Extravasation – STOP DRUG IMMEDIATELY!!
ChemotherapyChemotherapy Other Complications:
Bone marrow suppression
Nadir
Lowest point in cell count after chemo/radiation – highest risk for infection
Neutropenia
7-14 days after chemo
Absolute Neutrophil Count (ANC)
Limitations of chemotherapy:
Few agents cross the blood-brain barrier
The phenomenon of resistant tumor
Most agents are most effective on dividing cells, but…
As a tumor grows, more cells become inactive
From Osborne Book
From Osborne Book
Chart 64-21 (continued)Chart 64-21 (continued) Routes of Routes of AdministrationAdministration
From Osborne Book
From Osborne Book
Chart 64-21 (continued)Chart 64-21 (continued) Routes of Routes of AdministrationAdministration
From Osborne Book
From Osborne Book
Cancer Drug ExamplesCancer Drug Examples
5FU
Megace
Side effects and toxicitiesThe result of the destruction of normal cellsFast-growing cells most susceptible to damageCell destruction → fatigue, anorexia, and taste alterations Gastrointestinal system effectsGenitourinary system effects
Nursing management related to side effects and toxicities
From Osborne Book
Side Effect ManagementSide Effect Management Drink 8-12 cups of clear liquid a day
Small frequent meals
Bland foods
Rest
Encourage wig
Be gentle with hair washing
No styling products
Check mouth for sores
No sugar
Drinks room temp
Do not rub/scratch skin
MANAGEMENTMANAGEMENT
Continue dexamethasone
Begin radiation to affected area
Opioid medications to manage pain
Analgesics ATC & additional doses for breakthrough pain
Laxative to prevent & manage constipation
Physical therapy
NUTRITIONNUTRITION The nutritional status of cancer patients can be altered in a
variety of ways
Anorexia, or loss of appetite, usually peaks 4 weeks into treatment and subsides shortly after treatment ends
Cancer cachexia
Nutritional screening
Nutritional support: oral nutrition, enteral feedings, parenteral nutritional support
Artificial nutrition and hydration can raise ethical questions for patients who have cancer, particularly those at end of life
From Osborne Book
Figure 64.7Figure 64.7 Cancer cachexia. Cancer cachexia. SourceSource: © : © Welcome Trust Images/Custom Medical Welcome Trust Images/Custom Medical Stock PhotoStock Photo
From Osborne Book
BiotherapyBiotherapy
Treatment with agents whose origin is from biological sources and/or affects biological responses
monoclonal antibodies and cytokines
hematopoietic growth factors
interferons (INF)
interleukins
From Osborne Book
Uses of Biologic Response Uses of Biologic Response ModifiersModifiers Definition- natural
substances produced in small amts. by body’s immune system; reproduced by recombinant DNA technology
How does this differ from chemotherapy?
Goal – enhance pts. Immunologic response to tumor cells
Three categories based on Three categories based on Activity of BRMActivity of BRM
Modulation or induce a host’s recognition to a tumor: Intron A (alpha
interferon) anti viral
Interleukin-2 : T/B lymphocytes
cause flu-like S&S
premedicate, labs, VS, check I & O & monitor for arrhythmias
Tumoricidal action
TNF, monoclonal antibodies, LAK, TIL (activated by interleukin-2)
Colony stimulating factors:
G-CSF (Neupogen), GM-CSF (Leukine), EPO (Procrit)
Transplants and hormone Transplants and hormone therapytherapy
Bone marrow- used with leukemia/lymphoma
Stem cell- bone marrow depression
Umbilical cord blood These 3 are done to restore blood
manufacturing cells
Hormone therapy-used to supress natural hormone secretion, block hormone actions, or provide supplemental hormones
From Osborne Book
Complications of transplantationPrimarily due to the conditioning regimeCan include bleeding, infection, nausea and vomiting, diarrhea, mucositis, and graft-versus-host disease (GVHD) May also have late effects
Nurses must be aware of the signs of graft failure and GVHDGraft failure rare, but nurse must expertly assess patientRequires another transplant or death will result
From Osborne Book
Oncological emergenciesOncological emergencies
Hypercalcemia
Syndrome of inappropriate antidiuretic hormone (fluid does not come off)
Disseminated intravascular coagulation (DIC)
Superior Vena Cava Syndrome (redness/edema of face, tachycardia, distended neck veins) Teach client not to bend forward
Spinal cord compression secondary to tumor
From Osborne Book
Nurse’s Role in early Nurse’s Role in early detection/ prevention for detection/ prevention for Septic ShockSeptic Shock Check vital signs, shaking,
chills, hypotension
Report temperature of 100.4 or above
Check skin for rash
Check peripheral or central IV sites
Avoid injections
Assess pulmonary function
Check urine changes
Avoid catheterization
Control environment
Give CSF & antibiotics
Three phases of Septic ShockThree phases of Septic Shock
Phase I -warm stage, caused by gram negative organisms increase heart rate, skin warm, increased temp.
antibiotics need to be started immediately
Phase II - warm to cold stage shift of fluid, cold, clammy, decreased bp,
increased pulse, decreased urine output
give IV fluids, lasix, dopamine
Phase III of Septic ShockPhase III of Septic Shock
Full cold stage
Alteration of cardiac output
Monitor hemodynamics
Give dopamine, dobutamine, IV fluid to maintain PAWP bet. 12-18, ventilate
Chart 64-24 (continued)Chart 64-24 (continued) Oncologic Oncologic EmergenciesEmergencies
From Osborne Book
From Osborne Book
Other possible Oncologic Other possible Oncologic EmergenciesEmergencies
What would cause them? DIC Pericardial
effusion/cardiac tamponade
SIADH
Tumor Lysis Syndrome tumor destroys
cells and releases cellular components that form imbalances : increased K, P, uric acid; decreased calcium
Rx: allopurinal, Ca, dialysis
Quality of LifeQuality of Life
The oncology nurse can positively affect QOL by prioritizing symptoms and implementing appropriate relief measures
For patients at end of life, nurses should be familiar with the concepts of hospice and palliative care
From Osborne Book
SurvivorshipSurvivorship What does the 5 year
survival rate mean?
Extended survival has certain considerations: teaching needs
resocialization
employment
insurance coverage
American Cancer Society
End of LifeEnd of Life
Death: lungs and heart cease to function
Causes: illness or trauma that overwhelms the body
Direct causes are: respiratory failure or shock
Multi-organ failureMulti-organ failure Inadequate blood flow to body tissues deprive cells of
oxygen which leads to acidosis, hyperkalemia, and tissue ischemia
First organs hit: kidneys, liver, heart, brain
› May also be in lung with septicemia
Vfib, asystole, or PEA can occur at any point of shock or hypoxemia
After cardiac arrest, respiratory arrest occurs within minutes
Clinical death refers to cessation of heartbeat and breathing with no evidence of brain function present
Incidence of deathIncidence of death
Dying is a part of life cycle
2.5 or more people die each year in the USA from CAD and cancer
Natural processNatural process
Stages of death
› Pallor mortis: body becomes pale. 15-120 minutes post death
› Algor mortis: body temp falls
› Rigor mortis: muscle stiffness. Relaxation occurs after about 72 hours post onset of rigor
› Liver mortis: blood begins to pool on lowest part example: to back if lying on back. 20 minutes to 3 hours after death
› Decomposition: we start to decompose
http://www.youtube.com/watch?v=BuF5qxIDa3c
http://www.youtube.com/watch?v=Qo5mCB9gbfY&feature=PlayList&p=C477E57325CB86CC&index=0
carecare
Palliative: philosophy that provides compassion and supportive approach to the dying
Helps to relieve symptoms
Provides emotional and spiritual support
Hospice as a ConsiderationHospice as a Consideration
Symptom control and pain management
Comfort and dignity is a philosophy
First hospice in USA in 1974 in New Haven, Conn.
Eligibility: life expectancy of 6 months or less
24 hour, 7 day /week coverage
HOSPICEHOSPICE
Hospice is not a building – it is a model of care
Distress symptomsDistress symptoms
Pain
Dyspnea
n/v
Fatigue
Weakness
Constipation
Anorexia
delirium
Assessments Assessments
Past medical hx
Assess emotions (see next slide)
Assess LOC
Teach family signs of distress (pain, restlessness, moaning)
Assess skin for temp, color, mottling, cyanosis
Assess vs: they will drop as death nears
Assess culture for customs/rituals
Assess lungs for cheyne stokes
Provide a comfortable environment (music, massage, no restraints, family near, lights dim, etc)
Emotions with impending deathEmotions with impending death
Withdrawl is 1st
Vision like appearances
› Talk/mumble to people that are not present
› Picking at air
› Affirm their experience
Letting go
› May be agitated or perform repetitive tasks
Saying goodbye
› Saying goodbye is important
› Touching, hugging, saying I love you, crying is okay
› Acknowledge these expressions as natural end
Tx Tx
Pain management
Fatigue management
Dyspnea management
Oxygen
n/v management
Agitation management
Grief management for pt and family
Offer support
Be realistic
Encourage reminiscence
Promote spirituality
Foster hope
Post mortem care Post mortem care
Pronouncement of death
Call PCP and other care providers
Call NORS
Allow family to view body
At Alegent, security or pastoral care will go over funeral arraignments like mortuary
At Alegent, a silk rose is placed on the door and given to family when they leave as well as the belongings of the deceased
Euthanasia Euthanasia
Passive: involves withdrawing or withholding tx that might prolong the life of a person who cannot be cured
This is accepted by all
Active : involves a healthcare provider taking action that purposefully and directly causes the client’s death
This is not allowed
Advance DirectivesAdvance Directives
Written document that specifies the client’s wishes should something happen to them.
DPOA-HC: appoints someone to make decisions in the event the client is unable
Living will: instructs doctors and family what life sustaining or lack of they wish to have done.
Transplantations Transplantations
http://www.youtube.com/watch?v=SvxpyfZ9Rsk
The Road to TransplantThe Road to Transplant
Treatment
Evaluation by a major transplant center
Listed or Not Listed
Waiting
Evaluation for TransplantEvaluation for Transplant
3-4 day process
Many tests: extensive lab work (40+ labs), ultrasounds, doppler studies, x-rays, bone scan, echocardiogram, upper GI, SBS
Consultations my many disciplines including surgeon, transplant coordinator, psychology, psychiatry, social work, child life, child development, specialist MD
Criteria for TransplantCriteria for Transplant End stage disease
Failure to treat
Benefits> Risk
absence of malignancy & infection
Able to survive surgery
Sepsis
Loss of line sites
MELD/PELD (liver)
NORS score/rating
What is the testing for What is the testing for histocompatability?histocompatability?
ABO and Rh
HLA - Human leukocyte or lymphocyte antigen
Contraindication – positive tissue typing for crossmatch with HLA antibodies
PRA - panel of reactive antibodies
Complications of TransplantComplications of Transplant
Rejection
Infection
Death
Multi-system involvement/ failure
What are the types of graft What are the types of graft rejection?rejection? Hyperacute
minutes to hours
preformed B cell antibodies to donor antigens
not always treatable
Acute
4 days to 4months
cell mediated
Treatable
Reversible – OKT3
Chronic
months or years
T and B cell
treatment not usually successful
Graft-versus- Host
with bone marrow transplants
donor T cells react
S&S: skin, liver, GI
HYPERACUTE REJECTIONHYPERACUTE REJECTION
Can be avoided with crossmatching prior to transplant
What are the medications for What are the medications for immunosuppression?immunosuppression?
Imuran
inhibits DNA/RNA
blocks antibodies
cellcept or cytoxan could be substitute
ATG
alters T cell function
serum sickness
ALG as a substitute
Thymoglobulin
Muromonab-CD3 or OKT3 monoclonal antibody
blocks T cell function
premedicate
prevention/treatment of rejection
cytokine release syndrome
Basiliximab-chimeric antibody (mouse/human)
Medications continued...Medications continued... Tacrolimus (fk-506)/ Sirolimus (renal
dysf)
-100 times more potent than CSA
-Many drug interactions- Nephrotoxic with NSAIDS
-Blocks interleukin 2 production
Cyclosporine
-nephrotoxic, hepatotoxic
Corticosteroids-drug interactions!
What are the types of donor What are the types of donor bone marrow?bone marrow?
Autologous - donor is recipient, How is this possible?
Allogenic - human with similar HLA type
Syngeneic - identical twin
Peripheral blood stem cell harvest - apheresis
BM Transplantation processBM Transplantation process
Harvesting
marrow is obtained from the posterior and anterior iliac crests and filtered
Bone marrow infusion
thaw bone marrow and infuse through an IV with a filter
Post transplant nadir period
day 0 is day of transplant and nadir point of pancytopenia
care directed to neutropenia, thrombocytopenia, and anemia (protective isolation)
pre-engraftment
Transplantation process if Transplantation process if allogenicallogenic
Conditioning goals: remove
malignant cells inactivate the
immune system empty the
marrow cavities
Nursing care related to conditioning ( the side effects of chemo such as cytoxan):
alopecia
anorexia, nausea
stomatitis
SIADH
hemorrhagic cystitis
Post-engraftment periodPost-engraftment period
New blood cells are circulating in peripheral blood 2-4 weeks after transplant
Continue on Cyclosporine A and steroids
Continued protection for patient for 2-3 months
Nursing Care of the Bone Nursing Care of the Bone Marrow Transplant PatientMarrow Transplant Patient
Conditions that require BMT:
leukemia, aplastic anemia, immune deficiency diseases, tumors of the breast, ovarian, testicular
Why is bone marrow transplant important as a treatment for malignant disease?
Allows the client to receive high doses of chemotherapy without concerns of myelosuppression
Nursing Diagnoses related to Nursing Diagnoses related to BMTBMT
Risk for infection
PC: Bleeding
Alteration in fluid volume
Ineffective breathing pattern
Altered Sensory-perception
Altered skin integrity R/T GVHD
Impaired family/individual coping
Recipient ConcernsRecipient Concerns
Pre-transplant concerns Maintain physical
health/ current labs
Dental screening
Treat chronic conditions
Psychological preparation
Prepared every minute
Fear/ Cost
Post-transplant concerns
Potential for infection
Alteration in elimination
Knowledge deficit of health maintenance
Increased demand of care partner
Fatigue
Donor ConcernsDonor Concerns
Quality of Life
Criteria for being a donor
Responsibility
Support
Major Types of TransplantsMajor Types of Transplantsand resultant nursing careand resultant nursing care Kidney
check urine output & electrolytes
Heart
orthotopic approach
heterotopic approach
Heart-lung, lung
mechanical ventilation
Liver
Pancreas
Corneal
Other:
Stem cell
Bone
Skin
Small Bowel
Heart valves
Liver/Small Bowel
Corneal transplantCorneal transplant
Surgical removal of diseased cornea and replaced with donor
Use a calm approach
Assess for signs of infection prior to surgery
Regional anesthesia is used
Antibiotics injected after
Dressing in place and removed the next day by the surgeon
Pt to lie on non operative side
A shield is to be worn at nite for the 1st month
Graft rejection is possible
Liver transplantLiver transplant
Not candidate if: severe cardiovascular instability, severe respiratory disease, active alcohol or substance abuser, metastatic malignant disease, inable to follow directions regarding meds and self care
Donor livers are primarily from trauma victims
Living donors can also be used
The liver is the only organ that can grow back
Renal transplantRenal transplant
Not a cure
2-70 yrs is age range to get transplant
Thorough assessment before
Cardiac disease excludes candidate
Monitor urinary status closely
Cancer clients get dialysis
Diabetes clients need very close monitoring
donorsdonors
Kidney donors may be living or dead
Matching is difficult
Kidneys donors must be : free of disease and infection, no history of cancer, no htn or renal disease, adequate renal function
Post opPost op
Urological management is key
Monitor for rejection
Monitor urine color
Pink and bloody right after
Normal after several days-weeks
Daily specimens obtained and cultured
Instruct about meds and rejection
Heart transplantHeart transplant
2300 transplants each year
Criteria to get: life expectancy less than 1 year, age less than 65, normal pulmonary vascular resistance, no active infections, stable psychosocial status, no drug or etoh abuse
Post op: monitor for bleeding, similar recovery to cabg, monitor for tamponade, instruct client to change position slowly b/c of orthostatic hypotension 2nd to denervation, instruct to follow medication schedule religiously to prevent rejection which usually happens in first 3 months, instruct client to follow recommended diet, allow 10 minutes warm up and cool down with exercise
Role of the Nurse in Role of the Nurse in Transplantation IssuesTransplantation Issues The assessment/ physical
exam
The psychosocial evaluation
coping mechanisms
support systems
anxiety
depression
loss of control
The nurse needs to express caring/empathy to client issues: cost
ethical concerns
legal regulations
uniform anatomical gift act
National Organ Transplant Act
UNOS
Success of TransplantSuccess of Transplant Liver- 83% at 1 year/ 71% 5 year(cad)
Liver- 85% 1 year/ 81% 5 year (living)
Small bowel/ Liver-Small bowel- approximately 65% one year/ 46% 5 year
Heart- 83% at one year/ 69% 5 year
Heart/Lung- 65% at one year/41% 5 year
Kidney- 94% one year/ 82% 5 year (cad)
Kidney- 97% one year/91% 5 year (living)
Living DonationLiving Donation
Usually between 18-60 years of age
May give single kidney, lobe of lung, segment of the liver, or portion of the pancreas
Tissue typing, crossmatching, and antibody screen are performed, as well as urine tests, CXR, EKG, arteriogram, and psychologic/psychiatric evaluation
Positive Aspects of Living Positive Aspects of Living DonationDonation Eliminates waiting list-surgery may be
scheduled(decreases stress of Tx)
Recipient may begin taking immunosup. Drugs 2 days before transplant
Higher rate of compatibility...between blood related living donor
Psychological benefit
Websites to VisitWebsites to Visit United Network for Organ Sharing
(UNOS) www.unos.org
American Society of Transplantation (AST) www.asts.org
Nebraska Medical Center www.unmc.edu
www.nebraskatransplant.org
Transplant Recipients International Organization www.trioweb.org
http://www.youtube.com/watch?v=IFSNDqjOS_8&feature=related