nursing care of the client with cancer

Nursing Care of the Client with Cancer

Cancer BackgroundA.Definition 1. Family of complex diseases 2. Affect different organs and organ systems 3. Normal cells mutate into abnormal cells that

take over tissue 4. Eventually harm and destroy host 5. Historically, cancer is a dreaded disease

B.Oncology 1. Study of cancers 2. Oncology nurses specialize in the care,

treatment of clients with cancer


Incidence and Prevalence1. Cancer accounts for about 25% of

death on yearly basis2. Males: 3 most common types of

cancer are prostate, lung and bronchial, colorectal

3. Females: 3 most common types of cancer are breast, lung and bronchial, and colorectal

Nursing Care of the Client with Cancer Risk factors for cancer: (some are controllable; some are not) 1. Heredity: 5 – 10% of cancers; documented with some breast

and colon cancers 2. Age: 70% of all cancers occur in persons > 65 3. Lower socio-economic status 4. Stress a. Leads to greater wear and tear on body in general b. Type C personality (“cancer personality”) persons who tend

to others’ needs to exclusion of their own 5 Diet: certain preservatives in pickled, salted foods; fried

foods; high-fat, low fiber foods; charred foods 6. Occupational risk: exposure to know carcinogens, radiation,

high stress 7. Infections, especially specific organisms and organ (e.g.

papillomavirus causing genital warts and leading to cervical cancer) 8. Tobacco Use: Lung, oral and laryngeal, esophageal, gastric,

pancreatic, bladder cancers 9. Alcohol Use: also tied with smoking 10. Sun Exposure (radiation) e.g. skin cancer


Nursing role includes health promotion to lower the controllable risks

1. Routine medical check up and screenings2. Client awareness to act if symptoms of cancer occur 3. Screening examination recommendations by American

Cancer Society; specifics are made according to age and frequencies

a. Breast Cancer: self-breast exam, breast examination by health care professionals, screening mammogram

b. Colon and Rectal Cancer: fecal occult blood, flexible sigmoidoscopy, colonoscopy

c. Cervical, Uterine Cancer: Papanicolaou (Pap) test d. Prostate Cancer: digital rectal exam, Prostate-

specific antigen (PSA) test


Physiology of CancerA.Background1. Normal Cell Growth includes two events a. Replication of cellular DNA b. Mitosis (cell division)2. Four Phases of Cell Cycle a. G1: Gap 1 Phase; cell enlarges, synthesizes

proteins to prepare for DNA replication b. Synthesis (S) Phase: DNA replicates and

chromosomes duplicate c. G2: Gap 2 Phase: cell prepares for mitosis d. Mitosis M Phase: mitosis occurs with 2 copies

of cell (daughter cells) e. G1 or G0 phase: resting phase


3. Cell cycle is under control of cyclins which control process by working with enzymes; some cyclins “brake” (stop) the cellular division

4. Forms the basis of how some chemotherapeutic agents work against cancers

5. Differentiation: normal process occurring over many cell cycles for special tasks


a. Some unproductive differentiations occur (seen on biopsy reports)

1. Hyperplasia: increase in number or density of normal cells

2. Metaplasia: protective response to adverse conditions

3. Dysplasia: loss of DNA control over differentiation (e.g. changes in cervical cells in response to continued irritation)

4. Anaplasia: regression of cell to immature or undifferentiated cell type

b. Hyperplasia, metaplasia, and dysplasia are all reversible


Theories of Carcinogenesis (what causes cancer to occur)1. Cellular Mutation a. Cells begin to mutate (change the DNA to unnatural cell

reproduction) b. Three stages: initiation, promotion, progression c. Example: cells mutate after years of smoking: lung cancer2. Oncogenes/Tumor Suppressor Genes Abnormalities a. Oncogenes are genes that promote cell proliferation and can

trigger cancer b. Tumor suppressor genes normally suppress oncogenes3. Exposure to Known Carcinogens a. Act by directly altering the cellular DNA (genotoxic) b. Act by affecting the immune system (promotional)


4. Viruses (weaken immune system or cause malignancies)

5 Drugs and Hormones a. Sex hormones often affect cancers of the

reproductive systems (estrogen in some breast cancers; testosterone in prostate cancer)

b. Glucocorticoids and steroids alter immune system

6. Chemical Agents a. Industrial and chemical b. Examples: hydrocarbons in soot ; arsenic in

pesticides; chemicals in tobacco7. Physical Agents a. Exposure to radiation b. Example: nuclear power plant accidents


Neoplasms: also called tumors (mass of new tissue that grows independently of surrounding organs

1. Types of neoplasmsa. Benign 1. Localized growths respond to body’s homeostatic

controls 2. Encapsulated 3. Stop growing when they meet a boundary of another

tissue 4. Can be destructive

b. Malignant 1. Have aggressive growth, rapid cell division outside the

normal cell cycle 2. Not under body’s homeostatic controls 3. Cut through surrounding tissues causing bleeding,

inflammation, necrosis (death) of tissue


Malignant tumors can metastasizea. Tumor cells travel through blood or lymph

circulation to other body areas and invade tissues and organs there.

1. Primary tumor: the original site of the malignancy

2. Secondary tumor (sites): areas where malignancy has spread i.e. metastasis (metastatic tumor)

3. Common sites of metastasis are lymph nodes, liver, lungs, bones, brain

4. 50 – 60 % of tumors have metastasized by time primary tumor identified

b. Cancerous cells must avoid detection by immune system


3. Malignant neoplasms can recur after surgical removal of primary and secondary tumors and other treatments

4. Malignant neoplasms vary in differentiation. a. Highly differentiated are more like the originating

tissue b. Undifferentiated neoplasms consist of immature

cells with no resemblance to parent tissue and have no useful function

5. Malignant cells progress in deviation with each generation and do no stop growing and die, as do normal cells

6. Malignant cells are irreversible, i.e. do not revert to normal

7. Malignant cells promote their own survival by hormone production, cause vascular permeability; angiogenesis; divert nutrition from host cells

The steps of metastasis


Effects of Cancer 1.Disturbed or loss of physiologic functioning,

from pressure or obstruction a. Anoxia and necrosis of organs b. Loss of function: bowel or bladder

obstruction c. Increased intracranial pressure d. Interrupted vascular/venous blockage e. Ascites f. Disturbed liver functioning


2. Hematologic Alterations: Impaired function of blood cells

a. Abnormal wbc’s: impaired immunity b. Diminished rbc’s and platelets: anemia and

clotting disorders3. Infections: fistula development and tumors may

become necrotic; erode skin surface4. Hemorrhage: tumor erosion, bleeding, severe anemia5. Anorexia-Cachexia Syndrome: wasting away of client a. Unexplained rapid weight loss, anorexia with

altered smell and taste b. Catabolic state: use of body’s tissues and

muscle proteins to support cancer cell growth


6. Paraneoplastic Syndromes: ectopic sites with excess hormone production

a. Parathyroid hormone (hypercalcemia) b. Ectopic secretion of insulin (hypoglycemia) c. Antidiuretic hormone (ADH: fluid retention) d. Adrenocorticotropic hormone (ACTH)7. Pain: major concern of clients and families associated with

cancer

a. Types of cancer pain 1. Acute: symptom that led to diagnosis 2. Chronic: may be related to treatment or to progression

of diseaseb. Causes of pain 1. Direct tumor involvement including metastatic pain 2. Nerve compression 3. Involvement of visceral organs


8. Physical Stress: body tries to respond and destroy neoplasm

a. Fatigue b. Weight loss c. Anemia d. Dehydration e. Electrolyte imbalances9. Psychological Stress a. Cancer equals death sentence b. Guilt from poor health habits c. Fear of pain, suffering, death d. Stigmatized


Collaborative CareA. Diagnostic Tests: used to diagnose cancer1. Determine location of cancer a. Xrays b. Computed tomography c. Ultrasounds d. Magnetic resonance imaging e. Nuclear imaging f. Angiography2. Diagnosis of cellular type of can be done through tissue

samples from biopsies, shedded cells (e.g. Papanicolaou smear) washings

a. Cytologic Examination: tissue examined under microscope

b. Identification System of Tumors: Classification – Grading -- Staging


1.Classification: according to the tissue or cell of origin, e.g. sarcoma, from supportive

2.Grading: a. Evaluates degree of differentiation and

rate of growth b. Grade 1 (least aggressive) to Grade 4

(most aggressive)3.Staging a. Relative tumor size and extent of

disease b. TNM (Tumor size; Nodes: lymph node

involvement; Metastases)


3. Tumor markers: specific proteins which indicate malignancy

a. PSA (Prostatic-specific antigen): prostate cancer b. CEA (Carcinoembryonic antigen): colon cancer c. Alkaline Phosphatase: bone metastasis4 Direct Visualization a. Sigmoidoscopy b. Cystoscopy c. Endoscopy d. Bronchoscopy e. Exploratory surgery; lymph node biopsies to

determine metastases


Other non-specific testsa. CBC, Differentialb. Electrolytesc. Blood Chemistries: (liver enzymes:

alanine aminotransferase (ALT); aspartate aminotransferase (AST) lactic dehydrogenase (LDH)


Treatment Goals: depending on type and stage of cancerA. Cure 1. Recover from specific cancer with treatment 2. Alert for reoccurrence 3. May involve rehabilitation with physical and occupational

therapy 4. Three Seasons of survival a. Diagnosis/treatment b. Extended survival: treatment completed and watchful

waiting c. Permanent survival: risk of recurrence is small B. Control: of symptoms and progression of cancer 1. Continued surveillance 2. Treatment when indicated (e.g. some bladder cancer,

prostate cancer)C. Palliation of symptoms: may involve terminal care if client’s

cancer is not responding to treatment


Treatment Options (depend on type of cancer) alone or with combination

A.Chemotherapy 1. Chemotherapy a. Includes phase-specific and non-phase

specific drugs for specific cancer types b. Often combinations of drugs in specific

protocols over varying time periods c. Cell-kill hypothesis: with each cell cycle a

percentage of cancerous cells are killed but some remain; repeating chemo kills more cells until those left can be handled by body’s immune system


2. Classes of Chemotherapy Drugsa. Alkylating agents 1. Action: create defects in tumor DNA 2. Examples: Nitrogen Mustard, Cisplatinb. Antimetabolites 1. Action: specific for S phase 2. Examples: Methotrexate; 5 fluorouracil 3. Toxic Effects: nausea, vomiting, stomatitis, diarrhea,

alopecia, leukopeniac. Antitumor Antibiotics 1. Action: non-phase specific; interfere with DNA 2. Examples: Actinomycin D, Bleomycin 3. Toxic Effect: damage to cardiac muscle


d. Miotic inhibitors 1. Action: Prevent cell division during M phase 2. Examples: Vincristine, Vinblastine 3. Toxic Effects: affects neurotransmission, alopecia,

bone marrow depressione. Hormones 1. Action: stage specific G1 2. Example: Corticosteroids f. Hormone Antagonist 1. Action: block hormones on hormone-binding tumors

(breast, prostate, endometrium; cause tumor regression 2. Examples: Tamoxifen (breast); Flutamide (prostate) 3. Toxic Effects: altered secondary sex characteristics


Effects of Chemotherapy a. Tissues (fast growing) frequently affected b. Examples: mucous membranes, hair cells,

bone marrow, specific organs with specific agents, reproductive organs (all fetal toxic, impair ability to reproduce)

4. Administration of chemotherapeutic agentsa. Trained and certified personnel, according to

established guidelinesb. Preparation 1. Protect personnel from toxic effects 2. Extreme care for correct dosage; double

check with physician orders, pharmacist’s preparation

c. Proper management clients’ excretement


d. Routes 1. Oral 2. Body cavity (intraperitoneal or intrapleural) 3. Intravenousa. Use of vascular access devices because of threat of

extravasation (leakage into tissues) and long-term therapy

b. Types of vascular access devices 1. PICC lines (peripherally inserted central

catheters) 2. Tunnelled catheters (Hickman, Groshong) 3. Surgically implanted ports (accessed with 90o

angle needle)


Nursing care of clients receiving chemotherapy1. Assess and manage a. Toxic effects of drugs (report to physician) b. Side effects of drugs: manage nausea and

vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions

2. Monitor lab results (drugs withheld if blood counts seriously low); blood and blood product administration

3. Assess for dehydration, oncologic emergencies4. Teach regarding fatigue, immunosuppression

precautions5. Provide emotional and spiritual support to clients and

families


B.Surgery 1. Diagnosis, staging, and sometimes treatment

of cancer 2. Involves removal of body part, organ,

sometimes with altered functioning (e.g. colostomy) 3. Debulking (decrease size of) tumors in

advanced cases 4. Reconstruction and rehabilitation (e.g. breast

implant post mastectomy) 5. Psychological support to deal with surgery as

well as cancer diagnosis


C.Radiation Therapy1. Treatment of choice for some tumors to kill or reduce

tumor, relieve pain or obstruction2. Delivery a. Teletherapy (external): radiation delivered in

uniform dose to tumor b. Brachytherapy: delivers high dose to tumor and

less to other tissues; radiation source is placed in tumor or next to it

c. Combination3. Goals a. Maximum tumor control with minimal damage to

normal tissues b. Caregivers must protect selves by using shields,

distancing and limiting time with client, following safety protocols


4. Treatment Schedules a. Planned according to radiosensitivity of

tumor, tolerance of client b. Monitor blood cell counts5. Side Effects a. Skin (external radiation): blanching, erythema,

sloughing b. Ulcerated mucous membranes: pain, lack of

saliva c. Gastrointestinal: nausea and vomiting,

diarrhea, bleeding, sometimes fistula formation d. Radiation pneumonia

Penetrating capacity of different types of radiation

The inverse square law of radiation exposure


D.Biotherapy 1. Modification of biologic processes that result

in malignancies; based on immune surveillance hypothesis

2. Used for hematological malignancies, renal and melanoma

3. Monoclonal antibodies (inoculate animal with tumor antigen and retrieve antibodies against tumor for human)

E. Photodynamic Therapy 1. Client giving photosensitizing compound which

concentrates in malignant tissue 2. Later given laser treatment to destroy tumor


F. Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation

1. Stimulation of nonfunctioning marrow or replace bone marrow 2. Common treatment for leukemiasG. Pain Control 1. Includes pain directly from cancer, treatment, or

unrelated 2. Necessary for continuing function or comfort in

terminally ill clients 3. Goal is maximum relief with minimal side effects 4. Multiple combinations of analgesics (narcotic and non-

narcotic) and adjuvants such as steroids or antidepressants; includes around the clock (ATC) schedule with additional medications for break-through pain

5. Multiple routes of medications 6. May involve injections of anesthetics into nerve, surgical

severing of nerves radiation 7. May need to progress to stronger pain medications as

pain increases and client develops tolerance to pain medication

Nursing Care of the Client with Cancer Nursing Diagnoses for Clients with CancerA. Anxiety 1. Therapeutic interactions with client and family; community

resources such as American Cancer Society, “I Can Cope” 2. Availability of community resources for terminally ill (Hospice

care in-patient, home care)B. Disturbed Body Image 1. Includes loss of body parts (e.g. amputations); appearance

changes (skin, hair); altered functions (e.g. colostomy); cachexic appearance, loss of energy, ability to be productive

2. Fear of rejection, stigmaC. Anticipatory Grieving 1. Facing death and making preparations for death: will be

consideration 2. Offer realistic hope that cancer treatment may be successful


D. Risk for InfectionE. Risk for Injury 1. Organ obstruction 2. Pathological fracturesF. Altered Nutrition: less than body requirements 1. Consultation with dietician, lab evaluation of nutritional

status 2. Managing problems with eating: anorexia, nausea and

vomiting 3. May involve use of parenteral nutritionG. Impaired Tissue Integrity 1. Oral, pharyngeal, esophageal tissues (due to chemotherapy,

bleeding due to low platelet counts, fungal infections such as thrush)

2. Teach inspection, frequent oral hygiene, specific non-irritating products, thrush control


Oncologic EmergenciesA.Pericaridal Effusion and Neoplastic Cardiac Tamponade 1. Concern: compression of heart by fluid in

pericardial sac, compromised cardiac output 2. Treatment: pericardiocentesisB.Superior Vena Cava Syndrome 1. Concern: obstruction of venous system with

increased venous pressure and stasis; facial and neck edema with slow progression to respiration distress

2. Treatment: respiratory support; decrease tumor size with radiation or chemotherapy

C.Sepsis and Septic Shock 1. Concern: Early recognition of infection 2. Treatment: prompt


D.Spinal Cord Compression 1. Concern: pressure from expanding

tumor can cause irreversible paraplegia; back pain initial symptom with progressive paresthesia and leg pain and weakness

2. Treatment: early detection and radiation or surgical decompression

E.Obstructive Uropathy 1. Concern: blockage of urine flow;

undiagnosed can result in renal failure 2. Treatment: restore urine flow

Compression of the superior vena cava in SVC syndrome


F. Hypercalcemia 1. Concern: high calcium from ectopic parathyroid

hormone or metastases 2. Behaviors: fatigue, muscle weakness, polyuria,

constipation progressing to coma, seizures 3. Treatment: restore fluids with intravenous saline; loop

diuretics; more definitive treatmentsG. Hyperuricemia 1. Concern: occurs with rapid necrosis of tumor cells as

with chemotherapy; can result in renal damage and failure 2. Prevention and treatment with fluids and Alopurinol

(Zyloprim)H. SIADH (Syndrome of Inappropriate Antidiuretic Hormone

Secretion) 1. Concern: ectopic ADH production from tumor leads to

excessive hyponatremia 2. Treatment: restore sodium level

nursing care of the client with cancer

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