Oncologic Nursing
Content
ONCOLOGIC NURSING
DIFFERENCE BENIGN S (Tumor) Differentiatio Well n Encapsulatio (+) n Metastasis (-) Prognosis Good Tx Modalities Surgery
NEOPLASIA
MALIGNANT (CA) Poor (-) (+) Poor Surgery, Irradiation, Chemotx, BM
Predisposing Factors: Carcinogenesis
• G-enetic • I-mmunosuppression • V-iral (Human Papilloma, Epstein-Barr, Hepa B) • E-nv’tal
– Physical •Radiation, UV rays, nuclear explosion •Chronic irritation, direct trauma – Chemical •Acids, alkalis, hydrocarbons, dye •Food (↑fat, ↓fiber) & Food additives (Nitrites) •Drugs (Stillbestrol, urethane) •Hormones •Smoking
Predisposing Factors: Carcinogenesis
•Men: Bronchogenic/Lung CA, liver CA,
prostate CA (middle aged, >40 y/o, with BPH, hormonal) •Women: Breast CA (hormonal, encourage SBE 1 wk after mens), cervical CA (80%- multiple sex partners, 20% early pregnancy) •Ovarian CA
Classification of Cancer
• Based on tissue typing • Carcinoma- arises from surface
epithelium & glandular tissue • Sarcoma- arises from connective tissue • Multiple myeloma- arises from plasma cells (in BM) • Lymphoma- arises from lymph glands • Leukemia- arises from blood cells
Grading of Cancer
• Classifies the cellular aspects of CA • Grade I: cells differ slightly from N cells,
well-differentiated (mild dysplasia) • Grade II: cells are more abN, mod. differentiated (mod. dysplasia) • Grade III: cells are very abN, poorly differentiated (severe dysplasia) • Grade IV: cells are immature (anaplasia), undifferentiated
Staging of Cancer
• Classifies the clinical aspects of CA • Stage O: carcinoma in situ • Stage I: tumor limited to the tissue of
origin, localized tissue growth • Stage II: limited local spread • Stage III: extensive local & regional spread • Stage IV: metastatis
WARNING/DANGER SIGNS OF CANCER
• C-hange in bowel/bladder habits • A- sore that does not heal • U-nusual bleeding/discharge • T-hickening of a lump in breast or elsewhere • I-ndigestion/dysphagia • O-bvious change in a wart or mole • N-agging cough/hoarseness • U-nexplained anemia • S-udden wt loss
EARLY DETECTION OF CANCER •Mammography •Pap smear •Stool for occult blood •Sigmoidoscopy, colonoscopy •Breast self-examination •Testicular self-examination •Skin inspection
Breast Self-Examination (BSE)
•Done 7-10 days after menses •Postmenopausal or s/p
hysterectomy: specific day of the month •Inspection: In front of the mirror with arms at sides, arms overhead & arms at hips (WOF changes in shape, dimpling of skin or any changes in nipple)
Breast Self-Examination (BSE)
• Palpation: While in shower/bath or
lying down with folded towel under breast being examined • Use the R hand to examine L breast & vice versa • Use the pads of 2nd , 3rd & 4th fingers • Use small, circular motions in spiral or in an up-and-down motion to examine entire breast & under the arm (WOF lump, hard knot or thickened tissue)
Testicular Self-Examination (TSE)
• Same day, q month, right after a warm
shower (scrotal skin is moist & relaxed) • Gently lift each testicle, each one should feel like an egg, firm but not hard & smooth without lumps • Using both hands, place middle fingers underside of each testicle & thumbs on top & gently roll the testicles (WOF lumps, swelling or mass)
CANCER TX MODALITIES: Chemotherapy • Kills CA cells & rapidly producing cells
(skin, hair, BM, Reproductive tract, GIT,) – Antimetabolites: N2 mustard – Plant alkaloid: Vincristine & Vinblastine – Alkylating: Methotrexate – Hormones (DES)/ steroids – Antineoplastic antibiotics
CANCER TX MODALITIES: Surgery
•Prophylactic
– With premalignant condition or with strong family hx of CA •Curative – Removal of all gross & microscopic tumor •Control (cytoreductive) – “debulking” procedure, ↓ the no. of CA cells, ↑ the chance of other tx will be successful
CANCER TX MODALITIES: Surgery
• Palliative
– Improves quality of life during survival time – ↓ pain; relieve obstruction (airway, GI or GU), relieve pressure on brain & spinal cord, prevent hemorrhage, remove infected or ulcerated tumors or drain abscesses • Reconstructive or rehabilitative – Improves quality of life by restoring maximal function & appearance (breast reconstruction s/p mastectomy)
CANCER TX MODALITIES: Chemotherapy
• Major S/E & Nursing Interventions • Hair: alopecia
– Encourage pt to wear wigs, cap – Temporary, hair will regrow in 3-6 mos. after chemo with new color & texture • BM: depression – Anemia: CBR, O2 as ordered – Leukemia: reverse isolation, strict HW, asepsis – Thrombocytopenia: Bleeding precautions
CANCER TX MODALITIES: Chemotherapy
• Major S/E & Nursing Interventions • GIT: N/V
– Antiemetics 4-6 hrs. pre-chemo & post chemo as ordered – NPO temporarily – Bland diet post chemo • Stomatitis – Oral care – Ice chips/popsicles • Diarrhea – Antidiarrheals – Monitor VS, I/O, WOF dehydration • WOF paralytic ileus (with Vincristine)
CANCER TX MODALITIES: Chemotherapy
•Major S/E & Nursing Interventions •Reproductive tract: sterility
– Encourage sperm banking for M •Renal damage: ↑ uric acid – Allopurinol as ordered •Neuro disturbance: peripheral neuropathy – Skin, hand & foot care (like in PVD & DM)
CANCER TX MODALITIES: Radiation
• Use of ionizing radiation that kills CA &
rapidly growing cells & inhibit their growth • Types of energy – Alpha rays: don’t penetrate skin tissue – Beta rays: penetrate skin (e.g. internal radiation) – Gamma rays: penetrate deeper, underlying tissues (e.g. external radiation)
CANCER TX MODALITIES: Radiation
• Factors Affecting Delivery
– Half-life: time required for the ½ of the radioisotope to decay – Time: less time, less exposure – Distance: the farther the source, the lesser the exposure – Shielding: Alpha & Beta rays can be blocked by gloves, Gamma rays can be blocked by thick, lead gown & concrete
CANCER TX MODALITIES: Radiation
• Methods of Delivery
– Internal: utilizes injection/ implantation of radioactive isotopes proximal to CA sites for specified period of time •Sealed: within a container, don’t contaminate with body fluids •Unsealed: e.g. Phosphorus 32 – External: uses electromagnetic waves e.g. Cobalt
CANCER TX MODALITIES:
Teletherapy/Beam Radiation
• Source: external radiation • Pt does not emit radiation & does
not pose a hazard to anyone else • Wash area with water & mild soap, using the hand than a washcloth, rinse & pat dry with soft towel • Don’t remove radiation markings from the skin
CANCER TX MODALITIES:
Teletherapy/Beam Radiation • No powder, ointment, lotion or cream on
area unless ordered • Wear soft clothing over the area, avoid constrictive garments • Avoid sun & heat exposure • WOF weeping of skin (moist desquamation) & if noted, cleanse the area with warm water & pat dry, apply antibiotic or steroid cream as ordered & expose the site to air
CANCER TX MODALITIES: Brachytherapy Radiation •Source: internal radiation (sealed or unsealed) •For a pd. of time the pt emits radiation & pose a hazard to others
CANCER TX MODALITIES: Brachytherapy Radiation
•Unsealed Radiation Source
– Administered PO or IV or instillation into body cavities – It enters body fluids, eliminated via various excreta (radioactive & harmful to others esp. the 1st 48 hrs)
CANCER TX MODALITIES: Brachytherapy Radiation
•Sealed Radiation Source
– Temporary or permanent solid implant within tumor target tissues – The pt emits radiation while the implant is in place, but the excreta is not radioactive – Place the pt in a private room with private bath – Place a caution sign on the pt’s door
CANCER TX MODALITIES: Brachytherapy Radiation
•Sealed Radiation Source
– Organize nursing tasks to minimize exposure to radiation source – Nursing staff assignments should be rotated, a nurse should never care for more than 1 pt with radiation implant at a time, avoid assigning a pregnant nurse – Limit time to 30 mins per care provider/shift
CANCER TX MODALITIES: Brachytherapy Radiation
• Sealed Radiation Source
– Wear a dosimeter film badge to measure radiation exposure – Wear a lead shield – Do not allow children <16 y/o or pregnant woman to visit the pt – Limit visitors to 30 min./day, at least 6 ft from the pt – Save bed linens & dressings until the source is removed then dispose – Other equipments can be removed from the room at any time
CANCER TX MODALITIES: Brachytherapy Radiation
•Dislodged Sealed Radiation Source
– Don’t touch it with bare hands, use a long-handled forceps to place the source in a lead container kept in the pt’s room & notify MD – If unable to locate the radiation source, bar visitors & notify MD
CANCER TX MODALITIES: Brachytherapy Radiation
• Sealed Radiation Source Removal
– – – Pt is no longer radioactive Inform the pt that sexual partner cannot “catch” CA Pt may resume sexual intercourse after 7-10 days for cervical or vaginal implant – Perform povidone-iodine douche as ordered for cervical implant – Administer Fleet enema as ordered – Notify MD if N/V/D, frequent urination, vaginal or rectal bleeding, hematuria, foul-smelling vaginal discharge, abdominal pain/distention or fever occurs
CANCER TX MODALITIES: Radiation
• Major S/E & Nursing Interventions
– Skin erythema, redness, irritation & sloughing of tissue •Assist in bathing the pt •Force fluids •Avoid lotion, talcum powder; may use cornstarch or olive oil – BM depression (same as in chemo) – GIT disturbance: Dysgeusia- ↓ taste sensation esp. with internal implant •Oral care, avoid hot & cold foods
LEUKEMIA
•Group of malignant disease •Rapid ↑ immature WBC,
competes nutrition with mature WBC and production of RBC and platelets •N= 500 RBC: 1 WBC
LEUKEMIA
CLASSIFICATION OF LEUKEMIA
• Lympho- affects lymphocytes • Myelo- affects myeloblasts • Acute/Blastic- affects immature cells • Chronic/Cystic- affects mature cells • Most common in children: Acute
Lymphocytic Leukemia (ALL), peak onset 2-6 y/o, M>F • Acute Myelogenous Leukemia (AML): peak onset 15-39 y/o
Signs and Symptoms: LEUKEMIA
• From invasion of BM (“Nadir”)
– Infection: ↑T, poor wound healing, sore throat, bone weakens→ fracture, bone & joint pains, lymphadenopathy – Bleeding: hemorrhage, petechiae, epistaxis, hematoma, hematuria, hematemesis, hepatosplenomegaly – Anemia: pallor, fatigue, anorexia, constipation
• From invasion of CNS
Signs and Symptoms: LEUKEMIA
– ↑ ICP: ↓ LOC, severe HA, vomiting, papilledema, seizures – CN VII or spinal nerve involvement • From invasion of kidneys, testes, prostate, ovaries, GI and lungs
LEUKEMIA
• Diagnostic Tests
– PBS- (+) immature WBC – CBC- ↑ immature WBC, ↓ RBC, ↓ platelets • Done weekly during maintenance phase of chemotherapy – Lumbar Puncture- CNS affectation • Shrimp/fetal/C-position, avoid neck flexion may occlude airway of infants and children
LEUKEMIA
• Diagnostic Tests
– Bone Marrow Aspiration- (+) blast cells (immature WBC), common site: iliac crest • Post op: apply direct pressure, lie on affected side to stop bleeding – Bone Scan- to determine bone involvement (fractures) – CT Scan: to determine organ involvement
LEUKEMIA
• Triad Management
– Surgery (most preferred) – (Cranial) Irradiation – Chemotherapy • BM transplant
Nursing Management: LEUKEMIA
– Assess for common side effects: anorexia, nausea and vomiting (give antiemetics 30mins prior to chemo and continue until 1 day post chemo), WOF dehydration
Nursing Management: LEUKEMIA
– Assure pt that alopecia and hirsutism are temporary side effects, hair will regrow in 3-6 mos. With new color & texture
– Assess for stomatitis (oral ulcers) • Oral care: alcohol-free mouthwash, pNSS with or without NaHCO3 • Use soft-bristled toothbrush, cotton plegets • Apply Xylocaine (topical anesthetic) on mouth before meals • Diet: soft and bland according to child’s preference, small frequent feedings
Nursing Management: LEUKEMIA
Nursing Management: LEUKEMIA – Protect pt from infection •Strict hand washing •Reverse isolation – Protect pt from additional fatigue •Bed rest •Activities balanced with rest
Nursing Management: LEUKEMIA
– Protect pt from bleeding •Minimize parenteral injections •Apply pressure on venipuncture sites •Use electric razor in shaving
Nursing Management: LEUKEMIA
– Encourage verbalization of feelings & concerns – Introduce the family to other families of children with CA – Consult social services & chaplains as necessary
• Involves lymph nodes, tonsils, spleen &
BM • (+) Reed-Sternberg cell in the nodes • (+) bx of cervical lymph nodes (affected 1st) • (+) CT scan of liver & spleen
HODGKIN’S DISEASE/LYMPHOMA
MULTIPLE MYELOMA
•Malignant proliferation of plasma
cells and tumors within the bone, destroying the bone & invading the lymph nodes, spleen & liver •abN plasma cells produce an abN Ab (myeloma protein or Bence Jones protein) found in blood & urine ∀↓ production of Ig & Ab, ↑uric acid & Ca→ RF
S/Sx: MULTIPLE MYELOMA
• Bone pain (pelvis, spine, ribs) • Osteoporesis (bone loss, pathological fractures) • Spinal cord compression & paraplegia • Weakness & fatigue • Recurrent infections • Anemia • Bence Jones proteinuria, ↑ total serum protein, Ca
& uric acid levels • RF • Thrombocytopenia, granulocytopenia
Nursing Interventions: MULTIPLE MYELOMA
• Administer as ordered
– – – – Chemotherapy IVF & diuretics (to eliminate Ca) BT for anemia Analgesics, antibiotics
• WOF bleeding, infection, fractures, RF • Force fluids • Encourage ambulation • Provide skeletal support during moving, turning &
ambulating • Maintain hazard-free env’t
TESTICULAR CANCER
•Occurs between ages 15-40 •Common sites of mets: lymph nodes,
bone, lungs, adrenal glands & liver •Types – Germinal tumors (Seminomas, Nonseminomas) – Nongerminal tumors (Interstitial cell tumors, Androblastoma)
•Painless testicular swelling •Dragging sensation in the
S/Sx: TESTICULAR CANCER
scrotum •S/Sx of mets: palpable lymphadenopathy, abdominal masses, gynecomastia •Late S/Sx: back or bone pain & respiratory Sx
Tx: TESTICULAR CANCER
• Chemotherapy • Radiation • Surgery
– Unilateral orchiectomy- for dx & primary surgical mgt. – Radical retroperitoneal lymph node dissection- to stage the CA & ↓ tumor vol. • Reproductive options: sperm storage, donor insemination & adoption
Nursing Interventions: s/p Testicular Surgery
•Suture removal: 7-10 days post-op •May resume N activities within 1
week except for lifting heavy objects > 20 lbs or stair climbing •Perform monthly testicular self-exam on the remaining testicle
BREAST CANCER
• Common sites of mets: lymph nodes,
bone, lungs, brain & liver • Precipitating factors – Genetics – Early menarche & late menopause – Nulliparity – Obesity – High-dose radiation exposure to chest
S/Sx: BREAST CANCER
• Mass felt during BSE (usually in the upper outer
quadrant or beneath the nipple) • Fixed, irregular, nonencapsulated mass • Painless (early stage) or painful (late stage) mass • Nipple retraction or elevation • Assymetrical breast (affected breast higher) • Bloody or clear nipple d/c
S/Sx: BREAST CANCER
• Skin dimpling, retraction or ulceration • Skin edema or peau d’orange skin • Axillary lymphadenopathy • Lymphedema of affected arm • Presence of lesion on mammography • S/Sx of lung/bone mets
• Chemotx • Radiation tx • Hormonal manipulation in post
Nonsurgical Tx: BREAST CANCER
menopausal women • Meds: Tamoxifen (Nolvadex) for estrogen receptor-positive tumors
• Lumpectomy: removal of tumor with
Surgical Tx: BREAST CANCER
lymph node dissection • Simple Mastectomy: removal of breast tissue & nipple, lymph nodes left intact • Modified Radical Mastectomy: removal of breast tissue, nipple & lymph nodes, muscles left intact • Halsted Radical Mastectomy: removal of breast tissue, nipple, lymph nodes & underlying muscles
• Oophorectomy: for estrogen
Surgical Tx: BREAST CANCER
receptor-positive tumors • Ablative therapy with adrenalectomy or chemical ablation which blocks cortisol, androstenedione & aldosterone production
Nursing Interventions: s/p Breast Surgery
• Semi-Fowlers’ position, turn from back to unaffected
side, with affected arm elevated above the heart level to promote drainage & prevent lymphedema • Use a pressure sleeve if edema is severe • Maintain Jackson-Pratt suction, record the amount & characteristic of draiange • No IV, injections, BP, venipunctures in affected arm • Low Na-diet, diuretics for severe lymphedema • Refer to MD & PT for appropriate exercise program
Health Teaching: s/p Breast Surgery
• Protect & avoid overuse of the hand & arm s t
during the 1 few months • Keep the affected arm elevated to prevent lymphedema • Incision care with lanolin to soften & prevent wound contractures • BSE on the remaining breast • Avoid strong sunlight or heat to the affected arm • Don’t carry anything heavy over the affected arm
Health Teaching: s/p Breast Surgery
• Avoid constrictive clothing/jewelry, trauma, cuts, bruises or
burns to the affected arm • Wear gloves when gardening, washing dishes/clothes • Use thick oven mitten mitts when cooking • Use a thimble when sewing • Apply lanolin hand cream several times daily • Use cream cuticle remover • Notify MD if S/ of inflammation occur in the affected arm • Wear a Medic-Alert bracelet stating lymphedema arm
CERVICAL CANCER
• Premalignant changes: (Stage I) mild dysplasia to
(Stage II) mod. dysplasia to (Stage III) severe dysplasia to carcinoma in situ • Common sites of mets: pelvis & lymphatics • Precipitating factors – Low socioeconomic groups – Early 1st marriage – Early & frequent intercourse – Multiple sex partners – High parity – Poor hygiene
S/Sx: CERVICAL CANCER
• Painless vaginal bleeding postmenstrually &
postcoitally • Foul-smelling or serosanguinous vaginal d/c • Leakage of urine or feces from the vagina • Dysuria, hematuria • Pelvic, lower back, leg or groin pain • A/, wt loss • Changes on Pap smear
Tx: CERVICAL CANCER
• Nonsurgical
– Chemotherapy – Cryosurgery – External radiation – Internal radiation (intracavitary) – Laser therapy • Surgical – Conization – Hysterectomy – Pelvic exenteration
•Energy from the beam is
CERVICAL CA: Laser Therapy
absorbed by fluid in the tissues, causing them to vaporize •Minimal bleeding & slight vaginal d/c is expected after the procedure, healing occurs in 612 wks
CERVICAL CA: Cryosurgery
•Involves freezing of the tissues by a probe
with subsequent necrosis •No anesthesia required •Cramping may occur during the procedure •A heavy, watery d/c is expected several wks after the procedure, use tampons •Avoid sexual intercourse
CERVICAL CA: Conization
•A cone-shaped area of the cervix is
removed •For women who want further child bearing •Long-term follow-up is needed (new lesions may develop) •Cx: hemorrhage, uterine perforation, incompetent cervix, cervical stenosis & preterm labor
CERVICAL CA: Hysterectomy
•Vaginal approach for microinvasive
CA if childbearing is not desired •Radical hysterectomy & bilateral lymph node dissection for CA that spread beyond the cervix but not to the pelvic wall
Nursing Interventions: s/p Hysterectomy
•Monitor vaginal bleeding (>1 saturated
pad/hr) •Avoid stair climbing for 1 mo. •Avoid tub baths & sitting for long periods •Avoid strenous activity or lifting >20 lbs •Avoid sexual intercourse for 3-6 wks
•Radical surgical procedure for
CERVICAL CA: Pelvic exenteration
recurrent CA •When the bladder is removed, an ileal conduit is created & located at the R side of the abdomen to divert urine •A colostomy is created on the L side of the abdomen for the passage of feces
CERVICAL CA: Types of Pelvic Exenteration
•Anterior
– Removal of uterus, ovaries, fallopian tubes, vagina, bladder, urethra & pelvic lymph nodes – Removal of uterus, ovaries, fallopian tubes, descending colon, rectum & anal cnal – Combo of anterior & posterior
•Posterior •Total
Nursing Interventions: s/p Pelvic exenteration
•Administer perineal irrigation with halfstrength H2O2 & NS •Avoid strenous activity for 6 mos. •Perineal opening may drain for several mos. •Ileal conduit & colostomy care •Sexual counseling: vaginal intercourse is not possible s/p anterior & total pelvic exenteration
OVARIAN CANCER
•Grows rapidly, spreads fast, often
bilateral •Common sites of mets: pelvis, lymphatics & peritoneum •Usually detected late: Poor prognosis •Exploratory laparotomy: to dx & stage the tumor
S/Sx: OVARIAN CANCER
•Abdominal discomfort or
swelling •GI disturbance •Dysfunctional vaginal bleeding •Abdominal mass
Tx: OVARIAN CANCER
•External radiation: if with mets •Chemotherapy: done post-op for
all stages of CA •Intraperitoneal chemotx: instillation into abdominal cavity •Immunotherapy: promotes tumor resistance •Surgery: TAHBSO
• Slow-growing tumor asso. with menopausal years • Common sites of mets: ovaries, pelvis, peritoneum,
lymphatics & via blood to the lungs, liver & bone • Precipitating Factors – Hx of uterine polyps – Nulliparity – Polycystic ovary disease – Estrogen stimulation – Late menopause – Family hx
ENDOMETRIAL CANCER
S/Sx: ENDOMETRIAL CANCER •Postmenopausal bleeding •Watery, serosanguinous discharge •Low back, pelvic or abdominal pain •Enlarged uterus in advanced stages
•External or internal radiation •Chemotherapy for advanced or
Tx: ENDOMETRIAL CANCER
recurrent CA •Medroxyprogesterone (Depo-Provera) or Megestrol) Megace for estrogendependent tumors •Tamoxifen (Nolvadex): antiestrogen •Surgery: TAHBSO
• Predisposing Factors
GASTRIC CANCER
– Diet: high in complex CHO, grains & salt, low in fresh green, leafy vegetables & fruits – Use of nitrates – Smoking, alcoholism – Hx of gastric ulcers • Cx: hemorrhage, obstruction, mets & dumping syndrome • Goal of Tx: remove the tumor & provide nutritional support
•A/N/V, wt loss •Fatigue, anemia •Indigestion, epigastric discomfort •A sensation of pressure in the
stomach •Dysphagia •Ascites •Palpable mass
S/Sx: GASTRIC CANCER
•Chemotx •Radiation •Surgery
Tx: GASTRIC CANCER
– Subtotal gastrectomy •Bilroth I: Gastroduodenostomy •Bilroth II: Gastrojejunostomy – Total gastrectomy •Esophagojejunostomy
• Fowler’s position for comfort: Pain meds as ordered • Monitor Hgb, Hct: BT as ordered • NPO for 1-3 days post-op until peristalsis returns • Monitor I/O: IVF & e+ as ordered • Monitor NGT suction, don’t irrigate or remove NGT • Progressive diet to 6 small bland meals/day • Monitor wt, nutritional status: Small, bland, easy
Nursing Interventions: GASTRIC CANCER
digestible meals with vit & mineral supplements • WOF Cx: hemorrhage, dumping syndrome, diarrhea, hypoglycemia, Vit B12 deficiency
•More common in blacks than in
PANCREATIC CANCER
whites, in smokers & in men •Linked with DM, alcohol use, hx of pancreatitis, high fat diet, env’tal chemicals •With poor prognosis
S/Sx: PANCREATIC CANCER •N/V •Jaundice •Unexplained wt. loss •Clay-colored stool •Glucose intolerance •Abdominal pain
•Radiation •Chemotherapy •Whipple’s procedure:
Tx: PANCREATIC CANCER
pancreaticoduodenectomy with removal of distal third of the stomach, pancreaticojejunostomy, gastrojejunostomy & choledochojejunostomy
•Develop in the cells lining the bowel wall or
INTESTINAL TUMORS
develop as polyps in the colon or rectum •Cx: bowel perforation with peritonitis, abscess & fistula formation, hemorrhage & complete gut obstruction •Common sites of mets: via lymphatics & blood, colon & other organs
• A/V, malaise, wt loss • Blood in stools, anemia • AbN stools
S/Sx: INTESTINAL TUMORS
– Ascending colon tumor: diarrhea – Descending colon tumor: constipation with some diarrhea, ribbon-like stool – Rectal tumor: alternating constipation & diarrhea • Guarding or abdominal distention • Abdominal mass & cachexia (late signs)
Nursing Interventions: INTESTINAL TUMORS
• WOF bowel perforation: ↓BP, ↑HR, ↑T, weak
pulse, distended abdomen • WOF intestinal obstruction: (EARLY S/Sx↑peristalsis, ↑ to ↓ bowel sounds) fecal vomiting, pain, constipation, distended abdomen • Radiation pre-op • Chemotherapy post-op • Surgery: bowel resection & creation of colo or ileostomy
COLO/ILEOSTOMY PRE-OP CARE
•Consult with enterostomal therapist to
identify optimal placement of ostomy •Low-residue diet for 1-2 days pre-op •Give intestinal antiseptics & antibiotics, laxatives & enemas as ordered
COLOSTOMY POST-OP CARE
• Apply petroleum jelly over the stoma to keep it
moist followed by dry sterile gauze if pouch system is not yet in place • Monitor the stoma for size, unusual bleeding or necrotic tissue • Monitor the stoma for color vascularity – N: pink or red indicating ↓ – Pale: anemia, Violet/Blue/Black: compromised circulation
COLOSTOMY POST-OP CARE
• Check pouch system for proper fit & leakage • Ascending colon colostomy: expect liquid stool • Transverse colon colostomy: expect loose to semiformed
stool • Descending colon: expect close to N stool • Empty pouch when 1/3 full, remove feces from the skin • Avoid gas/odor-forming foods
COLOSTOMY POST-OP CARE
•WOF perineal wound
infection (if present) •Administer as ordered –Analgesics & antibiotics –Stoma irrigation
ILEOSTOMY POST-OP CARE
•Post-op drainage: dark green to yellow (as
the pt begins to eat) •Expect liquid stool •WOF dehydration & e+ imbalance •Avoid suppositories through ileostomy
• Lungs: common target for mets from other organs • Bronchiogenic carcinoma: direct extension & via
lymphatics • 4 Major Types – Small (Oat) Cell – Epidermal (Squamous Cell) – Adenocarcinoma – Large cell anaplastic carcinoma
LUNG CANCER
•Causes
LUNG CANCER
–Cigarette smoking –Env’tal & occupational pollutants •Dx: CXR (lesion or mass), bronchoscopy & sputum cytological studies
•Cough •Dyspnea •Hoarseness •Hemoptysis •Chest pain •A/ wt loss •Weakness
S/Sx: LUNG CANCER
Nursing Interventions: LUNG CANCER
• Fowler’s position • WOF RR distress, tracheal deviation • Activity as tolerated, rest periods, active/passive
ROM • Diet: ↑calorie, high CHON, ↑Vit • Administer as ordered – O2, bronchodilators, steroids – Analgesics – CPT
Tx: LUNG CANCER
• Radiation • Chemotherapy • Immunotherapy • Surgery
– Laser therapy: to relieve endobronchial obstruction – Thoracentesis & pleurodesis: to remove pleural fluid & relieve hypoxia – Thoracotomy with pneumonectomy or lobectomy or segmental resection
Pre-op Care: LUNG CANCER
Explain the potential post-op need for chest tubes • Closed chest drainage •pneumonectomy & the is not used for serum fluid that accumulates in the empty thoracic cavity will consolidate, preventing mediastinal shift
•Maintain chest tube drainage
Post-op Care: LUNG CANCER
system, WOF SQ emphysema •Avoid complete lateral turning •Activity as tolerated, active ROM of the operative shoulder •Administer O2 as ordered
• 1. For Induction
– To achieve complete remission (disappearance of leukemic cells) – Meds: Oral Prednisone Vincristine and Lasparaginase IV
4 LEVELS OF CHEMOTHERAPY
•2. For Sanctuary
– To treat leukemic cells that invaded testes and CNS – Meds: Intrathecal Methotrexate
4 LEVELS OF CHEMOTHERAPY
•3. For Maintenance
– To continue remission – Meds: Oral Methotrexate, 6Mercaptopurine and Cytarabine
4 LEVELS OF CHEMOTHERAPY
4 LEVELS OF CHEMOTHERAPY • 4. For Reinduction
– To treat leukemic cells after relapse occurs *Antigout agents: Allopurinol (Zyloprim) to treat/prevent hyperuricemic nephropathy (force fluids)
Alkylating Meds
• Cell-cycle nonspecific • Nitrogen Mustards
– Chlorambucil (Leukeran) & Mechlorethamine (Mustargen): hyperuricemia – Cyclophosphamide (Cytoxan): taken without food, S/E: alopecia, hemorrhagic cystitis (hematuria, dysuria) – Ifosfamide (Ifex) – Melphalan (Alkeran) – Uracil mustard
Alkylating Meds
• Nitrosoureas
– Carmustine (BiCNU) – Lomustine (CeeNU) – Streptozocin (Zanosar) Alkylating-like Meds – Altretamine (Hexalen) – Busulfan (Myleran): hyperuricemia – Cisplatin (Platinol): ototoxicity & nephrotoxicity (given amifostine [Ethyol] prior to ↓ risk), hypoK, hypoCa, hypoMg – Dacarbazine (DTIC-Dome) – Thiotepa (Thioplex)
•
• Cell-cycle nonspecific • Bleomycin SO4 (Blenoxane): pulmonary
Anti-tumor Antibiotics
toxicity • Dactinomycin (Actinomycin D, Cosmegan) • Daunorubicin (Cerubidine, DaunoXome): causes CHF & dysrhythmias • Doxorubicin (Adriamycin) & Idarubicin (Idamycin): cardiotoxicity (given Dexraxozane [Zinecard] to prevent cardiomyopathy)
Anti-tumor Antibiotics • Mitomycin (Mutamycin) • Mitoxantrone (Novantrone) • Pentostatin (Nipent) • Plicamycin (Mithracin): affects bleeding time • Valrubicin (Valstar)
• • • •
Antimetabolites
Cell-cycle phase-specific (S phase) Capecitabine (Xeloda) Cladribine (Leustatin) Cytarabine (ara-C, Cytosar-U): alopecia, stomatitis, hyperuricemia, hepatotoxicity • Floxuridine (FUDR) • Fludarabine (Fludara)
• Methotrexate (Folex) & 5-Fluorouracil
Antimetabolites
• • • •
(Adrucil): alopecia, stomatitis, hyperuricemia, photosensitivity, hepatotoxicity, hema, GI & skin toxicity – Leucovorin rescue (given leucovorin [folinic acid or citrovorum factor) to prevent toxicity r/t Methotrexate Hydroxyurea (Hydrea) 6-Mercaptopurine (Purinethol): hyperuricemia, hepatotoxicity Procarbazine (Matulane) Thioguanide
• • • • • •
Cell-cycle phase-specific: M phase Docetaxel (Taxotere) Etoposide (VePesid) Teniposide (Vumon) Vinblastine SO4 (Velban) Vincristine SO4 (Oncovin): neurotoxicity (numbness & tingling of fingers & toes), peripheral neuropathy, ptosis • Vinorelbine (Navelbine)
Mitotic Inhibitors (Vinca Alkaloids)
Immunomodulator Agents
• Stimulate immune system to
recognize CA cells & destroy them (Interleukins) • Slow down tumor cell division, causes CA cells to differentiate into non-proliferative forms (Interferons)
Immunomodulator Agents
• • • •
Aldesleukin (Proleukin, Interleukin-2) Interferon alfa-2a Interferon alfa-2b Interferon alfa-n3 (Alferon N) Levamisole (Ergamisole) • Recombinant interferon-α (Intron A, Roferon A) • Rituximab (Rituxan)
Colony-Stimulating Factors
• Induce rapid BM recovery after
chemotherapy • Granulocyte-Macrophage: Sargramostim (Leukin, Prokine) • Granulocyte: Filgrastim (Neupogen) • Erythropoetin: Epoetin alfa (Epogen)
Side Effects: Chemotherapy
– Stomatitis/Mucositis – Alopecia – A/N/V, Diarrhea – Anemia, Neutropenia, Thrombocytopenia – Infertility – Extravasation/Phlebitis
DIFFERENCE BENIGN S (Tumor) Differentiatio Well n Encapsulatio (+) n Metastasis (-) Prognosis Good Tx Modalities Surgery
NEOPLASIA
MALIGNANT (CA) Poor (-) (+) Poor Surgery, Irradiation, Chemotx, BM
Predisposing Factors: Carcinogenesis
• G-enetic • I-mmunosuppression • V-iral (Human Papilloma, Epstein-Barr, Hepa B) • E-nv’tal
– Physical •Radiation, UV rays, nuclear explosion •Chronic irritation, direct trauma – Chemical •Acids, alkalis, hydrocarbons, dye •Food (↑fat, ↓fiber) & Food additives (Nitrites) •Drugs (Stillbestrol, urethane) •Hormones •Smoking
Predisposing Factors: Carcinogenesis
•Men: Bronchogenic/Lung CA, liver CA,
prostate CA (middle aged, >40 y/o, with BPH, hormonal) •Women: Breast CA (hormonal, encourage SBE 1 wk after mens), cervical CA (80%- multiple sex partners, 20% early pregnancy) •Ovarian CA
Classification of Cancer
• Based on tissue typing • Carcinoma- arises from surface
epithelium & glandular tissue • Sarcoma- arises from connective tissue • Multiple myeloma- arises from plasma cells (in BM) • Lymphoma- arises from lymph glands • Leukemia- arises from blood cells
Grading of Cancer
• Classifies the cellular aspects of CA • Grade I: cells differ slightly from N cells,
well-differentiated (mild dysplasia) • Grade II: cells are more abN, mod. differentiated (mod. dysplasia) • Grade III: cells are very abN, poorly differentiated (severe dysplasia) • Grade IV: cells are immature (anaplasia), undifferentiated
Staging of Cancer
• Classifies the clinical aspects of CA • Stage O: carcinoma in situ • Stage I: tumor limited to the tissue of
origin, localized tissue growth • Stage II: limited local spread • Stage III: extensive local & regional spread • Stage IV: metastatis
WARNING/DANGER SIGNS OF CANCER
• C-hange in bowel/bladder habits • A- sore that does not heal • U-nusual bleeding/discharge • T-hickening of a lump in breast or elsewhere • I-ndigestion/dysphagia • O-bvious change in a wart or mole • N-agging cough/hoarseness • U-nexplained anemia • S-udden wt loss
EARLY DETECTION OF CANCER •Mammography •Pap smear •Stool for occult blood •Sigmoidoscopy, colonoscopy •Breast self-examination •Testicular self-examination •Skin inspection
Breast Self-Examination (BSE)
•Done 7-10 days after menses •Postmenopausal or s/p
hysterectomy: specific day of the month •Inspection: In front of the mirror with arms at sides, arms overhead & arms at hips (WOF changes in shape, dimpling of skin or any changes in nipple)
Breast Self-Examination (BSE)
• Palpation: While in shower/bath or
lying down with folded towel under breast being examined • Use the R hand to examine L breast & vice versa • Use the pads of 2nd , 3rd & 4th fingers • Use small, circular motions in spiral or in an up-and-down motion to examine entire breast & under the arm (WOF lump, hard knot or thickened tissue)
Testicular Self-Examination (TSE)
• Same day, q month, right after a warm
shower (scrotal skin is moist & relaxed) • Gently lift each testicle, each one should feel like an egg, firm but not hard & smooth without lumps • Using both hands, place middle fingers underside of each testicle & thumbs on top & gently roll the testicles (WOF lumps, swelling or mass)
CANCER TX MODALITIES: Chemotherapy • Kills CA cells & rapidly producing cells
(skin, hair, BM, Reproductive tract, GIT,) – Antimetabolites: N2 mustard – Plant alkaloid: Vincristine & Vinblastine – Alkylating: Methotrexate – Hormones (DES)/ steroids – Antineoplastic antibiotics
CANCER TX MODALITIES: Surgery
•Prophylactic
– With premalignant condition or with strong family hx of CA •Curative – Removal of all gross & microscopic tumor •Control (cytoreductive) – “debulking” procedure, ↓ the no. of CA cells, ↑ the chance of other tx will be successful
CANCER TX MODALITIES: Surgery
• Palliative
– Improves quality of life during survival time – ↓ pain; relieve obstruction (airway, GI or GU), relieve pressure on brain & spinal cord, prevent hemorrhage, remove infected or ulcerated tumors or drain abscesses • Reconstructive or rehabilitative – Improves quality of life by restoring maximal function & appearance (breast reconstruction s/p mastectomy)
CANCER TX MODALITIES: Chemotherapy
• Major S/E & Nursing Interventions • Hair: alopecia
– Encourage pt to wear wigs, cap – Temporary, hair will regrow in 3-6 mos. after chemo with new color & texture • BM: depression – Anemia: CBR, O2 as ordered – Leukemia: reverse isolation, strict HW, asepsis – Thrombocytopenia: Bleeding precautions
CANCER TX MODALITIES: Chemotherapy
• Major S/E & Nursing Interventions • GIT: N/V
– Antiemetics 4-6 hrs. pre-chemo & post chemo as ordered – NPO temporarily – Bland diet post chemo • Stomatitis – Oral care – Ice chips/popsicles • Diarrhea – Antidiarrheals – Monitor VS, I/O, WOF dehydration • WOF paralytic ileus (with Vincristine)
CANCER TX MODALITIES: Chemotherapy
•Major S/E & Nursing Interventions •Reproductive tract: sterility
– Encourage sperm banking for M •Renal damage: ↑ uric acid – Allopurinol as ordered •Neuro disturbance: peripheral neuropathy – Skin, hand & foot care (like in PVD & DM)
CANCER TX MODALITIES: Radiation
• Use of ionizing radiation that kills CA &
rapidly growing cells & inhibit their growth • Types of energy – Alpha rays: don’t penetrate skin tissue – Beta rays: penetrate skin (e.g. internal radiation) – Gamma rays: penetrate deeper, underlying tissues (e.g. external radiation)
CANCER TX MODALITIES: Radiation
• Factors Affecting Delivery
– Half-life: time required for the ½ of the radioisotope to decay – Time: less time, less exposure – Distance: the farther the source, the lesser the exposure – Shielding: Alpha & Beta rays can be blocked by gloves, Gamma rays can be blocked by thick, lead gown & concrete
CANCER TX MODALITIES: Radiation
• Methods of Delivery
– Internal: utilizes injection/ implantation of radioactive isotopes proximal to CA sites for specified period of time •Sealed: within a container, don’t contaminate with body fluids •Unsealed: e.g. Phosphorus 32 – External: uses electromagnetic waves e.g. Cobalt
CANCER TX MODALITIES:
Teletherapy/Beam Radiation
• Source: external radiation • Pt does not emit radiation & does
not pose a hazard to anyone else • Wash area with water & mild soap, using the hand than a washcloth, rinse & pat dry with soft towel • Don’t remove radiation markings from the skin
CANCER TX MODALITIES:
Teletherapy/Beam Radiation • No powder, ointment, lotion or cream on
area unless ordered • Wear soft clothing over the area, avoid constrictive garments • Avoid sun & heat exposure • WOF weeping of skin (moist desquamation) & if noted, cleanse the area with warm water & pat dry, apply antibiotic or steroid cream as ordered & expose the site to air
CANCER TX MODALITIES: Brachytherapy Radiation •Source: internal radiation (sealed or unsealed) •For a pd. of time the pt emits radiation & pose a hazard to others
CANCER TX MODALITIES: Brachytherapy Radiation
•Unsealed Radiation Source
– Administered PO or IV or instillation into body cavities – It enters body fluids, eliminated via various excreta (radioactive & harmful to others esp. the 1st 48 hrs)
CANCER TX MODALITIES: Brachytherapy Radiation
•Sealed Radiation Source
– Temporary or permanent solid implant within tumor target tissues – The pt emits radiation while the implant is in place, but the excreta is not radioactive – Place the pt in a private room with private bath – Place a caution sign on the pt’s door
CANCER TX MODALITIES: Brachytherapy Radiation
•Sealed Radiation Source
– Organize nursing tasks to minimize exposure to radiation source – Nursing staff assignments should be rotated, a nurse should never care for more than 1 pt with radiation implant at a time, avoid assigning a pregnant nurse – Limit time to 30 mins per care provider/shift
CANCER TX MODALITIES: Brachytherapy Radiation
• Sealed Radiation Source
– Wear a dosimeter film badge to measure radiation exposure – Wear a lead shield – Do not allow children <16 y/o or pregnant woman to visit the pt – Limit visitors to 30 min./day, at least 6 ft from the pt – Save bed linens & dressings until the source is removed then dispose – Other equipments can be removed from the room at any time
CANCER TX MODALITIES: Brachytherapy Radiation
•Dislodged Sealed Radiation Source
– Don’t touch it with bare hands, use a long-handled forceps to place the source in a lead container kept in the pt’s room & notify MD – If unable to locate the radiation source, bar visitors & notify MD
CANCER TX MODALITIES: Brachytherapy Radiation
• Sealed Radiation Source Removal
– – – Pt is no longer radioactive Inform the pt that sexual partner cannot “catch” CA Pt may resume sexual intercourse after 7-10 days for cervical or vaginal implant – Perform povidone-iodine douche as ordered for cervical implant – Administer Fleet enema as ordered – Notify MD if N/V/D, frequent urination, vaginal or rectal bleeding, hematuria, foul-smelling vaginal discharge, abdominal pain/distention or fever occurs
CANCER TX MODALITIES: Radiation
• Major S/E & Nursing Interventions
– Skin erythema, redness, irritation & sloughing of tissue •Assist in bathing the pt •Force fluids •Avoid lotion, talcum powder; may use cornstarch or olive oil – BM depression (same as in chemo) – GIT disturbance: Dysgeusia- ↓ taste sensation esp. with internal implant •Oral care, avoid hot & cold foods
LEUKEMIA
•Group of malignant disease •Rapid ↑ immature WBC,
competes nutrition with mature WBC and production of RBC and platelets •N= 500 RBC: 1 WBC
LEUKEMIA
CLASSIFICATION OF LEUKEMIA
• Lympho- affects lymphocytes • Myelo- affects myeloblasts • Acute/Blastic- affects immature cells • Chronic/Cystic- affects mature cells • Most common in children: Acute
Lymphocytic Leukemia (ALL), peak onset 2-6 y/o, M>F • Acute Myelogenous Leukemia (AML): peak onset 15-39 y/o
Signs and Symptoms: LEUKEMIA
• From invasion of BM (“Nadir”)
– Infection: ↑T, poor wound healing, sore throat, bone weakens→ fracture, bone & joint pains, lymphadenopathy – Bleeding: hemorrhage, petechiae, epistaxis, hematoma, hematuria, hematemesis, hepatosplenomegaly – Anemia: pallor, fatigue, anorexia, constipation
• From invasion of CNS
Signs and Symptoms: LEUKEMIA
– ↑ ICP: ↓ LOC, severe HA, vomiting, papilledema, seizures – CN VII or spinal nerve involvement • From invasion of kidneys, testes, prostate, ovaries, GI and lungs
LEUKEMIA
• Diagnostic Tests
– PBS- (+) immature WBC – CBC- ↑ immature WBC, ↓ RBC, ↓ platelets • Done weekly during maintenance phase of chemotherapy – Lumbar Puncture- CNS affectation • Shrimp/fetal/C-position, avoid neck flexion may occlude airway of infants and children
LEUKEMIA
• Diagnostic Tests
– Bone Marrow Aspiration- (+) blast cells (immature WBC), common site: iliac crest • Post op: apply direct pressure, lie on affected side to stop bleeding – Bone Scan- to determine bone involvement (fractures) – CT Scan: to determine organ involvement
LEUKEMIA
• Triad Management
– Surgery (most preferred) – (Cranial) Irradiation – Chemotherapy • BM transplant
Nursing Management: LEUKEMIA
– Assess for common side effects: anorexia, nausea and vomiting (give antiemetics 30mins prior to chemo and continue until 1 day post chemo), WOF dehydration
Nursing Management: LEUKEMIA
– Assure pt that alopecia and hirsutism are temporary side effects, hair will regrow in 3-6 mos. With new color & texture
– Assess for stomatitis (oral ulcers) • Oral care: alcohol-free mouthwash, pNSS with or without NaHCO3 • Use soft-bristled toothbrush, cotton plegets • Apply Xylocaine (topical anesthetic) on mouth before meals • Diet: soft and bland according to child’s preference, small frequent feedings
Nursing Management: LEUKEMIA
Nursing Management: LEUKEMIA – Protect pt from infection •Strict hand washing •Reverse isolation – Protect pt from additional fatigue •Bed rest •Activities balanced with rest
Nursing Management: LEUKEMIA
– Protect pt from bleeding •Minimize parenteral injections •Apply pressure on venipuncture sites •Use electric razor in shaving
Nursing Management: LEUKEMIA
– Encourage verbalization of feelings & concerns – Introduce the family to other families of children with CA – Consult social services & chaplains as necessary
• Involves lymph nodes, tonsils, spleen &
BM • (+) Reed-Sternberg cell in the nodes • (+) bx of cervical lymph nodes (affected 1st) • (+) CT scan of liver & spleen
HODGKIN’S DISEASE/LYMPHOMA
MULTIPLE MYELOMA
•Malignant proliferation of plasma
cells and tumors within the bone, destroying the bone & invading the lymph nodes, spleen & liver •abN plasma cells produce an abN Ab (myeloma protein or Bence Jones protein) found in blood & urine ∀↓ production of Ig & Ab, ↑uric acid & Ca→ RF
S/Sx: MULTIPLE MYELOMA
• Bone pain (pelvis, spine, ribs) • Osteoporesis (bone loss, pathological fractures) • Spinal cord compression & paraplegia • Weakness & fatigue • Recurrent infections • Anemia • Bence Jones proteinuria, ↑ total serum protein, Ca
& uric acid levels • RF • Thrombocytopenia, granulocytopenia
Nursing Interventions: MULTIPLE MYELOMA
• Administer as ordered
– – – – Chemotherapy IVF & diuretics (to eliminate Ca) BT for anemia Analgesics, antibiotics
• WOF bleeding, infection, fractures, RF • Force fluids • Encourage ambulation • Provide skeletal support during moving, turning &
ambulating • Maintain hazard-free env’t
TESTICULAR CANCER
•Occurs between ages 15-40 •Common sites of mets: lymph nodes,
bone, lungs, adrenal glands & liver •Types – Germinal tumors (Seminomas, Nonseminomas) – Nongerminal tumors (Interstitial cell tumors, Androblastoma)
•Painless testicular swelling •Dragging sensation in the
S/Sx: TESTICULAR CANCER
scrotum •S/Sx of mets: palpable lymphadenopathy, abdominal masses, gynecomastia •Late S/Sx: back or bone pain & respiratory Sx
Tx: TESTICULAR CANCER
• Chemotherapy • Radiation • Surgery
– Unilateral orchiectomy- for dx & primary surgical mgt. – Radical retroperitoneal lymph node dissection- to stage the CA & ↓ tumor vol. • Reproductive options: sperm storage, donor insemination & adoption
Nursing Interventions: s/p Testicular Surgery
•Suture removal: 7-10 days post-op •May resume N activities within 1
week except for lifting heavy objects > 20 lbs or stair climbing •Perform monthly testicular self-exam on the remaining testicle
BREAST CANCER
• Common sites of mets: lymph nodes,
bone, lungs, brain & liver • Precipitating factors – Genetics – Early menarche & late menopause – Nulliparity – Obesity – High-dose radiation exposure to chest
S/Sx: BREAST CANCER
• Mass felt during BSE (usually in the upper outer
quadrant or beneath the nipple) • Fixed, irregular, nonencapsulated mass • Painless (early stage) or painful (late stage) mass • Nipple retraction or elevation • Assymetrical breast (affected breast higher) • Bloody or clear nipple d/c
S/Sx: BREAST CANCER
• Skin dimpling, retraction or ulceration • Skin edema or peau d’orange skin • Axillary lymphadenopathy • Lymphedema of affected arm • Presence of lesion on mammography • S/Sx of lung/bone mets
• Chemotx • Radiation tx • Hormonal manipulation in post
Nonsurgical Tx: BREAST CANCER
menopausal women • Meds: Tamoxifen (Nolvadex) for estrogen receptor-positive tumors
• Lumpectomy: removal of tumor with
Surgical Tx: BREAST CANCER
lymph node dissection • Simple Mastectomy: removal of breast tissue & nipple, lymph nodes left intact • Modified Radical Mastectomy: removal of breast tissue, nipple & lymph nodes, muscles left intact • Halsted Radical Mastectomy: removal of breast tissue, nipple, lymph nodes & underlying muscles
• Oophorectomy: for estrogen
Surgical Tx: BREAST CANCER
receptor-positive tumors • Ablative therapy with adrenalectomy or chemical ablation which blocks cortisol, androstenedione & aldosterone production
Nursing Interventions: s/p Breast Surgery
• Semi-Fowlers’ position, turn from back to unaffected
side, with affected arm elevated above the heart level to promote drainage & prevent lymphedema • Use a pressure sleeve if edema is severe • Maintain Jackson-Pratt suction, record the amount & characteristic of draiange • No IV, injections, BP, venipunctures in affected arm • Low Na-diet, diuretics for severe lymphedema • Refer to MD & PT for appropriate exercise program
Health Teaching: s/p Breast Surgery
• Protect & avoid overuse of the hand & arm s t
during the 1 few months • Keep the affected arm elevated to prevent lymphedema • Incision care with lanolin to soften & prevent wound contractures • BSE on the remaining breast • Avoid strong sunlight or heat to the affected arm • Don’t carry anything heavy over the affected arm
Health Teaching: s/p Breast Surgery
• Avoid constrictive clothing/jewelry, trauma, cuts, bruises or
burns to the affected arm • Wear gloves when gardening, washing dishes/clothes • Use thick oven mitten mitts when cooking • Use a thimble when sewing • Apply lanolin hand cream several times daily • Use cream cuticle remover • Notify MD if S/ of inflammation occur in the affected arm • Wear a Medic-Alert bracelet stating lymphedema arm
CERVICAL CANCER
• Premalignant changes: (Stage I) mild dysplasia to
(Stage II) mod. dysplasia to (Stage III) severe dysplasia to carcinoma in situ • Common sites of mets: pelvis & lymphatics • Precipitating factors – Low socioeconomic groups – Early 1st marriage – Early & frequent intercourse – Multiple sex partners – High parity – Poor hygiene
S/Sx: CERVICAL CANCER
• Painless vaginal bleeding postmenstrually &
postcoitally • Foul-smelling or serosanguinous vaginal d/c • Leakage of urine or feces from the vagina • Dysuria, hematuria • Pelvic, lower back, leg or groin pain • A/, wt loss • Changes on Pap smear
Tx: CERVICAL CANCER
• Nonsurgical
– Chemotherapy – Cryosurgery – External radiation – Internal radiation (intracavitary) – Laser therapy • Surgical – Conization – Hysterectomy – Pelvic exenteration
•Energy from the beam is
CERVICAL CA: Laser Therapy
absorbed by fluid in the tissues, causing them to vaporize •Minimal bleeding & slight vaginal d/c is expected after the procedure, healing occurs in 612 wks
CERVICAL CA: Cryosurgery
•Involves freezing of the tissues by a probe
with subsequent necrosis •No anesthesia required •Cramping may occur during the procedure •A heavy, watery d/c is expected several wks after the procedure, use tampons •Avoid sexual intercourse
CERVICAL CA: Conization
•A cone-shaped area of the cervix is
removed •For women who want further child bearing •Long-term follow-up is needed (new lesions may develop) •Cx: hemorrhage, uterine perforation, incompetent cervix, cervical stenosis & preterm labor
CERVICAL CA: Hysterectomy
•Vaginal approach for microinvasive
CA if childbearing is not desired •Radical hysterectomy & bilateral lymph node dissection for CA that spread beyond the cervix but not to the pelvic wall
Nursing Interventions: s/p Hysterectomy
•Monitor vaginal bleeding (>1 saturated
pad/hr) •Avoid stair climbing for 1 mo. •Avoid tub baths & sitting for long periods •Avoid strenous activity or lifting >20 lbs •Avoid sexual intercourse for 3-6 wks
•Radical surgical procedure for
CERVICAL CA: Pelvic exenteration
recurrent CA •When the bladder is removed, an ileal conduit is created & located at the R side of the abdomen to divert urine •A colostomy is created on the L side of the abdomen for the passage of feces
CERVICAL CA: Types of Pelvic Exenteration
•Anterior
– Removal of uterus, ovaries, fallopian tubes, vagina, bladder, urethra & pelvic lymph nodes – Removal of uterus, ovaries, fallopian tubes, descending colon, rectum & anal cnal – Combo of anterior & posterior
•Posterior •Total
Nursing Interventions: s/p Pelvic exenteration
•Administer perineal irrigation with halfstrength H2O2 & NS •Avoid strenous activity for 6 mos. •Perineal opening may drain for several mos. •Ileal conduit & colostomy care •Sexual counseling: vaginal intercourse is not possible s/p anterior & total pelvic exenteration
OVARIAN CANCER
•Grows rapidly, spreads fast, often
bilateral •Common sites of mets: pelvis, lymphatics & peritoneum •Usually detected late: Poor prognosis •Exploratory laparotomy: to dx & stage the tumor
S/Sx: OVARIAN CANCER
•Abdominal discomfort or
swelling •GI disturbance •Dysfunctional vaginal bleeding •Abdominal mass
Tx: OVARIAN CANCER
•External radiation: if with mets •Chemotherapy: done post-op for
all stages of CA •Intraperitoneal chemotx: instillation into abdominal cavity •Immunotherapy: promotes tumor resistance •Surgery: TAHBSO
• Slow-growing tumor asso. with menopausal years • Common sites of mets: ovaries, pelvis, peritoneum,
lymphatics & via blood to the lungs, liver & bone • Precipitating Factors – Hx of uterine polyps – Nulliparity – Polycystic ovary disease – Estrogen stimulation – Late menopause – Family hx
ENDOMETRIAL CANCER
S/Sx: ENDOMETRIAL CANCER •Postmenopausal bleeding •Watery, serosanguinous discharge •Low back, pelvic or abdominal pain •Enlarged uterus in advanced stages
•External or internal radiation •Chemotherapy for advanced or
Tx: ENDOMETRIAL CANCER
recurrent CA •Medroxyprogesterone (Depo-Provera) or Megestrol) Megace for estrogendependent tumors •Tamoxifen (Nolvadex): antiestrogen •Surgery: TAHBSO
• Predisposing Factors
GASTRIC CANCER
– Diet: high in complex CHO, grains & salt, low in fresh green, leafy vegetables & fruits – Use of nitrates – Smoking, alcoholism – Hx of gastric ulcers • Cx: hemorrhage, obstruction, mets & dumping syndrome • Goal of Tx: remove the tumor & provide nutritional support
•A/N/V, wt loss •Fatigue, anemia •Indigestion, epigastric discomfort •A sensation of pressure in the
stomach •Dysphagia •Ascites •Palpable mass
S/Sx: GASTRIC CANCER
•Chemotx •Radiation •Surgery
Tx: GASTRIC CANCER
– Subtotal gastrectomy •Bilroth I: Gastroduodenostomy •Bilroth II: Gastrojejunostomy – Total gastrectomy •Esophagojejunostomy
• Fowler’s position for comfort: Pain meds as ordered • Monitor Hgb, Hct: BT as ordered • NPO for 1-3 days post-op until peristalsis returns • Monitor I/O: IVF & e+ as ordered • Monitor NGT suction, don’t irrigate or remove NGT • Progressive diet to 6 small bland meals/day • Monitor wt, nutritional status: Small, bland, easy
Nursing Interventions: GASTRIC CANCER
digestible meals with vit & mineral supplements • WOF Cx: hemorrhage, dumping syndrome, diarrhea, hypoglycemia, Vit B12 deficiency
•More common in blacks than in
PANCREATIC CANCER
whites, in smokers & in men •Linked with DM, alcohol use, hx of pancreatitis, high fat diet, env’tal chemicals •With poor prognosis
S/Sx: PANCREATIC CANCER •N/V •Jaundice •Unexplained wt. loss •Clay-colored stool •Glucose intolerance •Abdominal pain
•Radiation •Chemotherapy •Whipple’s procedure:
Tx: PANCREATIC CANCER
pancreaticoduodenectomy with removal of distal third of the stomach, pancreaticojejunostomy, gastrojejunostomy & choledochojejunostomy
•Develop in the cells lining the bowel wall or
INTESTINAL TUMORS
develop as polyps in the colon or rectum •Cx: bowel perforation with peritonitis, abscess & fistula formation, hemorrhage & complete gut obstruction •Common sites of mets: via lymphatics & blood, colon & other organs
• A/V, malaise, wt loss • Blood in stools, anemia • AbN stools
S/Sx: INTESTINAL TUMORS
– Ascending colon tumor: diarrhea – Descending colon tumor: constipation with some diarrhea, ribbon-like stool – Rectal tumor: alternating constipation & diarrhea • Guarding or abdominal distention • Abdominal mass & cachexia (late signs)
Nursing Interventions: INTESTINAL TUMORS
• WOF bowel perforation: ↓BP, ↑HR, ↑T, weak
pulse, distended abdomen • WOF intestinal obstruction: (EARLY S/Sx↑peristalsis, ↑ to ↓ bowel sounds) fecal vomiting, pain, constipation, distended abdomen • Radiation pre-op • Chemotherapy post-op • Surgery: bowel resection & creation of colo or ileostomy
COLO/ILEOSTOMY PRE-OP CARE
•Consult with enterostomal therapist to
identify optimal placement of ostomy •Low-residue diet for 1-2 days pre-op •Give intestinal antiseptics & antibiotics, laxatives & enemas as ordered
COLOSTOMY POST-OP CARE
• Apply petroleum jelly over the stoma to keep it
moist followed by dry sterile gauze if pouch system is not yet in place • Monitor the stoma for size, unusual bleeding or necrotic tissue • Monitor the stoma for color vascularity – N: pink or red indicating ↓ – Pale: anemia, Violet/Blue/Black: compromised circulation
COLOSTOMY POST-OP CARE
• Check pouch system for proper fit & leakage • Ascending colon colostomy: expect liquid stool • Transverse colon colostomy: expect loose to semiformed
stool • Descending colon: expect close to N stool • Empty pouch when 1/3 full, remove feces from the skin • Avoid gas/odor-forming foods
COLOSTOMY POST-OP CARE
•WOF perineal wound
infection (if present) •Administer as ordered –Analgesics & antibiotics –Stoma irrigation
ILEOSTOMY POST-OP CARE
•Post-op drainage: dark green to yellow (as
the pt begins to eat) •Expect liquid stool •WOF dehydration & e+ imbalance •Avoid suppositories through ileostomy
• Lungs: common target for mets from other organs • Bronchiogenic carcinoma: direct extension & via
lymphatics • 4 Major Types – Small (Oat) Cell – Epidermal (Squamous Cell) – Adenocarcinoma – Large cell anaplastic carcinoma
LUNG CANCER
•Causes
LUNG CANCER
–Cigarette smoking –Env’tal & occupational pollutants •Dx: CXR (lesion or mass), bronchoscopy & sputum cytological studies
•Cough •Dyspnea •Hoarseness •Hemoptysis •Chest pain •A/ wt loss •Weakness
S/Sx: LUNG CANCER
Nursing Interventions: LUNG CANCER
• Fowler’s position • WOF RR distress, tracheal deviation • Activity as tolerated, rest periods, active/passive
ROM • Diet: ↑calorie, high CHON, ↑Vit • Administer as ordered – O2, bronchodilators, steroids – Analgesics – CPT
Tx: LUNG CANCER
• Radiation • Chemotherapy • Immunotherapy • Surgery
– Laser therapy: to relieve endobronchial obstruction – Thoracentesis & pleurodesis: to remove pleural fluid & relieve hypoxia – Thoracotomy with pneumonectomy or lobectomy or segmental resection
Pre-op Care: LUNG CANCER
Explain the potential post-op need for chest tubes • Closed chest drainage •pneumonectomy & the is not used for serum fluid that accumulates in the empty thoracic cavity will consolidate, preventing mediastinal shift
•Maintain chest tube drainage
Post-op Care: LUNG CANCER
system, WOF SQ emphysema •Avoid complete lateral turning •Activity as tolerated, active ROM of the operative shoulder •Administer O2 as ordered
• 1. For Induction
– To achieve complete remission (disappearance of leukemic cells) – Meds: Oral Prednisone Vincristine and Lasparaginase IV
4 LEVELS OF CHEMOTHERAPY
•2. For Sanctuary
– To treat leukemic cells that invaded testes and CNS – Meds: Intrathecal Methotrexate
4 LEVELS OF CHEMOTHERAPY
•3. For Maintenance
– To continue remission – Meds: Oral Methotrexate, 6Mercaptopurine and Cytarabine
4 LEVELS OF CHEMOTHERAPY
4 LEVELS OF CHEMOTHERAPY • 4. For Reinduction
– To treat leukemic cells after relapse occurs *Antigout agents: Allopurinol (Zyloprim) to treat/prevent hyperuricemic nephropathy (force fluids)
Alkylating Meds
• Cell-cycle nonspecific • Nitrogen Mustards
– Chlorambucil (Leukeran) & Mechlorethamine (Mustargen): hyperuricemia – Cyclophosphamide (Cytoxan): taken without food, S/E: alopecia, hemorrhagic cystitis (hematuria, dysuria) – Ifosfamide (Ifex) – Melphalan (Alkeran) – Uracil mustard
Alkylating Meds
• Nitrosoureas
– Carmustine (BiCNU) – Lomustine (CeeNU) – Streptozocin (Zanosar) Alkylating-like Meds – Altretamine (Hexalen) – Busulfan (Myleran): hyperuricemia – Cisplatin (Platinol): ototoxicity & nephrotoxicity (given amifostine [Ethyol] prior to ↓ risk), hypoK, hypoCa, hypoMg – Dacarbazine (DTIC-Dome) – Thiotepa (Thioplex)
•
• Cell-cycle nonspecific • Bleomycin SO4 (Blenoxane): pulmonary
Anti-tumor Antibiotics
toxicity • Dactinomycin (Actinomycin D, Cosmegan) • Daunorubicin (Cerubidine, DaunoXome): causes CHF & dysrhythmias • Doxorubicin (Adriamycin) & Idarubicin (Idamycin): cardiotoxicity (given Dexraxozane [Zinecard] to prevent cardiomyopathy)
Anti-tumor Antibiotics • Mitomycin (Mutamycin) • Mitoxantrone (Novantrone) • Pentostatin (Nipent) • Plicamycin (Mithracin): affects bleeding time • Valrubicin (Valstar)
• • • •
Antimetabolites
Cell-cycle phase-specific (S phase) Capecitabine (Xeloda) Cladribine (Leustatin) Cytarabine (ara-C, Cytosar-U): alopecia, stomatitis, hyperuricemia, hepatotoxicity • Floxuridine (FUDR) • Fludarabine (Fludara)
• Methotrexate (Folex) & 5-Fluorouracil
Antimetabolites
• • • •
(Adrucil): alopecia, stomatitis, hyperuricemia, photosensitivity, hepatotoxicity, hema, GI & skin toxicity – Leucovorin rescue (given leucovorin [folinic acid or citrovorum factor) to prevent toxicity r/t Methotrexate Hydroxyurea (Hydrea) 6-Mercaptopurine (Purinethol): hyperuricemia, hepatotoxicity Procarbazine (Matulane) Thioguanide
• • • • • •
Cell-cycle phase-specific: M phase Docetaxel (Taxotere) Etoposide (VePesid) Teniposide (Vumon) Vinblastine SO4 (Velban) Vincristine SO4 (Oncovin): neurotoxicity (numbness & tingling of fingers & toes), peripheral neuropathy, ptosis • Vinorelbine (Navelbine)
Mitotic Inhibitors (Vinca Alkaloids)
Immunomodulator Agents
• Stimulate immune system to
recognize CA cells & destroy them (Interleukins) • Slow down tumor cell division, causes CA cells to differentiate into non-proliferative forms (Interferons)
Immunomodulator Agents
• • • •
Aldesleukin (Proleukin, Interleukin-2) Interferon alfa-2a Interferon alfa-2b Interferon alfa-n3 (Alferon N) Levamisole (Ergamisole) • Recombinant interferon-α (Intron A, Roferon A) • Rituximab (Rituxan)
Colony-Stimulating Factors
• Induce rapid BM recovery after
chemotherapy • Granulocyte-Macrophage: Sargramostim (Leukin, Prokine) • Granulocyte: Filgrastim (Neupogen) • Erythropoetin: Epoetin alfa (Epogen)
Side Effects: Chemotherapy
– Stomatitis/Mucositis – Alopecia – A/N/V, Diarrhea – Anemia, Neutropenia, Thrombocytopenia – Infertility – Extravasation/Phlebitis
