Nursing Management of Cancer

Nursing 304

I. Cancer is unregulated growth of cells; Carcinogens are agents capable of producing

cellular alterations.

II. Complications of Cancer, Radiation and Chemotherapy

A. Hematopoietic System (Nadir)

1. Anemia

Nursing care for depressed red cells:

2. Leukopenia/ granulocytopenia/ neutropenia

Nursing care for depressed white cells:

3. Thrombocytopenia
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Nursing Care of depressed platelets:

B. GI System--cells rapidly proliferate, thus affected by chemo & radiation

Chemo will have systemic effect and radiation will affect area radiated
1. Oral Cavity
a. Stomatitis

b. Teeth

c. Salivary Glands (Xerostomia-- mouth dryness).

d. Taste Buds
1. Hypogeusia (Hypo-goo-zea)--alteration in or loss of taste
sensation due to radiation damage to tongue
2. Dysgeusia (Dis-goo-zea)--an unpleasant, usually metallic
taste
3. Aguesia (A-goo-zea)--absence of taste sensation

2. Esophagitis

NURSING CARE when upper GI affected:

1.
2.
3.
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4.
5.
6.
7.
8.
9.
10.
11.
12.

2. Abdomen--
a. Nausea and Vomiting
b. Abdominal cramping and diarrhea
c. Constipation
d. Cachexia
e. Intestinal obstructions

NURSING CARE for GI:

1.
2.
3.
4.
5.
6.
7.
C. Skin Toxicity
1. Hyperpigmentation
2. Photosensitivity--acceleration of the tanning process caused by sun
3. Erythematous skin rashes--due to dilation of blood vessels in the skin..
4. Desquamation due to radiation:
a. Dry desquamation
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b. Moist desquamation

5. Radiation recall

6. Alopecia

7. Tissue Extravasation (more later)

NURSING CARE OF SKIN PROBLEMS:

1.
2.
3.
4.
5.
6.

D. Head

E. Chest-- Esophagitis, Pneumonitis, Pulmonary fibrosis

NURSING CARE:
1.
2.
3.
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4.
5.
6.
7.

F. Pelvis (cervix, endometrium, prostate, bladder, rectum);

External beam and internal implants utilized; SE include diarrhea,
cystitis, vaginal, urethral, and rectal stenosis, sexual
dysfunction as a result of bowel, bladder, and gonad irritation.
Sexual Function--radiation to pelvis whether by external
beam or internal implant can:
a. Narrow the walls of the vagina (teach about vaginal
dilator and encourage to continue sexual
intercourse, if desired, to keep vaginal walls
open and flexible)
b. Decrease vaginal secretions (teach to use lubricants)
c. Inflame and scar vagina
d. Partial or permanent sterility in males (sperm banking)
e. Ovarian function can be eradicated totally
f. Premature menopause
g. Loss of libido
h. Fatigue and weakness
NURSING CARE for Pelvic Complications:

G. Renal Toxicity

Tumor Lysis Syndrome

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H. Neurotoxicity

I. Cardiotoxicity

J. Pain

K. Body Image

L. Superior vena cava syndrome (SVCS)

M. Spinal cord compression

N. Third spacing of fluids

O. Paraneoplastic syndrome

P. Second Malignancies

Q. Death--Hospice care
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III. Theories of the Etiology of Cancer (there are many--these are only 2)
A. Cellular Transformation and Derangement
1. Theory:

2. Agents:

B. Immune Response Failure

1. Theory:

2. Immune response can be repressed by:

IV. Basic Principles

A. Differentiation is

B. Cell cycle

C. Contact inhibition

D. Benign--not recurrent or aggressive; does not metastasize; does not cause systemic
symptoms or death unless it interferes with vital functions due to location,
i.e. brain tumor (acoustic neuroma)
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E. Malignant-- undifferentiated, immature cells; invade, erode, and spread

F. TNM Classification System (Tumor, Node, Metastasis)

Also see chapter on breast cancer
T--tumor size (describes primary tumor)
T O (no evidence of tumor)
T IS (in situ)
T 1 (< or equal to 2 cm)
T2 (> 2 but not > 5 cm)
T3 (> 5 cm)
T4 (extension to chest wall, inflammation)

N--degree of spread to nodes

N 0 (no evidence of lymph node involvement)
N 1-4 (ascending degree of node involvement)
N X (regional lymph nodes unable to be assessed clinically)

M--metastasis
M 0 (no evidence of distant metastasis)
M 1 - 4 (ascending degree of metastasis)
G. 3 Stages of cancer cell growth
1. Initiation--something causes cell’s genetic structure to change;
a. Chemical Carcinogens--Drugs, Chemicals, Diet
b. Physical Carcinogens
1. Ionizing radiation--secondary cancer from radiation to primary cancer
2. UV radiation--short rays of sun worse
3. Foreign bodies--asbestos
4. Certain DNA and RNA viruses--oncogenic--can transform cells
i.e., HIV ------>Kaposi's Sarcoma
Hep B------->Liver cancer
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2. Promotion--2 mutations are required for cancer to develop in a cell; Proliferation

of cells with first mutation leads to a population of cells where a 2nd
mutation can occur. Some promoters are specific to specific cancers--
Alcohol---->GI tract cancer
Smoking--->Lung cancer
Some carcinogens can initiate and promote cancer—ex: smoke

3. Progression--includes increased growth rate, invasiveness and metastasis. As

tumor increases in size, it develops own blood supply--tumor angiogenesis.

V. Prevention and Early Detection Very Important--Major role for nursing

A. Seven Warning Signs
a. C-- Change in bowel or bladder habits
b. A--A sore that does not heal
c. U--Unusual bleeding or discharge
d. T--Thickening or lump in breast or elsewhere
e. I--Indigestion or difficulty swallowing
f. O--Obvious change in wart or mole
g. N--Nagging cough or hoarseness

B. Education
1. Diet high in vegetables, fruits, whole grains, vitamins A and C; Limit salt-cured,
smoked, nitrite-cured foods, alcohol, fats
2. Avoid smoking, obesity, sunlight
3. Regular Physical Exam (Yearly after age 40)
4. Screening for all
a. Skin inspection for changes
b. Annual rectal exam after age 40
c. Annual stool for occult blood after age 50
d. Annual oral exam
5. Screening for women:
a. Monthly breast self-examination after age 20
b. Mammogram every 1 - 2 years between 40 and 49, then yearly
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c. Regular (every 1 -3 years) Pap Smear and Pelvic Exam

6. Screening for men
a. Testicular self-examination monthly
b. Yearly rectal exam for prostate cancer

VI. Treatment Modalities for Cancer

A. Surgery
1. Diagnostic procedures(cytology specimens, needle biopsy, incisional biopsy,
excisional biopsy)
2. Prophylactic
3. Curative--if believed can get it all
4. Palliative--done to help if benefit outweighs risk (debulking)
a. To reduce pain
b. To relieve obstructions (GI, GU, Resp, spinal cord, etc.)
c. To prevent hemorrhage
d. To remove infected and ulcerating tumors or drain abscesses
5. Reconstructive--restoration of form and function to improve quality of life
B. Radiation Therapy (RT)
1. Goal: destroy cancer cells with minimized damage to other tissues;
Destroys cancer cell's replication by damaging DNA. Cells
that divide rapidly are more radiosensitive. Also,
normal cells are more capable of repairing the DNA damage done
by radiation.

2. Types of Radiation
a. External RT--Teletherapy

b. Internal RT
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Two types of Internal RT:

1. Sealed-Source RT (Brachytherapy)

a. Intracavity

b. Interstitial

2. Unsealed-Source RT

3. Radiation Safety
a. Time

b. Distance

c. Shielding

d. Standards--safety officer, film badges (dosimetry badge)

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C. Chemotherapy-- Antineoplastic drugs.

1. Goal: destroy malignant cells with minimal damage to others; disrupts
development and reproduction of cells. Interferes with good and
bad cells, thus a major limitation. Cells that are the most active and rapidly
dividing are most sensitive (thus GI cells, hematopoietic system, and
hair follicles are affected). One dosing does not kill all the cancer cells,
thus takes repeat therapy.
2. Classification of Chemotherapeutic Agents
Classified according to pharmacological action and effect on cell cycle.
Cell cycle specific--drugs that affect the cell during certain phases.
Cell cycle nonspecific--drugs that do not require the cell to be in a
specific phase to be effective.
Combination therapy—enhances effectiveness

3. Administration Safety
a. Safe Preparation and handling

b. Safe Disposal

4. Chemotherapy Administration Routes--must know if vesicant or not

a. Intravenous
1. Peripheral Access--peripheral line or PIC (midline)
EXTRAVASATION MANAGEMENT:
1.
2.
3.
4.
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5.
6.
7.
8.

2. Central Vascular Access

a. Central venous catheter

b. Implanted Venous Port--Venous Access Device (VAD)

Example is a Port-a-Cath or Bard Implanted Port on
chest or Omaya Reservoir under scalp

3. Other less common routes-- Topical, oral, SQ, IM, or

Intrathecal (lumbar puncture to get to brain and spinal cord)
Intraarterial (into an artery that feeds a tumor)
Intrapleural (into intrapleural space of lungs)
Intraperitoneal
Intravesicle (bladder empties first, then must retain 1 - 3 hours)

4. Outpatient Chemo Administration

Nurse must teach client:

D. Bone Marrow Transplantation (BMT)--goal is cure.

3 Types of Bone Marrow Donors:
a. Autologous--self

b. Syngeneic—identical twin
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c. Allogenic-parent, sibling, or matching donor

Stem Cell transplantation

Graft-versus-Host Disease (GVHD)

STEM CELLS IN BONE MARROW

I. Myeloid Cells

A. Erythrocytes: RBCs

B. Thrombocytes: Platelets

C. Leukocytes: WBCs

1. Monocytes:
Phagocytic
Only 4-8 % of WBCs
2nd response

2. Granulocytes
a. Neutrophils
Phagocytic
50-70% of WBCs
1st response

b. Basophils
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Release histamine and heparin in allergic

response
< 2 % of WBCs

c. Eosinophils
Neutralize histamine
Defend against parasites
2-4 % of WBCs
E. Biologic Response Modifiers--Biotherapy, obtained through genetic engineering.
a. Purpose is to strengthen and manipulate the immune system.
b. Examples of Biologic Response Modifiers:
1. Monoclonal antibodies (MoAbs)--used diagnostically to identify
tumor cells, as a delivery agent of radioisotopes to tumor site, and
to deliver immunotoxins to tumor site
2. Interferons (IFN)--small proteins with cellular activity in three areas:
antiviral, immunomodulatory, and antiproliferative
3. Interleukins--produced by lymphocytes and function to
promote normal hematopoiesis. Responsible for growth of
T
cells. Side effects as well as desirable effects. (Ex: capillary leak
syndrome leading to edema.)
4. Colony stimulating factors (CSF)--do not treat cancer but help with
negative effects of treatment
a. Erythropoietin (EPO)--FDA approved; affects erythrocyte
production; Also used in clients with anemia in end
stage renal failure. Procrit or Epogen.
b. Neupogen

5. Tumor necrosis factor (TNF)