KA4 NursingCareinOncologyDEF

Nursing Care in Oncology
ERIKA HAJNOV FUKASOV
OSTRAVA 2014
This project is co-financed by the European Social Fund and the public budget of the Czech Republic.
The material was created as part of the Education for Competitiveness Operational
Programme:
Modernization Diversification Innovation
Registration number: CZ.1.07/2.2.00/28.0247
CONTENTS
Introduction .......................................................................................... 3
1 EPIDEMIOLOGY AND ETIOLOGY.4
1.1 Epidemiology of tumours .................................................... 4
1.2 Etiology of tumours..5
1.2.1 Genetic influence on the formation of tumours....5
1.2.2 External factors and tumour formation.....5
2 DIAGNOSTICS AND PATHOLOGY OF MALIGNANT
DISEASES .......................................................... .................8
2.1 Tumour pathology....9
3 ONCOLOGY TREATMENT AND ITS PLANNING...13
3.1 Division of the treatment according to its goal..13
3.2 Evaluating the treatment results.....14
3.3 Monitoring after the treatment...14
4 SURGICAL TREATMENT .............................................. 16
5 RADIOTHERAPY RADIATION TREATMENT ......... 19
5.1 Radiosensitivity and radioresistance .................................. 20
5.2 Types of ionising radiation ................................................ 20
5.3 Radiation sources...20
5.4 Fractionation regimen/spreading out the radiation dose....22
5.5 Planning and procedures of radiotherapy..22
6 SIDE EFFECTS OF RADIOTHERAPY...25
7 ANTI-TUMOUR FARMACOTHERAPY36
7.1 Cytostatics..37
7.1.2 Cytostatic dosage........38
7.1.3 Application methods..39
7.1.4 Application of chemotherapy.39
7.1.5 Maintaining documentation42
7.1.6 Dealing with waste.42
7.1.7 Toxicity of chemotherapy..42
7.2 Biological treatment...47
7.3 Anti-tumour hormone therapy........49
8 PAIN IN ONCOLOGY 54
8.1 Assessing cancer pain55
8.2 Basic principles of cancer pain treatment.57
8.3 Breakthrough pain58
8.4 Side effects of opioids..59
9 COMMUNICATION IN ONCOLOGY...62
10 NUTRITION IN ONCOLOGY65
11 PALLIATIVE CARE...68
REFERENCES..72
Symbols and their meaning
Study guide the author enters the text; specific means of communicating with
the student, of encouraging him, and of supplying additional information.
Keywords
Time needed to read the chapter
Example example taken from life, practice or social reality used to clarify or
concretize the problem.
Terms to remember
Summary summing up the subject-matter, summary of the chapter.
References books quoted in the study material or used to supplement/extend it.
Questions and exercises testing the student's understanding of the text and the
subject-matter; checking out whether he/she remembers the essential information
and is able to apply it when solving problems.
Tasks have to be carried out immediately as they help mastering the following
subject-matter.
Mail tasks when carrying them out the student follows instructions and proves
his/her ability to take initiative. The tasks are registered and assessed continuously
throughout the entire course.
Questions to think about
Section for those who want to know more contains information and exercises
expanding the basic course. The passages and tasks are not mandatory.
Tests and questions solutions, answers and results are included in the
supporting study material.
Solutions and answers to individual tasks, assignments and tests.

Introduction
Dear students,
Nowadays, oncology diseases are much more common in this country than
in the past. They are one of the most common causes of death in the Czech
Republic.
The study material lying in front of you is intended for
undergraduate students in the field of nursing and should lead to expanding
the knowledge of clinical oncology and nursing care of patients with
oncology diseases. The treatment of patients with malignant tumours takes
place mainly in cancer centres or oncology wards, but patients diagnosed
with a malignant disease can be found in any other ward, too. The study
material is written in such a way so as to provide useful information for the
everyday work of all nurses who encounter oncology patients in their
practice.
The material contains chapters focused on general information about
etiology and the possibilities of prevention, which should help with the early
recognition of a malignant tumour. Other chapters deal with the individual
alternatives of treatment. The material also contains chapters providing
information about how to cope with the complications connected with
neoplastic diseases.
A recommended reading list will always be found at the end of each
chapter.
HAVING STUDIED THE TEXT YOU WILL KNOW:

the individual specific features of nursing care in oncology,
the basic therapeutic procedures in oncology,
the risk of further complications as a result of the therapy used and
how to deal with them.
YOU WILL GET:

an overview of malignant tumours, their clinical manifestation,
diagnostics, treatment and nursing care.
You will be able to:

seek, detect and deal with the problems and complications that arise
in patients diagnosed with an oncology disease,
focus not only on the treatment and nursing care of patients
diagnosed with a malignant disease, but also on the prevention of the
development of neoplastic diseases.
Time needed to read the course material : 20 hours.
3
1 EPIDEMIOLOGY AND ETIOLOGY
In this chapter you will learn:
information about the mapping of the occurrence of malignant

diseases;
about the causes of malignant tumour formation;
about the growth, spreading, types and classification of tumours.
Keywords:
epidemiology, epidemiological indicators, etiology, tumour pathology.
Time needed to read the chapter: 60 minutes.
A neoplastic disease is the uncoordinated growth of atypical cells, which

spread into the surrounding tissue, penetrate into the lymphatic and
circulatory systems and affect distant organs.
1.1 Epidemiology of tumours
Epidemiology is a science which studies diseases in relation to the entire

population. It surveys the occurrence of diseases in the population and tries
to find the causes and connections which partake in the development of
these diseases. Epidemiology in oncology must provide a sufficiently
accurate evaluation of the existing characteristics of the sickness and death
rate due to tumours, and prepare prognoses for both the near and distant
future. A mandatory reporting of malignant tumours was introduced in the
Czech Republic in 1951. Information about newly diagnosed malignant
tumours is reported to the National Cancer Registry (NOR). Information
about patients diagnosed with a malignant tumour is stored in the Registry
(NOR) even in the case of complete recovery or death.
Epidemiological indicators:
- Incidence of a neoplastic disease the number of newly diagnosed
malignant tumours during one year. The number is usually given per
100,000 people in the population.
- Prevalence of a neoplastic disease the estimated number of
patients with a certain malignant tumour up to a particular date in a
given year.
This indicator rises with the growth of incidence and longer survival,
and falls with the growth of mortality.
- Mortality due to malignant diseases gives the number of the
deceased, most often per 100,000 people a year.
4
1.2 Etiology (the causes of formation) of tumours
The causes of the development of malignant diseases are complex. They are
partly inherited from parents, but a part of them also has roots in the world
around us. The identification of the main causes of tumours is absolutely
vital for their primary prevention. This means lowering the risk of the very
development of a neoplastic disease by influencing its causes the risk
factors.
The causes of malignant diseases can be:
- genetic;
- internal factors;
- external factors.
1.2.1 Genetic influence on the formation of tumours
The frequent occurrence of certain tumours in one family is called familial

occurrence, and their formation at a young age is grounds for genetic
testing. Although the hereditary forms of tumours represent only a small
part of all tumours, it is necessary to know the mechanism of their
formation, the risks associated with them and the possible principles of
intervention in the case of a diagnostically hereditary predisposition.
Genetically conditioned tumours have one thing in common they affect
people below the average age where nonfamilial tumours normally occur.
If suspicion of a genetically conditioned neoplastic disease arises in
the family medical history, it is important to see a specialist in genetics, who
will examine certain genes and their mutations, which are known to induce
malignant diseases in the bearer. In the case of a positive result proving
that the person with the tumour carries a gene which increases the
probability of tumour formation, it is possible to invite healthy family
members (siblings, children) for genetic testing. The aim is to prove whether
they, too, do not carry this risk gene. If they do, they will be offered special
care in the form of regular preventive check-ups and, if necessary, even
some measures aimed to prevent the formation of a tumour, or to diagnose it
at an early stage.
1.2.2 External factors and tumour formation
The development of an oncology disease is caused partly by external and

partly by internal factors. The degree by which external factors contribute to
the development of malignant diseases is not insignificant and it is
necessary to take these factors seriously and try to minimise them in
everyday life.
Factors partaking in tumour mortality:
Tobacco and smoking causes 90 % of deaths due to lung cancer in men
and 80 % in women. Smokers display a higher occurrence of bladder,
kidney and pancreatic cancer. Passive smokers are also at risk.
5
Physical activity reduces the risk of cancer development. Reasonable
physical activity stimulates the activity of the immune system.
Nutritional factors substances which pass from food into the circulatory
system in the intestine and which form a long term protective, neutral or
anti-tumour influence. What we have eaten during our lives and what we
eat significantly influences our health.
Obesity increases the occurrence of some types of tumours (colon cancer,
breast cancer, endometrial cancer).
Alcohol is one of the significant etiological factors of neoplastic diseases.
Infections viruses can induce malignant diseases.
- HPV human papillomavirus. Viruses are transmitted by sexual contact or
some other type of contact with the infected body parts. Infection with some
virus strains is connected with the development of cervical cancer.
- Hepatitis B virus there is a connection between liver cancer and hepatitis
B.
- Helicobacter pylori this infection is epidemiologically connected with
stomach cancer.
- Other viruses their influence in the development of malignant diseases is
not significant in Europe.
- Ionising and UV radiation is proved to have an ability to induce
malignant diseases. The number of solid tumours which are formed in the
radiated area increases with the length of the monitored period. UV
radiation increases the probability of skin tumours, melanoma or the
development of skin cancer. Tanning salons are also considered risky as far
as the formation of skin tumours is concerned. There is a period of many
years between the increased radiation of the skin and the formation of a skin
tumour.
- Chemical carcinogenesis many chemical substances have the potential to
induce malignant diseases.
Tumour prevention:
- primary is focused on preventing the disease from developing. Its goal is
to prevent health problems, to eliminate risk factors, etc. It is the
responsibility of every person, but the state also partakes in primary
prevention (by improving the environment) in a significant way;
- secondary an early detection of the disease and its early treatment;
- tertiary prevention refers to follow-up and recovery care, to activities
leading to health recovery, etc.
Role of the nurse in prevention:

- providing information about the prevention and early
symptoms of neoplastic diseases;
- providing and passing on information about the prevention of
malignant diseases;
- passing on information about specialised outpatient surgeries
and outpatient surgeries that provide consulting in the
required areas;
- partaking in prevention programmes;
- educating nurses in the prevention of malignant diseases.
6
Summary
In this chapter you have become familiar with the term neoplastic disease,
with epidemiological indicators related to the occurrence of cancer and with
the possible causes of tumour formation. Subsequently you have learned
about the role of the nurse in the prevention of tumours and how he/she can
influence their formation.
Questions and tasks:

1. What are the genetic factors of the development of a neoplastic disease?
2. Give an example of the primary prevention of cancer.
3. Which viruses can induce a neoplastic disease?
Further reading related to the chapter:

COLLECTIVE WORK. Onkologick rizika. 1st ed. Brno: Masarykv
onkologick stav, 2001. 96 pp. ISBN 80-238-7620-1.
HRUB, M., FORETOV, L., VORLKOV, H. Role sestry v prevenci
a vasn diagnostice ndorovch onemocnn. 1st ed. Brno: GAD studio,
2001. 77 pp. ISBN 80-238-7618.
VORLEK, J., ABRAHMOV, H., VORLKOV, H. et al. Klinick
onkologie pro sestry. 1st ed. Praha: Grada Publishing a. s., 2006. 328 pp.
ISBN 80-247-1716.6.
7
2 DIAGNOSTICS AND PATHOLOGY OF
MALIGNANT DISEASES
about the importance of accurate diagnostics in oncology;

about the basic diagnostic methods in oncology;
information about the examination of bioptic material.
Keywords:
diagnostic methods, diagnostics of tumours, nursing diagnoses.
Time needed to read the chapter: 60 min.
Diagnostic methods help in:

- making a diagnosis;
- determining the stage of the disease;
- evaluating the success of the treatment;
- the periodic monitoring of the patient and detecting a
possible relapse of the disease;
- planning therapy;
- detecting complications of the disease or its treatment.
Case history
Case history is extremely significant for the early detection of a tumour.
Some warning signs may be the early symptoms of a malignant disease:
- irregular discharge or bleeding from body cavities;
- swelling, hardening of the breast, in-drawing of the skin on the breast,
festering, deformation of the nipple, nipple discharge;
- non-healing wounds on the mucous membranes and skin, swelling or
hardening of the skin;
- changes of birth marks and warts;
- persistent swallowing and gastrointestinal disorders;
- lack of appetite and weight loss;
- persistent tickly cough and hoarseness, expectoration of blood.
Complete physical examination

When detecting the early stages of malignant tumours, the doctor uses the
diagnostic methods of internal medicine to examine the patient. For more
information see Oetovatelsk pe v internch oborech (VRUBLOV, Y.,
2011).
Laboratory tests
Laboratory tests are important for determining the extent of the disease and
for assessing the overall condition of the patient. When taking a sample, the
nurse must use the appropriate sampling technique to obtain the required
8
amount of tissue or fluid sample for the examination. The nurse explains the
reason, importance and individual steps of the procedure to the patient and
subsequently performs the sampling itself, respecting the patients intimacy.
Microscopic examination of biological material

CYTOLOGY
- cytology is an examination of a cell suspension (exudate,
urine, ), a smear test (cervicovaginal smears), etc. It is a
quick and cheap method, suitable especially for screening
and for precancerous conditions in oncology.
HISTOLOGY
= the evaluation of tissues, organs or organ systems. It is divided according
to the purpose and size of the samples:
- diagnostic puncture, excision, micro-incision (sizes ranging
from 1 mm to 1 cm);
- the final surgical specimens are parts of the tissue or organs,
several centimetres or even decimetres in size. They are
dissected and then examined by a pathologist.
Endoscopic examination
= the direct examination of the hollow systems of the body with the help of
special endoscopic techniques:
- laryngoscopy;
- bronchoscopy;
- oesophagoscopy;
- gastroduodenoscopy;
- ERCP;
- proctoscopy, colonoscopy;
- laparoscopy;
- cystoscopy.
Screening diagnostic tools
can prove the presence and position of the tumour, its invasion of the
surrounding tissue, its affection of the lymphatic system, etc.:
- X-ray;
- CT;
- MR;
- mammography;
- radionuclide diagnostics;
- positron emission tomography PET;
- PET CT.
2.1 Tumour pathology
Benign limited growth, stays in the place of origin, does not undergo
metastasis, grows slowly, although it can compress the surrounding tissue.
Malignant unlimited growth, infiltrates the surrounding tissue, undergoes
metastasis.
Tumour growth:
9
- expansive mechanically compresses the surrounding tissue
and eventually causes its atrophy;
- infiltrative the tumour cells grow into the cells of the
surrounding tissue without destroying them directly;
- invasive the tumour cells grow into the cells of the
surrounding tissue, damaging and destroying them.
Spread of tumours
- continued local growth;
- metastasis through the lymphatic system;
- metastasis through the bloodstream.
Types of tumours
- benign and malignant mesenchymal tumours (sarcomas);
- benign (papillomas) and malignant (carcinomas) epithelial
tumours;
- neuroectodermal tumours of the CNS and peripheral nervous
system benign (pigmented nevus) and malignant
(melanoma);
- leukaemia;
- lymphomas;
- mixed tumours, germinal tumours and teratoma;
- choriocarcinoma forms in the fetal part of the placenta;
- mesothelioma in the pleural, pericardial and peritoneal
cavity.
Classification of malignant tumours

Tumours are classified according to their histological structure, biological
properties and anatomical location. There is an established international
staging system, which evaluates the extent of the malignant disease and
whose aim is to:
- help to plan the treatment;
- allow to make a prognosis of the disease;
- help to evaluate the results of the treatment;
- make the exchange of information about the results and
methods of treatment among the wards easier;
- help in the research of malignant tumours.
The TNM staging system determines the anatomical extent of the neoplastic
disease.
T the extent of the primary tumour;
N the condition of the regional lymph nodes;
M the presence or absence of metastases.
The extent of the tumour process in the individual categories of the
TNM system is determined by putting a number after the letter. The higher
the number after the letter, the greater the extent of the tumour.
T1 to T4, TX if it is not possible to determine a category;
N0 to N4, NX;
M0, MI, MX.
For each location of the tumour there are two stages:
10
- the pretreatment TNM stage, which is determined on the
basis of clinical, X-ray or endoscopic examination even
before the decision about the final treatment is made;
- the surgical histopathological stage pTNM, which stems
from the clinical stage and is supplemented based on the
results from the examination of the surgical specimen.
Nursing diagnostics
Making the right medical diagnosis is an important step in planning and
carrying out the treatment of the patient in all medical fields. For nursing
care it is equally important to make nursing diagnoses of the patients, on the
basis of which the nurse seeks solutions to satisfy their needs. Here, using
the current Differential diagnostics (MAREKOV, J., JAROOV, D.,
2005) would be a good step. It comprises domains which are divided into 13
areas:
1. Healthcare support
2. Nutrition
3. Excretion
4. Activity rest
5. Perception cognition
6. Self-perception
7. Relationships
8. Sexuality
9. Stress management resistance to stress
10. Life principles
11. Safety protection
12. Comfort
13. Growth/development
Summary
In this chapter you have gained some basic information about the diagnostic
methods and procedures in diagnosing malignant diseases. You have been
given a brief overview of the types of tumours and the most basic
information about the classification of tumours. For nursing care not only in
oncology, the medical diagnosis of a malignant disease is not enough;
identifying the patients needs is also important because it enables the
nurses to make a nursing diagnosis and subsequently to perform
interventions which lead to the satisfaction of these needs.

1. What is the difference between a malignant and benign tumour?
2. Explain the term histological examination.
Mail task No. 2

Describe what the PET examination means, into which group of diagnostic
methods it belongs and on what principle it works.
11
COLLECTIVE WORK. Diagnostika a lba vybranch malignch
ndorovch onemocnn. Brno: Masarykv onkologick stav, 2005. 204
pp. ISBN 80-86793-04-4.
MAREKOV, J. Oetovatelsk diagnzy v NANDA domnch. Praha:
Grada, 2006. 264 pp. 80-247-1399-3.
AFRNKOV, A., NEJEDL, M. Intern oetovatelstv. Praha: Grada,
1st ed., 2006. 211 pp. 80-247-1777-8.
VRUBLOV, Y. Oetovatelsk pe v internch oborech. Ostrava:
University of Ostrava, 2011. 69 pp.
12
3 ONCOLOGY TREATMENT AND ITS PLANNING
about the principles and planning of the treatment;

about the division of the treatment according to its goal;
about evaluating the results of the treatment.
Keywords:
oncology therapy, prediction of the treatment response, remission, relapse.

The goal of anti-tumour treatment is the death of tumour cells. The
treatment of malignant diseases is much more demanding for the patient,
and as such differs from the treatment of other diseases. The treatment is
aimed against the patients own cells, which have transformed into tumour
cells, and so while they are being destroyed, some physiological cells and
tissues are being destroyed or damaged as well. Due to the treatment the
quality of the patients life is temporarily, or sometimes even permanently,
decreased. It is advisable to bear this fact in mind while planning the
treatment.
To make the right choice of treatment it is important to make an
accurate diagnosis, which contains information about:
- the type of tumour and tissue from which the tumour was
formed;
- the degree of malignancy;
- the extent to which the patients body is affected.
To draw up a treatment plan it is necessary to have accurate
information about the neoplastic disease. Based on this information we can
predict the treatment response the prediction of the treatment response (a
prognostic factor predicting the survival of the patient).
Oncology therapy has four pillars:
- surgical therapy;
- radiotherapy;
- medicamentous therapy;
- supportive treatment.
It is recommended that specialists from the fields mentioned above
partake in planning the anti-tumour treatment of the patient. In the treatment
of most tumours all accessible treatment possibilities are gradually used;
therefore we speak about multidisciplinary therapy.
3.1 Division of the treatment according to its goal
13
Curative treatment sets the highest aim completely ridding the body of
the disease and curing the patient. It mostly uses a combination of treatment
methods. The price for curing the disease is a temporary decrease of the
quality of the patients life.
We choose non-curative treatment in those cases where we are not able to
cure the disease with any accessible means (e.g. due to the nature or degree
of advancement of the tumour and disease, its natural resistance to the
treatment, or other serious illnesses which hinder applying curative therapy).
Adjuvant this treatment is applied with a curative aim when, after
surgically removing the tumour, we expect the presence of micrometastases,
which are not discernible by the usual screening methods.
Neoadjuvant preoperative treatment is applied with the aim of
shrinking the primary tumour and destroying micrometastases.
Supporting (symptomatic) treatment strives for the best possible quality
of the patients lives and the lives of their loved ones throughout the entire
oncology treatment. It is focused on reducing the complications induced
directly by the tumour (dyspnoea, pain) and on anti-tumour treatment
(mucositis after radiotherapy or chemotherapy, infectious complications).
Palliative treatment comprehensive supportive treatment of patients
with an advanced disease in the final stages of their lives and of their loved
ones.
3.2 Evaluating the treatment results
Recovery an ordinary course of further life until its natural end, regardless
of the disease the patient has undergone.
Symptom-free survival marks the percentage of patients who, after a
certain time (3, 5, 10 years), live without any signs of the disease.
Overall survival marks the percentage of patients who are still alive after a
certain time (after 3, 5 or 10 years) after the beginning of the treatment,
whether with some signs of the treatment or without.
Remission a complete disappearance of the symptoms of the disease
during the clinical examination and routine laboratory testing.
Relapse a progression a relapse, progression or recurrence are terms used
for symptoms newly detected in a person who was in remission.
3.3 Monitoring after the treatment
The patient is monitored not only throughout the oncology treatment, but
also after it is finished.
The goal of monitoring the patient after the treatment of the
malignant disease has ended is to detect a recurrence of the original tumour
or other tumours in time, and therefore not to miss the moment when a
renewal of the treatment is advisable. The probability of the formation of a
new tumour is higher in patients who have previously undergone oncology
treatment. It is therefore necessary to schedule the follow-up examinations
for each patient individually. The intervals between the examinations and
the diagnostic methods used for monitoring depend on many factors. These
14
are mainly the type of tumour, the method of treatment, the age of the
patient and any other diseases they might have.
Summary
In this chapter you have found information about the basic division of anti-
tumour treatment. Besides the four pillars, oncology treatment is also
divided according to the intention and goal with which the patient undergoes
it. When the treatment is finished, it is important to monitor the patient
regularly, in certain time intervals, in order to detect any symptoms marking
possible complications, a return of the disease or the formation of a new
tumour.

1. What is the difference between a relapse and a recurrence?
2. What does adjuvant treatment mean?
3. What are the time intervals between the examinations following the
treatment?

ADAM, Z., VORLEK, J., KOPTKOV, J. Obecn onkologie a
podprn lba. 1st ed. Praha: Grada Publishing, a. s. 2003. 787 pp. ISBN
80-247-0677-6.
pp. ISBN 80-86793-04-4.
15
4 SURGICAL TREATMENT
about the division and description of procedures in surgical

oncology;
about the role of the nurse in surgical oncology.
Keywords:
surgical methods.
Surgical treatment is used:

- in diagnostics;
- in prophylaxis;
- in curative and palliative treatment;
- when dealing with complications.
Surgical methods are the keystone of oncology therapy in the early stages of
tumours. When dealing with tumours sensitive to radiotherapy or
cytostatics, the result also depends on the suitable timing of the surgery.
Better results are often achieved if the surgery is performed after
preoperative radiotherapy or chemotherapy, which can result in the tumour
getting smaller.
Diagnostic surgery is in many cases irreplaceable when making an
accurate diagnosis; it enables us to obtain material for a histological
examination. It enables us not only to obtain bioptic material, but it can also
make the specification of the stage of advancement of the disease (staging)
easier.
Prophylactic surgery treatment which is used in those cases
where detecting precancerous conditions is successful, whether it is
achieved clinically or through special laboratory testing. Some examples
include prophylactic colectomy in connection with familial adenomatous
polyposis or the risk of developing colorectal cancer.
Radical (curative) surgery removing the tumour and its border
formed by the surrounding tissue. Often the regional lymph nodes are
removed as well (e.g. lymphadenectomy). It is possible only with localised
tumours or with the so-called in situ tumours.
Palliative surgery prevents the development of complications
which can be a threat to the patients life bleeding, intestinal obstruction, a
compression of the surrounding organs. It also serves to shrink or slow the
growth of the primary tumour or its metastases. Some surgeries are often
indicated with the aim of maintaining or even improving the quality of the
life of patients with a developed neoplastic disease.
Reconstructive surgery is the correction of consequences caused
by previous curative surgery. Emphasis is placed on aesthetic effect.
16
Emergency oncosurgery and dealing with complications brought
on by the treatment during anti-tumour therapy patients may develop
complications as side effects of this treatment, which call for a solution in
the form of emergency surgery. On the other hand, radiation-induced
complications, such as post-treatment strictures and stenoses, often result in
surgery as well.
The success rate of surgical therapy in oncology depends not only on
the surgery itself, but also on optimum inter-field collaboration and
preoperative and postoperative nursing care.
Role of the nurse in surgical oncology
Preoperative care:
- to engage the patient in decision making;
- to provide the patient with the necessary information;
- to find out if the patient comprehends and understands the provided
information;
- to determine cultural differences in the patients understanding and
interpretation.
Perioperative care/before the transfer to the operating theatre:

- identification of the patient;
- physical and mental care;
- preparation of the skin, operating field, intestine;
- fasting 46 hours before the surgery;
- personal hygiene including make-up and nail polish removal;
- removing and storing the patients personal belongings (dentures,
contact lenses, prosthetic devices);
- accompaniment and leaving the patient with the nurse in the surgery
foyer.
Postoperative care:
Complications following the surgery may endanger the patients recovery
and they also entail substantial expenses. Because the immune system of
oncology patients is weakened, there is a higher probability of infectious
complications. Also, a surgical wound heals more slowly. The nurse checks
the vital functions, body temperature and discharge from the surgical wound
and drainage tubes in regular intervals, evaluates the postoperative pain,
monitors changes in the patients mobility, changes in hyperaemia or limb
swelling. She collaborates with the doctor and reacts to the abovementioned
changes in the patients condition.
Complications of surgery:
- early within 24 hours;
- intermediate up to 3 weeks postoperative;
- late anytime later, even after several years.
Complications:
- local on the surgical site;
- general affect other systems.
17
Complications following the surgery may endanger the patients
recovery and they also entail substantial expenses. The most common
postoperative complications include:
- nausea and vomiting, restlessness, confusion;
- surgical site infection;
- deep vein thrombosis, pulmonary embolism;
- pneumonia;
- urinary tract infection;
- paralytic ileus;
- decubiti.
The prevention of the development of complications within the
nurses sphere of competence:
- ensuring cooperation through the right education;
- correctly positioning the patient (in collaboration with a physiotherapist),
guiding the patient through breathing exercises, early mobilisation of
patients after the surgery, exercising the lower limbs, bandaging the lower
limbs, postoperative administration of low molecular weight heparins,
monitoring the peripheral nervous system.
Summary
Surgical methods are used in diagnostics, prophylaxis, in both curative and
palliative treatment, and also when dealing with a whole range of neoplastic
disease complications. They are one of the fundamental pillars of the current
care of patients diagnosed with an oncology disease.
Based on the information about the patient, the nurse actively seeks the
patients needs, makes current nursing diagnoses and plans nursing goals
and interventions in the preoperative and perioperative period. Subsequently
he/she changes the plan during the surgery itself and, based on changes of
the patients condition, sets current nursing goals and interventions.

1. Give an example of palliative surgery performed to treat a colonic
disease.
2. How does the nurse prevent the development of postoperative
complications?
Mail task No. 4

Draw up a specific case history of a patient with colostomy, including
nursing diagnoses.

onkologie pro sestry. 2., revised edition with supplement. Praha: Grada
publishing, a. s., 2012. 448 pp. ISBN 978-80-247-3742-3.
18
5 RADIOTHERAPY RADIATION TREATMENT
about the division of radiotherapy according to the radiation source;

about the division of radiotherapy according to the position of the
radiation source;
about the algorithm of radiotherapy and brachytherapy.
Keywords:
radiosensitivity, radioresistance, teleradiotherapy, brachytherapy.

In the case of many neoplastic diseases radiotherapy is a part of the standard

treatment programme and is often combined with surgical treatment or
chemotherapy.
Together with surgical treatment and chemotherapy it is one of the
basic methods of malignant tumour treatment. It is treatment with ionising
radiation based on the fact that most tumour cells are more sensitive to
radiation than normal cells in healthy tissue. The goal of radiotherapy is to
transfer a sufficient radiation dose into an exactly defined target volume
with maximum accuracy in a certain time and with minimal burden for the
healthy tissue (to apply the right dose into the right place).
Radiotherapy according to the position of the radiation source:

- external radiotherapy teletherapy;
- internal radiation brachytherapy.
Radiotherapy according to the goal/intention of the treatment:

1. curative its goal is to damage the tumour deposit as much as
possible or to destroy it completely and to cure the patient. It is
radical and uses high radiation doses according to the sensitivity of
the tumour in the healthy tissue. The treatment usually takes 68
weeks.
2. adjuvant supporting radiation, usually postoperative. The goal is
to destroy potential anticipated populations which cannot be detected
objectively, e.g. postoperative radiation following radical surgery,
involving the radiation of scars and possibly the lymph node region.
Adjuvant radiotherapy decreases the amount of relapses and
improves the total survival time. The applied radiation doses are
usually lower than in curative treatment.
3. neoadjuvant the goal is to shrink the tumour before the main
treatment is carried out (e.g. preoperative radiotherapy). In many
cases it is therefore possible to achieve operability in initially
inoperable findings. Often it is applied together with chemotherapy.
19
4. palliative its main goal is to eliminate or at least reduce the
patients complications (especially pain, compression or bleeding).
Prolonging the patients survival is only a secondary goal. The doses
are chosen according to the type of damage, radiation intent,
condition of the patient and other factors.
5. nonneoplastic its main goal is to bring relief from the
complications caused by a nonneoplastic disease. It utilises
especially the antiphlogistic and analgetic effect of low radiation
doses. It is used to treat degenerative diseases of the movement
apparatus (heel spur, tennis elbow).
The effect of radiation manifests itself on the molecular level by affecting

the DNA (genes), and on the cellular level, where it can be seen in the
changes of growth activity. The biological effect of radiation is influenced
by a number of factors. The basic factor is the absorbed dose. The unit of
the absorbed dose is 1 Gy (1 gray). Another important quantity is the
absorbed dose rate a dose applied in a certain time, as well as LET (linear
energy transfer) and RBE (relative biological effectiveness), which allows
us to compare the biological effects of various kinds of radiation.
5.1 Radiosensitivity and radioresistance
Both malignant tumours and healthy tissue have different sensitivity to

ionising radiation. We can roughly estimate the sensitivity of a tumour to
radiation through a number of indicators, such as the histological type, the
tissue from which the tumour originates, the organ location, the degree of
affection, the irradiated volume, etc. Radiotherapy takes into account the
difference between the radiosensitivity of normal tissue and cancerous
tissue. The goal of anti-tumour radiotherapy is to affect the tumour as much
as possible and to damage the surrounding tissue as little as possible. In
radiotherapy this relationship is defined by a therapeutic ratio. The bigger it
is, the more intensive the effect of the radiation on the tumour is and the less
damaged the healthy tissue is.
5.2 Types of ionising radiation
In clinical practice two types of ionising radiation are used

electromagnetic (photonic) and corpuscular (particulate). Electromagnetic
radiation is divided according to its origin into x-radiation (X-ray, braking)
and -radiation (gamma), which comes from the nuclei of radioactive atoms
and is formed during their disintegration.
5.3 Radiation sources
o Teleradiotherapy
In this method the radiation source is placed away from the patient so that
they are radiated from a distance.
20
External radiotherapy is the most widely used method of radiation.
The conventional radiation source is X-ray radiation, generated in X-ray
machines. X-ray radiotherapeutical machines were used as the main devices
until the 1960s. Due to a number of disadvantages they are now used only in
palliation (e.g. the radiation of bone metastases).
At present, external radiation is done by linear accelerators, which
generate accelerated electrons used for the radiation. Often a heavy metal
target is put in the way of the electrons, thus creating breaking x-radiation,
which is then used.
o Brachytherapy
Brachytherapy is radiation from a short distance. In brachytherapy the
radioactive radiation source is placed directly onto the tumour site so that it
is exposed to a high concentration of the radiation dose. It is used in those
cases where the deposit is accessible and its volume is relatively small.
Brachytherapy can be used either as the only means of treatment to achieve
the radical dose, or in combination with external radiation as a boost to
supplement the dose administered onto the tumour site. It can also be used
in combination with surgery.
Division according to the position of the radionuclide emitter:
1. Intracavitary the applicator is placed into the body cavity from
which the tumour originates (e.g. gynaecological tumours).
2. Intraluminar the conductors and the radiation source are inserted
into the lumen of a tubular organ (e.g. lung, gullet, biliary tract
tumours).
3. Interstitial the radiation source is inserted directly into the tumour
site (e.g. into the tumour bed following partial mastectomy).
4. Surface special applicators in the form of moulages are placed on
the surface of the affected skin or mucous membrane.
Thanks to new high-activity radiation sources and new devices it is possible
to administer a sufficient radiation dose very quickly with brachytherapy. It
is also possible to perform the treatment at an outpatient surgery so that the
patient may go home after the radiation. In the case of more complicated
applications, the treatment is performed after administering general
anaesthesia, which requires hospitalisation.
o CyberKnife
CyberKnife is based on the technology of a linear accelerator, where the
weight is very small. It is mounted on a robotic arm which can move in six
axes. The screening system monitors the patient during the radiation and if
there is any change of position, the system stops the radiation and, based on
the images, the robotic arm aims the linear accelerator directly towards the
tumour deposit again.
In stereotactic radiosurgery the treatment is usually performed in a single
session and thus copies surgery. Higher doses in stereotactic radiosurgery
are usually divided into several fractions.
o Systemic application of radioisotopes

The treatment is based on the administration of a radionuclide in the form of
a soluble compound (salt, an organic compound), which behaves like a
21
nonradioactive isotope of the same element. The treatment is used especially
for thyroid cancer, given that it accumulates iodine. In this case radioactive
iodine is used.
5.4 Fractionation regimen/spreading out the radiation dose:
- conventional fractionation radiating five days a week (10

Gy/week) until the total dose of 6070 Gy is reached;
- hypofractionation means applying higher individual doses in
longer intervals, while the total dose is reduced. It is often used in
palliative radiation;
- hyperfractionation means applying smaller individual radiation
doses several times a day. This method has a protective effect on
healthy tissue, but it brings with it bigger acute changes. The
minimal required interval between the fractions is 6 hours (e.g. when
radiating the head and neck).
5.5 Planning and procedures of radiotherapy
o Procedure/algorithm of radiotherapy
When planning radiation treatment, the main task is to ensure an even
distribution of the maximum dose into a predetermined volume. The process
of planning begins with an accurate localisation of the tumour deposit
planning CT. The patients CT is planning, not diagnostic, which means that
the result is a series of sections of the area in question, based on the doctors
requirements. The preparation of the patient takes place on a simulator,
which enables the doctor to localise, simulate and verify the irradiated
volumes. Simulators are X-ray based diagnostic devices which can
simulate the conditions of the radiation itself. Verification images are made
to check the correct position of the patient.
Patient fixation is an important condition of performing the radiation
treatment correctly. The position during radiation must always be stable and
easy to repeat. Any movement disrupts the planned distribution of the dose.
The fixation and position during the simulation must be the same as during
the radiation itself (including fixation aids). If a fixation mask is used, it is
made in a special room prior to the CT examination.
During the radiation itself, the patient takes exactly the same position
as during the CT examination. Before the radiation takes place, the patients
position is verified using screening methods.
o Algorithm of brachytherapy
Planning brachytherapy has its specific features depending on the technique
used. The procedure itself takes place in sterile conditions in a
brachytherapy treatment room. The patient takes an appropriate position
according to the character of the application performed on them (e.g. the
gynaecological position for the treatment of female genital organ tumours).
Before the radiation begins, the patient is informed about the length of the
22
radiation. The procedure itself takes place after administering local or
general anaesthesia.
1. The doctor inserts the tubular applicators and determines their

position based on the location of the tumours. The insertion is done
without a radioactive source.
2. X-ray pictures are taken to determine the spatial placement of the
applicators, the exact calculation of the dose and irradiated volume.
The pictures are taken directly in the brachytherapy treatment room.
3. In the process of planning, data are transferred from the pictures into
a planning system.
4. The planning system displays the given parameters in space. A
radiation physicist then uses it to calculate the distribution of the
dose and the irradiation time. The doctor confirms that the
calculation is correct.
5. The transfer of data into a computer-controlled afterloading device.
The applicators are connected to the afterloading device by means of
transfer tubes. The radiation machine automatically connects the
applicators to a radioactive radiation source. After a set period of
time, the radiation source automatically slides back into a safety box.
The clinical condition of the patient and the radiation process is monitored
by the nurse on screens in the control room of the machine. VF monitoring
is in progress at this time. The nurse also has the possibility of audio
communication with the patient. The radiation itself takes several minutes,
during which the patient is lying alone and motionless in the treatment
room, in the radiation position. If necessary, the radiation can be
discontinued and the nurse or doctor can be at the patients side very
quickly.
The radiation takes place either in one session, or in weekly intervals
(34), depending on the given dose and intention of the radiation.
The entire radiation process is documented in a radiation record.
After the radiation is finished, the applicators are removed, and in the case
of general anaesthesia, the patient is transferred to the inpatient ward for
observation. In the case of local anaesthesia, the overall condition of the
patient following the procedure is evaluated by the doctor, after which the
patient is allowed to go home.
Summary
Radiotherapy is a treatment method based on the effect of ionising radiation
on living tissue. Two types of ionising radiation are used in clinical practice.
According to the position of the radiation source, ionising radiation can be
divided into external/teleradiotherapy and brachytherapy/radiation from a
short distance. In this chapter you have gained some basic information about
the planning and procedures in radiotherapy and about treatment with
radiation. This will be necessary when we pick up on the topic in the
following chapter.
23
1. What is the radiation regime in which the patient is radiated several times
a day called?
2. What does brachytherapy mean?
3. Why is patient fixation during radiation important?

ABRAHMOV, Jitka. Vybran otzky z onkologie XI. Praha: Galn, 2007,
194 pp. ISBN 978-80-7262-527-7.
McKAYOV, J., HIRANOOV, N. Jak pet chemoterapii a ozaovn:
prvodce onkologickho pacienta po vlastnm osudu. 1st ed. Praha: Triton
s.r.o., 2005. 206 pp. ISBN 80-7254-542-6.
24
6 SIDE EFFECTS OF RADIOTHERAPY
about the side effects of radiotherapy;

about the general guidelines of nursing care of radiated patients;
about the specific features of nursing care of patients displaying side
effects of radiotherapy.
Keywords:
side effects, mucous membrane damage, skin reactions, desquamation,

postradiation reactions.

Early/acute and late/chronic
Despite optimalisation and the latest radiation techniques, a part of the

radiation also affects healthy tissue. Depending on the extent, the side
effects of radiotherapy are divided into general/systemic and local.
General symptoms appear when radiating bigger volumes. The most

common ones are fatigue, drowsiness, lack of appetite, nausea and mental
changes. Other systemic side effects include hematologic toxicity damage
of blood cell formation, which manifests itself when big volumes of bone
marrow are radiated. Most often it takes the form of leukopenia,
thrombocytopenia and anaemia. In literature these symptoms are referred to
as the postradiation syndrome. Special treatment is not necessary; often it
is enough to alter the daily programme and get enough rest.
Local changes are limited to the radiated area.

In clinical practice, side effects are evaluated according to their
development as early acute, late chronic and very late.
Acute side effects can already be observed during radiotherapy and up to

three months after it is finished. The intensity of acute reactions is related to
the total dose and the length of radiotherapy. These side effects are
reversible. The most common ones are radiodermatitis, alopecia, mucositis,
colitis, cystitis, etc.
Chronic changes occur only after several months or years if the sweat or
ceruminous glands have been destroyed. The side effects can manifest
themselves through atrophy, changes in skin pigmentation, subcutaneous
fibrosis or the development of lymphedema. During radiation the patient can
also experience hair loss and alopecia. Whether the loss is temporary or
permanent depends on individual sensitivity and the applied dose.
25
o Skin reactions
Acute postradiation changes most often affect the skin; the extent of the
damage depends on:
- the total radiation dose;
- the dose administered during each fraction;
- the radiated area;
- the fairness and sensitivity of the patients skin.
There is a higher risk of skin reactions in patients who undergo
radiotherapy simultaneously with chemotherapy or biological treatment.
Other individual factors affecting the individual sensitivity to radiation
include the presence of comorbidities, age and the individual sensitivity of
the patient.
Stages of postradiation skin reactions:

1. erythema the most common clinical manifestation in the first three
weeks. The skin is pink or even red; there can also be oedema. It
resembles a sunburn;
2. dry desquamation peeling, often in connection with itching. It
occurs 3 to 6 weeks after the radiation treatment begins. Due to the
damage of ceruminous glands, the skin is dry and peels off. This
condition is not permanent, it is reversible;
3. wet desquamation blister formation, epithelial layer peeling. This
condition is also reversible. It is possible to discontinue the radiation
for some time on the doctors orders;
4. ulceration, necrosis irreversible skin damage due to radiation. It
should not occur in modern radiotherapy. It is an indication for
surgical intervention.
General guidelines of radiotherapy

During radiotherapy the skin is sensitive and can be damaged easily. To
prevent distinctive changes from taking place or to reduce this skin reaction,
it is advisable to follow these guidelines:
- maintain hygiene habits!!!,

- after the start of radiation, wash and shower your skin only with
warm water and do not use any degreasing agents (soaps, gels,
deodorants or other beauty products);
- for shaving use a shaver, ideally an electric one; do not use
aftershave;
- wear loose, not tight-fitting clothes, ideally made from cotton;
during neck radiation be careful with shirt and T-shirt collars they
can easily cause mechanical irritation and subsequent damage to the
skin in the radiated area;
- keep your skin dry;
- do not irritate or warm your skin mechanically or chemically;
- do not expose the radiated skin to the sun.
26
By following these guidelines the intensity of skin reactions to radiation is
reduced, but they cannot be prevented completely. The skin becomes drier,
reddens and sometimes its surface can be broken. These acute changes of
the skin eventually disappear after the treatment is finished, although in
some cases a long term thickening of the skin in the radiated areas cannot be
ruled out.
Treatment of skin changes:

- as prevention, it is possible to start treating the radiated area as
needed with Flamigel as early as the first radiation session, up to five
times a day;
- in the case of skin reddening, it is advisable to apply cooling gel
strips, lubricate the skin with Calcium Pantothenicum ung,
Panthenol gel, Olvizone or Water Jel R1+R2 after the radiation;
- in the case of dry desquamation peeling it is advisable to use a
diluted Betadine compress and to thoroughly lubricate the skin with
Calcium Pantothenicum ung, Panthenol gel, Olvizone or Water Jel
R1+R2, while removing any crusts attached to the skin;
- in the case of wet desquamation, the skin peels off in strips and
secerns heavily; this condition is accompanied by severe soreness
and a high risk of infection. It is advisable to apply the Menalind
Professional skin protection cream to small oozing areas or to
lubricate the skin with Flamigel;
- the treatment of wet desquamation is carried out under antiseptic
conditions due to the risk of infection;
- defects are flushed with a saline or Ringers solution;
- defects are disinfected with a solution that does not burn the patient
(Octenisept, Betadine solution);
- in the case of foul-smelling or infected weeping wounds it is
advisable to apply moist wound healing absorbent materials,
micro-adherent dressing, healing bandages, a hydrogel colloidal
sheet (Mepilex, Mepilex transfer, Mepitel, Inadine, Flaminal Hydro),
- do not apply corticosteroid ointments, alcoholic solutions, do not use
gentian violet or methyl blue;
- an ulcer is a kind of damage which almost does not occur any more.
It is ulcerative colitis which weeps, is sore and does not tend to heal.
It forms in places with poor tissue perfusion or in areas that have
been radiated before;
- always inform the attending doctor about the development of
postradiation skin reactions and consult the wound care nurse
specialist about the treatment of the defect.
The radiated area must be kept clean and grease-free. Treat and lubricate the
skin only after the radiation. Before the radiation itself, wash the oily skin
with warm water. The radiated area must not be oily prior to the
radiation!
o Skin adnexa damage
27
Skin adnexa damage occurs only in those areas of the skin that have been
radiated directly. It includes hair loss during head radiation or hair falling
out e.g. during the radiation of the hairy parts of the chest in men. It usually
begins after three weeks of radiotherapy and, depending on the total dose,
may be irreversible. The activity of sweat and ceruminous glands is limited
after the radiation. Depending on the dose, this activity may also be
destroyed permanently.
o Mucous membrane damage
One of the common and poorly tolerated reactions is the affection of

mucous membranes. The symptoms depend on the location. At first
erythema and oedema appear on the membranes we call this first degree
damage. Afterwards fibrin coatings are formed second degree. The patient
may develop a bacterial or mycotic infection, and later on ulcerations and
mucous membrane bleeding may appear third degree.
In the oral cavity it is stomatitis, whose symptoms include soreness,
burning, swallowing difficulties, etc. The taste buds are also affected and
the patient is no longer able to distinguish different tastes. Breaking the
outer epithelial layer increases the risk of infections, especially mycotic.
In the gullet esophagitis manifests itself through swallowing disorders,
soreness and burning below the sternum.
The symptoms of radiation-induced gastritis are nausea, vomiting, lack
of appetite and increased fatigue.
Side effects of radiotherapy in the oral cavity

Acute reddening of the mucous membrane, swelling, pain,
irritation and defects.
Late taste disorder, tooth damage, ulceration of the mucous
membrane, xerostomia.
Clinical picture
Mucositis in the oral cavity is the most common manifestation of oral
toxicity of oncology treatment. It negatively affects the duration of the
treatment and increases the risk of infectious complications. It is defined as
an inflammatory ulcerative disease of the mucous membranes and the
submucosa. It often leads to weight loss, dehydration and the necessity to
hospitalise the patient so that they can be administered parenteral nutrition.
Clinically it starts to manifest itself in patients radiating the neck area in
the second half of their treatment. In these patients we can observe mucous
membrane leakage with a pale tinge. Erythematous patches or atrophy
(especially perceptible on a smooth tongue where the papillae have been
destroyed) can also appear, as well as defects of varying extent and depth,
usually covered with a whitish or yellowish false membrane, which is
gradually rejected from the edges within the next few days. In the case of
severe mucositides the mucous membrane may bleed.
The defects often affect the lips, too. The mucous membrane is damaged,
the nerve endings in the oral cavity are bared and exposed to excessive
28
irritation. The damaged mucous membrane becomes fragile and infected.
Painful defects are formed and the mucous membrane starts bleeding. The
patient rejects not only solid food, but later even spoon food and liquids.
Their health deteriorates, the quality of their life decreases and they develop
further complications. The damage is accompanied by discomfort and
distinct soreness in the oral cavity.
A great benefit for the patients is installing gastrostomy (PEG) before
they undergo radiotherapy.
Changes of the oral mucosa pose a very serious problem

When radiating the area of the nasal cavity, nasopharynx, oral cavity and
throat, the most common side effect is that the radiated skin turns red or
even brown. There can also be complications caused by the engorgement of
the radiated mucous membranes:
mouth pain;
difficulty in chewing, in some cases a reduced ability to open the
mouth;
difficulty in biting food;
reduced salivary flow, thickened saliva, a feeling of excessive
dryness in the oral cavity xerostomia, which develops when the
salivary glands have been affected. It is extremely important to
prevent it from developing, as the treatment is slow and not very
effective. Late xerostomia dramatically affects the patients quality
of life;
changes in taste perception, sometimes even the loss of the ability to
distinguish the individual types of taste;
swallowing problems (painful swallowing, the inability to swallow
solid food and later, as the radiation dose increases, even liquid
food);
difficulty speaking , hoarseness.
The intensity of these complications increases together with the radiation

dose. However, these complications gradually subside after the treatment
has ended. It happens only rarely that some of them persist for a longer time
after the end of the treatment. Some late side effects may appear after the
radiation is finished (up to 23 years), e.g. skin changes (pigmentation, dry
and less elastic skin) or dryness in the oral cavity.
Phases of oral mucositis:

I. reddening, mild swelling, painless defects, eating without
changes;
II. painful reddening, swelling, defects, the patient receives solid
food;
III. painful reddening, swelling, defects inside the mouth, the patient
receives only liquid food;
IV. pain, swelling, defects, the patient does not receive any food
through the mouth and receives liquids only to a limited extent
they require parenteral nutrition.
29
Predominant factors leading to the development of the abovementioned
complications:
bad eating habits;
neglected hygiene of the oral cavity;
neglected dental care;
chronic alcoholism;
nicotinism;
potentiation of radiotherapy by chemotherapy, biological treatment.
Nursing care of the oral cavity

Basic hygienic nursing care should include ensuring that the patients teeth
are brushed regularly with a soft toothbrush. Cleaning dentures and
removing them for the night (or even during the day if the patient suffers
from mucositis) should be a matter of course. The patient should regularly
rinse the oral cavity with an appropriate solution, which should generally be
non-irritating, non-toxic and non-repulsive for the patient. As the
mechanical effect of rinsing itself may be significant in keeping the mucous
membranes clean, it is important for the patient to rinse at all.
So far it has not been proved that that any specific solution is better
than others. If there is no clear infection of the oral cavity, it is probably not
necessary to persist in using antimicrobial solutions more than is needed.
Choosing the appropriate means

Individual approach is essential, taking into account a different tolerance to
solutions, sprays or viscous gels. The temperature and frequency of rinsing
or gargling should be decided by the patient alone, so as to make it as
pleasant and bearable for them as possible.
Antiseptic solutions
Due to their irritating effects, solutions containing alcohol are generally not
recommended. On the other hand, a calming sensation may be brought on
by simple rinsing with a saline solution, sage preparations or a number of
commercial preparations, which the patient alone considers beneficial.
Octenidol: an antiseptic pharmaceutic substance, quick to take effect
(within 30 seconds and with effects lasting up to 24 hours), does not contain
alcohol. It is effective even in the case of a MRSA colonisation. It has an
unpleasant taste and does not suit all patients.
Antiseptic painkilling solutions

Solutions containing benzydamine (Tantum, Orophar) or benzocaine
(septolete) bring relief from pain to some extent. Beware, however, as they
contain a high level of ethanol!
Local analgesics
Magistral preparations containing anaesthetics, e.g. lidocaine, trimecaine
(procaine syrup), can be used locally. However, they are not very suitable,
especially in the case of a higher concentration of anaesthetics, as they
suppress the swallowing reflex and raise the danger of aspiration. They also
30
increase the risk of inflicting a trauma while chewing. The application of
more viscous preparations directly into the painful defects is more suitable.
Rinsing the oral cavity with morphine.
Rinsing with 1% or 2% morphine decreases the intensity and duration
of local pain without the side effects of this opiate. There is no increase of
the morphine level in the systemic circulation, either.
Gelclair a concentrated gel which creates an adhesive protective film
in the oral cavity. This film covers the nerve endings and eases the pain of
the mucous membranes for up to several hours. The protective film forms a
barrier between the mucous membranes and food and saliva. The
recommended dose is three times a day or according to the patients needs,
ideally one hour before eating or drinking. It is not recommended to rinse
the mouth with disinfectant solutions at this time, either. It does not contain
anaesthetics or alcohol.
Additional treatment
The aqueous solution Caphosol is a preparation comprising two individually
wrapped aqueous solutions a phosphate solution (Caphosol A) and a
calcium solution (Caphosol B). The electrolyte solution is intended for
moistening, lubricating and cleaning the oral cavity, including the oral
mucosa, tongue and oropharynx. Caphosol is recommended in the case of
dryness in the mouth or oropharynx.
Patients can reduce the symptoms of mucositis by:

thoroughly brushing not only their teeth, but also their tongue with
a soft child toothbrush;
regularly brushing their denture and removing it for the night;
rinsing the oral cavity with solutions that are customary in the
ward non-irritating, non-toxic and pleasant for the patient;
observing the condition of the mucous membrane, taking notice of
reddening or defects, even under the denture;
observing pain when swallowing liquids or solid food;
changing their eating habits (non-irritating food);
reducing smoking and drinking alcohol;
modifying their diet if complications arise.
Oral mucositis has an extensive hidden potential of unknown and
unresolved problems. The wrong interventions and education of a patient
suffering from mucositis can have fatal consequences for them. They can
cause the treatment to stall, worsen the nutritional status and generally
decrease the quality of the patients life.
o Postradiation intestinal changes
In the case of radiotherapy covering the intestine, rectum or the area of the
lesser pelvis, postradiation changes occur even in the case of small doses.
Local symptoms may manifest themselves through nausea, lack of appetite,
vomiting, diarrhoea, flatulence or stomach aches. Damage of the mucous
31
membranes of the urogenital tract, especially the urinary bladder, can be
observed in the form of cystitis.
Local side effects

When radiating the pelvis, the side effects are caused mainly by the
irritation of the intestine or urinary bladder. The most common
complications are lack of appetite, nausea or vomiting, the urge to defecate
or frequent loose stool, and frequent urination.
Nausea and vomiting can be solved by drawing up a radiation time
plan. It usually helps if the patients stomach is empty (e.g. radiating in the
morning before breakfast) or if the radiation is administered between two
meals (before lunch, before dinner). Sometimes a medicamentous solution is
necessary, such as antiemetics before the radiation.
In the case of diarrhoeal stool, it is especially dietary measures that help
to reduce the complications (being served rice and carrot broth). During
radiation the dietary measures serve to prevent and reduce the side effects of
radiating. The patients diet should be substantial and balanced. It is
recommended to eat smaller portions of food more frequently, to eat and
drink slowly, to avoid food that is hard to digest, fatty, fried, flatulent,
excessively spicy, aromatic, and food that has not been heat treated.
Between meals the patient should receive a sufficient amount of non-
irritating drinks. In the case of increasing complications that do not react to
the abovementioned dietary measures, a consultation with a diet therapist or
doctor is necessary, or possibly the application of medicamentous treatment.
When radiating the area of the stomach or lesser pelvis, it is not advisable to
consume food that can:
increase dyspeptic complications e.g. flatulence pulses, fresh
pastry, vegetables, dairy products, sugary food and beer;
speed up the peristalsis coffee and fizzy drinks (CO2).
When radiating the pelvis in women, it is usually impossible to avoid the

ovaries. In women of reproductive age, the activity of these organs dies out
permanently because of this, which induces menopause.
When radiating the rectum, a weeping reaction may appear in the groin,
genital area and anus. Fistulas, stenoses and ulcers pose a serious
complication, and must often be dealt with surgically.
When radiating the area of the urinary bladder, there is a risk of
developing an acute urinary bladder inflammation. This can, however, be
prevented to some extent by drinking a sufficient amount of liquids. The
patient must drink a sufficient amount of liquids even after long term
radiation treatment directed at the urinary bladder area, as there is a risk of
postradiation shrinking of the bladder. The recommended amount is 2.5 3
L of liquids per day.
Damage of organs by radiotherapy
- Heart damage acute changes in the heart occur very rarely, most often
in the pericardium area. Late changes may occur even in the space of several
years. A pacemaker is not a contraindication of the radiation. The radiation
32
technique is chosen so that it is not in the radiation beam and its function is
therefore not affected.
- Lungs acute radiation pneumonitis appears 13 months after the end of
radiotherapy. Its development depends on the size of the radiated area, age
and current application of chemotherapy. Clinically it manifests itself
through a dry cough, dyspnoea, temperature and a correlate in an X-ray
picture or lung CT scan. The inflammation subsides after treatment with
corticosteroids and antibiotics. It can, however, also transform into chronic
fibrosis. Pulmonary fibrosis may develop even without a previous acute
reaction.
- Reproductive organs are largely radiosensitive. Testicles are highly
sensitive to radiation; at first a reduction of sperm formation occurs, and
consequently also the reduction of hormone production. Even a dose of 56
Gy leads to permanent sterility. An effort is made to keep the reproductive
organs out of the irradiated volume. Before the beginning of treatment in
men it is possible to store the sperm in liquid nitrogen for later use. The
radiation of ovaries can also cause sterility and stop the production of
oestrogen. The degree of affection depends on the dose and age of the
patient. In women it is possible to partially protect the gonads by
hormonally stopping the ovulation cycle.
- Nervous system damage of the CNS is not common because brain tissue
is not very sensitive. Radiating the brain may lead to the development of
oedema. It can be accompanied by headaches, nausea and vomiting. After
antioedematous therapy the symptoms subside. Myelopathy may appear
during the radiation of the spinal cord, causing the patients to feel sharp
convulsions or paresthesia shooting from the neck into the upper limbs. The
symptoms usually subside spontaneously, whereas chronic myelitis poses a
serious complication. The symptoms depend on the height of the affected
spinal cord.
- Thyroid gland after radiating the area of the head, neck or breast to
destroy malignant lymphoma, it is necessary to take into account the risk of
hypothyroidism development.
Late side effects of radiotherapy
Late side effects appear after the end of radiotherapy in the space of several
weeks, months or even years (1.53 years). They occur mainly in
connective tissue, blood vessels, lungs, kidneys, nervous tissue and muscles.
Unlike acute changes, late changes are irreversible. They include especially
fibrotic skin and subcutaneous changes, skin atrophy, microvascular damage
resulting in lymphedema, urinary bladder fibrosis, neuropathy, etc. Late
changes can occur suddenly or gradually; sometimes they are preceded by
distinct acute reactions. These usually do not mean a higher risk of the
development of late changes. Late changes depend especially on the amount
of the individual dose on the fraction. They are not overly dependent on
the total dose or on the length of radiotherapy.
It is necessary to know all the possibilities of postradiation changes,
prevent their acute manifestations, and treat them early and effectively if
they develop. The correct indication of the radiation and its highly qualified
performance is also essential.
33
Role of the nurse in radiotherapy
Knowledge of the nurse:

- the sources of ionising radiation and methods of radiotherapy;
- the difference between curative, adjuvant, neoadjuvant and palliative
radiation;
- the side effects of radiotherapy.
Skills of the nurse:

- the ability to educate the patient about the side effects of
radiotherapy and the possibilities of preventing their development;
- distinguishing among the different types of skin reactions;
- the ability to treat postradiation skin reactions;
- communication with the patient and their loved ones.
Responsibilities of the nurse:

- providing the patient information about the organisation of the
radiation treatment;
- contacting a nutritional therapist when needed;
- monitoring the radiated area daily in the course of radiotherapy;
- actively seeking for any side effects of radiotherapy;
- informing the doctor about any changes.
Nursing interventions:
1. before the beginning of radiotherapy:
- educating the patient about the possible side effects;
- educating about how to prevent the side effects from developing;
- educating about the treatment of postradiation reactions;
- educating about regime measures;
- educating about unlimited contact with the patients loved ones
(the radiated patient does not endanger their surroundings with
radiation);
2. during the treatment:

- regularly monitoring the radiated area;
- monitoring the nutritional status;
- monitoring pain relief;
- treating the radiated area;
- detecting any radiation side effects;
- informing the doctor about all changes;
- contacting a wound care nurse specialist as needed;
- contacting a nutritional therapist as needed;
3. after the end of the treatment:

- educating about reducing the occurrence of side effects;
- educating about the inadvisability of mechanically irritating the
radiated skin,
about the inadvisability of chemically irritating the radiated area
about the inadvisability of exposing the skin to the sun;
about wearing suitable clothes;
34
- educating about the suitable treatment of postradiation reactions.
Summary
A successful performance of radiation treatment is largely dependent on the
level of collaboration between the radiotherapy staff and the nurse and
patient. Before the beginning of the treatment, all patients are informed
about its basic principles, the radiation period and length, the possibility of
developing side effects, treating the radiated area and also about the dietary
restrictions.
In this chapter you have gained the information needed for the
prevention and treatment of postradiation side effects.

1. How will you proceed when nursing the skin of a patient suffering from
wet desquamation?
2. What are the general guidelines in the nursing care of a radiated patients
skin?
3. What is xerostomia?
Mail task No. 6

Draw up a nursing care plan for a radiated patient with a tumour in the ENT
area.

ABRAHMOV, Jitka. Vybran otzky z onkologie XI. Praha: Galn,
2007, 194 pp. ISBN 978-80-7262-527-7.
s.r.o., 2005. 206 pp. ISBN 80-7254-542-6.
NEZU, A. et al. Pomoc pacientm pi zvldn rakoviny. 1st ed. Brno:
Spolenost pro odbornou literaturu, 2004. 311 pp. ISBN 80-7364-000-7.
35
7 ANTI-TUMOUR FARMACOTHERAPY
about the main groups of medications with anti-tumour effects;

about the general guidelines of nursing care of chemotherapy
patients;
about the specific features of nursing care of patients who suffer
from the side effects of chemotherapy.
Keywords:
cytostatics, biological treatment, application of cytostatics, paravenous

leakage.
Anti-tumour farmacotherapy is a broad term it includes anti-tumour

chemotherapy, anti-tumour hormone therapy and biological treatment.
o Chemotherapy
Chemotherapy refers to administering medications that are the products of
chemical synthesis. Chemotherapeutic drugs are medications used not only
for the treatment of malignant tumours, but also for treating other (fungal,
bacterial, viral and parasitic) diseases. In oncology the term chemotherapy
refers to administering medications called cytostatics. These medications
are of synthetic origin, or they can be derivatives of substances obtained
from plants or fungi.
o Anti-tumour hormone therapy

Some tumours are derived from hormone tissue and their growth can be
affected by hormone therapy. This means that the growth of some tumours,
especially breast or prostate tumours, can be dependent on the presence of
certain hormones. Administering substances that work against hormones
causes the tumour growth to slow down or cease, or the tumour to shrink.
o Immunotherapy
Is a method based on the finding that the body sometimes reacts against the
tumour by means of its own immune system. In practice we use e.g. the
stimulation of the patients immune system after the urinary bladder has
been removed by applying the bacteria used as a vaccine against
tuberculosis for a certain period of time.
o Biological treatment
Biological treatment refers to those medicinal preparations which are
concocted by means of biological preparation. These substances are
36
chemically identical or similar to the substances produced by the cells of the
human body. Biotherapy differs from the physiological situation by the
applied dose and therapeutic concentrations, which far exceed physiological
values. Biotherapy blocks tumour growth by affecting specific molecules or
paths in the process: cancerogenesis, the process of metastasis, cell growth.
Unlike classical chemotherapy, which attacks all fast-dividing cells,
biotherapy works directly in the tumour.
Biological treatment:
is targeted at a specific structure in the cell (receptor, etc.);
partially recognises the difference between a healthy cell and a
tumour cell;
is effective with specific types of tumours.
7.1 Cytostatics
Chemotherapy is not an alternative to any other kind of treatment; it is a

systemic treatment method which can effectively destroy milligrams of
tissue without spatial restriction. In oncology, chemotherapy refers to
cytostatic treatment. Cytostatics stop cell division and destroy cells by
damaging their genetic information. Their aim is to kill tumour cells.
Cytostatics differ from one another in the way they damage cells and in their
ability to penetrate some kinds of tissue. A cytostatic drug may be greatly
effective against one type of tumour, but completely ineffective against
other tumours. This means that there is small metabolic diversity between
tumour cells and healthy cells. We do not have cytostatics that work
selectively only against tumour cells. The fact that tumour cells are
damaged by cytostatics more than healthy cells is related to their division
rate. The difference in the division rate of tumour cells and healthy cells is
one of the most important factors that determine which cell will be damaged
more by cytostatics and which less. Another factor which affects the way
cytostatics work against malignant cells is the difference in the
concentration which specific cytostatics reach in the individual organs and
tissues.
The higher sensitivity of some tumour cells to cytostatics is given by the
fact that tumour cells usually have bigger or smaller repair mechanisms. If a
healthy cell is affected, there is a high probability that the damage is
reversible. On the other hand, if a tumour cell is affected, there is a higher
probability that it will die. Some types of tumours are, for different reasons,
not sensitive to cytostatics, and administering them may therefore be
harmful to the patient. Characteristics related to sensitivity to chemotherapy:
chemosensitivity the tumour is sensitive to chemotherapy;
chemocurability the tumour is sensitive to chemotherapy and, what
is more, administering cytostatics is beneficial for the patient;
chemoresistance the tumour is not sensitive to chemotherapy.
A big problem with cytostatics is their individual metabolism in each
person. The result is that one patient may experience life threatening side
effects, while another patient with the same dose may tolerate them without
any greater difficulties. Chemotherapy as a treatment method is used
37
separately, or in combination with biological treatment, surgical treatment
or radiotherapy.
If the patient is administered one cytostatic drug, it is called
monotherapy. If they are administered more cytostatics, it is called
combined treatment. The goal of chemotherapy is to inflict maximum
damage to tumour cells with minimum damage to healthy tissue. Even from
this point of view it is advantageous to combine more cytostatics which
have a common target effect, but different side effects. In comparison with
monotherapy, the degree of damage to the organism is reduced, while the
intensity of the treatment is increased.
When combining, the following things are taken into consideration:
that only those cytostatics are used whose effect has been
sufficiently proved in monotherapy;
that the cytostatics used have a different mechanism of action in
order to delay resistance;
that the cytostatics used do not have the same side effects.
7.1.2 Cytostatic dosage
The recommended doses are set on the basis of clinical experience. Most
often the cytostatic dosage is set according to the surface area of the
patients body, which is calculated from their height and weight. With most
cytostatics the kidney and liver function must be taken into account when
setting the dosage. Some cytostatics work better in combinations rather than
individually; chemotherapy often consists of more medications. This
method is called combined chemotherapy.
Setting the dose according to the patients weight is used less often.
This method of setting the dose is used for example when administering the
cytostatic dose orally.
Setting the dose according to the body surface area. This method of
calculation and dosage is the standard procedure.
It is also necessary to modify the cytostatic dose according to the
kidney and liver function and the current blood count. It is important to
know the metabolic pathways of cytostatics and to know with which
medications it is necessary to lower the dose when the kidney or liver
function is poor.
The effects of chemotherapy depend on the type of tumour and its
location in the organism. In relation to this we expect the following of
chemotherapy:
- curing the patient, destroying the tumour;
- preventing the tumour from spreading;
- slowing tumour growth;
- reducing the complications caused by the tumour improving the
quality of life.
Division of chemotherapy according to the goal of the treatment

Curative chemotherapy its goal is to cure the patient. In curative
treatment more intensive side effects are acceptable.
38
Adjuvant chemotherapy administering cytostatics only to those patients
where the tumour has been surgically removed up to healthy tissue and
where further tumour tissue cannot be found by common diagnostic
procedures. However, the existence of micrometastases is presumed, which
ought to be destroyed by this type of treatment. Adjuvant chemotherapy is
normally administered to patients following breast cancer or colon cancer
surgery.
Concomitant chemotherapy administering chemotherapy together with
radiation treatment (they potentiate each others effect).
Neoadjuvant chemotherapy administering cytostatics before surgically
removing the tumour. Its goal is to shrink a locally advanced tumour before
surgical treatment, to improve its operability and to destroy possible
micrometastases.
Palliative chemotherapy shrinks the tumour and leads to reducing the
symptoms caused by the tumour. It improves the quality of the patients life,
it does not cure them.
7.1.3 Application methods

- orally in the form of pills or capsules;
- locally an ointment or liquid is rubbed into the skin;
- intramuscularly (into the muscle);
- subcutaneously (beneath the skin);
- intralesionally (directly into the tumour in the skin);
- intraarterially (arterial port, into the artery);
- intravenously (PVC, CVC, intravenous port);
Based on the duration of the application, we distinguish the
following when administering cytostatics intravenously: bolus
administration (injection administration, short infusion), infusion
administration of cytostatics by means of infusion and continual
application (an infusion lasting hours or even days).
- intracavitally intrapleurally;
intraperitoneally;
- intrathecally applying the medication into the spinal canal.
The principle of successful treatment is to administer cytostatics in such

intervals that in the breaks between the administrations there is no
substantial increase in the number of malignant cells; instead the number
should gradually decrease after each administration.
7.1.4 Application of chemotherapy

The administration of cytostatics itself is most often ordered to be done
intravenously. The nurse is responsible for the insertion and care of the PVC
and of the application procedure itself. Ordering intraarterial or intracavital
administration is less common. During these procedures the nurse only
assists the doctor. When applying chemotherapy, the nurses follow the
doctors orders and respect the application schedule. Chemotherapy is
applied by a portable infusion pump or dispenser, and the nurses monitor the
injection site and its surroundings in regular intervals. Immediately after
applying cytostatics the vein must always be flushed with a saline solution
39
with the exception of Oxaliplatin, where the use of a 5% glucose solution is
prescribed. In the course of applying chemotherapy, the nurse maintains
contact with the patient, respects their subjective feelings, detects any signs
of developing complications and reacts to them immediately. Working with
cytostatics includes:
prescription (is within the doctors sphere of competence based on
the indication);
diluting and preparing chemotherapy (this is done at the pharmacy,
in an isolator, cytostatics are diluted by pharmacists or
pharmaceutical assistants);
transport (provided by the staff of the transport department);
administering and applying chemotherapy (at the outpatient
chemotherapy unit or inpatient ward if the patient is hospitalised);
dealing with side effects;
waste disposal and dealing with waste;
emergency.
o Risk of extravasation
From the point of view of safe application, cytostatics can be divided into
three groups according to whether there is a risk of extravasation
development when the medication leaks outside the vein. Extravasation is a
damage of tissue surrounding the injection site with an inflammatory
character or even necrosis.
Groups of cytostatic substances:
non-vesicant drugs do not cause damage (Hycamptin, Oxaliplatin,
Cytarabin, methotrexate);
irritants irritate, burn when passing through the efferent vein, but
do not cause necrosis when they leak outside the vein (Dakarbazin,
Fluorouracil);
vesicant drugs high risk of necrosis when the cytostatic drug leaks
outside the vein (Doxorubicin, Epirubicin, Vincristine, Mitomycin,
Vinblastine).
Preventing the development of paravenous leakage:

instructing the patient about the possible risks (informed
agreement);
the cytostatic drug is applied by the doctor or an experienced
nurse working without professional supervision; it is within
his/her sphere of competence to apply medications intravenously
and to apply chemotherapy;
choosing a suitable place for intravenous application (due to a
lower risk of phlebitis, it is advisable to choose bigger veins with
a high blood flow and veins on the forearm as it ensures a
sufficient distance from joints);
if the venous system is insufficient, it is advisable to discuss
inserting a CVC or an intravenous port with the patient;
choosing a suitable size of the PVC; needles must not be used for
the application!!!
a suitable fixation of the PVC and limb to prevent inadvertent
movement;
40
informing the patient about the need to alert the nurse to every
sensation, such as burning, itching or soreness on the injection
site and its surroundings;
in between applying the individual cytostatics, the nurse flushes
the site with a saline solution. After the application of cytostatics
is finished, the nurse flushes the infusion line with at least 100
ml of saline solution;
after the application of cytostatic drugs has begun, the nurse
carefully and repeatedly, in regular intervals, monitors the
functionality of the PVC, monitors the injection site and its
surroundings, and immediately deals with any signs of
developing extravasation (leakage, swelling, redness, ).
Risk factors for the development of paravenous leakage:
an unfavourable state of the venous system;
uncooperative patients, motor restlessness;
latent damage caused by previous chemotherapy and radiation of
the injection site;
other factors, such as polyneuropathy or disorders of
consciousness.
Symptoms of paravenous leakage:
immediately during paravenous leakage burning or stinging
pain, swelling, chemical phlebitis, hipokinesia. Painful deposits
are often related to the gradual loss of skin covering;
after several hours vasodilation, increasing pain and brown
pigmentation that remains after the swelling has subsided;
within several days the skin may start flaking on the surface.
Painful red induration may gradually start to subside or change
into necrosis;
within weeks in the weeks following paravenous leakage the
pain still endures. Induration may gradually change into necrosis,
which heals very slowly, or into subcutaneous sclerosis;
developing permanent damage the amount and type of
cytostatic drug determine the extent of necrosis and the extent of
permanent damage caused to the patient. The damage concerns
not only soft subcutaneous tissue, but the vessel, neural and joint
structures may also be permanently affected.
The nurse notifies the doctor not only about the leakage of a cytostatic drug
outside the target vessel itself, but he/she also reports those cases where the
leakage of a cytostatic drug is only suspected. Afterwards he/she proceeds
as if the leakage outside the vein has occurred.
Procedure:
stop the application, do not interfere with the intravenous
access (do not remove the PVC);
notify the doctor;
attempt to aspirate the medication that has leaked;
if a blister forms, aspirate it with an insulin syringe (use a new
syringe for each new attempt);
41
afterwards follow the doctors orders and the standards of
treating the extravasation of the individual cytostatic drugs;
instruct the patient;
report any incidents and keep everything well documented;
check the patient within 24 hours.
7.1.5 Maintaining documentation

Maintaining documentation is an integral part of the nurses job. When
applying chemotherapy, the nurse plans, performs, continuously monitors
and evaluates nursing care and consistently records everything in the
medical records. In the case of preparing and applying chemotherapy, the
monitoring is multistage, checking the cytostatics received from the
pharmacy. The nurse keeps records about inserting and caring for venous
entries and about the application of chemotherapy. He/she regularly writes
entries to Port Patient Identification Cards and records the occurrence and
extent of side effects caused by chemotherapy. In the case of monitoring
fluid balance and vital functions, he/she also records the obtained values.
7.1.6 Dealing with waste
When working with cytostatics, everything that was or could have been
contaminated by cytostatic drugs is treated as hazardous waste, and dealt
with according to valid regulations. If the infusion bags are damaged or the
cytostatic drugs leak outside their package, or in the case of staining the
skin, spilling, breaking or contaminating the surface with a cytostatic
substance, it is considered to be an emergency situation. It is necessary to
proceed according to the emergency plan, which every workplace where
cytostatics are handled is advised to have.
It is also necessary to treat the patients clothes, bedclothes and the
personal clothes of staff handling cytostatics as contaminated clothes and to
deal with them according to valid regulations.
7.1.7 Toxicity of chemotherapy
The toxicity of chemotherapy depends on:

- the intensity of the treatment;
- the administered medication.
It can pose a serious complication for the patient.
The side effects of chemotherapy can be divided into:
- Immediate (hours, days):
nausea and vomiting;
phlebitis;
local necrosis (in the case of paravenous application);
hyperuricemia (a high level of uric acid);
allergic reactions or even anaphylaxis;
kidney failure;
skin rashes;
42
teratogenic effects (if the cytostatic drug is administered to a
pregnant woman).
- Early (days, weeks):
myelosuppression;
alopecia;
mucositis/stomatitis;
diarrhoea.
- Delayed (weeks, months):
anaemia;
azoospermia (sperm disappearance);
hepatotoxicity;
hyperpigmentation;
pulmonary fibrosis.
- Late (months, years):
sterility;
hypogonadism;
secondary tumours.
- Most common:
nausea and vomiting;
reduced blood cell production;
affection of mucous membranes;
allergies;
alopecia;
neurotoxicity;
nephrotoxicity;
cardiotoxicity;
phlebitis;
gonadal disorders;
febrile reactions.
1. immediate
- usually appear after the first administration (1020 ml of solution);
- hypertension, hypotension, tachycardia, difficulty breathing, skin
reddening, restlessness, tremor, cold sweat, pain, cough, blurred vision all
of these lead to an allergic reaction;
- prevention: monitoring the patient, timely education and informing the
patient about the possible side effects.
2. early, delayed, late complications

- Reduced blood cell production (myelosuppression) and other
haematological side effects
All cytostatics have a myelosuppressive effect, with the exception of
Vincristine and Bleomycin, depending on the dose and the mechanism of
cytostatic action. This is where all the complications related to
myelosuppression (the reduction of the number of erythrocytes,
thrombocytes and neutrophils) stem from. The number of these
complications and the degree of myelosuppression also depends on the stage
of the treatment. It is usually most prominent after the first cycle of
chemotherapy. However, as the number of cycles grows, bone marrow is
43
gradually suppressed. Growth factors (Neupogen, Neulasta) are therefore
employed to improve blood cell formation.
- Febrile neutropenia
Is one of the most common diseases developed by patients suffering from a
neoplastic disease. Anti-tumour treatment especially leads to the reduction
of neutrophil granulocytes neutropenia, which is one of the most serious
risk factors of infectious complications. We can say that a patient has
developed febrile neutropenia when the decrease of neutrophiles in their
peripheral blood is 0.5 x 109/L smaller than a single measured temperature
above 38.3 C or twice the measured temperature in the space of one hour
above 38 C. Depending on the number of neutrophiles, neutropenia can be
divided into mild, moderate and severe.
Clinical manifestations there may be no signs of inflammation, and so the
most important sign of infection is when the body temperature rises above
38 C. However, it is more common to see a clinically clearly localised
infection, where neutropenia manifests itself through infection (see the
following part of the text Clinical infections).
It is important to monitor both the manifestations of the infection in the
patient and the clinical examination, as well as the results of laboratory
testing CBC, BV, microbiological testing (taking a blood sample for
haemocultures), lung X-rays if the patient develops a temperature, and other
screening examinations.
The prevention of infection in neutropenic patients is an important part
of the care of neutropenic patients. At the hospital the nurse is in close
contact with the patient, and observing preventive measures can
significantly lower the risk of the patient developing infectious
complications.
Education educating the patient, staff and relatives about the necessity to
follow a stricter hygiene regime.
Environment it is best to put the patient in a separate room;
- the patient only leaves the room for as long as is absolutely necessary
(with a surgical mask over their mouth);
- it is not advisable to keep live plants in the room (mildew in the earth and
water);
- daily cleaning of the room with a suitable disinfectant according to the
disinfection guidelines;
- the staff only stay in the room for as long as is absolutely necessary;
- neutropenic patients are not treated by staff suffering from respiratory
diseases;
- the patients room should be marked;
- following a stricter hygiene regime wearing a surgical mask, accepting
visitors is not recommended (only without any signs of infection and after
consulting the attending doctor), consistent hand hygiene before entering the
room.
In the home environment it is advisable to avoid visits to areas with a large

culmination of people.
Patient hygiene regular, whole body hygiene (even after using the
toilet);
44
- consistent hand hygiene;
- oral cavity hygiene using soft toothbrushes, patients suffering from
mucositis are not advised to use a toothbrush, only to rinse their mouth with
disinfectant solutions or a sterile saline solution.
Staff hand hygiene the most important part of preventing the
transmission of hospital strains of bacteria and yeasts and cannula infection.
A thorough hand disinfection should take place:
- before entering and after leaving the patients room;
- always between attending each new patient in the room;
- always before contact with the outer mouth of the venous catheter.
Diet with a minimum risk of the patient developing a food infection.
The diet for a neutropenic patient should generally be low bacterial.
- Infectious complications
Infections can usually be expected after cytostatic treatment, as they are the
result of a generally weakened immune system of a person. Every patient
should be instructed about these complications and their seriousness.
Patients treated with ordinary cytostatics usually suffer from infections
affecting mucous membrane surfaces most often the mucous membranes
of the respiratory tract.
A severe infection manifests itself through:
fever;
increased heart rate;
a decrease in blood pressure below the values typical of that
person;
hyperventilation;
a temporary decrease in mental functions (apathy).
Patients who develop these symptoms may be suffering from a life
threatening infection.
The most common infectious agents are Streptococcus pneumoniae,
Staphylococcus aureus, Klebsiella pneumoniae and Pseudomonas
aeruginosa. The prevention of infectious complications involves educating
the patient about a suitable at home regime, advising them to spend
minimum time in areas with a larger culmination of people (public
transport, cinemas, supermarkets), advising them against moving and
spending time among ill people (cold, cough, ).
- Nausea and vomiting

The total intensity of nausea and vomiting depends on the dose and type of
cytostatic drug. It is necessary to anticipate this type of side effect
beforehand and suppress it by administering antiemetics before or during
the application of cytostatics, and, in the case of intravenous application,
often even after. Between the individual cycles of chemotherapy, aftercare
patients are also treated with antiemetics per os (Zofran, Kytril, Degan,
Torecan-suppository form). A diet is also an integral part of the treatment
(dietary measures, drinking regime, small portions 56 a day).
It is necessary to anticipate this type of side effect beforehand and to
suppress it, because if effective medication is not administered immediately
during the first or second cycle of chemotherapy and the patient vomits,
they can develop a great fear of further chemotherapy and vomit only on the
basis of the reflex they have developed.
45
- Damage of the mucous membranes of the alimentary tract with diarrhoea
and constipation
The mucosal epithelium regenerates quite quickly, and that is why the cells
of the mucous membranes of the alimentary tract, as well as of other
mucosal surfaces, are very often damaged by cytostatic treatment. These
manifestations are most common when the patient is treated with
5-fluorouracil; this treatment can often be followed by bloody diarrhoea.
The extent of mucous membrane damage is classified according to the
WHO scale (grades 14). It is important to educate the patient about the
possibility of mucous membrane damage, to give them advice about the
necessity of a stricter personal hygiene, about minimising the use of
dentures and about a stricter hygiene of the oral cavity.
A suitable prevention is the education of the patient about the appropriate
diet, inappropriate food (with live cultures: niva blue cheese, hermeln
soft-ripened cheese, hard nuts) and, if the patient suffers from diarrhoea,
about monitoring the intensity and frequency of their stool. In the case of
damage of the mucous membranes of the oral cavity, it is extremely
important to educate the patient about the necessity of a stricter hygiene,
about rinsing the oral cavity after every meal (Tantum Verde, sage), about
denture care, food hygiene and the technological procedures in food
preparation. If the mucous membrane of the oral cavity is damaged after
applying chemotherapy, the nurse proceeds with the treatment as if it were a
case of a postradiation reaction of the mucous membrane of the oral cavity.
Depending on the dose, almost all cytostatics can damage the mucous
membrane of the alimentary tract and initially cause diarrhoea. However, if
the mucous membrane is severely damaged due to toxicity, diarrhoea can
change into constipation or even intestinal obstruction (ileus).
- Cardiotoxicity
Side effects affecting the heart may appear in the course of the treatment
(acute toxicity), immediately following the treatment (subacute toxicity),
several months after the treatment (chronic toxicity) or in the form of late
effects many years after the treatment has ended (late toxicity). Damage
may appear some time after the end of the treatment and depends on the
total amount of cytostatics administered to the patient during their life
(cumulative toxicity). It is important to document all cytostatic doses the
patient has ever been administered. Anthracyclines are cytostatics with the
most severe cardiotoxicity.
Prevention: monitoring ECG in the course of the treatment and
undergoing an echo test as ordered by the doctor.
- Nephrotoxicity
Kidney damage is a typical side effect of platinum cytostatics (Cisplatin).
The damage initially manifests itself through magnesium deficiency, which
the patient may experience in the form of a tingling sensation, and later it
can even develop into the retention of nitrogenous substances in the body.
Prevention: monitoring the physiological values by the doctor.
- Neurotoxic symptoms
46
Cytostatics can damage not only peripheral nerves, but also the CNS.
Peripheral neuropathy causes tingling (paraesthesia) and numbness, initially
in the fingers and toes, but later it can also affect the fibres responsible for
movement. This toxicity is usually reversible and subsides in the space of
several weeks or months after the treatment is finished.
- Gonadal toxicity
Gonadal damage is typical of alkylating cytostatics. In men it is possible to
perform a semen cryopreservation before the beginning of chemotherapy
treatment. In women the situation is more complicated; using hypothalamic
hormones, it is possible to induce a temporary menopause and hope that the
reduced perfusion of eggs will lead to their smaller damage.
It is possible to extract some eggs before the beginning of the treatment
and afterwards perform assisted reproduction.
- Skin and adnexal toxicity of cytostatics

Hair loss alopecia is the most common and best known side effect of
cytostatics. Sometimes even the eyelashes or eyebrows may fall out, which
causes sweat to leak into the eyes. The development of alopecia depends on
the type and dose of cytostatic drug. It constitutes a highly depressing
experience for the patients.
It is important to give the patient timely information about the
development of side effects, about writing out a voucher for a wig, to
encourage them to work on their self-acceptance, and to assure them that
after the therapy ends, their hair will grow back.
- Hand-foot syndrome painful reddening of the palms and feet suitable
footwear, dermatologist, lubricating with suitable cosmetics.
- Onycholysis the detachment of the nail from the nail bed (preventing
injuries, dermatologist) taxanes.
7.2 Biological treatment
The term biotherapy refers to the application of substances which are

chemically identical or similar to the substances produced by the cells of the
human body. It is targeted at the individual molecules of cell signalling
pathways related to proliferation, apoptosis or cell differentiation. The
treatment is accurately targeted at target structures (growth factors, growth
factor receptors, etc.).
Division of biological treatment and the mechanism of action of the

individual types
The biological treatment of cancer can often be confusing because it is
divided into several groups.
Each of them fights cancer with its own mechanism:
1. monoclonal antibodies;
2. cancer vaccine;
3. growth factors;
4. tumour growth inhibitors;
5. inhibitors of the formation of tumour blood vessels;
47
6. cytokines;
7. gene therapy.
Monoclonal antibodies
Antibodies which are all the same, as they originate from one immune cell
clone. First the right type of immune cell is chosen, suitable for fighting a
specific neoplastic disease, and then it is genetically modified. Tumour cells
have abnormal proteins on their surface, which the antibody detects.
Genetically modified antibodies therefore specifically bind to the surface of
tumour cells. Here they either stop the growth of these cells, destroy them,
or carry the medication or radiation directly towards them. They leave the
remaining healthy tissue alone, therefore having no side effects.
Cancer vaccine
Preventively strengthens the immune system and helps it to destroy tumour
cells. In short, vaccination gives the immune system instructions about what
the cells, viruses or bacteria causing the neoplastic disease look like. The
immune system remembers these instructions and, upon encountering
danger, immediately intervenes.
Growth factors
These growth factor stimulating colonies help the body fight the neoplastic
disease by stimulating the growth of red and white blood cells as well as
platelets. They are used mainly in patients treated with chemotherapy to
stimulate bone marrow and to restore the number of the abovementioned
blood cells.
Tumour growth inhibitors

Substances inhibiting the growth factors of tumour cells, which are
subsequently unable to divide and grow.
Inhibitors of the formation of tumour blood vessels

Tumour tissue is very energy hungry, so it forms new vessels around itself.
These are supposed to bring nutrients which the tumour needs for its
growth. The so-called angiogenesis (vessel formation) inhibitors prevent
this from happening, so the tumour starves and shrinks.
Cytokines
Help the immune system fight tumour cells.
Gene therapy
Is still at research stage; specialists put high hopes in this research. It refers
to searching for a way of preventing the neoplastic disease from developing
by changing the genes which support its development.
Biological treatment in general:

- a promising method of treating oncology patients;
- can be combined with chemotherapy, which increases its
effectiveness;
- it already has a firm place in the treatment of oncology patients;
48
- their number is still growing and the indications are being extended;
- the downside is the high price of these preparations.
Starting treatment with biological therapy:

- the treatment procedure is always chosen individually;
- samples of biological and histological material are taken to confirm
the corresponding antibodies;
- biological medications are administered on a long term basis, i.e. for
a year or longer, in certain intervals;
- they are applied either separately or in combination with cytostatics
or hormones.
Side effects skin toxicity
The occurrence of this type of side effects is very high. In the case of
monoclonal substances they occur in 76 % of patients. The median time to
the development of a skin reaction is between 2 and 3 weeks. It takes 34
weeks for the skin reaction to develop fully. Even though the nursing staff
do not usually consider these reactions to be very serious, the patients
generally perceive them very negatively and often decide to discontinue the
treatment because of them.
It is important to prevent skin reactions:
- prevent the skin from drying out (no long and hot baths, no perfumed
soaps and alcoholic solutions);
- oil baths;
- use hypoallergenic deodorants;
- protective gloves for work;
- use soft comfortable footwear;
- do your manicure and pedicure before starting the treatment;
- use lubricating creams, dandruff shampoo;
- drink a sufficient amount of liquids.
7.3 Anti-tumour hormone therapy
The presence of hormones is important for the growth of the so-called

hormone-sensitive and hormone-dependent tumours. It is important to
prevent the proliferation of these hormone-sensitive tumour cells.
The hormone active treatment used in oncology is divided into these
groups:
1. medication inhibiting the effect of female sex hormones
anti-oestrogens Tamoxifen tablets (for breast cancer
treatment), long term treatment, even several years. During
long term administration it is necessary to regularly monitor
the thickness of uterine lining as it increases the incidence of
endometrial cancer;
aromatase inhibitors Arimidex tablets, Femara tablets, their
effect inhibits oestrogen formation;
gestagens (progesterones) high doses of progesterone,
reduce the plasma concentrations of oestrogen. High doses of
gestagens increase the appetite and are used to treat cancer
cachexia;
49
2. antiandrogens are used to treat patients with hormone-dependent breast
cancer;
3. corticosteroids Prednisone and Dexamethasone are used in oncology;
Hydrocortisone is used only exceptionally to deal with acute conditions.
Mind the side effects when administering high doses (stomach irritation,
opportunistic infections, oral and esophageal candidiasis with severe
soreness, changes in appetite, mental status changes, impaired wound
healing, ).
Role of the nurse in chemotherapy

Nurses handling cytostatics must know:
the guidelines of handling cytostatic drugs;
the risks related to the application of cytostatics;
the effects of cytostatics and side effects of chemotherapy;
the procedure in the case of cytostatic contamination;
the procedure in the case of extravasation development (the leakage
of a cytostatic drug outside the target vessel)
promptly stop the application of the cytostatic drug;
leave the needle at the application site and aspirate the
medication that has leaked out;
inform the doctor and follow his/her orders.
The application of chemotherapy in the form of bolus administration is

performed by the doctor or a general nurse specialist working without
professional supervision after finishing the adaptation process. The
application of infusion chemotherapy is performed by a general nurse
working without professional supervision after finishing the adaptation
process. The staff working with cytostatics must be trained in handling them
in the course of the adaptation process, after which the training is repeated
periodically once a year.
Nurses handling cytostatics must be able to:

- follow all safety and protection rules for storing and applying
cytostatics;
- apply cytostatics into the PVC, CVC or port;
- care for the venous access;
- monitor the patients condition and detect any signs of the side
effects of chemotherapy;
- handle and work with infusion pumps, portable dispensers;
- communicate with the patient and their relatives;
- deal with emergencies related to cytostatic administration.
Nurses handling cytostatics have the responsibility to:

- regularly and continuously educate themselves in new trends in
cytostatic treatment;
- follow the regulations and methods of safe handling of
cytostatics;
- give the patients information about the organisation of
chemotherapy application, the names of the medications and
50
their effects, about the method, frequency and duration of
cytostatic administration, about the possible side effects;
- draw up a nursing care plan for patients treated with
chemotherapy;
- maintain medical records.
Procedure of the nurse during the application of chemotherapy and when

monitoring its side effects:
- cytostatics are diluted centrally at the pharmacy and then dispatched
to the ward;
- the nurse receives the medication, checks it against the requisition
form and delivery note (first name and surname, national
identification number, the name and amount of the cytostatic drug)
and confirms the delivery with his/her signature;
- identifies the patient in the hospital bed;
- ensures venous access and cares for it;
- checks that the patient understands the information given to them by
the doctor and provides additional information if needed;
- educates the patient about the possible side effects and how to cope
with them;
- discusses with the patient the signs and symptoms which should be
reported to the nurse or doctor;
- applies cytostatics or assists the doctor in the application procedure,
- after each application of cytostatics and after the application is
finished, the nurse flushes the site with at least 10 ml of saline
solution;
- keeps the application procedure well documented in the medical
records in accordance with legal norms;
- maintains nursing documentation;
- monitors the application site in regular intervals;
- continuously monitors the side effects of chemotherapy and
documents them;
- when treating inpatients, the nurse checks that they have the
necessary information in case they need advice or help.
Role of the nurse in monitoring the side effects of chemotherapy

Optimal care of oncology patients can only be achieved by multidisciplinary
approach involving the mutual collaboration of the doctor, nurses, patient
and other staff. Besides the collaboration of the patient, the support of their
family and friends is also extremely important during the treatment.
Basic duties of the nurse during the application of chemotherapy:
- communicating with the patient and their relatives;
- caring for venous entries and applying chemotherapy;
- monitoring the side effects of chemotherapy;
- maintaining documentation and disposing of waste.
Caring for venous entries

The aim of ensuring a venous entry is the safe application of medications.
For the application of chemotherapy the PVC, CVC, Hickman catheter or a
port is used.
51
Duties of the nurse when caring for intravenous entries:
- educating the patient about the procedure (when using the CVC or
Hickman catheter or before implanting the port a written form of
informed consent is needed);
- educating the patient about the side effects;
- choosing a suitable site (when inserting the PVC);
- following the current nursing standards;
- planning continuous care of intravenous entries;
- performing and documenting care;
- ensuring the continuity of care and evaluating its results.
Caring for intravenous entries and applying chemotherapy is within the

spehere of competence of experienced nurses, working without professional
supervision, or nurse specialists only. Wards treating patients with ports or
Hickman catheters should train their own nurses, who are able to cope with
this kind of nursing care.
Summary
Anti-tumour farmacotherapy encompasses cytostatic and biological
treatment and hormone therapy. The greatest amount of information has
been given to you about chemotherapy. Thanks to a quick overview of the
topic you have learned about the indication and planning of cytostatic
treatment, and about the prescription and dosage of the treatment. You have
gained important knowledge regarding the method of application of
chemotherapy and the application itself, about maintaining documentation
and dealing with waste.
However, medications with anti-tumour effects also have side effects,
which endanger the patients in various time intervals from the time of
application. The toxicity of chemotherapy depends on the intensity of the
treatment. Besides detecting the signs of developing side effects, the nurses
role also involves the ability to react adequately and to intervene in time
using suitable nursing interventions based on the nursing care plan.

1. Which methods of applying cytostatics do you know?
2. How are the side effects of chemotherapy divided?
3. Do you know any cancer vaccines?
4. What is anti-tumour biological treatment?
Mail task No. 7
Draw up a nursing care plan (including nursing diagnoses) for a patient

suffering from neutropenia.
52
ABRAHMOV, J. Vybran otzky z onkologie XI. Praha: Galn, 2007, 194
pp. ISBN 978-80-7262-527-7.
s.r.o., 2005. 206 pp. ISBN 80-7254-542-6.
NOVOTN, J., VTEK, P. et al. Onkologie v klinick praxi. Standardn
pstupy v diagnostice a lb vybranch zhoubnch ndor. Praha: Mlad
fronta a. s., 2012, 531 pp. ISBN 978-80-204-2663-5.
53
8 PAIN IN ONCOLOGY IN ONCOLOGY PATIENTS
about the division of pain in relation to the neoplastic disease;

about assessing cancer pain;
about the principles of cancer pain treatment.
Keywords:
pain, metastases, pain scale, pain assessment.
Pain is one of the most common and most feared clinical symptoms in
oncology patients. Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described in terms of
such damage. Pain is always subjective.
Pain:
1. acute develops due to tissue damage caused by injury or disease
(primary tumour);
lasts several days or weeks;
the location of the pain is easy to determine;
if the intensity is higher, the pain constitutes a mental
burden;
the treatment is determined by a general practitioner or a
specialist;
farmacotherapy analgesics; their effects are strong.
2. chronic there is no possibility of finding a simple causal

relationship between tissue damage and the experience;
lasts longer than is typical of the given affected tissue or
organ;
last longer than 36 months;
constitutes a mental burden;
the treatment is determined by a team of specialists;
farmacotherapy analgesics, adjuvant and auxiliary
substances; their effects are often insignificant.
Cancer pain is a collective term for a whole range of painful conditions. The
patients may suffer from several types of pain at the same time, and each of
them may require a different treatment procedure.
Pain in relation to the neoplastic disease:

pain induced by the tumour (bone metastases, the tumour
infiltrating soft tissue);
54
pain induced by diagnostics and anti-tumour therapy
(diagnostic procedures punctures, painful neuropathy after
chemotherapy, muscle spasms, pain after surgery, after
radiotherapy radiation dermatitis);
pain with no direct link to the neoplastic disease, caused by
an overall weakening of the patient (migraine, postherpetic
neuralgias).
Pain depending on the prevailing pathophysiological mechanism:

nociceptive somatic pain induced by the irritation of nerve
endings (nociceptors) in local tissue damage (bone
metastases, the tumour infiltrating the muscles and skin);
nociceptive visceral pain induced by the irritation of
nociceptors in the abdominal cavity and the lesser pelvis,
sometimes indicated by the patient as being felt in a different
location on the body surface referred pain (in patients
suffering from pancreatic, liver, intestinal or bladder cancer);
neuropathic pain develops as a result of damage to structures
of the peripheral or central nervous system the patient
describes the pain as burning, tingling and electric-like
(neuropathy after chemotherapy, damage of nerve plexus);
mixed pain bears the features of both nociceptive and
neuropathic pain (e.g. a tumour in the lesser pelvis which
infiltrates the bones and muscles of the pelvic wall and at the
same time destroys nerve plexus).
8.1 Assessing cancer pain
General case history

- finding the cause of the pain;
- assessing the condition in relation to the neoplastic disease;
- assessing the mechanism of pain;
- O P Q R S T:
O onset localising the pain (determining what hurts the patient);
- the patient should not only describe the pain, but also show it (pain
map the patient plots the location of the pain into a picture of a
person);
P provocation/aggravating factors (movement, position, food);
Q quality of the pain and its character (a patient suffering from pain
can describe the pain with various adjectives. Based on this description
it is often possible to deduce the type of pain and its possible causes);
R radiation of the pain;
S severity of the pain its intensity, tolerability, sleep how the pain
affects sleep.
Assessing the intensity of the pain pain assessment tools.
55
- Simple tools to measure the intensity of the pain.
Verbal pain scale (e.g. no pain mild pain moderate pain severe
pain unbearable pain);
- it is presumed that the patient understands the individual categories.
Visual analogue scale the patient indicates the intensity of their pain
along a continuous line between two end-points, or sometimes in a
triangle representing the continuum of pain intensity ranging from no
pain to the worst pain that the patient can imagine. In practice it is
necessary to continuously check that the patient understands the method
and that they use it correctly.
Numeric rating scale the patient assigns a number to the intensity of

pain they are currently feeling, usually ranging from 0 to 10. The
patients generally understand the numeric rating scale better than the
analogue and visual scales.
T time/pain duration changes of the pain since onset (determining
when the pain started, how it has evolved, how often it appears, whether
the pain is constant or intermittent, what the divergences throughout the
day are, which factors reduce the pain and which aggravate it). The
intensity of the pain often fluctuates throughout the day. The patient is
advised to record the current intensity of their pain.
56
The goal of pain treatment is the elimination of pain achieved by
eliminating the cause. If it is not possible, analgesics are used to reduce the
pain. The medication and dose must be chosen in consultation with the
patient (if they are capable of such consultation). The highest aim is to
eliminate the pain completely. However, reaching this goal is limited by the
side effects of analgesics, which is why the aim is to achieve at least such a
level of pain that is subjectively easy to bear. The price for achieving
complete painlessness is often fatigue, drowsiness and a reduced ability to
communicate. The goal of pain treatment in patients suffering from a
neoplastic disease is to achieve the best possible quality of their lives. The
first step is to ensure a sufficient amount of undisturbed sleep, the second is
relief from pain when the body is in a state of rest, and the last but not least
step is the aim to achieve relief from pain during physical activity.
Cancer pain treatment is a part of complex oncology treatment. The
modalities used in the treatment can be divided into causal and
symptomatic. Causal pain treatment uses the procedures of anti-tumour
treatment; its goal is to shrink or remove the tumour (radiotherapy,
chemotherapy, surgery, hormone therapy) or to reduce its biological activity
(radiotherapy, biological treatment).
Pain treatment is symptomatic. Symptomatic procedures influence the
development, transmission and further processing of the painful stimulation.
The fundamental pillar of cancer pain treatment is farmacotherapy, although
psychotherapy, rehabilitations and invasive methods also play an important
role.
If non-invasive therapy involving medications is performed accurately
and correctly, it is possible to keep pain under control in 8090 % of
oncology patients. Analgesics are the keystone of cancer pain treatment, but
very often it is necessary to administer additional medications as well this
is called comedication. Analgesics must be administered to oncology
patients in fixed time intervals, which means precise application by the
clock.
8.2 Basic principles of cancer pain treatment
- the basic guideline for choosing analgesics is the intensity of the

pain
mild pain non-opioid analgesics;
moderate pain weak opioids in combination with
non-opioid analgesics;
severe pain strong opioids, sometimes in
combination with non-opioid analgesics;
- in the case of constant pain, analgesics are administered in regular
intervals (not as needed)
the dosing interval should ensure that an even plasma
level of the medication is maintained and that the next
dose is administered before the pain reappears;
57
- the amount of the dose is individual and should always be titrated
gradually until a reasonable relief from pain is achieved, but at the
same time the side effects are still tolerable;
- analgesics should be administered in the least invasive way possible
using the extended release oral dosage form or the
transdermal dosage form;
- the effects of analgesics and the side effects should be assessed
regularly, taking into consideration the quality of the patients life;
- the treatment of the side effects of analgesics is part of a complex
treatment plan; it is important to actively deal with the symptoms of
the neoplastic disease (fatigue, anxiety, depression, nausea);
- if the response to the administered systemic analgesics is ineffective,
it is possible to consider invasive analgesic procedures (regional
anaesthesia, neurosurgical methods).
Mild pain treatment grade 1 on the WHO scale:

- non-opioid analgesics
analgesics antipyretics (acetylsalicylic acid,
Paracetamol, metamizole Novalgine, Algifen);
non-steroidal antiphlogistics (ibuprofen, diclofenac,
indomethacin, Nimesulide).
Moderate pain treatment grade 2 on the WHO scale:

Patients with whom sufficient relief was not achieved by grade 1 analgesics
are indicated to use a combination of a non-opioid analgesic and the so-
called weak opioid:
- weak opioids codeine, dihydrocodeine, tramadol (most used in
practice), whose side effects are very similar to those of strong
opioids.
Strong pain treatment grade 3 on the WHO scale:

Patients suffering from strong pain or patients suffering from moderate pain
that was impossible to reduce with grade 2 medications on the WHO scale
are indicated the so-called strong opioids.
It is possible to administer non-opioid and adjuvant analgesics in
combination with strong opioids. The dosage of strong opioids is strictly
individual and the analgesic effect depends on the amount of the dose. The
maximum daily dose is not formally set. The initial doses are often
increased depending on the intensity of the pain. If relief is not achieved, the
daily dose is usually increased by 3050 %. Before assessing the effect of
the applied dose, it is necessary to wait until an even plasma level is
achieved. Only then is it possible to assess whether the dose is sufficient, or
whether it should be increased. In patients with intense or unstable pain it is
more suitable to start the treatment by using parenteral opioids.
Strong opioids:
rapid-release morphine, controlled-release morphine, Fentanyl TTS,
controlled-release oxycodone, buprenorphine, hydromorphone.
8.3 Breakthrough (episodic) pain
58
The intensity of the pain in oncology patients often fluctuates considerably
throughout the day. Besides developing constant pain, the patient may also
experience an increase of the intensity of their pain dependent on some
types of movement and activities. A transient burst of high intensity pain
with a stable level of basic pain in patients treated with opioids is called
breakthrough episodic pain.
Breakthrough pain can be divided into:
spontaneous;
incidental: related to a certain event;
1. predictable (movement, defecation, food intake);
2. unpredictable (sneezing, peristalsis);
procedural (rehabilitation, redressing);
end-of-dose failure.
The basic strategy of breakthrough pain treatment is administering a

supplemental rescue dose of a fast-acting analgesic (opiate or non-opiate)
if any pain appears. However, at the same time the patient continues to take
the original dose regularly. Each patient with chronic cancer pain should be
given medications by the doctor to cope with basic chronic pain and also
rescue medications for treating breakthrough pain. The amount of the rescue
medication must be set individually.
8.4 Side effects of opioids
In the initial stage of being administered opioid analgesics, patients usually

suffer from nausea (310 days), sometimes accompanied by vomiting,
vertigo and apathy. After longer administration these symptoms subside
completely. It is necessary to educate the patient about the possible
complications before starting pain treatment with opioids. Prophylaxis
consists in administering common antiemetics. The initial apathy does not
require any special treatment.
Side effects of opioids:
- constipation prevention is important (higher liquid intake,
administration of laxatives);
- nausea and vomiting administration of antiemetics;
- restlessness, confusion, apathy monitoring the state of
consciousness, preventing the patient from falling, changing opioids
if the symptoms persist;
- itching administration of antihistamines;
- tics and jerky movements monitoring movement and changing
analgesics if needed;
- respiratory depression finding out if it is the result of administering
opioids; if so, an antidote is administered (Naloxone).
Role of the nurse in monitoring pain
59
Before starting pain treatment it is necessary to assess the pain
accurately. Pain is subjective, and can therefore only be measured
accurately by the patients. Subsequently, it is important for the nurse to:
- obtain accurate information about the pain when receiving the patient
and document everything in the records;
- set a nursing diagnosis, goal and interventions;
- monitor the pain and the effects of analgesics in regular time intervals
or in dependence on the administration of the analgesic;
- use pain assessment instruments to measure the pain;
- pay attention to the location, character, spreading and time course of
the pain;
- monitor the provoking factors which induce pain in the patient;
- monitor the presence of side effects;
- make use of teamwork and the suitable possibilities of supportive
therapy (massages, exercise, relaxation techniques, relief positions, );
- encourage the patient and help them as well as their family with a
soothing word and the general conduct;
- keep everything well documented.
Summary
Insufficiently treated pain leads to insomnia, fatigue, depression and a
feeling of exhaustion. Patients in pain usually eat and drink very little,
which contributes to the worsening of their nutritional status, immunity and
general physical fitness. Untreated pain reduces the patients motivation to
continue treatment, worsens their cooperation and subsequently also the
results of anti-tumour treatment. Contemporary medicine is able to reduce
pain to a tolerable level in most oncology patients; relief from pain is
usually achieved by a non-invasive administration of analgesics.
Monitoring and assessing pain performed by the nurse provides the
doctors with important information about whether the pain treatment
ordered to the patient is really helping them. Nursing documentation gives a
detailed overview of the intensity of the pain in dependence on time and the
administered medications, nursing interventions and supportive agents.

1. Divide pain in relation to the neoplastic disease.
2. Which instruments for assessing pain do you know?
3. What is breakthrough pain? Explain the strategy of its treatment.
4. Describe the role of the nurse in monitoring pain.
5. Which types of opioids, depending on the form and method of
application, do you know?

ADAM, Z., KREJ, M., VORLEK, J. et al. Obecn onkologie. 1st ed.
Praha: Galn, 2011. 393 pp. ISBN 978-80-7262-715-8.
60
pp. ISBN 80-86793-04-4.
KOZK, J., ROKYTA, R., KRIAK, M. et al. Opioidy a bolest. Praha:
Galn, 2001. 56 pp. ISBN 80-7262-080-0.
SOFAER, B. Bolest. Pruka pro zdravotn sestry. 1st Czech ed. Praha:
Grada Publishing, a. s., 1997. 104 pp. ISBN 80-7169-309-X.
61
9 COMMUNICATION IN ONCOLOGY
about the guidelines of communicating with patients;

about therapeutic communication;
about communication barriers.
Keywords:
communication, therapeutic communication, communication barriers.

Communication
Communication is an important aspect of medical and nursing care. It is
important as it enables the patients and their loved ones to decide about their
care, and it is also an essential source of information about the possibilities
of treatment and side effects of therapy. The goal of effective professional
communication is to create an atmosphere of trust and cooperation. It is
necessary to provide information repeatedly and continuously, and to use
feedback from the patient to obtain information about their health condition
and the extent to which they have understood the information provided to
them.
Effective communication contributes to the patient adopting a positive
attitude towards the treatment, reduces fear, helps in the case of anxiety and
stress, improves the patients cooperation, etc. Effective communication
enables the nurse to:
- learn about the patients main feelings and problems;
- help to break and receive bad news;
- help to decide about the treatment;
- watch for any unfavourable reactions by the patient (both physical
and mental).
Nurses also play an important role in the education of patients:

- they give the patients verbal and written information (about the
treatment, about the development of possible side effects, they
educate the patients about suitable prevention);
- they encourage the patients to do activities suitable for them;
- they use feedback to check whether the patients have understood the
information provided to them;
- they encourage the patients and their loved ones for the entire
duration of the treatment;
- they link their information with the multidisciplinary team;
- they help the patients to deal with situations involving breaking and
receiving news about the disease and treatment;
62
- they watch for any unfavourable reactions by the patient (both
physical and mental).
Communication does not only involve the transfer of information. It is a

process of exchanging information, mutual understanding and support,
coping with difficult and sometimes painful problems, and overcoming
emotional distress related to these problems. It requires time, determination
and a sincere willingness to hear out and understand the worries of other
people. We can call it therapeutic communication in the sense of a
conscious, intentional and purposeful use of verbal and nonverbal
communication skills in the interaction between the nurse and the patient.
However, this communication does not only concern the medic and the
patient. It must also take place between the medic and the patients family,
the patient and their family, and among the individual health care providers
from various wards.
Therapeutic communication uses many skills of formal counselling.

Effective communication requires:
- preparing the surroundings ensuring privacy and a sufficient
amount of time;
- clarifying the purpose of the conversation;
- inducing trust;
- the ability to obtain information;
- active listening and analysing the verbal and nonverbal
manifestations of the patient;
- empathy;
- clarifying problems;
- clarifying the patients mental manifestations;
- summarising the problems.
The communication can be made more difficult by the so-called

communication barriers, which can occur both on the part of the patient and
on the part of the medics.
Communication barriers on the part of the patient:

- an unwillingness to confide their problems;
- an individual preference of a certain method of communication;
- multicultural problems affecting the communication;
- cognitive disorders.
Barriers on the part of medics:

1. Values, attitudes and beliefs the personal values of the medic affect the
values and decisions of the patient. When communicating with the patient,
the conversation should be directed at them.
2. A lack of communication skills and a fear of the nurse that he/she will not
be able to answer all the patients questions.
63
Summary
Communication in healthcare is a very important aspect for all those who
take part in it (the patient, family, medics). The communication can be made
more difficult by the so-called communication barriers. The most common
communication barriers on the part of the patient are an unwillingness to
confide their problems, multicultural problems, cognitive disorders or an
individual preference of a certain method of communication by the patient.
On the part of medics we can come across barriers such as a lack of
communication skills or different values and attitudes. Good communication
skills are essential in all areas of healthcare. Communication skills are one
of the basic professional skills of nurses. Communication is the keystone for
finding and meeting the needs of the patient. Nurses who communicate well
are the solicitors of their patients and are indispensable in the treatment and
nursing process.

1. What are communication barriers?
2. What is therapeutic communication?

KIVOHLAV, J. Psychologie nemoci. 1st ed. Praha: Grada publishing,
2002. ISBN 80-247-0179-0.
64
10 NUTRITION IN ONCOLOGY
about the risk of developing malnutrition;

about the specific features of nutrition in oncology patients;
about the indication for enteral and parenteral nutrition.
Keywords in this chapter:
malnutrition, weight loss, PEG.
Nutrition is an important part of anti-tumour treatment. In the case of most

neoplastic diseases, one of the manifestations is the weight loss of the
patient even before the oncology treatment begins. Oncology patients
suffering from fever, diarrhoea or vomiting also suffer from a lack of
appetite, and if their condition lasts several days, further weight loss occurs.
In hospital the patients can also lose weight due to the necessity of fasting
before some procedures. Often the food intake of the patients is made worse
by the perception of odours and the hospital environment.
Malnutrition is characterised by anorexia, weight loss, muscle mass and
subcutaneous fat loss, and is accompanied by general weakness and
anaemia. In almost one half of patients with tumours, signs of malnutrition
are already present when the diagnosis is made. Cancer-associated
malnutrition constitutes a negative prognostic factor. The greater the weight
loss and the more severe the malnutrition, the higher the risk of
complications of anti-tumour treatment. These can interfere with the
subsequent therapeutic treatment plan and worsen the overall result of anti-
tumour treatment.
Oncology patients should eat smaller portions in shorter time intervals.
It is advisable to serve protein products in the form of yoghurt, cottage
cheese or cheese with the meals. However, problems arise in patients with a
lower food intake (they eat little), who are unable to manage the increased
amount of food. In these cases sipping is recommended. At this time there
are several companies on the market offering a wide range of flavours
(Nutridrink, Fresubin, Nutrilac, etc.), products for diabetics (Diasip,
Novasource Diabet), no fat products (Nutridrink Jouce Style, Providextra
Drink), high protein products (Ressource Protein, Nutridrink protein),
products containing fibre (Nutridrink Multi Fiber, Isossource Fiber) or
products for patients with decubitis (Cubitan).
Oncology patients are not served food which is unsuitable for them.
This means especially citrus fruit (grapefruit), soft-ripened and blue cheese
(hermeln, niva), pork feast specialties, legumes, flatulent vegetables and
spicy food. The patients are sensitive to various odours and should therefore
avoid aromatic food.
65
Artificial clinical nutrition
Patients in whom it is impossible to maintain the nutritional status through
oral nutrition may be indicated for enteral or parenteral nutrition.
Enteral nutrition is preferred in oncology patients in those cases where
the function of the gastrointestinal tract has been at least partly retained. In
comparison with parenteral nutrition, enteral nutrition carries a lower risk of
complications. The biggest problem with enteral nutrition is the insertion
and tolerance of nasogastric tubes, which is why abdominal access is more
suitable for long term nutrition (PEG, jejunal feeding tube, gastrostomy). In
the past patients with enteral nutrition were served ordinary food, which was
blended to make the application easier. Nowadays a pharmaceutical diet is
preferred, which is more full value as regards the content.
Parenteral nutrition means supplying nutrients intravenously, which is
why this method is dependent on intravenous access. The most common
venous access is the CVC or PVC. Through the peripheral venous system,
which is inserted into superficial veins on the upper limb, it is possible to
administer only some less concentrated solutions (up to 850 mOsm/L).
More concentrated solutions increase the risk of chemically irritating the
endothelium, and thus cause phlebitis. Parenteral nutrition is a treatment
procedure used especially when the gastrointestinal tract fails to function.
The disadvantage of a long term application of parenteral nutrition is that
the patient develops intestinal atrophy and that the intestinal mucosal barrier
is weakened, which means there is a high risk of developing an endogenous
infection. It is advisable to supplement this method with enteral nutrition
whenever possible. Employing both methods is not counter-productive; in
many cases they can even complement each other.
Weight loss has a mental impact on the patient, e.g. it reduces their ability to
cooperate and rest actively.
Summary
From a general point of view, malnutrition means a bad nutritional status,
which encompasses not only malnutrition, but also excessive nutrition
(obesity). Weight loss is one of the most important parameters of
malnutrition. When the weight loss exceeds a certain limit, it becomes an
important indicator of malnutrition (e.g. a 10 % weight loss in the last 6
months). In oncology it is important to actively seek patients with a risk of
malnutrition. An effective procedure is nutritional risk screening, which is
performed by the nurse in hospitalised patients. In patients demonstrating
significant malnutrition as well as in patients with a high risk of developing
malnutrition it is always necessary to consider which form of nutritional
support is the most suitable. The possibilities, forms, advantages and
disadvantages of nutritional support have been presented to you in this
chapter.
66
1. What is nasogastric nutrition and which complications may arise when it
is administered?
2. Which criteria are used to assess the patients nutritional status?
Mail task No. 10

Draw up a nursing care plan for an oncology patient with PEG including
nursing diagnostics.

GROFOV, Z. Nutrin podpora. Praktick rdce pro sestry. 1st ed. Praha:
Grada Publishing, a. s., 2007. 237 pp. ISBN 978-80-247-1868-2.
67
11 PALLIATIVE CARE
the definition of palliative care;

about the principles of palliative care in oncology patients;
about the most common physical symptoms.
Keywords:
palliative care, supportive care, symptoms.

The term palliative is derived from the Latin word pallium, which means
mask or cloak. This ethymology implies that the goal of palliative care
is to cover the effects of an incurable disease with a healing mask or to
provide a cloak to those who have been left out in the cold because curative
treatment cannot help them.
According to the World Health Organisation (1990):

Palliative care is the active total care of patients whose disease is not
responsive to curative treatment. Control of pain, of other symptoms and of
psychological, social and spiritual problems is paramount. The goal of
palliative care is the achievement of the best quality of life for patients and
their families.
The term palliative care is very close to the term supportive care, which
strives for the best possible quality of life for patients and their loved ones
for the entire duration of the oncology disease. Supportive care does not aim
to destroy tumour cells, but to reduce the complications induced by the
tumour, anti-tumour treatment or the oncology disease itself.
In oncology the term palliative includes all non-curative treatment of
patients (treatment which does not cure). In complex oncology treatment the
procedures of anti-tumour and supportive treatment complement each other.
Some procedures of non-curative anti-tumour treatment can significantly
improve the quality of life even for patients at an advanced or final stage of
cancer (e.g. analgesic radiotherapy). The goal of anti-tumour palliative
chemotherapy and palliative radiotherapy is to prolong survival and to
reduce or prevent the symptoms and complications of the tumour.
Modern oncology treatment is not possible without interdisciplinary
collaboration when putting together the treatment plan. Considering the
complex complications of oncology patients in palliative care, it is
necessary to collaborate not only with medical professions, but with other
professions as well (social workers, nutritional therapists, clergy,
physiotherapists, volunteers, etc.).
68
Besides hospices, mobile hospices and palliative care wards, palliative
care is also provided to oncology patients in oncology wards and centres.
11.1 Symptoms
A symptom indicates a change of function felt by the patient. It warns a

person that something is not right and that they should seek medical advice.
Before starting the treatment of a patients symptoms, it is important to find
the cause of the given symptom, the importance of the symptom for the
patient and the means by which the symptom can be reduced. Together with
the patient it is necessary to determine which of the symptoms and other
problems are most significant for them and to deal with those first.
However, we must not forget the side effects that the chosen treatment of a
particular symptom may cause. It is therefore necessary to compare the
effect of the symptomatological treatment on the patients quality of life
with the patients condition without the treatment, as an intensive treatment
of symptoms may induce several other symptoms as well.
The most common physical symptoms are:

o dyspnoea a subjective feeling of lacking air and difficulty
breathing (we try to calm the patient, make them take the least
uncomfortable position possible, ensure fresh air and breathing and
relaxation exercises);
o cough we try to remove irritating odours, ensure a suitable position
and fresh air, humidify the air;
o death rattle noisy raspy breathing caused by the accumulation of
mucus in the airways and an inability of the patient to expectorate
(the patient is usually no longer aware of their surroundings or
themselves); nursing interventions aspiration are carried out with
respect to the relatives and fellow patients;
o nausea and vomiting dietary measures easily digestible food,
small portions of food, selective diet according to the patients taste,
removing negative odours, not forcing to patient to eat and drink;
o constipation sufficient hydration, ensuring intimacy during
defecation, reducing pain related to defecation;
o intestinal obstruction syndrome usually dealt with surgically;
o lack of appetite reduced or missing appetite;
o cancer cachexia a complex protein, lipid and carbohydrate
metabolism disorder;
o hiccups;
o pruritus;
o delirium a quantitative consciousness impairment with fluctuating
intensity accompanied by the impairment of attention, perception,
cognitive functions and psychomotor manifestations;
o anxiety and depression;
o psychosocial aspects of an advanced disease.
In the last moments of life biological needs become less important,
while social and spiritual needs gain significance.
69
In palliative care of oncology patients it is also necessary, with the patients
agreement, to engage the patient and their family in planning the care of
symptoms. We must realise that:
- in the case of advanced diseases it is often not possible to remove the
symptom completely, and that dealing with one symptom can cause
other symptoms to worsen;
- when attempting to reduce the symptom, we must respect the
patients wishes.
Nursing care focuses on the following areas:

- skin care;
- the prevention of decubiti and positioning;
- care of the patients nutrition nutritional care;
- care of defecation;
- care of the drinking regime;
- care of the airways;
- care of the oral cavity.
The role of the nurse involves detection, adequate intervention and
regular monitoring of the patient and interventions. Care of symptoms is
addressed by O'Connor, Aranda (2007) in their book Palliative Care
Nursing: A Guide to Practice.
Summary
The principles of palliative care can be used in a whole range of chronic
diseases. This chapter dealt with the palliative care of oncology patients.
Palliative care in oncology is a type of supportive care of patients at an
advanced or final stage of incurable diseases. Palliative medicine aims to
maintain a good quality of life. It tries to offer effective treatment and
support concerning physical complications and psychosocial and spiritual
needs not only to the patient, but also to their family. Its goal is to prevent
the patient from suffering from unbearable physical symptoms and to enable
them to see their life as meaningful until the end. The treatment and care
stem from the specific needs of the patient. From the vast subject of
palliative care you have gained basic information about the care of oncology
patients in palliative care and a list of the most common symptoms that
health care providers deal with in these patients.

1. What are the specific features of palliative care in oncology?
2. When is the term death rattle used in relation to patients in palliative
care?
3. What is palliative radiotherapy?

INGLETONOV, CH. (eds.). Principy a praxe paliativn pe. 1st ed.
Brno: Spolenost pro odbornou literaturu, 2007. pp. 175198. ISBN 978-80-
87029-25-1.
70
MAREKOV, J. Oetovatelsk diagnzy v NANDA domnch. 1st ed.
Praha: Grada, 2006. 264 pp. ISBN 80-247-1399-3.
PAYNEOV, S., SEYMOUROV, J., INGLETONOV, CH. (eds.).
Principy a praxe paliativn pe. 1st ed. Brno: Spolenost pro odbornou
literaturu, 2007. pp. 153174. ISBN 978-80-87029-25-1.
71
REFERENCES
ADAM, Z., VORLEK, J., KOPTKOV, J. Obecn onkologie a

podprn lba. 1st ed. Praha: Grada Publishing, a. s., 2003. 787 pp. ISBN
80-247-0677-6.
ADAM, Z. et al. Hematologie pehled malignch hematologickch
nemoc. 2nd ed. Praha: Grada, 2008. 390 pp.
ADAM, Z., KREJ, M., VORLEK, J. et al. Obecn onkologie. 1st ed.
Praha: Galn, 2011. 393 pp. ISBN 978-80-7262-715-8.
BRTLOV, S. Sociologie medicny a zdravotnictv. 6th ed. Praha: Grada,
2005. 188 pp. ISBN 80-247-1197-4.
BUGOV, R. Paliativn pe v geriatrii. 1st ed. Ostrava: University of
Ostrava, 2011. 101 pp. ISBN 978-80-7368-835-6.
CEKA, R. et al. Interna. Praha: Triton, 2010. 1st ed. 855 pp. ISBN 978-80-
7387-423-0.
HRUB, M., FORETOV, L., VORLKOV, H. Role sestry v prevenci
a vasn diagnostice ndorovch onemocnn. 1st ed. Brno: GAD studio,
2001. 77 pp. ISBN 80-238-7618.
MAREKOV, J. Oetovatelsk diagnzy v NANDA domnch. 1st ed.
Praha: Grada, 2006. 264 pp. ISBN 80-247-1399-3.
KELNER, P. Protindorov chemoterapie. 1st ed. Praha: Galn, 1996. 614
pp. ISBN 80-85824-36-1.
KLENER, P., VORLEK, J. et al. Podprn pe v onkologii. 1st ed.
Praha: Galn, 1998. 231 pp. ISBN 80-902501.2-2.
pp. ISBN 80-86793-04-4.
COLLECTIVE WORK. Onkologick rizika. 1st ed. Brno: Masarykv
onkologick stav, 2001. 96 pp. ISBN 80-238-7620-1.
NOVOTN, J., VTEK, P. et al. Onkologie v klinick praxi. Standardn
pstupy v diagnostice a lb vybranch zhoubnch ndor. Praha: Mlad
fronta a. s., 2012. 531 pp. ISBN 978-80-204-2663-5.
O'CONNOR, M., ARANDA, S. Paliativn pe pro sestry vech obor. 1st
ed. Praha: Grada, 2005. 324 pp. ISBN 80-247-1295-4.
ROKYTA, R. et al. Bolest. Praha: TIGRIS, spol. s r. o., 2006. 684 pp. ISBN
802350000000.
AFRNKOV, A., NEJEDL, M. Intern oetovatelstv. 1st ed. Praha:
Grada, 2006. 211 pp. ISBN 80-247-1777-8.
VORLEK, J. et al. Klinick onkologie I. dl obecn onkologie. Brno:
Vydavatelstv Masarykovy univerzity, 1995. 231 pp. ISBN 80-210-1256-0.
VORLEK, J. et al. Paliativn medicna. 1st ed. Praha: Grada publishing,
1998. pp. 307349. ISBN 80-7169-437-1.
onkologie pro sestry. 1st ed. Praha: Grada Publishing a. s., 2006. 328 pp.
ISBN 80-247-1716.6.
72
This project is co-financed by the European Social Fund and the public budget of
the Czech Republic.
Name: Nursing Care in Oncology

Authors: Mgr. Erika Hajnov Fukasov
Edition: first, 2014
Number of pages: 73
Projects: Modernization Diverzifikation Inovation
Reg. number of the project:CZ.1.07/2.2.00/28.0247
Publisher: University of Ostrava
Hajnov Fukasov
University of Ostrava
73

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ERIKA HAJNOV FUKASOV

Time needed to read the chapter

Summary summing up the subject-matter, summary of the chapter.

References books quoted in the study material or used to supplement/extend it.

Questions to think about

Solutions and answers to individual tasks, assignments and tests.

HAVING STUDIED THE TEXT YOU WILL KNOW:

YOU WILL GET:

You will be able to:

Time needed to read the course material : 20 hours.

information about the mapping of the occurrence of malignant

epidemiology, epidemiological indicators, etiology, tumour pathology.

Time needed to read the chapter: 60 minutes.

A neoplastic disease is the uncoordinated growth of atypical cells, which

1.1 Epidemiology of tumours

Epidemiology is a science which studies diseases in relation to the entire

1.2.1 Genetic influence on the formation of tumours

The frequent occurrence of certain tumours in one family is called familial

1.2.2 External factors and tumour formation

The development of an oncology disease is caused partly by external and

Role of the nurse in prevention:

Questions and tasks:

Further reading related to the chapter:

about the importance of accurate diagnostics in oncology;

diagnostic methods, diagnostics of tumours, nursing diagnoses.

Time needed to read the chapter: 60 min.

Diagnostic methods help in:

Complete physical examination

Microscopic examination of biological material

2.1 Tumour pathology

Classification of malignant tumours

Questions and tasks:

Mail task No. 2

about the principles and planning of the treatment;

oncology therapy, prediction of the treatment response, remission, relapse.

Time needed to read the chapter: 30 min.

3.1 Division of the treatment according to its goal

3.2 Evaluating the treatment results

3.3 Monitoring after the treatment

Questions and tasks:

Further reading related to the chapter:

about the division and description of procedures in surgical

Time needed to read the chapter: 40 min.

Surgical treatment is used:

Role of the nurse in surgical oncology

Perioperative care/before the transfer to the operating theatre:

Questions and tasks:

Mail task No. 4

Further reading related to the chapter:

In this chapter you will learn:

about the division of radiotherapy according to the radiation source;

radiosensitivity, radioresistance, teleradiotherapy, brachytherapy.

In the case of many neoplastic diseases radiotherapy is a part of the standard

Radiotherapy according to the position of the radiation source:

Radiotherapy according to the goal/intention of the treatment:

The effect of radiation manifests itself on the molecular level by affecting

5.1 Radiosensitivity and radioresistance

Both malignant tumours and healthy tissue have different sensitivity to

5.2 Types of ionising radiation

In clinical practice two types of ionising radiation are used

5.3 Radiation sources

o Systemic application of radioisotopes