NEO 113 JuLy 16, 2011

Oncology defined
Branch of medicine that

deals with the study, detection, treatment and management of cancer

Root words
Neo- new
Plasia- growth Plasm- substance Trophy- size +Oma- tumor Statis- location

Root words
A- none
Ana- lack Hyper- excessive Meta- change Dys- bad, deranged

CANCER NURSING
Etiology of cancer 1. PHYSICAL AGENTS Radiation Exposure to irritants Exposure to sunlight Altitude, humidity

CANCER NURSING
Etiology of cancer 2. CHEMICAL AGENTS Smoking Dietary ingredients Drugs

CANCER NURSING
Etiology of cancer

Genetics and Family History

Colon Cancer Breast cancer

CANCER NURSING
Etiology of cancer Dietary Habits

Low-Fiber High-fat Processed foods alcohol

CANCER NURSING
Etiology of cancer

Viruses and Bacteria

DNA viruses- HepaB, Herpes, EBV, CMV, Papilloma

Virus RNA Viruses- HIV, HTCLV Bacterium- H. pylori

CANCER NURSING
Etiology of cancer

Hormonal agents
DES

OCP especially estrogen

CANCER NURSING
Etiology of cancer

Immune Disease
AIDS

CANCER NURSING
Body Defenses Against TUMOR 1. T cell System/ Cellular Immunity
Cytotoxic T cells kill tumor cells

2. B cell System/ Humoral immunity B cells can produce antibody 3. Phagocytic cells Macrophages can engulf cancer cell debris

CANCER NURSING
Cancer Diagnosis
1. BIOPSY The most definitive 2. CT, MRI 3. Tumor Markers

CANCER NURSING
Cancer Staging The degree of DIFFERENTIATION Stage 1- Low grade Stage 4- high grade

CANCER NURSING
GENERAL MEDICAL MANAGEMENT 1. Surgery- cure, control, palliate 2. Chemotherapy 3. Radiation therapy 4. Immunotherapy 5. Bone Marrow Transplant

CANCER NURSING
GENERAL Pharmacology 1. antimetabolites 2. antibiotics 3. plant alkaloids 4. antiemetics

CANCER NURSING
GENERAL Promotive and Preventive Nursing Management 1. Lifestyle Modification 2. Nutritional management 3. Screening 4. Early detection

SCREENING
1. Male and female- Occult Blood, CXR, and DRE
2. Female- SBE, CBE, Mammography and Paps Smear 3. Male- DRE for prostate, Testicular self-exam

Nursing Assessment
Utilize the ACS 7 Warning Signals CAUTION C- Change in bowel/bladder habits A- A sore that does not heal U- Unusual bleeding T- Thickening or lump in the breast I- Indigestion O- Obvious change in warts N- Nagging cough and hoarseness

Nursing Assessment
Weight loss
Frequent infection Skin problems Pain Hair Loss Fatigue Disturbance in body image/ depression

Nursing Intervention
MAINTAIN TISSUE INTEGRITY
Handle skin gently Do NOT rub affected area Lotion may be applied Wash skin only with SOAP and Water

Nursing Intervention
MANAGEMENT OF STOMATITIS
Use soft-bristled toothbrush Oral rinses with saline gargles/ tap water Avoid ALCOHOL-based rinses

Nursing Intervention
MANAGEMENT OF ALOPECIA Alopecia begins within 2 weeks of therapy Regrowth within 8 weeks of termination Encourage to acquire wig before hair loss occurs Encourage use of attractive scarves and hats Provide information that hair loss is temporary BUT anticipate change in texture and color

Nursing Intervention
PROMOTE NUTRITION

Serve food in ways to make it appealing

Consider patients preferences Provide small frequent meals

Avoids giving fluids while eating

Oral hygiene PRIOR to mealtime Vitamin supplements

Nursing Intervention
RELIEVE PAIN

Mild pain- NSAIDS

Moderate pain- Weak opiods Severe pain- Morphine Administer analgesics round the clock with additional dose for breakthrough pain

Nursing Intervention
DECREASE FATIGUE

Plan daily activities to allow alternating rest periods

Light exercise is encouraged Small frequent meals

Nursing Intervention
IMPROVE BODY IMAGE

Therapeutic communication is essential

Encourage independence in self-care and decision

making Offer cosmetic material like make-up and wigs

Nursing Intervention
ASSIST IN THE GRIEVING PROCESS

Some cancers are curable

Grieving can be due to loss of health, income,

sexuality, and body image Answer and clarify information about cancer and treatment options Identify resource people Refer to support groups

Nursing Intervention
MANAGE COMPLICATION: INFECTION Fever is the most important sign (38.3) Administer prescribed antibiotics X 2weeks Maintain aseptic technique Avoid exposure to crowds Avoid giving fresh fruits and veggie Handwashing Avoid frequent invasive procedures

Nursing Intervention
MANAGE COMPLICATION: Septic shock

Monitor VS, BP, temp

Administer IV antibiotics Administer supplemental O2

Nursing Intervention
MANAGE COMPLICATION: Bleeding Thrombocytopenia (<100,000) is the most common

cause <20, 000 spontaneous bleeding Use soft toothbrush Use electric razor Avoid frequent IM, IV, rectal and catheterization Soft foods and stool softeners

Colon cancer

COLON CANCER
Risk factors
1. Increasing age 2. Family history 3. Previous colon CA or polyps 4. History of IBD 5. High fat, High protein, LOW fiber 6. Breast Ca and Genital Ca

COLON CANCER
Sigmoid colon is the most common site
Predominantly adenocarcinoma If early 90% survival 34 % diagnosed early 66% late diagnosis

COLON CANCER
PATHOPHYSIOLOGY
Benign neoplasm DNA alteration malignant

transformation malignant neoplasm cancer growth and invasion metastasis (liver)

COLON CANCER
ASSESSMENT FINDINGS 1. Change in bowel habits- Most common
2. Blood in the stool 3. Anemia 4. Anorexia and weight loss 5. Fatigue

6. Rectal lesions- tenesmus, alternating D and C

Colon cancer
Diagnostic findings
1. Fecal occult blood 2. Sigmoidoscopy and colonoscopy 3. BIOPSY 4. CEA- carcino-embryonic antigen

Colon cancer
Complications of colorectal CA
1. Obstruction 2. Hemorrhage 3. Peritonitis 4. Sepsis

Colon cancer
MEDICAL MANAGEMENT
1. Chemotherapy- 5-FU 2. Radiation therapy

Colon cancer
SURGICAL MANAGEMENT
Surgery is the primary treatment Based on location and tumor size Resection, anastomosis, and colostomy (temporary or

permanent)

Colon cancer
NURSING INTERVENTION Pre-Operative care 1. Provide HIGH protein, HIGH calorie and LOW residue diet 2.Provide information about post-op care and stoma care 3. Administer antibiotics 1 day prior

Colon cancer
NURSING INTERVENTION Pre-Operative care 4. Enema or colonic irrigation the evening and the morning of surgery 5. NGT is inserted to prevent distention 6. Monitor UO, F and E, Abdomen PE

Colon cancer
NURSING INTERVENTION Post-Operative care 1. Monitor for complications Leakage from the site, prolapse of stoma, skin irritation and pulmo complication 2. Assess the abdomen for return of peristalsis

Colon cancer
NURSING INTERVENTION Post-Operative care 3. Assess wound dressing for bleeding 4. Assist patient in ambulation after 24H 5.provide nutritional teaching Limit foods that cause gas-formation and odor Cabbage, beans, eggs, fish, peanuts Low-fiber diet in the early stage of recovery

Colon cancer
NURSING INTERVENTION Post-Operative care 6. Instruct to splint the incision and administer pain meds before exercise 7. The stoma is PINKISH to cherry red, Slightly edematous with minimal pinkish drainage 8. Manage post-operative complication

Colon cancer
NURSING INTERVENTION: COLOSTOMY CARE
Colostomy begins to function 3-6 days after surgery The drainage maybe soft/mushy or semi-solid

depending on the site

Colon cancer

NURSING INTERVENTION: COLOSTOMY CARE BEST time to do skin care is after shower Apply tape to the sides of the pouch before shower Assume a sitting or standing position in changing the pouch

Colon cancer
NURSING INTERVENTION: COLOSTOMY CARE Instruct to GENTLY push the skin down and the pouch

pulling UP Wash the peri-stomal area with soap and water Cover the stoma while washing the peri-stomal area

Colon cancer
NURSING INTERVENTION: COLOSTOMY CARE
Lightly pat dry the area and NEVER rub Lightly dust the peri-stomal area with nystatin powder

Colon cancer
NURSING INTERVENTION: COLOSTOMY CARE
Measure the stomal opening The pouch opening is about 0.3 cm larger than the

stomal opening Apply adhesive surface over the stoma and press for 30 seconds

Colon cancer
NURSING INTERVENTION: COLOSTOMY CARE
Empty the pouch or change the pouch when 1/3 to full

Breast Cancer
The most common cancer in FEMALES
Numerous etiologies implicated

Breast Cancer
RISK FACTORS 1. Genetics- BRCA1 And BRCA 2 2. Increasing age ( > 50yo) 3. Family History of breast cancer 4. Early menarche and late menopause 5. Nulliparity 6. Late age at pregnancy

Breast Cancer
RISK FACTORS 7. Obesity 8. Hormonal replacement 9. Alcohol 10. Exposure to radiation

Breast Cancer
PROTECTIVE FACTORS 1. Exercise 2. Breast feeding 3. Pregnancy before 30 yo

Breast Cancer
ASSESSMENT FINDINGS 1. MASS- the most common location is the upper outer quadrant 2. Mass is NON-tender. Fixed, hard with irregular borders 3. Skin dimpling 4. Nipple retraction 5. Peau d orange

Breast Cancer
LABORATORY FINDINGS
1. Biopsy procedures 2. Mammography

Breast Cancer
Breast cancer Staging
TNM staging I - < 2cm II - 2 to 5 cm, (+) LN III - > 5 cm, (+) LN IV- metastasis

Breast Cancer
MEDICAL MANAGEMENT
1. Chemotherapy 2. Tamoxifen therapy 3. Radiation therapy

Breast Cancer
SURGICAL MANAGEMENT

1. Radical mastectomy 2. Modified radical mastectomy 3. Lumpectomy 4. Quadrantectomy

Breast Cancer
NURSING INTERVENTION : PRE-OP 1. Explain breast cancer and treatment options 2. Reduce fear and anxiety and improve coping abilities 3. Promote decision making abilities 4. Provide routine pre-op care: Consent, NPO, Meds, Teaching about breathing exercise

Breast Cancer
NURSING INTERVENTION : Post-OP 1. Position patient: Supine Affected extremity elevated to reduce edema

Breast Cancer
NURSING INTERVENTION : Post-OP 2. Relieve pain and discomfort Moderate elevation of extremity IM/IV injection of pain meds Warm shower on 2nd day post-op

Breast Cancer
NURSING INTERVENTION : Post-OP 3. Maintain skin integrity Immediate post-op: snug dressing with drainage Maintain patency of drain (JP) Monitor for hematoma w/in 12H and apply bandage and ice, refer to surgeon

Breast Cancer
NURSING INTERVENTION : Post-OP 3. Maintain skin integrity Drainage is removed when the discharge is less than 30 ml in 24 H Lotions, Creams are applied ONLY when the incision is healed in 4-6 weeks

Breast Cancer
NURSING INTERVENTION : Post-OP Promote activity Support operative site when moving Hand, shoulder exercise done on 2ndday Post-op mastectomy exercise 20 mins TID NO BP or IV procedure on operative site

Breast Cancer
NURSING INTERVENTION : Post-OP Promote activity Heavy lifting is avoided Elevate the arm at the level of the heart On a pillow for 45 minutes TID to relieve transient edema

Breast Cancer
NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS Lymphedema 10-20% of patients Elevate arms, elbow above shoulder and hand above elbow Hand exercise while elevated Refer to surgeon and physical therapist

Breast Cancer
NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS Hematoma Notify the surgeon Apply bandage wrap (Ace wrap) and ICE pack

Breast Cancer
NURSING INTERVENTION : Post-OP MANAGE COMPLICATIONS Infection Monitor temperature, redness, swelling and foulodor IV antibiotics No procedure on affected extremity

Breast Cancer
NURSING INTERVENTION : Post-OP TEACH FOLLOW-UP care Regular check-up Monthly BSE on the other breast Annual mammography

Discussion of
Palliative Care Oncologic Emergencies Lung Cancer Male & Female reproductive Cancers Brain Tumors

Critical Thinking
Scenario: A 49 y/o male has a 32 year history of

cigarette smoking. He often eats out with associates and typically eats red meat and potatoes. One of his associates is a 51 y/o female whose mother dies of breast cancer. She is 40lbs over her ideal weight because she likes to snack during the day. She is also a heavy coffee drinker because she is from Seattle.

Case Study 1
R.T. is a 64-year-old man who comes to his primary care providers (PCPs) offi ce for a yearly examination. He initially reports having no new health problems; however, on further questioning, he admits to having developed some fatigue, abdominal bloating, and intermittent constipation. His nurse practitioner completes the examination, which includes a normal rectal exam with a stool positive for guaiac. Diagnostic studies include a CBC with differential, chem 14, and carcinoembryonic antigen (CEA). R.T. has not had a recent colonoscopy and is referred to a gastroenterologist for this procedure. A 5-cm mass found in the sigmoid colon confirms a diagnosis of a polypof the colon. A referral is made for surgery. The pathology report describes the tumor as stae 11, which means that the cancer has extended into the mucous layer of the colon. A metastatic work-up is negative.
1. 2.

3.
4. 5.

Identify 6 risk factors for colon cancer: Discuss the recommended screening procedures related to colon cancer. What warning sign did R.T. have? What would early signs be for colorectal cancer? What would late signs be?

Case Study 1
R.T. is a 64-year-old man who comes to his primary care providers (PCPs) offi ce for a yearly examination. He initially reports having no new health problems; however, on further questioning, he admits to having developed some fatigue, abdominal bloating, and intermittent constipation. His nurse practitioner completes the examination, which includes a normal rectal exam with a stool positive for guaiac. Diagnostic studies include a CBC with differential, chem 14, and carcinoembryonic antigen (CEA). R.T. has not had a recent colonoscopy and is referred to a gastroenterologist for this procedure. A 5-cm mass found in the sigmoid colon confirms a diagnosis of a polypof the colon. A referral is made for surgery. The pathology report describes the tumor as stae 11, which means that the cancer has extended into the mucous layer of the colon. A metastatic work-up is negative. After bowel prep, R.T. is admitted to the hospital for an exploratory laparotomy, small bowel resection and sigmoid colectomy. - What are five major complications for him? 7. After surgery, R.T. is admitted to the surgical intensive care unit (SICU) with a large abdominal dressing. The nurse rolls R.T. side to side to remove the soiled surgical linen, and the dressing becomes saturated with a large amount of serosanguineous drainage. Would the drainage be expected after abdominal surgery? Explain.
6.

Case Study 2
You are a home health nurse who has been seeing P.C., who was diagnosed with lung cancer approximately 1 year ago. Her provider recently informed her that her cancer is no longer treatable; the focus of her treatment will change from curative measures to symptom relief. She is confused and somewhat angry with her provider. She vaguely remembers the term palliative treatment when discussing her situation with her provider but doesnt know what it means.
1.

How would you describe palliative treatment?

Case Study 2
You are a home health nurse who has been seeing P.C., who was diagnosed with lung cancer approximately 1 year ago. Her provider recently informed her that her cancer is no longer treatable; the focus of her treatment will change from curative measures to symptom relief. She is confused and somewhat angry with her provider. She vaguely remembers the term palliative treatment when discussing her situation with her provider but doesnt know what it means. Case progress Note: P.C. confides that she always felt that she might not survive her illness, but has never formally written down her wishes concerning what types of treatment she would or would not want. You advise her to complete an advance directive and/or living will or to complete a medical durable power of attorney and/or a surrogate decision maker form. In current practice, it is very likely that a part of the home health intake process will be completion of a Physicians Order on Life Sustaining Treatments (POLST) Paradigm form. 2. What is the purpose of these documents?

Case Study 2
3. What health care decisions are considered in these documents? 4. How are advance directives and living wills formalized? 5. P.C. states she is confused and has mixed feelings about her health care wishes right now. She asks, If I fill out this form, can I change my mind down the road? How should you answer this question? 6. You inform P.C. that you will help with symptomatic control of her illness. What areas will you focus on, and what question would you ask P.C.? 7. As P.C. becomes more frail and incoherent, what treatment will be given?

Discussion
Culturally appropriate treatment Share your experiences