Nursing Oncology

Oncology Nursing

Oncology defined Branch of medicine that deals with the study, detection, treatment and management of cancer and neoplasia

“Root words” Neo- new Plasia- growth Plasm- substance Trophy- size Oma- tumor

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

CELL CHANGES 1. Atrophy 2. Hypertrophy 3. Hyperplasia 4. Metaplasia 5. Dysplasia 6. Anaplasia 7. Neoplasia

ETIOLOGY: MULTIFACTORIAL GENETIC FACTORS SMOKING DIETARY: NITRATES (NITROSAMINES), BENZOPYRENE HORMONAL / CHEMICAL AGENTS BIOLOGIC AGENTS: MOLDS, VIRUSES & BACTERIA OTHERS

Characteristics of Neoplasia Uncontrolled growth of Abnormal cells 1. Benign 2. Malignant 3. Borderline

Characteristics of Neoplasia BENIGN Well-differentiated Slow growth Encapsulated Non-invasive Does NOT metastasize

Characteristics of Neoplasia MALIGNANT Undifferentiated Erratic and Uncontrolled Growth Expansive and Invasive Secretes abnormal proteins METASTASIZES

Reasons for Successful Metastasis 1. cancer cells release ENZYMES to escape from the lymphatic and blood vessels 2. secondary site should provide nourishment to cancer cells 3. secondary site should have adequate blood supply

Nomenclature of Neoplasia Tumor is named according to: • Parenchyma Hepatoma- liver Osteoma- bone Myoma- muscle

Nomenclature of Neoplasia Tumor is named according to: 2. Pattern and Structure, either GROSS or MICROSCOPIC Fluid-filled CYST Glandular ADENO Finger-like PAPILLO Stalk POLYP

Nomenclature of Neoplasia Tumor is named according to: 3. Embryonic origin Ectoderm ( usually gives rise to epithelium) Endoderm (usually gives rise to glands) Mesoderm (usually gives rise to Connective tissues)

BENIGN TUMORS Suffix- “OMA” is used Adipose tissue- LipOMA Bone- osteOMA Muscle- myOMA Blood vessels- angiOMA Fibrous tissue- fibrOMA

MALIGNANT TUMOR Named according to embryonic cell origin 1. Ectodermal, Endodermal, Glandular, Epithelial Use the suffix- “CARCINOMA” Pancreatic AdenoCarcinoma Squamous cell Carcinoma

MALIGNANT TUMOR Named according to embryonic cell origin 2. Mesodermal, connective tissue origin Use the suffix “SARCOMA FibroSarcoma Myosarcoma AngioSarcoma

“PASAWAY” 1. “OMA” but Malignant 

HepatOMA, lymphOMA, gliOMA, melanOMA

2. THREE germ layers 

“TERATOMA”

3. Non-neoplastic but “OMA” 

HEMATOMA

CANCER NURSING Review of Normal Cell Cycle 3 types of cells 1. PERMANENT cells- out of the cell cycle 

Neurons, cardiac muscle cell

2. STABLE cells- Dormant/Resting (G0) 

Liver, kidney

3. LABILE cells- continuously dividing 

GIT cells, Skin, endometrium , Blood cells

CANCER NURSING Cell Cycle

G0------------------G1SG2M G0- Dormant or resting G1- normal cell activities S- DNA Synthesis G2- pre-mitotic, synthesis of proteins for cellular division M- Mitotic phase (I-P-M-A-T)

CANCER NURSING Proposed Molecular cause of CANCER: Change in the DNA structure altered DNA function Cellular aberration  cellular death  neoplastic change Genes in the DNA- “proto-oncogene” And “anti-oncogene”

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

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

CANCER NURSING Etiology of cancer 3. Genetics and Family History Colon Cancer Premenopausal breast cancer

CANCER NURSING Etiology of cancer 4. Dietary Habits  Low-Fiber  High-fat  Processed foods  alcohol

CANCER NURSING Etiology of cancer 5. Viruses and Bacteria DNA viruses- HepaB, Herpes, EBV, CMV, Papilloma Virus RNA Viruses- HIV, HTCLV Bacterium- H. pylori

CANCER NURSING Etiology of cancer 6. Hormonal agents DES-diethylstilbestrol OCP especially estrogen

CANCER NURSING Etiology of cancer 7. Immune Disease AIDS

CANCER NURSING CARCINOGENSIS Malignant transformation IPP Initiation Promotion Progression

CANCER NURSING CARCINOGENSIS INITIATION Carcinogens alter the DNA of the cell Cell will either die or mutate

CANCER NURSING CARCINOGENSIS PROMOTION Repeated exposure to carcinogens Abnormal gene will express Latent period

CANCER NURSING CARCINOGENSIS PROGRESSION Irreversible period Cells undergo NEOPLASTIC transformation then malignancy

CANCER NURSING Spread of Cancer 1. LYMPHATIC  Most

common

2. HEMATOGENOUS  Blood-borne,

commonly to Liver and Lungs

3. DIRECT SPREAD  Seeding

of tumors

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 Grading The degree of DIFFERENTIATION Grade 1- Low grade Grade 4- high grade

CANCER NURSING Cancer Staging 1. Uses the T-N-M staging system T- tumor N- Node M- Metastasis 2. Stage 1 to Stage 4

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

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 Pap’s Smear 3. Male- DRE for prostate, Testicular self-exam

Nursing Assessment Utilize the 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 moisturizing 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 patient’s preferences  Provide small frequent meals  Avoid giving fluids while eating  Oral hygiene PRIOR to mealtime  Vitamin supplements

Nursing Intervention RELIEVE PAIN  Mild pain- NSAIDS Moderate pain- Weak opioids  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  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

INCIDENCE OF CANCER MALES 1. PROSTATE CANCER  2. LUNG CANCER  3. COLORECTAL CANCER 

FEMALES 1. BREAST CANCER  2. LUNG CANCER  3. COLORECTAL CANCER 

Colon cancer

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

COLON CANCER Sigmoid colon is the most common site Predominantly adenocarcinoma (starts as adenomatous polyps arising in sigmoid and rectum)

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 (alternating D and C) 2. Blood in the stool 3. Anemia 4. Anorexia and weight loss 5. Fatigue 6. Rectal lesions/mass 7. Tenesmus

FOCUS IS ON EARLY DETECTION & INTERVENTION If early 90% survival 34% diagnosed early 66% late diagnosis

Colon cancer Complications 1. Obstruction 2. Hemorrhage 3. Perforation 4. Peritonitis 5. Sepsis 6. direct extension of cancer to adjacent organs

Colon cancer Diagnostic findings 1. DRE at age 40, annually 1. Fecal occult blood 2. Sigmoidoscopy and colonoscopy – begin at age 50, every 3-5 years 3. BIOPSY 4. CEA- carcino-embryonic antigen (to estimate prognosis, monitor treatment and recurrence)

Colon cancer MEDICAL MANAGEMENT 1. Chemotherapy- 5FU 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 PREVENTION is primary issue CLIENT Teaching:  DIET:

high fiber diet (fruits, vegetables, whole grains, legumes)  Screening recommendations  Seek medical consult for bleeding and warning signs of cancer

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 pulmonary complication 2. Assess the abdomen for return of peristalsis

Co lo n 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 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 peristomal 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 ¼ full (Brunner)  ½ to 1/3 full (Kozier)

Breast Cancer The most common cancer in FEMALES Numerous etiologies implicated

Types of Breast Cancer 1. adenocarcinoma : INFILTRATING DUCTAL CARCINOMA - 70% 2. INFLAMMATORY CARCINOMA – most malignant 3. PAGET’S disease - NIPPLE

Breast Cancer RISK FACTORS 1. Genetics 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(peau d’ orange) 4. Nipple retraction/discharge 5. axillary adenopathy

Breast Cancer LABORATORY FINDINGS 1. Biopsy procedures Percutaneous needle biopsy Needle aspiration from mammary duct Excision biopsy 2. Mammography- American Cancer Society recommends annual screening at age 40

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 – interferes with ESTROGEN ACTIVITY 3. Radiation therapy

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 SURGICAL MANAGEMENT 1. simple Mastectomy 2. Radical mastectomy 3. Modified radical mastectomy 4. Lumpectomy OR Segmental Resection 5. Quadrantectomy

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 (wall climbing, overhead pulleys, rope turning, arm swings) NO BP or IV procedure on operative site

POST MAST ECTOM Y EXERCI SES

Wall climbing

POST MAST ECTOM Y EXERCI SES

Overhead pulleys

POST MAST ECTOM Y EXERCI SES

Rope turning

POST MAST ECTOM Y EXERCI SES

Arm swing

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 foul-odor 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 POSTOP RADIATION Therapy (can also be used preop & intraop)

Recommendation of ACS Monthly BSE beginning at age 20, 5-7 days AFTER menstruation Clinical breast examination every 3 years age 20-39 years Clinical breast examination and annual mammography at age 40

NURSING DIAGNOSES 1. Anxiety 2. Decisional Conflict 3. Anticipatory Grieving 4. Risk for Infection 5. Risk for injury 6. Body Image disturbance

LUNG CANCER Leading cause of CANCER DEATHS in US for both male and female categories Cancer well-advanced at time of diagnosis Most patients die within one year of initial diagnosis 5-year survival is only 15%

LUNG CANCER Etiology: 1. AGE, incidence increases with age 50 2. SMOKING – 80% of lung cancer is positively associated with SMOKING 3. IONIZING radiation, INHALED IRRITANTS (ASBESTOS0

LUNG CANCER LUNG LESION:  SMALL

or OAT CELL Carcinoma – 25%

 *PARANEOPLASTIC

 NON-SMALL

SYNDROME

CELL Carcinoma – 75%

 ADENOCARCINOMA  SQUAMOUS

CELL CARCINOMA  LARGE CELL CARCINOMA

LUNG CANCER Signs and Symptoms:  CHRONIC

COUGH, Hemoptysis, wheezing, shortness of breath, dull aching chest pain, hoarseness, dysphagia  SYSTEMIC: weight loss, anorexia, fatigue, bone pain, generalized weakness

LUNG CANCER METASTASIS  BRAIN

– mental behavioral changes impaired gait and balance  BONE – bone pain, pathologic fractures, anemia  LIVER – jaundice, anorexia, RUQ pain *SUPERIOR VENA CAVA SYNDROME

LUNG CANCER DIAGNOSTIC TESTS  CHEST

X-ray  SPUTUM studies  BRONCHOSCOPY  CT SCAN/MRI  BIOPSY  CBC, LIVER FUNCTION STUDIES

LUNG CANCER TREATMENT:  SURGERY

goal: to remove as much involved tissue as possible while preserving the lung function  CHEMOTHERAPY  RADIATION goal: to cure or relieve symptom

NURSING DIAGNOSES 1. Ineffective Breathing Pattern 2. Activity Intolerance 3. Pain 4. Anticipatory Grieving

PROSTATE CANCER CAUSE: UNKNOWN Most primary prostatic CA: ADENOCARCINOMAS Skeletal Metastasis, especially to the VERTEBRAE (COMPRESSION/ FRACTURES OF SPINE)

PROSTATE CANCER Manifestations:  EARLY:

ASYMPTOMATIC  URINARY S/SX: SIMILAR TO BPH: urgency, frequency, hesitancy, dysuria, nocturia, hematuria, blood in ejaculate  Metastasis: BONE

PROSTATIC CANCER DIAGNOSTIC TESTS:  DRE

(yearly after age 50)  Annual PSA levels, >4ng/ml  TRANSRECTAL ULTRASOUND  PROSTATIC BIOPSY Needle biopsy  Bone scan, MRI, CT scans

PROSTATIC CANCER SURGERY:  TURP:

EARLY DISEASE IN OLD MEN  RETROPUBIC PROSTATECTOMY/PERINEAL PROSTATECTOMY  RADICAL PROSTATECTOMY  REMOVAL

OF PROSTATE, PROSTATIC CAPSULE, SEMINAL VESICLES, PORTION OF BLADDER NECK

PROSTATIC CANCER HORMONAL MANIPULATION: Orchiectomy Administration of female hormonal agents RADIATION: BRACHYTHERAPY (implanted radioactive seeds to eradicate remaining cancer cells, to reduce metastasis, to relieve spinal cord compression)

PROSTATIC CANCER NURSING DIAGNOSES:  1.

Urinary incontinence following treatment: stress or urge incontinence or mixed  2. Sexual Dysfunction  3. Acute/Chronic Pain