Nursing Oncology

Oncology By: Ruby Ruth T. Roces, R.N., M.D.

Oncology defined 

It is a branch of medicine that deals with the study, detection, treatment and management of cancer

glossary Neoplasia-uncontrolled cell growth that follows no physiologic demand  Anaplasia-cells that lack normal cellular characteristics and differ in shape and organization  Metaplasia-conversion of one type of mature cell into another; reversible 

Dysplasia-bizarre cell growth resulting in cells that differ in size, shape or arrangement from other cells of the same type.  Hypoplasia-incomplete or underdevelopment w/ decreased number of cells 

Hyperplasia-Increase in the number of cells  Hypotrophy-decrease in the organ size /function  Hypertrophy-increase in the size 

“Root words”     

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

Classification of Neoplasia 1. Benign 2. Malignant 3. Borderline/ in situ

WAYS TO DIFFERENTIATE A BENIGN FROM A MALIGNANT TUMOR Characteristics

Benign

Malignant

Rate of growth

Slow- growing

Varies, but usually fast-growing

Differentiation

Well differentiated

Poorly differentiated

Local invasion

Local invasion, encapsulated, local effects

Invasive, expansive,infiltrating, destructive, w/ generalized effects

Metastases

Non metastatic

metastatic

Nomenclature of Neoplasia Tumor is named according to: 1. Parenchyma, Organ or Cell  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  Squamos cell Carcinoma 

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

“Exceptionistas” 1. “OMA” but Malignant 

HepatOMA, lymphOMA, gliOMA, melanOMA

2. THREE germ layers 

“TERATOMA”

3. Non-neoplastic but “OMA”  

Choristoma Hamatoma

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 Theories to the Pathogenesis of Cancer  Cellular transformation and derangement theory  Immune response failure theory

CANCER NURSING Etiology of cancer 1. PHYSICAL AGENTS  Radiation (thyroid CA)  Exposure to irritants (skin CA)  Exposure to sunlight (skin CA)

CANCER NURSING Etiology of cancer 2. CHEMICAL AGENTS  Smoking (Lung CA)  Dietary ingredients (gastric CA)  Drugs

CANCER NURSING Etiology of cancer 3. Genetics and Family History  Colon Cancer  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 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 repair

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 

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2. HEMATOGENOUS 

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Most common

Blood-borne, commonly to Liver and Lungs

3. DIRECT INVASION/EXTENSION 

Seeding of tumors

CANCER NURSING 

Body Defenses Against TUMOR 1. T cell System/ Cellular Immunity 

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2. B cell System/ Humoral immunity 

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Cytotoxic T cells kill tumor cells B cells can produce antibody

3. Phagocytic cells 

Macrophages can engulf cancer cell debris

CANCER NURSING 

Cancer Diagnosis 1. BIOPSY 

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The most definitive

2. CT, MRI- for visualization and staging 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 Promotive and Preventive Nursing Management  1. Lifestyle Modification  2. Nutritional management  3. Screening  4. Early detection

SCREENING 

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1. Male and female- Occult Blood, CXR, and DRE 2. Female- SBE, CBE, Mammography and Pap’s Smear 3. Male- DRE for prostate, Testicular selfexam

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

CANCER MANAGEMENT GENERAL MEDICAL MANAGEMENT - Treatment goals: cure, control and palliation  1. Surgery  2. Chemotherapy  3. Radiation therapy  4. Immunotherapy  5. Bone Marrow Transplant

CANCER MANAGEMENT SURGERY  Diagnostic- excision, incision, needle  primary method of treatment- local and wide excision  prophylactic  Palliative- relieve complications of CA  Reconstructive- improve function or obtain a more desirable cosmetic effect

CANCER MANAGEMENT NURSING MANAGEMENT  Provide education and emotional support  Assess patient’s responses to the surgery  Monitor for possible complications such as infection, bleeding fluid and electrolyte imbalance and organ dysfunction  Plan for discharge, ff-up and home care

CANCER MANAGEMENT RADIATION THERAPY  Cure, control, prophylaxis  Used to disrupt cell growth  Cells are most vulnerable during DNA synthesis and mitosis therfore those body tissues which undergo frequent cell division are most sensitive to radiation.(BM,lymphatic,skin,GIT,gonads)

CANCER MANAGEMENT MAINTAIN TISSUE INTEGRITY  Frequently assess for changes  Handle skin gently  Do NOT rub affected area  Lotion may be applied (water-based)  Wash skin only with SOAP and Water

CANCER MANAGEMENT RISK FOR RADIATION INJURY  Protect caregivers fr exposure to radioactive implants  Identify max time that can be spent safely inpxs room  Use of shielding equipments  Explain to px the need for such precautions to keep px from feeling isolated

CANCER MANAGEMENT    

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

CANCER MANAGEMENT CHEMOTHERAPY  Destroys tumor cells by interfering w/ cellular functions and reproduction  Used primarily to treat systemic disease rather than localized lesions

CANCER MANAGEMENT  

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ADMINISTRATION: Topical, Oral, IM, IV, Subcutaneous, arterial, intracavitary, intrathecal Dosage based on TBSA Special care needed for vesicants- causes extravasation (daunorubicin, doxorubicin, nitrogen mustard, mitomycin, vincristine and vindesine. If suspected stop immediately and apply ice except in vonca alkaloid

CANCER MANAGEMENT Common side effects:  Nausea and vomiting, stomatitis, anorexia, diarrhea  Myelosuppression  Nephrotoxicity-danorobucin, doxorubucin  CHF- cisplastin, methroxate, mitomycin  Pulmonary fibrosis-bleomycin and busulfan

CANCER MANAGEMENT  

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Sterility Reversible Neurologic damage- taxanes and plant alkaloids, peripheral neuropathy and hearing loss- cisplatin fatigue

Nursing Intervention 

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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 Avoids giving fluids while eating Oral hygiene PRIOR to mealtime Vitamin supplements

Nursing Intervention  

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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  

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DECREASE FATIGUE Plan daily activities to allow alternating rest periods Light exercise is encouraged Small frequent meals

Nursing Intervention   

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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   

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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 

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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 

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MANAGE COMPLICATION: Septic shock Monitor VS, BP, temp Administer IV antibiotics Administer supplemental O2

Nursing Intervention  

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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

Mortality and Morbidity Rates

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 

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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 

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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 

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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 

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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 

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

Colon cancer 

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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 

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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

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 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

Lung cancer  

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6th-7th decade Number 1 in the morbidity and mortality survey among all cancers Equal incidence for both men and women 85% caused by inhalation of carcinogenic materials most commonly cigarette smoking

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Squamous cell carcinoma- more centrally located, commonly in the segmental and subsegmental bronchi. AdenoCarcinoma- presents more peripherally as peripheral mass or nodules; most prevalent lung Ca for both M and F Large cell carcinoma-fast growing tumor that arise peripherally

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Bronchioalveolar cell CA- arises fr the terminal bronchus and alveoli; usually slow growing Small cell Ca- arises primarily as a proximal lesion but may arise in any part of the tracheobronchial tree

Lung Cancer Etiology  Tobacco use  Genetic- > acquired genetic lesion

Lung Cancer Clinical Manifestations:  Cough  Hemoptysis  Wheeze, stridor  Dyspnea  Pneumonitis  Pain  Symptoms of lung abscess

Lung Cancer 

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Metastatic spread- tracheal obstruction, dysphagia, hoarseness, Horner’s syndrome, auperior vena cava syndrome, plural effusion, respiratory failure. Systemic symptoms Endocrine syndromes-hypercalcemia (epidermoid), SIADH (sm cell), gynecomastia (large cell), clubbing (non-sm. Cell)

Lung Cancer Stage

TNM descriptors

5-yr survival rate

I

T1-2,N0,M0

60-80

II

T1-2,N1,M0

25-50

IIIA

T3,N0-1,M0 T1-3,N2,M0

25-40 10-30

IIIB

Any T4 or N3,M0

<5

IV

Any M0

<5

Lung Cancer T1-< 3 cm T2->3 cm T3- direct extension into chest wall T4- invades mediastinum N0 N1-peribronchial N2-ipsilateral mediastinal N3-contralateral mediastinal

Lung Cancer    

TREATMENT Surgery Radiotherapy Chemotherapy

Prostate Cancer Etiology 

Age-related

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Blacks>white

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95 % are adenocarcinomas

Prostate Cancer Manifestations:  Rel. to urinary flow obstuction  Urinary frequency, ec in caliber of stream, diminished force, hesitancy, dribbling, nocturia and overflow incontinence  Dysuria  Back or hip pain

Prostate Cancer Diagnostics:  DRE  PSA- > 10 ng/ml  Biopsy- transrectal prostate biopsy under sonography (TRUS)

Prostate Cancer Treatment  Surgery- radical retropubic prostatectomy  Radiation therapy *both are associated w/ impotence  Androgen deprivation- for those w/ metastatic disease (leuporide, flutamide)  Chemotherapy- for palliation

Non-Hodgkins Lymphoma  

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Heterogenous group of cancers Originates from neoplastic growth of lymphoid tissue Mostly involves malignant B lymphocytes; only 5% are T lymphocytes

Non-Hodgkins Lymphoma Manifestations:  Symptoms are highly variable  Typically diagnosed at a latter stage when px is more symptomatic; lymphadenopathy is noticeable (stages III or IV)  1/3 of cases have “B symptoms” (recurrent fever, drenching night sweats, & unintentional wt. loss of >10%

Non-Hodgkins Lymphoma Assessment & Diagnostics  Histopathology  Immunophenotyping  Cytogenetic analysis Staging – based on data obtained from CT scan, bone marrow biopsies, CSF analysis

Non-Hodgkins Lymphoma Treatment:  based on actual classification & stage of disease, prior treatment, & px’s ability to tolerate therapy  Radiation alone maybe beneficial in localized nonaggressive forms  In aggressive types, combination chemotherapy are given in early stages  Intermediate forms – chemotherapy + radiotherapy for st. I & II disease

Urinary bladder Cancer     

ETIOLOGY AND RISK FACTORS 65 Yrs.- median age Smoking Cyclophosphamide exposure Schistoma haematobium

Urinary bladder Cancer Manifestations:  Hematuria- mOst common symptom  Urinary changes may accompany later  Usually asymptomatic at early stages

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Diagnosis: Urinalysis- hematuria IVP- decreased bladder filling Cystoscopy- diagnostic

Urinary bladder Cancer    

Treatment: Based on extent of disease Surgical Resection Intravesical chemotherapy

Quiz 1 a 64 y.o patient status post- hemi colectomy was tachycardic. Examination of the mucus membrane showed a dry mouth. What is your assessment to the possible cause of tachycardia in this patient?  infection  3rd spacing  Dehydration  sepsis

2 difference between a benign fr malignant neoplasm include all of the ff except  well differentiated  poorly demarcated  no metastatic potential  non invasive

3. radiation therapy is effective in actively dividing cells. All of the ff are ex of those except  GIT  Fatty tissues  Nerve  skin

4. screening should be done to detect cancers. Routine Screening tests involves all of the following except    

breast exam DRE Ultrasound Occult blood exam

5. chemotherapy was advised in a patient diagnosed w/ skin Cancer. Vinblistine was the agent ordered. You know that vinblistine is a vesicant type of agent and causes    

extravasation intravasation nephrotoxicity ototoxicity

6. Most frequent cause of fever w/in 24 hrs in a post-op patient is…. 7-9. internal Radiation therapy poses a risk for both patient and caregiver. Give 3 ways to avoid unnecessary exposure 10. Most common manifestation of lung cancer in early stages is…..