Lesson 8.1

Chapter 8

Lesson 8.1

Chapter 8

Care of Patients with Cancer

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Learning ObjectivesLearning Objectives

Theory

1. Identify characteristics of neoplastic (abnormal tissue) growth.

2. Identify at least five factors that may contribute to the development of a malignancy.

3. State at least four practices that can contribute to prevention and early detection of cancers.

4. Describe ways to include the recommendations of the American Cancer Society for routine checkups and detection of cancers into patient education.

5. Discuss the pros and cons of the various treatments available for cancer.

6. State the major problems and appropriate nursing interventions for a patient coping with expected side effects of radiation or chemotherapy.

7. State the stages of the grieving process experienced by the dying cancer patient.

Clinical Practice

1. Devise a general plan of nursing care for the patient receiving chemotherapy.

2. Discuss the teaching necessary for the patient who has bone marrow suppression from cancer treatment.

3. Institute nursing interventions to help the patient cope with the common problems of cancer and its treatment.

4. Utilize appropriate nursing interventions to help patients and families deal with the psychosocial effects of cancer and its treatment.

5. Identify nursing interventions to help the patient cope with death and dying.

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Figure 8-1Figure 8-1

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Physiology of CancerPhysiology of Cancer

• Neoplasm

• Benign and encapsulated

• Malignant

• Metastasis

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Figure 8-2Figure 8-2

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Classification of TumorsClassification of Tumors

• Organs or tissues from which they first began

• Main groups of cancers:– Sarcomas– Carcinomas – Leukemias and lymphomas – Melanomas

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MetastasisMetastasis

• Moving of malignant cells to another site:– Blood and body fluids – Entering a body cavity

• Prognosis (prediction of survival) depends on how much the malignant cells have attacked body tissues

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TNM Staging System TNM Staging System

• T for primary tumor• N for regional nodes• M for metastasis Examples:

– T1, N0, M0 means that the tumor is small and localized (no involvement of regional lymph nodes and no metastasis)

– T1, N2, M0 indicates a small (T1) tumor with moderate regional involvement (N2) but no metastasis to distant sites (M0)

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TNM Staging System for Cancer

TNM Staging System for Cancer

• T0 No evidence of primary tumor• TIS Carcinoma in situ• T1 T2 T3 T4 Progressive increase in tumor size and involvement• TX Tumor cannot be assessed

• N0 Regional lymph nodes not demonstrably abnormal• N1 N2 N3 Increasing degrees of demonstrable abnormality

of regional lymph nodes• NX Regional lymph nodes cannot be assessed clinically

• M0 No evidence of distant metastasis• M1 M2 M3 Ascending degrees of distant metastasis, including

metastasis to distant lymph nodes• M4 Multiple organ involvement

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Causative FactorsCausative Factors

• Mutation: – Oncogenes and tumor suppressor genes

• Carcinogens: – Certain chemicals, sources of radiation, and

viruses

• Age

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Chemical CarcinogensChemical Carcinogens

• Petrofluorocarbons (e.g., polychlorinated biphenyls or PCBs) and some pesticides (e.g., DDT)

• Cigarette smoking

• Immunosuppressive drugs

• Synthetic estrogens

(Refer to Table 8-2 for more information.)

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Other Causes of CancerOther Causes of Cancer

• Promoters

• Chronic irritation

• Physical carcinogens:– Radiation – Radon gas

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Figure 8-3Figure 8-3

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Cancer and VirusesCancer and Viruses

• Hepatitis B virus (HBV) and liver cancer• Epstein‑Barr virus (EBV) and Burkitt's

lymphoma • Human T‑cell lymphotropic virus (HTLV)

and T‑cell leukemia and lymphoma • Human papillomavirus (HPV), cervical

carcinoma, and throat cancer in nonsmokers

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Genetic Predisposition Genetic Predisposition

• Breast cancer is more likely to occur in women who have a close female relative who developed breast cancer before the age of 50

• Gene markers in colon cancer, breast cancer, and leukemia

• Human Genome Project• Genetic markers or oncogenes

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Cultural Cues 8-1: Race FactorsCultural Cues 8-1: Race Factors

• Some populations are at a higher risk for certain types of cancer

• For example, of the four types of melanoma, African Americans are most susceptible to the acral lentiginous type whereas whites are least susceptible to it

• Cases of lentigo maligna melanoma are found most often in Hawaii

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Contributing FactorsContributing Factors

• Intrinsic factors

• Stress

• Diet

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Measures to Prevent CancerMeasures to Prevent Cancer

• Encouraging maintenance of normal weight

• Stimulators and inhibitors

• Alcohol

• Environment

(Refer to Table 8-3 for major risk factors for cancer.)

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Nutritional Therapies 8-1: Dietary Recommendations to Minimize Risk for

Cancer

Nutritional Therapies 8-1: Dietary Recommendations to Minimize Risk for

Cancer

• Eat a varied diet and avoid obesity.• Reduce total saturated and unsaturated fat intake to 30% of total

caloric intake.• Eat more high-fiber foods: Whole-grain cereals, breads, pastas, fresh

fruits, and vegetables.• Include foods rich in vitamins A and C in the daily diet. • Eat cruciferous vegetables and those containing beta carotene daily:

Cabbage, broccoli, Brussels sprouts, kohlrabi, cauliflower, carrots, yellow squash.

• Avoid smoked, salt-cured, nitrite-cured, and charred (blackened) foods.• Keep alcohol consumption moderate: No more than two drinks or two

glasses of wine or beer per day (one drink for women).

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Detection of CancerDetection of Cancer

• Screening

• Warning signals

• Cytology

• Occult blood

(Refer to Box 8-2 for information on measures for early detection of cancer.)

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Box 8-1: The Seven Warning Signs of Cancer

Box 8-1: The Seven Warning Signs of Cancer

CAUTION• Change in bowel or bladder habits

• A sore that does not heal

• Unusual bleeding or discharge

• Thickening or lump in breast or elsewhere

• Indigestion or difficulty in swallowing

• Obvious change in wart or mole

• Nagging cough or hoarseness

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Diagnostic Tests Diagnostic Tests

• Biopsy

• Imaging studies:– “Hot spot" and “cold spot” on x-rays– Computed tomography – Magnetic resonance imaging

• Endoscopy

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Laboratory TestsLaboratory Tests

• Prostate‑specific antigen

• Tumor markers:– Used to confirm a diagnosis, the response

to therapy– Used to detect a relapse– CEA and CA 19‑9

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Nursing Management After a Cancer Diagnosis:

Assessment

Nursing Management After a Cancer Diagnosis:

Assessment

• Thorough physical assessment• Psychosocial assessment of the patient

and family or significant others: – Psychosocial needs– Coping abilities and techniques– Resources for support and care(Refer to Box 8-4 for common nursing diagnoses for used for patients with cancer.)

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Common TherapiesCommon Therapies

• Surgery

• Radiation

• Chemotherapy

• Hormone manipulation

• Immunotherapy with biologic response modifiers

• Bone marrow transplantation

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Nursing Care of Patients Undergoing

External Radiation Therapy Nursing Care of Patients Undergoing

External Radiation Therapy

• Help the patient cope with the diagnosis of cancer and its treatment with radiation therapy

• Teach how to recognize and manage the expected side effects of radiation:– Skin care

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Principles of Radiation Protection

Principles of Radiation Protection

• The distance between the nurse and the patient

• The amount of time spent in actual proximity to the patient

• The degree of shielding provided

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Figure 8-5Figure 8-5

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ChemotherapyChemotherapy

• Antineoplastic drugs decrease the number of malignant cells in a generalized malignancy (Refer to Table 8-5 more information.)

• Cytotoxic and not limited to malignant cells• Steroids • Vesicants

(Refer to Table 8-6 for information on assessing toxic effects of chemotherapy.)

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Other Treatment ModalitiesOther Treatment Modalities

• Hormone therapy• Immunotherapy using biologic response

modifiers:– Interleukins and interferons– Monoclonal antibodies – Miscellaneous agents, including cancer vaccines

• Bone marrow transplantation • Gene therapy

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Common Problems Related to Cancer or Cancer Therapy

Common Problems Related to Cancer or Cancer Therapy

• Anorexia, mucositis, and weight loss

• Nausea, vomiting, and diarrhea

• Constipation • Cystitis

• Immunosuppression, bone marrow suppression, and infection

• Hyperuricemia• Fatigue • Alopecia • Pain

(Refer to Patient Teaching 8-2, Table 8-7, and Box 8-7 for more information.)

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Nutritional Therapies 8-2: Nutritional Formulas and Preparations for

Supplemental Feedings

Nutritional Therapies 8-2: Nutritional Formulas and Preparations for

Supplemental Feedings

PRODUCT COMPANY• Carnation Instant Breakfast Clintec/Carnation• Delmark Instant Breakfast Sandoz• Forta Shake Ross• Meritene Powder Novartis• Sustacal Powder, Sustacal Liquid Mead, Johnson• Ensure Abbott• Promote Ross• Isocal Novartis• Prosobee Mead, Johnson• Resource Sandoz

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Table 8‑8: Common Sites of Metastasis

Table 8‑8: Common Sites of Metastasis

CANCER TYPE SITES OF METASTASIS• Breast cancer Bone, lung, liver, brain• Lung cancer Brain, bone, liver, lymph

nodes, pancreas• Colorectal cancer Liver, lymph nodes,

adjacent structures• Prostate cancer Bone (especially spine and

legs), pelvic nodes• Melanoma GI tract, lymph nodes, lung,

brain• Primary brain Central nervous system

Cancer

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Care for the Dying Cancer Patient

Care for the Dying Cancer Patient

• Psychological process of death

• Grieving

• Fear

• Palliative care

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Box 8-8: Kübler-Ross’ Stages of Dying

Box 8-8: Kübler-Ross’ Stages of Dying

• Denial (This can’t happen to me!)

• Anger (Why me?)

• Bargaining (Yes me, but . . .)

• Depression (It is me, I give up . . .)

• Acceptance (I’m ready . . .)

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Box 8-9: Common Fears of the Dying Patient

Box 8-9: Common Fears of the Dying Patient

Almost all dying patients face varying levels of fear. Specifically, these fears may include:

• Fear of the unknown• Fear of abandonment and loneliness• Fear of loss of relationships• Fear of loss of experiences in the future• Fear of dependency and loss of

independence• Fear of pain

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Nursing Management of the Dying Patient

Nursing Management of the Dying Patient

• Anticipatory guidance • Terminal hydration • End-stage symptom management • Pain • Dyspnea • Death rattle • Delirium

(Table 8-9 provides information on spiritual beliefs and practices regarding death in various religions.)