Grades of Tumor degree of maturity of differentiation 1. Grade 1 differentiated and least malignant.

t. Has the parent cell (low grade) 2. Grade 2 moderately undifferentiated 3. Grade 3 undifferentiated and high degree of malignancy 4. Grade 4 least differentiated and high degree of malignancy (high grade)

Staging of tumor evaluates the spread of the tumor. Can determine size of tumor and existence of metastasis. T tumor; size and degree of local extension N - node; number of regional lymph nodes invaded by tumor M - metastatsis; used to direct treatment and predict outcomes i.e.: T2N1M0 = primary tumor at stage 2 abnormality or regional lymph nodes at stage 1, and no evidence of metastasis CAUTION 7 warning signals; used in nursing assessment C change in bowel/bladder habits A sores that does not heal U unusual bleeding T thickening or lump in breast or other areas I indigestion or dysphagia O obvious change in wart or mole N nagging cough or hoarseness Pain does not appear until later stages when tumor enlarges enough to cause pressure on the tissues.

Types of Tumors Carcinoma are majority of all cancers 90% Malignant tumors of epithelial tissues

Squamous carcinoma in squamous epithelium Bronchogenic has originated in the bronchus of the respiratory tract Carinomas hage a tendency to metastasize which can be spread by the lymphatic system. Sarcoma tumors of the connective tissue and spread by the blood stream Mixed occurs in adjacent tissues such as in the lining of the stomach wall and sarcoma arises in adjacent muscular layer. Found in kidney, ovary, testes. Leukemia cancer in blood Lymphoma are located in the lymphoid tissue Melanoma in the skin Tumors are swelling or enlargement neoplasms

Benign tumors remains at the original site of development. Enclosed in a capsule so that tumor cells do not invade surrounding tissues. Has a slower growth rate than malignant tumors. Can resemble normal cells. Does not recur after removal and does not cause death unless it alters the function of an organ. Does not manifest cachexia (extreme weakness/fatigue/wasting malnutrition) and has pain due to nerve endings.

Malignant tumors rapid growth; can spread unless removed before metastasis. Cells are permanently changed. Has no capsule. Charactherized by extensive tissue destruction. Has a chance to recur after removal (75% recurrence to return after 1 year). No pain due to no nerve endings. Dx. H&P and diagnostic studies since the disease has many forms.

DIAGNOSTIC TESTS Lab tests

Serum alkaline Acid phosphatase Serum and urine Ca+ Anemia Alkaline phosphatase Serum calcitonin CEA colorectal cancer PSA and CA 125 blood test to check the GI or reproductive system o PSA prostate; determines effectiveness of tx. and assess recurrence. Elevated with BPH for men. o PCA - 0-4 ng/ml for reproductive o CA 125 recurrence of ovarian ca and pancreatic ca. o Guaiac

CT scan important; determines the size and/or shape. Radioisotopes via IV or PO. Identifies the distribution of cancer. Used mainly in thyroid and brain tumors. MRI PET determines organ function rather than focusing on the structure or anatomy of that organ. Cytology less accurate than biopsy. A microscopic exam of cells. PAP smear evaluates the endometrium, cervix, and vagina. Biopsy a definite way to confirm cancer. Excisional removal of part of a tissue. Frequently used on tumors that are frequently accessible tumors. Incisional removal of section/wedge of a tissue. Used only if tumor is too large to be removed. Needle aspiration similar to breast biopsy in which samples are

obtained from easily accessible areas. No anesthesia needed. Endoscopic exams bronchoscope, colonoscopy, sigmoidoscopy are examples. o Bronchoscopy (check handout) examines the airway for growth. Requires anesthesia. Ultrasound can show size, consistency, and shape of the tissue/organs.

TREATMENTS Before treatment, tumor must be staged and graded. The methods of treatment may be used alone or in combination. Main treatment is via surgery and the succeeding treatments are radiation, chemotherapy, immunotherapy, etc.

Surgery removal of entire cancer is the best and frequent method used. Can be diagnostic, prophylactic, palliative, or reconstructive. Its goal is to remove all the malignant cells before it metastasizes. Adjunct therapies are chemo and/or radiation therapy. Surgery can be: o Preventive o Diagnostic o Palliative relief of symptoms where comfort is promoted for the patient. Can be removal of tumor or lymph nodes. o Radiation destroys the rapidly dividing cells while leaving the rest of the body to recover. Can eliminate dead cancer cells by altering the chemical structure and behavior of the DNA in cells that are cancerous. 60% of cancer patients undergo radiation therapy. Also used as pre-op to reduce the size of a tumor. Post-op destroys malignant cells not removed by surgery. Provides a palliative comfort. Do not apply ointments, powder, moist, lotion over the area.

Avoid heat or cold applications. Avoid direct sunlight. Avoid infections Wear loose-fitting clothes Diet high CHON and calories. Fluid intake of 2-3 qt. / day.

I. External radiation used before or after surgery. Given over several weeks. Ensure that tattoo or mark is not washed off. II. Internal radiation a. Unsealed introduction of radioactive liquid into the mouth to enter the bloodstream or a cavity. b. Sealed has small seeds implanted around the tumors. Can deliver the highest dose onto the tumor. Given PO or IV for a systemic effect. Placed in solid tumors in the body for local effect. Can also be topical for using on skin lesions. Caregivers must be aware and minimize their self from exposing to the radiation. Can be achieved by planning the procedure beforehand, wearing protective clothing (shield), minimize the time of the procedures, and maintain a distance of at least 3 feet from the patient.

Chemotherapy can be given by the RN with chemotherapy credentials. He/she can give vesicant drugs and all first doses of chemotherapy. Subsequent dosed of nonvesicant. Assessment and general nursing care: I. Neutropenia (infection) a. Monitor VS Q4H or per MD order. b. Monitor WBC and ANC. c. Check lung sounds and provide breathing exercises if needed. d. Inspect body tissues.

e. Check IV site QD. f. Be aware of meds (steroids, antipyretics) that can mask signs of infections. g. Observe for s/sx. of infections Q4H or PRN: i. Temp. >100.5 degrees F ii. Flushing, diaphoresis iii. Shaking/chills iv. White patches on mouth v. Redness, swelling, heat/pain in different areas of the body. vi. Productive or non-productive cough/tachypnea/dyspnea vii. Abnormal urine, stool, and sputum viii. Frequent urination with burning ix. Flu-like symptoms/rash

II. Thrombocytopenia (bleeding) a. Monitor platelet count (<20,00/mm3) PRN

Chemotherapy Mouth Care Initial care must provide oral care by assessing the oral cavity and obtain a baseline. Give oral care after meals and at bedtime. BMT patients should be instructed to not wear dentures for at least 8 hours daily. Assess for mouth tenderness, dry mucous membranes, etc.

Next assessment is the fluid balance to prevent and minimize fluid volume deficit. Can give antiemetics and follow up its effectiveness. Provide oral fluids if patient tolerates it. Monitor I&O and obtain daily weights. Assess for orthostatic BP.

N/V and diarrhea should be assessed after. May give antiemetic 30

mins. before chemotherapy, meals, and PRN. Provide adequate rest periods.

Assess nutritional status by providing small frequent meals with high CHON and high calorie meals. Can give supplements if needed. Goal of the diet is to prevent weight loss, replace nutritional losses, and provide well balanced meals.

DRUG MANAGEMENT Antineoplastic Agents Psychological assessment: Pain Body image Anxiety Grieving

Sociological assessment: Family process Social interaction Financial concerns

Nursing Diagnosis Pain Hopelessness Self care deficit