DANE DELION BSN 3 PAGE 1 OF 22

MAIN CATEGORIES OF CANCER Interphase - 90% growth, DNA replication, cell func.

G0 - resting stage. Cell leaves to carry out function

Carcinoma: cancer that begins in the skin or in tissues
that line or cover internal organs
Sarcoma: begins in bone, cartilage, fat, muscle, blood
vessels, or connective/supportive tissues.
Leukemia: begins in blood forming tissue, such as
bone marrow, and causes large numbers of abnormal
blood cells to be produced and enter the blood.
Lymphoma and myeloma: begins in cells of the
immune system, bone marrow
CNS cancers: begin in tissues of the brain and spinal
cord; ex: nerve cells: neuroblastoma
Classification of Cancer
According to behavior of tumor
• Benign:
• tumors that cannot spread by invasion or
metastasis; hence they only grow locally
• Malignant:
• capable of spreading by invasion/metastasis.
• Metastases share name of the primary tumor
• Spread to vital organs (liver, brain) — life
threatening
G1- growth and prep of chromosomes for replication
S phase- DNA replication occurs
G2- prepare for mitosis
M phase- mitosis occurs 10%
• Prophase: chromosomes condensing; nucleus
present
• Metaphase- chromosomes line up in middle of cell;
nucleus dissembled
• Anaphase- chromosomes move away to opposite
sides via spindles
• Telophase - new nuclei forms on both sides to form
new cells.
• Cytokinesis- splits cells into 2.
Cell cycle quality control:
• Checkpoints in G1 & G2
• Apoptosis: self destruction of cell
• Mitosis checkpoints: detect failure of spindle fibers
& arrest cell in metaphase.
• Gene mutations = checkpoint failure = cancer

CANCER
Healthy cells Cancerous cells
• Large cytoplasm • Small cytoplasm
• Single nucleus • Multiple nuclei
• Single nucleolus • Multiple and large Gene mutations:
• Fine chromatin nucleoli 1. Tumor suppressor gene mutations: Cancer cells
• Coarse chromatin avoid apoptosis and keep growing and dividing,
resulting in a tumor. This is a recessive mutation
so both alleles in the gene need to be mutated to
cause the cancer.
CELL PARTS & CYCLE “brakes of a car”
2. Proto-oncogene mutations: dominant genes, only
Nucleus- control center; controls genetic info one allele needs to be stated to cause cancer.—
Mitochondria- powerhouse; converts sugar to energy proto-onco gene mutates into an oncogene, a cell
via cellular respiration. will keep diving even when there are no messages
Ribosomes- site of protein synthesis to divide.
Golgi apparatus- packaging center of cell; packages “gas of a car”
& secretes proteins
Centrioles- organizes microtubules (spindle fibers) for Abnormal cell growth —> Tumor/neoplasm formation
mitosis —> apoptosis fails —> Invasion & Metastasis
Chromosomes- condensed DNA and proteins, codes
for genetic traits Invasion: direct migration and penetration by cancer
Endoplasmic Reticulum- Transports intracellular cells into neighboring tissues
materials.
Metastasis: ability of cancer cells to penetrate into
Cell cycle lymphatic and blood vessels, circulate through the
DANE DELION BSN 3 PAGE 2 OF 22

bloodstream, and then invade normal tissues elsewhere Physical Agents:

in the body. • Exposure to sunlight
• UV rays— skin cancer
Establishment and growth: tumor cells established • Clothing styles
and grow in secondary site: lymph nodes or in organs • Use of sunscreen
from venous circulation • Occupation
• Recreational habits
Carcinogenesis Stages: • humidity, altitude, latitude.
• Radiation
1. Initiation: carcinogens cause mutations in the • Repeat x-ray procedures
cellular DNA. • Radiation therapy
• Spontaneous • Nuclear weapon manufacturing sites/nuclear
• Carcinogens: chemicals, physical factors, power plants — inc. incidence of: leukemia,
biologic agents multiple myeloma, cancers of lung, bone,
2. Promotion: allow a cell that has undergone breast, thyroid, and other tissues.
initiation to become cancerous. (Doesn’t affect cells • Radon — lung cancer. // ventilation in homes
that haven’t undergone initiation). Leads to the • Chronic irritation or inflammation
formation of pre-neoplastic or benign lesion. • Tobacco carcinogens
• Drugs • Industrial chemicals and asbestos
• Sex hormones Chemical Agents
3. Spread/Progression: cancer grows into • Tobacco/smoking
surrounding tissue or organs (stimulate angiogenesis) , • Cancer of head, neck, lungs, esophagus,
nearby or distant. Spread via lymphatic system or stomach, pancreas, cervix, kidney, bladder,
blood stream. myeloblastic leukemia.
• Passive smoke
• Proliferation— rapid reproduction by cell • Lung cancer, childhood leukemia, larynx,
division: hyperplasia, dysplasia, and pharynx, brain, bladder, rectum, breast
metaplasia, neoplasia • Cigars
• Metastasis — spread or transfer of cancer • Pipes
cells • Roll your own products
• Water pipes (hookah)
• E-cigs
• Chewing tobacco
ETIOLOGY
• oral, pancreatic, and esophageal cancer
• Vinyl chloride (used for plastic manufacture,
• Viruses and bacteria asbestos factories, construction works)
• Physical agents • Polycyclic hydrocarbons (from refuse burning, auto
• Chemicals and truck emissions, oil refineries, air pollution)
• Genetics • Arsenic, soot, and tars
• Lifestyle factors • Fertilizers
• Hormones • Pesticides
• Formaldehydes
Viruses: • Dyes (aniline dyes used in beauty shops, hair bleach)
• Human papilloma virus (HPV) • Betel nut and lime (chewed as stimulants in some
• Cervical, head, and neck cancers cultures)
• Hepatitis B Virus (HBV)
• Liver cancer Genetics
• Epstein-Barr virus (EBV) • Extra, too few, or translocated chromosomes
• Burkitt lymphoma, & nasopharyngeal cancer • Chronic myelogenous leukemia,
meningiomas, acute leukemia,
Bacteria: retinoblastomas, Wilms tumor.
• Chronic inflammatory reactions to bacteria & • Cancer in two or more first degree relatives
production of carcinogenic metabolites • Onset of cancer in family member <50 y/o
• H. Pylori — gastric cancer • Same type of cancer in several family members
• Individual fam members with >1 type of cancer
• Rare cancer in 1 or > family members
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• Positive family history inc, risk to develop

dse.
Lifestyle factors • ovarian, colorectal, prostate, melanoma,
• Diet leukemia, sarcomas, and primary brain
• Ingestion of carcinogens & absence of tumors.
protective substances in diet • Stress — affects hypothalamus and pituitary gland
• Fats • Depression
• Alcohol: cancers of mouth, pharynx, larynx, • Grief
esophagus, liver, rectum and breast • Anger
• Salt cured/smoked meats • Aggression
• Nitrate / nitrite containing foods • Despair
• Red and processed meats • < immunocompetence; immunodeficiency =
• Obesity growth and proliferation of cancer cells
• breast, colon, endometrium, esophagus, • Precancerous lesions
kidney • Pigmented moles
• pancreas, thyroid, gallbladder, ovary, cervix, • Burn scars
multiple myeloma, Hodgkin lymphoma, • Senile keratosis
prostate. • Leukoplakia
• Insufficient physical activity • Benign polyps or adenoma of colon/stomach
• Fibrocystic dse. Of breast
• Obesity
Hormonal Agents
• Disturbances in endogenous hormonal production
• breast, prostate, uterus PATHOPHYSIOLOGY
• Diethylstilbestrol (synthetic estrogen)
• Menstruation before 12
• Menopause after 55 Abnormal cell formed by mutated DNA
• Null parity ↓
• Delayed childbirth (After 30 y/o)
• Estrogen & progesterone therapy Cells grow and proliferate
• hepatocellular, endometrial, and breast cancer ↓
• Decreases risk of ovarian cancer
Metastasis occurs when abnormal cells invade other
tissue through lymph and blood

PREDISPOSING FACTORS
(cancer dev linked to immune system failure)
• Age — older individuals Ways the tumor cells evade the immune system:
• Longer exposure to carcinogens • Don’t present with Tumor assoc. antigen(TAA)
• Alterations in the immune system • Altered cell membranes (genetic mutations)
• Sex • Induce T-lymph anergy/tolerance
• Male: prostate cancer • Block killing of tumor
• Female: breast cancer • Induce cell death of the lymphocyte
• Urban residence • Release cytokines
• Greater exposure to carcinogens • inhibit antigen presenting cells (APCs)
• Stressful lifestyle • Over expression of suppressor T lymphocytes
• Greater consumption of preservatives & cured permits uncontrolled cell growth
foods
• Low levels of antibodies
• Geographic distribution
• Impairs proliferation of helper T-cells
• Japan: gastric cancer / may be RT national diet • Combine with antibodies to hide from the normal
(raw foods), ethnic customs, and pollution. immune defense mechanism
• US: breast cancer
• Occupation — > risk of exposure to carcinogens
• Chemical factory workers
• Farmers
• Radiology
• Department personnel
• Heredity
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PROLIFERATION PATTERNS Sarcomas

• Cells found in supporting tissue of the body such as
bone, cartilage, fat, connective tissue, and muscle
• Hyperplasia
• Dysplasia Lymphomas
• Metaplasia • Arise in the lymph nodes and tissues of the body’s
• Anaplasia immune system
• Neoplasia
Leukemias
Hyperplasia • Cancer of immature blood cell that grow in the bone
marrow and tend to accumulate in large numbers in
• Excessive rate of cell division — > # of cells the blood stream.
• Cell structure and arrangement normal
• Reversible
• Normal tissue response to something irritating COMMON CAUSES OF CANCER
• Ex: callus

Dysplasia Breast cancer

• Early menarche
• Bizarre cell growth differing in size, shape, and • Late menopause
cell arrangement
• nulliparous/older than 30 at the birth of first
• Potentially malignant
child.
• “Carcinoma in situ” — uncontrolled growth
of cells that remain in same location — may Lung cancer
be metastatic malignancy — removed asap
• Tobacco use
Metaplasia • Asbestos
• Conversion of one type of cell in a tissue to • Radiation exposure
another type not normal for that tissue • Air pollution
Anaplasia
• change in DNA cell structure and orientation Colorectal cancer
to one another, characterized by a loss of • Men
differentiation and a return to a more primitive • Familial polyposis
form • Ulcerative colitis
Neoplasia • High fat low fiber diet
• Uncontrolled cell growth, either benign or
malignant that follows no physiological
demand.
Prostate cancer
• ≥ 50 y.o men
• Highest incidence in African Americans
Creating a cancer cell: • Positive fam hx
Brakes on cell growth (tumor suppressor genes) be • Exposure to cadmium
released at the same time, accelerators for cell growth
(oncogenes) are being activated. Cervical cancer
• Tumors amplify their own supply of growth signals. • Sexual behavior
• Cytokines and proteases released. • First intercouse at an early age
• Destroys basement membrane and surrounding • Multiple sex partners
matrix — leads to metastasis: BV or lymphatic sys. • Sexual partner who has had multiple sexual
partners
• HPV and AIDS
Carcinomas • Low socioeconomic status
• Most common • Cigarette smoking
• Arise from cells that cover external and internal body
surfaces Head and neck cancer
• lung, breast, and colon • Males
• Alcohol and tobacco use
• Poor oral hygiene
• Long term sun exposure
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EFFECTS OF CANCER • More painful

• Starts to bleed
• Occupational exposures — asbestos, tar, nickel, • Tumor causes impaired circulation and oxygenation.
textile, wood, leather work, machine tool
experience. U: Unusual bleeding or discharge
• Blood in stool or urine
• Discharge from any parts of body
Skin cancer
• Fair complexion T: Thickening or lump in breast or elsewhere
• Positive fam hx • Any lump found in the breast doing SBE
• Moles • Scrotum during self exam
• Exposure to coal, car, creosote, arsenic, radium • Other lumps found in body
• Sun exposure between 11am to 3pm
I: Indigestion or difficulty swallowing
• Feeling pressure in throat or chest which makes
swallowing uncomfy
• Disruption of function: D/T obstruction or • Feeling full without food or with small amount
pressure Obvious changes in wart or mole
• Hematologic alterations: can impair function • A: asymmetry
of blood cells • B: border
• Hemorrhage: tumor erosion, bleeding, severe • C: color
anemia • D: Diameter
• Anorexia-Cachexia syndrome: wasted
appearance of client. N: Nagging cough or hoarseness
• Change in voice
Paraneoplastic Syndromes: ectopic sites with excess • Hoarseness
hormone production • Sputum with blood

↑ Parathyroid hormone→ hypercalcemia U: Unexplained anemia

• Cancer slows down erythropoietin production
↑ secretion of insulin→ hypoglycemia • RBCs wear out faster than normal and not replaced
as quickly.
↑ Antidiuretic hormone (ADH) → fluid
retention, HTN & peripheral edema S: Sudden weight loss
• Tumor uses your blood and nutrients and releases
↑ Adrenocorticotropic hormone (ACTH): waste products inside the body
cause excessive secretion of cortisone (ie:
fluid retention, ↑ glucose levels)
PHYSICAL ASSESSMENT
Pain: major concern of clients and families associated
with cancer • Tumors can release chemicals that increase the
body’s metabolism.
Physical Stress: body tries to respond and destroy
neoplasm Inspection
• Skin & mucous membranes: lesions, bleeding,
Psychological Stress petechiae, irritation
• Stool, urine, vomitus: acute or occult blood
C: Change in bowel/bladder habits • Scalp: noting hair texture and hair loss
• color, consistency
• size/shape of stools Palpation
• Blood present • Abdomen for any masses, bulges, abnormalities
• Alternating constipation and diarrhea (most common • Lymph node enlargement
characteristic of colon cancer)
Auscultation
A: A sore that does not heal
• Lung sounds
• Doesn’t seem to be getting better over time • Heart sounds
• Getting buffer • Bowel sounds
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LABORATORY AND DIAGNOSTIC TEST
Laboratory tests
• CBC
• hemoglobin
• Hematocrit (low in anemia, may indicate
malignancy)
• Leukocytes
• Platelets
• Tumor markers: identify substance (specific
proteins) in the blood that are made by the tumor)
• PSA (prostatic-specific antigen): prostate
cancer
• CEA (carcinoembryonic antigen): colon
cancer
• AFP (alpha-feto-protein)
• HCG (human chorionic gonadotropin
• Alkaline phosphatase: bone metastasis
• Biopsy
• Needle aspiration
• Incisional- remove part of tumor
• Excisional- remove whole tumor.
vagina. Cells are placed on a slide and sent to
laboratory.
• Early detection form pap test has helped lower the
death rate from cervical cancer more than 75%
• Additional test may be necessary
Mammography:
• Most beneficial during menopause
• Not sufficient enough as definitive proof for
presence or absence of breast cancer. Additional tests
may be necessary.
PSA test & Digital Rectal Exam
• Men ≥ 50 y.o
• Biopsy to confirm
• Experts are trying to develop blood tests that might
alert people to malignancies while cancers are still in
their early stages.
Fecal Occult Blood Test (FOBT)
• Detects invisible amount of blood in the feces
• Screening test for colon cancer
• Stool sample is smeared on a chemically treated card
• If blood is confirmed in the stool, more tests will be

Determine location of cancer:

• X-rays
• Computed tomography DIAGNOSIS OF CANCER
• Ultrasounds
• Magnetic resonance imaging conducted to find source of bleeding
• Nuclear imaging • Sigmoidoscopy: rectum, lower colon
• Angiography • colonoscopy: colon and upper part
• Endoscopic exams

Biopsy:
Diagnosis of cell type: • Surgical removal of a small piece of tissue for
• Tissue samples: from biopsies, shedded cells microscopic examination. For leukemias, a small
(papanicolau (PAP) smear) & washings blood sample serves the same purpose.
• Cytologic examination: tissue examined under • Microarrays can be used to determine which genes
microscope are turned on or off in the sample
• Proteomic profiles: analysis of protein activity
Direct Visualization:
• Sigmoidoscopy Appearance under microscope:
• Cystoscopy • Irregularly shaped dividing cells
• Endoscopy • Variation in nuclear size and shape
• Bronchoscopy • Variation in cell size and shape
• Exploratory surgery: lymph node biopsies to • Loss of specialized cell features
determine metastases.

• Loss of normal tissues organization

CANCER SCREENING • Poorly defined tumor boundary

Papanicolau (PAP) smear • Determine the presence and extent of cancer

• Early detection of cancer in the cervix • Identify possible disease metastasis
• Doctor uses small brush or wooden scraper to • Evaluate function of involved and uninvolved organ
remove a sample of cells from the cervix and upper systems
DANE DELION
TUMOR STAGING AND GRADING
• Obtain tissues and cells for analysis, including
evaluation of tumor stage and grade.
Staging
• Determines size of tumor
• Existence of local invasion
• Lymph node involvement
• Distant metastasis
• TNM systems
• T - tumor
• Tx - primary tumor cannot be assessed
• T0 - No evidence of primary tumor
• Tis - carcinoma in situ
• T1-4 - increasing size and or local extent
of the primary tumor
• N - node
• Nx regional lymph nodes cannot be
assessed
• N0 - no regional lymph node metas.
• N1-3 - inc. involvement
• M - metastasis
• Mx - distant metas. Cannot be assist
• M0 no distant metas.
• M1 distant metastasis
• Stage 0-IV
• Stage 0: abno. Cells haven’t spread. “in
situ”
• Stage I-III: cancers havn’t spread
beyond primary site or have only
spread to nearby tissue.
• Stage IV: metas. To distant areas of
body.
• Categories of cancer
• In situ: abnormal cells are present but
have not spread to nearby tissue
• Localized: cancer is limited to the
place where it started, with no sign that
it has spread
• Regional: cancer has spread to nearby
lymph nodes, tissues or organs
• Distant: cancer has spread to distant
parts of body
• Unknown: there is not enough
information to figure out this stage
Grading
• Pathologic classification of tumor cells
• Type of tissue
• Degree of differentiation
• Grade I-IV
• Grade I- well differentiated, less aggressive,
better prognosis
BSN 3 PAGE 7 OF 22
NURSING PROCESS
• Grade II - cells look somewhat abno.
Moderately differentiated, intermediate grade
tumors.
• Grade III - very abno. Considered high
grade.
• Grade IV- poorly differentiated/
undifferentiated: more aggressive, less
responsive to treatment
NURSING Dx
• Acute or chronic pain
• Impaired skin integrity
• Impaired oral mucous membrane
• Risk for injury
• Risk for infection
• Fatigue
• Imbalance nutrition: less than body requirements
• Risk for imbalanced fluid volume
• Anxiety
• Disturbed body image
• Ineffective coping
• Social isolation
OUTCOMES
• Pain relief
• Integrity of skin and oral mucosa
• Absense of injury and infection
• Fatigue relief
• Maintenance of nutritional intake
• Maintenance of F&E balance
• Improved body image
• Absence of complications
• Knowledge of prevention and cancer treatment
• Effective coping through recovery and grieving
process
• Optimal social interaction
IMPLEMENTATION/MANAGEMENT
• Prevention and detection
• Primary prevention
• Reducing modifiable risk factors in
external and internal environment
• Secondary prevention
• Recognizing early signs and symptoms
and seeking prompt treatment
• Prompt intervention to halt cancerous
process
• Tertiary prevention
• Focus on monitoring and preventing
recurrence of the primary cancer as
well as screening for development of
DANE DELION BSN 3 PAGE 8 OF 22

second malignancies in cancer SURGERY

survivors
• Chemo, radiation Surgery:
Removal of diseased tissue
• Diagnostic
CANCER PREVENTION • Prophylactic
• Palliative
• Avoid tobacco • Reconstructive
• Protect yourself from excessive sunlight • Cure
• Wear protective clothing • Control
• Sun screen lotions
• Sun is brightest from 11am-4pm
• Limit alcohol intake Surgery as Primary Treatment (Curative)
• Limit fats and calories: lessen meat consumption • Debulking: removal of entire tumor or as much as
• Consume fruits and vegetables: 5-9 servings/ day feasible + surrounding tissue and regional lymph
• Avoid cancer viruses nodes. Cytoreduction
• Avoid carcinogens at work • Local excisions
• Avoid industrial pollution • Outpatient basis
• Small margin
• Normal tissue easily accessible
TREATMENTS • Wide/radical (enbloc dissections)
• Primary tumor
• Lymph nodes
Primary goal: cure the patient • Adjacent involved structures
• Render him clinically and pathologically free of • Surrounding tissues
disease and return their life expectancy to that of • May result in disfigurement, altered
healthy individuals of the same age and sex. functioning, needing rehabilitation or
reconstructive proc.
Alternative goal: • Robotics— precision and dexterity
• Prolong survival while maintaining the pt’s • Prostate
functional status and QOL • Gynecologic cancers
• Salvage surgery — performed in addition to
Third goal: treatment of local recurrence
• Relieve symptoms such as pain for patients in whom • Mastectomy after primary lumpectomy
the likelihood of cure or prolonged survival is very
low.
Prophylactic Surgery:
• Removal of precancerous lesions or benign tumor
Major modalities: • Family hx/genetic predisposition
• Surgery • Presence of abno s/s/x
• Radiation • Alt options of managing risk
• Chemotherapy • colectomy, mastectomy, oophorectomy
• immunotherapy/biologic therapy
• Molecularly targeted therapy
• Monoclonal antibody therapy Palliative Surgery:
• Hormonal manipulation • Cure is not an option
• Photodynamic therapy. • Relieve symptoms
• Make patient as comfortable as possible
Treatment is determined by: type and extent of tumor • Ulceration
involvement, Tx goals, performance status, age, and • Obstruction
client’s co-morbid conditions. • Hemorrhage
• Pain
• Malignant effusions

Reconstructive/rehabilitative Surgery:
• Improve function or obtain a more desirable
cosmetic effect.
• Breast
DANE DELION BSN 3 PAGE 9 OF 22

• Head and neck

• Skin cancers
Mostly effective in
Nursing Management • Small tumors
• Rapidly dividing
• General preoperative nursing care • Poorly differentiated (no longer resembling the tissue
• Radiation and chemotherapy may contribute to post of origin)
op complications
• Infection Radiation dosage
• Impaired wound healing • Sensitivity of target tissues
• Altered pulo/renal function • Size of tumor
• VTE • Radiation tolerance of surrounding normal tissues
• F+E imbalance • Critical structures adjacent to tumor target
• Organ dysfunction
• Pre op:
• Provide verbal + written information about External Radiation
surgical procedure • EBRT- external beam radiation therapy
• Prophylactic antibiotics • Beam of highly charged protons or gamma
• Diet rays to penetrate the body and target the tumor
• Bowel preparation with pinpoint accuracy.
• Serve as a patient advocate and liaison— encourage • Volumetric images
family to take an active role in decision making • CT
when possible • MRI
• Provide consistent information • PET scans
• Allows for more precision to target the tumor
— less toxicity
RADIATION • IMRT- intensity modulated radiation therapy
• Intensity/energy levels can be controlled at the
different angles aimed at the tumor.
• Reduce tumor size • Higher doses delivered to tumor while sparing
• Prevent local recurrence healthy surrounding tissues
• Relieve symptoms of metastatic disease • Daily fractions or hyperfractionated— shorten
• Treat oncologic emergencies pt duration of treatment sched.
• Superior vena cava syndrome • IGRT- image guided radiation therapy
• Bronchial airway obstruction • Continuous monitoring of tumor c
• Spinal cord compression • Ultrasound
• X-ray
Electromagnetic radiation • CT scans
X-rays • Allows for automatic adjustment of beams as
Gamma rays tumor changes in shape or position
• Respiratory gating
Particulate radiation • Tx synchronizes with pt’s respiratory cycle
Electrons • Beam adjusts as tumor moves
Beta particles • SBRT- stereotactic body radiotherapy
Protons • High doses of radiation penetrate very deeply
Neutrons into the body to control deep-seated tumors
Alpha particles • 1-5 tx days
• Proton therapy
Functions of ionizing radiation • Deliver high energy dose to a deep tumor with
• Alters DNA molecules of cells, leading to cell death decrease doses of radiation to tissues in front
• Damage DNA through formation of free radicals and virtually no radiation exits to pts healthy
• Replicating cells most vulnerable tissue behind tumor
• Bone marrow • Close proximity to critical structures (heart,
• Lymphatic tissue BV)
• GI epithelium
• Hair follicles Internal Radiation
• Gonads • Local or systemic
• Localized treatment
DANE DELION BSN 3 PAGE 10 OF 22

• Higher dose and intensity of radiation provided than

EBRT

Brachytherapy Toxicity
• Temporary (HDR) or permanent implant (LDR) • Localized in region being treated
• Placement of radioactive sources within or • Risk inc. with assoc. chemo
immediately next to cancer site. • Acute/early — 2 weeks within initiation
• Rods • Late effects — 6 months to 1 yr post tx
• Seeds • Chronic
• Beads • Fibrosis
• Ribbons • Atrophy
• Catheters • Ulceration
• Lumens w/in organs • Necrosis
• Interstitial tissue compartments • Dysphagia
• UTZ, CT, and MRI guide placement • Incontinence
• Cognitive impairment
HDR- High dose radiation • Sexual dysfunction
• Tx time is shorter
• Red. Exposure to personnel • Altered Skin Integrity
• Outpatient basis over several days • Alopecia
• Hyperpigmentation
Local Internal Radiation • Radiation dermatitis
• Intraluminal HDR • Erythema and dry desquamation
• Insertion of catheters into lumens of organs • Moist or wet desquamation (dermis
• Lesions in exposed, skin oozing serous fluid)
• Bronchus • Ulceration
• Esophagus • Risk factors:
• Rectum • Dose and form of radiation
• Bile duct • Inclusion of skin folds
• Surface • Increased age
• Tx for tumors of eye • Medical comorbidities
• Retinoblastoma • Tx interruption, delays, or cessation of
• Ocular melanoma therapy.
• Interstitial HDR
• Catheter placed into perineum closest to
affected organ • Alterations in oral mucosa
• Prostate • Stomatitis (inflam. Oral tissues)
• Pancreatic • dec. Salivation
• Breast cancer • Xerostomia
• Intracavitary radioisotopes • Change or loss in taste
• Gynecologic cancers • Mucositis (inflam. Of lining of mouth, throat,
• Radioisotopes are inserted into specifically and GI tract)
positioned applicators within the vagina.
• LDR requires hospitalization Stomach/colon involvement
• Anorexia
Systemic Internal Radiation • Vomiting
• IV administration of a therapeutic radioactive isotope • Diarrhea
• Iodine (I-131) — thyroid cancer
• Radium- 223 dichloride — prostate cancer Bone marrow involvement
bone metastases • Anemia
• Leukopenia
• Thrombocytopenia
• Risk for infection & hemorrhage
DANE DELION BSN 3 PAGE 11 OF 22

Systemic S/E- secondary to substances released CHEMOTHERAPY

when tumor cells are destroyed.
• Fatigue
• malaise • The use of antineopalstic drugs in an attempt to
• Anorexia destroy cancer cells by interfering with cellular
functions including replication and DNA repair.
Late Effects (6 months+) • Systemic dse.
• Fibrosis • May be combined with surgery, radiation, or both
• Atrophy • Reduce tumor size preoperatively (neoadjuvant)
• Ulceration • Destroy any remaining tumor cells post op (adjuvant)
• Necrosis • Treat some forms of leukemia (primary)
• May affect:
• Lungs Classification:
• Heart
• CNS MOA:
• Bladder • Cycle-specific agents: agents destroy cells that are
• Dysphagia actively reproducing (S phase)
• Incontinence • M phase (plant alkaloids) half mitotic spindle
• Cognitive impairment formation.
• Sexual dysfunction • Cell cycle nonspecific agents: prolonged effect on
cells.
Nursing Management:
• Promote healing, patient comfort, and quality of life. Chemical Group:
• ERBT: assess the patient’s skin • Alkylating agents:
• Assess nutritional status • Nitrosoureas
• General feelings of well being • Antimetabolites
• Explain that weakness and fatigue are symptoms that • Antitumor antibiotics
result from treatment and do not represent • Topoisomerase inhibitors
deterioration or progression of the disease. • Plant alkaloids (mitotic inhibitors)
• Hormonal agents
Protecting Caregivers: • Misc. agents
• Pts receiving internal radiation emit radiation while
the implant is in place, therefore contact with the HC Adjunct chemotherapeutic agents: additional meds
team is guided nu principles of time, distance, and given with chemo to enhance activity/protect normal
shielding to minimize exposure of personnel to cells.
radiation. • leucovorin is often given with 5-FU.
• Assign pt to a [private room • Enhances ability of fluorouuacil to remain in the
• Post appropriate notices about radiation safety intracellular environment.
precautions • Rescues normal cells from high doses of
• Dosimeter badges methotrexate
• Pregnant women shouldn’t be assigned to the • Reduces/lessens toxicity: severe bone marrow
patient’s care depression, mucositis, diarrhea, lover and lung
• Limit visitors to 30 mins daily and kidney damage.
• 6 foot distance from radiation source.
• Explain precautions to keep the patient from feeling Dosage:
isolated. Determined by:
• Pt’s total body surface area
• Weight
• Previous exposure & response to radiation
therapy
• Organ function
• Modification required if
• Critical lab values
• Dangerous toxicities
• Maximum lifetime dose limits must be adhered to
because of the danger or long term irreversible organ
complications.
• Ex: doxorubicin lifetime limit = 550mg/m2
(Risk of cardiomyopathy)
DANE DELION BSN 3 PAGE 12 OF 22

Extravasion: occurs when IV agents escape the vein TOXICITY

and leak into surrounding tissues
• GI system - antitumor & antimetabolites
Nonvesicant, irritant, vesicant • CINV
• Triggered by activation of vomiting centers in
Vesicant: causes inflammation, tissue damage, and medulla, chemoreceptor trigger zone, GI tract,
potential necrosis of tendons, muscles, nerves, and pharynx, cerebral cortex.
BVs. • Peripheral, autonomic, vestibular, or cognitive
pathways
Severe sloughing and ulceration may require skin • Pharmacologic: corticosteroids, phenothiazines,
grafting. sedatives, histamines, serotonin blockers
• Non-pharmacologic: relaxation technique,
Chemo classified as vesicants: imagery, acupressure, acupuncture, small
• dactinomycin (Cosmegen) frequent meals, bland foods, comfort foods.
• daunorubicin (DaunoXome) • Stomatitis/mucositis: inflammation of mouth,
• doxorubicin (Adriamycin) throat, and GI tract
• nitrogen mustard (Mustargen) • Diarrhea
• mitomycin (Mutamycin)
• vinblastine (Velban)
• vincristine (Oncovin) • Hematopoietic System
• Myelosupression (depressed BM function) Tx with
*Antidotes must be available where vesicant G-CSF or GM-CSF stimulate production of WBCs
chemotherapy agents are administered. esp neutrophils.
*Should never be given in peripheral veins in hands or • Leukopenia
wrist • Neutropenia
• Anemia — EPO
• Short duration: forearm • Thrombocytopenia — inc risk for bleeding &
• Prolonged admin: right atrial silastic catheters, infection — Il-11 stir. Production of
implanted venous access devices, peripherally megakaryocytes. Toxic effects: HSR, capillary
inserted central catheters (PICCs) leak syndrome, PE, atrial dysrhythmias, N/V,
diarrhea
HSRs - IgE mediated • Nursing responsibilities: frequent monitoring of
• Associated with life threatening outcomes blood cell counts, Educate pt about how to prevent
• Rash infection, injury, blood loss
• Urticaria
• Fever • Renal System — methotrexate & mitomycin
• Hypotension • Impaired water secretion
• Cardiac instability • SIADH
• Dyspnea • Decreased renal perfusion
• Wheezing • Precipitate cell products after cell lysis
• Throat tightness • Interstitial nephritis
• Syncope • Excretion of uric acid — kidney damage
• Intracellular contents released into circulation:
Ex: carboplatin, oxaliplatin (Eloxatin), L-asparaginase hyperphosphatemia, hyperkalemia, hypocalcemia,
obstructive neuropathy.
• Nursing responsibilities: monitor BUN, serum
Anaphylactoid reactions (nonallergic) creatinine, creatinine clearance, adequate
• Cytokine release syndrome hydration, diuresis, alkalization of urine,
allopurinol to prevent renal toxicity.
Ex: rituximab and cetuximab • Hemorrhagic cystitis — cyclophosphamide and
ifosfamide therapy.
• Hematuria, dysuria, suprapubic pain, life
threatening hemorrhage
• Tx: aggressive IV hydration, freuen voiding,
diuresis. MEsna binds to metabolites to prevent
HC.
DANE DELION
• Cardiopulmonary system - Anthracyclines
• (Daunorubicin 300 mg/m2, doxorubicin 550 mg/
m2)
• RF: >70 y.o, preexisting cardiac dse, HTN,
tobacco use, renal/hepatic function.
• Dextrazoxane (Zinecard) — cardioprotectant
• Monitor cardiac ejection fraction & other signs of
HF.
• Pulmonary function - bleomycin, carmustine,
busulfan, mitomycin, paclitaxel
• Alveolar damage
• Bronchospasm
• Pneumonitis
• Pulmonary fibrosis
• Monitor closely for changes in pulmo function.
• Capillary leak syndrome with resultant PE —
cytarabine, mitomycin, cyclophosphamide,
carmustine.
• Dyspnea & cough —> ARD —> Respi failure
• Reproductive system
• Sterility
• Ovulation problems, early menopause
• Temp or perm. Azoospermia (absence of
spermatozoa)
• Sperm banking
• Cryopreservation of oocytes, embryos, or ovarian
tissue
• Reliable methods of birth control; not to assume
sterility has resulted.
• Neurologic system
• Metabolic encephalopathy — ifosfamide,
methotrexate, cytarabine
• Sensory alterations in hands and feet — taxanes and
plant alkaloids
• Tingling, prickling, numbing sensations
• Freezing or burning pain, sharp, stabbing, electric
shock pain
• Loss of deep tendon reflexes, muscle weakness, loss
of balance and coordination
• Paralytic ileus
• Oxaliplatin— lip parenthesis, discomfort or
tightness in back of throat, inability to breathe, jaw
pain
• Instruct pts to avoid drinking cold fluids or being
exposed to cold temps. Cisplatin may cause
peripheral neuropathies and hearing loss.
BSN 3 PAGE 13 OF 22
• Cognitive impairment “chemo brain”
• Difficulty remembering dates
• Multitasking
• Managing numbers and finances
• Organization
• Face/object recognition
• Inability to follow directions
• Feeling easily distracted
• Motor & behavioral changes
• RF: comorbidities, age, medications, impaired
nutrition, organ dysfunction, anemia, fatigue, F&E
imbalances.
• NURSING MANAGEMENT
• Monitor laboratory and physical assessments of
metabolic indices and the dermatologic, hematologic,
hepatic, renal, cardiovascular, renal, neurologic and
pulmonary systems.
• Monitor toxicity
• Assess F&E status
• Anorexia, N/V, altered taste, mucositis, diarrhea
• Assess cognitive status
• Modifying risks for infection and bleeding
• Administering chemotherapy
• Be familiar with agents that are mostly
associated with HSRs, signs and symptoms, time
sensitive HSR interventions.
• Monitor for extravasion (swelling, redness,
burning pain @ site, absence of blood return
from IV, resistance to flow of IVF)
• Monitor central lines (risk for infection,
thrombosis)
• Prevent N/A
• Administer antiemetics 30 mins before
chemotherapy
• Managing cognitive changes
• Nonpharma: exercise, natural restorative
environmental intervention, cognitive training
programs
• Maintain F&E balances, nutrition deficits,
fatigue, pain, and infection to minimize their
contribution to cognitive impairment.
• Managing fatigue
• Address factors contributing to fatigue
• Encourage balanced rest and exercise
• Rearrange daily schedule to conserve energy
expenditure, encourage pt to ask for help from
family and significant others
• Promote patient’s normal sleeping habits
• Relaxation techniques and guided imagery.
• Protecting Caregivers
• Emergency spill kits
• Take precautions when handling bodily fluids or
excreta from the pt
• Follow institutional policies regarding the prep,
handling, and disposing of chemotherapeutic
agents and supplies.
DANE DELION BSN 3 PAGE 14 OF 22

HEMATOPOIETIC STEM CELL TRANSPLANTATION

(HSCT) Hepatic Sinusoidal Obstructive Syndrome (HSOS)
• (Veno-oclusive disease)
• Standard to treat hematologic malignancies • High risk of development during the first 30 days of
• Malignant myeloma HSCT
• Acute leukemia • Capillary that receives blood from the terminal
• Non-hodgkin lymphoma branches of the hepatic artery and portal vein and
• Allogenic: from a donor other than the patient. deliver it into central veins.
(Family member or match from National Bone • Inflammation of the epithelium that lines these
Marrow Registry or Cord Blood registry) capillaries.
• Autologous: from the patient • Embolization of RBCs
• Syngenetic: from an identical twin • Destruction, fibrosis, and occlusion of sinusoids.
• Myeloablative: high dose chemo and total body
irradiation S/Sx:
• Nonmyeloablative: mini-transplants, does not • Weight gain
completely destroy bone marrow cells. • Hepatomegaly
• inc. bilirubin
• Ascites
Ablative alloHSCT • Jaundice
• High dose chemotherapy and radiation completely • Encephalopathy
eradicates the bone marrow to help prevent rejection
of donor stem cells. Dec incidence:
• HSCs infused via IV, beings engraftment. 2-4+ • Peripheral stem cells
weeks later, new bone marrow becomes functional, • Specific chemotherapy dosing
proceeds new RBCs, WBC, and platelets. • Nonmyeloablative regimens.
• ADVANTAGE: Graft-vs-tumor effect— donor
cells recognize malignant cells and act to eliminate Graft Vs. Host Disease (GVHD)
them. • Donated stem cells attack recipient’s tissues during
• Acute S/E: the start of engraftment.
• Alopecia • Acute: < 100 days
• Hemorrhagic cystitis • Chronic > 100 days
• N/V/D
• Encephalopathy S/sx:
• PE • Rash —> blistering —> desquamation (similar to
• Acute kidney injury 2nd degree burns)
• F&E imbalances • Mucosal inflammation: eyes & GI tract
• Severe mucositis • Diarrhea: 2L/day
• Chronic S/E: • Biliary stasis c/ abdominal pain
• Sterility • Hepatomegaly
• Pulmonary, cardiac, renal, hepatic, neurologic • Inc. liver enzymes
dysfunction • Obstructive jaundice
• Osteoporosis
• Avascular bone necrosis Prevention:
• Diabetes • Immunosuppressant drugs
• Secondary malignancy • Cyclosporine
• Methotrexate
Nonablative alloHSCT • Tacrolimus
• Lower chemo doses; aimed at destroying malignant • Mycophenolate mofetil
cells
• Suppresses immune system to allow engraftment of Other complications:
donor stem cells. • Encephalopathy
• Less organ toxicity and infection • Hemolytic uremeia syndrome
• Indications: older patients, pts c underlying organ • Hemolytic anemia
dysfunction. • Thrombotic thrombocytopenia purpura

Before engraftment pts are at risk for:

• Infection Autologous HSCT (AuHSCT)
• Sepsis • Do not have a suitable donor
• Bleeding
DANE DELION BSN 3 PAGE 15 OF 22

• Pts c healthy bone marrow but require bone ablative After therapy
doses of chemotherapy to cure an aggressive Recipient:
malignancy. • Ongoing nursing assessments during follow up
Indications: lymphoma, multiple myeloma, exams
neuroblastoma, Ewing sarcoma, germ cell tumors. • Psych evals
• Assess fam and caregivers needs
Process: • Provide education, support, and information about
1) stem cells collected from patient other resources
2) Preserved for re-infusion
3) Purged (treated to kill any malignant cells) Donor:
4) Pt treated with high dose chemo & radiation • May experience mood alterations, low self esteem,
5) Stem cells re-infused guilt during transplantation failure.
• Educate and support
Advantage: no need for immunosuppressants • Reduce anxiety
Disadvantage: tumor cells may remain in the bone • Promote coping
marrow despite conditioning regimens. • Encourage to maintain realistic expectations.

Syngenetic transplants:
• Less incidence of GVHD & rejection HYPERTHERMIA
• Less graft vs tumor effect
• Genetic defects may still be transmitted
• T > 41.5ºC
• Another matched sibling or an unrelated donor may
• Radio waves
be a more suitable donor to combat an aggressive
• UTZ
malignancy.
• Microwaves
• Magnetic waves
• Hot water baths
Nursing Management:
• Hot wax immersions
Pre-treatment:
• Nutritional assessments
Hyperthermia + Radiation
• Extensive physical exams
• Cells during the S-phase are more sensitive to heat
• Organ function tests
than radiation
• Psych evals
• Additional heat damages tumor blood vessels to
• Blood work (past infectious antigen exposure:
prevent them from repairing themselves after
hepatitis, CMV, herpes simplex, HIV, syphilis)
radiation
• Social support systems
• Financial and insurance resources
Hyperthermia + Chemotherapy
• Informed consent
• Alters cell membrane permeability
• Patient education
• Increased uptake of chemotherapeutic agent
• Enhances function of immune T cells and
During treatment:
macrophages to combat malignant cells
• Close monitoring and symptom management
• Monitor V/S, O2 sat.
Delivery: local/regional
• Neutropenic diet
• Into tumor
• Asses for adverse effects: fever, chills, SOB, chest
• On the skin
pain, cutaneous reax, N/V, hypo/hypertension,
• In a body orifice
tachycardia, taste changes
• Regional perfusion
• Reactions to DMSO: N/A, chills, dyspnea,
dysrhythmias, hypotension, cardiac or respi arrest.
S/E:
• Engraftment syndrome: noninfectious fever, skin
• Burns
rash, weight gain, diarrhea, pulmonary infiltrates.
• Fatigue
Tx: corticosteroid therapy
• Hypotension
• Support with blood products and hemopoietic growth
• Peripheral neuropathies
factors
• Thrombophlebitis
• Monitor for potential infections: herpes simplex,
• N/V
CMV, EBV, Candida infections, varicella zoster,
• Diarrhea
• Pulmonary comp: PE, pneumonia
• Electrolyte imbalance
• Monitor for renal comp.
• Cardiovascular stress
DANE DELION
TARGETED THERAPIES
• Work against cancer cell capabilities:
• Malignant transformation
• Uncontrolled reproduction
• Growth and metastasis
• Blocking apoptosis
• Altered genetic coding
• Like a lock and key mechanism
• Biologic response modifiers (monoclonal antibodies,
growth factors, cytokines)
• Gene therapy
BRM
• Uses naturally occurring or recombinant agents to
alter the immunologic relationship between the
tumor and the host.
• Goal: destroy/stop malignant growth
• Basis: restoration, modification, stimulation,
augmentation of body’s natural immune defenses to
cancer.
Nonspecific BRMs
• bacille Calmette-Guérin
• Corynebacterium parvum
• These agents stimulate an immune response that will
eradicate malignant cells
• Localized malignant melanoma and localized bladder
cancer.
Monoclonal Antibodies (MoAbs)
• Targeted antibodies for specific malignant cells
• Can be combined with:
• Radioactive materials
• Chemo
• Toxins
• Hormones
• Other BRMs
• Destroy cancer cells and spare normal cells
• Identify key antigen proteins on tumors that aren’t
present on normal tissue, blocks pathway of
communication btwn malignant cell and extracellular
environment, resulting in an inability to initiate
apoptosis, reproduce, or invade surrounding tissue.
• Assists in DX ovarian, colorectal, breast, prostate
cancers, leukemias, lymphoma.
• Used in purging residual tumor cells from stem cells
collections for pts undergoing HSCT.
• Trastuzumab (Herceptin): HER2 receptors over
expressed in breast & other cancers
• Rituxumab (Rituxin): CD20 antigen — non
hodgkin lymphoma, B-cell chronic lymphocytic
leukemia.
BSN 3 PAGE 16 OF 22
Cytokines:
• Produced by cells of the immune system in order to
modulate immune responses
• IFNs
• ILs
• CSFs
IFNs:
• Antiviral
• Antitumor
• Immunomodulatory properties
• Effects:
• Antiangiogenesis
• Direct destruction of tumor cells
• Inhibition of growth factors
• Disruption of cell cycle
• Hematologic cancers
• Severe toxicities
ILs:
• Produced by T-cells, NK cells, and dendritic cells
• IL-2: approved to treat renal cell cancer and
metastatic melanoma
• Toxicities may be severe; Il treatments limited
Cancer Vaccines
• Mobilize body’s immune responses to prevent or
treat cancer
• Autologous vaccines: cancer cells are taken from
patient’s own tissue (biopsy), killed, and prepared to
be reinjected into the patient.
• Allogeneic vaccines: cancer cells taken from another
person
• Prophylactic vaccines: prevent disease
• HPV2 (Ceravix): rec for female only. Protects
against HPV 16 & 18; responsible for 70% of all
cervical cancers
• HPV4 (Gardasil): male & female. (HPV 6,11,16
& 18)
• HPV9 (Gardasil-9): male and female. 9 HPV
types, cervical, anal, vaginal, and vulval cancers.
• Therapeutic vaccines: kill existing cancer cells and
inhibit further cancer growth
• Sipuleucel T (Provenge, Dendreon Corp)
metastatic prostate cancer no longer responding
to hormone therapy.
Gene therapy
• Correct genetic defects, manipulate genes to induce
tumor cell destruction, assist the body’s immune
defenses
• No FDA approved gene therapies.
• Developmental approaches:
• Tumor directed therapy: introduction of a
suicide gene into tumor cells
• Active immunotherapy: invoke anti tumor
responses
• Adoptive immunotherapy: altered lymphocytes
programmed to cause tumor destruction.
DANE DELION BSN 3 PAGE 17 OF 22

Nursing Management— Targeted therapies
• Monitoring therapeutic and adverse effects
• ADVERSE EFFECTS: fever, myalgia, N/V,
capillary leak syndrome, PE, hypotension.
• Severe HSRs seen with MoAb infusions.
• Promoting Home, Community based, and
transitional care
• Educate pts and caregivers about continuity of
care
• Teach administration technique and proper
disposal
• Teach how to manage common symptoms
• Collaborate with physicians, social workers,
third party payers, and pharmaceutical
companies to help patient support cost of oral
medications.
• Encourage compliance with follow up
appointments
may invade ulcerated areas and cause a
secondary infection.
• Side effects: severe oral pain, affect swallowing,
nutritional intake, speech, QOL, coping abilities,
and willingness to adhere to treatment regimens.
• Management:
• Oral cavity assessment
• Assess for dehydration, pain, and nutritional
impairment
• Maintain good oral hygiene: brushing,
flossing, rinsing & dental care
• Cryotherapy (oral ice during infusion)
• Low level laser therapy
• Sodium bicarbonate mouth rinses
• Palifermin (Kepivance) — promotes
epithelial cell repair and accelerated
replacement of cells in the mouth and GI
tract.

NURSING CARE OF PATIENTS WITH CANCER • Radiation dermatitis: radiation associated

impairment of skin integrity
• S/sx:
• Maintaining tissue integrity • Pain
• Promoting nutrition • Irritation
• Relieving pain • Pruritus
• Improving body image and self esteem • Burning
• Addressing sexuality • Skin sloughing
• Assisting in grieving process • With drainage (wet desquamation)
• Management of psychosocial distress • W/o drainage (dry desquamation)
• Monitoring and managing potential complications • Management:
• Promoting home, community based, and transitional • Maintenance of skin integrity
care • Cleansing
• Promotion of comfort
• Pain reduction
I. MAINTAINING TISSUE INTEGRITY • Prevention of additional trauma
• Stomatitis: inflammatory process of the mouth • Prevention and management of infection
including music and tissues surrounding teeth. • Promotion of a moist wound healing
• Risk factors: environment
• medications (doxorubicin, 5 FU, IL-2, IFN, • Use moisturizer on skin
molecular temsirolimus, everolimus) • Avoid sun exposure to area of treatment
• Poor oral hygiene • Avoid tape or bandages (source of irritation)
• General debilitation
• Existing dental dse • Alopecia: temporary or permanent thinning or
• Impaired salivary gland function complete loss of hair.
• Myelosupression • Risk factors:
• Tobacco use • Whole brain radiation
• Diminished renal function • Chemotherapy
• Impaired nutritional status • Targeted agents
• S/sx: • Onset:
• changes in sensation • 2-3 weeks after initiation of chemo/rad.
• erythema Regrowth usually happens 8 weeks after
• edema last Tx.
• painful ulcerations. • 1-3 months after targeted therapy: patchy,
• Onset: 5-14 days after chemotherapeutic agents frontal or temporal hair loss. May cause
• Pathophysiology: injury and apoptosis of basal change in hair growth rate, texture,
epithelial cells, leading to loss of epithelial curliness, and pigment.
renewal, atrophy, and ulceration. Organisms
DANE DELION BSN 3 PAGE 18 OF 22

• Management: Anorexia
• Cryotherapy during admin of chemo (seldom • Causes:
used) — risk for scalp metastasis • Alterations in taste (inc. salty, sour, metallic
• Provide information about hair loss and tastes. Altered responses to sweet and bitter
support the patient and family in coping flavors)
• Assist pts to identify proactive choices that • Early satiety after eating only a small amount of
may improve their responses to cancer and food.
perceived lack of control. • Decrease in digestive enzymes
• Abnormalities in the metabolism of glucose
• Malignant Skin Lesions: local metastasis of the and triglycerides
tumor into the epithelium and its surrounding lymph • Prolonged stimulation of gastric volume
and blood vessels. receptors
• Risk factors: most commonly assoc. with breast • Psychological distress (fear, pain, depression,
cancer. isolation)
• S/sx: • Food aversion r/t N/V
• Erythema
• Discolored nodules Malabsorption: patients unable to absorb nutrients
• Wounds involving edema from the GI system
• Exudates • Tumor activity (impaired enzyme production,
• Tissue necrosis interference with protein & fat digestion)
• Fun gating lesions — overgrowth of malodorous • Cancer treatment (chemo & radiation cause
organisms damage to mucosal cells of the bowel,
• Pain sclerosis of intestinal BV, fibrotic changes in
• Discomfort GI tissue).
• Embarrassment • Management: surgical intervention to
• Complications: • Change peristaltic patterns
• Hemorrhage • Alter gastrointestinal sections
• Vessel compression/obstruction • Reduce absorptive surfaces of GI mucosa
• Airway obstruction (esp in head neck cancer)
• Management: Cancer Related Anorexia-Cachexia Syndrome
• Assess for size, appearance, condition of (CACS): increased energy expenditure, decreased
surrounding tissue, odor, bleeding, drainage, and intake. May occur during curative or palliative stages.
associated pain/symptoms • Pathophysiology:
• Monitor for signs of infection • Immunologic + neuroendocrine + metabolic
• Wound cleansing processes = anorexia, unintentional weight
• Reduction of superficial bacteria loss, inc. metabolic demand c impaired
• Control of bleeding metabolism of glucose and lipids.
• Odor reduction • Altered metabolism + tumor responses =
• Protection from further skin trauma cytokine release & generalized systemic
• Pain management inflammation.
• Emotional support of pt and family • S/Sx:
• Weightless
II. PROMOTING NUTRITION • Malnutrition (loss of adipose tissue, visceral
• Nutritional impairment: may contribute to physical protein, and skeletal muscle mass)
and psychosocial consequences • Loss of appetite
• Decreased protein and caloric intake • Early satiety
• Metabolic or mechanical effects of cancer • Fatigue
• Systemic dse • Complications:
• S/E of treatment • Anemia
• Pt’s emotional status • Peripheral edema
• Progressive debilitation
• Decreased QOL
• Psychological distress
• Anxiety
• Management:
• Assess and address factors that interfere with
oral intake or associated with increased risk of
decreased nutritional status
DANE DELION BSN 3 PAGE 19 OF 22

• Initiate appropriate referrals for • Clients at greatest risk of sexual dysfunction: tumors
interdisciplinary collaboration to manage that involve sexual/pelvic organs, tx that affect
factors that interfere with oral intake hormonal systems mediating sexual function.
• Educate pt to avoid unpleasant sights, odors,
and sounds during mealtimes VII. MANAGEMENT OF PSYCHOSOCIAL
• Suggest foods that are well tolerated by pt. DISTRESS
• Respect ethnic and cultural food preferences • Actual/potential losses
• Fear of the unknown
III. RELIEVING PAIN • Symptoms due to cancer/cancer tx
• Assess patient for the source and site of pain • Changes in family and social roles
• Factors that influence patient’s perception and • Financial concerns
experience of pain • Sense of loss of control
• Fear • S/sx: vulnerability, sadness, fears, depression,
• Apprehension anxiety, panic, social isolation, existential and
• Fatigue spiritual crisis
• Anger • Referral to mental health providers may be helpful to
• Social isolation address specific concerns
• Pharmacologic & nonpharma approaches
• Surgical interventions may relieve pain VIII. MONITORING AND MANAGING
POTENTIAL COMPLICATIONS
IV. DECREASING FATIGUE
• Acute fatigue: serves a protective function, occurs Infection:
after an energy demanding experience • Leukopenia- decrease in circulating WBCs
• Cancer related fatigue: a distressing, persistent, • Granulocytopenia- decrease in neutrophils
subjective sense of physical, emotional, and • Monitor lab studies (WBC counts. ANC <1,500
cognitive tiredness related to cancer or cancer cells/mm3 risk for infection. <500 cells/mm3 severe
treatment that is not proportional to recent activity risk for infection)
and interferes with usual functioning. • Assess common sites of infection:
• Exercise • Pharynx
• Physical activity • Skin
• Cognitive behavioral therapy to address sleep • Perineal area
• Progressives uncle relaxation • Urinary
• Yoga • Respiratory tracts
• Mindfulness medication • Invasive catheters
• Antidepressants • Long term IV cath.
• Anxiolytics • Typical s/sx of infection may not be present in
• Hypnotics myelosuppressed patients bc the dec number of
• Psychostimulants circulating WBCs + diminished inflamm. response
• Report fever immediately
V. IMPROVING BODY IMAGE AND SELF • Collect cultures from wound drainage, exudates,
ESTEEM sputum, urine, stool, or blood
• Nurse serves as a listener and counselor to both • Provide education to patient and family about
patient and family infection prevention, s/sx to report, and importance
• Consider patients culture and age when discussing of adherence to microbial therapy.
concerns and potential interventions
• Encourage continued participation in activities and Septic Shock:
decision making • Life threatening complication
• Encourage pt to verbalize concerns • S/sx must be identified early and aggressive
• Assist in selecting and using cosmetics, scarves, hair intervention must be made
pieces, hats, and clothing that increase their sense of • Pts at highest risk: neutropenic, hematologic
attractiveness malignancies.

VI. ADDRESSING SEXUALITY Bleeding and Thrombocytopenia: < 100,000/mm3

• Discuss fertility plans prior to initiation of any • Risk factors
therapy • Infiltration of bone marrow
• Make referrals for specialized evaluation beyond • Abno. antibody function (leukemia, lymphoma)
scope of nursing intervention • Bacterial + viral infections
• Medications (heparin, vancomycin)
DANE DELION
• Posttransfusion antibody destruction
• Coagulopathies associated with infection or
malignancies (gastric & pancreatic cancer)
• Risk for VTE
• Provide pt and family teaching about s/sx of
VTE to report to provider
• Early s/sx:
• Petechiae
• Ecchymosis
• Dec in HCT or HGB
• Management:
• Bleeding precautions
• Use soft toothbrush for mouth care
• Use electric razor for shaving
• Emery board for nail care
• Avoid IM injections, use smallest needle
possible
• Apply pressure to venipuncture site for at
least 5 minutes
• Avoid bladder catheterizations
• Avoid medications that interfere with
clotting
IX. PROMOTING HOME, COMMUNITY
BASED, AND TRANSITIONAL CARE
• Educating patients about self care
• Vascular access devices
• Infusion pumps
• Drainage catheters
• Wounds
• Administration of medication
• Share strategies about how to manage side
effects
• Which side effects should be reported
promptly to physician
• Stress importance of patient safety and
infection prevention
• Outcomes: provide a sense of comfy, decrease
distress, improve coping, foster self management,
promote adherence, and enhance QOL.
• Continuing and transitional care
• Assess the home environment
• Suggest modifications to address pt’s
physical and safety needs
• Ongoing nursing visits or phone contact
from home
• Referrals and coordinate available
community resources.
CANCER SURVIVORSHIP CARE
• Prevention & detection of new and recurrent cancer
• Mammography
• Pap smear
• Smoking cessation programs
• Nutrition counseling
BSN 3 PAGE 20 OF 22
• Surveillance for cancer spread, recurrence, or second
cancers
• Colonoscopy post colon cancer
• Mammography post breast cancer
• Liver function tests
• PSA test post prostate cancer
• Intervention for consequences of cancer and its
treatments
• Lymphedema therapy
• Pain management
• Enterostomal therapy
• Fertility care
• Psychosocial support or care
• Reconstructive surgery
• Coordination between specialists and primary
providers to meet health needs
• Care for comorbidities
• Influenza vax
• Bone densitometry
• Monitor for chemo induced cardiotoxicity
GERONTOLOGIC CONSIDERATIONS
• Impaired immune system
• Special precautions to prevent infection
• Monitor for atypical s/sx of infection
• Altered drug absorption, distribution,
metabolism, and elimination
• Careful chemo calculations
• Frequently assess for drug response
• Dose adjustments
• Increased prevalence of comorbidities
• Monitor how cancer affects pt’s other diseases
• Monitor pts tolerance to Tx
• Monitor for drug interactions
• Diminished renal, respiratory, and cardiac
reserve
• Prevent decreases in renal function, atelectasis,
pneumonia, cardiovascular compromise
• Dec. skin and tissue integrity; reduction of body
mass; delayed healing
• Prevent pressure ulcers
• Monitor for dermatologic changes resulting
from Tx
• Monitor nutritional status
• Dec. musculoskeletal strength
• Prevent falls, Assess supports for ADLs at home,
teach use of assistive mobility devices
• Dec. neurosensory functioning: loss of vision,
hearing, and distal extremity tactile senses
• Provide instruction modified for pt’s vision and
hearing changes
• Provide instruction regarding safety and skin
care for distal extremities
• Assess home for safety
• Altered social and economic resources
DANE DELION BSN 3 PAGE 21 OF 22

• Assess for financial concerns, living conditions, • Back/neck pain

and resources for support • Worsened by: movement, supine recumbent
• Potential changes in emotional and cognitive position, coughing, sneezing, or valsalva
capacity maneuver.
• Provide education and support modified for • Numbness, tingling
patients level of functioning and safety. • Motor loss
• Bowel/bladder dysfunction
• Dx:
ONCOLOGIC EMERGENCIES • Percussion at level of compression
• Abnormal reflexes
• Sensory and motor abnormalities
• Superior Vena Cava Syndrome (SVCS): the • MRI, bone scan, CT scan
superior vena cava becomes blocked by a tumor, • Tx:
enlarged lymph node, thrombus, or drainage from • Radiation
head, neck, arms, and thorax. • surgery— debulk the tumor
• Advance staged cancer — therapy shifts from • Vertebral augmentation
curative to palliative • Vertebroplasty
• Lung cancer & lymphomas • Kyphoplasty
• S/Sx: • Chemotherapy
• Dyspnea • Nursing Management:
• Facial swelling • Asses neurologic function
• Enlarged neck and chest veins • Control pain with pharmacologic and non
• ICP: visual disturbances, headache, altered Pharma methods
mental status • Prevent complications from immobility
• Dx: • ROM exercise
• CXR • Urinary catheterization
• CT scan • Provide encouragement and support
• MRI
• Histology • Hypercalcemia: excess calcium in the blood,
• Venogram kidneys cannot excrete it fast enough, bones can’t
• Tx: reabsorb it.
• Emergency: stent and radiation therapy • Results from cytokine release, hormonal
• Non-emergency: histology diagnosis & substances, and growth factors released by
appropriate treatment (chemotherapy, other cancer cells.
medications: thrombolytics, anticoagulants) • Breast, lung, renal cancer, myeloma, and
• Supportive measures O2 therapy, leukemias.
corticosteroids, diuretics • S/sx:
• Nursing Management: • Fatigue
• Identify pt at risk for SVCS: non-small cell lung • Weakness
cancers, lymphomas, mediastinal metastases • Confusion
from breast cancer. • Hyporeflexia
• Provide pt education regarding s/sx to report • Polydipsia
• Monitor cardiopulmonary and neurologic status • Dehydration
• Semi fowler position • Dysrhythmias
• Monitor pt’s fluid volume status • Dx: serum calcium test > 10.5 mg/dL
• Avoid upper extremity venipuncture and BP • Ionized serum calcium > 1.29 mmol/L
measurement; instruct pt to avoid tight or • Tx:
restrictive clothing • Identify patients at risk for hypercalcemia
• Educate pts and family
• Need to consume 2-4L fluid daily unless CI
• Spinal Cord Compression: spinal cord becomes • Promotion of mobility and importance of
compressed at the thoracic, cervical, or sacral level preventing demineralization and breaking down
by a tumor. of bones.
• Often associated by cancers that metastasize to the
bone: breast, lung, prostate, lymphoma,
nasopharyngeal, and multiple myeloma.
• S/sx:
• Inflammation
DANE DELION BSN 3 PAGE 22 OF 22

• Tumor lysis syndrome: the release of intra-tumor

cellular contents into the blood stream that lead to
electrolyte imbalances (hyperkalemia,
hyperphosphatemia, hypocalcemia) which have end
organ effects on heart, kidneys, and CNS.
• Lung cancer, leukemia, lymphoma
• S/sx:
• Acute kidney injury (creatinine > 1.5 times
upper limit of normal)
• Dysrhythmias
• Seizures
• Neuro: fatigue, weakness, memory loss, altered
mental state, muscle cramps, tetany
• Cardiac: HTN, dysrhythmias, cardiac arrest
• GI: anorexia, N/V, abdominal cramps, increased
bowel sounds
• Renal: flank pain, oliguria, anuria, acidic urine
pH
• Other: gout, malaise, pruritis
• Dx:
• Serum electrolyte levels
• Urinalysis
• ECG to detect cardiac changes
• Tx:
• Aggressive fluid hydration
• Diuretics (loop diuretics)
• Allopurinol
• IV sodium bicarb.
• Hemodialysis
• Nursing management:
• Identify at risk patients
• Assess for s/sx of electrolyte imbalances
• Assess urine pH to confirm alkalization
• Monitor serum electrolyte and uric acid levels