NSG706 Principles and Methods of Comprehensive Nursing: Advanced MS Nursing

ONCOLOGY: Nursing Management in Cancer Client

Objectives

Review on the characteristics of benign and malignant neoplasms Carcinogenesis and causes of cancer Assessment findings Diagnosis and treatment Nursing management

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

Oncologic Nursing

Root words

Neo- new Plasia- growth Plasm- substance Trophy- size +Oma- tumor Statis- location

Root words

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

Terminology

TUMOR swelling that can be caused by a number of conditions, including inflammation and trauma. NEOPLASMS classified as benign or malignant Abnormal mass of tissue in which growth exceeds and is uncoordinated with that of the normal tissue.

Characteristics of Neoplasia

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

Characteristics of Neoplasia

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

Characteristics of Neoplasia

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

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

1. OMA but Malignant

HepatOMA, lymphOMA, gliOMA, melanOMA

2. THREE germ layers

TERATOMA

3. Non-neoplastic but OMA

Choristoma Hamartoma

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------------------G1SG2M G0- Dormant or resting G1- normal cell activities S- DNA Synthesis G2- pre-mitotic, synthesis of proteins for cellular division M- Mitotic phase (I-P-M-A-T)

CANCER NURSING

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

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

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

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

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

CANCER NURSING
Etiology of cancer 5. Viruses and Bacteria DNA viruses- HepaB, Herpes, EBV, CMV, Human 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

CARCINOGENESIS Malignant transformation IPP Initiation Promotion Progression

CANCER NURSING

CARCINOGENESIS INITIATION
Carcinogens alter the DNA of the cell Cell will either die or repair

CANCER NURSING

CARCINOGENESIS PROMOTION
Repeated exposure to carcinogens Abnormal gene will express Latent period

CANCER NURSING

CARCINOGENESIS PROGRESSION
Irreversible period Cells undergo NEOPLASTIC transformation then malignancy

CANCER NURSING

Spread of Cancer 1. LYMPHATIC

Most common

2. HEMATOGENOUS
Blood-borne, commonly to Liver and Lungs

3. DIRECT SPREAD
Seeding of tumors

CANCER NURSING

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

Cytotoxic T cells kill tumor cells

2. B cell System/ Humoral immunity

B cells can produce antibody

3. Phagocytic cells
Macrophages can engulf cancer cell debris

CANCER NURSING

Cancer Diagnosis 1. BIOPSY

The most definitive

2. CT, MRI 3. Tumor Markers

4. Pap smear 5. Polymerase Chain Reaction - in vitro technique

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

GOAL: cure, control, palliate

CANCER NURSING
GENERAL MEDICAL MANAGEMENT 1. Surgery 2. Chemotherapy 3. Radiation therapy 4. Immunotherapy 5. Bone Marrow Transplant

CANCER NURSING
GENERAL Promotive and Preventive Nursing Management 1. Lifestyle Modification 2. Nutritional management 3. Screening 4. Early detection

SCREENING

1. Male and female- Occult Blood, CXR, and DRE 2. Female- SBE, CBE, Mammography and Paps Smear 3. Male- DRE for prostate, Testicular self-exam

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

Nursing Diagnosis

Acute or chronic pain Impaired skin integrity Impaired oral mucous membrane Risk for injury Risk for infection

Nursing Diagnosis

Fatigue Imbalanced nutrition: less than body requirements Risk for imbalanced fluid volume Disturbed body image Deficient knowledge Ineffective coping Social isolation

Nursing Intervention

MAINTAIN TISSUE INTEGRITY Handle skin gently Do NOT rub affected area Lotion may be applied Wash skin only with SOAP and Water

Nursing Intervention

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

Nursing Intervention

MANAGEMENT OF ALOPECIA Alopecia begins within 2 weeks of therapy Regrowth within 8 weeks of termination Encourage to acquire wig before hair loss occurs Encourage use of attractive scarves and hats Provide information that hair loss is temporary BUT anticipate change in texture and color

Nursing Intervention
PROMOTE NUTRITION Serve food in ways to make it appealing Consider patients preferences Provide small frequent meals Avoids giving fluids while eating Oral hygiene PRIOR to mealtime Vitamin supplements

Nursing Intervention

Promote measures that ensure adequate nutritional intake. Promote a high-protein, high-calorie diet (if the client is not diabetic) Provide a bland diet as indicated. Adjust the clients diet before and after treatment according to food preferences. Provide refreshing mouth care before meals.

Nursing Intervention

Promote measures that relieve pain and discomfort Assess the clients pain, rule out any complications of treatment therapy or disease process, provide pain management as needed, and evaluate the effectiveness of pain medication.

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

Nursing Intervention
IMPROVE BODY IMAGE Therapeutic communication is essential Encourage independence in self-care and decision making Offer cosmetic material like make-up and wigs

Nursing Intervention

Provide measures to reduce social isolation. Provide frequent staff checks on the client, with time to talk whenever possible. Promote diversionary activities, such as television, radio, hobbies depending on mobility.

Nursing Intervention
ASSIST IN THE GRIEVING PROCESS Some cancers are curable Grieving can be due to loss of health, income, sexuality, and body image Answer and clarify information about cancer and treatment options Identify resource people Refer to support groups

Nursing Intervention

MANAGE COMPLICATION: INFECTION Fever is the most important sign (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
MANAGE COMPLICATION: Septic shock Monitor VS, BP, temp Administer IV antibiotics Administer supplemental O2

Nursing Intervention
MANAGE COMPLICATION: Bleeding Thrombocytopenia (<100,000) is the most common cause <20, 000 spontaneous bleeding Use soft toothbrush Use electric razor Avoid frequent IM, IV, rectal and catheterization Soft foods and stool softeners

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

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

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

NURSING INTERVENTION: COLOSTOMY CARE BEST time to do skin care is after shower Apply tape to the sides of the pouch before shower Assume a sitting or standing position in changing the pouch

Colon cancer

NURSING INTERVENTION: COLOSTOMY CARE Instruct to GENTLY push the skin down and the pouch pulling UP Wash the peri-stomal area with soap and water Cover the stoma while washing the peristomal area

Colon cancer

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

Colon cancer

NURSING INTERVENTION: COLOSTOMY CARE Measure the stomal opening The pouch opening is about 0.3 cm larger than the stomal opening Apply adhesive surface over the stoma and press for 30 seconds

Colon cancer

NURSING INTERVENTION: COLOSTOMY CARE Empty the pouch or change the pouch when
1/3 to full (Brunner) 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