NEO 113

JuLy 16, 2011

Oncology defined
Branch of medicine that
deals with the study,
detection, treatment and
management of cancer
 “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
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
 Genetics and Family History
 Colon Cancer
 Breast cancer
CANCER NURSING
Etiology of cancer
 Dietary Habits
 Low-Fiber
 High-fat
 Processed foods
 alcohol
CANCER NURSING
Etiology of cancer
Viruses and Bacteria
 DNA viruses- HepaB, Herpes, EBV, CMV, Papilloma
Virus
 RNA Viruses- HIV, HTCLV
 Bacterium- H. pylori
CANCER NURSING
Etiology of cancer
Hormonal agents
 DES
 OCP especially estrogen
CANCER NURSING
Etiology of cancer
Immune Disease
 AIDS
 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
CANCER NURSING
Cancer Staging
The degree of DIFFERENTIATION
 Stage 1- Low grade
 Stage 4- high grade
CANCER NURSING
GENERAL MEDICAL MANAGEMENT
 1. Surgery- cure, control, palliate
 2. Chemotherapy
 3. Radiation therapy
 4. Immunotherapy
 5. Bone Marrow Transplant
CANCER NURSING
GENERAL Pharmacology
 1. antimetabolites
 2. antibiotics
 3. plant alkaloids
 4. antiemetics
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 Pap’s 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 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 patient’s preferences
 Provide small frequent meals
 Avoids giving fluids while eating
 Oral hygiene PRIOR to mealtime
 Vitamin supplements
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
 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 peri-stomal 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 ¼ full
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
Discussion of

 Palliative Care
 Oncologic Emergencies
 Lung Cancer
 Male & Female reproductive Cancers
 Brain Tumors
Critical Thinking
 Scenario: A 49 y/o male has a 32 year history of
cigarette smoking. He often eats out with
associates and typically eats red meat and
potatoes. One of his associates is a 51 y/o female
whose mother dies of breast cancer. She is 40lbs
over her ideal weight because she likes to snack
during the day. She is also a heavy coffee drinker
because she is from Seattle.
Case Study 1
R.T. is a 64-year-old man who comes to his primary care provider’s (PCP’s) offi ce for a yearly
examination. He initially reports having no new health problems; however, on further questioning, he
admits to having developed some fatigue, abdominal bloating, and intermittent constipation. His
nurse practitioner completes the examination, which includes a normal rectal exam with a stool
positive for guaiac. Diagnostic studies include a CBC with differential, chem 14, and
carcinoembryonic antigen (CEA). R.T. has not had a recent colonoscopy and is referred to a
gastroenterologist for this procedure.
A 5-cm mass found in the sigmoid colon confirms a diagnosis of a polypof the colon. A referral
is made for surgery. The pathology report describes the tumor as stae 11, which means
that the cancer has extended into the mucous layer of the colon. A metastatic work-up is negative.

1. Identify 6 risk factors for colon cancer:

2. Discuss the recommended screening procedures related to colon cancer.
3. What warning sign did R.T. have?
4. What would early signs be for colorectal cancer?
5. What would late signs be?
Case Study 1
R.T. is a 64-year-old man who comes to his primary care provider’s (PCP’s) offi ce for a yearly
examination. He initially reports having no new health problems; however, on further questioning, he
admits to having developed some fatigue, abdominal bloating, and intermittent constipation. His
nurse practitioner completes the examination, which includes a normal rectal exam with a stool
positive for guaiac. Diagnostic studies include a CBC with differential, chem 14, and
carcinoembryonic antigen (CEA). R.T. has not had a recent colonoscopy and is referred to a
gastroenterologist for this procedure.
A 5-cm mass found in the sigmoid colon confirms a diagnosis of a polypof the colon. A referral
is made for surgery. The pathology report describes the tumor as stae 11, which means
that the cancer has extended into the mucous layer of the colon. A metastatic work-up is negative.

6. After bowel prep, R.T. is admitted to the hospital for an exploratory laparotomy, small bowel
resection and sigmoid colectomy. - What are five major complications for him?
7. After surgery, R.T. is admitted to the surgical intensive care unit (SICU) with a large
abdominal dressing. The nurse rolls R.T. side to side to remove the soiled surgical linen,
and the dressing becomes saturated with a large amount of serosanguineous drainage.
Would the drainage be expected after abdominal surgery? Explain.
Case Study 2
You are a home health nurse who has been seeing P.C., who was diagnosed with lung cancer
approximately 1 year ago. Her provider recently informed her that her cancer is no longer treatable;
the focus of her treatment will change from curative measures to symptom relief. She is confused and
somewhat angry with her provider. She vaguely remembers the term palliative treatment when
discussing her situation with her provider but doesn’t know what it means.

1. How would you describe palliative treatment?

Case Study 2
You are a home health nurse who has been seeing P.C., who was diagnosed with lung cancer
approximately 1 year ago. Her provider recently informed her that her cancer is no longer treatable;
the focus of her treatment will change from curative measures to symptom relief. She is confused and
somewhat angry with her provider. She vaguely remembers the term palliative treatment when
discussing her situation with her provider but doesn’t know what it means.

Case progress Note:

P.C. confides that she always felt that she might not survive her illness, but has never formally written
down her wishes concerning what types of treatment she would or would not want. You advise her
to complete an advance directive and/or living will or to complete a medical durable power of attorney
and/or a surrogate decision maker form. In current practice, it is very likely that a part of the home
health intake process will be completion of a Physicians Order on Life Sustaining Treatments (POLST)
Paradigm form.

2. What is the purpose of these documents?

Case Study 2
3. What health care decisions are considered in these documents?

4. How are advance directives and living wills formalized?

5. P.C. states she is confused and has mixed feelings about her health care wishes right now.
She asks, “If I fill out this form, can I change my mind down the road?” How should you
answer this question?

6. You inform P.C. that you will help with symptomatic control of her illness. What areas
will you focus on, and what question would you ask P.C.?

7. As P.C. becomes more frail and incoherent, what treatment will be given?
Discussion

 Culturally appropriate treatment

 Share your experiences