Cancer and oncology nursing Flashcards
prevalence
all cancer cases at a designated point in time
incidence
newly diagnosed cases of cancer during a specific period
- in a defined population
- expressed as a rate per 100,000 persons
- allows for comparison of populations
when looking at the statistics for cancer deaths, why does the number of deaths go up, but the percentage goes down?
we are seeing more and more cases of cancer every year, but percentage of ppl dying from it is going down because we are becoming more preventative and catching it early.
what is cancer?
-group of many different diseases
-abnormal cellular structure
-loss of normal controls on cell growth/death
-spread of malignant cells to parts of body beyond site of origin (metastasis)
Cancer overrides everything, apoptosis, etc
cancer growth patterns
Non-neoplastic growth patterns: hypertrophy, hyperplasia, metaplasia, dysplasia, anaplasia.
Neoplastic: neoplasm, benign or malignant
- Metaplasia:
- Dysplasia:
- Anaplasia: new cells completely different from parent cell. This change has been happening over long time. Late in staging.
-Neoplasm: new growth that may be benign or malignant
hypertrophy
cells enlarge
hyperplasia
more cells develop
metaplasia
may or may not lead to cancer. transposition of cells. Abnormal cell structure. Can have transposition/oddness of cells without cancer.
dysplasia, plus example
precancerous cells. Cells are altered in such a way that they are precancerous. If a patient has dysplasia of cells, and are easy to remove, they are removed (ie in cervix which is common) because they may turn into cancer. However, if deep inside the kidney or something, it’d be diff
anaplasia
new cells completely different from parent cell. This change has been happening over long time. Late in staging.
neoplasm
new growth. can be benign or malignant
normal cells vs cancer cells:
normal:
limited cell division, apoptosis, specific morphology, have a small nuclear-cytoplasmic ratio, perform specific differentiated functions, adhere tightly together, nonmigratory, grow in orderly/regulated manner (contact inhibition), euploid with 23 pairs of chromosomes
cancer:
rapid or continuous cell division, do not respond to signals for apoptosis, show anaplastic morphology (loss of normal arrangement of cells), have a large nuclear-cytoplasmic ratio, lose some or all differentiated functions, adhere loosely together (adherence is important for metastasis), able to migrate thru embryonic cells, grow by invasion, aneuploid
carcinogenesis, what is it, whats the theory, whatre the steps
Process of tumor development. Multistep process with multiple influences.
2 step theory: : cancer causing thing (ie smoking, sun exposure) PLUS the body’s inability to respond enough (immune system) –> permanent/ irreversible change to cell DNA
1. initiation 2. promotion 3. progression
carcinogen
Carcinogen: initiating agent. Starts the cancer process and then if immune system can’t stop it THEN u get cancer
-chemical, biological, physical, hormonal
cocarcinogen
promote/assist carcinogenesis
when do we want to be able to find the cancer?
Want to find it at initiation when it’s only changed a few cells. 2 hit theory is very important for understanding that immune system doesn’t only work for communicable diseases but also for cancer. HIV/aids pt have high rate of cancer because their immunocompromised
benign tumors
Show normal cell growth patterns, but the new tissue is not needed. (Can also show abnormal cell growth tho). They don’t respond to apoptosis, contact inhibition, any signals. But key thing is that they’re not harmful, don’t metastasize, are well encaspulated
examples of benign tumors
fibromas (anywhere in body in the connective tissue)
lipomas (in fat)
leiomyomas (fibroids in the uterus)
malignant tumors
Faster growing than benign, more likely to spread. These are true cancer in healthcare (laymen call everything cancer).
Differentiate benign and malignant by using word tumor.
Malignant cells divide almost continuously and gradually lose appearance of cells from which they arose
as malignant tumors become worse…
Further stage they become less and less like the original normal cell.
examples of malignant tumors
carcinoma in situ (hasn’t spread yet: stage 0).
malignant fibrosarcomas
bronchogenic carcinomas (lung type of cancer, specifically in wall of bronchus)
tumor nomenclature
- differentiated
- undifferentiated
- cell classification: cell type, originating tissue, malignant/benign, site, function
differentiated vs undifferentiated tumor cells
- differentiated (more like parent cell)
- undifferentiated (Looks a lot less like parent cell. More undiff it is, the less it acts and looks like parent cell. See cells like this on biopsy, signals that the cancer has been growing for a while.)
cancer grading
microscopic examination of biopsy of differentiation and number of mitoses of the cells.
GX: grade can not be assessed
G1: well differentiated (resembles parent cell)
G2: moderately differentiated
G3: poorly differentiated
G4 undifferentiated (does not look like parent cell
cancer staging
clinical, radiographic, surgical examination of extent/spread –> treatment, prognosis
More detailed than grading. Get stage from cat scans, x rays, etc. Tells us more than just what the cells look like.
grading v staging
grading on basis of cell appearance/activity compared with parent cell
staging classifies it on clinical aspects of the cancer and determines exact location and degree of metastasis at diagnosis
cancer staging systems
TNM, AJC
TNM
T1-4 = tumor size N0-3 = lymph node involvement M0-1 = metastasis
AJC
stages 0-IV = size of primary lesion and presence of nodal spread and metastasis
where does metastasis from blood cancer tend to go to
liver cause of blood flow.
where does mets from prostate/pancreas cancer tend to go to
bones because its prostate/pancreas are nearby legs, spine, etc.
patient has prostate cancer staged as T3, N2, M1. what does this mean?
tumor extends thru prostate capsule.
mets in single or multiple lymph nodes (2-4 cm).
distant metastasis
how does cancer compromise function?
Malignant cells do not perform intended tasks
Crowd out functioning cells
Form tumors that cause pressure on adjacent structures
Obstruct vessels
Impinge on nerves
Angiogenesis
common sites of mets, s/s
Brain (headaches, seizures, vertigo) Respiratory (cough, hemoptysis, dyspnea) Lymph nodes Liver (hepatomegaly, jaundice) Skeletal (pain, fractures, spinal cord compression)
angiogenesis: what is it, side effect?
development of new blood vessels within a tumor. easy and abundant access to blood and other nutrients necessary for growth. small localized tumor that gets angiogenesis can grow and spread.
happens when cancer sends out signaling molecule to surrounding tissue: seeding. this signals angiogenesis.
se: Anemia can be a side effect of the process of feeding tumor more than feeding tissue around it after angiogenesis.
metastasis, common sites/why
spread of cancerous cells from origin to a distant site.
-extension into surrounding tissues
-release of tumor cells
-local seeding
-bloodborne metastasis
-lymphatic spread
Liver/lung are both common sites for metastasis because tumor cells break off.
disease-related consequences of cancer
(These are not consequences of tx; consequences of cancer itself.)
- Impaired immune and hematopoietic function: Body can’t keep up with its hematopoietic fx, can’t make the RBCs fast enough.
- Altered GI structure and function: because GI is pliable tube, tumor can grow into it and block it
- Motor and sensory deficits: Could be impingement on nerves or eff on muscles but mostly neural thing
- Decreased resp function
- Pain and discomfort (psychological and physical): Big one. Acute/chronic/cancer pain. Has its own category because it has not only pain/discomfort of cancer in body, but also emotional and mental pain, treatment pain. Most cancer pts have pain, and its very hard to treat and has a large psych portion to it. There’s something we talk about in pain and talk about in cancer: that means its probs a test question cause its 2 topics in one.
risk factors for cancer
depends on type of cancer.
Also consider the 2 hit theory again.
Increasing age, hormones, immune dysfunction, chemical carcinogens (alter DNA), certain medications (DES, immunosuppressants), tobacco (all forms and secondhand smoke), nutrition and physical activity, asexual activity, sexual activity (Cervical cancer being caused by warts, condylomas), alcohol consumption, radiation (ionizing radiation, UV radiation, radon), viruses (HEP B, epstein barr, HPV), environmental and workplace factors
levels of cancer care
prevention (primary)
screening and early detection (secondary)
palliative
primary prevention of cancer
keeping it from happening at all ie using sunscreen, exercising, eating right, lifestyle habits, no smoking, vaccines, get regular healthcare
secondary prevention for cancer
preventing secondary complications from a dx: ie removing lymph nodes around a tumor, doing screenings to catch things early so we have more chances to eliminate it. So early detection and treatments to keep it from spreading/happening
palliative care
Tertiary prevention: keeping pt at highest level of functioning. It’s there, didn’t catch it early, so now we just have to do things that will help the patient to function as well as possible. To include palliative care, but palliative is not the only kind of tertiary care. Not gonna cure cancer, but will help pt have better functioning, less pain, higher QOL.
pt education for warning signs of cancer:
CAUTION
Change in bowel/bladder habits
A sore that doesnt heal
Unusual bleeding or discharge from body orifice
Thickening or lump in breast or elsewhere
Indigestion or difficulty swallowing
Obvious change in wart/mole
Nagging cough/hoarseness
pt ed: warning signs for melanoma
ABCDE
Asymmetry (does 1/2 look like the other 1/2?)
Border irregularity (it not nice and smooth border, bad)
Change in color or pigmentation
Diameter greater than 6mm (size of a pencil eraser)
Cancer treatment goals
remove/destroy malignant cells.
prevent spread of malignant cells.
slow growth of malignant cells.
types of cancer treatments
surgery, radiation chemo others (hormone, gene, and immunomodulation therapy) complementary and alternative therapies
another way to think about cancer treatment?
Another way to talk about cancer treatment: cure, control, palliation.
We never say cancer is “gone”. We recognize it can happen again. So cure just means a prolonged absence of cancer, keeping in mind that relapse can happen. Usually ~5 yrs is determined “cured.”
Control: cure is not possible. Control by preventing the spread of malignant cells. But don’t anticipate the absence.
Palliation: cure/control not possible. Do palliative care to keep pt highest level of fx, comfortable physically/emotionally.
reasons for surgery for cancer:
To establish a diagnosis and treatment
Primary treatment: removal, cancers gone.
Adjuvant treatment: radiation plus surgery for tx.
Salvage treatment: ex, take out half liver cause other half is still good.
Palliative treatment
combination tx: radiation shrinks the tumor, then they go in with surgery to remove the tumor.
reconstructive tx
radiation therapy for cancer purpose
Can be used alone or with other treatments.
Destroys the ability of cancer cells to
multiply.
types of radiation therapy for cancer + side effects
External beam
Brachytherapy
Side Effects: Site dependent
Long term consequences
external beam radiation
They try to pinpoint as much as possible. Tumor absorbs the radiation, which then kills the cancer cells. But some of the tissue also absorbs it.
can use Immobilizing mask made to specifically fit this patient. Every time they get radiation, this will help them hold their head in position and not move it around. Only for pt with head/neck cancer.
side effects of external beam
Vary according to treatment site and dependent on the total absorbed dose:
Local skin changes and hair loss
Altered taste sensations (head and neck, affects salivary glands/moisture)
Fatigue related to increased energy (fighting takes a lot of energy from body)
Inflammatory responses that cause tissue fibrosis and scarring
what do 2nd degree burns on pt from radiation mean
2nd degree burns from radiation (they did something wrong.)
brachytherapy
internal radiation therapy.
Seeding: these are tiny radiation capsules. For prostate cancer, they seed entire prostate. They emit radiation, and because they’re so small, it’s very localized and less surrounding tissue damage. These are not removed after. Seeding can be done in lots of places.
This one is for cervical. Gets removed after done. Patient must be on bed rest while receiving the radiation. This is radioactive. Every pt receiving this kind of brachytherapy has a lead container and u use tongs to pick it up and put it in the container if it falls out. Scary cause its radioactive.
nursing care for clients with radiation:
- Consider time, distance, and shielding: : limit TIME in the area. Be as FAR away as possible. Use something like the special wall for SHIELDING. Try to do more nursing tasks at same time to reduce exposure time, limit time in their room.
- Teach accurate objective facts to help pt’s cope
- Do not remove markings
- Administer skin care
- Avoid lotions/ointments on day of treatment: May cause second degree burn. Put it on after radiation to protect the skin.
- Avoid direct exposure of skin to sun: It’ll cause more damage. Cells are already fragile.
- Care for xerostomia: dry mouth. Head/neck radiation. Salivary glands may be destroyed.
- bone exposed to radiation is more fragile. Be careful moving them in bed, they need to ambulate carefully.
chemo administration considerations
First, must be chemo certified. Special gloves, handling, etc training.
When you have an order for chemo, it is more important than anything else. For ex: if at 10 you’re supposed to give chemo, vitamins, and antibiotics, you START CHEMO FIRST as CLOSE to the ordered time as possible. Dosing and how far apart the dosing is spread has been calculated to kill the most cells while doing the least damage so wanna be as close as possible to ordered time.
Timing is really important so after tx theres left behind as few cells as possible so the bodys immune system can finish the job.
nrsg care for chemo pt:
Most chemotherapies are vesicants: need central line ending in SVC. Don’t want it to get into soft tissue and cause irreparable damage.
Chemo can be IV, oral, even topical for certain cancers. But ALWAYS protect self no matter the route.
chemo administration prep, routes
prep:
Verification of agent, dose, schedule
Safe preparation, handling, and disposal
Dose calculations
Routes of administration:
Intravenous, regional, oral, etc.
chemo side effects/ toxicities
The result of the destruction of normal cells
fast growing cells most susceptible to damage:
-myelosuppression, n/v, mucositis along entire GI tract, diarrhea/constipation, alopecia/hair loss
cell destruction, fatigue, anorexia, taste alterations
what does myelosuppression lead to
neutropenia, thrombocytopenia, anemia: leads to infection, fatigue, bleeding
why do cancer pts with chemo harvest sperm/eggs before tx
Ppl often harvest sperm/eggs before tx because tx can make them infertile.
acute chemo toxicity
vomiting, allergy, dysrhythmia
delayed chemo toxicity
mucositis: mouth sores, gastritis, diarrhea. alopecia, bone marrow suppression
chronic chemo toxicity
reduced cardiac contractility, elevated liver enzymes, elevated BUN/creat
chemo access
port a cath, tunneled cath
other cancer treatments
- hormone therapy: If its fed by hormones like some breast cancers
- immunotherapy biological response modifiers: To get immune system to work better to kill some cancer cells
- gene therapy
cancer care: psychosocial aspects
-Support for client and family
-Promoting positive self-concept
-Promoting coping
-Diagnosis and treatment
-Survivorship
-Recurrent disease and progression
-Terminal illness
Notes: No matter if prognosis is dire or treatable, cancer really affects people.
Things like wigs, makeup days, always involve social worker with pt with cancer dx.
nutrition with cancer pts
Body is using so much energy to fight cancer and sometimes the tx.
Anorexia: Peaks 4 wks into tx. Let pt know anorexia may last for a little bit after tx, but appetite will come back shortly after treatment ends. Teach them about calorie dense foods and stuff so they don’t get cachexia. Always involve RD. so we need social worker, dietician,
Cancer cachexia.
Nutritional screening
fatigue w/ cancer
Most common symptom of cancer and its therapy.
Cancer treatments and severity of disease increase risk of developing fatigue .
effects of fatigue w/ cancer
Mood disturbances
Poor concentration
Decreased perception and capacity to work.
Changes in compliance with medical treatment.
decreased ability to perform ADLs.
This is a big deal. Problem because fatigue only exacerbates the system: immune system has a harder time fighting.
Whatever we can do to help them balance activity and rest.
how to assess fatigue?
piper fatigue scale. Four dimensions of fatigue: 1. Physical (sensory) 2. Mental (cognitive/mood) 3. Emotional (affective) 4. effects on ADLs (behavioral/severity)
cancer pain
Most ppl with cancer have pain. Mostly not a problem in early stages.
Beginning of tx: 30% have pain.
Further into treatment, and more advanced cancer, 90% have pain and 50% fail to get relief.
nrsg considerations for cancer pain
Do good assessments, teach them appropriate use of pain meds at home, do whatever u can to manage their pain.
Implement frequent assessmements of pain status.
Provide patient and family counseling or education.
Participate in ongoing reevaluation and management of pain control.
QOL thru cancer continuum, whys it impt?
Higher QOL, longer survivor times (studies were done).
QOL not necessarily about going to HI, disneyland, etc. really it’s about oftentimes just letting them keep their regular life routine. Taking kids to school. Keep house clean. Etc.
how can oncology nurses improve pt QOL
prioritize symptoms, implement relief measures.
for pts at end of life: hospice, palliative care.
what are the oncological emergencies?
- DIC/sepsis
- SIADH
- spinal cord compression
- hypercalcemia
- SVCS
- tumor lysis syndrome
SEPSIS/DIC
sepsis can lead to shock. pt immune system is overwhelmed. sepsis and shock can lead to coagulation problems: dic. (extremities first.)
sepsis/dic collaborative management:
Wanna fight levels of infection early, and be aware immune system is decreased.
Prevention is the best measure
IV antibiotics
anticoagulants, cryoprecipitated clotting factors.
So now we giving them strong antibiotics, giving them ISO to protect them from environment. If they get DIC, give them clotting factors even tho the tiny clots are causing other problems because the inability to clot places pt at greater risk.
Antibioitcs are really impt
SIADH
Inappropriate meaning too much ADH. Water is reabsorbed to excess by the kidney and put into system circulation.
SIADH –> water intoxication. Blood becomes very very dilute. This is extreme dilutional hyponatremia. (there are 2 kinds of hyponatremia).
Can lead to cerebral edema. Crosses BBB.
SIADH can lead to?
water intoxication, can lead to cerebral edema by crossing BBB.
SIADH collaborative management
Fluid restriction
Increased Na intake
Drug therapy with demeclocycline in opposition to antidiuretic hormone
spinal cord compression
Tumor directly enters spinal cord or vertebrae collapse from tumor degradation of bone
Also happens in pt with bone cancer: if bone of spine starts to degrade, it can no longer protect spinal cord or it itself will press on spinal cord.
spinal cord compression collaborative management
Early recognition and treatment Palliative High dose corticosteroids High dose radiation Surgery External back or neck braces to reduce pressure in spinal cord
Often surgery or radiation to shrink it enough to not cause a compression problem.
But if not possible, surgery to remove the tumor which is very dangerous and always a last resort. May be plates/ortho surgery if its in the actual spine. Usually very low or high in the spine (will usually do back/neck brace to protect the spine)
Always think about whos susceptible, and then what do u do.
hypercalcemia
May be from metastasis or a cancer that started in bone.
Occurs most often in pt’s w/ bone metastasis: tx diminishes the bone integrity and Ca leaks out.
hypercalcemia s/s
Fatigue, loss of appetite, N/V, constipation, polyuria, severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, EKG changes
hypercalcemia collaborative management
Oral hydration to dilute Ca, drug therapy to decrease amount of Ca, dialysis if its bad enough
SVCS
SVC Very large, but still a vein, so walls are thinner than artery. So can be compressed. Patient’s with cancer affecting lymph system often get SVC syndrome:
Superior vena cava is compressed or obstructed by tumor growth. Painful, life threatening emergency
SVCS s/s
(edema of face, arms, and hands; dyspnea, erythema) Since the fluids above cannot drain.
hardly ever see facial edema in general.
SVCS collaborative management
High dose radiation therapy, surgery rarely; Surgery is risky. May respond to radiation well.
SVCS late stage s/s
hemorrhage, cyanosis, change in mental status (going across BBB), decreased cardiac output, and
hypotension (having a big effect on circulation).
tumor lysis syndrome
If tx for cancer goes too fast and too many cells die, since all that garbage from the cells goes into the blood stream, sometimes all those dead cell contents cannot be eliminated quick enough by the body –> will cause potassium to go up leading to fatal dysrhythmias since potassium is most common electrolyte within the cell.
pt at risk for tumor lysis syndrome?
Pts at risk: usually lymphoma/leukemia cancers since these respond quickly to therapy.
what else is seen in pt with tumor lysis syndrome other than increased potassium in blood? why is it concerning?
Also see increase in uric acid and calcium in the blood in addition to potassium. Uric acid /calcium concerning also because they can crystallize, esp the uric acid, and then when going thru the kidney, can destroy kidney. Renal failure.
tumor lysis syndrome collaborative management
prevention, hydration, drug therapy
