Chapter 24: Care Of Patients With Cancer Flashcards
Radiation therapy
To destroy cancer cells with minimal exposure of the normal cells to the damaging actions of radiation it’s a local treatment. Cells damaged by radiation either die or become unable to divide. Gamma rays are the most commonly used
Radiation delivery types for cancer therapy are teletherapy and brachytherapy.
The type used depends on the patient’s general health and on the shape, size, and location of the tumor to be irradiated
The ideal radiation dose is one that can kill the cancer cells with an acceptable level of damage to normal tissues (damage to normal tissues cannot be avoided)
Care of a patient with sealed implants of radioactive sources
Private room, radioactive sign, lead shields, door closed, wear dosimeter film badge and a lead apron while providing care, no pregnant nurses, visitors only 30 minutes per day, never touch the source, Save dressings and bed linens until source is removed.
Skincare during radiation therapy
Wash area daily, use hand not cloth, rinse soap, do not remove markings, dry, no lotions unless prescribed, soft clothing, no clothing that rubs or bothers the site, avoid sun for a year, avoid heat exposure
Cells damaged by chemotherapy
Usually affects cells that divide rapidly. Skin, hair, intestinal tissues, spermatocytes, and blood forming cells
Chemotherapy drug categories
Anti-metabolites. Counterfeit chemicals that fool cancer cells into using them, preventing cell division
Antitumor antibiotics damage DNA or RNA synthesis
Anti-mitotic agents: Plant source that interferes with formation of microtubules
Alkylating agents: Cross-links DNA preventing RNA synthesis
Topoisomeerase inhibitors: Causes damage to DNA and RNA synthesis
B:
Antimetabolites are similar to normal metabolites needed for vital cell processes. Antimetabolites closely resemble normal metabolites and are “counerfeit” metabolites tha fool cancer cells into using the antimetabolites in cellular reactions, their presence impairs cell division
Antitumor antibodies damage the cell’s DNA and interrupt DNA or RNA synthesis
Antimitotic agents interfere with the formation and actions of microtubules so cells cannot complete mitosis during cell division, therefore the cancer cell either does not divide at all or divides only once
Alkylating agents cross-link DNA, making the two DNA strands bind together tightly. This tight binding prevents proper DNA and RNA synthesis, which inhibit cell division
Topoisomerase inhibitors disrupt an enzyme (topoisomerase) needed for DNA synthesis and cell division. Topoisomerase inhibitors prevent proper DNA maintenance, causing DNA breakage and cell death
Miscellaneous chemotherapeutic agents are thos with mechanisms of action that are either unknown or do not fit those of other drug categories
Vesicants
Chemicals that damaged tissue when in contact. Can cause infiltration. Signs include pain, infection, and tissue loss
Infection resulting from neutropenia
This is a major dose limiting side effect of cancer chemotherapy and a common cause of death for patients during treatment. Most come from an overgrowth of normal flora
Chemo brain
Changes in cognitive function. Reduced ability to concentrate, memory loss, difficulty learning new information.
Hormonal manipulation
Some tumors require specific hormones to divide. Hormonal manipulation can help control some types of cancer, but does not cure. They can be hormone agonists, hormone antagonists, Or hormone inhibitors.
Side effects of hormonal manipulation
Have Masculinizing Effects in women such as chest and facial hair, ceasing of periods, decreasing breast tissue, acne, hypercalcemia, liver dysfunction, bone loss. If receiving hormones you may have heavy menses, fluid retention, breast tenderness. Estrogens increase the risk for deep vein thrombosis.
Men may have female manifestations such as decreasing facial hair, smoother skin, fat redistribution, gynecomastia, testicular atrophy, erection more difficult
Hypercalcemia: The early manifestations of hypercalcemia include fatigue, loss of appetite, N/V, constipation, and polyuria (increased urine output). Hypercalcemia reduces excitable membrane activity, causing decreased intestinal motility. Check bowel sounds and return of intestinal motility is an indication that serum calcium levels are decreasing. Increase oral fluids and observe for muscle weakness
Photodynamic therapy PDT
Uses injection that makes cells sensitive to loght and a laser light to cause a chemical reaction and destroy cancers. Most commonly used for nonmelanoma skin cancers, ocular tumors, G.I. tumors, lung cancers in the airways. Patient is extremely light-sensitive. Light sensitivity remains for at least 30 days, causing the patient to be homebound for about 1 to 3 months to protect the skin. Even a penlight or a pulse oximeter could cause a burn. Must avoid lights as well as the sun.
Immunotherapy: biological response modifiers
BRM’s As cancer therapy
They are cytokines, which are small protein hormones made by white blood cells. They enhance the immune system
Interleukins Help immune system cells recognize and destroy abnormal body Cells
Interferons Are cell produce proteins that protect noninfected cells. Slow tumor cell division, stimulate the growth and activation of natural killer cells, help cancer cells resume a more normal appearance and function(revert to original characteristics), inhibit the expression of oncogene.
Monoclonal antibodies Bind with the cell and prevent cell division
Used for melanoma, hairy cell leukemia, renal cell carcinoma, ovarian cancer, and cutaneous T-cell lymphoma
Thalidomide reduces the tumor angiogenesis factor which is needed to give blood supply to the tumor. Treatment of multiple myeloma
BRMs as supportive therapy
Help with a rapid recovery of bone marrow after suppression by chemotherapy. Patients are at less risk for infection, anemia, and bleeding. Patients can receive their chemotherapy on time and may be able to tolerate higher doses. They can alternately stimulate the growth of leukemia or lymphoma cells
Side effects of BRM therapy
Inflammatory reactions including edema which is widespread. This can affect the function of organs and can be life-threatening. Fever(Tylenol, rigors(Demerol), flulike malaise. Peripheral neuropathy which includes sensation, visual disturbances, decreased hearing, unsteady balance, orthostatic hypotension. Skin rashes, dryness, itching, peeling.
Immediate: fever, chills, rigor, malaise
Gene therapy
Experimental. Insert a viral enzyme to make them more susceptible to being killed by antiviral agents. Human leukocyte antigen makes the cells able to be recognize easier so they can be eliminated and destroyed.
Targeted therapy
Combination of gene therapy and immunotherapy. Block the growth factor. Not all patients with the same cancer type will respond the same these treatments. Patients could have an allergic reaction to these antibodies.
Don’t worry about
Sepsis/septicemia
Life-threatening condition and common cause of death in patients with cancer. This occurs because of their high risk for infection due to a low immune function
Disseminated intravascular coagulation. DIC
Problem with the blood clotting process. Caused by sepsis, by the release of thrombin, or by blood transfusions. Most often seen in leukemia, adenocarcinomas of the lung, pancreas, stomach, and prostate. Clotting occurs throughout the small blood vessels, uses up the existing clotting factors and platelets, and is followed by extensive bleeding. Can have pain, strokelike manifestations, dyspnea, tachycardia, oliguria, bowel necrosis. It’s a life-threatening and has high mortality. The best plan is to prevent it by using strict aseptic technique and recognizing the indications of infection. IV antibiotic therapy is started, heparin is given early on, later on clotting factors to prevent hemorrhage.
Syndrome of inappropriate antidiuretic hormone
SIADH
Carcinoma of the lung is the most common cause but other cancers can cause it especially tumors of the brain. Water is reabsorbed in excess by the kidneys. Casas hyponatremia and fluid retention. Weakness, muscle cramps, decreased appetite, fatigue. weight gain, nervous system changes, personality changes, confusion, muscle weakness. As sodium drop you can get seizures, coma, and deaths
Restrict fluids, increased sodium intake, and drug therapy. You may reduce the cause either radiation or chemotherapy. Prevent fluid overload to avoid pulmonary edema and heart failure. Monitor for pulse quality, neck pain distention, crackles in the lungs, peripheral Edema, decreased urine, at least every two hours
Spinal cord compression
Occurs from tumors on the spinal cord or when vertebrae collapse from deterioration. Causes back pain and neurological problems leading to paralysis. Manifestations are back pain, weakness, numbness and tingling, decreased hot cold sensitivity, unsteady gait, constipation, incontinence, difficulty starting the stream of urine.
Treatment is high-dose corticosteroids, radiation reduce the tumor, surgery, braces.
B:
Spinal cord compression (SCC) and damage occur either when a tumor directly enters the spinal cord or when the vertebrae collapse from tumor degradation of the bone
Collaborative management:
ØEarly recognition and treatment, assess neurologic changes, including back pain, muscle weakness or a sensation of heaviness in the arms or legs, numbness or tingling in the hands or feet, inability to distinguish hot and cold, and unsteady gait, constipation, incontinence, difficulty stopping or starting urine
ØPalliative
ØHigh-dose corticosteroids
ØHigh-dose radiation
ØSurgery
ØExternal back or neck braces to reduce pressure in spinal cord
Hypercalcemia
Usually with bone metastasis. Other cancer type have a tumor that will secrete PTH causing release of calcium. Dehydration also worsens this. Manifestations include fatigue, decreased appetite, nausea and vomiting, constipation, polyurea. More serious is muscle weakness, decreased reflexes, paralytic ileus, dehydration, ECG changes.
Be treated by increasing hydration or using drugs (glucocorticoids, calcitonin) that will lower calcium levels. Dialysis can be used
Superior vena cava syndrome
Caused by obstruction or compression by tumor growth or clots in the vessel. Usually with lymphomas in lung cancer. Cancer of the breast, esophagus, colon, and testes can also cause this. Manifestations come from blocking blood flow to the head neck and upper trunk. Upper extremity edema. Manifestations: edema of the face, tightness of the color of the shirt which is called Stokes sign, Edema in the arms, hands, dyspnea, erythema of the upper body, epistaxis, hemorrhage, cyanosis, decreased mental status, decreased cardiac output, hypotension.
Is usually a late manifestation and the tumor is usually widespread. High-dose radiation may provide relief, surgery is usually not used, a stent could be placed.
Tumor lysis syndrome
TLS
When tumors are destroyed rapidly their contents including potassium and purines are released into the bloodstream faster than they can be eliminated. It is positive sign the cancer treatment is effective. If untreated it can cause secere tissue damage and death. Hyperkalemia can cause severe cardiac dysfunction. Purines are converted to uric acid which can block the kidney tubule leading to renal failure.
Prevention through hydration is the best management. Patient should drink at least 3000 to 5000 mL a day. Some fluids should be alkaline to decrease uric acid. Nausea and vomiting must be controlled to decrease dehydration. Diuretics may be given with caution, drugs that increase the excretion of purines are given; drugs to reduce potassium can be given. IV glucose and insulin may be given for severe hyperkalemia. Dialysis may be needed
Adjuvant therapy
Chemotherapy that is used along with surgery or radiation
Alopecia
Hair loss. Usually regrows within a month after completion of chemotherapy.
Anemia
Clinical sign of abnormal condition related to a reduction in one of the following: the number of red blood cells, amount of hemoglobin, or hematocrit which is the percentage of packed red blood cells. Causes fatigue.
Biological response modifiers
BRMs
Class of immunomodulating drugs that attempts to modify the course of disease. Stimulates bone marrow production of the immune system cells. Usually not covered by insurance they are expensive Some of these drugs increase production of many cell types increasing the patient’s risk for hypertension, blood clots, strokes, and heart attack.
Cachexia
Extreme body wasting and malnutrition that develops from an imbalance between food intake and energy use
Chemotherapy
Treatment of cancer with chemical agents that have systemic effects; used to cure and increase survival time.
Plays a major role in cancer therapy.
Cancer cells can separate from the original tumor, spread to new areas, and establish new cancers at distant sites (metastasize)
Chemotherapy is useful in treating cancer because it effects are systemic, providing the opportunity to kill metastatic cancer cells that may have escaped local treatment. Chemotherapy used along with surgery or radiation is termed adjuvant therapy
It has some selectivity for killing cancer cells over normal cells
Normal cells most affected—skin, hair, intestinal tissues, spermatocytes, blood-forming cells
Cytoprotectant
Drugs that protect specific healthy cells; given to patients to decrease the impact of chemotherapy on normal tissues
Cytoreductive surgery/cancer control
Surgery done to remove part of a tumor while leaving a known amount of gross tumor behind
Cytotoxic
Having cell-damaging effects
Diagnostic surgery
Biopsy. Surgery done to remove all or part of a suspected lesion for examination and testing
Dose
In radiation therapy, the amount of radiation absorbed by recipient tissue during radiation therapy as determined by intensity of exposure, duration of exposure, and closeness of the radiation source to the cells.
Dose-dence chemotherapy
Chemotherapy that uses higher doses more often for aggressive cancer treatment, especially breast cancer
Emetogenic
Substance that induces nausea and vomiting
Extravasation
Escape of fluids or drugs into the subcutaneous tissue; a complication of IV infusion. Also called infiltration. If leakage of the chemotherapy agent is less than .5 mL, it usually resolves. If larger surgical intervention may be necessary. You must closely monitor the access site
If swelling, pain, or burning, stop and remove IV
Management will depend on the specific drug. Cold or warm compresses may be used, antidotes or chemoprotective agents may be injected into the site of extravasation. Coordinate with the oncologist and pharmacist to determine the specific antidote needed for the extravasated drug
Mucositis
Open sores on mucous membranes. This includes the entire G.I. tract. In the mouth it is called stomatitis. Frequent mouth assessment and oral hygiene are key in managing this.
Nadir
In chemotherapy, the period of greatest bone marrow suppression, when the patient’s platelet count maybe very low
Neutropenia
Decrease number of leukocytes, especially neutrophils, which causes immunosuppression. Infection does not always show up with a fever or purlent drainage
Peripheral neuropathy
Inflammation of peripheral nerves; polyneuritis or polyneuropathy. Anti-mitotic’s and platinum-based drugs can cause this. Priority nursing care is to teach how to prevent injury. Include loss of sensation in the hands and feet, orthostatic hypotension, erectile dysfunction, neuropathic pain, loss of taste, severe constipation.
Prophylactic surgery
Surgery done to remove at risk tissue to prevent cancer development
Second look surgery
Done to assess the disease status in patients who have been treated and have no symptoms of remaining cancer tumor
Thrombocytopenia
Reduction in the number of blood platelets below the level needed for normal coagulation, resulting in increased tendency to bleed
Vesicant
Chemicals that cause tissue damage on direct contact
Xerostomia
Abnormal dryness of the mouth caused by a severe reduction in the flow of saliva
Cancers left untreated cause:
Reduced immunity and blood producing function
Altered G.I. structure and function
Motor and sensory deficits
Decreased respiratory function
Teletherapy
Radiation source is external
Patient is not radioactive
You must know the exact location of the tumor
Patient must be able to remain in the same position each time
Side effects include local hair loss and skin damage which are permanent. Fibrosis and scarring. Fatigue. Altered taste.
- Teletherapy is radiation delivered from a source outside of the patient
The source is external, the patient is not radioactive and is not hazardous to others
Exact location of the tumor is detremined for therapy accuracy
Once the pattern of radiation delivery is determined, the patient must always in be exactly the same position for all treatments (Camporeale, 2008)
ØPosition-fixing devices and markings, either on the patient’s body or on the devices, ensure the proper position each day of treatment
Markings may be small permanent “tattoos” ink outlines on the skin, or a marked covering laid over the skin during positioning. Molds and splints may be used also
Brachytherapy
Radiation source is in contact with the tumor.
Patient is radioactive and harmful to others
Liquid or solid implant
Example is thyroid cancer
Side effects include permanAvoid direct skin exposure to sunlight
Care for xerostomia (dry mouth) more prone to tooth decay. Advise patient to perform oral care after every meal and before sleep
Bone exposed to radiation more vulnerable to fractureent hair loss and skin damage which are local. Fibrosis and scarring. Fatigue. Altered taste.
Brachytherapy means “short”’ or “close” therapy
The radiation source comes into direct, continuous contact with the tumor tissues for a specific time period
This method provides a high dose of radiation in tumor tissues and a very limited does in surrounding normal tissues
Brachytherapy uses radioactive isotopes either in solid form or within body fluids.
Isotopes can be delivered to the tumor tissues in several ways
Note: With all types of brachytherapy, the radiation source is within the patient. Therefore the patient emits radiation for a period of time and is a hazard to others (Waring & Gosselin, 2010)
When isotopes are used they are unsealed andsuspended in a fluid, they are given by the oral or IV routes or instilled within body cavities
An example of brachytherapy with soluble isotopes is the ingestion or injection of the radionuclide iodine -131 (¹³¹) (an iodine base with a half-life of 8.05 days) to treat some thyroid cancers. The iodine concentrates in the thyroid gland and destroys the thyroid cancer cells.
Note: When the isotopes are unsealed, they enter body fluids and eventually are eliminated in waste products, which are radioactive and should not be directly touched by other people. This material is radioactive for about 48 hours after instillation of the isotope. Do not share toilet with other people for 3 days (72 hours) ensures that the isotope has been completely eliminated and the patient’s wastes are no longer radioactive
Note: Anyone who is pregnant should not enter the room. Individual care providers should wear lead apron and should not spend more than 30 minutes a day in the room with the patient receiving brachytherapy
After the isotope is completely eliminated from the body, neither the patient nor the body wastes are radioactive
Note: When solid implants are in place, the patient emits radiation but excreta are not radioactive and do not pose a hazard to anyone
If a radiation implant becomes dislodged and the nurse finds the implant on the floor or in the patient’s bed the nurse should use tongs to place the implant into the radiation container (lead lined). If the proper equipment is not available in the patient’s room, the radiation department must be notified
Chemotherapy
Is a systemic treatment.
Last 2 to 8 hours at a time
Side effects include immunosuppression, infection, hemorrhagic cystitis, cardiac muscle damage, decreased bone density, anemia, neutropenia, thrombocytopenia, nausea and vomiting, alopecia, mucostitis, skin changes, anxiety, sleep disturbance, chemobrain, altered bowels
Herceptin/ trastuzumab
Is a form of targeted therapy, which combines gene therapy and immunotherapy. This epithelial growth factor receptor EGFR binds excessive amounts of a certain type of EGFR produced by breast cancer cells in response to the activation of the HER2//neu gene. Binding this receptor prevents the division of cancer cells and make them more easily killed by immune cells
Thalomid(thalidomide)
Is a type of biological response modifier. It reduces the level of tumor angiogenesis factor which is needed to maintain blood supply to the tumor. The tumor is poorly nourished so the cells die. This is used for multiple myeloma
Neupogen-filgrastim
A type of biological response modifier that affects neutrophils. It is used for chemotherapy induced neutropenia
Oncologic emergency
Sepsis and disseminated intravascular coagulation
Syndrome of inappropriate antidiuretic hormone
spinal cord compression
Hypercalcemia
Superior vena cava syndrome
tumor lysis syndrome
Cancer is a chronic disease and a number of complication from the cancer and its treatment can occur.
Early diagnosis and immediate intervention of these emergencies conditions are essential to avoid life-threatening situations
Sepsis or septicemia is a condition in which organisms enter the bloodstream (bloodstream infection) and can result in septic shock, a life-threatening condition. Patients with cancer are at risk for infection and sepsis due to WBCs are often low and immune function is impaired
Disseminated intravascular coagulation (DIC) is a problem with the blood-clotting process. DIC is often caused by gram-negative sepsis, by the release of thrombin or thromboplastin (clotting factors) from cancer cells, or by blood transfusions
Collaborative management:
ØPrevention (best measure) strict adherence to aseptic technique during invasive procedures and contact with nonintact skin and musous membranes
Treatment:
ØIV antibiotic therapy
ØAnticoagulants, cryoprecipitated clotting factors
Cancers left untreated cause.
Cancers that are left untreated often cause:
ØReduced immune and blood-producing function
ØAltered GI structure and function
ØMotor and sensory deficits
ØDecreased respiratory function
These impairments can cause physical and emotional distress. Without intervention, cancer invasion of normal tissues leads to death
Reduced immunity and blood producing functions
Impaired immune and blood-producing functions occur most often in patients with leukemia and lymphoma and can occur with any cancer that invades the bone marrrow.
Tumor cells enter the bone marrow and reduce the production of healthy white blood cells (WBCs), which are needed for normal immune function. Patients with cancer, and those with leukemia, are at an increased risk for infection
When cancer invades the bone marrow, it also causes anemia by decreasing the number of red blood cells (RBCs) and causes thrombocytopenia by decreasing the number of platelets.
These changes may be caused by the cancer itself or by cancer treatment, especially chemotherapy. The patient feels weak and fatigues and is at risk for bleeding
Altered GI structure and function
Cancer can alter GI function and impair nutrition
Abdominal tumors may obstruct or compress structures anywhere in the GI tract reducing the ability to absorb nutrients and eliminate wastes
Tumors often also increase metabolic rate and increase the need for nutrients at a time when the patient has less energy for meal preparation or eating
Malnutrition and death are due to liver cancer that damages this important organ that has many important metabolic functions
Anorexia is not uncommon and interferes with their ability to met energy needs. Cachexia (extreme body wasting and malnutrition) develops from an imbalance between food intake and energy use (increased catabolism)
A diet high in protein and carbohydrates to maintain weight and provide nutrients is needed for energy and cellular repair
A misconception by the patient and family is a belief that cancer can be cured more easily if weight is gained or maintained. There is no one nutritional plan that meets the meets of patients with cancer
Motor and sensory deficits
Motor and sensory deficits occur when cancers invade bone or the brain or compress nerves.
Bone metastasis, the primary cancer stared in another organ (e.g., lung, prostate, breast).
The bone sites most often affected are the vertebrae, ribs, pelvis, humerus, scapula, sternum, skull, and clavicle
Bone metastasis causes pain, fractures, spinal cord compression, and hypercalcemia, each of which reduces mobility
Reduced oxygenation
Cancer can disrupt oxygenation in several ways and often results in death
Tumors in the airways cause airway obstruction. In the lung tissue the lung capacity is decreased
Tumors can press on blood and lymph vessels in the chest, blocking blood flow through the chest and lungs, which results in pulmonary edema and dyspnea
Tumors can thicken the alveolar membrane and damage pulmonary blood vessels, reducing gas exchange
With any lung tumor patients have hypoxia and poor tissue oxygenation
Cancer management
The purpose of cancer management is to prolong survival time or improve quality of life.
Without cancer therapy, most patients with cancer would die within months of diagnosis
Cancer therapy includes surgery, radiation, chemotherapy, hormonal manipulation, photodynamic therapy, immunotherapy, and targeted therapy
These therapies may be used separately or in combination to kill cancer cells and this will depend on the type of cancer, if the cancer has spread, and the health of the patient
Surgery as cancer treatment
Surgery for cancer involves the removal of the diseased tissue
If cancer is confined to the removed tissue, surgery alone can result in a “cure” for that cancer
Oldest form of cancer treatment
ØProphylaxis (prophylactic surgery) removes “at-risk” tissue to prevent cancer development (e.g., removing a benign polyp from the colon before it can develop into colon cancer is a prophylactic action
ØPerformed when there is an existing premalignant condition or a family history that strongly predisposes to development of a specific cancer
ØDiagnosis (diagnostic surgery-biopsy) is the removal or all or part of a suspected lesion for examination and testing
ØIt provides proof of the presence of cancer
ØCure (curative surgery) removes al cancer tissue
ØCancer control (or cytoreductive surgery) removes part of but not the entire tumor. Also known as “debulking” surgery alone cannot result in a cure (e.g., spinal cord tumor or brain tumor)
ØIt decreases the number of cancer cells and increases the changes that other therapies can be successful
ØPalliation (pallative surgery) focuses on improving the quality of life during the survival time, not on a cure (e.g., removal of a tumor causing pain, obstruction)
ØSecond-look surgery is “rediagnosis” after treatment. The purpose is to assess the disease status in patients who have been treated and have no symptoms of remaining tumor
ØReconstruction or rehabilitation surgery increases function, enhances appearance, or both (e.g., breast reconstruction, replacement esophagus, bowel reconstruction, revision of scars, and placement of penile implants
Radiation side effects.
The immediate and long-term side effects of all types of radiation are limited to the tissues exposed to the radiation. Therefore the side effects:
ØVary according to site
Local skin changes and hair loss (likely permanent depending on total absorbed dose)
Altered taste sensations
Fatigue related to increased energy demands and may last for months
Inflammatory responses that cause tissue fibrosis and scarring
ØFor example, women who receive high-dose rate HDR therapy for uterine cancer may develop radiation-induced changes in the colon (which was also irradiated) years later, resulting in constipation and obstruction
Care for radiation pt
Most patients are anxious about radiation and look to the nurse to explain the purpose and side effects of radiation therapy. Important to teach:
Øaccurate objective facts to help patient cope
Teaching includes:
Skin becomes dry and may breakdown.
ØRefer to Chart 24-2 Skin Protection During Radiation Therapy
ØDo not remove temporary ink markings until therapy is complete
Administer skin care
ØUse lotions to protect skin according to department policy
Note: Skin in the radiation path is more sensitive to sunburn and damage. Advise against direct skin exposure to the sun during treatment and for at least 1 year after completing radiation therapy
Avoid direct skin exposure to sunlight
Care for xerostomia (dry mouth) more prone to tooth decay. Advise patient to perform oral care after every meal and before sleep
Bone exposed to radiation more vulnerable to fracture
Chemo treatment issues
Dosages for most chemotherapy drugs are calculated according to the type of cancer and the patient’s size
Chemotherapy drugs are given on a regular basis and are timed to maximize cancer cell kill and minimize damage to normal cells
Scheduling may vary somewhat to accommodate a patient’s response to therapy, but chemotherapy is usually scheduled every 3 to 4 weeks for a specified number of times (on average, 4 to 12 times). Newer protocols of giving higher doses of chemotherapy more often, called dose-dense chemotherapy, are often used for aggressive cancer treatment such as breast cancer. This results in more intense side effects than traditional dosing schedules
Note: If chemotherapy has been delayed due to low white blood count, this is not considered a missed treatment but only a delay. Patient’s may be concerned that a delay in treatment fearing that the cancer cells will overgrow. Assure them that waiting a week for WBC to increase will not be significant for cancer cell overgrowth
Administration most chemotherapy drugs are given IV, although other routes may be used
For specific cancer types, the chemotherapy may be infused or instilled into a body cavity
Special education for competency does not mean that only an advanced practice nurse can perform this function; however, ti does mean that the person should be a registered nurse who has completed an approved chemotherapy course. Responsibility for monitoring the patient during chemotherapy administration, however, rests with all nurses providing patient care
A serious complication of IV infusion is extravasation which occurs when drug leaks into the surrounding tissues also called infiltration.
When the drugs given are vesicants (chemicals that damage tissue on direct contact) the results of extravasation can include pain, infection, and tissue loss.
Close monitoring of the access site is critical during chemotherapy administration to prevent leakage of larger volumes (0.5 mL or greater)
Extensive tissue damage will require surgical intervention
NOTE: If a patient complains of pain/burning at the IV site discontinue the infusion!
Chemotherapy PPE
Nurses must have knowledge about drug use, dosage ranges, side/adverse effects, schedule, specific precautions
Most chemotherapy drugs, even oral drugs, are absorbed through the skin and mucous membranes. Nurses are at risk for absorbing them and PPE must be used when administering oral and IV chemotherapy, as well handling excreta from patients within 48 hours of receiving IV chemotherapy.
PPE includes eye protection, masks, double gloves or “chemo” gloves, and gown
Chemotherapy pt centered care.
Temporary and permanent physical damage can occur to normal tissues from oral or IV chemotherapy because it is systemic
Anemia (decreased number of red blood cells and hemoglobin), neutropenia (decreased numbers of white blood cells leading to immunosuppression, infection), and thrombocytopenia (decreased number of platelets)
Common distressing side effects include:
ØChemotherapy-induced nausea and vomiting
ØMucositis (open sores on mucous membranes), advise to rinse mouth with water after every meal to remove food particles, sue a soft-bristled toothbrush to prevent trauma to the gums, do not use alcohol based mouth rinse to kill bacteria as this is drying and can exacerbate mucosa irritation, and do not floss as this can irritate gums
ØAlopecia (hair loss)
ØChanges in cognitive function
ØPeripheral neuropathy
Chemo and older adults
Older adults are at even greater risk for chemotherapy-induced neutropenia because of age-related changes in bone marrow function. Using growth factors, such as filgrastim (Neupogen) and pegfilgrastim (Neulasta), before neutropenia occurs rather than later can reduce the severity of neutropenia and the risk for infectious complications (Flores & Ershler, 2010)
The priority nursing interventions for the patient with neutropenia are protecting him or her from infection within the health care system and teaching the patient and family how to reduce infection in the home. Total patient assessment, including skin and mucous membrane inspection, lung sounds. Mouth assessment, and close inspection of venous access device insertion sites, should be performed every 8 hours by a registered nurse for hospitalized patients.
Dietary teaching for neutropenia includes eating a low-bacteria diet. This includes avoiding raw fruits or vegetables, undercooked meat, eggs, or fish
Antiemetic therapy
Ondansetron (Zofran) teach patient to change positions slowly to avoid falls. May induce bradycardia, hypotension, and vertigo
Granisetron (Kytril) assess the patient for headache and is common side effect
Granisetron transdermal (Sancuso) assess the patient for headache and is common side effect
Dolasetron (Anzemet) assess the patient for headache and is common side effect
Palonosetron (Aloxi) assess the patient for headache and is common side effect
Drug combinations are individualized for best effect. Be sure the antiemetics are given before chemotherapy is started!
Epidermal Growth Factor/Receptor Inhibitors
Targeted therapy
Block epidermal growth factor (EGFR) from binding to cell surface receptor
ØTrastuzumab (Herceptin) binds the excessive amounts of a certain type of epidural growth factor/receptor (EGFR) produced by some breast cancer, ovarian, and colon cancer cells in response to the activation of the HER2/neu gene. Binding this receptor prevents cancer cell division and increases the sensitivity to chemotherapy and immune system actions
ØIf the cancer does not have the protein that this drug attacks it will not be effective
SIADH
Most commonly found in carcinoma of the lung
Water is reabsorbed to excess by kidneys; put into system circulation. Retained water dilutes blood serum sodium levels. Mild manifestations include weakness, muscle cramps, loss of appetite, and fatigue (115 to 120 mEq/L) With greater fluid retention, weight gain, nervous system changes, personality changes, confusiion, and extreme muscle weakness. As sodium level drops toward 110 mEq/L, seizures and coma and death may follow
Collaborative care:
ØPatient safety prevent fluid overload from becoming worse leading to pulmonary edema and heart failure
ØRestore normal fluid balance
ØSupportive care
