Med-Surg: Chapter 13: Overview of Cancer Care Flashcards
1
Q
Cancer
A
constellation of diseases involving a malignant (unregulated) transformation of cells within a specific body system
- all cancers characterized by uncontrolled growth of malignant cells that compromises the integrity and function of normal, healthy cells
- second leading cause of death
2
Q
Carcinogen
A
cancer trigger
- internal or external exposures that predispose individuals to DNA destruction, resulting in cellular mutation that may lead to malignant transformation of cells
- exposure varies across nations for different reasons, leading to different cancer disease patterns
- most common risk factor for cancer
ex: ionizing radiation, benzene, HPV, sun exposure, and tobacco - carcinogen alone is unlikely to trigger cancer
3
Q
Most Common Risk Factor for Cancer
A
exposure to a carcinogen
4
Q
Examples of Carcinogens
A
- ionizing radiation
- benzene
- HPV
- sun exposure
- tobacco
5
Q
Carcinogenesis
A
the initiation and promotion of cancer
- involves a series of other molecular changes that occur after exposure to carcinogens
- > for this reason, not all individuals with known risk factors or known exposure to a carcinogen develop the disease
6
Q
Believed to Influence the Development of Cancer
A
- environmental, hormonal, and lifestyle factors
- infectious diseases
- medications
- immune status
- nutritional factors
7
Q
Nonmodifiable Risk Factors for Cancer
A
factors that the individual cannot change
- age
- genetic predisposition
- advanced age increases the risk; r/t greater exposure to carcinogens over time and changes in immune function
8
Q
Modifiable Risk factors for Cancer
A
- lifestyle; a sedentary and poor diet and/or smoking
- cancer associations with specific diseases, such as the relationship between colon cancer and inflammatory bowel disease or hepatic cancer resulting from hepatitis C infection, are modifiable but only as much as the management of the triggering disease
9
Q
Pathophysiology of Carcinogenesis
A
cancer initiation begins with carcinogen exposure, which triggers single- or multiple-gene mutations
-an individual likely experiences multiple carcinogen exposures and genetic mutations over time; however, the immune system protects the individual by recognizing the mutation and initiating cell death
>in carcinogenesis, the mutated cells are not detected by the immune system an are therefore able to proliferate and progress into cancer
10
Q
Cancer is Characterized by 2 hallmark characteristics
A
- Uncontrolled cell growth
- Altered cell differentiation
11
Q
Uncontrolled Cell Growth
A
> Normal cells grow in a structured pattern, and stimulation for cell growth is tightly controlled so that the number of cells produced by the body is roughly equivalent to the number of cells lost through cell death or shedding
-Cancer cell growth and proliferation are unregulated by typical mechanisms
> Normal Cells are regulated by contact inhibition and stop growing and reproducing when they come into contact with other cells
-Cancer Cells lack contact inhibition
> A regular cell cycle that ends with programmed cell death (apoptosis), is common with normal cells
-Cancer cells do not undergo apoptosis
> Normal cells need to anchor to either neighboring cells or basement cells so that they can plug into a nutrient-rich extracellular matrix to remain viable
-Cancer cells do not have this type of anchorage dependence and can grow and flourish in atypical patterns and environments
> This uncontrolled growth can result in dysplasia , or deranged cell growth, in which cells vary in size, shape, and organization
Neoplasia (uncontrolled cell proliferation); describes a new cell-growth pattern that is characteristic of cancer
12
Q
What are Cancer Cells
A
malignant neoplasms that grow uncontrollably and invade surrounding tissues and vessels
-have the capacity to destroy normal tissue, steal nutrition, create their own blood vessels, and survive even under anoxic or acidotic conditions
13
Q
Altered Cell Differentiation
A
> healthy, fully developed cells are well differentiated and have specific structural and functional characteristics
- A malignant cell derives from a parent cell, such as a breast tissue cell, but no longer performs the expected functions of the parent cell, and the structure may be different as well
- when a cell loses expected structure and function, it is called anaplasia
- as cancer proliferation progresses, the cancer cell loses similarity to the parent cell
> there is a range in pathological presentation: cancer cells may be well differentiated and look similar to the parent cell
- may be undifferentiated and look nothing like the parent cell
- or somewhat in between
> Poorly differentiated cells are more difficult to treat
-these cancers often associated with more refractory and aggressive tumors, even if from the same tissue origin
14
Q
Anaplasia
A
when a cell loses expected structure and function
-as cancer proliferation progresses, the cancer cell loses similarity to the parent cell
15
Q
Tumor Grading
A
mechanism to classify or describe tumors
- used to plan treatment
- the extent of differentiation is an important element in grading malignant neoplasms
16
Q
Metastasis
A
spreading of tumors
- cancer cells replicate and expand locally into masses of cells known as malignant tumors
- cancer cells spread by cell-to-cell transfer, through the lymphatic system, or through the blood (hematogenous)
- metastasize in a predictable pattern
17
Q
Metastasis: Spread by cell-to-cell transfer
A
characterized by direct invasion into adjacent cells
18
Q
Metastasis: Spreads by Lymphatic System
A
lymphatic spread occurs when the tumor cells migrate into the lymphatic system using lymph channels that serve the organ where the cancer originated
-once in a lymph node, the cancer cell may be destroyed, grow into a mass, remain dormant, or spread to more distant lymph nodes and potentially into the vasculature
19
Q
Metastasis: Hematological Spread by cancer cells
A
spread through the blood system
-occurs when the cancer cell migrates into the venous system that drains the organ where the cancer originated
20
Q
The Stages of Cancer Metastasis
A
- Cancer cells in the primary site
- Cancer cells invade surrounding tissues and blood vessels/ lymph vessels
- Cancer cells are transported by the circulatory system/ lymphatic system to distant sites
- Cancer cells reinvade and grow at a new location
21
Q
Examples how Cancer Cells Metastasize in Predictable patterns
A
> Prostate cancer is notable for a tendency to spready by cell-to-cell transfer, so advanced disease is most likely to present with metastasis to nearby tissues, such as the rectum, pelvic floor, lower spine, or hip
> Colorectal cancer commonly metastasizes hematogenously, and b/c the blood supply in closest proximity to the colon is the portal circulation, the liver is the common site for metastasis
> when a tumor metastasizes, it often remains molecularly similar to the tumor of origin
- prostate cancer that has metastasized to the rectum has the same cellular and molecular qualities as prostate cancer; the prostate cancer cell has simply relocated to the rectum to create a prostate cancer tumor in the rectum; in other words, a rectal tumor originating from cancer of the rectum is different from a rectal tumor originating from cancer of the prostate
- the tumor in the prostate is the Primary tumor, and the tumor in the rectum is the Secondary tumor (or metastatic tumor)
22
Q
Cancers are Divided into Two main Categories
A
- Solid-tumor malignancies
- Hematological malignancies
23
Q
Solid-Tumor Malignancies
A
arise from specific body organs and grow into masses that invade and erode normal body tissue as they expand in size
-ex: lung cancer
24
Q
Hematological Malignancies
A
arise form cells of the hematopoietic cell line or from secondary immune organs such as lymph nodes or spleen
-the hematopoietic stem cell gives rise to all myeloid and lymphoid cells in the body, which later develop into cells of the blood system and immune system; a hematological malignancy can therefore affect any of the blood cells in the hematopoietic cell line, including RBCs, WBCs, and Platelets
>Three major Subcategories of Hematological Malignancies
-Leukemia: cancers involving blood cells
-Lymphoma: cancers involving the lymphatic system
-Multiple myeloma: cancers involving plasma cells and immunoglobulins
25
Staging
a classification system that considers the size of the tumor, burden of the disease, and extent of disease spread
-the stage of disease is used to plan patient assessment, clinical management, and treatment strategies
>basic components of solid malignancy staging are tumor size (T), number of lymph nodes involved (N), and presence of metastases (M)
-this TNM staging has differing combinations of tumor size or lymph nodes involved for each different kind of cancer
>Cancer is staged along a continuum of one (I) through four (IV)
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Cancer is staged along a continuum of one (I) through four (IV)
- Stage I: a small tumor without obvious spread outside the organ
- Stage II: invasion of deeper tissues or involvement of local lymph nodes
- Stage III: large or locally invasive tumors
- Stage IV: cancers that have metastasized; all hematological malignancies are cancer stage IV
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Why are all Hematological Malignancies cancer stage IV?
b/c the disease is not well contained or localized b/c the hallmark clinical feature is that it is present in the hematological system at diagnosis
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Patients With Cancer Initially Present with Three General Types of Symptoms
- CAUTION symptoms
- Constitutional Symptoms
- Malignancy-specific signs and symptoms
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CAUTION
an acronym used to describe common "warning signs" for cancer
- patients experience a caution symptom; serves as the impetus for visiting a doctor
- CAUTION symptoms occurring for more than 2 weeks warrant evaluation
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The CAUTION or "warning signs" of Cancer
```
C: Change in bowel or bladder habits
A: A sore that does not heal
U: Unusual bleeding or discharge
T: Thickening or lump in the breast or any other part of the body
I: Indigestion or difficulty swallowing
O: Obvious change in a wart or mole
N: Nagging cough or hoarseness
```
31
Constitutional Symptoms
```
constellation of vague symptoms
-fatigue
-unexplained weight loss
-fever of unknown etiology
-night sweats
>this term is a formal classification in B-cell lymphoma;
```
32
Symptoms Characteristic of a Specific Malignancy
clinical presentation varies on the basis of the disease
-related to the location of the primary cancer, the location of metastatic disease, metabolic changes associated with the malignancy, and the specific pathology of the disease
>symptoms and complications of solid-tumors are often r/t tumor-mass compression or erosion into normal anatomical structures
-ex: individuals with primary brain cancer may present with pain secondary to tumor compression of nerves in the skull or signs of increased intracranial pressure from tumors that are occupying space within the cranium and minimizing room for functioning neurons, blood flow, and cerebrospinal fluid; causes pain and other CNS changes
33
Oncological Emergencies
acute clinical complications that may occur in the presence of malignancy
- require urgent treatment to prevent long-term physiological deficits
- may be secondary to the processes of tumor growth and invasion of body organs, metabolic changes from malignant cells, or a result of treatment
- categorized as structural, metabolic, and hematological
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Types Oncological Emergencies
- Bowel Obstruction
- Hypercalcemia
- Leukostasis
- Pericardial effusions/ tamponade
- Pleural effusions
35
Oncological Emergencies: Bowel Obstruction
most commonly found in tumors involving the bowel such as colon cancer and pancreatic cancer and abdominal masses such as ovarian, hepatic, and prostate cancers
>Pathophysiology: masses in bowel lumen obstruct normal flow of enteral contents, GI fluids, and wastes
- external compression causes bowel obstruction
- obstructions can be partial or complete and involve the small or large bowel
- greatest danger of obstruction is rupture or perforation
>Clinical Presentation: causes reverse peristalsis with vomiting and abdominal distention
- bowel sounds are increased prior to the obstruction and diminished or absent after the obstruction
- stools may be thin or ribbonlike
- or constipation with intermittent diarrhea
>Management: best treated with surgery when resectable
- NPO/parenteral nutrition
- peristaltic stimulants unless complete obstruction, when stimulants may cause intestinal rupture
>Nursing Implications: detailed GI assessment
- appetite
- bowel movements
- constipation
- diarrhea
- thin, ribbonlike stools
- bowel sounds
- presence of nausea, vomiting, distention, pain
36
Oncological Emergencies: Hypercalcemia
most commonly found in cancers that metastasize to bone, such as breast, lung, and renal cancers; can be r/t paraneoplastic hormone production in lung and pancreatic cancers
>Pathophysiology: produced by bone demineralization (resorption) with release of calcium into systemic circulation
- bone invasion with tumor can activate osteoclasts
- tumors may create their own parathormone-like substance, or renal dysfunction can contribute to this process
>Clinical Presentation:
-delirium, somnolence (excess sleepiness), muscle weakness, polyuria, bradycardia, nausea, and constipation
>Management: hydration with normal saline dilutes calcium and enhances excretion of calcium
- Bisphosphonates (e.g. pamidronate, zoledronate) used as treatment or prevention of hypercalcemia in patients with bone metastases
- Monoclonal antibody directed at the RANK ligand (denosumab) lowers calcium
>Nursing: monitoring of calcium, phosphorus, and renal function
- assessment for hypercalcemia: delirium, somnolence, muscle weakness, fatigue, polyuria, bradycardia, nausea, constipation
- provide hydration and medication as ordered
37
Oncological Emergencies: Leukostasis
most commonly found in acute myelocytic leukemia with high white blood cell counts
>Pathophysiology: excessive immature white blood cells (commonly myelocytes) causing capillary sludging, thrombosis, and rupture of vessels
>Clinical Presentation: congestion and dysfunction due to cell migration, inflammatory response, and hemorrhage within the organ
-commonly affect the kidney, lung, and brain
>Management: emergency chemotherapy
- leukopheresis
- supportive interventions
>Nursing: monitor WBC count
- assess for signs of occluded microcirculation: blurred vision, headache, transient ischemic attacks, cerebrovascular accidents, dyspnea, poor peripheral perfusion, and oliguria
- assess for signs of bleeding
38
Oncological Emergencies: Pericardial Effusions/ Tamponade
most commonly found in cancers of the chest such as lung and breast cancers and also lymphoma; can be found in any cancer that has metastasized to the chest
>Pathophysiology: small amounts of pericardial fluid (15-30 mL) exist in the pericardial space to allow for heart distention with blood filling the ventricles
- when there is excess fluid accumulation in this space, it causes positive pressure in this space and impedes venous return of blood
- this reduced blood inflow leads to impaired cardiac output
>Clinical Presentation: dyspnea is most common
- acute signs of poor perfusion of noncardiac origin
- b/c it often progresses slowly in cases of neoplastic effusions, signs of progressive right heart failure may be more likely
>Management: immediate evacuation of excess fluid by needle or catheter pericardiocentesis or surgical placement of a pericardial window or shunt
-until these procedures are performed, large amounts of fluids are administered to increase the venous pressure above the pericardial pressure, permitting inflow of blood
>Nursing: assess vital signs, signs of dyspnea, poor perfusion, and signs of heart Failure (respiratory distress, fatigue, and edema)
- prepare for pericardiocentesis
- administer IV fluid as ordered
39
Oncological Emergencies: Pleural Effusions
most commonly found when there are tumors in the chest, such as breast and lung tumors; can be present in patients with leukemia, lymphoma, ovarian cancer, pancreatic cancer, and prostate cancer
>Pathophysiology: approximately 50-150 mL of fluid is normally in the pleural space to provide lubrication for lung expansion, but when excess fluid is in the space, it impedes breathing, increasing the work of breathing and compressing alveoli
>Clinical Presentation: Dyspnea
- increased work of breathing with use of accessory muscles
- unequal chest excursion
- diminished breath sounds
- resulting hypoxemia can cause confusion, anxiety, and agitation
>Management: intermittent therapeutic thoracentesis
- catheter drainage of pleural fluid (traditional chest tube or long-term silastic pleural catheter) used for palliation of symptoms unless surgical talcpleurodesis can be performed
- bedside catheter pleurodesis with bleomycin, doxycycline, and talc may still be used when other therapies unavailable
>Nursing: assess for dyspnea, SOB, breath sounds, chest excursion equality, and signs of hypoxemia
-assess for how frequently symptoms are appearing or worsening
40
Primary Prevention of Cancer
focused on identifying and modifying risk factors for cancer to reduce the probability that an individual will develop cancer
- risk factor modification
- immunization
- chemoprevention
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Primary Prevention: Risk Factor Modification
help individuals identify their own cancer risk behaviors and modify their behavior
- avoiding known carcinogens
ex: multilevel approach to reducing tobacco use
- cancers linked to tobacco include cancers of bladder, breast, lung, and pancreas
42
Cancer Prevention Measures (Primary)
- avoid exposure to known carcinogens such as tobacco
- wear sunscreen everyday
- prevent and/or treat infectious diseases known to be related to cancer: Hepatitis B and C, human papillomavirus (HPV), HIV, Helicobacter pylori (H. pylori)
- maintain healthy weight
- engage in regular moderate to vigorous physical activity
- eat a healthy, plant-based diet
- limit consumption of alcohol based beverages: no more than one drink a day for women and no more than two drinks per day for men
- recognize family risks, consider assessment or prophylactic interventions for genetic mutations, or alter screening practices
43
Primary Prevention: Immunization
some cancers believed to be triggered by viral exposure; ex is cervical cancer, believed to be triggered by HPV exposure
- other: hepatitis C, and Epstein-Barr Virus (EBV)
- immunizations against these viruses for susceptible individuals
44
Primary Prevention: Chemoprevention
is the administration of medications to reduce the risk of specific cancers in high-risk patients
-primary prevention strategy for some survivors of early-stage hormonal cancers such as breast and prostate cancers
45
Secondary Prevention
cancer screening for early detection and management of the disease
- individuals with cancer-related risk factors should have access to noninvasive screening tests that can identify cancer in its early stages, when it can be treated effectively with minimal risk recurrence
- screening tests should be highly sensitive (able to detect in low-risk population with few false negatives) and specific (able to accurately detect with few false positives)
- must be cost-effective, easy to perform, and have minimal adverse effects
- evaluation of the family history for genetic cancer syndromes
46
Tertiary Prevention
focuses on reducing morbidity and mortality once a disease has been diagnosed
-treatment and management of the side effects of cancer or its treatment may be considered tertiary prevention
47
Diagnostic Evaluation
dependent on the suspected cancer subtype, possible disease location, and expected extensiveness of the disease
- laboratory tests, radiological tests, ultrasound, invasive techniques, or combinations of these methods
- initial diagnostic tests are performed to confirm the presence of masses associated with cancer
- radiological tests helpful for the detection of unusual masses
- confirmation of malignant tissue through biopsy with cytopathological diagnosis, a diagnosis of disease based on evaluation of cell pathology from cells obtained at biopsy
48
Laboratory Tests
>prostate-specific antigen (PSA) test: obtained via venous blood sample; used to validate the presence of prostate cancer
- high PSA = prostate cancer; presence is actually indicative of inflammation; will reduce as the tumor shrinks in response to therapy
- has a high sensitivity (ability to accurately find cancer in patients who have cancer--true positive) but a low specificity (test yields false positives)
>laboratory tests used to track responses to therapy
-ex: when patients are aware of their blood counts during chemotherapy, they are more able to understand when they are at risk for bleeding or infection and adjust their activities of daily living
>Tumor markers may be assessed at initial diagnosis but also intermittently throughout and after treatment for disease response
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Imaging
use radiographical, sonographical, or other technology to create images of the body for clinical evaluation
- used to assess the structure or function of body organs or systems
- effective in identifying tissue masses (common presenting sign of cancer); allow for the detection of these tissue masses that are undetectable on physical examination
- used to detect metastasis
>Computed Tomography (CT) scan: indicated for general assessment of mass locations and involvement of vessels or body organs
>Positron emission tomography (PET) scans for metabolically active tumors
-PET scans involve the injection of radioactive material that, when imaged, appears to accumulate in areas of increased metabolic activity ("hot spots") that correspond to areas of disease
>Magnetic Resonance Imaging (MRI): evaluates changes in brain, joint, and breast tissues
>Some imaging technologies use contrast, or the administration of dyes or radiosensitive markers, to enhance imaging details; contrast helpful in identifying the involvement of blood and lymphatic vessels
>Radiological imaging tests are useful in the diagnosis and assessment of solid tumor masses but may not be as useful for the diagnosis of hematological malignancies that are diffuse and do not present with masses (except malignant lymphoma)
50
Biopsy
primary method of obtaining samples required to determine the presence of malignancy
- surgical method of obtaining a tissue sample for evaluation
- commonly used in solid-tumor evaluation
- can be incisional (into the mass) or excisional (cut out the total mass and a margin around it)
- Hematological malignancies are evaluated via bone marrow aspiration and biopsy, with cytopathological molecular testing for subtle cell differences
51
Incisional Biopsy
into the mass
- known as core biopsy
- when this is performed, there is a danger of tracking malignant cells through the surrounding normal tissue
52
Excisional Biopsry
cut out the total mass and a margin around it
- preferred over incisional
- less traumatic method of obtaining a tissue sample is via fine-needle aspiration (FNA) biopsy
- can be used when cells of interest are located close to the skin and can be extracted via a needle
- yields fewer cells than traditional biopsy methods, but histological analysis is improved b/c structure is maintained
53
Endoscopic Procedures
Such as endoscopy and bronchoscopy, are performed with a rigid or flexible tube, light, and lens allow visualization of hollow, tube-like structures in the body (e.g. gastrointestinal tract) and may be necessary in order to access tissue for biopsy
ex: use of bronchoscopy in the work up for lung cancer
- bronchoscopy allows for visualization of the airways while also providing access to hard-to-reach tissue for sampling
54
Goal of care
Goal of care: cure, remission, maintenance/ prevention of progression to extend life, or palliation
- if not curable, goal= reduce tumor burden or prevent prevention
- increase years of life
55
Remission
disease-free state in which it is unclear if the disease has been eradicated or if this disease-free state will remain stable
- often goal of hematological malignancies
- long-term remissions based on suppression of the oncogene (gene that has potential to cause cancer) that produces cancers such as hairy cell leukemia and chronic myelogenous leukemia
- these patients remain disease-free as long as they consistently take their medications targeting the faulty cellular pathway
56
Palliation
the alleviation of the burdensome symptoms of cancer
| -not the primary consideration if a long-term disease-free status is possible
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Treatment Modalities
-Surgical Treatment
-Radiation Therapy
-Medication Treatment
>may be single therapy or multimodality
>if multimodality approach, the definitive treatment is referred to as the primary therapy
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Neoadjuvant Therapy
therapy that is used to shrink the tumor prior to definitive removal or destruction
-used with many large solid tumors that are not resectable at diagnosis but may be after initial treatment to shrink the size of the mass has been completed
59
Adjuvant Therapy
a treatment that is used in a patient who is currently disease-free or in remission but at high risk for relapse b/c of remaining microscopic malignant cells that will regrow at a later time
60
Surgical Treatment
surgical resection of a tumor is the preferred cancer treatment modality b/c it offers the greatest probability of producing a cancer-free state
- primary treatment modality for solid-tumor malignancies
- goal= total excision of malignant tumors and the local area of potential metastasis immediately surrounding the tumor
- surgical oncology also includes debulking of tumor masses (partially removing a tumor that cannot be completely excised)
- redirection of vital functions after tumor removal and reconstructive procedures are components of surgical oncology
61
Surgical Oncology: Redirection and reconstructive procedures
are necessary because surgical procedures for cancer usually involve the removal of the tumor as well as a margin of normal surrounding tissue, which may affect organs that perform vital function
- surgery may often involve the reconstruction of normal blood vessels and nerves or the construction of drains
- removal of large masses may require the construction of diversions and ostomies, which are surgical opening to allow for the elimination of body waste
62
Nursing Considerations for Surgical Oncology
- thorough understanding of the patient's goals of care, overall treatment plan, anticipated physical deficits, barriers to or facilitators of postoperative recovery, and self-care or education needs
- familiarize themselves with the recent medical history and consider patient's physical and psychological status in planning care
- pain management
- airway maintenance (spirometry)
63
Radiation Therapy
localized delivery of ionizing radiation to intentionally destroy DNA structures within malignant cells and induce cell death
- a radiation therapy treatment plan is designed with the goal of maximizing tumor exposure to radiation while minimizing injury to normal cells
- can be delivered externally via an external beam, internally via placement in a cavity or reservoir in the body (brachytherapy), or systemically via injection of a radioactive substance
64
External-beam Radiation-Therapy
-treatment plan designed to deliver a planned total dose and is divided into "fractions"
-fraction are the doses delivered in a single treatment
-the normal fraction cycle= daily dose for 5 days followed by 2 days rest; repeated for 5 to 18 cycles
-radiation doses may be further divided into more than once per day (hyperfractionation) for the purposes of enhancing delivery to rapidly dividing tumor cells or to minimize some adverse effects
>total radiation dose is determined by the amount of radiation needed to destroy the type and size of tumor
>Cyber-knife most common technique used
65
Brachytherapy
internal delivery of low dose or high dose radiation
- radioactive isotopes are placed in "seeds" which are then administered to the patient
- seeds may be infused via a catheter or surgically implanted
- low-dose brachytherapy allows for the continuous delivery of radiation in the body for as long as the source of active radiation remains in the body; used in gynecological, prostate, head and neck, and brain cancers
- radioactive isotopes are introduced into the body and allowed to dwell for a certain period and then removed in one treatment session
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Systemic Radiation Therapy
involves the vascular administration of radioactive substance
- sometimes used for thyroid cancer; thyroid naturally attracts iodine, so the isotype concentrates in a local area after systemic delivery
- may be administered with target therapy, such as a monoclonal antibody, to help the active isotope find the desired target
67
Complications of Radiation Therapy
- patients evaluated before treatment and regularly throughout for symptoms of inflammation, irritation, and altered mucosal integrity in the area receiving radiation; may be as minor as erythema on the skin; assessment of radiation injury to internal structures such as the trachea may present as more subtle symptoms like chest discomfort or cough
- Fibrosis is a late effect of radiation, causing internal adhesions, fibrotic skin changes, and structures (e.g. vaginal); interventions (e.g. vaginal dilator) employed or implemented on a as needed basis (e.g. feeding tubes for patients receiving neck and throat radiation)
- fatigue common adverse effect of both cancer and treatment
68
Interventions for the adverse effect of Fatigue
- provide patient education and support for activities of daily living such as transportation and self-care, realizing the prevalence and distress this symptom presents for patients
- pacing of activities
- mild to moderate exercise
- early patient education and reassurance can reduce risk of misperceptions by patients and families or the fear that fatigue signals advancement of the cancer
69
How to minimize harmful exposure to radiation
-oncology nurse donning all appropriate personal protective equipment and following self-care standards of the institution
>is true for the nurse who handles potentially radioactive waste from patients receiving brachytherapy that may be eliminated in body fluids
-provide same education to family members prevents unintentional radiation exposure
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Antineoplastic Medications
broad class of chemicals and drugs used to treat cancer
71
4 Categories of Antineoplastic Therapy
- chemotherapy
- immunologic therapies
- targeted agents
- hormonal agents
72
Antineoplastic Therapies
indicated in patients with more advanced disease, diseases of the blood or bone marrow, or cancers that are not amenable to single modality surgical or radiation therapy
-administered systemically IV, making it appropriate for widespread advanced cancers; but can lead to a systemic side-effect profile
73
What are some "normal" rapidly dividing cells that are destroyed along with cancer cells with antineoplastic therapies that are delivered systemically
hair, skin, intestinal tissues, and blood-forming cells
-another complication: extravasation, or the infiltration of the medication out of the vessel and into the surrounding tissue
74
Many antineoplastic medications are considered what?
Vesicants
| -medications that can cause extensive damage to the tissue on direct contact
75
Vesicants
medications that can cause extensive damage to the tissue on direct contact
-ex is antineoplastic medications
76
Common Adverse Effects Associated with Antineoplastic Medications
- Alopecia
- Myelosuppression (bone marrow suppression)
- nausea/vomiting
- hemorrhagic cystitis
- oral mucositis
- hypersensitivity
- infertility
- diarrhea
- skin toxicities (palmar-plantar erythema)
- cardiotoxicity
- hepatic (liver) toxicity
- pulmonary fibrosis
- clotting abnormalities--thrombosis and/or bleeding
- peripheral neuropathy--weakness, numbness, and pain in hands or feet
- capillary permeability syndrome
- menopausal symptoms
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Common Adverse Effects Associated with Antineoplastic Medications: Alopecia
variable, but loss of hair begins soon after therapy begins
-variable, but hair begins to grow back several weeks after completion of therapy
-when growing back, hair comes back different: curly, thicker, or a different color
>Nursing Implications:
-loss of hair may cause self-image disturbance; be encouraged to investigate wigs or other head coverings to use during therapy
-cover their heads while outside to protect against sun damage
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Common Adverse Effects Associated with Antineoplastic Medications: Myelosuppression
bone marrow suppression
>Nursing:
-complete blood count (CBC) will be assessed frequently
-call provider if fever presents; patients with myelosuppression and fever may be managed aggressively to prevent severe sepsis or shock
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Common Adverse Effects Associated with Antineoplastic Medications: Nausea/vomiting
- prophylactic antiemetic therapy as ordered
| - assess fluid and nutritional status
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Common Adverse Effects Associated with Antineoplastic Medications: Hemorrhagic cystitis
- IV hydration before and after chemotherapy
| - prophylactic bladder protectant medication mesna (chemoprotectant medication to help prevent bladder toxicities)
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Common Adverse Effects Associated with Antineoplastic Medications: Oral mucositis
inflammation and ulceration of the mucosal lining of the mouth, causing pain and difficulty with eating
- frequent oral rinsing (every2 to 4 hours) with toothbrushing to reduce severity
- use of 2% viscous lidocaine mouth rinse if ordered to help control pain
- oral saliva substitute may be recommended for comfort or to reduce severity of symptoms
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Common Adverse Effects Associated with Antineoplastic Medications: Hypersensitivity
- administer premedication for hypersensitivity
| - emergency equipment readily available
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Common Adverse Effects Associated with Antineoplastic Medications: Infertility
consider sperm or egg banking priory to therapy if desired
84
Common Adverse Effects Associated with Antineoplastic Medications: Diarrhea
- antimotility agents as ordered
| - assess fluid and nutritional status
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Common Adverse Effects Associated with Antineoplastic Medications: Skin toxicities (palmar-plantar erythema)
- use of emollients to reduce skin toxicities
| - report severity of skin toxicities b/c it may require therapy break
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Common Adverse Effects Associated with Antineoplastic Medications: Cardiotoxicity
- cardiac function will be monitored with echocardiograms or multi-gated acquisition scans (MUGAs)
- many medications are held if decreased ejection fraction is found
- serum troponin levels may be drawn during curative therapy with doxorubicin to identify patients who may receive prophylactics treatment with cardioprotectant agents
- maintain fluid and electrolyte balance to reduce the risk of dysrhythmias
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Common Adverse Effects Associated with Antineoplastic Medications: Hepatic (liver) toxicity
-hepatic function tests will be assessed frequently
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Common Adverse Effects Associated with Antineoplastic Medications: Pulmonary Fibrosis
-pulmonary function tests will be assessed periodically
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Common Adverse Effects Associated with Antineoplastic Medications: Clotting abnormalities
thrombosis and/or bleeding
- some antineoplastic medications are never given within 6-8 weeks of major surgery b/c of bleeding risk
- prophylactic anticoagulation to prevent thromboses
- frequently assess for bleeding
- teach bleeding precautions; avoid falls or trauma, so no aggressive sports; avoid sharps such as razors, scissors, nail clippers, use stool softeners to avoid straining
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Common Adverse Effects Associated with Antineoplastic Medications: Peripheral Neuropathy
weakness, numbness, and pain in hands or feet
-teach fall precautions, remove scatter rugs from home; remove any trip hazards such as electrical cords; use of nonslip mats in bathtub or shower
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Common Adverse Effects Associated with Antineoplastic Medications: Capillary Permeability Syndrome
- administer fluid replacement for hypovolemia as ordered
| - weight assessment and management to avoid fluid overload
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Common Adverse Effects Associated with Antineoplastic Medications: Menopausal Symptoms
-teach possible effects regarding menopausal symptoms- hot flashes, insomnia, fatigue
93
Stem Cell and Bone Marrow Transplants
Hematopoietic Stem cell transplantation (HSCT) and bone marrow transplantation (BMT) are treatment methods for some cancers and hematological disorders
-involves two major steps:
>administration of high-dose antineoplastic therapy followed by the infusion of hematopoietic stem cells (HSCT) or whole bone marrow (BMT); allows for the administration of high doses of antineoplastic/ radiation therapy that would normally not be tolerated b/c high dose chemotherapy and radiotherapy permanently damage bone marrow
-used for patients with nonmalignant hematological and immunologic disorders and hematological malignancies
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Geriatric/ Gerontological Consideration
- older adults may have comorbidities that require complex therapy or my already have some organ dysfunction
- older individuals may have unique reimbursement and treatment challenges, warranting a thorough socioeconomic evaluation for barriers to successful completion of the treatment plan
Nurses must be mindful of:
>Polypharmacy: multiple medications
-conduct medication reconciliation with patients; be mindful of medication interactions
>Organ Dysfunction:
-assess kidney and liver function in the physical assessment and via laboratory monitoring; be conscientious of the need for medication dose alterations, such as renal dosing, to minimize harm
>Clinical presentation of infection:
-may not present with traditional s/s of infection such as fever or pain; onset of acute confusion may be secondary to an infectious process
>Increased risk for injury from falls:
-control the environment to minimize risk from falls, and conduct frequent rounding (toileting, etc.) to assist with activities of daily living (ADLs); particularly for the patient at risk for bleeding
>Decreased ability to tolerate intensive oncology treatment regimens:
-assess for side effects that are more likely and potentially more severe in the elderly patient secondary to decreased ability to maintain hydration, thermoregulation, and elimination of toxic material; manage side effects proactively
>Caregiver support and available home care resources:
-patients may have personal limitations and lack established caregiver support to meet their clinical and daily functional needs
>Interactions between comorbidities and cancer therapies
-most older individuals have an average of three to five comorbid health conditions, and many of these are affected by the adverse effects of therapy. Coordinated management of the oncological plan and comorbidities may require increased vigilance and modification of the primary care plan or oncological therapy
