This ppt created with the help of material from Osborne, K. et al (2010) Medical Surgical Nursing Preparation for Practice. Pearson: Boston.

GOAL OF CANCER CAREGOAL OF CANCER CARE

Combination of treatments effective in controlling most cancers

http://www.youtube.com/watch?v=j_wRpa2b5XI

CARCINOGENCARCINOGEN

Any chemical, physical, or genetic agent that can irreversibly alter cellular DNA

Abnormal cells produced

Tobacco smoke – can both initiate & promote cancer growth

ROLE OF IMMUNE SYSTEMROLE OF IMMUNE SYSTEM

Surveillance of tumor-associated antigens

22ndnd leading cause of death in leading cause of death in USAUSA

Metastasizing cancer Cell

1 out of 4 Americans will have CA at some time in their life

DefinitionDefinition

According to the American Cancer Society:

A large group of diseases characterized by uncontrolled growth and spread of abnormal cells

Top 3 Cancers that cause Top 3 Cancers that cause DeathsDeathsfigure 64-1figure 64-1

Men Lung Prostate Colorectal

Women Lung Breast Colorectal

Neoplasm (aka TUMOR)Neoplasm (aka TUMOR)

Cells that reproduce abnormally and in an uncontrolled manner

4 types of Malignancies4 types of Malignancies

Carcinoma: skin, glands, lining of digestive urinary and reproductive tracts

Sarcoma: bone, muscle, other connective tissues

Melanomas: pigment cells in the skin

Leukemias and lymphomas: blood forming tissues: lymphoid tissue, plasma cells, and bone marrow

Early Diagnosis Is Key for survival

7 Warning Signs7 Warning Signs

C – change in bowel or bladder habits

A – a sore that does not heal

U – unusual bleeding or discharge

T - thickening or lump in breast or other

I – indigestion or difficulty swallowing

O – obvious change in wart or mole

N - nagging cough or hoarseness

Stage 1Stage 1

The malignant cells are confined to the tissue of origin. Not invasive with other tissues

Stage 2Stage 2

Limited spread of the cancer in the local area usually near lymph nodes

Stage 3Stage 3

The tumor is larger or has spread from the local site of origin into nearby tissues

regional lymph nodes are likely to be involved

Stage 4Stage 4

The cancer has metastasized to distant parts of the body

THE TNM Staging SystemTHE TNM Staging System

Specifies the status of the primary tumor, regional lymph nodes, and distant mets

T: tumor

N: regional nodes

M: distant mets

Malignant TransformationMalignant Transformation

4 steps Initiation: DNA exposed to carcinogen

Promotion: sufficient exposure to agent to encourage/enhance cell growth

Progression: accelerated growth, enhanced invasion, altered appearance and activity

Metastasis: tumor develops blood vessels

Penetrates capillaries and form fibrin network (undetectable by immune system)

Dissolve lining of blood vessels to invade surrounding tissue

Set up their own blood supply

TreatmentsTreatments

Surgery:

Done for:

diagnosis Symptom relief maintain function Reconstruction Possible cure

Surgery continuedSurgery continued

Preop/postop care varies

The recommended treatment is based on the cancers: type, location, and mets

RadiotherapyRadiotherapy

Uses ionizing radiation

Dose: 1 gray equals 100 rads

Used to treat malignant cells

Has delayed and immediate effects

Delayed: altered DNA which impairs the cells ability to reproduce

Immediate: cell death due to damage of cell membrane

Figure 64.4 Figure 64.4 Immobilizers for radiation Immobilizers for radiation therapy. therapy.

From Osborne Book

Caregiver Safety with radiationCaregiver Safety with radiation

The less time spent near the source the less exposure

Unless direct care being given stay 6 ft away from the source

Effective shielding depends on type of rays (the denser the material the more protection)

External radiationExternal radiation

PROCEDURE Source is outside the body Special xray machine provides treatment # of treatments depends on the doctor

Example: 5 times a week for 2-8 weeks

PATIENT PREP Treatment simulation to determine exact

dosage needed and schedule The skin is marked with permanent,

waterproof ink, by the radiologist for the exact site

Instruct client not to remove markings without permission

Internal Radiation Internal Radiation (Brachytherapy)(Brachytherapy)

PROCEDURE Sources

Iodine, phosphorus, radium, iridium, radon, cesium

Instruct client that they pose a threat until the source is removed unless permanently implanted small beads used

2 TYPES Sealed

Unsealed

Sealed Sealed Source is sealed in a container and inserted

into the body (CESIUM) Sources may be placed in threads, beads,

needles, seeds, or molds To protect visitors from exposure the client

needs: To be placed in isolation Have a sign on the door indicating radiation No pregnant women or kids under 18 allowed in

room Limit time with visitors Have organized schedule for cares

Figure 64.5Figure 64.5 Brachytherapy applicator. Brachytherapy applicator.

From Osborne Book

Staff to wear film badges to monitor exposure

Recognize that Sealed sources can become dislodged

Portable lead shields provides minimal protection Immediately notify MD if source becomes dislodged.

Do not touch source with bare hands

Unsealed Unsealed Body fluids may be contaminated

Must wear gloves when working with patient

Contaminated fluids, dressings, etc may require additional precautions depending on the agency.

Disposable utensils are recommended

Equipment being removed from room must be checked for radiation level first

Radiation side effectsRadiation side effects

Normal cells may be harmed (hair follicles, bone marrow, lining of gi tractand urinary tract)

Anemia-deficiency of RBC Low WBCs

Take 2-6 wks to recover Bruising/Bleeding( low platelets)

Takes 2-6 wks to recover Alopecia (hair loss) Anorexia Dry mouth Harms reproductive cells

ChemotherapyChemotherapy

Use of chemical agents to treat (Antineoplastics)

Destroy rapidly dividing cells

Curative in some cases

Decreases symptoms in others

Chemotherapy and the Cell Chemotherapy and the Cell CycleCycle Stages of cancer:

Initiation (alteration of cell’s genetic structure)

Promotion (reversible proliferation of altered initiated cells)

Progression (increase in growth rate and possible metastasis)

Chemo kills at a constant % of cancer cells

Can be cell cycle specific (G(1), S, G(2), or M) or

Cell Cycle non-specific - G(0) or dividing phase

Chemotherapy CategoriesChemotherapy Categories

Alkylating agents

Nitrosoureases

Plant Alkaloids

Antitumor Antibiotics

Antimetabolites

Hormonal agents

Miscellaneous agents such as : L-

asparaginase Procarbazine

ChemotherapyChemotherapyUse of chemical agents to treat

cancer (Antineoplastics) Destroy rapidly dividing cells

Can be done with or without radiationComplication:

Extravasation – STOP DRUG IMMEDIATELY!!

ChemotherapyChemotherapy Other Complications:

Bone marrow suppression

Nadir

Lowest point in cell count after chemo/radiation – highest risk for infection

Neutropenia

7-14 days after chemo

Absolute Neutrophil Count (ANC)

Limitations of chemotherapy:

Few agents cross the blood-brain barrier

The phenomenon of resistant tumor

Most agents are most effective on dividing cells, but…

As a tumor grows, more cells become inactive

From Osborne Book

From Osborne Book

Chart 64-21 (continued)Chart 64-21 (continued) Routes of Routes of AdministrationAdministration

From Osborne Book

From Osborne Book

Chart 64-21 (continued)Chart 64-21 (continued) Routes of Routes of AdministrationAdministration

From Osborne Book

From Osborne Book

Cancer Drug ExamplesCancer Drug Examples

5FU

Megace

Side effects and toxicitiesThe result of the destruction of normal cellsFast-growing cells most susceptible to damageCell destruction → fatigue, anorexia, and taste alterations Gastrointestinal system effectsGenitourinary system effects

Nursing management related to side effects and toxicities

From Osborne Book

Side Effect ManagementSide Effect Management Drink 8-12 cups of clear liquid a day

Small frequent meals

Bland foods

Rest

Encourage wig

Be gentle with hair washing

No styling products

Check mouth for sores

No sugar

Drinks room temp

Do not rub/scratch skin

MANAGEMENTMANAGEMENT

Continue dexamethasone

Begin radiation to affected area

Opioid medications to manage pain

Analgesics ATC & additional doses for breakthrough pain

Laxative to prevent & manage constipation

Physical therapy

NUTRITIONNUTRITION The nutritional status of cancer patients can be altered in a

variety of ways

Anorexia, or loss of appetite, usually peaks 4 weeks into treatment and subsides shortly after treatment ends

Cancer cachexia

Nutritional screening

Nutritional support: oral nutrition, enteral feedings, parenteral nutritional support

Artificial nutrition and hydration can raise ethical questions for patients who have cancer, particularly those at end of life

From Osborne Book

Figure 64.7Figure 64.7 Cancer cachexia. Cancer cachexia. SourceSource: © : © Welcome Trust Images/Custom Medical Welcome Trust Images/Custom Medical Stock PhotoStock Photo

From Osborne Book

BiotherapyBiotherapy

Treatment with agents whose origin is from biological sources and/or affects biological responses

monoclonal antibodies and cytokines

hematopoietic growth factors

interferons (INF)

interleukins

From Osborne Book

Uses of Biologic Response Uses of Biologic Response ModifiersModifiers Definition- natural

substances produced in small amts. by body’s immune system; reproduced by recombinant DNA technology

How does this differ from chemotherapy?

Goal – enhance pts. Immunologic response to tumor cells

Three categories based on Three categories based on Activity of BRMActivity of BRM

Modulation or induce a host’s recognition to a tumor: Intron A (alpha

interferon) anti viral

Interleukin-2 : T/B lymphocytes

cause flu-like S&S

premedicate, labs, VS, check I & O & monitor for arrhythmias

Tumoricidal action

TNF, monoclonal antibodies, LAK, TIL (activated by interleukin-2)

Colony stimulating factors:

G-CSF (Neupogen), GM-CSF (Leukine), EPO (Procrit)

Transplants and hormone Transplants and hormone therapytherapy

Bone marrow- used with leukemia/lymphoma

Stem cell- bone marrow depression

Umbilical cord blood These 3 are done to restore blood

manufacturing cells

Hormone therapy-used to supress natural hormone secretion, block hormone actions, or provide supplemental hormones

From Osborne Book

Complications of transplantationPrimarily due to the conditioning regimeCan include bleeding, infection, nausea and vomiting, diarrhea, mucositis, and graft-versus-host disease (GVHD) May also have late effects

Nurses must be aware of the signs of graft failure and GVHDGraft failure rare, but nurse must expertly assess patientRequires another transplant or death will result

From Osborne Book

Oncological emergenciesOncological emergencies

Hypercalcemia

Syndrome of inappropriate antidiuretic hormone (fluid does not come off)

Disseminated intravascular coagulation (DIC)

Superior Vena Cava Syndrome (redness/edema of face, tachycardia, distended neck veins) Teach client not to bend forward

Spinal cord compression secondary to tumor

From Osborne Book

Nurse’s Role in early Nurse’s Role in early detection/ prevention for detection/ prevention for Septic ShockSeptic Shock Check vital signs, shaking,

chills, hypotension

Report temperature of 100.4 or above

Check skin for rash

Check peripheral or central IV sites

Avoid injections

Assess pulmonary function

Check urine changes

Avoid catheterization

Control environment

Give CSF & antibiotics

Three phases of Septic ShockThree phases of Septic Shock

Phase I -warm stage, caused by gram negative organisms increase heart rate, skin warm, increased temp.

antibiotics need to be started immediately

Phase II - warm to cold stage shift of fluid, cold, clammy, decreased bp,

increased pulse, decreased urine output

give IV fluids, lasix, dopamine

Phase III of Septic ShockPhase III of Septic Shock

Full cold stage

Alteration of cardiac output

Monitor hemodynamics

Give dopamine, dobutamine, IV fluid to maintain PAWP bet. 12-18, ventilate

Chart 64-24 (continued)Chart 64-24 (continued) Oncologic Oncologic EmergenciesEmergencies

From Osborne Book

From Osborne Book

Other possible Oncologic Other possible Oncologic EmergenciesEmergencies

What would cause them? DIC Pericardial

effusion/cardiac tamponade

SIADH

Tumor Lysis Syndrome tumor destroys

cells and releases cellular components that form imbalances : increased K, P, uric acid; decreased calcium

Rx: allopurinal, Ca, dialysis

Quality of LifeQuality of Life

The oncology nurse can positively affect QOL by prioritizing symptoms and implementing appropriate relief measures

For patients at end of life, nurses should be familiar with the concepts of hospice and palliative care

From Osborne Book

SurvivorshipSurvivorship What does the 5 year

survival rate mean?

Extended survival has certain considerations: teaching needs

resocialization

employment

insurance coverage

American Cancer Society

End of LifeEnd of Life

Death: lungs and heart cease to function

Causes: illness or trauma that overwhelms the body

Direct causes are: respiratory failure or shock

Multi-organ failureMulti-organ failure Inadequate blood flow to body tissues deprive cells of

oxygen which leads to acidosis, hyperkalemia, and tissue ischemia

First organs hit: kidneys, liver, heart, brain

› May also be in lung with septicemia

Vfib, asystole, or PEA can occur at any point of shock or hypoxemia

After cardiac arrest, respiratory arrest occurs within minutes

Clinical death refers to cessation of heartbeat and breathing with no evidence of brain function present

Incidence of deathIncidence of death

Dying is a part of life cycle

2.5 or more people die each year in the USA from CAD and cancer

Natural processNatural process

Stages of death

› Pallor mortis: body becomes pale. 15-120 minutes post death

› Algor mortis: body temp falls

› Rigor mortis: muscle stiffness. Relaxation occurs after about 72 hours post onset of rigor

› Liver mortis: blood begins to pool on lowest part example: to back if lying on back. 20 minutes to 3 hours after death

› Decomposition: we start to decompose

http://www.youtube.com/watch?v=BuF5qxIDa3c

http://www.youtube.com/watch?v=Qo5mCB9gbfY&feature=PlayList&p=C477E57325CB86CC&index=0

carecare

Palliative: philosophy that provides compassion and supportive approach to the dying

Helps to relieve symptoms

Provides emotional and spiritual support

Hospice as a ConsiderationHospice as a Consideration

Symptom control and pain management

Comfort and dignity is a philosophy

First hospice in USA in 1974 in New Haven, Conn.

Eligibility: life expectancy of 6 months or less

24 hour, 7 day /week coverage

HOSPICEHOSPICE

Hospice is not a building – it is a model of care

Distress symptomsDistress symptoms

Pain

Dyspnea

n/v

Fatigue

Weakness

Constipation

Anorexia

delirium

Assessments Assessments

Past medical hx

Assess emotions (see next slide)

Assess LOC

Teach family signs of distress (pain, restlessness, moaning)

Assess skin for temp, color, mottling, cyanosis

Assess vs: they will drop as death nears

Assess culture for customs/rituals

Assess lungs for cheyne stokes

Provide a comfortable environment (music, massage, no restraints, family near, lights dim, etc)

Emotions with impending deathEmotions with impending death

Withdrawl is 1st

Vision like appearances

› Talk/mumble to people that are not present

› Picking at air

› Affirm their experience

Letting go

› May be agitated or perform repetitive tasks

Saying goodbye

› Saying goodbye is important

› Touching, hugging, saying I love you, crying is okay

› Acknowledge these expressions as natural end

Tx Tx

Pain management

Fatigue management

Dyspnea management

Oxygen

n/v management

Agitation management

Grief management for pt and family

Offer support

Be realistic

Encourage reminiscence

Promote spirituality

Foster hope

Post mortem care Post mortem care

Pronouncement of death

Call PCP and other care providers

Call NORS

Allow family to view body

At Alegent, security or pastoral care will go over funeral arraignments like mortuary

At Alegent, a silk rose is placed on the door and given to family when they leave as well as the belongings of the deceased

Euthanasia Euthanasia

Passive: involves withdrawing or withholding tx that might prolong the life of a person who cannot be cured

This is accepted by all

Active : involves a healthcare provider taking action that purposefully and directly causes the client’s death

This is not allowed

Advance DirectivesAdvance Directives

Written document that specifies the client’s wishes should something happen to them.

DPOA-HC: appoints someone to make decisions in the event the client is unable

Living will: instructs doctors and family what life sustaining or lack of they wish to have done.

Transplantations Transplantations

http://www.youtube.com/watch?v=SvxpyfZ9Rsk

The Road to TransplantThe Road to Transplant

Treatment

Evaluation by a major transplant center

Listed or Not Listed

Waiting

Evaluation for TransplantEvaluation for Transplant

3-4 day process

Many tests: extensive lab work (40+ labs), ultrasounds, doppler studies, x-rays, bone scan, echocardiogram, upper GI, SBS

Consultations my many disciplines including surgeon, transplant coordinator, psychology, psychiatry, social work, child life, child development, specialist MD

Criteria for TransplantCriteria for Transplant End stage disease

Failure to treat

Benefits> Risk

absence of malignancy & infection

Able to survive surgery

Sepsis

Loss of line sites

MELD/PELD (liver)

NORS score/rating

What is the testing for What is the testing for histocompatability?histocompatability?

ABO and Rh

HLA - Human leukocyte or lymphocyte antigen

Contraindication – positive tissue typing for crossmatch with HLA antibodies

PRA - panel of reactive antibodies

Complications of TransplantComplications of Transplant

Rejection

Infection

Death

Multi-system involvement/ failure

What are the types of graft What are the types of graft rejection?rejection? Hyperacute

minutes to hours

preformed B cell antibodies to donor antigens

not always treatable

Acute

4 days to 4months

cell mediated

Treatable

Reversible – OKT3

Chronic

months or years

T and B cell

treatment not usually successful

Graft-versus- Host

with bone marrow transplants

donor T cells react

S&S: skin, liver, GI

HYPERACUTE REJECTIONHYPERACUTE REJECTION

Can be avoided with crossmatching prior to transplant

What are the medications for What are the medications for immunosuppression?immunosuppression?

Imuran

inhibits DNA/RNA

blocks antibodies

cellcept or cytoxan could be substitute

ATG

alters T cell function

serum sickness

ALG as a substitute

Thymoglobulin

Muromonab-CD3 or OKT3 monoclonal antibody

blocks T cell function

premedicate

prevention/treatment of rejection

cytokine release syndrome

Basiliximab-chimeric antibody (mouse/human)

Medications continued...Medications continued... Tacrolimus (fk-506)/ Sirolimus (renal

dysf)

-100 times more potent than CSA

-Many drug interactions- Nephrotoxic with NSAIDS

-Blocks interleukin 2 production

Cyclosporine

-nephrotoxic, hepatotoxic

Corticosteroids-drug interactions!

What are the types of donor What are the types of donor bone marrow?bone marrow?

Autologous - donor is recipient, How is this possible?

Allogenic - human with similar HLA type

Syngeneic - identical twin

Peripheral blood stem cell harvest - apheresis

BM Transplantation processBM Transplantation process

Harvesting

marrow is obtained from the posterior and anterior iliac crests and filtered

Bone marrow infusion

thaw bone marrow and infuse through an IV with a filter

Post transplant nadir period

day 0 is day of transplant and nadir point of pancytopenia

care directed to neutropenia, thrombocytopenia, and anemia (protective isolation)

pre-engraftment

Transplantation process if Transplantation process if allogenicallogenic

Conditioning goals: remove

malignant cells inactivate the

immune system empty the

marrow cavities

Nursing care related to conditioning ( the side effects of chemo such as cytoxan):

alopecia

anorexia, nausea

stomatitis

SIADH

hemorrhagic cystitis

Post-engraftment periodPost-engraftment period

New blood cells are circulating in peripheral blood 2-4 weeks after transplant

Continue on Cyclosporine A and steroids

Continued protection for patient for 2-3 months

Nursing Care of the Bone Nursing Care of the Bone Marrow Transplant PatientMarrow Transplant Patient

Conditions that require BMT:

leukemia, aplastic anemia, immune deficiency diseases, tumors of the breast, ovarian, testicular

Why is bone marrow transplant important as a treatment for malignant disease?

Allows the client to receive high doses of chemotherapy without concerns of myelosuppression

Nursing Diagnoses related to Nursing Diagnoses related to BMTBMT

Risk for infection

PC: Bleeding

Alteration in fluid volume

Ineffective breathing pattern

Altered Sensory-perception

Altered skin integrity R/T GVHD

Impaired family/individual coping

Recipient ConcernsRecipient Concerns

Pre-transplant concerns Maintain physical

health/ current labs

Dental screening

Treat chronic conditions

Psychological preparation

Prepared every minute

Fear/ Cost

Post-transplant concerns

Potential for infection

Alteration in elimination

Knowledge deficit of health maintenance

Increased demand of care partner

Fatigue

Donor ConcernsDonor Concerns

Quality of Life

Criteria for being a donor

Responsibility

Support

Major Types of TransplantsMajor Types of Transplantsand resultant nursing careand resultant nursing care Kidney

check urine output & electrolytes

Heart

orthotopic approach

heterotopic approach

Heart-lung, lung

mechanical ventilation

Liver

Pancreas

Corneal

Other:

Stem cell

Bone

Skin

Small Bowel

Heart valves

Liver/Small Bowel

Corneal transplantCorneal transplant

Surgical removal of diseased cornea and replaced with donor

Use a calm approach

Assess for signs of infection prior to surgery

Regional anesthesia is used

Antibiotics injected after

Dressing in place and removed the next day by the surgeon

Pt to lie on non operative side

A shield is to be worn at nite for the 1st month

Graft rejection is possible

Liver transplantLiver transplant

Not candidate if: severe cardiovascular instability, severe respiratory disease, active alcohol or substance abuser, metastatic malignant disease, inable to follow directions regarding meds and self care

Donor livers are primarily from trauma victims

Living donors can also be used

The liver is the only organ that can grow back

Renal transplantRenal transplant

Not a cure

2-70 yrs is age range to get transplant

Thorough assessment before

Cardiac disease excludes candidate

Monitor urinary status closely

Cancer clients get dialysis

Diabetes clients need very close monitoring

donorsdonors

Kidney donors may be living or dead

Matching is difficult

Kidneys donors must be : free of disease and infection, no history of cancer, no htn or renal disease, adequate renal function

Post opPost op

Urological management is key

Monitor for rejection

Monitor urine color

Pink and bloody right after

Normal after several days-weeks

Daily specimens obtained and cultured

Instruct about meds and rejection

Heart transplantHeart transplant

2300 transplants each year

Criteria to get: life expectancy less than 1 year, age less than 65, normal pulmonary vascular resistance, no active infections, stable psychosocial status, no drug or etoh abuse

Post op: monitor for bleeding, similar recovery to cabg, monitor for tamponade, instruct client to change position slowly b/c of orthostatic hypotension 2nd to denervation, instruct to follow medication schedule religiously to prevent rejection which usually happens in first 3 months, instruct client to follow recommended diet, allow 10 minutes warm up and cool down with exercise

Role of the Nurse in Role of the Nurse in Transplantation IssuesTransplantation Issues The assessment/ physical

exam

The psychosocial evaluation

coping mechanisms

support systems

anxiety

depression

loss of control

The nurse needs to express caring/empathy to client issues: cost

ethical concerns

legal regulations

uniform anatomical gift act

National Organ Transplant Act

UNOS

Success of TransplantSuccess of Transplant Liver- 83% at 1 year/ 71% 5 year(cad)

Liver- 85% 1 year/ 81% 5 year (living)

Small bowel/ Liver-Small bowel- approximately 65% one year/ 46% 5 year

Heart- 83% at one year/ 69% 5 year

Heart/Lung- 65% at one year/41% 5 year

Kidney- 94% one year/ 82% 5 year (cad)

Kidney- 97% one year/91% 5 year (living)

Living DonationLiving Donation

Usually between 18-60 years of age

May give single kidney, lobe of lung, segment of the liver, or portion of the pancreas

Tissue typing, crossmatching, and antibody screen are performed, as well as urine tests, CXR, EKG, arteriogram, and psychologic/psychiatric evaluation

Positive Aspects of Living Positive Aspects of Living DonationDonation Eliminates waiting list-surgery may be

scheduled(decreases stress of Tx)

Recipient may begin taking immunosup. Drugs 2 days before transplant

Higher rate of compatibility...between blood related living donor

Psychological benefit

Websites to VisitWebsites to Visit United Network for Organ Sharing

(UNOS) www.unos.org

American Society of Transplantation (AST) www.asts.org

Nebraska Medical Center www.unmc.edu

www.nebraskatransplant.org

Transplant Recipients International Organization www.trioweb.org

http://www.youtube.com/watch?v=IFSNDqjOS_8&feature=related