NURSING MANAGEMENT OF CLIENTS WITH DISTURBANCES IN CELLULAR FUNCTIONING

LEARNING OBJECTIVES:

At the end of the discussion, the students will be able to:

1. Summarize the nursing roles and opportunities in cancer prevention, detection, diagnosis and treatment of cancer2. Enumerates the case finding and early detection methods of cancer.3. Explains the major health problems of client with cancer and its specific nursing diagnosis with interventions.4. Identify the psychosocial implications of

cancer.5. Differentiate the modes of treatment for cancer and its specific nursing responsibilities.6. Discuss the nursing management for oncologic

emergencies.

CANCER CANCER affects every age group. The incidence of cancer is higher in men than in

women and higher in industrialized sectors and nations

Refers to class of diseases or disorders characterized by the development of abnormal cells that divide uncontrollably and have the ability to infiltrate and destroy normal body tissue

WARNING SIGNS OF CANCER

C - Change in bowel or bladder habits A - Sore that does not heal U - Unusual bleeding T - Thickening or lump I - Persistent indigestion O - Obvious change in warts or mole N - Nagging cough or persistenthoarseness A - Anemia L - Loss of appetite

DETECTION AND PREVENTION OF CANCER

PRIMARY PREVENTIONAcquisition of knowledge and skills

necessary to educate client, community about cancer risk.

SECONDARY PREVENTIONCancer screening programs for

individuals who are found to be at high risk for cancer

NURSING RESPONSIBILITIES IN EARLY DETECTION OF CANCER

STEPS TO REDUCE CANCER RISKWhen teaching individual patients or groups,

nurses can recommend the following cancer prevention strategies:

1. Increase consumption of fresh vegetables (especially those of the cabbage family.)

2. Increase fiber intake.3. Increase intake of Vitamin A.4. Increase intake of foods rich in Vitamin C.5. Practice weight control.6. Reduce intake of dietary fat.7. Practice moderation in consumption of salt-cured,

smoked and nitrate-cured foods.8. Stop smoking cigarettes and cigars.9. Reduce alcohol intake.10. Avoid overexposure to sun.

RECOMMENDATION FOR EARLY DETECTION OF CANCER

BREAST CANCER Risk Factors• Menarche before age 11 • Menopause after age 50• Family history of breast cancer – especially

mother or sister• History of uterine cancer• Nulliparity or birth of first child after age 30• History of uterine cancer• Link with obesity, diabetes and hypertension• Presence of benign breast cyst.

Screening• Breast Self-Examination• Regular mammograms (screen all middle aged

woman)

COLORECTAL CANCER COLORECTAL means colon and rectum combined Highest for people older than 85 years of age High for people with family history of colon

cancer, polyps adenomatous, of inflammatory bowel disease, high fat, high protein (with high intake of beef), low fiber diet, genital or breast cancer in women

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Diagnostic Procedure1. Colonoscopy – an insertion of fiber optic scope

through the rectum for direct visualization of the colon.

2. Digital Rectal Examination

PROSTATE CANCERRisk Factors• Increasing age, after age 50• Having father or brother with prostate cancer

doubles the risk of relatives • A diet high in red meat increase risk• Difficulty and frequent urination, urinary

retention, decreased size and force of the urinary stream

• Every man older than 40 should have DRE ( Digital rectal exam ) as part of regular check up

• The more advanced lesion, it becomes “ stony hard “ and fixed

DIAGNOSTIC PROCEDURE Digital Rectal Examination Prostate Specific Antigen

TESTICULAR CANCER• Primarily affect young to middle-aged men (20 to

35 years old)• Most testicular tumors originate in gonadal cells.

Signs: Early sign – firm painless, smooth testicular mass

varying in size Late sign – ureteral obstruction, abdominal mass,

shortness of breath

Screening: Testicular Self-Examination(TSE)

CERVICAL CANCER• Refers to the cancer of the neck of the uterus.

Assessment: Painless vaginal bleeding post-menstrual and

post-coital Foul-smelling or serosanguinous vaginal

discharge Pelvic, lower back, leg or groin pain

Diagnostic Procedure1. Pap’s Smear

THYROID CANCER

- Lesions that are single, hard, & fixed on palpation or associated with cervical lymphadenopathy, suggest malignancy.

SCREENING:Use of fine or large bore needle biopsy, Ultrasound, MRI, CT Scan & Thyroid Scan

LUNG CANCER Most common from cigarette smoking. Genetic, underlying respiratory diseases, COPD,

TB most common symptom is a cough or change in

cough Repeated unresolved URTI

Diagnostic Examination:Chest x – ray - is performed to search for pulmonary density, a solitary peripheral nodule (coin lesion), atelectasis and infection.

NURSING PROCESS: THE PATIENT WITH CANCER

I. ASSESSMENT• Regardless of type of cancer treatment or

prognosis many patients with cancer are susceptible to the following problems and complications.

• An important role of the oncology nurse is to assess the patient for these problems and complications

1. Infection

A. Assess factors that promotes infection: · Impaired skin & mucus membrane integrity · Chemotherapy · Radiation Therapy · Biologic Response Modifiers · Malignancy · Malnutrition · Urinary Catheter, Intravenous Catheter · Other Invasive Procedures · Contaminated Equipment · Age · Chronic Illness · Prolonged Hospitalization

B. Monitoring laboratory studies to detect early changes in WBC count

– Leukopenia– Granulocytopenia– Neutropenia

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C. Chest x- ray

2. Bleeding

A. Assess factors that contribute to bleeding– Bone marrow suppression from radiation– Chemotherapy– Medications that interfere with

coagulation and platelet functioning B. Common bleeding sites:

– Skin and mucous membranes– Intestinal– Genito-Urinary Tract– Respiratory tract– Brain

C. Signs of bleeding– Gross hemorrhage– Blood in the stools, urine, sputum, or

vomitus– Oozing at injection sites– Bruising (ecchymosis)– Petechiae– Changes in mental status

3. Skin ProblemsAssess predisposing factors and other risk factors

4. Hair Loss Assess also the psychological impact of this side

effect on the patient and the family

5. Nutritional Concerns

COMMON NUTRITIONAL PROBLEMS 1. Anorexia 2. Mal-absorption 3. Cachexia

A. Impaired nutritional status may contribute to: Disease progression Immune incompetence Increased incidence of infection Delayed tissue repair Diminished functional ability Decreased capacity to continue

chemotherapy

B.Physical signs of weight loss and cachexia are secondary to decreased protein and caloric intake, metabolic, mechanical effects of cancer and systemic disease, side effects of the treatment or emotional status of the patient.

C. Determine diet history, any episodes of anorexia, changes in appetite, altered taste, nausea, diarrhea, situation and foods that aggravate or relieve anorexia and medication history

D. Clinical and laboratory data useful in assessing Patient’s nutritional status

o Anthropometrical measurementso Serum protein levelso Serum electrolyteso Skin response to intradermal

injectiono Hemoglobin and hematocrit

levelso Serum Iron Levels

6. Pain

A. Related factors causing pain: Underlying disease Pressure exerted by tumor Diagnostic procedures Cancer treatment

B. Assess site of pain, pain perception, pain scalesC. Give emphasis not only to physical pain but psychosocial as well.

7. Fatigue Fatigue has been recognized as one of the

significant and frequent symptoms experienced by patients receiving cancer therapy.

Assess for feelings of weariness, weakness, lack of energy, inability to carry out ADL, lack of motivation, and inability to concentrate

Assess for physiologic and psychological stressors that contribute to fatigue, (pain, nausea, constipation, fear, anxiety)

8. Psychosocial Status

9. Body Image and Self-Esteem

II. Nursing Diagnosis• Risk for infection related to altered immunologic

response• Impaired skin integrity: erythematous and wet

desquamation reaction to radiation therapy.• Impaired oral mucous membranes related to

stomatitis.• Imbalanced nutrition: less than body

requirements related to nausea and vomiting.

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• Fluid and electrolyte imbalance related to anorexia, nausea & vomiting, altered taste, diarrhea

• Anticipatory grieving related to loss of body parts and altered role functioning

• Disturbed body image and situational low self-esteem related to changes in appearance, function and roles

• Self – care deficit due to fatigue, malaise, and protective isolation

• Anxiety due to knowledge deficit and uncertain future

• Disturbed body image r/t changes in appearance, function and roles

• Grieving r/t anticipatory loss and altered role functioning

• Potential for spiritual distress• Deficient knowledge about disease process,

treatment, complication management, and self-care measures

III. Planningo Maintenance of tissue integrityo Maintenance of nutritiono Relief of paino Relief of fatigueo Improve body imageo Effective progression through grieving

processo Absence of complications

Nursing Interventions

Managing Stomatitis o Provide good oral hygiene.o Use soft bristled toothbrushes and nonabrasive

toothpaste.o Oral swabs with sponge like applicators maybe

use in place of toothbrush.o Avoid alcohol based mouth rinses.o Lubricate cracked and dry lipso Adequate food and fluid intake is encouraged

Maintaining Tissue Integrityo Handle affected area gently.o Avoid rubbing or use of hot or cold water, soaps,

powder, lotion and cosmetics avoidedo Avoid tissue injury by wearing loose-fitting

clothing.o Aseptic technique should be observed during

dressing and wound care.

Assisting Patients to cope with Alopecia: o Provide information about hair loss, support

patient and family in coping with disturbing effects of therapy.

o Instruct to acquire a wig or hairpiece before hair loss.

o Encourage use of attractive scarves and hats.

Managing Malignant Skin Lesion:o Carefully assessing and cleansing the skin.o Reducing superficial bacteria.o Controlling the bleeding.o Reducing odor.o Protecting the skin from pain and further trauma.

Promoting Nutrition: o Prepare foods that are appealing.o Patient’s preferences as well as physiologic and

metabolic requirements are considered when selecting foods.

o Encouraged small frequent feedings.o Inform patient the advantage of receiving

alternative methods of feeding by parenteral or enteral route.

Relieving Pain:o Provide adequate rest and sleepo Promote diversional activitieso Provide adequate rest and sleepo Offer Empathyo Give pain reliever medications as ordered

Decreasing Fatigueo Help the patient and the family to understand

that is an expected and temporary side effect of cancer process and of many treatments used.

o Help patient identify sources of fatigueo Plan activities to conserve energy as well as

alternate periods of rest.o Regular, light exercise is recommended

Body Image and Self-Esteemo Positive approach is necessary o Encourage independence and continued

participation in self-care decision makingo Patient should be assisted to assume tasks and

participate in those activities that are personally of most value.

o Identify any negative feeling that that the patient has or threats to body image.

o Referral to support groupsAssisting in the Grieving process 

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o Grieving is a normal response to fears and anticipated losses that include, loss of heath, normal sensations, body image, social interaction, sexuality and intimacy.

o Assess response of patient and family about the diagnosis and planned treatment.

o Assist in answering inquiries and questions, identifying resources and support people.

o Assist patient and family acquire knowledge to cope with the disease process

o Assist patient and family members to acknowledge and cope with their reactions and feelings.

Managing and Monitoring Potential Complications

1. Infectiono Strict asepsis techniqueo Health teaching on how to recognize signs and

symptoms of infectiono Maintain skin integrity.o Monitoring laboratory data. o Administration of antibiotics as ordered

2. Septic Shocko Assess signs and symptoms of septic shock.o Neurologic assessmento Fluids and electrolyte status monitoringo Administration of intravenous fluids, blood products, vasopressors, oxygen and broad spectrum antibiotic as ordered.

3. Bleeding and Hemorrhageo Monitor laboratory values especially platelet counto Assess the patient for bleedingo Taking steps to prevent trauma and minimize the risk for bleeding

PROMOTING HOME AND COMMUNITY BASED CARE

1. Teaching Patients Self-Care2. Continuing Care

NURSING MANAGEMENT DIFFERENTMODALITIES OF TREATMENT

1. SURGERY

Types: Diagnostic Prophylactic Palliative Reconstructive

The patient undergoing surgery for cancer requires general peri-operative nursing care with specific care related to the patient’s age, organ impairment, nutritional deficits, disease of coagulation and altered immunity that may increase the risk.

Peri-operatively, the nurses asses the patient response to the surgery.

Monitor possible complication: Post-Operative teaching about wound care, activity nutrition and medications information is given.

2. RADIATION THERAPY

Ionizing radiation that is used to: Interrupt cellular growth Cure cancer Used to control malignant disease when tumor

cannot be removed surgically used when local metastasis is present

Used prophylactically to prevent leukemia; infiltration to the brain and spinal cord.

SOURCE OF RADITAION THERAPY

External Radiation therapy (Teletherapy)-administer through an x-ray machine

Internal Radiation Therapy-administer near or within the tumor

Types: Sealed Source (Brachytherapy ) Unsealed

BRACHYTHERAPY - From the greek word “bradys” means, “short

- distance”- Also known as internal radiotherapy, sealed

source radiotherapy, curietherapyorendocurietherapy is a form of radiotherapy where a radiation source is a place inside or next to the area requiring treatment.

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BRACHYTHERAPY- Is commonly used as an effective treatment

for cervical, prostate, breast and skin cancer and can also be used to treat tumors in many other body sites.

- Can be used alone or in combination with other therapy such as surgery EBRT and chemotherapy

SIDE EFFECT OF RADIATION THERAPYAND IT’S RESPONSE

1. Skin Reaction- Erythema, dry/moist desquamation - Atrophy telangiectasia, depigmentation - Necrotic or ulcerative lesion

o Nursing Responsibility: Observe for early signs of skin reaction and report

immediately Keep area dry Was area with water, no soap and pat to dry and

do not rub Do not apply ointment, powders, lotion on the

area Do not apply heat, avoid sunshine or cold Use soft fabric for clothing DO NOT ERASE MARKING ON THE SKIN

2. Infection3. Hemorrhage4. Fatigue (radiation cause exhaustion)5. Weight loss6. Stomatitis7. Diarrhea8. Nausea and Vomiting 9. Headache10. Alopecia11. Cystitis 12. Social Isolation

PRINCIPLES OF RADIATION PROTECTION

1. Distance - Maintain a distance of at least 3 feet when

not performing nursing procedure 2. Time

- Limit contact with the patient for 5 minutes each time, a total of 30 minutes per shift

3. Shielding - Use lead shield during contact with client

SAFETY PRECAUTION IN RADIATION THERAPY

Assigning to a private room Posting notices Dosi meter badge must be worn Not assigning pregnant staff Prohibit children Limit visits 30 minutes daily Maintain 3 feet distance

3. CHEMOTHERAPY- Anti-neoplastic agents that are used in an attempt to

destroy tumor cells by interfering with cellular function and reproduction.

Goal:Cure, Control, Palliation

Route:Topical, Oval, IV, IM, Subcutaneous, Arterial, Intra-cavity, and Intrathecal.

Special Problem:Extravasation

Contraindication:

1. Infection2. Recent Surgery3. Impaired Renal or hepatic functions4. Recent Rad. Therapy5. Pregnancy6. Bone Marrow Depression

2. CHEMOTHEPEUTIC AGENT

1. Alkylating - Busulfan, cabopatin, chlorambucilm,

asplatin, cyclophosphamide, decabazine, hexamathyl, melamine, fosfamde nitrogen mustard, theothecin.

- Alter DNA structure by misreading DNA code initiating breaks in DNA molecule, cross linking DNA strands.

2. Antimetablikes - Cytaraine 5-flourfacil (5-FU)

Pentatastine- Interfere with biosynthesis of

metabolic or nucleic acid necessary for RNA and DNA synthesis.

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3. Plant alkaloids- etoposide, teniposide, vinblastine,

vineristine- Arrest metaphase by inhibiting

mitotic tubular formation (spindle) inhibit DNA and protein synthesis.

4. Anti-tumor Antibiotic- Bleomian, doxorubicin,mitomycin- Interfere with DNA synthesis by

binding to DNA, prevent RNA synthesis

Vesicant – are those agent if deposited into the subcutaneous tissues can cause extravasation

Dactoinomycin Paunorubicin Doxorubicin Nitrogen mustard Mitomycin Vinblastine Vincristine

INDICATION OF EXTRAVASATION DURINGADMINISTRATON OF VESICANTS

Absence of blood return from the intravenous catheter

Resistance to flow of the intravenous fluid Swelling, pain, and redness at the site

Of the extravasation is suspected:

Medication administration must be stopped immediately

Ice applied on the site (expect for vesicant) vinca alkaloid

Physician may aspirate any infiltrate medication from the tissue and infect neutralizing solution onto the area reduce to reduce tissue damage

Example of neutralizing solution: Sodium thiosulfate, Nyaluronidase, and Sodium Bicarbonate

SIDE EFFECT OF CHEMOTHERAPY

1. Gastrointestinal System a. Nausea and Vomitingb. Diarrhea

c. Constipation 2. Integumentary System

a. Pruritus, Urticaria, and systemic signsb. Stomatitisc. Alopeciad. Skin Pigmentation e. Nail Changes

3. Hematopoetic System a. Anemiab. Neutropeniac. Thrombocytopenia

4. Genito – Urinary System a. Hemorrhagic changesb. Urine color changes

5. Reproductive System a. Premature menopause or amenorrhea

SAFETY PRECAUTIONS IN ADMINISTERING CHEMOTHERAPY

*Use of biologic safety cabinet for the preparation of all chemotherapeutic agents

*Wear surgical gloves when handling anti-neoplastic agent and the excretions of patients who received chemotherapy

*Wear disposable long sleeved gown when prepares and administering chemotherapeutic agents

*Use Leur lock fitting in all intravenous tubing used to deliver chemotherapy

*Disposable of all equipment used in chemotherapy preparation and administration in appropriate, leak – proof, puncture proof container.

*Dispose of all chemotherapeutic waste as hazardous material.

4. THERMAL THERAPY or HYPERTHERMIAThe generation of temperatures greater

than physiologic fever range ( above 41.5 ‘C ) has been used for many years to destroy tumors in human cancer.

Using radio waves can produce heat, ultrasound, microwaves, magnetic waves, and hot water baths, hot wax immersions.

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Principles:1. Malignant cells are sensitive to harmful effects of

high temperatures.2. Malignant cells lack repair mechanisms necessary

to repair cell damage by elevated temperature.3. Most tumor cells lack an adequate blood supply

during periods if increased cellular demand such as during Hyperthermia.

Nursing Management:o Local skin care

5. BIOLOGIC RESPONSE MODIFIERS- is also called IMMNUNOTHERAPY- Substances that are able to trigger the immune

system to indirectly affect tumors.- These include cytokines such as interferons and

interleukins.- The basis of BRM is restoration, stimulation,

modification and augmentation of the body’s natural defense against cancer

- E.g. BCG – treat bladder cancer

BRM (Biological Response Modifiers)Nursing Management:

• Patients receiving BRM therapy have many of the same needs as cancer patients undergoing treatment approaches

• BRM therapies are still investigational a considered a last-chance effort by many patients.

• Essential that the nurse assess the need for education, support and guidance for the patient and family in planning and evaluating patient care.

6. PHOTODYNAMIC THERAPY- A ternary treatment for cancer involving 3 key

components: a photosensitizer, light and tissue oxygen.

- A photosensitizer is a chemical compound (Porfimer) that can be excited by a light of a specific wavelength.

- Use as a treatment for basal cell carcinoma.

MAJOR SIDE EFFECT:

PHOTOSENSITIVITY FOR 4 TO 6 WEEKS AFTER TREATMENT

NURSING MANAGEMENT:• Instruct client to protect themselves from direct

and indirect sunlight to prevent skin burns.• Liver and renal function should be monitor

• Offer emotional support and educate the client and family regarding the therapy

8. GENE THERAPY• A technique for correcting defective genes

responsible for disease development.• A gene is inserted into the genome to replace an

abnormal, disease causing gene.• Viruses are used as a gene therapy vectors such

as retrovirus, adenovirus,herpes simplex virus.

9. BONE MARROW TRANSPLANTATION

Types1. Autologous – from patient2. Allogenic - from a donor other than a patient. Eg.family member, matched unrelated donor,(bone marrow registry)3. Syngeneic - from an identical twin

Procedure:1. Donor suitability is determined through tissue antigen typing of human leukocyte antigen (HLA) and mixed leukocyte culture (MLC)2. Donor bone marrow is aspirated from multiple sites along iliac crest under general anesthesia3. Donor marrow is infused IV into the recipient

COMPLICATIONS:1. Failure of engraftment2. Infection: highest risk in 3 to 4 weeks3. Pneumonia: non-bacterial or intestinal

pneumonia are principal causes of death on the first 3 months post-transplant

4. (GVHD) Graft vs., host disease: principal complication caused by an immunologic reaction of engrafted lymphoid cells against the tissue of the recipient

- Acute GHVD – develops within first 100 days post-transplant and affects GUT, liver, marrow, and lymphoid tissue -Chronic GVHD – Develops 100 – 400 days post-transplant manifested by multi- organ involvement

5. Recurrent malignancy 6. Late complications such as cataracts, and endocrine abnormalities

NURSING CARE PRETRANSPLANT

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1. Recipient immunosuppression attained with total body irradiation (TBI) and chemotherapy to eradicate existing disease and create space in host marrow to allow transplanted cells to grow.

2. Provide protective environment.A. Client should be in laminar airflow room or strict reverse isolation.B. Objects must be sterilized before being brought to the room.C. When working with children, introduce new people were they can be seen, but outside child’s room so they can see what they look like without isolation garb.

3. Monitor central lines frequently. Check patency and observe signs of infection such as fever, redness around sight.4. Provide care for client receiving chemotherapy and radiation therapy that induce immunosuppression.

NURSING CARE POST TRANSPLANT 1. Prevent Infection.2. Provide mouth care for stomatitis and mucositis.3. Provide skin care.4. Monitor carefully for bleeding. 5.Maintain fluid and electrolyte balance and promote nutrition. 6. Provide client teaching and discharge planning concerning:

• Home environment (cleaning, pets, visitors)• Diet modifications• Medication regimen –schedule, dosage, effects,

side effects.• Communicable disease and immunizations• Daily hygiene and skin care• Fever• Activity

9. UNPROVEN & UNCONVENTIONAL THERAPIES

• Also called Complementary and Alternative Medicine.

• CAM treatments are the diverse group of medical and health care systems, practices & products that are not presently considered to be effective by the standards of medicine.

Nursing Management

Trusting relationship, supportive care, and promotion of hope with the patient and family.

Truthful responses should be given in nonjudgmental manner to questions and inquiries about unproven methods.

The nurse should encourage any patient who uses unconventional therapies to inform the physician about such use.

NURSING MANAGEMENT FOR ONCOLOGIC EMERGENCIES:

1. SUPERIOR VENA CAVA SYNDROME (SVCS)

INTERVENTIONS: Assess for signs and symptoms of SVCS. Monitor cardiopulmonary and neurologic status. Promote energy conservation to minimize

shortness of breath. Prepare the patient for radiation therapy to the

mediastinal area.

2. SPINAL CORD COMPRESSION

INTERVENTIONS: Assess for back pain and neurological deficits. Prepare the client for radiation and/or

chemotherapy. Surgery may be needed to remove the tumor and

relieve the pressure to spinal cord. Instruct the client in the use of neck or back

braces if they are prescribed.

3. HYPERCALCEMIA

INTERVENTIONS: Monitor calcium level. Administer oral or parenteral Normal Saline fluids

as prescribed. Administer medications to lower the calcium

level as prescribed. Prepare the client for dialysis if the condition

becomes life threatening or is accompanied by renal impairment.

4. PERICARDIAL EFFUSION & CARDIAC TAMPONADE

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INTERVENTIONS: Monitor vital signs and oxygen saturation

frequently. Assess for pulsusparadoxus. Monitor ECG tracings Assess heart and lung sounds. Monitor and record intake and output Elevate the head of patient’s bed. Minimize patient’s physical activity. Reposition and encourage the patient to cough. Provide frequent oral hygiene. As needed, maintain patient IV access, reorient

the patient, and provide supportive measures and appropriate patient instruction.

5. DIC/CONSUMPTION COAGULOPATHY

INTERVENTIONS: Measure and document Intake & output Inspect all body orifices & tubes for bleeding Prevent bleeding Administer anticoagulant as prescribed. Administer cryoprecipitated clotting factors if DIC

progress and hemorrhage is the primary problem.

6. SIADH

INTERVENTIONS: Monitor accurate recording of intake and output. Initiate fluid restriction and increased sodium

intake as prescribed. Administer antidiuretic hormone antagonist as

prescribed. Monitor serum sodium levels.

7. TUMOR LYSIS SYNDROME

INTERVENTIONS: Monitor Intake and Output. Encourage oral/IV hydration. Administer diuretics as prescribed. Administer medications that increase the

excretion of purine as prescribed. Prepare to administer IV infusion of glucose

and insulin to treat hyperkalemia. Prepare the client for dialysis if hyperkalemia

and hyperuricemia persist despite treatment.

PSYCHOSOCIAL ASPECTS OF CANCER CARE

When cancer becomes a part of life’s journey it is hardwork.

Providing support for client (your presence as a caring person)

Providing support for the family Promoting positive self-concept Promoting coping throughout the cancer

continuum

A. Diagnosis and treatment (clients received diagnosis and treatment in different ways)

B. Survivorship (client who entered successful treatment enter an indeterminate period of long –term survivorship)

C. Recurrent disease and progression (most clients live with the threat or reality of recurrent disease)

D. Terminal illness, “when everything is done that can be done, compassion is the only thing that brings beauty and meaning to our lives. It is the irreplaceable gift.

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