NEO 113JuLy 16, 2011

Oncology defined

Branch of medicine that deals with the study, detection, treatment and management of cancer

“Root words”Neo- newPlasia- growthPlasm- substanceTrophy- size+Oma- tumorStatis- location

“Root words”A- noneAna- lackHyper- excessiveMeta- changeDys- bad, deranged

CANCER NURSINGEtiology of cancer

1. PHYSICAL AGENTSRadiationExposure to irritantsExposure to sunlightAltitude, humidity

CANCER NURSINGEtiology of cancer

2. CHEMICAL AGENTS Smoking Dietary ingredients Drugs

CANCER NURSINGEtiology of cancer

Genetics and Family History Colon Cancer Breast cancer

CANCER NURSING

Etiology of cancer Dietary Habits Low-Fiber High-fat Processed foods alcohol

CANCER NURSINGEtiology of cancer

Viruses and BacteriaDNA viruses- HepaB, Herpes, EBV, CMV,

Papilloma VirusRNA Viruses- HIV, HTCLVBacterium- H. pylori

CANCER NURSINGEtiology of cancer

Hormonal agentsDESOCP especially estrogen

CANCER NURSINGEtiology of cancer

Immune DiseaseAIDS

CANCER NURSINGBody Defenses Against TUMOR

1. T cell System/ Cellular ImmunityCytotoxic T cells kill tumor cells

2. B cell System/ Humoral immunityB cells can produce antibody

3. Phagocytic cellsMacrophages can engulf cancer cell debris

CANCER NURSINGCancer Diagnosis

1. BIOPSY The most definitive

2. CT, MRI3. Tumor Markers

CANCER NURSINGCancer Staging

The degree of DIFFERENTIATIONStage 1- Low gradeStage 4- high grade

CANCER NURSINGGENERAL MEDICAL MANAGEMENT1. Surgery- cure, control, palliate2. Chemotherapy3. Radiation therapy4. Immunotherapy5. Bone Marrow Transplant

CANCER NURSINGGENERAL Pharmacology1. antimetabolites2. antibiotics3. plant alkaloids4. antiemetics

CANCER NURSINGGENERAL Promotive and Preventive Nursing

Management1. Lifestyle Modification2. Nutritional management3. Screening4. Early detection

SCREENING1. Male and female- Occult Blood, CXR, and

DRE2. Female- SBE, CBE, Mammography and

Pap’s Smear3. Male- DRE for prostate, Testicular self-

exam

Nursing AssessmentUtilize the ACS 7 Warning SignalsCAUTIONC- Change in bowel/bladder habitsA- A sore that does not healU- Unusual bleedingT- Thickening or lump in the breastI- IndigestionO- Obvious change in wartsN- Nagging cough and hoarseness

Nursing AssessmentWeight lossFrequent infectionSkin problemsPainHair LossFatigueDisturbance in body image/ depression

Nursing InterventionMAINTAIN TISSUE INTEGRITYHandle skin gentlyDo NOT rub affected areaLotion may be appliedWash skin only with SOAP and Water

Nursing InterventionMANAGEMENT OF STOMATITISUse soft-bristled toothbrush Oral rinses with saline gargles/ tap waterAvoid ALCOHOL-based rinses

Nursing InterventionMANAGEMENT OF ALOPECIA

Alopecia begins within 2 weeks of therapy

Regrowth within 8 weeks of terminationEncourage to acquire wig before hair loss

occursEncourage use of attractive scarves and

hatsProvide information that hair loss is

temporary BUT anticipate change in texture and color

Nursing InterventionPROMOTE NUTRITIONServe food in ways to make it appealingConsider patient’s preferencesProvide small frequent mealsAvoids giving fluids while eatingOral hygiene PRIOR to mealtimeVitamin supplements

Nursing InterventionRELIEVE PAINMild pain- NSAIDS

Moderate pain- Weak opiodsSevere pain- MorphineAdminister analgesics round the clock with

additional dose for breakthrough pain

Nursing InterventionDECREASE FATIGUEPlan daily activities to allow alternating

rest periodsLight exercise is encouragedSmall frequent meals

Nursing InterventionIMPROVE BODY IMAGETherapeutic communication is essentialEncourage independence in self-care and

decision makingOffer cosmetic material like make-up and

wigs

Nursing InterventionASSIST IN THE GRIEVING PROCESSSome cancers are curableGrieving can be due to loss of health,

income, sexuality, and body imageAnswer and clarify information about

cancer and treatment optionsIdentify resource peopleRefer to support groups

Nursing InterventionMANAGE COMPLICATION:

INFECTIONFever is the most important sign (38.3)Administer prescribed antibiotics X

2weeksMaintain aseptic technique Avoid exposure to crowds Avoid giving fresh fruits and veggieHandwashingAvoid frequent invasive procedures

Nursing InterventionMANAGE COMPLICATION: Septic shockMonitor VS, BP, tempAdminister IV antibioticsAdminister supplemental O2

Nursing InterventionMANAGE COMPLICATION: BleedingThrombocytopenia (<100,000) is the most

common cause <20, 000 spontaneous bleedingUse soft toothbrushUse electric razorAvoid frequent IM, IV, rectal and

catheterizationSoft foods and stool softeners

COLON CANCERRisk factors1. Increasing age2. Family history3. Previous colon CA or polyps4. History of IBD5. High fat, High protein, LOW fiber6. Breast Ca and Genital Ca

COLON CANCERSigmoid colon is the most common sitePredominantly adenocarcinomaIf early 90% survival34 % diagnosed early66% late diagnosis

COLON CANCERPATHOPHYSIOLOGYBenign neoplasm DNA alteration

malignant transformation malignant neoplasm cancer growth and invasion metastasis (liver)

COLON CANCERASSESSMENT FINDINGS

1. Change in bowel habits- Most common

2. Blood in the stool3. Anemia4. Anorexia and weight loss5. Fatigue6. Rectal lesions- tenesmus, alternating D

and C

Colon cancerDiagnostic findings1. Fecal occult blood2. Sigmoidoscopy and colonoscopy3. BIOPSY4. CEA- carcino-embryonic antigen

Colon cancerComplications of colorectal CA1. Obstruction2. Hemorrhage3. Peritonitis4. Sepsis

Colon cancerMEDICAL MANAGEMENT1. Chemotherapy- 5-FU2. Radiation therapy

Colon cancerSURGICAL MANAGEMENTSurgery is the primary treatmentBased on location and tumor sizeResection, anastomosis, and colostomy

(temporary or permanent)

Colon cancerNURSING INTERVENTIONPre-Operative care1. Provide HIGH protein, HIGH calorie and

LOW residue diet2.Provide information about post-op care and

stoma care3. Administer antibiotics 1 day prior

Colon cancerNURSING INTERVENTIONPre-Operative care4. Enema or colonic irrigation the evening

and the morning of surgery5. NGT is inserted to prevent distention6. Monitor UO, F and E, Abdomen PE

Colon cancerNURSING INTERVENTIONPost-Operative care1. Monitor for complicationsLeakage from the site, prolapse of stoma,

skin irritation and pulmo complication2. Assess the abdomen for return of

peristalsis

Colon cancerNURSING INTERVENTIONPost-Operative care3. Assess wound dressing for bleeding4. Assist patient in ambulation after

24H5.provide nutritional teachingLimit foods that cause gas-formation

and odorCabbage, beans, eggs, fish, peanutsLow-fiber diet in the early stage of

recovery

Colon cancer

NURSING INTERVENTIONPost-Operative care6. Instruct to splint the incision and

administer pain meds before exercise7. The stoma is PINKISH to cherry

red, Slightly edematous with minimal pinkish drainage

8. Manage post-operative complication

Colon cancerNURSING INTERVENTION: COLOSTOMY

CAREColostomy begins to function 3-6 days after

surgeryThe drainage maybe soft/mushy or semi-solid

depending on the site

Colon cancerNURSING INTERVENTION: COLOSTOMY

CAREBEST time to do skin care is after showerApply tape to the sides of the pouch before

showerAssume a sitting or standing position in

changing the pouch

Colon cancerNURSING INTERVENTION: COLOSTOMY

CAREInstruct to GENTLY push the skin down and

the pouch pulling UPWash the peri-stomal area with soap and

waterCover the stoma while washing the peri-

stomal area

Colon cancerNURSING INTERVENTION: COLOSTOMY

CARELightly pat dry the area and NEVER rubLightly dust the peri-stomal area with

nystatin powder

Colon cancerNURSING INTERVENTION: COLOSTOMY

CAREMeasure the stomal openingThe pouch opening is about 0.3 cm larger

than the stomal openingApply adhesive surface over the stoma and

press for 30 seconds

Colon cancerNURSING INTERVENTION: COLOSTOMY

CAREEmpty the pouch or change the pouch

when1/3 to ¼ full

Breast CancerThe most common cancer in FEMALESNumerous etiologies implicated

Breast CancerRISK FACTORS1. Genetics- BRCA1 And BRCA 22. Increasing age ( > 50yo)3. Family History of breast cancer4. Early menarche and late menopause5. Nulliparity6. Late age at pregnancy

Breast CancerRISK FACTORS7. Obesity8. Hormonal replacement9. Alcohol10. Exposure to radiation

Breast CancerPROTECTIVE FACTORS1. Exercise2. Breast feeding3. Pregnancy before 30 yo

Breast CancerASSESSMENT FINDINGS1. MASS- the most common location is the

upper outer quadrant2. Mass is NON-tender. Fixed, hard with

irregular borders3. Skin dimpling4. Nipple retraction5. Peau d’ orange

Breast CancerLABORATORY FINDINGS1. Biopsy procedures2. Mammography

Breast CancerBreast cancer StagingTNM stagingI - < 2cmII - 2 to 5 cm, (+) LNIII - > 5 cm, (+) LNIV- metastasis

Breast CancerMEDICAL MANAGEMENT1. Chemotherapy2. Tamoxifen therapy3. Radiation therapy

Breast CancerSURGICAL MANAGEMENT

1. Radical mastectomy2. Modified radical mastectomy3. Lumpectomy4. Quadrantectomy

Breast CancerNURSING INTERVENTION : PRE-OP1. Explain breast cancer and

treatment options2. Reduce fear and anxiety and

improve coping abilities3. Promote decision making abilities4. Provide routine pre-op care:Consent, NPO, Meds, Teaching about

breathing exercise

Breast CancerNURSING INTERVENTION : Post-OP1. Position patient: SupineAffected extremity elevated to reduce

edema

Breast CancerNURSING INTERVENTION : Post-OP2. Relieve pain and discomfortModerate elevation of extremityIM/IV injection of pain medsWarm shower on 2nd day post-op

Breast CancerNURSING INTERVENTION : Post-OP3. Maintain skin integrityImmediate post-op: snug dressing with

drainageMaintain patency of drain (JP)Monitor for hematoma w/in 12H and apply

bandage and ice, refer to surgeon

Breast CancerNURSING INTERVENTION : Post-OP3. Maintain skin integrityDrainage is removed when the discharge

is less than 30 ml in 24 HLotions, Creams are applied ONLY when

the incision is healed in 4-6 weeks

Breast CancerNURSING INTERVENTION : Post-OPPromote activitySupport operative site when movingHand, shoulder exercise done on

2nddayPost-op mastectomy exercise 20 mins

TIDNO BP or IV procedure on operative

site

Breast Cancer

NURSING INTERVENTION : Post-OPPromote activityHeavy lifting is avoidedElevate the arm at the level of the

heartOn a pillow for 45 minutes TID to

relieve transient edema

Breast Cancer

NURSING INTERVENTION : Post-OPMANAGE COMPLICATIONSLymphedema10-20% of patientsElevate arms, elbow above shoulder

and hand above elbowHand exercise while elevatedRefer to surgeon and physical

therapist

Breast Cancer

NURSING INTERVENTION : Post-OPMANAGE COMPLICATIONSHematomaNotify the surgeonApply bandage wrap (Ace wrap) and

ICE pack

Breast CancerNURSING INTERVENTION : Post-OPMANAGE COMPLICATIONSInfectionMonitor temperature, redness, swelling

and foul-odorIV antibioticsNo procedure on affected extremity

Breast CancerNURSING INTERVENTION : Post-OPTEACH FOLLOW-UP careRegular check-upMonthly BSE on the other breastAnnual mammography

Discussion of

Palliative CareOncologic EmergenciesLung CancerMale & Female reproductive CancersBrain Tumors

Critical ThinkingScenario: A 49 y/o male has a 32 year

history of cigarette smoking. He often eats out with associates and typically eats red meat and potatoes. One of his associates is a 51 y/o female whose mother dies of breast cancer. She is 40lbs over her ideal weight because she likes to snack during the day. She is also a heavy coffee drinker because she is from Seattle.

Case Study 1R.T. is a 64-year-old man who comes to his primary care provider’s (PCP’s) offi ce for a

yearly examination. He initially reports having no new health problems; however, on further questioning, he admits to having developed some fatigue, abdominal bloating, and intermittent constipation. His nurse practitioner completes the examination, which includes a normal rectal exam with a stool positive for guaiac. Diagnostic studies include a CBC with differential, chem 14, and carcinoembryonic antigen (CEA). R.T. has not had a recent colonoscopy and is referred to a gastroenterologist for this procedure.

A 5-cm mass found in the sigmoid colon confirms a diagnosis of a polypof the colon. A referral

is made for surgery. The pathology report describes the tumor as stae 11, which meansthat the cancer has extended into the mucous layer of the colon. A metastatic work-up is

negative.

1. Identify 6 risk factors for colon cancer:2. Discuss the recommended screening procedures related to colon cancer.3. What warning sign did R.T. have?4. What would early signs be for colorectal cancer?5. What would late signs be?

Case Study 1R.T. is a 64-year-old man who comes to his primary care provider’s (PCP’s) offi ce for a

yearly examination. He initially reports having no new health problems; however, on further questioning, he admits to having developed some fatigue, abdominal bloating, and intermittent constipation. His nurse practitioner completes the examination, which includes a normal rectal exam with a stool positive for guaiac. Diagnostic studies include a CBC with differential, chem 14, and carcinoembryonic antigen (CEA). R.T. has not had a recent colonoscopy and is referred to a gastroenterologist for this procedure.

A 5-cm mass found in the sigmoid colon confirms a diagnosis of a polypof the colon. A referral

is made for surgery. The pathology report describes the tumor as stae 11, which meansthat the cancer has extended into the mucous layer of the colon. A metastatic work-up is

negative.

6. After bowel prep, R.T. is admitted to the hospital for an exploratory laparotomy, small bowel resection and sigmoid colectomy. - What are five major complications for him?

7. After surgery, R.T. is admitted to the surgical intensive care unit (SICU) with a largeabdominal dressing. The nurse rolls R.T. side to side to remove the soiled surgical linen,and the dressing becomes saturated with a large amount of serosanguineous drainage.Would the drainage be expected after abdominal surgery? Explain.

Case Study 2You are a home health nurse who has been seeing P.C., who was diagnosed with lung

cancer approximately 1 year ago. Her provider recently informed her that her cancer is no longer treatable; the focus of her treatment will change from curative measures to symptom relief. She is confused and somewhat angry with her provider. She vaguely remembers the term palliative treatment when discussing her situation with her provider but doesn’t know what it means.

1. How would you describe palliative treatment?

Case Study 2You are a home health nurse who has been seeing P.C., who was diagnosed with lung cancer

approximately 1 year ago. Her provider recently informed her that her cancer is no longer treatable; the focus of her treatment will change from curative measures to symptom relief. She is confused and somewhat angry with her provider. She vaguely remembers the term palliative treatment when discussing her situation with her provider but doesn’t know what it means.

Case progress Note:P.C. confides that she always felt that she might not survive her illness, but has never formally

writtendown her wishes concerning what types of treatment she would or would not want. You advise

herto complete an advance directive and/or living will or to complete a medical durable power of

attorneyand/or a surrogate decision maker form. In current practice, it is very likely that a part of the

homehealth intake process will be completion of a Physicians Order on Life Sustaining Treatments

(POLST)Paradigm form.

2. What is the purpose of these documents?

Case Study 23. What health care decisions are considered in these documents?

4. How are advance directives and living wills formalized?

5. P.C. states she is confused and has mixed feelings about her health care wishes right now.

She asks, “If I fill out this form, can I change my mind down the road?” How should you

answer this question?

6. You inform P.C. that you will help with symptomatic control of her illness. What areas

will you focus on, and what question would you ask P.C.?

7. As P.C. becomes more frail and incoherent, what treatment will be given?

Discussion

Culturally appropriate treatmentShare your experiences