Chapter 15 - Lecture notes 1 PDF

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Nursing management of the patient with oncologic disorders includes care of patients throughout the cancer trajectory from prevention through end-of-life care. Precision medicine – development of biologic databases (human genome sequencing). Advance research focus on developing a plan of care to prevent and cure cancer. Epidemiology: Most cancer occurs in older adults, people 55 of age or older. Incidence is higher in men than in women and death rates vary by geography (higher risk in an area high use of tobacco). Pathophysiology of the Malignant Process: Cancer – genetic mutation of the cellular DNA. (inherited or acquired)  abnormal cell behavior. Altered cell begins to proliferate abnormally, casing activation of immune system. Due to genetic mutation, signaling either turns off or on for the cell, allowing some to abnormal proliferate. Metastasis (spread of cancer) through lymph nodes or blood vessel (angiogenesis). Characteristics of Malignant Cells: Carcinogenesis: Carcinogens – agents that promote malignant transformation. 1. Initiation – mutation in the cellular DNA. Normally DNA repair or apoptosis (cell death) but some can escape it. 2. Promotion – repeat exposure to carcinogen causing proliferation abnormally.  Benign lesion. 3. Progression – Malignant behavior, ability to stimulate angiogenesis and metastasize. Protooncogenes (normal gene) turn on cells and cancer suppresser genes turns off cells. When mutated cells proliferate abnormally. Genetics in Nursing Practice: Inherited mutations (germ-line cells) Assessment – obtain family history (at least 3 generation), physical findings, lifestyle risks (smoking, obesity, alcohol abuse), occupation (asbestos, radon), manage patients fear and allow them to verbalize their concerns and clarify any of their questions. Proliferative Patterns: Hyperplasia – enlargement of organ/tissue cause by increase production of cells Dysplasia – Presence of abnormal type of cell within a tissue Metaplasia – Abnormal chance in the nature of a tissue Malignant neoplasm – Cancerous tumor that can metastasize.

Etiology: Factors that induce carcinogenesis 1. Viruses and Bacteria a. Infecting invades (normal + virus DNA)  cell division. b. HPV, HBV, EBV c. Bacteria – Helicobacter pylori  Gastric cancer 2. Physical agents a. Sunlight & Radiation (higher incidence of leukemia, multiple myeloma, lung, bone, breast) b. Chronic irritation or inflammation c. Tobacco d. Chemical & asbestos 3. Chemicals a. Toxic effects by altering DNA structure b. Tobacco smoking (lung, head, neck, stomach, cervix, kidney, bladder, AML, pancreas) – combustible forms (cigars, water pipes, hookah) c. Chewing tobacco (young adults) – oral, pancreatic, esophageal 4. Genetic/Family a. Due to genetic, shared environment, cultural or lifestyle factors. b. Found in germline and somatic 5. Lifestyle factors a. Long-term ingestion of carcinogens – poor diet (fats, alcohol, salt-cured, smoked meats, nitrate, red and processed meats) b. Obesity (breast cancer, endometrium, ovary, cervix, multiple myeloma, Hodgkin, prostate) c. Sedentary 6. Hormones a. Endogenous hormone (breast, prostate, uterus) b. Exogenous hormones Role of the Immune System: Destroys before cell growth becomes uncontrolled. Patients who are immunocompromised have an increase incidence of cancer. (transplant, AIDS, previously treated for one cancer)

Normal Immune Response: Have the ability to recognize and combat cancer cells. Tumor-associated antigens (TAA) found on the membrane of many cancer cells. T lymphocytes response by releasing cytokines. 1. Proliferation of cytokines to direct destruct cancer cells 2. Apoptosis 3. Additional immune system (b-cell, natural killer cells) Immune System Evasion: 1. Block death of tumor and induce cell death in the lymphocyte 2. Cancer cells release cytokines that inhibit APC, they’re not label as foreign 3. Cancer cell can be altered to avoid immune cell recognition – immunogenicity 4. TAA combine with antibodies to hide 5. Impair helper T due to cancer cell release cytokines Detection and Prevention of Cancer: A. Primary a. Reducing the risks through health promotion & risk reduction strategies b. Immunization (HPV, HBV) B. Secondary a. Screening and early detection (early stage who lack S+S) b. Detection of early stage makes treatment easier C. Tertiary a. Monitoring for and preventing recurrence b. Screening for the development of second malignancies in cancer survivors (lymphoma & leukemia high rate due to chemotherapy & radiation), inherited, environmental exposure, lifestyle factors

Seven Warning Signs of Cancer: C – Change bowel or bladder habits A – A sore that doesn’t heal U – Unusual bleeding or discharge T- Thickening or lump in the breast or elsewhere I – Indigestion of difficulty swallowing O – Obvious change in a wart or mole (ABCD) N – Nagging cough or hoarseness Diagnosis of Cancer: 1. Presence and extent of cancer 2. Identify possible disease metastasis 3. Evaluate the function of involves and uninvolved body systems and organs 4. Obtain tissue and cells for analysis (stage & grade) Nurses help address the patients fear and anxiety by explaining the test, sensation and patient’s role during the testing procedure. Encourages the patient and family to voice their fears, and reinforces and clarifies information. Tumor Staging and Grading: Need to be done prior to treatment to provide baseline data to evaluate outcome. Treatment options and prognosis are based on tumor stage and grade. Staging – size, local invasion, lymph node involvement, and distant metastasis Grading – patho classification of tumor cell originate.

Grade I (well-differentiated tumors) Grade IV (undifferentiated) – more aggressive and less responsive to treatment and poorer prognosis. Anatomic Stage Group: Once staged and graded, it’s assigned for treatment decision. Management off Cancer: Treatment options are based on treatment goals. o Complete eradiation of malignant disease (CURE) o Containment of cancer growth (CONTROL) o Relief of symptoms & improve quality of life (PALLIATION) Patient and family must have a clear understanding of the treatment options and goals. Treatment Approaches 1. Surgery 2. Radiation therapy 3. Chemotherapy 4. Hematopoietic stem cell transplantation (HSCT) 5. Hyperthermia 6. Targeted therapy Surgery: Ideal is to remove the entire cancer. o Diagnostic surgery o Primary method of treatment o Prophylactic o Palliative o Reconstructive Diagnostic Surgery: Biopsy performed to obtain a tissue sample for analysis. Most of the time the biopsy is taken from the actual tumor. May take lymph nodes due to metastasize, knowing metastasize will have a better treatment approach. Sentinel lymph node biopsy (SLNB) – minimal invasive surgical, regional lymph node staging Biopsy Types: Biopsy type is determined by size and location. Patient have options before definitive plans are made.  Excisional o Small, easily accessible tumors of the skin, GI, and upper respiratory tract o Can remove the entire tumor and surrounding marginal tissues o Removal of surround tissue decrease the possibility that residual microscopic malignant cells and can lead to recurrence of the tumor. o Decrease the change of seeding tumor cells  Incisional o Tumor mass is too large to be removed o Wedge of tissue from the tumor is removed for analysis  Needle o Sample suspicious masses that are easily and safely accessible o Fast, inexpensive, east, local anesthesia o Patient may experience slight temporary physical discomfort

o Fine-needle aspiration (FNA) aspirating cell rather than intact tissue o A core needle biopsy procedure to obtain a small core tissue for accurate diagnoses Surgery as Primary Treatment: Goal is to remove the entire tumor (any involved surrounding tissue & regional lymph nodes).  Local o Outpatient basis, and when the mass is small o Removal of the mass and a small margin of normal tissue  Wide (radical excision) (en bloc dissections) o Removal of the primary tumor and involve lymph nodes & tissue o Might be disfiguring and altered function might need reconstruction or rehab o Tumor can be removed completely and chance of cure or control are good  Salvage o Additional treatment option to treat the local recurrence of cancer after the use of a less extensive primary approach. Prophylactic Surgery: Risk reduction surgery removing non-vital tissues or organs that are at increased risk of developing cancer. Colectomy, mastectomy, and oophorectomy. Strong family history, abnormal physical finding, history of another cancer that can lead to this one, abnormal biopsy. Palliative Surgery: Cure is not possible, surgical interventions to relieve symptoms, and make the patient as comfortable as possible, and promote quality of life. Reconstructive Surgery: May follow curative or extensive surgery to improve function of cosmetic effect. Nurse assess the patients’ needs and the impact that altered functioning and body image. Nursing Management: General periop nursing care. Surgery might be combine with other treatment methods (radiation & chemotherapy). Postop complications such as infection, impaired wound healing, altered pulmonary or renal function, VTE. 1. Preop – gets consent, and give patient and family verbal and written information. 2. Postop – assess patient response to surgery and monitor patient for possible complications (infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance) Education addresses wound care, pain management, activity, nutrient, and medication.

Radiation Therapy: Radiation may be used to  Cure localized cancer  Control cancer when tumor can’t be removed  Prophylactically to prevent local recurrence  Palliative to relieve symptoms Ionizing radiation directly breaks the DNA helix causing cell death. Radiation therapy is localized treatment, and only the tissues that are within the treatment field are affected. Tissue that undergo frequent cell division are most sensitive to radiation. Sensitivity is enhanced in tumors that are smaller in size, and that contain cells that are rapidly dividing (highly proliferative) and poorly differentiated (diff from origin). Radiation Dosage: Radiation dosage depends on the sensitivity of the target tissues to radiation, the size of the tumor, tolerance of the surround normal tissue, and critical structure adjacent to the tumor. In external-beam radiation therapy (EBRT) the total radiation dose it delivered over several weeks called fractions. This allow healthy tissue to repair and achieve greater cell kill. Administration of Radiation: Depends on the location and type of cancer  EBRT (Most common) o Shape an invisible beam of highly charged to penetrate the body and target the tumor o CT, MRI, PET – volumetric images (surrounding normal tissue and organs) to decrease radiation-induce toxicity to allow conformal radiation (precisely around the tumor) o Intensity-modulated radiation therapy (IMRT) – higher doses to be delivered while sparing the healthy structure surrounding the tumor. o Image-guided radiation therapy (IGRT) – x-ray or CT during treatment to allow for automatic adjustment to spare healthy tissue and reduce side effects o Stereotactic body radiotherapy (SBRT) – higher doses to penetrate very deeply into the body to control deep-seated tumors o Proton therapy – advantage is capable to delivery high linear energy dose to deepseated tumor, with decreased doses of radiation to the tissue in front of the tumor.  Internal radiation o Systemic radiotherapy – strategies for getting the radionuclides closer to the tumor. o Localized implantation (Brachytherapy)  Placement of radioactive sources within it immediately next to the cancer site to provide a highly targeted, intense dose of radiation beyond a dose that is provided by EBRT. This form of delivery helps to spare exposure to normal surrounding tissue. Implanted by needles, rods, seeds, beads, ribbons, or catheters placed into body cavities, lumens within organs, or interstitial tissue compartments.  Patients may have fears, the nurse will explain the approach and safety precautions to protect the patients, family and health care staff.  It may be delivered as a temporary or permanent implant.  High-dose radiation (HDR) shorter time, low-dose radiation (LDR) longer time

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 HDR advantage – shorter time, reduce exposure, outpatient basis several days  LDR requires hospitalization Systemic radioisotopes – IV admin of a therapeutic radioisotope targeted to a specific tumor Surface molds Toxicity: Most often localized in the region being irradiated and may increase if combine with chemo. Occurs when normal cells within the treatment area are damaged and cellular death exceeds regeneration. Body tissue most affected are those that normally proliferated rapidly (skin, epithelial lining of the GI tract, and bone marrow)  Skin integrity o Alopecia o Radiation dermatitis – dry desquamation (flaking of skin) to wet (dermis exposed, skin oozing serous fluid)  potential ulceration o Factors that contribute – skin folds, age, comorbidities o Re-epithelialization occurs after treatments have been completed. o Hyperpigmentation – 2 to 4 weeks after  Stomatitis (inflammation of the oral tissues) o Decrease salivation and xerostomia (dry mouth) o Change or loss of taste  Mucositis (inflammation of the lining of the mouth, throat, and GI tract) o Symptoms subside and GI Re-epithelialization after treatment is completed.  Effect on bone marrow o Anemia o Leukopenia (decrease WBC) – increase risk for infection o Thrombocytopenia (decrease in platelets) – increase risk for bleeding  Systemic side effects o Fatigue o Malaise o Anorexia o Subside within 6 months of completion  Long-term effects & tissue changes o Permanent tissue damage, loss of elasticity, decrease vascular supply o Severe – fibrosis, atrophy, ulceration, necrosis o Dysphagia, incontinence, cognitive impairment and sexual dysfunction

Nursing Management: Work collaboratively to manage symptoms associated with radiation in order to promote healing, patients comfort, and quality of life. Diminished body mass index (BMI) and elevated radiation doses have been associated with greater toxicity and symptoms. The nurse assesses the patients skin regularly. Assess nutritional status and general feelings of well-being. If systemic symptoms (weakness and fatigue) occur, nurse explain these symptoms are a result of treatment and is no progression of the disease. Protecting Caregiver: Safety precautions in caring for a patient receiving brachytherapy (internal)  Assigning the patient to a private room  Post appropriate notices about radiation safety precautions  Staff wear dosimeter badges

 Pregnant staff members are no assigned to the patients care  Prohibiting children or pregnant visitor  Limiting visit from others to 30 minutes daily and seeing that visit maintain a 6ft distance Patients with seed implants typically are able to return home, exposure to others is minimal. Nurse should explain the rational of these precautions to keep the patients from feeling isolated. Chemotherapy: Use of antineoplastic drugs to destroy cancer cells by interfering with cellular functions. Use to treat systemic than local. Chemo may be combined with surgery or radiation therapy, to reduce tumor size preop (neoadjuvant), to destroy remaining tumor cells (adjuvant), treat leukemia or lymphoma. Goal is to cure, control, palliation. Cell Kill: Each time a tumor is exposed to chemo, a percentage of the tumor cells are destroyed. Repeated dose to achieve regression of the tumor. Eradication of 100% is almost impossible, the goal is to eradicate enough so the remaining malignant cell can e destroyed by the body’s immune system. Actively proliferating cells within a tumor are the most sensitive to chemo. Classification of Chemotherapeutic Agents: These agents destroy cells that are actively reproducing by means of the cell cycle; most affect cells in the S phase by interfering with DNA and RNA synthesis. The use of combination therapy also helps prevent the development of drug-resistant cells. Adjunct Chemotherapeutic Agents: Additional medications are given with chemo agents to enhance activity or protect normal cells. Administration of Chemotherapeutic Agents: May be given in hospital, outpatients, home setting by multiple routes. The route depends on type of agent, dose, location, and extent of malignant disease being treated. Patient education is essential to promote safety at home. Dosage: Dosage based on patient TBSA, weight, previous exposure and response to chemo or radiation. Dosages are determined to maximize cell kill while minimizing impact on healthy tissues and subsequent toxicities. For certain chemo agents, there is a maximum lifetime dose limit that must be adhered to because of the danger of lone-term irreversible organ complications. Extravasation: IV chemo agent have potential damage to tissue if they inadvertently leak from a vein into surrounding tissue (extravasation). Consequence ranges from mild discomfort to severe tissue destruction.  Nonvesicant  Irritant o pH (5 or 9) – Inflammatory reactions but usually cause no permanent tissue damage  Vesicant o Inflammation, tissue damage, possibility necrosis of tendons, muscles, nerves, and blood vessels – agents bind to cell DNA and cause cell death o Localized painful reaction that usually improves over time. o Sloughing and ulceration of the tissue may progress to tissue necrosis, a skin graft may be needed, and may take several weeks to become apparent.

o Never be given in peripheral vein involving the hand or wrist. o Peripheral administration is permitted for short-duration infusions only (forearm) o Prolonged administration, right atrial silastic catheters, implanted venous access, PICC is inserted to promote safety during medication admin. Hypersensitivity Reactions: Chemo agents pose a high risk for HSRs. Unexpected adverse reaction associated with mild or progressively worsening S+S. Repeated exposure increases the like hood of a reaction. When S+S of HSR occur, the medication should be discontinued immediately. Some chemo agents that are essential in treatment, desensitization procedures may be possible and the patients is retreated with the agent at reduced dosage or slower infusion rates. Toxicity: Acute or chronic and very susceptible damage to the cells that rapidly grow.  GI system (common side effect Nausea & Vomiting [CINV]) o Chemo inducing CINV may affect quality of life, psychological status, nutrition, fluid and electrolyte status, functional ability, compliance with treatment. o CINV, occurring prior to chemo, may by the triggered of the smell of the infusion setting, the sight of the nurse or the outpatient waiting room. o Managing CINV – Corticosteroids, phenothiazines, sedatives, and histamines used in combination with serotonin blockers to provide antiemetic protection. Manage delayed CINV, antiemetic may be combined and are given for the first week at home after chemotherapy. o Nonpharmacologic approaches such as relaxation techniques, imagery, acupressure, or acupuncture can help decrease stimuli contributing to symptoms. o Small, frequent meals, bland foods, and comfort foods may reduce severity of S+S. o Stomatitis o Mucositis  Hematopoietic System o Myelosuppression (depression of bone marrow function)  decreased WBCs (leukopenia), granulocytes (neutropenia), RBCs (anemia), and platelets (thrombocytopenia) and increased risk of infection and bleeding. o Frequent monitoring of blood cell counts o Educate patient to protect against infection, injury, and blood loss, particularly while counts are low. o Granulocyte colony-stimulating factor [G-CSF] and granulocyte-macrophage colonystimulating factor [GM-CSF])—can be given after chemo to stimulate the bone marrow to produce WBCs, neutrophils in accelerated rate and decreasing the neutropenia. o G-CSF and GM-CSF decrease the episodes of infection and the need for antibiotics and allow for more timely treatment cycles of chemotherapy with less need to reduce the dosage. Erythropoietin (EPO) stimulates RBC production, thus decreasing the symptoms of treatment-induced chronic anemia and reducing the n...