Lecture 9 - Concepts and principles for nursing care of adults experiencing acute and chronic PDF

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Concepts and principles for nursing care of adults experiencing acute and chronic illnesses with stableor predictable outcomes, across health care settings and throughout the care continuum....

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Lecture 9: CANCER Overview of Cancer ● Incidence - The total number of people who receive a diagnosis of cancer ● Prevalence - The total number of people who are living with a diagnosis of cancer Cancer Terminology ● Adenocarcinoma – cancer that arises from glandular tissues. Eg. Cancers of the breast, lung, thyroid, colon and pancreas ● Anaplastic – tumor cells that are completely  undifferentiated and bear no resemblance to cells of tissues of  their origin ● Aneuploid – tumor cells that do  not have the normal 46 chromosomes in a human cell – often worse prognosis ● ● ●

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Carcinoma – a form of cancer that is composed of epithelial cells; develops in tissues covering or lining the organs of the body such as the skin, uterus or breast Carcinoma in situ – earliest stage of cancer – tumor still confined to local area Differentiation – process of maturation of a cell line of cancer cells - when fully differentiated or well differentiated – more closely resemble the normal cells in the tissue of origin ○ Well differentiated - normal looking cells ○ poorly/un - cannot tell the difference between normal cells and cancer cells Oncogenes – specific segments of cellular deoxyribonucleic acid (DNA) that, when inappropriately activated, contribute to the transformation of normal cells into malignant cells (malignant - cancerous & benign - not cancerous) Sarcoma – a cancer of supporting or connective tissue such as cartilage, bone, muscle or fat Tumor markers – Chemicals in the blood that are produced by certain cancers

Etiology of cancer ● Likely to be multifactorial ● Origin of cancer may be ○ Genetic ○ Chemical ○ Environmental ○ Viral or immunological ○ May arise from causes not yet identified Development of Cancer → Initiation ○ Carcinogens may be [chemicals that increase the patient's risk for cancer]: ■ Chemical ■ Radiation ■ Viral ● Carcinogens can be ○ Detoxified ○ Harmlessly excreted ● Cells damaged by carcinogens may ○ Self-repair ○ Die ○ Replicate into daughter cells with same genetic alteration ● Viral carcinogens ○ Human immunodeficiency virus (HIV) " Kaposi’s sarcoma [opportunistic infection] ○ Hepatitis B virus " Hepatocellular carcinoma ○ Human papillomavirus (HPV) " Squamous cell carcinomas Development of Cancer → Latent period ● May range from 1 to 40 years ● Thought to comprise both the initiation and the promotion stages ● Length of latent period associated with mitotic rate of tissue of origin and environmental factors ● For disease to be clinically  evident, tumour must reach a critical mass Development of Cancer → Progression ● Characterized by ○ Increased growth rate of tumour ○ Invasiveness

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○ Metastasis Most frequent sites of metastasis  are lungs, brain, bone, liver, and adrenal glands Metastasis process begins with rapid growth of primary tumour ○ Develops its own blood supply ■ Critical for survival and growth of tumour ■ ⅔ pt get fast growing cancer and ⅓ get slow growing → in 5-6 wks a slow growing cancer can grow 1.5 cm (that is significant) Tumour angiogenesis is formation  of blood vessels within tumour ○ A highly vascularized/if tumor grows many vessels, suspect cancer Certain segments of primary tumour can detach and invade surrounding tissues Metastasis process cont. ○ Detached cells can invade lymph nodes and vascular  vessels to travel to distant sites ○ Most mobile  tumour cells do not survive ○ Surviving tumour cells must create an environment conducive to growth and development

Cancer prevention ● Progress r/t modifiable risk factors ○ Tobacco use ○ Excessive body weight (obesity) → higher BMI increased risk for hormones and growth factor ○ Lack of physical activity ○ Unhealthy eating habits ○ Exposure to the sun ● How is that working out for us? ● 60% of Canadians do not eat recommended amounts of fruits and vegetables ● 54% women and 44% men are physically inactive ● 15% are obese ● 56% of men and 39% of women are at an unhealthy weight 7 warning signs of cancer ● 1.Change in bowel or bladder habits ● 2.A sore that does not heal ● 3.Unusual bleeding/discharge ?any body orifice ● 4.Thickening or a lump in breast/elsewhere ● 5.Indigestion or difficulty in swallowing (GERD) ● 6.Obvious change in a wart or mole ● 7.Nagging cough or hoarseness Diagnosis of Cancer ● Patient may experience fear and anxiety. ● Nurse should ○ Give clear explanations, repeat if necessary ○ Give written information for reinforcement ○ Actively listen to patient’s concerns ●

Diagnostic plan includes ○ Health history ○ Identification of risk factors ○ Physical examination ○ Specific diagnostic studies

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Indicated diagnostic studies depend on site of cancer. ○ Biopsy involves histological examination by a pathologist of a piece of tissue. ■ Tissue may be obtained by ● Needle or aspiration - if there is a breast mass (aspirate cells then they get tested) ● Incisional procedure (portion) ● Excisional procedure (wide local) - debulking [taking out as much as you can]

General Principles of Cancer Treatment ● https://www.youtube.com/watch?v=64tUb6B0jSU&list=PLXHkcVcOZEWyy5__JEpKI2HoSlN6To1Sm&index=2

GRADING and STAGING Classification of Cancer ● Tumours can be classified by ○ Anatomical site ■ Identified by the tissue of origin ■ Ex carcinoma or sarcoma, lymphoma/leukemia all originate in diff parts of body ○ Histological analysis ■ Grading severity ■ Differentiated vs undifferentiated ○ Extent of disease ■ Staging Classification systems provide a standardized way to: ● Communicate with health care team ● Assist in determining the most effective treatment plan ● Evaluate treatment plan ● Determine prognosis  ● Compare groups statistically ***Classification of Cancer*** ● Grade I ○ Cells differ slightly from normal cells and are well differentiated ● Grade II ○ Cells are more abnormal and moderately affected ● Grade III ○ Cells are very abnormal and poorly differentiated ● Grade IV ○ Cells are immature and primitive and undifferentiated ○ Cells of origin is difficult to determine Clinical staging classifications ● 0: Cancer in situ (local cells) ● 1:Tumor limited to tissue of origin; localized tumor growth ● 2:limited local spread ● 3:extensive local and regional spread ● 4:metastasis ● Carcinoma in situ is a commonly used term in classification of cancer. It is defined as a lesion with all  the histological features of cancer except invasion. If left untreated, carcinoma in situ eventually becomes invasive. TNM classification system ● Anatomic extent of disease is based on three parameters (Not applied to leukemia) ○ Tumour size and invasiveness (T) ○ Spread to lymph nodes (N) ○ Metastasis (M) ■ **Table 18-6 TNM Classification System** KNOW HOW TO APPLY IT ● Primary Tumour Size (T) ○ T0 = No evidence of primary tumour ○ Tis = carcinoma in situ ○ T1-T4 - Ascending degrees of increase in tumor size and involvement ● Involvement of Regional Lymph Nodes (N) ○ N0 - no evidence of disease in lymph nodes ○ N1-N3 - ascending degree of nodal involvement ○ Nx - regional lymph nodes unable to be assessed clinically ● Distant Metastases (M) ○ M0 - No distant metastases ○ M1 - Distant metastases

Colorectal Cancer (CRC) Etiology and pathophysiology ● Cause is unclear ● Adenocarcinoma (glandular tissue) is the most common type of colorectal cancer ● Common sites of metastasis are: ○ Regional lymph nodes ○ Liver ○ Lungs ○ Peritoneum ● Other complications: bleeding, perforation, peritonitis, fistula formation ○ Chest or thorax & MRIs Risk factors for colon cancer ● Family Hx colorectal cancer ● Hx IBD (ulcerative colitis or Crohn’s disease) ● Aged 50 or older ● Smoke ● Consume excessive alcohol ● Physically inactive ● Obesity ● Hx ovarian, endometrial, breast cancer (women) ● High fat, low fibre diet (controversial) Clinical Manifestations ● Usually non-specific or absent until the disease is advanced ● Left side lesions: ○ Rectal bleeding ○ Alternating constipation and diarrhea ○ Change in stool ○ Sensation of incomplete evacuation ○ Obstruction symptoms appear earlier in the left-side b of the smaller lumen size ● Right side lesions: ○ Usu asymptomatic ○ Vague abdominal discomfort or crampy ○ Colickly abdominal pain Diagnostic studies ● Family history and physical examination ● Digital rectal examination - many rectal cancers are within reach of the finger ● Fecal Immunochemical Test (FIT) → aka Fecal occult blood test (FOBT) ■ No red meat, ASA, NSAIDs before testing to avoid false positives ○ Non-symptomatic, 50  years old or older, no risk factors (except age) recommended screening is every two years (Cancer Care Ontario) ● Flexible sigmoidoscopy ○ No drug or dietary restrictions prior to test ● Colonoscopy: procedure of choice → q 5 years ○ long flexible tube with a camera ○ exams the lining of rectum & colon ○ recommended for ↑ risk, eg close relatives (parent, sibling or child) who has the disease Collaborative care ● Prognosis and treatment correlate with pathological staging of the disease ● TMN (Tumour, Nodes, Metastasis) staging ● Surgical therapy (curative) ● Chemotherapy (when + lymph nodes or metastatic disease) ○ Adjuvant therapy following colon resection ○ Primary treatment for non-resectable colorectal cancer ● Radiation therapy ○ Preoperatively as adjuvant to colon resection and chemotherapy

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Palliative for advanced lesions

Nursing Management ● Assessment ● Diagnoses ○ Diarrhea or constipation related to altered bowel elimination patterns ○ Acute pain related to difficulty in passing stools because of partial or complete obstruction from tumour ○ Fear related to diagnosis of colorectal cancer, interventions and possible terminal illness ○ Ineffective coping related to diagnosis of cancer and adverse effect of treatment ■ Mucous membrane involvement - dry and dehydrates ■ Kills all cells [undifferentiated and differentiated] ■ CBC - low blood count, pancytopenia (low Hgb, low neutrophil, low wbc, leukopenia [less than 0.5]) ● Planning – overall goals: ○ Appropriate treatment (therapy) ○ Normal bowel elimination patterns ○ Quality of life ○ Relief of pain ○ Feelings of comfort and well-being ● Implementation and evaluation Prostate Cancer Overview ● Prostate cancer is an androgen-dependent adenocarcinoma [feeds off of androgens] ● A malignant  tumor usually begins in the outer part of the prostate [ outside then goes into] ○ Able to palpate prostate - rubbery and grooves ● In most men – prostate cancer grows very slowly ● Some men never know they have the condition ● 90% are adenocarcinomas ● Spread via 3 routes – direct extension, lymph system or bloodstream ● Becomes clinically relevant when local invasion or distant metastasis interrupts the function of the urinary and other organ systems ○ Get symptoms of Lower urinary tract obstruction Risk factors ● Nonmodifiable risk factors: ○ Age ○ Ethnicity (African ancestry [high risk] vs Asian [low risk]) ■ Testosterone - prostate gets larger ○ Family hx ● Modifiable risk factors: ○ Long-term exposure to testosterone ○ Diet high in fats ○ Occupational exposure → people working with batteries (cadium_ increases risk of prostate cancer Clinical manifestations ● Asymptomatic in the early stages → often dx on check ups ● May have symptoms: ○ dysuria, hesitancy, dribbling, frequency, urgency, hematuria, nocturia, retention, interruption of urinary stream, inability to urinate ● Potential metastatic disease: Pain in the lumbosacral area radiating to hips or legs with urinary symptoms ● Common sites of metastasis are: pelvic lymph nodes, bones, bladder, lungs, liver Early Detection and Screening for Prostate Cancer ● PSA (Prostate Specific Antigen) – a g lycoprotein produced by the prostate ○ Blood test to  help detect prostate cancer ○ Normal to find small quantities but problems of prostate cause a rise ○ PSA levels vary according to age – tend  to rise gradually in men over 60 ○ Elevated levels caused by several prostate problems – not necessarily cancer ○ Some men with prostate cancer may have normal PSA levels

PSA LEVEL IN NG/ML

USUAL DESCRIPTION FOR AVERAGE MAN

0 to 4 ng/ml

Within normal range

4 to 10 ng/ml

Slightly elevated

10 to 20 ng/ml

Moderately elevated

Greater than 20 ng/ml

Highly elevated

Age range in years

Expected PSA levels NG/ML

40 to 49 years

0 to 2.5 PSA

50 to 59 years

2.6 to 3.5 PSA

60 to 69 years

3.6 to 4.5 PSA

70 to 70 years

4.6 to 6.5 PSA

Screening – the controversy ● Pros ○ Incidence and mortality rates comparable to breast cancer ○ Effective method of detection (PSA + biopsy) ○ Effective treatments ○ Similar to screening for other cancers, that are being widely adopted ● Cons ○ Values-sensitive decision (values can change) ○ PSA testing may reveal clinically insignificant tumors that are treated with significant side effects, resulting in diminished QOL ■ Recommended not to test PSA bc High false positive ■ If high risk factor than can use PSA Diagnosis of Prostate Cancer ● Biopsy ● Imaging studies ○ XRays, Ultrasound, CT scans, MRIs, bone scans ● Transrectal ultrasound Transrectal Ultrasound ● Allows for closer look at the prostate ● Ultrasound probe inserted into rectum and positioned next to prostate – uses sound waves to create a picture of the prostate ● BPH is non-cancerous and usually starts in different zones of prostate – usually used to identify  which areas of the prostate should be biopsied in order to confirm or r/o presence of prostate cancer Prostatic Biopsy ● A digital rectal exam (DRE) – an elevated PSA level or both cause suspicion of prostate cancer – the next step is usually a biopsy of the prostate ● Done via ultrasound probe and biopsy gun inserted into rectum ● Generates a sudden noise but no sensation of a needle stick ○ Pts take Pico-saylex or cleanse with 4L of salt water before exam Prostatic Biopsy Preparation ● All anticoagulant medications including OTC drugs such as aspirin or dietary supplements such as high dose vitamin E should be discontinued 7 days before and 1 day following ● Bowel cleansing – enema or suppository on selected clients ● Antimicrobial therapy on day of procedure ● Pathologic analysis used to determine presence of malignancy and its stage

Other Diagnostic Tests

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If prostate cancer is found – additional tests such as bone scan, chest xray, CT, MRI of abdomen and pelvis to identify presence of nodal or distant organ metastasis, TRUS (Trans rectal ultrasound)

Prostate Cancer – Staging System ● TNM system (Tumor, node, metastases) ● T1 and T2 – tumors remain contained within prostatic capsule and diagnosed as localized prostate cancer ● T3 and T4 – have spread beyond prostatic capsule and are classified as advanced stage prostate cancers – associated with metastatic spread to lymph nodes (N1) and spread to distant organs (M1) Prostate Cancer – Gleason grading system ● Named after pathologist Donald Gleason Graded on scale of 1 to 5 ● Grade 1 cancers – closest to normal cells ○ Well differentiated - defined edges and packed tightly ○ Tiny gland round ○ Tumor not expected to grow quickly ● Grade 2 cancers – cells less normal looking and less well differentiated – glands still round but loosely packed – less distinct edges ● Grade 3 Cancer ○ Cells are moderately differentiated ○ Glands not really discernible ○ Tissue appears composed of solid cellular sheets ● Grade 4 cancers ○ Cells are poorly diff ○ Glands are of diff size and shapes ○ Fused together in masses or chains ● Grade 5 Cancers ○ Cells are very strange looking and poorly diff ○ glands not really discernabl ○ tissue appears composed of solid cellular sheets. single cells or nests of tumor. ○ Above 7 - rapid growth Gleason Score ● Biopsy often has a number of different grades present Prostate Cancer – Gleason grading system ● Pathologist decides which two grades most evident in biopsy ● These grades are added to reach Gleason score – between 2 and 10 ● A score of 2 to 6 usually considered low – may be similar to normal prostate cells and grow slowly ● A score of 7 (3+4 or 4+3) is considered intermediate in strangeness and speed of growth ● A score of 8-10 – called high – usually cells are very different from prostate cells and grow quickly ● If lower score contains Gleason grade 4 or 5 cells – eg. Grade 6 (4+2) more dangerous than (3+3). Treatment Options for Prostate Cancer ● Watchful Waiting – decision for this approach: ○ Life expectancy less than ten years ○ Presence of significant comorbid disease ○ Presence of low-grade, low-stage tumour ● Surgery ● Radiation Therapy→ insert radioactive beads into prostate ; Radioactive prostate ; pt teaching about sex, sitting on lap, etc ● Hormonal Therapy ● Chemotherapy ● Cryotherapy ● Alternative Therapy Surgery ● Radical Prostatectomy – treatment of choice for localized cancer provided client’s health adequate to undergo physical stress of anesthesia and surgery ○ Involves removal  of entire prostate gland, its outer capsule, the seminal vesicles, sections of the vas deferens, adjacent lymph nodes and (in many cases) the bladder neck

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Complications following radical prostatectomy ○ Bleeding ○ Infection ○ Urinary incontinence ○ ED ○ Rectal injury ○ Anal sphincter damage with fecal incontinence Radiation Therapy Approximately 30% of patients with organ confined prostate cancer are treated with radiation

External Beam Radiation ● Local treatment that directs radioactive beams to a particular area to kill cancer cells directly or indirectly by cutting off their blood supply ● Benefits – effective treatment for men who are poor surgical risk ○ No hospitalization necessary ● Disadvantages – risk that some prostate cancer will remain or will recur after therapy ○ Man may have to travel long distances – treatment lasts between 7 and8 weeks ● Side Effects: Immediate – fatigue, decreased energy, weight loss, changes in appetite ○ May be GI or rectal problems ○ Urinary problems – eg burning sensation, frequency, urgency ● Long term SE– permanent infertility, ED, Urinary frequency and urgency, rectal problems Implant or Radioactive Seeds – internal radiation (Brachytherapy) ● Benefits:  Convenience – avoids both lengthy recovery time necessary after surgery and long-term treatment schedule needed to complete course of external beam radiation ○ Implantation close to cancer cells – higher cumulative dose of radiation to cancer cells while limiting exposure of healthy cells to harmful radiation ● Disadvantages – cancer  cells may remain after treatment or a new cancer may grow ○ If treatment is ineffective, other local treatments such as more radiation or surgery may be impossible or very difficult ○ Not as readily available as external beam radiation ○ Implants may set off security detection devices ● Side effects – Immediate – discomfort in pelvic area or perineum ○ Increase in frequency and urgency – burning with urination ○ Rarely prostate swells and blocks urinary flow necessitating catheter ● Long Term – most become infertile ○ Some experience gradual ED ○ Urinary incontinence possible ○ Rarely – rectal pain, burning and bleeding

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Hormonal Therapy Blocks testosterone production – includes estrogens, gonadotropin releasing hormone analogs and antiandrogens Surgical Hormonal treatment – orchiectomy Most often used to treat cancer that has spread outside the prostate gland (Stages N1 or M1), to treat recurrence of prostate cancer after another therapy used or treat men at high risk of experiencing recurrence after surgery or radiation therapy

Hormonal Therapy ● Benefits: May slow growth of prostate cancer – some men’s lives prolonged for 10-15 years ○ One of best available for decreasing complications and pain experienced by men with metastatic prostate cancer ○ Readily available and easily administered ● Disadvantages – does not cure cancer ○ Work only for certain amount of time...