pain management

Pain Management

Safety, Security and Comfort Needs of the Acutely Ill Client:

PAINThe 5th Vital Sign

Definitions of Pain

“Pain is whatever the experiencing person says it is, existing whenever he/she says it does.” -Mc Caffery 1968

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” - Intl. Assoc. for the study of pain

Food for Thought

Costs $100 Billion each year Longer hospitalization Rehospitalizations ER visits Sick days Permanent Disability

Only 30% of cancer patients get adequate pain relief

15-20% of Americans have acute pain 25-30% of Americans have chronic pain Leading cause disability for those < 45 y/o

The Mechanisms of Pain

Transduction- Transmission- movement of pain

impulsesPerception- recognition of painModulation- activation

Transduction- Conversion of mechanical, thermal or

chemical stimulus into a neuronal action. Peripheral nerve sites- peripheral afferent

nociceptor (PAN) Action Potential causes movement of pain

stimulus What causes it? Nociceptive- Release of Chemicals Neuropathic- Abnormal processing of stimuli by

the nervous system

Transmission- movement of pain impulses from the site of transduction to the brain. Transmission along the nociceptor fibers to

the level of the spinal cord. Dorsal horn processing. (Dermatomes) Transmission to the thalamus and the

cortex.

Perception- recognition of pain However, there is no precise location where pain

perception occurs. Individualized Imagery is a good pain-reduction therapy. Subjective

Sensory: Recognition that you have pain. Affective: Emotional responses to pain. Behavioral: How someone expresses or controls pain. Cognitive: Person’s beliefs & attitudes about pain. Sociocultural: Age, Gender, education level, culture

and support systems.

Modulation- activation of descending pathways that either inhibit or facilitate effects on pain transmission.

Types of Pain

Nociceptive PainNormal processing of stimuli that

damages or has the potential to damage, normal tissues if prolonged.

Different types of origins: Somatic Pain: Arises from bone, joint,

muscle, skin or connective tissue. Visceral Pain: Arises from visceral organs,

such as pancreas or stomach.

Somatic Pain

Described as “achy”, stabbing, sharpExamples:

Bone pain, fractures Muscle tears, sprains Joint pain Soft tissue injury

Visceral Pain

Diffuse and difficult to localize if d/t obstruction of hollow viscus

Sharp, aching when due to injury to other visceral structures such as; Pancreatitis Kidney Stones Menstrual Cramps Bowel Obstruction

Neuropathic Pain

Multiple Pain Syndromes Often difficult to treat. Believed to be the abnormal firing of the

peripheral or central nervous system. Often described as burning, stinging,

shooting, traveling, or electric-like. Caused by phantom limb pain, complex

regional limb pain complex regional pain syndromes, diabetic neuropathy, post-herpetic neuralgia, or trigeminal neuralgia

Comparing Nociceptive & Neuropathic Pain

Normal processing of stimuli that damages normal tissue.

Responds to opioids or nonopiods.

Somatic pain- arises from bone, joint, muscle, skin or connective tissue

Visceral pain Tumor involvement that

causes aching and is fairly well-localized

Obstruction causes intermittent cramping and poor localized pain.

Abnormal processing by peripheral or central nervous system.

Responds to adjuvant analgesics.

Centrally Generated Pain Peripherally Generated

Pain- Pain felt along entire

nerve pathways. Peripheral nerve injury-

pain felt partially along the damaged nerve

Acute VS. Chronic Pain

ACUTE Sudden Short Duration < 3

months Mild--> Severe Can identify specific

cause. Predictable prognosis Can be single event

or recurrent. as healing

progresses.

CHRONIC Continues for more than one

month after healing or an acute lesion, or

Recurs over a chronic period of time.

Pathophysiology may be unclear.

Unpredictable prognosis Is associated with a lesion

that is not expected to heal. Chronic cancer pain or

chronic non-malignant pain.

Sources of Pain

Visceral Pain Muscloskeletal Neuropathic

Generalized pain related to visceral stretch. Described as sharp ache.

Usually localized. Described as dull ache.

Irritation of verve. Described as burning, sharp, shooting.

Classic referral pain. PT, massage, heat & cold helpful.

PT helpful.

Responds best to opioids.

Some response w/opioids. Adjuvants helpful. NSAID’s/Steroids, muscle relaxers

Opioids usually not helpful- only dull the pain. Adjuvants helpfulTricyclic AD, anti-convulsants.

Acute VS. Chronic Pain Cont’

May be associated with sympathetic hyperactivity and anxiety.

Usually resolves Treated with short-

acting drugs.

May be associated with depressed mood, sleep disturbance and disability.

Treated with long-acting drugs and adjuvant therapy.

Pharmacology of Pain Management

Individualized- Based on the patient’s medical and pain histories.

Multi-modal- Targets multiple sites of action. Optimize effects Minimize adverse effects

Pharmacology of Pain Management Cont’

Routes of Administration Oral Sublingual Transmucosal (Actiq) Transdermal (Fentanyl duragesic patch) Parenteral: IV, IM, SQ Nebulized Rectal Epidural/Intrathecal (Morphine, Fentanyl)

How do Opioids work? Opioids act on the opioid receptor sites and

activate endogenous pain suppression systems in the CNS (Mu receptor sites).

Receptor sites are found in: Dorsal horn of the spinal cord Pituitary gland GI tract

Endogenous & exogenous opioids control pain by locking onto opioid receptor sites and blocking the release of neurotransmitters.

How NSAID’s and Acetaminophen work? Non-opioids include NSAID’s, Tylenol and Aspirin. They act on the peripheral nerve endings at the site of

injury altering the prostaglandin system. NSAID’s have an anti-inflammatory effect. Acetaminophen does NOT have an anti-inflammatory

effect. Like ASA, it has analgesic and antipyretic effects.

Side effects: NSAID’s: GI irritation, possible nephrotoxicity. Acetaminophen can cause hepatoxicity. Limit 4 grams/24hr

Pharmacology of Pain Management Cont’ Short Acting Pain Medications

Provide analgesia within 30 min. Diluadid, Morphine

Actiq-fastest acting oral medication- onset within 5 min. (transmucosal)

MSIR oral solution/Roxanol-elixir form of morphine. Helpful for pts. with difficulty swallowing. Titratable.

Oxycodone/MSIR tablets- used for short-term therapy or supplemental dosing (breakthrough pain).

Compounds: Tylenol #3, Hydrocodone- Lortab/Vicodin, Oxycodone- Percocet.

Propoxyphene- Darvon/Darvocet

Long Acting Opioids Usually used for long-term pain. For patients requiring frequent breakthrough

dosed of opioids. More predictable serum levels Easier to use; lower dosing intervals,

improved compliance

Comparing Long Acting Opioids

MSContin/Oxycontin

8-12 hour duration DO NOT CRUSH

TABLETS!!! Reassess and titrate

as needed. 12-24 titration

Fentanyl/duragesic Transdermal 72 H duration Convenient Reassess and titrate as

needed. Effective for patients

with chronic pain and intolerance to orals.

Do not cut patch. Place above waist and

not on bone. 24-48 titration

Meperidine

Has a metabolite that is 2x as potent as a convulsant and 1/2 as potent as an analgesic.

Breaks down to nomeperidine which has an active metabolite that accumulates w/multiple dosing.

Hepatic or renal failure and increases toxicity. Accumulation of active metabolites can produce

irritability, tremors, muscle twitching, jerking, agitation or seizures.

Common Nonopiod Analgesics

Drug Adult dose

Considerations

Acetaminophen(Tylenol)

650-975 mg q 4 hr

Used for headaches, osteoarthritis,; lacks peripheral anti-inflammatory activity of NSAID’s.

Aspirin 650-975 mg q 4 hr

Used for headaches, osteoarthritis, general pain, antipyretic, inhibits platelet aggregation.

Ibuprofen 400 mg q 4-6 hr

Antipyretic, Used for osteoarthritis, available as liquid

Indomethacin (Indocin)

150-200 mg/day

Used for gout, antinflammatory,antirheumatic

Naproxen (Naprosyn)

500 mg initial dose, then 250 mg q 6-8

Used for gout, headaches, smooth muscle contraction, available in liquid

Adjuvant Analgesics

Nontraditional analgesics, most approved for other indications.

Multipurpose drugsFor muscloskeletal pain

Muscle relaxants (Baclofen, Zanaflex)For neuropathic pain

Antidepressants- SSRI’s, TCA’s, SSRI's (Pamelor, Cymbalta)

Anticonvulsants- Topamax, Gabapentin, Lyrica

Approved for post-herpatic neuralgia, diabetic neuropathy.

Non-pharmacological Treatments

Rehabilitative: such at PT/OT Psychological Interventional

Nerve blocks Trigger point injections

Complementary therapies Acupuncture Breathing (Lamaze) Relaxation /Yoga Meditation Hypnosis Massage Transcutaneous Electrical Nerve Stimulation

(TENS)

Nursing Pain Assessment

Subjective Assessment “I have pain….”; Pt. complains of pain. It is what the client says it is. Location- Where? Description- How does it feel?

Objective Assessment Intensity- Rating scale:

0 = pain 10 = worst possible pain

Duration- When did it start, How long does it last, Is it continuous or intermittent?

Objective Assessment cont.’ Alleviating & contributing factors

What makes the pain better or worse? Associative factors

Nausea Vomiting Altered LOC

Impact of pain How does it affect their lives?

Past/Pertinent medical hx Past pain experiences Recent surgery, chemical use or abuse

Objective Assessment cont.’ Vital Signs Face

Facial grimace Clenched jaw

Muscle tone Relaxed Rigid

Vocalization Moaning, crying, grunting, whimpering

Nursing Diagnosis

Alteration in Comfort Impaired Gas Exchange Alteration in Cardiac Output Potential for Ineffective Airway Clearance Anxiety Impaired Physical Mobility Ineffective Coping Potential for Infection Altered Bowel Elimination

Planning, Goal Setting & Interventions

Alleviate Pain!!!!!!!! Improve Comfort. By when? From what to what? 0-10

Interventions Pain Medication!! Adjuvants Positioning Responsibility Involve Family Humor

Preventing Complications!!!!!!

Important Definitions

Tolerance- an adaptive process due to exposure to a drug over time. Results in a decrease response to a drug’s effect over time.

Physical Dependence- a physiologic phenomenon that should be expected in persons with persistent use of certain drugs. Patients will experience a withdrawal syndrome if a drug is abruptly stopped, there is a rapid dose reduction, or if the person is given a reversal agent. Withdrawal can be prevented by gradual taper Reversal Agents

Narcan- Opioids Romazacon- Benzodiazapam

Important Definitions Cont.’

Pseudoaddiction- This is not true addiction and is created by under treatment of pain. A term used to describe behaviors seen in persons who fear or who are experiencing uncontrolled pain and want to obtain medication for adequate pain relief. The “clock-watching”, requesting extra opioids, and demanding behaviors are eliminated when the pain is relieved.

Addiction- A primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors. Characteristics include: Impaired control over drug use Compulsive use Continued use despite harm The need to use an opioid for effects other than

for pain relief and craving.

Breakthrough Pain- Transitory increase in pain to greater than

moderate intensity which occurs on top of the baseline pain.

Distinguished from: Continuous or uncontrolled pain Acute episodic pain.

Portenoy RK, Hagen NA. Pain, 1990;41:273-281

Breakthrough Pain

50% of all inpatients are under treated. Types

Incident Idiopathic/spontaneous End-of-dose failure

Characteristics Moderate-to-severe intensity Rapid onset Often unpredictable Short duration 3-4 episodes per day Associated with a more severe pain syndrome IMPAIRMENT OF QUALITY OF LIFE!!!

Pain: Gerontologic Considerations

45-80% of older adults have chronic pain. Inadequately assessed and treated. Common types: osteoarthritis, low back pain

and previous fracture sites. Chronic pain can lead to :

Depression Sleep disturbances Decreased mobility Increased health care utilization $$$$ Physical & social role dysfunction

Ethical Issues in Pain Management

Requests for Assisted Suicide Only legal in Oregon.

Use of Placebos How do you feel about them? Check institutions policy.

Cognitively impaired individualsPatients with substance abuse

problems

Pain: Gerontologic Considerations Cont.’

Believe that pain is “normal”.Nothing can be done.Labeled as “burdensome” or “bad pt.”Fear of drugs.Pain tolerance DECREASES with age.Cognitive, sensory-perceptual , and

motor problems may impair ability to communicate or process information. Post-stroke aphasia, paraplegia, dementia,

delirium, vision, hearing impairments

The Effect of Pain on the Body

SYSTEM RESPONSESEndocrine Adrenocorticotropic Hormone(ACTH),

cortisol, antidiuretic hormone (ADH), epinephrine, norepinephrine, renin, aldosterone, insulin, testosterone

Metabolic Gluconeogenesis, glyconeolysis, hyperglycemia, glucose intolerance, insulin resistance, muscle protein catabolism, lipolysis

Cardiovascular heart rate, cardiac output, peripheral vascular resistance, hypertension, myocardial 02 consumption, and coagulation

Respiratory Tidal volume & cough, atelectasis, shunting, hypoxemia, sputum retention, infection

The Effect of Pain on the Body Cont.’

Genitourinary Urinary output, urinary retention

Gastrointestinal Gastric and bowel motility

Musculoskeletal Muscle spasm, impaired muscle function, fatigue, immobility

Neurologic Reduction in cognitive functions, mental confusion

Immunologic Immune response

Myofascial Pain Syndrome

Soft Tissue Pain (Somatic) Specific to one regional area of the body Pressure or strain causes the pain to travel. Cause thought to be related to muscle

trauma or chronically strained muscles. Pain originates within the fascia of skeletal

muscles. Deep aching pain accompanied by:

“Burning, stinging, and stiffness”

Fibromyalgia Syndrome

Widespread, nonarticular muscloskeletal pain and fatigue with multiple tender points.

Non-degenerative, non-progressive & non-inflammatory.

Effects over 6 million Americans More women than men; 20-55 years old. Possible causes;

Abnormal levels of serotonin, norepi and other neurotransmitters.

Hyperfunctioning of the hypothalamic-pituitary-adrenal axis (HPA).

Fibromyalgia Syndrome Treatment

Supportive management NSAID’s Tricyclic Anti-depressants or SSRI’s Well balanced diet Behavioral Therapy Financial concerns and support Carefully graduated exercise program.

Chronic Fatigue Syndrome

Disorder characterized by debilitating fatigue and a variety of associated complaints.

3x more likely in women; onset 25-45 years old.

Etiology unknown Ideas:

Viral infection usually precipitates the syndrome. Abnormal immune function. Alterations in the CNS. Possible dysfunction of the HPA axis. Depression usually occurs in patients.

Nursing Care of the Client with Cancer

End-of-Life Care

Cancer BackgroundA.Definition 1. Family of complex diseases 2. Affect different organs and organ systems 3. Normal cells mutate into abnormal cells that

take over tissue 4. Eventually harm and destroy host 5. Historically, cancer is a dreaded disease

B.Oncology 1. Study of cancers 2. Oncology nurses specialize in the care,

treatment of clients with cancer

Incidence and Prevalence1. Cancer accounts for about 25% of

death on yearly basis2. Males: 3 most common types of cancer

are prostate, lung and bronchial, colorectal3. Females: 3 most common types of

cancer are breast, lung and bronchial, and colorectal

Nursing Care of the Client with Cancer Risk factors for cancer: (some are controllable; some are not) 1. Heredity: 5 – 10% of cancers; documented with some breast

and colon cancers 2. Age: 70% of all cancers occur in persons > 65 3. Lower socio-economic status 4. Stress

a. Leads to greater wear and tear on body in general5 Diet: certain preservatives in pickled, salted foods; fried foods; high-fat, low fiber foods; charred foods, high fat foods, diet high in red meat

6. Occupational risk: exposure to know carcinogens, radiation, high stress

7. Infections, especially specific organisms and organ (e.g. papillomavirus causing genital warts and leading to cervical cancer)

8. Tobacco Use: Lung, oral and laryngeal, esophageal, gastric, pancreatic, bladder cancers

9. Alcohol Use: also tied with smoking 10. Sun Exposure (radiation) e.g. skin cancer

Nursing role includes health promotion to lower the controllable risks

1. Routine medical check up and screenings2. Client awareness to act if symptoms of cancer occur 3. Screening examination recommendations by American

Cancer Society; specifics are made according to age and frequencies

a. Breast Cancer: self-breast exam, breast examination by health care professionals, screening mammogram

b. Colon and Rectal Cancer: fecal occult blood, flexible sigmoidoscopy, colonoscopy

c. Cervical, Uterine Cancer: Papanicolaou (Pap) test d. Prostate Cancer: digital rectal exam, Prostate-

specific antigen (PSA) test

Physiology of CancerA. Background1. Normal Cell Growth includes two

eventsa. Replication of cellular DNA b. Mitosis (cell division)

2. Cell cycle is under control of cyclins, and suppresor gene products which control process by working with enzymes;

cyclins promote cell division suppresor gene products limit cell

division 3. Forms the basis of how some

chemotherapeutic agents work against cancers

Theories of Carcinogenesis (what causes cancer to occur)

1. Cellular Mutation a. Cells begin to mutate (change the DNA to unnatural

cell reproduction) 2. Oncogenes/Tumor Suppressor Genes Abnormalities a. Oncogenes are genes that promote cell

proliferation and can trigger cancer b. Tumor suppressor genes normally suppress

oncogenes but are damaged3. Exposure to Known Carcinogens a. Act by directly altering the cellular DNA (genotoxic) b. Act by affecting the immune system (promotional)

4. Viruses viruses break the DNA chain and mutates

the normal cells DNAEpstein-Barr virusHuman papilloma virusHepatitis virus

5. Drugs and Hormones a. Sex hormones often affect cancers of the

reproductive systems (estrogen in some breast cancers; testosterone in prostate cancer)

b. Glucocorticoids and steroids alter immune system

6. Chemical Agents a. Industrial and chemical b. Can initiate and promote cancer b. Examples: hydrocarbons in soot ; arsenic in

pesticides; chemicals in tobacco7. Physical Agents a. Exposure to radiation

Ionizing radiation found in x-rays, radium, uranium UV radiation

Sun, tanning beds8. Immune function

1. Protects the body from cancerous cells2. Increased rate of cancer in immunocompromised pts

Neoplasms: also called tumors (mass of new tissue that grows independently of surrounding organs

1. Types of neoplasmsa. Benign 1. Localized growths respond to body’s homeostatic

controls 2. Encapsulated 3. Stop growing when they meet a boundary of another

tissue 4. Can be destructive b. Malignant 1. Have aggressive growth, rapid cell division outside the

normal cell cycle 2. Not under body’s homeostatic controls 3. Cut through surrounding tissues causing bleeding,

inflammation, necrosis (death) of tissue

Malignant tumors can metastasizea. Tumor cells travel through blood or lymph

circulation to other body areas and invade tissues and organs there.

1. Primary tumor: the original site of the malignancy

2. Secondary tumor (sites): areas where malignancy has spread i.e. metastasis (metastatic tumor)

3. Common sites of metastasis are lymph nodes, liver, lungs, bones, brain

4. 50 – 60 % of tumors have metastasized by time primary tumor identified

b. Cancerous cells must avoid detection by immune system

Nursing Care of the Client with CancerC. Malignant neoplasms can recur after surgical removal of primary

and secondary tumors and other treatments D.Malignant neoplasms vary in differentiation. a. Highly differentiated are more like the originating

tissue b. Undifferentiated neoplasms consist of immature

cells with no resemblance to parent tissue and have no useful function

E. Malignant cells progress in deviation with each generation and do no stop growing and die, as do normal cells

F. Malignant cells are irreversible, i.e. do not revert to normal

G.Malignant cells promote their own survival by hormone production, cause vascular permeability; angiogenesis; divert nutrition from host cells

The steps of metastasis

Effects of Cancer 1. Disturbed or loss of physiologic functioning, from pressure or

obstruction a. Anoxia and necrosis of organs b. Loss of function: bowel or bladder obstruction c. Increased intracranial pressure d. Interrupted vascular/venous blockage e. Ascites f. Disturbed liver functioning G. Motor and sensory deficits

Cancer invades bone, brain or compresses nervesh. Respiratory difficulties

a. Airway obstructionb. Decreased lung capacity

Nursing Care of the Client with Cancer2. Hematologic Alterations: Impaired function of blood cells

1. Secondary to any cancer that invades the bone marrow (leukemia)2. May also be caused by the treatment

a. Abnormal wbc’s: impaired immunity b. Diminished rbc’s and platelets: anemia and clotting

disorders3. Infections: fistula development and tumors may become

necrotic; erode skin surface4. Hemorrhage: tumor erosion, bleeding, severe anemia5. Anorexia-Cachexia Syndrome: wasting away of client a. Unexplained rapid weight loss, anorexia with altered

smell and taste b. Catabolic state: use of body’s tissues and muscle

proteins to support cancer cell growth

Nursing Care of the Client with Cancer6. Paraneoplastic Syndromes: ectopic sites with excess hormone

production a. Parathyroid hormone (hypercalcemia) b. Ectopic secretion of insulin (hypoglycemia) c. Antidiuretic hormone (ADH: fluid retention) d. Adrenocorticotropic hormone (ACTH)7. Pain: major concern of clients and families a. Types of cancer pain 1. Acute: symptom that led to diagnosis 2. Chronic: may be related to treatment or to progression

of diseaseb. Causes of pain 1. Direct tumor involvement including metastatic pain 2. Nerve compression 3. Involvement of visceral organs

8. Physical Stress: body tries to respond and destroy neoplasm

a. Fatigue b. Weight loss c. Anemia d. Dehydration e. Electrolyte imbalances9. Psychological Stress a. Cancer equals death sentence b. Guilt from poor health habits c. Fear of pain, suffering, death d. Stigmatized

Collaborative CareA. Diagnostic Tests: used to diagnose cancer1. Determine location of cancer a. Xrays b. Computed tomography c. Ultrasounds d. Magnetic resonance imaging e. Nuclear imaging f. Angiography2. Diagnosis of cellular type of can be done through tissue

samples from biopsies, shedded cells (e.g. Papanicolaou smear) washings

a. Cytologic Examination: tissue examined under microscope

b. Identification System of Tumors: Classification – Grading -- Staging

1.Classification: according to the tissue or cell of origin, e.g. sarcoma, from supportive

2.Grading: a. Evaluates degree of differentiation and

rate of growth b. Grade 1 (least aggressive) to Grade 4

(most aggressive)3.Staging a. Relative tumor size and extent of disease b. TNM (Tumor size; Nodes: lymph node

involvement; Metastases)

3. Tumor markers: specific proteins which indicate malignancy

a. PSA (Prostatic-specific antigen): prostate cancer b. CEA (Carcinoembryonic antigen): colon cancer c. Alkaline Phosphatase: bone metastasis4 Direct Visualization a. Sigmoidoscopy b. Cystoscopy c. Endoscopy d. Bronchoscopy e. Exploratory surgery; lymph node biopsies to

determine metastases

Other non-specific testsa. CBC, Differentialb. Electrolytesc. Blood Chemistries: (liver enzymes:

alanine aminotransferase (ALT); aspartate aminotransferase (AST) lactic dehydrogenase (LDH)

Nursing Care of the Client with CancerTreatment Goals: depending on type and stage of cancerA.Cure 1. Recover from specific cancer with treatment 2. Alert for reoccurrence 3. May involve rehabilitation with physical and

occupational therapyB.Control: of symptoms and progression of cancer 1. Continued surveillance 2. Treatment when indicated (e.g. some bladder

cancer, prostate cancer)C.Palliation of symptoms: may involve terminal care if

client’s cancer is not responding to treatment

Treatment Options (depend on type of cancer) alone or with combination

A. Chemotherapy 1. Effects are systemic and kills the

metastatic cells 2. Often combinations of drugs in specific

protocols over varying time periods Much more effective then a single agent

Consider the timing of the nadir of each drug• The time when the bone marrow activity and WBC counts

are at their lowest levels after chemo• Different times for different drugs

3. Cell-kill hypothesis: with each cell cycle a percentage of cancerous cells are killed but some remain; repeating chemo kills more cells until those left can be handled by body’s immune system

B. Classes of Chemotherapy Drugs1. Alkylating agents 1. Action: create defects in tumor DNA 2. Examples: Nitrogen Mustard, Cisplatin2. Antimetabolites 1. Action: similar to metabolites needed for vital cell

processes Counterfeit metabolites interfere with cell division

2. Examples: Methotrexate; 5 fluorouracil 3. Toxic Effects: nausea, vomiting, stomatitis, diarrhea,

alopecia, leukopenia3. Antitumor Antibiotics 1. Action: interfere with DNA 2. Examples: Actinomycin D, Bleomycin 3. Toxic Effect: damage to cardiac muscle

4.Antimiotic agents 1. Action: Prevent cell division 2. Examples: Vincristine, Vinblastine 3. Toxic Effects: affects neurotransmission,

alopecia, bone marrow depression5.Hormone agonist 1. Action: large amounts of hormones upset the

balance and alter the uptake of other hormones necessary for cell division

2. Example: estrogen, progestin, androgen

6.Hormone Antagonist 1. Action: block hormones on hormone-

binding tumors (breast, prostate, endometrium; cause tumor regression Decreasing the amount of hormones can decrease

the cancer growth rate Does not cure, but increases survival rates

2. Examples: Tamoxifen (breast); Flutamide (prostate)

3. Toxic Effects: altered secondary sex characteristics

7. Hormone inhibitors Aromatase inhibitors (Arimidex, Aromasin)

Prevents production of aromatase which is needed for estrogen production

Used in post menopausal women Side effects

• Masculinizing effects in women• Fluid retention

Effects of Chemotherapy a. Tissues (fast growing) frequently affected b. Examples: mucous membranes, hair cells, bone

marrow, specific organs with specific agents, reproductive organs (all fetal toxic, impair ability to reproduce).

Administration of chemotherapeutic agentsa. Trained and certified personnel, according to established

guidelinesb. Preparation 1. Protect personnel from toxic effects

Drugs absorbed through skin and mucous membranes Protective clothing and extreme care

2. Extreme care for correct dosage; double check with physician orders, pharmacist’s preparation

c. Proper management clients’ excrement

d. Routes 1. Oral 2. Body cavity (intraperitoneal or

intrapleural) 3. Intravenous

a. Use of vascular access devices because of threat of extravasation (leakage into tissues) and long-term therapy

a. If the drug is a vessicant it may result in pain, infection and tissue loss

e.Types of vascular access devices1. PICC lines (peripherally inserted

central catheters)2. Tunnelled catheters (Hickman,

Groshong)3. Surgically implanted ports

(accessed with 90o angle needle

Hickman Catheter

Portacath

PICC Line

Managing side effects of chemotherapyA. Nausea and vomiting

80% of patients will develop it Antiemetics such as Zofran, Tigan,

Compazine as well as Ativan to control the symptoms

Monitor for dehydration and need for IV fluids

B. Bone marrow suppression Decreased number of RBC

Leads to hypoxia, fatigue Hgb 9.5-10 gm/dl require oral iron supplements Hgb below 8 gm/dl require transfusion May use Epogen to stimulate RBC production

Decrease number of WBC (normal 4,500-11,000 mm3) especially neutrophils (normal 3,000-7,000 cells/cc) Neutropenia-count below 2000 Pt at extreme risk for infection May order granulocyte colony stimulating factor (leukine) to

stimulate bone marrow to increase WBC count

Neutropenic precautions Private room Good handwashing Monitor temp q 4 hours, monitor for chills, UTI, pneumonia Limit visitors to healthy adults No flowers or plants Monitor neutrophil count

Thrombocytopenia Drop in platlet count (normal 150,000-400,000/mm3)

below 100,000 Test pt for bleeding in stool and urine Avoid punctures for IV or IM Handle pt gently Use electric razor Avoid placing foley or rectal thermometers Avoid oral trauma with soft bristle brushes, avoid

flossing, avoid hard candy Watch for ALOC, pupil changes that might indicate

intracranial bleeds Stool softeners to avoid straining

C. Mucocitis Inflammation and ulceration of mucous

membranes and entire GI tract Rinse mouth with ½ normal saline and ½

peroxide every 12 hours Topical analgesic medication Avoid mouthwashes with alcohol Avoid spicy or hard food Watch nutritional status

D. Alopecia Hair loss 2-3 weeks after treatment is started Affects all the hair, including eyebrows,

eyelashes Within 4-8 weeks after treatment hair begins

to grow back Before hair loss, have the pt pick out a wig

that is similar to hair color

E. Peripheral neuropathy Numbness and tingling to fingers and toes

in a glove and sock pattern May cause gait and possible fall problems

F. Provide emotional and spiritual support to patient and families

Surgery 1. Diagnosis, staging, and sometimes treatment of cancer 2. May be prophylaxis or removal of at risk tissue or organ

prior to development of cancer (breast cancer) 3. Involves removal of body part, organ, sometimes with

altered functioning (e.g. colostomy) 4. Debulking (decrease size of) tumors in advanced cases 5. Reconstruction and rehabilitation (e.g. breast implant

post mastectomy) 6. Palliative surgery to improve the quality of life

Removal of tumor tissue that is causing pain or obstruction 5. Psychological support to deal with surgery as well as

cancer diagnosis

Nursing Care of the Client with CancerRadiation Therapy1. Treatment of choice for some tumors to kill or reduce tumor, relieve pain or obstruction

Destroy cancer cells with minimal exposure to normal cells Cells die or are unable to divide2. Delivery

a. Teletherapy (external): radiation delivered in uniform dose to tumor

Beam radiation b. Brachytherapy: delivers high dose to tumor

and less to other tissues; radiation source is placed in tumor or next to it in the form of seeds

Radiation source within the patient so pt emits radiation for a period of time and is a hazard to others

c. Combination

3.Goals a. Maximum tumor control with minimal

damage to normal tissues b. Caregivers must protect selves by

using shields, distancing and limiting time with client, following safety protocols Private room Caution sign on the door for radioactive material Dosimeter film badge by staff No pregnant staff Limit visitors to ½ hour per day and keep them at

least 6 ft from the source

4. Treatment Schedules a. Planned according to radiosensitivity of

tumor, tolerance of client b. Monitor blood cell counts5. Side Effects a. Skin (external radiation): blanching, erythema,

sloughing, breakdown Use mild soak Dry skin with a patting motion, not rubbing Don’t use powders or lotions unless prescribed by

radiologist Wear soft clothing over the site Avoid the sun and heat

b. Ulcerated mucous membranes: pain, lack of saliva (xerostoma)

c. Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation

d. Radiation pneumonitis 1-3 months after treatment Cough, SOB, fever Treated with steroids to decrease inflammation

Monoclonal antibodies (inoculate animal with tumor antigen and retrieve antibodies against tumor for human) Antibodies target specific substances

needed by the cancer cell for growth (Herceptin for breast cancer)

Gene therapyexperimentalMay insert gene into the tumor cells to

make them more susceptible to being killed by antiviral agents

May insert genes for cytokines that increase their effectiveness in killing cancer cells

Angiogenesis inhibitor drugs prevent new blood vessels from

forming and delivering blood to the tissue

F. Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation

1. Stimulation of nonfunctioning marrow or replace bone marrow 2. Common treatment for leukemiasG. Pain Control 1. Includes pain directly from cancer, treatment, or unrelated 2. Necessary for continuing function or comfort in terminally

ill clients 3. Goal is maximum relief with minimal side effects 4. Multiple combinations of analgesics (narcotic and non-

narcotic) and adjuvants such as steroids or antidepressants; includes around the clock (ATC) schedule with additional medications for break-through pain

5. Multiple routes of medications 6. May involve injections of anesthetics into nerve, surgical

severing of nerves radiation 7. May need to progress to stronger pain medications as pain

increases and client develops tolerance to pain medication

Nursing Care of the Client with Cancer Nursing Diagnoses for Clients with CancerA. Anxiety 1. Therapeutic interactions with client and family; community

resources such as American Cancer Society, “I Can Cope” 2. Availability of community resources for terminally ill (Hospice

care in-patient, home care)B. Disturbed Body Image 1. Includes loss of body parts (e.g. amputations); appearance

changes (skin, hair); altered functions (e.g. colostomy); cachexic appearance, loss of energy, ability to be productive

2. Fear of rejection, stigmaC. Anticipatory Grieving 1. Facing death and making preparations for death: will be

consideration 2. Offer realistic hope that cancer treatment may be successful

D. Risk for InfectionE. Risk for Injury 1. Organ obstruction 2. Pathological fracturesF. Altered Nutrition: less than body requirements 1. Consultation with dietician, lab evaluation of nutritional

status 2. Managing problems with eating: anorexia, nausea and

vomiting 3. May involve use of parenteral nutritionG. Impaired Tissue Integrity 1. Oral, pharyngeal, esophageal tissues (due to chemotherapy,

bleeding due to low platelet counts, fungal infections such as thrush)

2. Teach inspection, frequent oral hygiene, specific non-irritating products, thrush control

Oncologic EmergenciesA. Pericaridal Effusion and Neoplastic

Cardiac Tamponade1. Concern: compression of heart by

fluid in pericardial sac, compromised cardiac output

2. Treatment: pericardiocentesis

B. Superior Vena Cava Syndrome 1. obstruction of venous system with

increased venous pressure and stasis; facial and neck edema with slow progression to respiration distress Late signs are cyanosis, decreased cardiac output

and hypotension 2. Treatment: respiratory support;

decrease tumor size with radiation or chemotherapy

Compression of the superior vena cava in SVC syndrome

C. Sepsis and Septic Shock 1. Early recognition of infection

Patients at risk secondary to low WBC and impaired immune system

2. Treatment: prompt intervention with antibiotics and vasopressors

D. DIC disseminated intravascular coagulation Triggered by severe illness, usually sepsis

in cancer patients Abnormal clotting uses up existing clotting

factors and platelets quickly then the pt hemorrhages

Mortality rate is 70% Prevention of sepsis is key

E. Spinal Cord Compression 1. Pressure from expanding tumor or

vertebral collapse can cause irreversible paraplegia

2. Back pain initial symptom with progressive paresthesia and paralysis Paralysis is usually permanent

3. Treatment: early detection High dose corticosteroid to decrease the swelling radiation or surgical decompression

F. Obstructive Uropathy1. Concern: blockage of urine flow;

undiagnosed can result in renal failure2. Treatment: restore urine flow

G. Hypercalcemia 1. High calcium (normal 9-10.5) usually from bone metastases 2. May also come from cancer of the lung, head, neck, kidney

and lymph nodes that secrete parathyroid hormone that causes the bone to release calcium

2. Symptoms include fatigue, muscle weakness, polyuria, constipation, progressing to coma, seizures

3. Treatment restore fluids with intravenous saline which also increases the

excretion of calcium loop diuretics increase calcium excretion Calcium chelators such as mithracin Inhibit calcium resorption from the bone with calcitonin,

diphosphonate

H. Tumor Lysis Syndrome 1. Occurs with rapid necrosis of tumor cells

with chemotherapy When tumor cells die they release potassium and

purines Potassium (norm 3.5-5.5) elevation causes cardiac

arrhthymias, muscle weakness, twitching, cramps Purines convert to uric acid which causes renal

failure, flank pain, gout when elevated above 10 mg/dl

Hyperphosphatemia with secondary to hypocalcemia causes heart block, HTN, renal failure

Treatment Hydration Instruct pt to increase fluid intake before

and after chemo May need IV hydration Diuretics to increase urine flow Allopurinol to increase uric acid excretion May need dialysis

I. SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion)

1. Ectopic ADH production from tumor leads to excessive hyponatremia

2. holds onto too much fluid which decreases sodium level (normal 135-145)

3. Symptoms Weakness, muscle cramps, fatigue, ALOC, headache, seizures

2. Treatment: restore sodium level Fluid restriction Increase sodium Antibiotic demeclocycline works in opposition to ADH

Limits ADH effect on distal renal tubules so they can excrete water

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