new cellular aberration lecture2010

CELLULAR ABERRATION

CANCER

•Came from the Latin word CANCRI which means crab.

•It is a disease characterized by stretching out in many directions like the legs of the crab.

•A large group of disease characterized by uncontrolled growth and spread of abnormal cells.

Who can get cancer?

•75% occur after the age 50•6% occurs in pediatric age group of 0-14 years•In the Philippines, about 80, 000 per year or 1 out of every 5 Filipinos who live to age 74 will get cancer•In US, cancer causes more than 550, 000 deaths annually. ACS estimates that roughly 83 million Americans now living will eventually have some form of cancer.

Who can get cancer?

Worldwide, about 103 people die of cancer everyday or about 4 in every hour

Etiologic/Risk FactorsA. INTERNAL RISK FACTORS

•AGE

Age of exposure to carcinogens may increase the cancer risk. Fetuses, infants and children are at greater risk because they are still developing. Blistering sunburns in children under age 12 may predispose them to skin cancer

Risk Factors

•GENDER

Overall, women have a lower cancer incidence

than men and higher survival rate.

In females, breast, colon, lung, and uterine

cancers are the most common.

In males, prostate, lung, GIT and bladder cancers

predominate.

Risk Factors

•RACE

Cancer incidence and mortality are higher in blacks due to economic, social and environmental factors that may delay prompt detection and increase exposure to industrial carcinogens.

Risk Factors

•GENETIC FACTOR

Certain cancers tend to run in families. For example, women who have first degree relatives (mother, sister) with breast cancer are at greater risk than the general population.

Risk Factors

•IMMUNOLOGIC FACTORS

According to the Immune Surveillance Theory, antigenic differences between normal and cancerous cells may help the body eliminate malignant cells. Thus, immunosuppression may increase susceptibility to cancer.

Risk Factors

•PSYCHOLOGICAL FACTORS

Emotional stress may increase a person's cancer risk by leading to poor health habits (smoking, alcohol drinking), by depressing the immune system, or by leading him to ignore early warning signs.

Risk Factors

B. EXTERNAL RISK FACTORS•CHEMICAL CARCINOGENS

Chemical exposure like in nickel refining and asbestos industry may increase the risk of an individual to get cancer.

Risk FactorsChemical carcinogens typically cause

cancer in

two step process:

• INITIATION involves exposure to the carcinogen.

• This irreversible step converts normal cells to latent

• tumor cells.In PROMOTION, repeated exposure to the same or some other substance stimulates the latent cells to become active neoplastic cells.

Risk Factors•RADIATION

Ionizing radiation of all kinds (from X-rays to nuclear radiation) are carcinogenic, although their potencies vary.

Fair-skinned people have higher risk for skin cancer from UV radiation. Skin cancer develops on exposed extremities, and its incidence correlates with the amount of exposure.

Risk Factors•VIRUSES

Some human viruses have carcinogenic potential.

EPSTEIN-BARR VIRUS has been linked to

lymphoma and nasopharyngeal carcinoma

• DEOXYRIBONUCLEIC ACID VIRUS (Herpes

• simplex virus type 2) have been associated with

• uterine and cervical cancer . RIBONUCLEIC ACID VIRUS are linked to

breast cancer in mice.

Risk Factors

•DIET

Certain foods may supply carcinogens (or

precarcinogens), affect carcinogen formation, or

modify carcinogen's effect.

Diet has been implicated in colon cancer, which

may result from low fiber intake and excessive

fat consumption.

Liver tumors are linked to food additives such as

nitrates and alfatoxin ( fungus that grows on

stored grains, nuts and other food stuff)

Risk Factors

•TOBACCO USE

• Lung cancer is the leading cause of cancer deaths in both men and women. Cigarette smoking accounts for about 30% of all cancers and is implicated in cancers of the mouth, pharynx, larynx, esophagus, pancreas, cervix and bladder. Pipe smoking and chewing tobacco are linked to oral cancer

Risk Factors

•ALCOHOL USE

Heavy beer consumption may increase the risk of colorectal cancer through an unknown mechanism.

•CHEMOTHERAPEUTIC DRUGS

• Some chemotherapeutic drugs may be directly carcinogenic or may enhance neoplastic development by suppressing the immune system.

Risk Factors

•HORMONES

By altering the body's normal endocrine balance, hormones may contribute to neoplastic development-especially in endocrine sensitive organs such as breast or prostate.

Theories of Pathogenesis of Cancer

•CELLULAR TRANSFORMATION AND DERAGEMENT THEORY

• Conceptualizes that healthy cells may transform into cancer cells by unknown mechanisms whenever exposed to certain etiologic agents.

•FAILURE OF THE IMMUNE RESPONSE THEORY

Advocates that all individuals possess cancer cells however these cancer cells are being recognize by

pathogenesis

The immune response system and they are being destroyed. FAILURE of the immune response system will lead to inability to destroy cancer cells.

Diagnostic Aids Used to Detect Cancer

•TEST

•Tumor Marker Identification

•DESCRIPTION

•Analysis of blood and body fluids

•ORGANS

•Breast, colon, lungs, ovaries, prostate

diagnostics

•TEST

•Magnetic Resonance Imaging

•DESCRIPTION

•Use of magnetic fields and radio frequency signals to create sectioned images of various body structures

•ORGANS/AREA

•Pelvic, thoracic, abdomen

DIAGNOSTICS

•TEST

•Computed Tomography (CT Scan)

•DESCRIPTION

•Use of narrow beam X-ray to scan layers of tissues for a cross sectional view

•ORGANS/AREA

•Neurologic, pelvic, skeletal, abdominal, thoracic

diagnostics

•TEST

•Ultrasonography

•DESCRIPTION

•Usu of high frequency sound waves echoing off body tissues, converted electronically into images used to assess tissues within the body

•ORGANS/AREA

•Abdominal, pelvic

diagnostics

•TEST

•Endoscopy

•DESCRIPTION

•Direct visualization of body cavity to passage way

•To aspirate or excise small tumor

•AREA/ORGAN

•Bronchi, GIT

diagnostics

•TEST

•Sigmoidoscopy/ Colonoscopy

•DESCRIPTION

•Direct visualization of the intestinal tract

•ORGAN/AREA

•Colorectal, sigmoid

9 warning signals of cancer

C-hange in bowel or bladder habits

A- sore that does not heal

U- nusual bleeding or di9scharge

T- hickening of lumps in breast or elsewhere

I- ndigestion or difficulty in swallowing

O- bvious change in wart or mole

N- agging cough or hoarseness of voice

A- nemia

L- oss of weight

Effects of cancer

1. Malfunction of the organ due to the destruction of

1. blood vessels

2. Pressure effect

Tumor can cause pressure which can cause

damage to adjacent structure

3. Cachexia

Characterized by weakness, body malaise,

anemia and weight loss.

Effects of cancer4. Obstruction

Due to tumor growth, hallow organs are being

compressed and obstructed.

5. Hemorrhage or bleeding

Tumor growth causes rupture of blood vessels

6. Effusion

When lymphatic flow is obstructed, it can cause

filling up of fluids on cavities

Effects of cancer

7. Ulceration and Necrosis

Tumor erodes blood vessels and pressure on

tissue causes ischemia

8. Vascular thrombosis, embolism, thrombophlebitis

9. Pain

A late sign of cancer

Prevention of cancer

SKINAvoid over exposure to sunlight

ORALAnnual oral exam of mouth and teeth

BREASTMonthly breast self examination from age 20 up

LUNGSAvoid cigarette smoking, DO annual CXR

Prevention of cancerCOLON

•Digital rectal examination for persons over 40 years old, rectal biopsy, proctoscopic exam, guiac stool exam for person 50 years old and above

UTERUS

•Annual Pap smear for female age aged 40

*Annual PE, blood and urine exam

*Choosing the right behavior and preventing exposure to certain environmental risk factors

DIETARY RECOMMENDATION

1. Cut down total fat intake. Eat more high fiber foods.

2. Be moderate in the consumption of alcoholic beverages.

3. Be moderate in the consumption of salt-cured, smoked cured and nitrate-cured foods.

4. Include foods rich in Vitamin C and A in daily diet

DIETARY RECOMMENDATION

5. Include anti-oxidant foods in daily diet

Example:

Beta Carotene- found in carrots and orange

Lutein- best known for its association to healthy eyes found in green leafy vegetables.

Lycopene- a potent anti-oxidant found in tomatoes, water melon, guava and papaya

Therapeutic Modalities of Cancer

A. SURGICAL INTERVENTIONS

SURGICAL PROCEDURES FOR BREAST CANCER

PATIENT

LUMPECTOMY• Lumpectomy is the removal

of the breast tumor (the "lump") and some of the normal tissue that surrounds it. Lumpectomy is a form of “breast-conserving” or "breast preservation" surgery. There are several names used for breast-conserving surgery: biopsy, lumpectomy, partial mastectomy, re-excision, quadrantectomy, or wedge resection. Technically, a lumpectomy is a partial mastectomy.

SIMPLE OR TOTAL MASTECTOMY

• Simple or total mastectomy concentrates on the breast tissue itself:

• The surgeon removes the entire breast.

• No muscles are removed from beneath the breast

MODIFIED RADICAL MASTECTOMY

• Modified radical mastectomy involves the removal of both breast tissue and lymph nodes:


• Axillary lymph node dissection is performed, during which levels I and II of underarm lymph nodes are removed (B and C in illustration).

• No muscles are removed from beneath the breast.

RADICAL MASTECTOMY

• Radical mastectomy is the most extensive type of mastectomy:


• Levels I, II, and III of the underarm lymph nodes are removed (B, C, and D in illustration).

• The surgeon also removes the chest wall muscles under the breast.

PARTIAL MASTECTOMY

• Partial mastectomy is the removal of the cancerous part of the breast tissue and some normal tissue around it. While lumpectomy is technically a form of partial mastectomy, more tissue is removed in partial mastectomy than in lumpectomy.

SUBCUTANEOUS (NIPPLE SPARING) MASTECTOMY

• During subcutaneous ("nipple-sparing") mastectomy, all of the breast tissue is removed, but the nipple is left alone. Subcutaneous mastectomy is performed less often than simple or total mastectomy because more breast tissue is left behind afterwards that could later develop cancer.

Breast caPREOPERATIVE CARE

•Psychological support- involve the husband as

necessary

•Teach arm exercise to prevent lymph edema

• Inform about wound suction drainage

• e.g. Hemovac, Jackson Pratt

• Deep breathing exercise to prevent post

• operative

• respiratory complications.

DO’S AND DON’TS AFTER THE SURGERY

Do’s

• Before exercising actively, be certain that post-surgery swelling subsides and that surgical wounds are healing.

• Try to start moving as soon as possible after surgery.

• Keep arm elevated after surgery to prevent swelling. Use two pillows to support arm when lying down or sitting.

• Stretch both sides of upper body a few times per day. 3-5 slow repetitions of each stretch.

• Know the difference between discomfort and unusual pain. If pain or fatigue persists, stop and rest.

• After surgery, try to walk around (indoors) for a few minutes 2 - 3 times daily to regain stamina.

• Avoid lifting anything over 2-3 pounds, particularly with the involved arm.

• Enlist anyone you can to accompany you and encourage you to walk frequently.

• Use discretion and follow your intuition. When in doubt, check in with your physician, nurse, or physical therapist.

• Above all, strive for a little improvement every day. Persevere!

• Continue an exercise upon unusual discomfort or persistent pain.

• Continue an exercise upon unusual fatigue. Rest for a moment, breathe, relax, and then continue slowly and carefully. If fatigue persists, stop exercising.

• Hesitate to call your physician immediately when experiencing unusual or persistent pain or swelling.

Don'ts• Let mastectomy arm hang down, especially when

holding or carrying objects.

• Move arm quickly, or with jerking, pulling motions. Learn to move slowly and smoothly, especially when changing positions, lifting bags, opening doors, etc.

• Carry anything over two pounds after surgery until you receive approval from your physician. Limit carrying anything over 5 pounds indefinitely with involved arm to prevent swelling.

• Wear shoulder bags on involved arm. The pressure of the strap on the shoulder can cause lymphedema. Avoid use of shoulder bags indefinitely.

Breast ca

POST OPERATIVE CARE

•Move arm quickly, or with jerking, pulling motions. Monitor hemovac output (serosanguinous for the first 24 hours)

•Check behind of the patient for bleeding. Blood flows to back by gravity.

Breast ca

•Post signs warning against taking BP, starting IV line or drawing blood on affected side.

Initiate exercise to prevent stiffness and contracture of the shoulder girdle

•Reinforce special mastectomy exercise as prescribed

•Provide adequate analgesia to promote ambulation and exercise.

Breast ca

•Encourage regular coughing and deep

breathing exercises

•Prepare client for size and appearance of the

incision and provide support when incision is

viewed for the first time

•Provide client with detailed information

concerning breast prosthesis. Fitting is not

possible for 4-6 weeks

Breast ca

•A temporary prosthesis or lightly padded bras worn until healing is completed.

Teach patient to avoid constrictive clothing and report persistent edema, redness or infection of incision.

•Teach patient the importance of continuing monthly BSE on the remaining breast

Prevention of lymph edema

AVOID

cuts, scratches, pinpricks, hangnails, insect bites, burns and strong detergent

DONT'S (On the affected arm)

carry purse or anything heavy, wear wrist watch or jewelry, pick and cut cuticles, work near thorny plants, dig garden, reach into hot oven, hold a cigarette, injections, BP taking and withdrawal of bllood.

Prevention of lymph edema

DO'S

wear loose rubber gloves when washing dishes, wear a thimble when sewing, apply lanolin hand cream to prevent dryness, contact physician if arms get red, warm or swollen, return for check up, wear tag “CAUTION-LYMPHEDEMA”

POST-OPEXERCISES

BALL SQUEEZE• Stand or sit comfortably.

• Hold a soft rubber ball in the hand on your operated side.

• With your elbow slightly bent and your palm toward the ceiling, lift your hand higher than your heart.

• Squeeze and relax your hand ten times, twice a day.

• Gradually increase the number

of times you do the exercise each day.

FRONT ARM RAISE• Stand or sit comfortably.

• Relax your arms and allow them to hang at your sides.

• Keeping your palms down, slowly raise your arms in front of you, taking two counts to reach shoulder level.

• Slowly lower your arms back down to your sides in two counts.

• Repeat this exercise 8 to 10 times, three times a day.

HAND CLAP• Stand or sit comfortably.

• Relax your arms and allow them to hang at your sides.

• Slowly raise your arms out to the sides, until they are at shoulder level.

• Continue to raise both arms, trying to clap your hands overhead.

• Slowly lower your arms, taking 4 counts to return your arms to your sides.

• Repeat this exercise 8 to 10 times, three times a day.

WALL WALKING

• Stand with one side of your body facing a wall and your feet about 6 inches away from it.

• Starting with your hand at eye level, walk your finger up the wall as high as you can. Hold the stretch for 10 seconds and then walk your fingers back down.

• Repeat the exercise with your other arm.

• Repeat this exercise 8 to 10 times, twice a day.

SHOULDER SQUEEZE• Standing, bend your elbows and

bring your arms up in front of you to shoulder level.

• With one arm stacked on top of the other, align your fingertips with your elbows.

• Next, push your elbows back, squeezing your shoulders together.

• Hold for 12 seconds.


ARM STRETCH• Standing, grasp a pole or rod in front of you

with both hands. Try a golf club or broomstick.

• Place the hand on your operated side over the end.

• Gently, use the strength of your good arm to push the end of the stick as high as you comfortably can.

• Hold for 12 seconds.


• Slowly raise your arms out to the sides, until they are at shoulder level.

LUNG CANCER

Pneumonecto

my ► total lung

removal.

It can be done in one of two

ways:Traditional Pneumonectomy

Only the diseased lung is removed.

Extrapleural Pneumonectomy

The diseased lung is removed, together with a

portion of the membrane covering the

heart(Pericardium), part of the diaphragm, and

the membrane lining the chest cavity (Parietal

pleura) on the same side of the chest.

Lobectom

ysurgical removal

of one of the five

lobes of the lung.

Wedge

Resection► A surgical procedure during

which the surgeon removes a

small, wedge-shaped portion of

the lung containing the

cancerous cells along with

healthy tissue that surrounds

the area. The surgery is

performed to remove a small

tumor or to diagnose

Lung Cancer.

Segmental Resection► Removes a larger

portion of the lung lobe

than a wedge resection,

but does not remove

the whole lobe.

Do’s: Shower daily and wash incision and

drain sites. Let the water stream run over the incision

and drain sites. Leave the incisions uncovered of the chest

tubes and the drain sites may drain for several

days, and therefore may need a Band-Aid.Wear comfortable clean clothing

preferably cotton clothing

Ambulate early. Stop when you

are short of breath, rest, and then

continue. Fatigue and tiredness

are expected. It is entirely normal

that you may have to take a nap

in the morning or in the

afternoon. Avoid spending

prolonged periods of time lying

down during the daytime hours.

Don'ts: If you were a smoker, do not

restart. If your environment-your

apartment or house-still contains

curtains, linens, and furniture full

of smoke and tobacco odor that

can give you the urge to smoke

again, please have them cleaned.

Do not lift anything heavier than 10

pounds for about 4-6 weeks.

Remember that your recovery overall

takes about 10-12 weeks.

Do not drive until your surgeon says

that you can. Generally, at about 3

weeks you will be allowed to drive

locally.

Management for client with cervical cancer

SURGERY:

•EXCISIONAL BIOPSY for preinvassive lesions

•CRYOSURGERY technique of exposing tissues to extreme cold in order to produce well demarcated areas of cell injury and destruction

•LASER destruction of the tumor

•CONIZATION is removal of the cone shape section of the cervix

•HYSTERECTOMY for invasive squamous cancer.

• Also called a cone biopsy

• A procedure that is used to remove a cone-shaped piece of tissue from the cervix and cervical canal

• A surgical procedure that is used to remove the uterus, including the cervix

• There are three different procedures that may be used to perform a total hysterectomy

VAGINAL HYSTERECTOMY

- In which the uterus and cervix are In which the uterus and cervix are taken out through the vaginataken out through the vagina

TOTAL ABDOMINAL TOTAL ABDOMINAL

HYSTERECTOMYHYSTERECTOMY

- - In which the uterus and cervix In which the uterus and cervix

are taken out through a large are taken out through a large

incision (cut) in the abdomenincision (cut) in the abdomen

TOTAL LAPAROSCOPIC HYSTERECTOMY

- - In which the uterus and cervix are In which the uterus and cervix are taken out through a small incision taken out through a small incision in the abdomen using a in the abdomen using a laparoscopelaparoscope

• A BSO is a surgical procedure that is used to remove the ovaries and the fallopian tubes

• Is a surgical procedure that is used to remove the uterus, cervix and part of the vagina

• Ovaries, fallopian tubes, or nearby lymph nodes may also be removed

• Surgeons will need to make artificial openings (stomas) for the urine and the stool

• women may need plastic surgery to make an artificial vagina after they have had a pelvic exenteration

• Is a treatment that uses elecrical current (passed through a thin wire loop) as a knife to remove abnormal tissue or cancer

Cervical ca

PREOPERATIVE PREPARATION:

•Advise client to be admitted in the hospital 1 day prior to operation

•Take time to talk to the client on what she expects from the surgery and about her menstrual and reproductive status after surgery

•Review what the surgical approach involves and the extent of the excision

Cervical ca

•If the client is having an abdominal hysterectomy, tell her that she will need to:

•Douche and have an enema the evening before the surgery

•Take a shower with an antibacterial soap shortly before the surgery

•Shave her pubic area

•*Have an indwelling urinary catheter inserted because surgery causes urine retention

Cervical ca preop prep

*Have an NGT or rectal tube inserted if she develops abdominal distentionExpect temporary abdominal cramping , pelvis and lower back pain after the procedure

If the client is scheduled for vaginal hysterectomy, tell her to expect abdominal cramping afterwards. She will also have a perineal pad in place because moderate amounts of drainage occurs post operatively.

Cervical ca preop prep•Inform the client that after surgery, she needs to lie in a supine position or in low Fowler's position

•Demonstrate the exercises that she will need to perform to prevent venous stasis

POST OPERATIVE CARE

•For- vaginal hysterectomy, change her perineal pad frequently. Provide analgesics to relieve cramps.

• Change perineal pads frequently because moderate amounts of drainage because moderate amounts of drainage occurs post-operativelyoccurs post-operatively

• Provide analgesics to relief crampsto relief cramps

• Monitor urinary output because urinary because urinary retention commonly occursretention commonly occurs

• Encourage patient to perform the prescribed exercises and to ambulate early and frequently to prevent to prevent venous stasisvenous stasis

Venous stasis

–retardation of the venous outflow

in a part

Cervical ca post op care

•If she has had an abdominal hysterectomy, tell her to remain in a supine position or a low Fowler's position. Encourage her to perform the prescribed exercises and to ambulate early and frequently to prevent venous stasis. Monitor UO because retention commonly occurs.

•If abdominal distention develops, relieve it by inserting NGT or rectal tube as ordered. Note bowel sounds during routine assessment.

• Avoid heavy lifting to avoid pressure on to avoid pressure on incision siteincision site

• Avoid rapid walking, dancing• Advice to eat high protein, high residue

diet to avoid constipationto avoid constipation• Give 2.8 Liters/day • May resume sexual activity 6 weeks

after surgery

• Explain that abrupt hormonal fluctuations may cause the client to feel may cause the client to feel depressed or irritable for a whiledepressed or irritable for a while

• Encourage family members to respond calmly and with understanding

• If the ovaries were removed, client may client may receive hormone replacement therapyreceive hormone replacement therapy

Cervical ca

HOME CARE:

•If the client had vaginal hysterectomy, instruct to report severe cramping, heavy bleeding or hot flushes (common for Oophorectomy) to her doctor immediately.

•Encourage client to walk a little more each day and avoid sitting for prolonged period. Swimming is permissible.

Surgical removal of

the uterus is

recommended for all

stages of uterine

cancer unless the

cancer is widespread.

In the early stages, it

may be curative.

• A cut is made in the lower abdomen to to expose the tissues and blood vessels expose the tissues and blood vessels that surround the uterus and cervixthat surround the uterus and cervix

• These tissues are cut and the blood vessels are tied off to remove the uterusto remove the uterus

• Stitches are placed in these deep structures, which will eventually dissolve

• The first night after the surgery, you you may be asked to sit up in bed and walk may be asked to sit up in bed and walk a short distancea short distance

• If there is no evidence of complications and you are able to drink fluids on your own, the catheter the catheter in your bladder and IV will be in your bladder and IV will be removedremoved

• Eat balanced diet rich in fresh fruits and vegetables.

• Dependig on how much blood loss occurred during surgery, you may you may require a daily iron supplementrequire a daily iron supplement

• Advise to eat high-fiber foods, drinking plenty of water, and if necessary, use stool softeners

• Shower instead of taking a bath for at least the first two weeks after surgery

• Keep your incision sites clean and dry to avoid infectionto avoid infection

• Do not douche or put anything in your vagina, such as tampon, until your doctor tells you otherwise. Speak to your doctor about when you may resume having sexual intercourse

• Take daily walks as tolerated

• Avoid heavy lifting for four to six weeks

• Ask your practitioner whether any type of physical therapy or nutritional counseling may be helpful to speed your recovery

LUNG CANCER

Pneumonecto

my ► total lung

removal.

It can be done in one of two

ways:Traditional Pneumonectomy

Only the diseased lung is removed.

Extrapleural Pneumonectomy

The diseased lung is removed, together with a

portion of the membrane covering the

heart(Pericardium), part of the diaphragm, and

the membrane lining the chest cavity (Parietal

pleura) on the same side of the chest.

Lobectom

y surgical removal of

one of the five lobes

of the lung.

Wedge

Resection► A surgical procedure during

which the surgeon removes a

small, wedge-shaped portion of

the lung containing the cancerous

cells along with healthy tissue that

surrounds the area. The surgery is

performed to remove a small

tumor or to diagnose

Lung Cancer.

Segmental

Resection► Removes a larger

portion of the lung lobe

than a wedge resection,

but does not remove

the whole lobe.

Management of client with lung cancer

PREOPERATIVE PREPARATION:•Explain the anticipated surgery to the client and inform him that he will receive a general anesthetic.

Lung ca pre-op prep

•Inform the client that post operatively, he may have chest tubes in place and may receive oxygen.

•Teach him deep breathing techniques and explain that he will perform these after surgery to facilitate lung reexpansion. Also teach him to use an incentive spirometer; record the volumes he achieves to provide a baseline.

Lung ca

POST OPERATIVE CARE:

•After pneumonectomy, the client should lie only on the operative side or on his back until stabilized. This prevents fluids from draining into the unaffected lung if the sutured bronchus opens.

•Make sure that the chest tube is functioning, if present, and observe for signs of tension pneumothorax.

•Provide analgesics as ordered

Lung ca post op care

•Have the client begin coughing and deep breathing exercises as soon as his condition is stable. Auscultate his lungs, place him in semi Fowler's position, and have him splint his incision to facilitate coughing and deep breathing.

•Perform passive range of motion exercises the evening of surgery and 2-3 times daily thereafter. Progress to active range of motion exercises.

Lung ca home care

•Tell the client to continue his coughing and deep breathing exercises to prevent complications. Advise him to report changes in sputum characteristics to his doctor.

•Instruct the client to continue performing range of motion exercises to maintain mobility of his shoulder and chest wall.

•Tell the client to avoid contact with people who have an URTI and to refrain from smoking

Lung ca home care

•Provide instructions for wound care and dressing changes as necessary.

Do’s: Shower daily and wash incision and

drain sites. Let the water stream run over the incision and drain sites. Leave the incisions for the chest

tubes and drain sites uncovered. The sites

may

drain for several days, and

therefore

may need a Band-Aid.

Post-OP Care

Wear comfortable clean clothing

preferably cotton clothingAmbulate early. Stop when you are short

of breath, rest, and then continue. You

may not see a daily increase, but over a

week's time you should see an increase in

the distance that you are able to walk

Post-OP Care

Post-OP Care

• Do’s:• We suggest that you weigh

yourself twice a week and that you keep a record of your weight.

Post-OP Care

Do take your pain medications as needed. In the beginning, you should take your medications on a regular basis as they were prescribed. Often, you receive two types of pain medication, one of which should be taken constantly to produce a steady level of analgesia -pain relief-. The other medication is given for "breakthrough" pain or the peaks, which you take as needed depending on your daily activities.

Management of client with prostate cancer

SURGERY;

•SUPRAPUBIC PROSTATECTOMY

A surgical approach that involves a lower abdominal incision. Operation of choice when the prostate is too large to be resected transurethally.

•TRANSURETHRAL PROSTATECTOMY

Excision of part of the prostate gland through the urethra.

•PERINEAL PROSTATECTOMY

Excision of part or all the prostate gland with an incision in the perineum.

PREOPERATIVE CARE:

•Assess the client's ability to empty his bladder.

•Clients taking any drug or supplement with anti coagulant effects must discontinue before surgery

Prostate ca preop care•Respond to the concerns of the client and significant others with emphatic listening, accurate information and on going support.


•Observe the vital signs and maintenance of urinary drainage

•Document the urine color, including the presence of blood clots, each time urine out put is recorded

Prostate ca post op care

•Ensure catheter patency frequently to make sure the catheter is draining, blockage of an irrigated bladder rapidly leads to over distention, secondary hemorrhage and formation of blood clots or infections.

Management of client with thyroid cancer

THYROIDECTOMY

Surgical removal of the thyroid gland

PREOPERATIVE CARE:

•Administration of anti-thyroid drugs

•Preparation is about 2-3 months

•Provide adequate rest

•Achieve and maintain optimal weight

•Maintain good health status

Thyroid ca


•Take vital signs every 15 minutes until stable, every 1 hour for the next 24 hours

•Place client in sitting position with head and arms well supported as soon as she recovered from anesthesia

•Watch for edema or swelling due to bleeding into the wound

Thyroid ca post op care•Suction mouth and throat if necessary

•Cough and deep breathing exercise every hour

•Give fluids by mouth as tolerated

•Give Morphine SO4 for pain

•Observe for hoarseness and evidence of injury to parathyroid gland

•Signs and symptoms:

•Tingling and tightness of the fingers, anxiety, and mental depression

Thyroid ca post op care

•Have the following at bed side:Tracheostomy setEndotracheal tubeLaryngoscopeOxygenGive mist inhalation until chest is clearTake temperature every 4 hours for 24 hoursAssess for hypocalcemia and monitor calcium, magnesium and phosphorous.

Management of client with colorectal cancer

SURGERY:

•For tumors of the cecum or ascending colon, right hemicolectomy for advanced disease may include resection of the terminal segment of the ileum, cecum, ascending colon, and right half of the transverse colon with corresponding mesentery.

•For tumors of the proximal and middle transverse colon, right colectomy includes transverse colon and mesentery corresponding to mid colonic vessels

Colerectal ca

Alternatively, the surgeon may perform segmental resection of the transverse colon and associated mid colonic vessels.

•For sigmoid colon tumors usually limited to the sigmoid colon and mesentery.

•Upper rectum tumors usually call for anterior or low anterior resection. A newer method, using a stapler, allows resections much lower than were previously possible.

Colorectal ca

•For tumors in the lower rectum, abdominoperineal resection and permanent sigmoid colostomy are usually performed.

PREOPERATIVE PREPARATION:

•Before the surgery, arrange for the client to visit an enterostomal therapist, who can provide more detailed information and for chosing the best location for the stoma

Colorectal ca preop prep

•Try to have the client meet with an ostomy client who can share his personal insights into the realities o living with and caring for a stoma

•Evaluate his nutritional and fluid status. Typically, the client will receive TPN to prepare him for the physiologic stress of surgery.

•Record the client's fluid intake and output and weight daily. Watch for early signs of dehydration.

Colorectal ca preop prep

•Expect to draw periodic blood samples for hematocrit and hemoglobin determinations. Be prepared to transfuse blood if ordered.


•Monitor I and O, and weigh daily. Maintain fluid and electrolyte balance, and watch for signs of dehydration (decrease UO, poor skin turgor) and electrolyte imbalance.

Colorectal ca post op care

•Provide analgesics as ordered, Be especially alert for pain in the patient with an abdominoperineal resection because of the extent and location of the incisions.

•Note and record the color, consistency and odor of fecal drainage from the stoma. If the client has double barrel colostomy, check for mucus drainage from the inactive (distal) stoma. The nature of fecal drainage is determined by the type of ostomy

Colorectal ca post op care

Surgery, generally, the less colon tissue that's removed, the more closely drainage will resemble normal stool. For the first few days after surgery, fecal drainage probably will be mucoid (and probably blood tinged) and mostly odorless. Report excessive blood and mucus content, which could indicate hemorrhage or infection.

Watch out for sepsis

•Observe the client for signs of peritonitis or sepsis, caused by bowel contents leaking into the abdominal cavity. Remember that clients receiving antibiotics or TPN are at an increased risk for sepsis.

•Provide for meticulous wound care, changing dressings often. Check dressing and drainage sites frequently for signs of infection (purulent discharge, foul odor0 or fecal drainage.

Watch for sepsis

If the client has had an abdominoperineal resection, irrigate the perineal area as ordered.

•Regularly check the stoma and the surrounding skin for irritation and excoriation, and take corrrective measures. Also observe the stoma's appearance. The stoma should look smooth, cherry red and slightly edematous, immediately report any discoloration or excessive swelling, which may indicate circulatory problems that could lead to ischemia.

Watch out for sepsis

During the recovery period, encourage the client to express his feelings and concerns, reassure an anxious or depressed patient that these common post operative reaction should fade as he adjusts to the ostomy. Continue to arrange for visits by an enterostomal therapist.

Colorectal ca home care

HOME CARE INSTRUCTIONS FOR CLIENT WITH COLOSTOMY:

•Teach client or caregiver how to apply, remove and empty the pouch. Teach him how to irrigate the colostomy with warm tap water to gain some control over elimination.. Reassure him that he can regain continence with dietary control and bowel retraining.

Home care•Instruct the client to change the stoma appliance as needed, to wash the stoma site with warm water and mild soap every 3 days, and to change the adhesive layer. These measures help prevent skin irritation and excoriation.

•Discuss dietary restrictions and suggestions to prevent stoma blockage, diarrhea, flatus and odor. Tell the client to stay on a low fiber diet for 6-8 weeks and to add new foods to his diet gradually.

Home care•Suggest the use of ostomy deodorant or odor proof pouch if he include odor producing foods to his diet.

•Trial and error will help the client determine which foods cause gas. Gas producing fruits include apples, melons, avocados, and cantaloupe, gas producing vegetables are beans, corn, and cabbage.

•The client is especially susceptible to fluid and electrolyte losses. He must drink plenty of fluids

Home care

Especially in hot weather and when he has diarrhea. Fruit juice and bouillon, which contain potassium are particularly helpful.

•Warn the client to avoid alcohol, laxatives and diuretics which will increase fluid loss and may contribute to an imbalance.

If the client had an abdominoperineal resection,suggest sitz bath to help relieve perineal discomfort. Recommend refraining from intercouse until the perineum heals.

Acute leukemia

A cancerous WBC precursor called blast proliferate in the bone marrow or lymph tissue and then accumulate in peripheral blood, bone marrow and body tissues

CLASSIFICATIONS:

•ACUTE LYMPHOBLASTIC LEUKEMIA

marked by abnormal growth of lymphocyte precursors (lymphoblast)

Classification of leukemia

•ACUTE MYELOGENOUS LEUKEMIA

characterize by rapid accumulation of myeloid precursors (myeloblast)

•ACUTE MONOCYTIC LEUKEMIA or SCHILLING'S TYPE

involves a marked increase in monocyte precursor (monoblast)

•ACUTE MYELOMONOCYTIC and ACUTE ERYTHROLEUKEMIA

Risk factors of leukemia

The cause of leukemia is unknown, but according to some experts, the following are the risk factors

•A combination of viruses

•Genetic and immunologic factors

•Exposure to radiation and certain chemicals

pathophysiology

The pathogenesis of acute leukemia is not clearly understood. Immature, nonfunctioning WBCs appears to accumulate first in the tissue where they originate (lymphocytes in lymph tissues, granulocyte in bone marrow). These immature WBCs then spill into the blood stream and infiltrate other tissues. Eventually, they cause organ malfunction from encroachment or hemorrhage.

Signs and symptoms

ACUTE LEUKEMIA

•High fever of sudden onset

•Abnormal bleeding

•Easy bruising with even minor trauma

•Prolonged menses

NON SPECIFIC SIGNS

•Low grade fever

•Pallor, weakness and lassitude

Signs and symptoms

ALL, AML,ACUTE MONOCYTIC LEUKEMIA

•Dyspnea

•Fatigue

•Malaise

•Tachycardia

•Palpitations

•Systolic ejection murmur

•Abdominal or bone pain

Signs and symptoms

MENINGEAL LEUKEMIA

•Confusion

•Lethargy

•headache

Laboratory exams

•BONE MARROW BIOPSY

Performed in client with typical clinical findings but whose aspirate is dry or free from leukemic cells. It shows proliferation of immature WBCs.

•WBC differential determines cell type

•CBC shows decreased levels of hemogobin (anemia), platelets (thrombocytopenia) and neutrophils (neutropenia).

Laboratory exams

•LUMBAR PUNCTURE detects meningeal involvement

•URIC ACID measurement may be done to detect hyperuricemia

Nursing management

•Control infection by placing the client in reverse isolation. Coordinate care so client does not come in contact with staff who also care for clients with infection or infectious disease. Avoid using IFC and giving IM injections, which can pave way for infection. Screen staff and visitors for contagious disease. Watch for and report signs and synptoms of infection.

Nursing management

•Monitor the client's vs q 2-4 hours. A temperature of 38.3C accompanied by a decrease in WBC count calls foe prompt antibiotic therapy.

•Watch for bleeding. If occurs, apply ice compress and pressure, elevate the affected extremity. Avoid giving aspirin-containing drugs, taking rectal temp,,giving rectal suppositories and performing DRE.

Nursing management

•Watch for signs s/s of meningeal leukemia. If these occurs, provide care after intrathecal chemo. After instillation, place the client in Trendelenberg position for 30 mnutes. Give plenty of fluids, and keep him supine for 4-6 hours. Check lumbar puncture site for bleeding.

•If the client has receiving cranial radiation, teach him about potential adverse effects, and try to minimize them.

Nursing management•Take steps to prevent hyperuricemia- a possible result of rapid chemotherapy induced leukemic cell lysis. Give the client about 2L of fluids daily, and administer acetazolamide, sodium bicarbonate tablets and allopurinol as ordered. Check urine pH often-it should be above 7.5. Watch for rashes and other hypersensitivity reactions to allopurinol.

•Control mouth ulcers by checking often for obvious ulcers and gum swelling and by providing frequent mouth care and saline solution rinses.

Nursing management

•Check the rectal area daily for induration, swelling, erythema, skin discoloration and drainage.

•Minimize stress by providing a calm, quiet atmosphere that promotes rest and relaxation.

•Provide psychological support by establishing a trusting relatioship with the client. Allow him and his family to expres their anger, anxiety and depression. Encourage them to ;participate in client care as much as possible.

Nursing management•For client with terminal disease that resists chemo, provide supportive care directed at promoting comfort; managing pain, fever and bleeding; and offering emotional support. Provide the opportunity for religious counseling, if appropriate. Discuss the option of home or hospice care.

•Evaluate the patient. He and his family should understand the rationale for treatment and potential complications of chemo. They should also know how to recognize s/s of infection and understand

Nursing management

And understand that they must notify the doctor if these occur. They should be able to discuss treatment options and verbalize concerns about a poor prognosis..

B. CHEMOTHERAPY

A. DESCRIPTION

OTHER TERM:

chemo, antineoplastic drugs, anticancer, cytotoxic drugs

•Used to describe drugs that kill cancer cells directly

•It promotes tumor cell destruction by interfering with cellular function and reproduction

Principles of chemotherapy1. The intent of chemo is to destroy as many tumor cells as possible with minimal effect on healthy cells.

2. Therapeutic strategies

•Adjuvant therapy

•Neoadjuvant therapy

•Induction therapy

•Consolidation therapy

3. Cancer cells depend on the same mechanisms for cell division as in normal cells.

Principles of chemo

4. Chemo agents can be effective in one of the five phases of the cell cycle

Normal cell cycle•G0 PHASE (resting phase)

Cells have not yet started to divide. Last for few hours to few years.

•G1 PHASE (gap one)

The cells starts making more protein to get ready to divide.

•S PHASE (synthesis)

The proteins containing the genetic code (DNA) doubles so that both new cells are formed will have the right amount of DNA.

Normal cell cycle

•G2 PHASE (gap two)

Period of protein and RNA synthesis and the mitotic spindle apparatus is formed.

•M PHASE (mitosis)

The cell actually divides into two identical cells

Goals for chemotherapy treatment

1. To cure a specific cancer

2. To control tumor growth

3. To relieve symptoms caused by cancer

4. To destroy microscopic cancer cells

5. To shrink tumors before surgery or radiation

Contraindications of chemotherapy

1. INFECTION. The anti-tumor drugs are immunosuppressives.

2. RECENT SURGERY. The drugs may retard healing process

3. IMPAIRED RENAL AND HEPATIC FUNCTIONS. The drugs are hepatotoxic and nephrotoxic

4. RECENT RADIATION THERAPY. Also immunosuppresive.

Contraindications of chemotherapy

4. PREGNANCY. The drugs may cause congenital defects.

5. BONE MARROW DEPRESSION. The drugs may aggravate the condition. The WBC levels must be within normal limits.

Classifications of chemo agents

1. ALKALYTING AGENT

ACTION: *Most active during the resting phase of the cell.

* It interfere with DNA and RNA growth

EXAMPLES: Cyclophosphamide, Busulfan, Carmustine, Carboplastic, Leukeran, Lomustine, Cisplatin, Dacarbazine, Ifosfamide, Mesna, Semustine, Melphalan

Alkalyting agents

ADVERSE EFFECTS:

Nausea, vomiting, alopecia, hemorrhagic cystitis, thrombocytopenia, myelosuppression

NURSING CONSIDERATIONS:

•Monitor liver functions and CBC

•Drink 2-3L of fluids daily

•Reassurance for hair loss

•Administer anti emetic drugs as ordered

•Observe for hypersensitivity reactions.

Alkylating agents

Classifications of chemo drugs

2. ANTIMETABOLITES

ACTIONS:

•Drugs are very similar to normal substances within the cell

•Attack cells at very specific phase of the S Phase

•Inhibit cell reproduction by interfering with manufacture of protein

•Cell cycle specific drug

antimetabolites

Classifications of chemo drugsEXAMPLES OF ANTIMETABOLITES:

Azacytadine, Cytarabine, 5 Flouraouracil, Hydroxy Urea, 5-Mercaptopurine, Methotrexate, Thioguanine, Gemcitabine, Taxanes, Taxotere

ADVERSE EFFECTS:

•N/V,stomatitis

•Thrombocytopenia, diarrhea

•Myelosuppression, alopecia

•Renal and hepatic dysfunctions

•Neuropathy

antimetabolites


•Monitor liver function, CBC, Urea and Creatinine

•Provide oral hyiene

•Administer antiemetic drugs as ordered

•Observe other s/s of side effects


3. ANTINEOPLASTIC ANTIBIOTICS

ACTIONS:

•Interfere with DNA by stopping enzymes and mitosis or altering the membranes surrounding the cell

•Works in all phases of cell cycle

EXAMPLES:

Bleomycin, Dactomycin, Adriamycin, Mitomycin

Antitumor antibiotics

Antineoplastic antibiotics

ADVERSE REACTIONS:

•N/V, stomatitis

•Myelosuppression, thrombocytopenia

•Renal and hepatic dysfunctions

•Alopecia


•Hydration, monitor lab test

•Antiemetics, oral care


4. PLANT ALKALOIDS

Derived from certain types of plants

a. Vinca Alkaloids- made from periiwinkle plants Catharantus rosea

b. Taxanes- made from bark of the Pacific few tree Taxus

c. Podophylotoxins- derived fro the May apple plant

d. Campotheca acuminata- derived from the Asian “Happy Tree”

Plant alkaloids

ACTIONS:

•Attack the cell during various phases of cell division especially the M Phase

•Cell cycle specific

•Known as Mitotic o Topoisomerate inhibitors

EXAMPLES:

Velba, Vincristine, Vinblastine, Tenipride, Nevelbine

ADVERSE EFFECTS:

Diarrhea, neuropathy, alopecia, stomatitis, paiin in the IV site

Topoisomerase Inhibitors

Mitotic Spindle Poisons


NURSING CONSIDERATIONS (PLANT ALKALOIDS)

•Hydration

•Avoid handling pointed and breakable objects

•Reassure that hair will grow again after the therapy

•Provide mouth care

•Observe IV site


5. HORMONE OR HORMONE MODULATORS

ACTION:

A. Natural Hormones- drugs that are useful in treating some types of cancer

EX. Corticosteroids

B. Some sex hormones alter the action or production of female and male hormone. They are used to inhibit the new growth of the breast, prostate and endometrial lining

EX. Tamoxifen or Nalvadex, Testofactone or Teslac

hormoneADVERSE EFFECTS:

•Signs and symptoms of menopause

•Bone marrow depression, retinopathy

•Teslac may produce altered libido, facial hair growth, enlargement of the clitoris


•Monitor CBC

•Health teaching regarding changes on reproductive system and vision

Routes of administration for chemo agents

•Oral

•IV

•IM

•Intrathecal or intraventricular

•Intraarterial

•Intracavitary

•Intravesical

•topical

Administration of IV chemo agents

1. PREPARATORY PHASE

A. Patient Education

•Review treatment goals

•Review treatment plans and adverse reactions

•Review strategies to manage reactions

•Instruct client on a reportable condition

B. Before administering chemo drugs, check for:

Doctors order, medication, history, type of drugs, route, dose, duration of therapy, and current laboratory results

Administration of IV chemo drugsC. Calculate the dosage according to mg/kg

body weight or mg/m2 by body surface area.

D. Verify client's name and identification

E. Be aware of the agents that cause anaphylactic reaction

2. PERFORMANCE PHASE

A. Insertion of IV access

•Select venipuncture site free from sclerosis, thrombosis or scar formation

Check for blood return or patency of the site

Types of vascular access devices

1. Peripherally inserted catheter (Per-Q-Cath)

•Placed in the arm and treaded through the vein up to the near the heart

•Allows for continuous access for peripheral vein for several weeks.

•No surgery is needed. Care for the catheter is required.

Vascular access2. MID LINE CATHETER (Per-Q-Cath Midline)

•Also placed in the arm but the catheter is not inserted as far as PIC

•Used for intermediate length therapy when a regular peripheral IV is not advisable. No surgery needed. Care of the catheter is required.

3. TUNNELED CENTRAL VENOUS CATHETER (Hickman, Broviac, Groshon)

•Catheter with multiple lumens surgically placed in large central vein in the chest and the catheter

Vascular access

Tunneled under the skin. Care of the catheter is needed.

4. IMPLANTABLE VENOUS ACCESS PORT (Port-A-Cath, BardPort, Medi-Port)

A port of plastic, stainless steel or titanium with silicone septum. The catheter is surgically placed under the skin of the chest or arm in a large central vein. The port is accessed by a needle to give chemotherapy.

Vascular access

5. IMPLANTABLE PUMP

A titanium pump with an internal power source surgically implanted to give continuous infusion chemotherapy usually at home. There is a refillable reservoir for continuous infusion.

Administration of IV chemo drugs

B. ADMINISTRATION PHASE

SEQUENCE OF DRUG ADMINISTRATION

1. The recommended practice is to administer vesicant first. Check IV site for:

•Good vein integrity

•Vein is stable and less irritated

•Assessment for vein patency

•Less chance of compromised vascular integrity

Sequence of drug administration2. Apply a disposable absorbent plastic (backed pack under the area)

3. Put protective gown, gloves and goggles if necessary. Order of protective equipment:

•Donning- mask, gown, gloves, goggles

•Removing-gown, gloves, goggles, mask

4. Monitor IV site regularly. Observe for EXTRAVISATIONS or accidental infiltration of vesicant or irritant chemo drugs from the vein into the surrounding tissues of the IV site.

extravisation

SIGNS AND SYMPTOMS

•Pain, burning sensation and inflammation

IF LEFT UNTREATED

•There will be hyperpigmentation, sloughing, necrosis and ulceration.

FOR SEVERE EXTRAVISATIONS

•May result in damage to tendons and nerves

END RESULT: AMPUTATION

Management for extravisation

•STOP vesicant and IV fluids

•Wear gloves, leave catheter in place, disconnect line from IV site

•Attach a syringe and aspirate

•Notify the physician

•Administer prescribed antidote

extravisation

FOR SUBCUTENEOUS EXTRAVISATION:

•Wear gloves, remove IV catheter, avoiding excess pressure on the site

•Inject antidote SC of the affected site. Use gauge 25 neeedle.

•Instruct client to rest, elevate the site, apply ice for 24 -48 hours then resume normal activity.

•Assess for a plastic surgery consult

Admin of chemo drugs

C. FOLLOW UP PHASE

•Documentation

•Monitoring of pain and erythema, induration or necrosis

•Monitoring for the other adverse effects of the drug

Side effects of chemo agents and their nursing interventions

1. GASTROINTESTINAL SYSTEM

•N/V, diarrhea, constipation

Nursing Actions:

•Replace fluids and electrolyte losses

•Low fiber diet to relieve diarrhea

•Increase fluid intake and high fiber diet to relieve

• constipation

•Administration of antiemetic drugs as ordered

NAUSEA AND VOMITING Chemotherapy drugs cause

nausea and vomiting for a variety of

reasons. One reason is they irritate

the lining of the stomach and

duodenum (the first section of the

small intestine). This stimulates

certain nerves that activate the

vomiting center (VC) and the

chemoreceptor trigger zone (CTZ) in

the brain which leads to vomiting.

Another way these areas of the brain

can be activated is through

obstruction (intestinal blockage),

delayed gastric emptying, or

inflammation

CONSTIPATION Constipation is the passage (usually with discomfort) of infrequent, hard, dry stool. If you have constipation, you may also notice bloating, increased gas, cramping, or pain. Constipation affects about half of people with cancer and about 3 out of 4 of those with advanced cancer. It can lead to nausea and a decreased appetite.

DIARRHEA Diarrhea is the passage of increased volume of loose or watery stools several times a day with or without discomfort. Along with diarrhea, you may have gas, cramping, and bloating. Diarrhea occurs in about 3 out of 4 people who receive chemotherapy because of the damage to the rapidly dividing cells in the digestive (gastrointestinal) tract.

APPETITE LOSS AND WEIGHT CHANGES Most chemotherapy medicines

cause some degree of anorexia, a

decrease in or complete loss of

appetite. Loss of appetite, as well as

weight loss, may also result directly

from effects of the cancer on the

body's metabolism.

Anorexia may be mild. If it is severe,

it may lead to cachexia, a form of

malnutrition with muscle loss. Proper

nutrition is important during cancer

treatment. It helps strengthen the

body to fight the disease and

infection and also cope with cancer

treatments and their side effects.

TASTE CHANGES Cancer treatments and

the cancer itself can change the way some food tastes. Taste changes can contribute to anorexia, poor nutrition, and weight changes. With taste changes caused by chemotherapy,

Side effects of chemo

2. INTEGUMENTARY SYSTEM

*Pruritus, urticaria

•Provide good skin care

•Observe for anaphylactic reactions

*Stomatitis

•Provide good oral care

•Avoid hot and spicy foods

*Skin pigmentation

•Inform client that it is temporary


* Alopecia

Reassure that it is temporary

Encourage to wear wigs, hat, or

headscarf

*Nail Changes

Reassure that nails may grow

normally after chemo


3. HEMATOPOIETIC SYSTEM

•Anemia-provide frequent rest period

•Neutropenia-protect from infection, avoid people with infection

FATIGUE Fatigue is an extreme tiredness that is not relieved with rest. It is one of the most common side effects of cancer and chemotherapy. It can be one of the most debilitating side effects people experience.


*Thrombocytopenia- protect from trauma, avoid aspirin

4. GENITO-URINARY SYSTEM

*Hemorrhagic Cystitis

•Provide 2-3 L of fluids per day

•Monitor UO

•Assess for urinary frequency, ugency

•Monitor BUN, Creatinine

Side effects of chemo5. REPRODUCTIVE SYSTEM

*Amenorrhea and decrease libido for males

•Reassure that menstruation and libido will resume after chemo

6. NEUROMASCULAR SYSTEM

*Paresthesia, Hearing Loss, Blurring of vision

•Determine presence of tingling sensations on toes and fingers

•Evaluate muscle weakness

•Determine peripheral nerve damage and report

NERVOUS SYSTEM CHANGES Some chemotherapy drugs can cause

direct or indirect changes in the central nervous system (brain and spinal cord), the cranial nerves, or peripheral nerves. The cranial nerves are connected directly to the brain and are important for movement and touch sensation (feeling) of the head, face, and neck. Cranial nerves are also important for vision, hearing, taste, and smell. Peripheral nerves lead to and from the rest of the body and are important in movement, touch sensation, and regulating activities of some internal organs.

Safe handling of chemotherapeutic agents

1. Wear mask, back closing gown and gloves.

2. Skin contact with drugs must be washed immediately with soap and water.

3. Eyes must be flushed immediately with copious amounts of water.

4. Sterile or alcohol wet pledgets should be used to wrap around the neck of the ampule

when breaking

or withdrawing the drug.

Safe handling 5. Expel air bubbles on wet cotton.

6. Vent vials to reduce internal pressure when mixing.

7. Wipe external surfaces of syringes and IV bottles.

8. Avoid self inoculation by needle stab.

9. Clearly label the hanging IV bottle with “antineoplastic chemotherapy”

10. Contaminated needles and syringes must be disposed in a clearly marked leak proof and puncture proof container.

Safe handling

11. Dispose half empty ampules, vials, IV bottles by putting into plastic bag. Seal and then put into another plastic bag or box, clearly marked “hazardous waste” before disposal.

12. Only trained personnel should involve in the administration of the drugs.

13. Ideally, preparation of drugs should be in a laminar flow conditions with filtered air.

Personal safety to minimize exposure via skin ingestion

1. Do not eat, drink, chew gum, or smoke while preparing or handling chemo agents.

2. Keep all food and drink away from preparation area.

3. Wash hands before and after handling chemo agents.

4. Avoid hand to mouth or hand to eye contact while handling chemo agents or body fluids of the person receiving chemo.

Personal safety4. Wear nitrite examination gloves at all times when preparing or working with chemo agents.

5. Wash hands before putting on and after removing gloves

6. Change gloves after each use, tear, puncture or medication spill every after 60 minutes of wear.

7. Wear along sleeves non absorbent gown with elastic at the wrist and back closure.

8. Eyes and face shields should be worn if splashes are likely to happen.

Personal safety

10. Use syringe and IV tubings with Luer locks (with locking device to hold needle firmly in place)

11. Label all syringes and IV tubings containing chemo agents as hazardous material.

12. Place an absorbent pad directly under the injection site to absorb any accidental spillage.

13. If any contact with the skin occurs, immediately wash the area thoroughly with soap and water.

Personal safety14. If contact,made with the eye, immediately flush the eye with water and seek medical attention.

15. Spills kit should be available in all areas where chemo agents stored, prepared and administered

Safe disposal of antineoplastic agents, body fluids and excreta1. Discard gloves and gown into a leak proof container, which should be marked as contaminated or hazardous waste.

2. Use puncture proof and leak proof containers for needles and other sharp and breakable objects.

3. Linen contaminated with chemotherapy or excreta from patients who have received the drug within 48 hours should be contained in specially marked hazardous waste bags.

III. RADIATION THERAPY

ROLE IN CANCER PREVENTION:

•Primary curative role

•Adjunct to other therapy

•Palliation

SOURCES OF RADIATION THERAPY:

1. External Radiation Therapy (Teletherapy). Administer via an X-ray machine

Sources of radiation

2. Internal Radiation Therapy

Administer within or near the tumor

TYPES:

•Sealed Source (Brachytherapy)

•Unsealed Source (oral, IV)

Side effects of radiation therapy

1. SKIN REACTIONS

A. Erythema, dry or moist desquamation

B. Atopic, telangectasia, depigmentation, necrotic or ulcerative lesions.

NURSING RESPONSIBILITIES:

•Observe early signs of skin reaction and report

•Keep area dry

•Wash area with water, no soap and pat dry ( do not rub)

Side effects

•Do not apply ointments, powders or lotions on the area

•Do not apply heat, avoid direct sunlight or cold

•Use soft cotton fabrics for clothing

•Do not erase markings on the skin. These serve as guide for areas of irradiation.

Side effects

2. INFECTION

Due to bone marrow suppression


•Monitor blood count weekly

•Good personal hygiene, nutrition and adequate rest

•Teach signs of infection to report to physician

Side effects of radiation

3. HEMORRHAGE

Platelets are vulnerable to radiation


•Monitor platelet count

•Avoid physical trauma or use of aspirin

•Teach signs of hemorrhage

•Monitor stool or skin for signs of hemorrhage

•Use direct pressure over injection sites until bleeding stops.


4. FATIQUE

Result of high metabolic demands for tissue repair and toxic waste removal.

MANAGEMENT:

Plenty of rest and good nutrition

5. WEIGHT LOSS

Anorexia, pain and effect of cance


6. STOMATITIS

Ulceration of oral mucus membrane

NURSING INTERVENTIONS:

•Administer analgesics before meals

•Bland diet, no smoking and alcohol drinking

•Good oral hygiene by using saline rinse every 2 hours

•Sugarless lemon drops or mint to increase salivation


7. Diarrhea

8. N/V

9. Headache

10. Alopecia

11. Cystitis

12. Social Isolation

Principles of radiation protection

DISTANCE

Maintain a distance of atleast 3 feet when not performing nursing procedures

TIME

Limit contact for 5 minutes each time, a total of 30 minutes per shift

SHIELDING

Use lead shield during contact with client

Teaching guidelines regarding radiation therapy

•It is painless

•Lie very still in a special table while the intervention is being given and client may be placed in a special position to maximize tumor irradiation.

•Each treatment may usually last for few minutes. Client may hear sounds of the machine being operated, and the machine may move during the therapy

Teaching guidelines•As a safety precaution for the therapy personnel, client will remain alone in the treatment room while the machine is in operation.

•The technologist will be right outside the room observing the client through a window or by a closed circuit TV. Client and technologist may communicate

•There is no residual radioactivity after the therapy. Safety precautions are necessary only during the time the client is actually receiving irradiation

IV. BONE MARROW TRANSPLANTATIONBone marrow cells are collected from the

client or another donor and then administer to the client after his diseased bone marrow is destroyed by chemotherapy or radiation.

PATIEN TEACHING:

•Inform the client that bone marrow transplant will deplete his WBCs, putting him at high risk for infection immediately after the procedure. As a safeguard, he will be placed on reverse isolation for several weeks.

Bone marrow transplant

2. Prepare client for pretransplantation regimen, which may include chemotherapy and radiation. During this regimen, he should expect adverse reactions such as parotitis, diarrhea, fever, N/V and symptoms of bone marrow depression (fever, fatique, chills, bruising and bleeding)

Nursing management for BMT

1. During transfusion, monitor client's v/s closely to allow prompt detection of reactions such as fever, dyspnea and hypotension.

2. Assess the client every 4 hours for infection symptoms, such as fever and chills.

3. Maintain strict asepsis when caring for the client. Take measure to protect him from injury.

Management of BMT

4. Watch for signs of graft-versus-host disease, such as dermatitis, hepatitis, hemolytic anemia and thrombocytopenia. GVHD usually occurs during the first 90 days after transplant and may become chronic, or it may cause transplant failure, lymphatic depletion, infection o death.

Management of BMT

HOME INSTRUCTIONS:

•Tell client to guard against infection. Warn him that he may remain unusually vulnerable to infection for up to 1 year after BMT.

•Urge him to keep regular medical appointments so doctor can monitor his progress and detect late complications.

V. IMMUNOSUPPRESSANT THERAPY

Iatrogenic (treatment induced) immunodeficiency may be a complicating adverse effect of chemotherapy or other treatment.

TYPES OF IMMUNOSUPPRESSANT DRUGS:1. ANTILYMPHOCYTE SERUM

It is a powerful non specific immunosuppressant that destroys circulating lymphocytes. It reduces T-cell number and function, thus suppressing cell mediated immunity.

ISTAntilymphocyte serum has been used effectively to prevent cell-mediated rejection of tissue grafts or transplants.

2. ANTITHYMOCYTE GLOBULIN

ATG causes specific destruction of T lymphocytes. Usually, it is given immediately before transplantation and continued for sometime afterward. Adverse effects of ATG include anaphylaxis and serum sickness,arising 1-2 weeks

IST

After injection. Serum sickness is marked by fever, malaise, rash, arthalgias and sometimes glomerulonephritis or vasculitis.

3. CORTICOSTEROIDS

These are adrenocortical hormones used widely to treat immune-mediated disorders because of their potent anti-inflammatory and immunos uppressant effects by stabilizing the vascular memebrane, blocking tissue infiltration by neutrophils and

IST

And monocytes and thus inhibiting inflammation. They also kidnap T-cells in the bone marrow, causing lymphopenia.

4. CYCLOSPORINE

Selectively suppresses the proliferation and development of T-mediated cells, resulting in depressed cell-mediated immunity.

IST

4. CYTOTOXIC DRUGS

Kill immunocompetent cells while they are replicating. Unfortunately, most of these agents are not selective, they intefere with ALL rapidly proliferating cells. As a result, they cause depletion of lymphocytes and phagocytes and interfere with lymphocyte synthesis and release of immunoglobulins and lymphokines.

VI. PAIN MANAGEMENT

1. OPIOD ANALGESICS

Prescribe to relieve moderate to severe pain

TYPES:

•AGONIST- are drugs that produce analgesia by binding to CNS opiate receptors. These are the drug of choice for severe chronic

examples: codeine, hydromophone, meperidine, morphine

opiod

•AGONIST-ANTAGONISTS- also produce analgesia y binding to CNS receptors. They are of limited use for clients with chronic pain because many have ceiling effect or upper dosing limit.

Examples: buprenorphine, butorphanol, nalbuphine, pentazocine

opiods

CONTRAINDICATED FOR CLIENT WITH:

•Severe respiratory depression like COPD

•Renal and hepatic impairment

•Head injuries or any condition that raise ICP

NURSING MANAGEMENT:

1. Before giving opiods, make sure the client is not taking a CNS depressant such barbiturate.

2. During the administration, check clients v/s and watch for respiratory depression.

opiods

ADVERSE EFFECTS:

•N/V

•Constipation

•Respiratory depression

•Hypotension

Pain management2. NON OPIODS ANALGESICS

Are prescribed to manage mild to moderate pain

EXAMPLES: NSAIDs- aspirin, ibuprofen, indomethacin, naproxen, acetaminophen

ADVERSE EFFECTS OF NSAIDs:

•Inhibit platelet aggregation (rebound when drug stopped)

•GI irritation. Hepatotoxicity, nephrotoxicity, headache, liver damage (in long term use)

Non opiods

NURSING MANAGEMENT:

1. Give medication with food or water to minimize GI upset.

2. Instruct client to remain standing for 15-20 minutes after taking his medication if he experiences esophageal irritation.

3. Notify the doctor if the client experiences gastric burning or pain.

Non opiods

•Avoid injury that could cause bleeding because NSAIDs increase bleeding time.

•Ask client if he experiences persistent tinnitus ( a reversible dose related adverse effect)

•Exercise caution when taking ibuprofen and naproxen when driving or use machinery because they can cause dizziness.

•Submit client to periodic blood test to detect possible nepro or hepatotoxicity.

Pain management

3. ADJUVANT ANALGESICS are drugs that have other primary indications but are used as analgesics in some cicumstances. Adjuvants may be given in combination with opiods or use alone to treat chronic pain. Clients receiving adjuvants should be reevaluated periodically to monotor their pain level and check for adverse reactions.

Adjuvant analgesics

EXAMPLES:

•ANTICONVULSANTS may be use to treat neuropathic pain ( pain generated by peripheral nerves), e.g. Carbamazepine, gabapentin, phenytoin

•LOCAL ANESTHETICS may be use to manage neuropathic pain or as alternative to general anesthesia.e.g. Amide drugs-bupivacaine,lidocaine;

•Ester drugs-cocaine, tetracaine

Adjuvant analgesics

•TOPICAL ANESTHETICS are applied directly to the skin or mucus membranes to prevent or relieve minor pain

•MUSCLE RELAXANT S can be classified as neuromuscular agents, antispasmodic agents, and agents used for short term pain relief and muscle spasm

•TRICYCLIC ANTIDEPRESSANTS (TCAs) are antidepressant with the longest history in managing neuropathic pain.

Adjuvant analgesics

• SELECTIVE SERATOTIN REUPTAKE INHIBITORS (SSRIs) are anti depressant with pain relief as well. (sertraline, paroxetine)

•BENZODIAZEPINES are used primarily to ease anxiety and muscle spasm.(diazepam, midazolam)

•PSYCHOSTIMULANTS are use mainly to treat Parkinson and ADHD, it can also be use in managing acute and chronic pain disorders.(caffein, dextroamphetamine)

Adjuvant analgesics

•CHOLINERGIC BLOCKERS are used to treat spastic or hyperactive conditions of the GIT. They relax muscles and decrease GI secretions. (scopolamine hydrobromide, belladonna)

4. NEUROSURGERY

Is an extreme form of pain management and is rarely needed

neurosurgery

EXAMPLES:

•NEURECTOMY-resection or partial or total excision of a spinal or cranial nerve.

•RHIZOTOMY-cutting a nerve to relieve pain

•CORDOTOMY-may be unilateral, to relieve pain on one side of the body or bilateral, to relieve visceral pain on both side of the body.

Neurosurgery

•CRYOANALGESIA- deactivates a nerve using a cooled probe that causes temporary nerve injury.

•RADIO FREQUENCY LESIONING may affect the nerve from the heat generated, the magnetic field created by the radio waves, or both.

Pain management5. TRANSCUTENOUS ELECTRIC NERVE STIMULATION

Relieves acute and chronic pain by using a mild electric current that stimulates nerve fibers to block the transmission of pain impulses in the brain

6. COGNITIVE BEHAVIORAL TECHNIQUES

May be used to help the client reduce the suffering associated with pain. These techniques include biofeedback, distraction, guided imagery, hypnosis and meditation

VII. COMPLICATIONS OF CANCER

1. SUPERIOR VENA CAVA SYNDROME

Compression or invasion of tumor in superior vena cava.

If untreated, SVCS may lead to cerebral anoxia ( because not enough oxygen reaches the brain), laryngeal edema, bronchial obstruction and death.

svcsNURSING MANAGEMENT

•Identify clients at risk for SVCS

•Monitor and report clinical manifestations of SVCS

•Monitor cardiopulmonary and neurologic status

•Avoid upper extremity venipuncture and blood pressure measurement

•Facilitate breathing by positioning the client properly

•Promote energy conservation to minimize shortness of breath

SVCS

•Monitor the client's fluid volume status and administer fluids cautiously to minimize edema.

•Assess for thoracic radiation-related problems such as dysphagia and esophagitis.

•Monitor for chemo-related problems, such as myelosuppression.

•Provide post op care as appropriate

Complications of ca

2. SPINAL CORD COMPRESSION

Potentially leading to permanent neurologic impairment and associated morbidity and mortality.

Compression of the cord and its nerve roots may result from tumor, lymphomas, intervertebral collapse or interruption of blood supply to the nerve tissues.

SCCNURSING MANAGEMENT:

•Perform ongoing assessment of neulogic function to identify existing and progressing dysfunction.

•Control pain with pharmacologic and non pharmacologic measures.

•Prevent complications of immobility resulting from pain and decrease function.

•Maintain muscle tone by assisting with ROM exercises.

SCC

NURSING MANAGEMENT:

•Institute intermittent urinary catheterization and bowel training programs for client with bladder or bowel dysfunction.

•Provide encouragement and support to client and family coping with pain and altered functioning, lifestyle, roles and independence.

Complications of ca

3. HYPERCALCEMIA

In clients with cancer, hypercalcemia is a potentially life-threatening metabolic abnormality resulting when the calcium released from the bones is more than the kidneys can excrete or the bones can reabsorb.

hypercalcemiaNURSING MANAGEMENT:

•Identify clients at risk for hypercalcemia and assess for S/S of hypercalcemia.

•Educate client and family, prevention and early detection can prevent fatality.

•Teach at risk clients to recognize and report S/S f hypercalcemia

•Encourage clients to consume 2-3L of fluids per day unless contarindicated by existing cardiac disease

hypercalcemiaNURSING MANAGEMENT;

•Explain the use of dietary and pharmacologic interventions such as stool softeners and laxatives for constipation.

•Advise client to maintain nutritional intake without restricting normal calcium intake.

•Discuss antiemetic therapy if N/V occur.

•Promote mobility y emphasizing its importance in preventing demineralization and breakdown of bones.

Complications of ca

4. PERICARDIAL EFFUSION AND CARDIAC TAMPONADE

Cardiac tamponade is an accumulation of fluid in the pericardial space. The accumulation compresses the heart thereby impedes expansion of the venticles and cardiac filling during diastole.

As ventricular volume and cardiac output fall, the heart pump fails, and circulatory collapse develops.

Complications of ca

NURSING MANAGEMENT:

•Monitor V/S and oxygen saturation frequently.

•Assess for pulsus paradoxus (pulse becomes weaker during inspiration)

•Monitor ECG tracings

•Assess heart and lung sounds, neck vein filling, level of consciousness, respiratory status, and skin color and temperature.

•Monitor and record I and O

Pericardial effusion

•Review laboratory findings (ABG, electrolytes levels)

•Elevate the head of the client's bed to ease breathing.

•Minimize client's physical activity to reduce oxygen requirements; administer supplemental oxygen as prescribed.

•Provide frequent oral hygiene

Pericardial effusion

•Reposition and encourage the client to cough and take deep breaths every 2 hours.

•As needed, maintain patent IV access, reorient the client, and provide supportive measures and appropriate client instruction.

Complications of ca

5. DESSIMINATED INTRAVASCULAR COAGULATION

Complex disorder of coagulation or fibrinolysis (destruction of clots), which results in thrombosis and bleeding.

DIC is most commonly associated with hematologic cancers (leukemia), cancer of prostate, GIT, and lungs.

DIC

NURSING MANAGEMENT:

•Monitor V/S

•Measure and document I and O

•Assess skin color and temperature; lung, heart, bowel sounds, level of consciousness, headache, visual disturbances, chest pain, decreased UO, and abdominal tenderness

•Inspect all body orifice, tube insertion site, incisions and bodily excretions for bleeding.

DIC

•Review laboratory test results

•Minimize physical activity to decrease injury risk and oxygen requirements.

•Prevent bleeding

•Assist the client to turn, cough, and take deep breaths every 2 hours.

•Reorient the client if needed, maintain a safe environment, and provide appropriate client education and supportive measures.

Complications of ca

6. SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH)

The continuous, uncontrolled releases of antidiuretic hormone (ADH), produced by tumor cells or by the abnormal stimulation of the hypothalamic-pituitary network, leads to increased extracellular fluids volume, water intoxication, hyponatremia, and excretion of urinary sodium.

SIADH

NURSING MANAGEMENT:

•Maintain I and O measurements

•Assess level of consciousness, lung and heart sounds, V/S, daily weight and urine specific gravity; also assess for N/V anorexia, edema, fatigue and lethargy.

•Monitor lab test results, including serum electrolytes, osmolality, BUN, creatinine, and urinary sodium levels.

SIADH

NURSING MANAGEMENT

•Minimize the client's activity; provide appropriate oral hygiene; maintain environmental safety; and restrict fluid intake if necessary.

•Reorient the client and provide instruction and encouragement as needed.

new cellular aberration lecture2010

Documents

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