NR203 Test 2 Cancer/Chemotherapy 8 Final

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Cancer incidence and Trends: Mortality rates exceeded by heart disease
1994 Prostate Cancer more prominent than lung and colon
50% increase since 1980
Breast cancer is second, lung 3rd Colorectal 4th. 5 year survival rate for all cancer 58%.
Cancer is many diseases
25% of all deaths attributable to cancer
Cell Cycle-not just cancer cells: Phases of cell growth
G1 first growth phase
Prepares for synthesis of DNA
S DNA synthesis
G2 second growth phase
Prepares for division
M-Mitosis (division)
Cells mature or undergo replication
G0 resting phase-cells do not multiply
Known Carcinogens-things that are known to be cancer causing: Viruses Herpes 2 virus
HPV virus-genital warts.
Drugs and Hormones
Chemotherapeutic drugs
Recreational drugs
Estrogen and DES
Chemical agents
Physical Agents
Solar Radiation
Ionizing radiation
Differentiation- Define: Differentiation- A normal process occurring over many cell cycles that allows cells to specialize in certain tasks
Unproductive cellular alterations that can happen 4 types: Hyperplasia: overgrowth of tissue. Increase in # or density of normal cells.
men with enlarged prostates-Benign prostatic hypertrophy-BPH
Dysplasia-Loss of DNA control, over- differentiation. Abnormal degree of variation in size, shape, appearance, and disturbance in usual arrangement. Cervix.-hysterectomy.
Metaplasia-Change in normal pattern of differentiation into cell types that are not normally found in the location of the body-ex. Smoker lungs
Dysplasia is more serious
Anaplasia-regression of a cell to an immature or regression of a cell type.
Lack of cell differentiation, altered in appearance, size, shape, look different from the cells that they originated from. Malignant cells can be identified by changes occurring among groups of cells and within individual cells. These changes are known as "anaplasia." Anaplasia is a feature of malignancy; it is not found in normal tissues or in benign neoplasms.
Risk factors for developing cancer-Noncontrollable: Hereditary Inherited-genetic defects
Age-66% of all cancers occur in people over age 65.
Gender
Poverty
Inadequate access to health care, especially preventative screening and counseling
Controllable risk factors for developing cancer: Stress-unmanaged keeps epinephrine, cortisone at high levels. Type C cancer personality: Not very good at coping.
Depression
Diet-preserved high fat low fiber foods.-not good.
Occupation-asbestos
Infection
Tobacco Use
Alcohol Use
Use of recreational drugs
Obesity
Sun exposure
What promotes cancer interaction of lots of different things.: Promoters: viruses, unhealthy lifestyle, smoking, poor diet, physical agents, chemical agents
What are some environmental factors that can cause cancer: Stress
Chronic disease
Depressed immune system
Benign neoplasms-explain: Local
Cohesive
Well defined borders
Pushes other tissues out of the way
Slow growth
Encapsulated
Easily removed
Does not recur
Malignant Neoplasms: Invasive-invade tissues, organs, blood
Noncohesive
Doesnâ€™t stop at border
Invades and destroys surrounding tissues
Rapid growth
Metastasizes
Not easy to remove
Can recur
Characteristics of Malignant neoplasms: Loss of regulation of the rate of mitosis
Loss of specialization and differentiation
Loss of contact inhibition
Progressive acquisition of a cancerous phenotype
Irreversibility
Altered cell structure
Simplified metabolic activities
Transplantability
Ability to promote their own survival
Various cancers and sites of metastases: Bronchogenic: Spinal cord, brain, liver, bone
Breast: Regional lymph nodes, vertebrae, brain, liver
Colon: Liver, lung, brain, ovary
Prostate: Bladder, bone (esp. vertebrae), liver
Malignant melanoma Lung, liver, spleen, regional lymph nodes
Lab and diagnostic tests for cancer: Diagnosis: Location, microscopic, blood tests
Grading: differentiated and growth rate
Grade 1=Most differentiated, least malignant
Grade 4=Least differentiated, and most aggressively malignant

Staging: Amount of spread
Tumor: T0-T4
Nodes: NO-N12
Metastasis MO-M3

Cytologic Exam
Exfoliation
Aspiration
Needle aspiration

Tumor Markers
-Oncofetal antigens
AFP (Anti-fecal Protein)
CEA (Carcino embryonic antigen)
-Hormones
HCG (human Chorionic genotrofin?)
PTH (Parathyroid Growth Hormone)
-Tissue specific proteins
PSA (Prostatic specific antigen)

Oncologic Imaging
X-ray imaging
Computed Tomography
Magnetic resonance imaging
Ultrasonography

Direct visualization
-Sigmoidoscopy
-Cystoscopy
-Endoscopy
-Bronchoscopy

Exploratory surgery with biopsy
Cancer therapy basis: Overall aggressiveness of the cancer
Potential for spreading of the cancer
Potential hazards of therapy itself
Established success rate of therapy
Antineoplastic Drugs: Interfere with the cell cycle of both Ca and normal cells
Cells most at risk:
Those in rapid proliferation
Blood forming cells
Bone marrow
Hair follicles
GI tract

Side effects:
Blood disorders
N/V
Hair loss

Not all Ca cells destroyed

Cycle specific drugs
Act at certain phases of cell division
Nonspecific drugs
Chemotherapeutic agents types: Alkylating agents
-Poison mustard used in WW1

Antimetabolites

Mitotic Inhibitors
-derived from plants

Antibiotics
-Derived from microorganisms

Hormones

Radioactive

Misc.
Alkylating agents: Act by interfering with the structure of DNA
Defective DNA unable to reproduce
Cycle nonspecific
Affect all rapidly proliferating cells
Cause irreversible infertility
Cyclophosphamide (Cytoxan)
Antimetabolites: Cycle specific agents
Act only on dividing cells during S phase
Most effective on rapid growing cancers.
Methotrexate (MTX)
Mitotic Inhibitors-Plant alkaloids (Think Vinca): Most interfere with cell division or mitosis
Others act in G2 or S phase
Vincristine Sulfate (Oncovin)
VP-16
Cytotoxic Antibiotics: Derived from various species of streptomyces
Not used to treat infection
Not selectively toxic to bacterial cells

Binds to almost everything they contact and kills cells by damaging cell membrane
Cycle nonspecific

Toxicity: damage to cardiac muscle.

Doxorubicin (Adriamycin)Big Red
Hormones and Hormone Antagonists: Selectively suppresses the growth of certain tissues of the body without cytotoxic action

Sex hormones:
Estrogens, Androgens, and Progestins

Corticosteriods
Main hormone used in cancer therapy
Phase specific (G1)
Tx of malignant lymphomas to suppress lymphocyte production

Tamoxifen (Nolvadex)
steroids (prednisone)
Radioactive Drugs: Concentrate in a specific tissue and emit radiation within a short time
Combination therapy: Single agent is rarely as effective in treatment of Ca as combination therapy
Rationale for selection:
Exhibit different toxicities
Different Mechanisms of action ie different phases of cell cycle
Individually active against specific cancer
More pronounced beneficial effect when used together than alone
Smaller doses can be utilized of each agent
If extravasation occurs, if tissue damage or necrosis occurs Ex. if a vesicant drug infiltrates: Follow procedure of institution
This may include:
Antidote
Steroids
Sodium Bicarbonate
Cold compress in 6-12 hours
Warm compress may be preferred
Define vesicant, irritant, and extravasation: Vesicant drugs are very toxic, so tissue damage can occur
Irritant: Cause discomfort at IV site-potassium
Extravasation-
Monitor lab studies: Depression of bone marrow
WBC < 4,000
Platelet count < 200,000
Uric acid > 35 mg/100ml
Glucose: FBS > 120
2 hr PP>120
Report to physician

Fluid and electrolyte balance:
Force Fluids-to prevent deposits of urates in the kidneys

Maintain urine output of at least 2 Liters/day
Offer 3000 ml if not contraindicated: cardiac, renal impairment, older patients, and children
Zyloprim may be given to inhibit formation of uric acid
Other treatments for cancer: Surgery: diagnosis and staging in 90%
Primary treatment of more than 60%
Radiation therapy
Kill the tumor
Reduce its size
Decrease pain
Relieve obstruction

Types:
Teletherapy external
Brachytherapy direct

Immunotherapy
Biologic response modifiers (BRM)

Photodynamic therapy
Photofrin
Laser treatment 3 days later

Bone Marrow
Transplantation
Surgery: diagnosis and staging in 90%
Primary treatment of more than 60%
Radiation therapy
Kill the tumor
Reduce its size
Decrease pain
Relieve obstruction

Types:
Teletherapy external
Brachytherapy direct

Immunotherapy
Biologic response modifiers (BRM)

Photodynamic therapy
Photofrin
Laser treatment 3 days later

Bone Marrow
Transplantation
Nursing implications for external radiation tx: External
Adverse effects: skin changes, blanching, erythema, hemorrhage, ulceration, n/v, diarrhea
Assess lung sounds for rales
Record other medications
Monitor WBC and platelets
Teaching:
Plain H2O, no soap, etc.
Do not rub, scratch, or scrub
Apply neither heat or cold
Wear loose, soft clothing
Protect skin from sun exposure during and 1 year after SPF 15
Plenty of rest and eat a balanced diet
Nursing implications for internal radiation treatment: Internal: an implant is placed into the affected tissue
Patient must be in a Private room
Limit visits to 10-30 min. at least 6ft away
Monitor S.E.
-burning sensations, excessive perspiration, chills and fever, N/V, diarrhea
Assess for fistulas or necrosis
Teaching:
Stay in bed and rest quietly while in place
Avoid close contact with others until discontinued
Dispose of excretory materials in special containers or in a toilet not used by others
Eat a balanced diet
Carry out ADLs as able.
Nursing Implications for Immunotherapy: Monitor for side effects
Monitor enzymes
Evaluate response
Assess coping behaviors
Manage fatigue and depression
Encourage self care.
Close supervision
Teaching:
Increase fluid intake,
Take analgesics and antipyretic meds
Maintain bed rest until symptoms abate
SC injection or IV pump management.
Pain management in the cancer patient: Type:
Direct tumor involvement
Associated with treatment
Unrelated to Ca or Tx
Give medication on a regular schedule
No limit to amount client can receive.
MS is the drug of choice
Pharmacologic:
Careful initial and ongoing assessment
Evaluate functional goals
Nonnarcotic drugs (ASA or ibuprofen) with adjuvants (corticosteroids or antidepressants).
Progress to stronger drugs (Percodan or Darvon to dilaudid)
Try combinations and escalate dosages.
Bone marrow transplantation: To stimulate non functioning marrow or replace marrow
BMT given as an IV infusion of bone marrow cells from donor to patient
Commonly used in leukemias
Being expanded to include treatment of solid tumors, such as breast tumors.
Other important Nursing Measures: Carefully monitor I&O
Rapid weight changes
Skin turgor
Vital sign changes
Lung sounds
Laboratory values
Mood changes
Anorexia, Nausea and Vomiting: Provide Foods that the patient enjoys, but in small amounts
Food high in protein and vit. C to encourage cellular growth and repair
Vitamin and Mineral supplements
Give antiemetics: (pre better than post)
Ondansetron (Zofran)
Granisetron (Kytril)
Dronabinon (Marinol)
Metocloramide (Reglan)
Limit excess physical activity, liquids only before drug tx, relaxation techniques, hypnosis, guided imagery.
Stomatitis: Daily assessment of integrity of oral mucous membranes
Routine mouth care q 2-4 hours, q2hr if develops
Thoroughly rinse mouth after meals
Avoid commercial mouth washes, use 1 tsp baking soda in 500 ml of H20
Soft bristle toothbrush or toothette
Use bland, high caloric liquids
Local anasthetics such as lidocaine 30 min. before meals, children 1 hr before meals
Xerostomia (Dry mouth): Drink fluids
Rinse mouth with baking soda solution
Artificial saliva
Lubricate lips with water soluble gel
Protection Against infection: Lowest point (nadir) of bone suppression is 9-10 days where cancer patients are most prone to infection
Common sites:
Lower respiratory tract
Perineal area
Pharynx
GU tract
Skin
Usual s/s of infection are absent
Most common indication of infection is fever, although patient taking steroids may not develop this sign
Prevention: Improving host
Reducing exposure
Suppressing organisms.
Aseptic technique: Isolation from infectious persons
Life support island with life-threatening leucopenia
Visitors are limited
Hand washing
Wearing masks
No uncooked foods
No cut flowers
Patients own flora often responsible for infection:
Ensure good hygiene care
Special perineal care, cleansing of axillae, perineum and groin, with providone-iodine or using antifungal powder.
Safety needs-cancer patient: Handle pt gently
Avoid ASA and alcohol (interfere with action of platelets)
Prevent fx due to osteoporosis if large doses of corticosteroids
Pad bed rails
Maintain pressure on injection sites for 3-5 minutes
Know antidotes for various anticancer agents.
Alopecia: Alopecia-hair loss
Apply tourniquet around forehead during IV therapy
Keep in place 10-15 minutes after treatment complete
Hypothermia to scalp with chilled air, ice cap, 10 min. before, during, and 30 min after treatment
Do not use if indications that drug should reach the scalp (leukemia, etc.)
Use wig or bandanna to camouflage hair loss.
Oncologic Emergencies: Pericardial effusion and Neoplastic Cardiac tamponade
Superior vena cava syndrome
Sepsis and septic shock
Spinal cord compression
SIADH
Obstructive Uropathy
Hypercalcemia
Hyperuricemia
Nursing Diagnoses cancer patients: Anxiety
Body image disturbance
Anticipatory grieving
Risk for infection
Risk for injury
Altered Nutrition: less than body requirements
Impaired tissue integrity
Pain
Safe handling of cytotoxic drugs.: Wear while giving or mixing
Surgical Mask
Protective goggles or glasses
Gloves
Long-sleeved protective gown
Wash hands
Check tubing to ensure all connections are tight
Label with special hazard label
Bleed infusion into gauze is plastic bag
All contaminated materials are disposed of in hazard container and wash hands thoroughly
Manage spills
-Spill kit
-Disposable respirator mask and shoe covers suggested
Post procedure.
Functional health care pattern: what does cancer fit under?: Nutrition Metabolic alterations-Fits in the cancer prospective.

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