ALSALMAN A.

ANAM

BSN IV A

JANUARY 8, 2013

ONCOLOGY NURSING REVIEWER

A. Benign VS Malignant Neoplasm Characteristic Speed Growth

Benign Neoplasm Grows slowly Usually continues to grow throughout life unless surgically removed

Malignant Neoplasm Usually grows rapidly Tends to grow relentlessly throughout life Grows by infiltrating surrounding tissues May remain localized (in situ) but usually infiltrates other tissues

Mode of Growth

Grows by enlarging and expanding Always remains localized; never infiltrates surrounding tissues

Capsule

Almost always contained within a fibrous capsule Capsule advantageous because encapsulated tumor can be removed surgically

Never contained within a capsule Absence of capsule allows neoplastic cells to invade surrounding tissues Surgical removal of tumor difficult

Cell characteristics Recurrence

Usually well differentiated Unusual when surgically removed

Usually poorly differentiated Common following surgery because tumor cells spread into surrounding tissues

Metastasis Effect of Neoplasm

Never occur Not harmful to host unless located in area where it compresses tissue or obstructs vital organs

Very common Always harmful to host Causes disfigurement, disrupted organ function, nutritional imbalances May result in ulcerations, sepsis, perforations,

Prognosis

Very good Tumor generally removed surgically

Depends on cell type and speed of diagnosis Poor prognosis if cells are poorly differentiated and evidence of metastatic spread exists Good prognosis indicated if cells still resemble normal cells and there is no evidence of metastasis

B. Recommendations of the American Cancer Society for Early Cancer Detection 1. For detection of breast cancer age 20, routinely perform monthly breast selfexamination 20-39 should have breast examination by a healthcare provider every 3 years 40 and older should have a yearly mammogram and breast self-examination by a healthcare provider

Immunosuppression

Client Education

for extra rest periods as needed ain balanced diet 2-3 liters/day)

2. For detection of colon and rectal cancer age 50 and older should have a yearly fecal occult blood test toilets after use should be done every 5 years every 10 years Nursing Management dislodging the implant.

bedrest to avoid

; double-flush

apy may lead to bone marrow suppression

3. For detection of uterine cancer (Pap) smear for sexually active females and any female over age 18 -risk women should have an endometrial tissue sample

close contact with persons receiving internal radiation: understand the principles of protection from exposure to radiation: time, distance, and shielding (SDT) Time: minimize time spent in close proximity to the radiation source; a common standard is to limit contact time to 30 minutes total per 8-hour shift;

4. For detection of prostate cancer 50, have a yearly digital rectal examination 50, have a yearly prostate-specific antigen (PSA) test C. American Cancer Societys seven warning signs of cancer (uses acronym CAUTION US): 1. Change in bowel or bladder habits 2. A sore that does not heal 3. Unusual bleeding or discharge 4. Thickening or lump in breast or elsewhere 5. Indigestions or difficulty in swallowing 6. Obvious change in wart or mole 7. Nagging cough or hoarseness 8. Unexplained Anemia 9. Sudden loss of weight

Distance: maintain the maximum distance 6 feet possible from the radiation source Shielding: use lead shields and other precautions to reduce exposure to radiation private room 6 feet from the client and limit visitors to 10-30 minutes proper handling and disposal of body fluids, assuring the containers are marked appropriately

use long-handled forceps and place the implant into a lead container; never directly touch the implant Do not allow pregnant women to come into any contact with radiation wear a

D. Internal Radiation Therapy (Brachytheraphy) Sources of Internal Radiation

monitoring device to measure exposure ures

E. External Radiation Therapy (Teletheraphy)

radiation treatment using a semipermanent type of ink -30 minutes per day, 5 day per Side Effects week, for 2-7 weeks ent does not pose a risk for radiation exposure to other people

H. Staging of Cancer: Classifies the clinical aspects of CA Side Effects Stage O: carcinoma in situ Stage I: tumor limited to the tissue of origin, localized tissue hemorrhage) growth Stage II: limited local spread Stage III: extensive local & regional spread ion Stage IV: metastatis

Client Education

I. EARLY DETECTION OF CANCER Mammography Pap smear Stool for occult blood Sigmoidoscopy colonoscopy Breast self-examination Testicular self-examination Skin inspection -Examination (BSE) Done 7-10 days after menses Postmenopausal or s/p hysterectomy: specific day of the month Inspection: In front of the mirror with arms at sides, arms overhead & arms at hips (WOF changes in shape,

pat skin dry; do not use soaps, deodorants, lotions, perfumes, powders or medications on the site during the duration of the treatment; do not wash off the treatment site marks

do not apply extreme temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor -fitting over the treatment area n exposure during the treatment and for at least 1 year after the treatment is completed; when going outdoors, use sun-blocking agents with sun protector factor (SPF) of at least 15

promoting health and repair of normal tissues Nursing Management

dimpling of skin or any changes in nipple)

-Examination (BSE) Palpation: While in shower/bath or lying down with folded towel under breast and platelet counts being examined Use the R hand to examine L breast & vice versa Use the pads of 2 nd , 3 rd & 4 th fingers Use small, immunosuppression, thrombocytopenia circular motions in spiral or in an up-and-down motion to examine entire breast & under the arm (WOF lump, hard knot F. Predisposing Factors: Carcinogenesis G-enetic I-mmunosuppression V-iral (Human Papilloma, Epstein-Barr, Hepa B) E-nvironmental Physical- Radiation, UV rays, nuclear explosion Chronic irritation, direct trauma Chemical - Acids, alkalis, hydrocarbons, dye, Food ( fiber) fat& Food additives (Nitrites), Drugs (Stillbestrol, urethane), Hormones, Smoking or thickened tissue) Testicular Self-Examination (TSE) Same day, q month, right after a warm shower (scrotal skin is moist & relaxed) Gently lift each testicle, each one should feel like an egg, firm but not hard & smooth without lumps Using both hands, place middle fingers underside of each testicle & thumbs on top & gently roll the testicles (WOF lumps, swelling or mass) CANCER TX MODALITIES: Surgery Prophylactic With premalignant condition or with strong family hx of CA Curative Removal of all gross & microscopic tumor G. Grading of Cancer: Classifies the cellular aspects of CA Grade I: cells differ slightly from N cells, well-differentiated (mild dysplasia) Grade II: cells are more abN, mod. differentiated (mod. dysplasia) Grade III: cells are very abN, poorly differentiated (severe dysplasia) Grade IV: cells are immature (anaplasia), undifferentiated Control (cytoreductive) debulking procedure, the no. of CA cells, the chance of other tx will be successful CANCER TX MODALITIES: Surgery Palliative pain; Improves quality of life during survival time

relieve obstruction (airway, GI or GU), relieve pressure on brain & spinal cord, prevent hemorrhage, remove infected or ulcerated tumors or drain abscesses

Reconstructive or rehabilitative Improves quality of life

by restoring maximal function & appearance (breast reconstruction s/p mastectomy) CANCER TX MODALITIES: Chemotherapy Kills CA cells & rapidly producing cells (skin, hair, BM, Reproductive tract, GIT,) Antimetabolites: N2 mustard Plant alkaloid: Vincristine & Vinblastine Alkylating: Methotrexate Hormones (DES)/ steroids Antineoplastic antibiotics CANCER TX MODALITIES: Chemotherapy Major S/E & Nursing Interventions Hair: alopecia Encourage pt to wear wigs, cap Temporary, hair will regrow in 3-6 mos. after chemo with new color & texture BM: depression Anemia: CBR, O2 as ordered Leukemia: reverse isolation, strict HW, asepsis Thrombocytopenia: Bleeding precautions CANCER TX MODALITIES: Chemotherapy Major S/E & Nursing Interventions GIT: N/V Antiemetics 4-6 hrs. pre-chemo & post chemo as ordered NPO temporarily Bland diet post chemo Stomatitis Oral care Ice chips/popsicles Diarrhea Antidiarrheals Monitor VS, I/O, WOF dehydration WOF paralytic ileus (with Vincristine) CANCER TX MODALITIES: Chemotherapy Major S/E & Nursing Interventions Reproductive tract: sterility Encourage sperm banking for M Renal damage: uric acid Allopurinol as ordered Neuro disturbance: peripheral neuropathy Skin, hand & foot care (like in PVD & DM) Alkylating Meds Cell-cycle nonspecific Nitrogen

Antimetabolites Cell-cycle phase-specific (S phase) Capecitabine (Xeloda) Cladribine (Leustatin) Cytarabine (ara-C, Cytosar-U): alopecia, stomatitis, hyperuricemia, hepatotoxicity Floxuridine (FUDR) Fludarabine (Fludara) Antimetabolites Methotrexate (Folex) & 5-Fluorouracil (Adrucil): alopecia, stomatitis, hyperuricemia,

photosensitivity, hepatotoxicity, hema, GI & skin toxicity Leucovorin rescue (given leucovorin [folinic acid or citrovorum factor) to prevent toxicity r/t Methotrexate Hydroxyurea (Hydrea) 6-Mercaptopurine (Purinethol): hyperuricemia, hepatotoxicity Procarbazine (Matulane) Thioguanide Mitotic Inhibitors (Vinca Alkaloids) Cell-cycle phasespecific: M phase Docetaxel (Taxotere) Etoposide (VePesid) Teniposide (Vumon) Vinblastine SO4 (Velban) Vincristine SO4 (Oncovin): neurotoxicity (numbness & tingling of fingers & toes), peripheral neuropathy, ptosis Vinorelbine (Navelbine) Immunomodulator Agents Stimulate immune system to recognize CA cells & destroy them (Interleukins) Slow down tumor cell division, causes CA cells to differentiate into non-proliferative forms (Interferons) Immunomodulator Interleukin-2) Agents Aldesleukin alfa-2a (Proleukin, alfa-2b

Interferon

Interferon

Interferon alfa-n3 (Alferon N) Levamisole (Ergamisole) Recombinant interferonRituximab (Rituxan) 26. Colony-Stimulating Factors Induce rapid BM recovery after chemotherapy Granulocyte-Macrophage: Sargramostim (Leukin, Prokine) Granulocyte: Filgrastim (Neupogen) Erythropoetin: Epoetin alfa (Epogen) 27. CANCER TX MODALITIES: Radiation Use of ionizing radiation that kills CA & rapidly growing cells & inhibit their growth Types of energy Alpha rays: dont penetrate skin tissue Beta rays: penetrate skin (e.g. internal radiation) Gamma rays: penetrate deeper, underlying tissues (e.g. external radiation) 28. CANCER TX MODALITIES: Radiation Factors Affecting Delivery Half-life: time required for the of the radioisotope to decay Time: less time, less exposure Distance: the farther the source, the lesser the exposure Shielding: Alpha & Beta rays can be blocked by gloves, Gamma rays can be blocked by thick, lead gown & concrete 29. CANCER TX MODALITIES: Radiation Methods of Delivery Internal: utilizes injection/ implantation of (Intron A, Roferon A)

Mustards Chlorambucil (Leukeran) & Mechlorethamine (Mustargen): (Cytoxan): hyperuricemia taken without food, Cyclophosphamide S/E: alopecia,

hemorrhagic cystitis (hematuria, dysuria) Ifosfamide (Ifex) Melphalan (Alkeran) Uracil mustard Alkylating Meds Nitrosoureas Carmustine (BiCNU) Lomustine (CeeNU) Streptozocin (Zanosar) Alkylatinglike Meds Altretamine (Hexalen) Busulfan (Myleran): hyperuricemia Cisplatin (Platinol): ototoxicity & nephrotoxicity (given amifostine [Ethyol] prior to risk), hypoK, hypoCa, hypoMg Dacarbazine (DTIC-Dome) Thiotepa (Thioplex) Anti-tumor Antibiotics Cell-cycle nonspecific Bleomycin SO4 (Blenoxane): pulmonary toxicity Dactinomycin (Actinomycin D, Cosmegan) Daunorubicin (Cerubidine, DaunoXome): causes CHF & dysrhythmias Doxorubicin (Adriamycin) & Idarubicin (Idamycin): cardiotoxicity (given Dexraxozane [Zinecard] to prevent

cardiomyopathy) Anti-tumor Mitoxantrone Antibiotics Mitomycin (Mutamycin) (Nipent)

radioactive isotopes proximal to CA sites for specified period of time Sealed: within a container, dont contaminate with body fluids Unsealed: e.g. Phosphorus 32 External: uses electromagnetic waves e.g. Cobalt

(Novantrone)

Pentostatin

Plicamycin (Mithracin): affects bleeding time Valrubicin (Valstar)

 30. CANCER TX MODALITIES: Teletherapy/Beam Radiation Source: external radiation Pt does not emit radiation & does not pose a hazard to anyone else Wash area with water & mild soap, using the hand than a washcloth, rinse & pat dry with soft towel Dont remove radiation markings from the skin 31. CANCER TX MODALITIES: Teletherapy/Beam Radiation No powder, ointment, lotion or cream on area unless ordered Wear soft clothing over the area, avoid constrictive garments Avoid sun & heat exposure WOF weeping of skin (moist desquamation) & if noted, cleanse the area with warm water & pat dry, apply antibiotic or steroid cream as ordered & expose the site to air 32. CANCER TX MODALITIES: Brachytherapy

38.

CANCER

TX

MODALITIES:

Brachytherapy

Radiation Sealed Radiation Source Removal Pt is no longer radioactive Inform the pt that sexual partner cannot catch CA Pt may resume sexual intercourse after 7-10 days for cervical or vaginal implant Perform povidoneiodine douche as ordered for cervical implant Administer Fleet enema as ordered Notify MD if N/V/D, frequent urination, vaginal or rectal bleeding, hematuria, foulsmelling vaginal discharge, abdominal pain/distention or fever occurs 39. CANCER TX MODALITIES: Radiation Major S/E & Nursing Interventions Skin erythema, redness, irritation & sloughing of tissue Assist in bathing the pt Force fluids Avoid lotion, talcum powder; may use cornstarch or olive oil BM depression (same as in chemo) GIT disturbance: Dysgeusia- taste sensation esp. with internal implant Oral care, avoid hot & cold foods 40. LEUKEMIA Group of malignant disease Rapid immature WBC, competes nutrition with mature WBC and production of RBC and platelets N= 500 RBC: 1 WBC 41. LEUKEMIA 42. CLASSIFICATION OF LEUKEMIA Lymphoaffects lymphocytes Myeloaffects myeloblasts

Radiation Source: internal radiation (sealed or unsealed) For a pd. of time the pt emits radiation & pose a hazard to others 33. CANCER TX MODALITIES: Brachytherapy

Radiation Unsealed Radiation Source Administered PO or IV or instillation into body cavities It enters body fluids, eliminated via various excreta (radioactive & harmful to others esp. the 1 st 48 hrs) 34. CANCER TX MODALITIES: Brachytherapy

Radiation Sealed Radiation Source Temporary or permanent solid implant within tumor target tissues The pt emits radiation while the implant is in place, but the excreta is not radioactive Place the pt in a private room with private bath Place a caution sign on the pts door 35. CANCER TX MODALITIES: Brachytherapy

Acute/Blastic- affects immature cells Chronic/Cysticaffects mature cells Most common in children: Acute Lymphocytic Leukemia (ALL), peak onset 2-6 y/o, M>F Acute Myelogenous Leukemia (AML): peak onset 15-39 y/o 43. Signs and Symptoms: LEUKEMIA From invasion of BM (Nadir) Infection: T, poor wound healing, sore throat, bone weakens lymphadenopathy epistaxis, fracture, bone & joint pains, hemorrhage, petechiae,

Radiation Sealed Radiation Source Organize nursing tasks to minimize exposure to radiation source Nursing staff assignments should be rotated, a nurse should never care for more than 1 pt with radiation implant at a time, avoid assigning a pregnant nurse Limit time to 30 mins per care provider/shift 36. CANCER TX MODALITIES: Brachytherapy

Bleeding:

hematoma,

hematuria,

hematemesis,

hepatosplenomegaly Anemia: pallor, fatigue, anorexia, constipation 44. Signs and Symptoms: LEUKEMIA From invasion of CNS ICP: LOC, severe HA, vomiting, papilledema, seizures CN VII or spinal nerve involvement From invasion of kidneys, testes, prostate, ovaries, GI and lungs 45. LEUKEMIA Diagnostic Tests PBS- (+) immature WBC CBC- immature WBC, RBC, platelets Done weekly during maintenance phase of chemotherapy TX MODALITIES: Brachytherapy Lumbar Puncture- CNS affectation Shrimp/fetal/Cposition, avoid neck flexion may occlude airway of infants and children 46. LEUKEMIA Diagnostic Tests Bone Marrow

Radiation Sealed Radiation Source Wear a dosimeter film badge to measure radiation exposure Wear a lead shield Do not allow children <16 y/o or pregnant woman to visit the pt Limit visitors to 30 min./day, at least 6 ft from the pt Save bed linens & dressings until the source is removed then dispose Other equipments can be removed from the room at any time 37. CANCER Radiation Dislodged Sealed Radiation Source Dont touch it with bare hands, use a long-handled forceps to place the source in a lead container kept in the pts room & not ify MD If unable to locate the radiation source, bar visitors & notify MD

Aspiration- (+) blast cells (immature WBC), common site: iliac crest Post op: apply direct pressure, lie on

affected side to stop bleeding Bone Scan- to determine bone involvement (fractures) CT Scan: to determine organ involvement 47. LEUKEMIA Triad Management Surgery (most preferred) transplant 48. Nursing Management: LEUKEMIA Assess for common side effects: anorexia, nausea and vomiting (give antiemetics 30mins prior to chemo and continue until 1 day post chemo), WOF dehydration 49. Nursing Management: LEUKEMIA Assure pt that alopecia and hirsutism are temporary side effects, hair will regrow in 3-6 mos. With new color & texture 50. Nursing Management: LEUKEMIA Assess for stomatitis (oral ulcers) Oral care: alcohol-free (Cranial) Irradiation Chemotherapy BM

Weakness & fatigue Recurrent infections Anemia Bence Jones proteinuria, total serum protein, Ca & uric acid levels RF Thrombocytopenia, granulocytopenia 58. Nursing Interventions: MULTIPLE MYELOMA Administer as ordered Chemotherapy IVF & diuretics (to eliminate Ca) BT for anemia Analgesics, antibiotics WOF bleeding, infection, fractures, RF Force fluids Encourage ambulation Provide skeletal support during moving, turning & ambulating Maintain hazard-free envt 59. TESTICULAR CANCER Occurs between ages 15-40 Common sites of mets: lymph nodes, bone, lungs, adrenal glands & liver Types Germinal tumors (Seminomas, Nonseminomas) Nongerminal tumors (Interstitial cell tumors, Androblastoma) 60. S/Sx: TESTICULAR CANCER Painless testicular swelling Dragging sensation in the scrotum S/Sx of mets: palpable lymphadenopathy, abdominal masses,

mouthwash, pNSS with or without NaHCO3 Use softbristled toothbrush, cotton plegets Apply Xylocaine (topical anesthetic) on mouth before meals Diet: soft and bland according to childs preference, small frequent feedings 51. Nursing Management: LEUKEMIA Protect pt from infection Strict hand washing Reverse isolation Protect pt from additional fatigue Bed rest Activities balanced with rest 52. Nursing Management: LEUKEMIA Protect pt from bleeding Minimize parenteral injections Apply pressure on venipuncture sites Use electric razor in shaving 53. Nursing Management: LEUKEMIA Encourage verbalization of feelings & concerns Introduce the family to other families of children with CA Consult social services & chaplains as necessary 54. HODGKINS DISEASE/LYMPHOMA Involves lymph nodes, tonsils, spleen & BM (+) T, A/, malaise, fatigueReed-Sternberg cell in the nodes S/Sx &

gynecomastia Late S/Sx: back or bone pain & respiratory Sx 61. Tx: TESTICULAR CANCER Chemotherapy

Radiation Surgery Unilateral orchiectomy- for dx & primary surgical mgt. Radical retroperitoneal lymph node dissection- to stage the CA & tumor vol. Reproductive options: sperm storage, donor insemination & adoption 62. Nursing Interventions: s/p Testicular Surgery Suture removal: 7-10 days post-op May resume N activities within 1 week except for lifting heavy objects > 20 lbs or stair climbing Perform monthly testicular self-exam on the remaining testicle 63. BREAST CANCER Common sites of mets: lymph nodes, bone, lungs, brain & liver Precipitating factors Genetics Early menarche & late menopause Nulliparity Obesity High-dose radiation exposure to chest 64. S/Sx: BREAST CANCER Mass felt during BSE (usually in the upper outer quadrant or beneath the nipple) Fixed, irregular, nonencapsulated mass Painless (early stage) or painful (late stage) mass Nipple retraction or elevation Assymetrical breast (affected breast higher) Bloody or clear nipple d/c 65. S/Sx: BREAST CANCER Skin dimpling, retraction or ulceration Skin edema or peau dorange skin Axillary lymphadenopathy Lymphedema of affected arm Presence of lesion on mammography S/Sx of lung/bone mets 66. Nonsurgical Tx: BREAST CANCER Chemotx Radiation tx Hormonal manipulation in post menopausal women Meds: Tamoxifen (Nolvadex) for estrogen receptor-positive tumors 67. Surgical Tx: BREAST CANCER Lumpectomy: removal of tumor with lymph node dissection Simple Mastectomy: removal of breast tissue & nipple, lymph

weakness, wt loss Anemia, thrombocytopenia Enlarged lymph nodes, spleen & liver (+) bx of cervical lymph nodes (affected 1 st ) (+) CT scan of liver & spleen 55. HODGKINS DISEASE/LYMPHOMA Management External radiation (tx of choice) Multiagent chemotx (if extensive) WOF S/E: infection, bleeding Sperm banking (possibility of sterility for M) 56. MULTIPLE MYELOMA Malignant proliferation of plasma cells and tumors within the bone, destroying the bone & invading the lymph nodes, spleen & liver abN plasma cells produce an abN Ab (myeloma protein or Bence Jones protein) found in blood & urine production of Ig & Ab, uric acid & Ca RF 57. S/Sx: MULTIPLE MYELOMA Bone pain (pelvis, spine, ribs) Osteoporesis (bone loss, fractures) Spinal cord compression & pathological paraplegia

nodes left intact Modified Radical Mastectomy: removal of breast tissue, nipple & lymph nodes, muscles left intact Halsted Radical Mastectomy: removal of breast tissue, nipple, lymph nodes & underlying muscles 68. Surgical Tx: BREAST CANCER Oophorectomy: for estrogen receptor-positive tumors Ablative therapy with adrenalectomy or chemical ablation which blocks cortisol, androstenedione & aldosterone production 69. Nursing Interventions: s/p Breast Surgery SemiFowlers position, turn from back to unaffected side, with affected arm elevated above the heart level to promote drainage & prevent lymphedema Use a pressure sleeve if edema is severe Maintain Jackson-Pratt suction, record the amount & characteristic of draiange No IV, injections, BP, venipunctures in affected arm Low Na-diet, diuretics for severe lymphedema Refer to MD & PT for appropriate exercise program 70. Health Teaching: s/p Breast Surgery Protect & avoid overuse of the hand & arm during the 1 st few months Keep the affected arm elevated to prevent lymphedema Incision care with lanolin to soften & prevent wound contractures BSE on the remaining breast Avoid strong sunlight or heat to the affected arm Dont carry anything heavy over the affected arm 71. Health Teaching: s/p Breast Surgery Avoid

vaporize Minimal bleeding & slight vaginal d/c is expected after the procedure, healing occurs in 6-12 wks 76. CERVICAL CA: Cryosurgery Involves freezing of the tissues by a probe with subsequent necrosis No anesthesia required Cramping may occur during the procedure A heavy, watery d/c is expected several wks after the procedure, use tampons Avoid sexual intercourse 77. CERVICAL CA: Conization A cone-shaped area of the cervix is removed For women who want further child bearing Long-term follow-up is needed (new lesions may develop) Cx: hemorrhage, uterine perforation,

incompetent cervix, cervical stenosis & preterm labor 78. CERVICAL CA: Hysterectomy Vaginal approach for microinvasive CA if childbearing is not desired Radical hysterectomy & bilateral lymph node dissection for CA that spread beyond the cervix but not to the pelvic wall 79. Nursing Interventions: s/p Hysterectomy Monitor vaginal bleeding (>1 saturated pad/hr) Avoid stair climbing for 1 mo. Avoid tub baths & sitting for long periods Avoid strenous activity or lifting >20 lbs Avoid sexual intercourse for 3-6 wks 80. CERVICAL CA: Pelvic exenteration Radical surgical procedure for recurrent CA When the bladder is removed, an ileal conduit is created & located at the R side of the abdomen to divert urine A colostomy is created on the L side of the abdomen for the passage of feces 81. CERVICAL CA: Types of Pelvic Exenteration Anterior Removal of uterus, ovaries, fallopian tubes, vagina, bladder, urethra & pelvic lymph nodes Posterior Removal of uterus, ovaries, fallopian tubes, descending colon, rectum & anal cnal Total Combo of anterior & posterior 82. Nursing Interventions: s/p Pelvic exenteration Administer perineal irrigation with half-strength H2O2 & NS Avoid strenous activity for 6 mos. Perineal opening may drain for several mos. Ileal conduit & colostomy care Sexual counseling: vaginal intercourse is not possible s/p anterior & total pelvic exenteration 83. OVARIAN CANCER Grows rapidly, spreads fast, often bilateral Common sites of mets: pelvis, lymphatics & peritoneum Usually detected late: Poor prognosis Exploratory laparotomy: to dx & stage the tumor 84. S/Sx: OVARIAN CANCER Abdominal discomfort or swelling GI disturbance Dysfunctional vaginal bleeding Abdominal mass 85. Tx: OVARIAN CANCER External radiation: if with mets Chemotherapy: done post-op for all stages of CA Intraperitoneal chemotx: instillation into abdominal cavity Immunotherapy: promotes tumor resistance Surgery: TAHBSO

constrictive clothing/jewelry, trauma, cuts, bruises or burns to the affected arm Wear gloves when gardening, washing dishes/clothes Use thick oven mitten mitts when cooking Use a thimble when sewing Apply lanolin hand cream several times daily Use cream cuticle remover Notify MD if S/ of inflammation occur in the affected arm Wear a Medic-Alert bracelet stating lymphedema arm 72. CERVICAL CANCER Premalignant changes: (Stage I) mild dysplasia to (Stage II) mod. dysplasia to (Stage III) severe dysplasia to carcinoma in situ Common sites of mets: pelvis & lymphatics Precipitating factors Low socioeconomic groups Early 1 st marriage Early & frequent intercourse Multiple sex partners High parity Poor hygiene 73. S/Sx: CERVICAL CANCER Painless vaginal bleeding postmenstrually & postcoitally Foul-smelling or serosanguinous vaginal d/c Leakage of urine or feces from the vagina Dysuria, hematuria Pelvic, lower back, leg or groin pain A/, wt loss Changes on Pap smear 74. Tx: CERVICAL CANCER Nonsurgical

Chemotherapy Cryosurgery External radiation Internal radiation (intracavitary) Laser therapy Surgical

Conization Hysterectomy Pelvic exenteration 75. CERVICAL CA: Laser Therapy Energy from the beam is absorbed by fluid in the tissues, causing them to

 86. ENDOMETRIAL CANCER Slow-growing tumor asso. with menopausal years Common sites of mets: ovaries, pelvis, peritoneum, lymphatics & via blood to the lungs, liver & bone Precipitating Factors Hx of uterine polyps Nulliparity Polycystic ovary disease Estrogen stimulation Late menopause Family hx 87. S/Sx: ENDOMETRIAL CANCER Postmenopausal bleeding Watery, serosanguinous discharge Low back, pelvic or abdominal pain Enlarged uterus in advanced stages 88. Tx: ENDOMETRIAL CANCER External or internal radiation Chemotherapy for advanced or recurrent CA Medroxyprogesterone Megace for (Depo-Provera) or Megestrol)

the stomach, pancreaticojejunostomy, gastrojejunostomy & choledochojejunostomy 97. INTESTINAL TUMORS Develop in the cells lining the bowel wall or develop as polyps in the colon or rectum Cx: bowel perforation with peritonitis, abscess & fistula formation, hemorrhage & complete gut obstruction Common sites of mets: via lymphatics & blood, colon & other organs 98. S/Sx: INTESTINAL TUMORS A/V, malaise, wt loss Blood in stools, anemia AbN stools Ascending colon tumor: diarrhea Descending colon tumor: constipation with some diarrhea, ribbon-like stool Rectal tumor: alternating constipation & diarrhea Guarding or

estrogen-dependent

tumors Tamoxifen

abdominal distention Abdominal mass & cachexia (late signs) 99. Nursing Interventions: INTESTINAL TUMORS WOF bowel perforation: BP, HR, T, weak pulse, distended abdomen WOF intestinal obstruction: (EARLY S/Sx- peristalsis, to bowel sounds) fecal vomiting, pain, constipation, distended abdomen

(Nolvadex): antiestrogen Surgery: TAHBSO 89. GASTRIC CANCER Predisposing Factors Diet: high in complex CHO, grains & salt, low in fresh green, leafy vegetables & fruits Use of nitrates Smoking, alcoholism Hx of gastric ulcers Cx: hemorrhage, obstruction, mets & dumping syndrome Goal of Tx: remove the tumor & provide nutritional support 90. S/Sx: GASTRIC CANCER A/N/V, wt loss Fatigue, anemia Indigestion, epigastric discomfort A sensation of pressure in the stomach Dysphagia Ascites Palpable mass 91. Tx: GASTRIC CANCER Chemotx Radiation Surgery Subtotal gastrectomy Bilroth I: Gastroduodenostomy Bilroth II: Gastrojejunostomy Total gastrectomy

Radiation pre-op Chemotherapy post-op Surgery: bowel resection & creation of colo or ileostomy 100. COLO/ILEOSTOMY PRE-OP CARE Consult with enterostomal therapist to identify optimal placement of ostomy Low-residue diet for 1-2 days pre-op Give intestinal antiseptics & antibiotics, laxatives & enemas as ordered 101. COLOSTOMY POST-OP CARE Apply petroleum jelly over the stoma to keep it moist followed by dry sterile gauze if pouch system is not yet in place Monitor the stoma for size, unusual bleeding or necrotic tissue Monitor the stoma for color N: pink or red indicating vascularity Pale: anemia, Violet/Blue/Black: compromised circulation 102. COLOSTOMY POST-OP CARE Check pouch system for proper fit & leakage Ascending colon colostomy: expect liquid stool Transverse colon

Esophagojejunostomy 92. Nursing Interventions: GASTRIC CANCER Fowlers position for comfort: Pain meds as ordered Monitor Hgb, Hct: BT as ordered NPO for 1-3 days post-op until peristalsis returns Monitor I/O: IVF & e+ as ordered Monitor NGT suction, dont irrigate or remove NGT 93. Nursing Interventions: GASTRIC CANCER

Progressive diet to 6 small bland meals/day Monitor wt, nutritional status: Small, bland, easy digestible meals with vit & mineral supplements WOF Cx: hemorrhage, dumping syndrome, diarrhea, hypoglycemia, Vit B12 deficiency 94. PANCREATIC CANCER More common in blacks than in whites, in smokers & in men Linked with DM, alcohol use, hx of pancreatitis, high fat diet, envtal chemicals With poor prognosis 95. S/Sx: PANCREATIC CANCER N/V Jaundice Unexplained wt. 96. loss Clay-colored stool Glucose

colostomy: expect loose to semiformed stool Descending colon: expect close to N stool Empty pouch when 1/3 full, remove feces from the skin Avoid gas/odor-forming foods 103. COLOSTOMY POST-OP CARE WOF perineal wound infection (if present) Administer as ordered Analgesics & antibiotics Stoma irrigation 104. ILEOSTOMY POST-OP CARE Post-op drainage: dark green to yellow (as the pt begins to eat) Expect liquid stool WOF dehydration & e+ imbalance Avoid

intolerance Abdominal pain Tx: PANCREATIC CANCER Radiation procedure: Chemotherapy Whipples

suppositories through ileostomy 105. LUNG CANCER Lungs: common target for mets from other organs Bronchiogenic carcinoma: direct extension & via lymphatics 4 Major Types Small (Oat)

pancreaticoduodenectomy with removal of distal third of

Cell Epidermal (Squamous Cell) Adenocarcinoma Large cell anaplastic carcinoma 106. LUNG CANCER Causes Cigarette smoking Envtal & occupational pollutants Dx: CXR (lesion or mass), bronchoscopy & sputum cytological studies 107. S/Sx: LUNG CANCER Cough Dyspnea Hoarseness Hemoptysis Chest pain A/ wt loss Weakness 108. Nursing Interventions: LUNG CANCER Monitor VS, pulse oximetry Fowlers position WOF RR distress, tracheal deviation, bleeding, infection & e+ imbalance Activity as tolerated, rest periods, active/passive ROM Diet: calorie, high CHON, Vit Administer as ordered O2, bronchodilators, steroids Analgesics CPT 109. Tx: LUNG CANCER Radiation Chemotherapy Immunotherapy Surgery Laser therapy: to relieve endobronchial obstruction Thoracentesis & pleurodesis: to remove pleural fluid & relieve hypoxia Thoracotomy with pneumonectomy or lobectomy or segmental

post-op, WOF hemorrhage Continuous bladder irrigation (CBI) post-op to maintain the urine at a pink color Bladder spasms are common post-op, give antispasmodics as ordered WOF dribbling & incontinence Sterility may or may not occur post-op 117. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal Technique Via

abdominal & bladder incision Via low abdominal incision without opening the bladder Via incision bet. scrotum & anus Hemorrhage Yes No No Bladder spasms Yes Yes but less Urinary incontinence common 118. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal CBI Yes Yes - Sterility Yes Yes Yes Remarks Abdominal dressing soaked frequently with urine, Longer healing time than TURP Minimal abdominal drainage WOF infection, (No rectal tubes, rectal temp. taking & enema) Teach perineal exercises
119. Nursing Interventions: s/p TURP Monitor VS, U.O., hematuria & clots, Hgb & Hct levels Force fluids Expect red to light pink urine for 24 hrs, turning to amber in 3 days (then encourage ambulation) WOF arterial bleeding (bright red urine with clots): CBI & notify MD WOF venous bleeding (burgundy-colored urine): notify MD who will apply traction on the catheter Continuous urge to void is N but not encouraged to prevent bladder spasms Antibiotics, analgesics, stool softeners & antispasmodics as ordered 120. Nursing Interventions: s/p TURP Monitor 3-way foley catheter (for the balloon (30-45 cc), inflow & outflow) Use pNSS only to prevent water intoxication or hypoNa ( LOC, HR, BP) Maintain infusion rate as ordered, if (+) clots: rate For obstructed catheter: turn off CBI, irrigate with 30-50 ml pNSS, notify MD if it does not resolve CBI is d/c usually after 1-2 days, WOF continence & urinary retention

resection 110. Pre-op Care: LUNG CANCER Explain the potential post-op need for chest tubes Closed chest drainage is not used for pneumonectomy & the serum fluid that accumulates in the empty thoracic cavity will consolidate, preventing mediastinal shift 111. Post-op Care: LUNG CANCER Monitor VS, breath sounds Maintain chest tube drainage system, WOF SQ emphysema Avoid complete lateral turning Activity as tolerated, active ROM of the operative shoulder Administer O2 as ordered 112. PROSTATE CANCER Slow-growing, androgen type of adenocarcinoma in M >50 y/o Common sites of mets: bloodstream, lymphatics, pelvis, spine, bone 113. S/Sx: PROSTATE CANCER (-) in early stages Hard, pea-sized nodule on rectal exam Hematuria Late S/Sx: wt loss, urinary obstruction, pain radiating from the lumbosacral area down the leg Prostate-specific Ag test: monitors the pts response to tx serum acid phosphatase: indicates spread & mets 114. Tx: PROSTATE CANCER Hormonal manipulation LT: leuprolide acetate (Lupron), flutamide (Eulexin) or DES Goserelin acetate (Zoladex) when orchiectomy or estrogen administration is not acceptable for the pt Radiation & Chemotx for hormone-resistant tumors 115. Tx: PROSTATE CANCER Palliative surgery: Orchiectomy (to testosterone production) Cryosurgical ablation (liquid nitrogen freezes the prostate, dead cells are absorbed by the body) Transurethral resection of the prostate (TURP) or prostatectomy 116. PROSTATE CA: TURP Insertion of a scope into the urethra to excise prostatic tissue Bleeding is common

121. Discharge Health Teaching: s/p TURP Avoid heavy lifting, stressful exercise, driving, Valsalva maneuver & sexual intercourse for 2-6 wks Drink 2.4-3L fluids/day before 8 pm Avoid alcohol, caffeine & spicy foods to prevent overstimulation of the bladder Pt may pass small clots & tissue debris for several days If urine becomes less in amount & bloody, rest & force fluids, notify MD if persistent 122. Nursing Interventions: s/p Suprapubic Prostatectomy Monitor foley catheter & suprapubic catheter drainage As ordered, clamp the suprapubic cath after foley cath is removed (2-4 days post-op) & instruct the pt to void, measure residual urine by unclamping the cath & measuring the U.O. Prepare for removal of suprapubic cath if pt consistently empties bladder & residual urine is <75 ml