ONCOLOGY NURSING

Common Terminologies Oncogene cancer genes that alter normal genes Proto oncogenes repressed oncogene that can activated by etiologic and risk factors Anaplasia no resemblance to tissues of origin Metaplasia replacement of the original cell with another type of cell Carcinoma cancer cell composed of epithelial cells that can spread Neoplasm growth of new tissue Tumor same with neoplasm Dysplasia alteration in the size, shape and organization of differentiated cells Hyperplasia an increase in the number of normal cells

Classification of Cancer: Squamous cell carcinoma surface epithelial Adenosarcoma glandular epithelial Fibrosarcoma fibrous connective tissue Liposarcoma adipose tissue Chondrosarcoma cartilage Osteosarcoma bone Hemangiosarcoma blood vessels Lymphangiosarcoma lymph vessels Leiomyosarcoma smooth muscles Rhabdomyosarcoma striated muscles Glioma glial cells Neurolemic sarcoma nerve sheath Leukemia blood Classification of Benign: Glandular tissue adenoma Bone osteotoma Nerve cells neuroma Fibrous tissue - fibroma

Cancer Cells
Tumor can be: BENIGN Localized Encapsulated Hyperplasia, o functional activity No metastasis MALIGNANT Systemic Non encapsulated Anaplasia, metaplasia (o or q function of the organ involved) With metastasis (direct invasion, lymphatic, embolism, diffusion) Harmful Hardly differentiated Rapid growth

Etiology
Exact cause is still unknown Viruses cancer of the liver, burkitt s lymphoma Chemical Agents tar, asphalt, arsenicals, fuels, oil Drugs chemodrugs Physical Agents radiation Predisposing Factors: Age (60% of cancer clients are over 65 y/o) Sex Breast cancer for females and Prostate CA for males Geographic location cancer of the stomach (Japan) Occupation factory workers (lung cancer) Hereditary breast, ovaries and colon Diet cured and salted foods (stomach) Stress decreased immune system Precancerous lesions moles, polyps (colon and stomach) Early Detection: (SECONDARY) y Chest xray and sputum cytology (lung cancer) y Physical exam (every year for over 40 y/o) skin, lymph nodes, mouth, thyroid, breast, testes, rectum, prostate

Fatal if it occurs in restricted area (skull) Fully differentiated Slow growth

Cancer
y y y y y y y Synonymous to death and pain Chronic disease that has acute exacerbation Not a single disease with single cause Common in men Leading cancer is lung cancer Male: prostate Female: breast

y y y y y y y

y y y y

Oral Exam - annually TSE monthly following shower Digital Rectal Exam annually for 40y/o and above Sigmoidoscopy for 50 y/o and above annually for 2 years then every 3 years if negative Fecal Occult Blood doctor s recommendation BSE every month after menstruation Breast Clinical Exam done by physician (every 3 years for 20-40 y/o then yearly for over 40 y/o) Mammography once for 35-40 y/o, then yearly for over 50 y/o Pap smear age 18 and all sexually active women then yearly after 3 negative results Pelvic Exam same with pap smear Endometrial tissue sampling menopause

7 SAFEGUARDS
U B B L terus annual pap smear reast regular BSE asic PE yearly for all adults ung control or preferably stop smoking, annual chest xray for high risk O ral annual oral exam by the doctor C olon or Rectum DE, Proctosigmoidoscopy (40y/o) S kin avoid undue exposure to sunlight (10-2 PM)

Diagnostic Exam
Biopsy FNA Incision Excision CT scan MRI PET Direct Visualization Bronchoscopy Gastroscopy Proctosigmoidoscopy Mammogram Pap smear UTZ Angiogram Lymphangiogram Blood Studies Antigen-skin-testing Staging and Grading T Tumor T0-T4 N Node N0-N3 M Metastasis M0-M1 Normal Stage I Stage II Stage III Stage IV T0, N0, M0 T1, N0, M0 T2, N1, M0 T3, N2, M0 with metastasis

Factors that lead to Cancer

y y y y y y y y Smoking lung cancer Sunlight (10am to 2pm) basal/squamous cell (skin cancer) Ionizing Radiation medical and dental xrays Nutrition and diet (high fats and low fiber diet) Alcohol liver, oral and esophagus cancer Chewing of tobacco (mouth, larynx and throat) Estrogen endometrial cancer Occupational hazards (nickel and asbestos)

7 Warning Signals (CAUTION US)

C A U T I O N U S hange in bowel and bladder habits sore that does not heal nusual bleeding or discharge hickening or lump in breast or elsewhere ndigestion or difficulty in swallowing bvious change in wart or mole agging cough or hoarseness of the voice nexplained anemia udden weight loss

Tis carcinoma in situ (non-infiltrating) X can t be assessed

Staging System T Tumor N Node M Metastasis

y T0-T4 N0-N3 M0-M3 y y

Tis carcinoma in situ (non-infiltrating) X can t be assessed Normal Stage I Stage II Stage III Stage IV T0, N0, M0 T1, N0, M0, < 2cm diameter of the tumor T2, N1, M0, > 2 < 5cm diameter of the tumor T3, N2, M0, > 5cm diameter of the tumor any size of the tumor with metastasis

Clients usually ignored cardinal signs of Cancer Most often cancer is detected during routine exam Questions that need to be answered: Example (Is the disease curable or not?)

Client Reaction during Diagnoses

Client will use coping strategies to q his anxiety level such as: y Denialy Rational inquiry-seek more information y Affect Reversal-make light of the situation (laughing etc.) y Mutuality-share concerns and talk with other persons y Suppression-conscious forgetting y Displacement or redirection-do other things

Grading System Microscopic study of the cell The poorer the differentiation of the cells the poorer is the prognosis Carcinogenesis: Process of cancer formation y Initiation exposure to carcinogens y Promotion exposure to carcinogenic chemicals will promote the function of proto oncogenes y Transformation conversion to malignant cell y Progression malignant behavior of the cells

Client Reaction during Diagnoses

y y y y y y y Confrontational Redefine or revise Passive acceptance Disengagement Externalization or Projection Moral masochism Compliance and cooperational

Intervention Phase
y Therapeutic communications (silence, non judgemental, acceptance, active friendliness, setting limits) Strategizing how to use effective coping mechanism (client and SO) Cancer management will involve surgery, radiation, chemo and immunotherapy in combination.

Stages of Metastatic Process

y y y Invasion of adjacent tissue Spread of cancer cells Establishment and growth at secondary site y y

Effective Test must be

y y y y Specific for the type of Cancer Reliable Economical on terms and benefits Acceptable to the client (most important)

Surgery
Used in diagnosing, staging and treating the client FNA, I&E biopsy Cytology specimens Palliative relieves pain, airway obstruction. Reconstructive restore maximal function and appearance Preventive removal of target organ

Points to Remember
y Most client fear of death upon confirmation of Cancer

Radiation Therapy
y o y y y y y y y y y y Range will be 2,000-5,000 centigrays (cGy) 5,000 cGy will o SE Normal cells and cancer cells are both affected The goal is to destroy malignant cells without harming normal cells by: Fractionation-small frequent dose Alternating the site Alpha particle-fast moving helium nucleus (slight penetration) Beta particle-fast moving electron (moderate penetration) Gamma ray-similar to light ray (high penetration) Sodium Iodide (131 I)-for thyroid gland Gold (198 Au)-effective for ascites and pleural effusion Sodium Phosphate (32 P)-for RBC Destroys the ability of the cell to reproduce by damaging the DNA

Potential hazard exist because it s not encased y Isotope maybe excreted via body fluids y Flush the toilet several times after use y Protect staff and visitors y Marked room and kardex with RADIATION HAZARD SEALED SOURCE y radioisotope is placed into needles, beads, seeds, ribbons or catheter then implanted directly into the tumor. y Requires a private room and bathroom y Room must be lead-shield proof y Lead container and long forcep on bedside y Check linen and other materials for the presence of isotope y

Chemotherapy
Use of chemicals to destroy cancer cells Interferes DNA & RNA activities associated with cell division y Often used in combination with radiation therapy Cytotoxic - is an agent capable of destroying cells Cytotoxic drug - alkylating and antimetabolites y y

Radiation Safety
y y y y y Distance - the greater the distance the lesser the exposure Time - the less time spent close to radiation the less exposure (max of 30 min per shift) Shielding - use lead aprons and gloves Standards - kept as low as reasonably achievable Monitoring device - film badge (measure the whole exposure of the nurse)

Antineoplastic Drugs
Alkylating Agents Attack the DNA of rapidly dividing cell Nitrosurea: Carmustine (BCNU) Nitrogen Mustard: Chlorambucil (Leukeran) Cyclophosphamide (Cytoxan) Vinca Alkaloids Interfere with mitosis (M phase) Vincristine (Oncovin) Vinblastine (Velban) Antimetabolites Inhibits protein synthesis (S phase) Azathioprine (Imuran) Fluorouracil (5-FU) Methotrexate (Mexate) given with leucovorin to protect normal cells Antibiotics Inhibit RNA Doxorubicin HCl (Adriamycin) Mithramycin (Mithracin)

Types of RADIATION
External Radiation Administered by high energy xray machine (radioisotope Cobalt for Prostate and Lung CA) Internal Radiation Via injection or orally

Internal Radiation
UNSEALED SOURCE y Radioisotope is administered IV or orally y NaP04 (32 P) IV for polycythemia vera y (131 I) PO for Grave s disease

Antimetabolites Inhibits protein synthesis (S phase) Azathioprine (Imuran) Fluorouracil (5-FU) Methotrexate (Mexate) given with leucovorin to protect normal cells Antibiotics Inhibit RNA Doxorubicin HCl (Adriamycin) Mithramycin (Mithracin) Hormone Inhibit RNA and protein synthesis in tissues that are dependent on the opposite sex Androgens, Estrogens, Progestins, Steroids (Analogue, Exogenous) Hormone Antagonist: Mitotane (Lysodren) cortisol antagonist, Tamoxifen Citrate (Nolvadex) estrogen antagonist Immune Agents Introduction of an agent to stimulate production of antibodies Bacillus Calmette-Guerin (BCG)

C&R Goal:
Destroy all malignant cells without excessive destruction of normal cell y Control growth of tumor when cure is not possible Note: all rapid dividing cells (GI mucosa, hair follicles and bone marrow) are susceptible to the action of chemo and radiation therapy. y

Reasons of Combining Drugs

Synergy - two or more agents works together to enhance the effect Adjuvant - an additional treatment o s malignant cell destructions, q s the SE Principle of MDT is instituted to avoid and prevent the SE

C&R SIDE EFFECTS

Common: nausea and vomiting Stomatitis Alopecia (2-3 weeks to occur) Bone marrow depression

Neurologic/Sensory/Perceptual Meningeal irritation CN and peripheral neuropathy Cerebellar toxicity Ototoxicity Cardiac Pericardial Effusion Arrhythmias CHF Pulmonary Pleural Effusion Pneumonitis GIT Stomatitis Esophagitis Pharyngitis Taste alteration Anorexia Nausea and vomiting Constipation and diarrhea Weight loss C&R SIDE EFFECTS GUT Nephrotoxicity Hemorrhagic cystitis Hyperuricemia Urine color changes Reproductive Loss of libido Impotence Amenorrhea Irregular menses Menopausal symptoms Azoospermia Sterility Gynecomastia Hepatic Hepatotoxicity Integumentary Alopecia Dermatitis and ulcers Hematopoietic q bone marrow activity anemia, prone to infection and bleeding tendency Metabolic TLS and Hyperkalemia

Perceived Change in Body Image

Obvious reminder of disability need for prosthesis (breast, leg and eye) need for hardware (wheel chair, crutches) need for medication (CR therapy) extent of disability or limitation

Type of loss
y y y y symbols of sexuality social acceptability (colostomy) ability to communicate (laryngectomy, aphasia) anatomic changes (amputation) y y y y y 50% die from the disease time from diagnosis to death ranges from weeks- years not all clients become terminally ill others die during initial treatment; others die from complications of treatment Endpoint: no response to treatment and progressions cannot be controlled standard of care for terminally ill cancer clients symptom control pain management providing comfort and dignity 24 hour 7 day coverage services are given based on client s need not on its ability to pay caring can be just successful as curing; when curing is not an option care is exercised during the final stage of life to care without functional and structural impairment if cure is not possible goals must = prevent further metastasis = relieve symptoms = maintain high quality of life

y y y y y y y y y y y

Breast Cancer Cancer of the Stomach Cancer of the Colon Cancer of the Liver Cancer of the Pancreas Wilm s Tumor Hodgkin s and Non Hodgkin s Leukemia Prostate Cancer Common: cerebellar astrocytoma, brain stem glioma, medulloblastoma (brain stem) s/sx: increased ICP, headache, n&v, projectile vomiting, decreased LOC, seizures, papilledema Intervention: symptomatic, surgery, radiation and chemotherapy (vincristine and cyclophosphamide) Follow peri-op craniotomy Cause: smoking s/sx: hoarseness of the voice, dysphagia, coughing, bloody sputum Intervention: laryngectomy and radical neck dissection Most preventable type of cancer Cause: smoking Types: adenocarcinoma (common), small cell (fatal) s/sx: chronic cough, wheezing, dyspnea, repeated unresolved URTI, chest/shoulder pain, hemoptysis, hoarseness, dysphagia, head and neck edema Intervention: chemo and radiation, surgery (wedge, segment, lobe, entire lung) s/sx: non tender fixed lump (tail of spence), dimpling, bleeding Stage I (<2cm) Stage II (>2<5cm + Nodes) Stage III (>5cm + nodes) Stage IV (metastasis) Intervention: chemo and radiation, surgery Lumpectomy, segmental mastectomy (lobe), simple mastectomy (entire breast), MRM, RM, URBAN

Brain Tumor

Terminally Ill

y y y y y y y y

Cancer of the Larynx

HOSPICE CARE
y y y y y y

Lung Cancer

Ethical Issues
y y

Goals of Intervention
y y

Breast Cancer
y y

CANCER
y y y Brain Tumor Cancer of the Larynx Lung Cancer

Follow post-op nursing management

Cancer of the Stomach

y y y y y y y y y y y y y y y y y y Most common GI cancer, cured foods, low in fiber s/sx: vague fullness, bleeding LATE: ascites, palpable mass Intervention: C&R, surgery (billroth I&II) Follow post-op procedures Cause: low fiber high cholesterol diet, POLYPS s/sx: change in BM, bleeding, obstruction Adenocarcinoma Intervention: C&R, surgery Follow post-op procedures Colostomy care Usually a complication of CIRRHOSIS or from metastasis Hepatic failure s/sx: similar to cirrhosis Intervention: C&R, (Fluorouracil 5 FU, Cytoxan, Oncovin), liver transplant GALL BLADDER CA 1 YEAR SURVIVAL Mostly adenocarcinomas Head of the pancreas s/sx: obstruction of the CBD, anorexia, weight loss, pain (upper abdomen, left hypochondriac), jaundice Dx: increased serum lipase and bilirubin Intervention: C&R, surgery (WHIPPLE S, pancreatoduodenectomy, anastomosis of stomach, duodenum, CBD and pancreatic duct)

y y y y y

AML reduction of granulocytes CML myeloid stem cell, blood cells s/sx: related to blood level derangement DX: bone marrow biopsy Filgrastim (Neupogen) = stimulates neutophils production

Hodgkin s and Non-Hodgkin s Lymphoma

y y y Obstruction of the lymph nodes s/sx: edema Hodgkin s painless, localized (left thoracic duct and right lymphatic duct), lymph node biopsy reveals REED-STERNBERG cell or GIANT cell Non-Hodgkin s painful, systemic CHLORAMBUCIL (LEUKERAN) PO 10 mg OD

Cancer of the Colon

Cancer of the Liver

y y

Wilm s Tumor
Nephroblastoma Renal parenchyma, left kidney (unilateral) y Stage I kidney, stage II beyond kidney encapsulated, stage III abdomen, stage IV metastasis, stage V bilateral y s/sx: during bathing and dressing mass will be noticed, non-tender, IVP reveals mass, y NO PALPATION y Intervention: Nephrectomy (good prognosis)

Cancer of the Pancreas

y y

Cancer of the Skin

y y Types: basal cell (common), squamous cell (rapid), malignant (less frequent) Precancerous: leukoplakia (mouth and lips), nevi (moles, color change to black, bleeding, irritation), senile keratosis (brown scalelike spots among elderly) Cause: UV light, chemicals and irritation Intervention: protection against sunlight, irritants and chemicals, lotion (para-amino benzoic acid), report change in lesion, CHEMOTHERAPY & IMMUNOTHERAPY

Prostate Cancer
y y y y y y BPH cancer of the prostate s/sx: asymptomatic Dx: elevation of CEA, PSA, AP Intervention: Prostatectomy Follow post-op procedure of prostatectomy TESTICULAR CA (curable) CRYPTORCHIDISM y y ALL immature proliferation CLL same, adult y y

Leukemia

Set A CANCER POST TEST 1. Which of the following would be considered an iatrogenic cause of cancer? A. ionizing radiation from radon b. ionizing radiation from uranium ore c. xrays to treat tumor d. ultraviolet radiation from the sun 2. A nurse is providing health education in a community setting about measures to avoid excessive sun exposure. Which of the following statement is true: a. reapply sun screen only when you go to the water b. avoid peak exposure hours from 10 AM to 2 PM c. wear loosely woven clothing for added ventilation d. apply sunscreen after exposure 3. A nurse is palpating a female clients breast. The area of the breast in which tumors are commonly found in the? A. upper inner quadrant b. lower inner quadrant c. lower outer quadrant d. upper outer quadrant 4. Which of the following statements would be correct about pap smear? A. it is recommended every other year b. repeat every 3 years after 4 consecutive negative results c. it should be done at age 18 or earlier if sexually active d. colposcopy is needed after 4 negative results 5. What is the single most important risk factor for cancer? A. family history b. lifestyle c. age d. menopause or hormonal events 6. Which of the following is an environmental factor of cancer? A. gender

b. air pollution c. immunologic status d. age 7. Kris is on the terminal stage of breast cancer. Her doctor decided to perform an operation to lessen her intractable pain. This operation is considered as: a. reconstructive b. curative c. palliative d. rehabilitative 8. Which of the following nursing interventions would be most helpful in making the respiratory effort of a client with metastatic lung cancer more efficient? a. teaching the diaphragmatic breathing techniques b. administering cough suppressants as ordered c. teaching and encouraging pursed lip breathing d. placing the client in a low semi fowlers position 9. To manage possible nausea and vomiting, the nurse should discuss, a. eating frequent, small meals through out the day b. eating three normal meals a day c. eating only cool foods with no odor d. limiting the amount of food intake 10. What are the common side effects of chemo and radiation therapy? A. stomatitis, nausea and vomiting, depression B. stomatitis, loss of hair and anemia C. fatigue, alopecia and bone marrow depression D. dysphagia, anemia and fatigue 11. Common site of metastatic activity? A. bone B. brain C. lungs D. liver 12. What is the early sign of Cancer of the Larynx? A. hoarseness of the voice B. dysphagia C. coughing D. bloody sputum 13. Common type of lung cancer? A. Small oat cell B. Squamous C. Large cell D. adenocarcinoma 14. All of the following are considered early sign of breast cancer EXCEPT?

A. bloody discharge B. dimpling or peau d orange C. tender lump D. fixed lump 15. What is the early sign of Stomach Cancer? A. Melena B. Hematochezia C. Vague fullness of the stomach D. Ascites 16. T1N2M1 means? A. normal B. stage I C. stage III D. stage IV CANCER POST TEST Matching Type I. CA liver a. mole II. CA pancreas b. painful adenopathy III. Wilm s c. bone marrow biopsy IV. Hodgkin s d. kernicterus V. Non Hodgkin s e. painless adenopathy VI. CA skin f. increased ICP VII. Leukemia g. whipple s procedure h. no palpation Set A Key Answers CANCER POST TEST Matching Type I. CA liver a. mole II. CA pancreas b. painful adenopathy III. Wilm s c. bone marrow biopsy IV. Hodgkin s d. kernicterus V. Non Hodgkin s e. painless adenopathy VI. CA skin f. increased ICP VII. Leukemia g. whipple s procedure h. no palpation Set A Key Answers Set B CANCER POST TEST 1. A client with nagging cough makes an appointment to see the physician, after reading that this is one of 7 warning signals of cancer. What is another warning sign of cancer? A. rashes B. nausea and vomiting C. alopecia D. dysphagia CANCER POST TEST

2. Which type of cancer causes the most death in women? A. breast B. ovarian C. lung D. all of the above 3. To elicit more information regarding hoarseness of the voice the nurse should ask which question? A. do you eat high fats low fibers B. do you strain your voice C. do you smoke cigarettes D. do you eat spicy foods 4. What is the most common adverse effect of chemotherapy? A. alopecia B. stomatitis C. nausea and vomiting D. anemia 5. A client is receiving an internal radioactive implant and discovers the implant in the bed linen, what should a nurse do? A. report to the physician at once B. pick up with a long-handled forceps and put it in a lead container C. put the implant back in place using long handled forceps D. leave the room immediately and notify the radiation department 6. Which of the following is likely to decrease pain of stomatitis secondary to CHEMO? A. recommend to discontinue therapy B. provide a solution of hydrogen peroxide and water for use as mouth rinse C. monitor platelet count D. check regularly for s/sx of stomatitis 7. The nurse instructs the client the diagnosis of breast cancer is confirmed by? A. BSE breast self examination B. mammography C. FNAB fine needle aspiration biopsy D. chest xray 8. For client newly diagnosed with radiation induced thrombocytopenia, the nurse should include which specific intervention? A. bedrest must be encouraged B. reverse isolation upon admission C. check petechia every shift D. all of the above

9. Risk for impaired skin integrity from external radiation had been made, what will be your nursing intervention? A. apply talcum powder on the site B. remove tumor skin marking after radiation C. wear protective gears when giving direct care D. avoid use of soap on the irradiated areas 10. Which of the following organs is an occasional site of metastasis activity? A. liver B. colon C. lungs D. brain E. bones Set B Key Answers 1. D 2. C 3. C 4. C 5. B 6. B 7. C 8. C 9. D 10. B