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 Factors
A. 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 Factors
Chemical 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.

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

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

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 Use of high frequency sound waves echoing of 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

Classification of Tumors
C ARCINOMAS: EPITHELIAL TISSUE BODY SURFACES, LINING OF BODY CAVITIES ETC:(ADENOCARCINOMA) S ARCOMAS: CONNECTIVE TISSUE STRIATED MUSCLE, BONE, ETC (OSTEOSARCOMA) L YMPHOMAS AND LEUKEMIAS HEMATOPOIETIC SYSTEM N ERVOUS TISSUE TUMORS EX. NERVE CELLS-NEUROBLASTOMA M YELOMA
Develops in the plasma cells of bone marrow

Naming Cancers

Effects of cancer
1. Malfunction of the organ due to the destruction of 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 cancer
4. 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
SKIN
Avoid over exposure to sunlight ORAL Annual oral exam of mouth and teeth BREAST Monthly breast self examination from age 20 up LUNGS Avoid cigarette smoking, DO annual CXR

Prevention of cancer
COLON
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 saltcured, 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: The surgeon removes the entire breast. 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: The surgeon removes the entire breast.

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 ("nipplesparing") 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 ca
PREOPERATIVE 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.

DOS AND DONTS AFTER THE SURGERY

Dos
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. 35 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 CAUTIONLYMPHEDEMA

POST-OP EXERCISES

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.

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

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. Repeat this exercise 6 to 8 times, twice a day. Slowly raise your arms out to the sides, until they are at shoulder level.

LUNG CANCER

Pneumonectomy
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.

Lobectomy
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.

Dos:

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 taken out through the vagina

TOTAL ABDOMINAL HYSTERECTOMY - In which the uterus and cervix are taken out through a large incision (cut) in the abdomen

TOTAL LAPAROSCOPIC HYSTERECTOMY - In which the uterus and cervix are taken out through a small incision in the abdomen using a laparoscope

 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 distention Expect 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 occurs post-operatively Provide analgesics to relief cramps Monitor urinary output because urinary retention commonly occurs

 Encourage patient to perform the prescribed exercises and to ambulate early and frequently to prevent venous 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 incision site Avoid rapid walking, dancing Advice to eat high protein, high residue diet to 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 depressed or irritable for a while Encourage family members to respond calmly and with understanding If the ovaries were removed, client may receive 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 expose the tissues and blood vessels that surround the uterus and cervix These tissues are cut and the blood vessels are tied off to remove the uterus Stitches are placed in these deep structures, which will eventually dissolve

 The first night after the surgery, you may be asked to sit up in bed and walk a short distance If there is no evidence of complications and you are able to drink fluids on your own, the catheter in your bladder and IV will be removed

 Eat balanced diet rich in fresh fruits and vegetables. Dependig on how much blood loss occurred during surgery, you may require 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 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

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.

Dos:
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
Dos:
Wear comfortable clean clothing preferably cotton clothing Ambulate 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

Dos:

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. Eat nutritious foods.

Post-OP Care
Dos: 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.

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.

Management of client with prostate cancer

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.

POST OPERATIVE CARE: 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
POST OPERATIVE CARE: 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 set Endotracheal tube Laryngoscope Oxygen Give mist inhalation until chest is clear Take temperature every 4 hours for 24 hours Assess 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. POST OPERATIVE CARE: 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.

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

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.

TakeNursing management a steps to prevent hyperuricemiapossible 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.

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

Nursing management

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 chemotherapy
1. 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 drugs

EXAMPLES 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
NURSING CONSIDERATIONS: Monitor liver function, CBC, Urea and Creatinine Provide oral hyiene Administer antiemetic drugs as ordered Observe other s/s of side effects

Classifications of chemo drugs

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 NURSING CONSIDERATIONS: Hydration, monitor lab test Antiemetics, oral care

Classifications of chemo drugs

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

Classifications of chemo drugs

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

Classifications of chemo drugs

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

hormone
ADVERSE EFFECTS: Signs and symptoms of menopause Bone marrow depression, retinopathy Teslac may produce altered libido, facial hair growth, enlargement of the clitoris NURSING CONSIDERATIONS: 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 drugs

C. 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

Administration of IV chemo drugs C. 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 access
2. 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 administration

2. 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 EXTRAVASATIONS or accidental infiltration of vesicant or irritant chemo drugs from the vein into the surrounding tissues of the IV site.

Extravasation
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

- 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

Side effects of chemo

* Alopecia Reassure that it is temporary Encourage to wear wigs, hat, or headscarf *Nail Changes Reassure that nails may grow normally after chemo

Side effects of 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.

Side effects of chemo

*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

5. REPRODUCTIVE SYSTEM *Amenorrhea and decrease libido for males Reassure that menstruation and libido will resume after chemo 6. NEUROMUSCULAR 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

Side effects of chemo

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 safety at all times 4. Wear nitrite examination gloves

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 safety
14. 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 excreta

1. 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 NURSING RESPONSIBILITIES: 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 NURSING RESPONSIBILITIES: 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.

Side effects of radiation

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

Side effects of radiation

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

Side effects of radiation

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 TRANSPLANTATION

Bone 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.

IST
Antilymphocyte 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 management
2. 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 drugsbupivacaine,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 management 5. 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.

NURSING MANAGEMENT svcs 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.

SCC
NURSING 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.

hypercalcemia
NURSING 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

hypercalcemia
NURSING 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.