CANCER

• The cancer patient: Cancer is a multisystem stressor. Regardless of the specific type of cancer, certain aspects of the disease and of nursing care are the same. The following principles apply universally and should be referred to when studying individual kinds of cancer.
  • Pathophysiology: result of altered cellular mechanisms. Several theories about causation, but current thinking is multiple causation. Alterations result in a progressive, uncontrolled multiplication of cells, with selective ability to invade and metastasize.
  • Risk factors:
    1. Heredity, e.g., retinoblastoma.
    2. Familial susceptibility, e.g., breast.
    3. Acquired diseases, e.g., ulcerative colitis.
    4. Virus, e.g., Burkitt’s tumor.
    5. Environmental factors:
       • Tobacco.
       • Alcohol.
       • Radiation.
       • Occupational hazards.
       • Drugs, e.g., immunosuppressive, cytotoxic.
       • Asbestos.
    6. Age.
    7. Air pollution.
    8. Diet, e.g., high animal protein.
    9. Chronic irritation.
    10. Precancerous lesions, e.g., gastric ulcers.
    11. Stress.
  • Assessment:
    1. Specific symptoms depend on the anatomical and functional characteristics of the organ or structure involved.
    2. Mechanical effects:
       • Pressure - tumors growing in confined areas such as bone produce pain early, whereas tumors growing in expandable areas such as the abdomen may be undetected for some time.
       • Obstruction - tumors that compress tubular structures such as the esophagus, bronchi, or lymph channels may cause symptoms such as swallowing difficulties, shortness of breath, edema. Symptoms depend on location of tumor and on the particular organ or structure receiving pressure.
       • Interruptions of blood supply - compression of blood vessels or diversion of blood supply may cause necrosis or ulceration or may precipitate hemorrhage.
    3. Systemic effects:
       • Anorexia, weakness, weight loss.
       • Metabolic disturbances - malabsorption syndrome.
       • Fluid and electrolyte imbalances.
       • Hormonal imbalances - increased antidiuretic hormone (ADH), adrenocorticotropic hormone (ACTH), thyrotropin (TSH), or parathyroid hormone (PTH).
       • Diagnostic tests:
         1. Biopsy - excision of part of tumor mass
         2. Needle biopsy - aspiration of cells from subcutaneous masses or organs such as liver.
         3. Exfoliative cytology - scraping of any endothelium (cervix, mucous membranes, skin) and applying to slide.
         4. X-rays - detect tumor growth in GI, respiratory, and renal systems.
         5. Endoscopy - visualization of body cavity through endoscope.
         6. Computed tomography (CT) - visualization of a body part whereby layers of tissue can be seen utilizing the very narrow beams of this type of x-ray equipment.
         7. Magnetic resonance imaging (MRI) - a scanning device using a magnetic field for visualization.
       • Lab data:
         1. Blood and urine tests - refer to Appendix A for normal values.
         2. Alkaline phosphatase - greatly increased in osteogenic carcinoma (>92 U/L).
         3. Calcium - elevated in multiple myeloma bone metastases (>10.5 mg/dL).
         4. Sodium - decreased in bronchogenic carcinoma (<135 mEq/L).
         5. Potassium - decreased in extensive liver carcinoma (<3.5 mEq/L).
         6. Serum gastrin - measures gastric secretions. Decreased in gastric carcinoma. Normal value 0-180 ng/L.
         7. Neutrophilic leukocytosis - tumors.
         8. Eosinophilic leukocytosis - brain tumors, Hodgkin’s disease.
         9. Lymphocytosis - chronic lymphocytic anemia.
  • Analysis/nursing diagnosis:
    1. Pain related to diagnostic procedures, pressure, obstruction, interruption of blood supply, or potential side effects of drugs.
    2. Anxiety related to fear of diagnosis or disease progression, treatment, and its known or expected side effects.
    3. Altered nutrition, less than body requirements, related to anorexia.
    4. Risk for injury related to radioactive contamination of excreta.
    5. Body image disturbance related to loss of body parts, change in appearance as a result of therapy.
    6. Powerlessness related to diagnosis and own perception of its meaning.
    7. Self-esteem disturbance related to impact of cancer diagnosis.
    8. Risk for infection related to immunosuppression from radiation and chemotherapy.
    9. Altered urinary elimination related to dehydration.
    10. Risk for injury related to normal tissue damage from radiation source.
    11. Fluid volume deficit related to nausea and vomiting.
    12. Diarrhea related to radiation of bowel.
    13. Constipation related to dehydration.
  • Nursing care plan/implementation - general care of the cancer patient:
  1. Goal: promote psychosocial comfort.
     1. Assist with diagnostic workup by providing psychological support and information about specific disease, diagnostic tests, diagnosis, and treatment options.
     2. Reduce anxiety by listening, making referrals for special problems (peer support groups, self-help groups such as Reach to Recovery), supplying information, or correcting misinformation, as appropriate.
     3. Stress-management techniques.
     4. Nursing management related to depressed patient.
  2. Goal: minimize effects of complications.
     1. Anorexia/anemia:
        1. Decrease anemia by:
           • Providing well-balanced, ironrich, small, frequent meals.
           • Administering supplemental vitamins and iron as ordered.
           • Administering packed red blood cells as ordered.
           • Maintaining hyperalimentation as ordered.
           • Monitoring red blood cell count.
        2. Enhance nutrition by providing nutritional supplements and a diet high in protein; necessary because of increased metabolism related to metastatic process. Consult with dietitian for suggestions of best food for individual patient.
     2. Hemorrhage: monitor platelet count and maintain platelet infusions as ordered. Teach patient to monitor for any signs of bleeding.
     3. Infection: observe for signs of sepsis (changes in vital signs, temperature of skin, mentation, urinary output or pain); monitor laboratory values (WBCs); administer antibiotics as ordered.
     4. Pain and discomfort: alleviate by frequent position changes, diversions, conversations, guided imagery, relaxation, back rubs, and narcotics as ordered.
     5. Assist in adjusting to altered body image by encouraging expression of fears and concerns. Do not ignore patient’s questions, and give honest answers: be available.
     6. Fatigue. Encourage periods of rest and a decrease in daily exertion.
  3. Goal: general health teaching.
     1. Self-care skills to maintain independence; e.g., patient who has a colostomy should know how to manage the colostomy before going home.
     2. Importance of follow-up care and routine physical examinations to monitor for general health and possible signs of further disease.
     3. Dietary instructions, adjustments necessary to maintain nutrition during and after treatment.
     4. Health maintenance programs: teach hazards of the use of tobacco and alcohol. Avoid high-fat, low-roughage diet.
     5. Risk factors: family history, stress, age, diet, occupation, environment.
     6. Access to information: patients should have telephone numbers where questions can be answered and symptoms reported 24 hours a day.
  • General surgical intervention: surgery may be diagnostic, curative (when the lesion is localized or with minimal metastases to the lymph nodes), palliative (to decrease symptomatology), or reconstructive.
  1. Nursing care plan/implementation - preoperative:
     • Goal: prevent respiratory complications.
       1. Coughing and deep-breathing techniques.
       2. No smoking for 1 wk before surgery
     • Goal: counteract nutritional deficiencies.
       1. Diet:
          • High protein, high carbohydrate for tissue repair.
          • Vitamin and mineral supplements.
          • Hyperalimentation as ordered.
       2. Blood transfusions may be needed if counts are low.
     • Goal: reduce apprehension.
       1. Clarify postoperative expectations.
       2. Explain care of ostomies or tubes.
       3. Answer patient’s questions honestly.
  2. Postoperative:
     • Goal: prevent complications.
       1. Monitor respiratory status and hemodynamic status.
       2. Wound care; active and passive exercises as allowed; respiratory hygiene; coughing, deep breathing, and turning; fluids.
     • Goal: alleviate pain and discomfort.
       1. Encourage early ambulation, depending on surgical procedure.
       2. Administer prescribed medications as needed.
       3. Administer stool softeners and enemas as ordered.
     • Goal: health teaching.
       1. Involve patient, significant others, and family members in rehabilitation program.
       2. Prepare for further therapies, such as radiation or chemotherapy.
       3. Support groups, as appropriate: Reach to Recovery, Ostomy Associates, Laryngectomy Association.
       4. Develop skills to deal with disease progression if cure not realistic or metastasis evident.
  
  
  • Chemotherapy: used as single treatment or in combination with surgery and radiation, for early or advanced diseases. Used to cure, increase survival time, or decrease specific lifethreatening complications. Antineoplastic agents’ primary mode of action involves interfering with the supply and utilization of building blocks of nucleic acids, as well as interfering with intact molecules of DNA or RNA, which are needed for replication and cell growth. Bone marrow, hair follicles, and the gastrointestinal tract are three areas of the body in which cells are actively dividing; this is why most side effects are related to these areas of the body. Most often antineoplastic agents are used in combination.
    1. Types: alkylating agents, antimetabolites, antitumor antibiotics, antimiotic agents, plant alkaloids, enzymes, hormones, and biotherapy. (e.g., BCG, interferon).
    2. Major problem: lacks specificity, thus affecting normal as well as malignant cells.
    3. Major side effects: bone marrow depression, stomatitis, nausea and vomiting, gastrointestinal ulcerations, diarrhea, and alopecia.
    4. Routes of administration: oral, intramuscular, intravenous (Hickman or Groshong catheter), subclavian lines, porta caths, peripheral, intra-arterial (may have infusion pump for continuous or intermittent flow rate), intracavity (e.g., bladder through cystoscopy).
    5. Nursing care plan/implementation:
    • Goal: assist with treatment of specific side effects.
      1. Nausea and vomiting - antiemetic drugs as ordered and scheduled; small, frequent, high-calorie, high-potassium, high-protein meals; chopped or blended foods for ease in swallowing; include milk and milk products when tolerated for increased calcium; carbonated drinks; frequent mouth care; antacid therapy as ordered; rest after meals; avoid food odors during preparation of meals; pleasant environment during meals; appropriate distractions; IV therapy; nasogastric tube for control of severe nausea or as route for tube feeding if unable to take food by mouth; hyperalimentation.
      2. Diarrhea - low-residue diet; increased potassium; increased fluids; atropine SO₄-diphenoxylate HCI (Lomotil) or kaolin-pectin (Kaopectate) as ordered; avoid hot or cold foods/liquids.
      3. Stomatitis (painful mouth) - soft toothbrushes or sponges (toothettes); mouth care q2 - q4; viscous lidocaine HCI (Xylocaine) as ordered before meals. Oral salt and soda mouth rinses; avoid commercial mouthwashes that contain high level of alcohol, which could be very irritating to mucous membranes. Avoid hot Oil foods/liquids; include bland foods at cool temperatures; remove dentures if sores are under dentures; moisten lips with lubricant.
      4. Skin care - monitor: wounds that do not heal, infections (patient receives frequent sticks for blood tests and therapy); avoid sunlight; use sunblock, especially if receiving doxorubicin (Adriamycin).
      5. Alopecia - be gentle when combing or lightly brushing hair; use wigs, night caps, scarves; provide frequent linen changes. Advise patient to have hair cut short before treatment with drugs known to cause alopecia (bleomycin, cyclosphosphamide, dactinomycin, daunorubicin hydrochloride, doxorubicin hydrochloride, 5 fluorouracil, ICRF-159, hydroxyurea, methotrexate, mitomycin, VP 16-213, vincristine). Other techniques may be used, depending on patient’s age and protocol in clinical agency.
      6. Extravasation - infiltration of chemotherapeutic agents into surrounding tissues. Document and treat according to agency protocols for administered drug.
    • Goal: health teaching.
    1. Orient patient and family to purpose of proposed drug regimen and anticipated side effects.
    2. Advise that frequent checks on hematological status will be necessary (patient will receive frequent IV sticks, lab tests).
    3. Advise patient/family on increased risk for infection (avoid uncontrolled crowds and individuals with upper respiratory tract infections or childhood diseases).
    4. Monitor injection site for signs of extravasation (infiltration); site must be changed if leakage suspected, and guidelines to neutralize must be followed according to drug protocol.
    6. Nursing precautions with chemotherapy:
       • Nurse should wear gloves and mask when preparing chemotherapy drugs for administration. Mixing of drug into IV bag done under laminar flow hood.
       • Drugs are toxic substances, and nurses must take every precaution to handle them with care.
       • When expelling air bubbles from syringes, care must be taken that the drugs are not sprayed into the atmosphere.
       • Contaminated needles and syringes should be disposed of intact (to prevent aerosol generation) in plastic-lined box according to environmental standards. Disposable equipment should be used whenever possible.
       • If skin becomes contaminated with a drug, wash under running water.
       • Nurses should know the half-life and excretion route of the drugs being administered and take the special precautions necessary. For example, while die drug is actively being excreted, use gloves when touching patient, stool, urine, dressings, vomitus, etc.
       • If the nurse is in the early phase of pregnancy, she should seek specific information about risks to her unborn child before caring for the patient receiving chemotherapeutic agents.