Chapter 7 Body Systems

Chapter 7 Body Systems

Medical-Surgical Nursing: Concepts & Practice 3rd edition Chapter 8 Care of Patients with Cancer Copyright 2017, Elsevier Inc. All rights reserved. 2 Theory Objectives Analyze organization of neoplastic (abnormal tissue) growth. Identify at least five factors that may contribute to the development of a malignancy. List at least four practices that can contribute to prevention and early

detection of cancers. Include the recommendations of the American Cancer Society (ACS) for routine checkups and detection of cancers into patient education. Copyright 2017, Elsevier Inc. All rights reserved. 3 Theory Objectives (Cont.) Explain the advantages and disadvantages of the various treatments available for cancer. Illustrate the major problems for a patient who is coping with side effects

of radiation or chemotherapy for cancer and state the appropriate nursing interventions. Apply knowledge of the stages of the grieving process experienced by the dying cancer to patients coping level. Copyright 2017, Elsevier Inc. All rights reserved. 4 Clinical Practice Objectives

Devise an individual plan of care for the patient receiving chemotherapy. Formulate a teaching plan for the patient who has bone marrow suppression from cancer treatment. Institute nursing interventions to help the patient cope with the common problems of cancer and its treatment. Use appropriate nursing interventions to help patients and families deal with the psychosocial effects of cancer and its

treatment. Employ nursing interventions to help the cancer patient cope with death and dying. Copyright 2017, Elsevier Inc. All rights reserved. 5 Impact of Cancer see p. 145 Figure 8-1 Cancer is a group of diseases that characteristically grow in an uncontrolled manner with the spread of abnormal cells. If all of the cancers that are detectable early were diagnosed in localized stages, the 5-year survival rate would be 95%.

Copyright 2017, Elsevier Inc. All rights reserved. 6 Physiology of Cancer Neoplasm Benign neoplasm Malignant neoplasm Metastasis Copyright 2017, Elsevier Inc. All rights reserved. 7

Neoplasm An abnormal replication of cells Copyright 2017, Elsevier Inc. All rights reserved. 8 Benign Neoplasm Neoplasm that is usually harmless Almost always encapsulated (surrounded by a fibrous capsule) The capsule prevents the release of cells and restricts their spread to other parts of the body. Can create problems if they press

against and interfere with the normal structure and function of nearby organs Copyright 2017, Elsevier Inc. All rights reserved. 9 Malignant Neoplasm Changes a cells DNA makeup and function Cancer cells do not look or behave like normal cells.

The nuclei of malignant (cancer) cells are large and irregular. They fail to follow the rules that regulate the reproduction of normal cells. They do not seem to know when to stop multiplying. The offspring of cancerous cells proliferate (multiply) in great numbers. Copyright 2017, Elsevier Inc. All rights reserved. 10

Malignant Neoplasm (Cont.) They grow increasingly disorganized, often forming tumor masses. Some cancerous cells take on new characteristics so that they do not in any way resemble the cells of the original tissue. The malignant cells invade neighboring tissues and travel to other parts of the body;

there they establish another colony of malignant cells. Their demand for nutrients depletes the supply of nourishment available for normal cells. Copyright 2017, Elsevier Inc. All rights reserved. 11 Normal and Malignant Skeletal Muscle Cells From McCance KL, Huether SE, Brashers VL, Rote ND: Pathophysiology: The biologic basis for disease in adults and children, ed. 6, Philadelphia, 2010, Elsevier. Copyright 2017, Elsevier Inc. All rights reserved.

13 Classification of Tumors Tumors are classified according to the substances they are formed from -omaswelling -sarcomamesenchymal originbone,muscle -carcinomaepithelial origin skin, mucus membranes

Copyright 2017, Elsevier Inc. All rights reserved. 14 Metastasis Movement of cancer cells from the original cancer site to other areas of the body Not all malignant cells metastasize, but the great majority of malignant cells do. Copyright 2017, Elsevier Inc. All rights reserved. 15 Modes of Dissemination of Cancer

Copyright 2017, Elsevier Inc. All rights reserved. 16 Prognosis Prognosis depends on how much the malignant cells have attacked body tissues Copyright 2017, Elsevier Inc. All rights reserved. 17 In Situ

Localized growth that remains at the original site and has not yet released its cells even though the growth may have invaded underlying tissues Copyright 2017, Elsevier Inc. All rights reserved. 18 Localized All of the malignant cells are in the area where the new growth started in situ At this stage, the disease is much more easily destroyed.

Copyright 2017, Elsevier Inc. All rights reserved. 19 Regional Malignancy Cells from the original malignancy have spread to the body area right around the tumor, such as to nearby lymph nodes. The spread has been limited, however, by the bodys protective mechanisms. Cells may continue to grow and multiply. If the regional cancer is not successfully treated, malignant cells will eventually break away and spread throughout the body.

Copyright 2017, Elsevier Inc. All rights reserved. 20 TNM Staging System Tprimary tumor Nregional nodes Mmetastasis The number written beside each letter indicates how much the malignancy has spread and attacked other tissues. Copyright 2017, Elsevier Inc. All rights reserved. 21

TNM Staging System (Cont.) T1, N0, M0 means that the tumor is small and localized (no involvement of regional lymph nodes and no metastasis). T , N , M indicates a small (T ) tumor 1 2 1 1 with moderate regional involvement (N2) that has metastasized to one distant site or organ (M1). Copyright 2017, Elsevier Inc. All rights reserved.

22 Causative Factors All cancer results from defects in the DNA of genes. Can be inherited or caused by mutation Oncogenes ( cancer causing genes)and tumor suppressor genes ( control the growth of cells in the body) Immunocompetence ability of the immune system to deal with foreign

cells Carcinogens in external and internal (hormones/inherited genes)environment Copyright 2017, Elsevier Inc. All rights reserved. 23 Mutation Permanent change in the DNA sequence of a gene Copyright 2017, Elsevier Inc. All rights reserved. 24

Oncogenes Cancer-causing genes Mistakes in the instructions inside a cells DNA genetic code, whereby newly created cells are no longer normal The defective gene tells the new cells to multiply at a higher rate. The defective coding prevents the newly

created defective cells from dying and being reabsorbed. Results in a tumor, or mass Copyright 2017, Elsevier Inc. All rights reserved. 25 Tumor Suppressor Genes Healthy, normal genes that control the growth of cells in the body Copyright 2017, Elsevier Inc. All rights reserved. 26

Immunocompetence The capability of ones immune system to deal with foreign cells Bacterial Viral Malignant Copyright 2017, Elsevier Inc. All rights reserved. 27

Chemical Carcinogens Cancer-causing substances Carcinogens in the external environment Certain chemicals Sources of radiation Viruses Carcinogens in the internal environment

Hormones Inherited genes Advanced age Copyright 2017, Elsevier Inc. All rights reserved. 28 Occupational Carcinogens Petrofluorocarbons (polychlorinated biphenyls or PCBs) Some pesticides (e.g., DDT) Pitch, asphalt, crude paraffin, and petroleum products

Irritating substances in the air Tobacco smoke Asbestos Chemical wastes from industry and automobiles Copyright 2017, Elsevier Inc. All rights reserved. 29 Occupational Carcinogens (Cont.) Soot

Aniline dyes Vinyl chloride, nickel, arsenic, and chromate Benzene Copyright 2017, Elsevier Inc. All rights reserved. 30 Tobacco Cigarette smoking is linked to cancer of the lung and is thought to be linked to esophageal, pancreatic, bladder, and kidney cancers. Encourage those who smoke to quit.

Ninety percent of lung cancers in men and 79% in women are related to smoking. Use of tobacco in conjunction with the intake of alcohol is related to several other types of cancer. Copyright 2017, Elsevier Inc. All rights reserved. 31 Promoters Promoters are not carcinogenic when

found alone, but when they are in the body with a known carcinogen, cancer occurs faster. Alcohol is a promoter. When nicotine is present, cancers occur at a faster rate in those who are heavy consumers of alcohol than in someone who uses nicotine but does not drink alcohol. It is thought that about 90% of all head and neck cancers are tobacco plus alcohol related.

Copyright 2017, Elsevier Inc. All rights reserved. 32 Promoters (Cont.) Chronic irritation A contributing cause of cancer The presence of a mole or exposure to chemical carcinogen or ultraviolet (UV) rays Copyright 2017, Elsevier Inc. All rights reserved. 33

Carcinogenic Drug Therapies Immunosuppressive drugs used to suppress organ transplant rejection are a cause of non-Hodgkins lymphoma. Synthetic estrogens are linked to a higher incidence of endometrial cancer; many of the drugs used to treat cancer affect the immune system and can predispose to other types of cancer. Copyright 2017, Elsevier Inc. All rights reserved. 34 Physical Carcinogens: Radiation

May originate from x-ray machines, radioactive elements, or UV rays from the sun Capable of penetrating certain body tissues and causing the development of malignant cells in the affected area Copyright 2017, Elsevier Inc. All rights reserved. 35 Radiation (Cont.) People with fair complexions have

less protective pigment and therefore are more likely to develop skin cancer from UV radiation than are people with darker skin. Copyright 2017, Elsevier Inc. All rights reserved. 36 Radiation (Cont.) There is continued concern about the dangers that excessive radiation in the environment presents, especially the long-term effects that are not

immediately apparent but may eventually prove to be related to malignancy. In addition to leukemia, cancers of the skin, bone marrow, breast, lung, and thyroid are believed to be closely linked to exposure to radiation. Copyright 2017, Elsevier Inc. All rights reserved. 37 Radon Gas People who live in areas that have more

radon emission from the earth have a higher incidence of malignancy in the population than people in areas that are low in radon. Copyright 2017, Elsevier Inc. All rights reserved. 38 Viruses Experiments involving animals have demonstrated that a number of cancers can be produced in animals by injecting them with a filtrate from virus-infected malignant growths. These viruses are known as oncoviruses because of their ability to cause cancer.

Copyright 2017, Elsevier Inc. All rights reserved. 39 Viruses (Cont.) Viruses are capable of introducing new genetic material into a normal cell and transforming it into a malignant one. Cell reproduction can be altered when

viruses interact with carcinogens. Viruses such as the human immunodeficiency virus (HIV) can damage the immune system and decrease immunocompetence, causing the body to become more susceptible to the growth of abnormal cells. Copyright 2017, Elsevier Inc. All rights reserved. 40 Viruses (Cont.) The hepatitis B virus is carcinogenic for liver cancer. The Epstein-Barr virus causes Burkitts lymphoma. Cases of adult T-cell leukemia and

lymphoma are caused by human T-cell lymphotropic virus. Several types of the HPV cause cervical carcinoma and are related to throat and mouth cancer in nonsmokers. Copyright 2017, Elsevier Inc. All rights reserved. 41 Genetic Predisposition Research is revealing that there is a genetic predisposition to various types of cancer. Breast cancer is more likely to occur in women who have a close female

relative who developed breast cancer before the age of 50 years. Gene markers have been found for colon cancer, breast cancer, prostate cancer, pancreatic cancer, and leukemia. Copyright 2017, Elsevier Inc. All rights reserved. 42 Genetic Predisposition (Cont.) However, only 5% to 10% of cancers are related to a directly inherited gene. The remaining cancers are caused by genes that are damaged (mutated) throughout the lifetime and are not

inherited. Some people are more susceptible to these mutations. Copyright 2017, Elsevier Inc. All rights reserved. 43 Cultural Considerations Some populations are at a higher risk for certain types of cancer.

Of the four types of melanoma, African Americans are most susceptible to the acral lentiginous type ( definition here), and whites are least susceptible to it. Lentigo maligna melanoma is found most often in Hawaii. Copyright 2017, Elsevier Inc. All rights reserved. 45 Human Genome Project Current research is focused on finding genetic markers, or oncogenes. Such markers, or the proteins they

produce, could identify high-risk individuals who then might undergo more vigorous, regular diagnostic testing to detect any malignancy in the very earliest stages. Copyright 2017, Elsevier Inc. All rights reserved. 46 Contributing Factors Intrinsic factors

Age Sex Race Stress Diet Alcohol Exposure to carcinogens Copyright 2017, Elsevier Inc. All rights reserved. 48 Diet and Nutrition

Encourage maintenance of normal weight. Obesity is considered a risk factor in many cancers. It also makes early detection of many cancers difficult. Nitrite and nitrate food additives are also known to be cancer stimulators

(encouraging cancer). Research has shown foods eaten in combination with foods containing Vitamin C, there is less chance of carcinogen nitrosamines damaging the body. Copyright 2017, Elsevier Inc. All rights reserved. 49 50 Alcohol Moderation in the drinking of alcohol is recommended because alcohol consumption alone has been shown to increase risk for several cancers. Excessive alcohol consumption also can

lead to liver damage and possibly to liver cancer. Copyright 2017, Elsevier Inc. All rights reserved. 51 Warning Signs of Cancer Unusual bleeding or discharge A sore that does not heal A change in bowel or bladder habits A lump in the breast or other part of the body A nagging cough An obvious change in a mole Difficulty swallowing

Copyright 2017, Elsevier Inc. All rights reserved. 52 Older Adult Care Points Older patients are at increasingly higher risk for developing cancer. Their immune systems are not as efficient as that of a younger person. Many of the cancer screening programs are suggested to begin at age 40 or 50 years. Copyright 2017, Elsevier Inc. All rights reserved.

53 Diagnostic Tests Biopsy Radiologic studies Endoscopy Laboratory tests Copyright 2017, Elsevier Inc. All rights reserved. 54 Biopsy

Biopsy is the removal of living cells for the purpose of examining them under a microscope Surgical excisioncutting out Aspirationsuction Frozen section Fine-needle aspiration Percutaneous Copyright 2017, Elsevier Inc. All rights reserved.

55 Radiologic Studies Mammography Radionuclide or isotopetumor seeking Cold spottumor does not accept the isotope Hot spottumor accepts the isotope

Computed tomography (CT) scanning Noninvasive Reveals the size, shape, contour, and density of an organ Copyright 2017, Elsevier Inc. All rights reserved. 56 Radiologic Studies (Cont.) Magnetic resonance imaging (MRI)

View slices of tissue Can sometimes see tumors and abnormalities that other techniques miss Patients with pacemakers, certain metal fragments or clips, or shrapnel in the body cannot use MRI because the powerful magnets used in this technique can bend and twist metal and can damage the body. Copyright 2017, Elsevier Inc. All rights reserved. 57

Laboratory Tests CBC Prostate-specific antigen (PSA) Current recommendations include offering a baseline PSA test for male patients older than 50 years. To be repeated at various intervals depending on the patients risk factors Copyright 2017, Elsevier Inc. All rights reserved.

59 Laboratory Tests (Cont.) Tumor markers CA-125 is used to detect the presence of ovarian cancer or its recurrence after therapy. Carcinoembryonic antigen (CEA) and CA 199 detect the recurrence of gastrointestinal, pancreatic, and liver cancer after initial

treatment. CA 27-29 is used most frequently to follow the progress in breast cancer treatment and later to check for recurrence. Copyright 2017, Elsevier Inc. All rights reserved. 60 Assessment Comprehensive assessments include

Physiological effects of the disease Patient knowledge and understanding of disease process, treatment, and prognosis Psychosocial needs of patient and family Anticipation of therapeutic effects of various treatment modalities Preparation for lifestyle changes and anticipation of death Copyright 2017, Elsevier Inc. All rights reserved. 61 Planning

Patient will remain free from infection. Patient will remain free from hemorrhage. Patient will verbalize relief from nausea. Patient will be able to eat with minimal discomfort. Patient will maintain present weight. Patient will adjust to new body image

within 3 weeks as evidenced by verbalization. Patient will verbalize fears and develop coping mechanisms to decrease fear. Copyright 2017, Elsevier Inc. All rights reserved. 62 Evaluation Determine whether the expected outcomes specified for the patient are being met or have been met. Assess signs of complications, side effects of therapy, nutritional status, and pain. Change ineffective interventions to meet desired outcomes. Collaborate with the patient and the

other members of the health care team. Copyright 2017, Elsevier Inc. All rights reserved. 63 Common Therapies, Problems, and Nursing Care Surgery, radiation, and chemotherapy Hormone manipulation, immunotherapy with biologic response modifiers, and bone marrow or stem cell transplantation Each of the modes of treatment may be used singly or in combination with one or more of the other methods available.

Copyright 2017, Elsevier Inc. All rights reserved. 64 Surgery Biopsyobtain specimen Prophylaxispreventive treatment Explorativedetermine effectiveness of therapy Palliativeoffer pain relief Curativeattempt cure Reconstructive Copyright 2017, Elsevier Inc. All rights reserved.

65 Radiation Therapy Radiation destroys malignant cells (which are more sensitive to radiation than are normal cells) without permanent damage to adjacent body tissues. The course of radiation is spread over a period of days to weeks. The RAD (radiation absorbed dose) is the unit used for measuring dosages of radiation. Copyright 2017, Elsevier Inc. All rights reserved.

66 Considerations for Using Radiation Tumor sensitivity to radiation Tumor location Tumor size Copyright 2017, Elsevier Inc. All rights reserved. 67 Internal Radiation Therapy Involves introducing a radioactive element into the body The material may be administered in

different ways. Placed in a sealed container and inserted into a body cavity at the site of the tumor or placed directly into the tumor Administered in an unsealed form and taken orally or injected by syringe Copyright 2017, Elsevier Inc. All rights reserved. 68

Internal Radiation Therapy (Cont.) The radiation source must come into direct contact with the tumor tissue for a specified time. Most implants emit a lower level of radiation while in constant contact with the tumor cells. Because the radiation source is within the patient, radiation is emitted for a period and can be a hazard to others. Nurses caring for patients receiving internal radiation must take extra precautions. Copyright 2017, Elsevier Inc. All rights reserved.

69 Internal Radiation Therapy Radiation Exposure The amount of radiation a nurse might receive while caring for a patient being treated with internal radioactive elements depends on three factors:

The distance between the nurse and the patient The amount of time spent in actual proximity to the patient The degree of shielding provided Copyright 2017, Elsevier Inc. All rights reserved. 71 Radioactivity As soon as an element becomes radioactive, it begins to lose its characteristic of radioactivity.

The rate at which it becomes less radioactive is called its half-life, which is the amount of time it takes for half of its radioactivity to dissipate. Whereas the half-life of radium is about 1600 years, the half-life of iodine is only about 8 days. Cesium is a radioactive element frequently used to treat malignancies of the mouth, tongue, vagina, and uterine cervix. Copyright 2017, Elsevier Inc. All rights reserved. 72

External Radiation Therapy 74 Isotopes Some isotopes are given orally, and others are administered into a body cavity. The isotopes are unsealed sources of radiation. If radioactivity is a hazard, it is a problem only for the duration of the half-life of the isotope. The substance is eliminated through body secretions such as sweat, sputum, vomit, urine, or feces.

Copyright 2017, Elsevier Inc. All rights reserved. 75 Ionizing Radiation Ionizing radiation can have both an immediate and a delayed effect on malignant cells. It can damage the cell membrane immediately, causing lysis (bursting) or decomposition of the cell, or it can cause a break in both strands of the DNA in the cells nucleus. Copyright 2017, Elsevier Inc. All rights reserved.

76 External Radiation Therapy Nursing care goals Help the patient and family cope with the diagnosis of cancer and its treatment with radiation therapy. Teach the patient and family how to recognize and manage the expected side effects of radiation.

Copyright 2017, Elsevier Inc. All rights reserved. 77 Audience Response Question 1 In helping a 40-year-old patient cope with breast cancer, the nurse should help the patient focus on which aspect(s) of radiation therapy and care? (Select all that apply.) 1. 2.

3. 4. 5. Complying with scheduled radiation therapies Taking precautions on exposing other family members Protecting the skin by applying lotion Wearing snug-fitting clothing Understanding the therapeutic effects and side effects Copyright 2017, Elsevier Inc. All rights reserved. 78 Chemotherapy

Antineoplastic agents Decrease the number of malignant cells in a generalized malignancy (e.g., leukemia) or to reduce the size of a localized tumor and thereby lessen the severity of symptoms Cytotoxic agents

Poisonous to cells; however, normal cells do not reproduce in exactly the same way as malignant cells, so normal cells are able to repair themselves more rapidly and effectively Steroids often are used in combination with antineoplastic drugs for cancer treatment. Copyright 2017, Elsevier Inc. All rights reserved. 79 Chemotherapy (Cont.) Techniques of administration

Intra-arterial Intraperitoneal Intraventricular Intrathecal (within a space of the spine) Intravenous infusion Vesicants Chemicals causing tissue damage upon

direct contact Can cause severe local injury if they escape from the vein into which they are administered Copyright 2017, Elsevier Inc. All rights reserved. 80 Nursing Implications for Chemotherapy Toxicity on cells that have a short lifespan

Blood cells Hair follicles Epithelial cells of mucous membranes Most chemotherapeutic agents are excreted in body fluids. Most are teratogenic (can cause birth defects). Copyright 2017, Elsevier Inc. All rights reserved. 81 Hormone Therapy Used as an adjunct to other types of cancer therapy

Can slow tumor growth or prevent cancer recurrence When a hormone is added to the body, the balance of naturally produced hormones changes. Copyright 2017, Elsevier Inc. All rights reserved. 82 83 Hormone Therapy (Cont.) Giving large amounts of one hormone prevents the uptake of other hormones. If the tumor growth is aided by one type

of hormone, giving another type prevents the uptake of the growthpromoting hormone and slows the progress of the tumor. Copyright 2017, Elsevier Inc. All rights reserved. 84 Side Effects of Hormone Therapy Androgens and antiestrogen receptor drugs produce masculinizing effects in women.

Facial and chest hair Menses may stop Breast tissue will shrink Fluid retention Acne Hypercalcemia and liver dysfunction can occur with prolonged therapy. Copyright 2017, Elsevier Inc. All rights reserved. 85 Side Effects of Hormone Therapy

(Cont.) In men taking estrogens or progestins to combat prostate cancer, there is a feminizing effect. Decreased facial hair Redistribution of body fat Breast development (gynecomastia)

Smoothing of the facial skin Risk of thrombus formation Over time, testicular and penile atrophy may occur, and it may become more difficult to attain and maintain an erection. Copyright 2017, Elsevier Inc. All rights reserved. 86 Immunotherapy Using Biologic Response Modifiers Biologic response modifiers Interferons and interleukins Monoclonal antibodies (MoAbs) Cancer vaccines Immunomodulating agents

Copyright 2017, Elsevier Inc. All rights reserved. 87 Biologic Response Modifiers (BRMs) Agents that manipulate the immune system in the hope of controlling or curing a malignancy with little or no toxic effect on normal cells

Either stimulate or suppress immune activity BRMs stimulate the immune system to recognize cancer cells and to institute action to destroy them Enhance a quicker recovery of the bone marrow after radiation or chemotherapy Copyright 2017, Elsevier Inc. All rights reserved. 88 Interleukins and Interferons Interleukins help the immune system cells recognize and destroy abnormal

cells. Interferons slow down cell division in cancer cells, stimulate natural killer cells, hold back the appearance of oncogenes, and assist cancerous cells to revert back to more normal cells. Copyright 2017, Elsevier Inc. All rights reserved. 89 Monoclonal Antibodies (MoAbs) Direct antitumor effects Rituximab (Rituxan) and trastuzumab (Herceptin) are examples of MoAbs that have been approved by the U.S. Food

and Drug Administration. Copyright 2017, Elsevier Inc. All rights reserved. 91 Cancer Vaccines Stimulate the immune system to attack the cancer cells (therapeutic) Stimulate the production of antibodies against a cancer-causing virus (prophylactic) Copyright 2017, Elsevier Inc. All rights reserved.

92 Nonspecific Immunomodulating Agents May stimulate the immune system and either restore depressed immune function or increase immune inflammatory responses Copyright 2017, Elsevier Inc. All rights reserved. 93 Other Therapies Bone marrow transplant

Stem cells Gene therapy Copyright 2017, Elsevier Inc. All rights reserved. 94 Evaluating Effectiveness of Medical Treatment Second-look surgery

The oncologist conducts an ongoing evaluation of each patients status to determine how effective the prescribed treatment has been and to plan for a future course of therapy if it is needed. It is particularly important to know whether there has been a reduction in the size of the tumor and an abatement of the patients symptomsthis is the purpose of secondlook surgery. Copyright 2017, Elsevier Inc. All rights reserved. 95 Tumor Marker Levels CEA

Glycoprotein produced during fetal life but not normally present after birth Its production may resume again, however, and CEA levels can be increased by some kinds of liver disease, heavy cigarette smoking, and especially by gastrointestinal and colorectal cancers. Can be used as a tumor marker to evaluate the effectiveness of treatment because CEA levels usually fall to within the normal range about 1 month after successful treatment of

cancer Copyright 2017, Elsevier Inc. All rights reserved. 96 Tumor Marker Levels (Cont.) PSA Prostate cancer CA-125

Ovarian cancer Copyright 2017, Elsevier Inc. All rights reserved. 97 Complementary and Integrative Medicines Therapies used in addition tobut not as a replacement fortraditional Western (allopathic) medicine Copyright 2017, Elsevier Inc. All rights reserved.

98 Common Problems Related to Cancer or Cancer Treatment Anorexia and malnutrition

Mucositis and oral care Significant weight loss of 2 or more lb per week Nausea, vomiting, and diarrhea Constipation Cystitis

Immunosuppression and decreased white blood cells (WBCs) Anemia Bleeding problems Hyperuricemia Fatigue Alopecia Pain Copyright 2017, Elsevier Inc. All rights reserved. 99 Constipation

Certain antineoplastic drugs, such as vincristine, vinblastine, and taxol, cause constipation. Copyright 2017, Elsevier Inc. All rights reserved. 101 Anorexia Loss of appetite Often associated with changes in taste and with inflammation of the mouth and tongue Megestrol (Megace) (female hormone) has proven to work well to stimulate the appetite.

Copyright 2017, Elsevier Inc. All rights reserved. 102 Anorexia (Cont.) Nursing implications

Thorough mouth care should be started several days before the beginning of chemotherapy or radiation therapy to the head and neck. Frequent oral intake of liquids that are not irritating chemically Use of artificial saliva helps to buffer the acidity in the mouth and thus to reduce irritation of the oral mucosa. Frequent and consistent mouth care to preserve teeth and prevent infections of the gums Copyright 2017, Elsevier Inc. All rights reserved. 103

Mucositis Irritation and inflammation of the mucosa in the mouth Copyright 2017, Elsevier Inc. All rights reserved. 104 Mucositis (Cont.) Patient teaching

Encourage consistent oral hygiene. Use a soft brush or tooth sponges. Irrigate the mouth to remove debris and counteract acidity. Increase fluid intake to 3000 mL/day. Relieve mouth pain of mucositis or stomatitis (inflammation of the mouth) with special topical compounds (e.g., Xylocaine Viscous). Avoid spicy foods, alcohol, and tobacco. Copyright 2017, Elsevier Inc. All rights reserved.

105 Weight Loss Nursing implications Monitor weight. Increase protein intake.

Small, frequent feedings. Attend to preferences for foods. Provide pleasant and restful environment during meals. Supplement feedings. Copyright 2017, Elsevier Inc. All rights reserved. 106 Nausea and Vomiting Caused by radiation therapy of the abdomen or lower back often starting 7 to 10 days after the beginning of treatment

Copyright 2017, Elsevier Inc. All rights reserved. 107 Nausea and Vomiting (Cont.) Nursing implications

Choose antiemetic regimens based on potential of chemotherapy regimen to cause nausea. Encouraging eating before treatment seems to decrease nausea. Give liquids, liquid supplements, or easily digested foods at 3- to 4-hour intervals in small amounts. Provide comfort measures and mouth care. Monitor for dehydration and electrolyte imbalances when excessive vomiting occurs. Copyright 2017, Elsevier Inc. All rights reserved. 108

Diarrhea Caused by radiation to the abdomen, lower back, or pelvis, chemotherapy effect on intestinal mucosa Copyright 2017, Elsevier Inc. All rights reserved. 109 Diarrhea (Cont.) Patient teaching

Avoid high-fiber foods. Add low-fiber foods such as bananas and cheese. Cleanse rectal area and apply petroleum jelly, A&D ointment, or Desitin cream to decrease discomfort and prevent skin breakdown. Monitor for signs of dehydration and electrolyte imbalance. Copyright 2017, Elsevier Inc. All rights reserved.

110 Constipation (Cont.) Patient teaching Increase fluids (as allowed). Add fiber to the diet.

Administer stool softeners and fiber laxatives. Exercise. Monitor for the beginning signs of constipation. Consider suppositories or enemas. Copyright 2017, Elsevier Inc. All rights reserved. 111 Cystitis Caused by Cytoxan and ifosfamide Copyright 2017, Elsevier Inc. All rights reserved.

112 Cystitis (Cont.) Patient teaching Monitor for hesitancy, urgency, and pain during urination. Check urine for cloudiness and signs of

hematuria (blood in the urine). Increase fluids to 2 to 3 L/day. Encourage frequent bladder emptying. Copyright 2017, Elsevier Inc. All rights reserved. 113 Bone Marrow Suppression Major reason that doses of chemotherapy must be limited Slows production of erythrocytes, leukocytes, platelets Some can cause severe suppression Usually is temporary Improvement in bone marrow function occurs within weeks to months of

completed therapy. Copyright 2017, Elsevier Inc. All rights reserved. 114 Bone Marrow Suppression (Cont.) WBC count monitored for a count of less than 3000/mm3, indicating neutropenia Neupogen or Leukine is given to raise the neutrophil count and the WBC count. Often administration of these agents is started before the WBC count drops low.

Copyright 2017, Elsevier Inc. All rights reserved. 115 Bone Marrow Suppression (Cont.) Nursing implications Anemia places an increased workload on

the heart and lungs. When the platelet count reaches a low of 50,000/mm3, any small injury can lead to an episode of prolonged bleeding. At 20,000/mm3, spontaneous bleeding that is difficult to control may occur. If less than 50,000/mm3, bleeding precautions are observed. Copyright 2017, Elsevier Inc. All rights reserved. 116 Bone Marrow Suppression (Cont.)

If less than 10,000 to 15,000/mm3, the patient is transfused. Administer platelets if the count falls to 20,000/mm3. Take measures to help lower the risk of bleeding. Be gentle. Avoid irritating foods. Prevent infection.

Copyright 2017, Elsevier Inc. All rights reserved. 117 Infection Prevention Report the following signs of infection to the physician immediately. Temperature over 100 F (38 C) Persistent cough

Colored or foul-smelling drainage from wound or nose Presence of a boil or abscess Cloudy, foul-smelling urine or burning on urination Copyright 2017, Elsevier Inc. All rights reserved. 118 Hyperuricemia Caused by antimetabolite destruction of cancer cells Copyright 2017, Elsevier Inc. All rights reserved.

119 Hyperuricemia (Cont.) Nursing implications Encourage high fluid intake to prevent problems of hyperuricemia (high uric acid in the blood). Administer allopurinol to decrease the incidence of gout caused by the hyperuricemia; it is started at the beginning

of therapy in an effort to prevent the problem. Copyright 2017, Elsevier Inc. All rights reserved. 120 Fatigue Fatigue from immunosuppression treatment requires an adjustment of lifestyle. The patient may feel tired and without energy. The patient may be impatient and irritable and withdraw from social environment. A decrease in activity may lead to a

decline in function that is irreversible. Copyright 2017, Elsevier Inc. All rights reserved. 121 Fatigue (Cont.) Patient teaching

Avoid unnecessary bed rest. Maintain a good balance between energy and activity. Minimize emotional distress. Maintaining activities of daily living. Use energy-saving devices and prioritizing activities. Maintain a good nutritional status with high protein intake. Supplement meals to ensure adequate calorie

intake. Increase fluids to 3 L/day on day 3 unless contraindicated. Copyright 2017, Elsevier Inc. All rights reserved. 122 Alopecia Hair loss (alopecia) resulting from chemotherapy is temporary. Occasionally, radiation therapy to the head causes permanent hair loss.

Copyright 2017, Elsevier Inc. All rights reserved. 123 Alopecia (Cont.) Patient teaching Hair begins regrowth about 1 month after chemotherapy ends. New hair may be different in texture and

color from the original hair. Before hair loss occurs, the patient should decide if he or she will wear a wig or head cover until the hair is regrown. Copyright 2017, Elsevier Inc. All rights reserved. 124 Pain For many cancer patients, pain is a daily reality. Pain reduces appetite, limits activity, and interferes with sleep. Most cancer pain (90%) can be relieved or at least controlled by a combination of measures.

Often, however, the pain of cancer is undertreated. Copyright 2017, Elsevier Inc. All rights reserved. 125 Pain (Cont.) Pain must be

Assessed and documented regularly Discussed openly with family and the reports of pain must be believed and understood Addressed with options that are appropriate for the setting and for family Treated with interventions in a timely fashion Copyright 2017, Elsevier Inc. All rights reserved. 126 Nonpharmacologic Interventions

Nonpharmacologic interventions are combined with oral, topical, and parenteral analgesia to achieve relief or good control of pain. Copyright 2017, Elsevier Inc. All rights reserved. 127 Fear and Ineffective Coping Assess the patients and familys usual coping techniques. Pay attention to the patients partner. Be honest about the adverse effects but take a positive approach. Consider psychosocial and spiritual

care. Assist the patient to use strengths in planning for fighting the disease. Copyright 2017, Elsevier Inc. All rights reserved. 128 Fear and Ineffective Coping (Cont.) Coordinate family strengths to continue with daily life. Speak with the patient and partner about sexual concerns. Refer to a social worker to coordinate resources. Encourage a sense of humor and

looking for little pleasure and enjoyment in life on a daily basis. Copyright 2017, Elsevier Inc. All rights reserved. 129 Oncologic Emergencies Tumor lysis syndrome, including hyperkalemia and hypercalcemia Hypercalcemia Disseminated intravascular coagulation (DIC) Pericardial effusion and cardiac tamponade Spinal cord compression

Superior vena cava syndrome Copyright 2017, Elsevier Inc. All rights reserved. 130 Common Fears of the Dying Patient The unknown Abandonment and loneliness Loss of relationships Loss of experiences in the future Dependency and loss of independence Pain

Copyright 2017, Elsevier Inc. All rights reserved. 131 Common Fears of the Dying Patient (Cont.) The nurse is most helpful to the patient in just being there for the patient and expressing caring. Provide comfort and strength for the patient. Explain to the family that patients go through these stages and the behavior is normal. Review own beliefs about death and dying and reaffirm those beliefs. Take a periodic inventory of your ability

Copyright 2017, Elsevier Inc. All rights reserved. 132 Kbler-Ross Stages of Dying see handout Denial (This cant happen to me!) Anger (Why me?) Bargaining (Yes me, but. . .) Depression (I give up. . .) Acceptance (Im ready. . .) Copyright 2017, Elsevier Inc. All rights reserved.

133 Palliative Care Palliative care (comfort care) is directed at meeting the needs of the dying patient by providing comfort and maintaining a high quality of life. Copyright 2017, Elsevier Inc. All rights reserved. 134 Copyright 2017, Elsevier Inc. All rights reserved. 1

The Day of the Dead It is celebrated on November 2 (a date close but unrelated to Halloween). Intention to open a sort of communication with the dead, allowing deceased souls to hear the prayers and tributes offered to them. The occasion is celebratory rather than dark; the community often hosts dances or plays. 136

Palliative Care (Cont.) Anticipatory guidance and stages of dying Terminal hydration End-stage symptom management Pain Dyspnea Death rattle Delirium

Copyright 2017, Elsevier Inc. All rights reserved. 137 Anticipatory Guidance Prepare the family and patient by anticipating the death. Give guidance about physical changes, symptoms, and complications. This may also aid the patient and family in deciding about possible hospice care.

Two stages of dying Pre-active, which may take weeks or months Active, which lasts only a few days Copyright 2017, Elsevier Inc. All rights reserved. 138 Terminal Hydration A dying patient gradually reduces fluid intake. Dehydration can

increase because of the disease process. Dry mouth and thirst may be induced by drugs. Copyright 2017, Elsevier Inc. All rights reserved. 139 Terminal Hydration (Cont.) Nursing implications

The nurse must educate the patient and family on the benefits and burdens of hydration. Many times, the course is for patients to choose what to take and to be allowed to refuse further nourishment. Copyright 2017, Elsevier Inc. All rights reserved. 140 End-Stage Symptom Management

Comfort is the goal of palliative care. Administering only oral medications is the preferred choice, but this may not be possible as death draws near. The goal is to allow a pain-free death. In some cases, it may be possible to administer transdermal or rectal pain medications. Copyright 2017, Elsevier Inc. All rights reserved. 141

Pain Transdermal fentanyl has helped eliminate the burden of pain at the end of life. Sometimes this regimen is supplemented with rescue doses of morphine. Whatever the regimen, studies have shown that pain relief, either total or at least enough to make the pain tolerable, is possible 75% to 97% of the time. Copyright 2017, Elsevier Inc. All rights reserved.

142 Dyspnea When patients are near death, they often subjectively feel as if they cannot get enough air. It is difficult to determine what causes this feeling, but several measures can be taken. Place in Fowlers position.

Reduce activities. Adjust air temperature. Give bronchodilators and morphine to ease breathing. Copyright 2017, Elsevier Inc. All rights reserved. 143 Death Rattle Noisy ventilation is heard when patients can no longer clear their throats of normal secretions. Family members are often alarmed and are afraid the patient will choke to death. In these cases, scopolamine or atropine, drugs that are known to reduce

secretions, may be used to quiet the patient and bring breathing back to normal. Copyright 2017, Elsevier Inc. All rights reserved. 144 Delirium Dying patients may experience hallucinations or altered mental status. The nurse must first search for causes such as pain, positional discomfort, or bladder distention and address those physical problems. The nurse should discuss the delirium

with the patients family and encourage the family to talk to the patient in quiet tones while remaining calm. Copyright 2017, Elsevier Inc. All rights reserved. 145 Audience Response Question 2 A terminally ill woman reminiscing about the good old days becomes increasingly confused and talks of seeing relatives who have died. Which nursing intervention(s) would be

appropriate? (Select all that apply.) 1. 2. 3. 4. Discuss the patients behaviors with the family. Force oral fluids. Encourage the family to talk to the patient in quiet tones. Promote a calm environment. Copyright 2017, Elsevier Inc. All rights reserved. 146

Licensed Practical Nurse (Hospic e)- Evenings Per Diem 2 -3 Days per week VNA Health Group Essex Fells, NJ $37k-$49k(Glassdoor est.) 25 days ago Licensed Practical Nurs e Aequor Technologies Piscataway, NJ $39k-$53k(Glassdoor est.) 11 days ago

Licensed Practical Nurse (LPN) - Home Care Vitas Innovative Hospice Care Copyright 2017, Elsevier Inc. All rights reserved. 1

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