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Pathophysiology Review
-Cancer cells demonstrate uncontrolled cell growth that follows no physiologic demand

-Malignancies are classified by the tissue of origin (Table 16-1 pg 383)

-Malignant cells

-Agents/factors implicated carcinogenesis (Viruses & Bacteria, Physical agents, Chemical agents, Genetic and Familial factors, Dietary factors, Hormonal agents)

-Immune system failure
Characteristics of malignant cells
-Cell membranes contain proteins called tumor-specific antigens

-Nuclei are large and irregularly shaped

-Mitosis occurs more frequently than in normal cells

-If glucose & O2 are unavailable they use anaerobic metabolism to produce energy

-Metastasis occurs mainly through circulatory and lymphatic systems

-Tumors may shed cells or emboli that travel and seed surfaces of other organs
Malignancies are classified by the tissue of origin
Table 16-1 pg 383
ex:TABLE 16-1 Names of Selected Benign and Malignant Tumors According to Tissue Types
Tissue Type Benign Tumors Malignant Tumors
Epithelial
Surface Papilloma Squamous cell carcinoma
Glandular Adenoma Adenocarcinoma
Connective
Fibrous Fibroma Fibrosarcoma
Adipose Lipoma Liposarcoma
Cartilage Chondroma Chondrosarcoma
Bone Osteoma Osteosarcoma
Blood vessels Hemangioma Hemangiosarcoma
Lymph vessels Lymphangioma Lymphangiosarcoma
Lymph tissue Lymphosarcoma
Muscle
Smooth Leiomyoma Leiomyosarcoma
Striated Rhabdomyoma Rhabdomyosarcoma
Neural Tissue
Nerve cell Neuroma Neuroblastoma
Glial tissue Glioma (benign) Glioblastoma, astrocytoma, medulloblastoma, oligodendroglioma
Nerve sheaths Neurilemmoma Neurilemmal sarcoma
Meninges Meningioma Meningeal sarcoma
Hematologic
Granulocytic Myelocytic leukemia
Erythrocytic Erythrocytic leukemia
Plasma cells Multiple myeloma
Lymphocytic Lymphocytic leukemia or lymphoma
Monocytic Monocytic leukemia
Endothelial Tissue
Viruses & Bacteria
(Agents/factors implicated carcinogenesis)
-Epstein-Barr suspect as cause of Burkitt lymphoma, nasopharyngeal and non-Hodgkin's lymphoma

-Herpes Simplex II, cytomegalovirus and human papillomavirus associated with cancer of cervix

-Hepatitis B&C implicated in cancer of liver
Physical agents
(Agents/factors implicated carcinogenesis)
Sunlight, radiation, chronic irritation/inflammation and tobacco use
Chemical agents
(Agents/factors implicated carcinogenesis)
-tobacco smoke - SINGLE MOST LETHAL AGENT

-chemical substances in workplace
Genetics and Familial factors
(Agents/factors implicated carcinogenesis)
5% of cancer in adults has familial predisposition
Dietary factors
(Agents/factors implicated carcinogenesis)
fats, alcohol, salt-cured or smoked meats, nitrates, high caloric
Hormonal agents
(Agents/factors implicated carcinogenesis)









Hormonal agents
(Agents/factors implicated carcinogenesis)
-disturbances in hormonal balance, either by the body's own (endogenous) hormone production or by administration of exogenous hormones.

-Cancers of the breast, prostate, and uterus are thought to depend on endogenous hormonal levels for growth.

-Diethylstilbestrol (DES) has long been recognized as a cause of vaginal carcinomas.

-Oral contraceptives and prolonged estrogen replacement therapy are associated with an increased incidence of hepatocellular, endometrial, and breast cancers, but they decrease the risk of ovarian cancer.

-the Women's Health Initiative studies support discontinuing hormonal therapy with estrogens and progestins because of the increased risk of breast cancer, coronary heart disease, stroke, and blood clots

-Hormonal changes with reproduction are also associated with cancer incidence.

-Increased numbers of pregnancies are associated with a decreased incidence of breast, endometrial, and ovarian cancers.
Prevention and Early Detection
-Primary Prevention: concerned with reducing the risks of cancer in healthy people.

-Secondary Prevention: involves detection and screening to achieve early diagnosis and prompt intervention to halt the cancer process.
Primary Prevention
Primary prevention is concerned with reducing the risks of cancer in healthy people.

-Education
--Risk factors
--Dietary changes
--Lifestyle changes
Secondary Prevention
Secondary prevention involves detection and screening to achieve early diagnosis and prompt intervention to halt the cancer process.

-Screening programs
-Public awareness of health-promoting behaviors
Diagnosis of Cancer





Diagnosis of Cancer (con't)
-Tumor markers
-MRI
-CAT Scan
-PET Fusion: combines CT & PET Scan
-Fluoroscopy
-Ultrasound
-Endoscopy
-Nuclear medicine imaging
-Radioimmunoconjugates - antibodies labeled with isotope congregate around tumor
Tumor Staging and Grading
Staging - determines size of tumor and presence of metastasis
-TNM system
-Other systems for system specific staging
TNM System
T: extent of primary tumor
N: Lymph node involvement
M: extent of metastasis
TNM Classification System
-Primary Tumor (T)
-Regional Lymph Nodes (N)
-Distant Metastasis (M)
Primary Tumor (T)
Tx - Primary tumor cannot be assessed
T0 - No evidence of primary tumor
Tis
Carcinoma in situ
T1, T2, T3, T4 - Increasing size and/or local extent of primary tumor
Regional Lymph Nodes (N)
Nx - Regional lymph nodes cannot be assessed
N0 - No regional lymph node metastasis
N1, N2, N3 - Increasing involvement of regional lymph nodes
Distant Metastasis (M)
Mx - distant metastasis cannot be assessed
M0 - No distant metastasis
M1 - Distant metastasis
Tumor Staging and Grading
-Grading - define type of tissue from which tumor originated

-Cells obtained through cytology from tissue scrapings, body fluids, secretions, biopsy or surgical excision

-Tumor assigned numerical value from I-IV.
--Grade I - well differentiated which closely resemble tissue of origin
--Grade IV - not well differentiated and are more aggressive and less responsive to treatment
Cancer treatment goals





Cancer treatment goals (con't)
-Cure: complete eradication of disease

-Control: prolonged survival and containment of cancer growth

-Palliation: relief of symptoms
Cancer Treatment
-Surgery
-Radiation Therapy
-Chemotherapy
-Bone Marrow Transplant (BMT)
-Hyperthermia
-Targeted Therapies
-Photodynamic Therapy
-Unproven and Unconventional Therapies
Surgery (Cancer Treatment)
-Most frequently used treatment method

-Diagnostic: Biopsy

-Primary treatment - remove entire tumor and any involved surrounding tissue

-Prophylactic Surgery - removal of non-vital tissues or organs that are likely to develop cancer

-Palliative Surgery - relieve complications such as obstructions, ulcerations, hemorrhage, pain

-Reconstructive surgery - follows some curative or radical surgery in attempt to improve function or a more desirable cosmetic effect (breast, head and neck, skin cancers)
Diagnostic: Biopsy
Tissue sample for analysis
-Excisional: used for easily accessible tumors
-Incisional: wedge of tissue removed
-Needle biopsy: fast, relatively inexpensive, easy to perform, local anesthesia
Surgery for Primary Treatment
Remove entire tumor and any involved surrounding tissue
-Local: tumor and small margin of normal tissue
-Wide: tumor, lymph nodes, adjacent structures, surrounding tissue at risk for spread
Prophylactic Surgery
Removal of non-vital tissues or organs that are likely to develop cancer
-Family history and genetic predisposition
-Presence or absence of symptoms
-Potential risks and benefits
-Ability to detect cancer at an early stage
-Patient's acceptance of postop outcome
-Colectomy, mastectomy, oophorectomy
Palliative surgery
Relieve complications such as obstructions, ulcerations, hemorrhage, pain
Reconstructive surgery


Reconstructive surgery (con't)
Follows some curative or radical surgery in attempt to improve function or a more desirable cosmetic effect
-breast, head and neck, skin cancers
Radiation Therapy (Cancer Treatment)
Ionizing radiation used to interrupt cellular growth

-More than half pts have some form of radiation at some point during treatment (external radiation, Internal radiation)

-Total radiation dose delivered over several weeks to allow healthy tissue to repair and expose more cells to radiation as they begin active cell division

-Toxicity of radiation localized to region being irradiated
External radiation
delivered from outside body to target area
Internal radiation
(brachytherapy) delivers high dose of radiation to localized area through implanted by needles seeds, beads, catheters
--Radioisotopes remain in place for prescribed period and removed
Toxicity of radiation localized to region being irradiated
Altered skin integrity, hair loss, erythema, desquamation, stomatitis, xerostomia (dryness of mouth), decreased salivation
Chemotherapy (Cancer Treatment)
-Alkylating Agents (carboplatin, cisplatin, etc)
-Nitrosureas (carmustine, lomustine, etc)
-Topoisomerase I Inhibitors (irinotecan, topotecan)
-Antimetabolites (cytarabine, 5-FU, Hydroxyurea, 6-mercaptopurine, methotrexate)
-Antitumor Antibiotics (Bleomycin, Adriamycin)
-Mitotic Spindle Poisons (plant alkaloids: etoposide, vinblastine, vincristine; Taxanes: paclitaxel, docetaxel)
-Hormonal Agents (androgens, antiandrogens, estrogens, antiestrogens)
-Miscellaneous Agents (asparaginase, procarbazine)
Alkylating Agents (carboplatin, cisplatin, etc)

*
-Alter DNA structure by misreading DNA code
-Cell cycle-nonspecific
-Bone marrow suppression, nausea, vomiting, cystitis (cyclophosphamide, ifosfamide), stomatitis, alopecia, gonadal suppression, nephrotoxic
end in tin nonspecifi
Nitrosureas (carmustine, lomustine, etc)
-Similar to alkylating agents
-Cell cycle-nonspecific
-Myelosuppression, thrombocytopenia, n/v
end in tine, nonspecific
Topoisomerase I Inhibitors (irinotecan, topotecan)
-Induces breaks in DNA by binding to enzyme topoisomerase I, preventing cells from dividing
-Cell cycle-specific (s phase)
-Bone marrow suppression, diarrhea, n/v, hepatotoxic
end in can, T is specific for S
Antimetabolites (cytarabine, 5-FU, Hydroxyurea, 6-mercaptopurine, methotrexate)

*
-Interfere with biosynthesis of metabolites necessary for RNA and DNA synthesis
-Cell cycle-specific (S phase)
-n/v, diarrhea, bone marrow suppression, proctitis, stomatitis, renal & hepatotoxic
the meds are the bad boys, 5-
FU, hydro, merca, metho
A is specific to S
Antitumor Antibiotics (Bleomycin, Adriamycin)

*
-Interfere with DNA synthesis by binding DNA and preventing RNA synthesis
-Cell cycle-nonspecific
-Bone marrow suppression, n/v alopecia, anorexia, cardiac toxicity
end in mycin
non specific
Mitotic Spindle Poisons (plant alkaloids: etoposide, vinblastine, vincristine; Taxanes: paclitaxel, docetaxel)

*
-Arrest metaphase by inhibiting mitotic tubular formation
-Cell cycle-specific (M phase)
-Bone marrow suppression, neuropathies, stomatitis, bradycardia, alopecia
may have Tax in name, or vin

Mitotic is specific to M
Hormonal Agents (androgens, antiandrogens, estrogens, antiestrogens)
*
-Bind to hormone receptor sites that alter cell growth
-Cell cycle-nonspecific
-Hypercalcemia, jaundice, increased appetite, masculinization/feminization, Na+ and fluid retention, n/v, hot flashes
end in gens

non-specific
Miscellaneous Agents (asparaginase, procarbazine)
-Mechanism of action unknown
-Cell cycle specificity varies
-Anorexia, n/v, bone marrow suppression, hepatotoxic, anaphylaxis, hypotension, altered glucose metabolism
Administration of Chemotherapy
-Dosage based on patient's total body surface area, previous response to chemo and function of major organ systems
-Special Problems: Extravasation and Toxicity (acute or chronic)
Extravasation
-Vesicants: Cause tissue necrosis and damage to underlying tendons, nerves and blood vessels (dactinomycin, daunorubicin, doxorubicin, nitrogen mustard, mitomycin, vinblastine, vincristine, vindesine)

-med stopped, MD may try to aspirate from tissues, inject neutralizing solution to reduce tissue damage (sodium bicarbonate, sodium thiosulsfate, hyaluronidase)
Toxicity (acute or chronic)



Toxicity (acute or chronic) -(con't)
-GI
-Hematopoietic
-Renal
-Cardiopulmonary
-Reproductive
-Neurologic
GI
Toxicity (acute/chronic) from Chemotherapy
-n/v - involve multiple pathways
-corticosteroids, phenothiazines, sedatives, histamines in combination with serotonin blockers
Hematopoietic
Toxicity (acute/chronic) from Chemotherapy
-myelosuppression
-decreases WBC, RBC, and platelets
-increases risk for infection and bleeding
-common cause for limiting dose
-Colony stimulating factor (Neupogen) and erythropoietin (Epogen)
Renal
Toxicity (acute/chronic) from Chemotherapy
-Direct effects during excretion and accumulation of end products after cell lysis
-Lysis results in increased uric acid
-Intracellular contents increase potassium and phosphates and decreased calcium
-Monitor BUN and creatinine
Cardiopulmonary
Toxicity (acute/chronic) from Chemotherapy
-Antitumor antibiotics (daunorubicin and doxorubicin) cause irreversible cumulative cardiac toxicities
-Monitor ejection fraction and signs of heart failure
-Bleomycin and caramustine and busulfan known for toxicity of lung function - pulmonary fibrosis
Reproductive
Toxicity (acute/chronic) from Chemotherapy
-Testicular and ovarian function affected
-Sterility
-Early menopause, azoospermia
Neurologic
Toxicity (acute/chronic) from Chemotherapy
-Taxanes and plant alkaloids cause neuro damage with repeated doses
-peripheral neuropathies, loss of deep tendon reflexes, paralytic ileus
Bone Marrow Transplant
(Cancer Treatment)
Types of BMT
-Allogenic: donor other than the pt
-Autologous: from the pt
-Syngeneic: from an identical twin
Allogenic BMT






Allogenic BMT (con't)
Donor other than the pt

-Should cause a lethal graft-versus-disease effect in the malignant cells

-Ablative allogenic BMT: pt under goes ablative doses of chemo and possibly radiation to destroy all existing bone marrow and malignant disease



-BMT infused and travel to sites where they produce bone marrow (2-4 weeks)

-Nonablative BMT: lower doses of chemo (older pts or those with underlying organ dysfunction)

-Immunosuppressive drugs to prevent graft-versus-host disease

-First 100 days crucial
Autologous BMT
From the pt

-Stem cells recovered and reinfused after ablative chemo
Hyperthermia (Cancer Treatment)










Hyperthermia (Cancer Treatment)
-generation of temps greater the 106.7 to destroy tumors

-malignant cells may be more sensitive to high temps:
--Cells lack mechanisms to repair damage
--Lack adequate blood supply to provide needed O2 during increased cellular demand
--Lack vessels of adequate size for dissipation of heat
--Body's immune system may be indirectly stimulated with hyperthermia

-Produced by radio waves, ultrasound, microwaves, magnetic waves, hot-water baths, hot wax immersions, probes inserted around tumor and attached to heat source

-Local or regional

-Whole body hyperthermia to treat disseminated disease - extracorporeal circulation

-Adverse effects: burns, tissue damage, fatigue, hypotension, peripheral neuropathies, thrombophlebitis, n/v, diarrhea, electrolyte imbalance
Targeted Therapies (Cancer Treatment)
-Biologic Response Modifiers
-Gene Therapy
Biologic Response Modifiers
(Targeted Therapy)





Biologic Response Modifiers
(Targeted Therapy) - (con't)
Naturally occurring or recombinant agent that alters immunologic relationship between tumor and host for therapeutic effect

-Nonspecific Biologic Response Modifiers
-Monoclonal antibodies
-Cytokines
-Retinoids
-Cancer Vaccines
Nonspecific Biologic Response Modifiers
-Antigens (BCG and corynebacterium parvum) stimulate immune system to eradicate malignant cells - malignant melanoma, localized bladder cancer
Monoclonal antibodies
-Targeted antibodies are grown for specific malignant cells - deliver radioactive source to malignant cells
Cytokines
-substances produced by cells of immune system to enhance production and function of immune system (Interferons, Interleukins, Hematopoietic Growth Factors)
Interferons
-antiviral and antitumor properties
Interleukins
-produced by lymphocytes and monocytes and act by signaling and coordinating other cells of the immune system
Hematopoietic Growth Factors
Colony-Stimulating Factors
-Regulate production of all cells in the blood and target effects of myelotoxic cancer therapies
Retinoids
Vitamin A derivatives
-Used in treating acute promyelocytic leukemia and cutaneous T-cell lymphoma
Cancer Vaccines
mobilize body's immune response
-stimulate the immune system to recognize and attack cancer cells
Gene Therapy
(Targeted Therapy)
Correct genetic defects or manipulate genes to induce tumor cell destruction
Photodynamic Therapy
(Cancer Treatment)
-Photosensitizing agents are administered IV and are retained in higher concentrations in malignant tissue.
-Activated by a light source, usually laser
-Used for esophageal, lung, precancerous lesions of esophagus
Unproven and Unconventional Therapies
(Cancer Treatment)









Unproven and Unconventional Therapies
(Cancer Treatment) - (con't)
-Machines and devices: often decorated with lights and produce vibrations and other sensations

-Drugs and Biologic Agents: herbs, proteins, mega vitamins, immune therapy, enzymes, hydrogen peroxide

-Metabolic and Dietary Regimens: grape diet, carrot juice diet, intake of garlic, onions, various teas, coffee enemas, raw liver

-Mystical and Spiritual Approaches: psychic surgery, faith healing, prayer groups
Nursing Management: Surgery
-Routine post operative care
-Care pertinent to area of body/organ effected
Nursing Management: Radiation
-Education

-Post radiation complications - n/v, stomatitis, xerostomia, diarrhea, etc.

-Implants:
--Educate pt/family on visiting precautions, etc.
--Principles of time, distance and shielding to minimize exposure to health care team and visitors
--Private room, dosimeter badges, maintain 6 ft. distance when possible
--Pt on bedrest - Monitor bed linens for any seeds/beads
--Post notice of radiation
Nursing Management: Chemotherapy
-Assess fluid and electrolytes
-Modify risks for infection and bleeding
-Careful administration of chemotherapy
-Protection of caregivers
--Follow specific precautions (pg. 416, Chart 16-7)
Chemotherapy Specific Precautions























Chemotherapy Specific Precautions (con't)
Pg. 416, Chart 16-7: Safety in Administering Chemotherapy -

Safety recommendations from the Occupational Safety and Health Administration (OSHA), Oncology Nursing Society (ONS), hospitals, and other health care agencies for the preparation and handling of antineoplastic agents follow:

-Use a biologic safety cabinet for the preparation of all chemotherapy agents.

-Wear surgical gloves when handling antineoplastic agents and the excretions of patients who received chemotherapy.

-Wear disposable, long-sleeved gowns when preparing and administering chemotherapy agents.

-Use Luer-Lok fittings on all intravenous tubing used to deliver chemotherapy.

-Dispose of all equipment used in chemotherapy preparation and administration in appropriate, leak-proof, puncture-proof containers.

-Dispose of all chemotherapy wastes as hazardous materials.

When followed, these precautions greatly minimize the risk of exposure to chemotherapy agents.
Nursing Management: Bone Marrow Transplantation
-Pre-transplant care
-During BMT
-Post BMT
-Donors
Pre-Transplant care (BMT) - Nursing Management
-Nutritional assessment, physical assessment, diag. tests, blood tests
-Patient's support system
-Patient/family education
During BMT -
Nursing Management
-High dose chemo
-Total body irradiation
-Manage toxicities: n/v, diarrhea, mucositis, hemorrhagic cystitis

-During stem cell infusion:
--Monitor VS, O2 sat, resp status, cardiac status, n/v, hypotension
--Reverse isolation
--Monitor for renal failure from tumor lysis syndrome
Post BMT -
Nursing Management
-Monitor for infections, restrictive pulmonary abnormalities
-Chronic GVHD involves skin, liver, intestine, esophagus, eyes, lungs, joints, vaginal mucosa
Donor -
Nursing Management
-Mood alterations, decreased self-esteem, guilt if transplant fails
Nursing Management: Hyperthermia
-Patient/family education about procedure, goal and effects
-Monitoring
-Skin care at site of implanted probes
Nursing Management: Biologic Response Modifier Therapy
-Assess need for education, support and guidance
-Monitoring therapeutic and adverse effects
-Promoting home and community based care
Nursing Management: Unconventional Therapies
-Establish trusting relationship
-Provide supportive care
-Promote hope
-Truthful responses in non-judgmental manner
-Inform of characteristics common to fraudulent therapies
-Encourage pt to inform physician of use of these therapies
Assessment
(Nursing Process)
-Infection: labs, signs of infection
-Bleeding
-Skin Problems
-Hair Loss
-Nutritional concerns
-Pain
-Fatigue
-Psychosocial Status
-Body Image
Nursing Diagnoses
(Nursing Process)
-Impaired oral mucosa membrane
-Impaired Tissue Integrity: alopecia, skin lesions
-Imbalanced Nutrition - less than body requirements
-Anorexia
-Malabsorption
-Chachexia
-Chronic Pain
-Fatigue
-Altered body image
-Anticipatory grieving
Chachexia
Characterized by loss of body weight, adipose tissue, visceral protein, and skeletal muscle
Interventions
(Nursing Process)








Interventions
(Nursing Process)
-Manage stomatitis and xerostomia
--Good oral hygiene
--Oral rinses
--Soft diet
--Lubricate lips

-Maintain tissue integrity

-Help pt cope with alopecia
--Wigs - match pt's hair, acquire prior to hair loss
--Turbans - use at home

-Promote nutrition

-Relieve pain

-Decrease fatigue (pg. 439, Table 16-10)

-Improve body image and self-esteem

-Assist in grieving process

-Monitor and manage potential complications
Decrease Fatigue























Decrease Fatigue (con't)















Decrease Fatigue (con't)
(pg. 439 - Table 16-10)

Fatigue is the most commonly reported side effect in patients who receive chemotherapy and radiation therapy. The nurse assesses for feelings of weariness, weakness, lack of energy, inability to carry out necessary and valued daily functions, lack of motivation, and inability to concentrate. The patient may become less verbal and may appear pale, with relaxed facial musculature. The nurse assesses physiologic and psychological stressors that can contribute to fatigue, including pain, nausea, dyspnea, constipation, fear, and anxiety.

-Encourage several rest periods during the day, especially before and after physical exertion.

-Increase total hours of nighttime sleep.

-Rearrange daily schedule and organize activities to conserve energy expenditure.

-Encourage patient to ask for others' assistance with necessary chores, such as housework, child care, shopping, cooking.

-Encourage reduced job workload, if possible, by reducing number of hours worked per week.

-Encourage adequate protein and calorie intake.

-Encourage use of relaxation techniques, mental imagery.

-Encourage participation in planned exercise programs.

-For collaborative management, administer blood products as prescribed.
Rationale: Lowered hemoglobin and hematocrit predispose patient to fatigue due to decreased oxygen availability.

-Assess for fluid and electrolyte disturbances.

-Assess for sources of discomfort.

-Provide strategies to facilitate mobility.
Oncologic Emergencies








Oncologic Emergencies (con't)
(Page 438-442, Table 16-13)
-Superior Vena Cava Syndrome
-Spinal Cord Compression
-Hypercalcemia: bone destruction, tumors that promote calcium release
-Pericardial Effusion and Cardiac Tamponade
-Disseminated Intravascular Coagulation (DIC)
-Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH)
-Tumor Lysis Syndrome
Superior Vena Cava Syndrome
-Compression or invasion of the superior vena cava by tumor, enlarged lymph nodes, intraluminal thrombus that obstructs venous circulation, or drainage of the head, neck, arms, and thorax. Typically associated with lung cancer, SVCS can also occur with breast cancer, Kaposi's sarcoma, thymoma, lymphoma and mediastinal metastases. If untreated, SVCS may lead to cerebral anoxia (because not enough oxygen reaches the brain), laryngeal edema, bronchial obstruction, and death.
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. The prognosis depends on the severity and rapidity of onset. About 60% of compressions occur at the thoracic level, 30% in the lumbosacral level, and 10% in the cervical region. Metastatic cancers (breast, lung, kidney, prostate, myeloma, lymphoma) and related bone erosion are associated with spinal cord compression.
Hypercalcemia
-bone destruction, tumors that promote calcium release

-Clinical:
Fatigue, weakness, confusion, decreased level of responsiveness, hyporeflexia, nausea, vomiting, constipation, polyuria (excessive urination), polydipsia (excessive thirst), dehydration, and dysrhythmias

-Diagnostic:
Serum calcium level exceeding 11 mg/dL
Pericardial Effusion and Cardiac Tamponade
-Cardiac tamponade is an accumulation of fluid in the pericardial space.
Disseminated Intravascular Coagulation (DIC)
-Complex disorder of coagulation or fibrinolysis (destruction of clots), which results in thrombosis or bleeding.

-DIC is most commonly associated with hematologic cancers (leukemia); cancer of prostate, gastrointestinal (GI) tract, and lungs; chemotherapy (methotrexate, prednisone, l-asparaginase, vincristine, and 6-mercaptopurine); and disease processes such as sepsis, hepatic failure, and anaphylaxis.
Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH)
-Serum sodium levels lower than 120 mEq/L.

-The continuous, uncontrolled release of antidiuretic hormone (ADH), produced by tumor cells or by the abnormal stimulation of the hypothalamic–pituitary network, leads to increased extracellular fluid volume, water intoxication, hyponatremia, and increased excretion of urinary sodium. As fluid volume increases, stretch receptors in the right atrium respond by releasing a second hormone, atrial natriuretic factor (ANF). The release of ANF causes increased renal excretion of sodium, which worsens hyponatremia.
Tumor Lysis Syndrome
-Potentially fatal complication associated with radiation- or chemotherapy-induced cell destruction of large or rapidly growing cancers such as leukemia, lymphoma, and small cell lung cancer. The release of intracellular contents from the tumor cells leads to electrolyte imbalances—hyperkalemia, hypocalcemia, hyperphosphatemia, and hyperuricemia—because the kidneys can no longer excrete large volumes of the released intracellular metabolites.
End of Life Care
-Precepts of end of life care
-Technology and end of life care
-Sociocultural Context
-Settings for End of Life Care
Precepts of end of life care
-Respect patients' goals, preferences, and choices
-Attend to the medical, emotional, social and spiritual needs of dying people
-Use strengths of interdisciplinary resources
-Acknowledge and address caregiver concerns
-Build mechanisms and systems of support
Technology and end of life care
-Shifted place of death from home to hospital or extended care facility
-Affected societal view of death
-Influences how clinicians care for dying pt
-Influences how family participate in care and choose among end of life care options
-How families prepare for terminal illness and death
-How families heal after the death of a loved one
Sociocultural Context
(End of Life Care)




Sociocultural Context
(End of Life Care) - (con't)
-Care/cure dichotomy has emerged
-Care-focused perspective
-Clinicians' Attitudes Toward Death
-Glaser's Awareness Contexts
-Patient and Family Denial
-Assisted Suicide
Care/cure dichotomy has emerged
-Cure is ultimate good
-Care is second best - only if cure is not possible
-Alleviating suffering not as valued as curing - associated with failing
-Family fear that comfort-focused care will result in no care or lower-quality care
Care-focused perspective
Treating mind, body and spirit are inextricable
Clinicians' Attitudes Toward Death
-Greatest barrier to improving care at end of life
-Clinicians' reluctance to discuss disease & death openly stems from their own anxieties about death
Glaser's Awareness Contexts
-Closed awareness: pt unaware of terminal state, others are aware

-Suspected awareness: pt suspects what others know and attempts to find out details

-Mutual pretense awareness: pt, family, and healthcare professionals are aware pt dying but pretend otherwise

-Open awareness: all are aware that pt is dying and openly acknowledge that reality
Patient and Family Denial
-Useful coping mechanism enabling pt to gain emotional distance from something that is too painful to contemplate fully
-Protect themselves because of fear of abandonment
Assisted Suicide
Providing another person the means to end his or her own life
-Discussions highlight inadequacies in the care of the dying
-Not supported by ANA or AMA
Settings for End of Life Care
-Palliative Care: Active, total care of pts whose disease is not responsive to treatments

-Hospice Care
Palliative Care








Palliative Care (con't)
Active, total care of pts whose disease is not responsive to treatments

-Emphasizes management of psychological, social and spiritual problems in addition to control of pain and other physical symptoms
-Emphasizes interdisciplinary collaboration
-More than 50% die in hospital
-Hospitals have financial barriers to providing high quality palliative care in acute care settings
-Trend favoring care of dying pts in long term care facilities will continue as population ages
-Long term care residents typically have poor access to high-quality palliative care
-Since 1986 home hospice programs have been able to enroll long term care residents in hospice programs
Hospice Care
-Principles of Hospice
-Underutilized by pts and physicians
-Medicare started covering Hospice in 1983
-Hospice assumes responsibility for providing and paying for the care and treatment related to the underlying illness for which hospice was elected
-Four (4) levels of Hospice Care
-Patient may revoke Hospice and return to regular Medicare
Principles of Hospice
-Death must be accepted
-Patient's total care is best managed by an interdisciplinary team whose members communicate regularly with each other
-Pain and other symptoms of terminal illness must be managed
-The pt and family should be viewed as a single unit of care
-Home care of the dying is necessary
-Bereavement care must be provided to family members
-Research and education should be ongoing
Eligibility Criteria for Hospice



















Eligibility Criteria for Hospice (con't)
(Pg. 455, Table 17-3)

-General:
--Serious, progressive illness
--Limited life expectancy
--Informed choice of palliative care over cure-focused treatment

-Hospice-Specific:
--Presence of a family member or other caregiver continuously in the home when the patient is no longer able to safely care for him/herself (some hospices have created special services within their programs for patients who live alone, but this varies widely)

-Medicare and Medicaid Hospice Benefits:
--Medicare Part A; Medical Assistance eligibility
--Waiver of traditional Medicare/Medicaid benefits for the terminal illness
--Life expectancy of 6 months or less
--Physician certification of terminal illness
--Care must be provided by a Medicare-certified hospice program
Four levels of Hospice Care
-Routine home care
-Inpatient respite care: 5 day inpatient stay to relieve caregivers
-Continuous care: management of medical crisis
-General inpatient care: inpatient stay for symptoms management that can't be provided in home
Nursing Care of Terminally Ill Patients
-Psychosocial issues
-Communication
-Culturally Sensitive End of Life Care
-Spiritual Care
-Hope
Psychosocial issues
(Nursing Care of Terminally Ill Patients)
-Support pt/family as they conduct life review, values clarification, treatment decisions, end of life closure

-Advance directives
Communication
(Nursing Care of Terminally Ill Patients)











Communication
(Nursing Care of Terminally Ill Patients)

















Communication (con't)
-Nurses should consider their own experiences with and values concerning illness and death

-Guidelines for Communicating with Seriously Ill
--Deliver and interpret the technical information necessary for making decisions without hiding behind medical terminology
--Realize that the best time for the patient to talk may be when it is least convenient for you
--Being fully present during any opportunity for communication is often the most helpful form of communication
--Allow the pt and family to set the agenda regarding the depth of the conversation

-Resist impulse to fill "empty space" in communication with talk

-Allow pt/family sufficient time to reflect and respond after asking a question

-Prompt gently: "Do you need more time to think about this?"

-Avoid distractions

-Avoid the impulse to give advice

-Avoid canned responses: "I know just how you feel."

-Ask questions

-Assess understanding - your own and the pt's by restating, summarizing and reviewing
Culturally Sensitive End of Life Care
-Nurse should assess and document the pt/family's specific beliefs, preferences, and practices regarding end of life care, preparation for death, and after-death rituals
Spiritual Care
"SPIRIT" mnemonic to include spiritual assessment:
S = Spiritual belief system
P = Personal spirituality
I = Integration and involvement with others in a spiritual community
R = Ritualized practices and restrictions
I = Implications for medical care
T = Terminal events planning
Hope








Hope
Nursing Interventions for enabling and supporting hope:
-Listen attentively
-Encourage sharing of feelings
-Provide accurate information
-Encourage and support pt's control over his/her circumstances, choices, and environment whenever possible
-Assist pts to explore ways for finding meaning in their lives
-Encourage realistic goals
-Facilitate effective communication within families
-Making referrals for psychosocial and spiritual counseling
-Assist with development of supports in the home or community when none exist
Post Mortem Care
-Auscultation for absence of breath sounds and heart sounds
-Flat EKG if possible
-Recording exact time of death
-Family members encouraged to spend time with deceased
-Support family in grief and mourning
-Follow policy for post mortem care
-Documentation
Follow policy for Post Mortem Care
-Remove IVs, tubes, drains, etc.
-Clean body if necessary

-Place in body wrap

-Complete tag and place accordingly
Documentation (Post Mortem Care)
-Facility's policies and procedures to guide the nurse's actions

-Nurses follow the facility's procedure for preparation of the body and transportation to the facility's morgue
Chart 16-3: TNM Classification System
The extent of the primary tumor
N The absence or presence and extent of regional lymph node metastasis
M The absence or presence of distant metastasis
The use of numerical subsets of the TNM components indicates the progressive extent of the malignant disease.
Primary Tumor (T)
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1, T2, T3, T4 Increasing size and/or local extent of the primary tumor
Regional Lymph Nodes (N)
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1, N2, N3 Increasing involvement of regional lymph nodes
Distant Metastasis (M)
Mx Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
--
-G1 phase—RNA and protein synthesis occur
-S phase—DNA synthesis occurs
-G2 phase—premitotic phase; DNA synthesis is complete, mitotic spindle forms
-M phase- Mitosis—cell division occurs
Cell cycle time
TABLE 16-6 Antineoplastic Agents
Drug Class and Examples Mechanism of Action Cell Cycle Specificity Common Side Effects
1.Alkylating Agents
Busulfan, carboplatin, chlorambucil, cisplatin, cyclophosphamide, dacarbazine, hexamethyl melamine, ifosfamide, melphalan, nitrogen mustard, oxaliplatin, thiotepa Alter DNA structure by misreading DNA code, initiating breaks in the DNA molecule, cross-linking DNA strands Cell cycle–nonspecfic Bone marrow suppression, nausea, vomiting, cystitis (cyclophosphamide, ifosfamide), stomatitis, alopecia, gonadal suppression, renal toxicity (cisplatin)
2. Nitrosureas
Carmustine (BCNU), lomustine (CCNU), semustine (methyl CCNU), streptozocin Similar to the alkylating agents; cross the blood–brain barrier Cell cycle–nonspecfic Delayed and cumulative myelosuppression, especially thrombocytopenia; nausea, vomiting
3. Topoisomerase I Inhibitors
Irinotecan, topotecan Induce breaks in the DNA strand by binding to enzyme topoisomerase I, preventing cells from dividing Cell cycle–specfic (S phase) Bone marrow suppression, diarrhea, nausea, vomiting, hepatotoxicity
4. Antimetabolites
5-Azacytadine, capecitabine (Xeloda), cytarabine, edatrexate fludarabine, 5-fluorouracil (5-FU), FUDR, gemcitabine, hydroxyurea, leustatin, 6-mercaptopurine, methotrexate, pentostatin, 6-thioguanine Interfere with the biosynthesis of metabolites or nucleic acids necessary for RNA and DNA synthesis Cell cycle–specfic (S phase) Nausea, vomiting, diarrhea, bone marrow suppression, proctitis, stomatitis, renal toxicity (methotrexate), hepatotoxicity
5. Antitumor Antibiotics
Bleomycin, dactinomycin, daunorubicin, doxorubicin (Adriamycin), idarubicin, mitomycin, mitoxantrone, plicamycin Interfere with DNA synthesis by binding DNA; prevent RNA synthesis Cell cycle–nonspecfic Bone marrow suppression, nausea, vomiting, alopecia, anorexia, cardiac toxicity (daunorubicin, doxorubicin)
6. Mitotic Spindle Poisons
Plant alkaloids: etoposide, teniposide, vinblastine, vincristine (VCR), vindesine, vinorelbine Arrest metaphase by inhibiting mitotic tubular formation (spindle); inhibit DNA and protein synthesis Cell cycle–specfic (M phase) Bone marrow suppression (mild with VCR), neuropathies (VCR), stomatitis
Taxanes: paclitaxel, docetaxel Arrest metaphase by inhibiting tubulin depolymerization Cell cycle–specfic (M phase) Bradycardia, hypersensitivity reactions, bone marrow suppression, alopecia, neuropathies
7.Hormonal Agents
Androgens and antiandrogens, estrogens and antiestrogens, progestins and antiprogestins, aromatase inhibitors, luteinizing hormone–releasing hormone analogues, steroids Bind to hormone receptor sites that alter cellular growth; block binding of estrogens to receptor sites (antiestrogens); inhibit RNA synthesis; suppress aromatase of P450 system, which decreases estrogen level Cell cycle–nonspecfic Hypercalcemia, jaundice, increased appetite, masculinization, feminization, sodium and fluid retention, nausea, vomiting, hot flashes, vaginal dryness
8. Miscellaneous Agents
Asparaginase, procarbazine Unknown or too complex to categorize Varies Anorexia, nausea, vomiting, bone marrow suppression, hepatotoxicity, anaphylaxis, hypotension, altered glucose metabolism
Chart 16-6: Plan of Nursing Care The Patient With Cancer
Nursing Diagnosis: Risk for infection related to altered immunologic response
Goal: Prevention of infection
Nursing Diagnosis: Impaired skin integrity: erythematous and wet desquamation reactions to radiation therapy
Goal: Maintenance of skin integrity
Nursing Diagnosis: Impaired oral mucous membrane: stomatitis
Goal: Maintenance of intact oral mucous membranes
Nursing Diagnosis: Impaired tissue integrity: alopecia
Goal: Maintenance of tissue integrity; coping with hair loss
Nursing Diagnosis: Imbalanced nutrition, less than body requirements, related to nausea and vomiting
Goal: Fewer episodes of nausea and vomiting before, during, and after chemotherapy
Nursing Diagnosis: Imbalanced nutrition: less than body requirements, related to anorexia, cachexia, or malabsorption
Goal: Maintenance of nutritional status and of weight within 10% of pretreatment weight
Nursing Diagnosis: Fatigue
Goal: Increased activity tolerance and decreased fatigue level
Nursing Diagnosis: Chronic pain
Goal: Relief of pain and discomfort