1 Nursing Care & Interventions in Managing Those with Cancer Keith Rischer RN, MA, CEN.

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Nursing Care & Interventions in Managing Those with

CancerKeith Rischer RN, MA, CEN

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Today’s Objectives…1. Identify the goals of cancer therapy.2. Distinguish between cancer surgery for cure and

cancer surgery for palliative care.3. Discuss the nursing care needs for clients

undergoing therapy for cancer.4. Discuss radiation therapy.5. Identify nursing interventions for patients

undergoing chemotherapy.6. Discuss care of patients with neutropenia7. Discuss care of patients with thrombocytopenia8. Explain the rationale for hormonal manipulation

therapy.9. Explain the basis of targeted therapy for cancer.

Consequences of Cancer

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Impaired immune and hematopoietic function Bone marrow

Anemia and thrombocytopenia

Altered gastrointestinal structure and function Tumors obstruct structures Tumors increase metabolic rate Tumors in liver reduce liver function Diet high in protein and carbohydrates

supplement when 5% weight loss Monitor albumin

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Consequences of Cancer

Motor and sensory deficits Bone metastases Spinal cord

compression Pain

Decreased respiratory function Airway obstruction Tumor compression Pleural effusions

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Surgery as Cancer Treatment

Oldest form of cancer treatment used for: Prophylaxis

Remove at risk tissue Diagnosis (biopsy) Cure Control (debulks) Palliation Determining efficacy of therapy

(second look) Reconstruction

Side effects of surgical therapy

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Radiation Therapy

Purpose Mechanism of action

Ionizing radiation Cells die or unable to divide

Exposure amount delivered

Dose amount absorbed

Killing effects of radiation Given in a series of divided

doses Fractionation…180-280

rads qd typical Some organs can tolerate

more radiation YouTube - Radiation Therap

y to Treat Cancer

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Radiation Therapy

Teletherapy (Beam) Distant-external treatment

Brachytherapy Unsealed Body fluids potential hazard

Isotopes given IV or instilled in body cavities Iodine ingestion for thyroid cancer

Sealed Body fluids NOT hazard, but pt. may be

Implanted in proximity to tumor

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Nursing Care w/Sealed Implants

Private room with private bath “Caution: Radioactive Material” note Nurse wears dosimeter film badge No pregnant women or children under 16 not to

visit Limit visitors 30 min/day

Stay 6 ft away Never touch radioactive source with hands Save all dressings and bed linens until

radioactive source is removed.

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Side Effects of Radiation Therapy

Local skin changes Hair loss Altered taste sensations Fatigue

Debilitating Can last for months

Tissue fibrosis and scarring of healthy tissue

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Nursing Care w/Radiation Therapy

Education Skin care

Dry skin in path of radiation Do not use lotions or ointments. Avoid direct exposure of the skin to the sun.

Care for xerostomia (dry mouth). Bone exposed to radiation is more vulnerable to fracture. Reproductive effects

Depends on site Harvest sperm or ova

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Chemotherapy

Mechanism Cytotoxic Some selectivity Damages cell DNA

cell division

Rapidly dividing cells more sensitive to chemo Skin, hair Intestinal tissues Spermatocytes Blood-forming cells

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Chemotherapy Drug Categories Table 28-6 p.492

Antimetabolites Act as counterfeit metabolites so cells can’t divide Cell cycle specific

Antitumor antibodies Interrupt DNA and RNA Cell cycle nonspecific

Alkylating agents Cross link DNA-prevents DNA/RNA synthesis Cell cycle nonspecific

Antimitotic agents Interfere with mitosis-prevent division Cell cycle specific

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5-Fluorouracil (5-FU) Anti-metabolite IV SE

Decr. WBC & plateletsStomatitisAnorexiaDarkening of skin…sun sensitivity

Nursing responsibilitiesUse sunscreen when outsideMenstrual changes…decreased sperm counts

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Cytoxan (Cyclophosphamide) Alkylating agent po or IV SE

N&V 2-4 hours after tx Pancytopenia 14 days after tx Alopecia 2-3 weeks after tx Loss of appetite

Nursing Considerations Can cause hemorrhagic cystitis…incr. po and stop if

hematuria Mesna (Mesnex) often given to protect

po or IV

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Vincristine (Oncovin)

Anti-mitotic IV SE

Constipation/abd. CrampingStomatitisAlopecia 2-3 weeks after tx

Nursing considerations Increase fiber

Chemotherapy Treatment Issues

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Combination chemotherapy More effective-possible more toxic

Drug dosage Dependant on type of cancer & client size

Drug schedule – Usually every 3 to 4 weeks for 6-12x

Drug administration IV route most common Use central lines or ports to avoid vessel irritation

ExtravasationYouTube - P9290001 Getting her port access

ed www.freehelpforcancer.com

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Side Effects of Chemotherapy

Fatigue Alopecia or hair loss Nausea and vomiting

Antiemetics Zofran Ativan Compazine

Mucositis-open sores mouth (stomatitis) see Mouth

care chart 28-6 p.496 Skin changes Bone marrow suppression

Anemia Immunosuppression Thrombocytopenia

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Neutropenia Highest risk

Chemo/radiation Liver/kidney disease Tumors bone marrow, sm. Cell lung CA, lymphoma,

breast cancer, elderly >70 yrs Treatment

Filgrastim: granulocyte colony stimulating factor Red Flag

T>100.4 and ANC <500 Medical management

Cultures IV abx Nursing assessments/priorities

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Neutropenic Precautions chart 28-7 p.497

Good handwashing!!! Private room – cleaned daily Do not use supplies from

common areas – straws, etc. No water pitchers

Limit # of health care providers, visitors

VS q 4 hrs Watch for sepsis

Inspect mouth, skin, mucous membranes q 8 hrs

Inspect any open areas for sx infection

No flowers and potted plants Fungi

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Absolute Neutrophil Count (ANC)

Normal Range > 2,500/mm3 1000-2500…safe to continue chemotherapy 1000-1500 minimal risk 500-1000 moderate risk <500 SEVERE risk

WBC x(%neutrophils + % bands) Example: breast CA after chemo

WBC 2000, neutrophils 14.8%, bands 5%

2000 x (0.148 +.05)= 2000 x 0.198=396

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Thrombocytopenia

Reduction of platelets below normal range Normal = 150,000-400,000 mm3

Etiology: Bone marrow suppression

Critical values 50,000 or less- risk of bleeding <20,000 spontaneous life threatening hemorrhages

(brain bleed) Consider platelet transfusion if febrile or bleeding

<10,000 transfusions recommended

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Nursing Priorities w/Thrombocytopenia chart 28-9 p.497

Handle gently Avoid punctures Apply ice to trauma No rectal temps, lubricate suppositories Electric razor Mouth care –

no flossing, avoid dental work, avoid hard foods, check denture fit

Avoid contact sports Shoes with firm soles

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Hormone Therapy

Patho Types of CA

Breast, prostate, endometrium Treatment

Surgical (remove the hormone producing organ)Pharmocologic suppression

Steroids or estrogen

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Stem Cell/Bone Marrow Transplant

Goal Give higher than usual dose of chemo to prepare way

for engraftment of stem cell transfusion Bone marrow wiped out WBC>0.1

Bone marrow/stem cells harvested from pelvis/iliac crest of matched donor or self (autologous) Strained-administered as IV infusion NHL, multiple myeloma, some breast/testicular CA

Takes 2-4 weeks before stem cells will take very high risk of infection

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Oncology Case Study

70yr male PMH:

metastatic GB CA-dx 2006 w/hepatic resection, radiation therapy completed, currently on weekly chemo

Malignant pleural effusions CAD, HTN

HPI: Progressive worsening of SOB since last thoracentesis 2 weeks ago. Sudden onset of severe SOB early am. Incr. weakness w/nausea. No c/o CP

VS: T-98.2 P-123 (ST) R-22 BP 101/68 sats 90% RA Assessment:

Resp: severely diminished right side Other systems WNL

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Oncology Case Study

Medical/Nursing Priorities… Nursing Assessments… Nursing Interventions…

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Oncology Case Study: Oncology Floor

83 yr. female new admission PMH: rectal CA 1987 w/surgical

resection/colostomy and radiation Chief c/o: Persistent low abd. crampy pain

w/nausea CT: large poorly differentiated carcinoma

in pelvis w/migration to lymph nodesSmall bowel obstruction: ? tumor

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Oncology Case Study: Priorities

Medical…NG to LISNPO IVF: NS @ 100cc/hr

Nursing…Pain controlNausea controlVolume status

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Breast Cancer

Article YouTube - Breast cancer real story