Chapter 17 Chapter 17 PVN 143 Care of the Patient with Cancer Rebecca Maier, BSN Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. www. concorde.edu
Chapter 17Chapter 17
PVN 143
Care of the Patient with Cancer
Rebecca Maier, BSN
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
www.concorde.edu
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OncologyBranch of medicine that deals with the study of
tumors1 of 2 men will have cancer1 of 3 women will have cancerSecond leading cause of death in the United
StatesCancer is not one disease, but a group of
diseases characterized by the uncontrolled growth and spread of abnormal cells
Lung cancer is the leading cause of cancer-related death in both men and women
More children 14 years of age and younger die of cancer than of any other disease
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Development, Prevention, and Detection of Cancer
Carcinogenesis and the primary prevention of cancer
CarcinogenesisThe process by which normal cells are transformed into cancer cells
Various factors are possible origins of cancer
CarcinogensSubstances known to increase the risk for the development of cancer
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PathophysiologyMitosis (maturation and replacement)Hypertrophy (cells get larger)Hyperplasia (# of cells increase)Neoplasia
Mitosis
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Cell Mitosis
X
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Hypertrophy
X
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Hyperplasia
X
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Neoplasia
X
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Development, Prevention, and Detection of Cancer
Carcinogenesis and the prevention of cancer (continued)
Risk factorsSmoking
87% of people who develop lung cancer are smokers
Dietary habitsPlay a role in development of colon,
rectum, and breast cancerExposure to radiation
Ultraviolet rays are a factor in the development of basal and squamous cell skin cancers and melanoma
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Development, Prevention, and Detection of Cancer
Carcinogenesis and the prevention of cancer (continued)Risk factors (continued)
Exposure to environmental carcinogensFumes from rubber or dust from chloride are
examplesSmokeless tobacco
Increases the risk of cancer of the mouth, larynx, pharynx, and esophagus
Frequent, heavy consumption of alcoholMay result in oral cancer and cancer of the
larynx, throat, esophagus, and liver
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Hereditary CancersAbout 90% of cancers are NOT inheritedGenetic susceptibility
Incidence of breast cancer is higher in women with a family history of this disease
Incidence of lung cancer is high in smokers with a family history of this disease
Incidence of leukemia is greater in an identical twin
Neuroblastoma occurs with increased frequency among siblings
Colon cancer is more likely to occur in women who have a history of breast cancer
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Hereditary CancersCancer risk assessment and cancer genetic counselingFirst step toward identifying hereditary cancer predisposition
Provides education, health promotion, informed consent, and support
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Cancer Prevention and Early DetectionPlanned periodic examination and
recognition of cancer’s warning signsColorectal testsProstate cancer detectionPelvic examination with Papanicolaou (Pap)
smear for womenBreast cancer detection (self-examinations)Skin examinations
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Pathophysiology of CancerCell mechanisms and growth
Normal cellsWhen cells are destroyed, cells of the
same type reproduce until the correct number have been replenished
Cancer cellsInstead of limiting their growth to meet
specific needs, they continue to reproduce in a disorderly and unrestricted manner
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Pathophysiology of CancerCell mechanisms and growth (continued)
NeoplasmUncontrolled or abnormal growth of cellsBenign: Not recurrent or progressive;
nonmalignantMalignant: Growing worse and resisting
treatment; cancerous growths; tumorsMetastasis
Tumor cells spread to distant parts of the body
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FIGURE S48 Control of replication. Normal cells cannot divide indefinitely. The end of their chromosomes are controlled by telomeres. Telomeres get shorter with each division until the cells stop dividing. In cancer cells the telomerase gene is "switched on," producing an enzyme that rebuilds the telomeres. Thus the cancer cells continue to divide indefinitely.
Images borrowed from McCance, K.L., Huether, S.E. (2002). Pathophysiology: the biologic basis for disease in adults & children (4th ed.).
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Progression to Neoplasm
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Pathophysiology of CancerDescription, grading, and staging of tumors
DescriptionCarcinoma : Malignant tumors composed of epithelial
cells; tend to metastasizeSarcoma: Malignant tumor of connective tissues, such
as bone or muscleGrading
Tumors are classified as grade 1 to grade 4 Grade 1: Mild dysplasia—cells only slightly
different from normal cellsGrade 2: Moderate dysplasia—moderately well
differentiated Grade 3: Severe dysplasia—poorly
differentiatedGrade 4: Anaplasia—cells difficult to determine
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FIGURE S12 Composition of the blood.
Images borrowed from Applegate, E. (2000). The anatomy and physiology learning system (2nd ed.).
Slide 25Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Pathophysiology of CancerDescription, grading, and staging of tumors
(cont.)Staging
Tumor, nodes, metastasis (TNM) staging system for cancer is used to indicate tumor size, spread to lymph nodes, and extent of metastasisStage 0: Cancer in situStage I: Tumor limited to the tissue of origin
Stage II: Limited local spreadStage III: Extensive local and regional spread
Stage IV: Metastasis
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Pathophysiology of CancerDescription, grading, and staging of tumors
DescriptionCarcinoma: malignant tumors composed of epithelial cells; tend to metastasize
Sarcoma: malignant tumor of connective tissues, such as bone or muscle
GradingTumors are classified as grade 1 to grade 4Grade 1—least malignantGrade 4—most malignant
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Pathophysiology of Cancer
Cell mechanisms and growth (continued)Neoplasm
Uncontrolled or abnormal growth of cells
Benign: not recurrent or progressive; nonmalignant
Malignant: growing worse and resisting treatment; cancerous growths; tumors
MetastasisTumor cells spread to distant parts of the body
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Characteristics of Cancer CellsRapid or Continuous Cell DivisionDo Not Respond to Signals for ApoptosisShow Anaplastic MorphologyHave a Large Nuclear-Cytoplasmic RatioLose Some or All Differentiated FunctionsAdhere Loosely TogetherAre Able to MigrateGrow By InvasionAre Not Contact InhibitedAre Aneuploid
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ClassificationBy Tissue Origin
Sarcoma (connective tissue)Carcinoma (glandular tissue)Blastoma (less differentiated, embryonal tissue)
Lymphoma (lymph tissue)Leukemia (WBC’s)
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Sarcoma
X
• Blood Vessels
• Lymph Vesseles
• Skin and Fat
• Nerves• Muscles,
tendons, ligaments
• Bone and Cartilage
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Carcinoma
X
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Blastoma
X
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Metastasis (Secondary Tumor)
Extension Into Surrounding TissueBlood Vessel PenetrationRelease of Tumor Cells Invasion
Local SeedingBloodborne MetastasisLymphatic Spread
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GRADING OF TUMORSDifferentiation:
individual characteristics of normal body cells that allow them to perform different body functions
Grading evaluates tumor cells in comparison to normal cells
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Grading and StagingIndicates how far the cancer has spread anatomically
Puts patients with similar prognosis and treatment in the same group
Staging applies to all cancers except leukemia (not anatomically localized)
X
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Carcinogenesis (Oncogenesis)Initiation (damage to DNA:proto-oncogenes
turned on)Latency Period (Months to Years)Promotion (hormones, drugs, chemicals)Progression (TAF triggers blood supply,
cells change features)Metastasis
X
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Characteristics of Benign Tumor Cells
Continuous or Inappropriate Cell Growth
Show Specific MorphologyHave a Small Nuclear-Cytoplasmic RatioPerform Specific Differentiated FunctionsAdhere Tightly TogetherAre NonmigratoryGrow in an Orderly MannerAre Euploid
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GRADING OF TUMORS (cont.)
The higher the grade, the higher the number and the worse the prognosis.
A grade I tumor is the most differentiated and a grade IV tumor is the most undifferentiated
Tumors containing poorly differentiated cells are more aggressive in growth and may display uncharacteristic behaviors, leading to a poorer prognosis.
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GRADING OF TUMORS
Well differentiated–tumor cells that retain many identifiable tissue characteristics of original cell.
Undifferentiated–tumor cells having little similarity to tissue of origin.
Tumor grading (I-IV) is based on degree of differentiation of malignant cells.
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Grading
• well differentiated (Grade 1)
• moderately differentiated (Grade 2)
• Poorly differentiated (Grade 3)
• Undifferentiated (Grade 4)
X
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Differentiationof cells related to grading
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Staging Prostate CancerT1 The tumor is too small to be seen on
scans or felt during examination of the prostate. (It has been discovered by needle biopsy.)
T2 The tumor is completely inside the prostate gland
T3 The tumour has broken through the capsule (covering) of the prostate
T4 The tumour has spread into other body organs (secondary prostate cancer) nearby such as the rectum (back passage) or bladder
X
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PRIMARY TUMOR STAGING: TBladder CancerT0: No tumor present Tis: Carcinoma in situ, "flat tumor" Ta: Papillary tumor, with only bladder
mucosa involved, non-invasive T1: Invasion into subepithelial connective
tissue (lamina propria) T2a: Invasion into bladder superficial muscle T2b: Invasion into bladder deep muscle T3: Invasion into fat surrounding bladder T4a: Regional spread into prostate, vagina,
uterus T4b: Tumor fixed to pelvic or abdominal wall TX: Unable to assess primary tumor
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X
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LYMPH NODE STAGING: N N0: No lymph node involvement found N1: Single unilateral regional node involvement
N2: Contralateral or bilateral lymph nodes involved
N3: Fixed mass of regional lymph nodes
N4: Juxtaregional lymph node involvement
NX: Regional lymph nodes cannot be assessed
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FIGURE 7-5 Nodal involvement by stage in Hodgkin's disease (based on modified Ann Arbor Staging System).
(From Belcher, A.E. [1992]. Blood disorders, Mosby’s clinical nursing series. St. Louis: Mosby.)
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DISTANT METASTATIC SPREAD STAGING: M
M0: No distant metastasis identified M1: Distant metastasis found MX: Distant metastases cannot be
assessed
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TUMOR STAGINGStages I-IVStage I: small localized tumor
Stage IV: usually inoperable, metastatic
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TUMOR STAGINGTNM staging (1-4)T : the extent of primary tumor
N : the amount of regional lymph nodes that are involved
M : the degree of metastasis
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BreastCancer
X
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BreastCancer
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BreastCancer
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Breast Cancer
Stage 4Advanced or
(metastatic) disease: Metastases present at different sites, such as bone, liver, lungs, and brain and including supraclavicular lymph node involvelement
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FIGURE S50 Tumor staging by the TNM system.
Images borrowed from McCance, K.L., Huether, S.E. (2002). Pathophysiology: the biologic basis for disease in adults & children (4th ed.).
Slide 60Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
CANCER IS PREVENTABLE80 – 90% CANCER ARE DUE TO OUR
HABITS AND ACTIVITIESCANCER INVOLVES ALMOST EVERY PART
OF THE BODYCANCER CELLS MULTIPLY IN AN
UNCONTROLLABLE & HAPAZARD MANNER
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EARLY DETECTION OF CANCER
CANCER DEVELOPS IN THE BODY VERY SILENTLY
UNTIL IT COMES TO CERTAIN STAGE PATIENTS LEAD A NORMAL LIFE WITHOUT ANY COMPLAINTS
INITIALLY IT PRODUCES MILD SMPTOMS AS FOUND IN OTHER AILMENTS
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HOW TO DETECT DISEASE EARLYSEVEN DANGER SIGNALS CHANGE IN BLADDER & BOWEL HABITS SORE THROAT NOT HEALING UNUSUAL BLEEDING OR DISCHARGE THICKENING OR LUMP IN BREAST OR
ANYWHERE INDIGESTION AND DIFFICULTY IN
SWALLOWING OBVIOUS CHANGE IN WAT OR MOLE NAGGING COGH OR HOARSENESS OF
VOICE
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LARYNGEAL CANCER – WARNING SIGNS
PERSISTENT HOARSENESS SORENESS IN RHE NECK FELLING OF HAVING A LUMP IN THE THROAT DIFFICULTY IN SWALLOEING
RISK FACTORS – TOBACCO CONSUMPTION AND ALCOHOL INTAKE
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ORAL CANCER – WARNING SIGNS
PERSISTENT WHITE OR RED PATCHES, USUALLY PAINLESS
ANY PERSISTENT LUMP OR SWELLING
RISK FACTORS – TOBACCO CONSUMPTION AND ALCOHOL INTAKE
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LUNG CANCER – WARNING SIGNS CHRONIC COUGH COUGHING OUT OF BLOOD CHANGE IN THE VOICE CHEST PAIN SHORTNESS OF BREATHRISK FACTORS – SMOKING, EXPOSURE TO :
ASBESTOS, COAL TAR DERIVATIVES AND
RADIATION
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BREAST CANCER – WARNING SIGNS
FIRM LUMP SMALL CHANGES IN THE NIPPLE DISCHARGE FROM THE NIPPLERISK FACTORS – EARLY MENSTRUATION
LATE MENOPAUSE FIRST CHILD AFTER 35 YRS OF
AGE CHILDLESSNESS FAMILY HISTORY - BREAST
CANCER HIGH FAT & LOW FIBRE DIET
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COLORECTAL CANCER – WARNING SIGNS
BLOOD IN STOOLFEELING OF BEING
BLOATEDCHANGE IN BOWEL HABITSCONSTIPATION
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Diagnosis of CancerBiopsy
Incisional, excisional, needle aspirationEndoscopyDiagnostic imaging
Bone scanningTomographyComputed tomography (CT)Radioisotope studiesUltrasound testingMagnetic resonance imaging
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Figure 17-3
Types of biopsy. (From Belcher, A. E. [1992]. Cancer nursing.
St. Louis: Mosby.)
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Diagnosis of CancerLaboratory tests
Serum alkaline phosphataseSerum calcitonin Carcinoembryonic antigen (CEA)PSA and CA-125Stool examination for blood
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Cancer TherapiesSurgery
PreventiveDiagnosticCurativePalliative
Radiation therapyExternal radiation therapyInternal radiation therapy
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Cancer TherapiesChemotherapy
Side effectsLeukopeniaAnemiaThrombocytopeniaAlopeciaStomatitisNausea, vomiting, and diarrheaTumor lysis syndrome
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Cancer TherapiesBiotherapy
Three major mechanisms of biological response modifiers (BRMs)1. Increases, restores, or modifies the host defenses
against the tumor2. Toxic to tumors3. Modifies the tumor biology
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Cancer TherapiesBone marrow transplantation
Process of replacing diseased or damaged bone marrow with normally functioning bone marrow
Peripheral stem cell transplantationAlternative to bone marrow transplantThis procedure is based on the fact that
peripheral or circulating stem cells are capable of repopulating the bone marrow
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Advanced CancerPain management
OpioidsMorphine, hydromorphone, fentanyl, methadoneSustained-release morphine
MS Contin, Roxanol SRAdministration
IV drips, intrathecally, and epidurallyAvoid peaks and valleys
Patient self-controlDistraction, massage, relaxation, biofeedback,
hypnosis, and imagery
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Advanced CancerPain management (continued)
Patients should not be subjected to severe suffering from potentially controllable pain
Fear of addiction should not be a factor when considering pain relief for the terminally ill
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Advanced CancerNutritional therapy
ProblemsMalnutritionAnorexia Altered taste sensationNausea/vomitingDiarrheaStomatitisMucositis
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Advanced CancerCommunication and psychological support
Factors that may determine how the patient copes Ability to cope with stressful events in the pastAvailability of significant othersAbility to express feelings and concernsAge at the time of diagnosisExtent of diseaseDisruption of body imagePresence of symptomsPast experience with cancerAttitude associated with cancer
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Advanced CancerTerminal prognosis
Most patients with advanced cancer know they are dying
Honesty and openness are the best approaches
Spiritual activities may provide mental and emotional strength
Social worker assists the patient and family in planning for home care
Hospice services can be arranged—efforts are directed toward relief from pain and other problems
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Nursing ProcessNursing diagnoses
Coping, compromised family
Activity intolerance, related to malaise
Risk for infection, related to inflammation of protective mucous membranes
Pain, acute; Pain, chronic
Self-care deficit
Knowledge, deficient Nutrition: less than body
requirements; imbalanced, related to anorexia
Infection, risk for Fluid volume, deficient
risk for Fluid volume, excess