amer a. hasanien, rn, cns,...

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Amer A. Hasanien, RN, CNS, PhD

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsAmer A. Hasanien, RN, CNS, PhD

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True/False

1. Estimate is that almost 75% of all cancers in the United States is

related to environmental and lifestyle factors.

2. Patients receiving internal radiation emit radiation while the

implant is in place.

3. Eradication of 100% of a malignant tumor cell is almost

impossible.

4. Pain and fatigue are the two most common side effects of

chemotherapy.

5. Prophylactic cancer vaccines have been proven to prevent

prostrate, breast, and lung cancers.


Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Tumor Staging and Grading

• Staging determines the size of the tumor, the existence of local invasion, lymph node involvement, and distant metastasis.

• The tumor, nodes, and metastasis (TNM) system (Chart 15-3) is one system used to describe many solid tumors


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• Grading is the pathologic classification of tumor cells.

• Grading systems seek to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and histologic characteristics of the tissue of origin (differentiation).

• Samples of cells used to establish the tumor grade may be obtained from tissue scrapings, body fluids, secretions, washings, biopsy, or surgical excision.


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• The grade rang from I to IV.

– Grade I, well-differentiated tumors, closely resemble the tissue of origin in structure and function.

– Grade IV, poorly differentiated or undifferentiated, do not clearly resemble the tissue of origin in structure or function.



Nursing Care of Patients With Cancer

• VIP


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Maintaining Tissue Integrity: Stomatitis

• Stomatitis, a form of mucositis, is an inflammatory process of the mouth including the mucosa and tissues surrounding the teeth.

• Characterized by changes in sensation, mild redness (erythema), and edema or, if severe, by painful ulcerations, bleeding, and secondary infection.

• Commonly develops 5 to 14 days after initiating cancer treatment (chemo or radio therapy)

• Severe oral pain can significantly affect swallowing, nutritional intake, speech, quality of life, coping abilities, and willingness to adhere to treatment regimens.



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• Nursing care:

– Assess patient for dehydration, infection, pain, and nutritional impairment

– Assist the patient in minimizing the risk of oral complications associated with cancer therapies (good oral hygiene, including brushing, flossing, rinsing, and dental care)

– Palifermin (Kepivance) IV medication, is beneficial in the prevention of oral mucositis. (Palifermin promotes epithelial cell repair and accelerated replacement of cells in the mouth and gastrointestinal tract)



Maintaining Tissue Integrity: Radiation-Associated Skin Impairment

• Patients may develop radiation dermatitis that may be associated with pain, irritation, pruritus, burning, and diminished quality of life.

• Nursing care:

– maintenance of skin integrity, cleansing, promotion of comfort, pain reduction, prevention of additional trauma, prevention and management of infection, and promotion of a moist wound-healing environment


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Radiation Dermatitis


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Maintaining Tissue Integrity: Erythematous Areas

• Avoid use of soaps, cosmetics, perfumes, powders, lotions and ointments, deodorants

• Use only lukewarm water to bathe area

• Avoid rubbing or scratching area

• Avoid shaving area with straight-edged razor

• Avoid applying hot-water bottles, heating pads, ice, adhesive tape to area

• Avoid exposing area to sunlight or cold weather

• Avoid tight clothing in area; use cotton clothing

• Apply vitamin A and D ointment to area



Maintaining Tissue Integrity: Wet Desquamation (تقشير البثرات)

• Do not disrupt any blisters that have formed

• Avoid frequent washing of area

• Report any blistering

• Use prescribed creams or ointments

• If area weeps, apply nonadhesive absorbent dressing

• If area is without drainage, use moisture-, vapor-permeable dressings such as hydrocolloids, hydro gels on noninfected areas

• Consult with enterostomal therapist (ET), physician if eschar forms Amer A. Hasanien, RN, CNS, PhD

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Desquamation

(تقشُّر)



Alopecia

• Temporary or might be permanent (brain radiation)

• A complication of brain radiation therapy and various chemotherapeutic agents

• Usually begins 2 to 3 weeks after the initiation of treatment; regrowth most often begins within 8 weeks after the last treatment


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Alopecia

• Discuss potential hair loss, regrowth with patient, family

• Explore potential impact of hair loss on self-image, interpersonal relationships, sexuality

• Prevent or minimize hair loss

• Prevent trauma to scalp

• Suggest ways to assist in coping with hair loss:

– Encourage patient to wear own clothes, retain social contacts

– Explain that hair growth usually begins again once therapy is completed

• Refer to nursing care plan VIP Amer A. Hasanien, RN, CNS, PhD


Altered Nutrition: Nausea and Vomiting

• Assess patient’s previous experiences, expectations of nausea and vomiting, including causes, interventions used

• Adjust diet before, after drug administration according to patient preference, tolerance

• Prevent unpleasant sights, odors, sounds in environment

• Use distraction, music therapy (X), biofeedback, self-hypnosis, relaxation techniques, guided imagery before, during, after chemotherapy


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Altered Nutrition: Nausea and Vomiting (cont’d)

• Administer prescribed antiemetic, sedatives, corticosteroids before chemotherapy, afterward as needed

• Ensure adequate fluid hydration before, during, after drug administration; assess intake, output

• Encourage frequent oral hygiene

• Provide pain relief measures if necessary

• Consult with dietician as needed

• Assess, address other contributing factors to nausea, vomiting



Nutritional Problems

• Anorexia

• Malabsoprtion

• Cachexia (malnutrition)


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Anorexia

• causes of anorexia are alterations in taste (manifested by

increased salty, sour, and metallic taste sensations), and altered responses to sweet and bitter flavors.

• Patients undergoing radiation therapy to the head and neck may experience “mouth blindness,” which is a severe impairment of taste.


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Malabsorption

• Malignancy can affect GI activity in several ways

– impaired enzyme production,

– interference with both protein and fat digestion

– Chemotherapy and radiation cause damage to mucosal cells of the bowel (mucositis), resulting in impaired nutrient absorption.



Cancer-Related Anorexia-Cachexia Syndrome

• A complex biologic process that results from a combination of increased energy expenditure and decreased intake


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Nutritional Problems: Expected Outcomes

• Exhibits weight loss no greater than 10% of pretreatment weight

• Reports decreasing anorexia, increased interest in eating

• Demonstrates normal skin turgor

• Identifies rationale for dietary modifications

– Patient, family verbalize strategies to address, minimize nutritional deficits

• Participates in calorie counts, diet histories



Nutritional Problems: Expected Outcomes (cont’d)

• Uses appropriate relaxation, imagery before meals

• Exhibits laboratory, clinical findings indicative of adequate nutritional intake

• Consumes diet high in required nutrients

• Carries out oral hygiene before meals

• Reports that pain does not interfere with meals


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Nutritional Problems: Expected Outcomes (cont’d)

• Reports decreasing episodes of nausea, vomiting

• Participates in increasing levels of activity

• States rationale for use of tube feedings or parenteral nutrition

• Participates in management of tube feedings or parenteral nutrition if prescribed



Relieving Pain

• Moderate to severe pain is reported by approximately 30% to 70% of patients with cancer during treatment.

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• Nursing interventions may include:

– Assess other factors contributing to patient’s pain: fear, fatigue, other symptoms, psychosocial distress, etc.

– Provide education to patient and family

– Address myths or misconceptions about the use of opioid analgesics.

– Offer nonpharmacologic strategies to relieve pain



Altered Body Image

• Assess patient’s feelings about body image, level of self-esteem

• Identify potential threats to patient’s self-esteem

– Validate concerns with patient

• Encourage continued participation in activities, decision making

• Encourage patient to verbalize concerns

• Individualize care for patient

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Altered Body Image (cont’d)

• Assist patient in self-care when fatigue, lethargy, nausea, vomiting, other symptoms prevent independence

• Assist patient in selecting and using cosmetics, scarves, hair pieces, clothing that increase his or her sense of attractiveness

• Encourage patient, partner to share concerns about altered sexuality and sexual function, to explore alternatives to usual sexual expression

• Refer to collaborating specialists as needed


Assisting in the Grieving Process

• Grieving is a normal response to actual or potential losses:

– loss of health, normal sensations, body image, social interaction, intimacy, independence, and usual social roles.

• The nurse empowers the patient and family to explore preferences for issues related to end-of-life care,

– such as withdrawal of active disease treatment, desire for the use of life-support measures, and symptom management approaches.

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Hospice

• Comprehensive, multidisciplinary approach to care of patients with terminal illness, their families

• Focuses on

– Quality of life

– Palliation of symptoms

– Psychosocial, spiritual care


Question

Which measure should the RN not teach a client about protecting the skin between radiation treatments?

A. Handle the area gently.

B. Avoid irritation with soap and water.

C. Use a heating pad every day on the area.

D. Wear loose fitting clothes.

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Answer

C. Use a heating pad every day on the area.

Rationale: Measures to protect a client’s skin between radiation treatments include handling the area gently, avoiding irritation with soap and water, and wearing

loose-fitting clothing. The client should not use a heating pad every day on the area because it will not promote

tissue repair.


Monitoring and Managing Potential Complications

• Infection

• Septic shock

• Bleeding, hemorrhage

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Factors Contributing to Infection

• Impaired skin, mucous membrane integrity

• Chemotherapy

• Radiation therapy

• Malignancy

• Malnutrition

• Medications

• Urinary catheter

• Intravenous catheter


Factors Contributing to Infection (cont’d)

• Other invasive procedures

• Contaminated equipment

• Age

• Chronic illness

• Prior infections

• Recent travel

• Pet excreta

• Prolonged hospitalization

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• The typical signs of infection (swelling, redness, drainage, and pain) may not occur in myelosuppressed patients because of decreased circulating WBCs and a diminished local inflammatory response. Fever may be the only sign of infection


Septic Shock

• Septicemia, septic shock life-threatening complications that must be prevented or detected, treated promptly

• Patients who are neutropenic and/or who have hematologic malignancies are at greatest risk

• Signs, symptoms include altered mental status, either subnormal or elevated temperature, cool and clammy skin, decreased urine output, hypotension, tachycardia, other dysrhythmias, electrolyte imbalances, tachypnea, abnormal arterial blood gas values

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Bleeding and Hemorrhage

• Thrombocytopenia (decrease in circulating platelet count): most common cause of bleeding in patients with cancer, usually defined as platelet count of less than 100,000/mm3 (0.1 × 1012/L)

• A platelet count lower than 20,000/mm3 (0.02 × 1012/L) is associated with an increased risk for spontaneous bleeding.

• Plan of nursing care addresses nursing assessment parameters, interventions for patients at risk for bleeding


Question

Is the following statement true or false?

The most common cause of bleeding in cancer patients is thrombocytopenia.

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Answer

True

Rationale: The most common cause of bleeding in cancer patients is thrombocytopenia.


Nursing Care of the Patient Undergoing Radiation Therapy

• Patient, family education

• Restrictions, precautions

• Skin care

• Oral care

• Protection of care providers

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Nursing Care of the Patient Undergoing Radiation Therapy

• Types of radiation therapy:

– External Radiation (EBRD, external-beam radiation therapy). Highly charged electrons from an external source (machine) penetrate the body and target the tumor with pinpoint accuracy.

– Internal radiation implantation (called, brachytherapy). Temporary applications may be delivered as high-dose radiation (HDR) for short periods of time or low-dose radiation (LDR) for a more extended period of time.

Brachy, short distance.


• The patient is maintained on bed rest in a specially prepared private room typically for 72 hours and log-rolled to prevent displacement of any intracavitary delivery device.

• Low-residue diets and antidiarrheal agents are provided to prevent bowel movements during therapy (which could

displace the radio-isotopes).

• Visitors and personnel must limit their time and proximity to the patient due to the risk of radiation exposure.

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• If systemic symptoms, such as weakness and fatigue, occur, the nurse explains that these symptoms are a result of the treatment and do not represent deterioration or progression of the disease.

• The nurse needs to protect him/her self from radiation

– contact with the patient is guided by principles of time, distance, and shielding to minimize exposure to radiation.

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• Safety precautions used in caring for a patient receiving radiotherapy include

– Assigning the patient to a private room,

– Posting appropriate notices about radiation safety precautions,

– Having staff members wear dosimeter badges,

– Making sure that pregnant staff members are not assigned to the patient’s care,

– Prohibiting visits by children or pregnant visitors,

– Limiting visits from others to 30 minutes daily, and seeing that visitors maintain a 6-foot distance (≈ 2 m) from the radiation source.

Dosimeter badges


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Chemotherapy

• Agents used to destroy tumor cells by interfering with cellular function, replication

• Chemotherapy is used primarily to treat systemic disease rather than localized lesions that are amenable to surgery or radiation.


Chemotherapy Toxicity

• Gastrointestinal

• Hematopoietic

• Renal

• Cardiopulmonary

• Reproductive

• Neurologic

• Cognitive

• Fatigue

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Nursing Management in Chemotherapy

• Assessing fluid, electrolyte status (resulting from anorexia, nausea, vomiting, altered taste, mucositis, and diarrhea)

• Assessing cognitive status (cognitive impairment might occur) (management: exercise, natural restorative environmental intervention (walking in nature or gardening), and cognitive training programs)

• Modifying risks for infection, bleeding (resulting from suppression of the bone marrow and immune system)

• Administering chemotherapy (next section)

• Prevent nausea and vomiting (antiemetic)

• Protecting caregivers


• Administering chemotherapy:

– Nurses must be aware of agents associated with hyper sensitivity reactions.

– Avoid extravasation. Agents require less than 1 h for administration→ use peripheral line. Agents that require more than 1 h for administration → use a central line (e.g., right atrial catheter, implanted venous access device).

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Extravasation


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• Indications of extravasation include the following:

– Absence of blood return from the IV catheter

– Resistance to flow of IV fluid

– Burning or pain, swelling, or redness at the site

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Protecting Caregivers

• Nurses may be exposed to low doses of the chemotherapeutic agents by direct contact, inhalation, or ingestion.

• This might results in

– skin and eye irritation, nausea, vomiting, nasal mucosal ulcerations, infertility, low-birth-weight babies, congenital anomalies, spontaneous abortions, and mutagenic substances in urine. (all have been reported in nurses).

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Biological safety cabinets (BSC)


Closed system transfer device


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Needleless administration systems


Surgical N95 respirator


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True/False

1. Estimate is that almost 75% of all cancers in the United States is

related to environmental and lifestyle factors.

2. Patients receiving internal radiation emit radiation while the

implant is in place.

3. Eradication of 100% of a malignant tumor cell is almost

impossible.

4. Pain and fatigue are the two most common side effects of

chemotherapy.

5. Prophylactic cancer vaccines have been proven to prevent

prostrate, breast, and lung cancers.

35


Question

A patient with pancreatic cancer underwent surgery for removal of a malignant tumor in his pancreas. Despite the tumor being removed, the physician informs the patient that he needs to start chemotherapy. Which of the following may be a reason for the physician to opt for chemotherapy?

a) Stomatitis

b) Metastasis

c) Angiogenesis

d) fatigue



Answer

b. Metastasis

Chemotherapy treats systemic and metastatic cancer. It can also be used to reduce tumor size preoperatively, or

to destroy any remaining tumor cells postoperatively. Angiogenesis is the growth of new capillaries from the

tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Fatigue

and stomatitis are side effects of radiation and chemotherapy.


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Question

A patient is undergoing chemotherapy treatment for prostate cancer and has lost considerable weight due to nausea and vomiting. Which of the following nursing interventions is appropriate for the patient?

a) Decreasing dietary fluids 2 days prior to chemotherapy

b) Administering beta blockers as ordered by the physician

c) Increasing fresh fruits in the patient’s diet

d) Adjusting meal plan before and after chemotherapy



Answer

d. Adjusting meal plan before and after chemotherapy

The nurse readjust the patient’s meal plan before and after chemotherapy administration. The nurse should take into consideration the patient’s likes and dislikes and avoid

foods with strong odors. The nurse should ensure adequate fluid hydration before, during, and after drug

administration when the patient has side effects of nausea and vomiting. Administration of fresh fruits is not

recommended when the patient is at risk of infection, such as during chemotherapy. Beta blockers are not

administered for control of nausea and vomiting.


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Question

The nurse is completing an admission assessment on a patient receiving interstitial implants for his prostate cancer. The nurse documents this as being which of the following?

a) Contact molds

b) Systemic radiation

c) External beam radiation therapy

d) Brachytherapy



Answer

d. Brachytherapy

Brachytherapy is the only term used to denote use of internal radiation implants.


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بحمد هللا

انتهى الفصل

لكم مني كل التقدير واالحترام

ودعائي لكم بالتوفيق

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تقييم مدرس المادة


Thank YouAmer A. Hasanien, RN, CNS, PhD

amer a. hasanien, rn, cns,...

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