chapter 17 pvn 143 care of the patient with cancer rebecca maier, bsn mosby items and derived items...

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.).

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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.).

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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