Nursing Care & Interventions in Managing Those with Cancer Keith Rischer RN, MA, CEN In the West-50% of people dx w/CA are cured and many live 5 years or longer after dx Profound impact on physical-psychological health

Today’s Objectives… Identify the goals of cancer therapy. Distinguish between cancer surgery for cure and cancer surgery for palliative care. Discuss the nursing care needs for clients undergoing therapy for cancer. Discuss radiation therapy. Identify nursing interventions for patients undergoing chemotherapy. Discuss care of patients with neutropenia Discuss care of patients with thrombocytopenia Explain the rationale for hormonal manipulation therapy. Explain the basis of targeted therapy for cancer.

Consequences of Cancer 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 CANCER CAN DEVELOP IN ANY ORGAN DESTROYS NORMAL TISSUE AND DECREASING FUNCTION IN THAT TISSUE OR ORGAN Monitor albumin… May be necessary to use enteral or parental feedings

Consequences of Cancer Motor and sensory deficits Bone metastases Spinal cord compression Pain Decreased respiratory function Airway obstruction Tumor compression Pleural effusions Motor and sensory deficits When cancers invade bone or brain and compress nerves. Bone sites most often vertebrae, ribs, pelvis, and femur Bone metastases cause fractures If spinal cord damaged When cancer spreads to brain – sensory, motor ,and congnitive 4

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 Cure 30% when used alone Palliation improve quality of life-improve quality of life during survival time Side effects of surgical therapy Loss of organ…body image

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 Therapy to Treat Cancer Purpose: to destroy cancer cells with minimal exposure of the normal cells to the damaging actions of radiation-CELLS UNABLE TO DIVIDE If the dose of radiation is high enoufg-all cells are killed immediately…different cells absorb radiation differently Can be primary treatment…w/chemo or with chemo and surgery and palliative Reduces pain seen in bone mets Treat CA emergencies such as SVC syndrome or spinal cord compression Mechanism of action Ionizing radiation…atoms within cell are kicked out of orbit resulting in release of intracellular energy Dose…dose is always less than the exposure Dependant on intensity of exposure, duration and proximity of radiation to the cells Killing effects of radiation Given in a series of divided doses…to allow greater destruction of cancer cells while reducing damage to normal cells fractionation Some organs can tolerate more radiation…therefore total dose depends on size and location of tumor Example…1200 total rads for liver tumor…breast tumor may be 6000 rads OVER 30 DAYS which would destroy the liver

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 Teletherapy – Distant treatment, so markings on pt. Outside the body Brachytherapy – radioactive isotopes either in solid form or within body fluids. Radiation source within the body. Radioactive Iodine for thyroid cancer Unsealed or sealed sources

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.

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 Vary according to the site and tissues exposed Local skin changes and hair loss that will likely be permanent depending on the total absorbed dose Altered taste sensations Fatigue related to increased energy demands Inflammatory responses that cause tissue fibrosis and scarring 9

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 NORMAL TISSUES MOST SENSITIVE TO EXTERNAL RADIATION ARE BONE MARROW CELLS, SKIN, MM, HAIR FOLLICLES AND REPRODUCTIVE TISSUES

Chemotherapy Mechanism Rapidly dividing cells more sensitive to chemo Cytotoxic Some selectivity Damages cell DNA cell division Rapidly dividing cells more sensitive to chemo Skin, hair Intestinal tissues Spermatocytes Blood-forming cells Treating cancer with chemical agents…SYSTEMIC VS. LOCAL Major role in cancer therapy TO CURE AND INCREASE SURVIVAL TIME PRIMARY TREATMENT FOR MOST BLOOD AND SOME SOLID TUMORS Used primarily for systemic disease rather than localized Essential w/metastasis…no other alternative 50 different chemo drugs-used alone or in combo..MORE EFFECTIVE IF USED IN COMBO 11

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 Antimitotic agents Interfere with mitosis-prevent division Classified as either cell cycle specific or not Antimitotic agents from plant sources. MAXIMUM AMOUNT OF DRUG DOSES USED TO CAUSE MAX CELL KILLING OR CAUSE SECOND MALIGNANCIES SUCH AS LEUKEMIA Chemo can cause death at times inadvertantly Chemo impacts both cancer cells and rapidly proliferating cells such as those of the bone marrow SE seen immediately to a few days…to weeks to months later MOST SUPPRESS BONE MARROW LEADING TO PANCYTOPENIA AND NEUTROPENIA ANOREXIA n&v THOUGHT TO BE DUE TO CHEMORECEPTOR TRIGGER ZONE IN THE MEDULLA THAT STIMULATES VOMITING FATIGUE-MOST PREVALENT PROBLEM 96% SPECIAL HANDLING AND DISPOSAL OF MOST CHEMO DRUGS

5-Fluorouracil (5-FU) Anti-metabolite IV SE Nursing responsibilities Decr. WBC & platelets Stomatitis Anorexia Darkening of skin…sun sensitivity Nursing responsibilities Use sunscreen when outside Menstrual changes…decreased sperm counts Used to tx colon CA

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

Vincristine (Oncovin) Anti-mitotic IV SE Constipation/abd. Cramping Stomatitis Alopecia 2-3 weeks after tx Nursing considerations Increase fiber

Chemotherapy Treatment Issues 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 Extravasation YouTube - P9290001 Getting her port accessed www.freehelpforcancer.com Extravasation – if large amount, extensive tissue damage may occur. Immediate treatment depends on drug – some cold compresses, some warm. Antidotes may be injected into the site. Photograph the site. Follow protocol for hospital 16

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 Fatigue – 70% to 100% of patients. Not that therapy is not working. ?Patho – accumulation of wastes, anemia Alopecia or hair loss – drugs vary. Hair comes back about 1 month after completion. Assist with head coverings. “Look Good, Feel Good” from American Cancer Center Nausea and vomiting – some are emetogenic (vomiting inducing). Anticipatory nausea Antiemetics (Zofran, Aloxi) Mucositis in the entire gastrointestinal tract esp mouth (stomatitis). Mouth care chart 28-6 Skin changes Anxiety, sleep disturbance Bone marrow supression Reduces circulating number of leukocytes, erythrocytes, and platelets Decreased neutrophils (neutropenia) cause immunosuppresion which places client at extreme risk for infection. Drug therapy Protection from infection

Neutropenia Highest risk Treatment Red Flag Medical management 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

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 Severe >500 normal 4000-11000 WHAT CAUSES FEVER??? Phagocytic response of WBC granuliocytes especially neutrophils When this inflammatory response is lessened- physiologic response is diminished and much more subtle Normal bacterial flora of pt can now contribute to life threatening infection

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 REFLECTS TRUE IMMUNOLOGIC STATUS AND RISK OF INFECTION…IS MORE ACCURATE THAN WBC AND NEUTROPHILS ALONE

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 Most cases are acquired by dz processes such as spleenmegaly, bone marrow suppression (chemo or infectious) or HEPARIN Immune Thrombocytopenic Purpura (ITP): Abnormal destruction of circulating platelets by the spleen - caused by an autoimmune reaction –platelets coated with antibodies—spleen sees as foreign and destroyed— Normal life of platelets 8-10 days---ITP 1-3 days Heparin induced thrombocytopenia -platelets decrease due to immune response to Heparin… Tx-stop heparin and use alternative anticoagulants such as argatroban or lepirudin Any pt on Heparin IV or subq routinely monitored for platelet decreases-watch closely! Bone marrow suppression-chemo most common Very important #’s: 50,000 or less- risk of bleeding <20,000 spontaneous life threatening hemorrhages (brain bleed) <10,000 transfusions recommended

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

Hormone Therapy Patho Types of CA Treatment Breast, prostate, endometrium Treatment Surgical (remove the hormone producing organ) Pharmocologic suppression Steroids or estrogen Patho Administration of drugs designed to alter hormonal environment of cancer cells negatively Used on cancers that are found to be responsive or dependant on hormones for growth Treatment

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

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

Oncology Case Study Medical/Nursing Priorities… Nursing Assessments… Nursing Interventions… CT-Positive PE CXR-large right pleural effusion Will need coumadin or heparin LT after DC

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 nodes Small bowel obstruction: ? tumor

Oncology Case Study: Priorities Medical… NG to LIS NPO IVF: NS @ 100cc/hr Nursing… Pain control Nausea control Volume status

Breast Cancer Article YouTube - Breast cancer real story