1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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… 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

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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 - P Getting her port accessed
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

17. 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

18. 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

19. 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
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

20. Absolute Neutrophil Count (ANC)
Normal Range
> 2,500/mm3
…safe to continue chemotherapy
minimal risk
moderate risk
<500 SEVERE risk
WBC x(%neutrophils + % bands)
Example: breast CA after chemo
WBC 2000, neutrophils 14.8%, bands 5%
2000 x ( )= 2000 x 0.198=396
REFLECTS TRUE IMMUNOLOGIC STATUS AND RISK OF INFECTION…IS MORE ACCURATE THAN WBC AND NEUTROPHILS ALONE

21. Thrombocytopenia Reduction of platelets below normal range
Normal = 150, ,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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

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

29. Breast Cancer
Article
YouTube - Breast cancer real story