CARE OF PATIENTS WITH CANCER
Characteristics of Normal Cells
The Biology of Normal Cells
1) Have limited cell division
2) Undergo Apoptosis
3) Show specific morphology
4) Perform specific differentiated functions
5) Adhere tightly together
6) Non migratory
7) Grow in orderly and well regulated manner
8) Are euploid
* Normal cell growth (cell cycle) consists of 5 intervals or phases
* Differentiation – refers to the process whereby cells develop specific
structures and functions in order to specialize in certain
tasks
* Cellular adaptation
a. Hypertrophy – refers to an increase in size of normal cells
b. Atrophy – refers to the shrinkage of cell size
c. Hyperplasia – refers to an increase in the number of normal cells
d. Metaplasia – refers to a conversion from the normal patters of differentiation of one type of cell into another type of cell not normal for that tissue
e. Dysplasia – refers to an alteration in the shape, size, appearance and distribution of cells
f. Anaplasia – refers to disorganized, irregular cells that have nor structure and have loss of differentiation; the result is always malignant
Evolution of Cancer Cells
Cancer – refers to a disease whereby cells mutate into abnormal cells that proliferate abnormally
Neoplasia – refers to an abnormal cell growth or tumor
- a mass of new tissue functioning independently and
serving no useful purpose
Invasion – occurs when cancer cells infiltrate adjacent tissues
surrounding the neoplasm
Metastasis – occurs when malignant cells travel through the blood or
lymph system and invade other tissues and organs to form
a secondary tumor
C. Characteristics of malignant cells
1. Rapid cell division and growth: regulation of the rate of mitosis is lost
2. No contact inhibition: cells do not respect boundaries of other cells and
invade their tissue areas
3. Loss of differentiation: cells lose specialized characteristics of function for
that cell type and revert back to an earlier, more primitive cell type
4. Ability to migrate (metastasize): cells move to distant areas of the body and
establish new site malignant lesions (tumors)
5. Alteration in cell structure: differences are evident between normal and
malignant cells with respect to cell membrane, cytoplasm and overall cell
shape
6. Self-survival
a. may develop ectopic sites to produce hormones needed for own
growth
b. can develop a connective tissue stroma to support growth
c. May develop own blood supply by secreting angiotensin growth
factor to stimulate local blood vessels to grow into tumor
D. Epidemiology of Cancer
1. Incidence of cancer
a. Cancer affects every age group though most cancer and cancer
deaths occur in people older than 65 years of age
b. Cancer ranks 3rd as the cause of morbidity in the Philippines
c. Highest incidence of all cancer is prostate cancer
d. Highest cancer incidence in males in order of frequency: prostate
cancer, lung cancer and colorectal cancer
e. Highest cancer incidence in females in order of frequency: breast
cancer, lung cancer and colorectal cancer
2. Common sites of cancer and their sites of metastasis
Cancer Type
Sites of Metastasis
1. Brain Cancer
Central Nervous System
2. Breast cancer
Brain
Liver
Regional lymph nodes
Vertebrae
3. Colon cancer
Brain
Liver
Lung
Lymph nodes
Ovaries
4. Lung cancer
Bone
Brain
Liver
Lymph nodes
Pancreas
Spinal cord
5. Prostate cancer
Bladder
Bone
Liver
External factors causing CANCER
1. Chemical Carcinogens- over 1,000 chemicals are known to be carcinogenic
• Alcoholic beverages (Liver, esophagus, mouth, breast colon)
-- serves as a promoter in cancers of the liver and esophagus
- when combined with tobacco, the risks for other cancers are even
higher
• Anabolic Steroid (Liver)
• Arsenic (Lung; Skin)
• Asbestos (Lung; peritoneum)
• Benzene (Leukemia
· Diesel exhaust (Lung)
· Hair dyes (bladder)
· Pesticides (Lungs)
· Sunlight (Skin; eyes)
· Tobacco (Lungs; esophagus; mouth; pharynx; larynx
n smokeless tobacco (snuff and chewing tobacco) increases the risk of
oral and esophageal cancers
* long-term exposure to secondhand smoke increases the risk for lung and
bladder cancers
2. Physical Carcinogens
– Radiation
– Chronic Irritation- GERD
3. Viral Carcinogens
- some viral infections tend to increase risk of cancer
Ex: Epstein Barr
Genital herpes
Papillomavirus
Hepatitis B
Human cytomegalovirus
4. Dietary Factors
- diets in high fat, low in fiber and those containing nitrosamines found in
preserved meats and pickled foods promote certain cancers such as colon,
breast, esophageal and gastric
Personal factors causing CANCER
1. Immune Functions
2. Age
a. Increased risk for people over age of 65
b. Factors attributed to cancer in elderly include hormonal changes, altered
immune responses and the accumulation of free radicals
c. Age has been identified as the single most important factor related to the
development of cancer
3. Gender
a. certain cancers are more commonly seen in specific genders
ex: breast cancer –more common in female
colon cancer – more common in males
4. Genetic Risk
- 15% of cancers may be attributed to a hereditary component
Ex: Breast, colon, lung, ovarian and prostate cancers
5. Race – can affect any population
- African-Americans experience a higher rate of cancer than any other racial
or ethnic group
CARCINOGENESIS: Transformation of Normal Cells into Cancer Cells
1. Initiation – occurs when carcinogen damages DNA
- carcinogenesis cause changes in the structure and function of the cell at
the genetic or molecular level. This damage may be reversible or may
lead to genetic mutations if not repaired; however the mutations may
not lead immediately to cancer
2. Promotion – occurs with additional assaults to the cell, resulting in further genetic
damage
3. These genetic events result in a malignant conversion
4. Progression – the cells are increasingly malignant in appearance and behaviour
and develop into an invasive cancer with metastases to distant body
parts
Comparison of the Characteristics of Normal and Cancer Cells
Characteristic
Normal Cells
Cancer Cells
Mitotic cell division
Mitotic division lead to 2 daughter cells
Mitosis leads to multiple daughter cells that may or may not resemble the parent. Multiple mitotic spindles
Appearance
1. Cells of same type homogeneous in size, shape, and growth
2. Cells cohesive, form regular pattern of expansion
3. Uniform size to nucleus
4. Have characteristic pattern of organization
5. Mixture of stem cells (precursors) and well-differentiated cells
1. cells larger and grow more rapidly than normal; pleomorphic
2. Cells not as cohesive; irregular patterns of expansion
3. Larger, more prominent nucleus
4. Lack characteristic pattern of organization of host cell
5. Anaplastic, lack of differentiated cell characteristics, specific functions
Growth pattern
1. do not invade adjacent tissue
2. Proliferate in response to specific stimuli
3. Grow in ideal conditions (ex: nutrients, oxygen, space, correct biochemical environment)
4. Exhibit contact inhibition
5. Cell birth equals or is less than cell death
6. Stable cell membrane
7. Constant or predictable growth rate
8. Cannot grow outside specific environment (ex: breast cells grow only in breast)
1. invade adjacent tissues
2. Proliferation in response to abnormal stimuli
3. Grow in adverse conditions such as a lack of nutrients
4. Do not exhibit contact inhibition
5. Cell birth exceeds cell death
6. Loss of cell control a result of cell membrane changes
7. Growth rate erratic
8. Able to break off cells that migrate through bloodstream or lymphatics or seed to distant sites and grow in other sites
Function
1. have specific, designated purpose
2. Contribute to the overall well-being of the host
3. Function in specific, predetermined manners
(ex: cells in the thyroid secrete thyroid hormone)
1. serve no useful purpose
2. do not contribute to the well-being of the host; parasitic, actually feed off host without contributing anything
3. If cells function at all, they do not function normally or they may actually cause damage (ex: lung cancer cells secrete ACTH and cause excessive stimulation of adrenal cortex)
Other
1. develop specific antigens, characteristic of the particular cell formed
2. Chromosomes remain constant throughout cell division
3. Complex metabolic and enzyme pattern
4. Cannot invade, erode, or spread
5. cannot grow in present of necrosis or inflammation
1. develop antigens completely different from a normal cell
2. chromosomal aberrations
3. have more primitive and simplified metabolic and enzyme pattern
4. invade, erode and spread
5. grow in presence of necrosis and inflammatory cells such as lymphocytes and macrophages
6. exhibit periods of latency that vary from tumor to tumor
7. have own blood supply and supporting stroma
Metastasis
- ability of cancer cells to spread from the original site of the tumor to distant organs
Stages:
1. Detachment
* tumor cell loses cohesiveness and it has increasing motility
* tumor cell detaches from the primary tumor and create defects in the
basemement membranes with resulting stromal invasion and spread into the
circulation
2. Migration
* Cancer cells migrate via the lymph or blood circulation or by direct
extension
* the lymphatic system provides the most common pathway for the initial
spread of malignant cancer cells
* The blood vessels carry cancer cells from the primary tumor to the capillary
beds of the lungs, liver and bones
* Direct tumor extension of tumors to adjacent tissues also occurs
3. Dissemination
* Cancer cells are established at the secondary site which may result from
entrapment due to the size of the tumor clump, adherence to cells at the new
site through specific interactions, or by binding to exposed basement
membrane
4. Angiogenesis
* Vascularization of the tumor
The Immune System and Cancer
Two critical components of the immune response
1. the ability to recognize a pathogen as foreign
2. the ability to mount a response to eliminate the pathogen
* T-cell lymphocyte, macrophages, and antigens recognize cancers cells as
non-self and destroy them
· Immune Surveillance Theory
– proposes that immune responses, particularly cell-mediated
responses, provide a defense against cancer cells by recognizing the
antigens on the surface of some neoplastic cells as foreign
- they are killed by cytotoxic T cells that have receptors for specific tumor
antigens and by interferon-activated natural killer (NK) lymphocytes
and macrophages
- macrophages phagocytize the pathogen and present it as antigen to T and
B lymphocytes
· Failure of Immune Defenses
- the immune system may be unable to recognize cancer cells as foreign or to mount an immune response due to the following:
a. it’s immature, old or weak
b. malnutrition or chronic ailment
c. cancer cells escape detection because they resemble normal cells.
Others produce substances that shield them from recognition or they
may be coated with fibrin
d. use of immunosuppressive drugs which can suppress immune system
Classification of Neoplasms
1. Benign – from latin word “benigunus”- kind
2. Malignant
Comparision of the characteristics of Benign and Malignant neoplasm
Characteristic
Benign Neoplasm
Malignant Neoplasm
Speed Growth
Grows slowly
Usually continues to grow throughout life unless surgically removed
May have periods of remission
Usually grows rapidly
Tends to grow relentlessly throughout life
Rarely, neoplasm may regress spontaneously
Mode of Growth
Grows by enlarging and expanding
Always remains localized; never infiltrates surrounding tissues
Grows by infiltrating surrounding tissues
May remain localized (in situ) but usually infiltrates other tissues
Capsule
Almost always contained within a fibrous capsule
Capsule does not prevent expansion of neoplasm but does prevent growth by nfiltrations
Capsule advantageous because encapsulated tumor can be removed surgically
Never contained within a capsule
Absence of capsule allows neoplastic cells to invade surrounding tissues
Surgical removal of tumor difficult
Cell characteristics
Usually well differentiated
Mitotic figures absent or scanty
Anaplastic cells absent
Cells function poorly in comparison with normal cells from which they arise
If neoplasm arises in glandular tissue, cells may secrete hormones
Usually poorly differentiated
Large numbers of normal and abnormal mitotic figures present
Cells tend to be anaplastic
Cells too abnormal to perform any physiologic functions
Occasionally a malignant tumor arising in glandular tissue secretes hormnes
Recurrence
Unusual when surgically removed
Common following surgery because tumor cells spread into surrounding tissues
Metastasis
Never occur
Very common
Effect of Neoplasm
Not harmful to host unless located in area where it compresses tissue or obstructs vital organs
Does not produce cachexia (weight loss, debilitation, anemia, weakness, wasting)
Always harmful to host
Causes death unless removed surgically or destroyed by radiation or chemotherapy
Causes disfigurement, disrupted organ function, nutritional imbalances
May result in ulcerations, sepsis, perforations, hemorrhage, tissue slough
Almost always produces cachexia, which leaves person prone to pneumonia, anemia, and other conditions
Prognosis
Very good
Tumor generally removed surgically
Depends on cell type and speed of diagnosis
Poor prognosis if cells are poorly differentiated and evidence of metastatic spread exists
Good prognosis indicated if cells still resemble normal cells and there is no evidence of metastasis
Classification of cancer according to tissue of origin
1. Carcinoma - refers to a tumor that arises from epithelial tissue; the name of
the cancer identifies the location
example: basal cell carcinoma
2. Sarcoma - refers to a tumor arising from supportive tissues; the name of the
cancer identifies the specific tissue affected
example: osteosarcoma
Tissue of Origin
Benign Neoplasms
Malignant Neoplasms
Connective Tissue
Bone
Fibrous tissue
Adipose tissue
Osteoma
Fibroma
Lipoma
Osteosarcoma
Fibrosarcoma
Liposarcoma
Epithelial Tissue
Glandular
Surface
Adenoma
Papilloma
Adenocarcinoma
Squamous cell carcinoma
Hematopoietic
Erythrocytes
Granulocytes
Lymphatic tissue
Erythroleukemia
Leukemia
Hodgkin’s disease, malignant lymphoma
Lymphocytes
Plasma cells
Lymphocytic leukaemia
Multiple myeloma
Cancer Prevention and Control
1. Prevention – involves measures to avoid or reduce exposure to carcinogens
- activities are aimed at interventions before pathologic change has
begun
2. Screening – helps to identify high-risk populations and individuals
3. Early Detection – involves finding a precancerous lesion or a cancer at its earliest,
most treatable stage
- also called secondary prevention
- methods
a. inspection
b. palpation
c. use of tests or procedures
Approaches to Cancer prevention
1. Education
2. regulation – prohibit the sale of tobacco and alcohol to minors, limiting smoking in
public places, imposing excise taxes, regulating the use of
manufactured carcinogens such as asbestos, and prohibiting carcinogens
in foods
3. host modification
- aims to alter the body’s internal environment to decrease the risk of or to
reverse a carcinogenic process
Cancer Prevention
1. Skin: Avoid exposure to sunlight
2. Oral: Annual oral examination
3. Breast: Monthly BSE from age 20
4. Lungs: Avoid cigarette smoking; annual chest x-ray
5. Colon: DRE for person over age 40. Rectal biopsy, proctosigmoidoscopic examination, Guiac stool examination for persons age 50 and above
6. Uterus: annual Pap’s smear from age 40
7. Basic: annual physical examination and blood examination
Dietary Recommendations against cancer
1. Avoid obesity
2. Cut down on total fat intake
3. Eat more high fiber foods – raw fruits and vegetables, whole grain cereal
4. Include food rich in vitamin A and C in daily diet
5. Include cruciferous vegetables in the diet-brocolli, cabbage, cauliflower, brussel sprouts
6. Be moderate in the consumption of alcoholic beverages
7. Be moderate in the consumption of salt-cured, smoked-cured and nitrate-cured foods
Recommendations of the American Cancer Society for Early Cancer Detection
1. For detection of breast cancer
a. Beginning at age 20, routinely perform monthly breast self-examination
b. Women ages 20-39 should have breast examination by a healthcare provider
every 3 years
c. Women age 40 and older should have a yearly mammogram and breast
self-examination by a healthcare provider
2. For detection of colon and rectal cancer
a. all persons age 50 and older should have a yearly fecal occult blood test
b. digital rectal examination and flexible sigmoidoscopy should be done every
5 years
c. Colonoscopy with barium enema should be done every 10 years
3. For detection of uterine cancer
a. yearly papanicolao (Pap) smear for sexually active females and any female
over age 18
b. At menopause, high-risk women should have an endometrial tissue sample
4. For detection of prostate cancer
a. beginning at age 50, have a yearly digital rectal examination
b. beginning at age 50, have a yearly prostate-specific antigen (PSA) test
American Cancer Society’s seven warning signs of cancer (uses acronym CAUTION):
1. Change in bowel or bladder habits
2. A sore that does not heal
3. Unusual bleeding or discharge
4. Thickening or lump in breast or elsewhere
5. Indigestions or difficulty in swallowing
6. Obvious change in wart or mole
7. Nagging cough or hoarseness
Diagnostic tests of Cancer
1. Biopsy/cytology
a. Histologic and cytologic examination of specimens are performed by the
pathologist on tissues collected by needle aspiration of solid tumors, exfoliation
from epithelial surface, and aspiration of fluid from blood or body cavities
b. Tissues may be obtained by excisional biopsy, incisional biopsy, and needle
biopsy
c. By examination of these tissues, the name, grade, and stage of the tumor can be
identified
2. Papanicolao Test (Pap Smear)
Class I: Normal
Class II: Inflammation
Class III: Mild to moderate dysplasia
Class IV: Probably malignant
Class V: Malignant
3. Ultrasound
4. MRI
5. X-rays
6. CT scan
7. Radiographic techniques
8. Antigen Skin test
9. Laboratory tests
a. Alpha-feto-protein
b. HCG
c. Prostatic Acid Phosphatase (PSA)
d. Carcinoembroyenic antigens (CEA)
10. Endoscopic examination
11. Monoclonal antibodies
C. Tumor markers
1. Tumor markers are protein substances found in the blood or blody fluids
2. Are released either by the tumor itself, or by the body as a defense in response to
the tumor (called host response)
3. Tumor markers are derived from the tumor itself. And include the ff:
a. Oncofetal antigens, present normally in fetal tissue, may indicate an
anaplastic process in tumor cells; carcinoembyonic antigen (CEA)
and alpha-fetoprotein (AFP) are examples of oncofetal antigens.
b. Hormones are present in large quantities in the human body;
however, high levels of hormones may indicate a hormone-secreting
malignancy; hormones that may be utilized as tumor markers include
the antidiuretic hormone (ADH), calcitonin, catecholamines, human
chorionic gonadotropin (HCG), and parathyroid hormone (PTH)
c. Isoenzymes that are normally present in a particular tissue may be
released into bloodstream if the tissue is experiencing rapid,
excessive growth as the result of tumor; are examples include
neuron-specific enolase (NSE) and prostatic acid phosphatase (PAP)
d. Tissue-specific proteins identify the type of tissue affected by
malignancy; an example of a tissue-specific protein is the protastic-
specific antigen (PSA) utilized to identify prostate cancer
4.Host-response tumor makers include the following:
a. C-reactive protein
b. Interleukin-2
c. Lactic dehydrogenase
d. Serum Ferritin
e. Tumor necrosis factor
Staging
1. The TNM tumor system is utilized for classifying tumors
a. T indicates the tumor size
1) T0 indicates no evidence of tumor
2) Tis indicates tumor in situ
3) T1,T2,T3,T4 indicate progressive degrees of tumor size and involvement
b. N indicates lymph node involvement
1) N0 indicates no abnormal lymph nodes detected
2) N1a, N2a indicate regional nodes involved with increasing degree from
N1a to N2a, no metastases detected
3) N1b, N2b, N3b indicate regional lymph nodes involvement with increasing
Degree from N1b to N3b, metastasis suspected
4) Nx indicates inability to assess regional nodes
c. M indicates distant metastases
1) M0 indicates no evidence of distant metastasis
2) M1, M2,M3 indicate ascending degrees of distant metastasis and includes
distant lymph nodes
Different Modalities for Cancer
1. Surgical interventions
2. Chemotherapy
3. Radiation therapy
4. Immunotherapy
6. Bone Marrow transplantation
Surgical Intervention
1. Preventive surgery- removal of precancerous lesions or benign tumors
2. Diagnostic surgery- biopsy
3. Curative surgery- removal of an entire tumor
4. Reconstructive surgery – improvement of structures and function of an organ
5. Palliative surgery – relief of distressin signs and symptoms; retardations of metastasis
Common Nursing Techniques and Procedures
A. Radiation therapy
1. Is used to kill a tumor, reduce the tumor size, relieve obstruction, or decrease
pain
2. Causes lethal injury to DNA, so it can destroy rapidly multiplying cancer cells,
as well as normal cells
3. Can be classified as internal radiation therapy (bachytherapy) or external
radiation therapy (teletherapy)
B. The client undergoing brachytheraphy ( internal radiation)
1. Sources of internal radiation
a. Implanted into affected tissue or body cavity
b. Ingested as a solution
c. Injected as a solution into the bloodstream or body cavity
d. Introduced through a catheter into the tumor
2. Side effects of internal radiation
a. Fatigue
b. Anorexia
c. Immunosuppression
d. Other side effects similar to external radiation
3. Priority nursing diagnoses: Impaired tissue integrity; fatigue; anxiety; risk for
infection; Social isolation; Imbalanced nutrition: less than body requirements
4. Client education
a. Avoid close contact with others until treatment is completed
b. Maintain daily activities unless contraindicated, allowing for extra rest
periods as needed
c. Maintain balanced diet; may tolerate food better if consumes small,
frequent meals
d. Maintain fluid intake ensure adequate hydration (2-3 liters/day)
e. If implant is temporary, maintain bedrest to avoid dislodging the implant.
f. Excreted body fluids may be radioactive; double-flush toilets after use
g. Radiation therapy may lead to bone marrow suppression
5. Nursing management of client receiving internal radiation
a. Exposure to small amounts of radiation is possible during close contact with
persons receiving internal radiation: understand the principles of protection
from exposure to radiation: time, distance, and shielding
1) Time: minimize time spent in close proximity to the radiation
source; a common standard is to limit contact time to 30 minutes
total per 8-hour shift; minimum distance of 6 feet used when
possible
2) Distance: maintain the maximum distance possible from the
radiation source
3) Shielding: use lead shields and other precautions to reduce exposure
to radiation
b. Place client in private room
c. Instruct visitors to maintain at least a distance of 6 feet from the client and
limit visitors to 10-30 minutes
d. Ensure proper handling and disposal of body fluids, assuring the containers
are marked appropriately
e. Ensure proper handling of bed linens and clothing
f. In the event of a dislodged implant, use long-handled forceps and place the
implant into a lead container; never directly touch the implant
g. Do not allow pregnant woman to come into any contact with radiation
sources; screen visitors and staff for pregnancy
h. If working routinely near radiation sources, wear a monitoring device to
measure exposure
i. Educate client in all safety measures
6. Evaluation: client demonstrates measures to protect others from exposure to
radiation, identifies interventions to reduce risk of infection, remains free from
infection, achieves adequate fluid and nutritional intake, and participates in
activities of daily living (ADLs) at level of ability
C. The client undergoing external radiation therapy (teletheraphy)
1. The radiation oncologist marks specific locations for radiation treatment using
a semipermanent type of ink
a. Treatment is usually given 15-30 minutes per day, 5 day per week, for 2-7
weeks
b. The client does not pose a risk for radiation exposure to other people
2. side effects of external radiation therapy
a. Tissue damage to target area (erythema, sloughing, hemorrhage)
b. Ulcerations of oral mucous membranes
c. Gastrointestinal effects such as nausea, vomiting, and diarrhea
d. Radiation pneumonia
e. Fatigue
f. Alopecia
g. Immunosuppression
3.Priority nursing diagnoses: risk for infection; impaired skin integrity; social
isolation; disturbed body image; anxiety; fatigue
4. Client education exam for external radiation
a. Wash the marked area of the skin with plain water only and pat skin dry; do not use soaps, deodorants, lotions, perfumes, powders or medications on the site during the duration of the treatment; do not wash off the treatment site marks
b. Avoid rubbing, scratching, or scrubbing the treatment site; do not apply extreme temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor
c. Wear soft, loose-fitting over the treatment area
d. Protect skin from sun exposure during the treatment and for at least 1 year after the treatment is completed; when going outdoors, use sun-blocking agents with sun protector factor (SPF) of at least 15
e. Maintain proper rest, diet, and fluid intake as essential to promoting health and repair of normal tissues
f. Hair loss may occur; choose a wig, hat, or scarf to cover and protect head (refer to care of client with alopecia later in chapter)
5. Nursing management of the client receiving external radiation
a. Monitor for adverse side effects of radiation
b. Monitor for significant decreases in white blood cell counts and platelet
counts
c. Client teaching (refer to later sections for management of
immunosuppression, thrombocytopenia
6. Evaluation; client identifies interventions to reduce risk of infection, remains
free from infection, achieves adequate fluid and nutritional intake, participates
in activities of daily living (ADLs) at level of ability, and maintains intact
skin.
The Client Undergoing a Bone Marrow Transplant (BMT)
1. BMT – used in the treatment of leukemias, usually in conjunction with radiation or chemotherapy
a. Autologous BMT – the client is infused with own bone marrow harvested
during remission of disease
b. Allogenic BMT – the client is infused with donor bone marrow harvested
from a healthy individual
2. The bone marrow is usually harvested from the iliac crest, then frozen and stored until transfusion
3. Before receiving the BMT, the client must first undergo a phase of immunosuppressive therapy to destroy the immune system, infection, bleeding, and death are major complications that can occur during this conditioning phase
4. After immunosuppression, the bone marrow is transfused intravenously through a central line
5. Side of BMT
a. malnutrition
b. infection related to immunosuppression
c. bleeding related to thrombocytopenia
6. Priority Nursing Diagnoses
a. Risk for infection
b. Risk for hemorrhage
c. Risk for imbalanced nutrition
d. Social isolation
e. Anxiety
7. Nursing Management of client undergoing a bone marrow transplant
a. Monitor for graft-versus-host disease
b. Provide private room for the hospitalized client; client will be hospitalized for
6-8 weeks
c. Encourage contact with significant others by using telephone, computer, and
other means of communication to reduce feelings of isolation
d. Refer to management for imbalanced nutrition, immunosuppression and
thrombocytopenia
8. Evaluation: client evaluates understanding of risks and participates in activities that
reduce risk of infection, hemorrhage, and malnutrition; client demonstrates
effective coping mechanisms
The Client Undergoing other therapeutic interventions
1. Immunotherapy/biologic response modifiers (BMR)
a. Enhances the person’s own immune responses in order to modify the biologic
processes resulting in malignant cells
b. Currently considered experimental in use
c. Monoclonal antibodies: antibodies are recovered from an inoculated animal
with a specific tumor antigen, then given to the person with that particular
cancer type; the goal is: destruction of the tumor
d. Cytokines: normal growth-regulating molecules possessing antitumor abilities
1) Interleukin-2(IL-2) increases immune response effective and
destroys abnormal cells
2) Interferons are substances produced by cells to protect them from
viral infection and replication; interferon-alpha 2b is most
commonly used
3) Hematopoietic growth factors such as granulocyte colony-
stimulating factor (G-CSF) and erythropoietin, balance the
suppression of granulocytes and erythrocytes resulting from
chemotherapy
e. natural killer cells (NK cells) : exert a spontaneous cytotoxic effect on
specific cancer cells; they also secrete cytokines and provide a resistance to
metastasis
2. Gene therapy
a. Current use in investigational
b. Increases susceptibility of cancer cells to the destruction by other treatments;
insertion of specific genes enhances ability of client’s own immune system to
recognize and destroy cancer cells
3. Photodynamic theory
a. Used to treat specific superficial tumors such as those of the surface of
bladder, bronchus, chest wall, head, neck and peritoneal cavity
b. Photofirin, a photosensitizing compound, is administered intravenously where
it is retained by malignant tissue
c. Three days after injection, the drug is activated by a laser treatment which
continues for 3 more days
d. The drug produces a cytotoxic oxygen molecule (singlet oxygen)
e. During intravenous administration, monitor for chills, nausea, rash, local skin
reactions, and temporary photosensitivity
f. Drug remains in tissues 4-6 weeks after injection; direct or indirect exposure
to sun activates drug, resulting in chemical sunburn; educate client to protect
skin from exposure to sun
Oncologic Emergencies: Diagnosis and Management
1. Spinal Cord Compression
a. Occurs secondary to pressure from expanding tumors
b. Early symptoms include back and leg pain, coldness, numbness, tingling,
paresthesias, progression leads to bowel and bladder dysfunction, weakness,
and paralysis
c. Early detection is essential: investigate all complaints of back pain or
neurological changes
d. Treatment is aimed at reducing tumor size by radiation and/or surgery to
relieve compression and prevent irreversible paraplegia; may receive
corticosteroids to reduce cord edema
e. Nursing interventions include early recognition of symptoms, neurological
checks and medication administration
2. Superior vena cava syndrome
a. Compression or obstruction of the superior vena cava (SVC)
b. Usually associated with cancer of the lungs and lymphomas
c. signs and symptoms are the result of blockage of venous circulations of head,
neck, and upper trunk
d. Early signs and symptoms are periorbital edema and facial edema
e. Symptoms progress to edema of neck, arms, and hands, difficulty swallowing,
shortness of breath
f. Late signs and symptoms are cyanosis, altered mental status, headache, and
hypotension
g. Death may occur if compression is not relieved
h. Treatment included high-dose radiation to shrink tumor and relieve symptoms
i.Nursing interventions include:
a. Monitoring vital signs
b. providing oxygen support
c. preparing tracheostomy if necessary
d. initiating seizure precautions
e. administering corticosteroids to reduce edema
3. Disseminated intravascular coagulopathy (DIC)
a. Severe disorder of coagulation, often triggered by sepsis, whereby abnormal
clot formation occurs in the microvasculature; this process depletes the
clotting factors and platelets, allowing extensive bleeding to occur tissue
hypoxia occurs as a result of the blockage of blood vessels from the clots
b. Signs and symptoms are related to decreased blood flow to major organs
(tachycardia, oliguria, dyspnea) and depleted clotting factors (abnormal
bleeding and hemorrhage)
c. Treatment includes anticoagulants to decrease stimulations of coagulation and
transfusion of one or more of the following:
1) fresh frozen plasma (FFP)
2) cryoprecipitate
3) platelets
4) packed RBC
d. Nursing interventions include assessing client, monitoring for bleeding,
applying pressure dressings to venipuncture sites, and preventing risk of
sepsis
e. Mortality for clients experiencing DIC is greater than 70% despite aggressive
treatment
4. Cardiac tamponade
a. Pericardial effusion secondary to metastases or esophageal cancer can lead to
compression of heart, restricting heart movement and resulting in cardiac
tamponade
b. Signs and symptoms are related to cardiogenic shock or circulatory collapse:
anxiety, cyanosis, dyspnea,hypotension, tachycardia,tachypnea,impaired
levels of consciousness, and increased central venous pressure
c. Pericardiocentesis is performed to remove fluid from pericardial sac
d. Nursing interventions
1) administering oxygen
2) maintaining intravenous line
3) Monitoring vital signs
4) hemodynamic monitoring
5) administration of vasopressor agents
COMMON CANCER DISORDERS
I. BREAST CANCER
- unregulated growth of abnormal cells in breast tissue
Etiology and pathophysiology
A. cause is unknown but many risk factors influence development
1. Female gender and white Caucasian race
2. family history of mother or sister with breast cancer
3. medical history of cancer of other breast, endometrial cancer or atypical
Hyperplasia
4. Menarche before age 12 (early) or menopause after age 50(Late)
5. First birth after 30 years of age, oral contraceptive use (early or prolonged),
prolonged use of estrogen replacement therapy
6. Lifestyle factors: high-fat diet, obesity, high socioeconomic status, breast
trauma, smoking, ingesting more than 2 alcoholic drinks daily
7. Exposure to radiation through chest x-ray, fluoroscopy
B. Begins as a single transformed cells and is hormones-dependent; does not
develop in women without functioning ovaries who never received hormones
replacement therapy
C. Most often occurs in ductal areas of breast
D. Noninvasive: does not penetrate surrounding tissues; may be ductal or lobular;
usually diagnosed through mammogram or nipple discharge
E. Invasive: penetration of tumor into surrounding tissue
Manifestations
1. Lump in upper outer quadrant of breast, usually nontender but may be tender
2. dimpling of breast tissue surrounding nipple, or bleeding from the nipple
3. Asymmetry with affected breast being higher
4. Regional lymph nodes swollen and tender
Management
1. Radiation therapy
2. Mastectomy
a) Segmental mastectomy – or lumpectomy; removes the tumor and margin of
breast tissue surrounding the tumor
b) simple mastectomy – removal of the complete breast but no other structures
c) Modified radical mastectomy – removal of the breast and axillary lymph
nodes but chest wall muscles are not resected
d) Radical mastectomy – removal of the breast, axillary lymph nodes and
underlying chest wall muscles
e) Breast reconstruction – may be performed at the time of mastectomy or may
be done at a later time; can be accomplished through submuscular breast
implant, placing an implant after using a tissue expander, using muscles with
intact blood supply from the back or abdomen, or creating a free muscle flap
with the gluteus maximus muscle
3. Medication therapy
a. Tamoxifen (Novadex) interferes with estrogen activity for treating advanced
breast cancer
b. Chemotherapy – when axillary nodes are involved
Care of patient undergoing mastectomy
1. Maintain usual postoperative assessment
2. Begin emotional support before surgery and continue in postoperative period
3. Turn, cough and deep breathe to prevent respiratory complications; restrictive surgical dressing may decrease chest expansion
4. Position client on back or unaffected side
5. Jackson-Pratt drain or Hemovac may be in place to drain fluids that accumulate when lymph nodes are removed
6. Note signs of bleeding on dressing and reinforce pressure dressing as needed
7. Encourage early range of motion exercise to prevent contractures are lymphedema
8. Use unaffected arm only to provide IV fluids and take blood pressure
9. Discharge instructions
a) Use caution when lifting heavy objects with arms on affected side
b) Avoid injury and infection on affected side; wear rubber gloves when
washing dishes and garden gloves when working outside
c) Don’t allow procedures, such as blood pressure or venipunctures on the
affected side
d) Refer client to support group for psychosocial support
B. PROSTATE CANCER
- unregulated growth of abnormal cells in the prostate gland
Etiology/pathophysiology
1. Adenocarcinoma is most common type; high levels of testosterone may play a
Role
2. Usually begins in peripheral tissue on back and sides of the gland
3. Metastasis via lymph and venous changes is common; bony tissue is major
site of distant metastasis- especially pelvic bones and spine
4. Is seen predominantly over 40 years of age
Clinical Manifestations
1. Clients in early stages often show no symptoms; tumor may be found during
digital prostate exam
2. Genitourinary: dysuria, frequency, reduced force of stream, hematuria,
nocturia,abnormal prostate found on DRE
3. Musculoskeletal: back pain, migratory bone pain, bone or joint pain
4. Neurologic: nerve pain, muscle spasms, bowel or bladder dysfunction,
bilateral weakness of lower extremities
5. Systemic: fatique and weight loss
Diagnostic and Laboratory tests
1. Prostate-specific antigen (PSA) levels
2. Transurectal ultrasound (obtained if PSA results are abnormal)
3. tissue biopsy
4. bone scan
5. MRI
6. CT scans to detect metastasis
Therapeutic Management
1. Hormone therapy
2. Radiation therapy
3. Brachy therapy (Radioactive seeds implanted in the prostate)
4. Prostatic cryosurgery
5. Surgery
a) Orchiectomy – decreases androgen production
b) Radical procedures include removal of gland, capsule,ampulla,vas
deferens,seminal vesicles, adjacent lymph nodes, and cuff of bladder
neck
c) Suprapubic prostatectomy – abdominal and bladder incisions to
remove prostate tissue
d) Retropubic prostatectomy – low abdominal incision without opening
bladder
e) Perineal prostatectomy – incision between scrotum and anus
(perineal area)
f) Homium laser – laser treatment; less bleeding, fewer complications
and shorted hospital day
6. Medication therapy
a. estrogen therapy of luteinizing hormone antagonist (Lupron) given
to slow rate of growth and extension of tumor
Nursing Management of Patient Undergoing Prostate Surgery
1. Maintain usual postoperative assessment
2. If dressings are present, monitor for drainage and change as needed
3. Monitor vital signs closely for 24 hours, observing for signs of hemorrhage (frank blood in urine, large blood clots, decreased haemoglobin and hematocrit, tachycardia, and hypotension)
4. IN clients who have a urinary catheter following surgery, traction may be applied against the prostatic fossa to prevent bleeding; the balloon at the tip of the catheter exerts pressure to prevent hemorrhage; the surgeon positions the external end of the catheter by anchoring it tightly to the client’s inner thigh to maintain traction; the catheter should not be repositioned
5. A client who has a large indwelling catheter may feel the urge to void, which results from stimulation of the micturition center, explain to the client that this is a normal sensations; efforts by the client to void or strain will increase the risk of bleeding and aggravate pain
6. Continuous bladder irrigation (CBI) may be ordered on a client postoperatively
a. The purpose of the CBI is to prevent the formation of blood clots
b. If blood clots do form, the urinary catheter will become plugged and prevent
outflow of urine; the obstruction will also cause bladder spasms and pain
c. A key nursing intervention for the client in CBI is to keep the outflow from the
catheter light pink or clear; the rate of administration of the irrigating solution is
therefore titrated to keep the color of the outflow this color and prevent blood
clots from forming; it is essential to calculate intake and output to determine true
urine output
d. Indications that the rate of the irrigations is inadequate include: decreased
outflow from the catheter; bladder spasms; and dark-colored or frankly
bloody drainage
7. Monitor client for signs of hemorrhage;bladder spasms and frank bloody output may indicate bleeding
8. The irrigating solution used during and after surgery may be absorbed causing fluid shifts and dilutional hyponatremia, referred to as TURP syndrome; monitor the client for signs of hyponatremia and bradycardia, nausea and vomiting, monitor serum sodium levels and haemoglobin and hematocrit; in addition, other signs of volume excess will also be evident, including hypertension and confusion
9. If manual irrigations are ordered, maintain sterile technique
10. Medicate as needed for pain
Characteristics of Normal Cells
The Biology of Normal Cells
1) Have limited cell division
2) Undergo Apoptosis
3) Show specific morphology
4) Perform specific differentiated functions
5) Adhere tightly together
6) Non migratory
7) Grow in orderly and well regulated manner
8) Are euploid
* Normal cell growth (cell cycle) consists of 5 intervals or phases
* Differentiation – refers to the process whereby cells develop specific
structures and functions in order to specialize in certain
tasks
* Cellular adaptation
a. Hypertrophy – refers to an increase in size of normal cells
b. Atrophy – refers to the shrinkage of cell size
c. Hyperplasia – refers to an increase in the number of normal cells
d. Metaplasia – refers to a conversion from the normal patters of differentiation of one type of cell into another type of cell not normal for that tissue
e. Dysplasia – refers to an alteration in the shape, size, appearance and distribution of cells
f. Anaplasia – refers to disorganized, irregular cells that have nor structure and have loss of differentiation; the result is always malignant
Evolution of Cancer Cells
Cancer – refers to a disease whereby cells mutate into abnormal cells that proliferate abnormally
Neoplasia – refers to an abnormal cell growth or tumor
- a mass of new tissue functioning independently and
serving no useful purpose
Invasion – occurs when cancer cells infiltrate adjacent tissues
surrounding the neoplasm
Metastasis – occurs when malignant cells travel through the blood or
lymph system and invade other tissues and organs to form
a secondary tumor
C. Characteristics of malignant cells
1. Rapid cell division and growth: regulation of the rate of mitosis is lost
2. No contact inhibition: cells do not respect boundaries of other cells and
invade their tissue areas
3. Loss of differentiation: cells lose specialized characteristics of function for
that cell type and revert back to an earlier, more primitive cell type
4. Ability to migrate (metastasize): cells move to distant areas of the body and
establish new site malignant lesions (tumors)
5. Alteration in cell structure: differences are evident between normal and
malignant cells with respect to cell membrane, cytoplasm and overall cell
shape
6. Self-survival
a. may develop ectopic sites to produce hormones needed for own
growth
b. can develop a connective tissue stroma to support growth
c. May develop own blood supply by secreting angiotensin growth
factor to stimulate local blood vessels to grow into tumor
D. Epidemiology of Cancer
1. Incidence of cancer
a. Cancer affects every age group though most cancer and cancer
deaths occur in people older than 65 years of age
b. Cancer ranks 3rd as the cause of morbidity in the Philippines
c. Highest incidence of all cancer is prostate cancer
d. Highest cancer incidence in males in order of frequency: prostate
cancer, lung cancer and colorectal cancer
e. Highest cancer incidence in females in order of frequency: breast
cancer, lung cancer and colorectal cancer
2. Common sites of cancer and their sites of metastasis
Cancer Type
Sites of Metastasis
1. Brain Cancer
Central Nervous System
2. Breast cancer
Brain
Liver
Regional lymph nodes
Vertebrae
3. Colon cancer
Brain
Liver
Lung
Lymph nodes
Ovaries
4. Lung cancer
Bone
Brain
Liver
Lymph nodes
Pancreas
Spinal cord
5. Prostate cancer
Bladder
Bone
Liver
External factors causing CANCER
1. Chemical Carcinogens- over 1,000 chemicals are known to be carcinogenic
• Alcoholic beverages (Liver, esophagus, mouth, breast colon)
-- serves as a promoter in cancers of the liver and esophagus
- when combined with tobacco, the risks for other cancers are even
higher
• Anabolic Steroid (Liver)
• Arsenic (Lung; Skin)
• Asbestos (Lung; peritoneum)
• Benzene (Leukemia
· Diesel exhaust (Lung)
· Hair dyes (bladder)
· Pesticides (Lungs)
· Sunlight (Skin; eyes)
· Tobacco (Lungs; esophagus; mouth; pharynx; larynx
n smokeless tobacco (snuff and chewing tobacco) increases the risk of
oral and esophageal cancers
* long-term exposure to secondhand smoke increases the risk for lung and
bladder cancers
2. Physical Carcinogens
– Radiation
– Chronic Irritation- GERD
3. Viral Carcinogens
- some viral infections tend to increase risk of cancer
Ex: Epstein Barr
Genital herpes
Papillomavirus
Hepatitis B
Human cytomegalovirus
4. Dietary Factors
- diets in high fat, low in fiber and those containing nitrosamines found in
preserved meats and pickled foods promote certain cancers such as colon,
breast, esophageal and gastric
Personal factors causing CANCER
1. Immune Functions
2. Age
a. Increased risk for people over age of 65
b. Factors attributed to cancer in elderly include hormonal changes, altered
immune responses and the accumulation of free radicals
c. Age has been identified as the single most important factor related to the
development of cancer
3. Gender
a. certain cancers are more commonly seen in specific genders
ex: breast cancer –more common in female
colon cancer – more common in males
4. Genetic Risk
- 15% of cancers may be attributed to a hereditary component
Ex: Breast, colon, lung, ovarian and prostate cancers
5. Race – can affect any population
- African-Americans experience a higher rate of cancer than any other racial
or ethnic group
CARCINOGENESIS: Transformation of Normal Cells into Cancer Cells
1. Initiation – occurs when carcinogen damages DNA
- carcinogenesis cause changes in the structure and function of the cell at
the genetic or molecular level. This damage may be reversible or may
lead to genetic mutations if not repaired; however the mutations may
not lead immediately to cancer
2. Promotion – occurs with additional assaults to the cell, resulting in further genetic
damage
3. These genetic events result in a malignant conversion
4. Progression – the cells are increasingly malignant in appearance and behaviour
and develop into an invasive cancer with metastases to distant body
parts
Comparison of the Characteristics of Normal and Cancer Cells
Characteristic
Normal Cells
Cancer Cells
Mitotic cell division
Mitotic division lead to 2 daughter cells
Mitosis leads to multiple daughter cells that may or may not resemble the parent. Multiple mitotic spindles
Appearance
1. Cells of same type homogeneous in size, shape, and growth
2. Cells cohesive, form regular pattern of expansion
3. Uniform size to nucleus
4. Have characteristic pattern of organization
5. Mixture of stem cells (precursors) and well-differentiated cells
1. cells larger and grow more rapidly than normal; pleomorphic
2. Cells not as cohesive; irregular patterns of expansion
3. Larger, more prominent nucleus
4. Lack characteristic pattern of organization of host cell
5. Anaplastic, lack of differentiated cell characteristics, specific functions
Growth pattern
1. do not invade adjacent tissue
2. Proliferate in response to specific stimuli
3. Grow in ideal conditions (ex: nutrients, oxygen, space, correct biochemical environment)
4. Exhibit contact inhibition
5. Cell birth equals or is less than cell death
6. Stable cell membrane
7. Constant or predictable growth rate
8. Cannot grow outside specific environment (ex: breast cells grow only in breast)
1. invade adjacent tissues
2. Proliferation in response to abnormal stimuli
3. Grow in adverse conditions such as a lack of nutrients
4. Do not exhibit contact inhibition
5. Cell birth exceeds cell death
6. Loss of cell control a result of cell membrane changes
7. Growth rate erratic
8. Able to break off cells that migrate through bloodstream or lymphatics or seed to distant sites and grow in other sites
Function
1. have specific, designated purpose
2. Contribute to the overall well-being of the host
3. Function in specific, predetermined manners
(ex: cells in the thyroid secrete thyroid hormone)
1. serve no useful purpose
2. do not contribute to the well-being of the host; parasitic, actually feed off host without contributing anything
3. If cells function at all, they do not function normally or they may actually cause damage (ex: lung cancer cells secrete ACTH and cause excessive stimulation of adrenal cortex)
Other
1. develop specific antigens, characteristic of the particular cell formed
2. Chromosomes remain constant throughout cell division
3. Complex metabolic and enzyme pattern
4. Cannot invade, erode, or spread
5. cannot grow in present of necrosis or inflammation
1. develop antigens completely different from a normal cell
2. chromosomal aberrations
3. have more primitive and simplified metabolic and enzyme pattern
4. invade, erode and spread
5. grow in presence of necrosis and inflammatory cells such as lymphocytes and macrophages
6. exhibit periods of latency that vary from tumor to tumor
7. have own blood supply and supporting stroma
Metastasis
- ability of cancer cells to spread from the original site of the tumor to distant organs
Stages:
1. Detachment
* tumor cell loses cohesiveness and it has increasing motility
* tumor cell detaches from the primary tumor and create defects in the
basemement membranes with resulting stromal invasion and spread into the
circulation
2. Migration
* Cancer cells migrate via the lymph or blood circulation or by direct
extension
* the lymphatic system provides the most common pathway for the initial
spread of malignant cancer cells
* The blood vessels carry cancer cells from the primary tumor to the capillary
beds of the lungs, liver and bones
* Direct tumor extension of tumors to adjacent tissues also occurs
3. Dissemination
* Cancer cells are established at the secondary site which may result from
entrapment due to the size of the tumor clump, adherence to cells at the new
site through specific interactions, or by binding to exposed basement
membrane
4. Angiogenesis
* Vascularization of the tumor
The Immune System and Cancer
Two critical components of the immune response
1. the ability to recognize a pathogen as foreign
2. the ability to mount a response to eliminate the pathogen
* T-cell lymphocyte, macrophages, and antigens recognize cancers cells as
non-self and destroy them
· Immune Surveillance Theory
– proposes that immune responses, particularly cell-mediated
responses, provide a defense against cancer cells by recognizing the
antigens on the surface of some neoplastic cells as foreign
- they are killed by cytotoxic T cells that have receptors for specific tumor
antigens and by interferon-activated natural killer (NK) lymphocytes
and macrophages
- macrophages phagocytize the pathogen and present it as antigen to T and
B lymphocytes
· Failure of Immune Defenses
- the immune system may be unable to recognize cancer cells as foreign or to mount an immune response due to the following:
a. it’s immature, old or weak
b. malnutrition or chronic ailment
c. cancer cells escape detection because they resemble normal cells.
Others produce substances that shield them from recognition or they
may be coated with fibrin
d. use of immunosuppressive drugs which can suppress immune system
Classification of Neoplasms
1. Benign – from latin word “benigunus”- kind
2. Malignant
Comparision of the characteristics of Benign and Malignant neoplasm
Characteristic
Benign Neoplasm
Malignant Neoplasm
Speed Growth
Grows slowly
Usually continues to grow throughout life unless surgically removed
May have periods of remission
Usually grows rapidly
Tends to grow relentlessly throughout life
Rarely, neoplasm may regress spontaneously
Mode of Growth
Grows by enlarging and expanding
Always remains localized; never infiltrates surrounding tissues
Grows by infiltrating surrounding tissues
May remain localized (in situ) but usually infiltrates other tissues
Capsule
Almost always contained within a fibrous capsule
Capsule does not prevent expansion of neoplasm but does prevent growth by nfiltrations
Capsule advantageous because encapsulated tumor can be removed surgically
Never contained within a capsule
Absence of capsule allows neoplastic cells to invade surrounding tissues
Surgical removal of tumor difficult
Cell characteristics
Usually well differentiated
Mitotic figures absent or scanty
Anaplastic cells absent
Cells function poorly in comparison with normal cells from which they arise
If neoplasm arises in glandular tissue, cells may secrete hormones
Usually poorly differentiated
Large numbers of normal and abnormal mitotic figures present
Cells tend to be anaplastic
Cells too abnormal to perform any physiologic functions
Occasionally a malignant tumor arising in glandular tissue secretes hormnes
Recurrence
Unusual when surgically removed
Common following surgery because tumor cells spread into surrounding tissues
Metastasis
Never occur
Very common
Effect of Neoplasm
Not harmful to host unless located in area where it compresses tissue or obstructs vital organs
Does not produce cachexia (weight loss, debilitation, anemia, weakness, wasting)
Always harmful to host
Causes death unless removed surgically or destroyed by radiation or chemotherapy
Causes disfigurement, disrupted organ function, nutritional imbalances
May result in ulcerations, sepsis, perforations, hemorrhage, tissue slough
Almost always produces cachexia, which leaves person prone to pneumonia, anemia, and other conditions
Prognosis
Very good
Tumor generally removed surgically
Depends on cell type and speed of diagnosis
Poor prognosis if cells are poorly differentiated and evidence of metastatic spread exists
Good prognosis indicated if cells still resemble normal cells and there is no evidence of metastasis
Classification of cancer according to tissue of origin
1. Carcinoma - refers to a tumor that arises from epithelial tissue; the name of
the cancer identifies the location
example: basal cell carcinoma
2. Sarcoma - refers to a tumor arising from supportive tissues; the name of the
cancer identifies the specific tissue affected
example: osteosarcoma
Tissue of Origin
Benign Neoplasms
Malignant Neoplasms
Connective Tissue
Bone
Fibrous tissue
Adipose tissue
Osteoma
Fibroma
Lipoma
Osteosarcoma
Fibrosarcoma
Liposarcoma
Epithelial Tissue
Glandular
Surface
Adenoma
Papilloma
Adenocarcinoma
Squamous cell carcinoma
Hematopoietic
Erythrocytes
Granulocytes
Lymphatic tissue
Erythroleukemia
Leukemia
Hodgkin’s disease, malignant lymphoma
Lymphocytes
Plasma cells
Lymphocytic leukaemia
Multiple myeloma
Cancer Prevention and Control
1. Prevention – involves measures to avoid or reduce exposure to carcinogens
- activities are aimed at interventions before pathologic change has
begun
2. Screening – helps to identify high-risk populations and individuals
3. Early Detection – involves finding a precancerous lesion or a cancer at its earliest,
most treatable stage
- also called secondary prevention
- methods
a. inspection
b. palpation
c. use of tests or procedures
Approaches to Cancer prevention
1. Education
2. regulation – prohibit the sale of tobacco and alcohol to minors, limiting smoking in
public places, imposing excise taxes, regulating the use of
manufactured carcinogens such as asbestos, and prohibiting carcinogens
in foods
3. host modification
- aims to alter the body’s internal environment to decrease the risk of or to
reverse a carcinogenic process
Cancer Prevention
1. Skin: Avoid exposure to sunlight
2. Oral: Annual oral examination
3. Breast: Monthly BSE from age 20
4. Lungs: Avoid cigarette smoking; annual chest x-ray
5. Colon: DRE for person over age 40. Rectal biopsy, proctosigmoidoscopic examination, Guiac stool examination for persons age 50 and above
6. Uterus: annual Pap’s smear from age 40
7. Basic: annual physical examination and blood examination
Dietary Recommendations against cancer
1. Avoid obesity
2. Cut down on total fat intake
3. Eat more high fiber foods – raw fruits and vegetables, whole grain cereal
4. Include food rich in vitamin A and C in daily diet
5. Include cruciferous vegetables in the diet-brocolli, cabbage, cauliflower, brussel sprouts
6. Be moderate in the consumption of alcoholic beverages
7. Be moderate in the consumption of salt-cured, smoked-cured and nitrate-cured foods
Recommendations of the American Cancer Society for Early Cancer Detection
1. For detection of breast cancer
a. Beginning at age 20, routinely perform monthly breast self-examination
b. Women ages 20-39 should have breast examination by a healthcare provider
every 3 years
c. Women age 40 and older should have a yearly mammogram and breast
self-examination by a healthcare provider
2. For detection of colon and rectal cancer
a. all persons age 50 and older should have a yearly fecal occult blood test
b. digital rectal examination and flexible sigmoidoscopy should be done every
5 years
c. Colonoscopy with barium enema should be done every 10 years
3. For detection of uterine cancer
a. yearly papanicolao (Pap) smear for sexually active females and any female
over age 18
b. At menopause, high-risk women should have an endometrial tissue sample
4. For detection of prostate cancer
a. beginning at age 50, have a yearly digital rectal examination
b. beginning at age 50, have a yearly prostate-specific antigen (PSA) test
American Cancer Society’s seven warning signs of cancer (uses acronym CAUTION):
1. Change in bowel or bladder habits
2. A sore that does not heal
3. Unusual bleeding or discharge
4. Thickening or lump in breast or elsewhere
5. Indigestions or difficulty in swallowing
6. Obvious change in wart or mole
7. Nagging cough or hoarseness
Diagnostic tests of Cancer
1. Biopsy/cytology
a. Histologic and cytologic examination of specimens are performed by the
pathologist on tissues collected by needle aspiration of solid tumors, exfoliation
from epithelial surface, and aspiration of fluid from blood or body cavities
b. Tissues may be obtained by excisional biopsy, incisional biopsy, and needle
biopsy
c. By examination of these tissues, the name, grade, and stage of the tumor can be
identified
2. Papanicolao Test (Pap Smear)
Class I: Normal
Class II: Inflammation
Class III: Mild to moderate dysplasia
Class IV: Probably malignant
Class V: Malignant
3. Ultrasound
4. MRI
5. X-rays
6. CT scan
7. Radiographic techniques
8. Antigen Skin test
9. Laboratory tests
a. Alpha-feto-protein
b. HCG
c. Prostatic Acid Phosphatase (PSA)
d. Carcinoembroyenic antigens (CEA)
10. Endoscopic examination
11. Monoclonal antibodies
C. Tumor markers
1. Tumor markers are protein substances found in the blood or blody fluids
2. Are released either by the tumor itself, or by the body as a defense in response to
the tumor (called host response)
3. Tumor markers are derived from the tumor itself. And include the ff:
a. Oncofetal antigens, present normally in fetal tissue, may indicate an
anaplastic process in tumor cells; carcinoembyonic antigen (CEA)
and alpha-fetoprotein (AFP) are examples of oncofetal antigens.
b. Hormones are present in large quantities in the human body;
however, high levels of hormones may indicate a hormone-secreting
malignancy; hormones that may be utilized as tumor markers include
the antidiuretic hormone (ADH), calcitonin, catecholamines, human
chorionic gonadotropin (HCG), and parathyroid hormone (PTH)
c. Isoenzymes that are normally present in a particular tissue may be
released into bloodstream if the tissue is experiencing rapid,
excessive growth as the result of tumor; are examples include
neuron-specific enolase (NSE) and prostatic acid phosphatase (PAP)
d. Tissue-specific proteins identify the type of tissue affected by
malignancy; an example of a tissue-specific protein is the protastic-
specific antigen (PSA) utilized to identify prostate cancer
4.Host-response tumor makers include the following:
a. C-reactive protein
b. Interleukin-2
c. Lactic dehydrogenase
d. Serum Ferritin
e. Tumor necrosis factor
Staging
1. The TNM tumor system is utilized for classifying tumors
a. T indicates the tumor size
1) T0 indicates no evidence of tumor
2) Tis indicates tumor in situ
3) T1,T2,T3,T4 indicate progressive degrees of tumor size and involvement
b. N indicates lymph node involvement
1) N0 indicates no abnormal lymph nodes detected
2) N1a, N2a indicate regional nodes involved with increasing degree from
N1a to N2a, no metastases detected
3) N1b, N2b, N3b indicate regional lymph nodes involvement with increasing
Degree from N1b to N3b, metastasis suspected
4) Nx indicates inability to assess regional nodes
c. M indicates distant metastases
1) M0 indicates no evidence of distant metastasis
2) M1, M2,M3 indicate ascending degrees of distant metastasis and includes
distant lymph nodes
Different Modalities for Cancer
1. Surgical interventions
2. Chemotherapy
3. Radiation therapy
4. Immunotherapy
6. Bone Marrow transplantation
Surgical Intervention
1. Preventive surgery- removal of precancerous lesions or benign tumors
2. Diagnostic surgery- biopsy
3. Curative surgery- removal of an entire tumor
4. Reconstructive surgery – improvement of structures and function of an organ
5. Palliative surgery – relief of distressin signs and symptoms; retardations of metastasis
Common Nursing Techniques and Procedures
A. Radiation therapy
1. Is used to kill a tumor, reduce the tumor size, relieve obstruction, or decrease
pain
2. Causes lethal injury to DNA, so it can destroy rapidly multiplying cancer cells,
as well as normal cells
3. Can be classified as internal radiation therapy (bachytherapy) or external
radiation therapy (teletherapy)
B. The client undergoing brachytheraphy ( internal radiation)
1. Sources of internal radiation
a. Implanted into affected tissue or body cavity
b. Ingested as a solution
c. Injected as a solution into the bloodstream or body cavity
d. Introduced through a catheter into the tumor
2. Side effects of internal radiation
a. Fatigue
b. Anorexia
c. Immunosuppression
d. Other side effects similar to external radiation
3. Priority nursing diagnoses: Impaired tissue integrity; fatigue; anxiety; risk for
infection; Social isolation; Imbalanced nutrition: less than body requirements
4. Client education
a. Avoid close contact with others until treatment is completed
b. Maintain daily activities unless contraindicated, allowing for extra rest
periods as needed
c. Maintain balanced diet; may tolerate food better if consumes small,
frequent meals
d. Maintain fluid intake ensure adequate hydration (2-3 liters/day)
e. If implant is temporary, maintain bedrest to avoid dislodging the implant.
f. Excreted body fluids may be radioactive; double-flush toilets after use
g. Radiation therapy may lead to bone marrow suppression
5. Nursing management of client receiving internal radiation
a. Exposure to small amounts of radiation is possible during close contact with
persons receiving internal radiation: understand the principles of protection
from exposure to radiation: time, distance, and shielding
1) Time: minimize time spent in close proximity to the radiation
source; a common standard is to limit contact time to 30 minutes
total per 8-hour shift; minimum distance of 6 feet used when
possible
2) Distance: maintain the maximum distance possible from the
radiation source
3) Shielding: use lead shields and other precautions to reduce exposure
to radiation
b. Place client in private room
c. Instruct visitors to maintain at least a distance of 6 feet from the client and
limit visitors to 10-30 minutes
d. Ensure proper handling and disposal of body fluids, assuring the containers
are marked appropriately
e. Ensure proper handling of bed linens and clothing
f. In the event of a dislodged implant, use long-handled forceps and place the
implant into a lead container; never directly touch the implant
g. Do not allow pregnant woman to come into any contact with radiation
sources; screen visitors and staff for pregnancy
h. If working routinely near radiation sources, wear a monitoring device to
measure exposure
i. Educate client in all safety measures
6. Evaluation: client demonstrates measures to protect others from exposure to
radiation, identifies interventions to reduce risk of infection, remains free from
infection, achieves adequate fluid and nutritional intake, and participates in
activities of daily living (ADLs) at level of ability
C. The client undergoing external radiation therapy (teletheraphy)
1. The radiation oncologist marks specific locations for radiation treatment using
a semipermanent type of ink
a. Treatment is usually given 15-30 minutes per day, 5 day per week, for 2-7
weeks
b. The client does not pose a risk for radiation exposure to other people
2. side effects of external radiation therapy
a. Tissue damage to target area (erythema, sloughing, hemorrhage)
b. Ulcerations of oral mucous membranes
c. Gastrointestinal effects such as nausea, vomiting, and diarrhea
d. Radiation pneumonia
e. Fatigue
f. Alopecia
g. Immunosuppression
3.Priority nursing diagnoses: risk for infection; impaired skin integrity; social
isolation; disturbed body image; anxiety; fatigue
4. Client education exam for external radiation
a. Wash the marked area of the skin with plain water only and pat skin dry; do not use soaps, deodorants, lotions, perfumes, powders or medications on the site during the duration of the treatment; do not wash off the treatment site marks
b. Avoid rubbing, scratching, or scrubbing the treatment site; do not apply extreme temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor
c. Wear soft, loose-fitting over the treatment area
d. Protect skin from sun exposure during the treatment and for at least 1 year after the treatment is completed; when going outdoors, use sun-blocking agents with sun protector factor (SPF) of at least 15
e. Maintain proper rest, diet, and fluid intake as essential to promoting health and repair of normal tissues
f. Hair loss may occur; choose a wig, hat, or scarf to cover and protect head (refer to care of client with alopecia later in chapter)
5. Nursing management of the client receiving external radiation
a. Monitor for adverse side effects of radiation
b. Monitor for significant decreases in white blood cell counts and platelet
counts
c. Client teaching (refer to later sections for management of
immunosuppression, thrombocytopenia
6. Evaluation; client identifies interventions to reduce risk of infection, remains
free from infection, achieves adequate fluid and nutritional intake, participates
in activities of daily living (ADLs) at level of ability, and maintains intact
skin.
The Client Undergoing a Bone Marrow Transplant (BMT)
1. BMT – used in the treatment of leukemias, usually in conjunction with radiation or chemotherapy
a. Autologous BMT – the client is infused with own bone marrow harvested
during remission of disease
b. Allogenic BMT – the client is infused with donor bone marrow harvested
from a healthy individual
2. The bone marrow is usually harvested from the iliac crest, then frozen and stored until transfusion
3. Before receiving the BMT, the client must first undergo a phase of immunosuppressive therapy to destroy the immune system, infection, bleeding, and death are major complications that can occur during this conditioning phase
4. After immunosuppression, the bone marrow is transfused intravenously through a central line
5. Side of BMT
a. malnutrition
b. infection related to immunosuppression
c. bleeding related to thrombocytopenia
6. Priority Nursing Diagnoses
a. Risk for infection
b. Risk for hemorrhage
c. Risk for imbalanced nutrition
d. Social isolation
e. Anxiety
7. Nursing Management of client undergoing a bone marrow transplant
a. Monitor for graft-versus-host disease
b. Provide private room for the hospitalized client; client will be hospitalized for
6-8 weeks
c. Encourage contact with significant others by using telephone, computer, and
other means of communication to reduce feelings of isolation
d. Refer to management for imbalanced nutrition, immunosuppression and
thrombocytopenia
8. Evaluation: client evaluates understanding of risks and participates in activities that
reduce risk of infection, hemorrhage, and malnutrition; client demonstrates
effective coping mechanisms
The Client Undergoing other therapeutic interventions
1. Immunotherapy/biologic response modifiers (BMR)
a. Enhances the person’s own immune responses in order to modify the biologic
processes resulting in malignant cells
b. Currently considered experimental in use
c. Monoclonal antibodies: antibodies are recovered from an inoculated animal
with a specific tumor antigen, then given to the person with that particular
cancer type; the goal is: destruction of the tumor
d. Cytokines: normal growth-regulating molecules possessing antitumor abilities
1) Interleukin-2(IL-2) increases immune response effective and
destroys abnormal cells
2) Interferons are substances produced by cells to protect them from
viral infection and replication; interferon-alpha 2b is most
commonly used
3) Hematopoietic growth factors such as granulocyte colony-
stimulating factor (G-CSF) and erythropoietin, balance the
suppression of granulocytes and erythrocytes resulting from
chemotherapy
e. natural killer cells (NK cells) : exert a spontaneous cytotoxic effect on
specific cancer cells; they also secrete cytokines and provide a resistance to
metastasis
2. Gene therapy
a. Current use in investigational
b. Increases susceptibility of cancer cells to the destruction by other treatments;
insertion of specific genes enhances ability of client’s own immune system to
recognize and destroy cancer cells
3. Photodynamic theory
a. Used to treat specific superficial tumors such as those of the surface of
bladder, bronchus, chest wall, head, neck and peritoneal cavity
b. Photofirin, a photosensitizing compound, is administered intravenously where
it is retained by malignant tissue
c. Three days after injection, the drug is activated by a laser treatment which
continues for 3 more days
d. The drug produces a cytotoxic oxygen molecule (singlet oxygen)
e. During intravenous administration, monitor for chills, nausea, rash, local skin
reactions, and temporary photosensitivity
f. Drug remains in tissues 4-6 weeks after injection; direct or indirect exposure
to sun activates drug, resulting in chemical sunburn; educate client to protect
skin from exposure to sun
Oncologic Emergencies: Diagnosis and Management
1. Spinal Cord Compression
a. Occurs secondary to pressure from expanding tumors
b. Early symptoms include back and leg pain, coldness, numbness, tingling,
paresthesias, progression leads to bowel and bladder dysfunction, weakness,
and paralysis
c. Early detection is essential: investigate all complaints of back pain or
neurological changes
d. Treatment is aimed at reducing tumor size by radiation and/or surgery to
relieve compression and prevent irreversible paraplegia; may receive
corticosteroids to reduce cord edema
e. Nursing interventions include early recognition of symptoms, neurological
checks and medication administration
2. Superior vena cava syndrome
a. Compression or obstruction of the superior vena cava (SVC)
b. Usually associated with cancer of the lungs and lymphomas
c. signs and symptoms are the result of blockage of venous circulations of head,
neck, and upper trunk
d. Early signs and symptoms are periorbital edema and facial edema
e. Symptoms progress to edema of neck, arms, and hands, difficulty swallowing,
shortness of breath
f. Late signs and symptoms are cyanosis, altered mental status, headache, and
hypotension
g. Death may occur if compression is not relieved
h. Treatment included high-dose radiation to shrink tumor and relieve symptoms
i.Nursing interventions include:
a. Monitoring vital signs
b. providing oxygen support
c. preparing tracheostomy if necessary
d. initiating seizure precautions
e. administering corticosteroids to reduce edema
3. Disseminated intravascular coagulopathy (DIC)
a. Severe disorder of coagulation, often triggered by sepsis, whereby abnormal
clot formation occurs in the microvasculature; this process depletes the
clotting factors and platelets, allowing extensive bleeding to occur tissue
hypoxia occurs as a result of the blockage of blood vessels from the clots
b. Signs and symptoms are related to decreased blood flow to major organs
(tachycardia, oliguria, dyspnea) and depleted clotting factors (abnormal
bleeding and hemorrhage)
c. Treatment includes anticoagulants to decrease stimulations of coagulation and
transfusion of one or more of the following:
1) fresh frozen plasma (FFP)
2) cryoprecipitate
3) platelets
4) packed RBC
d. Nursing interventions include assessing client, monitoring for bleeding,
applying pressure dressings to venipuncture sites, and preventing risk of
sepsis
e. Mortality for clients experiencing DIC is greater than 70% despite aggressive
treatment
4. Cardiac tamponade
a. Pericardial effusion secondary to metastases or esophageal cancer can lead to
compression of heart, restricting heart movement and resulting in cardiac
tamponade
b. Signs and symptoms are related to cardiogenic shock or circulatory collapse:
anxiety, cyanosis, dyspnea,hypotension, tachycardia,tachypnea,impaired
levels of consciousness, and increased central venous pressure
c. Pericardiocentesis is performed to remove fluid from pericardial sac
d. Nursing interventions
1) administering oxygen
2) maintaining intravenous line
3) Monitoring vital signs
4) hemodynamic monitoring
5) administration of vasopressor agents
COMMON CANCER DISORDERS
I. BREAST CANCER
- unregulated growth of abnormal cells in breast tissue
Etiology and pathophysiology
A. cause is unknown but many risk factors influence development
1. Female gender and white Caucasian race
2. family history of mother or sister with breast cancer
3. medical history of cancer of other breast, endometrial cancer or atypical
Hyperplasia
4. Menarche before age 12 (early) or menopause after age 50(Late)
5. First birth after 30 years of age, oral contraceptive use (early or prolonged),
prolonged use of estrogen replacement therapy
6. Lifestyle factors: high-fat diet, obesity, high socioeconomic status, breast
trauma, smoking, ingesting more than 2 alcoholic drinks daily
7. Exposure to radiation through chest x-ray, fluoroscopy
B. Begins as a single transformed cells and is hormones-dependent; does not
develop in women without functioning ovaries who never received hormones
replacement therapy
C. Most often occurs in ductal areas of breast
D. Noninvasive: does not penetrate surrounding tissues; may be ductal or lobular;
usually diagnosed through mammogram or nipple discharge
E. Invasive: penetration of tumor into surrounding tissue
Manifestations
1. Lump in upper outer quadrant of breast, usually nontender but may be tender
2. dimpling of breast tissue surrounding nipple, or bleeding from the nipple
3. Asymmetry with affected breast being higher
4. Regional lymph nodes swollen and tender
Management
1. Radiation therapy
2. Mastectomy
a) Segmental mastectomy – or lumpectomy; removes the tumor and margin of
breast tissue surrounding the tumor
b) simple mastectomy – removal of the complete breast but no other structures
c) Modified radical mastectomy – removal of the breast and axillary lymph
nodes but chest wall muscles are not resected
d) Radical mastectomy – removal of the breast, axillary lymph nodes and
underlying chest wall muscles
e) Breast reconstruction – may be performed at the time of mastectomy or may
be done at a later time; can be accomplished through submuscular breast
implant, placing an implant after using a tissue expander, using muscles with
intact blood supply from the back or abdomen, or creating a free muscle flap
with the gluteus maximus muscle
3. Medication therapy
a. Tamoxifen (Novadex) interferes with estrogen activity for treating advanced
breast cancer
b. Chemotherapy – when axillary nodes are involved
Care of patient undergoing mastectomy
1. Maintain usual postoperative assessment
2. Begin emotional support before surgery and continue in postoperative period
3. Turn, cough and deep breathe to prevent respiratory complications; restrictive surgical dressing may decrease chest expansion
4. Position client on back or unaffected side
5. Jackson-Pratt drain or Hemovac may be in place to drain fluids that accumulate when lymph nodes are removed
6. Note signs of bleeding on dressing and reinforce pressure dressing as needed
7. Encourage early range of motion exercise to prevent contractures are lymphedema
8. Use unaffected arm only to provide IV fluids and take blood pressure
9. Discharge instructions
a) Use caution when lifting heavy objects with arms on affected side
b) Avoid injury and infection on affected side; wear rubber gloves when
washing dishes and garden gloves when working outside
c) Don’t allow procedures, such as blood pressure or venipunctures on the
affected side
d) Refer client to support group for psychosocial support
B. PROSTATE CANCER
- unregulated growth of abnormal cells in the prostate gland
Etiology/pathophysiology
1. Adenocarcinoma is most common type; high levels of testosterone may play a
Role
2. Usually begins in peripheral tissue on back and sides of the gland
3. Metastasis via lymph and venous changes is common; bony tissue is major
site of distant metastasis- especially pelvic bones and spine
4. Is seen predominantly over 40 years of age
Clinical Manifestations
1. Clients in early stages often show no symptoms; tumor may be found during
digital prostate exam
2. Genitourinary: dysuria, frequency, reduced force of stream, hematuria,
nocturia,abnormal prostate found on DRE
3. Musculoskeletal: back pain, migratory bone pain, bone or joint pain
4. Neurologic: nerve pain, muscle spasms, bowel or bladder dysfunction,
bilateral weakness of lower extremities
5. Systemic: fatique and weight loss
Diagnostic and Laboratory tests
1. Prostate-specific antigen (PSA) levels
2. Transurectal ultrasound (obtained if PSA results are abnormal)
3. tissue biopsy
4. bone scan
5. MRI
6. CT scans to detect metastasis
Therapeutic Management
1. Hormone therapy
2. Radiation therapy
3. Brachy therapy (Radioactive seeds implanted in the prostate)
4. Prostatic cryosurgery
5. Surgery
a) Orchiectomy – decreases androgen production
b) Radical procedures include removal of gland, capsule,ampulla,vas
deferens,seminal vesicles, adjacent lymph nodes, and cuff of bladder
neck
c) Suprapubic prostatectomy – abdominal and bladder incisions to
remove prostate tissue
d) Retropubic prostatectomy – low abdominal incision without opening
bladder
e) Perineal prostatectomy – incision between scrotum and anus
(perineal area)
f) Homium laser – laser treatment; less bleeding, fewer complications
and shorted hospital day
6. Medication therapy
a. estrogen therapy of luteinizing hormone antagonist (Lupron) given
to slow rate of growth and extension of tumor
Nursing Management of Patient Undergoing Prostate Surgery
1. Maintain usual postoperative assessment
2. If dressings are present, monitor for drainage and change as needed
3. Monitor vital signs closely for 24 hours, observing for signs of hemorrhage (frank blood in urine, large blood clots, decreased haemoglobin and hematocrit, tachycardia, and hypotension)
4. IN clients who have a urinary catheter following surgery, traction may be applied against the prostatic fossa to prevent bleeding; the balloon at the tip of the catheter exerts pressure to prevent hemorrhage; the surgeon positions the external end of the catheter by anchoring it tightly to the client’s inner thigh to maintain traction; the catheter should not be repositioned
5. A client who has a large indwelling catheter may feel the urge to void, which results from stimulation of the micturition center, explain to the client that this is a normal sensations; efforts by the client to void or strain will increase the risk of bleeding and aggravate pain
6. Continuous bladder irrigation (CBI) may be ordered on a client postoperatively
a. The purpose of the CBI is to prevent the formation of blood clots
b. If blood clots do form, the urinary catheter will become plugged and prevent
outflow of urine; the obstruction will also cause bladder spasms and pain
c. A key nursing intervention for the client in CBI is to keep the outflow from the
catheter light pink or clear; the rate of administration of the irrigating solution is
therefore titrated to keep the color of the outflow this color and prevent blood
clots from forming; it is essential to calculate intake and output to determine true
urine output
d. Indications that the rate of the irrigations is inadequate include: decreased
outflow from the catheter; bladder spasms; and dark-colored or frankly
bloody drainage
7. Monitor client for signs of hemorrhage;bladder spasms and frank bloody output may indicate bleeding
8. The irrigating solution used during and after surgery may be absorbed causing fluid shifts and dilutional hyponatremia, referred to as TURP syndrome; monitor the client for signs of hyponatremia and bradycardia, nausea and vomiting, monitor serum sodium levels and haemoglobin and hematocrit; in addition, other signs of volume excess will also be evident, including hypertension and confusion
9. If manual irrigations are ordered, maintain sterile technique
10. Medicate as needed for pain
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