Description 1.

Cancer is a disease process whereby cells proliferate abnormally, ignoring growth-regulating signals in the environment surrounding the cells 2. Most cancer cells occur in people older than 65 years of age 3. The incidence of cancer is higher in men than in women and higher in industrialized sectors and nations. 1. Cancer produces serious health problems Characteristics of Malignant Cells Self-sufficiency in growth signals Insensitivity to antigrowth signals Tissue invasion and metastasis Limitless potential for replication Sustained angiogenesis Evading apoptosis Patterns of Cell Growth Hyperplasia increase in the number of cells of a tissue; most often associated with periods of rapid body growth Metaplasia conversion of one type of mature cell into another type of cell Dysplasia bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same type of tissue Anaplasia cells that lack normal cellular characteristics and differ in shape and organization with respect to their cells of origin; usually, anaplastic cells are malignant. Neoplasia uncontrolled cell growth that follows no physiologic demand Metastasis Cancer cells move from their original location to other sites.

Common Sites of Metastasis Breast Cancer Bone, Lung Lung Cancer Brain Colorectal Cancer Liver Prostate Cancer Bone, Spine, and Legs Brain Tumors Central Nervous System

Routes of Metastasis 1. Local Seeding 2. Blood-borne metastasis 3. Lymphatic spread Cancer Classification 1. Solid tumors 2. Hematological cancers Grading and Staging Staging determines the size of the tumor and the existence of metastasis. The TNM system is frequently used.

Factors that influence Cancer Development 1. Environmental Factors 1. Chemical carcinogen 2. Physical carcinogen 3. Viral carcinogen

Diagnostic tests Diagnostic tests to be performed depend on the suspected primary or metastatic site(s) of the cancer 1. Biopsy 1. The definitive means of diagnosing cancer and provides histological proof of malignancy. 2. It involves the surgical incision of a small piece of tissue for microscopic examination Types Needle Incisional Excisional Staging 1. Bone marrow examination 2. Chest radiograph 3. Complete blood count 4. Computed tomography scan 5. Cytological studies 6. Liver function studies 7. Magnetic resonance imaging 8. Presence of oncofetal antigens such as carcinoembryonic antigen and alpha fetoprotein 9. Proctoscopic examination 10. Radiographic studies 11. Radioisotope scans

PREVENTION Avoidance of known or potential carcinogens and avoidance or modification of the factors associated with the development of cancer cells. Early Detection Mammography Papanicolaous (Pap) test Stools for occult blood (Guaiac test) Sigmoidoscopy; colonoscopy Breast Self-Examination Testicular Self-Examination Skin inspection

PAIN CONTROL 1. Causes of Pain 1. Bone destruction 2. Obstruction of an organ 3. Compression of peripheral nerves 4. Infiltration/distention of tissue 5. Inflammation/necrosis 6. Psychological, such as fear or anxiety 1. Interventions 1. Assess the clients pain 2. Collaboration with other members of the health care team to develop a pain management program. 3. Pharmacologic Interventions 4. Salicylates, acetaminophen (Tylenol), and nonsteroidal antiinflammatory drugs - Mild or moderate pain 5. Narcotics [codeine sulfate, meperidine (Demerol), morphine sulfate, and hydromorphone hydrochloride (Dilaudid)] for severe pain 6. Monitor vital signs, side effects, and for effectiveness of medications 7. Nonpharmacological techniques of pain control

8. Do not undermedicate the cancer client who is in pain.

SURGERY 1. Surgery is used to diagnose, stage, and treat cancer. 2. Prophylactic Surgery 1. Performed in clients with an existing premalignant condition or a known family history 2. An attempt is made to remove the tissue or organ at risk and thus prevent the development for cancer 1. Curative surgery 1. Control (cytoreductive) surgery 1. A debulking procedure that consists of removing part of the tumor. 2. It decreases the number of cancer cells and increases the chance that other therapies will be successful. 1. Palliative Surgery

1. Performed to improve quality of life during the survival time reduce pain relieve airway obstruction relieve obstructions in the gastrointestinal or urinary tract relieve pressure on the brain or spinal cord prevent hemorrhage remove infected or ulcerated tumors -

or drain abscesses. 1. Reconstructive or rehabilitative surgery is performed to improve quality of life by restoring maximal function and appearance 1. Side effects of surgery 1. Loss or loss of function of a specific body part 2. Reduced function as a result of organ loss 3. Scarring or disfigurement 4. Grieving about altered body image or imposed change in lifestyle.

CHEMOTHERAPY 1. Description 1. Chemotherapy kills or inhibits the reproduction of neoplastic cells and also attacks and kills normal cells. 2. The effects are systemic 3. Normal cells most profoundly affected include those of the skin, hair, and lining of GIT, spermatocytes, and hematopoietic cells. 4. Usually several medications are used in combination (combination therapy) to increase the therapeutic response. 5.Combination chemotherapy is planned to avoid prescribing medications withNadirs. 6. May be combined with other treatments, such as surgery and radiation. 7. The preferred route of administration is intravenously. Side effects

1. Alopecia 2. Anorexia, nausea, and vomiting 3. Mucositis

4. Skin changes 5. Immunosuppression 6. Anemia 7. Thrombocytopenia 8. Low white blood cell count (neutropenia) 9. Infertility Interventions 1. Physiological Integrity 1. Monitor complete blood count (CBC), white blood cell count, platelet count, and electrolytes 2. Initiate bleeding precautions if thrombocytopenia occurs 3. Monitor for petechiae, ecchymosis, bleeding of the gums, and nosebleeds 4. Avoid intramuscular injections and venipunctures as much as possible 5. Initiate neutropenic precautions if the white blood cell count decreases. 6. Monitor for fever, sore throat, unusual bleeding, or signs and symptoms of infection. 7. Inform the client that loss of appetite also may be due to a bitter taste in the mouth from the medications. 8. Monitor for nausea and vomiting 9. Administer antiemetics 10. Encourage hydration 11. Promote a fluid intake of at least 2,000 mL a day. 12. Administer Allupurinol (Zyloprim) as prescribed

Mouth Care for the Client with Mucositis Inspect mouth daily Offer complete mouth care before and after every meal and at bedtime. Brush teeth and tongue with a soft-bristled toothbrush or sponges. Provide mouth rinses every 12 hours Administer topical anesthetic agents to the mouth sores as prescribed. Avoid the use of alcohol- or glycerin-based mouthwashes or swabs. Avoid foods that are hard or spicy. Safe Effective Care Environment

1. Prepare IV chemotherapy in an air-vented space (biohazard cabinet area). 2. Wear gloves, a gown, eye protectors, and a mask when handling IV medications. 3. Pregnant nurses should not prepare or administer IV chemotherapy 4. Discard IV equipment in designated biohazard containers 5. Prepare to administer the antineoplastic medication in short, high-dose, intermittent courses 6. Monitor for phlebitis with IV administration because these medications irritate the veins. 7.Monitor fore x t ra v a s a t io n antidote - sodium thiosulfate, hyaluronidase, and sodium bicarbonate

Health Promotion and Maintenance Instruct the client to: 1. Avoid hot food and high-fiber foods if diarrhea is a problem 2. Inspect the oral mucosa for erythema and ulcers, to rinse mouth after meals and to provide good oral hygiene. 3. Use saline or sodium bicarbonate mouth rinses for mouth sores. 4. Use antifungal medications for mouth sores, if prescribed for the development of a superinfection. 5. Avoid crowds and persons with infections and to report signs of infection 6. Use a soft toothbrush and an electric razor to minimize the risk of bleeding. 7. Avoid aspirin-containing products 8. void alcohol to minimize the risk of toxicity 9. Consult the physician before receiving vaccinations 10. Instruct individuals with colds or infections to wear a mask when visiting or to avoid visiting the client

RADIATION THERAPY 1. Description 1. Radiation therapy destroys cancer cells with minimal exposure of normal cells to the damaging effects of radiation; the cell is damaged, die or become unable to divide. 2. Is effective on tissues directly within the path of the radiation beam.

3. Side efects include skin changes and irritation, alopecia, fatigue, and altered taste sensation; also, the effects vary according to the site of treatment Types of Radiation Therapy 1. Teletherapy 1. Also called beam radiation; the actual radiation source is external to client 2.The client does not emit radiation and does not pose a hazad to anyone else. Client Education Wash area with water or mild soap and water Do not remove the radiation markings from the skin. Use no powders, ointments, lotions, or creams on the area unless prescribed. Wear soft clothing over the area, avoiding belts, buckles, straps, or any clothing that binds or rubs the skin Avoid sun and heat exposure Monitor for moist desquamation (weeping of the skin) If moist desquamation occurs, cleanse the area with warm water and pat dry, apply antibiotic ointment or steroid cream as prescribed, and expose the site to air

1. Brachytherapy 1. The radiation source comes into direct, continuous contact with tumor tissue for a specific time. 2.2. The radiation source is within the client for a period of time, the client emits radiation and can pose a hazard to others 3. Bracytherapy includes an unsealed or a sealed source of radiation. 4. Unsealed radiation source 1. Via the oral or IV route or by instillation into body cavities. 2.The source is not confined completely to one body area, and it enters body fluids and eventually is eliminated via various excreta, which are radioactive and harmful to others; most of the source is eliminated from the

body within 48 hours; then neither the client nor the excreta are radioactive or harmful 3. Sealed radiation source 1. A sealed, temporary or permanent radiation source (solid implant) is implanted within the tumor target tissues 2. b. The client emits radiation while the implant is in place, but the excreta are not radioactive Care of the Client with a Sealed Radiation Source Place the client in a private room with a private bath. Place a caution sign on the clients door. Organize nursing tasks to minimize exposure to the radiation source Nursing assignments to a client with a radiation implant should be rotated. Limit time to 30 minutes per care provider per shift. Wear a dosimeter film badge to measure radiation exposure. A nurse should never care for more than one client with a radiation implant at one time. Do not allow a pregnant nurse to care for the client. Do not allow children under the age of 16 or a pregnant woman to visit the client. Limit visitors to 30-minutes per day; visitors should be at least 6 feetfrom the source Save bed linens and dressings until the source is removed; then dispose of in the usual manner. Other equipment can be removed from the room at any time.

LEUKEMIA 1. Description 2. Leukemia is malignant exacerbation in the number of leukocytes, usually at an immature state, in the bone marrow. 3. It may be acute or chronic

4. It affects the bone marrow 5. The cause is unknown and appears to involve gene damage of cells 6. Risk factors include genetic, viral, immunological, and environmental factors and exposure to radiation, chemicals, and medications. Classification of Leukemia ACUTE LYMPHOCYTIC LEUKEMIA Mostly lymphoblasts present in bone marrow Age of onset is less than 15 years ACUTE MYELOGENOUS LEUKEMIA Mostly myeloblasts present in bone marrow Age of onset is between 15 to 39 years CHRONIC MYELOGENOUS LEUKEMIA Mostly granulocytes present in bone marrow Age of onset is after 50 years

CHRONIC LYMPHOCYTIC Mostly lymphocytes present in bone marrow Age of onset is after 50 years 1. Assessment 2. Anorexia, fatigue, weakness, weight loss 3. Anemia 4. Bleeding 5. Petechiae 6. Prolonged bleeding after minor abrasions or lacerations 7. Elevated temperature 8. Lymphadenopathy and splenomegaly 9. Palpitations, tachycardia, orthostatic hypotension 10. Pallor and dyspnea on exertion 11. Headache 12. Bone pain and joint swelling

13. Normal, elevated, or reduced white blood cell count 14. Decreased hemoglobin and hematocrit levels 15. Decreased platelet count 16. Positive bone marrow biopsy identifying leukemic blast phase cells

1. Infection 1. A major cause of death in the immunosupressed client 2. It can occur through autocontamination or cross-contamination 3. Common sites of infection are the skin, respiratory tract, and gastrointestinal tract. 4. Initiate protective isolation procedures. 5. Ensure frequent and thorough hand washing 6. Ensure that anyone entering the clients room is wearing a mask. 7. Use strict aseptic technique for all procedures. 8. Keep supplies for the client separate from supplies for other clients 9. Limit the number of caregivers entering the clients room 10. Maintain the client in private room 11. Place the client in a room with high-efficiency particulate air filtration or laminar air flow system if possible. 12. Reduce exposure to environmental organisms by eliminating fresh or raw fruits and vegetables 13. Be sure that the clients room is cleaned daily. 14. Assist the client with daily bathing 15. Assist the client to perform oral hygiene frequently 16. Initiate a bowel program 17. Avoid invasive procedures 18. Change wound dressings daily 19. Assess the urine for color and cloudiness. 20. Assess skin and oral mucous membranes for signs of infection. 21. Auscultate lung sounds, and encourage the client to cough and deep breathe. 22. Monitor temperature, pulse, and blood pressure. 23. Monitor white blood cell and neutrophil counts 24. Notify the physician if signs of infection are present, and prepare to obtain specimens for culture of open lesions, urine, and sputum. 25. Administer prescribed antibiotic, antifungal, and antiviral medication 26. Instruct the client - to avoid crowds and those with infections/ - about a low-bacteria diet and to avoid drinking long-standing water - to avoid activities that expose the client to infection - that neither they nor their household contacts should receive immunization with a live virus.

1. Bleeding 2. During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, fewer than 10,000 cells/mm3. 3. Platelet count falls below 50,000 cells/mm3 at risk for bleeding 4. Platelet count is fewer than 20,000 cells/mm3 - spontaneous bleeding and may need platelet transfusion 5. Packed red blood cells - for clients with anemia and fatigue 6. Monitor laboratory values. 7. Examine the client for signs and symptoms of bleeding 8. Handle the client gently 9. Measure abdominal girth 10. Provide soft foods that are cool to warm. 11. Avoid injections 12. Pad side rails and sharp corners of the bed and furniture. 13. Avoid rectal suppositories, enemas, and thermometers. 14. If the female client is menstruating, count the number of pads or tampons used. 15. Instruct the client to use a soft toothbrush and avoid dental floss. avoid blowing the nose. avoid constrictive or tight clothing or shoes. avoid using nonsteroidal anti-inflammatory drugs and products that contain aspirin. 1. Fatigue and Nutrition 2. Assist the client in selecting a well-balanced diet. 3. Provide small, frequent meals (high calorie, high protein, high carbohydrate) that require little chewing. 4. Assist the client in self-care and mobility activities. 5. Allow adequate rest periods during care. 6. Do not perform activities unless they are essential. 7. Administer blood products for anemia as prescribed.

1. Additional interventions 2. Chemotherapy 3. Administer antibiotic, antibacterial, antiviral, and antifungal medications as prescribed. 4. Prepare the client for transplantation as prescribed. 5. Administer colony-stimulating factors as prescribed. 6. Maintain infection and bleeding precautions. 7. Provide an adequate diet. 8. Provide an activity schedule that will conserve energy. 9. Instruct the client in appropriate home care measures. 10. Provide psychosocial support and support services for home care. 1. 1. Induction therapy is aimed at achieving a rapid, complete remission of all manifestations of the disease. 2. Consolidation therapy is administered early in remission with the aim of cure. 3. Maintenance therapy may be prescribed for months or years following successful induction and consolidation therapy; the aim is to maintain remission. HODGKINS DISEASE 1. Description 1. Hodgkins disease (lymphoma) is a malignancy of the lymph nodes that originates in a single lymph node or a single chain of nodes 2. Metastasis occurs to other, adjacent lymph structures and eventually invades nonlymphoid tissue 3.The disease usually involves lymph nodes, tonsils, spleen, and bone marrow and is characterized by the presence of theR e e d - S te rn b e rg cell in the nodes 4. Possible causes include viral infections and previous exposure to alkylating chemical agents. 5. Prognosis depends on the stage of the disease

Staging in Hodgkins Disease Stage I Involvement of a single lymph node region or an extra-lymphatic organ or site

Stage II Involvement of two or more lymph node regions on the same side of the diaphragm or localized involvement of an extralymphatic organ or site StageI I I Involvement of lymph node regions on both sides of the diaphragm Stage IV Diffuse or disseminated involvement of one or more extralymphatic organs with or without associated lymph node involvement

1. Assessment 1. Fever 2. Malaise, fatigue, and weakness 3. Night sweats 4. Loss of appetite and significant weight loss 5. Anemia and thrombocytopenia 6. Enlarged lymph nodes, spleen and liver 7. Positive biopsy of lymph nodes, with cervical nodes most often affected first 8. Presence of Reed-Sternberg cell in nodes 9. Positive computed tomography of the liver and spleen 1. Interventions 1. For stages I and II without mediastinal node involvement, the treatment of choice is extensive external radiation of the involved lymph node regions. 2. With more extensive disease, radiation along with multiagent chemotherapy is used. 3. Monitor for side effects related to chemotherapy or radiation therapy. 4. Monitor for signs of infection and bleeding. 5. Maintain infection and bleeding precautions 6. Discuss the possibility of sterility with the male client receiving radiation, and inform the client of options related to sperm banks. MULTIPLE MYELOMA 1. Description 2. A malignant proliferation of plasma cells and tumors within the bone. 3. An excessive number of abnormal plasma cells invade the bone marrow, develop into tumors, and ultimately destroy bone; invasion of the lymph nodes, spleen, and liver occurs.

4. The abnormal plasma cells produce an abnormal antibody (myeloma protein or the Bence Jones protein) that is found in the blood and urine. 5. Multiple myeloma causes decreased production of immunoglobulin and antibodies and increased levels of uric acid and calcium, which can lead to renal failure. 6. The cause of the disease is unknown. 1. Assessment 2. Bone (skeletal) pain, especially in the pelvis, spine, and ribs. 3. Weakness and fatigue 4. Recurrent infections 5. Anemia 6. Bence Jones proteinuria and elevated total serum protein level. 7. Osteoporosis 8. Thrombocytopenia and granulocytopenia 9. Elevated calcium and uric acid levels 10. Renal failure 11. Spinal cord compression and paraplegia 1. Interventions 2. Provide support care to control symptoms and prevent complications, especially bone fractures, renal failure, and infections 3. Maintain neutropenic and bleeding precautions as necessary. 4. Monitor for signs of bleeding, infection, and skeletal fractures. 5. Encourage fluids up to 3 to 4 L a day 6. Monitor for signs of renal failure. 7. Encourage ambulation 8. Provide skeletal support during moving, turning, and ambulating; provide a hazard-free environment. 9. Administer chemotherapy as prescribed IV fluids and diuretics blood transfusions analgesics 1. Prepare the client for local radiation therapy if prescribed. 2. Instruct the client in home care measures and the signs and symptoms of infection.

TESTICULAR CANCER 1. Description 1. Testicular cancer arises from germinal epithelium from the sperm-producing germ cells or from nongerminal epithelium from other structures in the testicles 2. Testicular cancer most often occurs between the ages of 15 and 40 3. Metastasis occrus to the lung, liver, bone and adrenal glands. Types of Testicular Cancer Germinal Tumors Nongerminal Tumors Seminomas Interstitial cell tumors Nonseminomas Androblastoma 1. Prevention: Routine Testicular self-examination Procedure for TSE 1. The best time to perform this examination is right after a shower when the scrotal skin is moist and relaxed, making the testicles easy to feel. 2. Gently lift each testicle. Each one should feel like an egg, but not hard, and smooth with no lumps. 3. Using both hands, place your middle fingers on the underside of each testicle and your thumbs on top. 4. Gently roll the testicle between the thumb and fingers to feel for any lumps, swelling, or mass. 5. If you notice any changes from one month to the next, notify your physician or nurse practitioner.

1. Assessment 1. Painless testicular swelling occurs. 2. Dragging sensation is evident in the scrotum 3. Palpable lymphadenopathy, abdominal masses, and gynecomastia may indicate metastasis 4. Late signs include back or bone pain and respiratory symptoms

1. Interventions 1. Administer chemotherapy as prescribed 2. Prepare the client for radiation therapy as prescribed for unilateral orchiectomy, if prescribed, for diagnosis and primary surgical management. for radical retroperitoneal lymph node dissection, if prescribed 1. Discuss reproduction sexuality, and fertility information and options with the client. 2. Identify reproductive options such as sperm storage, donor insemination, and adoption. 1. Postoperative Interventions 1. Monitor for signs of bleeding and wound infection, and intake and output 2. Notify the physician if chills, fever, increasing pain or tenderness at the incision site, or drainage of the incision occurs. 3. Instruct the client that he may resume normal activities within 1 week, except for lifting objects heavier than 20 lb or stair climbing. 4. Instruct the client to perform a monthly testicular self-examination on the remaining testicle 5. Inform the client that sutures will be removed 7 to 10 days after surgery

PROSTATE CANCER 1. Description 1. This slow-growing cancer of the prostate gland is usually an androgen-dependent type of adenocarcinoma. 2. The risk increases in men with each decade after age 50. 3. Prostate cancer can spread via direct invasion of surrounding tissues or by metastasis, through the bloodstream and lymphatics, to the bony pelvis and spine 4. Bone metastasis is a concern. 2. Assessment 1. Asymptomatic in early stages 2. Hard, pea-sized nodule palpated on rectal examination 3. Hematuria 4. Late symptoms such as weight loss, urinary obstruction, and pain radiating from the lumbosacral area down the leg. 5. Prostate-specific antigen (PSA) test is not necessarily an indicator of malignancy and use is routine to monitor the clients response to therapy.

6. Spread and metastasis is indicated by elevated serum acid phosphatase. 3. Nonsurgical Interventions 1. Prepare the client for hormone manipulation therapy as prescribed. 2. Administer LH, such as leuprolide acetate(Lupron), flutamide (Eulexin), or diethylstilbestrol (DES), as prescribed 3. Goserelin acetate (Zoladex) may be prescribed for palliation in advanced prostatic cancer when orchiectomy or estrogen admnistration is not acceptable or indicated for the client. 4. Prepare the client for radiation (internal or external)or surgery 5. Prepare the client for administration of chemotherapy in cases of hormone-resistant tumors. 4. Surgical interventions 1. Prepare the client for orchiectomy (palliative) if prescribed 2. Prepare the client for transurethral resection of the prostate (TURP) or prostatectomy if prescribed. 3. Cryosurgical ablation through a liquid nitrogen 1. Transurethral Resection of the Prostate (TURP) 1. The procedure involves insertion of a scope into the urethra to excise prostatic tissue. 2. Bleeding is common following TURP, and monitoring for hemorrhage is an important nursing intervention. 3. Continuous bldder irrigation (CBI) is prescribed postoperatively to maintain the urine at a pink color. 4. Bladder spasms are common following surgery and antispasmodics may be prescribed. 5. Dribbling or incontinence may occur postoperatively 6. Sterility may or may not occur following the surgical procedure.

Postoperative Interventions 1. Monitor v/s, urinary output, and for hemorrhage and clots. 2. Increase fluids to 2400 to 3000 mL a day unless contraindicated. 3. Monitor for arterial bleeding as evidenced by bright red urine with numerous clots 4. Monitor for venous bleeding as evidenced by burgundy-colored urine output 5. Monitor hemoglobin and hematocrit levels. 6. Expect red to light pink urine for 24 hours, turnng to amber in 3 days. 7. Ambulate the client as early as possible and as soon as urine begins to clear in color. 8. Inform the client that a continuous feeling of an urge to void is normal. 9. Instruct the client to avoid attempts to void around the catheter because this will cause bladder spasm. 10. Adminsiter antibiotics, analgesics, stool softeners, and antispasmodics as prescribed. 11. Monitor three-way Foley catheter, which will have a 30-45 mL retention balloon. 12. Maintain CBI with sterile bladder irrigation solution as prescribed to keep the catheter free of obstruction and maintain the urine pink in color.

BREAST CANCER 1. Description 1. Breast cancer is classified as invasive when it penetrates the tissue surrounding the mammary duct and grows in an irregular pattern. 2. Metastasis occurs via lymph nodes. 3. Common sites of matastasis are the bones, lungs, also brain, and liver. 4. Diagnosis is made by breast biopsy through a needle aspiration or by surgical removal of the tumor with microscopic examination for malignant cells.

1. Precipitating factors 1. Family history 2. Early menarche and late menopause 3. Previous cancer of the breast, uterus, or ovaries 4. Nulliparity 5. Obesity 6. High-dose radiation exposure to chest 1. Assessment 1. Mass felt during BSE 2. Mass usually felt in the upper outer quadrant or beneath the nipple 3. A fixed, irregular nonencapsulated mass 4. A painless mass except in the late stages 5. Nipple retraction or elevation 6. Asymmetry, with the affected breast being higher 7. Bloody or clear nipple discharge 8. Skin dimpling, retraction, or ulceration 9. Skin edema or peau dorange skin 10. Axillary lymphadenopathy 11. Lymphedema of affected arm 12. Symptoms of bone or lung metastasis 13. Presence of the lesion on mammography 1. Prevention: Monthly Breast Self-Examination (BSE) 1. Perform 7 to 10 day after menses. 2. Postmenopausal clients or clients who have had a hysterectomy should select a specific day of the month and perform BSE monthly on that day.

1. Nonsurgical Interventions 1. Chemotherapy 2. Radiation Therapy 3. Hormonal manipulation via the use of medication in postmenopausal women or other medications such as tamoxifen (Nolvadex) for estrogen receptor-positive tumors. 1. Surgical interventions 1. Surgical breast procedures with possible breast reconstruction 1. Lumpectomy 1. Tumor is excised and removed 2. Lymph node dissection may also be performed 3. Simple Mastectomy 1. Breast tissue and the nipple are removed 2. Lymph nodes are left intact 3. Modified Radical Mastectomy 1. Breast tissue, nipple, and lymph nodes are removed. 2. Muscles are left intact 3. Halsted Radical Mastectomy 1. Breast tissue, nipple, underlying muscles, and lymph nodes are removed. 2. Oophorectomy for estrogen receptor-positive tumors 3. Ablative therapy with adrenalectomy or chemical ablation, which blocks the production of cortisol, androstenedione, and aldosterone.

1. Postoperative interventions 1. Monitor v/s 2. Position in semi-Fowler position; turn from back to unaffected side, with the affected arm elevated above the level of the heart 3. Encourage coughing and deep breathing.

4. If a drain (usually Jackson-Pratt) is in place, maintain suction and record the amount of drainage and drainage characteristics. 5. Assess operative site for infection, swelling, or the presence of fluid collection under the skin flaps. 6. Monitor incision site for restriction of dressing, impaired sensation, or color changes of the skin. 7. If breast reconstruction was performed, the client will return from surgery with a surgical brassiere and the temporary prosthesis in place. 8. Place a sign above the bed stating No IVs, No Injections, No BPs, No Venipunctures in Affected Arm 9. Provide the use of a pressure sleeve as prescribed if edema is severe. 10. Administer diuretics and provide a low-salt diet as prescribed for severe lymphedema. 11. Consult with the physician and the physical therapist regarding the appropriate exercise program. 12. Assist with exercise as prescribed to decrease lymphedema and muscle weakness. 13. Instruct the clinet about home care measures. 1. Avoid overuse of the arm during the first few months. 2. To prevent lymphedema, keep the affected arm elevated. 3. Provide incision care with lanolin to soften and prevent wound contracture 4. Encourage the client to perform BSE on the remaining breast. 5. Protect the affected hand and arm 6. Avoid strong sunlight to the affected arm 7. Do not let the affected arm hang dependent 8. Do not carry a pocketbook or anything heavy over the affected arm. 9. Avoid trauma, cuts, bruises, or burns to the affected side. 10. Avoid wearing constricted clothing or jewelry on the affected side. 11. Wear gloves when gardening. 12. Use thick oven mitts when cooking 13. Use thimble when sewing. 14. Apply lanolin hand cream several times daily. 15. Use cream cuticle remover 16. Call the physician if signs of inflammation occur in the affected arm. 17. Wear a Medic-Alert bracelet stating lymphedema arm.

CERVICAL CANCER 1. Description 1. Preinvasive cancer is limited to the cervix 2. Invasive cancer is in the cervix and other pelvic structures 3. Metastasis usually is confined to the pelvis, but distant metastasis occurs through lymphatic spread.

1. Precipitating factors 1. Low socioeconimic groups 2. Early first marriage 3. Early and frequent intercourse 4. Multiple sex partners 5. High parity 6. Poor hygiene 1. Assessment 1. Painless vaginal bleeding postmenstrually and postcoitally early sign 2. Foul-smelling or sersanguineous vaginal discharge 3. Pelvic, lower back, leg, or groin pain 4. Anorexia and weight loss 5. Leakage of urine and feces from the vagina 6. Dysuria 7. Hematuria 8. Cytological changes on Papanicolaous test 1. Interventions Nonsurgical 1. Chemotherapy 2. Cryosurgery involves freezing of the tissues by a probe with subsequent necrosis 1. No anesthesia is required, although cramping may occur during the procedure 2. A heavy, watery discharge will occur for several weeks following the procedure 3. Instruct the client to avoid intercourse and the use of tampons while the discharge is present.

4. External lradiation 5. Internal radiation implants (intracavitary) 6. Laser therapy Surgical 1. Conization a cone shaped area of the cervix is removed. It is performed in women who desire further childbearing. 1. The risks of the procedure include hemorrhage, uterine perforation, incompetent cervix, cervical stenosis, and preterm labor in future pregnancies. 2. Hysterectomy 1. Performed for microinvasive cancer if childbearing is not desired. 2. A vaginal approach is most commonly performed. 3. A radical hysterectomy and bilateral lymph node dissection may be performed for cancer that has spread

beyond the cervix but not to the pelvic wall. 4. Pelvic Exenteration a radical surgical procedure performed for recurrent cancer if no evidence of tumor outside the pelvis and no lymph node involvement exists 1. When the bladder is removed, an ileal conduit is created and located on the right side of the abdomen to divert urine. 2. A colostomy may need to be created and is located on the left side of the abdomen for the passage of feces. Types of Pelvic Exenteration 1. Anterior removal of the uterus, ovaries, fallopian tubes, vagina, bladder, urethra, and pelvic lymph nodes 2. Posterior removal of the uterus, ovaries, fallopian tubes, descending colon, rectum, and anal canal 3. Total combination of anterior and posterior

OVARIAN CANCER 1. Description 1. Ovarian cancer grows rapidly, spreads fast, and is often bilateral 2. Metastasis occurs by direct spread to the organs in the pelvis, by distal spread through lymphatic drainage, or by peritoneal seeding 3. Prognosis is usually poor because the tumor usually is detected late. 4. An exploratory laparotomy is performed to diagnose and stage the tumor. 1. Assessment 1. Abdominal discomfort or swelling 2. Gastrointestinal disturbances 3. Dysfunctional vaginal bleeding 4. Abdominal mass 1. Interventions 1. External radiation is used if the tumor has invaded other organs 2. Chemotherapy is used postoperatively for all stages of ovarian cancer 3. Intraperitoneal chemotherapy involves the instillation of chemotherapy into the abdominal cavity 4. Immunotherapy alters the immunological response of the ovary and promotes tumor resistance 5. Total abdominal hysterectomy and bilateral salpingo-oophorectomy may be necessary.

ENDOMETRIAL CANCER 1. Description 1. Endometrial cancer is a slow-growing tumor associated with the menopausal years. 2. Metastasis occurs through the lymphatic system to the ovaries and pelvis; via the blood to the lungs, liver, and bone; or intraabdominally to the peritoneal cavity. 1. Precipating factors 1. History of uterine polyps 2. Nulliparity 3. Polycystic ovary disease 4. Estrogen stimulation 5. Late menopause 6. Family history 1. Assessment 1. Postmenopausal bleeding 2. Watery, serosanguineous discharge 3. Low back, pelvic, or abdominal pain 4. Enlarged uterus in advanced stages 1. Nonsurgical Interventions 1. External radiation or internal radiation is used alone or in combination with surgery, depending on the stage of cancer. 2. Chemotherapy is used to treat advanced or recurrent disease 3. Progestation therapy with medication such as medroxyprogesterone (Depo-Provera) or megestrol acetate(Megace) is used for estrogen-dependent tumors 4. Tamoxifen (Nolvadex), an antiestrogen, also may be prescribed. 1. Surgical interventions: total abdominal hysterectomy and bilateral salpingo-oophorectomy

PANCREATIC CANCER 1. Description 2. Pancreatic cancer is the most common neoplasm affecting the pancreas. 3. Pancreatic cancer is more common in blacks than in whites, in smoker, and in men. 4. The occurrence of pancreatic cancer has been linked to diabetes mellitus, alcohol use, history or previous, smoking, ingestion of high-fat diet, and exposure to environmental chemicals.

5. Symptoms usually do not occur until the tumor is large; therefore the prognosis is poor. 1. Assessment 1. Nausea and vomiting 2. Jaundice 3. Unexplained weight loss 4. Clay-colored stools 5. Glucose intolerance 6. Abdominal pain 1. Interventions 2. Radiation 3. Chemotherapy 1. Whipples procedure, which involves a pancreaticoduodenectomy with removal of the distal third of the stomach, pancreaticojejunostomy, gastrojejunostomy, and choledochojejunostomy 2. Postoperative care measures are similar to care of a client with pancreatitis and the client following gastric surgery.

BLADDDER CANCER 1. Description 2. Bladder cancer is papillomatous growths in the bladder urothelium that undergo malignant changes and that may undergo malignant changes and that may infiltrate the bladder wall. 3. Predisposing factors include cigarette smoking, exposure to industrial chemicals, and exposure to radiation 4. Common sites of metastasis include the liver, bones, and lungs. 5. As the tumor progresses, it can extend into the rectum, vagina, other pelvic soft tissues, and retroperitoneal structures. 1. Assessment 1. Gross, painless hematuria 2. Frequency, urgency, dysuria 3. Clot-induced obstruction 4. Bladder biopsy confirms the diagnosis 1. Radiation 2. Most bladder cancers are poorly radiosensitive and require high doses of radiation. 3. Radiation therapy is more acceptable for advanced disease that cannot be eradicated by surgery. 4. Palliative radiation may be used to relive pain and bowel obstruction and control potential hemorrhage and leg edema caused by venous or lymphatic obstruction

5. Intracavitary radiation may be prescribed, which protects adjacent tissue. 6. External radiation combined with chemotherapy or surgery may be prescribed because the external radiation alone may be ineffective. 7. Complications of radiation 1. abacterial cystitis 2. protitis 3. fistula formation 4. ileitis or colitis 5. bladder ulceration and hemorrhage

1. Chemotherapy 1. Intravesical instillations 1. An alkylating chemotherapeutic agent is instilled into the bladder. 2. This method provides a concentrated topical treatment with little systemic absorption. 3. Chemotherapeutic agents used may include thiotepa, mitomycin (Mutamycin), doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), and bacilli Calmette-Guerin. 4. The medication is injected into a urethral catheter and retained for 2 hours. 5. Following instillation, the clients position is rotated every 15 to 30 minutes, starting in the supine position to avoid lying on a full bladder. 6. After 2 hours, the client avoids in a sitting position and is instructed to increase fluids to flush the bladder. 7. Treat the urine as biohazard and send to the radioisotope laboratory for monitoring 8. For 6 hours following intravesical chemotherapy, disinfect the toilet with household bleach after the client has voided. 1. Systemic chemotherapy 1. Systemic chemotherapy is used to treat inoperable or late tumors. 2. Agents used may include cisplatin (platinol), doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), methotrexate (Folex), and pyridoxine. 1. Complications of chemotherapy 1. bladder irrigation 2. hemorrhagic cystitis 1. Surgical Interventions 1. Transurethral resection of bladder tumor 1. local resection and fulguration (destruction of tissue by electrical current through electrodes placed in

direct contact with the tissue) 2. performed for early tumors for cure of for inoperable tumors for palliation 1. Partial Cystectomy 2. Partial cystectomy is the removal of up to half of the bladder. 3. The procedure is done for early tumors and for clients who cannot tolerate a radical cystectomy.

1. Cystectomy and Urinary diversion 2. The procedure involves removal of the bladder and the urethra in women, and the bladder, the urethra, and usually the prostate and seminal vesicles in men. 3. When the bladder and urethra are removed, permanent urinary diversion is required. 4. The surgery may be performed in two states if the tumor is extensive, with the creation of the urinary diversion first and the cystectomy several weeks later. 5. If a radical cystectomy is performed, lower extremity lymphedema may occurs as a result of lymph node dissection, and impotence may occur in the male client. 1. Ileal conduit The ileal conduit also is called ureteroileostomy or Brickers procedure. 1. Kock Pouch The Kock pouch is a continent internal ileal reservoir created from a segment of the ileum and ascending colon. 1. Indiana pouch A continent reservoir is created from the ascending colon and terminal ileum, making a pouch larger than the Kock pouch. 1. Creation of a Neobladder Creation of a neobladder is similar to the creation of an internal reservoir, with the difference being that instead of emptying through an abdominal stoma, the bladder empties through a pelvic outlet into the urethra.

1. Percutaneous nephrostomy or pyelostomy 2. These procedures are used when the cancer is inoperable to prevent obstruction 3. The procedures involve a percuationeous or surgical insertion of a nephrostomy tube into the kidney for drainage 1. Ureterostomy The ureters are attached to the surface of the abdomen, where the urine directly into a drainage appliance without a conduit. 1. Vesicostomy 2. The bladder is sutured to the abdomen, and a stoma is created in the bladder wall 3. The bladder empties through the stoma. 1. Preoperative Intervention 1. Administer bowel preparation as prescribed 2. Assist the surgeon and the enterostomal nurse in selecting an appropriate skin site for creation of the abdominal stoma. 3. Encourage the client to talk about his or her feelings related to the stoma creation 1. Postoperative Interventions 1. Monitor vital signs. 2. Assess incision site. 3. Assess stoma every hour for the first 24 hours. 4. Monitor for edema in the stoma 5. If the stoma appears dark and dusky, notify the physician immediately.

6. Monitor for prolapse or retraction of the stoma. 7. Assess for return bowel function; monitor for peristalsis, which will return in 3 to 4 days. 8. Maintain NPO status as prescribed until bowel sounds return. 9. Monitor urine flow, which is continuous (30 to 60 mL per hour) following surgery. 10. Notify the physician if the urine output is less than 30 mL an hour if no urine output occurs for more than 15 minutes. 11. Monitor urinary output closely and irrigate catheter (if present) gently to prevent obstruction, as prescribed, with 60 mL of NS. 12. Monitor for hematuria.

13. Monitor for signs of peritonitis. 14. Monitor for bladder distention following a partial cystectomy. 15. Monitor for shock, hemorrhage, thrombophlebitis, and lower extremity lymphedema following a radical cystectomy. 16. Monitor the urinary drainage pouch for leaks, and check skin integrity. 17. Monitor the pH of the urine 18. Instruct the client regarding the potential for urinary tract infection or the development of calculuses. 19. Instruct the client to assess the skin for irritation and to monitor the urinary drainage pouch for any leakage. 20. Encourage the client to express feelings about changes in body image, embarrassment, and sexual dysfunction.

ONCOLOGICAL EMERGENCIES 1. Sepsis and Disseminated Intravascular Coagulation (DIC) 1. Description: The client with an oncological disorder is at increased risk for infection; DIC is caused by sepsis 2. Interventions 1. Maintain strict aseptic technique with the immunocompromised client and monitor closely for infection 2. Administer antibiotics intravenously anticoagulants during the early phase of DIC cryoprecipitated clotting factors, as prescribed, when DIC progresses and hemorrhage is the primary problem. 1. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) 1. Description 1. Tumors can produce, secrete, or stimulate the brain to synthesize antiduretic hormone. 2. Mild symptoms include weakness, muscle cramps, loss of appetite, and fatigue; serum sodium levels range from 115 to 120 mEq/L. 3. More serious signs and symptoms related to water intoxication and include weight gain, personality changes, confusion, and extreme muscle weakness. 4. As the serum sodium level approaches 110 mEq/L seizures, coma, and eventually death will occur, unless the condition is treated

5. Interventions 1. Initiate fluid restriction and increased sodium intake as prescribed 2. Administer demeclocycline (Declomycin) as prescribed, an antagonist to antiduretic hormone 3. Monitor serum sodium levels.

1. Spinal Cord Compression 1. Description 1. Spinal cord compression occurs when a tumor directly enters the spinal cord or when the vertebral column collapses from tumor entry. 2. Spinal cord compression causes back pain, usually before neurological deficits occur 3. Neurological deficits related to the spinal level of compressionand include numbness; tingling; loss of urethral, vaginal, and rectal sensation; and muscle weakness 4. Interventions 1. Assess for back pain and neurological deficits 2. Prepare the client for radiation and/or chemotherapy to reduce the size of the tumor and relieve compression. 3. Surgery may need to be performed to remove the tumor and relieve the pressure on the spinal cord 4. Instruct the client in the use of neck or back braces if they are prescribed. 1. Hypercalcemia 1. Description 1. Hypercalcemia is a late manifestation of extensive malignancy that occurs most often in clients with bone metastasis 2. Decreased physical mobility contributes to or worsens hypercalcemia 3. Early signs include fatigue, anorexia, nausea, vomiting, constipation, and polyuria 4. More serious signs and symptoms include severe muscle weakness, diminished deep tendon reflexes, paralytic ileus, dehydration, and electrocardiogram changes. 5. Interventions 1. Monitor serum calcium level 2. Administer oral or parenteral (NS) fluids as prescribed. 3. Administer medications to lower the calcium level as prescribed. 4. Prepare the client for dialysis if the condition becomes life -threatening or is accompanied by renal impairment

1. Spinal Cord Compression 1. Description 1. Spinal cord compression occurs when a tumor directly enters the spinal cord or when the vertebral column collapses from tumor entry. 2. Spinal cord compression causes back pain, usually before neurological deficits occur 3. Neurological deficits related to the spinal level of compressionand include numbness; tingling; loss of urethral, vaginal, and rectal sensation; and muscle weakness 4. Interventions 1. Assess for back pain and neurological deficits 2. Prepare the client for radiation and/or chemotherapy to reduce the size of the tumor and relieve compression. 3. Surgery may need to be performed to remove the tumor and relieve the pressure on the spinal cord 4. Instruct the client in the use of neck or back braces if they are prescribed. 1. Hypercalcemia 1. Description 1. Hypercalcemia is a late manifestation of extensive malignancy that occurs most often in clients with bone metastasis 2. Decreased physical mobility contributes to or worsens hypercalcemia 3. Early signs include fatigue, anorexia, nausea, vomiting, constipation, and polyuria 4. More serious signs and symptoms include severe muscle weakness, diminished deep tendon reflexes, paralytic ileus, dehydration, and electrocardiogram changes. 5. Interventions 1. Monitor serum calcium level 2. Administer oral or parenteral (NS) fluids as prescribed. 3. Administer medications to lower the calcium level as prescribed. 4. Prepare the client for dialysis if the condition becomes life -threatening or is accompanied by renal impairment

1. Superior Vena Cava Syndrome 1. Description 1. Superior vena cava syndrome occurs when the vein is compressed or obstructed by tumor growth. 2. Signs and symptoms result from blockage of blood flow in the venous system of the head, neck, and upper trunk. 3. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and tightness of the shirt of blouse collar (Stokes Sign) 4. As the condition worsens, edema in the arms and hands, dyspnea, erythema of the upper body, and epistaxis occur 5. Life-threatening signs and symptoms include hemorrhage, cyanosis, mental status changes, decreased cardiac output, and hypotension 6. Interventions 1. Assess for signs and symptoms of superior vena cava syndrome 2. Prepare the client for radiation therapy to the mediastinal area. 1. Tumor Lysis Syndrome 1. Description 1. Tumor lysis syndrome occurs when large quantities of tumor cells are destroyed rapidly and are released into the bloodstream faster than the homeostatic mechanisms of the body can handle them. 2. Tumor lysis syndrome is a positive sign that cancer treatment is effective; however, if left untreated, it can cause severe tissue damage and death. 3. Hyperkalemia and hyperuricemia occur; hyperuricema can lead to acute renal failure. 4. Interventions 1. Encourage oral hydration; IV hydration may be prescribed for the client experiencing nausea 2. Instruct the client regarding the importance of fluid intake during chemotherapy 3. Administer medications that increase the excretion of purines, such as allopurinol (Zyloprim), as prescribed. 4. Prepare to administer IV infusion of glucose and insulin to treat hyperkalemia 5. Prepare the client for dialysis if hyperkalemia and hyperuricemia persist despite treatment