University of Southern Philippines Foundation College of Nursing

A Presentation of

Submitted by: Denzo, Eveden V. Barlisan, Bryle Caballes, Kevin Craig Cervantes, Jed

Mrs. Cherylane Sabellano, RN, MAN NCM 106 Clinical Instructor

Introduction
Cervical cancer is one of the most common cancers that affect a woman s reproductive organs. It is the rapid, uncontrolled growth of severely abnormal cells on the cervix, the lower part of the uterus that opens into the vagina. Fortunately, when detected at an early stage, cervical cancer is highly curable. Changes in cervical cells before cancer develops are called dysplasia (dis-PLAY-zha). Pap test screening, when done regularly, is the single most important tool for preventing cervical cancer because it can detect abnormal cervical cell changes before they become cancerous, when treatment is most effective. Various strains of the human papillomavirus (HPV), a sexually transmitted infection, are responsible for most cervical cancer cases. When exposed to HPV, a woman s immune system typically prevents the virus from doing harm. In a small group of women, however, the virus survives for years before it eventually converts some cells on the surface of the cervix into cancer cells. Half of cervical cancer cases occur in women between ages 35 and 55. There are two main types of cervical cancer: squamous cell (epidermoid) cervical cancer and adenocarcinoma cervical cancer. About 75% of all cervical cancer is squamous cell cancer.

Signs and Symptoms

Since abnormal cervical cell changes rarely cause symptoms, it is important to have regular Pap test screening. As cervical cell changes progress to cervical cancer, symptoms may develop. Early cervical cancer generally produces no signs or symptoms. As the cancer progresses, signs and symptoms may appear. Cervical Cancer Symptoms or Signs of Cervical Cancer can be as follows:  Vaginal bleeding after intercourse, between periods or after menopause  Abnormal vaginal discharge containing mucus that may be tinged with blood that may be heavy and have a foul odor  Pelvic pain or pain during sexual intercourse  Significant unexplained change in the menstrual cycle.  Bleeding when something comes in contact with the cervix, such as during sexual intercourse or insertion of a diaphragm.  Anemia because of abnormal vaginal bleeding.  Ongoing pelvic, leg, or back pain.  Urinary problems because of blockage of a kidney or ureter.

 Leakage of urine or fecal content into the vagina because an abnormal opening (fistula) has developed between the vagina and the bladder or rectum.  Weight loss.

Risk Factors
 Human Papillomavirus (HPV): HPV has the strongest link to cervical cancer development. It is an extremely common virus that is transmitted through sexual contact. There are over one hundred different strains of HPV, with most posing no health risk. However, a handful of strains affect the cervix, which could lead to cervical cancer. HPV usually does not present symptoms, so a regular Pap smear is vital to detecting cervical damage caused by HPV.  Smoking: When people think of smoking, lung cancer usually comes to the mind first, not cervical cancer. The carcinogens in cigarettes can cause damage to the cervical cells, possibly leading to cervical cancer. Studies have shown that smoking can accelerate the cervical damage caused by HPV.  Sexual History: Certain sexual behavior may increase your risk of developing cervical cancer. Having many sex partners or having sex with someone who has had many sexual partners may increase your risk of developing HPV, thus possibly developing cervical cancer. Having sex at an early age also increases the risk for cervical cancer. It is thought that having sex with an uncircumcised male may increase your risk as well. Studies have shown that women whose partners were circumcised were less likely to develop cervical cancer.  HIV Infection: Women infected with the human immunodeficiency virus (HIV) are at a greater risk of developing cervical cancer. HIV compromises the immune system, making it harder for the body to ward off an HPV infection. A weakened immune system may also cause cervical cancer to develop at a more rapid pace.  Genetics: Having a family history of cervical cancer may increase the risk for cervical cancer. It is estimated that if an immediate family member, like a mother or sister, has had cervical cancer, the risk is increased two to three times.  Multiple Births: Studies have shown that women who carry seven or more full-term pregnancies are at a higher risk of developing cervical cancer.  Oral Contraceptives: There is a small cervical cancer risk in using birth control pills for longer than five years. Many physicians agree that the benefits of oral contraceptives far outweigh the risks. If you are concerned with the risk of cervical cancer from birth control pills, talk to your doctor.  DES Exposure: Diethylstilbestrol (DES) is a drug used in the past for women who were at high risk of having a miscarriage. It was used between 1940 to 1971. Women born to those who were given DES are at a slight risk of developing a rare form of cervical cancer because of the DES exposure. One out of 1,000 women who were exposed in utero will develop this type of cancer.  Failure to Get Screened Regularly for Cervical Cancer: Women who have regular Pap smears greatly reduce their risk of developing cervical cancer. A Pap smear can detect abnormal cervical changes before they progress to cervical cancer.

Pathophysiology

Cervical Dysplasia     Mild/CIN 1 Moderate/CIN 2 Sever/Cin 3 Carcinoma in SITU

Squamous cell carcinoma at the squamocolumnar junction, near the external end of the cervix.

Spread of squamous cell carcinoma occurs first by direct extension to the:       Vaginal mucosa Enter pelvic wall Lower uterine segment Bladder Parametrium Bowel

CACHEXIA, or general wasting syndrome. This syndrome often accompanies the terminal stage of cervical cancer.

Metastasis occurs mainly through lymphatic spread with some occuring through the circulatory system.

TNM Classification
Cervical carcinoma has its origins at the squamous-columnar junction whether in the endocervical canal or on the portion of the cervix. The precursor lesion is dysplasia or carcinoma in situ (cervical intraepithelial neoplasia [CIN]), which can subsequently become invasive cancer. This process can be quite slow. Longitudinal studies have shown that in untreated patients with in situ cervical

cancer, 30% to 70% will develop invasive carcinoma over a period of 10 to 12 years. However, in about 10% of patients, lesions can progress from in situ to invasive in a period of less than 1 year. As it becomes invasive, the tumor breaks through the basement membrane and invades the cervical stroma. Extension of the tumor in the cervix may ultimately manifest as ulceration, exophytic tumor, or extensive infiltration of underlying tissue including bladder or rectum. In addition to local invasion, carcinoma of the cervix can spread via the regional lymphatics or bloodstream. Tumor dissemination is generally a function of the extent and invasiveness of the local lesion. While cancer of the cervix generally progresses in an orderly manner, occasionally a small tumor with distant metastasis is seen. For this reason, patients must be carefully evaluated for metastatic disease. Pretreatment surgical staging is the most accurate method to determine the extent of disease. Because there is little evidence to demonstrate overall improved survival with routine surgical staging, the staging usually should be performed only as part of a clinical trial. Pretreatment surgical staging in bulky but locally curable disease may be indicated in select cases when a nonsurgical search for metastatic disease is negative. If abnormal nodes are detected by computed tomography scan or lymphangiography, fine-needle aspiration should be negative before a surgical staging procedure is performed. Table 1. Primary Tumor (T) TNM Categories TX T0 Tisb T1 T1ac I IA FIGO Stages Primary tumor cannot be assessed. No evidence of primary tumor. Carcinoma in situ (preinvasive carcinoma). Cervical carcinoma confined to uterus (extension to corpus should be disregarded). Invasive carcinoma diagnosed only by microscopy. Stromal invasion with a maximum depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm. Vascular space involvement, venous or lymphatic, does not affect classification. Measured stromal invasion 3.0 mm in depth and 7.0 mm in horizontal spread. Measured stromal invasion >3.0 mm and 5.0 mm with a horizontal spread of 7.0 mm. Clinically visible lesion confined to the cervix or microscopic lesion >T1a/IA2.

T1a1 T1a2 T1b

IA1 IA2 IB

TNM Categories T1b1 T1b2 T2 T2a T2a1 T2a2 T2b T3 T3a T3b T4

FIGO Stages IB1 IB2 II IIA IIA1 IIA2 IIB III IIIA IIIB IVA Clinically visible lesion 4.0 cm in greatest dimension. Clinically visible lesion >4.0 cm in greatest dimension. Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of vagina. Tumor without parametrial invasion. Clinically visible lesion 4.0 cm in greatest dimension. Clinically visible lesion >4.0 cm in greatest dimension. Tumor with parametrial invasion. Tumor extends to pelvic wall and/or involves lower third of vagina, and/or causes hydronephrosis or nonfunctioning kidney. Tumor involves lower third of vagina, no extension to pelvic wall. Tumor extends to pelvic wall and/or causes hydronephrosis or nonfunctioning kidney. Tumor invades mucosa of bladder or rectum, and/or extends beyond true pelvis (bullous edema is not sufficient to classify a tumor as T4).

Table 2. Regional Lymph Nodes (N) TNM Categories NX N0 N1 IIIB FIGO Stages Regional lymph nodes cannot be assessed. No regional lymph node metastasis. Regional lymph node metastasis.

Table 3. Distant Metastasis (M) TNM Categories M0 FIGO Stages No distant metastasis.

TNM Categories M1

FIGO Stages IVB Distant metastasis (including peritoneal spread, involvement of supraclavicular, mediastinal, or para-aortic lymph nodes, lung, liver, or bone).

Table 4. Anatomic Stage/Prognostic Groups (FIGO 2008) Stage 0b I IA IA1 IA2 IB IB1 IB2 II IIA IIA1 IIA2 IIB III IIIA IIIB T Tis T1 T1a T1a1 T1a2 T1b T1b1 T1b2 T2 T2a T2a1 T2a2 T2b T3 T3a T3b T1 3 IVA IVB T4 Any T N N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 Any N N1 Any N Any N M M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1

Table 5. Carcinoma of the Cervix Uteri Stage I IA IA1 IA2 IB IB1 IB2 II IIA IIA1 IIA2 IIB III IIIA IIIB IV The carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded). Invasive carcinoma, which can be diagnosed only by microscopy with deepest invasion 5 mm and largest extension 7 mm. Measured stromal invasion of 3.0 mm in depth and extension of 7.0 mm. Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension of not >7.0 mm. Clinically visible lesions limited to the cervix uteri or preclinical cancers greater than stage IA.b Clinically visible lesion 4.0 cm in greatest dimension. Clinically visible lesion >4.0 cm in greatest dimension. Cervical carcinoma invades beyond the uterus but not to the pelvic wall or to the lower third of the vagina. Without parametrial invasion. Clinically visible lesion 4.0 cm in greatest dimension. Clinically visible lesion >4.0 cm in greatest dimension. With obvious parametrial invasion. The tumor extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis or nonfunctioning kidney.c Tumor involves lower third of the vagina with no extension to the pelvic wall. Extension to the pelvic wall and/or hydronephrosis or nonfunctioning kidney. The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to stage IV. Spread of the growth to adjacent organs. Spread to distant organs.

IVA IVB

Prognosis by stage
For any type of cancer the prognosis or the outcome of the disease depends on the stage of the cancer. Of all those women diagnosed with cancer of the cervix, about 70% will be alive for 5 years after diagnosis. Younger women have a better survival rate than older women. This is at least partly because the disease in younger women tends to be diagnosed at an earlier stage. The cervical cancer prognosis and survival rate can be studied by stage as follows: Stage 0 This is the earliest stage of cervical cancer before it has become invasive. This stage is also called as a pre-cancerous stage. Because the cells are confined to the outer tissues of the cervix, the cancer cannot spread. Just about every woman diagnosed at this stage will be cured. Stage 1 Stage 1 cervical cancer is often divided into two stages 1A and 1B. Of all those women diagnosed with stage 1A cervical cancer, 95% will be alive for 5 years more. For stage 1B cervical cancer 70 to 90% will be alive for 5 years more. Stage 2

Stage 2 is divided into 2 groups stage 2A and 2B. For all those women diagnosed with stage 2A cervical cancer, on average 70 to 90% will be alive for 5 years more. For stage 2B the figures are slightly lower. 60 to 65% of women will be alive for 5 years more after diagnosis. Stage 3 As it is quiet evident that the survival statistics fall with the more advanced stages of cervical only 30 to 50% live at least five years after a diagnosis. Stage 4 As it is the most advanced stage, and the cancer will have already spread, the survival statistics are lowest for stage 4 cervical cancers. Only 20 to 30% will live 5 years or longer. Other factors affecting the prognosis of cervical cancer are the age and general physical condition of the woman are the common factors. The 5-year survival rates (the chance of still being alive 5 years after the diagnosis) for women with cervical cancer who have appropriate treatment are approximately: * 80 to 85% for tumors limited to the cervix and uterus * 60 to 80% when the upper part of the vagina is involved * 30 to 50% for tumors beyond the cervix and upper vagina, but still in the pelvis * 14% when the cancer has invaded the bladder or rectum or has spread beyond the pelvis Without treatment, or when treatment fails, cervical cancer is fatal within two years for about 95% of women.

Beyond HPV: Cervical Cancer Causes

The following risk factors are thought to increase your risk of developing cervical cancer when you have also been exposed to certain types of HPV:

 Skipping your Pap test. Women who do not have regular Pap tests are more likely to develop cervical cancer, since Pap tests allow doctors to detect and remove abnormal cervical cells before they become cervical

  

cancer. Women who don t get screened are the ones who are at the highest risk of developing cervical cancer, says Dr. del Carmen. Smoking cigarettes. Women who smoke cigarettes are at an increased risk of developing cervical cancer. Smoking has been associated with the body s inability to fight off the HPV virus, says del Carmen, making it a culprit, if not a direct cervical cancer cause. Decreased immunity. People who have conditions that weaken their immune system, such as HIV or AIDS, may be at increased risk of developing cervical cancer. Anyone who is immunocompromised has a more difficult time fighting off the virus, says del Carmen. Prolonged use of the Pill. Women who have used birth control pills for five years or more may be at increased risk for cervical cancer. Having more than four children. Women who have five or more children may have a slightly elevated risk of developing cervical cancer. Having a mother who used DES while pregnant with you. The risk of a rare form of cervical cancer is increased in women whose mothers used diethylstilbestrol, or DES, a hormone given to some women who had previous miscarriages.

Decreasing Your Risk of HPV

The best way to prevent cervical cancer is to avoid getting HPV. There are ways to reduce this risk, including:  Delaying sex until you are older. Postponing the age of first sexual activity decreases the risk of HPV infection.  Limiting your number of sexual partners. Those with more partners are at higher risk.  Using condoms. But keep in mind that condoms are not completely effective in blocking HPV infection, because the HPV is often on skin surfaces not covered by the condom, such as the surrounding genital area or anal area.  Avoiding sex with someone who has had many sexual partners. The more partners, the more likely they are to have HPV.  Getting vaccinated against HPV. Women ages 9 to 26 can be vaccinated against certain types of HPV, including the two types most likely to be cervical cancer causes.

Types of Treatment
A. Surgery y Conization: This type of surgery is a simple procedure which involves removing with a scalpel a cone-shaped piece of cervical tissue where the abnormality is found.

y y

y y y

Laser surgery: This type of operation uses narrow beam of intense light to kill cancerous and precancerous cells. Loop electrosurgical excision procedure (LEEP): This technique uses a wire loop to pass electrical current, which cuts like a surgeon s knife and remove cells from the mouth of the cervix. Cryosurgery: This type of technique involves freezing and killing cancerous and precancerous cells. Hysterectomy: This major surgery involves removal of the cancerous and precancerous areas, the cervix and the uterus. Radical trachelectomy: Women with early-stage cervical cancer may be able to preserve their fertility by having this surgical procedure, which involves removing the cervix and the lower part of the uterus. This type of surgery is performed on women who want to bear children in future. Lymph nodes in the pelvis are also removed during this procedure to determine whether the cancer has spread.

B. Chemotherapy Chemotherapy involves the use of drugs to stop or slow the growth of cancer cells. Chemotherapy may cause side effects, but these often get better or go away when chemotherapy is over. Chemotherapy drugs may be given in several forms, including pills or through an IV (intravenous) injection. Side Effects:  Nausea and vomiting  Loss of appetite and weight  Loss of hair  Diarrhea  Mouth sores  An increased chance of infection (from a shortage of white blood cells)  Bleeding or bruising after minor cuts or injuries (because of a shortage of blood platelets)  Shortness of breath (due to low red blood cell counts)  Fatigue Common Drugs:   Cisplatin is the primary drug used. Carboplatin, Paclitaxel, Topotecan, Gemcitabine, 5-FU, Vinorelbine

C. Radiation Radiation uses high-energy rays (similar to X-rays) to try to kill the cancer cells and stop them from spreading. The rays are aimed at the part of the body where the cancer is.

Treatment options for cervical cancer by stage

The stage of a cervical cancer is the most important factor in choosing treatment. However, other factors that affect this decision include the exact location of the cancer within the cervix, the type of cancer (squamous cell or adenocarcinoma), your age, your overall physical condition, and whether you want to have children. Stage 0 (carcinoma in situ) Although the AJCC staging system classifies carcinoma in situ (CIS) as the earliest form of cancer, doctors often think of it as a pre-cancer. That is because the cancer cells in CIS are only in the surface layer of the cervix they have not grown into deeper layers of cells. Treatment options for squamous cell carcinoma in situ are the same as for other pre-cancers (dysplasia or cervical intraepithelial neoplasia [CIN]). Options include cryosurgery, laser surgery, loop electrosurgical excision procedure (LEEP/LEETZ), and cold knife conization. For adenocarcinoma in situ, hysterectomy is usually recommended. For those who wish to have children, treatment with a cone biopsy may be an option. The cone specimen must have no cancer cells at the edges, and the patient must be closely watched. After the woman has finished having children, a hysterectomy is recommended. A simple hysterectomy is also an option for treatment of squamous cell carcinoma in situ, and may be done if it returns following other treatments. All cases of CIS can be cured with appropriate treatment. However, pre-cancerous changes can recur (come back) in the cervix or vagina, so it is very important for your doctor to watch you closely. This includes follow-up with regular Pap smears and in some instances with colposcopy. Stage IA is divided into stage IA1 and stage IA2

Stage IA1: For this stage you have 3 options * If you still want to be able to have children, first the cancer is removed with a cone biopsy, and then you are watched closely to see if the cancer comes back. * If the cone biopsy doesn t remove all of the cancer (or if you are done having children), the uterus will be removed (hysterectomy). * If the cancer has invaded the blood vessels or lymph vessels, you might need a radical hysterectomy along with removal of the pelvic lymph nodes.

Stage IA2: There are 3 treatment options * Radical hysterectomy along with removal of lymph nodes in the pelvis * External beam radiation therapy plus brachytherapy * Radical trachelectomy with removal of pelvic lymph nodes can be done if you still wants to be able to have children

If you have surgery, the tissue removed will be examined in the laboratory to see if the cancer has spread further than expected. If the cancer has spread to the tissues next to the uterus (called the parametria) or to any lymph nodes, radiation therapy is usually recommended. Often chemotherapy will be given with the radiation therapy. If the pathology report says that the tumor had positive margins, this means that some cancer may have been left behind. This is also treated with pelvic radiation (given with cisplatin chemotherapy). The doctor may advise brachytherapy, as well. Stage IB is divided into stage IB1 and stage IB2

Stage IB1: There are 3 options available: * The standard treatment is a radical hysterectomy with removal of lymph nodes in the pelvis. Some lymph nodes from higher up in the abdomen (called para-aortic lymph nodes) are also removed to see if the cancer has spread there. If cancer cells are found in the edges of the tissues removed (positive margins) or if cancer cells are found in lymph nodes during this operation, radiation therapy may be given, possibly with chemotherapy, after surgery. * The second treatment option is high-dose internal and external radiation therapy. * Radical trachelectomy with removal of pelvic (and some para-aortic) lymph nodes is an option if the patient still wants to be able to have children

Stage IB2: There are 3 options available * The standard treatment is the combination of chemotherapy with cisplatin and radiation therapy to the pelvis plus brachytherapy. * Another choice is radical hysterectomy with removal of pelvic (and some para-aortic) lymph nodes. If cancer cells are found in the lymph nodes removed, or in the margins, radiation therapy may be given, possibly with chemotherapy, after surgery. * Some doctors advise radiation given with chemotherapy (first option) followed by a hysterectomy.

Stage II is divided into stage IIA and stage IIB Stage IIA: Treatment for this stage depends on the size of the tumor. * One choice for treatment is brachytherapy and external radiation therapy. This is most often recommended if the tumor is larger than 4 cm (about 1 inches). Chemotherapy with cisplatin will be given along with the radiation. * Some experts recommend removing the uterus after the radiation therapy is done. * If the cancer is not larger than 4 cm, it may be treated with a radical hysterectomy and removal of lymph nodes in the pelvis (and some in the para-aortic area). If the tissue removed at surgery shows

cancer cells in the margins or cancer in the lymph nodes, radiation treatments to the pelvis will be given with chemotherapy. Brachytherapy may be given as well. Stage IIB: Combined internal and external radiation therapy is the usual treatment. The radiation is given with the chemotherapy drug cisplatin. Sometimes other chemo drugs may be given along with cisplatin.

Stage III and IVA Combined internal and external radiation therapy given with cisplatin is the recommended treatment. If cancer has spread to the lymph nodes (especially those in the upper part of the abdomen) it can be a sign that the cancer has spread to other areas in the body. Some experts recommend checking the lymph nodes for cancer before giving radiation. One way to do this is by surgery. Another way is to do a CT or MRI scan to see how big the lymph nodes are. Lymph nodes that are bigger than usual are more likely to have cancer. Those lymph nodes can be biopsied to see if they contain cancer. If lymph nodes in the upper part of the abdomen (the para-aortic lymph nodes) are cancerous, doctors may want to do other tests to see if the cancer has spread to other parts of the body.

Stage IVB At this stage, the cancer has spread out of the pelvis to other areas of the body. Stage IVB cervical cancer is not usually considered curable. Treatment options include radiation therapy to relieve the symptoms of cancer that has spread to the areas near the cervix or to distant sites (such as the lungs or bone). Chemotherapy is often recommended. Most standard regimens use a platinum compound (such as cisplatin or carboplatin) along with another drug such as paclitaxel (Taxol), gemcitabine (Gemzar), topotecan, or vinorelbine (Navelbine). Clinical trials are testing other combinations of chemotherapy drugs, as well as some other experimental treatments.

Recurrent cervical cancer Cancer that comes backs after treatment is called recurrent cancer. Cancer can come back locally (in the pelvic organs near the cervix) or come back in distant areas (spread through the lymphatic system and/or the bloodstream to organs such as the lungs or bone). If the cancer has recurred in the pelvis only, extensive surgery (by pelvic exenteration) may be an option for some patients. This operation may successfully treat 40% to 50% of patients. (See the

discussion under Surgery in the section, How are cervical cancers and pre-cancers treated? ) Sometimes radiation or chemotherapy may be used for palliative treatment (treatment to relieve symptoms but not expected to cure). If your cancer has recurred in a distant area, chemotherapy or radiation therapy may be used to treat and relieve specific symptoms. If chemotherapy is used, you should understand the goals and limitations of this therapy. Sometimes chemotherapy can improve your quality of life, and other times it can diminish it. You need to discuss this with your doctors. Fifteen percent to 25% of patients may respond at least temporarily to chemotherapy. New treatments that may benefit patients with distant recurrence of cervical cancer are being evaluated in clinical trials. You may want to think about participating in a clinical trial. Cervical cancer in pregnancy A small number of cervical cancers are found in pregnant women. If your cancer is a very early cancer, such as stage IA, then most doctors believe that it is safe to continue the pregnancy to term. Several weeks after delivery, a hysterectomy or a cone biopsy is recommended (the cone biopsy is suggested only for substage IA1). If the cancer is stage IB or higher, then you and your doctor must decide whether to continue the pregnancy. If not, treatment would be radical hysterectomy and/or radiation. If you decide to continue the pregnancy, the baby should be delivered by cesarean section as soon as it is able to survive outside the womb. More advanced cancers, should be treated immediately.

Nursing Management
 Acute pain related to treatment for genital cancer. The patient should verbalize an adequate relief of pain along with the ability to realistically cope with the pain if it is not completely relieved.  Anxiety related to loss of reproductive function and fear of cancer. The patient should be able to recognize the signs of anxiety, demonstrate positive coping mechanisms, and describe a reduction in the level of anxiety experienced.  Altered body image related to surgical changes in genital organs. The patient demonstrates enhanced body image and self-esteem as evidenced by ability to look at, talk about, and care for actual or perceived altered body part function. 1. Promote measure that relieve pain and discomforts

2.

3.

4.

5.

Assess the client s pain rate out any complications of treatment therapy or disease process, provide pain management as needed, and evaluate effectiveness of pain medication. Promote measures to help decrease the client s fatigue and increase activity level y Provide rest periods during the day, especially before and after priority activities y Reassure the client that fatigue commonly results from radiation therapy, chemotherapy, bone marrow transplant, and blood transfusions and is not an indicator for worsening disease Promote measures to enhance body image y Encourage the client to verbalize feelings concerning change in body image y Encourage the client to verbalize concerns about altered image regarding sexuality or sexual concerns and to explore alternatives to her usual expression Promote measures that help the client and family cope effectively with disease process and grieving process y Allow and encourage verbalization of anger, sadness, or resentment Provide nursing interventions for the client undergoing radiation therapy y Explain to the client that external radiation therapy usually is applied by high energy radiograph machines