Healthy Cells

Cells represent the smallest, functional unit of our existence which contains cytoplasm and a nucleus (i.e. metabolism, reproduction, day to day functions) Cells have a specialized function depending on their location in the body.

Cells grow, replicate and repair body organs. The genetic material (DNA/RNA) and your immune system regulate this process.

Things you need to understand

Surface-to-volume

ratio of cells Chemical signals such as growth factors and hormones Contact inhibition Cyclins and cyclin-dependent kinases (Cdks) complexes

Surface-to-volume ratio of cells

The ratio of surface to volume of the cell is very important. A cell get its food and gets rid of wastes through its surface. As a cell increases in size its surface to volume ratio decreases. In other words the cell will reach a point where its surface isn't big enough to feed the volume of the cell or get rid of its wastes fast enough. (Sort of like having an elephant with very small openings on either end.) The amount of DNA and RNA available in a cell can also limit a cell's growth. If a cell tries to grow too large there will simply not be enough time for the DNA to produce enough RNA to code for all the proteins that would need to be made for the cell. (Sort of like having a kitchen for the Army but only one book of recipes to cook from.)

Chemical signals such as growth factors and hormones

Mitogens, which stimulate cell division, primarily by relieving intracellular negative controls that otherwise block progress through the cell cycle. 2.Growth factors, which stimulate cell growth (an increase in cell mass) by promoting the synthesis of proteins and other macromolecules and by inhibiting their degradation. 3.Survival factors, which promote cell survival by suppressing apoptosis.

Contact inhibition
Cell

property where they tend to grow only until they meet other cells. Contact inhibition: cessation of replication of dividing cells that come into contact, as in the center of a healing wound.

Cyclins and cyclindependent kinases (Cdks) complexes

are

a family of protein kinases first discovered for their role in regulating the cell cycle. They are also involved in regulating transcription, mRNA processing, and the differentiation of nerve cells.

Define Cancer
Cancer

is a term used to describe a large group of diseases that are characterized by a cellular malfunction. Healthy cells are programmed to know what to do and when to do it. Cancerous cells do not have this programming and therefore grow and replicate out of control. They also serve no physiological function. These cells are now termed a neoplasm.

Cancer is one of the most common diseases in the developed world: 1 in 4 deaths are due to cancer 1 in 17 deaths are due to lung cancer Lung cancer is the most common cancer in men Breast cancer is the most common cancer in women There are over 100 different forms of cancer

Cancer

Cancer

The division of normal cells is precisely controlled. New cells are only formed for growth or to replace dead ones. Cancerous cells divide repeatedly out of control even though they are not needed, they crowd out other normal cells and function abnormally. They can also destroy the correct functioning of major organs.

What causes cancer?

Cancer

gene. Mutated genes that cause cancer are called oncogenes. It is thought that several mutations need to occur to give rise to cancer Cells that are old or not functioning properly normally self destruct and are replaced by new cells. However, cancerous cells do not self destruct and continue to divide rapidly producing millions of new cancerous cells.

arises from the mutation of a normal

 A factor

which brings about a mutation is called a mutagen. is mutagenic.

A mutagen Any

agent that causes cancer is called a carcinogen and is described as carcinogenic. some mutagens are carcinogenic.

So

Carcinogens

Ionising radiation X Rays, UV light Chemicals tar from cigarettes Virus infection papilloma virus can be responsible for cervical cancer. Hereditary predisposition Some families are more susceptible to getting certain cancers. Remember you cant inherit cancer its just that you maybe more susceptible to getting it.

Benign or malignant?

Benign tumours do not spread from their site of origin, but can crowd out (squash) surrounding cells eg brain tumour, warts. Malignant tumours can spread from the original site and cause secondary tumours. This is called metastasis. They interfere with neighbouring cells and can block blood vessels, the gut, glands, lungs etc. Why are secondary tumours so bad? Both types of tumour can tire the body out as they both need a huge amount of nutrients to sustain the rapid growth and division of the cells.

Tumors

Benign Tumors (noncancerous) Enclosed in a fibrous shell or capsule. Take up space Concerned if they interfere with surrounding tissues or vessels or impede the function of the body.

Malignant Tumors (cancerous) Not usually contained metastasis Invade and emit clawlike protrusions that disrupt the RNA and DNA of normal cells (these cancerous cells act like a virus).

The Development of Cancer

Within

every nucleus of every one of the human body's 30 trillion cells exists DNA, the substance that contains the information needed to make and control every cell within the body. Here is a close-up view of a tiny fragment of DNA.

1. DNA of a normal cell

This piece of DNA is an exact copy of the DNA from which it came. When the parent cell divided to create two cells, the cell's DNA also divided, creating two identical copies of the original DNA.

2. Mutation of DNA

Here is the same section of DNA but from another cell. If you can imagine that DNA is a twisted ladder, then each rung of the ladder is a pair of joined molecules, or a base pair. With this section of DNA, one of the base pairs is different from the original. This DNA has suffered a mutation, either through mis-copying (when its parent cell divided), or through the damaging effects of exposure to radiation or a chemical carcinogen.

3. Genetically altered cell

Body cells replicate through mitosis, they respond to their surrounding cells and replicate only to replace other cells. Sometimes a genetic mutation will cause a cell and its descendants to reproduce even though replacement cells are not needed. The DNA of the cell highlighted above has a mutation that causes the cell to replicate even though this tissue doesn't need replacement cells at this time or at this place.

4. Spread and second mutation

The genetically altered cells have, over time, reproduced unchecked, crowding out the surrounding normal cells. The growth may contain one million cells and be the size of a pinhead. At this point the cells continue to look the same as the surrounding healthy cells. After about a million divisions, there's a good chance that one of the new cells will have mutated further. This cell, now carrying two mutant genes, could have an altered appearance and be even more prone to reproduce unchecked.

5. Third mutation

Not all mutations that lead to cancerous cells result in the cells reproducing at a faster, more uncontrolled rate. For example, a mutation may simply cause a cell to keep from self-destructing. All normal cells have surveillance mechanisms that look for damage or for problems with their own control systems. If such problems are found, the cell destroys itself. Over time and after many cell divisions, a third mutation may arise. If the mutation gives the cell some further advantage, that cell will grow more vigorously than its predecessors and thus speed up the growth of the tumour.

6. Fourth mutation

The new type of cells grow rapidly, allowing for more opportunities for mutations. The next mutation paves the way for the development of an even more aggressive cancer. At this point the tumour is still contained.

7. Breaking through the membrane

The newer, wilder cells created by another mutation are able to push their way through the epithelial tissue's basement membrane, which is a meshwork of protein that normally creates a barrier. The invasive cells in this tumour are no longer contained. At this point the cancer is still too small to be detected.

8. Angiogenesis

Often during the development of earlier stages of the tumour, or perhaps by the time the tumour has broken through the basement membrane (as pictured above), angiogenesis takes place. Angiogenesis is the recruitment of blood vessels from the network of neighbouring vessels. Without blood and the nutrients it carries, a tumour would be unable to continue growing. With the new blood supply, however, the growth of the tumour accelerates; it soon contains thousand million cells and, now the size of a small grape, is large enough to be detected as a lump

9.Invasion and dispersal

The tumour has now invaded the tissue beyond the basement membrane. Individual cells from the tumour enter into the network of newly formed blood vessels, using these vessels as highways by which they can move to other parts of the body. A tumour as small as a gram can send out a million tumour cells into blood vessels a day.

10. Tumour cells travel metastasis

What makes most tumours so lethal is their ability to metastasize -- that is, establish new tumour sites at other locations throughout the body. Secondary tumours. Metastasis is now underway, as tumour cells from the original cancer growth travel throughout the body. Most of these cells will die soon after entering the blood or lymph circulation.

11. Metastasis

To form a secondary tumour, a tumour cell needs to leave the vessel system and invade tissue. The cell must attach itself to a vessel's wall. Once this is done, it can work its way through the vessel and enter the tissue. Although perhaps less than one in 10,000 tumour cells will survive long enough to establish a new tumour site, a few survivors can escape and initiate new colonies of the cancer.

Carcinoma in Situ

Normal

Hyperplasia

Mild dysplasia

Carcinoma in situ (severe dysplasia)

Cancer (invasive)

Education and Supportive Care

Risk Factors (multifactorial)

Exposure to Cancer-causing agents Cellular Mutations (what agents cause this? Environment & Lifestyle agents) Genetics & Hormone exposure (i.e. breast cancer) Occupation and Environment Factors Social and Psychological Factors Chemicals in Food Viral (i.e. herpes, HPV, mononucleosis) create an opportunistic environment Medical Factors

Examples of Human Cancer Viruses

Some Viruses Associated with Human Cancers

Education and Supportive Care

Effects of Cancer

Disruption of Function- can be due to obstruction or pressure Hematologic Alterations: can impair function of blood cells Hemorrhage: tumor erosion, bleeding, severe anemia Anorexia-Cachexia Syndrome: wasted appearance of client

Effects of Cancer

Paraneoplastic Syndromes: ectopic sites with excess hormone production

Parathyroid hormone hypercalcemia secretion of insulin hypoglycemia Antidiuretic hormone (ADH) fluid

retention, HTN & peripheral edema

Adrenocorticotropic hormone (ACTH): cause excessive secretion of cortisone (ie: fluid retention, glucose levels)

Effects of Cancer

Pain: major concern of clients and families associated with cancer Physical Stress: body tries to respond and destroy neoplasm Psychological Stress

Education and Supportive Care

ASSESSMENT

Nursing History
Health History chief complaint and history

of present illness (onset, course, duration, location, precipitating and alleviating factors)
Cancer signs: CAUTION US!

Warning Signs of Cancer

CAUTION US!
Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickenings or lumps Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging or persistent cough or hoarseness Unexplained anemia Sudden unexplained weight loss

Warning Signs of Cancer

Change

in bowel or bladder habits

A person with colon cancer may have diarrhea or

constipation, or he may notice that the stool has become smaller in diameter A person with bladder or kidney cancer may have urinary frequency and urgency

Warning Signs of Cancer

A

sore that does not heal

Small, scaly patches on the skin that bleed or do

not heal may be a sign of skin cancer A sore in the mouth that does not heal can indicate oral cancer

Warning Signs of Cancer

Unusual

bleeding or discharge

Blood in the stool is often the first sign of colon

cancer Similarly, blood in the urine is usually the first sign of bladder or kidney cancer Postmenopausal bleeding (bleeding after menopause) may be a sign of uterine cancer

Warning Signs of Cancer

Thickenings

or lumps

Enlargement of the lymph nodes or glands (such

as the thyroid gland) can be an early sign of cancer Breast and testicular cancers may also present as a lump

Warning Signs of Cancer

Indigestion

or difficulty in swallowing

Cancers of the digestive system, including those

of the esophagus, stomach, and pancreas, may cause indigestion, heartburn, or difficulty swallowing

Warning Signs of Cancer

Obvious

change in a wart or mole

Moles or other skin lesions that change in shape,

size, or color should be reported

Warning Signs of Cancer

Nagging

or persistent cough or hoarseness

Cancers of the respiratory tract, including lung

cancer and laryngeal cancer, may cause a cough that does not go away or a hoarse (rough) voice

Warning Signs of Cancer

Unexplained Sudden

anemia

unexplained weight loss

Physical Assessment

Inspection skin and mucus membranes for lesions, bleeding, petechiae, and irritation

Assess stools, urine, sputum, vomitus for acute or occult bleeding Scalp noting hair texture and hair loss Abdomen for any masses, bulges or abnormalities Lymph nodes for enlargement

Palpation

Auscultation of lung sounds, heart sounds and bowel sounds

Laboratory & Diagnostic Tests

Cancer detection examination Laboratory tests

Complete blood cell count (CBC) Tumor markers identify substance

(specific proteins) in the blood that are made by the tumor

PSA (Prostatic-specific antigen): prostate cancer CEA (Carcinoembryonic antigen): colon cancer Alkaline Phosphatase: bone metastasis
Biopsy

Diagnostic Tests
Determine
X-rays Computed tomography Ultrasounds Magnetic resonance imaging Nuclear imaging Angiography

location of cancer:

 Diagnosis

of cell type:

Tissue samples: from biopsies, shedded

cells (e.g. Papanicolaou (PAP) smear) Cytologic Examination: tissue examined under microscope

 Direct

Visualization:

Sigmoidoscopy Cystoscopy Endoscopy Bronchoscopy Exploratory surgery; lymph node biopsies to

determine metastases

Education and Supportive Care

Cancer Detection and Diagnosis

Early Cancer May Not Have Any Symptoms

Cervical Cancer Screening

Normal Pap smear

Abnormal Pap smear

Breast Cancer Screening

Prostate and Ovarian Cancer Screening

Colon Cancer Screening

Biopsy

Pathology

Proteomic profile

Patients tissue sample or blood sample

Genomic profile

Microscopic Appearance of Cancer Cells

Education and Supportive Care

Tumor Staging and Grading

Staging

determines size of tumor and existence of metastasis Grading classifies tumor cells by type of tissue The TNM system is based on the extent of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of metastasis (M).

Primary Tumor (T) TX T0 Tis T1, T2, T3, T4 NX N0 N1, N2, N3 Primary tumor cannot be evaluated No evidence of primary tumor Carcinoma in situ (early cancer that has not spread to neighboring tissue) Size and/or extent of the primary tumor Regional lymph nodes cannot be evaluated No regional lymph node involvement (no cancer found in the lymph nodes) Involvement of regional lymph nodes (number and/or extent of spread)

Regional Lymph Nodes (N)

Distant Metastasis (M) MX M0 M1 Distant metastasis cannot be evaluated No distant metastasis (cancer has not spread to other parts of the body) Distant metastasis (cancer has spread to distant parts of the body)

Education and Supportive Care

NURSING DIAGNOSES
Acute

or chronic pain Impaired skin integrity Impaired oral mucous membrane Risk for injury Risk for infection Fatigue Imbalanced nutrition: less than body requirements

NURSING DIAGNOSES
Risk

for imbalanced fluid volume Anxiety Disturbed body image Deficient knowledge Ineffective coping Social isolation

OUTCOME IDENTIFICATION
1. 2. 3. 4. 5. 6. 7.

Pain relief Integrity of skin and oral mucosa Absence of injury and infection Fatigue relief Maintenance of nutritional intake and fluid and electrolyte balance Improved body image Absence of complications

OUTCOME IDENTIFICATION
8. 9. 10.

Knowledge of prevention and cancer treatment Effective coping through recovery and grieving process Optimal social interaction

Education and Supportive Care

IMPLEMENTATION/MANA GEMENT

Prevention and detection

Primary Prevention Reducing modifiable risk factors in the external and internal environment Secondary Prevention

Recognizing early signs and symptoms and seeking prompt treatment Prompt intervention to halt cancerous process

Cancer Prevention
Carcinogenic chemicals Carcinogenic radiation

Cancer viruses or bacteria

Avoid Tobacco
Lung Cancer Risk Increases with Cigarette Consumption

15x

Lung Cancer Risk

10x

5x

Non-smoker

15 30 Cigarettes Smoked per Day

Protect Yourself From Excessive Sunlight

Limit Alcohol and Tobacco

Combination of Alcohol and Cigarettes Increases Risk for Cancer of the 40x Esophagus
Risk Increase 30x 20x 10x

Alcoholic Drinks Consumed per Day

AND
Packs of Cigarettes Consumed per Day

Diet: Limit Fats and Calories

Correlation Between Meat Consumption and Colon Cancer Rates in Different Countries
40 30 Number of Cases (per 100,000 people) 20 10

80

100

200

300

Grams (per person per day)

Diet: Consume Fruits and Vegetables

Avoid Cancer Viruses

HPV Infection Increases Risk for Cervical Cancer

High

Cervical Cancer Risk

Low

Noninfected women

Women infected with HPV

Avoid Carcinogens at Work

Some Carcinogens in the Workplace

Industrial Pollution

Incidence of Most Cancers

1930

1950

Year

1970

1990

Back

Education and Supportive Care

 Classifications
Carcinomas Sarcomas Lymphomas Leukemias

Types of Cancer
of Cancer

Lung

Cancer

Killed 164,000 in 2000 Prevention-researchers theorize: 90% of all lung

cancers could be avoided by not smoking

An Overview of Cancer
Cellular

Change/Mutation Theories

Spontaneous errors External agents Oncogenes

Risks

for Cancer-Lifestyle

Smoking among greatest Nutrition/exercise

Factors Believed to Contribute to Global Causes of Cancer

Figure 13.1

What Causes Cancer?

Biological

Factors

Genetic predisposition Reproductive and hormonal risks

What Causes Cancer?

Occupational

and Environmental Factors

Asbestos, nickel, chromate Radioactive substances

Social

and Psychological Factors

Stress Decrease negative emotions

 Chemicals

What Causes Cancer?

in Food
Sodium nitrate Clostridium botulism

Viral

Factors

Herpes-related virus and human papillomavirus

Medical

Factors

Diethylstibestrol (DES) Chemotherapy

Table 13.1

Types of Cancer
Breast

Cancer

One in 8 women Risk increases with age Risk factors supported by research Prevention (self-exam and mammography) See figure 13.3 for self-examination procedure Treatment

Breast Self-Examination

Figure 13.3

Types of Cancer
Colon

and Rectum Cancer

3rd most common in men and women 135,400 in 2001 diagnosed Warning signals, e.g. blood in the stool, rectal bleeding

Prostate

Cancer

Most common in males today 189,000 new cases will be diagnosed in 2002 Estimated 30,200 men will die

Types of Cancer
Skin

Cancer: Sun Bathers Beware

1.3 million cases of skin cancer Treatable: basal or squamous Virulent: malignant melanoma ABCD rule about melanoma

What

are some ideas about the use of sunscreen?

Types of Cancer
Testicular

Cancer

Ages 17-34 at greatest risk Cause is unknown Undescended testicles present a great risk How and when should men examine their testicles?

(see Figure 13.4)

Testicular SelfExamination

Figure 13.4

Types of Cancer
Ovarian

Cancer

4th leading cause of death in young women Enlargement of abdomen common sign Prevention: annual pelvic exams

Endometrium

(Uterine) Cancer

Pap test for early detection Risk: early onset of intercourse Warning: abnormal bleeding

Types of Cancer
Cancer

of the Pancreas

Silent disease 29,700 cases in 2002 Only 4% survive Contributors: inflammation, diabetes, high-fat diet

Types of Cancer
Leukemia
Cancer of blood-forming tissues Leads to the creation of immature white blood cells Symptoms: fatigue / paleness / weight loss Can be acute or chronic

Education and Supportive Care

TREATMENT MODALITIES
Aimed

towards:

CURE - free of disease after treatment

normal life Control - Goal for chronic cancers Palliative Care: Quality of life maintained at highest level for the longest possible time

Surgery surgical removal of tumors; most commonly used treatment

Preventive or prophylactic Diagnostic surgery Curative surgery Reconstructive surgery Palliative surgery

Chemotherapy use of antineoplastic drugs to promote tumor cell death, by interfering with cellular functions and reproduction

 Radiotherapy

directing high-energy ionizing radiation to destroy malignant tumor cells without harming surrounding tissues
Teletherapy (external): radiation delivered in

uniform dose to tumor Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it

 Immunotherapy

use of chemical or microbial agents to induce mobilization of immune defenses. response modifiers (BRMs) use of agents that alters immunologic relationship between tumor and host in a beneficial way

Biologic

 Bone

marrow peripheral stem cell transplantation aspirating bone marrow cells from compatible donor and infusing them into the recipient therapy transfer of genetic materials into the clients DNA

Gene

NURSING MANAGEMENT
1.

Promote measures that relieve pain and discomfort.

Pharmacologic and non-pharmacologic interventions

1. 2. 3.

Promote measures to maintain intact skin integrity Promote measures that maintain oral mucosa Promote measures to prevent injury from abnormal bleeding
Monitor platelet count; avoid aspiring products,etc

NURSING MANAGEMENT
5.

Promote measures that identify and prevent infection

Monitor WBC count; encourage frequent handwashing and overall cleanliness

6. 7.

Help decrease the clients fatigue and increase his activity level Promote measures that ensure adequate nutritional intake
High protein, high calorie diet

6.

Ensure adequate fluid and electrolyte balance

NURSING MANAGEMENT
9.

Promote measures to enhance body image.

Take an honest gentle, caring approach; encourage client to express and verbalize feelings

Promote measures that address preventing complications of cancer therapy 10. Instruct client and family about the disease process and treatments; provide necessary information for self-care. 11. Help client and family cope effectively 12. Promote measures to reduce social isolation.
9.

Education and Supportive Care

What are Potential Routes of Exposure?

Direct

contact: skin and mucous membrane contact and absorption, inhalation, ingestion of contaminated foods, accidental needle stick. contact: via body fluids and excreta of clients within 48 hours of antineoplastic administration

Indirect

What are Potential Effects of Exposure to Hazardous Drugs?

Short term: within a few days or hours of exposure-contact dermatitis, alopecia (hair loss), local skin or mucous membrane irritation, blurred vision, allergic responses, dizziness, GI tract problems, headache Long term: occur within months or years after exposure- liver damage, chromosomal abnormalities, increased risk of cancer, reproductive risks

How to Limit Exposure to Hazardous Drugs: PPEs

During preparation, administration, and disposal of hazardous drugs, personal protective equipment should be worn, appropriate to the situation: Gloves: good quality, powder-free, well-fitted, double-glove recommended; change after each use, contamination, damage, or 30 min of continual use. Gown: disposable, long-sleeved, low-permeability, knitted or elastic cuffs, closed front Mask: n-95 particulate mask Goggles or face shield if splashing likely

Preparation

Most institutions, pharmacy does preparation Special training needed Designated area is used for prep Biological safety cabinet ( BSC ) or Hood is used PPEs are worn during prep Disposable, plastic-backed, absorbent pad used under area of prep Special care is used during prep to prevent droplet contamination Crushing or dividing of pill-form should be done in BSC Drugs must be clearly marked in sealed bag for transport

Administration

Wash hands thoroughly before and after drug administration Check dosage and calculations with second nurse Check for adherence to premedication schedule Wear gown and gloves- check for defects Wear mask and eye protection if danger of splash possible (i.e. intracavitary instillation ) Tubing should be primed using plain IV solution Never spike a hanging hazardous drug solution Place absorbent plastic-backed pad under pts arm Use special care with IV pushes- wrap with gauze Treat biologics (i.e. Rituxan, Herceptin) as hazardous- limited occupational exposure data

Disposal of hazardous drugs

All

contaminated materials and PPE used for administration need to be disposed of in puncture-proof, leak-proof container labeled chemo hazardous waste Keep lid closed Wash hands thoroughly Don gloves and wipe down equipment after use

Accidental Spill of Hazardous Drug

In case of a Hazardous spill, spill kit should always be available and staff trained on use. Kit should include: (see example) Cordon off area and inform of spill Don PPEs including booties Absorb liquid spill with spill pad Remove powdered agents with damp disposable towel or pad. Collect any glass fragments using scoop. Dispose of all contaminated materials in a sealed, thick, plastic bag labeled with chemo-warning label, then place in chemo waste bucket.

Client Education

Before start of therapy is ideal- however, teaching is an ongoing process Consider anxiety level Consider educational level and literacy Use more than one method and every opportunity Encourage client to be proactive- ask questions Advocate family/S.O. involvement and inclusion Encourage involvement in local support groups; clients own faith-based support Consider pivotal time for client- may be more receptive to healthy lifestyle changes

Care of Clients Receiving Chemotherapy

Classes

of Chemotherapy Drugs: agents:

Alkylating

Action: create defects in tumor DNA Ex: Nitrogen Mustard, Cisplatin Toxic Effects: reversible renal tubular necrosis

Classes of Chemotherapy Drugs

Antimetabolites:
Action: phase specific Ex: Methotrexate; 5 fluorouracil Toxic Effects: nausea, vomiting, stomatitis,

diarrhea, alopecia, leukopenia

Classes of Chemotherapy Drugs

Antitumor Antibiotics:
Action: non- phase specific; interfere with DNA Ex: Actinomycin D, Bleomycin, adriamycin

(doxorubicin) Toxic Effect: damage to cardiac muscle

Classes of Chemotherapy Drugs

Miotic

inhibitors:

Action: Prevent cell division during M phase

of cell division Ex: Vincristine, Vinblastine Toxic Effects: affects neurotransmission, alopecia, bone marrow depression

Classes of Chemotherapy Drugs

Hormones:
Action: stage specific G1 Ex: Corticosteroids

Hormone Antagonist:
Action: block hormones on hormone- binding tumors ie:

breast, prostate, endometrium; cause tumor regression Ex: Tamoxifen (breast); Flutamide (prostate) Toxic Effects: altered secondary sex characteristics

Chemotherapy Administration
Routes
Oral Body cavity (intraperitoneal or intrapleural) Intravenous
Use of vascular access devices because of threat of

of administration:

extravasation (leakage into tissues) & long-term therapy

Chemotherapy Administration
Types

of vascular access devices:

PICC lines: (peripherally inserted central

catheters) Tunneled catheters: (Hickman, Groshong) Surgically implanted ports: (accessed with 90o angle needle- Huber needles)

There are many types of vascular access devices that may be used in the administration of antineoplastics, supportive therapies, and lab monitoring. Very important to have knowledge and training before using and caring for these devices. Implanted ports: vascular, arterial, epidural, intraperitoneal Hickman or Groshong catheter Picc- peripherally inserted central catheter

Potential complications in Vascular Access Devices

Infection Occlusion Catheter

migration Malposition Catheter Fracture Extravasations Rupture- due to excessive pressure

There are many types of vascular access devices that may be used in the administration of antineoplastics, supportive therapies, and lab monitoring. Very important to have knowledge and training before using and caring for these devices. Implanted ports: vascular, arterial, epidural, intraperitoneal Hickman or Groshong catheter Picc- peripherally inserted central catheter

Potential complications in Vascular Access Devices

Infection Occlusion Catheter

migration Malposition Catheter Fracture Extravasations Rupture- due to excessive pressure

Nursing care of clients receiving chemotherapy

Assess

and manage:

Toxic effects of drugs (report to physician) Side effects of drugs: manage nausea and

vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions

Nursing care of clients receiving chemotherapy

Monitor lab results (drugs withheld if blood counts seriously low); blood and blood product administration Assess for dehydration, oncologic emergencies Teach regarding fatigue, immunosuppression precautions Provide emotional and spiritual support to clients and families

Side Effects : Supportive Care

There are three main areas affected by cytotoxic drugs: 1. Bone Marrow- most blood cells are produced here. Cytotoxics can cause myelosuppression, causing: A. anemia: WHO definition- Males hgb<13, hct<42% Females hgb<12, hct<36% In the oncology setting, tx with Epo is given when hgb<9, hct<30%. Blood transfusion may be needed. New guidelines limit use of Epo to noncurable cancers only Anemia may exacerbate &/or reveal underlying cardiac or pulmonary problems. Assessment critical.

B. Neutropenia: decreased number of circulating neutrophils as seen by an ANC <1000/mm3. Biggest risk of neutropenia is infection and sepsis. In a severely neutropenic client, only sign of infection may be fever. The greater the duration of the nadir, the higher the risk for infection. Tx can include: Neupogen, Neulasta, Leukine, delay of chemotherapy &/or dose reduction. Teaching on neutropenic precautions is critical. Tx is usually held for ANC < 1000/mm3

Calculation of Absolute Neutrophil Count

The absolute neutrophil count (ANC) is calculated by: ANC= %neutrophils + %bands X white blood cells 100 For example, to calculate the ANC of the client with the following counts: neutrophils = 50%, bands=8%, wbcs= 4000. ANC = ( 50% + 8% ) X 4000 ANC= ( 0.5 +0.8 ) X 4000 100 100 ANC= 2320 Infection Risk: ANC= <500 Severe ANC= 500-1000 Moderate ANC= 1000-1500 minimal ANC= 1500-2000 not significant

C. Thrombocytopenia: decrease in circulating platelets below 100,000/mm3. The thrombocytopenic client is at risk for bleeding and potential sequelea. Injections to increase plt count not normally given. May cause delay of tx, dose reduction, need for plt tx. Client teaching on reporting early S/S bleeding, risk factors and need to avoid ASA important. Invasive procedures also should be avoided. Risk factors may include: heavy alcohol or illicit drug use, age >60, previous tx w/chemo or radiation, current meds that can alter platelet production or function.

2.

GI tract- mouth down to rectal area lined with rapidly dividing mucosal cell. Chemo may cause: A. Oral mucositis. Current recommendation is saline rinse with buffer sodium bicarb. Altered taste, xerostomia and fungal infection are also potential mouth problems. B. Esophagitis, gastritis. C. Nausea/vomiting, loss of appetite. Consider emetogenic scale of agent(s) used. Age, previous experiences and culture are factors. D. Diarrhea, constipation

3. Hair Follicles some cytotoxic agents can cause alopecia, either partial or complete. Usually approximately 3-6 weeks after first chemo, hair loss occurs. Growth begins to return about 3-6 weeks after last tx. May regrow with different color or texture. Loss and regrowth generally painless; some clients do report mild soreness to scalp or itching. This can be a very difficult time psychologically for clients, especially women.

Other Effects
There are many other effects cytotoxic drugs may have on healthy tissues, requiring management and supportive care: Cardiac Neurologic Pulmonary Sexual/ reproductive Psychosocial Long-term effects

Fatigue

Surprisingly, fatigue is the most common problem with all classes Also near 100% with radiation treatment Very important to address- QOL issue Recent study found only intervention proven to reduce fatigue is exercise Encourage balanced diet, adequate nutrition, minimize alcohol and caffeine intake. Encourage clients to prioritize tasks, take short rest periods if needed, delegate workload.

Education and Supportive Care

Radiation Therapy
Radiation therapy for the treatment of cancer utilizes high energy particles (X-rays, gamma rays) to disrupt cellular DNA resulting in the biochemical damage of the chemical bonds which hold the DNA strands together. This damage, which leads to cell death (apoptosis), most often occurs during cell division. An estimated 60% of all cancer pt.s will receive some form of radiation treatment at some point in their treatment. Different delivery systems are used, depending on stage and type of disease. Radiation Oncologist and physicist carefully plan client treatment.

External Beam Therapy

Most common delivery system Linear accelerator utilized to deliver ionizing radiation Usually delivered in fractionated doses once per day, five days per week; number of weeks according to treatment plan Client positioned on treatment couch during delivery Client is NOT radioactive in any way after treatment May be given alone or concurrently with chemotherapy

Stereotactic Radiosurgery
Highly

precise method of radiation delivery to small area of tissue Not actually surgery Example: Gamma knife radiation for treatment of brain tumors or metastases. Client is NOT radioactive following this treatment May be used in conjunction with other tx

Brachytherapy
Sealed

source of radiation placed in or near tumor site Utilized when amt. of radiation required exceeds amt. which can be safely delivered through external beam Most commonly temporary, but some implants are inserted permanently. Client is considered radioactive only while source is in place. Body fluids are NOT radioactive since source is sealed.

Radioisotope Therapy
Unsealed

source (radiopharmaceutical

therapy) Depending on tumor type and locale, may be given orally, intravenously or intercavitary. May distribute fairly uniformly or uptake may concentrate in specific organ. Body fluids ARE radioactive; time depends on activity of isotope used.

Radiation Monitoring

Health care workers need to limit exposure to radiation. ALARA- As Low As Reasonably Achievable Personnel monitoring: those working in restricted areas should wear personal monitor device such as film badge. Should NOT be shared. Survey meter (Geiger counter) utilized to survey client, room and items in room to determine safe level after brachytherapy or radiopharmaceutical therapy.

Radiation Safety
Basic to minimizing exposure to radiation is the principle of : Time, Distance and Shielding when working with implant patients. Time- minimize time spent in room. Plan ahead to decrease repeated visits. Work quickly and efficiently while in room. Instruct client also to pool requests and use intercom for communication. Organized system should be used to rotate staff assigned to radioactive clients.

 Distance-

decrease the amount of exposure by increasing the distance between you and source. Doubling the distance from source decreases exposure to one fourth. For example: exposure of 40mrem/hr at one meter decreases to 10 mrem/hr at 2 meters.

 Shielding-

type and thickness of shielding depends on the type of radioactive source used. If a standing lead shield is required, vest will NOT provide protection. Important to stand behind the shield as much as possible while in room. Usually a lead-lined room geographically located away from other rooms is used for radioactive clients.

Goals of Radiation Therapy

Cure- to kill all malignant tumor cells while minimizing doses to normal surrounding tissue. Example: early stage prostate cancer. Control-to limit growth and spread of disease to allow client a symptom-free period of time. Example: NSC lung cancer. Adjuvant- often follows or precedes surgery and/or chemotherapy to ensure local control. Example: breast Palliation- to improve QOL by reducing or relieving symptoms or impending complication caused by metastatic disease. Not expected to increase life-span.

Site Specific Side effects

Site Brain Radiation effect Management Alopecia, late cognitive changes Avoid irritants to scalp, assess neurocognitive function Xerostomia, mucositis, dental carries, dysphagia Soft bland foods, saliva substitutes, analgesics, dental care Head and neck

Chest Abdomen Pelvis

Cough, pneumonitis, late fibrosis Expectorants, corticosteroids Nausea and vomiting Diarrhea, cystitis, infertility, sexual dysfunction Erythema, dry and moist desquamation Antiemetics, bland diet, maintain hydration Maintain hydration, antidiarrheals, fertility and intimacy counseling Avoid trauma; gentle cleansing, protect skin, creams and lotions as prescribed (i.e. steriod cream), avoid extreme temperatures ( i.e. ice or hot packs)

Skin