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I. Cancer is unregulated growth of cells; Carcinogens are
agents capable of producing cellular alterations.
II. Complications of Cancer, Radiation and Chemotherapy
A. Hematopoietic System (Nadir)
o Very low in RBC, WBC & platelets = Nadir
o Lowest point someone can be @ once we have
damaged good & bad cells
1. Anemia- reduction in RBC’s
a) Gas Exchange Impairment
b) Dyspnea- Shortness of Breath
c) Activity Intolerance
d) Low WBC, impaired immune system
e) Platelets, No clotting, would bleed/may bleed to death
− Nursing care for depressed red cells:
o Give O2
o Alternate Rest and Activity (RBC, normal 4-6 million -
Low RBC = low Hgb)
o CSF- Colony Stimulating Factor
 Procrit and epogen (exogenous erythropoietin) -
stimulate the bone marrow to produce RBC’s
 Iron, Administer Blood
o End up having to back up off the treatment, we try to
manage the symptoms, cause we don’t want to have to
back off
2. Leukopenia/ granulocytopenia/ neutropenia-  WBC
− Penia = decreased
− At risk for infection (High Risk)
− 5,000 – 10,000 = normal level
− May give granulocytes
− Nursing care for depressed white cells:
o No Flowers
o No Catheter – can introduce bacteria
o Reverse or protective isolation
o S/Sx of infection (Assess very carefully for infection)
o Sputum
o Urine – Should be clear yellow
o Assess puncture sites for any sign or warmth or redness
o Breath sounds
o Temperature ± 101.0 normally, for these patients 99.2
or 99.4

o Should Avoid raw & fresh fruits or vegetables,

everything needs to be cooked.
o Need to drink bottled water
o Nupagen & Neulasta may help make more WBC, but
may cause bone pain
3. Thrombocytopenia = Low Platelets
− Risk for bleeding
− 150,000 – 300,000 to 400,000 = Normal
− 20,000- High risk for bleeding (hemorrhage)
− Less than 10,000 Fatal
− Colony stimulating factors
− Neumega
− Give platelets
− Nursing Care of depressed platelets:
o Very Careful Oral Care, Do not Floss, may not even use
a toothbrush
o First signs of bleeding in:
 Urine, gums, or puncture site
o Stool softeners to prevent strain – can cause BV to burst
in brain, may also rupture a hemorrhoid
o Do not dig out fecal impactions or insert rectal
thermometer, could poke a hole into something
o Electric razors only
o Falls (remove rugs) Safety
o No Catheters
o No Dental work
o Avoid medications that decrease platelet aggregation
 Aspirin
 Excedrin
 Beyer
 BC Powder
 Goodies
o Administer Blood Products – platelets - Neumega
B. GI System
− cells rapidly proliferate, thus affected by chemo &
radiation Chemo will have systemic effect and radiation will
affect area radiated
1. Oral Cavity
a) Stomatitis
− Inflammation of the Stoma (mouth)
− could be ulceration in mouth
− Yeast infection of the mouth

b) Teeth- become loose and fall out = difficulty eating

c) Salivary Glands (Xerostomia—very dry mouth)

− Saliva becomes thick and ropey – difficult to spit out
− can give artificial salvia to thin and moisten mouth

d) Taste Buds- can be impacted

i. Hypogeusia (Hypo-goo-zea)
− alteration in or loss of taste sensation due to
radiation damage to tongue
ii. Dysgeusia (Dis-goo-zea)
− an unpleasant, usually metallic taste
iii. Aguesia (A-goo-zea)
− absence of taste sensation
2. Esophagitis- inflammation of exophagus
− May avoid eating, It’s quite painful
− Yeast Infections in the mouth, thrush, ulcers
− Viscas xelecane- numb mouth and esophagus to help
with intake
− Antifungals to remove yeast infection of the mouth
− Nystatin – treats thrush – Swish & Swallow
NURSING CARE when upper GI affected:
1. Avoid commercial mouth was (alcohol base)
2. Viscas (thickened) xelecane – numb mouth &
esophagus, given prior to meals
3. Oral care ac & pc – Baking Soda to a pint of water or 1
tsp salt to 1 pint of water
4. Artificial salvia
5. High protein, High Carb, High cal Diet (promide – protein
supplement) High Vitamins
6. Avoid Temp extremes
7. Determine preferred foods and drinks
8. Vitamin C, E, Zinc- helps with healing process, will get
9. Small frequent meals, may do better than 3 big meals
10. Tube feedings (NG, PEG Tube) may need
11. Total Parenteral Nutrition (TPN orHyperalamentation) IV
Fluid that has amino acids, electrolytes, and glucose
through a central line. (Procalamine – milder not
hypotonic) through a central line or a PICC line
12.Antibiotic and pain meds
3. Abdomen
a) Nausea and Vomiting- earliest most common SE
− Steroid treatments- anti-inflammatory
− Can get Acute gastritis

− High Risk for Aspiration

b)Abdominal cramping and diarrhea
− Low residue diet – residue = Avoid salads & Fiber
− Drugs- lomotil- slow GI motility
− Loose a lot of bicarb = metabolic acidosis
c) Constipation
− Due to low intake
− Hypokalemia- taking in little fluids
−  activity
− Fluids & fiber
d) Cachexia
− severe wasting ( HIV patients, End stage renal
failure, Alzheimer’s patients) They are extremely
thin, thay are literally starving to death
e) Intestinal obstructions
− NG Tubes, Suction after eating
1. Antiemetics (around the clock as ordered) normally 1
hour before chemo, BE PROACTIVE
2. Nonirritating low residue diets
3. Maintain fluids (Oral/IV)
4. I and O’s
5. Seitz bath (raw butt, from diarrhea) zinc oxide (couple a
times a day)
6. Do not wear irritating fragrances around patient
7. Frequent weights, monitor weights to keep patient
supplemented so that they don’t loose weight
8. Steroids (anti-inflammatory) given to prevent N/V, N/v is
a SE from inflammation in GI tract, so therefore we now
can give steroids
4. Skin Toxicity
a) Hyperpigmentation-  stimulation of the melanin in
the cells (color change) discolorations on their skin
b) Photosensitivity--acceleration of the tanning process
caused by the sun = they burn quickly
c) Erythematous skin rashes--due to dilation of blood
vessels in the skin
− Red Rashes
d) Desquamation due to radiation:
i. Dry desquamation
− Dry, flaky, itchy, irritated areas
− Keep moist with unscented, non-alcohol lotion
ii. Moist desquamation

− Skin breaks down and skin becomes leaky

− Keep clean & dry
iii. * Keep both clean – Normal saline- Peroxide
solution 1:1 mixture, use with a sterile sponge
e) Radiation recall
− Burn and shrink tumors
− Radiation burns skin but it eventually heals & they
are put on chemo and the skin breaks down again
− Chemo can cause it to recall
− Pain, high risk for infection
f) Alopecia
− Hair loss
− After therapy hair will grow back
− They need to determine what they will do about
their hair before it is gone (wigs, scarf’s, etc…)
g) Tissue Extravasation (more later)
− Chemo (drug) has infiltrated and going into tissue
− Causes severe tissue damage
− Vesicant Chemo(will cause necrosis & death in
tissues) - Never given in a peripheral line, Needs
to be given in a central line
− Central Lines
1. PIC Line- Midline - anticubital space
2. PICC Line - much longer
a) Protect from extremes of temperature
b) Don’t want pressure or trauma to area
c) Don’t massage area
d) Avoid the sun
e) Avoid products with alcohol & perfume
f) Loose Soft clothing
g) Tissue extravasation method
5. Head
− Cerebral edema
− Caused by Radiation
− Keep head of bed elevated – enhance venous flow
away from head
− Superior vena cava syndrome – Tumor in neck, head or
upper chest, it impairs blood flow away from the
superior vena cava = swelling, puffy face, changes in
6. Chest
− Esophagitis, Pneumonitis (Inflamed lungs),
pulmonary fibrosis (Hardening of the lungs)

− Impaired compliance & elastic recoil

a) Turn, Deep breath, and Cough (Incentive
b) Fluids (Oral)
c) Antitussive- Judiciously
d) May need O2 (FIO2)
e) Alternate Rest and Activity
f) Steroids/Bronchodilators
g) Expectorants
7. Pelvis
− Cervix, endometrium, prostate, bladder, rectum
− External beam and internal implants utilized;
− SE include diarrhea, cystitis, vaginal, urethral, &
rectal stenosis, sexual dysfunction as a result of bowel,
bladder, & gonad irritation.
− Sexual Function--radiation to pelvis whether by
external beam or internal implant can:
a) Narrow the walls of the vagina (teach about
vaginal dilator and encourage continuing
sexual intercourse, if desired, to keep
vaginal walls open and flexible)
b) Decrease vaginal secretions (teach to use
c) Inflame and scar vagina
d) Partial or permanent sterility in males (sperm
banking also in females so egg banking)
e) Ovarian function can be eradicated totally
f) Premature menopause
g) Loss of libido
h) Fatigue and weakness
− NURSING CARE for Pelvic Complications:
a) Shielding, can use shield if you’re trying to radiate
b) Birth control while on chemo or radiation & up to 5
years after
c) May need sperm bank or egg banking if treatment
can make them sterile
8. Renal Toxicity
− Risk for Hyperkalemia
− Uric acid levels elevated- Gout
− * Zyloprim (Allopurinol) help reduce uric acid levels
− A lot of drugs are nephrotoxic
−  uric acid with breakdown = Gout
9. Tumor Lysis Syndrome
− Caused by breaking down cells

− needs lots of hydration

− * Manatole- hypertonic – then give diuretic to draw it
back off
− damaged nerves
− Impaired coordination- Safety Issue – Can’t walk straight
− Paresthesia- numbness and tingling
− Bowel and bladder atonia- inability to urinate normally
or bowel problems
− Proprioception is off (close eyes and touch nose, this pt
may not be able to do it
− B/c of chemo
− kill cancer but now cardio in trouble
− Damage heart with treatment, we did it to kill the
− Pain meds
− Tolerance builds up
− On unbelievable doses of pain meds, takes that much to
keep them comfortable
13.Body Image
− Impaired
o Breast removal
o Hair Loss
o Colostomy
o Amputations
14. Superior vena cava syndrome (SVCS)
− Blood returns to heart
− Tumor somewhere high in chest or neck and inhibits
blood from returning to the heart
− Altered mental status
− Swelling in neck
o Elevate head of bed
o Seizure precaution
15.Spinal cord compression
− Numbness
− Inability to use extremities
− Impaired coordination
− Paralysis
− * Debulking- reduce in size
16.Third spacing of fluids
− Comes from Liver damage you develop impaired protein

− COP – Liver cancer

− Person stops eating and drinking have low protein
17.Paraneoplastic syndrome
− Tumor secretes substances that mimic other hormones
− Aldosterone, parathormone, ADH

18.Second Malignancies
− Had cancer years later on down the road they develop
another kind of malignance in response to first chemo
− * CEA
− * Lifelong monitoring
− Hospice care
− Cancer Kills
− Not qualified until 6 Months Left
III. Theories of the Etiology of Cancer (there are many--these
are only 2)
A. Cellular Transformation and Derangement (crazy cells,
altered cell growth)
1. Theory: Can occur from the cells changing into Cancer
2. Agents: Some Drugs can cause cancer or Sun damage =
skin cancer
o Kaposis sarcoma tumor that people with HIV get
o Hep B can cause Liver cancer
o Factories = cancer
o Asbestos = type of lung cancer
o Birth Control pills lead to cancer
o Smoking = lung cancer
B. Immune Response Failure (The old gray mare she ain’t what
she used to be)
1. Theory: The immune system surveys what is you and
what isn’t you and whatever isn’t you the body is trained to
o We are living longer so we see more cancer
2. Immune response can be repressed by:
− Immunosupressors: Transplant patients
− Aging
− Smoking and alcohol
− Poor nutrition (good protein intake)
− Chronic steroids

− Stress
IV. Basic Principles
A. Differentiation is process where cells diversify and acquire
specific structural and functional characteristics and mature. *
Cancer cells lack differentiation!!!
B. Cell cycle
− life of the cell
− Normal cells- go through normal cell life
− Cancer cells- Do not go through normal cell life, do weird
strange things, don’t follow the rules

C. Contact inhibition
− Normal cells have
− Cancer cells do not
− * When crowding occurs production of cells slow down, not
in the case of cancer cells they just keep growing.
D. Benign (spreads locally)
− not recurrent or aggressive; does not metastasize; does
not cause systemic symptoms or death unless it interferes
with vital functions due to location, i.e. brain tumor
(acoustic neuroma)
E. Malignant (spreads far away)
− undifferentiated, immature cells; invade, erode, & spread
1. Implantation- Local spreading
2. Cells can travel by vascular system
3. Lymphatic system
F. TNM Classification System (Tumor, Node, Metastasis)
− Also see chapter on breast cancer
− T--tumor size (describes primary tumor)
o T O (no evidence of tumor)
o T IS (in situ)
o T 1 (< or equal to 2 cm)
o T2 (> 2 but not > 5 cm)
o T3 (> 5 cm)
o T4 (extension to chest wall, inflammation)
− N--degree of spread to nodes
o N 0 (no evidence of lymph node involvement)
o N 1-4 (ascending degree of node involvement)
o N X (regional lymph nodes unable to be assessed
− M—metastasis
o M 0 (no evidence of distant metastasis)
o M 1 - 4 (ascending degree of metastasis)
G. 3 Stages of cancer cell growth
1. Initiation--something causes cell’s genetic structure to
a. Chemical Carcinogens--Drugs, Chemicals, Diet

b. Physical Carcinogens
i. Ionizing radiation--secondary cancer from
radiation to primary cancer
ii. UV radiation--short rays of sun worse
iii. Foreign bodies—asbestos
iv. Certain DNA and RNA viruses--oncogenic--can
transform cells i.e., HIV ------>Kaposi's Sarcoma
Hep B------->Liver cancer

2. Promotion
− 2 mutations are required for cancer to develop in a
cell; Proliferationof cells with first mutation leads to a
population of cells where a 2nd mutation can occur.
Some promoters are specific to specific cancers--
Alcohol---->GI tract cancer
Smoking--->Lung cancer
Some carcinogens can initiate and promote
cancer—ex: smoke
3. Progression
− includes increased growth rate, invasiveness &
metastasis. As tumor increases in size, it develops
own blood supply--tumor angiogenesis.
V. Prevention and Early Detection Very Important--Major role
for nursing
A. Seven Warning Signs
a. C-- Change in bowel or bladder habits
b. A--A sore that does not heal
c. U--Unusual bleeding or discharge
d. T--Thickening or lump in breast or elsewhere
e. I--Indigestion or difficulty swallowing
f. O--Obvious change in wart or mole
g. N--Nagging cough or hoarseness
B. Education
1. Diet high in vegetables, fruits, whole grains, vitamins A and
C; Limit salt-cured, smoked, nitrite-cured foods, alcohol,
2. Avoid smoking, obesity, sunlight
3. Regular Physical Exam (Yearly after age 40)
4. Screening for all
a. Skin inspection for changes
b. Annual rectal exam after age 40
c. Annual stool for occult blood after age 50
d. Annual oral exam
5. Screening for women:

a. Monthly breast self-examination after age 20

b. Mammogram every 1 - 2 years between 40 and 49,
then yearly
c. Regular (every 1 -3 years) Pap smear and Pelvic
6. Screening for men
a. Testicular self-examination monthly
b. Yearly rectal exam for prostate cancer

VI. Treatment Modalities for Cancer

A. Surgery
1. Diagnostic procedures (cytology specimens, needle
biopsy, incisional biopsy, excisional biopsy)

2. Prophylactic
3. Curative--if believed can get it all
4. Palliative--done to help if benefit outweighs risk
(debulking) (male less in size , makes things better but
won’t cure
a) To reduce pain
b) To relieve obstructions (GI, GU, Resp, spinal cord,
c) To prevent hemorrhage
d) To remove infected and ulcerating tumors or drain
5. Reconstructive
− restoration of form and function to improve quality of
B. Radiation Therapy (RT)
1. Goal: destroy cancer cells with minimized damage to other
tissues; Destroys cancer cell's replication by
damaging DNA. Cells that divide rapidly are more
radiosensitive. Also, normal cells are more capable
of repairing the DNA damage done by radiation.
2. Types of Radiation
a) External RT—Teletherapy
− Mark the site with a permanent marker, teach clients
not to scrub it off, it needs to stay on
− People go in- Radiation beams shot into them at
certain level and depth
− Not at risk to anyone else
− Special making so radiation Therapist knows where
to shot them
− Can leave after therapy

− * Fractionation- breaks up into smaller livable doses

of radiation, go in 5 days a week for a couple of
weeks, damage bad cells & save good cells
− *Alternate ports of entry, shoot them from different
angles to try & spare good tissue
b) Internal RT
− Radiation into them
− Risk for contaminating those around them/Are a
danger to others
− Two types of Internal RT:
i. Sealed-Source RT (Brachytherapy)
− have radiation placed inside of them in
something sealed
a) Intracavity
− Capsule inserted in a cavity
− Ex. Vagina
− Foul smelling vaginal drainage =
dead tissue
− Need to be in a private room with
lead lined walls
− If it falls out you wouldn’t put it
back in
− Keep in Supine position AAT
− You can get radiation from being
near them
− Typically don’t go home with these
b) Interstitial (in the tissue)
− Beads placed in knee (look like
Mardi Gras Beads)
− May go home with these
o Must sleep in different
o Can’t hold grandchildren
o Can’t hold grandchildren
ii. Unsealed-Source RT
− Floating around in them
− Oral/IV
− Body absorbs it
− Vomit/Urine- does contain radiation
o Gloves, eyewear, protective
o Flush toilet a couple of times
iii. Radiation Safety

a) Time – 30 min per 8hr shift with them

not @ one time
b) Distance- Further away you are the
better, do as much as you can from
the door
c) Shielding- lead lined apron
d) Standards--safety officer, film
badges (dosimetry badge)
C. Chemotherapy - Antineoplastic drugs.
1. Goal: destroy malignant cells with minimal damage to
others; disrupts development and reproduction of cells.
Interferes with good and bad cells, thus a major limitation.
Cells that are the most active and rapidly dividing are most
sensitive (thus GI cells, hematopoietic system, and hair
follicles are affected). One dosing does not kill all the cancer
cells, thus takes repeat therapy.

2. Classification of Chemotherapeutic Agents

− Classified according to pharmacological action and
effect on cell cycle
− Cell cycle specific--drugs that affect the cell during
certain phases
− Cell cycle nonspecific--drugs that do not require the
cell to be in a specific phase to be effective
− Combination therapy—enhances effectiveness
3. Administration Safety
a) Safe Preparation and handling
− Gloves
− Eyewear
− Gown
b) Safe Disposal
− excretions could be dangerous
− Test Question: Person getting chemo actively
vomiting what should you wear? EYEWEAR,
− Urinate in bed? WEAR GOWN/GLOVES
− Double flush, clean toilet after with bleach after
they have used it
4. Chemotherapy Administration Routes--must know if
vesicant or not
a) Intravenous
1.Peripheral Access--peripheral line or PIC

i. Stop Drug Infusion
ii. Take all fluid down disconnect IV line-
Leave Iv Cath in
iii. Syringe/Aspirate on IV Cath try to
aspirate back as much fluid as you can
iv. Find out antidote- Bicarbonate
v. Inject/Deliver antidote in cath, will go into
the tissue
vi. D/C cath
vii. Apply cold compress to vasoconstrict
Typically, unless it’s a vincadrug = warm
viii. Elevate Extremity to stop swelling
ix. Check ups – asses very often &
document findings, VERY OFTEN (maybe
every 0 minutes) If possible take a
picture of it right after it happens
− If not a vescant can put in a peripheral line
− Flush line to check patency
− Can give a vesicant through a PICC, but not
2. Central Vascular Access
a) Central venous catheter
− Central line
− PICC – subclavian or juglar central
line, have to be flushed periodically,
o NS & then Heparin behind it,
must do site care
o @ risk for infection
o use sterile technique
b)Implanted Venous Port--Venous Access
Device (VAD)
− Example is a Port-a-Cath or Bard
Implanted Port on chest or Omaya
Reservoir under scalp (Mediport)
3. Other less common routes
− Topical, oral, SQ, IM, or
− Intrathecal (lumbar puncture to get to
brain and spinal cord)
− Intraarterial (into an artery that feeds
a tumor)
− Intrapleural (into intrapleural space of

− Intraperitoneal
− Intravesicle (bladder empties first,
then must retain 1 - 3 hours)
4. Outpatient Chemo Administration
− Nurse must teach client:
o SE to expect
o Safe Storage
o How to handle equipment
o Double flushing, cleaning toilet with
o Washing contaminated linens once by
themselves & then with other things
D. Bone Marrow Transplantation (BMT)--goal is cure.
− 3 Types of Bone Marrow Donors:
a) Autologous – Self, saved & stored, can take out own
BM b/f treatment & if cancer isn’t in BM, they can then
put back in their own healthy BM
b) Syngeneic – Twin, someone just like them
c) Allogenic – Parent, Brother, Sister & Family Member

− Stem Cell transplantation

o Take from someone else & inject it into you & it ends up
in the Bone Marrow

− Graft (gift)-versus-Host Disease (GVHD)

o Normally worry about body rejecting the graft,
where the body realizes that it’s not a part of
you, so it starts to attack it.
o With this the Graft ends up attacking the host
 Someone who is immunocompromised the
healthy graft ends up attacking the sick
o Will see N/V/D, skin rashes, jaundice & fever
o Give steroids or immune suppressants to
suppress the graft
1. Myeloid Cells
a. Erythrocytes: RBCs
b. Thrombocytes: Platelets
c. Leukocytes: WBCs
− Monocytes:
− Phagocytic
− Only 4-8 % of WBCs

− 2nd response
2. Granulocytes
a. Neutrophils
− Phagocytic
− 50-70% of WBCs
− 1st response
b. Basophils
− Release histamine and heparin in allergic
response < 2 % of WBCs
c. Eosinophils
− Neutralize histamine
− Defend against parasites
− 2-4 % of WBCs
E. Biologic Response Modifiers
− Biotherapy, obtained through genetic engineering
a) Purpose is to strengthen and manipulate the immune
b) Examples of Biologic Response Modifiers:
1. Monoclonal antibodies (MoAbs)--used
diagnostically to identify tumor cells, as a
delivery agent of radioisotopes to tumor site,
and to deliver immunotoxins to tumor site
2. Interferons (IFN)--small proteins with cellular
activity in three areas: antiviral
immunomodulatory, and antiproliferative
3. Interleukins--produced by lymphocytes and
function to promote normal hematopoiesis.
Responsible forgrowth of T cells. Side effects
as well as desirable effects. (Ex: capillary leak
syndrome leading to edema.)
4. Colony stimulating factors (CSF)--do not
treat cancer but help with negative effects of
A. Erythropoietin (EPO)--FDA approved;
affects erythrocyte production; Also
used in clients with anemia in end
stage renal failure.
o Procrit or Epogen
B. Neupogen – makes WBC
o Neumega makes platelets
5. Tumor necrosis factor (TNF)