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ALSALMAN A. ANAM

BSN IV A

JANUARY 8, 2013

ONCOLOGY NURSING REVIEWER

A. Benign VS Malignant Neoplasm Characteristic Speed Growth

Benign Neoplasm

Malignant Neoplasm

Grows slowly

Usually grows rapidly Tends to grow relentlessly throughout life Grows by infiltrating surrounding tissues May remain localized (in situ) but usually infiltrates other tissues Never contained within a capsule

 

Usually

continues to grow throughout

Mode of Growth

life unless surgically removed Grows by enlarging and expanding Always remains localized; never infiltrates surrounding tissues

Capsule

Almost always contained within a

Cell characteristics Recurrence

Metastasis Effect of Neoplasm

Prognosis

fibrous capsule

Capsule advantageous because encapsulated tumor can be removed surgically Usually well differentiated Unusual when surgically removed

Never occur Not harmful to host unless located in area where it compresses tissue or obstructs vital organs

Very good Tumor generally removed surgically

Absence of capsule allows neoplastic

cells to invade surrounding tissues

Surgical removal of tumor difficult

Usually

Common following surgery because tumor cells spread into surrounding tissues Very common Always harmful to host

Causes

poorly differentiated

disfigurement, disrupted organ

function, nutritional imbalances

May result in ulcerations, sepsis, perforations,
May result in
ulcerations, sepsis,
perforations,

Depends on cell type and speed of diagnosis Poor prognosis if cells are poorly differentiated and evidence of metastatic spread exists Good prognosis indicated if cells still resemble normal cells and there is no evidence of metastasis

B. Recommendations of the American Cancer Society for

Early Cancer Detection

1. For detection of breast cancer

routinely perform monthly breast self-

examination

should have breast examination by a

age 20,
age 20,
examination should have breast examination by a age 20, 20-39 3 years 40 and older healthcare
20-39 3 years 40 and older
20-39
3 years
40 and older

healthcare provider every

20, 20-39 3 years 40 and older healthcare provider every should have a yearly mammogram and

should have a

yearly mammogram

and

breast self-examination by a healthcare provider

2. For detection of colon and rectal cancer

age 50 and older occult blood test
age 50 and older
occult blood test

should have a yearly fecal

50 and older occult blood test should have a yearly fecal should be done every 5

should be done every 5 years

every 10 years
every 10
years

For detection of uterine cancer (Pap) smear for

3.

10 years For detection of uterine cancer (Pap) smear for 3. sexually active females and any

sexually active females

and any female over age 18

for 3. sexually active females and any female over age 18 -risk women should have an

-risk

women

should

have

an

endometrial tissue sample

4. For detection of prostate cancer

50, 50,
50,
50,

have a yearly digital rectal examination have a yearly prostate-specific antigen (PSA) test

C. American Cancer Society’s seven warning signs of cancer (uses acronym CAUTION US):

Immunosuppression
Immunosuppression

Client Education

acronym CAUTION US ): Immunosuppression Client Education for extra rest periods as needed ain balanced diet
acronym CAUTION US ): Immunosuppression Client Education for extra rest periods as needed ain balanced diet

for extra rest periods as needed ain balanced diet

Education for extra rest periods as needed ain balanced diet 2-3 liters/day) bedrest to avoid dislodging
2-3
2-3
liters/day) bedrest
liters/day)
bedrest

to

avoid

dislodging the implant.

2-3 liters/day) bedrest to avoid dislodging the implant. ; double-flush toilets after use apy may lead

; double-flush

toilets after use

apy may lead todislodging the implant. ; double-flush toilets after use bone marrow suppression Nursing Management close contact

bone marrow suppression

Nursing Management

apy may lead to bone marrow suppression Nursing Management close contact with persons receiving internal radiation:

close contact with persons receiving internal radiation:

understand the principles of protection from exposure to radiation: time, distance, and shielding (“SDT”) from exposure to radiation: time, distance, and shielding Time: minimize time spent in close proximity to Time: minimize time spent in close proximity to the radiation source; a common standard is to limit contact time to

30 minutes total per 8-hour shift;

Distance: maintain the maximum distance from the radiation source maintain the maximum distance from the radiation source

Shielding: use use

exposure to radiation

6 feet
6 feet

possible

to reduce

anduse exposure to radiation 6 feet possible to reduce other precautions private room 6 feet from

other precautions

private room 6 feet
private room
6 feet

from

1. Change in bowel or bladder habits the client and limit visitors to 10-30 minutes
1.
Change in bowel or bladder habits
the client and limit visitors to
10-30 minutes
2.
A sore that does not heal
proper
handling
and
disposal
of
body
fluids
,
3.
Unusual bleeding or discharge
assuring the containers are marked appropriately
4.
Thickening or lump in breast or elsewhere
5.
Indigestions or difficulty in swallowing
use long-handled
6.
Obvious change in wart or mole
forceps and place the implant into a lead container
; never
7.
Nagging cough or hoarseness
directly touch the implant
8.
Unexplained Anemia
Do not allow pregnant women
to come into any contact
9.
Sudden loss of weight
with radiation
wear
a
D.
Internal Radiation Therapy (Brachytheraphy)
monitoring device to measure exposure

Sources of Internal Radiation

device to measure exposure Sources of Internal Radiation Side Effects ures E. External Radiation Therapy

Side Effects

measure exposure Sources of Internal Radiation Side Effects ures E. External Radiation Therapy (Teletheraphy) radiation
measure exposure Sources of Internal Radiation Side Effects ures E. External Radiation Therapy (Teletheraphy) radiation

ures

E. External Radiation Therapy (Teletheraphy)

Effects ures E. External Radiation Therapy (Teletheraphy) radiation treatment using a semipermanent type of ink -30

radiation treatment using a semipermanent type of ink -30 minutes per day, 5 day per

week, for 2-7 weeks ent does not pose a risk for radiation exposure to other peopleRadiation Therapy (Teletheraphy) radiation treatment using a semipermanent type of ink -30 minutes per day, 5

of ink -30 minutes per day, 5 day per week, for 2-7 weeks ent does not

Side Effects

Side Effects hemorrhage) ion Client Education pat skin dry; do not use soaps, deodorants, lotions, perfumes,

hemorrhage)

ion
ion

Client Education

Side Effects hemorrhage) ion Client Education pat skin dry; do not use soaps, deodorants, lotions, perfumes,

pat skin dry; do not use soaps, deodorants, lotions, perfumes, powders or medications on the site during the duration of the treatment; do not wash off the treatment site marks

of the treatment; do not wash off the treatment site marks do not apply extreme temperatures

do not apply extreme temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor -fitting over the treatment area n exposure during the treatment and for at least 1 year after the treatment is completed; when going outdoors, use sun-blocking agents with sun protector factor (SPF) of at least 15

agents with sun protector factor (SPF) of at least 15 promoting health and repair of normal
agents with sun protector factor (SPF) of at least 15 promoting health and repair of normal

promoting health and repair of normal tissues Nursing Management

health and repair of normal tissues Nursing Management and platelet counts immunosuppression, thrombocytopenia F.

and platelet counts

of normal tissues Nursing Management and platelet counts immunosuppression, thrombocytopenia F. Predisposing Factors:

immunosuppression, thrombocytopenia

F. Predisposing Factors: Carcinogenesis

G-enetic I-mmunosuppression V-iral (Human Papilloma, Epstein-Barr, Hepa B) E-nvironmental

Physical- Radiation, UV rays, nuclear explosion Chronic irritation, direct trauma

Chemical - Acids, alkalis, hydrocarbons, dye, Food (

fiber)fat& Food additives (Nitrites), Drugs (Stillbestrol, urethane), Hormones, Smoking

G. Grading of Cancer: Classifies the cellular aspects of CA

Grade I: cells differ slightly from N cells, well-differentiated (mild dysplasia) Grade II: cells are more abN, mod. differentiated (mod. dysplasia)

Grade III: cells are very abN, poorly differentiated (severe dysplasia) Grade IV: cells are immature (anaplasia), undifferentiated

H. Staging of Cancer: Classifies the clinical aspects of CA Stage O: carcinoma in situ Stage I: tumor limited to the tissue of origin, localized tissue growth Stage II: limited local spread Stage III: extensive local & regional spread Stage IV: metastatis

I. EARLY DETECTION OF CANCER

Mammography

Pap smear

Stool for occult blood

Sigmoidoscopy

colonoscopy

Breast self-examination

Testicular self-examination

Skin inspection

-Examination (BSE) Done 7-10 days after menses Postmenopausal or s/p hysterectomy: specific day of the month Inspection: In front of the mirror with arms at sides, arms overhead & arms at hips (WOF changes in shape, dimpling of skin or any changes in nipple) Testicular self-examination  Skin inspection -Examination (BSE) Palpation: While in shower/bath or lying

-Examination (BSE) Palpation: While in shower/bath or lying down with folded towel under breast being examined Use the R hand to examine L breast & vice versa Use the pads of 2 nd , 3 rd & 4 th fingers Use small, circular motions in spiral or in an up-and-down motion to examine entire breast & under the arm (WOF lump, hard knot or thickened tissue)changes in shape, dimpling of skin or any changes in nipple)  Testicular Self-Examination (TSE) Same

Testicular Self-Examination (TSE) Same day, q month, right after a warm shower (scrotal skin is moist & relaxed) Gently lift each testicle, each one should feel like an egg, firm but not hard & smooth without lumps Using both hands, place middle fingers underside of each testicle & thumbs on top & gently roll the testicles (WOF lumps, swelling or mass)

CANCER TX MODALITIES: Surgery Prophylactic With premalignant condition or with strong family hx of CA Curative Removal of all gross & microscopic tumor

Control (cytoreductive) “ debulking” procedure, the no.

of CA cells, the chance of other tx will be successful

CANCER TX MODALITIES: Surgery Palliative

Improves quality of life during survival time pain; relieve obstruction (airway, GI or GU), relieve pressure on brain & spinal cord, prevent hemorrhage, remove infected or ulcerated tumors or drain abscesses Reconstructive or rehabilitative Improves quality of life

by restoring maximal function & appearance (breast reconstruction s/p mastectomy)

CANCER TX MODALITIES: Chemotherapy Kills CA cells & rapidly producing cells (skin, hair, BM, Reproductive tract, GIT,) Antimetabolites: N2 mustard Plant alkaloid: Vincristine & Vinblastine Alkylating:

Methotrexate Hormones (DES)/ steroids Antineoplastic antibiotics

CANCER TX MODALITIES: Chemotherapy Major S/E & Nursing Interventions Hair: alopecia Encourage pt to wear wigs, cap Temporary, hair will regrow in 3-6 mos. after chemo with new color & texture BM: depression Anemia: CBR, O2 as ordered Leukemia: reverse isolation, strict HW, asepsis Thrombocytopenia: Bleeding precautions

CANCER TX MODALITIES: Chemotherapy Major S/E & Nursing Interventions GIT: N/V Antiemetics 4-6 hrs. pre-chemo & post chemo as ordered NPO temporarily Bland diet post chemo Stomatitis Oral care Ice chips/popsicles Diarrhea Antidiarrheals Monitor VS, I/O, WOF dehydration WOF paralytic ileus (with Vincristine)

CANCER TX MODALITIES: Chemotherapy Major S/E & Nursing Interventions Reproductive tract: sterility

Encourage sperm banking for M Renal damage: uric acid Allopurinol as ordered Neuro disturbance: peripheral neuropathy Skin, hand & foot care (like in PVD & DM)

Alkylating Meds Cell-cycle nonspecific Nitrogen Mustards Chlorambucil (Leukeran) & Mechlorethamine (Mustargen): hyperuricemia Cyclophosphamide (Cytoxan): taken without food, S/E: alopecia, hemorrhagic cystitis (hematuria, dysuria) Ifosfamide (Ifex) Melphalan (Alkeran) Uracil mustard

Alkylating Meds Nitrosoureas Carmustine (BiCNU) Lomustine (CeeNU) Streptozocin (Zanosar) Alkylating- like Meds Altretamine (Hexalen) Busulfan (Myleran):

hyperuricemia Cisplatin (Platinol): ototoxicity &

nephrotoxicity (given amifostine [Ethyol] prior to risk), hypoK, hypoCa, hypoMg Dacarbazine (DTIC-Dome) Thiotepa (Thioplex)

Anti-tumor Antibiotics Cell-cycle nonspecific Bleomycin SO4 (Blenoxane): pulmonary toxicity Dactinomycin (Actinomycin D, Cosmegan) Daunorubicin (Cerubidine, DaunoXome): causes CHF & dysrhythmias Doxorubicin (Adriamycin) & Idarubicin (Idamycin): cardiotoxicity (given Dexraxozane [Zinecard] to prevent cardiomyopathy)

Anti-tumor Antibiotics Mitomycin (Mutamycin) Mitoxantrone (Novantrone) Pentostatin (Nipent) Plicamycin (Mithracin): affects bleeding time Valrubicin (Valstar)

Antimetabolites Cell-cycle phase-specific (S phase) Capecitabine (Xeloda) Cladribine (Leustatin) Cytarabine (ara-C, Cytosar-U): alopecia, stomatitis, hyperuricemia, hepatotoxicity Floxuridine (FUDR) Fludarabine (Fludara)

Antimetabolites Methotrexate (Folex) & 5-Fluorouracil (Adrucil): alopecia, stomatitis, hyperuricemia, photosensitivity, hepatotoxicity, hema, GI & skin toxicity Leucovorin rescue (given leucovorin [folinic acid or citrovorum factor) to prevent toxicity r/t Methotrexate Hydroxyurea (Hydrea) 6-Mercaptopurine (Purinethol):

hyperuricemia, hepatotoxicity Procarbazine (Matulane) Thioguanide

Mitotic Inhibitors (Vinca Alkaloids) Cell-cycle phase- specific: M phase Docetaxel (Taxotere) Etoposide (VePesid) Teniposide (Vumon) Vinblastine SO4 (Velban) Vincristine SO4 (Oncovin): neurotoxicity (numbness & tingling of fingers & toes), peripheral neuropathy, ptosis Vinorelbine (Navelbine)

Immunomodulator Agents Stimulate immune system to recognize CA cells & destroy them (Interleukins) Slow down tumor cell division, causes CA cells to differentiate into non-proliferative forms (Interferons)

Immunomodulator Agents Aldesleukin (Proleukin, Interleukin-2) Interferon alfa-2a Interferon alfa-2b

Interferon alfa-n3 (Alferon N) Levamisole (Ergamisole) Recombinant interferon- (Intron A, Roferon A) Rituximab (Rituxan)

26. Colony-Stimulating Factors Induce rapid BM recovery after chemotherapy Granulocyte-Macrophage:

Sargramostim (Leukin, Prokine) Granulocyte: Filgrastim (Neupogen) Erythropoetin: Epoetin alfa (Epogen)

27. CANCER TX MODALITIES: Radiation Use of ionizing radiation that kills CA & rapidly growing cells & inhibit their growth Types of energy Alpha rays: don’t penetrate skin tissue Beta rays: penetrate skin (e.g. internal radiation) Gamma rays: penetrate deeper, underlying tissues (e.g. external radiation)

28. CANCER TX MODALITIES: Radiation Factors Affecting Delivery Half-life: time required for the ½ of the radioisotope to decay Time: less time, less exposure Distance: the farther the source, the lesser the exposure Shielding: Alpha & Beta rays can be blocked by gloves, Gamma rays can be blocked by thick, lead gown & concrete

29. CANCER TX MODALITIES: Radiation Methods of Delivery Internal: utilizes injection/ implantation of radioactive isotopes proximal to CA sites for specified period of time Sealed: within a container, don’t contaminate with body fluids Unsealed: e.g. Phosphorus 32 External: uses electromagnetic waves e.g. Cobalt

30. CANCER TX MODALITIES: Teletherapy/Beam Radiation Source: external radiation Pt does not emit radiation & does not pose a hazard to anyone else Wash area with water & mild soap, using the hand than a washcloth, rinse & pat dry with soft towel Don’t remove radiation markings from the skin

31. CANCER TX MODALITIES: Teletherapy/Beam Radiation No powder, ointment, lotion or cream on area unless ordered Wear soft clothing over the area, avoid constrictive garments Avoid sun & heat exposure WOF weeping of skin (moist desquamation) & if noted, cleanse the area with warm water & pat dry, apply antibiotic or steroid cream as ordered & expose the site to air

32. CANCER TX MODALITIES: Brachytherapy

Radiation Source: internal radiation (sealed or unsealed)

For a pd. of time the pt emits radiation & pose a hazard to

others

33. CANCER TX MODALITIES: Brachytherapy

Radiation Unsealed Radiation Source Administered PO or

IV or instillation into body cavities It enters body fluids,

eliminated via various excreta (radioactive & harmful to

others esp. the 1 st 48 hrs)

34. CANCER TX MODALITIES: Brachytherapy Radiation Sealed Radiation Source Temporary or

permanent solid implant within tumor target tissues The

pt emits radiation while the implant is in place, but the

excreta is not radioactive Place the pt in a private room with private bath Place a caution sign on the pt’s door

35. CANCER TX MODALITIES: Brachytherapy

Radiation Sealed Radiation Source Organize nursing tasks

to minimize exposure to radiation source Nursing staff

assignments should be rotated, a nurse should never care

for more than 1 pt with radiation implant at a time, avoid

assigning a pregnant nurse Limit time to 30 mins per care

provider/shift

36. CANCER TX MODALITIES: Brachytherapy Radiation Sealed Radiation Source Wear a dosimeter film badge to measure radiation exposure Wear a lead shield

Do

not allow children <16 y/o or pregnant woman to visit

the

pt Limit visitors to 30 min./day, at least 6 ft from the

pt Save bed linens & dressings until the source is removed then dispose Other equipments can be removed from the room at any time

37. CANCER TX MODALITIES: Brachytherapy Radiation Dislodged Sealed Radiation Source Don’t touch it with bare hands, use a long-handled forceps to place the source in a lead container kept in the pt’s room & notify

MD If unable to locate the radiation source, bar visitors &

notify MD

38. CANCER TX MODALITIES: Brachytherapy Radiation Sealed Radiation Source Removal Pt is no longer radioactive Inform the pt that sexual partner cannot “catch” CA Pt may resume sexual intercourse after 7-10 days for cervical or vaginal implant Perform povidone- iodine douche as ordered for cervical implant Administer Fleet enema as ordered Notify MD if N/V/D, frequent urination, vaginal or rectal bleeding, hematuria, foul- smelling vaginal discharge, abdominal pain/distention or fever occurs

39. CANCER TX MODALITIES: Radiation Major S/E & Nursing Interventions Skin erythema, redness, irritation & sloughing of tissue Assist in bathing the pt Force fluids Avoid lotion, talcum powder; may use cornstarch or olive oil BM depression (same as in chemo) GIT disturbance:

Dysgeusia- taste sensation esp. with internal implant Oral care, avoid hot & cold foods

40. LEUKEMIA Group of malignant disease Rapid immature WBC, competes nutrition with mature WBC and production of RBC and platelets N= 500 RBC: 1 WBC

41. LEUKEMIA

42. CLASSIFICATION OF LEUKEMIA Lympho- affects lymphocytes Myelo- affects myeloblasts Acute/Blastic- affects immature cells Chronic/Cystic- affects mature cells Most common in children: Acute Lymphocytic Leukemia (ALL), peak onset 2-6 y/o, M>F Acute Myelogenous Leukemia (AML): peak onset 15-39 y/o

43. Signs and Symptoms: LEUKEMIA From invasion of BM (“Nadir”) Infection: T, poor wound healing, sore

throat, bone weakens fracture, bone & joint pains, lymphadenopathy Bleeding: hemorrhage, petechiae, epistaxis, hematoma, hematuria, hematemesis, hepatosplenomegaly Anemia: pallor, fatigue, anorexia, constipation

44. Signs and Symptoms: LEUKEMIA From invasion

of CNS ICP: LOC, severe HA, vomiting, papilledema,seizures CN VII or spinal nerve involvement From invasion of kidneys, testes, prostate, ovaries, GI and lungs

45. LEUKEMIA Diagnostic Tests PBS- (+) immature

WBC CBC- immature WBC, RBC, platelets Done weekly during maintenance phase of chemotherapy Lumbar Puncture- CNS affectation Shrimp/fetal/C- position, avoid neck flexion may occlude airway of infants and children

46. LEUKEMIA Diagnostic Tests Bone Marrow Aspiration- (+) blast cells (immature WBC), common site: iliac crest Post op: apply direct pressure, lie on

affected side to stop bleeding Bone Scan- to determine bone involvement (fractures) CT Scan: to determine organ involvement

47. LEUKEMIA Triad Management Surgery (most preferred) (Cranial) Irradiation Chemotherapy BM transplant

48. Nursing Management: LEUKEMIA Assess for common side effects: anorexia, nausea and vomiting (give antiemetics 30mins prior to chemo and continue until 1 day post chemo), WOF dehydration

49. Nursing Management: LEUKEMIA Assure pt that alopecia and hirsutism are temporary side effects, hair will regrow in 3-6 mos. With new color & texture

50. Nursing Management: LEUKEMIA Assess for stomatitis (oral ulcers) Oral care: alcohol-free mouthwash, pNSS with or without NaHCO3 Use soft- bristled toothbrush, cotton plegets Apply Xylocaine (topical anesthetic) on mouth before meals Diet: soft and bland according to child’s preference, small frequent feedings

51. Nursing Management: LEUKEMIA Protect pt from infection Strict hand washing Reverse isolation Protect pt from additional fatigue Bed rest Activities balanced with rest

52. Nursing Management: LEUKEMIA Protect pt from bleeding Minimize parenteral injections Apply pressure on venipuncture sites Use electric razor in shaving

53. Nursing Management: LEUKEMIA Encourage verbalization of feelings & concerns Introduce the family to other families of children with CA Consult social services & chaplains as necessary

54. HODGKIN’S DISEASE/LYMPHOMA Involves lymph nodes, tonsils, spleen & BM (+) T, A/, malaise,

fatigueReed-Sternberg cell in the nodes S/Sx & weakness, wt loss Anemia, thrombocytopenia Enlarged lymph nodes, spleen & liver (+) bx of cervical lymph nodes (affected 1 st ) (+) CT scan of liver & spleen

55. HODGKIN’S DISEASE/LYMPHOMA Management External radiation (tx of choice) Multiagent chemotx (if extensive) WOF S/E: infection, bleeding Sperm banking (possibility of sterility for M)

56. MULTIPLE MYELOMA Malignant proliferation of plasma cells and tumors within the bone, destroying the bone & invading the lymph nodes, spleen & liver abN plasma cells produce an abN Ab (myeloma protein or

Bence Jones protein) found in blood & urine production

of Ig & Ab, uric acid& Ca RF

57. S/Sx: MULTIPLE MYELOMA Bone pain (pelvis, spine, ribs) Osteoporesis (bone loss, pathological fractures) Spinal cord compression & paraplegia

Weakness & fatigue Recurrent infections Anemia Bence

Jones proteinuria, total serum protein, Ca & uric acid levels RF Thrombocytopenia, granulocytopenia

58. Nursing Interventions: MULTIPLE MYELOMA Administer as ordered Chemotherapy IVF & diuretics (to eliminate Ca) BT for anemia Analgesics, antibiotics WOF bleeding, infection, fractures, RF Force fluids Encourage ambulation Provide skeletal support during moving, turning & ambulating Maintain hazard-free env’t

59. TESTICULAR CANCER Occurs between ages 15-40 Common sites of mets: lymph nodes, bone, lungs, adrenal glands & liver Types Germinal tumors (Seminomas, Nonseminomas) Nongerminal tumors (Interstitial cell tumors, Androblastoma)

60. S/Sx: TESTICULAR CANCER Painless testicular swelling Dragging sensation in the scrotum S/Sx of mets:

palpable lymphadenopathy, abdominal masses, gynecomastia Late S/Sx: back or bone pain & respiratory Sx

61. Tx: TESTICULAR CANCER Chemotherapy Radiation Surgery Unilateral orchiectomy- for dx & primary surgical mgt. Radical retroperitoneal lymph node

dissection- to stage the CA & tumor vol. Reproductive options: sperm storage, donor insemination & adoption

62. Nursing Interventions: s/p Testicular Surgery Suture removal: 7-10 days post-op May resume N activities within 1 week except for lifting heavy objects > 20 lbs or stair climbing Perform monthly testicular self-exam on the remaining testicle

63. BREAST CANCER Common sites of mets: lymph nodes, bone, lungs, brain & liver Precipitating factors Genetics Early menarche & late menopause Nulliparity Obesity High-dose radiation exposure to chest

64. S/Sx: BREAST CANCER Mass felt during BSE (usually in the upper outer quadrant or beneath the nipple) Fixed, irregular, nonencapsulated mass Painless (early stage) or painful (late stage) mass Nipple retraction or elevation Assymetrical breast (affected breast higher) Bloody or clear nipple d/c

65. S/Sx: BREAST CANCER Skin dimpling, retraction or ulceration Skin edema or peau d’orange skin Axillary lymphadenopathy Lymphedema of affected arm Presence of lesion on mammography S/Sx of lung/bone mets

66. Nonsurgical Tx: BREAST CANCER Chemotx Radiation tx Hormonal manipulation in post menopausal women Meds: Tamoxifen (Nolvadex) for estrogen receptor-positive tumors

67. Surgical Tx: BREAST CANCER Lumpectomy:

removal of tumor with lymph node dissection Simple Mastectomy: removal of breast tissue & nipple, lymph

nodes left intact Modified Radical Mastectomy: removal of breast tissue, nipple & lymph nodes, muscles left intact Halsted Radical Mastectomy: removal of breast tissue, nipple, lymph nodes & underlying muscles

68. Surgical Tx: BREAST CANCER Oophorectomy: for estrogen receptor-positive tumors Ablative therapy with adrenalectomy or chemical ablation which blocks cortisol, androstenedione & aldosterone production

69. Nursing Interventions: s/p Breast Surgery Semi- Fowlers’ position, turn from back to unaffected side, with affected arm elevated above the heart level to promote drainage & prevent lymphedema Use a pressure sleeve if edema is severe Maintain Jackson-Pratt suction, record the amount & characteristic of draiange No IV, injections, BP, venipunctures in affected arm Low Na-diet, diuretics for severe lymphedema Refer to MD & PT for appropriate exercise program

70. Health Teaching: s/p Breast Surgery Protect & avoid overuse of the hand & arm during the 1 st few months Keep the affected arm elevated to prevent lymphedema Incision care with lanolin to soften & prevent wound contractures BSE on the remaining breast Avoid strong sunlight or heat to the affected arm Don’t carry anything heavy over the affected arm

71. Health Teaching: s/p Breast Surgery Avoid constrictive clothing/jewelry, trauma, cuts, bruises or burns to the affected arm Wear gloves when gardening, washing dishes/clothes Use thick oven mitten mitts when cooking Use a thimble when sewing Apply lanolin hand cream several times daily Use cream cuticle remover Notify MD if S/ of inflammation occur in the affected arm Wear a Medic-Alert bracelet stating lymphedema arm

72. CERVICAL CANCER Premalignant changes: (Stage I) mild dysplasia to (Stage II) mod. dysplasia to (Stage III) severe dysplasia to carcinoma in situ Common sites of mets: pelvis & lymphatics Precipitating factors Low socioeconomic groups Early 1 st marriage Early & frequent intercourse Multiple sex partners High parity Poor hygiene

73. S/Sx: CERVICAL CANCER Painless vaginal bleeding postmenstrually & postcoitally Foul-smelling or serosanguinous vaginal d/c Leakage of urine or feces from the vagina Dysuria, hematuria Pelvic, lower back, leg or groin pain A/, wt loss Changes on Pap smear

74. Tx: CERVICAL CANCER Nonsurgical Chemotherapy Cryosurgery External radiation Internal radiation (intracavitary) Laser therapy Surgical Conization Hysterectomy Pelvic exenteration

75. CERVICAL CA: Laser Therapy Energy from the beam is absorbed by fluid in the tissues, causing them to

vaporize Minimal bleeding & slight vaginal d/c is expected after the procedure, healing occurs in 6-12 wks

76. CERVICAL CA: Cryosurgery Involves freezing of the tissues by a probe with subsequent necrosis No anesthesia required Cramping may occur during the procedure A heavy, watery d/c is expected several wks after the procedure, use tampons Avoid sexual intercourse

77. CERVICAL CA: Conization A cone-shaped area of the cervix is removed For women who want further child bearing Long-term follow-up is needed (new lesions may develop) Cx: hemorrhage, uterine perforation, incompetent cervix, cervical stenosis & preterm labor

78. CERVICAL CA: Hysterectomy Vaginal approach for microinvasive CA if childbearing is not desired Radical hysterectomy & bilateral lymph node dissection for CA that spread beyond the cervix but not to the pelvic wall

79. Nursing Interventions: s/p Hysterectomy Monitor vaginal bleeding (>1 saturated pad/hr) Avoid stair climbing for 1 mo. Avoid tub baths & sitting for long periods Avoid strenous activity or lifting >20 lbs Avoid sexual intercourse for 3-6 wks

80. CERVICAL CA: Pelvic exenteration Radical surgical procedure for recurrent CA When the bladder is removed, an ileal conduit is created & located at the R side of the abdomen to divert urine A colostomy is created on the L side of the abdomen for the passage of feces

81. CERVICAL CA: Types of Pelvic Exenteration Anterior Removal of uterus, ovaries, fallopian tubes, vagina, bladder, urethra & pelvic lymph nodes Posterior Removal of uterus, ovaries, fallopian tubes, descending colon, rectum & anal cnal Total Combo of anterior & posterior

82. Nursing Interventions: s/p Pelvic exenteration Administer perineal irrigation with half-strength H2O2 & NS Avoid strenous activity for 6 mos. Perineal opening may drain for several mos. Ileal conduit & colostomy care Sexual counseling: vaginal intercourse is not possible s/p anterior & total pelvic exenteration

83. OVARIAN CANCER Grows rapidly, spreads fast, often bilateral Common sites of mets: pelvis, lymphatics & peritoneum Usually detected late: Poor prognosis Exploratory laparotomy: to dx & stage the tumor

84. S/Sx: OVARIAN CANCER Abdominal discomfort or swelling GI disturbance Dysfunctional vaginal bleeding Abdominal mass

85. Tx: OVARIAN CANCER External radiation: if with mets Chemotherapy: done post-op for all stages of CA Intraperitoneal chemotx: instillation into abdominal cavity Immunotherapy: promotes tumor resistance Surgery:

TAHBSO

86. ENDOMETRIAL CANCER Slow-growing tumor asso. with menopausal years Common sites of mets:

ovaries, pelvis, peritoneum, lymphatics & via blood to the lungs, liver & bone Precipitating Factors Hx of uterine polyps Nulliparity Polycystic ovary disease Estrogen stimulation Late menopause Family hx

87. S/Sx: ENDOMETRIAL CANCER Postmenopausal bleeding Watery, serosanguinous discharge Low back, pelvic or abdominal pain Enlarged uterus in advanced stages

88. Tx: ENDOMETRIAL CANCER External or internal radiation Chemotherapy for advanced or recurrent CA Medroxyprogesterone (Depo-Provera) or Megestrol) Megace for estrogen-dependent tumors Tamoxifen (Nolvadex): antiestrogen Surgery: TAHBSO

89. GASTRIC CANCER Predisposing Factors Diet: high in complex CHO, grains & salt, low in fresh green, leafy vegetables & fruits Use of nitrates Smoking, alcoholism Hx of gastric ulcers Cx: hemorrhage, obstruction, mets & dumping syndrome Goal of Tx: remove the tumor & provide nutritional support

90. S/Sx: GASTRIC CANCER A/N/V, wt loss Fatigue, anemia Indigestion, epigastric discomfort A sensation of pressure in the stomach Dysphagia Ascites Palpable mass

91. Tx: GASTRIC CANCER Chemotx Radiation Surgery Subtotal gastrectomy Bilroth I: Gastroduodenostomy Bilroth II: Gastrojejunostomy Total gastrectomy Esophagojejunostomy

92. Nursing Interventions: GASTRIC CANCER Fowler’s position for comfort: Pain meds as ordered Monitor Hgb, Hct: BT as ordered NPO for 1-3 days post-op until peristalsis returns Monitor I/O: IVF & e+ as ordered Monitor NGT suction, don’t irrigate or remove NGT

93. Nursing Interventions: GASTRIC CANCER Progressive diet to 6 small bland meals/day Monitor wt, nutritional status: Small, bland, easy digestible meals with vit & mineral supplements WOF Cx: hemorrhage, dumping syndrome, diarrhea, hypoglycemia, Vit B12 deficiency

94. PANCREATIC CANCER More common in blacks than in whites, in smokers & in men Linked with DM, alcohol use, hx of pancreatitis, high fat diet, env’tal chemicals With poor prognosis

95. S/Sx: PANCREATIC CANCER N/V Jaundice Unexplained wt. loss Clay-colored stool Glucose intolerance Abdominal pain

96. Tx: PANCREATIC CANCER Radiation Chemotherapy Whipple’s procedure:

pancreaticoduodenectomy with removal of distal third of

the stomach, pancreaticojejunostomy, gastrojejunostomy & choledochojejunostomy

97. INTESTINAL TUMORS Develop in the cells lining the bowel wall or develop as polyps in the colon or rectum Cx: bowel perforation with peritonitis, abscess & fistula formation, hemorrhage & complete gut obstruction Common sites of mets: via lymphatics & blood, colon & other organs

98. S/Sx: INTESTINAL TUMORS A/V, malaise, wt loss Blood in stools, anemia AbN stools Ascending colon tumor: diarrhea Descending colon tumor: constipation with some diarrhea, ribbon-like stool Rectal tumor:

alternating constipation & diarrhea Guarding or abdominal distention Abdominal mass & cachexia (late signs)

99. Nursing Interventions: INTESTINAL TUMORS

WOF bowel perforation: BP,HR,T, weak pulse,

distended abdomen WOF intestinal obstruction:

(EARLY S/Sx- peristalsis,  to bowel sounds) fecal vomiting, pain, constipation, distended abdomen Radiation pre-op Chemotherapy post-op Surgery: bowel resection & creation of colo or ileostomy

100. COLO/ILEOSTOMY PRE-OP CARE Consult with enterostomal therapist to identify optimal placement of ostomy Low-residue diet for 1-2 days pre-op Give intestinal antiseptics & antibiotics, laxatives & enemas as ordered

101. COLOSTOMY POST-OP CARE Apply petroleum jelly over the stoma to keep it moist followed by dry sterile gauze if pouch system is not yet in place Monitor the stoma for size, unusual bleeding or necrotic tissue Monitor the stoma for color N: pink or red indicating vascularity Pale: anemia, Violet/Blue/Black:

compromisedcirculation

102. COLOSTOMY POST-OP CARE Check pouch system for proper fit & leakage Ascending colon colostomy: expect liquid stool Transverse colon colostomy: expect loose to semiformed stool Descending colon: expect close to N stool Empty pouch when 1/3 full, remove feces from the skin Avoid gas/odor-forming foods

103. COLOSTOMY POST-OP CARE WOF perineal wound infection (if present) Administer as ordered Analgesics & antibiotics Stoma irrigation

104. ILEOSTOMY POST-OP CARE Post-op drainage:

dark green to yellow (as the pt begins to eat) Expect liquid stool WOF dehydration & e+ imbalance Avoid suppositories through ileostomy

105. LUNG CANCER Lungs: common target for mets from other organs Bronchiogenic carcinoma: direct extension & via lymphatics 4 Major Types Small (Oat)

Cell Epidermal (Squamous Cell) Adenocarcinoma Large cell anaplastic carcinoma

106. LUNG CANCER Causes Cigarette smoking Env’tal & occupational pollutants Dx: CXR (lesion or mass), bronchoscopy & sputum cytological studies

107. S/Sx: LUNG CANCER Cough Dyspnea Hoarseness Hemoptysis Chest pain A/ wt loss Weakness

108. Nursing Interventions: LUNG CANCER Monitor VS, pulse oximetry Fowler’s position WOF RR distress, tracheal deviation, bleeding, infection & e+ imbalance Activity as tolerated, rest periods, active/passive ROM

Diet: calorie, high CHON,Vit Administer as ordered

O2,bronchodilators, steroids Analgesics CPT

109. Tx: LUNG CANCER Radiation Chemotherapy Immunotherapy Surgery Laser therapy: to relieve endobronchial obstruction Thoracentesis & pleurodesis:

to remove pleural fluid & relieve hypoxia Thoracotomy with pneumonectomy or lobectomy or segmental resection

110. Pre-op Care: LUNG CANCER Explain the potential post-op need for chest tubes Closed chest drainage is not used for pneumonectomy & the serum fluid that accumulates in the empty thoracic cavity will consolidate, preventing mediastinal shift

111. Post-op Care: LUNG CANCER Monitor VS, breath sounds Maintain chest tube drainage system, WOF SQ emphysema Avoid complete lateral turning Activity as tolerated, active ROM of the operative shoulder Administer O2 as ordered

112. PROSTATE CANCER Slow-growing, androgen type of adenocarcinoma in M >50 y/o Common sites of mets: bloodstream, lymphatics, pelvis, spine, bone

113. S/Sx: PROSTATE CANCER (-) in early stages Hard, pea-sized nodule on rectal exam Hematuria Late S/Sx: wt loss, urinary obstruction, pain radiating from the

lumbosacral area down the leg Prostate-specific Ag test:

monitors the pt’s response to tx serum acid phosphatase:

indicates spread & mets

114. Tx: PROSTATE CANCER Hormonal manipulation LT: leuprolide acetate (Lupron), flutamide (Eulexin) or DES Goserelin acetate (Zoladex) when orchiectomy or estrogen administration is not acceptable for the pt Radiation & Chemotx for hormone-resistant tumors

115. Tx: PROSTATE CANCER Palliative surgery:

Orchiectomy (to testosterone production) Cryosurgical ablation (liquid nitrogen freezes the prostate, dead cells are absorbed by the body) Transurethral resection of the prostate (TURP) or prostatectomy

116. PROSTATE CA: TURP Insertion of a scope into the urethra to excise prostatic tissue Bleeding is common

post-op, WOF hemorrhage Continuous bladder irrigation (CBI) post-op to maintain the urine at a pink color Bladder spasms are common post-op, give antispasmodics as ordered WOF dribbling & incontinence Sterility may or may not occur post-op

117. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal Technique Via abdominal & bladder incision Via low abdominal incision without opening the bladder Via incision bet. scrotum & anus Hemorrhage Yes No No Bladder spasms Yes Yes but less Urinary incontinence common

118. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal CBI Yes Yes - Sterility Yes Yes Yes Remarks Abdominal dressing soaked frequently with urine, Longer healing time than TURP Minimal abdominal drainage WOF infection, (No rectal tubes, rectal temp. taking & enema) Teach perineal exercises

119. Nursing Interventions: s/p TURP Monitor VS, U.O., hematuria & clots, Hgb & Hct levels Force fluids Expect red to light pink urine for 24 hrs, turning to amber in 3 days (then encourage ambulation) WOF arterial bleeding (bright red urine with clots): CBI & notify MD WOF venous bleeding (burgundy-colored urine): notify MD who will apply traction on the catheter Continuous urge to void is N but not encouraged to prevent bladder spasms Antibiotics, analgesics, stool softeners & antispasmodics as ordered

120. Nursing Interventions: s/p TURP Monitor 3-way foley

catheter (for the balloon (30-45 cc), inflow & outflow) Use pNSS only to prevent water intoxication or hypoNa ( LOC, HR,BP) Maintain infusion rate as ordered, if (+) clots:  rate For obstructed catheter: turn off CBI, irrigate with 30-50 ml pNSS, notify MD if it does not resolve CBI is d/c usually after 1-2 days, WOF continence & urinary retention

121. Discharge Health Teaching: s/p TURP Avoid heavy lifting, stressful exercise, driving, Valsalva maneuver & sexual intercourse for 2-6 wks Drink 2.4-3L fluids/day before 8 pm Avoid alcohol, caffeine & spicy foods to prevent overstimulation of the bladder Pt may pass small clots & tissue debris for several days If urine becomes less in amount & bloody, rest & force fluids, notify MD if persistent

122. Nursing Interventions: s/p Suprapubic Prostatectomy Monitor foley catheter & suprapubic catheter drainage As ordered, clamp the suprapubic cath after foley cath is removed (2-4 days post-op) & instruct the pt to void, measure residual urine by unclamping the cath & measuring the U.O. Prepare for removal of suprapubic cath if pt consistently empties bladder & residual urine is <75 ml