Care of Clients in Cellular Aberrations, Acute Biologic Crisis (ABC), Emergency and Disaster Nursing (NCM106) Cellular Aberration II

LOOKY HERE

Cancer Management
Goals of Cancer Treatment
Curative - Complete eradication of the malignant disease Control Prolonged survival and containment of cancer cell growth Palliation Relief of symptoms associated with the disease (promote comfort of the client) o E.g. PEG (Percutaneous Endoscopic Gastrostomy)

1. 2. 3.

4.

Cancer Management Methods of Radiation Administration / Delivery Types of Therapy a. Hormonal Therapy b. Biotherapy c. Transplantation Palliative Care (Drugs)

Treatment Modalities
Surgery Radiation therapy Hormonal Therapy Biotherapy Transplantation o Continuous planning with the patient and patients family o Understand the principles and interrelationships of treatments o Collaboration with the entire health team

Surgical Interventions: Surgery 90% of all patients with cancer will undergo a surgical procedure during the course of their management Considered to be the first line of treatment for solid tumors Commonly used for: o Diagnosis and staging o Prophylaxis and tumor removal o Palliation o Reconstruction Choice of Surgery Depends on Extent of the disease Location and structures involved Tumor growth rate and invasiveness Surgical risk to the patient Quality of life the patient will experience after the surgery Diagnostic Surgery - Performed to obtain tissue samples for analysis of cells suspected to be malignant (Biopsy) o Excisional o Incisional Removal of a small wedge o Needle Biopsy Curative Surgery - Also referred to as DEBULKING - Indicated for cancers that are: a. Locally or regionally combined b. Havent metastasized c. Have not invaded major organs - Two common techniques: 1. Local Excision Indicated for small mass Includes removal of the mass and a small margin of normal tissue 2. Wide Excision Also called as: Radical or en bloc dissection Performed if tumor can be removed completely

jcmendiola_Achievers 2013

Includes removal of the primary tumors, lymph nodes, adjacent involved streucture, and surrounding tissues that may be at high risk for tumor spread Other Surgical Approaches 1. Video-assisted Endoscopic Surgery KEY POINTS to REMEMBER: Plan for the effects of surgery to Used in thoracic and abdominal area the patient: body image, self 2. Salvage Surgery esteem, functional abilities Utilized in treatment of local recurrence of Surgical interventions are best cancer after less extensive primary surgery done at early stage of cancer (e.g. Mastectomy after primary lumpectomy and radiation therapy) 3. Electrosurgery Uses electric current to destroy tumor cells 4. Cryosurgery Uses liquid nitrogen to freeze tissue to cause cell destruction (e.g. Cancer of liver and prostate) 5. Chemosurgery Uses corrosive paste in combination with frozen sections to ensure complete removal of tumors (e.g. Skin cancer) 6. Laser Surgery Uses a laser beam to resect a tumor (e.g. Retinal and vocal cord surgery)

Prophylactic Surgery - Involves removal of non-vital tissues or organs that are likely to develop cancer - Factors to consider in choosing prophylactic surgery KEY POINTS to REMEMBER: Family history and genetic predisposition Long term physiologic and Presence or absence of symptoms psychological effects are known Potential risks and benefits Provide pre-operative teaching to patient and family Ability to detect cancer at early stage Plan for long-term follow-up care Patients acceptance of the postoperative outcome Palliative Surgery - Performed in an attempt to relieve complications of cancer (e.g. ulceration, obstructions, hemorrhage, pain and malignant effusions) - Nursing Actions: Provide complete perioperative assessment for all factors affecting the patient Provide education and emotional support Communicate with the physician and other health care team Assess patients response after surgery and monitor for possible complications Ensure patients safety and comfort Provide post-operative teaching: wound care, resumption of activities, nutrition and pharmacologic management Plan for discharge, follow-up and home care Radiation Therapy - More than 60% of patients with cancer receive radiation therapy alone or in combination with other forms of treatment - GOAL: To achieve local-regional control of the cancerous growth without permanently damaging the surrounding normal tissue - Uses of Radiation Therapy 1. Primary Treatment Primary Treatment for: a. Squamous cell carcinomas of head and neck b. Primary nervous system malignancies c. Localized lymphomas d. Germ cell tumors e. Cervical, pancreatic and prostate cancers

jcmendiola_Achievers 2013

2.

3.

4.

Requires longer duration of treatment and higher doses compared to palliative modalities Control Malignancy Used when tumor cannot be removed surgically Local nodal metastasis is present in patients with leukemia, radiation prevents infiltration to the brain or spinal cord Adjuvant Treatment Used as adjuvant to surgery (Administered presurgically or postsurgically) Enhance the ability of chemotherapy to cross the blood-brain barrier Palliative Treatment To reduce symptoms in 50% of patients with advanced cancer Effective in reducing pain and improving mobility
Radiation Source Alphaparticles o Stopped by a sheet of paper Beta Particles o Stopped by a layer of clothing or a few millimeter of a substance such as aluminum Gamma Particles o Stopped by several feet of concrete or a few inches of lead

Types of IONIZING RADIATION 1) Direct Ionization Uses radiation particles: Beta particles, protons, neurons and alpha particles 2) Indirect Ionization Use of electromagnetic rays: X-rays and gamma rays MECHANISM of ACTION of Radiation Therapy - Ionizing radiation penetrates tissues and giving up energy and producing fast moving electrons - Electrons interact with free or loosely bonded electrons of the absorber cells and subsequently produces free radicals which destroy DNA structure of the cell

(A) With p53

Damage is repaired

Ionizing Radiation DNA Damage

Normal cell division

Or

Induction of p53 causes cell cycle arrest

(B) Without p53 Ionizing Radiation DNA Damage

Massive mitotic Failure to cell death Cell division with damaged chromosomes Or

Tumor regress

Tumor cell lacking p53 CANCER

jcmendiola_Achievers 2013

Cells are most vulnerable to the disruptive effects of radiation during DNA synthesis and mitosis (Early S, G2 and M Phases of the Cell Cycle)

KEY POINTS to REMEMBER:

Radiation greatly injure rapidly proliferating and poorly differentiated cells (Cancerous tumor cells) Can also injure rapidly dividing cells (bone marrow, mucosal lining of GIT, lymphatic tissue, gonads, hair and nails)

KEY POINTS to REMEMBER:

Tumors that are well oxygenated also appear to be more sensitive to radiation Certain chemicals, including chemotherapy agents, act as radiosensitizers (Sensitive more hypoxic tumors to the effects of radiation therapy) Recovery from sub-lethal doses of radiation occurs in the interval between the 1st dose of radiation and subsequent doses Normal tissue usually is able to recover from radiation damage more rapidly than cancerous tissue

Methods of Radiation Administration / Delivery

A. External Radiation X-Ray Destroys cancer cells at the skin surface and underlying tissues Kilovoltage Therapy Devices Delivers maximal radiation to superficial lesions (Skin and breast) Linear Accelerators and Betatron Machines Delivers maximal X-ray and deliver dosage in deeper structure with less damage to skin Gamma-Rays Provides radiation beneath the surface of the skin with less adverse effects Cobalt 60 Decay of the particle releases gamma rays Particle-beam Radiation Therapy Accelerates sub-atomic particles through body tissues. Damages target cells as well as cells along its pathway B. Internal Radiation Internal Radiation Implantation (Brachytherapy) Involves the insertion of sealed radioactive sources into: 1. Body cavity (Intracavity) 2. Directly into body tissues (Interstitial) Specific Radioisotopes for implantation is selected on the basis of its half-life E.g. Intracavity Brachytherapy Radioactive needles, seeds and beads deliver radiation to the cavity Radioisotopes are inserted into specially positioned applicators Placement of applicator is verified by X-ray Radioisotopes remain in place for a prescribed period and then are removed Patients are maintained on bed rest and log-rolled to prevent displacement Interstitial Brachytherapy Radioactive needles, seeds and beads deliver radiation to the cavity Radioisotopes are inserted into specially positioned applicators Placement of applicator is verified by X-ray Radioisotopes remain in place for a prescribed period and then are removed Patients are maintained on bed rest and log-rolled to prevent displacement C. Unsealed Internal Radiation Radioisotopes injected intravenously or administered by mouth Iodine-131 Treatment for thyroid cancer Strontium-89 Control bone pain due to multiple metastasis

jcmendiola_Achievers 2013

Adverse Effects of Radiation Therapy

Altered skin integrity (Alopecia, erythema and desquamation) Alteration in oral mucosa (stomatitis, xerostomia, change in taste, and decreased salivation) GIT Disturbances (Anorexia, N?V, Diarrhea) Dyspnea, chest pain, Dysphagia Bone Marrow Suppression (Active anemia, leucopenia and thrombocytopenia)

Nursing Management
Patient Teaching: Provide supplementary teaching about effects of radiation on the tumor, as well as the normal cells and tissue Provide overview of the radiation administration, equipment used, and the duration of procedure Instruct about possible immobilizations during and after placement of isotopes If implants are to be placed, inform patient and family about restrictions (visitors and health team) and radiation precaution Avoid use of ointments, lotions, and powders on areas with skin irritation Gentle oral hygiene is encouraged to remove debris and promote healing of mouth ulcers Patient will feel fatigue and general weakness after each surgery Radiation Precautions Time All persons must (be informed) limit their exposure with the patient Distance There should always be a distance of about 6 feet and more Shielding Refers to the placement of thick lead shields between the care givers The radiation source must never be placed in the sewage via the sink or toilet (5 7 times of flushing) If dislodgement occurs, the safety officer or radiation therapist must be notified immediately If source of radiation must be picked up, it is picked up with a pair of long handled forceps or tongs, place it in a lead container

Patients With Radioactive Implants

Assign patient to a private room with private baths Place a Caution: Radioactive Material sign on the door of patients room Wear a dosimeter film badge when providing care for patient measures radiation exposure Wear lead apron during patient contact Pregnant women and children younger than 16 years are not allowed to visit Limit each visitor to hour per day. Be sure that they at are at least 6 feet away from the source

Protecting Skin and Mucosa

Wash irritated area with either mild soap and water only each day Do not remove ink or dye markings indicating the area focus of radiation beam Avoid wearing of belts, buckles, straps or any clothing that rubs the skin at radiation site Avoid exposure of irradiated area to the sun Avoid heat exposure Do not apply sun screens When outdoors, use an umbrella and other forms of shades

Hormonal Therapy
Consists of administration of drugs designed to alter the hormonal environment of cancer cells negatively Used for cancers that are responsive to or dependent on hormones for growth Breast cancer Prostate Cancer Endometrial cancer Other cancers reactive to hormonal therapy (Lesser degree) Kaposis Sarcoma Renal Cancer Liver

jcmendiola_Achievers 2013

Ovarian Pancreatic Goal of Hormonal Therapy Deprive cancer cells of the hormonal signals that stimulates cell division

Hormone Antagonist Hormones that competes with natural hormones at the receptor site Binds to specific hormone receptors or tumor cell Limits needed hormone to bind on tumor cell Hormone Inhibitors o Drugs that inhibit the production of specific hormones in the normal hormone-producing organs o Common Agents Used for Hormonal Manipulation Types of Agent Example Androgen Fluoxymesterone (Halotestin) Testolactone (Teslac) Estrogen Chlorotrianisene (Tace) Ethinylestradiol (Estinyl) Hormone Antagonists o Antiandrogens o Antiestrogens

Side Effects of Hormonal Manipulation

Androgens and Antiestrogen Masculinizing effects on females Excessive growth of facial and chest hair Cessation of menstrual period Shrinking of breast tissue Fluid retention Development of acne Hypercalcemia Estrogen, Progestin and Antiandrogens Loss of facial hair Increased smoothness of skin Gynecomastia Testicular penile atrophy Difficulty in achieving and maintaining erection

Biotherapy
Involves use of immunotherapy and biologic response modifiers (BRM) as a means of changing the persons own immune response to cancer Mechanism of Action Modification of host responses Suppression tumor growth or killing the tumor cell Modification of tumor cell biology Immunotherapy a. Active Immunotherapy Bacillus Calmette-Guerin (BCG) Treatment for superficial bladder cancer b. Passive Immunotherapy Transfer of cultured immune cells into a tumor-bearing host c. Adoptive Immunotherapy Transfer of sensitized NK cells of T lymphocytes, combined with cytokines to the tumor bearing host

jcmendiola_Achievers 2013

Biological Response Modifier - Stimulate specific immune system cells to attack and destroy cancer cells - Blocks cancer cells access to an essential function or nutrient a. Interleukin (ILs) Helps regulate inflammation and immune protection Helps immune system cells to recognize and destroy abnormal body cells E.g. IL-I, IL-2 and IL-6 b. Interferons (INFs) Cell produced proteins that can protect non-infected cells from viral infection and replication Cancer-related functions of INFs: Slow tumor cell division Stimulate the growth and activation of NK Cells Help Cancer cells a more normal appearance and function Inhibits the expressions of oncogenes COMMON BIOLOGIC RESPONSE MODIFIERS Agent Indications Sargramostim (Leukine, Prokine) Chemotherapy-induced Leukopenia Filgrastim (Neupogen) Chemotherapy-induced Neutropenia Pegfilgrastim (Neulasta) Chemotherapy-induced Neutropenia Epoetin alfa (Epogen, Procrit) Chemotherapy-induced Anemia Darbepoetin alfa (Aranesp) Chemotherapy-induced Fatigue Oprelvekin (Neumega) Chemotherapy-induced Thrombocytopenia

Side Effects of Biologic Response Modifiers

Generalized and severe inflammatory reactions Tissue swelling Fever and chills Flu-like general malaise Skin rashes, dryness, itching and peeling Peripheral neuropathy (SE of INF therapy)

Transplantation
Bone Marrow Transplantation - Used in the treatment of leukemia, usually in conjunction with radiation / chemotherapy Indications: Leukemia Severe aplastic anemia Lymphoma Multiple myeloma Immune deficiency disorders Solid-tumor cancers, such as breast or ovarian cancer TYPES OF BONE MARROW TRANSPLANTATION 1. Autologous BMT The donor is the patient himself/herself Stem cells are taken from the patient either by bone marrow harvest or apheresis (peripheral blood stem cells) and then given back to the patient after intensive treatment Often given the term rescue instead of transplant 2. Allogenic BMT The donor shares the same genetic type as the patient

jcmendiola_Achievers 2013

3.

Stem cells are taken by either bone marrow harvest or apheresis (peripheral blood stem cell) from a genetically-matched donor usually a brother / sister Other donors for allogenic bone marrow transplantation include the following: A Parent A haploid-identical match is when the donor is a parent and the genetics match is at least half identical to the recipient An Identical Twin A syngeneic transplant is an allogenic transplant Unrelated BMT (UBMT or MUD for Matched Unrelated Donor) The genetically matched marrow or stem cells are from an unrelated donor Unrelated donors are found through the national bone marrow registries Umbilical Cord Blood Transplant Stem cells are taken from an umbilical cord immediately after delivery of an infant These stem cells reproduce into mature functional blood cells quicker and more effectively than do stem cells taken from the bone marrow of another child or adult The stem cells are tested, typed, counted and frozen until they are ready to be transplanted

SIDE EFFECTS of COMPLICATIONS OF BMT Infection Infections are likely in the patients with severe bone marrow suppression Bacterial infections are most common Low Platelet and Low Red Blood Cells Thrombocytopenia (Low platelets) and Anemia (Low RBCs) as a result or non functional bone marrow Pain High doses of chemotherapy and radiation can cause severe mucositis (Inflammation of the mouth and GIT) Fluid Overload Kidneys cannot keep up with the large amounts of fluid being given in the form of intravenous (IV), medications, nutrition and blood products. The kidneys may also be damaged from the disease Respiratory Distress Infection, inflammation of the airway, fluid overload, graft-versus-host disease and bleeding are all potential life-threatening complications that may occur in the lungs and pulmonary system Organ Damage Temporary / permanent damage to the liver and heart may be caused by infection, graftversus-host disease, high doses of chemotherapeutic drugs / radiation / fluid overload Graft Failure May occur as a result of infection, recurrent disease, or if the stem cell count of the donated marrow was insufficient Graft-versus-Host Disease GVHD occurs when the recipients immune system reacts against the donors tissues The new cells do not recognize the tissues and organs of the recipients body

PALLIATIVE CARE
Pain Management
PAIN CARE BILL OF RIGHTS 1. Have your report of pain taken SERIOUSLY and be treated with dignity and respect by doctors, nurses, pharmacists and other health care professionals 2. Have your pain assessed and promptly treated 3. Be informed by your health care provider about they may be causing the pain, possible treatment and benefits, risk and cost of each. 4. Participate actively in decisions about how to manage your pain

jcmendiola_Achievers 2013

5. 6. 7.

Have your pain reassessed regularly and your treatment be adjusted if your pain has not been eased Be referred to a pain specialist if your pain persists Get clear and prompt answers to your questions. Take time to make decisions and refuse a particular type of treatment if you choose

DRUGS
Analgesics
Drugs that relieve pain without producing loss of consciousness / reflex activity Characteristics: It should be potent so that it will afford maximum relief of pain It should not cause dependence It should exhibit a minimum adverse effect (e.g. Constipation, hallucinations, respiratory depression, N/V) It should not cause tolerance It should act promptly and over a long period with a minimum amount of sedation It should be relatively inexpensive Uses: Mild Acute Pain Effectively treat with analgesics E.g. Aspirin, NSAIDS or Acetaminophen Unrelieved Moderate Pain Generally treat with a moderate potency opiate such as codeine or oxycodone Severe Acute Pain Treat with opiate agonist E.g. Morphine, hydromorphone, levorphanol Severe Chronic Pain Morphine Sulfate

Examples of Drugs
Meperidine (Demerol) Commonly prescribed opioid agent in management of pain Other agents may be used as adjunct therapy with analgesics such as antidepressants or anticonvulsants depending on the pains cause Drug Class: Opiate Agonist (Opiate) Used to refer drugs derived from opium such as heroin and morphine Another outdated term is narcotic Induces a stupor sleep Gradually refer to addiction morphine-like analgesics Actions: Capable to relieve severe pain without loss of consciousness Uses: Used to relieve acute / chronic / moderate to severe pain Used to provide preoperative sedation and supplement anesthesia

Corticosteroids
Hormones secreted by the adrenal cortex of the adrenal gland Divided into 2 categories Mineralocorticosteroids (Fludrocortisone, Aldosterone) Glucocorticosteroids (Cortisone, Hydrocortisone, Prednisone) MINERALOCORTICOSTEROIDS Actions: It affects fluid and electrolyte balance by acting on the distal and renal tubules, causing sodium and water retention and potassium and hydrogen excretion Uses: Used in combination with glucocorticosteroids to replace mineralocorticosteroid activity in patients who suffer from adrenocortical insufficiency

jcmendiola_Achievers 2013

Therapeutic Outcomes: Controls Blood Pressure Restoration of fluid and electrolyte balance GLUCOCORTICOSTEROIDS Uses: o Given because of the anti-inflammatory and anti-allergic properties o Relieve the symptoms of tissue inflammation o Effective for immunosuppression in treatment of certain cancers, organ transplants, and auto immune diseases o Used to treat N/V and secondary chemotherapy Therapeutic Outcomes o Reduced pain and inflammation o Minimized shock syndrome and faster recovery o Reduced N/V associated with chemotherapy

jcmendiola_Achievers 2013