CARE OF THE CLIENTS WITH CANCER Conceptualizes that normal cells may be transformed

Learning Outcomes into cancer cells due to exposure to some etiologic

At the end of lecture discussion, the student should be able agents.
to.
- Identify the nurse’s roles in the prevention of cancer and in 2. Failure of the Immune Response Theory
health education. Advocates that all individuals possess cancer cells.
- Discuss the pathophysiology of cancer and its clinical However the cancer cells are recognized by the immune
manifestations. response system. So, the cancer cells undergo
destruction. Failure of the immune system leads to
- Apply the nursing process to identify care of the client in the
inability to destroy the cancer cells.
diagnosis and treatment phases of cancer.
- Formulate plan of care for the client with early stage and Etiologic Factors to Cancer
advanced cancer. I. Viruses
- Value the nurse’s role in providing quality, comprehensive,
 “Oncogenic Viruses” may be one of the multiple
individualized ethical and humane care of clients with cancer.
agents acting to initiate carcinogenesis.
Terminologies Related to Cancer Nursing  Prolonged or frequent viral infection may cause
breakdown of the immune system or overwhelm
1. Cancer - A disease of the cell in which the the immune system.
normal mechanism of the control of growth and  Viral infection that increase risk of certain form
proliferation have been altered. It is invasive, of cancer are as follows:
spreading directly to surrounding tissues as well 1) Human papilloma Virus – Cervical Cancer
as to new sites in the body. Also called 2) Epstein – Barr Virus – Lymphoma
malignant neoplasm. 3) Hepatitis B and C – Hepatocellular Cancer
2. Benign Neoplasm - A harmless growth that 4) Helicobacter pylori – gastric cancer
does not spread or invade other tissues.
3. Neoplasia - Abnormal cellular changes and II. Chemical Carcinogens
growth of new tissues.  These factors act by causing cell mutation or
4. Hyperplasia - Increase in cell number alteration in cell enzymes and proteins causing
5. Hypertrophy - Increase in cell size altered cell replication.
6. Metaplasia - Replacement of one adult cell type Chemical carcinogens are as follows:
by a different adult cell type  Industrial Compounds
7. Dysplasia - Changes in cell size, shape, Vinyl chloride, Polycyclic aromatic hydrocarbons,
organization Fertilizers, weed killers, Dyes
8. Anaplasia - Reverse cellular development to a  Drugs
more primitive cell type Tobacco, Alcohol, Cytotoxic Drugs
9. Metastases - Spread of cancer cells to distant  Hormones
parts of the body to set up new tumours Estrogens, Diethylstilbestrol
10. Oncology - The medical specialty that deals  Foods, Preservatives
with the diagnosis, treatment and study of Nitrites, Talc, Food sweetener, Nitrosamines, Afflatoxins
cancer. Polycyclic Hydrocarbons
11. Adenocarcinoma - Cancer that arises from Charcoal Broiling
glandular tissues. III. Physical Agents
12. Carcinoma - A form of cancer that is composed Radiation: from X – rays or radioactive isotopes; from
of epithelial cells; develops in tissues covering or sunlight
lining organs of the body such us skin, uterus, or Physical irritation/trauma: from pipe smoking, multiple
breast. deliveries, jagged tooth, irritation of the tongue, “overuse
13. Sarcoma - A cancer supporting or connective of any organ/ body part.
tissues such as cartillage, bones, muscles, or IV. Hormones
fats. Estrogens as replacement therapy has been found to
14. Carcinogens - Factor associated with cancer increase incidence of vaginal, cervical, uterine cancers.
causation V. Genetics
When oncogene is exposed to carcinogens, changes in
Pathogenesis of Cancer cell structure occurs, malignant tumor develops.
Regardless of the cause, several cancers are associated
1. Cellular Transformation and Derangement
Theory. with familial patterns.
 Predisposing Factors to Cancer 5. Uterus
 Age  Cervix. All women who are or have been
 Sex sexually active or who are 40 and older should
 Urban vs. Rural Residence have an annual Pap test and pelvic examination.
 Geographic Distribution After 3 or more consecutive satisfactory
 Occupation examination with normal findings, the Pap may
 Heredity be performed less frequently. Test for human
 Stress papiloma virus (HPV) recommended.
 Precancerous Lesions  Endometrium. Women at high risk for cancer of
 Obesity the uterus should have a sample of endometrial
tissue examined when menopause begins.
Prevention, Screening, and Early Detection Common Causes of Cancer
Prevention 1. Breast Cancer
1. Primary prevention activities are aimed at  Early Menarche
intervention before pathologic change has  Late menopause
begun. These can help reduce cancer risk  Nulliparous or older than 30 years at the birth of
through alteration of lifestyle behaviours to a first child.
eliminate or reduce exposure to
carcinogens. 2. Lung Cancer
 Tobacco abuse
2. Secondary prevention or early detection  Asbestos
provides the opportunity to detect  Radiation exposure
precancerous lesions or early- stage  Air pollution
cancers, to treat them promptly.
3. Colorectal Cancer
Summary of American Cancer Society (ACS)  Greater incidence in men
Recommendations for the Early Detection of Cancer in  Familial polyposis
Asymptomatic People  Ulcerative colitis
 High-fat, low-fiber diet
1. Cancer – related check – up is recommended
every 3 years for people aged 20-40 years every 4. Prostate Cancer
year for people aged 40 and older.  Common among males who are 50 years old
and older
2. Breast. Women who are 40 years and older  African Americans have the highest incidence of
should have an annual mammogram, an annual prostate cancer in the world.
clinical breast exam (CBE) perform monthly  Positive family history
breast self-examination (BSE).  Exposure to cadmium

Women aged 20-39 should have CBE every 3 5. Cervical Cancer

years and should perform monthly BSE.  Sexual behaviour
 First intercourse at an early stage
3. Colon and Rectum. Men and women aged 50  Multiple sexual partner
years or older should follow one of the following  Sexual partner who has had multiple sexual
examination schedules: partner
 Human papilloma virus and AIDS (acquired
 Fecal occult blood test every year and flexible
immunodeficiency syndrome)
sigmoidoscopy every 5 years.  Low socioeconomic status
 Colonscopy every 10 years  Cigarette smoking
 Double – contrast barium enema every 5 – 10
years. 6. Head and Neck Cancer
 Digital rectal exam should be done at the same  More common among males.
 Alcohol and tobacco use
time as sigmoidoscopy, colonscopy or double –
 Poor oral hygiene
contrast barium enema.  Long term sun exposure
 Occupational exposures- asbestos, tar, nickel,
4. Prostate. Prostate- specific antigen (PSA) blood textile, wood or leather work, and machine tool
test and digital rectal examination (DRE), annual experience.
from aged 50.
Men in high – risk groups, such as those with 7. Skin Cancer
strong familial predisposition. (e.g. Two or more affected  Individual with fair complexion
first degree relatives).  Positive family history
 Moles (nevi)
  Exposure to coal tar, creosote, arsenic, radium
 Sun exposure between 11 AM to 3PM
Dietary Recommendations Against Cancer by American
Cancer Society
 Avoid obesity
 Cut down on total fat intake
 Eat more high fiber foods, like raw fruits and
vegetables, whole grain cereals.
 Include foods rich in vitamin A and C in daily
diet.
 Include cruciferous vegetables in the diet, like
broccoli, cabbage, cauliflower, Brussel sprouts.
 Be moderate in the consumption of alcoholic
beverages.
 Be moderate in the consumption of salt- cured,
smoked-cured, and nitrite-cured foods.
 High intake of fats may be associated with
breast, colon, and prostate cancer.
 Low intake o f fruits, vegetables, complex
carbohydrates and fiber is linked with cancer of
the colon, larynx, esophagus, prostate, bladder,
stomach and lungs.
 Salt-cured foods are associated with cancer of
the esophagus and stomach
 Excess alcohol intake is associated with cancer
of the mouth, larynx, esophagus, and liver
especially when combined with smoking.
Warning Signals of Cancer
 C- change in bowel or bladder habits
 sore that does not heal
 U- unusual bleeding or discharge
 U- unexplained sudden weight loss
 U- unexplained anemia
 T- thickening or lump in the breast or elsewhere
o indigestion or difficult in swallowing
 O- obvious change in wart or mole
 N- nagging cough or hoarseness of voice
Staging and Grading of Neoplasia
 Staging is determining the size of the tumor and
existence of metastases.
 Grading is classification of tumor cells.
 Staging is necessary at the time of diagnosis to
determine the extent of disease (local versus
metastatic), to determine prognosis and to guide
proper management.
 The American Joint Committee of Cancer
(AJCC) has developed the TNM classification
system that can be applied to all types.
T- tumor size
N- presence or absence of regional lymph node
involvement
M- presence or absence of distant metastasis
T- Primary tumor
Tx- primary tumor is unable to be assessed
To- no evidence of primary tumor
Tis- carcinoma is situ
T1,T2,T3,T4- increasing size and/or local extent of
primary tumor.
N- presence or absence or regional lymph node
involvement
Nx- regional lymph nodes are unable to be assessed.
No- no regional lymph node involvement
N1, N2, N3- increase involvement of regional lymph
nodes
M- absence or presence or distant metastasis
Mx- unable to be assessed
Mo- absence of distant metastasis
M1- Presence of distant metastasis
Cancer Detection Examinations
1. Cytologic Examination or Papanicolaou
(Pap’s Exam, Pap Smear)
Cytologic specimen can be obtained from tumors that
tend to shed cells from their surface, e.g., G.I. Tract
through endoscopy; respiratory tract through
laryngoscopy and bronchoscopy; genito-urinary tract
through colposcopy of the cervix and vagina, cystoscopy
of the bladder, laparoscopy of the pelvic and abdomen
minal cavity.
Interpretation of Papanicolaou Test
results are as follows;
 Class I. Normal
 Class II. Inflammation
 Class III. Mild to moderate
dysplasia
 Class IV. Probably Malignant
 Class V. Possibly Malignant
2. Biopsy. Involves obtaining tissue samples by
needle aspiration, or incision of tumor.
 Needle biopsy is done by aspiration of tumor
cells with needle and syringe.
 Excisional biopsy is done by removing the
entire tumor. It is done when the tumor is small.
 Incisional or subtotal biopsy is done by taking
only a part of the tumor. This is done when the
tumor is large.
3. Ultrasound, Magnetic Resonance Imaging
(MRI), Radiodiagnostic tests, Computerized
Axial Tomography (CT Scan) Endoscopic
Examinations.
4. Laboratory Test for Cancer
 Hematologic (CBC)
- Hemoglobin
- Hematocrit
- Leukocytes
- Platelets
 Tumor Markers
1. AFP (Alpha- Feto-Protein)
2. CEA (Carcinoembryonic Antigen)
3. HCG (Human Chorionic Gonadotropin)
4. Prostatic Acid Phosphatase
5. PSA (Prostatic Specific Antigen)
6. Hemoglobin and hemotocrit are low in anemia;
may indicate malignancy.
7. Leukocytes (wbc’s) are high in leukemia
(immature wbc’s), lymphomas; low in leukemia
(matue wbc’s) and metastic desease to bone
marrow.
8. Platelets are high in CML (chronic myelocytic
leukemia), Hodgkin’s disease; low in ALL ( acute
lympcyticleukemia), AML (acute myelocytic
leukemia), multiple myeloma, bone marrow
depression.
9. AFP is elevated in lung, testicular, pancreatic,
colon, gastric cancers and choriocarcinoma.
10. CEA is elevated in colorwectal, breast, lung,
stomach, pancreatic, and prostate cancers.
11. HCG is elevated in choriocarcinoma, germ cell
testicular cancer, ectopic production in lung,
liver, gastric, pancreatic, and colon cancers.
12. Prostatic acid phosphate is elevated in metastic
prospate cancer. PSA is elevated in prostate
cancer.
PATHOPHYSIOLOGIC BASIS OF MALIGNANT
NEOPLASIA
 The different predisposing factors and etiologic
factors cause cellular aberrations.
 Cellular aberrations result to the following:
- Cancer cell proliferation
- Paraneoplastic syndrome
- Anorexia- cachexia syndrome
 Cancer cell proliferation disrupts normal cell
growth and interfere with tissue function, and
result to the following:
1. Pressure. Due to increase in size of neoplastic
growth.
2. Obstruction. As tumor continues to grow, hollow
organs and vessels become compressed and
obstructed.
E.g. Esophagus, bronchi, uteres, bowel, blood vessels,
lymphatic system.
3. Pain
Due to:
- Pressure on nerve endings.
- Distention of organs/ vessles.
- Lack of oxygen to tissues and organs.
- Release of pain mediators by the tumor.
- A late sign of cancer
4. Effusion
- When lymphatic flow is obstructed, there may be
effusion in serious cavities.
E.g. Effusion into the pleural cavity: pleural effusion;
effusion into the abdominal cavity; ascites.
5. Ulceration and Necrosis
- Result as the tumor erodes blood vessels and
pressure on tissue causes ischemia ------ tissue
damage and bleeding ------ infection
6. Vascular Thrombosis, Embolism,
Thrombophlebitis
- Tumors tend to produce abnormal coagulation
factors that cause increased clotting (pulmonary
embolism ------ life – threatening).
 Paraneoplastic Syndrome – Malignant cells
produce enzymes, hormones and other
substances.
 Anemia
 Ca cells produce chemicals that interfere with
rbc production.
 Iron intake is greater in the tumor than that
deposited in the liver.
 Blood loss that results from bleeding leads to
anemia.
 Hypercalcemia
 Tumors of the bone, squamous cell lung cancer,
cancer of the breast, produce a parathyroid –
like hormone that increases or accelerates bone
breakdown and release of calcium.
 Also results from metastasis to the bones.
 Enhanced by immobilization and dehydration.
 DIC (Dessiminate Intravascular Coagulation)
 More likely to occur in cancer of the lungs,
pancreas, stomach, prostate
 Precipitation by the release of tissue
thromboplastin or endothelial injury.
 Anorexia- Cachexia Syndrome
 The final outcome of unrestrained cancer cell
growth.
 Malignant neoplasm deprive normal cell
nutrition.
 Tumors produce alteration in enzyme system
necessary for normal metabolism ----- stored fat
 is lost, tissues lose nitrogen (negative nitrogen
balance)
 Tumors revert to anaerobic metabolism ------
consume glucose; deplete glycogen stores in
the liver and convert glucose to lactate.
 Protein depletion, serum albumin levels
decrease.
 Tumors take up sodium. Water retention masks
malnutrition and is not immediately reflected as
weight loss.
 Ca cells produce anorexigenic substances that
act in the safety center of the hypothalamus,
causing anorexia.
 Taste sensation diminishes or becomes altered
and the individual may have aversion to eating,
particularly meat. Specifically, meat taste bitter
among clients with cancer.
Treatment Modalities for Cancer
 Surgical Interventions
 Radiation Therapy
 Chemotherapy
 Immunotherapy
 Bone Marrow Transplantation
The choice of treatment modality depends on the type of
tumor, the extent of the disease, and the client’s co-
morbid condition (e.g. Cardiac disease), performance
status, and wishes.
 Surgical Interventions
1. Diagnostic Surgery. This is done by cytologic
specimen collection and biopsy.
2. Preventive Surgery. This involves removal of
precancerous lesions and benign tumors, e.g.,
patients with familial polyposis and ulceratives
colitis undergo subtotal colectomies to prevent
colon cancer.
3. Curative Surgery. This involves removal of entire
tumor and surrounding lymph nodes. Cancers
that are localized to the organ of origin and the
regional lymph nodes are potentially curable by
surgery.
4. Reconstructive Surgery. this is done for
improvement of the appearance and function of
the organ affected. This is also an attempt to
improve the client’s quality of life.
5. Palliative Surgery. This is done for relief of
distressing signs and symptoms or for
retardation of metastasis. This is an attempt to
improve quality of life.
Examples of palliative surgery are as follows:
a) Reduce pain by interrupting nerve pathways or
implanting pain control pumps.
b) Relieve airway obstruction
c) Relieve obstructions in the GI and GU tracts.
d) Relieve pressure in the brain and the spinal
cord.
e) Prevent hemorrhage.
f) Remove infected and ulcerating tumors.
g) Drain abscesses.
 Radiation Therapy (RT)
 Radiation therapy may be used as a primary,
adjuvant, or a palliative treatment modality. As a
primary modality, it is the only treatment used
and aims to achieve local cure of the cancer
(e.g., early stage skin cancer, Hodgkin’s
disease, carcinoma of the cervix).
 As an adjuvant therapy, RT can be done
preoperatively or postoperatively to aid in
destruction of cancer cells. In addition, it can be
used in conjunction with chemotherapy to
enhance destruction of cancer cells,
 Ass a palliative therapy, RT can be used to
relieve pain caused by obstruction, pathologic
fractures, spinal cord compression and
metastases.
 Radiosensitivity, the relative sensitivity of tissues
to radiation, depends on the individual cell and
the characteristics of the tissue itself.
 RT is the use of high-energy ionizing radiation
that destroys a cell’s ability to reduce by
damaging its DNA.
 Rapidly dividing cells like cancer cells are more
vulnerable to radiation.
Therefore, radiation kills cancer cells while
sparing normal cells from excessive cell death.
The types of radiation therapy are as follows;
1. External Radiation Therapy (Teletherapy, DXT).
This administred through a high-energy X-ray or
gamma X-ray machine (e.g. Linear accelerator,
cobalt, betatron, or a machine containing
radioisotope).
The major advantage of high- energy radiation is its skin-
sparing effect. The maximum effect of radiation occurs at
tumor deep in the body, not on the skin surface.
There is no need for isolation.
2. Internal Radiation Therapy. This is administred
within or near the tumor or into the systemic
circulation.
 The major type of internal RT are as follows:
 Sealed source (brachytherapy). The radioisotope
is placed within or near the tumor. The radioactive
material is enclosed in a sealed container.

 Sealed source is used for both intracavity and
intertitial therapy.
 Intracavity RT is used to treat cancers of the
uterus and cervix. The radioisotope is placed in
the body cavity, generally for 24 to 72 hours
(cesium 137 or radium 226)
 In an interstitial therapy, the radiosotope is placed
in needles, beads, seeds, ribbons, or catheters,
which are then implanted directly into the tumor
( iridium 192, iodine 125, cesium 137, gold 198,
or radium 222).
 In sealed sources of internal radiation, the
radioisotope cannot circulate through the client’s
body nor can it contaminate the client’s urine,
sweat, blood or vomitus. Therefore, the client’s
excretions are not radioactive. However,
radiation exposure can result from direct contact
with the sealed radioisotope, such as touching
the container with bare hands or from lengthy
exposure to the sealed radioisotope.
 Unsealed source. The radioisotopes may be
administered intravenously, orally or by
instillation directly into the body cavity.
 In unsealed sources of internal radiation, the
radioisotope circulates through the client’s body.
Therefore, the clients urine, sweat, blood and
vomitus contain the radioactive isotope.
 Examples of unsealed sources of RT are iodine
131 given orally for Grave’s disease and thyroid
cancer; alrontium chloride 89 is administered
intravenously for relief of painful bony
metastases.
Principle of Radiation Protection – DTS
1. D-istance. The greater distance the radiation
source, the less the exposure dose of ionizing
rays. Maintain a distance of at least 3 feet when
not performing nursing procedures.
2. T-ime. Limit contact with the client for 5 minutes
each time, a total of 30 minutes per 8- hours
shift.
3. S-hielding. Use lead shield during contact with
client.
 Pregnant staff should not be assigned to clients
receiving internal RT.
 Staff members caring for the client with internal
RT should wear dosimeter badge while in the
client’s room.
 To prevent feeling of isolation, maintain contact
with the client while keeping distance from
radiation exposure. Talk with the client from the
doorway of the room.
 If the client with cancer of the cervix has
radioisotope implant into the uterus, the
following nursing intervention should be
implemented.
1. Client’s back is turned towards the door. To
minimize exposure of healthcare staff to
radioisotope entering the client’s room.
2. Encourage the client to turn to sides at regular
intervals.
3. The client should be on complete bed rest. To
prevent dislodgement of the radioisotope.
4. The client should be given enema before the
procedure. Bowel movement during the
procedure may cause dislodgement of the
radioisotope.
5. The client should be given low fiber diet to inhibit
defecation during the procedure until the device
is removed in 2 to 3 days. To prevent
dislodgement of the radioisotope.
6. The client should have foley catheter in place
during the procedure. To prevent bladder
distension and subsequently prevent irradiation
of the bladder. Irradiation of the bladder may
cause fistula formation between the bladder and
the uterus. This cause the urine to come out
from the vagina.
7. Have long forceps and lead container readily
available. Use long forceps to pick up dislodge
radioisotope and place it in the lead container.
 The client receiving an unsealed source of RT;
should have a private room and bath
 All surface including the floor area the client will
be walking on, are covered with Chux or paper.
 Foods are served on disposable plates and
utensils.
 Trash and linens are kept in the client’s room
and are not removed until the client is ready for
discharge. In general, linens are not changed
until they are grossly soiled. This is to minimize
radiation exposure of caregivers.
 The client is also instructed to rinse the sink with
copious amount of water after tooth brushing
and to flush the toilet several times after each
use. To prevent radiation contamination of other
people and the environment.
 Anyone entering the room wears a new pair of
booties each time to prevent tracking the
radioisotope out into the hallway.
  Caregiver should wear gloves when handling
body fluids.
 Any emesis (vomiting), especially that occurs
shortly after ingestion of oral radioisotope,
should be covered with absorbent pads, and the
radiation safety officer should be called
immediately.
Teaching Guidelines Regarding External Radiation
Therapy
1. It is painless.
2. Lie very still on a special table while the
intervention is being given and you may be
placed in a special position to maximize tumor
irradiation.
3. Each treatment usually lasts for few minutes.
You may hear sound of the machine being
operated, and the machine may move during the
therapy.
4. As a safety precaution for the therapy personnel,
you may remain alone in the treatment room
while the machine is in the operation.
5. The technologist will be right outside the room
observing you through a window or by a closed-
circuit TV. You may communicate.
6. There is no residual radioactivity after radiation
therapy. Safety precautions are necessary only
during the time you are actually receiving
irradiation. You may resume normal activities of
daily living.
Client Education on Skin Care In External Radiation
Therapy
Skin care within the treatment area includes the
following:
 Keep your skin dry.
 Do not wash the treatment area until you are
instructed to do so. when permitted, wash the
treated skin gently with mild soap, rinse well,
and pat dry. Use warm water or cool water, not
hot water.
 Do not remove the lines or ink marks placed on
your skin.
 Avoid using powders, lotion, creams, alcohol,
and deodorants on the treated skin.
 Wear loose- fitting clothing to avoid friction over
the treatment area. Do not apply tape to the
treatment area if dressings are applied.
 Shave with an electric razor. Do not use pre-
shave or after-shave lotions.
 Protect your skin from exposure to direct
sunlight, chlorinated swimming pools, and
temperature extremes
 Consult your radiation therapist or nurse about
specific measures for individual skin reaction.
Nursing Interventions for Side Effects of Radiation
Therapy
1. Skin Reaction
 Erythema, dry/moist desquamation.
 Atrophy, telangiectasia, depigmentation,
necrotic/ulcerative lesions.
Nursing interventions:
 Observe for early signs of skin reaction and
report to the physician.
 Keep area dry
 Wash area with water, no soap and pat dry(do
not rub). Mild soap is permitted .
 Do not apply ointments, powders or lotion on the
area. Cornstarch may be used.
 Do not apply heat; avoid direct sunshine or cold
on the area.
 Use soft cotton fabrics for clothing. To prevent
skin irritation
 Do not erase markings on the skin. These serve
as guide for areas of irradiation.
2. Infection
 This is due to bone marrow suppression.
Nursing interventions:
 Monitor blood counts weekly, especially wbc.
 Good personal hygiene, nutrition, adequate rest.
 Teach the client signs of infection to report to
physician.
3. Hemmorhage
 Platelets are vulnerable to radiation
Nursing interventions:
 Monitor platelet count
 Avoid physical trauma or use of aspirin (ASA)
 Teach signs of hemorrhage to report
 Monitor stool and skin for signs of hemorrhage.
 Use direct pressure over injection sites until
bleeding stops
4. Fatigue
 Result of high metabolic demands for tissue
repair and toxic waste removal.
 Plenty of rest and good nutrition.
5. Weight loss
 Anorexia, pain and effect of cancer.
6. Stomatitis and Xerostomia
 Ulceration of oral mucous membrane occurs
Nursing interventions:
 Administer analgesics before meals, as
prescribed.
 Bland diet, avoid smoking and alcohol.
 Good oral hygiene with saline rinse every 2
hours.
  Sugarless lemon drops or mint to increase
salivation.
7. Diarrhea, nausea and vomiting, headache,
alopecia and cystitis may also occur.
Social isolation is also experienced by the client due to
fear of contaminating others with radiation.
Chemotherapy
 The goals of chemotherapy may be cure,
control, or palliation of manifestations. It is a
systemic intervention. It is recommended when:
 Disease is widespread.
 The risk of undetectable disease is high.
 The tumor cannot be resected and is resistant to
RT
 The objective of chemotherapy is to destroy all
malignant tumor cells without excessive
destruction of normal cells
 Chemotherapy has the following characteristics:
 It affects both normal and cancer cells. The
rapidly dividing cells, both the normal and
cancer cells are vulnerable to destruction by
chemotherapy by disrupting cell function and
division. Mucous membrane, blood cells, hair
follicles, skin cells are rapidly dividing cells. Side
effects of chemotherapy tend to occur in these
structure.
 Chemotherapy has fraction cell-kill. Only a
certain number of cancer cells are killed with
each course of chemotherapy. Therefore,
chemotherapy must be given in a series.
 Chemotherapy has fraction cell-kill. Only a
certain number of cancer cells are killed with
each course of chemotherapy. Therefore,
chemotherapy must be given in a series.
 Chemotherapy may be cell-cycle specific (CCS)
or cell- cycle non-specific (CCNS). CCS
chemotherapy may destroy cancer cells at any
stage of cell division. Thus, combination
chemotherapy destroys more malignant cells
and produces fewer side effects because each
drug strikes the cancer cells at different stages
in the cycle.
Route of Administration of Chemotherapy
1. Intravenous Chemotherapy
 Extravasation (escape from the vein) of some
chemotherapeutic agents can cause tissue
necrosis in the area.
 Use of vascular access devices (VAD’s) are now
preferred as venous access. This provides
continuous chemotherapy, multiple access,
route for administration of parenteral fluids,
antibiotics, and frequent blood testing.
 VAD’s can be implanted (e.g Port-A-Cath),
central lines (e.g tunneled and non-tunneled),
and peripherally inserted central catheters
(PICC lines)
 The most commonly reported compilations of
VADs are infection and obstruction. (each
institution provides protocol of care of VADs,
e.g., change of dressing, flushing, blood raw,
etc.).
2. Regional Chemotherapy
 Allows high concentrations of drugs to be
directed to localized tumors.
The methods are as follows:
 Topical
Fluorouracil cream may be applied to
the skin to treat actinic keratoses.
 Intra-arterial
Intraarterial infusion enable major
organs or tumor sites to receive maximal exposure with
limited serum levels of medications.
 Intracavity
Intracavity therapy instills the medication directly
into an area such as the abdomen, bladder, or pleural
space.
 Intraperitoneal
Intraperitoneal chemotherapy is done to cancer
in the intra-abdominal area e.g. Ovarian cancer. This
allows high concentration of a chemotherapeutic agent
to be delivered to the actual tumor site with minimal
exposure of healthy tissues.
 Intrathecal
Intrathecal chemotherapy involves instilling
chemotherapeutic agents into the CNS through a
reservoir placed in the ventricle via an Omnaya
reservoir or via a lumbar puncture. This is done
because most medications given systematically are not
effective against CNS tumors because they cannot cross
the blood – brain barrier.
Contraindications to Chemotherapy are as follows:
 Infection. The anti-tumor drugs are
immunosuppressives.
 Recent surgery. The drugs may retard healing
process.
 Impaired Renal or Hepatic function. The drugs
are nephrotoxic and hepatotoxic.
 Recent Radiation Therapy. Also
immunosuppressive.
 Pregnancy. The drugs may cause congenital
defects.
 Bone Marrow Depression. The drugs may
aggravate the condition. The wbc levels must be
within normal limits.
 Safe Handling of Chemotherapeutic Agents  Provide good oral care.
 Avoid hot and spicy food
1. Wear mask, eye shield, gloves and back –  Alopecia
closing gown.  Reassure that it is temporary
 Encourage to wear wigs, hats or head scarf.
2. Skin contact with drug must be washed  Skin pigmentation
immediately with soap and water.  Inform that it is temporary
 Nail changes
3. Sterile/ alcohol- wet cotton pledgets should be  Reassure that nails may grow normally after
used, wrapped around the neck of the ampule or chemotherapy.
vial when breaking and withdrawing the drug.
3. Hematopoietic System
4. Expel air bubbles on wet cotton.  Anemia
 Provide frequent rest periods.
5. Vent vials to reduce internal pressure after
 Neutropenia
mixing.
 Protect from infection.
 Avoid people with infection.
6. Wipe external surface of syringes and IV bottles.
 Report fever, chills, diaphoresis, heat, pain,
7. Avoid self – inoculation by needle stab. erythema, or exudates on any body surface.
 Avoid rectal or vaginal procedures.
8. Clearly label the hanging IV bottle with  Avoid fresh fruits, raw meat, fish, vegetables,
“ANTINEOPLASTIC CHEMOTHERAPY” fresh flowers, potted plants.
 Change IV sites every other day.
9. Contaminated needles and syringes must be  Change all solutions and IV infusion
disposed in a clearly marked special container.  Thrombocytopenia
“leak-proof”, “puncture – proof”.  Protect from trauma
 Avoid ASA
10. Dispose half- empty ampules, vials, IV bottles by  Nadir. Is the time after chemotherapy
putting into plastic bag , seal and then into administration when wbc or platelet count is at
another plastic bag or box, clearly marked the lowest point. It occurs within 7 to 14 days
before placing for removal. Label as “Hazardous after drug administration.
waste.”
4. Genito- Urinary System
11. Hand washing should be done before and after  Hemorrhagic cystitis
removal of gloves.  Provide 2-3 L of fluids per day
 Urine color Changes
12. Only trained personnel should be involved in use  Reassure that it is harmless.
of drugs (preferably, chemotherapy certified
nurses). 5. Reproductive System
 Premature menopause or amenorrhea
13. Ideally, preparation of chemotherapeutic drugs  Reassure that menstruation resumes after
should be in laminar flow conditions with filtered chemotherapy.
air to prevent contamination with
microorganisms. Antiemetics to Relieve Nausea and Vomiting Related to
Chemotherapy
Nursing Intervention for Chemotherapy Side-Effects
1. Dronabinol (Marinol)
1. G.I. System- nausea and vomiting, diarrhea, 2. Ondansetron (Zofran)
constipation 3. Granisetron (Kytril)
 Administer antiemetic to relieve nausea and 4. Alprazolam (Zanax)
vomiting. 5. Lorazepam (Ativan)
 Replace fluid-electrolyte losses, low-fiber diet to 6. Haloperidol (Haldol)
relieve diarrhea. 7. Prochlorperazine (Compazine)
 Increase fluid intake and fiber in diet to
prevent/relieve constipation. Adverse Reaction to Chemotherapy

2. Integumentary System I. Hypersensitivity reaction

 Pruritus, urticaria, and systemic signs a) The clinical manifestation are as follows:
 Provide good skin care b) Dyspnea
 Stomatitis (oral mucositis) c) Chest tightness or pain
 d) Pruritus (itching)  It usually occurs in solid tumors like breast, lung,
e) Urticaria (wheals) head, neck and renal cancers. It may also occur
f) Tachycardia in hematologic cancer like multiple myeloma,
g) Dizziness leukemia.
h) Anxiety  Severe hypercalcemia may lead to renal failure,
i) Agitation coma, cardiac arrest and death.
j) Inability to speak  Calcitonin (Miacalcin) and oral glucocorticoids
k) Abdominal pain are given to lower serum calcuim.
l) Nausea
m) Hypotension 3. Tumor Lysis Syndrome
n) Cloudy mental status  The destruction of large number of malignant
o) Flushed appearance cells may rapidly release intracellular potassium,
p) Cyanosis phosphorous and nucleic acid into the
circulation.
If anaphylactic reaction occurs, the following nursing  Electrolyte imbalance and acute renal failure
interventions are implemented: may occur.
 Clients with malignancies that are very
a) Stop the drug administration. responsive to treatment are at higher risk,
b) Maintain IV access with 0.9% NS (NaCI) especially if they have large tumor burden
c) Keep an open airway (lymphomas, leukemias and small cell
d) Keep client in modified Trendelenburg position carcinoma)
(supine with legs elevated at 20 to 30), unless
contraindicated. The clinical manifestations of tumor lysis syndrome are
e) Notify the physician. as follows:
f) Monitor the client’s vital signs until he is stable. a) Weakness
g) Administer epinephrine, aminophylline, b) Nauseas
diphenhydramine and corticosteroids as c) Diarrhea
prescribed. d) Flaccid paralysis
e) ECG changes
II. Extravasation f) Muscle Cramps or Twitching
 Vesicant chemotherapeutic agents can cause or g) Oliguria
form a blister and cause tissue destruction. E.g. h) Hypotension
Adriamycin (Doxorubicin), Oncovin (Vincristine). i) Edema
 Irritant drugs can produce venous pain at the j) Altered mental status
site and along the vein.
 Pain, erythema, swelling and lack of blood return Collaborative management for tumor lysis syndrome
indicate an extravasation. include the following:
 Nursing interventions for extravasation include 1. Intravenous Hydration.
the following: 2. Allopurinol to decrease uric acid concentration.
 Stop the drug administration. 3. Sodium bicarbonate with IV hydration to
 leave the needle in place, and attempt to promote fecal excretion of excess phosphate.
aspirate any residual drug fro the tubing, needle, 4. Lowering of serum potassium levels with
and site. medications, retention enemas, IV 50%
 Administer an antidote, as prescribe. The dextrose.
remove the needle.
 Apply warm or cold compresses as indicated. 4. SIADH results from the abnormal production of
 Document the appearance of the site before and antidiuretic hormone (ADH). This may be
after chemotherapy. caused by small cell lung cancer, infection,
pulmonary disorders, emotional stress, CNS
Oncologic Emergencies disorders and some drugs, including
antineoplastic agents like Cytoxan
1. Infection and Pain (Cyclophosphamide), Oncovin (Vincristine)
 Infection arises from neutropenia. People with Velban (Vinblastin), Platinol – AQ (Cisplatin).
advance cancer have pain. Severe infection and
pain can interfere with the person’s ability to  SIADH is manifested by water retention and
enjoy quality life. Pain management is the decrease in sodium.
priority in care of clients with advanced cancer. 1. The signs and symptoms of SIADH are as
follows:
2. Hypercalcemia 2. Confusion
 This is due to bone reabsorption
3. Irritability
(demineralization). Serum calcium level is
greater than 11 mg/dL. 4. Headache
5. Muscle weakness
6. Lethargy
7. Decrease urine output
8. Edema
9. Nausea and vomiting
10. Anorexia
11. The collaborative management of SIADH are as
follows:
12. Fluid excretion (diuretics)
13. IV infusion of hypertonic saline (3% to 5%) if
severe, to prevent pulmonary edema.
14. Monitor intake and output.
15. Administer medications like Declomycine
(Demeclocycline), Lithane (Lithium), and urea.
5. Disseminated Intravascular Coagulation
(DIC)
 This condition is characterized by development
of extensive, abnormal clots in the
microcirculation (small blood vessels). The
widespread clotting depletes the general
circulation with clotting factors and platelets,
leading to excessive bleeding in the different
sites of the body.
 Clots that are obstructing the circulation
decrease blood flow to major organs, causing
pain, stroke-like manifestations, dyspnea,
tachycardia, oliguria, bowel necrosis.
 In clients with cancer, DIC is usually caused by
gram-negative infection or sepsis, release of
clotting factors from cancer cells, or blood
transfusion.
 DIC is most commonly associated with
leukaemia and adenocarcinomas of the lung,
pancreas, stomach and prostate.
 Diagnostic findings that support DIC are
prolonged prothrombin time and activated partial
thromboplastin time, very low platelet count and
prolonged clotting times.
 The medical management for DIC are as
follows:
1. Correctio9n of the basic problem (e.g., infection)
2. Administer blood products and medication as
prescribed.
3. IV heparin if with manifestations of thrombosis
(although, controversial)
4. Monitor the client for signs and symptoms of
bleeding.
6. Spinal Cord Compression
 It is caused by direct pressure on or comprise of
vascular supply to the spinal cord.
 Back pain is often the only presenting clinical
manifestation in majority of clients.
 This may result to irreversible neurologic
damage with paralysis and loss of bowel and
bladder control.
 Treatment is usually with RT. A laminectomy
may be an alternative. Steroids may be given to
reduce inflammation and swelling around the
spinal cord.
7. Superior Vena Cava Syndrome
 It results from external and internal obstruction
of the superior vena cava. The obstruction
reduces venous return to the heart and
decreases cardiac output.
 SVC syndrome is usually secondary to lung
cancer or lymphoma.
The clinical manifestations of SVC syndrome are as
follows:
1. Dyspenea
2. Facial swelling
3. Jugular vein distention
4. Sitting up and learning forward to breathe.
5. Swelling of arms, chest pain, dysphagia
6. External – beam RT and curative chemotherapy
are used for palliation.
8. Cardiac Tamponade
 Fluid collects in the pericardial sac (pericardial
effusion), it leads to cardiac tamponade.
 Pericardiocentesis may be performed to draw off
the fluid.
Other Treatment for Cancer
 Biotherapy. Is the use of biologic response
modifiers (BRM’s) e.g. Interferons, Interleukines
 Hematopoietic Growth Factors. E.g
Erythropoietin, Neupogen, Neumega.
 Monoclonal antibodies.
 Bone marrow transplantation.
Psychosocial Aspects of Cancer Care
1. Provide support for the client-your presence,
empathy, positive regard.
2. Provide support for the family.
3. Promote positive self-concept.
4. Promote coping with the cancer experience.
 Hospice care is now a trend in the care of clients
with terminal cancer (for those with prognosis of
having a lifespan of 1 to 6 months).
 The basic characteristics of a hospice program
are:
1. Control of manifestation, including pain relief.
2. Treatment of the client and family as a unit.
3. Provision of care by an interdisciplinary team.
4. 24 – hour, 7-day-a-week services.
5. Coordinated homecare with back-up inpatient
services.
 6. Use of trained volunteers to augment staff
services.
7. Spiritual support.
8. Bereavement follow-up.
9. Services given on the basis of need and not on
the ability to pay.
Care of the Client with Breast Cancer
The Risk Factors Associated with Breast Cancer are as
follows:
 Menarche before age 11
 Menopause after age 50
 Family history of breast cancer- especially
mother or sister.
 Nulliparity of birth of first child after age 30.
 History of uterine cancer.
 Link with obesity, diabetes and hypertension.
 Presence of benign breast disease.
Prevention of Breast Cancer
I. BSE (Breast Self- Examination)
 Start from age 20 years.
 Done after menstruation.
 During standing position, note specifically for
symmetry of the breasts.
 In lying position, elevate shoulders on the side
examined with pillow support.
 Palpate the breast from center to periphery in
circular motion.
II. Mammogram
 This involves X-ray examination of the breast.
 The breast is supported on flat, firm surface.
 This involves use of two X-ray films.
 Instruct client to avoid use of deodorant, cream
powder in the axilla. To prevent false positive
result.
Pathophysiology- classic symptoms that define breast
cancer include:
 Firm, non-tender, non-mobile mass.
 Solitary, irregular shape mass.
 Adherence of muscle or skin causing dimpling
effect.
 Involvement of upper outer quadrant or central
nipple portion of breast.
 A symmetry of the breast.
 “Orange Peel” skin.
 Retraction of the nipple.
 Abnormal discharge from the nipple.
Stages of Breast Cancer
 Stage I Tumor size is up to 2cm.
 Stage II Tumor size is up to 5cm with axillary
lymph node involvement.
 Stage III Tumor size is more than 5cm with
axillary and neck lymph node involvement.
 Stage IV Metastasis to distant organs (liver,
lungs, bone and brain)
Collaborative Management for the Client with Breast
Cancer
 Surgery
 Lumpectomy/Tylectomy. Involves removal of the
lump.
 Simple Mastectomy. Involves removal of the
entire breast
 Modified Radical Mastectomy (MRM). Involves
removal of the entire breast and axillary lymph
nodes. The pectoralis muscles are conserved.
 Radical mastectomy ( Halstead Surgery).
Involves removal of the entire breast, pectoralis
major and minor muscles and the axillary lymph
nodes. It is followed by skin grafting. This is
rarely done nowadays.
 Chemotherapy
 Radiation Therapy
 Surgery
Care of the Client Undergoing breast surgery
Preoperative Care
 Psychosocial Support. Include the husband
when necessary.
 Teach arm exercises to prevent lymph edema.
 Inform about wound suction drainage, e.g.
Hemovac, Jackson-Pratt.
 DBCT exercises to prevent post-op respiratory
complications.
Postoperative Care
 Place client in semi-Fowler’s position with arm
abducted and elevated on pillows. Fowler’s
position promotes lung expansion. Abduction
and elevation of arm on the affected side
promotes venous return and prevents
lymphedema.
 Monitor Hemovac Output (normal drainage is
serosanguinous for the first 24 hours).
Serosanguinous drainage is composed of
plasma and small amounts of rbc. It is pinkish or
reddish in appearance but no viscous.
 Check behind patient for bleeding. Blood flows
to the back by gravity.
 Post signs warning against taking blood
pressure, starting IVs, or drawing blood on the
affected side. To prevent obstruction of venous
and lymphatic flow.
 initiate exercise to prevent stiffness and
contractures of shoulder girdle. Give analgesic
before initiating exercises.
 Reinforce special mastectomy exercises as
prescribed. To prevent lymphedema.
 Pick at or cut cuticles
 Work near thorny plants or dig in garden
 Reach into hot oven
 Hold a cigarette
 Injections, withdrawal of blood, BP -taking
 DO’s
 Wear loose rubber glover when washing dishes.
 Wear a thimble when sewing.
 Apply lanolin hand cream to prevent dryness.
 Contact attending physician if arm gets red,
warm, or hard and swollen.
 Return for check-up
 Wear “Life Guard Med. Aid” tag: CAUTION-
LYMPHEDEMA

 Provide adequate analgesia to promote

ambulation and exercise. The client cooperates
with ambulation and exercise if she is free from
pain or discomfort.

 Encourage regular coughing and deep breathing

exercises. To promote lung expansion and
prevent atelectasis.

 Prepare client for size and appearance of the

incision and provide support when incision is
viewed for first time.

 Provide client with detailed information

concerning breast prosthesis. Fitting is not
possible for 4-6 weeks. A temporary prosthesis
or lightly padded bras may be worn until healing
is complete.

 Teach patient to avoid constructive clothing and

report persistent edema, redness, or infection of
incision.

 Teach patient importance of continuing monthly

breast examination on remaining breast.

Prevention of Lymphedema

 AVOID’s
 Cuts
 Scratches
 Pinpricks
 Hangnails
 Insect Bites
 Burns
 Strong detergents

 DONT’s (on the arm on affected side)

 Carry purse or anything heavy
 Wear wristwatch or jewelry.