Nursing Care Management

106-11 Course
COURSE DESCRIPTION:
• It deals with the principles and techniques
of nursing care management of sick clients
across lifespan in varied settings with
alterations/problems in cellular
aberrations, acute biologic crisis, including
emergency and disaster nursing and IV
Therapy.
COURSE OBJECTIVES: At the end of the
course, and given actual clients with
problems in cellular aberration, acute
biologic crisis and emergency, the student
should be able to:
1. Utilize the nursing process in the care of
individuals, families in community and
hospital settings
• - Assess with client/s his/her/their
condition/health status through interview,
physical examination, interpretation of
laboratory findings
• - Identify actual and potential nursing
diagnosis
COURSE OBJECTIVES…cont.
• - Plan appropriate nursing interventions
with client/s and family for identified
nursing diagnosis
• - Implement plan of care with client/s and
family
• - Evaluate the progress of his/her/their
client’s condition and outcomes of care.

2. Ensure a well organized and accurate

documentation system.
COURSE OBJECTIVES…cont.

3. Relate with client/s and their family and the

health team appropriately

4. Observe bioethical concept/s principles,

core value and nursing standards in the
care of clients
5. Promote personal and professional growth
of self and others
Learning Objectives in Alterations/problems

in Cellular Aberrations
1. Compare the structure and function of the normal cell and

cancer cell.
2. Differentiate between benign and malignant tumor.
3. Identify agents and factors that have been found to be
carcinogenic.
5. Describe the seven early warning signs of cancer.
6. Describe the roles of different therapies in treating
cancer.
7. Describe the special needs of clients receiving
chemotherapy.
8. Use the nursing process as a framework for care of
patients with cancer.
Cellular Aberration
... It's very isolating and has a bad stigma, [but] not everyone
dies from cancer. We need to learn how to live better with it."
http://www.postgazette.com/news/health/2011
When a cancer patient
becomes unexpectedly
ill during or after
treatment, very often
the health professionals
who deal with them are
taken by surprise.

....We may
not know
that cancer
is spreading
at an
Cancer is
fatal
Cancer
• is a term used for diseases in which
abnormal cells divide without control and
are able to invade other tissues. Cancer
cells can spread to other parts of the body
through the blood and lymph systems.
National Cancer Institute
Incidence/Risk
Factors
• Age, race, sex
– 50 years old & above
– black more than white
– female – prone to breast & cervical cancer
– male – prone to lung & prostate cancer
• Genetic predisposition
• Immune deficiency
• Smoking
• Excessive alcohol intake
Incidence…..
• Hormonal imbalances
• Occupational: exposure to carcinogens
(asbestos, vinyl chloride or benzene)
• X-ray overexposure
• Long exposure to sunlight
• Diet: high fat, lack of fiber
Origins of Cancer

These cells grow and divide in a controlled way to

produce more cells as they are needed to keep
the body healthy.
The genetic material (DNA) of a cell can become
damaged or changed, producing mutations that
affect normal cell growth and division.
Cancer types
• Carcinoma - cancer that begins in the skin
or in tissues that line or cover internal
organs. ( adenocarcinoma, basal cell carcinoma,
squamous cell carcinoma, and transitional cell
carcinoma).
• Sarcoma - cancer that begins in bone,
cartilage, fat, muscle, blood vessels, or
other connective or supportive tissue.
• Leukemia - cancer that starts in blood-
forming tissue such as the bone marrow
and causes large numbers of abnormal
blood cells to be produced and enter the
blood.
Cancer
types….cont.

• Lymphoma and myeloma - cancers that

begin in the cells of the immune system.
• Central nervous system cancers -
cancers that begin in the tissues of the
brain and spinal cord.
 ETIOLOGY
 VIRUSES
 CHEMICAL CARCINOGENS
 PHYSICAL STRESSORS
 HORMONAL FACTORS
 GENETIC FACTORS
Normal Cell Growth
• Growth of cells and tissues is expected
during infancy and childhood, and many
human body cells continue to grow by cell
division (“Mitosis”).

• The growth of these cells is well controlled

ensuring that the right number of cells is
always present in any tissue or organ.
 Normal Cell ….
• Some tissue and organs stop growing by cell
division after development is complete (ex.
Heart muscle cells can no longer divide after fetal
life; the number of heart muscles is fixed at birth)

– Hypertrophy= growth that causes the tissue to

increase in size but not in number

– Hyperplasia= growth that causes the tissue to

increase in size by increasing in number

– Neoplasia= any new or continued cell growth not

needed for normal development or replacement of
dead and damaged tissues
Characteristics of
Normal Cells
1.They have limited cell division
• Undergo “mitosis” for one of two (2)
reasons:
– To develop normal tissue
– To replace lost or damaged normal tissue

2. Undergo “apoptosis”
• Normal cells have a finite life span
• Purpose of apoptosis is to ensure each
organ has adequate number of cells at their
functional peak

3. Show specific morphology

• Each normal cell type has its distinct and
recognizable appearance, size, and shape
Characteristics…..
4.Have a small nuclear-cytoplasmic ratio
• The size of the normal cell nucleus is small
compared with the size of the rest of the
cell, including the cytoplasm

5. Perform specific differentiated functions

• Every cell has at least one specific function

6. Adhere tightly together

• Normal cells make proteins that protrude
from the cell surface, allowing cells to bind
closely and tightly together (fibronectin)
Characteristics…..
7. Are Non-migratory
• They do not wander from one tissue into the
next tissue

8. Grow in an orderly and well-regulated

manner
• Cell division follows a cell cycle (has phases
in the cycle)
• The steps of entering and completing the
cell cycle are tightly controlled and
regulated by proteins produced by
“suppressor genes”
Characteristics…..
9.They are contact inhibited
• Each cell only divides when some of its
surface is not in direct contact with another
cell

10. They are euploid

• Most normal cells have 23 pairs of
chromosomes
• Each mature cell has a specific structure
and function
Normal Cell Cycle
3 Types of Cells
1. PERMANENT cells- out of the cell cycle
– Neurons, cardiac muscle cell
2. STABLE cells- dormant/resting
– Liver, kidney
3. LABILE cells- continuously dividing
– GIT cells, Skin, endometrium , Blood cells
PATHOPHYSIOLOGY
OF THE
MALIGNANT
PROCESS
 Predisposing/etiologic factors

Genetic mutation of cellular DNA

Transformation of normal cell to abnormal cell

Abnormal cells form a clone and proliferate abnormally

(Pressure, obstruction, pain, effusion, ulceration and necrosis,
vascular thrombus, embolus, thrombophlebitis)

Further proliferation and invasion of surrounding tissues

Gain access to lymph and blood vessels

Metastasis
 Malignant versus Benign
Tumors

Benign (not cancer) (cancer) Malignant (cancer)

• Malignant
tumor cells cells
growinvade cells invade
only locallyneighboring
and cannot tissues,
neighboring tissues,
spread by invasion or vessels,
enter blood Malignant
enter (cancer)
blood vessels,
metastasis cells invade and metastasize to
neighboring tissues,
different sites
enter blood vessels,
and metastasize to
different sites
•
and metastasize to
different sites
WAYS TO DIFFERENTIATE A BENIGN
FROM A MALIGNANT TUMOR

Characteristics Benign Malignant

Rate of growth Slow- growing Varies, but usually fast-growing

Differentiation Well differentiated Poorly differentiated

Local invasion Local invasion, Invasive, expansive,infiltrating,

encapsulated, local destructive, w/ generalized
effects effects

Metastases Non metastatic metastatic

29
 Some Known Environmental Carcinogens
Carcinogen Associated Cancer Site or Neoplasm
Alcoholic beverages Liver, esophagus, mouth, pharynx, breast, colon, and
rectum
Anabolic steroids Liver
Arsenic Lung, skin
Asbestos Lung, peritoneum, pleura, pericardium
Benzene Myelogenous leukemia
Diesel exhaust Lung
Hair dyes Bladder

Nitrosamines (mga “inihaw”) GIT

Pesticides Lung
Sunlight Skin
Tobacco Lungs,liver, esophagus, mouth, pharynx, larynx,
pancreas, bladder, kidney, liver, stomach, colon, and
rectum 30
Classification of Neoplasms
• Benign Neoplasia
– Generally not life-threatening unless they
occur in a restricted area
HARMLESS, DOES NOT INFILTRATE OTHER
TISSUES.

– Classified according to tissue involvement:

• Glandular tissue (adenoma)
• Bone (osteoma)
• Nerve cells (neuroma)
• Fibrous tissue (fibroma)

– Growth remains circumscribed

31
 Classifications of
Neoplasms
• Malignant Neoplasia
ALWAYS HARMFUL, MAY SPREAD OR METASTASIZE TO TISSUES
FAR FROM THE ORIGINAL SITE.
– Cells infiltrate surrounding tissue

– Cells produce secondary lesions

– May spread (metastasize) by direct extension, lymphatic permeation,

embolization, and diffusion of cancer cells by mechanical means

– Tumors are classified according to the tissue involved

– Tumors are also classified by a universal system of staging

classification (TNM system)
• T=primary tumor
• N=lymph node involvement
• M=designates metastasis
• A number (0-4) after any of these letters designates the degree of involvement
32
 Classification of Tumors by Tissue
of Origin
Prefix Tissue of Origin Benign Tumor Malignant Tumor

Adeno Epithelial glands Adenoma Adenocarcinoma

Chondro Cartilage Chondroma Chondrosarcoma

Fibro Fibrous connective Fibroma Fibrosarcoma

Glio Glial cells (brain) Glioma Glioblastoma

Hemangio Blood vessel Hemangioma Hemangiosarcoma

Hepato Liver Hepatoma Hepatocarcinoma

Leiomyo Smooth muscle Leiomyoma Leiomyosarcoma

Lipo Fat/adipose Lipoma Liposarcoma

Lympho Lymphoid tissues Hodgkin’s lymphoma

Non-Hodgkin’s lymphoma
Burkitt’s lymphoma
Melano Pigment-producing skin Meningioma Melanoma

Meningio Meninges Meningioma

Meningioblastoma
Neuro Nerve tissue Neurofibroma Neurosarcoma
Neuroblastoma
Osteo Bone Osteoma Osteosarcoma

Rhabdo Skeletal muscle Rhabdomyoma Rhabdomyosarcoma

Squamous Epithelial layer of skin, mucous Papilloma

33
Squamous cell carcinoma of skin,
membranes, and organ linings bladder, lungs, cervix
 Carcinogenesis/Oncogenesis
Steps in Malignant Transformation:
1. Initiation
– Carcinogens penetrate a cell, get into the
nucleus, and damage the DNA
– The damage can turn on genes that should
remain turned-off
– A cell can become a cancer cell if the cellular
changes that occurred during this phase are
enhanced by promotion
2. Promotion
– The cancer cell can become a tumor if its growth
is enhanced
– “Latency period”=time between the cell’s intiation
and development of an overt tumor
– “Promoters” are substances that enhance growth
34
 Carcinogenesis…..cont.
Steps in Malignant Transformation:
3. Progression
– Cancer cells grow to the point of becoming a
detectable tumor, other events must occur for this
tumor to become a health problem (1cm of tumor=1
billion cells in it)
– The tumor must develop its own blood supply
– Tumor angiogenesis factor (TAF) triggers
capilliaries and other blood vessels in the area to
grow new branches into the tumor
– Tumor’s continued growth and differentiation can
allow it to become more malignant
– Primary Tumor=original tumor; identified from where
it arose

35
 Carcinogenesis…..cont.
Steps in Malignant Transformation:
4. Metastasis
– Movement from the primary location by
breaking off from the primary tumor
– Extension to surrounding tissues
– Blood vessel penetration
– Release of tumor cells
– Invasion
– Lymphatic spread

36
Cancer Grading & Staging
• Grading=a system that rates cancer cells
with the lowest rating given to those cells
that closely resemble normal cells, and the
high rating given to cancer cells that barely
resemble normal cells

• Staging=determines the exact location of

the cancer and its degree of metastasis at
diagnosis

37
Staging of Cancer
• Done in three ways:
– 1. Clinical staging- assesses clinical
manifestations and evaluates clinical signs for
tumor size and possible spread; Clinical tests are
used. (blood tests)

– 2. Surgical staging-assesses tumor size, number,

sites, and spread by inspection at surgery; cancer
cells can be obtained through biopsy

– 3. Pathologic staging-is the most definitive type;

determines by pathologic examination of tissues
obtained at surgery

38
 Cancer Classification (Grading)
Grade Cellular Characteristics
GX Grade cannot be determined
G1 Tumor cells are well differentiated and closely resemble the
normal cells from which they arose; considered a low grade
of malignant change; tumors are malignant but are
relatively slow growing

G2 Tumor cells are moderately differentiated; still retain some

characteristics of normal cell but have more malignant
characteristics

G3 Tumor cells are poorly differentiated; they have few normal

characteristics

G4 Tumor cells are poorly differentiated; retain no normal

characteristics

39
 Cancer (TNM
Classification)
Primary Tumor (T)

Tx Primary tumor cannot be assessed

T0 No evidence of primary tumor

T is Carcinoma in situ

T 1,T 2,T 3,T 4 Increasing in size and/or local extent of the primary tumor

Regional Lymph Nodes (N)

Nx Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N 1,N 2,N 3 Increasing involvement of regional lymph nodes

Distant Metastasis (M)

Mx Presence of distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis 40
Hundreds of chemicals are capable of inducing cancer in humans
or animals after prolonged or excessive exposure. There are many
well-known examples of chemicals that can cause cancer in
humans.
- The fumes of the metals cadmium, nickel, and chromium are
known to cause lung cancer.
- Vinyl chloride causes liver sarcomas.
- Exposure to arsenic increases the risk of skin and lung cancer.
- Leukemia can result from chemically induced changes in bone
marrow from exposure to benzene and cyclophosphamide,
among other toxicants.
- Other chemicals, including benzo[a]pyrene and ethylene
dibromide, are considered by authoritative scientific
organizations to be probably carcinogenic in humans because
they are potent carcinogens in animals.

Chemically-induced cancer generally develops many years after

exposure to a toxic agent. A latency period of as much as thirty
years has been observed between exposure to asbestos, for
example, and incidence of lung cancer.
Tobacco Use and Cancer

42
Examples of Human Cancer Viruses

43
Heredity and Cancer

44
Patterns of cell
Proliferation
•Hyperplasia

•Dysplasia
•Metaplasia
•Anaplasia
•Neoplasia

45
 HYPERPLASIA
INVOLVES AN INCREASE IN THE
NUMBER OF CELLS IN A TISSUE.
 Hyperplasia

tissue growth based on an excessive

rate of cell division, leading to a
larger than usual number of cells; the
process of hyperplasia is potentially
reversible; can be a normal tissue
response to an irritating stimulus. An
example is a callus

47
  METAPLASIA
– REFERS TO THE CONVERSION OF ONE
TYPE OF CELL IN A TISSUE TO
ANOTHER TYPE OF CELL.

an initial change from normal cells to a

different cell type (such as chronic irritation
of cigarette smoke causing ciliated
pseudostratified epithelium to be replaced
by squamous epithelium more able to
withstand the insult).
 ANAPLASIA
– INVOLVES A CHANGE IN THE DNA
CELL STRUCTURE AND IN THEIR
ORIENTATION TO ONE ANOTHER.
Reversion of cells to an immature or a
less differentiated form, as occurs in
most malignant tumors.
• Figure are shown simple morphological changes
occurring during necrosis, which involves an initial
generalized swelling and subsequent dissolution
of organelles with final rupture of plasma
membranes (Corcoran et al., 1994).
  DYSPLASIA
– REFERS TO THE CHANGE IN SIZE,
SHAPE OR ARRANGEMENT OF
CELLS.
.

Example:cervical dysplasia as a result of

human papillomavirus infection.
 Dysplasia

Bizarre cell growth differing in size,

shape and cell arrangement

53
 Metastasis
Metastasis: 3 stages

• –Invasion – neoplastic cells from primary tumor

invade into surrounding tissue with penetration
of blood or lymph.

• –Spread – tumor cells spread through lymph or

circulation or by direct expansion

• –Establishment and growth – tumor cells

are established and grow in secondary site:
lymph nodes or in organs from venous circulation
54
 Women, Tobacco &
Lung Cancer

• “Women who smoke

like men, die like
men.”
U.S. Surgeon General David Satcher

55
 Effects of Cancer
• Disruption of Function- can be due to
obstruction or pressure
• Hematologic Alterations: can impair
function of blood cells
• Hemorrhage: tumor erosion, bleeding,
severe anemia
• Anorexia-Cachexia Syndrome: wasted
appearance of client

56
 Effects of Cancer
• Paraneoplastic Syndromes: ectopic sites
with excess hormone production
• –↑Parathyroid hormone →hypercalcemia
• –↑secretion of insulin →hypoglycemia
• –↑Antidiuretic hormone (ADH) →fluid
retention, HTN & peripheral edema
• ↑Adrenocorticotropic hormone
(ACTH):cause excessive secretion of
cortisone(ie: fluid retention, glucose levels)

57
 Effects of Cancer

• •Pain: major concern of clients and

families associated with cancer
• •Physical Stress: body tries to respond
and destroy neoplasm
• •Psychological Stress

58
 Nursing Care of Clients with
Cellular Aberration
1. ASSESSMENT
• Nursing History
• –Health History – chief complaint and
history of present illness (onset, course,
duration, location, precipitating and
alleviating factors)

• –Cancer signs: CAUTION US!

59
 Warning Signs of Cancer
• CAUTION US!

• –Change in bowel or bladder habits

• –A sore that does not heal
• –Unusual bleeding or discharge
• –Thickenings or lumps
• –Indigestion or difficulty in swallowing
• –Obvious change in a wart or mole
• –Nagging or persistent cough or hoarseness
• –Unexplained anemia
• –Sudden unexplained weight loss
60
 Change in bowel or bladder
habits
• –A person with colon cancer may have
diarrhea or constipation, or he may notice
that the stool has become smaller in
diameter

• –A person with bladder or kidney cancer

may have urinary frequency and urgency

61
 A sore that does not heal

–Small, scaly patches on the skin that bleed or

do not heal may be a sign of skin cancer

A sore in the mouth that does not heal can

indicate oral cancer

62
 Unusual bleeding or discharge
• –Blood in the stool is often the first sign of
colon cancer
• –Similarly, blood in the urine is usually the
first sign of bladder or kidney cancer
• –Postmenopausal bleeding (bleeding after
menopause) may be a sign of uterine
cancer

63
 Thickenings or lumps
• –Enlargement of the lymph nodes or
glands (such as the thyroid gland) can be
an early sign of cancer

• –Breast and testicular cancers may also

present as a lump

64
 Indigestion or difficulty in
swallowing
• –Cancers of the digestive system,
including those of the esophagus,
stomach, and pancreas, may cause
indigestion, heartburn, or difficulty
swallowing

65
Obvious change in a wart or mole
• –Moles or other skin lesions that change in
shape, size, or color should be reported

66
 Nagging or persistent cough or
hoarseness
• –Cancers of the respiratory tract, including
lung cancer and laryngeal cancer, may
cause a cough that does not go away or a
hoarse (rough) voice

67
• Unexplained anemia
• •Sudden unexplained weight loss

68
 Physical Assessment

•Inspection
•– skin and mucus membranes for lesions, bleeding, petechia, and
irritation
•–Assess stools, urine, sputum, vomitus for acute or occult
bleeding
•–Scalp noting hair texture and hair loss

•Palpation
•–Abdomen for any masses, bulges or abnormalities
•–Lymph nodes for enlargement

•Auscultation – of lung sounds, heart sounds

and bowel sounds

69
 Laboratory & Diagnostic
Tests
• Cancer detection examination
• • Laboratory tests
• – Complete blood cell count (CBC)
• – Tumor markers – identify substance
(specific proteins) in the blood that are made by
the tumor

• • PSA (Prostatic-specific antigen): prostate

cancer
• • CEA (Carcinoembryonic antigen): colon cancer
• • Alkaline Phosphatase: bone metastasis
• – Biopsy

70
 Determine location of cancer

• –X-rays
• –Computed tomography
• –Ultrasounds
• –Magnetic resonance imaging
• –Nuclear imaging
• –Angiography

71
 Diagnosis of cell type

• –▪Tissue samples: from biopsies, shedded

cells
• (e.g. Papanicolaou (PAP) smear), & washings
• –▪ Cytologic Examination: tissue examined
• under microscope

72
 Direct Visualization

• –▪ Sigmoidoscopy
• –▪ Cystoscopy
• –▪ Endoscopy
• –▪ Bronchoscopy
• –▪ Exploratory surgery; lymph node biopsies
to determine metastases.

73
EARLY DETECTION
 BREAST SELF EXAMINATION

Performed every 7 to 10 days after menses

Postmenopausal clients or clients who have had

a hysterectomy should select a specific day of the
month and perform BSE monthly on that day.
First – while in the shower or bath, when the skin
is slippery with soap and water, examine your
breasts, use the pads of your second, third, fourth
fingers to press every part of the breast firmly.

Second – look at your breasts in a mirror stand

with your arms at your side
Third – raise your arms overhead and check for any
changes in the shape of your breasts, dimpling of the skin, or
any changes in the nipple.

Fourth – place your hand on your hips and press down

firmly, tightening the pectoral muscles. Observe for
asymmetry or changes, keeping in mind that your breasts
probably do not match exactly.
Fifth – while lying down, feel your breasts as described in
When examining your right breast, place a folded towel
under your right shoulder and put your right hand behind
your head.

Mark your calendar that you have completed your breast

self examination. Note any changes or unique characteristics
you want to check with your health care provider.
TESTICULAR SELF EXAMINATION
The best time to perform this examination is right after a
shower when your scrotal skin is moist and relaxed, making
the testicles easy to feel

gently lift each testicle. Each one should feel like an egg,
firm but not hard, and smooth with no lumps

using both hands, place your middle fingers on the

underside of each testicle and your thumb on top
Gently roll the testicle between the thumb and fingers to
feel for any lumps, swelling, or mass

If you notice any changes from one month to the next,
notify your physician or nurse practitioner.
 NURSING DIAGNOSES

• •Acute or chronic pain

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

81
• Risk for imbalanced fluid volume
• •Anxiety
• •Disturbed body image
• •Deficient knowledge
• •Ineffective coping
• •Social isolation

82
Goals of Management:
• 1.Pain relief
• 2.Integrity of skin and oral mucosa
• 3.Absence of injury and infection
• 4.Fatigue relief
• 5.Maintenance of nutritional intake and
fluid and electrolyte balance
• 6.Improved body image
• 7.Absence of complication

83
 OUTCOME IDENTIFICATION

• 1.Knowledge of prevention and cancer

treatment
• 2.Effective coping through recovery and
grieving process
• 3.Optimal social interaction

84
Cancer Prevention

85
Avoid Carcinogens at Work

86
 Staging Cancer
• Stage I – tumor size up to 2 cm.

• Stage II – tumor size up to 5 cm with axillary

and neck lymph node involvement.

• Stage III – tumor size is more than 5 cm with

axillary and neck lymph node involvement.

• Stage IV – metastasis to distant organs

(liver, lungs, bone and brain).
 Aimed

• –CURE - free of disease after treatment→

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

88
Surgical Management

Primary treatment- involves the removal of

a malignant tumor and a margin of
adjacent normal tissue.
– Local excision- is the simple excision of a
tumor and a small margin of normal tissue.
– Wide excision- includes the removal of the
primary tumor, regional lymph nodes, and
neighbouring structures.

89
Surgical Management

Adjuvant treatment- involves the removal of

tissues to decrease the risk of cancer
recurrence. It includes debulking
procedures.
– Debulking surgery is the removal of the bulk
of the tumor; should be performed before the
start of chemotherapy whenever possible.

90
Surgical Management

Salvage treatment- involves the use of an

extensive surgical approach to treat a local
recurrence after implementing a less
extensive primary approach.

Palliative treatment- is surgery that

attempts to relieve the complications of
cancer (eg, obstruction of the GI tract, pain
produced by tumor extension into
surrounding nerves).

91
Surgical Management
Reconstructive/rehabilitative surgery- is
the repair of defects from previous radical
surgical resection; can be performed early
(breast reconstruction) or delayed (head
and neck surgery).

Preventive/prophylactic surgery- is the

removal of lesions that, if left in the body,
are at risk of developing into cancer. An
example is polyps in the rectum or
mastectomy in women who are at high
risk.

92
CHEMOTHERAPY
Principles of Chemotherapy
Administration

• The intent of chemotherapy is to destroy

as many tumor cells as possible with
minimal effect on healthy cells.

• Cancer cells depend on the same

mechanisms for cell division that are found
in normal cells. Damage to those
mechanisms leads to cell death.
93
CHEMOTHERAPY
• Chemotherapy is utilized in different clinical
settings:

1. As induction chemotherapy for advanced disease

– This is given as the primary treatment for
patients who present with advanced cancer for
which no alternative treatment exists.
– As an adjunct to local methods of treatment.
– Adjuvant chemotherapy is the use of systemic
treatment after the primary tumor has been
controlled by surgery and/or radiation therapy.

2. To palliate symptoms of metastatic disease and or

prolong survival.

94
CHEMOTHERAPY
• Chemotherapeutic agents can be effective on
one of the four phases of the cell cycle or
during any phase of the cell cycle. The cell
cycle is divided into four stages:

1. G1 (gap one) phase: RNA and protein

synthesis (enzymes for DNA synthesis are
manufactured)

S (synthesis) phase: During a long time

period the DNA component doubles for the
chromosomes in preparation for cell division.

95
• G2 (gap two) phase: This is a short time
period; protein and RNA synthesis
occurs, and the mitotic spindle
apparatus is formed.

• M (mitosis) phase: In an extremely short

time period, the cell actually divides
into two identical daughter cells.

• Cells not active in the cell cycle are

designated as resting (G0). Cells in
this phase are, for the most part,
refractory to chemotherapy.

96
CHEMOTHERAPY
Therapeutic strategies:

Adjuvant therapy is given to patients who have

no evidence of residual disease but who are at
high risk for relapse.

• The justifications for adjuvant chemotherapy

are the high recurrence rate after surgery for
apparently localized tumors,

• the inability to identify cured patients at the time

of surgery, and the failure of therapy to cure
these patients after recurrence of disease.

97
CHEMOTHERAPY
• Neoadjuvant therapy is the administration of
several courses of chemotherapy before definitive
surgical intervention (eg, large breast masses). The
goal of therapy is to decrease the amount of tissue
that needs to be removed as well as to attempt to
maximize cure potential.

• High dose/intensive therapy is the administration

of high doses of chemotherapy, usually in
association with growth factor support or before
bone marrow transplant/stem cell rescue

98
CHEMOTHERAPY
• Preoperative chemotherapy is
administered prior to surgery in an attempt
to downstage the primary tumor so that
less invasive surgery can be performed.
For example, patients with large breast
tumors can preserve the breast and
undergo lumpectomy instead of
mastectomy.
.

99
CHEMOTHERAPY
• Dose intensification has received increasing
emphasis in recent years as a strategy for
overcoming resistance to chemotherapy.

• Malignant cells may be resistant to certain drugs

from the start of therapy (natural resistance) or
become resistant after therapy has begun (acquired
resistance).

• Dose intensification suggests that chemotherapy

should be given in the highest tolerated dose over
the briefest interval, with the growth factor support.

• This is being tested in certain malignancies and

remains unproved
100
CHEMOTHERAPY
Routes of administration:
– Oral -capsule, tablet, or liquid
– I.V. push (bolus) or infusion over a specified time
period
– Intramuscular
– Intrathecal/ intraventricular
– Intra-arterial
– Intracavitary -such as peritoneal cavity
– Intravesical -into uterus or bladder
– Topical

101
CHEMOTHERAPY

Dosage is based on surface area in both

adults and children.

Most chemotherapeutic agents have dose-

limiting toxicities that require nursing
interventions

102
 Frequently Used
Chemotherapeutic Agents
Alkylators

Cyclophosphamide (Cytoxan)
– 500-1,500 mg/m2 I.V. q3-4wk
– 50-100 mg/m2 PO daily for 14 d
• Hemorrhagic cystitis, alopecia
• Monitor liver function
• Drink 3 qt (3 L) fluids daily

Busulfan (Myleran)
– 4-8 mg PO, daily
• MarkedMarkedMild
• Pulmonary fibrosis, skin pigmentation

103
 Frequently Used
Chemotherapeutic Agents
Alkylators

BCNU (Carmustine)
– 150-200 mg/m2 I.V. q6wk
• Local pain during infusion, pulmonary fibrosis,
crosses blood-brain barrier/irritant
• Requires reconstitution with supplied diluent
CBCDA (Carboplatin)
– 300-500 mg/m2 I.V. q4wk
• Possible anaphylaxis, thrombocytopenia can be
severe and prolonged

104
 Frequently Used
Chemotherapeutic Agents
Alkylators
CCNU (Lomustine CeeNU)
– 130 mg/m2 PO q6wk
• crosses blood-brain barrier; take at
bedtime on empty stomach

Chlorambucil (Leukeran)
– 16 mg/m2/ day × 5 d q28d or 0.1-0.2 mg/kg
PO daily
• Infertility. Leukopenia delayed up to 3
wk

105
Cisplatin (Platinol)
– 50-120 mg/m2 I.V. q3-4wk
– 20 mg/m2 I.V. daily for 5 d q3-4wk
• Nephrotoxicity/neurotoxicity, magnesium wasting, ototoxicity,
anemia. Requires antiemetics before and after

Dacarbazine (DTIC)
– 150 mg/m2 daily I.V.— 5 d q4wk
– 375 mg/m2 on day 1 q15d
• Flu-like syndrome, alopecia, facial flushing, paresthesia,
vesicant

Ifosphamide (IFEX)
– 8-12 gm/m2/cycle over 3-5 days every 21-28 days
– I.V. for 5 d q3w
• Neurotoxicity, hemorrhagic cystitis, alopecia, concomitant
uroprotection with Mesna

106
Mesna
– 20 mg/kg 15 min before Ifex, repeated q3h for 4
doses
• Not an antineoplastic agent; binds to reactive
metabolite of IFEX or Cytoxan without affecting
antitumor activity

MeCCNU (Semustine, Methyl CCNU)

– 130 mg/m2 q6wk
• Delayed and cumulative anorexia

Mechlorethamine hydrochloride (nitrogen mustard)

– 6 mg/m2 day 1 and 8 q28d
• stomatitis, alopecia, chemical thrombophlebitis

107
 Personal Safety to Minimize
Exposure via Inhalation
• Chemotherapeutic agents should be
prepared in a class II biologic safety
cabinet (vertical laminar flow hood).

• Vent vials with filter needle to equalize the

internal pressure or use negative-pressure
techniques.

• Wrap gauze or alcohol pads around the

neck of ampules when opening to
decrease droplet contamination.
108
 Personal Safety to Minimize
Exposure via Inhalation
• Wrap gauze or alcohol pads around
injection sites when removing syringes or
needles from I.V. injection ports.

• Do not dispose of materials by clipping

needles or removing needles from
syringes.

• Use puncture- and leak-proof containers

for non-capped, non-clipped needles

109
 Personal Safety to Minimize
Exposure via Skin Contact
• Wear nitrile examination gloves at all times when
preparing or working with chemotherapeutic
agents.

• Wash hands before putting on and after removing

gloves.

• Change gloves after each use, tear, puncture, or

medication spill or after every 60 minutes of wear.

• Wear a long-sleeve, nonabsorbent gown with

elastic at the wrists and back closure.

110
 Personal Safety to Minimize
Exposure via Skin Contact
• Eye and face shields should be worn if
splashes are likely to occur.

• Use syringes and I.V. tubing with Luer

locks (which have a locking device to hold
needle firmly in place).

• Label all syringes and I.V. tubing

containing chemotherapeutic agents as
hazardous material.

111
 Personal Safety to Minimize
Exposure via Skin Contact
• Place an absorbent pad directly under the injection
site to absorb any accidental spillage.

• If any contact with the skin occurs, immediately

wash the area thoroughly with soap and water.

• If contact is made with the eye, immediately flush

the eye with water and seek medical attention.

• Spill kits should be available in all areas where

chemotherapy is stored, prepared, and
administered.

112
 Personal Safety to Minimize
Exposure via Ingestion
• Do not eat, drink, chew gum, or smoke while
preparing or handling chemotherapy.

• Keep all food and drink away from preparation

area.

• Wash hands before and after handling

chemotherapy.

• Avoid hand-to-mouth or hand-to-eye contact while

handling chemotherapeutic agents or body fluids of
the person receiving chemotherapy.

113
 Safe Disposal of Antineoplastic
Agents, Body Fluids, and Excreta
• Discard gloves and gown into a leak-proof
container, which should be marked as
contaminated or hazardous waste.

• Use puncture- and leak-proof containers for

needles and other sharp or breakable objects.

• Linens contaminated with chemotherapy or excreta

from patients who have received chemotherapy
within 48 hours should be contained in specially
marked hazardous waste bags.

114
Adverse Effects of Chemotherapy

• Adverse effects of chemotherapy are

graded on a scale of 0 to 4, with 0 being
normal and 4 indicating life-threatening.
Scoring of adverse effects will determine if
a delay in therapy is necessary, dose
modification is necessary, or cessation of
therapy must occur.

115
 Safe Disposal of Antineoplastic
Agents, Body Fluids, and Excreta
• Wear non-sterile nitrile gloves for
disposing of body excreta and handling
soiled linens within 48 hours of
chemotherapy administration.

• In the home, wear gloves when handling

bed linens or clothing contaminated with
chemotherapy or patient excreta within 48
hours of chemotherapy administration.
Place linens in a separate, washable pillow
case. Wash separately in hot water and
regular detergent.

116
Adverse Effects of Chemotherapy
Alopecia
– Most chemotherapeutic agents cause some
degree of alopecia. This is dependent on the
drug dose, half-life of drug, and duration of
therapy.
– Usually begins 2 weeks after administration of
chemotherapy. Regrowth takes about 3 to 5
months.
– The use of scalp hypothermia and tourniquets is
highly controversial.

117
Adverse Effects of Chemotherapy
Anorexia
– Chemotherapy changes the reproduction of
taste buds.
– Absent or altered taste can lead to a decreased
food intake.
– Concurrent renal or hepatic disease can
increase anorexia.

118
Adverse Effects of Chemotherapy
Fatigue
– The cause of fatigue is generally unknown but can be
related to anemia, weight loss, altered sleep patterns,
and coping.
Nausea and Vomiting
– Caused by the stimulation of the vagus nerve by
serotonin released by cells in the upper GI tract.
– Incidence depends upon the particular
chemotherapeutic agent and dosage.
– Patterns of nausea and vomiting:
• Anticipatory -conditioned response from repeated
association between therapy and vomiting.
• Acute -occurs 0 to 24 hours after chemotherapy
administration.
• Delayed- can occur 1 to 4 days after
chemotherapy administration

119
Adverse Effects of Chemotherapy
Mucositis
– Caused by the destruction of the oral mucosa,
causing an inflammatory response.
– Initially presents as a burning sensation with no
changes in the mucosa and progresses to
significant breakdown, erythema, and pain of the
oral mucosa.
– Consistent oral hygiene is important to avoid
infection.

120
Adverse Effects of Chemotherapy
Anemia
– Caused by suppression of the stem cell or
interference with cell proliferation pathways.
– May require red blood cell transfusion or
injection of erythropoietin or darbepoetin.

121
Adverse Effects of Chemotherapy
Neutropenia
– Defined as an absolute neutrophil count (ANC)
of 1,500/mm3 or less.
– Risk of infection is greatest with an ANC less
than 500/mm3.
– Caused by suppression of the stem cell.
– Usually occurs 7 to 14 days after administration
of chemotherapy.
– Can be prolonged.
– Patients should be taught to avoid infection
through proper hand washing, avoiding those
with illness, proper hygiene.
– Patients need to be monitored and treated
promptly for fever or other signs of infection.

122
Adverse Effects of Chemotherapy
Thrombocytopenia
– Caused by suppression of megakaryocytes.
– Incidence depends on the agent being used.
– Risk of bleeding is present when platelet count
falls below 50,000/mm3.
– Risk is high when count falls below 20,000/mm3.
– Risk is critical when count falls below
10,000/mm3.
– Patient should be taught to avoid injury, eg, no
razors, avoid vaginal douches and rectal
suppositories, and avoid dental floss during the
period of thrombocytopenia.
– May require platelet transfusions if count drops
below 20,000/mm3.

123
Adverse Effects of Chemotherapy
Hypersensitivity Reactions
– Nearly all of the available chemotherapeutic
agents can produce hypersensitivity reactions
(HSRs) in at least an occasional patient, and
some cause reactions in 5% or more of patients
receiving the drug. There are several agents (L-
asparaginase, paclitaxel, docetaxel, teniposide,
and doxil) for which HSRs are frequent enough
to be a major form of treatment-limiting toxicity.
– The mechanism is unknown for most of the
chemotherapeutic agents in use.
– Signs and symptoms include hives, pruritus,
back pain, shortness of breath, hypotension, and
anaphylaxis.
– All unexpected drug reactions should be
reported to the manufacturer.

124
NURSING ASSESSMENT
Integumentary System

• Inspect for pain, swelling with inflammation or

phlebitis, necrosis, or ulceration.
• Inspect for skin rash, characteristics, whether
pruritus, general or local.
• Assess areas of erythema and associated
tenderness or pruritus. Instruct patient to avoid
irritation to skin, sun exposure, or irritating soaps.
• Assess changes in skin pigmentation.
• Note reports of photosensitivity, tearing of the eyes.
• Assess condition of gums, teeth, buccal mucosa,
and tongue.

125
NURSING ASSESSMENT
GI System

• Assess for frequency, timing of onset, duration, and

severity of nausea and vomiting episodes before
and after chemotherapy.
– Usually occurs from 1 to 24 hours after
chemotherapy but may be delayed. Anticipatory
vomiting may occur after first course of therapy.
Can be initiated by various cues, including
thoughts, smell, or even sight of the medical
personnel.
• Observe for alterations in hydration, electrolyte
balance.

126
 NURSING ASSESSMENT

GI System

• Assess for diarrhea or constipation.

• Assess for anorexia.
• Assess for jaundice, right upper quadrant
abdominal pain, changes in the stool or urine, and
elevated liver function tests that indicate
hepatotoxicity.
• Monitor liver function tests and total bilirubin

127
NURSING ASSESSMENT
Hematopoietic System

Fever greater than 101° F (38.3° C) in a patient with an

ANC less than 500/mm3 is an emergency requiring
immediate administration of antibiotics.
• Assess for neutropenia ANC less than 500/mm3.
– Assess for any signs of infection (pulmonary,
integumentary, central nervous system, GI, and
urinary).
– Auscultate lungs for adventitious breath sounds.
– Assess for productive cough or shortness of breath.
– Assess for urinary frequency, urgency, pain, or odor.
– Monitor for elevation of temperature above 101° F,
chills.

128
NURSING ASSESSMENT
• Assess for thrombocytopenia
platelet count less than
50,000/mm3 (mild risk of bleeding);
less than 20,000/mm3 (high risk of
bleeding).
– Assess skin and oral mucous
membranes for petechiae,
bruises on extremities.
– Assess for signs of bleeding
(including nose, urinary, rectal,
or hemoptysis).
– Assess for blood in stools, urine,
or emesis.
129
 NURSING ASSESSMENT
• Assess for signs and symptoms of
intracranial bleeding if platelet
count is less than 20,000/mm3;
monitor for changes in level of
responsiveness, vital signs, and
pupillary reaction.
• Assess for anemia.
• Ascertain whether patient has
experienced dyspnea on exertion,
fatigue, weakness, palpitations, or
vertigo. Advise rest periods as needed.

130
NURSING ASSESSMENT
Respiratory and Cardiovascular Systems

• Assess lung sounds.

• Assess for pulmonary fibrosis, evidenced by a dry,
nonproductive cough with increasing dyspnea. Patients
at risk include those over age 60, smokers, those
receiving or having had pulmonary radiation, those
receiving cumulative dose of bleomycin (Blenoxane), or
those with any preexisting lung disease.
• Assess for signs and symptoms of heart failure or
irregular apical or radial pulses.
• Verify baseline cardiac studies (eg, electrocardiogram,
multiple-gated acquisition scan/ejection fraction) before
administering doxorubicin (Adriamycin) or high-dose
cyclophosphamide (Cytoxan).

131
NURSING ASSESSMENT
Neuromuscular System

• Determine whether patient is having difficulty with

fine motor activities, such as zipping pants, tying
shoes, or buttoning a shirt.
• Determine the presence of paresthesia (tingling,
numbness) of fingers or toes.
• Evaluate deep tendon reflexes.
• Evaluate patient for weakness, ataxia, or slapping
gait.
• Determine impact on activities of daily living and
discuss changes.
• Discuss symptoms of urinary retention or
constipation.
• Assess for ringing in ears or decreased hearing
acuity.
132
NURSING ASSESSMENT
Genitourinary System
• Monitor urine output.
• Assess for urinary frequency, urgency, or
hesitancy.
• Evaluate changes in odor, color, or clarity
of urine sample.
• Assess for hematuria, oliguria, or anuria.
• Monitor BUN and creatinine.

133
Nursing Diagnoses
• Risk for Infection related to neutropenia
• Risk for Injury related to bleeding from
thrombocytopenia
• Fatigue related to anemia
• Imbalanced Nutrition: Less Than Body
Requirements related to adverse effects of therapy
• Ineffective protection and risk for hypersensitivity
reaction related to chemotherapy
• Impaired Oral Mucous Membranes related to
stomatitis
• Disturbed Body Image related to alopecia and
weight loss

134
NURSING MANAGEMENT
• Preventing Infection
• Preventing Bleeding
• Minimizing Fatigue
• Promoting Nutrition
• Minimizing Stomatitis
• Preventing and Managing Hypersensitivity
Reactions
• Strengthening Coping for Altered Body
Image
• Patient Education and Health Maintenance

135
RADIATION THERAPY
Radiation therapy is the use of high-energy
ionizing rays to destroy a cancer cell's
ability to grow and multiply.

The goal of radiation therapy is to deliver a

precisely measured dose of irradiation to a
defined tumor volume with minimal
damage to surrounding healthy tissue. This
results in eradication of tumor, high quality
of life, prolongation of survival, and allows
for effective palliation or prevention of
symptoms of cancer, with minimal
morbidity
136
RADIATION THERAPY
General Considerations

• Different irradiation doses are required for tumor

control, depending on tumor type and the number
of cells present. Varying radiation doses can be
delivered to specific portions of the tumor
(periphery versus central portion) or to the tumor
bed in cases in which all gross tumor has been
surgically removed.

• Treatment portals must adequately cover all

treatment volumes plus a margin

137
RADIATION THERAPY
Goals of Therapy

Curative: When there is a probability of long-term

survival after adequate therapy; some adverse
effects of therapy, although undesirable, may be
acceptable.

Palliative: When there is no hope of survival for

extended periods, radiation can be used to palliate
symptoms, primarily pain. Lower doses of
irradiation (75% to 80% of curative dose) can
control the tumor and palliate symptoms without
excessive toxicity.

138
Principles of Radiation Therapy
• Higher doses of irradiation produce better tumor
control. For every increment of irradiation dose, a
certain fraction of cells will be killed.

• A boost is the additional dose administered through

small portals to residual disease; it is given to
obtain the same probability of control as for
subclinical aggregates.

• Radiosensitivity is the degree and speed of

response. This measure of susceptibility of cells to
injury or death by radiation depends on cancer
diagnosis and its inherent biologic activity. It is
directly related to reproductive capability of the cell.

139
 WAYS TO PREVENT
CANCER

 EXPLAIN TO THE CLIENT THE

RISK OF CANCER DEVELOPMENT.

DISCUSS THE NUTRITIONAL

GUIDELINES
 ENCOURAGE THE CLIENT TO
AVOID TOBACCO USE.

ENCOURAGE THE CLIENT TO

AVOID EXCESSIVE SUN
EXPOSURE.
Cancer Management
 SURGERY
 THE SURGICAL REMOVAL OF
TUMORS, THE MOST
COMMONLY USED TREATMENT
MODALITY FOR CANCER.
PREVENTIVE OR PROPHYLACTIC
SURGERY

 INVOLVES REMOVING
PRECANCEROUS LESIONS
 DIAGNOSTIC SURGERY

 DONE TO CONFIRM OR RULE

OUT MALIGNANCY FROM
ANALYSIS OF TISSUE SAMPLES
OBTAINED FROM INCISIONAL,
EXCISIONAL OR BIOPSIES.
RECONSTRUCTIVE
SURGERY
 AIMS TO IMPROVE THE
CLIENT’S QUALITY OF LIFE BY
RESTORING MAXIMAL
APPEARANCE.
PALLIATIVE SURGERY
 DONE TO RETARD TUMOR
GROWTH
 TO DECREASE TUMOR SIZE
RELIEVE DISTRESSING
MANIFESTATIONS OF CANCER
WHEN CURE IS NO LONGER
POSSIBLE.
RADIATION THERAPY
 INVOLVES DIRECTING HIGH-
ENERGY IONIZING RADIATION
TO DESTROY MALIGNANT
TUMORS WITHOUT HARMING
SURROUNDING TISSUES.
 CHEMOTHERAPY
 INVOLVES ADMINISTERING
ANTINEOPLASTIC DRUGS TO
PROMOTE TUMOR CELL DEATH
BY INTERFERING WITH
CELLULAR FUNCTIONS AND
REPRODUCTION.
BONE MARROW PERIPHERAL
STEM CELL
TRANSPLANTATION

 INVOLVES ASPIRATING BONE

MARROW CELLS FROM A
COMPATIBLE DONOR &
INFUSING THEM INTO THE
RECIPIENT
 IMMUNOTHERAPY

 USES THE BODY’S OWN

IMMUNE MECHANISM TO
COMBAT AND OVERCOME
CANCER.
 Cancer’s 7
Early Warning Signs
C – CHANGE IN BOWEL OR
BLADDER HABITS
A – A SORE THAT DOES NOT
HEAL
U – UNUSUAL BLEEDING OR
DISCHARGE
T – THICKENING OF LUMP IN
BREAST
I – INDIGESTION OR DIFFICULTY
IN SWALLOWING
O – OBVIOUS CHANGE IN WART
OR MOLE
N – NAGGING COUGH OR
HOARSENESS
Early detection of
cancer
 sigmoidoscopy
 Rectal examination
 prostate examination
 papanicolaou (Pap) test
 breast examination
 Cancer types
 Bladder - Painless
Cancer hematuria,
urinary
frequency,
pelvic or back
pain
 Cervical - Vaginal
Cancer discharge,
spotting,
abnormal
pap smear,
pain in back
& legs
 Colon - Change in
Cancer bowel habits,
passage of
blood in stool,
unexplained
anemia & wt.
loss
Esophageal -
Cancer Dysphagia
with solid
foods,
feeling of
mass in
throat
 Gastric - Abdominal
Cancer pain,
indigestion,
constipation,
weight loss
 Kidney - Classic triad
Cancer hematuria,ma
ss in flank
 Laryngeal - Persistent
Cancer hoarseness,
cough,
dyspnea,
throat pain
radiating to
ear
 Liver -Ascites,
Cancer liver mass
detected on
palpation,
jaundice,
weakness
 Lung -
Cancer Hemoptysis,
dyspnea,
chest pain,
persistent
cough
 Ovarian - Irregular
Cancer menses, pelvic
pain,
postmenstrual
bleeding
 Pancreatic - Jaundice,
Cancer abdominal
pain,
palpable
epigastric
mass
 Penile - Wartlike
Cancer growth of
ulcer on the
glans penis
 Prostate - Hematuria,
Cancer oliguria
 Multiple - Severe
Myeloma bone pain,
immobility
 Skin - Small
Cancer elevated
multicolored
nodules
 Testicular - Painless
Cancer enlargement
of the scrotum,
feeling of
heaviness in
the scrotum
 Uterine - Irregular
Cancer vaginal
bleeding,
abnormal
pap smear
 Vulvular - Pruritus,
Cancer vulvar
bleeding,
foul smell
discharge,
vulvar mass
or ulceration
rta ® 2007. © 1993-2006 Microsoft Corporation. All rights reserved.
human behavior
Mental health
a state of well
being in which a
person is able to
realize his
potentials
Characteristics of mentally
healthy person

attitude of self acceptance

growth development & self

actualization
 autonomous behavior
Perception of reality
Environmental mastery
Mental ill health
a state of imbalance
characterized by a
disturbance in a
person’s thoughts,
feelings and behavior
 poverty and abuses are
the major factors which
increases the risk of mental
illness at the home
 Mental hygiene

it is the science that deals

with measures to promote
mental health and prevent
mental illness
 CONDITIONS
REQUIRING CRISIS
INTERVENTION
BATTERED WIFE
SYNDROME
RAPE
CHILD ABUSE
ANXIETY
 ALZHEIMER’S DISEASE
AUTISM
SUBSTANCE ABUSE AND
SUBSTANCE DEPENDENCE
 ALCOHOLISM
CONCEPT OF LOSS
( GRIEF/
GRIEVING)
THANK
YOU
FOR