Oncologic Disorders Oncologic Disorders A neoplasmtumor is cellular

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Oncologic Disorders

Oncologic Disorders

Oncologic Disorders �A neoplasm/tumor is cellular growth that no longer responds to normal body

Oncologic Disorders �A neoplasm/tumor is cellular growth that no longer responds to normal body controls. �Cancerous cells differ from normal cells in appearance, growth, and function. The can occur over many years. �Clinical manifestations are the final stages in the process.

Oncologic Disorders Excessive growth of the neoplasm �deprives other cells of nutrients �Creates pressure

Oncologic Disorders Excessive growth of the neoplasm �deprives other cells of nutrients �Creates pressure on surrounding structures. Appearance: “undifferentiated “ cells have no resemblance to their tissue of origin. Growth: Cancer cells may metastasis to the outlying organs and eventually the bloodstream. They lack “contact inhibition” Function: Cancer cells contribute NOTHING useful to the host. They rob the host…

Shows lack of contact inhibition

Shows lack of contact inhibition

Pathophysiology �Hypertrophy …. increase in size by enlarging each cell. �Hyperplasia …. increasing the

Pathophysiology �Hypertrophy …. increase in size by enlarging each cell. �Hyperplasia …. increasing the number of cells. �Neoplasia is any new or continued cell growth not needed for normal development or replacement of dead and damaged tissues.

Oncologic Disorders: Benign vs Malignant Benign �They’re differentiated cells (specialized for structure and function)

Oncologic Disorders: Benign vs Malignant Benign �They’re differentiated cells (specialized for structure and function) that reproduce at a higher than normal rate. �Encapsulated, so they will not spread. �Tumor can be easily excised.

Oncologic Disorders: Benign vs Malignant Undifferentiated, nonfunctional cells that infiltrate surrounding tissue and break

Oncologic Disorders: Benign vs Malignant Undifferentiated, nonfunctional cells that infiltrate surrounding tissue and break away to spread to other organs. Grows relentlessly. Cells are too abnormal to produce physiologic functions. Causes death to host unless removed or destroyed.

Defect in Cellular Differentiation �Benign neoplasm �Well differentiated �Usually encapsulated �Expansive mode of growth

Defect in Cellular Differentiation �Benign neoplasm �Well differentiated �Usually encapsulated �Expansive mode of growth �Characteristics similar to parent cell �Metastasis is absent �Rarely reoccur �Malignant neoplasm �May range from well differentiated to undifferentiated �Able to metastasize �Infiltrative and expansive growth �Frequent recurrence �Moderate to marked vascularity �Rarely encapsulated �Become less like parent cell

Carcinogens �Radiation �Chemicals- tobacco, formaldehyde, arsenic, pesticides �Viruses- Hep B, C �Hormones (Increased risk

Carcinogens �Radiation �Chemicals- tobacco, formaldehyde, arsenic, pesticides �Viruses- Hep B, C �Hormones (Increased risk in tissues that are responsive to hormones: breast, endometrium, prostate, thyroid, testes) �Alcoholic beverages

Development of Caner �Viral carcinogens Virus Associated Cancer Epstein-Barr virus (EBV) Burkitt’s lymphoma Human

Development of Caner �Viral carcinogens Virus Associated Cancer Epstein-Barr virus (EBV) Burkitt’s lymphoma Human immunodeficiency Kaposi’s sarcoma virus (HIV) Hepatitis B virus Human papillomavirus Hepatocellular carcinoma Squamous cell carcinomas

QUESTION �The nurse is taking the social history from a client diagnosed with small

QUESTION �The nurse is taking the social history from a client diagnosed with small cell carcinoma of the lung. Which information is significant for this disease? � 1. The client worked with asbestos for a short time many years ago � 2. The client has no family history for this type of lung cancer � 3. The client has numerous tattoos covering both upper and lower arms � 4. The client has smoked two (2) packs of cigarettes a day for 20 years.

Cancer prevention and Screening 1. Self-Examination Techniques 2. Understanding of Risk Factors 3. ?

Cancer prevention and Screening 1. Self-Examination Techniques 2. Understanding of Risk Factors 3. ? ? . . . Screening schedule and screening procedures by HC providers. 4. Ask patient about the seven warning signs of cancer

Seven warning signs of cancer �C – Changes in B or B habits? �A

Seven warning signs of cancer �C – Changes in B or B habits? �A – A sore that does not heal? �U – Unusual bleeding or discharge? �T – Thickening or a lump in breast or elsewhere �I – Indigestion of difficulty swallowing �O – Obvious change in a wart or mole �N –Nagging cough or hoarseness

Health Practices That May Reduce CA Risk �Eat more fruits and cruciferous veggies, grains,

Health Practices That May Reduce CA Risk �Eat more fruits and cruciferous veggies, grains, and high fiber. �Limit salt cured, smoked food. �Limit fat intake �Limit alcohol intake �Maintain a healthy weight

Health Practices That May Reduce CA Risk �Baseline mammography at age 40 & annually

Health Practices That May Reduce CA Risk �Baseline mammography at age 40 & annually �Breast self-exams monthly after age 20 �Quit smoking �Annual digital rectal exam for prostate CA at age 40 and prostate specific antigen (PSA) with rectal prostate exam after age 50. �Digital exam for occult blood for colon CA at age 40 and colonoscopy at age 50. �Pap smear every 3 -5 years for cervical CA �Avoid the midday sun, wear hats, sunscreen

Development of Cancer �Activities of promotion are reversible Obesity � Smoking, alcohol � Dietary

Development of Cancer �Activities of promotion are reversible Obesity � Smoking, alcohol � Dietary fat � �About half of cancer- related deaths in the United States are related to Tobacco use � Unhealthy diet � Physical inactivity � Obesity �

Development of Cancer �Progression �Characterized by � Increased growth rate of tumor � Invasiveness

Development of Cancer �Progression �Characterized by � Increased growth rate of tumor � Invasiveness � Metastasis �Most frequent sites of metastasis are lungs, brain, bone, liver, and adrenal glands

Metastasis �Metastasis occurs through a progression of steps: 1. Extension into surrounding tissues 2.

Metastasis �Metastasis occurs through a progression of steps: 1. Extension into surrounding tissues 2. Blood vessel penetration 3. Release of tumor cells 4. Invasion 5. Local seeding 6. Bloodborne metastasis 7. Lymphatic spread Elsevier items and derived items © 2006 by Elsevier Inc.

Diagnosis and Diagnostic Screening Procedures �History �Physical Exam �Biopsy Grades of Tumors: - the

Diagnosis and Diagnostic Screening Procedures �History �Physical Exam �Biopsy Grades of Tumors: - the higher the grade the more likely it is to grow and spread. Gx: Grade can not be determined. . ? ? ? Grade 1: Well differentiated, looks normal Grade 2: Moderately well differentiated Grade 3: Poorly differentiated but tissue of origin can be established. Grade 4: Poorly differentiated and the tissue of origin may be impossible to determine.

STAGING �Method of Identifying the extent of the disease. �A systematic search for the

STAGING �Method of Identifying the extent of the disease. �A systematic search for the characteristics of the primary tumor. �Each site is classified based on three components. (TNM)

TNM -STAGING Primary Tumor (T) �Tx - No primary Tumor can be assessed. �T

TNM -STAGING Primary Tumor (T) �Tx - No primary Tumor can be assessed. �T 0 – No evidence of Primary Tumor. �T 1 S – carcinoma in situ (“in it’s place” means remaining in the tissue of origin…but is usually a precursor to malignant tumors!!. �T 1, T 2, T 3, T 4 – Increasing size and extent of the primary tumor �Clinical vs. pathologic staging (biopsy) = complementary

STAGING Regional Lymph Nodes �Nx – Can not be assessed. �N 0 – No

STAGING Regional Lymph Nodes �Nx – Can not be assessed. �N 0 – No regional lymph node involvement. �N 1, N 2, N 3 – Increasing involvement of regional lymph nodes

STAGING Distant Metastasis (M) �Presence of Mets can not be assessed. �M 0 –No

STAGING Distant Metastasis (M) �Presence of Mets can not be assessed. �M 0 –No distant Mets. �M 1 – Distant Mets Grading and staging information guides the physician in choosing the intervention and estimating the client’s prognosis.

Diagnosis � CBC- unexplained anemias/ bleeding disorders THIS WOULD BE CA OF THE WHAT?

Diagnosis � CBC- unexplained anemias/ bleeding disorders THIS WOULD BE CA OF THE WHAT? ? ? � Presence of oncofetal proteins – (are usually only present during fetal development) but are produced when the highly immature CA cells of specific organs produce them—ie: HCG is produced by tumors of the testicle, ovary, pancreas. � Metabolic manifestations - Cushing’s, hypercalcemia, SIADH, … � Stool tests - …check for blood � Cytologic tests – sputum, pap, growth. � CYRY, CT, PET � biopsy to check for abnormal cell- GIVES DEFINITIVE DIAGNOSIS!!!!!!

TREATMENTS… GOALS: �Cure? Is it possible? ? �Control: Slow the disease process. �Palliation: Alleviate

TREATMENTS… GOALS: �Cure? Is it possible? ? �Control: Slow the disease process. �Palliation: Alleviate the manifestations. �Rehabilitation: Maintain a high quality of life for as long as possible. �Surgery �Radiation �Chemotherapy

TREATMENTS…Surgery �Preventive – removed premalignant tumors �Biopsy – removes pieces of tissue for diagnostic

TREATMENTS…Surgery �Preventive – removed premalignant tumors �Biopsy – removes pieces of tissue for diagnostic purposes �Tumor Removal �Staging - Reveals the extent of the disease by sampling regional lymph nodes �Tumor debulking – reduces the tumor, then treat it with radiation or chemo �Palliative – Relieves symptoms caused by the tumor What special consideration do you think need to be made for the oncologic pt undergoing surgery? �Preop… �Post-op…

Management of Cancer Pain �Patient report should always be believed and accepted as primary

Management of Cancer Pain �Patient report should always be believed and accepted as primary source for pain assessment data �Drug therapy should be used to control pain �Fear of addiction is unwarranted

TREATMENTS…Radiation �Energy and ionization injures the cell membrane and alters the DNA so cells

TREATMENTS…Radiation �Energy and ionization injures the cell membrane and alters the DNA so cells can’t reproduce. �Affects all surrounding tissue but rapidly dividing cells are more vulnerable to the effects of radiation than slower growing cells. �More than 50% of CA pts receive RT at some point. �It may be primary, adjuvant, or palliative.

TREATMENTS…Radiation External Beam Internal Radiation �Delivers high energy rays directly to the affected area.

TREATMENTS…Radiation External Beam Internal Radiation �Delivers high energy rays directly to the affected area. Given in divided increments over a period of several weeks. Usually outpatient… A radiation port marks the target area. Maximum effect of radiation occurs at tumor depth, NOT on the skin’s surface. �Sealed or unsealed radioactive material is implanted adjacent to or within the tumor. It allows exposure to radioactivity for longer than external radiation does. �SEALED: Does not circulate in the body. The client’s urine sweat, blood, secretions or vomitus is not contaminated.

TREATMENTS…Radiation Internal Radiation � SEALED: cont’d… Only exposure with the sealed isotope with bare

TREATMENTS…Radiation Internal Radiation � SEALED: cont’d… Only exposure with the sealed isotope with bare hands will result in radioactive contamination. � The radioisotope is placed in an applicator, which is then placed in the body cavity OR is placed directly in the tumor with a needle or seed. – “preloading” � In “afterloading” a device is placed first and the radioactive isotope is loaded after it’s in place.

TREATMENTS…Radiation Internal Radiation �SEALED: cont’d…Can be permanent if the half life is short or

TREATMENTS…Radiation Internal Radiation �SEALED: cont’d…Can be permanent if the half life is short or temporary. �Unsealed; CIRCULATES IN THE BODY & contaminates body fluids. Must use disposable plates and utensils. Keep trash and linen in room until DG. Admin po, IV, or directly into body cavity. �Risk of contamination to others is HIGH!!!!

TREATMENTS…Radiation �Unsealed cont’d… �Distance: Stay Back. A nurse 2 feet away gets 15 x

TREATMENTS…Radiation �Unsealed cont’d… �Distance: Stay Back. A nurse 2 feet away gets 15 x more radiation than a nurse 8 feet away!!!! �Time: Limit the time you spend with the patient to 30 -45 min/shift. Plan efficiently!! Staff caring for the patient should be rotated. �What nursing DX do you think apply here? ? How do you think this impacts their recovery? ? ? �Shielding: Nurses to wear when working? Protective but cumbersome… private designed rooms with lead shielded walls are used. LEAD PIGS with long handled forceps must be available in case radiation sources become dislodged. PICK IT UP and PLACE IT IN THE PIG.

TREATMENTS…Radiation �Pregnant staff must be assigned to other pts. �Children under 18 NOT ALLOWED.

TREATMENTS…Radiation �Pregnant staff must be assigned to other pts. �Children under 18 NOT ALLOWED. �Staff must wear a dosimeter to monitor whole body exposure & keep LOW…

SIDE EFFECTS of RADIATION �SEs are r/t the impact on the tissue of the

SIDE EFFECTS of RADIATION �SEs are r/t the impact on the tissue of the surrounding area being treated. � Severity varies. Some are temporary and some may be permanent. �Example: �Tumors of the head & neck destroys health cells of the oral cavity, teeth & salivary glands. Injury to the lining of the oral cavity causes STOMATITIS… �What do you think the nursing implications are for a patient with stomatitis? ? ?

SIDE EFFECTS of RADIATION �Radiation to the chest can produce esophagitis, pneumonitis, or pulmonary

SIDE EFFECTS of RADIATION �Radiation to the chest can produce esophagitis, pneumonitis, or pulmonary diseases such as pulmonary fibrosis. �Radiation to the pelvic area can cause diarrhea, urethral stenosis, and/or sexual dysfunction. �What do you think radiation to the abdomen would cause? ? ?

SIDE EFFECTS of RADIATION �Altered taste sensation is common -- metabolites released by the

SIDE EFFECTS of RADIATION �Altered taste sensation is common -- metabolites released by the dead/dying cells. �Fatigue – Exercise may reduce radiation related fatigue vs rest? ? �Skin at the radiated area becomes dry & sensitive. �Bone marrow is affected. . What will you check? ?

Chemotherapy �“Chemo” is the administration of drugs that affect normal cell development. Both normal

Chemotherapy �“Chemo” is the administration of drugs that affect normal cell development. Both normal and malignant cells are affected. There are multiple side effects… �There are> 50 chemotherapeutic agents to treat CA. �They are grouped according to their activity during the cell cycle… One or many may be prescribed. Why do you think that is? ?

Chemotherapy Adjunctive Chemo�Chemotherapy can be combined with radiation, or surgery. �It may be used

Chemotherapy Adjunctive Chemo�Chemotherapy can be combined with radiation, or surgery. �It may be used before surgery to shrink tumors or after surgery to inhibit the spread of microscopic tumor cells. Treatment Goals: �Cure �Control �palliation

Chemotherapy �…given according to a treatment schedule. �Example: a 28 -day treatment cycle may

Chemotherapy �…given according to a treatment schedule. �Example: a 28 -day treatment cycle may be used where the pt is treated for 14 days, and then given no treatment for 14 days. Then the cycle begins again. Why do you think that is? ? �Delivery: Venous Access Devices (VAD)1. Central venous catheters. 2. Implanted venous access ports. 3. Infusion pumps

Chemotherapy �…is given over continuous time intervals �Chemo agents are potentially very irritating to

Chemotherapy �…is given over continuous time intervals �Chemo agents are potentially very irritating to the veins and surrounding tissues. They are called VESSICANTS…

Chemotherapy – Side effects �Chemotherapeutic agents do not differentiate between normal cells and malignancy.

Chemotherapy – Side effects �Chemotherapeutic agents do not differentiate between normal cells and malignancy. When damage to normal cells occurs, pts experience SE similar to those of radiation… N & V – common, early…. chemicals triggering the emetic zone or irritation of gastric lining directly. � Phenothiazines � Ondandetron (zofran) � Reglan � Anti histamine

Chemotherapy – Side effects �Mucositis- Cells of the lining of the oral cavity are

Chemotherapy – Side effects �Mucositis- Cells of the lining of the oral cavity are destroyed. Food and fluid intake is compromised. Salt and Na HC 03 - rinses may be helpful. What else can you do? ? ? How can you address nutrition & mouth dryness? ? ? Diarrhea & constipation- May be r/t the drugs or to secondary problems like anxiety…. < fluid intake. How can you address the problem of diarrhea? ? ? Constipation? ?

Chemotherapy – Side effects �Skin toxicity: hyperpigmentation, rashes, alopecia. How can you assist the

Chemotherapy – Side effects �Skin toxicity: hyperpigmentation, rashes, alopecia. How can you assist the pt with alopecia? ? ? Tissue extravasation – caused by infiltration of chemo into the tissues!! BAD NEWS!! Careful assessment of the IV is required before & after chemo. Use central access if at all possible. What should you do? ? ?

Chemotherapy – Side effects �…STOP THE ADMINISTRATION �Try to aspirate the residual from the

Chemotherapy – Side effects �…STOP THE ADMINISTRATION �Try to aspirate the residual from the IV tubing/needle. �Instill antidote as prescribed, then remove the needle. �No direct pressure on the site. �Apply warm or cold compresses (depending on the vesicant). �Observe for pain, induration, erythema, necrosis! �Elevate arm. �DOCUMENT everything.

Chemotherapy – Side effects �Anemia – Why? ? Nursing implications? ? ? �Thrombocytopenia -

Chemotherapy – Side effects �Anemia – Why? ? Nursing implications? ? ? �Thrombocytopenia - What’s that? ? What do you look for? ? What’s a normal count? ? ? �Neutropenia – stop chemo if total WBC < 3000 and neutrophil < 1500 What’s the pt at risk for? ? ? What are the nursing implications for neutropenic precautions? ? ? Renal toxicity… Pulmonary toxicity… Neuro Toxicity…

Chemotherapy �The safe handling of antineoplastic agents needs to be by trained personnel! One

Chemotherapy �The safe handling of antineoplastic agents needs to be by trained personnel! One could: � Inhale � Absorb � through skin Ingest contaminated materials. Gloves, Gown , Laminar flow hood

Cancer Psychologic Support �Support patient and family by �Being available especially during difficult times

Cancer Psychologic Support �Support patient and family by �Being available especially during difficult times �Exhibiting a caring attitude �Listening actively to fears and concerns �Providing relief from distressing symptoms

Emergencies…KNOW THESE!!! �Superior Vena Cava Sx- Blood is obstructed back to the right heart.

Emergencies…KNOW THESE!!! �Superior Vena Cava Sx- Blood is obstructed back to the right heart. Results in edema of the face, neck and upper extremities…later hypoxia to brain, cyanosis, other S & S of < CO �SIADH - lung CA, brain CA, almost anything… �Tumor Lysis Syndrome- CA cells rupture from the radiation or treatment they’re getting. Shows treatment is working! But results in severe hyper K+ and Hyperuricemia. Treat. . GIK? ? Dialysis? ? Kaexalate? ? Treat > 6. O…

Emergencies…KNOW THESE!!! � DIC. . What’s this? ?

Emergencies…KNOW THESE!!! � DIC. . What’s this? ?