Medical-Surgical Nursing 2

Prepared by Dr. Pea and Dr. Cabigon

Oncology: Nursing Management of Patients with Cancer

Definition of Terms
A.
B.
C.
D.
E.
F.
G.
H.
I.

Neoplasia new, altered and abnormal development of cells that may be benign or malignant
Tumor mass or swelling in or on the body
Anaplasia means lack of differentiation
Biopsy the removal & examination of tissue from the living body
Carcinogenesis development of cancerous cells from normal ones
Carcinoma any malignant tumor derived from epithelial tissue
Chemotherapy treatment of disease, especially cancer, by means of chemical agents/drugs
Dysplasia means deranged development, disordered maturation
Hyperplasia constitutes an increase in the number of cells in organ or tissue, which may then have increased
volume
J. Proliferation- refers to the process of cell renewal or replacement. In cancer, proliferation process continues without
the normal control mechanisms.
K. Differentiation- refers to the process by which cells diversify, acquire specific structural and functional characteristics
and mature. Cells in cancer are poorly differentiated.
CHARACTERISTICS OF BENIGN & MALIGNANT NEOPLASM
Characteristics
Benign
Malignant
Speed of Growth
Grows slowly
Grows rapidly
Mode of Growth
Remains localized
Infiltrates surrounding tissues
Capsule
Encapsulated
Not encapsulated
Cell characteristics
Well differentiated
Poorly differentiated
Recurrences
Extremely unusual
Common following surgery
Metastasis
Never occur
Very common
Effect of neoplasm
Not harmful to host
Always harmful
Prognosis
Very good prognosis
Poor prognosis
*[Tip]: Characteristics of Benign neoplasms NEWSLUG, Non-metastatic, Encapsulated, Well-differentiated, Slow
growth, Localized, Unusual recurrence, Good prognosis
Agents that can Predispose to Cancer
A. Chemical carcinogens
These act by causing cell mutation or alteration in cell enzymes & proteins causing altered cell replication.
Tobacco associated with a number of cancers, particularly cancers of the lung, larynx, mouth, esophageal,
stomach, pancreas, kidney, bladder and cervix
Ether and coal tar are also associated with lung cancer
Asbestos associated with lung cancer and mesothelioma (cancer that affects the thin membranes lining the
abdomen and chest)
Benzene associated with leukemias and Hodgkin lymphoma
Some other examples are: Industrial compounds (i.e. arsenic, beryllium, cadmium), Spoilt Foods, and
preservatives like nitrites.
B. Physical Agents
Physical irritation/trauma
Radiation (x-rays, gamma and ultraviolet radiation) from diagnostic or therapeutic x-rays, radioisotopes,
sunlight
These will usually cause cancer after long time of exposure and interaction
C. Genetics
The human DNA has specific genes for cancer called Oncogene. When this gene is exposed to carcinogens,
there will be changes in cell structure, and growth behavior, leading to become malignant cells.
D. Viruses these viruses are called oncogenic viruses. They infect the host DNA or RNA resulting in cell mutation.
DNA viruses:
1. Hepa B (HBV) associated with hepatocellular carcinoma
2. Herpes simplex virus (HSV) associated with Kaposis sarcoma (a type of skin cancer typically in AIDS
patient)
3. Human papillomavirus (HPV) can lead to cancers of cervix, anus and penis

4. Epstein Barr virus (EBV) associated with lymphoma

5. Merkel cell Polyomavirus (MCV) associated with the development of Merkel cell carcinoma (rare but
aggressive form of skin cancer)
RNA viruses
1. Human T-lymphotropic virus (HTLV) associated with leukemia
2. Hepa C viruses (HCV) associated with hepatocellular carcinoma
E. Immune system alterations as seen in patients with immunodeficiency disease, the elderly and those receiving
immunosuppressant drugs.
F. Hormonal factors hormones make the cell more sensitive to the process of carcinogenesis or may encourage the
growth and spread of an established tumor
Breast cancer associated with increased estrogen levels in the body (nulliparity, early menarch, late
menopause, obesity, estrogen replacement therapy, estrogen-containing contraceptives)
Endometrial cancer also associated with increased levels of estrogen (nulliparity, early menarch, late
menopause, obesity, estrogen replacement therapy)
Ovarian cancer associated with exposure to exogenous female sex hormones (estrogen replacement
therapy and long-acting hormonal contraceptives)
Oral contraceptives decrease risk of ovarian and endometrial cancers, but increase risk of breast cancer
Estrogen replacement therapy increases risk of breast, ovarian, endometrial and brain cancers
Prostate cancer the androgen receptor helps prostate cancer cells to survive
G. Dietary factors
High fat diet and low fiber intake for colon cancer
Cooking food at high temperatures, for example grilling or barbecuing meats, can lead to the formation of
minute quantities of many potent carcinogens that are comparable to those found in cigarette smoke
Aflatoxin (produced by the mold Aspergillus that colonizes nuts and grains) can lead to liver cancer
Other dietary carcinogens nitrosamines (from processed foods, like hotdogs and bacons), acryl amides
(from deep-fried foods) and trans-fat or unsaturated fat (from fast food, snack food, fried food)
Predisposing Factors
A. Age older people are more prone. This is a very important factor for cancer development.
B. Sex women for breast, men for prostate
C. Urban versus Rural residence
D. Geographic distribution
E. Occupation
F. Heredity
G. Stress
H. Precancerous lesions these can lead to transformation into cancer
Actinic keratosis or solar keratosis thick, scaly, or crusty patches of skin; may progress to squamous cell
carcinoma
Barrett's esophagus an abnormal change (metaplasia) in the cells of the inferior portion of the esophagus;
may progress to esophageal cancer
Atrophic gastritis chronic inflammation of the stomach mucosa, leading to loss of gastric glandular cells and
their eventual replacement by intestinal and fibrous tissues; may progress to gastric carcinoma
Cervical dysplasia or Cervical intraepithelial neoplasia (CIN) abnormal growth (dysplasia) of squamous
cells on the surface of the cervix; may progress to cervical cancer
I. Obesity (breast and colorectal)
Warning Signals of Cancer (CAUTION) by the American Cancer Society (ACS)
C
A
U
T
I
O
N

Change in bowel or bladder habits

A sore that does not heal
Unusual bleeding/discharge; unexplained anemia and sudden weight loss
Thickening or lumps in breast or elsewhere
Indigestion or difficulty of swallowing
Obvious change in wart or mole
Nagging cough or hoarseness of voice

Sites of Cancer and Danger Signals

A. Breast lump, thickening, dimpling in breast; unusual size and shape of breast; one breast unusually lower;
retraction, sore or bleeding in the nipple
B. Colon & rectum change in bowel habits/bleeding
C. Kidney & bladder urinary difficulty/bleeding

D.
E.
F.
G.
H.
I.

Lung persistent cough/lingering respiratory ailment

Prostate urinary difficulty
Mouth, larynx & pharynx sore that does not heal, difficulty in swallowing & hoarseness
Skin sore that does not heal, change in wart or mole
Stomach indigestion
Uterus unusual bleeding or discharge

Top 3 Leading Types of Cancers

A. Male
1. Prostate
2. Lung and Bronchus most mortality
3. Colon and Rectum
B. Female
1. Breast
2. Cervical 2nd in the Philippines
3. Lung and Bronchus most mortality
Metastasis pathways of spread:
A. Direct seeding of body cavities or surfaces whenever malignant neoplasm penetrates into a natural open field;
involves peritoneal cavity (most often), pleural, pericardial, subarachnoid space and joints
B. Lymphatic spread pattern of lymph node involvement follows the natural route of drainage; this is the most common
mode of spread
C. Hematogenous spread malignant cells are disseminated through the blood stream; Liver & lungs most frequently
involved in hematogenous dissemination
D. Direct transplantation of tumor cells (ex: on surgical instrument) theoretically, it can occur but exceedingly rare
Tumor Staging
Stage I malignant cells confined to tissue of origin
Stage II limited local spreading to near lymph nodes
Stage III tumor is larger, or spread into nearby tissue, or both; regional lymph nodes affected
Stage IV metastasis to distant parts of the body
TNM Classification specifies the extent of the primary tumor (T), extent of regional lymph node metastasis (N) and
absence or presence of distant metastasis (M)
A. Primary Tumor (T)
Tx primary tumor cannot be assessed
T0 no evidence of primary tumor
Tis carcinoma in situ
T1, T2, T3, T4 increasing size and/or local extent of the primary tumor
B. Regional Lymph Nodes (N)
Nx regional lymph nodes cannot be assessed
N0 no regional lymph node metastasis
N1, N2, N3 increasing involvement of regional lymph nodes
C. Distant Metastasis (M)
Mx distant metastasis cannot be assessed
M0 no distant metastasis
M1 distant metastasis
Goals of Cancer Therapy
A. Cure the aim of this modality is to make sure that the client will be disease-free & live normal expectancy
B. Control not curing but controlling by therapy over long periods of time
C. Palliative cure & control not possible; but maintain quality of life as high as possible
Therapeutic Modalities
A. Surgery
Preventive removal of precancerous lesions/benign tumors
Diagnostic biopsy
Curative removal of an entire tumor (en bloc resection)
Reconstructive improvement of structure/function of an organ
Palliative relief of distressing signs & symptoms (ex. oophorectomy w/ breast cancer to reduce estrogen
secretion retarding metastasis)

B. Chemotherapy this involves administering cytotoxic drug to intervene and interrupt the cell cycle
C. Immunotherapy or biotherapy involves treatment with agents derived from biologic sources or with agents that
affect biologic responses like interferons, interleukins, and monoclonal antibodies
D. Radiotherapy used for radiosensitive cancers like skin cancer, head and neck tumors, cervical cancer, seminoma
and early stage Hodgkins; the response of the cancer cells depend on the type and phase of cell cycle
Chemotherapy use of drugs to retard the growth of or destroy cancerous cells; use to cure, for palliation, combined w/
surgery, combined with radiation
A. Classification
Cell-cycle specific: attack cells at a specific point in the process of cell division
Cell-cycle non-specific: act at one time during cell division
B. Administration
IV most common route
Arterial infusion - direct
Regional perfusion
Intraperitoneal
Oral, IM (less common)
Nursing Interventions for General Chemotherapeutic Side Effects
A. GI system (NDx: Imbalanced Nutrition: Less than body requirements; Impaired oral mucous membranes)
N & V. Antiemetic are given; withhold food/fluid before start of chemo
Diarrhea. Replace fluid-electrolyte losses, low-fiber diet
Constipation. Increased fluid intake & fibers
Anorexia. Encourage high protein and high calorie diet, serve food in ways to make it appealing small frequent
feedings, avoid giving fluids while eating; light exercise before meals to stimulate appetite; red meats may taste
bitter (use of plastic utensils may help)
Xerostomia (dry mouth). Ice chips, hard candy, gentle mouth care with 1/2 strength non alcohol mouth wash and
water
Stomatitis. Provide good oral care; avoid hot & spicy food; eat soft foods; soft toothbrush, Rinse with normal
saline or sodium bicarbonate (baking soda) 4x/day; Avoid ALCOHOL-based rinses
Drug-food interaction. Specific antineoplastics can have serious interactions with food; foods high in Tryamine
(aged cheese, beer, bananas, caffeine, yogurt and liver) cause hypertensive crises when eaten after taking
procarbazine
B. Integumentary system (NDx: Impaired skin integrity, Disturbed body image)
Pruritus, urticaria. Provide good skin care
Drying and flaking of skin. Handle skin gently; Do NOT rub affected area; Lotion may be applied; Wash skin only
with SOAP and Water
Alopecia/skin pigmentation/nail changes. Reassure that it is temporary & encourage to wear wigs, hats, or head
scarf; but anticipate change in texture and color; alopecia begins within 2 weeks of therapy and regrowth within 8
weeks of termination
C. Hematopoeitic (NDx: Risk for injury, Risk for infection)
Anemia. Provide frequent rest periods
Neutropenia. Protect from infection; Avoid people with infection, crowds; neutropenic precautionsprivate room,
maintain aseptic technique and strict hand washing, fresh flowers, fruits and vegetables are prohibited because
they harbor bacteria; Avoid frequent invasive procedures; Fever is the most important sign; Administer prescribed
antibiotics X 2weeks
Bleeding. Thrombocytopenia (<100,000) is the most common cause; <20, 000 spontaneous bleeding; Protect
from trauma; Avoid ASA; Use soft toothbrush; Use electric razor; Avoid frequent IM, IV, rectal and catheterization;
Soft foods and stool softeners
D. Genito-Urinary system
Urine color changes. Reassure that it is harmless
Nephrotoxicity. Some chemotherapeutic agents can damage the kidneys; monitor BUN and creatinine
E. Reproductive system
Premature menopause/amenorrhea. Reassure menstruation resumes after chemotherapy
Sterility and impotence. May be temporary or permanent; may advise men to bank sperm
F. Miscellaneous
Fatigue. Plan daily activities to allow alternating rest periods; Light exercise is encouraged; Small frequent meals
Chemotherapeutic Agents drugs that act to destroy rapidly dividing cells

A. Alkylating agents cell-cycle nonspecific

Ex. cyclophosphamide, cisplatin, ifosfamide, busulfan, carboplatin, chlorambucil
SE: hemorrhagic cystitis (cyclophosphamide) and renal toxicity (cisplatin)
B. Nitrosureas similar to alkalating agents; cross the blood-brain barrier
Ex. carmustine, lomustine and steptozocin
C. Antitumor antibiotics cell-cycle nonspecific
Ex. doxorubicin, daunorubicin, bleomycin, plicamycin
SE: cardiac toxicity (doxorubicin, daunorubicin)
D. Antimetabolites cell-cycle specific (S phase)
Ex. methotrexate, 6-mercaptopurine, 5-fluorouracil, cytarabine and 6-thioguanine
SE: renal toxicity (methotrexate)
E. Natural products cell-cycle specific (M phase)
Ex. plant alkaloids (vinblastine, vincristine) and taxanes (paclitaxel, docetaxel)
SE: cause peripheral neuropathy
F. Topoisomerase I inhibitors cell-cycle specific (G1 phase)
Ex. irinotecan, topotecan
G. Topoisomerase II inhibitors cell-cycle specific (S phase)
Ex. etoposide, amsacrine
H. Hormones cell-cycle specific (M phase)
Ex. tamoxifen, androgens, flutamide, aminogluthetimide, corticosteroids
SE: hypercalcemia (tamoxifen), masculinization (androgens); gynecomastia (flutamide); sodium and water
retention and cushings disease (corticosteroids)
Immunotherapy use of biologic response modifiers destroy or interfere with tumor activities; to help modify the hosts
biologic response to tumor cells
A. Types:
Interferons
Lymphokines & cytokines (interleukin-2)
Monoclonal antibodies (traztuzumab)
Colony stimulating factors
B. Side effects
Influenza-like symptoms, fatigue, N&V, neutropenia (INF), cardiotoxicity (traztuzumab),
Radiation Therapy use of ionizing radiation to cause damage and destruction to cancerous growths
A. Effect: Radiation damage at the cellular level
Indirectly: water molecules w/in the cell are ionized
Directly: causes strand breakage in the double helix of DNA
Not every cell is damaged beyond repair
B. Use to cure, for palliation, combined w/ surgery
PreOP: to reduce size of tumor
PostOP: to retard or control metastasis
C. Administration
External involves electromagnetic rays
1. Orthovoltage machines superficial lesions
2. Megavoltage (Cobalt-60) deeper structures
3. Linear accelerators deep lesions; less harmful
Internal (Brachytherapy) injection/implantation of radioisotopes proximal to cancer site for a specific period of
time
1. Sealed implants radioisotope with a container and doesnt contaminate body fluid
2. Unsealed (radioactive iodine) radioisotope without a container and contaminates body fluid
Principles of Radiation Protection (DTS)
A. Distance. Maintain a distance of at least 3 ft. when not performing nursing procedures.
B. Time. Limit contact for 5 min each time, a total of 30min/shift.
C. Shielding. Use lead shield during contact with client.
Nursing Interventions for Radiotherapy Side-Effects
A. Skin reactions (erythema, desquamation, atrophy, necrotic/ulcerative lesions, depigmentation)
Keep area dry

B.

C.

D.
E.

F.
G.
H.
I.
J.
K.
L.

Wash area w/ water, no soap, pat dry, do not rub

Do not apply ointments, powders or lotion, heat
Use soft cotton fabrics for clothing
Force fluid 2000-3000 ml/day
Apply cornstarch or olive oil
Bone marrow suppression
Monitor blood counts weekly
Good personal hygiene, nutrition, adequate rest
Teach signs of infection to report to physician
Reverse isolation
Hemorrhage (platelets are vulnerable to radiation)
Monitor platelet count
Avoid physical trauma or use of aspirin
Teach signs of hemorrhage
Monitor for signs of bleeding
Use direct pressure over injection sites until bleeding stops
Fatigue (results from high metabolic demands for tissue repair & toxic waste removal)
Plenty of rest and good nutrition
Stomatitis
Administer analgesics before meals
Bland diet, no smoking/alcohol
Good oral hygiene/ saline rinse q 2 hrs
Sugarless lemon drops or mint to salivation
Nausea & vomiting
Weight loss (anorexia, pain & effect of Ca)
Diarrhea
Headache
Hair loss/ alopecia
Cystitis
Social isolation

Bone Marrow Transplantation

A. Used to treat
Acute lympphoblastic leukemia
Acute myelogenous leukemia
Aplastic anemia
Chronic myelogenous leukemia
B. Types:
Allogeneic BMT: bone marrow comes from a healthy donor (usually immediate family member)
Autologous BMT: client is given own bone marrow
Diagnostic Tests
A. Blood Tests
Blood chemistries, complete blood count and other specialized assay can provide important information about
the extent of malignancy and the effectiveness of therapy.
Tumor markers substances that are specific to a particular tumor and can be used to screen, diagnose, assess
prognosis, evaluate response to treatment and check for tumor recurrence can be used to measure hormones,
oncofetal proteins secreted by malignant tumors:
1. Carcinoembryonic antigen (CEA) bowel cancers; occasional lung and breast cancers
2. Carbohydrate antigen 19-9 (CA19-9) colon and pancreatic cancer
3. Carbohydrate 125 (CA125) ovarian cancer
4. Prostate specific antigen (PSA) prostate cancer
5. Beta Human Chorionic Gonadotropin (-hCG) hydatidiform mole, choriocarcinoma, testicular cancer
6. Alpha-fetoprotein (AFP) germ cell tumors, hepatocellular carcinoma, and metastatic cancer in the liver
7. AFP-L3 (lectin-reactive AFP) hepatocellular carcinoma
8. Thyroglobulin thyroid cancer
9. Cancer antigen 15-3 (CA15-3) breast cancer
10. Mucin 1 (MUC1) breast cancer
11. Epithelial Tumor Antigen (ETA) breast cancer

B.

C.
D.
E.
F.

G.
H.

12. Tyrosinase malignant melanoma

13. Melanoma-associated antigen (MAGE) malignant melanoma
14. LDH testicular cancer
Cytologic tests
These tests help detect suspected primary or metastatic disease and monitor therapy
They cannot determine the location and size of a malignancy
ASPIRATION TESTS fine needle aspiration of body fluids permits evaluation of a palpable mass, a lymph node
or a lesion that has been localized x-rays.
BONE MARROW ANALYSIS allows examination of bone marrow aspirate to identify leukemic cells; most
common collection site is the iliac crest; other sites: sternum (adult) and tibia (infants)
PAPANICOLAOU TESTS is widely used to detect cervical cancer, endometrial and extrauterine malignancy in
an asymptomatic patient.
Endoscopy
These can be performed on the entire GIT, respiratory tract, urinary tract and peritoneal cavity.
Histologic tests
Biopsy is a common procedure that provides a detailed description that helps classify malignancy
Nuclear imaging and Scanning
Include CT, MRI and Radionuclide imaging
Radiographic test
Are used to visualize internal body structures to detect, identify, and localize malignancy and guide biopsy.
These include CXR, mammography
Ultrasonography
This non-invasive procedure is used to evaluate organs and localize masses except the lungs and bones.
Stool occult examination
Permits early detection of colorectal cancer, providing positive results in 80% of patients with this disorder

Nursing Interventions for Cancer

A. Relieve anxiety and ineffective coping
Encourage to express feelings
Ineffective coping. Teaching, encouraging self-care within limitations, emphasizing abilities, encouraging the use
of coping strategies that have been successful in the past
Support groups. ACS has local community information. Reach for recovery, groups that help patients cope with
ostomies resulting from cancer of the colon, bladder, Larynx
B. Management to promote nutrition
Serve food in ways to make it appealing
Consider patients preferences
Provide small frequent meals
Avoids giving fluids while eating
Oral hygiene PRIOR to mealtime
Vitamin supplements
C. Management to relieve pain
Mild pain NSAIDS
Moderate pain Weak opiods (meperidine)
Severe pain Morphine
Administer analgesics round the clock with additional dose for breakthrough pain
D. Management to improve body image
Therapeutic communication is essential
Encourage independence in self-care and decision making
Offer cosmetic material like make-up and wigs
E. Management to assist in the grieving process
Some cancers are curable
Grieving can be due to loss of health, income, sexuality, and body image
Answer and clarify information about cancer and treatment options
Identify resource people
Refer to support groups
F. Manage side effects of chemotherapy and radiotherapy
Nursing Care of Terminally Ill Patient directed towards making the patient physically & psychologically as comfortable as
possible

A. Nutrition
High calorie & protein diet
Small frequent feedings

fluids intake, 1000-1500ml above the N

B. Activity
C. Prevent tissue breakdown & vascular complications
Frequent turning, skin massage, air mattresses
Active and passive ROM
D. Observe for toxic reactions to tx (diarrhea)
E. Supportive measures & drugs for pain relief
F. Maintain open communication with patient & family
G. Control of odor
Infectious organisms cause formation of offensive odors
Frequent change of dressings
Oncologic emergencies due to the disease or the treatment
A. Hypercalcemia
Most common life-threatening disorder associated with cancer
Lung cancer, breast cancer and multiple myeloma are the most prevalent malignancies associated with
hypercalcemia
The cause of hypercalcemia is when cancer spreads to or invades the bones and when malignant cells release
certain factors that cause calcium to be released from the bone
B. Syndrome of inappropriate antidiuretic hormone
Found in small cell carcinoma of the lung and brain tumors (but also found in pneumonia, head trauma, strokes,
meningitis and encephalitis)
Characterized by excessive release of antidiuretic hormone (ADH or vasopressin) from the posterior pituitary
gland or another source
The result is hyponatremia, and sometimes fluid overload
C. Disseminated intravascular coagulation a pathological activation of coagulation (blood clotting) mechanisms that
leads to the formation of small blood clots inside the blood vessels throughout the body
D. Superior vena cava syndrome
Result of the direct obstruction of the superior vena cava by malignancies such as compression of the vessel wall
by right upper lobe tumors or thymoma and/or mediastinal lymphadenopathy
The most common malignancies that cause SVCS is bronchogenic carcinoma
Leads to shortness of breath is the most common symptom, followed by trunk or extremity swelling
E. Spinal cord compression
Develops when the spinal cord is compressed by bone fragments from a vertebral fracture
The most common causes of cord compression are tumors, but abscesses and granulomas (e.g. in tuberculosis)
are equally capable of producing the syndrome
Back pain, a dermatome of increased sensation, paralysis of limbs below the level of compression, decreased
sensation below the level of compression, urinary and fecal incontinence and/or urinary retention
General Promotive and Preventive Nursing Management
A. Lifestyle Modification
B. Nutritional management
C. Screening
D. Early detection
Types of
Prevention
Cancer
Lung
Do not smoke
Uterine Cervix Having one sexual partner lower risk; clean safe sex
Liver
Vaccination vs. Hepatitis B virus; Minimal alcohol
intake; avoid moldy foods
Colon and
Prudent diet of a variety of foods also with high fiber
rectum
and low fat intake.
Mouth
Breast

Detection
None
Regular pap smear every 1-3 years
None

Regular medical check-ups after 40 years of age,

yearly occult blood test in stools; digital rectal exam;
sigmoidoscopy
Avoid smoking tobacco, betel quid chewing. Modify Through dental check-ups each year
consumption of alcohol; cavity and dental hygiene.
No conclusive evidence
Monthly self-exam and annual doctor exam;

Skin
Prostate

Avoid excessive sun exposure

No conclusive evidence

mammography for high risk groups of for >=50 yrs.

Old; Female
Skin self exam
Digital trans-rectal exam (early diagnosis)