Week 15: Caring for a Patient With Cancer

Components of Blood (within CBC)

• Plasma: Liquid component of blood

• Blood Cells:

  • Erythrocytes (RBCs): Transport O2 and CO2

  • Value: 4.5 to 6 million cells per microliter for males and 4 to 5.5 million cells per microliter for females.

  • Leukocytes (WBCs): Immune response

  • Value: 5,000 to 10,000 cells per microliter for adults.

  • Granulocytes (Polys)

    • Function: Phagocytosis

    • Types: Neutrophils, basophils, eosinophils

  • Agranulocytes: Lymphocytes, monocytes

  • Platelets (thrombocytes): Crucial for clotting

    • Value: 150,000 to 450,000 platelets per microliter of blood.

Normal/Abnormal Lab Values

• Hemoglobin (HGB):

  • Female: [12.0 - 16.0 g/dL]

  • Male: [13.5 - 17.5 g/dL]

• Hematocrit (HCT):

  • Female: [37.0 - 47.0%]

  • Male: [42.0 - 52.0%]

• Anemia: Deficiency in RBCs or poor hemoglobin/hematocrit quality

• Pancytopenia: Suppression of entire CBC (WBCs, RBCs, and platelets)

WBC Normal Ranges

• WBC Count: 4000 - 10,500 cells/uL

• Elevated WBCs (Leukocytosis): More than 10,500 cells/uL, often indicative of infection, inflammation, or stress within the body.

• Decreased WBCs (Leukopenia): Less than 4000 cells/uL, which can suggest bone marrow suppression, autoimmune disorders, or the effects of certain medications.

Neurtopenia

• Neutrophils below 1500 cells/uL, characterized by an increased risk of infections due to the decreased ability to fight off pathogens.

Platelet Count

• 150,000 - 450,000 cells/uL

  • Elevated Platelets: Thrombocytosis

  • Decreased Platelets: Thrombopenia

Thrombocytopenia

• Definition: Disorder with an abnormally low number of platelets

• Causes: Inadequate production in the bone marrow

  • Examples: Aplastic anemia, leukemia, folate deficiency, Vitamin B12 deficiency, side effects of chemotherapy

• Increased breakdown in the bloodstream, spleen, or liver

  • Examples: DIC, drug-induced thrombocytopenia, Immune thrombocytopenic purpura (ITP)

• Assessment findings: Bleeding from the mouth, gums, nosebleeds, bruising, petechiae

• Treatment: Dependent on the underlying cause

Nursing Care for Thrombocytopenia

• Minimize injury risk:

  • Avoid razors, injections, and body piercings

  • Use a soft-bristle toothbrush

  • Prevent constipation and straining at stool

  • Prevent falls

• Infection prevention: Steroid use increases infection risk

• Assessment: Monitor for bleeding, mucous membranes, bruising, petechiae, and labs (platelets, H/H)

Care for Patient with Altered WBCs

• Elevated WBC (Leukocytosis):

  • Causes: Infection, leukemia, immune system disorders, stress

• Decreased WBC (Leukopenia):

  • Causes: Bone marrow disruption/damage, chemotherapy/immunosuppressive therapy, HIV/AIDS

• Neutropenia: Decreased neutrophils, the largest component of WBCs

  • Monitor temperature and signs/symptoms of infection.

  • Initiate WBC growth factors to stimulate bone marrow production and help prevent further complications associated with low white blood cell counts.

  • Treatment: Depends on cause, may involve withholding chemotherapy

Neutropenic Precautions

• Strict hand hygiene practices

• Avoid fresh flowers and fresh unpeeled fruits/vegetables

• Limit exposure to crowds and ill individuals

• Assess for signs of infection/inflammation

• Promote good nutrition: high protein, high-calorie, fluids

Facts of Cancer

• Cancer Facts: Cancer is a heterogeneous group of diseases characterized by uncontrolled cell growth, which does not follow physiological demand.

• Leading Causes of Death (2015 Data):

  • Heart Disease: 633,842

  • Cancer: 595,930

  • Others include chronic lower respiratory diseases, accidents, strokes, Alzheimer's disease, diabetes, influenza and pneumonia, nephritis, suicide, etc.

Benign vs Malignant Tumors

• Benign Tumors:

  • Grow locally, not invasive, not cancerous

• Malignant Tumors:

  • Invade neighboring tissues, enter blood vessels, and metastasize to distant sites

7 Warning Signs of Cancer (CAUTION)

• C: Change in bowel or bladder habits

• A: Sore that does not heal

• U: Unusual bleeding or discharge

• T: Thickening of breast tissue or lump

• I: Indigestion or difficulty swallowing

• O: Obvious changes to moles or warts

• N: Nagging cough (lasting four weeks or longer)

Risk Factors for Cancer

1. Heredity: 5-10% of cancers; some specific types (breast and colon)

2. Age: 70% of all cancers occur in individuals > 65

3. Tobacco Use: Linked to multiple cancers

4. Alcohol Use: Further exacerbates risks associated with smoking

5. Stress: General, greater wear and tear on the body

6. Diet: High in fried, high-fat, low-fiber foods; charred foods, high red meat content

7. Occupational Risks: Exposure to known carcinogens, radiation, high-stress environments, infection through specific organisms

8. Sun Exposure

Nursing Assessment for Cancer

• Subjective Findings: Patients may report fatigue, pain, changes in appetite, and emotional distress related to their diagnosis.

• Objective Findings: Skin examination may reveal erythema, dryness, or lesions, while vital signs may indicate changes in temperature or blood pressure, reflecting the patient's overall health status.

• Diagnostics:

  • Imaging: X-ray, CT Scan, Ultrasound, MRI, Nuclear Imaging

  • Tissue Typing: Biopsy, Cytology

  • Tumor Markers include:

    • PSA (Prostate-specific antigen): prostate cancer

    • CEA (Carcinoembryonic antigen): colon cancer

    • Alkaline Phosphatase: bone metastasis

Effects of Cancer

• Physiological Disturbances: Due to pressure or obstruction

• Hematologic Alterations: Various blood-related complications

• Anorexia-Cachexia Syndrome: Weight loss and muscle wasting

• Pain: A critical concern for patients and families

• Stress: Both physical and psychological impacts on the patient

Cancer Care

Treatment Options

• Surgery: Oldest form of cancer treatment, includes preventive, curative, or control measures

• Chemotherapy: Utilization of chemicals for systemic therapy; requires careful monitoring of dosages

• Radiation Therapy: Aimed at localized treatment; common for many cancer types; may be external or internal (brachytherapy)

• Targeted Therapy and Immunotherapy: More recent advancements in the treatment of cancer

• Palliative Care: Important for patients not responding to other treatment strategies

Goals of Cancer Treatment

• Cure: Full recovery from the disease

• Control: Manage symptoms and disease progression

• Palliation: Focus on relieving symptoms for patients not likely to respond to curative treatment

Key Factors Influencing Treatment Decisions

• Tumor location, size, extent of disease, cell type, and the patient's needs and desires

Staging and In Situ Cancer

• Carcinoma in situ: Early-stage cancer, localized with no tendency to invade or metastasize

• TNM Classification System: Assessing cancer extent based on:

  • T: Tumor size and invasiveness

  • N: Presence or absence of local lymph node metastases

  • M: Metastasis to distant organs

Cancer Stage Examples according to TNM

• T-stage:

  • Tis: Tumor limited to the mucous membrane

  • T1: Tumor limited to pancreas, diameter ≤ 2 cm

  • T2: Tumor limited to pancreas, diameter > 2 cm

  • T3: Tumor extends beyond the pancreas without arterial involvement

  • T4: Tumor invades crucial arteries

• N-stage:

  • Nx: Lymph nodes can't be assessed

  • N0: No local lymph node metastases

  • N1: Local lymph node metastases present

• M-stage:

  • MX: Metastasis can't be assessed

  • M0: No distant metastasis

  • M1: Distant metastasis present

Health Promotion for Cancer

• Routine check-ups and screenings: Essential for early detection and management of cancer

• Client Awareness: Importance of acting on symptoms that may indicate cancer

  • Screening examples include:

    • Breast Cancer: Self-breast exams, clinical exams, mammograms

    • Colon Cancer: Fecal occult blood tests, sigmoidoscopy, colonoscopy

    • Cervical Cancer: Pap tests

    • Prostate Cancer: Digital rectal exam, PSA tests

Surgical Therapy for Cancer

• Goals: Vary from elimination of risk to palliative care

• Debulking procedures: Indicated when complete removal is unfeasible

• Supportive/Palliative Care: Including placement of feeding tubes, central venous devices, etc.

Chemotherapy

• Systemic Therapy: Utilization of chemicals; considered a mainstay for solid and hematologic cancers

• Administration: Calculated by body surface area and involves combination drugs, done PO, IM, or IV through a central venous access device (CVAD).

  • Intracavitary: injection into the peritoneum, bladder.

  • Intrathecal: injection into the subarachnoid space; used for metastasis to the CNS.

  • Intra-arterial: delivers the drug through the arteries supplying the tumor.

Side Effects of Chemotherapy

• Fatigue, Hair Loss, Loss of Appetite.

  • Alopecia: A common effect characterized by temporary or permanent hair loss that can occur during treatment; it can grow back as soon as 3 weeks after chemo administration.

• Mouth Sores, Nausea, Vomiting.

• Diarrhea, Skin Changes.

  • Erythrodysethesia syndrome (hand-foot syndrome): a condition characterized by redness, swelling, and pain on the palms of the hands and soles of the feet; it can cause ulcers and blisters.

• Psychosocial issues: Patients may experience anxiety, depression, and social isolation due to their diagnosis and treatment, which can significantly affect their overall well-being and quality of life (commonly seen in women).

• Potentially Serious Side Effects:

  • Infection, Bleeding or Bruising, Low Blood Cell Counts

• Chemotherapy Agents: Non-discriminatory, affect normal cells, leading to adverse effects

Emergency Situation in Chemotherapy

• Extravasation Injury: Can occur with irritant or vesicant agents

  • IV administration can be irritating, which can cause damage to the intima of the vein, causing phlebitis.

  • Vesicants may cause tissue breakdown/necrosis, leading to possible loss of the affected extremity.

• Routine Monitoring: Of IV sites is essential; ports are often recommended (especially for vesicant therapies).

Radiation Therapy

• Definition: Often utilized as a nonsurgical treatment; significant for at least 50% of cancer patients

• Types: External (teletherapy) and Internal (brachytherapy)

  • Gamma knife technology: cobalt.

  • Cyclotron: neutrons or protons.

  • Linear accelerator: ionizing radiation.

  • Low-energy beams: utilize non-ionizing radiation for targeted treatment, minimizing damage to surrounding tissues.

  • High-beam energy: delivers a concentrated dose of radiation directly to the tumor, effectively destroying cancer cells while sparing healthy skin tissues.

• Total doses are divided into fractions, allowing for better recovery of healthy tissues between treatments and enhancing the overall effectiveness of the therapy.

  • Typically, once a day for 5 days a week for 2-8 weeks.

Side Effects of Radiation Therapy

• Local Effects: Within the treated field with precautions to minimize skin impact

• Simulation for Treatment: Mapping out radiation fields and protecting critical structures

  • Treatment fields are defined, filmed, and marked out on the skin to outline the field.

Nursing Management of Chemo/Radiation

• Monitoring Bone Marrow Suppression: Focus on blood counts and risks of infection

  • It can be life-threatening.

  • Tell patients to avoid contact with people who may be sick.

• Nutritional Support: Address common GI reactions, incl. nausea, vomiting, and anorexia

  • Prophylactic administration of antiemetics.

  • Recommend frequent dental visits, soft-bristle toothbrushes, and regular oral hygiene practices to minimize discomfort and prevent infections.

  • Encourage small, frequent meals of high-protein and high-calorie foods.

• Psychosocial Support: Address mental and emotional well-being through support systems

  • Fear of dependency, loss of control, family stress, or fear of death.

• Pain Management: Both pharmacological and non-pharmacological methods to manage pain.

Advanced Cancer Therapies

Immunotherapy and Targeted Therapy

• Definition: Attack cancer cells directly with less collateral damage to normal cells

• Considerations: Potential side effects such as flu-like symptoms

  • Administer acetaminophen before treatment and q4hr after treatment.

    • For severe chills/rigors: IV meperidine

Hormone Therapy & Hematopoietic Stem Cell Transplantation

• Hormone Therapy: Utilizes medications to block hormones promoting cancer growth

• Stem Cell Transplantation: Options include allogeneic, syngeneic, and autologous transplants

Patient Care Considerations

Risks of Infection and Malnutrition

• Education on Signs of Infection: Urging patients to report fever over 100.4°F

• Nutritional Needs: Emphasis on soft, high-protein, and easy-to-digest foods

Cachexia and Anorexia

• Cachexia: A Syndrome causing weight loss and appetite loss; treatment may involve medications to stimulate appetite (megestrol acetate/magace).

Common Patient Issues

• Impaired oral mucous membranes

• Impaired skin integrity

• Nausea management

• Fatigue and activity intolerance

• Risk for infection/bleeding

• Distorted body image from treatments

Terminal Care and End-of-Life Considerations