week 3: cancer care

1. describe the pathophysiology and clinical manifestations of cancer. 2. describe the role of the nurse in providing and coordinating person centred care for people with cancer. 3. demonstrate and explain the safe technique for cytotoxic precautions. 4. demonstrate and explain the safe technique for the nursing management of a patient with a peripherally inserted central catheter (PICC).

describe the normal structure of cells

cell membrane

a semi-permeable barrier that surrounds the cell and controls movement of substances in and out

cytoplasm

the fluid inside the cell where metabolic reactions occur

nucleus

the control centre of the cell that contains DNA and genetic information responsible for cell growth, metabolism and reproduction

organelles

• mitochondria: produces energy (ATP)

• ribosomes: protein synthesis

• endoplasmic reticulum: transport of proteins and lipids

• golgi apparatus: modifies and packages proteins

describe the normal function of cells

• metabolism (energy production)

• growth and development

• protein synthesis

• cell division (mitosis)

• maintaining homeostasis

normal cells also follow a regulated cell cycle including growth, DNA replication, division and programmed cell death (apoptosis)

 

what is the normal function of the immune system?

the immune system protects the body from infection, disease and abnormal cells

the main functions include:

• defence against pathogens such as bacteria, viruses and fungi

• recognition and destruction of abnormal or damaged cells

• prevention of infection spread

• development of immune memory for faster responses to future infections

components of the immune system include:

innate (non-specific) immunity: first line of defence and includes:

• skin and mucous membranes

• inflammatory response

• white blood cells such as neutrophils and macrophages

adaptive (specific) immunity: targeted immune response and includes:

• B lymphocytes: produces antibodies

•  t lymphocytes: destroy infected or abnormal cells

• memory cells: provide long-term immunity

what is the normal anatomy of the cardiovascular system?

heart

a muscular pump with four chambers:

• right atrium

• right ventricle

• left atrium

• left ventricle

the heard pumps blood through 2 circulations

• pulmonary circulation: heart -> lungs -> heart

• systemic circulation: heart -> body -> heart

blood vessels

• arteries: carry oxygenated blood away from the heart

• veins: return blood to the heart

• capillaries: allow exchange of oxygen, nutrients and waste between blood and tissues

what is the normal physiology of the cardiovascular system?

• transports oxygen. nutrients, hormones and medications

• removes carbon dioxide and metabolic waste

• maintains blood pressure and circulation

• helps regulate body temperature and fluid balance

what are the principles of person-centred care?

person-centred care focuses on respecting and responding to an individual patient's needs, values and preferences

• respect and dignity

• individualised care

• patient involvement in decision-making

• holistic care

• effective communication

what is the biopsychosocial model?

the biopsychosocial model is a holistic approach to healthcare that recognises that health and illness are influeced by biological, psychological and social factors

biological factors

• disease processes

• genetics

• physical health conditions

psychological factors

• emotions

• stress

• mental health

• coping ability

social factors

• family support

• culture

• financial situation

• environment and lifestyle

what is the aetiology of cancer?

cancer occurs when mutations (changes) in a cell's DNA disrupt normal cell regulation, causing cells to grow and divide uncontrollably.

over time, these abnormal cells can accumulate and form tumours.

cancer usually develops through the interaction of genetic factors and environmental exposures that damage DNA.

what are the main causes of the development of cancer?

genetic mutations

• cancer begins when mutations occur in genes that control cell growth, repair and death

• these mutations may be inherited or develop during a person's lifetime

chemical carcinogens

• exposure to harmful chemicals can damage DNA and trigger mutations

• examples include tobacco smoke, asbestos, alcohol and certain industrial chemicals

physical carcinogens

• radiation such as UV light and ionising radiation can damage cellular DNA and increase cancer risk

biological factors

• some infections contribute to cancer development, including viruses, bacteria and parasites

• examples include human papillomavirus (HPV) and hepatitis B virus

what are benign tumours?

a noncancerous growth that stays localized in its primary location. It does not invade surrounding tissues or spread to distant parts of the body (metastasize).

what are malignant tumours?

a cancerous mass of abnormal cells that grow uncontrollably. Unlike non-cancerous (benign) tumors, malignant tumors can aggressively invade surrounding tissues and spread (metastasize) to distant parts of the body through the bloodstream or lymphatic system. [1, 2, 3]

what are the most common cancers diagnosed in women in Australia?

• breast cancer

• melanoma (skin cancer)

• colorectal (bowel) cancer

• lung cancer

• uterine cancer

what are the most common cancers diagnosed in men in Australia?

• prostate cancer

• melanoma (skin cancer)

• colorectal (bowel) cancer

• lung cancer

• Non-Hodgkin lymphoma

how does cancer develop?

cancer develops when normal cells become abnormal and grow uncontrollably

the process occurs in several stages:

1. DNA damage or mutation occurs in a normal cell

2. these mutations affect genes that control cell growth and division

3. the abnormal cell begins to divide uncontrollably

4. a mass of abnormal cells forms a tumour

5. Ii malignant, cancer cells can invade surrounding tissues and spread to other parts of the body through the blood or lymphatic system (metastasis)

normally, the body regulates cell growth and destroys damaged cells, but in cancer, this regulation fails

what are the risk factors for developing cancer?

lifestyle factors

• smoking and tobacco use

• excessive alcohol consumption

• poor diet

• physical inactivity

• obesity

environmental factors

• UV radiation from the sun

• exposure to harmful chemicals

• radiation

biological factors

• increasing age

• genetic predisposition or family history

• certain infections or viruses

what are some generic symptoms of cancer?

• persistent headache

• blurred vision

• weakness in limbs

• dizziness

• abnormal sweating

• unexplained weight loss or loss of appetite

• lump or swelling

• nausea and vomiting

• fatigue

• skin changes

how is cancer diagnosed?

due to the variability of cancer, multiple steps are involved in the diagnosis process, including:

• patient history and physical examination

• initial tests such as blood tests, urine tests, medical imaging (x-rays, MRI, CT, PET scan)

• tissue cell biopsy (depending on the location, may be obtained via a needle, surgical incision or scope)

• microscope examination to determine specific type of cancer and any cell markers to guide treatment

what is cancer staging?

Refers to the process of determining how large a cancer is, and how far it has spread. How cancers are treated is largely dependant on the stage and grade of the disease.

• TNM system

• numbered staging system

what is the TNM system?

method that describes the extent of cancer using three components

• Tumour: the size of the primary tumour and whether it has grown to nearby tissue

• Nodes: indicates whether the cancer has spread to nearby lymph nodes

• Metastasis: shows whether the cancer has spread to distant parts of the body

what is the number staging system?

classifies cancer into stages 0-4 based on tumour size and spread

• Stage 0: abnormal cells are present but have not spread

• Stage 1: small, localised cancer that has not spread to lymph nodes or other tissues

• Stage 2: cancer is larger or beginning to spread locally

• Stage 3: cancer has spread further into surrounding tissues and lymph nodes

• Stage 4: cancer has spread to distant organs in the body

what is the purpose of cancer treatment?

• prophylactic: preventative treatment (mastectomy in someone with a known cancer gene)

• curative: the intent is to cure the person of cancer

• control: to control the cancer and stop it from growing or spreading any further

• palliative: to manage symptoms that are caused by the cancer at any stage of disease when it is not possible to cure the cancer

• end of life: the final stage of life (final stage of palliative care) where the goal is to reduce suffering and distress

cancer treatment will also vary in modality depending on the overall goal of treatment, including:

• definitive: a single, primary modality (surgery to remove a melanoma)

• concurrent: multiple treatments at the same time (patient receiving both chemotherapy and radiation)

• adjuvant: treatment given after the primary treatment to reduce or destroy any remaining cancer cells (chemo following surgical removal)

• neo-adjuvant: treatment given before the primary treatment to help reduce the size of the tumour (chemo prior to surgery)

• maintenance/lifelong: some treatments can be taken for a person's life in order to control the cancer (immune or targeted therapies)

what are some common cancer treatments?

• surgery

• chemotherapy

• radiation therapy

• immunotherapy

• targeted therapy

what is The Plan?

provides a national framework to improve cancer prevention, treatment, care and outcomes across Australia. The Plan is guided by several key principles that shape how cancer care should be delivered:

• person-centred care

• equity and access

• culturally safe care

• collaboration and partnership

• evidence-based practice

• improving outcomes across the cancer journey

care considerations for a person with cancer

focuses on recognising the patient as an individual with unique needs, preferences, values and experiences. Nursing care should address the physical, emotional, psychological, social and spiritual needs of the person throughout the cancer journey

key aspects include:

1. effective communication

2. involving the person in decision making

3. holistic assessment and care

4. symptom management and comfort

5. emotional and psychological support

6. supporting family and carers

7. coordinated multidisciplinary care

8. cultural safety and respect

psychosocial aspects to cancer care

• limited time and workload pressure: integrate psychosocial screening tools into routine assessments

• lack of training or confidence in addressing psychosocial needs: provide ongoing education and skill-building programs

• limited access to psychosocial support services: develop clear and accessible referral protocols

• patient reluctant to seek psychosocial support: provide patient education and normalise psychosocial support

• systemic and organisational issues: advocate for institutional policies

what are antineoplastic medications?

antineoplastic drugs, also known as anticancer drugs, are predominately used to treat malignant tumours.

a common type of antineoplastic drug is 'chemotherapy' which is used to kill or slow the growth of cancer cells.

they are also beneficial for the treatment of cancer, however, they are also considered hazardous as they can be:

• carcinogenic: cause other types of cancer

• teratogenic: cause birth defects or fetal malformation

• mutagenic: cause changes to DNA

• genotoxic: cause damage to the genetic material of the cell

antineoplastic medications are also classified as cytotoxic as they cannot differentiate between health and cancerous cells

what are cytotoxic materials?

• bodily fluids (urine, faeces, vomit) of a person who has recently received a cytotoxic medication

• materials that have come into contact with cytotoxic waste (soiled linen or clothing)

• items containing cytotoxic materials identified with a purple cytotoxic label (infusions)

• materials that have come into contact with either cytotoxic drugs or their metabolites (packaging or IV lines)

exposure to cytotoxic materials

exposure can occur via multiple modes including inhalation (breathing in the substance), absorption (direct skin contact), ingestion ( hand to mouth contact), injection (contaminated sharp/needle stick injury) or eye splash..

cytotoxic precautions PPE

• protective eyewear with slide shields

• a transparent full face chemical splash shield

• P2 (N95) particulate filter is recommended to contain aerosols generated by handling hazardous drugs

• gowns are designed for use with hazardous drugs and are made from impermeable material

• gowns must have an enclosed front, long sleeves and elastic cuffs

• gloves are essential in minimising permeability

• gloves must be long enough to cover wrist cuffs of the gown while arm is bent or stretched

• 2 pairs of gloves are often worn during any activity involving hazardous drugs

cytotoxic precautions donning and doffing

donning

• gown

• respiratory protection (mask)

• gloves

• eye protection

• hair cover

• shoe covers

doffing

• remove gloves

• remove gown

• remove eye protection

• remove mask

• remove hair cover and shoe covers

• perform hand hygiene

safe disposal of cytotoxic materials

• 2-3 days (up to 7 days) after the last dose of chemotherapy, tiny amounts of some cytotoxins are excreted in urine, faeces, or vomit.

• body fluids including urine, faeces, and vomit can be disposed of in the toilet. double flush with the lid down to avoid splashing.

• wear gloves when handling waste.

• soiled disposable nappies/incontinence pads should be placed in a plastic bag and disposed of in dedicated cytotoxic bins.

• other soiled items such as cloth nappies, linen and clothing should be placed in a plastic bag then placed in dedicated cytotoxic linen bag/skip.

• healthcare facilities often have separate cytotoxic linen. linen skips/bags will have a plastic liner/insert.

• hand hygiene especially hand washing.

safe cytotoxic spill management

• immediate response: alert others

• PPE prevents absorption of cytotoxic drugs through the skin

• contain the spill

• use a cytotoxic spill kit

• dispose all contaminated waste materials in designated cytotoxic waste containers

• decontaminate area, hand hygiene and report incident

patient education regarding cytotoxic precautions

• removal of soiled items

• body fluids spills

• washing clothing or bedding

• vomiting containment

• toileting containment

• sexual intimacy

• pregnant or breastfeeding

what is a PICC line?

a Peripherally Inserted Central Catheter (PICC) is a type of Central Venous Access Device. PICCS are often inserted in lieu of a Central Venous Catheter (CVC) when long term administration of medications (e.g. antibiotics, chemotherapy) is required, for administration of total parenteral nutrition (TPN) or when there's significant difficulty inserting an intravenous cannula. 

a PICC is inserted into the basilic vein, and threaded through to the junction of the superior vena cava to sit just above the right atrium.

when a PICC is accessed a 10mL or 20mL syringe must be used as any syringe smaller <10mls creates too much pressure within the PICC line.

what are the main indications for a PICC line?

a PICC is a long, thin, flexible catheter inserted into a peripheral vein (usually in the arm) and advanced into the superior vena cava.

• long-term intravenous therapy (antibiotics, chemotherapy)

• administration of vesicant or irritant drugs

• parenteral nutrition

• frequent blood sampling

• difficult venous access

describe the risks associated with a PICC and conducting a PICC dressing change

• infection (catheter-associated bloodstream infections)

• thrombosis (formation of a blood clot in the vein)

• mechanical complications (catheter occlusion, migration or breakage)

• phlebitis (inflammation of the vein caused by the catheter or infused medications)

• air embolism (can occur if the catheter is not properly capped or flushed)

risks during PICC dressing change

• infection risk (contaminated technique)

• catheter dislodgement (pulling or twisting can reduce effectiveness)

• skin trauma (adhesive removal can damage fragile skin)

• bleeding (especially if anticoagulated

what is the role of the nurse in the management of a patient with a PICC

• maintenance and monitoring (perform regular site inspections, monitor for signs of infection, ensure dressing remains clean and dry)

• dressing changes (use aseptic technique, replace transparent dressings, change gauze dressings)

• flushing and patency (flush with saline, use proper technique)

• patient education (teach patient to monitor for infection and educate to prevent dislodgement or contamination)

• collaboration (liaise with the medical team)