Cancer (Oncology)

Categories of Cancer

  1. Carcinoma - cancer arising from epithelial tissue; (Eg. Basal Cell Carcinoma)

  2. Sarcoma - cancer arising from connective tissue, muscle or bone. (Eg. Osteocarcinoma)

  3. Lymphoma - cancer arising from lymphoid tissue. (eg., burkitts lymphomas)

  4. Leukemia - cancer of the blood forming cells in the bone marrow. (eg. Acute Lymphocytic Leukemia)


Seven Warning Signs of Cancer - “CAUTION”

Change in bowel or bladder habits

Any sore that does not heal

Unusual bleeding or discharge (e.g., vaginal bleeding, more or less bleeding; unusual bleeding)

Thickening or lump in the breast or elsewhere

Indigestion

Obvious change in wart or mole (sores too)

Nagging cough or hoarseness


Common sites of Metastasis - Important

Breast Cancer - bone, lungs

Brain tumor - central nervous system

Prostate cancer - bone, spine, legs

Lung Cancer - brain

Colorectal cancer (colon) - liver


Factors that influence cancer development

  1. Environmental Factors

    b. Physical carcinogens - x-ray radiation

c. Viral carcinogen - viruses capable of causing cancer are known as oncoviruses. (E.g, Epstein Barr Virus, Hep B., HPV)

  1. Dietary Factors: High fat (leads to cancer; not good for cardiac patients) and low fiber diet (Too little fiber can cause colon cancer). High animal fat intake, preservatives, contaminants, nitrates and additives

  2. Genetics

  3. Age: Advanced age

  4. Immune system - If immune system is low then you have a risk for cancer


Prevention:

  1. avoid of potential carcinogen

  2. Minimize the intake of red meat and eat more cruciferous (flower-like) vegetable such as broccoli, cauliflower, brussels sprouts and cabbage

Eat food high in Vit. A (apricots, colors, green leafy vegetables) and Vit C. fresh fruits and vegetables, citrus fruits


Early Detections:

  • Mammography (breast cancer)

  • Stool test for occult blood, if there is bleeding - Blood in the stool or urine not visible to the naked eye.

  • Breast - self examination (Early sign detection)

  • Skin inspection - Looking for lesions in the skin

  • Papanicolaou (Pap Smear Test)

  • Sigmoidoscopy - examines only the lower part of the colon (the sigmoid colon and rectum) Lower risk of complications compared to colonoscopy; Colonoscopy (colon) - examines the entire colon. 

  • Testicular self examination (Early sign detection)


  • Breast - self examination: (Early sign detection)

    • Perform 7-10 days after menses

    • Post menopausal client - choose any specific day of the month and perform a BSE monthly on that day; First or last day of the month)

    • Best done while in the shower or bath

    • While standing, looking in the mirror with arms at sides. Raise arm over head, check for change in shape, dimpling of the skin and change in the nipple

    • While lying down - fold towel under shoulder do give proper positioning; Use opposite arm to check the breast

  • Risk Factors

    • History of 1st degree relatives (mother, sister)

    • Menarche, before age 12

    • Obesity

    • Hormonal replacement

    • Diet high in fat

    • Exposure of the chest

    • Birth of first child after age 30

    • Menopause after age 55

    • Use of birth control pills

    • Alcohol intake

    • High dose of radiation


Prevention:

Monthly BSE

Hormonal manipulation via the use of medication

Tamoxifen - Nolvadex - for estrogen receptor positive tumors


Post-op Instructions on page:

  1. Monitor vital signs

  1. Semi-fowlers position - affected arm elevated above the level of the heart to promote drainage and prevent lymph edema

  2. Jackson Pratt - record the amount of drainage

  3. Put pressure sleeves (put to prevent lymphedema)

  4. Assist with exercise to decrease lymphedema

Home Care after mastectomy:

  • Put lotion for incision care to soften a prevent wound (the wound gets very stiff and causes contracture)

  • Avoid affected arm to strong sunlight

  • Do not carry hand bag or anything heavy over the affected arm

  • Avoid heavy constricting clothing or jewelry on the affected side

  • Wear gloves when gardening (any cut can cause edema)

  • Apply hand cream seven times daily

  • Notify physician if sign of infection


Surgical breast procedures

  • Lumpectomy - Removing tumor excised (Lymph note; not going to remove the whole breast)

  • Simple mastectomy - Breast tissue and nipple are removed. Lymph nodes are left intact

  • Modified radical mastectomy - Breast tissue the nipple and lymph nodes are removed. Muscles are left intact. (removing everything)


Cervical cancer

Risk factors:

  • Early sexual activity before age 17 years

  • Early child bearing

  • Multiple partners

  • Human Papilloma Virus (HPV)

  • Human immunodeficiency Infection (HIV) (more likely to be transmitted through blood or sexual fluid; lower than 200 pt. may have aids, 500 pt. has HIV)

  • Use of DES by mother during pregnancy

  • Chronic cervical infections


    Gardasil Vaccine - Prevents of HPV screening via regular gynecological examinations and pap smears


Data Collection

  1. Painless vaginal bleeding post menstrually and post coitally

  2. watery blood tinged vaginal discharge that becomes black and Foul smelling discharge

  3. Pelvic lower back, leg or groin pain

  4. Dysuria - Difficulty/painful urinating

  5. Anorexia/weight loss

  6. Leakage of urine and feces from vagina

  7. Hematuria

  8. metastasis - wt loss, dysuria (painful urination), hematuria, bleeding, chest pain and cough


Intervention for cervical cancer -

Laser therapy - minimal bleeding is associated with the procedure; Healing occurs 6-12 wks, slight vaginal bleeding

Cryosurgery - Freezing of the tissue by a probe with subsequent necrosis; Destroying cancer cells with freezing. No anesthesia required. Monitor for Cramping; Heavy drainage; avoid use of tampons and avoid intercourse for a few weeks.

Exploratory Laparotomy - opening up abdominal cavity; performed to diagnose and stage of the tumor

Conization - Cone shaped area of cervix is removed; to preserve fertility (can be pregnant after the surgery)

Risk after surgery; Perforation (a hole or tear that develops in the wall of an organ; A perforation is essentially a full-thickness injury to the wall of a hollow organ, creating a hole) and hemmorhage

Hysterectomy - Removal of the uterus (womb); What do you teach after hytserectomy is cough and deep breathing exercise to prevent pneumonia; No lifting10-20 pounds, avoid climbing the stairs for 1 month, avoid tub bathing, avoid sexual intercourse

Antiembolic stocking to avoid thrombophlebitis

Ovarian Cancer -

  • Can be bilateral and grow very fast; metastizes in the pelvic/pelvis area, prognosis is poor (find out later and it is late; lack of symptoms in early)

  • Data Collection - Abdominal discomfort

  • S/Sx - GI problems, dyspepsia, digestion, flatus, distention

  • Vaginal bleeding

  • How to detect - Blood test CA125;

  • Prevention - Chemotherapy, salpingo-oophorectomy, hysterectomy

Endometrial cancer -

  • Slow growing tumor associated with menopausal years

  • Metastasis through lymphatic system to the ovaries and pelvis and via the blood it can spread to the lungs, liver, bones or intra-abdominally (abdominal cavity) to the peritoneal cavity

Risk factors

  1. use of estrogen replacement therapy

  2. Nulliparity

  3. Increased age

  4. Late menopause

  5. Obesity

  6. Hypertension

  7. Diabetes Mellitus

  8. Family history of uterine cancer or hereditary


Data collection -

  • Post menopausal bleeding

  • Watery serosanguineous discharge

  • Low back, pelvic, abdominal pain

  • Enlarged uterus inadvanced stages

  • Tumor marker CA 125 is used to rule out the ovarian involvements


Non-surgical intervention

  1. External/Internal radiation

  2. Chemotherapy

  3. Progestational therapy:

    (depo-provera & Megace)

    Estrogen dependent tumors:

    Tamoxifen - an antiestrogen


Testicular cancer

Risk factors:

  • Infection, genetic or endocrine factors and cryptochidism (undescended tests)

  • Most often occurs between the ages of 15-40 years

  • Metastasis to the lung, liver, bones, and adrenal glands


Prevention: Routine TSE (testicular self examination)


Data collection:

  • Painless testicular swelling

  • Dragging sensation in the scrotum as well as discomfort, such as heaviness in the lower abdomen

  • Late signs include back or bone pain and respiratory symptoms

  • Common tumor marker for testicular cancer are alpha-fetoprotein


Intervention:

  1. Chemotherapy (all cancers)

  2. Radiation therapy (All cancers)

  3. Unilateral orchiectomy (removal of the testicle)

  4. Radical retroperitoneal lymph node dissection

  5. Reproduction option - sperm storage donor insemination and adoption


Post op:

  1. monitor for hemorrhage, sign of bleeding and wound infection

  2. I & O

  3. Can resume normal activities, no lifting heavier object than 20 lbs and climbing stairs

  4. Remove sutures 7-10 days

  5. Diet high in calcium, protein, and vitamin


Laryngeal Cancer -

Risk factors:

  • Use of tobacco

  • Nutritional deficiencies - Riboflavin

  • Chronic laryngitis

  • Use of alcohol and exposure to carcinogens

  • Voice strains (singing or using loud voice, or talking a lot)

  • Metastasis to the lungs is common


Diagnosis:

Laryngoscopy and biopsy. Positive cytology (looking at tissue) for cancer cells.

  • Persistent hoarseness and sore throat

  • Dysphagia

  • Change in voice

  • Feeling of lump in the throat - painless neck mass

  • Foul breath odor

  • Weakness and weight loss

  • Change in voice


Interventions:
Affects breathing problem; put pt. in fowler’s position to promote air exchange

  • Diet high in calories, protein, high vitamin diet. Nutrition vial (TPN) Total parenteral nutrition, or GT, jtube. (pt. has difficulty swallowing.)


Surgical interventions:

Laryngectomy - partial or total

Tracheostomy is performed with total larygnectomy; Care is trach care, breathing care and also monitoring your patient.


Post operative intervention -

  • monitor vital signs

  • Monitor respiratory status and airway patency and provide frequent suctioning to remove blood drainage

  • Humidification, loosening up the secretion

  • Pulse oximetry

  • Edema

  • Bleeding in the neck

  • Speech and language therapy; the larnyx is where our voice is coming out and they won’t be able to talk and speech is important (providing stoma care,)

  • Reinforce method of communication that is established preoperatively, teach them before. Speech therapy.

  • Prepare the client for rehabilitation and speech therapy.


Stoma Care after laryngectomy

  • Teach the client suction technique

  • Teach client regarding cleaning the incision and provide stoma care

  • Wear stoma guard to shield the stoma

  • Avoid swimming, showering and using aerosol sprays

  • Wear loose fitting high collar clothing to hide the stoma

  • Increase humidity in the home

  • Range of motion, exercise for arm, shoulder and neck

  • Alternated rest period with activity

  • Increase fluid 3000ml/day

  • Medical alert bracelet


Lung cancer

Risk factors:

  • Smoking; second-hand smoke. Air pollution

  • Vit. A deficiency hereditary

  • Exposure to environmental and occupational pollutant (inhaling chemicals)


Data Collection:

  1. Cough

  2. Dyspnea

  3. Hemoptysis (spitting up/vomiting blood)

  4. Anorexia, wt. loss


interventions:

  1. Monitor vital signs

  2. Monitor breathing patterns/breath sounds/sign of respiratory impairement

  3. Fowlers position

  4. Analgesics for pain management

  5. Oxygen and humidification to moisten and loosen secretions

  6. Monitor pulse oximetry

  7. Bronchodilator

  8. Diet high in Cal, High vitamins, high protein

  9. Monitor bleeding, infection and electrolyte imbalance


Non-surgical treatment

  1. Radiation therapy

  2. Chemotherapy


Surgical treatment

  1. Laser therapy

  2. Thoracentesis - removes fluid in the pleural space and relieve hypoxia

  3. Thoracotomy with segmental resection - surgical removal of one lobe segment

  4. Thoracotomy with pneumonectomy - opening thoracic cavity and surgical removal of a lung

    -All thoracotomy pts. will have chest tubes; monitoring chest tube for thoracotomy

Post-operative care

  1. Monitor vital signs

  2. Monitor cardiac and respiratory status

  3. Chest tube drainage system which drain air or blood that accumulates in the pleural space (removal of air or blood around the lungs)

Purpose of chest tube:

Draining fluid/Draining air: (3 bottles)

  1. First tube attached to the pt. is drainage

  2. Second bottle is called water seal drainage > monitor for bubbling means that there is a leakage in the bottle so you need to notify; Fluctuation (water going up and down) is OK in water sealed bottle, normal.)

[No fluctuation > check tubes > before removal of tubes x-ray to show that pt. don’t need the tube > remove the tubes > allow the lungs to reexpand]

  1. Suction bottle : Has some bubbling but no fluctuation/ attached with the suction, no fluctuation but some air bubbling, normal.


If tubing gets pulled out, you don’t want air to go in so you cover the wound with vaseline gauze or occlusive dressing (don’t want any moisture or air from entering or exiting).


Pancreatic Cancer - Cancer in the pancreas (get insulin and pancreatic enzymes)

Risk factors:

  • High fat diet

  • Smoking

  • Diabetes mellitus


Chronic pancreatitis can lead to cancer - exposure to industrial chemical; symptoms do not occur until the tumor. is large therefore the prognosis is very poor.

Data collection:

  • Jaundice

  • Glucose intolerance

  • Clay colored stools

  • Monitor Unexplained wt loss

  • Nausea and vomiting

  • Abdominal pain

  • Endoscopic retrograde cholangiopancreatography (ERC) for visualization of the pancreatic duct and biliary systems

Intervention:

  1. Whipple procedure - surgery for pancreas, or duodenostomy. Type of surgery, connecting with another part of the GI system.

Post op care:

  • Monitor blood glucose - hypoglycemia and hyperglycemia

  • Pt. not making enough Pancreatic enzyme - Fat Sol ADEK

    • Best time to give pancreatic enzyme is before eating or any kind of snack or meal time.


Esophagus Cancer -

Risk factor:

  • Tobacco

  • Alcohol

  • Chronic irritation (irritated with food)


Liver cancer -

  • Liver cirrhosis can lead to cancer

  • smoking


Gastic Ulcer - stomach

Risk factors:

  • Diet high in smoked food

  • Lacking fruits and vegetables

  • Gastric ulcer, helicobacter pylori bacteria (h.pyloric) (ulcers are caused by bacteria)

  • Hereditary

  • pernicious anemia and chronic gastritis


Intestinal tumors

  • Color cancer or rectum cancer


Complication:

  • bowel perforation with peritonitis

  • Abscess and fistula formation

  • Hemorrhage and intestinal obstruction

Data collection - blood in the stool

Anemia

Surgical procedures (gastric cancer):

Billroth I gastroduodenostomy- it is

Gastro dudonestomy - cut the stomach and joing with part of the duodenum

Cancer of the prostate:

  1. Adenocarcinoma - slow growing cancer of the prostate gland

  2. Risk increases in men after age of 50 years

  3. Prostate can spread via the blood stream and lymphatic system to the bony pelvis and spin

  4. Bone metastasis (spreading) is a concern

Data collection:
Pt. is asymptomatic - in early stages

Hard pea-sized palpated on rectal examination

Hematuria - painless bleeding

Late symptoms - weight loss, uwinary obstruction. Pain radiating from lumbosacral area down the leg

Diagnosis: Prostate - specific antigen level is elevated (Prostate PSA), and rectal exam


NON-SURGICAL INTERVENTIONS:

  1. Leutenizing Hormone - Leuprolide Avetate (LUPRON)

    Estrogens - diethystilbestrol, flutamind (eulexin) to slow the rate of growth of the tumor

  2. Radiation therapy - external or brachytherapy


Drugs for prostate cancer to shrink and slow - proscar, hytrim

Cryo surgery

TURP (Trans urethral (Prostectomy enlarged prostate gland)

  • a) complication - bleeding (3 way catheter; one for urine to drain, one for irrigation, Continuous bladder irrigation (washing the bladder continuously), and to inflate the bulb); Do not call for doctor, check for irrigation order, if pt. starts bleeding immediately start irrigating.

    • Foley catheters have TWO ends not three.

  • b) CBI - continuous bladder irrigation, keep doing this irrigation until the water/urine returns to clear or pink color; If pt. has pink colored urine, it is normal and document it, but if urine is bright red need to notify doctor immediately.

  • c)bladder spasms are common after surgery

    • Antispasmodics may be prescribed


Probentin medication; for spasm

Bentyl

  • Dribbling or incontinence may occur post-operatively; tell pt. they may have spasms

  • Sterility may not occur

Continuous bladder irrigation; 3-way catheter bladder irrigation.

Remember irrigation and traction; Traction is applied to prevent bleeding by pulling the catheter and taping to the abdomen or thigh to keep the leg straight.

Catheter traction is only stopped at physician order, usually released when bright red is irrigated, use normal saline


Once you discontinue foley catheter you need to monitor patient for incontinency, pt. may not be able to pee. Monitor for retention or incontinency. Not used to peeing normally; burning and frequency can be normal

  • avoid lifting 2-6 weeks; avoid valsava maneuver (also done in constipation), driving, secual intervouse, and stressful exercises/

  • Avoid alcohol, caffeinated beverages, spicy food to prevent overstimulation of the bladder, instruct drink fluid 2400 to 3000 ml each day before 8 pm

Cover with abdominal pad, not with gauze because it is will be soaked much faster/ must be documented separately ; foley and suprapubic catheter.


Suprapubic prostectomy: Going through the abdomen above the umbilicus, above the pubic area and below the umbilicus area. Perineum, intrabdominal,


Function of the bladder is to store the urine. They will remove the bladder. then the ureter will be attached somewhere so they urine will go out the body.

Bladder Cancer - If there is bladder cancer, the urine has to come out because the bladder is not functioning.

Risk factor

  • Smoking, environmental carcinogens such as dyes, paints, rubber, ink and leather

  • There are two ureters, and they can also use KOCK POUCH (bag inside the abdominal cavity; use a catheter to remove it)

  • The urine comes out of the ilieum ; ILEAL CONDUIT

Metastasis - liver, bones and lungs

Surgical intervention:



Multiple Myeloma - (Tumors within the bone) [Bone cancer]


  1. Bence Jones Proteinuria and elevated total serum protein level - Blood and

  2. Monitor uric acid and calcium for pt. with bone cancer


Lymphoma - Hodgkins disease

Malignancy of the lymph nodes that originate in single lymph node or a single chain

Metastasis usually involve the lymph nodes, tonsils, spleen and bone marrow, It is characterized by the presence of Reed Sternberg cell in the nodes

Possible causes - viral infection or exposure to chemical agent



Stages of Hodgkins Disease


Management of Cancer

Chemotherapy:

  • Kills the reproduction of neoplastic cells also kills normal cells (kills both good and bad cancers)

  • Chemotherapy is medication, combined 7 medications.

  • Cell cycle phase specific means affecting the cells only during a certain phase of the reproductive cycle and cell cycle phase. Chemotherapy attacks the cells that are multiplying, cell division.

  • S/E - alopecia, nausea, vomiting, mucositis (mouth infection), immunosuppression, thrombocytopenia means that it is affecting the bone marrow . red blood cell, white blood cell, platelet

Radiation therapy - destroys cancer cells with minimal exposure of normal cells to the damaging effects of radiation. The cells that are damaged, die or become unable to divide. (destroying cancer cells and they are not able to divide.)


External Radiation

  • Monitor skin

  • Does not effect anyone, but the pt. skin only

Brachytherapy:

  • Radiation comes into direct continuous contact with tumor tissues for a specific time.

  • Emit radiation and can pose a hazard to others.

  • Includes sealed or unsealed methods of radiation


Unsealed radiation source -

Sealed Radiation -

After it is removed pt. is no longer radioactive,

Bone Marrow Transplantation -


phlebitis - vein infected

extravasation - fluid leaks out of vein