Foundations of Nursing Practice: Cancer

Objective

Upon completion of this topic, the student will integrate knowledge and assessment skills in planning care and implementing interventions for patients with cancer.

Student Preparation Prior to Class

Read the following texts:
- Lewis 12th ed., Chapter 16
- ATI RN Adult Medical Surgical Nursing 12: Chapters 90, 91, 92, and 94
- ATI Nutrition for Nursing 8.0, Chapter 17

Learning Activities

Complete ATI Basic Concept Template for Nursing Management: Chemotherapy and radiation therapy during class activity.
Review nursing care plans for cancer patients.

Content Objectives

1. Outline the stages of cancer development.

A. Development of Cancer

Initiation:
- Cellular changes occur spontaneously or through exposure to carcinogens, resulting in cell damage.
- Damaged cells may die or repair; if they do not, they replicate the same damaged cells.
- Common carcinogens include:
- UV light (sun exposure and tanning beds)
- Chemical exposure
- Viruses (e.g., HIV, HPV, etc.).
- Patients with HIV/HPV are at high risk for cancer development.
Promotion:
- Transformed or initiated cells are stimulated to divide, leading to reversible proliferation and mutation.
- Cancer Prevention strategies include avoiding smoking, obesity, and alcohol.
Progression:
- Characterized by increased growth rates of tumors, invasiveness, and metastasis.
- Common sites of metastasis include:
- Lungs
- Liver
- Bone
- Brain
- Adrenal glands
- Tumor cells compete for survival, leading to increased mutations and more aggressive cell behavior.

2. Discuss the TNM classification systems for cancer.

B. TNM Classification of Cancer

Tumor (T):
- Refers to the presence of a solid mass of cells, can be benign (non-cancerous) or malignant.
- Classified according to:
  - Anatomic site
  - Histologic grading
  - Extent of disease (staging).
Nodes (N):
- Describes the spread of cancer to nearby lymph nodes.
Metastasis (M):
- Indicates whether cancer has spread to other parts of the body, beginning with rapid growth of the primary tumor and developing its own blood supply (tumor angiogenesis).
- Tumor cells can detach and invade surrounding tissues.
- Most common sites of metastasis are lungs, bone, brain, liver, and adrenal glands.
- Reference: TABLE 16.3 for comparison of benign vs. malignant tumors (do not memorize).

3. Discuss the role of the nurse in the prevention and detection of cancer.

C. Prevention and Detection

ATI Chapter 91

Patient Education:
- Encourage annual physical exams and regular health checks.
- Knowledge of family history and risk factors is crucial.
- Recommend screenings and self-exams.
- Advocate reducing exposure to known carcinogens (e.g., cigarette smoke, excessive sun exposure).
- Promote a healthy diet, exercise, adequate rest, and stress reduction.
ACS Screening Recommendations:
- Review PG 683 in the textbook (do not memorize).
7 Warning Signs of Cancer:
- Change in bowel or bladder habits
- A sore that does not heal
- Unusual bleeding or discharge from any area of the body
- Thickening or lump in the breast or any location
- Indigestion or trouble swallowing
- Obvious change in a wart or mole
- Persistent cough or hoarseness.
Diagnostic Studies:
- Cytology studies (e.g., Pap smear test)
- Tissue biopsy
- Chest X-ray
- Complete blood count (CBC) and chemistry profile
- Liver function studies
- Endoscopic examinations (e.g., colonoscopy)
- Stool for occult blood (e.g., guaiac test)
- Radiographic studies (e.g., mammography, ultrasound, CT scan, MRI)
- Radioisotope scans (e.g., bone, lung, liver, brain)
- Positron Emission Tomography (PET) scan, detects disease tracers in tissues and organs
- Tumor markers (e.g., carcinoembryonic antigen - CEA), substances often produced by cancer cells
- Genetic markers.

4. Explore cancer treatment options: surgery, chemotherapy, radiation therapy, biologic, and targeted therapies.

D. Collaborative Care Goals

Cure, Control, Palliation.

Surgical Therapy:
- Tumors may be entirely removed, which could resolve the issue.
- Prophylactic removal of nonvital organs can reduce cancer incidence, particularly in patients with a family history of cancer (e.g. mastectomy).
- Only necessary tissue is removed to spare normal tissue.
- Debulking procedures may be necessary if the tumor is not fully removable.
- Often, surgery is followed by chemotherapy or radiation therapy.
Chemotherapy:
- Administered to destroy remaining cancer cells when the entire tumor cannot be removed.
- Known as antineoplastic therapy, it utilizes chemicals as systemic treatment for cancer.
- Primary treatment for most solid tumors and hematological cancers, aiming for cure, control, or palliative care.
- Administered by certified nurses trained to handle chemotherapy drugs, usually intravenously (IV) via central venous access devices or orally.
- Risks include occupational hazards (drug exposure through skin or inhalation).
- Drugs classified as irritants may damage veins, causing phlebitis and limiting future peripheral venous access.
- Vesicant drugs infiltrate the skin, leading to severe tissue breakdown and necrosis.
Radiation Therapy:
- Involves emission of energy aimed at destroying cells, using ionizing radiation.
- Typically given as multiple small doses over a set duration, either:
  - Internally: via implantation of radioactive materials into or near the tumor
  - Externally: (teletherapy) using radiation beams.
- Internal Radiation Treatment:
  - Patients may become radioactive; limit contact time and wear film badges to monitor exposure.
- External Radiation Treatment:
  - Patient is never radioactive; treatment fields are marked on the skin with tattoos during simulation and should remain intact.
Biologic and Targeted Therapies:
- Immunotherapy: Utilizes the immune system to combat cancer by boosting or manipulating its responses.
- Biologic Therapy: A type of immunotherapy; includes cytokines, vaccines, and monoclonal antibodies.
- Target Therapy: Focuses on specific cell receptors and pathways essential for tumor growth.
- Common side effects: flu-like symptoms, tachycardia, orthostatic hypotension, neurological issues, skin rashes.

5. Describe nursing management for patients receiving chemotherapy, radiation therapy, and biologic and targeted therapy.

E. Nursing Management: Planning and Interventions

Chemotherapy and Radiation:
- Common Side Effects:
  - Bone Marrow Suppression:
  - Myelosuppression is prevalent with chemotherapy; it may lead to reductions in RBCs and WBCs, causing:
    - Infection (leukopenia)
    - Hemorrhage (thrombocytopenia)
    - Severe fatigue (anemia).
  - Monitoring: Regular CBC monitoring, noting neutrophil, platelet, and RBC counts.
  - “Nadir” Definition: The lowest blood cell counts post-chemotherapy cycle.
  - Precautions: No fresh flowers, no fresh fruit, limit exposure to sick people, and maintain hand hygiene.
- Fatigue Management: Encourage rest before activities, maintain hydration, and nutritional status.
- GI Problems Management: Assess for nausea/vomiting (N/V), anorexia, and dehydration.
  - Offer prophylactic antiemetics; recommend low-fiber, high-calorie, high-protein diets.
- Mucositis:
  - Caused by breakdown of mouth mucosa from chemotherapy; risk for infection.
  - Facilitate wound healing, avoid extreme temperatures, and prevent skin irritation.
- Pulmonary Effects:
  - Possible progressive and irreversible effects including cough, dyspnea, and pneumonitis.
  - Treatments: Bronchodilators, expectorants/cough suppressants, bed rest, and oxygen.
- Cardiac Effects: Increased vulnerability in patients with coronary artery disease; baseline and periodic echocardiograms are often performed.
- Cognitive Effects: Known as "Chemo Brain," includes mental fog, lasting weeks to years.
  - Engage patients in cognitive-reinforcing activities, promoting rest and engagement.
Biologic and Targeted Therapies:
- Management principles similar to chemotherapy with specific considerations for immunotherapy and its effects.
Hematopoietic Growth Factors:
- Utilize to improve bone marrow function and combat the side effects of chemotherapy.

6. Identify complications associated with advanced cancer.

F. Complications

Nutritional Problems:
- Malnutrition: Leads to fat and muscle depletion; nutritional counseling is indicated, particularly with a 5% weight loss.
- Altered Taste Sensation (Dysgeusia): Unknown physiological basis; teach patients to avoid disliked foods and experiment with spices.
- Wasting Syndrome:
  - Consists of anorexia and unintended weight loss, tissue wasting, muscle atrophy, immune dysfunction, and metabolic abnormalities.
Infection:
- Common sites include the lungs, GI tract, mouth, rectum, and peritoneal cavity.
- Increased risk is due to ulceration, tumor compression of organs, and neutropenia.
- Teach patients to monitor temperature and report any reading above 100.4°F to their provider.

7. Discuss physical and psychological support interventions for cancer patients and caregivers.

G. Support Interventions

Pain Management:
- Pain is subjective; always validate patient reports.
- Undertreatment results in needless suffering, reduced quality of life, and increased burden on caregivers.
- Inadequate pain assessment is the biggest barrier to effective pain management; fear of addiction to opioids is often unwarranted.
- Employ non-pharmacologic interventions (e.g., relaxation therapy, imagery).
Psychological Support:
- Key aspects include assessment and support; anxiety and fear are common in patients.
- Address fears of dependency, loss of control, family stress, financial burden, and mortality.
- Support Strategies for Patients and Families:
  - Provide accurate cancer information.
  - Establish relationships based on trust and confidence.
  - Be honest and use touch to express care.
  - Assist in setting realistic short-term and long-term goals, helping to maintain normal lifestyles, and fostering an atmosphere of hope.