CARE OF PATIENT WITH CELLULAR PROLIFERATION

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CARE OF PATIENT WITH CELLULAR PROLIFERATION

• Professor Joan Glasheen
• Lecturer

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OVERVIEW

• Progress in prevention, treatment, survival
• - Early detection
• - Sophisticated diagnostic tests
• - Aggressive chemotherapy, radiation, surgery
• - Effective management of side effects
• - Bone marrow transplants
• - Genetic research
• - Biological response therapy

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Epidemiology

• Variables/Risk Factors
• - Sex
• - Site
• - Age
• - Race
• - Heredity/genetics
• - Obesity
• - Socio-economic status
• - Geographic's
• - Environmental exposure

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Health Promotion

• Primary Prevention control of risk factors
• Secondary Prevention early detection
• - CAUTION 7 WARNING SIGNS
• - ACS Guidelines
• Tertiary Prevention monitoring for
  complications, symptom management, support groups

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Guidelines for early detection of cancer

• GENERAL
• Cancer related Checkup
• 18-40 years - every 3 years
• 40 years older - every year
• Health Counseling
• Smoking cessation, avoiding sun
• Exam for cancer of thyroid, testes,
• prostate, ovaries, skin, and lymph
• nodes.

• BREAST
• 20 - 40 Years
• Breast exam by MD every 3 years
• Breast self-exam every month
• Baseline mammogram between
• ages of 35 and 39. Every yr. gt40
• UTERINE/CERVIX
• Sexually active people or 18 yr. gt
• Papanicolaou (Pap) smear yearly
• pelvic examination

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GUIDELINES FOR EARLY DETECTION OF CANCER

• PROSTATE
• 50 yr. gt Prostate Specific antigen lt4mg/ml
• Combined with rectal examination, nearly 90 of
  clinically significant cancers can be detected.
• TESTICULAR
• 15 - 45 yr. Testicular self- exam

• COLON RECTUM
• Ages 40 years and older
• Digital rectal exam every year
• Ages 50 years and older
• Digital rectal exam every year
• Stool for occult blood year
• Protoscopic exam or flexible
• sigmoidoscopy every 5 yrs

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Anatomy Physiology

• Cell cycle (Go, resting, G2, S, G2, mitosis)
• Normal Cell Characteristics
• - Appearance
• - Growth pattern
• - Differentiated functions
• - Non-migratory

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Characteristics of Early Embryonic Cells

• Rapid continuous cell division
• Large nucleus
• Perform no differentiated functions
• Adhere loosely together
• Able to migrate
• Not contact inhibited

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Commitment Phase of Early Embryonic Cells

• Turn off proto-oncogenes
• Expression of specfic genes

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Biology of Abnormal Cells

• Benign Neoplasm
• - Grow slowly
• - Show specific morphology
• - Small nucleus
• - Differentiated functions
• - Adhere tightly together
• - Grow orderly manner
• - Non-migratory

• Malignant Neoplasm
• - Grows rapidly
• - Anaplastic morphology
• - Large nucleus
• - Undifferentiated
• - Adhere loosely together
• - Grow by invasion
• - Able to migrate

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Carcinogenesis/Oncogenesis

• Steps of Malignant Formation
• - Initiation (pure carcinogens)
• - Latency Period
• - Promotion
• - Progression

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Metastasis

• Malignant transformation
• - Extension into surrounding tissue
• Tumor vascularization
• - Penetration into blood vessels
• Blood vessel penetration
• - Release of tumor cells into blood
• Arrest and invasion
• - Invasion of tissue at site of arrest

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Routes of Metastasis

• Local Seeding
• Bloodborne
• Lymphatic
• Secondary Tumors
• Breast Bone lung
• Prostate Bone (spine legs) Pelvic nodes
• Lung Cancer Brain, bone, liver, lymph nodes,
  pancreas
• Melanoma GI tract, lymph nodes, lung, brain
• Colorectal Liver, lymph nodes, adjacent
  structures

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Cancer Classification

• Neoplasm
• - Benign suffix - oma
• - Malignant root sarco- or carcino-
• Tissue of origin
• - Epithelial glands, ducts, mucous membrane
• - Connective tissue bone, muscle, fat
• - Hematopoietic blood vessels, bone marrow,
• lymph tissue
• - Pigmented pigmented producing skin
• - Neural Nerve Tissue
• Name of scientist describing tumor Hodgkins,
  Wilms

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Tumor Classification

• Grading Histological make-up (cellular aspects
  of tumor) Gx G4
• Staging exact location extent of spread _at_
  diagnosis
• Clinical
• Surgical
• Pathological
• TNM Classification Tx, To, T1,2,3,4 Nx, No,
  N123
• Mx, M0, M1

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Phases of Cancer

• Pre-diagnosis
• Initial Diagnosis
• Treatment Phase
• Readmission Phase
• Reoccurrence
• Terminal
• Survival

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Assessment

• History depends on phase of cancer
• - Focus on system of body
• - Height, weight, vital signs
• - Focus on effects of treatment
• - Review medications
• - Determine knowledge level
• Subjective Data
• Objective Data

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Collaborative Assessment

• Laboratory blood tests
• CBC
• Platelet count
• WBC with differential
• Blood chemistry (ca alkaline phosphatase
• Coagulation studies (PT,Ptt)
• Tumor markers (specific for types of cancer)

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Collaborative Assessment

• Cytology Studies
• Biopsy
• Body Imaging MRI, CT Scan
• Radiological Studies
• Ultrasound
• Endoscopies
• Immune Studies antigen skin testing

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Nursing Diagnoses

• Physiological
• Imbalanced nutrition
• Fatigue
• Altered comfort
• Altered oral mucosa
• Impaired skin integrity
• Disturbed sensory perceptions

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Nursing Diagnoses

• Psycho-social
• Altered coping, individual/family
• Knowledge deficit
• Decisional conflict
• Grieving
• Powerlessness
• Hopelessness
• Altered body image

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Surgical Interventions

• Purposes
• - Diagnosis
• - Cure
• - Control
• - Palliation
• - Reconstruction

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Surgical Interventions

• Biopsies Needle, incisional, excisional,staging
• Local Incision
• Wide Local Incision
• Wide Excision
• Extended Radical Excision

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Radiation Therapy

• Treatment of disease with ionizing radiation -
  damage to DNA leads to cell death
• Underlying Principles
• - Dose Determination
• - Fractionalization
• Purposes
• - Cure
• - Control
• - Palliation

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Radiation Therapy

• Tele distant therapy beam radiation (Cobolt
  60)
• Patient Preparation
• Side Effects Site Specific
• Skin Changes Local - skin changes - erythema,
  dryness, moist desquamation, hyperpigmentation
• Head and Neck - mucous membrane
• Breast - erythema, swelling, discomfort
• Head/Brain - alopecia, CNS edema, motor neuro
  deficits
• Pelvis long bones - diarrhea, bone marrow
  suppression
• Lung chest wall pneumonitis, esophagitis
• Radiation Syndrome effects not related to site

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Brachytherapy

• Use of high energy radioactive materials within
  body tissues
• Rationale A very limited dose, directly absorbed
  into malignant tissue for specific period of time
• Types
• - Sealed isotopes (Molds, Plaques, Needles)
• - Unsealed (orally or IV for dx. or Rx. Of
  hyperthyroidism i.e.. iodine 131)

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Brachytherapy Safety Principles

• Caution Radioactive Material sign
• Know type place of implant
• Time, Distance, Shielding
• Body fluids precautions
• Wear dosimeter badge
• Never touch radiation source with bare hands
  (Lead container forceps in room)

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Chemotherapy

• Goals
• - Cure
• - Control
• - Palliation

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Pathophysiological Principles of Chemotherapy

• Cell Kill Hypothesis Any dose of Chemo. Will
  destroy only a fraction of malignant cells
  (Overhead)
• Cell Cycle Specific
• Cell Cycle Non-specific
• Combination Therapy (Tumor sensitivity, side
  effects, variation in timing of drug induced
  immunosuppression)
• Hormones and Steroids

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Classification of Chemotherapeutic Agents

• Alkylating Agents - Interferes with DNA
  Replications
• Antimetabolites - Inhibits DNA Synthesis
• Nitrosoureas - Interfere with DNA replication and
  repair.
• Antitumor antibiotics - Interfere with nucleic
  acid synthesis and function, inhibits RNA
  synthesis and DNA synthesis
• Plant Alkaloids) arrest or inhibits mitosis
• Hormonal Therapy

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Dosage Calculation

• Remember the Five Rights medication, time,
  route, dose, patient
• Calculate body surface area (BSA)
• Recalculate drug and dosage against order
• Check current labs
• Review drugs and potential side effects
• Verify informed consent
• Pre-medicate if ordered

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Preparation

• OSHA Standards
• - Reconstitute under Class II laminar flow
  biological safety cabinet
• - Wear protective clothing, latex gloves, gown,
  mask, goggles
• - Change protective clothing when contaminated
• - Careful disposal of drug contaminated items

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Routes of Chemo Therapy Administration (overhead)

• Oral
• Intravenous
• Intra-arterial
• Isolated limb perfusion
• Intracavity
• Intra-peritoneal
• Intraventricular
• Intrathecal
• Intravesical
• Intraperitoneal
• Intraventricular
• intrapleural

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Side Effects of Chemotherapy

• Gastrointestinal
• - Nausea Vomiting
• - Mucositis/stomatitis
• - Diarrhea Constipation
• Fatigue
• Alopecia
• Infection

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Side Effects of Chemotherapy

• Bone Marrow Suppression
• - Anemia
• - Neutropenia
• - Granulocytopenia
• - Leukopenia
• - Thrombocytopenia

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NIC Nutrition/Nausea Vomiting

• Explore food preferences
• Avoid spicy foods
• Monitor weight
• Assess for Sx. Of dehydration
• Small frequent meals
• Administer antiemetics

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NIC Mucositis/Stomatitis

• Assess oral mucosa
• Oral hygiene before after meals
• Rinse mouth with ½ strength peroxide/saline
• Avoid alcohol or glycerine mouth washes
• Antimicrobal therapy
• Topical Anesthetics
• Soft diet, popsicles
• Artificial saliva

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NIC - Alopecia

• Reassure that hair loss temporary
• Use mild shampoos, avoid dyes permanents
• Cut hair short purchase hair piece before loss
• Ice caps, pressure caps

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NIC - Anemia

• Assess hemaglobin, hematocrit
• Encourage frequent rest periods
• Monitor packed red cell infusions
• Administer procrit if ordered

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NIC Risk for infection

• Monitor WBC Handout on neutrapenia (Absolute
  Neutraphil Count (ANC)
• Private room (CHIPS precautions) WBC gt 1,000 mm3
• Avoid crowds
• Strict handwashing
• Low bacteria diet
• Monitor IV sites, arm pits, genitalia, anal areas
• Report temperature 100? F (38o C)

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NIC - Thrombocytopenia

• Assess platelet counts lt50,000 risk for bleeding
  lt 20,000 very high risk for hemorrhage
• Assess for bleeding any orifice, petechiae,
  ecchymosis, hematomas
• Avoid intramuscular injections, venopunctures
• Avoid trauma to anal area

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Immunotherapy Biological Response Modifiers

• Agents that restore, augment, or modulate the
  hosts normal immune system
• Interleukins
• Interferons
• Agents that have direct antitumor effect
• Agents that block access to cancer cells