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Complications of cancer
 Complications of cancer 150 150 Tony Guo
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Complications of cancer

  • Patients with cancer may develop complications from
    • Continual growth of the cancer into normal tissue
    • Side effects of treatment

Nutritional problems

  • Malnutrition
  • Altered taste sensation (dysgeusia)
    • Physiologic basis of altered taste is unknown
  • Wasting syndrome (Cancer cachexia)
    • Upper gastrointestinal and pancreatic cancer patient are at great risk
  • Infections
    • Usual sites of infection include the lungs, GU system, mouth, rectum, peritoneal cavity, and blood (septicemia).
    • Infection occurs as a result of the ulceration and necrosis caused by the tumor, compression of vital organs by the tumor, and neutropenia caused by the disease process or the cancer treatment.
Immunotherapy : Cancer
 Immunotherapy : Cancer 150 150 Tony Guo
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Immunotherapy

  • Immunotherapy uses the immune system to fight cancer
  • Some types called biologic therapy
  • Boost or manipulate the immune system and create an environment not conducive for cancer cells to grow
  • Attack cancer cells directly

Target therapy

  • Interferes with cancer growth by targeting specific cell receptors and pathways that are important in tumor growth
    • Does less damage to normal cells
    • Agents that target specific oncogenes are being developed

Hormone therapy

  • Sex hormones
    • Can stop the growth of cancer cells
  • Corticosteroids
    • Used in combination with drug regimens to help curb side effects

Hematopoietic Stem Cell Transplantation (HSCT)

  • Bone marrow transplant (BMT)
  • Peripheral stem cell transplantation (PSCT)
  • Allows high doses for treatment
    • Failing to respond to standard doses of chemotherapy or radiation
    • Develop resistance (refractory)
  • Procedure with many risks, including death
  • Highly toxic
  • Overall cure rates are steadily increasing
  • Tumor cells are eradicated and bone marrow is rescued by infusing healthy cells

Gene Therapy

  • Experimental therapy
    • Genetic material is introduced into cells to fight disease
    • Investigational
Nursing Implications : Cancer
 Nursing Implications : Cancer 150 150 Tony Guo
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Nursing Implications

  • Bone marrow suppression
    • Myelosuppression: most common side effect of chemotherapy
    • Treatment-induced reductions in RBCs and WBCs can result in
      • Infection
      • Hemorrhage
      • Overwhelming fatigue
  • Fatigue
    • Encourage conservation strategies
      • Rest before activity
      • Get assistance with activity
      • Remain active during periods of time patients feel better
    • Maintain nutritional and hydration status
    • Assess for reversible causes of fatigue
  • Gastrointestinal (GI) effects
    • Prophylactic administration of antiemetics
    • Assess for signs and symptoms of
      • Alkalosis, dehydration, and I and O
    • Nonirritating, low-fiber, high-calorie, high-protein diet
    • Antidiarrheal, antimotility, and antispasmodic medications
    • Anorexia
      • Monitor carefully to avoid weight loss
        • Weigh twice weekly
      • Recommend small, frequent, high-protein, high-calorie meals
      • Involve dietitian before treatment begins
  • Skin reactions
    • Occur in radiation treatment field
    • Acute or chronic
      • Develop 1 to 24 hours after treatment
      • Generally progressive as treatment dose accumulates
    • Dry desquamation
      • Erythema is an acute response followed by dry desquamation.
      • Dry reactions are uncomfortable and result in pruritus. Lubricate the dry skin with a nonirritating lotion emollient (such as aloe vera) that contains no metal, alcohol, perfume, or additives that can be irritating to the skin.
    • Wet desquamation
      • If the rate of cell sloughing is faster than the ability of the new epidermal cells to replace dead cells, a wet desquamation occurs with exposure of the dermis and weeping of serous fluid.
      • Wet reaction must be kept clean and protected from further damage.
      • Wet desquamation of tissues generally produces pain, drainage, and increased risk of infection.
    • Prevent infection
    • Facilitate wound healing
    • Protect irritated skin temperature extremes
    • Avoid constricting garments, harsh chemicals, and deodorants
    • Help patients deal with hair loss (alopecia)
  • Reproductive effects
    • Inform patient of expected sexual side effects
    • Use appropriate shielding
    • Encourage discussion of issues related to reproduction and sexuality
    • Refer to counseling if needed
Infiltrative Emergencies : Cancer
 Infiltrative Emergencies : Cancer 150 150 Tony Guo
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Infiltrative Emergencies
Cardiac Tamponade
  • Fluid accumulation in pericardium.
  • Caused by constriction of pericardium by tumor or pericarditis secondary to radiation therapy to the chest
  • Heavy feeling over chest, shortness of breath, tachycardia, cough, dysphagia, hiccups, hoarseness.
  • Nausea, vomiting, excessive perspiration.
  • Decreased level of consciousness, distant or muted heart sounds.
  • Extreme anxiety.
  • Decrease fluid around heart using (1) surgery to create a pericardial window or an (2) indwelling pericardial catheter.
  • Administer O2 therapy, IV hydration, and vasopressor therapy
Carotid Artery Rupture
  • Invasion of arterial wall by tumor or erosion following surgery or radiation therapy.
  • Occurs most frequently in patients with head and neck cancer
  • Bleeding: ranges from minor oozing to spurting of blood in the case of a “blowout” of artery.
  • Administer IV fluids and blood products.
  • Surgery: ligation of carotid artery above and below rupture site and reduction of local tumor
Metabolic Emergencies : Cancer
 Metabolic Emergencies : Cancer 150 150 Tony Guo
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Metabolic Emergencies
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
  • Tumor cells can produce abnormal or sustained production of antidiuretic hormone (ADH).
  • Many chemotherapy agents may also contribute to ectopic ADH production or potentiate ADH effects
  • Water retention and hyponatremia (hypotonic hyponatremia).
  • Weight gain without edema, weakness, anorexia, nausea, vomiting, personality changes, seizures, oliguria, decrease in reflexes, and coma
  • Treat underlying malignancy.
  • Take measures to correct sodium-water imbalance, including fluid restriction, oral salt tablets or isotonic (0.9%) saline administration, and IV 3% sodium chloride solution (severe cases).
  • Furosemide (Lasix) used in initial phases.
  • Monitor sodium level because correcting SIADH rapidly may result in seizures or death.
Hypercalcemia
  • Occurs in metastatic disease of bone or multiple myeloma, or when a parathyroid hormone–like substance is secreted by cancer cells.
  • Immobility and dehydration can contribute to or exacerbate hypercalcemia.
  • Serum calcium in excess of 12 mg/dL (3 mmol/L) often produces symptoms.
  • Apathy, depression, fatigue, muscle weakness, ECG changes, polyuria and nocturia, anorexia, nausea, and vomiting.
  • High calcium elevations can be life threatening.
  • Chronic hypercalcemia can result in nephrocalcinosis and irreversible renal failure.
  • Treat primary disease.
  • Hydration (3 L/day) and bisphosphonate therapy.
  • Diuretics (particularly loop diuretics) used to prevent heart failure or edema.
  • Infusion of bisphosphonate zoledronate (Zometa) or pamidronate (Aredia)
Tumor Lysis Syndrome (TLS)
  • Metabolic complication characterized by rapid release of intracellular components in response to chemotherapy and radiation therapy (less commonly).
  • Massive cell destruction releases intracellular components (potassium, phosphate, DNA, RNA) that are metabolized to uric acid by liver.
  • Hallmark signs: hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia.
  • Weakness, muscle cramps, diarrhea, nausea, and vomiting.
  • Occurs within first 24 to 48 hr. after initiation of chemotherapy.
  • May persist for about 5 to 7 days.
  • Metabolic abnormalities and concentrated uric acid (which crystallizes in distal tubules of kidneys) can lead to acute kidney injury.
  • Identify patients at risk.
  • Increase urine production using hydration therapy.
  • Decrease uric acid concentrations using allopurinol.
  • Use IV sodium bicarbonate to counter effects of acidic properties that are released
Obstructive Emergencies : Cancer
 Obstructive Emergencies : Cancer 150 150 Tony Guo
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Obstructive Emergencies
Superior Vena Cava Syndrome (SVCS)
  • Results from obstruction of superior vena cava by tumor or thrombosis.
  • Common causes are lung cancer, non-Hodgkin’s lymphoma, and metastatic breast cancer.
  • Presence of central venous catheter and previous mediastinal radiation increase risk of development.
  • Facial edema, periorbital edema.
  • Distention of veins of head, neck, and chest
  • Headache, seizures.
  • Mediastinal mass on chest x-ray.
  • Considered a serious medical problem.
  • Radiation therapy to site of obstruction.
  • Chemotherapy for tumors more sensitive to this therapy.
Spinal Cord Compression
  • Neurologic emergency caused by cancer in epidural space of spinal cord.
  • Common causes are breast, lung, prostate, GI, and renal cancers and melanomas.
  • Lymphomas can also invade epidural space.
  • Intense, localized, and persistent back pain accompanied by vertebral tenderness.
  • Motor weakness, sensory paresthesia and loss.
  • Autonomic dysfunction (e.g., change in bowel or bladder function)
  • Radiation therapy and corticosteroids.
  • Surgical decompressive laminectomy.
  • Activity limitations and pain management.
Third Space Syndrome
  • Shifting of fluid from vascular space to interstitial space.
  • Occurs secondary to extensive surgical procedures, immunotherapy, or septic shock.
  • Signs of hypovolemia: hypotension, tachycardia, low central venous pressure, decreased urine output
  • Fluid, electrolyte, and plasma protein replacement.
  • During recovery hypervolemia can occur, resulting in hypertension, elevated central venous pressure, weight gain, and shortness of breath.
Intraoperative care
 Intraoperative care 150 150 Tony Guo
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Intraoperative care

  • Historically, took place in OR
  • Now majority are ambulatory surgeries
  • Increase minimally invasive surgery (MIS)
    • Endoscopes
    • Other advanced technology
  • Specialties with highest numbers of surgical patients
    • Ophthalmology
    • Gynecology
    • Plastic surgery
    • Otorhinolaryngology
    • Orthopedic surgery
    • General surgery (e.g., hernia repair)
  • Surgical suite
    • Controlled environment
    • Designed to minimize spread of pathogens
    • Allows smooth flow of patients, staff, and equipment
  • Physical environment
    • Unrestricted areas
      • People in street clothes interact with those in scrubs
        • Holding area
        • Locker room
        • Information areas
          • Nursing station
          • Control desk
Implementation : HIV
 Implementation : HIV 150 150 Tony Guo
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Implementation

  • Primary prevention and health promotion are the most effective strategies for diseases of a chronic nature including HIV
    • When prevention fails
      • Disease results
      • Early intervention is facilitated by health promotion practices
  • Health promotions
    • HIV infection is preventable
      • Avoid risky behaviors
      • Modify risky behaviors
      • Candid, culturally sensitive, language- appropriate, age-specific information and behavior change counseling
  • Prevention of HIV
    • Decreasing risks: Sexual intercourse
      • Abstinence
      • Noncontact safe sex
      • Use of barriers
    • Decreasing risks: Drug use
      • Do not use drugs
      • Do not share equipment
      • Do not have sexual intercourse under the influence of any impairing substance
      • Refer for help with substance use
    • Decreasing risks: Perinatal transmission
      • Family planning
      • Prevent HIV in women
      • Appropriately medicate HIV-infected pregnant women
    • Decreasing risk:  Work
      • Adhere to precautions and safety measures to avoid exposure
      • Report all exposures for timely treatment and counseling
      • Post-exposure prophylaxis with combination ART can significantly decrease risk of infection
Nursing Assessment : HIV
 Nursing Assessment : HIV 150 150 Tony Guo
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Nursing Assessment

  • Do not make assumptions about who may be at risk
  • Candid conversation is important for effective management of HIV
  • Ask at-risk patients
    • Received blood transfusion or clotting factors before 1985?
    • Shared needles with another person?
    • Had a sexual experience with your penis, vagina, rectum, or mouth in contact with these areas of another person?
    • Had a sexually transmitted infection?

Planning

  • Goals for care are aimed at
    • Compliance with drug regimens
    • Adopting a healthy lifestyle
    • Beneficial relationships
    • Spiritual well-being in regard to life and death
    • Coping with the disease and its treatment
Interprofessional Care : HIV
 Interprofessional Care : HIV 150 150 Tony Guo
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Interprofessional Care

  • Initial patient visit
    • Gather baseline data
    • Begin to establish rapport and use patient input to develop a plan of care
    • Initiate teaching about spectrum of HIV, treatment, preventing transmission, improving health, and family planning

Drug therapy

  • Main goals
    • Decrease viral load
    • Maintain/increase CD4+T counts
    • Prevent HIV-related symptoms and opportunistic diseases
    • Delay disease progression
    • Prevent HIV transmission
  • Opportunistic diseases complicate management of HIV infection
    • Prevention is key
    • Onset can be delayed with adequate measures
    • Effective management has significantly increased life expectancy
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