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  1. THE CLIENT WITH CANCER: Cancer is a multisystem stressor. Regardless of the specific type of cancer, certain aspects of the disease and of nursing care are the same. The following principles apply universally and should be referred to when studying individual kinds of cancer.
    1. Pathophysiology: result of altered cellular mechanisms. Several theories about causation, but current thinking is multiple causation. Alterations result in a progressive, uncontrolled multiplication of cells, with selective ability to invade and metastasize.
    2. Risk factors:
      1. Heredity (e.g., retinoblastoma).
      2. Familial susceptibility (e.g., breast).
      3. Acquired diseases (e.g., ulcerative colitis).
      4. Virus (e.g., Burkitt's lymphoma).
      5. Environmental factors:
        1. Tobacco.
        2. Alcohol.
        3. Radiation.
        4. Occupational hazards.
        5. Drugs (e.g., immunosuppressive, cytotoxic).
        6. Asbestos.
      6. Age.
      7. Air pollution.
      8. Diet (e.g., high animal protein).
      9. Chronic irritation.
      10. Precancerous lesions (e.g., gastric ulcers).
      11. Stress.
    3. Assessment:
      1. Specific symptoms depend on the anatomical and functional characteristics of the organ or structure involved.
      2. Mechanical effects:
        1. Pressure—tumors growing in confined areas such as bone produce pain early, whereas tumors growing in expandable areas such as the abdomen may be undetected for some time.
        2. Obstruction—tumors that compress tubular structures such as the esophagus, bronchi, or lymph channels may cause symptoms such as swallowing difficulties, shortness of breath, edema. Symptoms depend on location of tumor and on the particular organ or structure receiving pressure.
        3. Interruptions of blood supply—compression of blood vessels or diversion of blood supply may cause necrosis or ulceration or may precipitate hemorrhage.
      3. Systemic effects:
        1. Anorexia, weakness, weight loss.
        2. Metabolic disturbances—malabsorption syndrome.
        3. Fluid and electrolyte imbalances.
        4. Hormonal imbalances—increased antidiuretic hormone (ADH), adrenocorticotropic hormone (ACTH), thyrotropin (TSH), or parathyroid hormone (PTH).
        5. Diagnostic tests:
          1. Biopsy—excision of part of tumor mass.
          2. Needle biopsy—aspiration of cells from subcutaneous masses or organs such as liver.
          3. Exfoliative cytology—scraping of any endothelium (cervix, mucous membranes, skin) and applying to slide.
          4. X-rays—detect tumor growth in GI, respiratory, and renal systems.
          5. Endoscopy—visualization of body cavity through endoscope.
          6. Computed tomography (CT)—visualization of a body part whereby layers of tissue can be seen utilizing the very narrow beams of this type of x-ray equipment.
          7. Magnetic resonance imaging (MRI)—a scanning device using a magnetic field for visualization.
          8. Positron emission tomography (PET)—a scanning device in which radioactive glucose is injected prior to scanning. Areas of high glucose uptake, such as rapidly dividing cancer cells, are dramatically displayed in the scan imagery; useful in detecting early cancers.
        6. Laboratory data:
          1. Blood and urine tests—refer to Appendix A for normal values.
          2. Alkaline phosphatase—greatly increased in osteogenic carcinoma (>92 units/L).
          3. Calcium—elevated in multiple myeloma bone metastases (>10.5 mg/dL).
          4. Sodium—decreased in bronchogenic carcinoma (<135 mEq/L).
          5. Potassium—decreased in extensive liver carcinoma (<3.5 mEq/L).
          6. Serum gastrin—measures gastric secretions. Decreased in gastric carcinoma. Normal value 0 to 180 ng/L.
          7. Neutrophilic leukocytosis—tumors.
          8. Eosinophilic leukocytosis—brain tumors, Hodgkin's disease.
          9. Lymphocytosis—chronic lymphocytic anemia.
    4. Analysis/nursing diagnosis:
      1. Pain related to diagnostic procedures, pressure, obstruction, interruption of blood supply, or potential side effects of drugs.
      2. Anxietyrelated to fear of diagnosis or disease progression, treatment, and its known or expected side effects.
      3. Altered nutrition, less than body requirements, related to anorexia.
      4. Risk for injury related to radioactive contamination of excreta.
      5. Body image disturbance related to loss of body parts, change in appearance as a result of therapy.
      6. Powerlessness related to diagnosis and own perception of its meaning.
      7. Self-esteem disturbance related to impact of cancer diagnosis.
      8. Risk for infection related to immunosuppression from radiation and chemotherapy.
      9. Altered urinary elimination related to dehydration.
      10. Risk for injury related to normal tissue damage from radiation source.
      11. Fluid volume deficit related to nausea and vomiting.
      12. Diarrhearelated to radiation of bowel.
      13. Constipation related to dehydration.
    5. Nursing care plan/implementation—general care of the client with cancer:
      1. Goal: promote psychosocial comfort (see also Chapter 10. Psychosocial Integrity).
        1. Assist with diagnostic work-up by providing psychological support and information about specific disease, diagnostic tests, diagnosis, and treatment options.
        2. Reduce anxiety by listening, making referrals for special problems (peer support groups, self-help groups such as Reach to Recovery), supplying information, or correcting misinformation, as appropriate.
        3. Stress-management techniques (see Orientation, Chapter 1. Orientation and Pre-Tests, The Psychology of Test-Taking).
        4. Nursing management related to client who is depressed (see Chapter 10. Psychosocial Integrity).
      2. Goal: minimize effects of complications.
        1. Anorexia/anemia:
          1. Decrease anemia by:
            1. foodImageProviding well-balanced, iron-rich, small, frequent meals.
            2. pillImageAdministering supplemental vitamins and iron as ordered.
            3. pillImageAdministering packed red blood cells as ordered.
            4. Maintaining hyperalimentation as ordered.
            5. Monitoring red blood cell count.
          2. foodImageEnhance nutrition by providing nutritional supplements and a diet high in protein; necessary because of increased metabolism related to metastatic process. Consult with dietitian for suggestions of best food for individual client.
        2. Hemorrhage: monitor platelet count and maintain platelet infusions as ordered. Teach client to monitor for any signs of bleeding.
        3. pillImageInfection: observe for signs of sepsis (changes in vital signs, temperature of skin, mentation, urinary output or pain); monitor laboratory values (WBCs); administer antibiotics as ordered.
        4. Pain and discomfort: alleviate by frequent position changes, diversions, conversations, guided imagery, relaxation, back rubs, and narcotics as ordered.
        5. Assist in adjusting to altered body image by encouraging expression of fears and concerns. Do not ignore client's questions, and give honest answers; be available.
        6. Fatigue. Encourage periods of rest and a decrease in daily exertion.
      3. Goal: general health teaching.
        1. Self-care skills to maintain independence (e.g., client who has a colostomy should know how to manage the colostomy before going home).
        2. Importance of follow-up care and routine physical examinations to monitor for general health and possible signs of further disease.
        3. Dietary instructions, adjustments necessary to maintain nutrition during and after treatment.
        4. foodImageHealth maintenance programs: teach hazards of the use of tobacco and alcohol. Avoid high-fat, low-roughage diet.
        5. Risk factors: family history, stress, age, diet, occupation, environment.
        6. Access to information: clients should have telephone numbers for facility where questions can be answered and symptoms reported 24 hours a day.
    6. General surgical intervention: surgery may be diagnostic, curative (when the lesion is localized or with minimal metastases to the lymph nodes), palliative (to decrease symptomatology), or reconstructive. (See also THE PERIOPERATIVE EXPERIENCE, The Perioperative Experience, and specific types of cancer, following.)
      1. Nursing care plan/implementation—preoperative:
        1. Goal: prevent respiratory complications.
          1. Coughing and deep-breathing techniques.
          2. No smoking for 1 week before surgery.
        2. Goal: counteract nutritional deficiencies.
          1.   foodImageDiet:
            1. High protein, high carbohydrate for tissue repair.
            2. pillImageVitamin and mineral supplements.
            3. Hyperalimentation as ordered.
          2. pillImageBlood transfusions may be needed if counts are low.
        3. Goal: reduce apprehension.
          1. Clarify postoperative expectations.
          2. Explain care of ostomies or tubes.
          3. Answer client's questions honestly.
      2. Postoperative:
        1. Goal: prevent complications.
          1. Monitor respiratory status and hemodynamic status.
          2. Wound care; active and passive exercises as allowed; respiratory hygiene; coughing, deep breathing, and turning; fluids (see III. POSTOPERATIVE EXPERIENCE, The Perioperative Experience).
        2. Goal: alleviate pain and discomfort.
          1. Encourage early ambulation, depending on surgical procedure.
          2. Administer prescribed medications as needed.
          3. pillImageAdminister stool softeners and enemas as ordered.
        3. Goal: health teaching.
          1. Involve client, significant others, and family members in rehabilitation program.
          2. Prepare for further therapies, such as radiation or chemotherapy.
          3. Referral: support groups, as appropriate: Reach to Recovery, Ostomy Associates, Laryngectomy Association.
          4. Develop skills to deal with disease progression if cure not realistic or metastasis evident.
    7. pillImageChemotherapy: used as single treatment or in combination with surgery and radiation, for early or advanced diseases. Used to cure, increase survival time, or decrease specific life-threatening complications. Antineoplastic agents' primary mode of action involves interfering with the supply and utilization of building blocks of nucleic acids, as well as interfering with intact molecules of DNA or RNA, which are needed for replication and cell growth. Bone marrow, hair follicles, and the gastrointestinal tract are three areas of the body in which cells are actively dividing; this is why most side effects are related to these areas of the body. Most often antineoplastic agents are used in combination.
      1. pillImageTypes: alkylating agents, antimetabolites, antitumor antibiotics, antimiotic agents, plant alkaloids, enzymes, hormones, and biotherapy (e.g., bacille Calmette-Guérin [BCG], interferon) (see Chapter 8. Physiological Integrity, Table 8.11. Antineoplastic Drug Classifications, Physiological Integrity).
      2. Major problem: lacks specificity, thus affecting normal as well as malignant cells.
      3. Major side effects: bone marrow depression, stomatitis, nausea and vomiting, gastrointestinal ulcerations, diarrhea, and alopecia (see Chapter 8. Physiological Integrity, Table 8.12. Common Side Effects of Chemotherapeutic Agents, Physiological Integrity).
      4. Routes of administration: oral, intramuscular, intravenous (Hickman or Groshong catheter), subclavian lines, portacaths, peripheral, intraarterial (may have infusion pump for continuous or intermittent flow rate), intracavitary (e.g., bladder through cystoscopy). (See 6. Nursing precautions with chemotherapy following for information about administration of IV chemotherapeutic agents.)
      5. Nursing care plan/implementation:
        1. Goal: assist with treatment of specific side effects.
          1. pillImage  foodImageNausea and vomiting—antiemetic drugs (e.g., prochloroperazine, ondansetron [Zofran]) as ordered and scheduled; small, frequent, high-calorie, high-potassium, high-protein meals; chopped or blended foods for ease in swallowing; include milk and milk products when tolerated for increased calcium; carbonated drinks; frequent mouth care; antacid therapy as ordered; rest after meals; avoid food odors during preparation of meals; pleasant environment during meals; appropriate distractions; IV therapy; nasogastric tube for control of severe nausea or as route for tube feeding if unable to take food by mouth; hyperalimentation.
          2. foodImagepillImageDiarrhea—low-residue diet; increased potassium; increased fluids; atropine SO4–diphenoxylate HCl (Lomotil) or kaolin-pectin (Kaopectate) as ordered; avoid hot or cold foods/liquids.
          3. pillImage  foodImageStomatitis (painful mouth)—soft toothbrushes or sponges (toothettes); mouth care q2–q4; viscous lidocaine HCl (Xylocaine) as ordered before meals. Oral salt-and-soda mouth rinses; avoid commercial mouthwashes that contain high level of alcohol, which could be very irritating to mucous membranes. Avoid hot foods/liquids; include bland foods at cool temperatures; remove dentures if sores are under dentures; moisten lips with lubricant.
          4. Skin care—monitor: wounds that do not heal, infections (client receives frequent sticks for blood tests and therapy); avoid sunlight; use sunblock, especially if receiving doxorubicin (Adriamycin).
          5. Alopecia—be gentle when combing or lightly brushing hair; use wigs, nightcaps, scarves; provide frequent linen changes. Advise client to have hair cut short before treatment with drugs known to cause alopecia (bleomycin, cyclosphosphamide, dactinomycin, daunorubicin hydrochloride, doxorubicin hydrochloride, 5-fluorouracil, ICRF-159, hydroxyurea, methotrexate, mitomycin, VP 16–213, vincristine). Other techniques may be used, depending on client's age and protocol in clinical agency.
          6. Extravasation—infiltration of chemotherapeutic agents into surrounding tissues. Document and treat according to agency protocols for administered drug.
        2. Goal: health teaching.
          1. Orient client and family to purpose of proposed drug regimen and anticipated side effects.
          2. Advise that frequent checks on hematological status will be necessary (client will receive frequent IV sticks, laboratory tests).
          3. Advise client/family on increased risk for infection (avoid uncontrolled crowds and individuals with upper respiratory tract infections or childhood diseases).
          4. Monitor injection site for signs of extravasation (infiltration); site must be changed if leakage suspected, and guidelines to neutralize must be followed according to drug protocol.
      6. Nursing precautions with chemotherapy:
        1. Nurse should wear gloves and mask when preparing chemotherapy drugs for administration. Mixing of drug into IV bag done under laminar flow hood.
        2. Drugs are toxic substances, and nurses must take every precaution to handle them with care.
        3. When expelling air bubbles from syringes, care must be taken that the drugs are not sprayed into the atmosphere.
        4. Contaminated needles and syringes should be disposed of intact (to prevent aerosol generation) in plastic-lined box according to environmental standards. Disposable equipment should be used whenever possible.
        5. If skin becomes contaminated with a drug, wash under running water.
        6. Nurses should know the half-life and excretion route of the drugs being administered and take the special precautions necessary. For example, while the drug is actively being excreted, use gloves when touching client, stool, urine, dressings, vomitus, etc.
        7. If the nurse is in the early phase of pregnancy, she should seek specific information about risks to her unborn child before caring for the client receiving chemotherapeutic agents.
    8. Radiation therapy: used in high doses to kill cancer cells, or palliatively for pain relief. Side effects of radiation therapy depend on site of therapy (side effects are also variable in each individual): nausea, vomiting, stomatitis, esophagitis (Candida), dry mouth, diarrhea, depression of bone marrow, suppression of immune response, decreased life span, and sterility.
      1. External radiation: cobalt or linear accelerator machine.
        1. Procedure: daily treatments, Monday through Friday, for prescribed number of times according to size and location of tumor (length of treatment schedule is usually 4 to 6 weeks). Client remains alone in room during treatment. (Nurse, therapist, family members cannot stay in room with client due to radiation exposure during treatment.) Client instructed to lie still so exactly same area is irradiated each treatment. Marks (tattoos or via permanent-ink markers) are made on skin to delineate area of treatment; marks must not be removed during entire treatment course.
        2. Nursing care plan/implementation:
          1. Goal: prevent tissue breakdown.
            1. Do not wash off site identification marks (tattoos cannot be removed); dosage area is carefully calculated and must be exact for each treatment.
            2. Assess skin daily and teach client to do same (most radiation therapy is done on outpatient basis, so client needs skills to manage independently).
            3. Keep skin dry; cornstarch usually the only topical application allowed; 100% aloe (no alcohol) for redness.
            4. Contraindications:
              1. Talcum powders, due to potential radiation dosage alteration.
              2. Lotions, due to increased moistening of skin.
              3. Products containing alcohol, due to increased dryness.
            5. Reduce skin friction by avoiding constricting bedclothes or clothing, and by using electric shaver.
            6. Dress areas of skin breakdown with nonadherent dressing and paper tape.
          2. Goal: decrease side effects of therapy.
            1. pillImageProvide meticulous oral hygiene.
            2. If diarrhea occurs, may need IV infusions, antidiarrheal medications; monitor bowel movements (possible adhesions from surgery and radiation treatments).
            3. Monitor vital signs, particularly respiratory function, and BP (sloughing of tissue puts client at risk for hemorrhage ).
            4. Monitor hematological status—bone marrow depression can cause fatal toxicosis and sepsis.
            5. Institute reverse isolation as necessary to prevent infections (reverse isolation usually instituted if less than 50% neutrophils).
          3. Goal: health teaching.
            1. Instruct client to avoid:
              1. Strong sunlight; must wear sunblock lotion, protective clothing over radiation site.
              2. Extremes in temperature to the area (hot-water bottles, ice caps, spas).
              3. Synthetic, nonporous clothes or tight constrictive clothing over area.
              4. foodImageEating 2 to 3 hours before treatment and 2 hours after, to decrease nausea; give small, frequent meals high in protein and carbohydrates and low in residue.
              5. Strong alcohol-based mouthwash; use daily salt-and-soda mouthwash.
              6. Fatigue, an overwhelming problem. Need to pace themselves, nap; may need someone to drive them to therapy; can continue with usual activities as tolerated.
              7. Crowds and persons with upper respiratory infections or any other infections.
            2. Provide appropriate birth control information for clients of childbearing age.
      2. Internal radiation: sealed (radium, iridium, cesium):
        1. Used for localized masses (e.g., mouth, cervix, breast, testes). Due to exposure from radiation source, precautions must be taken while it is in place. Health-care personnel and family must adhere to principles of time, distance, and shielding to decrease exposure ( shortest amount of time possible, stay as far away as possible from the source of radiation, and wear protective lead apron, gloves). If source of radiation accidentally falls out, it should be picked up only with forceps. Radiation officer should be notified immediately.Client should be in private room, and bed should be in the center of the room, if possible, to protect others. Unless the walls are lead lined, radiation will penetrate them; placing the bed in center of room will decrease exposure. Once the source of radiation has been removed, there is no exposure from client, excretions, or linens.
        2. Nursing care plan/implementation:
          1. Goal: assist with cervical radium implantation (cervical radium is used here as the most common example of internal radiation source).
            1. Before insertion—give douche, enema, perineal prep; insert Foley catheter, as ordered.
            2. After implantation—check position of applicator q24h.
              1. infoImageKeep client on bedrest in flat position to avoid displacing applicator (may turn to side for eating).
              2. Notify physician if temperature elevates, nausea and/or vomiting occur (indicates radiation reaction or infection ).
              3. After removal of implant (48 to 144 hours)—bathe, douche, and remove catheter as ordered.
          2. Goal: health teaching.
            1. Explain that nursing care will be limited to essential activities in postinsertion period.
            2. Signs and symptoms of complications so client can notify staff if something unusual happens (bleeding, radiation source falls out, fever, etc.).
        3. Nursing precautions for sealed internal radiation:
          1. Never handle radium directly—if applicators should accidentally be removed, pick up applicator by strings with long-handled forceps and notify radiation officer.
          2. Linen must remain in client's room and not be sent to laundry until source of radiation has been accounted for and returned to its container.
          3. Time, distance, and shielding are factors that increase or decrease potential effects on personnel. Need to minimize exposure of nursing staff, client's family, and other health professionals. Nurses who may be pregnant should not care for clients with internal radiation because of possible damage to the fetus from radiation exposure. Children under 16 should not be allowed to visit while internal radiation is in use.
      3. Internal radiation: unsealed (radioisotope/radionuclide):
        1. Source of radiation is given orally or intravenously or instilled into a cavity as a liquid.
        2. Nursing care plan/implementation: Goal: reduce radiation exposure of others.
          1. Isolate client and tag room with radioactivity symbol.
          2. Rotate personnel to avoid overexposure (principles of time, distance, and shielding). Staff should use good hand-washing technique. Client should be in a room with running water. (Nurse who may be pregnant should not care for client while radiation source still active.)
          3. Encourage family to maintain telephone contact or use intercom, to decrease exposure to others.
          4. Plan independent diversional activities.
        3. Specific nursing precautions (post in chart, on client's door):
          1. Radioactive iodine (131I): half-life 8.1 days; excreted in urine, saliva, perspiration, vomitus, feces.
            1. Wear gloves and isolation gowns when handling client, excreta, or dressings directly.
            2. Collect paper plates, eating utensils, dressings, and linen in impermeable bags; label and dispose according to agency protocol.
            3. Collect excreta in shielded container and send to laboratory daily to monitor excretion rate and disposal.
          2. Radioactive phosphorus (32P): half-life 14 days; injected into cavity or given IV or orally.
            1. infoImageIf injected into cavity, turn client q10–15 min for 2 hours to ensure distribution.
            2. No radiation hazard unless leakage from instillation site or from client's excreta, which are collected in lead-lined containers and brought to the radioisotope laboratory for disposal. Linen is collected in container, marked radioactive, and brought to the radioisotope laboratory for special handling.
            3. Seepage will stain linens blue; wear gloves when handling contaminated linens, dressings. Excreta disposed of as in (b).
          3. Radioactive gold (198Au): half-life 2.7 days; usually injected into pleural or abdominal cavity.
            1. May seep from instillation site or drainage tubes in cavity; stains purple.
            2. infoImageTurn client q15 min for 2 hours, as in (2)(a).
            3. Same precautions regarding handling excreta as in (1)(a) and (2)(b).
      4. Precautions for nurses:
        1. Use principles of time, distance, and shielding when caring for clients who are having active radiation therapy treatments.
        2. Nurses who may be pregnant should not accept an assignment caring for clients who have active radiation in place.
        3. Always use gloves, gowns to protect skin and clothing.
        4. Wear detection badge to determine exposure to energy source.
    9. pillImageImmunotherapy: it has been hypothesized that clinical malignancy may occur as a result of failure of the immunological surveillance system of the body to fight off cancer cells as they develop. The goal of immunotherapy is to immunize clients against their own tumors.
      1. Nonspecific immunotherapy—encourages a host immune response by use of an unrelated agent. Bacille Calmette-Guérin (BCG) vaccine and Corynebacterium parvum are the two agents used for this type of immunotherapy.
      2. Specific immunotherapy—uses substances that are antigenically related to the tumor that stimulate a specific host immune response.
      3. Side effects—malaise, chills, nausea, vomiting, diarrhea; local reaction at site of injection, such as pruritus, scabbing.
      4. Nursing care plan/implementation:
        1. Goal: decrease discomfort associated with side effects of therapy.
          1. Identify measures to lessen symptoms of side effects (see E. Nursing care plan/implementation—general care of the client with cancer, Physiological Integrity).
          2. Know type of immunotherapy being used, adverse and desirable effects of therapy.
          3. pillImageAdminister fluids, encourage rest.
          4. pillImageAdminister acetaminophen as ordered to decrease flu-like symptoms.
          5. Administer antiemetics as ordered for nausea.
          6. Monitor for respiratory distress.
          7. pillImageAdminister analgesics as ordered for pain.
        2. Goal: health teaching.
          1. Comfort measures to decrease side effects of therapy.
          2. Expected and side effects of therapy.
          3. Investigational nature of therapy.
          4. Care of site of administration.
          5. Answer questions honestly.
    10. Palliative care: when treatment has been ineffective in control of the disease, the nurse must plan palliative, terminal care. Cure is not possible for such clients in an advanced phase of malignancy. Symptoms increase in severity; clients and family have many special problems.
      1. General problems of clients with terminal cancer:
        1. Cachexia: progressive weakness, wasting, and weight loss.
        2. Anemia: leukopenia, thrombocytopenia, hemorrhage.
        3. Gastrointestinal disturbances: anorexia, constipation.
        4. Tissue breakdown leading to decubiti, seeping wounds.
        5. Urine: retention, incontinence, renal calculi, tumor obstruction of ureters.
        6. Hypercalcemiaoccurs in 10% to 30% of clients.
        7. Pain due to: tumor growth, obstruction, vertebral compression, or secondary to complications (e.g., decubiti, stiffened joints, stomatitis). Also neuropathy, due to prolonged use of neurotoxic chemotherapeutic agents such as vincristine.
        8. Fatigue: major and debilitating problem.
      2. Nursing care plan/implementation:
        1. Goal: make client as comfortable as possible; involve nursing staff, family, support personnel, clergy, volunteers, support groups. Hospice is very valuable program.
          1. foodImageNutrition: obtain nutritional consultation; high-calorie, high-protein diet; small, frequent meals; blenderized or strained; commercial nutritional supplements (Ensure, Vivonex, Sustacal).
          2. Prevent tissue breakdown and vascular complications: frequent turning, massage, air mattress, active and passive ROM exercises.
          3. pillImageGI tract disturbances: observe for toxic reactions to therapy, particularly vomiting and diarrhea; administer medications: antiemetics, antidiarrheal agents as ordered.
          4. Relieve pain.
            1. pillImageUse supportive measures such as massage, relaxation techniques, guided imagery; and drugs for pain relief: administer codeine, fentanyl, aspirin–oxycodone HCl (Percodan), pentazocine (Talwin), morphine, methadone, as ordered.
            2. Methods of administration: oral, injected, rectal, analgesic patches, or pumps (IV or SQ).
            3. Monitor for side effects of narcotics: depressed respiratory status, constipation, anorexia.
        2. Goal: assist client to maintain self-esteem and identity.
          1. Encourage self-care.
          2. Spend time with client; isolation is a great fear for the client who is dying.
        3. Goal: assist client with psychological adjustment—see nursing care for clients who are grieving, clients who are dying (see Chapter 10. Psychosocial Integrity).
    11. Evaluation/outcome criteria:
      1. Tolerates treatment modality—complications of surgery are avoided or minimized; tolerates chemotherapy; completes radiation therapy.
      2. Side effects of treatment are managed by effective nursing care and health teaching.
      3. Maintains good nutritional status.
      4. Uses effective coping mechanisms or seeks appropriate assistance to deal with psychosocial concerns.
      5. Makes choices for follow-up care based on accurate information.
      6. Finds methods to control pain and minimize discomfort.
      7. Participates in decisions regarding continuation of therapy (living will, health-care proxy, do-not-resuscitate [DNR] decisions).
      8. Dignity maintained until death and during dying.
  2. LUNG CANCER
    1. Pathophysiology: squamous cell carcinoma: undifferentiated, pleomorphic in appearance; accounts for 45% to 60% of all lung cancer; small cell (oat cell) carcinoma: small, dark cells located between cells of mucosal surfaces; characterized by early metastasis and poor prognosis; large cell (giant cell) carcinoma: located in the peripheral areas of the lung, has poor prognosis; adenocarcinoma: found in men and women; not necessarily related to smoking.
    2. Risk factors:
      1. Heavy cigarette smoking, 20-year smoking history.
      2. Exposure to certain industrial substances, such as asbestos.
      3. Increased incidence in women during the last decade of life.
    3. Assessment:
      1. Subjective data:
        1. Dyspnea.
        2. Pain: on swallowing; dull and poorly localized chest pain, referred to shoulders.
        3. Anorexia.
        4. History of cigarette smoking over a period of years; recurrent respiratory infections with chills and fever, especially pneumonia or bronchitis.
      2. Objective data:
        1. Wheezing; dry to productive persistent cough; hemoptysis, hoarseness.
        2. Weight loss.
        3. Positive diagnosis: cytology report of cells from bronchoscopy.
        4. Chest pain.
        5. Signs of metastasis.
    4. Analysis/nursing diagnosis:
      1. Ineffective breathing pattern related to pain.
      2. Impaired gas exchange related to tumor growth.
      3. Pain related to disease progression.
      4. Fear related to uncertain future.
      5. Powerlessness related to inability to control symptoms.
      6. Knowledge deficit (learning need) related to disease and treatment.
    5. Nursing care plan/implementation:
      1. Goal: make client aware of diagnosis and treatment options.
        1. Allow time to talk and to discuss diagnosis.
        2. Client makes informed decision regarding treatment.
      2. Goal: prevent complications related to surgery for client who is diagnosed early and for whom surgery is an option: wedge or segmental resection, laser therapy, lobectomy, or pneumonectomy are usual procedures.
        1. See Nursing care plan/implementation for the client having thoracic surgery, Respiratory System - Physiological Integrity.
        2. Monitor vital signs, including accurate respiratory assessment for respiratory congestion, blood loss, infection.
        3. Assist client to deep breathe, cough, change position.
      3. Goal: assist client to cope with alternative therapies when surgery is deemed not possible.
        1. Radiation: megavoltage x-ray, cobalt—usual form of radiation (see Nursing care plan/implementation for the client having radiation therapy, Physiological Integrity).
        2. pillImageChemotherapy:
          1. Cisplatin and VP-16 with irradiation has become standard form of induction chemotherapy. Cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), CCNU, methotrexate, vincristine sulfate (Oncovin) are the other drugs given for lung cancer.
          2. See Nursing care plan/implementation for the client having chemotherapy, Physiological Integrity.
      4. Goal: health teaching.
        1. Encourage client to stop smoking to offer best possible air exchange.
        2. foodImageEncourage high-protein, high-calorie diet to counteract weight loss.
        3. Force fluids, to liquefy secretions so they can be expectorated.
        4. Encourage adequate rest and activity to prevent problems of immobility.
        5. Desired effects and side effects of medications prescribed for therapy and pain relief.
        6. Coping mechanisms for maximal comfort and advanced disease (see Palliative care, Physiological Integrity).
    6. Evaluation/outcome criteria:
      1. Copes with disease and treatment.
      2. Side effects of treatment are minimized by proper nursing management.
      3. Acid-base balance is maintained by careful management of respiratory problems.
      4. Client is aware of the seriousness of the disease.
  3. COLON AND RECTAL CANCER
    1. Risk factors:
      1. Men, middle age, personal or family history of colon and rectal cancer, personal or family history of polyps in the rectum or colon, ulcerative colitis.
      2. Diet high in beef and low in fiber.
      3. Gardner's syndrome(multiple colonic adenomatous polyps, osteomas of the mandible or skull, multiple epidermoid cysts, or soft tissue tumors of the skin).
    2. Assessment:
      1. Subjective data:
        1. Change in bowel habits.
        2. Anorexia.
        3. Weakness.
        4. Abdominal cramping or vague discomfort with or without pain.
        5. Chills.
      2. Objective data:
        1. Diarrhea (pencil-like or ribbon-shaped feces) or constipation.
        2. Weight loss.
        3. Rectal bleeding; anemia.
        4. Fever.
        5. Digital examination reveals palpable mass if lesion is in ascending or descending colon.
        6. Signs of intestinal obstruction: constipation, distention, pain, vomiting, fecal oozing.
        7. Diagnostic tests:
          1. Digital examination.
          2. Slides of stool specimen, for occult blood.
          3. Proctoscopy.
          4. Sigmoidoscopy, colonoscopy.
          5. Barium enema.
        8. Laboratory data: occult blood, blood serotonin increased, carcinoembryonic antigen (CEA); positive radioimmunoassay of serum or plasma indicates presence of carcinoma or adenocarcinoma of colon; positive result after resection indicates return of tumor.
    3. Analysis/nursing diagnosis:
      1. Constipation or diarrhea related to presence of mass.
      2. Altered health maintenance related to care of stoma.
      3. Sexual dysfunction related to possible nerve damage during radical surgery.
      4. Body image disturbance related to colostomy.
    4. Nursing care plan/implementation (see also Nursing care plan/implementation—general care of the client with cancer, Physiological Integrity):
      1. Radiation: to reduce tumor or for palliation.
      2. pillImageChemotherapy: to reduce tumor mass and metastatic lesions.
        1. Antitumor antibiotics—mitomycin C, doxorubicin HCl (Adriamycin).
        2. Alkylating agents—methyl-CCNU.
        3. Antimetabolites—5-fluorouracil (5-FU).
        4. Steroids and analgesics for symptomatic relief.
      3. Prepare client for surgery (colostomy) if necessary.
    5. Evaluation/outcome criteria:
      1. Return of peristalsis and formed stool following resection and anastomosis.
      2. Adjusts to alteration in bowel elimination route following abdominoperineal resection (e.g., no depression, resumes lifestyle).
      3. Demonstrates self-care skills with colostomy.
      4. Makes dietary adjustments that affect elimination as indicated.
      5. Identifies alternative methods of expressing sexuality, if needed.
  4. BREAST CANCER
    1. Risk factors:
      1. Women older than age 50.
      2. Family history of breast cancer.
      3. Never bore children, or bore first child after age 30.
      4. Had breast cancer in other breast.
      5. Menarche before age 11.
      6. Menopause after age 50.
      7. Exposure to endogenous estrogens.
      8. Exposure to ionizing radiation.
      9. High alcohol and fat intake may increase risk.
    2. Assessment:
      1. Subjective data:
        1. Burning, itching of nipple.
        2. Reported painless lump.
      2. Objective data:
        1. Firm, nontender lump or mass.
        2. Asymmetry of breast.
        3. Nipple—retraction, discharge.
        4. Alteration in breast skin—redness, dimpling, ulceration.
        5. Palpation reveals lump.
        6. Diagnostic tests: mammography, needle biopsy, core biopsy, excisional biopsy—level of estrogen-receptor protein predicts response to hormonal manipulation of metastatic disease and may represent a prognostic indicator for primary cancer; carcinoembryonic antigen (CEA) useful with metastatic disease of the breast.
    3. Analysis/nursing diagnosis:
      1. Risk for injury related to surgical intervention.
      2. Body image disturbance related to effects of surgery, radiation, or chemotherapy.
      3. Altered sexuality patterns related to loss of breast.
    4. Nursing care plan/implementation (see also Nursing care plan/implementation—general care of the client with cancer, Physiological Integrity):
      1. Goal: assist through treatment protocol.
        1. Radiation—primary treatment modality; adjunctive, external, or implantation to primary lesion site or nodes.
        2. pillImageChemotherapy usually given in combinations.
          1. Cytotoxic agents to destroy tumor and control metastasis.
          2. Alkylating agents: cyclophosphamide (Cytoxan).
          3. Antitumor antibiotics: doxorubicin (Adriamycin).
          4. Antimetabolites: fluorouracil (5-FU); methotrexate (Amethopterine, MTX).
          5. Plant alkaloids: vincristine sulfate (Oncovin).
          6. Hormones to control metastasis, provide palliation: androgens, fluoxymesterone (Halotestin), testosterone (Teslac), diethylstilbesterol (estrogen).
          7. Antiestrogens: tamoxifen (Nolvadex) may be used after initial treatment.
          8. Cortisols: cortisone, prednisolone (Delta-Cortef), prednisolone acetate (Meticortelone), prednisone (Deltasone, Deltra).
        3. Surgery.
          1. Preoperative:
            1. Goal: prepare for surgery—types:
              1. Lumpectomy (with or without radiation)—used when lesion is small; section of breast is removed with clear margin around lesion (often accompanied by radiation therapy and then radium interstitial implant).
              2. Simple mastectomy—breast removed, no alteration in nodes.
              3. Modified radical mastectomy—breast, some axillary nodes, subcutaneous tissue removed; pectoralis minor muscle removed.
              4. Radical mastectomy—breast, axillary nodes, and pectoralis major and minor muscles removed.
              5. Reconstructive surgery—done at time of initial mastectomy or (most often) later, when other adjuvant therapy has been completed.
            2. Goal: promote comfort.
              1. Allow client and family to express fears, feelings.
              2. Provide correct information about diagnostic tests, operative procedure, postoperative expectations.
              3. Client may be hospitalized for 24 hours or less. Have telephone number available for questions. Make appropriate community referrals.
          2. Postoperative:
            1. Goal: facilitate healing.
              1. Observe pressure dressings for bleeding; will appear under axilla and toward the back.
              2. Report if dressing becomes saturated; reinforce dressing as need; monitor drainage from Hemovac or suction pump.
              3. infoImagePosition: semi-Fowler's to facilitate venous and lymphatic drainage; use pillows to elevate affected arm above right atrium, to prevent edema if nodes removed.
            2. Goal: prevent complications .
              1. Monitor vital signs for shock.
              2. Use gloves when emptying drainage.
              3. infoImageMaintain joint mobility—flexion and extension of fingers, elbow, shoulder.
              4. ROM as ordered to prevent ankylosis.
              5. If skin graft done, check donor site and limit exercises.
            3. Goal: facilitate rehabilitation.
              1. Encourage client, significant others, and family to look at incision.
              2. Involve client in incisional care, as tolerated.
              3. Refer to Reach to Recovery program of the American Cancer Society
              4. Exercise program, hydrotherapy for clients who are postmastectomy, to reduce lymphedema.
            4. Goal: health teaching.
              1. How to avoid injury to affected area; how to prevent lymphedema.
              2. Exercises to gain full ROM.
              3. Availability of prosthesis, reconstructive surgery.
              4. Correct breast self-examination (BSE) technique (client is at risk for breast cancer in remaining breast) (Figure. 6.16. Breast Self-Examination).Best time for examination: women who are premenopausal, seventh day of cycle; women who are postmenopausal, same day each month.
    5. Evaluation/outcome criteria:
      1. Identifies feelings regarding loss.
      2. Demonstrates postmastectomy exercises.
      3. Gives rationale for avoiding fatigue and avoiding constricting garments on affected arm; necessity for avoiding injury (cuts, bruises, burns) while carrying out activities of daily living.
      4. Describes signs and symptoms of infection.
      5. Demonstrates correct BSE technique.
  5. UTERINE CANCER (endometrial): originates from epithelial tissues of the endometrium; second only to cervical cancer as cause of pelvic cancer. Slow growing; metastasizes late; responsive to therapy with early diagnosis; Papanicolaou (Pap) test not as effective—more effective to have endometrial tissue sample (Table 6.40. Papanicolaou (Pap) Smear Classes and Table 6-41. Uterine Cancer: Recommended Treatment, by Stage of Invasion ). Table 6.42. International System of Staging for Cervical Carcinoma discusses cervical cancer.
    1. Risk factors:
      1. History of infertility (nulliparity).
      2. Failure of ovulation.
      3. Prolonged estrogen therapy.
      4. Obesity.
      5. Menopause after age 52.
      6. Diabetes.
    2. Assessment:
      1. Subjective data:
        1. History of risk factor(s).
        2. Pain (late symptom).
      2. Objective data:
        1. Obese.
        2. Abnormal cells obtained from aspiration of endocervix or endometrial washings.
        3. Postmenopausal uterine bleeding.
        4. Abnormal menses; intermenstrual or unusual discharge.
    3. Analysis/nursing diagnosis:
      1. Pain related to surgery.
      2. Risk for injury related to surgery.
      3. Body image disturbance related to loss of uterus
    4. Nursing care plan/implementation (see also Nursing care plan/implementation—general care of the client with cancer, Physiological Integrity):
      1. Goal: assist client through treatment protocol.
        1. Radiation—external, internal, or both with client who is a poor surgical risk.
        2. pillImageChemotherapy—to reduce tumors and produce remission of metastasis. Antineoplastic drugs: dacarbazine (DTIC), doxorubicin (Adriamycin), medroxyprogesterone acetate (Provera), megestrol acetate (Megace).
      2. Goal: prepare client for surgery—types:
        1. Subtotal hysterectomy: removal of the uterus; cervical stump remains.
        2. Total hysterectomy: removal of entire uterus, including cervix (abdominally [approximately 70%] or vaginally).
        3. Total hysterectomy with bilateral salpingo-oophorectomy: removal of entire uterus, fallopian tubes, and ovaries.
      3. Goal: reduce anxiety and depression: allow for expression of feelings, concerns about femininity, role, relationships.
      4. Goal: prevent postoperative complications .
        1. Catheter care—temporary bladder atony may be present as a result of edema or nerve trauma, especially when vaginal approach is used.
        2. Observe for abdominal distention and hemorrhage:
          1. Auscultate for bowel sounds.
          2. Measure abdominal girth.
          3. Use rectal tube to decrease flatus.
        3. Decrease pelvic congestion and prevent venous stasis.
          1. infoImageAvoid high Fowler's position.
          2. Antiembolic stockings as ordered.
          3. Institute passive leg exercises.
          4. Apply abdominal support as ordered.
          5. Encourage early ambulation.
      5. Goal: support coping mechanisms to prevent psychosocial response of depression: allow for verbalization of feelings.
      6. Goal: health teaching to prevent complications of hemorrhage, infection, thromboemboli.
        1. Avoid:
          1. Douching or coitus until advised by physician.
          2. Strenuous activity and work for 2 months.
          3. Sitting for long time and wearing constrictive clothing, which tend to increase pelvic congestion.
        2. Explain hormonal replacement if applicable; correct dosage, desired and side effects of prescribed medications.
        3. Explain:
          1. Menstruation will no longer occur.
          2. Importance of reporting symptoms (e.g., fever, increased or bloody vaginal discharge, and hot flashes).
    5. Evaluation/outcome criteria:
      1. Adjusts to altered body image.
      2. No complications—hemorrhage, shock, infection, thrombophlebitis.
  6. PROSTATE CANCER: malignant neoplasm, usually adenocarcinoma; most common cause of cancer in men.
    1. Risk factors:
      1. Men older than age 50.
      2. Familial history.
      3. Geographic distribution, environmental (e.g., industrial exposure to cadmium).
      4. Hormonal factors (testosterone).
      5. Diet (high fat).
    2. Assessment:
      1. Subjective data:
        1. Difficulty in starting urinary stream (hesitancy); urgency.
        2. Pain due to metastasis in lower back, hip, legs; perianal or rectal discomfort.
        3. Symptoms of cystitis; frequency, urgency.
      2. Objective data:
        1. Urinary: smaller, less forceful stream; terminal dribbling; frequency, nocturia; retention (inability to void after ingestion of alcohol or exposure to cold).
        2. Diagnostic tests: digital rectal examination (DRE); transrectal ultrasonography (TRUS). Needle biopsy or tissue specimen reveals positive cancer cells.
        3. Laboratory data: increased:
          1. Prostate-specific antigen (PSA)—over 4 ng/mL.
          2. Urine RBCs (hematuria).
          3. Gleason score for prostate cancer grading system (range: 2 to 10).
    3. Analysis/nursing diagnosis:
      1. Altered urinary elimination related to incontinence.
      2. Altered sexuality pattern related to nerve damage and erectile dysfunction.
      3. Anxiety related to diagnosis.
      4. Pain related to metastasis to bone.
    4. Nursing care plan/implementation (see also Nursing care plan/implementation—general care of the client with cancer, Physiological Integrity):
      1. Goal: assist client through decisions about treatment protocol (varies by stage: 0 to IV).
        1. Radiation—alone or in conjunction with surgery. Types: external beam radiation, 3-D conformal (focal), radioactive seed implants (brachytherapy).
        2. Surgery—cryosurgery; radical retropubic prostatectomy (see XI. PROSTATECTOMY, Physiological Integrity).
        3. pillImageOther options: hormones ( luteinizing hormone–releasing hormone agonists [Lupron, Zoladex, Casodex, Nilandron]), antiandrogen (flutamide [Eulexin]); drugs in conjunction with orchiectomy, to limit production of androgens ( androgen deprivation therapy ).
        4. Watchful waiting—recommended with small contained tumor; older men; where surgery is contraindicated for other serious health problems.
    5. Evaluation/outcome criteria (see XI. PROSTATECTOMY, Physiological Integrity).
  7. BLADDER CANCER: bladder is most common site of urinary tract cancer.
    1. Risk factors:
      1. Contact with certain dyes.
      2. Cigarette smoking.
      3. Excessive coffee intake.
      4. Prolonged use of analgesics with phenacetin.
      5. Three times more common in men.
    2. Assessment:
      1. Subjective data:
        1. Frequency, urgency.
        2. Pain: flank, pelvic; dysuria.
      2. Objective data:
        1. Painless hematuria (initially).
        2. Diagnostic tests:
          1. Cystoscopy, intravenous pyelogram (IVP)—mass or obstruction.
          2. Bladder biopsy, urine cytology—malignant cells.
        3. Laboratory data: urinalysis—increased RBCs (>4.8 × 1012/L—men, >4.3 × 1012/L—women).
    3. Analysis/nursing diagnosis:
      1. Risk for injury related to surgical intervention.
      2. Altered urinary elimination related to surgery.
    4. Nursing care plan/implementation (see also Nursing care plan/implementation—general care of the client with cancer, Physiological Integrity):
      1. Goal: assist client through treatment protocol.
        1. Radiation: cobalt, radioisotopes, radon seeds; often before surgery to slow tumor growth.
        2. pillImageChemotherapy:
          1. Antitumor antibiotics: doxorubicin HCl (Adriamycin), mitomycin.
          2. Antimetabolites: 5-fluorouracil (5-FU).
          3. Alkylating agents: thiotepa.
          4. Sedatives, antispasmodics.
      2. Goal: prepare client for surgery—types:
        1. Transurethral fulguration or excision: used for small tumors with minimal tissue involvement.
        2. Segmental resection: up to half the bladder may be resected.
        3. Cystectomy with urinary diversion: complete removal of the bladder; performed when disease appears curable.
      3. Goal: assist with acceptance of diagnosis and treatment.
      4. Goal: prevent complication during postoperative period.
        1. Transurethral fulguration or excision:
          1. Monitor for clots, bleeding, spasms.
          2. Maintain patency of Foley catheter.
        2. Urinary diversion with stoma:
          1. Protect skin, ensure proper fit of appliance—because constantly wet with urine (see also Ileal conduit, Physiological Integrity and Ostomies and stoma care, Physiological Integrity).
          2. Prevent infection by increasing acidity of urine and increasing fluid intake.
          3. Health teaching.
            1. Self-care of stoma and appliance.
            2. Expected and side effects of medications.
            3. Importance of follow-up visits for early detection of metastasis.
    5. Evaluation/outcome criteria:
      1. Accepts treatment plan.
      2. Uses prescribed measures to decrease side effects of surgery, radiation, chemotherapy.
      3. Plans follow-up visits for further evaluation.
      4. Maintains dignity.
  8. LARYNGEAL CANCER
    1. Risk factors:
      1. Eight times more common in men.
      2. Occurs most often after age 60.
      3. Cigarette smoking.
      4. Alcohol.
      5. Chronic laryngitis, vocal abuse.
      6. Family predisposition to cancer.
    2. Assessment:
      1. Subjective data:
        1. Dysphagia—pain in areas of Adam's apple; radiates to ear.
        2. Dyspnea.
      2. Objective data:
        1. Persistent hoarseness.
        2. Cough and hemoptysis.
        3. Enlarged cervical nodes.
        4. General debility and weight loss.
        5. Foul breath.
        6. Diagnosis made by history, laryngoscopy with biopsy and microscopic study of cells.
    3. Analysis/nursing diagnosis:
      1. Impaired verbal communication related to removal of larynx.
      2. Body image disturbance related to radical surgery.
      3. Ineffective airway clearance related to increased secretions through tracheostomy.
    4. Nursing care plan/implementation (see also Nursing care plan/implementation—general care of the client with cancer, Physiological Integrity): treatment primarily surgical (see Laryngectomy, Physiological Integrity); radiation therapy may also be indicated.
    5. Evaluation/outcome criteria: see Laryngectomy, Physiological Integrity.
  9. ADDITIONAL TYPES OF CANCER (Table 6.43. Selected Cancer Problems).