UNDERSTANDINGCANCER

• Essential Concepts of Cancer– What is Cancer?– Normal Cell Growth vs. Cancer Cell

Growth– Etiology and Causative Factors– Pathophysiology– Classification of Tumors– Effects of Cancer

• Nursing Process– Assessment– Laboratory & Diagnostic Tests– Tumor Staging and Grading– Nursing Diagnoses & Planning– Implementation and Management

• Treatment Modalities– Chemotherapy

• End-of-life Issues

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What Is Cancer?

CANCER is a complex of diseases which occurs when normal cells mutate into

abnormal cells that take over normal tissue, eventually harming and destroying the host

WHAT IS CANCER• A large group of diseases

characterized by:– Uncontrolled growth and spread of

abnormal cells– Proliferation (rapid reproduction by cell

division)– Metastasis (spread or transfer of cancer

cells from one organ or part to another not directly connected)

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Loss of Normal Growth Control

Cancer cell division

Fourth orlater mutation

Third mutation

Second mutation

First mutation

Uncontrolled growth

Cell Suicide or Apoptosis

Cell damage—no repair

Normal cell division

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Oncogenes

Mutated/damaged oncogene

Oncogenes accelerate cell growth and division

Cancer cell

Normal cell Normal genes regulate cell growth

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Example of Normal Growth

Cell migration

Dermis

Dividing cells in basal layer

Dead cells shed from

outer surface

Epidermis

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The Beginning of Cancerous Growth

Underlying tissue

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Tumors (Neoplasms)

Underlying tissue

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Invasion and Metastasis

3Cancer cells reinvade and grow at new location

1Cancer cells invade surrounding tissues and blood vessels

2Cancer cells are transported by the circulatory system to distant sites

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• Viruses• Chemical carcinogens• Physical stressors• Hormonal factors• Genetic factors

ETIOLOGY/CAUSATIVE FACTORS

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What Causes Cancer?Some viruses or bacteria

HeredityDiet

Hormones

RadiationSome chemicals

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Population-Based Studies

CANADA:Leukemia

Regions of Highest Incidence

BRAZIL:Cervicalcancer

U.S.:Coloncancer

AUSTRALIA:Skincancer

CHINA:Livercancer

U.K.:Lungcancer

JAPAN:Stomachcancer

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Genes and Cancer

Chromosomes are DNA molecules

Heredity

RadiationChemicals

Viruses

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Viruses

Virus inserts and changes genes forcell growth

Cancer-linked virus

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Examples of Human Cancer Viruses

Some Viruses Associated with Human Cancers

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Bacteria and Stomach Cancer

H. pyloriPatient’s tissue sample

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Tobacco Use and CancerSome Cancer-Causing Chemicals in Tobacco Smoke

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High-Strength Radiation

Most

High

LowLeast

Leukemia Incidence

X-ray Dose(atomic radiation)

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AIDS and Kaposi’s Sarcoma

Kaposi’ssarcoma

Withoutdisease

Depressedimmunesystem

HIV infection

KSHV infection

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Heredity and Cancer

Inherited factor(s)

All Breast Cancer Patients

Other factor(s)

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Heredity Can Affect Many Types of Cancer

Inherited Conditions That Increase Risk for Cancer

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PATHOPHYSIOLOGYABNORMAL CELL FORMED BY MUTATION OF DNA

CELL GROWS AND PROLIFERATES

METASTASIS OCCURS WHEN ABN. CELLS INVADE OTHER TISSUE,THROUGH LYMPH AND BLOOD

– Cancer development linked to immune system failure

– Example of clients susceptible to developing cancer

Classification of Cancer• According to Behavior of Tumor• Benign - tumors that cannot spread

by invasion or metastasis; hence, they only grow locally

• Malignant - tumors that are capable of spreading by invasion and metastasis. By definition, the term “cancer” applies only to malignant tumors

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Malignant versus Benign Tumors

Malignant (cancer) cells invade neighboring tissues, enter blood vessels, and metastasize to different sites

Time

Benign (not cancer) tumor cells grow only locally and cannot spread by invasion or metastasis

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Why Cancer Is Potentially Dangerous

Melanoma cells travel through bloodstream

Melanoma(initial tumor)

Brain

Liver

Patterns of cell Proliferation• Hyperplasia • Dysplasia• Metaplasia• Anaplasia

• Neoplasia

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Hyperplasia

HyperplasiaNormal

• tissue growth based on an excessive rate of cell division, leading to a larger than usual number of cells; the process of hyperplasia is potentially reversible; can be a normal tissue response to an irritating stimulus. An example is a callus

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Dysplasia

Hyperplasia Mild dysplasiaNormal

• Bizarre cell growth differing in size, shape and cell arrangement

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Carcinoma in Situ

Milddysplasia

Carcinoma in situ (severe dysplasia) Cancer

(invasive)

Normal Hyperplasia

Patterns of cell Proliferation• Metaplasia

• conversion of one type of cell in a tissue to another type not normal for that tissue

• Anaplasia • change in the DNA cell structure and

orientation to one another, characterized by loss of differentiation and a return to a more primitive form.

• Neoplasia• uncontrolled cell growth, either benign or

malignant

Metastasis• Metastasis: 3 stages

– Invasion – neoplastic cells from primary tumor invade into surrounding tissue with penetration of blood or lymph.

– Spread – tumor cells spread through lymph or circulation or by direct expansion

– Establishment and growth – tumor cells are established and grow in secondary site: lymph nodes or in organs from venous circulation

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Cancer Tends to Involve Multiple Mutations

Malignant cells invade neighboring tissues, enter blood vessels, and metastasize to different sites

More mutations, more genetic instability, metastatic disease

Proto-oncogenes mutate to oncogenes

Mutations inactivate DNA repair genes

Cells proliferate

Mutation inactivates suppressor gene

Benign tumor cells grow only locally and cannot spread by invasion or metastasis

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Mutations and Cancer

Genes Implicated in Cancer

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Cancer Tends toCorrupt Surrounding Environment

Growth factors = proliferation

Blood vessel

Proteases

Cytokines

Matrix

Fibroblasts, adipocytes

Invasive

Cytokines, proteases = migration & invasionBack

Classification of Tumors• CARCINOMAS: EPITHELIAL TISSUE

– BODY SURFACES, LINING OF BODY CAVITIES ETC: (ADENOCARCINOMA)

• SARCOMAS: CONNECTIVE TISSUE– STRIATED MUSCLE, BONE, ETC

(OSTEOSARCOMA)• LYMPHOMAS AND LEUKEMIAS

– HEMATOPOIETIC SYSTEM• NERVOUS TISSUE TUMORS

– EX. NERVE CELLS-NEUROBLASTOMA• MYELOMA

– Develops in the plasma cells of bone marrow

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Different Kinds of Cancer

Lung

Breast (women)

Colon

BladderProstate (men)

Some common sarcomas:Fat

Bone

Muscle

Lymphomas:Lymph nodes

Leukemias:Bloodstream

Some common carcinomas:

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Naming Cancers

Prefix Meaning

adeno- gland

chondro- cartilage

erythro- red blood cell

hemangio- blood vessels

hepato- liver

lipo- fat

lympho- lymphocyte

melano- pigment cell

myelo- bone marrow

myo- muscle

osteo- bone

Cancer Prefixes Point to Location

“ Women who smoke like men,

die like men.”

U.S. Surgeon General David Satcher

Women, Tobacco & Lung Cancer

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Effects of Cancer• Disruption of Function- can be due

to obstruction or pressure• Hematologic Alterations: can impair

function of blood cells• Hemorrhage: tumor erosion,

bleeding, severe anemia• Anorexia-Cachexia Syndrome:

wasted appearance of client

Effects of Cancer• Paraneoplastic Syndromes: ectopic

sites with excess hormone production– ↑ Parathyroid hormone→ hypercalcemia– ↑ secretion of insulin→ hypoglycemia– ↑ Antidiuretic hormone (ADH) → fluid

retention, HTN & peripheral edema

• ↑ Adrenocorticotropic hormone (ACTH): cause excessive secretion of cortisone (ie: fluid retention, ↑ glucose levels)

Effects of Cancer• Pain: major concern of clients and

families associated with cancer• Physical Stress: body tries to

respond and destroy neoplasm• Psychological Stress

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ASSESSMENTASSESSMENT• Nursing History

– Health History – chief complaint and history of present illness (onset, course, duration, location, precipitating and alleviating factors)

– Cancer signs: CAUTION US!

• CAUTION US!– Change in bowel or bladder habits– A sore that does not heal– Unusual bleeding or discharge– Thickenings or lumps– Indigestion or difficulty in swallowing– Obvious change in a wart or mole– Nagging or persistent cough or hoarseness– Unexplained anemia– Sudden unexplained weight loss

Warning Signs of CancerWarning Signs of Cancer

• Change in bowel or bladder habits– A person with colon cancer may have

diarrhea or constipation, or he may notice that the stool has become smaller in diameter

– A person with bladder or kidney cancer may have urinary frequency and urgency

Warning Signs of Cancer

• A sore that does not heal– Small, scaly patches on the skin that

bleed or do not heal may be a sign of skin cancer

– A sore in the mouth that does not heal can indicate oral cancer

Warning Signs of Cancer

• Unusual bleeding or discharge– Blood in the stool is often the first sign

of colon cancer– Similarly, blood in the urine is usually

the first sign of bladder or kidney cancer– Postmenopausal bleeding (bleeding

after menopause) may be a sign of uterine cancer

Warning Signs of Cancer

• Thickenings or lumps– Enlargement of the lymph nodes or

glands (such as the thyroid gland) can be an early sign of cancer

– Breast and testicular cancers may also present as a lump

Warning Signs of Cancer

• Indigestion or difficulty in swallowing– Cancers of the digestive system,

including those of the esophagus, stomach, and pancreas, may cause indigestion, heartburn, or difficulty swallowing

Warning Signs of Cancer

• Obvious change in a wart or mole– Moles or other skin lesions that change

in shape, size, or color should be reported

Warning Signs of Cancer

• Nagging or persistent cough or hoarseness– Cancers of the respiratory tract,

including lung cancer and laryngeal cancer, may cause a cough that does not go away or a hoarse (rough) voice

Warning Signs of Cancer

Warning Signs of Cancer• Unexplained anemia

• Sudden unexplained weight loss

Physical AssessmentPhysical Assessment• Inspection – skin and mucus membranes

for lesions, bleeding, petechiae, and irritation– Assess stools, urine, sputum, vomitus for acute or

occult bleeding– Scalp noting hair texture and hair loss

• Palpation – Abdomen for any masses, bulges or abnormalities– Lymph nodes for enlargement

• Auscultation – of lung sounds, heart sounds and bowel sounds

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Laboratory & Diagnostic Laboratory & Diagnostic TestsTests

• Cancer detection examination• Laboratory tests

– Complete blood cell count (CBC)– Tumor markers – identify substance

(specific proteins) in the blood that are made by the tumor• PSA (Prostatic-specific antigen): prostate

cancer• CEA (Carcinoembryonic antigen): colon cancer• Alkaline Phosphatase: bone metastasis

– Biopsy

Diagnostic TestsDiagnostic Tests• Determine location of cancer:

– X-rays– Computed tomography– Ultrasounds– Magnetic resonance imaging– Nuclear imaging– Angiography

• Diagnosis of cell type:– ▪Tissue samples: from biopsies,

shedded cells (e.g. Papanicolaou (PAP) smear), & washings

– ▪ Cytologic Examination: tissue examined under microscope

• Direct Visualization:– ▪ Sigmoidoscopy– ▪ Cystoscopy– ▪ Endoscopy– ▪ Bronchoscopy– ▪ Exploratory surgery; lymph node

biopsies to determine metastases

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Cancer Detection and Diagnosis

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Early Cancer May Not Have Any Symptoms

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Cervical Cancer Screening

Abnormal Pap smear

Normal Pap smear

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Breast Cancer Screening

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Prostate and Ovarian Cancer Screening

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Colon Cancer Screening

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Biopsy

Patient’stissue sample or

blood sample Genomic profile

Proteomic profile

Pathology

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Microscopic Appearance of Cancer Cells

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Tumor Staging and GradingTumor Staging and Grading• Staging determines size of tumor and

existence of metastasis• Grading classifies tumor cells by type

of tissue• The TNM system is based on the

extent of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of metastasis (M).

Primary Tumor (T)

TX Primary tumor cannot be evaluated

T0 No evidence of primary tumor

Tis Carcinoma in situ (early cancer that has not spread to neighboring tissue)

T1, T2, T3, T4 Size and/or extent of the primary tumor

Regional Lymph Nodes (N)

NX Regional lymph nodes cannot be evaluated

N0 No regional lymph node involvement (no cancer found in the lymph nodes)

N1, N2, N3 Involvement of regional lymph nodes (number and/or extent of spread)

Distant Metastasis (M)

MX Distant metastasis cannot be evaluated

M0 No distant metastasis (cancer has not spread to other parts of the body)

M1 Distant metastasis (cancer has spread to distant parts of the body)

NURSING DIAGNOSESNURSING DIAGNOSES• Acute or chronic pain• Impaired skin integrity• Impaired oral mucous membrane• Risk for injury• Risk for infection• Fatigue • Imbalanced nutrition: less than body

requirements

NURSING DIAGNOSESNURSING DIAGNOSES

• Risk for imbalanced fluid volume• Anxiety • Disturbed body image• Deficient knowledge• Ineffective coping• Social isolation

OUTCOME IDENTIFICATIONOUTCOME IDENTIFICATION1. Pain relief2. Integrity of skin and oral mucosa3. Absence of injury and infection4. Fatigue relief5. Maintenance of nutritional intake

and fluid and electrolyte balance6. Improved body image7. Absence of complications

OUTCOME IDENTIFICATION

8. Knowledge of prevention and cancer treatment

9. Effective coping through recovery and grieving process

10.Optimal social interaction

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IMPLEMENTATION/IMPLEMENTATION/MANAGEMENTMANAGEMENT

• Prevention and detection– Primary Prevention

• Reducing modifiable risk factors in the external and internal environment

– Secondary Prevention• Recognizing early signs and symptoms and

seeking prompt treatment• Prompt intervention to halt cancerous

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Cancer Prevention

Cancer viruses or bacteria

Carcinogenic radiation

Carcinogenic chemicals

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Avoid Tobacco

15x

10x

5x

Non-smokerCigarettes Smoked per Day

Lung Cancer Risk Increases with Cigarette Consumption

Lung Cancer

Risk

0 15 30

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Protect Yourself From Excessive Sunlight

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Limit Alcohol and Tobacco

40x

30x

20x

10x

Alcoholic Drinks Consumed per Day

Packs of Cigarettes Consumed per Day

Combination of Alcohol and Cigarettes Increases Risk for Cancer of the Esophagus

Risk Increase

AND

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Diet: Limit Fats and Calories

0

Number of Cases (per 100,000

people)

Grams (per person per day)

Correlation Between Meat Consumption and Colon Cancer Rates in Different Countries

40

30

20

10

30020010080

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Diet: Consume Fruits and Vegetables

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Avoid Cancer Viruses

Noninfected women

HPV Infection Increases Risk for Cervical Cancer

Cervical Cancer

Risk

Low

High

Women infected with HPV

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Avoid Carcinogens at Work

Some Carcinogens in the Workplace

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Industrial Pollution

1930

Incidence of Most Cancers

Year199019701950

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TREATMENT MODALITIESTREATMENT MODALITIES• Aimed towards:

– CURE - free of disease after treatment → normal life

– Control - Goal for chronic cancers– Palliative Care: Quality of life maintained

at highest level for the longest possible time

• Surgery – surgical removal of tumors; most commonly used treatment

• Preventive or prophylactic• Diagnostic surgery• Curative surgery• Reconstructive surgery• Palliative surgery

• Chemotherapy – use of antineoplastic drugs to promote tumor cell death, by interfering with cellular functions and reproduction

• Radiotherapy – directing high-energy ionizing radiation to destroy malignant tumor cells without harming surrounding tissues – Teletherapy (external): radiation

delivered in uniform dose to tumor– Brachytherapy: delivers high dose to

tumor and less to other tissues; radiation source is placed in tumor or next to it

• Immunotherapy – use of chemical or microbial agents to induce mobilization of immune defenses.

• Biologic response modifiers (BRMs) – use of agents that alters immunologic relationship between tumor and host in a beneficial way

• Bone marrow peripheral stem cell transplantation – aspirating bone marrow cells from compatible donor and infusing them into the recipient

• Gene therapy – transfer of genetic materials into the client’s DNA

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NURSING MANAGEMENTNURSING MANAGEMENT1. Promote measures that relieve pain and

discomfort.• Pharmacologic and non-pharmacologic

interventions

2. Promote measures to maintain intact skin integrity

3. Promote measures that maintain oral mucosa4. Promote measures to prevent injury from

abnormal bleeding• Monitor platelet count; avoid aspiring products,etc

NURSING MANAGEMENT5. Promote measures that identify and

prevent infection• Monitor WBC count; encourage frequent

handwashing and overall cleanliness

6. Help decrease the client’s fatigue and increase his activity level

7. Promote measures that ensure adequate nutritional intake

• High protein, high calorie diet

8. Ensure adequate fluid and electrolyte balance

NURSING MANAGEMENT9. Promote measures to enhance body image.

• Take an honest gentle, caring approach; encourage client to express and verbalize feelings

10.Promote measures that address preventing complications of cancer therapy

11. Instruct client and family about the disease process and treatments; provide necessary information for self-care.

12.Help client and family cope effectively13.Promote measures to reduce social isolation.

Care of Clients Receiving Care of Clients Receiving ChemotherapyChemotherapy

• Classes of Chemotherapy Drugs:

• Alkylating agents:– Action: create defects in tumor DNA– Ex: Nitrogen Mustard, Cisplatin– Toxic Effects: reversible renal tubular

necrosis

Classes of Chemotherapy Drugs

• Antimetabolites:– Action: phase specific– Ex: Methotrexate; 5 fluorouracil– Toxic Effects: nausea, vomiting,

stomatitis, diarrhea, alopecia, leukopenia

Classes of Chemotherapy Drugs

• Antitumor Antibiotics:– Action: non- phase specific; interfere

with DNA– Ex: Actinomycin D, Bleomycin,

adriamycin (doxorubicin)– Toxic Effect: damage to cardiac muscle

Classes of Chemotherapy Drugs

• Miotic inhibitors:– Action: Prevent cell division during M

phase of cell division– Ex: Vincristine, Vinblastine– Toxic Effects: affects neurotransmission,

alopecia, bone marrow depression

Classes of Chemotherapy Drugs

• Hormones:– Action: stage specific G1– Ex: Corticosteroids

• Hormone Antagonist:– Action: block hormones on hormone- binding

tumors ie: breast, prostate, endometrium; cause tumor regression

– Ex: Tamoxifen (breast); Flutamide (prostate)– Toxic Effects: altered secondary sex

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Effects of ChemotherapyEffects of Chemotherapy• Tissues: (fast growing) frequently

affected• Examples: mucous membranes, hair

cells, bone marrow, specific organs with specific agents, reproductive organs (all are fetal toxic; impair ability to reproduce)

Chemotherapy Chemotherapy AdministrationAdministration

• Routes of administration:– Oral– Body cavity (intraperitoneal or

intrapleural)– Intravenous

• Use of vascular access devices because of threat of extravasation (leakage into tissues) & long-term therapy

Chemotherapy Administration

• Types of vascular access devices:– PICC lines: (peripherally inserted central

catheters) – Tunneled catheters: (Hickman,

Groshong)– Surgically implanted ports: (accessed

with 90o angle needle- Huber needles)

Nursing care of clientsNursing care of clientsreceiving chemotherapyreceiving chemotherapy

• Assess and manage:– Toxic effects of drugs (report to

physician)– Side effects of drugs: manage nausea

and vomiting, inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea and vomiting with specific nursing and medical interventions

Nursing care of clientsreceiving chemotherapy

• Monitor lab results (drugs withheld if blood counts seriously low); blood and blood product administration

• Assess for dehydration, oncologic emergencies

• Teach regarding fatigue, immunosuppression precautions

• Provide emotional and spiritual support to clients and families

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REFERENCE• National Cancer Institute• Brunner and Suddarth’s Medical

Surgical Nursing

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