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OUR LIVES ARE MADE UP OF A MILLION MOMENTS, SPENT IN A MILLION DIFFERENT WAYS. BUT THERE IS NO GREATER MOMENT THAN WE FIND THAT LIFE ² WITH ALL ITS JOYS AND SORROWS ² IS MEANT TO BE LIVED ONE DAY AT A TIME.
Detection and Prevention of Cancer
PRIMARY PREVENTION Acquisition of knowledge and skills necessary to educate client, community about cancer risk. SECONDARY PREVENTION Cancer screening programs for individuals who are found to be at high risk for cancer
and detection Primary Prevention x Reducing modifiable risk factors in the external and internal environment Secondary Prevention x Recognizing early signs and symptoms and seeking prompt treatment x Prompt intervention to halt cancerous process
NURSING RESPONSIBILITIES IN EARLY DETECTION OF CANCER:
STEPS TO REDUCE CANCER RISK When teaching individual patients or groups, nurses can recommend the following cancer prevention strategies: 1. Increase consumption of fresh vegetables (especially those of the cabbage family.)
2. Increase fiber intake. 3. Increase intake of Vitamin A. 4. Increase intake of foods rich in Vitamin C. 5. Practice weight control. 6. Reduce intake of dietary fat. 7. Practice moderation in consumption of salt-cured, smoked and nitrate-cured foods. 8. Stop smoking cigarettes and cigars. 9. Reduce alcohol intake. 10. Avoid overexposure to sun.
RECOMMENDATION FOR EARLY DETECTION OF CANCER
A. BREAST CANCER
y y y y y y y y
Menarche before age 11 Menopause after age 50 Family history of breast cancer ² especially mother or sister History of uterine cancer Nulliparity or birth of first child after age 30 History of uterine cancer Link with obesity, diabetes and hypertension Presence of benign breast cyst.
Clinical Manifestations/ Assessment
y y y y y y y
Most are found in upper outer quadrant or central (nipple) portion of the breast Firm, non-tender, non-mobile mass Solitary, irregularly shaped mass Asymmetry of the breast Orange ² peel appearance of the skin or dimpling (late) Nipple retraction (late) Abnormal discharge from nipple
Breast Self Examination Regular mammograms (screen all middle aged woman)
COLORECTAL means colon and rectum combined y Highest for people older than 85 years of age y High for people with family history of colon cancer, polyps adenomatous, of inflammatory bowel disease, high fat, high protein (with high intake of beef), low fiber diet, genital or breast cancer in women
Colonoscopy ² an insertion of fiber optic scope through the rectum for direct visualization of the colon.
2. Digital Rectal Examination
y y y y
Increasing age, after age 50 Having father or brother with prostate cancer doubles the risk of relatives A diet high in red meat increase risk Difficulty and frequent urination, urinary retention, decreased size and force of the urinary stream Every man older than 40 should have DRE ( Digital rectal exam ) as part of regular check up The more advanced lesion, it becomes ´ stony hard ´ and fixed
DIGITAL RECTAL EXAMINATION
PROSTATE SPECIFIC ANTIGEN
Primarily affect young to middle-aged men (20 to 35 years old) y Most testicular tumors originate in gonadal cells. Signs: early sign ² firm painless, smooth testicular mass varying in size late sign ² ureteral obstruction, abdominal mass, shortness of breath Screening: Testicular Self Examination (TSE)
TESTICULAR SELF EXAMINATION
refers to the cancer of the neck of the uterus. Assessment: y Painless vaginal bleeding post-menstrual and post-coital y Foul-smelling or serosanguinous vaginal discharge y Pelvic, lower back, leg or groin pain
Cervical Cancer Screening
Normal Pap smear
Abnormal Pap smear
THYROID CANCER y - Lesions that are single, hard, & fixed on palpation or associated with cervical lymphadenopathy, suggest malignancy. SCREENING: Use of fine or large bore needle biopsy, Ultrasound, MRI, CT Scan & Thyroid Scan
LUNG CANCER y Most common from cigarette smoking. y Genetic, underlying respiratory diseases, COPD, TB y most common symptom is a cough or change in cough y Repeated unresolved URTI
Diagnostic Examination: Chest x ² ray - is
performed to search for pulmonary density, a solitary peripheral nodule (coin lesion), atelectasis and infection.
Microscopic Appearance of Cancer Cells
NURSING PROCESS: THE PATIENT WITH CANCER
I. ASSESSMENT y Regardless of type of cancer treatment or prognosis many patients with cancer are susceptible to the following problems and complications. y An important role of the oncology nurse is to assess the patient for these problems and complications
1. Infection A. Assess factors that promotes infection: y y Impaired skin & mucus membrane integrity y y Chemotherapy y y Radiation Therapy y y Biologic Response Modifiers y y Malignancy y y Malnutrition y y Urinary Catheter, Intravenous Catheter y y Other Invasive Procedures y y Contaminated Equipment y y Age y y Chronic Illness y y Prolonged Hospitalization
B. Monitoring laboratory studies to detect early changes in WBC count yy Leukopenia yy Granulocytopenia yy Neutropenia C. Chest x- ray
2. Bleeding A. Assess factors that contribute to bleeding y y Bone marrow suppression from radiation y y Chemotherapy y y Medications that interfere with coagulation and platelet functioning B. Common bleeding sites: y y Skin and mucous membranes y y Intestinal y y Genito-Urinary Tract y y Respiratory tract y y Brain
C. Signs of bleeding y y Gross hemorrhage y y Blood in the stools, urine, sputum, or vomitus y y Oozing at injection sites y y Bruising (ecchymosis) y y Petechiae y Changes in mental status
3. Skin Problems y Assess predisposing factors and other risk factors
Assess also the psychological impact of this side effect on the patient and the family
5. Nutritional Concerns Common Nutritional Problems: 1. Anorexia 2. Mal-absorption 3. Cachexia
A. Impaired nutritional status may contribute to: yy Disease progression yy Immune incompetence yy Increased incidence of infection yy Delayed tissue repair yy Diminished functional ability y Decreased capacity to continue chemotherapy
Physical signs of weight loss and cachexia is secondary to decreased protein and caloric intake, metabolic, mechanical effects of cancer and systemic disease, side effects of the treatment or emotional status of the patient.
C. Determine diet history, any episodes of anorexia, changes in appetite, altered taste, nausea, diarrhea, situation and foods that aggravate or relieve anorexia and medication history
D. Clinical and laboratory data useful in assessing Patient·s nutritional status y y Anthropometrical measurements y y Serum protein levels y y Serum electrolytes y y Skin response to intradermal injection y y Hemoglobin and hematocrit levels y y Serum Iron Levels
6. Pain A. Related factors causing pain: yy Underlying disease yy Pressure exerted by tumor yy Diagnostic procedures yy Cancer treatment B. Assess site of pain, pain perception, pain scales C. Give emphasis not only to physical pain but psychosocial as well.
7. Fatigue y y Fatigue has been recognized as one of the significant and frequent symptoms experienced by patients receiving cancer therapy. y y Assess for feelings of weariness, weakness, lack of energy, inability to carry out ADL, lack of motivation, and inability to concentrate y y Assess for physiologic and psychological stressors that contribute to fatigue, (pain, nausea, constipation, fear, anxiety) 8. Psychosocial Status 9. Body Image and Self-Esteem
II. Nursing Diagnosis y y Risk for infection related to altered immunologic
y y y y
response y Impaired skin integrity: erythematous and wet desquamation reaction to radiation therapy. y Impaired oral mucous membranes related to stomatitis. y Imbalanced nutrition: less than body requirements related to nausea and vomiting. y Fluid and electrolyte imbalance related to anorexia, nausea & vomiting, altered taste, diarrhea y Anticipatory grieving related to loss of body parts and altered role functioning Disturbed body image and situational low selfesteem related to changes in appearance, function and roles
y y y y y y
Self ² care deficit due to fatigue, malaise, and protective isolation Anxiety due to knowledge deficit and uncertain future Disturbed body image r/t changes in appearance, function and roles Grieving r/t anticipatory loss and altered role functioning Potential for spiritual distress Deficient knowledge about disease process, treatment, complication management, and self care measures
III. Planning yy Maintenance of tissue integrity yy Maintenance of nutrition yy Relief of pain yy Relief of fatigue yy Improve body image yy Effective progression through grieving process y Absence of complications
IV Nursing Interventions Managing Stomatitis o Provide good oral hygiene. o Use soft bristled toothbrushes and nonabrasive toothpaste. o Oral swabs with sponge like applicators maybe use in place of toothbrush. o Avoid alcohol based mouth rinses. o Lubricate cracked and dry lips y Adequate food and fluid intake is encouraged
Maintaining Tissue Integrity o Handle affected area gently. o Avoid rubbing or use of hot or cold water, soaps, powder, lotion and cosmetics avoided o Avoid tissue injury by wearing loosefitting clothing. o Aseptic technique should be observed during dressing and wound care.
Assisting Patients to cope with Alopecia: o Provide information about hair loss, support patient and family in coping with disturbing effects of therapy. o Instruct to acquire a wig or hairpiece before hair loss. o Encourage use of attractive scarves and hats.
Managing Malignant Skin Lesion: y Carefully assessing and cleansing the skin. y Reducing superficial bacteria. y Controlling the bleeding. y Reducing odor. y Protecting the skin from pain and further trauma.
Promoting Nutrition: o Prepare foods that are appealing. o Patient·s preferences as well as physiologic and metabolic requirements are considered when selecting foods. o Encouraged small frequent feedings. o Inform patient the advantage of receiving alternative methods of feeding by parenteral or enteral route.
Relieving Pain: y Provide adequate rest and sleep o Promote diversional activities o Offer Empathy o Give pain reliever medications as ordered
Decreasing Fatigue: o Help the patient and the family to understand that it is an expected and temporary side effect of cancer process and of many treatment used. o Help patient identify sources of fatigue o Plan activities to conserve energy as well as alternate periods of rest. o Regular, light exercise is recommended
Body Image and Self-Esteem
Positive approach is necessary o Encourage independence and continued participation in self-care decision making o Patient should be assisted to assume tasks and participate in those activities that are personally of most value. o Identify any negative feeling that that the patient has or threats to body image. o Referral to support groups
Assisting in the Grieving process:
o o o o
Grieving is a normal response to fears and anticipated losses that include, loss of heath, normal sensations, body image, social interaction, sexuality and intimacy. Asses response of patient and family about the diagnosis and planned treatment. Assist in answering inquiries and questions, identifying resources and support people. Assist patient and family acquire knowledge to cope with the disease process Assist patient and family members to acknowledge and cope with their reactions and feelings.
Managing and Monitoring Potential Complications: 1. Infection
Strict asepsis technique o Health teaching on how to recognize signs and symptoms of infection o Maintain skin integrity. o Monitoring laboratory data. o Administration of antibiotics as ordered
2. Septic Shock y Assess signs and symptoms of septic shock. y Neurologic assessment y Fluids and electrolyte status monitoring y Administration of intravenous fluids, blood products, vasopressors, oxygen and broad spectrum antibiotic as ordered.
3. Bleeding and Hemorrhage y Monitor laboratory values especially platelet count y Assess the patient for bleeding y Taking steps to prevent trauma and minimize the risk for bleeding
PROMOTING HOME AND COMMUNITY BASED CARE: y Teaching Patients Self-Care
NURSING MANAGEMENT FOR DIFFERENT MODALITIES OF TREATMENT
SURGERY Types : a. Diagnostic b. Prophylactic c. Palliative d. Reconstructive
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
The patient undergoing surgery for cancer requires general peri-operative nursing care with specific care relate to the patient·s age, organ impairment, nutritional deficits, disorder of coagulation and altered immunity that may increase the risk for post-operative complications. y The nurse provides education and emotional support by assessing patient and family needs.
Post operatively, the nurse assess the patient response to the surgery. y Monitor for possible complication y Post-operative teaching about wound care, activity, nutrition and medication information is given.
2. Radiation Therapy- ionizing Therapythat is used to:
y y y
interrupt Cellular growth Cure the cancer Used to control malignant disease when a tumor cannot be removed surgically Used when local nodal metastasis is present Used prophylactically to prevent leukemia, infiltration to the brain & spinal cord
Radiotherapy ² directing high-energy ionizing radiation to destroy malignant tumor cells without harming surrounding tissues Types: ² Teletherapy (external): radiation delivered in uniform dose to tumor; Teletherapy is external beam irradiation and uses a device located at a distance from the patient. It produces X-rays of varying energies and is administered by machines a distance from the body 31Â½ to 39 inches (80 to 100 cm).
Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it; In brachytherapy, the radiation device is placed within or close to the target tissue. Radiation is delivered in a high dose to a small tissue volume with less radiation to adjacent normal tissue, but requires direct tumor access.
Sources of Radiation Therapy
External Radiation Therapy (Teletherapy) - administered through an xray machine.
2. Internal Radiation Therapy - administered within or near the tumor. Types: a. Sealed Source (Brachytherapy) b. Unsealed source (oral, IV)
SIDE EFFECTS OF RADIATION THERAPY AND ITS NURSING RESPONSIBILITIES
SKIN REACTIONS - erythema, dry/moist desquamation - atrophy, telangiectasia, depigmentation, necrotic/ulcerative lesion. NURSING RESPONSIBILITIES: * Observe for early signs of skin reaction and report immediately.
* Keep area dry
* Wash area with water, no soap and pat dry (do not rub). * Do not apply ointments, powders or lotion on the area. * Do not apply heat, avoid direct sunshine or cold. * Use soft cotton fabrics for clothing. * Do not erase markings on the skin.
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
INFECTION HEMORRHAGE FATIGUE WEIGHT LOSS STOMATITIS DIARRHEA NAUSEA AND VOMITING HEADACHE ALOPECIA CYSTITIS SOCIAL ISOLATION
Principles of Radiation Protection:
DISTANCE - maintain a distance of at least 3 feet when not performing nursing procedures. TIME - Limit contact for 5 minutes each time, a total of 30 minutes per shift. SHIELDING - Use lead shield during contact with client.
Safety Precautions in Radiation Therapy
y y y y y y y
Assigning to a private room Posting notices Wear dosimeter badges Not assigning pregnant staff Prohibits children Limit visits 30 minutes daily Maintain 3 feet distance from the radiation source and use the Principle of time, distance and shielding.
-antineoplastic agents that are used in an attempt to destroy tumor cells by interfering with cellular functions and reproduction. Goals: cure, control, palliation Route: topical, oral, IV, IM, Subcutaneous, arterial, intra-cavitary & intrathecal Special Problem : EXTRAVASATION
1. Infection 2. Recent surgery 3. Impaired renal or hepatic function 4. Recent radiation therapy 5. Pregnancy 6. Bone marrow depression
busulfan, carboplatin, chlorambucil, cisplatin, cyclosphosphamide, dacarbazine, hexamethyl melamine, ifosfamide, melphalan, nitrogen mustard, thiotepa Alter DNA structure by misreading DNA code, initiating breaks in the DNA molecule, cross linking DNA strands.
Toxic Effects: reversible renal tubular necrosis
Antimetabolites cytarabine, 5flouroracil (5 FU), pentostatine - Interfere with the biosynthesis of metabolites or nucleic acids necessary for RNA and DNA synthesis
Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia
3. Plant alkaloids ² etoposide, teniposide, Vinblastine, Vincristine, - Arrest metaphase by inhibiting mitotic tubular formation (spindle), inhibit DNA and protein synthesis.
Antitumor antibiotics ² bleomicin doxorubicin, Mitomycin
Interfere with DNA synthesis by binding to DNA, prevent RNA synthesis
Toxic Effect: damage to cardiac muscle
Vesicants ² are those agents if deposited into the subcutaneous tissue can cause extravasation
y y y y y y y
Dactinomycin Daunorubicin Doxorubicin Nitrogen mustard Mitomycin Vinblastine Vincristine
Indications of extravasations during administration of vesicants includes:
Absence of blood return from the intravenous catheter y Resistance to flow of intravenous fluid y Swelling, pain, redness, at the site
If extravasation is suspected:
Medication administration stopped immediately
Ice applied to the site (except for vesicant vinca alkaloid)
Physician may aspirate any infiltrated medications from the tissues and inject neutralizing solution into the area to reduce tissue damage Examples of neutralizing solutions: (sodium thiosulfate, hyaluronidase, and sodium bicarbonate
Side Effects of Chemotherapy:
Gastro-intestinal system a. Nausea and Vomiting b. Diarrhea c. Constipation Integumentary system a. Pruritus, urticaria and systemic signs b. Stomatitis c. Alopecia d. Skin Pigmentation e. Nail Changes
Hematopoietic System a. Anemia b. Neutropenia c. Thrombocytopenia Genito-Urinary System a. Hemorrhagic Cystitis b. Urine color changes Reproductive system a. Premature menopause or amenorrhea
Safety Precautions in Administering Chemotherapy:
y y y
Use of biologic safety cabinet for the preparation of all chemotherapy agents. Wear surgical gloves when handling antineoplastic agents and the excretions of patients who received chemotherapy. Wear disposable, long sleeved gowns when preparing and administering chemotherapy agents. Use Luer- Lock fittings in all intravenous tubing used to deliver chemotherapy. Disposal of all equipment used in chemotherapy preparation and administration in appropriate, leakproof, puncture proof containers Disposal of all chemotherapy wastes as hazardous materials
4. THERMAL THERAPY or HYPERTHERMIA - The generation of temperatures greater than physiologic fever range ( above 41.5 ¶C ) has been used for many years to destroy tumors in human cancer. Using radio waves can produce heat, ultrasound, microwaves, magnetic waves, and hot water baths, hot wax immersions.
1. Malignant cells are sensitive to harmful effects of high temperatures. 2. Malignant cells lack repair mechanisms necessary to repair cell damage by elevated temperature. 3. Most tumor cells lack an adequate blood supply during periods if increased cellular demand such as during Hyperthermia.
Local skin care
5. BIOLOGIC RESPONSE
is also called IMMNUNOTHERAPY Substances that are able to trigger the immune system to indirectly affect tumors. These include cytokines such as interferons and interleukins. The basis of BRM is restoration, stimulation, modification and augmentation of the body·s natural defense against cancer E.g. BCG ² treat bladder cancer
Immunotherapy ² use of chemical or microbial agents to induce mobilization of immune defenses. Biologic response modifiers (BRMs) ² use of agents that alters immunologic relationship between tumor and host in a beneficial way
Patients receiving BRM therapy have many of the same needs as cancer patients undergoing treatment approaches y BRM therapies are still investigational a considered a last-chance effort by many patients. y Essential that the nurse assess the need for education, support and guidance for the patient and family in planning and evaluating patient care.
a ternary treatment for cancer involving 3 key components: a photosensitizer, light and tissue oxygen. A photosensitizer is a chemical compound (Porfimer) that can be excited by a light of a specific wavelength. Use as a treatment for basal cell carcinoma.
MAJOR SIDE EFFECT:
PHOTOSENSITIVITY FOR 4 TO 6 WEEKS AFTER TREATMENT
Instruct client to protect themselves from direct and indirect sunlight to prevent skin burns. y Liver and renal function should be monitor. y Offer emotional support and educate the client and family regarding the therapy.
8. GENE THERAPY
A technique for correcting defective genes responsible for disease development. y A gene is inserted into the genome to replace an abnormal, disease causing gene. y Viruses are used as a gene therapy vectors such as retrovirus, adenovirus,herpes simplex virus.
8. Bone Marrow
Types y 1. Autologous ² from patient y 2. Allogenic - from a donor other than a patient. Eg. family member, matched unrelated donor,(bone marrow registry) y 3. Syngeneic - from an identical twin
1. Donor suitability is determined through tissue antigen typing of human leukocyte antigen (HLA) and mixed leukocyte culture (MLC) y 2. Donor bone marrow is aspirated from multiple sites along iliac crest under general anesthesia y 3. Donor marrow is infused IV into the recipient
1. 2. 3. Failure of engraftment Infection: highest risk in 3 to 4 weeks Pneumonia: non bacterial or intestinal pneumonia are principal causes of death on the first 3 months post transplant 4. (GVHD) Graft vs., host disease: principal complication caused by an immunologic reaction of engrafted lymphoid cells against the tissue of the recipient
- Acute GHVD ² develops within first 100 days post transplant and affects GUT, liver, marrow, and lymphoid tissue y -Chronic GVHD ² Develops 100 ² 400 days post transplant manifested by multi- organ involvement 5. Recurrent malignancy 6. Late complications such as cataracts, and endocrine abnormalities
NURSING CARE PRETRANSPLANT 1. Recipient immunosuppression attained with total body irradiation (TBI) and chemotherapy to eradicate existing disease and create space in host marrow to allow transplanted cells to grow. 2. Provide protective environment. y A. Client should be in laminar airflow room or strict reverse isolation. y B. Objects must be sterilized before being brought to the room. y C. When working with children, introduce new people were they can be seen, but outside child·s room so they can see what they look like without isolation garb.
3. Monitor central lines frequently. Check patency and observe signs of infection such as fever, redness around sight. 4. Provide care for client receiving chemotherapy and radiation therapy that induce immunosuppression.
NURSING CARE POST TRANSPLANT 1. Prevent Infection. 2. Provide mouth care for stomatitis and mucositis. 3. Provide skin care. 4. Monitor carefully for bleeding. 5.Maintain fluid and electrolyte balance and promote nutrition.
6. Provide client teaching and discharge planning concerning: y Home environment (cleaning, pets, visitors) y Diet modifications y Medication regimen ²schedule, dosage, effects, side effects. y Communicable disease and immunizations y Daily hygiene and skin care y Fever y Activity
9. UNPROVEN & UNCONVENTIONAL THERAPIES
also called Complementary and Alternative Medicine. y CAM treatments are the diverse group of medical and health care systems, practices & products that are not presently considered to be effective by the standards of medicine.
Trusting relationship, supportive care, and promotion of hope with the patient and family. y Truthful responses should be given in nonjudgmental manner to questions and inquiries about unproven methods. y The nurse should encourage any patient who uses unconventional therapies to inform the physician about such use.
NURSING MANAGEMENT FOR ONCOLOGIC EMERGENCIES:
y y y y
SUPERIOR VENA CAVA SYNDROME (SVCS) INTERVENTIONS: Assess for signs and symptoms of SVCS. Monitor cardiopulmonary and neurologic status. Promote energy conservation to minimize shortness of breath. Prepare the patient for radiation therapy to the mediastinal area.
2. y y y
SPINAL CORD COMPRESSION INTERVENTIONS: Assess for back pain and neurological deficits. Prepare the client for radiation and/or chemotherapy. Surgery may be needed to remove the tumor and relieve the pressure to spinal cord. Instruct the client in the use of neck or back braces if they are prescribed.
3. HYPERCALCEMIA INTERVENTIONS: y Monitor calcium level. y Administer oral or parenteral Normal Saline fluids as prescribed. y Administer medications to lower the calcium level as prescribed. y Prepare the client for dialysis if the condition becomes life threatening or is accompanied by renal impairment.
y y y y y
PERICARDIAL EFFUSION & CARDIAC TAMPONADE INTERVENTIONS: Monitor vital signs and oxygen saturation frequently. Assess for pulsus paradoxus. Monitor ECG tracings Assess heart and lung sounds. Monitor and record intake and output
Elevate the head of patient·s bed. y Minimize patient·s physical activity. y Reposition and encourage the patient to cough. y Provide frequent oral hygiene. y As needed, maintain patient IV access, reorient the patient, provide supportive measures and appropriate patient instruction.
5. DIC/CONSUMPTION COAGULOPATHY INTERVENTIONS: y Measure and document Intake & output y Inspect all body orifices & tubes for bleeding y Prevent bleeding y Administer anticoagulant as prescribed. y Administer cryoprecipitated clotting factors if DIC progress and hemorrhage is the primary problem.
6. SIADH INTERVENTIONS: y Monitor accurate recording of intake and output. y Initiate fluid restriction and increased sodium intake as prescribed. y Administer antidiuretic hormone antagonist as prescribed. y Monitor serum sodium levels.
7. TUMOR LYSIS SYNDROME INTERVENTIONS: y Monitor Intake and Output. y Encourage oral/IV hydration. y Administer diuretics as prescribed. y Administer medications that increase the excretion of purine as prescribed. y Prepare to administer IV infusion of glucose and insulin to treat hyperkalemia. y Prepare the client for dialysis if hyperkalemia and hyperuricemia persist despite treatment.
Psychosocial aspects of cancer care:
When cancer becomes a part of life·s journey it is hardwork.
y y y y
Providing support for client (your presence as a caring person) Providing support for the family Promoting positive self concept Promoting coping throughout the cancer continuum
a. Diagnosis and treatment (clients received diagnosis and treatment in different ways) b. Survivorship (client who entered successful treatment enter an indeterminate period of long ²term survivorship) c. Recurrent disease and progression (most clients live with the threat or reality of recurrent disease) d. Terminal illness, ´ when everything is done that can be done, compassion is the only thing that brings beauty and meaning to our lives. It is the irreplaceable giftµ.
THE END«««««. GOD BLESS US ALL!
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