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IV.

ONCOLOGY
A. General Information:
1. Risk Factors:
a. Alcohol + tobacco = co-
carcinogenic
b. TOBACCO is the #1 cause of
preventable cancer.
c. Suspected dietary causes of
cancer:
Low fiber diet Nitrites
(processed sandwich meat)
Increased red meat, Alcohol
Increased animal fat,
Preservative, and additives
d. Increased incidence of
cancer in the
*that is why there is a higher
incidence of cancer > age 60
e. The most important risk
factor for cancer = Aging
f. Diet/exercise habits:
Cruciferous veggies
(broccoli, cauliflower, and
cabbage), Vitamin A foods
(colored veggies), and Vitamin
C could DECREASED risk
Regular physical activity
g. African Americans have a
GREATER incidence than
Caucasians.
h. Primary prevention: ways to
prevent actual occurrence
(sunscreen and no
smoking)
i. Secondary prevention: Using
SCREENING to detect cancer
early when there is
a greater chance for a cure or
control
j. Chronic IRRITATION brings
about uncontrolled growth of
abnormal cells.
2. Prevention:
a. Female:
Monthly self-breast exam over
age 20. ANYTIME AFTER DAY 7-12
YEARLY clinical breast exam
for women >40 years old
Between ages 20-39 needed every
3 years
ANNUAL pelvic exam
Pap smear: every 3 years if
theres been no problem
What should you instruct your
client not to do prior to a pap
smear?
NO DOUSHING, NO SEX
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Mammogram: yearly starting at
age 40 (2 views of each breast)
Before a mammogram, instruct
the client not to have on? NO
LOTION, POWDER, DEODORANT
Colonoscopy: at age 50 then
every 10 years after that time.
b. Male:
MONTHA+ self-breast exam
Monthly testicular exam-
testicular tumors grow VERY
VERY FAST.
Yearly digital exam and
yearly PSA (prostate specific
antigen) for men over
age 50
Colonoscopy at age 50 then
every 10 years
3. General S/S:
a. Caution: Change in
bowel/bladder habits
A sore that does not heal
Unusual bleeding/discharge
Thickening or lump in breast or
elsewhere
Indigestion or difficulty
swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
b. Cancer can invade bone
marrow ANEMIA and
thrombocytopenia BLEEDS
EASILY
c. Cachexia- extreme wasting
and malnutrition
4. General Tx:
a. Radiation therapy:
1) Internal Radiation
(brachytherapy)
With all brachytherapy, the
radioactive source is inside
the client;
radiation is being emitted
Types of Internal Radiation
Unsealed: client and body fluid
emit radiation
Isotope is given IV or PO
Radioactive for 24-48 hours
Sealed or solid: client emits
radiation; body fluids not
radioactive
Implanted close or in the TUMOR
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In general terms, do
radiation implants emit
radiation to the general
environment? YES
Nursing assignments should be
rotated DAILY , so that the
nurse
in not continuously exposed.
The nurse should only care for
ONE client with radiation
implant in a
given shift.
Precautions with Internal
Radiation
Private room
Wear a film badge at all times
Restrict visitors
Limit each visitor to 30 min
per day
No visitors less than 16 years
of age
Visitors may stay at least 6
feet from source
No pregnant visitors/nurses
Mark the room with instructions
for specific isotope
Wear gloves when exposed to
body fluids
How can you help prevent
dislodgment of the implant?
Keep the clienT on BEDREST .
Decrease FIBER in the diet.
Prevent bladder DISTENTION .
What do you do if the implant
becomes dislodged and you see
it?
*Dont forget this client is
immunosuppressed
2) External Radiation
(teletherapy, beam radiation):
Usual side effects of
external radiation are usually
limited to the exposed
tissues:
Erythema
Shedding of skin
Altered taste
Fatique
Pancytopenia (all blood
components are decreased)
Many signs and symptoms are
LOCATION and DOSE related
Is it okay to wash off the
markings? NO
Is it okay to use lotion on
the marking? NO
Protect site from sun for 1
year after completion of
therapy.
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b. Chemotherapy:
Works on the CELL cycle
Usually scheduled every 3-4
weeks
Most chemo drugs are given IV
via a port.
Many chemo drugs absorb
through the SKIN and MUCUS
MEMBRANES; be
careful handling them.
Usual side effects: alopecia,
N/V, mucositis,
immunosuppression, anemia,
thrombocytopenia
A vesicant is a type of chemo
that if infiltration
(extravasation) occurs will
cause tissue NECROSIS.
What are S/S of
extravasation? PAIN, SWELLING,
NO BLOOD RETURN
The #1 thing to remember with
extravasation is PREVENTION!
What do you do if this
happens? 1
ST
- STOP THE INFUSION,
2
ND
ICE PACKS
For NCLEX, stop the infusion
and think vasoconstriction to
prevent
spreading.
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B. General Ways to Prevent
Infection
1. Private ROOM
2. Wash hands.
3. Have own SUPPLY in room
4. Limit people (visitors and
nurses) in room.
5. Change dressing and IV
tubing DAILY.
6. Cough and deep breath.
7. No fresh FLOWERS or potted
PLANTS
8. Avoid crowds.
9. Do not share toiletries.
10. Bathe warm moist areas
TWICE A DAY (groin and under
the arms).
11. Wash hands after touching
pet.
12. Avoid raw FRUITS and
VEGETABLES .
13. Drink only fresh water.
Remember:
14. Slight increase in temp may
mean SEPSIS.
15. Absolute neutrophil count
is most important lab value.
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C. Specific Types of Cancer:
1. Cervical Cancer:
a. Risk factors:
The number one risk factor is
Human Papilloma Virus.
Repeated STDs
MULTIPLE sexual partners
Smoking and exposure to
second hand smoke
Dietary factors such as
certain nutritional
deficiencies: folate, beta-
carotene
and vitamin C.
Prolonged HORMONAL therapy
Mothers who took DES during
pregnancy put their daughters
at higher risk.
Family history.
Immunosuppression
Sex at a young AGE and
multiple pregnancies
b. S/S:
Often asymptomatic in pre-
invasive cancer
Invasive cancer classic
symptoms: PAIN LESS VAGINAL
bleeding
Other general S/S: watery,
blood-tinged vaginal discharge,
pelvic pain (and it
may occur with intercourse),
leg pain along sciatic nerve,
and flank/back
pain,
100% cure if detected early
c. Dx:
What is the test that helps
diagnose this? PAP SMEAR
Abnormal? Repeat test
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d. Tx:
Electrosurgical excision
Laser
Cryosurgery
PAAIATION and chemo for
late stages
Conization- remove part of
CERVIX
Hysterectomy
2. Uterine Cancer:
(Endometrial Cancer)
a. Risk Factors:
Greater than 50 years of age
Taking estrogen therapy
without progesterone
Positive family history
menopause LATE
No pregnancy (null parity)
b. S/S:
Major symptoms: post
MENOPAUSAL bleeding
Other S/S: watery/bloody
vaginal discharge, low back/abd
pain, pelvic pain
c. Dx:
CA-125 (blood test) to R/O
OVARIAN involvement
Test to evaluate for
metastasis:
CXR (chest x-ray)
IVP (Intra Venous
Pyelogram)
BE (Barium Enema)
CT
Liver and bone scan
The most definitive
diagnostic test is (dilatation
& curettage) and
endometrial biopsy.
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d. Tx:
1) Surgery: Hysterectomy
TAH (total abd hysterectomy)
= uterus and cervix only! :
Tubes & ovaries removed?
Bilateral oophorectomy
(ovaries)
Bilateral salpingectomy (tubes)
Radical Hysterectomy:
May remove all of the pelvic
organ
Client may have COLOSTOMY or
ileal conduit
The greatest time for
hemorrhage following this
surgery is during the
first 24HRS.
Why? Pelvic congestion of
BLOOD
Major complication with
abdominal hysterectomy?
Hemorrhage
Major complication with
vaginal hysterectomy? INFECTION
Will probably have a foley;
if she doesnt you better make
sure she
does what in the next 8 hours?
VOID
Why is it so important to
prevent abdominal distention
after this
surgery?
We do not want tension on thE
SUTURE LINE.
Dehiscence and evisceration
Why do we avoid high-
fowlers position in this
client?
Because high fowlers will make
more blood go where? TO THE
PELVIS

May have an abdominal and
perineal dressing to check. 2
DRESSING TO CHECK
As this client is at risk for
pneumonia, thrombophlebitis,
and
constipation what is one thing
you can do to prevent these
complications? EARLY AMBULATION
Avoid sex and driving.
Also avoid girdles and
douches.
Any exercise, including
lifting heavy objects that will
increase pelvic
CONGESTION should be avoided.
Is it possible that the
client could hemorrhage 10-14
days after this
surgery? YES
Is a whitish vaginal
discharge okay? YES
Showers OR baths? SHOWER
2) Radiation: intra-cavitary
radiation to prevent vaginal
recurrence
3) Chemotherapy: Doxorubicin
(Adriamycin), Cisplatin
(Plantinol-AQ)
4) Estrogen inhibitors:
Medroxyprogesterone (Depro-
Provera), Tamoxifen
(Nolvadex / Soltamox)
3. Breast Cancer:
a. Risk Factors:
One has a 3 fold risk
increase of developing breast
cancer if a FIRST degree
relative (mother, sister,
daughter) had pre-menopausal
breast cancer.
High dose radiation to thorax
prior to age 20
PERIOD onset prior to age 12
Menopause after age 50
No pregnancy (null parity)
First birth greater than 30
years old
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b. S/S:
Change in the appearance of
the breast (orange peel
appearance, dimpling,
retraction, discharge from
breast) or lump
Tail of Spence is where 48%
of breast tumors occur: located
in upper outer
quadrant
c. Tx:
1) Surgery:
Post op care:
Bleeding check dressings,
back (POOLING of blood),
hemovac,
Jackson-Pratt drain
Elevate arm on AFFECTED side.
Associated nursing care: Stay
away from arm on affected side
for
lifetime of client:
* No watch, no constriction, no
BPs or injections, wear
gloves when
gardening, watch small cuts, no
nail biting, and no sunburn, no
IV
Brush hair, squeeze tennis
balls, wall climbing, flex and
extend elbow
Why? Promotes circulation
Look at incision
Reach to Recovery (Support
Group)
Lymphedema
*Two functions of the lymphatic
system:
FIGHT infection and promotes
drainage
2) Chemotherapy drugs:
Paclitaxel (Taxol),
Doxorubicin (Adriamycin)
3) Hormonal Therapy:
Estrogen receptor blocking
agents: Tamoxifen (Nolvadex/
Soltamox)
Estrogen synthesis
inhibitors: Leuprolide
(Lupron), Goserelin
(Zoladex)
4) Radiation
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4. Lung Cancer:
a. Risk Factors:
Leading cause of cancer death
worldwide
Five year survival rate is
16%
Major risk factor: SMOKING
*When you have stopped smoking
for 15 years, the incidence of
lung
cancer is almost like that of a
non-smoker.
b. S/S:
Hemoptysis, dyspnea (may be
confused with TB, but TB has
night sweats),
hoarseness, cough, change in
endurance, chest pain,
pleuritic pain on
inspiration, displaced trach
May metastasize to bone
c. Dx:
1) Bronchoscopy:
NPO pre and NPO until GAG
REFLEX returns
Watch for respiratory
depression, hoarseness,
dysphagia, SQ emphysema.
What is SQ emphysema? AIR UNDER
THE TISSUE
Is it normal or abnormal to
have respiratory depression
after a
bronchoscopy? ABNORMAL
TOO LOW OR TOO HIGH PROBLEM,
SHOULD BE ALWAYS PERFECT
2) Sputum specimen:
Best time to obtain? In the
morning
Is this sterile? YES
What should the client do
first? RINSE MOUNTH WITH WATER
* Trying to decrease bacterial
count in the mouth
3) Chest x-ray:
4) CT:
5) MRI:
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d. Tx:
Surgery: The main treatment
for stage I and II
Lobectomy: TAKE OUT PART OF
THE LUNG
Chest tubes and surgical side
up
Pneumonectomy: REMOVAL OF
ENTIRE LUNG
Position on affected side
(surgical side down, good lung
up).
No chest tubes, why? THE LUNG
IS GONE, NO FLUID SPACE.
Avoid severe lateral
positioning mediastinal SHIFT
5. Laryngeal Cancer:
a. Risk Factors:
SMOKING (any form of tobacco
use), alcohol, voice abuse,
chronic
laryngitis, industrial
chemicals
b. S/S:
Hoarseness, lump in neck,
sore throat, cough, problems
breathing,
earache, weight loss, no early
signs
c. Dx:
Laryngeal exam, MRI
d. Tx:
1) Surgery:
Total laryngectomy (removal
of VOCAL cords, epiglottis,
thyroid
cartilage)
Since the whole larynx
(remember this includes the
epiglottis) is removed
this client will have a
permanent TRACHEOSTOMY.
Position post op? SEMI
FOWLERS, HOB 35 DEGREES
NG feedings to protect the
suture line (peristalsis could
disrupt SUTURE LINE)
Monitor drains.
Watch for CORRATED artery
rupture.
Rupture of innominate artery-
medical emergency
Frequent MOUTH care to
decrease bacterial count in the
mouth
NPO clients tend to get
pneumonia.
Bib (acts like a filter)
Humidified environment
* Remember, with a total
laryngectomy ALL breathing is
done
through the stoma.
2) Radiation:
3) Chemotherapy:
4) Speech Rehabilitation
When should client teaching
begin?
Good client
Refer to International
Association of
Laryngectomees.
*See if there are local groups
such as the Lost Cord Group.
Speech Devices
Electrolarynx is a handheld
device held up to the clients
cheek or neck, it
vibrates while the client forms
words
Most common device is a Blom-
Singer device
Connection is made between
trachea and esophagus
Once the fistula heals, client
can insert soft plastic device
and move air
from lungs to the trachea and
then over to the esophagus and
out of the
mouth. In the mouth the tongue
and lips can form words with
the rush of
air.

e. Miscellaneous Information:
1) Can the client with a total
laryngectomy:
Whistle? NO
Straw? NO
Smoke? YES
Swim? NO
2) Suctioning:
Sterile or non-sterile
techniques? STERILE
Hyper-oxygenate when? BEFORE
and AFTER
When do you stop advancing
the catheter? When you meet
resistance or
your client coughs.
Apply suction when? ON THE
WAY OUT
Intermittent or continuous?
INTERMITTENT *Dont be mean.
Suction no longer then 10
seconds.
Watch for arrhythmias. VAGUS
NERVE WILL BE STIMULATED
Which nerve can be stimulated?
vagus nerve
When VAGUS nerve is stimulated,
heart rate DOWN.
Is this client hypoxic? STOP
SUCTIONING AND HYPEROXIGINATE
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6. Colorectal Cancer (CRC):
a. Risk Factors:
May start as a POLYP
2/3 colorectal cancer occurs
in the rectosigmoidal region
Most frequent site of
metastasis: LIVER
*take bleeding precautions
Other problems to watch for:
bowel obstruction, perforation,
fistula to
bladder/vagina
Additional risk factors:
inflammatory bowel diseases,
genetic, dietary factors
(refined carbs, low fiber, high
fat, red meat, fried and
broiled foods) if you
have a first degree relative
with CRC your risk just
increased 3X the norm
95% of those who get CRC are
greater than 50 years old.
b. Dx:
Screening
Fecal occult blood testing
should begin at 50 YEARS OLD.
Flexible sigmoidoscopy every
5 years after age 50 or
colonoscopy every 10
years after age 50
The definitive test for
colorectal cancer =
COLONOSCOPY.
c. S/S:
Change in bowel habits,
constipation, diarrhea,
narrowing of stool
Other S/S: blood in the
stool, cramping abdominal pain,
weakness, fatigue,
anemic, abdominal fullness,
unexplained weight loss
May become obstructed
(visible peristaltic waves with
high pitched tinkling
bowel sounds)
d. Tx:
1) Surgery, radiation, and
chemo
2) May have a colostomy post op
Colectomy-part of COLON
removed
*may not need colostomy
Abdominoperineal resection-
removal of the COLON, anus,
rectum
*can you take a rectal temp on
this client? NO
Dont take rectal temp if
thrombocytopenic,
abdominoperineal resection,
immunosuppressed
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7. Bladder Cancer:
a. Risk Factors:
Greatest risk factor: SMOKING
b. S/S:
Major symptom: PAINLESS
intermittent gross/microscopic
hematuria
c. Dx:
Cystoscopy
d. Tx:
Surgery (all/part of
bladder) urinary diversion
(urostomy)
Ileal conduit (a piece of the
ileum is turned into a BLADDER;
ureters are placed in one end;
the other end is brought to the
abdominal
surface as a stoma)
May be impotent
Hourly OUTPUT
Increase FLUIDS (2,000-3,000
ml of fluid per day).
* flush out conduit
Mucus normal? YES
Intestines always make mucus
(the bladder is made from a
part of
intestine).
Change appliance in THE
MORNING (This is when output
will be at
its lowest).
It is OK to place a little
piece of 4X4 inside stoma
during skin care to absorb
urine... Just dont forget to
remove it
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8. Prostate Cancer:
a. S/S:
This client comes to the
doctor with S/S of benign
prostatic hyperplasia
(BPH): hesitancy, frequency,
frequent infections (because
the bladder is not
completely emptied), nocturia,
urgency, dribbling. Many
clients are
asymptomatic.
Most common sign is painless
HEMATURIA
Digital rectal exam done and
prostate is hard/nodular; this
usually means
prostate cancer.
b. Dx:
1) Lab work:
PSA will be increased.
Prostate-specific antigen (PSA)
This is a protein that is only
produced by the prostate.
Normal is less than 4 ng/ml.
If you have a two or more 1st
degree relatives with prostate
CA, start
PSA by at least age 45.
This is a blood test.
Alkaline phosphatase (if
means bone metastasis)
*Prostate cancer likes to go to
spine, sacrum, and pelvis.
Increased acid phosphatase
(if means bone metastasis)
2) Biopsy:
When prostate CA is
suspected, a biopsy must be
done for confirmation
prior to surgery.
c. Tx:
1) Watchful WAITING: in early
stages (for asymptomatic, older
adults
with other illness)
2) Surgery:
Radical Prostatectomy (done
with LOCALIZED prostate CA)
Take out the prostate and the
client is cancer free (if there
is no
metastasis).
May have erectile dysfunction
due to pudendal nerve damage
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May have incontinence (Kegel)
Client is sterile.
If there is no lymph node
involvement, no in acid
phosphatase, and no
metastasis, the surgeon will
try to preserve the pudendal
nerve.
Prostatectomy (TURP-
transurethral resection of the
prostate)
Usually reserved for BPH to
help urine flow, not a cure for
prostate CA
No incision (go through the
urethra)
Most common complication?
BLEEDING
With other procedures you
have to explain risk of
impotency/infertility.
Is it normal to see bleeding
after this surgery? YES
Continuous bladder irrigation
maintains PATENCY, flush out
clots
3-way catheter
No kinks
Subtract irrigant from output.
Keep up with amount of
irrigant instilled
What drug do you give for
bladder spasms? Belladonna and
Opium
Suppository (B&O suppository),
Oxybutynin (Ditropan)
*TESTING STRATEGY*
Always assess prior to
selecting
an implementation answer.
Always assess the client first.
*TESTING STRATEGY*
Never manually irrigate
catheter
with fresh surgery without a
physicians order.
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When catheter is removed what
do you watch for? Urine
retention
Temporary incontinence
expected (perineal exercises-
Kegel)
Avoid sitting, driving,
strenuous exercise; do not lift
too
muchWhy? BLEEDING
Docusate (Colace); avoid
straining Why? BLEED
Increase fluids: to flush out
HEMATURIA
The TURP is used for
symptomatic relief of
symptoms to allow the
urine to flow out This is not
a cure for prostate cancer.
3) Radiation:
4) Chemotherapy:
5) Hormone therapy:
May decrease testosterone
through bilateral orchiectomy
Estrogens
Leuprolide (Lupron)
9. Stomach Cancer:
a. Risk factors:
H-Pylori-associated with
stomach cancer
Pernicious anemia There is a
HIGHER instance of Achlorhydria
stomach cancer with people who
have pernicious anemia and
achlorhydria.
Related to: pickled foods,
salted meats/fish, nitrates,
increased salt
Billroth II (partial
gastrectomy with an
anastomosis)
Tobacco and Alcohol
b. S/S:
Most common: Heart BURN and
discomfort ABDOMINAL DISCOMFORT
Other S/S: loss of appetite,
weight loss, bloody stools,
coffee-ground vomitus,
jaundice (liver metastasis),
epigastric and back pain,
feeling of fullness,
anemia, stool + for occult
blood, achlorhydria (no HCL in
the stomach),
obstruction (S/S of an
obstruction: abdominal
distention, n/v, pain) (Tx for
obstruction: NPO, NG tube to
suction for abd decompression)
c. Dx:
Upper GI, CT, EGD
(esophagogastroduodenoscopy)
d. Tx:
1) Surgery (preferred):
Gastrectomy
Fowlers position (decrease
stress on THE STOMACH.)
Will have NG tube (for
decompression)
Is it ok to reposition?
Two major complications:
Dumping syndrome
B-12 deficient anemia-
Pernicious anemia
*Schillings test
(Measures the urinary excretion
of Vitamin B-12 for diagnosis
of pernicious anemia)
No stomach no intrinsic
factor cant absorb oral B-
12 cant make good
RBCs client is anemic
2) Chemotherapy: Fluorouracil
(5-FU), Doxorubicin
(Adriamycin),
Mutamycin (Mitomycin-C),
Cisplatin (Platinol-AQ)
3) Radiation: