PATHOPHYSIOLOGY OF THE MALIGNANT
alpha-fetoprotein (AFP) for liver cancer and
PROCESS
FAMILY HISTORY
• Obtain information about both maternal and
paternal sides of family.
• Obtain cancer history of at least three
generations.
• Look for clustering of cancers that occur at
earlier ages, multiple primary cancers in one
individual, cancer in paired or- gans, and two
or more close relatives with the same type
of cancer suggestive of hereditary cancer
syndromes.
PHYSICAL ASSESSMENT
• Physical findings that may predispose the
patient to cancer, such as multiple colonic
polyps, suggestive of a polyposis syndrome
• Skin findings, such as atypical moles, that
may be related to familial melanoma
syndrome
• Multiple café au lait spots, axillary freckling,
and two or more neurofibromas associated
with neurofibromatosis type I
• Facial trichilemmomas, mucosal
papillomatosis, multi-nodular thyroid goiter
or thyroid adenomas, macrocephaly,
fibrocystic breasts and other fibromas or
lipomas related to Cowden syndrome
CANCER STAGING
• Staging is the process of finding out how
much cancer is in a person’s body and
where it is located.
• It is how the doctor determines the stage
of a person’s cancer.
Exams and tests to stage cancer
1. Physical Exam
2. Imaging tests - Xrays, CT scans, MRIs,
Ultrasound and PET scans
3. Endoscopy exams
4. Biopsy
5. 5.Lab tests of cancer cells- prostate- specific
antigen (PSA) for prostate cancer, cancer
antigen 125 (CA 125) for ovarian cancer,
1
calcitonin for medullary thyroid cancer,
human chorionic gonadotropin (HCG) for
germ cell tumors, such as testicular cancer
and ovarian cancer.
CLINICAL STAGING
The clinical stage is an estimate of the extent of the
cancer based on results of physical exams, imaging
tests (x-rays, CT scans, etc.), endoscopy exams, and
any biopsies that are done before treatment starts.
For some cancers, the results of other tests, such as
blood tests, are also used in clinical staging.
TNM SYSTEM
Tumor (T), node (N), and metastasis (M) categories.
• T describes the original (primary) tumor.
• N tells whether the cancer has spread to the
nearby lymph nodes.
• M tells whether the cancer has spread
(metastasized) to distant parts of the body
The primary tumor (T category)
• A number after the T (such as T1, T2, T3,
or T4) might describe the tumor size and/or
amount of spread into nearby structures.
• The higher the T number, the larger the
tumor and/or the more it has grown into
nearby tissues.
The lymph nodes (N category)
• Lymph nodes near the primary tumor are
usually are checked to find out if cancer has
spread into them.
• The N category can be assigned a letter or a
number:
o NX means there is no information
about the nearby lymph nodes, or
they can’t be assessed.
o N0 means nearby lymph nodes do
not contain cancer.
• A number after the N (such as N1, N2, or
N3) might describe the size, location,
and/or the number of nearby lymph nodes
affected by cancer.
 • The higher the N number, the greater the example, stage III might be subdivided into
cancer spread to nearby lymph nodes. stages IIIA and IIIB).

Metastasis (M category) ii. Palpation – masses, tenderness,

• Doctors might also look at other parts of the
body to see if the cancer has spread.
• Cancer spread to parts of the body far from
the primary tumor is known as metastasis.
• The M category is assigned a number:
• M0 means that no distant cancer spread has
been found.
• M1 means that the cancer has been found
to have spread to distant organs or tissues.
GRADE
nodules, lesions, distension.
SITE
Anatomical location: Usually expressed in terms of
distance from a bony prominence (e.g. 2cm superior
to the angle of the right mandible) or a well-
demarcated site (e.g. left antecubital fossa)
Relationship to surrounding structures
• It may be possible to determine the
anatomical plane from information given in
the history or on examination

• For most cancers, the grade is a measure of e.g. a subcutaneous lump lying superficial to a muscle
how abnormal the cancer cells look under will become more prominent when the underlying
the microscope. This is also called muscle is contracted, an intramuscular or
differentiation. Grade can be important submuscular lump will become less visible
because cancers with more abnormal-
looking cells tend to grow and spread faster.
• The grade is usually assigned a number, with SIZE
lower numbers (for example, G1) used for
lower grade cancers.
• In low-grade (well-differentiated) cancers,
the cancer cells look fairly normal. In
general, these cancers tend to grow slowly
and often have a better outlook.
• In high-grade (poorly differentiated) cancers,
the cancer cells look more abnormal. High-
grade cancers often tend to grow quickly, so
they may need different treatments than
low-grade cancers.

ASSIGNING AN OVERALL STAGE (STAGE

GROUPING)

• Once the values for T, N, and M (and any

other factors that affect stage) have been
determined, they are combined to assign an
overall stage.
• For most cancers, the stage is a Roman
numeral from I (1) to IV (4). • Size can be estimated but ideally should be
• Stage I cancers are less advanced and often measured using a tape measure or ruler
have a better prognosis (outlook). Higher • This ensures accuracy and allows objective
stage cancers typically have spread farther assessment of any change in size
(or have other concerning features), so they • Size should be stated in at least two
might require more intense (or different dimensions
kinds of) treatment. Sometimes stages are
subdivided as well, using capital letters (for

2
SHAPE • Intrinsic pulsation is indicated by a swelling
that is pulsatile and expansile (e.g. an
abdominal aortic aneurysm)

SOME GENERAL SIGNS AND SYMPTOMS

ASSOCIATED WITH, BUT NOT SPECIFIC TO,
CANCER, INCLUDE:
• The lump should be considered in three
dimensions when describing its shape
• Descriptions should be made in geometrical
terms where possible (e.g. spherical, oval,
round etc.)

SURFACE (APPEARANCE AND COLOUR)

Appearance: Is it smooth or rough; flat or raised;

regular or irregular?

• Is there any evidence of ulceration (skin

breakdown) or necrosis (blackened, usually
secondary to ischemia)?
• Normal skin often overlies deep lumps, while
superficial swellings are more likely to result
in a change in the overlying skin

Color: The lump may be the color of the overlying skin

or may appear red and inflamed

• Certain lumps are abnormally pigmented

(e.g. melanoma)

CONSISTENCY
• This clinical feature describes a spectrum
between hard and soft and can be
considered under three categories: hard,
firm (rubbery or spongy) or soft
• Hard lumps suggest the possibility of cancer
• Fluid-filled lumps may be tense (and thus
quite hard), rubbery or spongy
• Soft lumps are more likely to be benign (e.g.
lipoma)
• In terms of comparisons: hard is like your
chin, firm is like your nose, soft is like your
ear-lobe
PULSATILITY
• Note whether the lump is pulsatile,
suggesting a vascular origin. Try to
determine whether the pulsation originates
from the lump itself or whether it is
transmitted from a nearby vessel
• Fatigue
• Lump or area of thickening that can be felt
under the skin
• Weight changes, including unintended loss or
gain
• Skin changes, such as yellowing, darkening
or redness of the skin, sores that won't heal,
or changes to existing moles
• Changes in bowel or bladder habits
• Persistent cough or trouble breathing
• Difficulty swallowing
• Hoarseness
• Persistent indigestion or discomfort after
eating
• Persistent, unexplained muscle or joint pain
• Persistent, unexplained fevers or night
sweats
• Unexplained bleeding or bruising

3
 c. Diagnostic studies/ Procedures
1. SCREENING
A. BREAST SELF EXAM (BSE)
Step 1: Begin by looking at your breasts in the mirror
with your shoulders straight and your arms on your
hips.
Here's what you should look for:
• Breasts that are their usual size, shape, and
color
• Breasts that are evenly shaped without
visible distortion or swelling
• If you see any of the following changes,
bring them to your doctor's attention:
• Dimpling, puckering, or bulging of the skin
• A nipple that has changed position or an
inverted nipple (pushed inward instead of
sticking out)
Step 2: Now, raise your arms and look for the same
changes.
Step 3: While you're at the mirror, look for any signs
of fluid coming out of one or both nipples (this could
be a watery, milky, or yellow fluid or blood).
Step 4: Next, feel your breasts while lying down, using
your right hand to feel your left breast and then your
left hand to feel your right breast.
• Use a firm, smooth touch with the first few
finger pads of your hand, keeping the
fingers flat and together. Use a circular
motion, about the size of a quarter.
• Cover the entire breast from top to bottom,
side to side — from your collarbone to the
top of your abdomen, and from your armpit
to your cleavage.
Step 5: Finally, feel your breasts while you are
standing or sitting. Many women find that the easiest
way to feel their breasts is when their skin is wet and
slippery, so they like to do this step in the shower.
Cover your entire breast, using the same hand
movements described in step 4.
Diagnostics Test
• Ultrasound -30 or are pregnant or
breastfeeding.
• Both an ultrasound and a mammogram are
typically recommended to evaluate a lump in
women who are over age 30 and not
pregnant or breastfeeding.
4
• If further testing is needed, your doctor may
recommend additional imaging with MRI
(magnetic resonance imaging), MBI
(molecular breast imaging), and/or a biopsy.
• He or she may also refer you to a breast
specialist typically a breast surgeon for
further evaluation.
PAP SMEAR
• A Pap smear, also called a Pap test, is a
procedure to test for cervical cancer in
women.
• Detecting cervical cancer early with a Pap
smear gives you a greater chance at a cure.
• Doctors generally recommend repeating
Pap testing every three years for women
ages 21 to 65.
• Women should start Pap smear screening at
age 21.
• Between the ages of 21-29, women whose
Pap smears are normal only need it
repeated every three years.
• Women ages 30 and over should have
testing for the human papillomavirus (HPV)
with their Pap smear. HPV is the cause of
cervical cancer.
Patient Preparation:
• To ensure that your Pap smear is most
effective, follow these tips prior to your test:
• Avoid intercourse, douching, or using any
vaginal medicines or spermicidal foams,
creams or jellies for two days before having
a Pap smear, as these may wash away or
obscure abnormal cells.
• Try not to schedule a Pap smear during your
menstrual period. It's best to avoid this time
of your cycle, if possible.
• A Pap smear is performed in your doctor's
office and takes only a few minutes. You
may be asked to undress completely or only
from the waist down.
 • You'll lie down on your back on an exam
table with your knees bent. Your heels rest
in supports called stirrups.
• Your doctor will gently insert an instrument
called a speculum into your vagina. The
speculum holds the walls of your vagina
apart so that your doctor can easily see your
cervix. Inserting the speculum may cause a
sensation of pressure in your pelvic area.
• Then your doctor will take samples of your
cervical cells using a soft brush and a flat
scraping device called a spatula. This usually
doesn't hurt.
Results
A Pap smear can alert your doctor to the presence of
suspicious cells that need further testing.
Normal results: If only normal cervical cells were
discovered during your Pap smear, you're said to have
a negative result. You won't need any further
treatment or testing until you're due for your next Pap
smear and pelvic exam
Abnormal results: If abnormal or unusual cells were
discovered during your Pap smear, you're said to
have a positive result. A positive result doesn't mean
you have cervical cancer. What a positive result
means depends on the type of cells discovered in
your test
RECTAL EXAM
A digital rectal exam (DRE) is a test for both men and
women. It allows a doctor to check the lower rectum,
pelvis, and lower belly for cancer and other health
problems, including:
• Prostate cancer in men
• Blood in the stool or an abnormal mass in
the anus or rectum
• Uterine or ovarian cancer in women, along
with a vaginal examination
5
• Men sometimes need a rectal examination
to check for problems with the prostate.
Before having a rectal examination
• Your doctor or nurse should explain what's
going to happen and why you need a rectal
examination.
• They'll know that some people can feel
embarrassed, but it's a common procedure.
Let the doctor or nurse know if:
• you'd prefer a man or woman to perform the
examination
• you'd like someone else in the room – it
could be a friend, family member or another
doctor or nurse
• you have severe pain in your bottom – they
may be able to use local anaesthetic to
numb the area
What happens during a rectal examination:
• First, you'll be asked to undress from the
waist down. If you're wearing a loose skirt,
you can usually just remove your underwear.
• Let the doctor or nurse know if you'd like to
get changed behind a curtain or be alone in
the room.
The doctor or nurse will:
• Ask you to lie down on your left side, with
your knees lifted up towards your chest. This
is the easiest position to examine your
rectum.
• Put on some gloves and look at the outside
of your bottom for any problems.
• Put some lubricating gel on 1 finger and
gently slide it into your rectum. This should
not be painful, but may be a little bit
uncomfortable.
• Sometimes ask you to squeeze around their
finger so they can assess how well the
muscles are working.
• If you're a man, the doctor or nurse may
press on your prostate. This can make you
feel the urge to pee, but it should not hurt.
• Once you're dressed, they'll discuss the
results of the examination with you.
NON-INVASIVE: BONE SCAN
A bone scan is an imaging test used to help diagnose
problems with your bones. It safely uses a very small
amount of a radioactive drug called a
radiopharmaceutical
A bone scan can also be used to determine whether
cancer has spread to the bones from another area of
the body, such as the prostate or breast.
NON-INVASIVE: THYROID SCAN
Thyroid scan and uptake uses small amounts of
radioactive materials called radiotracers, a special
camera and a computer to provide information about
your thyroid's size, shape, position and function that
is often unattainable using other imaging procedures.
• Thyroid scans are usually performed on an
outpatient basis in the nuclear medicine
department of a hospital. They can be
administered by a nuclear medicine
technologist. Your endocrinologist may or
may not be there during the procedure.
• Before any thyroid scan, you’ll receive
radionuclide in the form of a pill, liquid, or
injection.
• Thyroid scans are usually performed on an
outpatient basis in the nuclear medicine
department of a hospital. They can be
administered by a nuclear medicine
technologist. Your endocrinologist may or
may not be there during the procedure.
• Before any thyroid scan, you’ll receive
radionuclide in the form of a pill, liquid, or
injection.
6
Preparing for a Thyroid Scan:
• Tell your physician about any prescription or
over-the-counter medications you’re taking.
Discuss how they should be used before
and during the test.
• You may have to discontinue thyroid
medication from four to six wee before your
scan. Some heart medications and any
medicine containing iodine also may require
adjustments.
• For any thyroid scan, you may be asked to
avoid certain foods that contain iodine for
about a week before your procedure.
Typically, you shouldn’t eat: dairy products,
shellfish, sushi, seaweed, iodized salt,
seasonings that contain iodized salt
• You also should refrain from using:
• Antihistamines, cough syrups, multivitamins,
supplements containing iodine
• Other drugs that could affect the results of
an RAIU are: adrenocorticotropic hormone
(ACTH), barbiturates, corticosteroids,
estrogen, lithium, Lugol’s solution, which
contains iodine Nitrates, phenothiazines,
tolbutamide
Results
Normal thyroid scan: would show no abnormalities in
the size shape, and location of the thyroid gland. Your
thyroid will have an even green color on the image.
Red spots on the image indicate abnormal growths
in the thyroid. Normal results from metastatic scan
indicate an absence of thyroid tissue and no spread
of thyroid cancer.
Abnormal thyroid scan: may show a thyroid that’s
enlarged out of position, indicating a possible tumor.
Abnormal measurements also may show that your
thyroid gland collecte too much or too little of the
radionuclide.
Abnormal results of a thyroid scan may also indicate:
• colloid nodular goiter, which is a type of
thyroid enlargement due to too little iodine
• Graves’ disease, which is a type of
hyperthyroidism
• painless thyroiditis, which can involve
switching between hyperthyroidism and
hypothyroidism
• toxic nodular goiter, which is an enlargement
of a nodule on a existing goiter
•
INVASIVE: BIOPSY

2. Fine needle aspiration biopsy. During this

A biopsy is a sample of tissue taken from the body in
order to examine it more closely.
Types of biopsies
minimally invasive biopsy, the doctor uses a very
thin, hollow needle attached to a syringe. He or
she collects a small amount of tissue from the
suspicious area to examine and test. Your doctor
may use this biopsy for a mass that he or she can
feel through the skin or with image-guided biopsy
(see above).

1. Image-guided biopsy. Your doctor may use an

image-guided biopsy approach when he or she
cannot feel a tumor or when the area is deeper
inside the body. During this procedure, your doctor
guides a needle to the location with the help of an 3. Core needle biopsy. This type of biopsy uses a
imaging technique. Your doctor can do an image- larger needle to remove a larger tissue sample. It
guided biopsy using a fine needle, core, or is similar to a fine needle biopsy and is also
vacuum-assisted biopsy. This depends on the minimally invasive
amount of tissue needed, possible diagnoses, and
other factors. Your doctor will use one of the
following types of imaging based on the location
and other factors:
o Ultrasound
o Fluoroscopy
o Computed tomography (CT)
scan
o X-ray
o Magnetic resonance imaging 4. Vacuum-assisted biopsy. This type of biopsy
(MRI) scan uses a suction device to collect a tissue sample
o through a specially designed needle. Your doctor
can collect multiple or large samples from the
same biopsy site with this method. A vacuum-
assisted biopsy can sometimes be image guided

7

5. Excisional biopsy. During an excisional biopsy,
your doctor removes the entire suspicious area.
This is commonly used for suspicious changes on
the skin. Doctors also sometimes use it for a small,
easily removable lump under the skin. However,
fine needle aspiration or core needle biopsy are
more common for lumps that cannot be seen or
felt through the skin.
6. Shave biopsy. For this type of biopsy, the
doctor uses a sharp tool to remove tissue from
the skin surface.
7. Punch biopsy. During a punch biopsy, the
doctor inserts a sharp, circular tool into the skin.
He or she then takes a sample from below the skin
surface.
7. Endoscopic biopsy. An endoscope is a thin,
lighted, flexible tube with a camera. Doctors use
this tool to view the inside of the body, including
the bladder, abdomen, joints, or gastrointestinal
(GI) tract.
They insert endoscopes through the mouth or a
tiny surgical incision. The attached camera helps
8
the doctor see any abnormal areas. Doctors also
use them to take tiny samples of the tissue using
forceps. The forceps are also a part of the
endoscope.
8. Laparoscopic biopsy. This type of biopsy is used
for the abdomen. Similar to an endoscopic biopsy,
the doctor inserts a thin tube with a video camera
called a laparoscope into the abdomen through a
tiny incision. The camera helps the doctor see any
abnormal areas. Then doctors can insert a small
needle and take a tissue sample.
Getting ready for a biopsy:
Preparation for a biopsy depends on the type of
biopsy you will have. For example, there is little
preparation for a fine needle biopsy performed in
a doctor's office. In some cases, you will need to
remove your clothing and wear a gown.
Before your biopsy:
• Ask your doctor or nurse whether you can
eat or drink anything before the biopsy.
• Also ask if you should take your regular
medications that day. For certain biopsies,
your doctor will want to know if you are
taking blood thinners or aspirin. Tell your
 doctor about all medications and INVASIVE: CYSTOSCOPY
supplements you are taking.
Is a
• Tell your doctor about any drug allergies or
procedure
other medical conditions you may have.
that allows
• A member of your health care team will
your
explain the procedure to you.
doctor to
• You will be asked to sign a consent form that
examine
states you understand the benefits and risks
the lining of
of the biopsy and agree to have the test
your
done.
bladder
• Talk with your doctor about any concerns
and the
you have.
tube that
Results carries
urine out of
• The amount of time it will take for you to your body
receive the results of the biopsy depends on (urethra).
how many tests are needed on the sample
A hollow
to make a diagnosis. Based on this analysis,
a pathologist determines whether the tissue tube (cystoscope) equipped with a lens is inserted
removed contains a tumor and what type it into your urethra and slowly advanced into your
bladder.
is.
• A tumor can be benign or malignant:
• A benign tumor is not cancerous.
INVASIVE: LYMPH ANGIOGRAPHY
• A malignant tumor is cancerous and can
possibly spread to other parts of the body.
• A result can often be given within 2 to 3 days
after the biopsy. A result that requires a
more complicated analysis can take 7 to 10
days. Ask your doctor how you will receive
the biopsy results and who will explain them
to you.

Lymphangiography (or lymphography) is the use of

INVASIVE: CYST ASPIRATION imaging, such as X-ray or MRI , to visualize the body's
lymphatic system. This allows clinicians to map the
A cyst
anatomy of the lymphatic system and determine the
aspiration
exact locations of lymphatic leaks.
is a
procedure
used to
drain fluid INVASIVE: CEREBRAL ANGIOGRAPHY
from a
breast
cyst. The
vast
majority
of cysts
are benign (non- cancerous), though some are quite
tender. Aspirating the fluid from a cyst may alleviate
symptoms or discomfort. In some cases, specimens
are sent to pathology. If the cyst is not benign, early
detection is essential and increases treatment options
and the likelihood of successful recovery. Cerebral angiography is a diagnostic test that uses an
X-ray. It produces a cerebral angiogram, or an image
that can help your doctor find blockages or other

9
abnormalities in the blood vessels of your head and
neck. Blockages or abnormalities can lead to a stroke
or bleeding in the brain.
General risk factors for cancer include:
• Older age
• A personal or family history of cancer
• Using tobacco
• Obesity
• Alcohol
• Some types of viral infections, such as
human papillomavirus (HPV)
• Specific chemicals
• Exposure to radiation, including ultraviolet
radiation from the sun
D. Analysis/ Nursing Diagnosis
POTENTIAL FOR INFECTION
Risk Control: Infectious Process: Identifies signs and
symptoms of infection/Maintains a clean
environment/Practices infection control strategies:
universal precautions, hand sanitization. (Rate the
outcome and indicators of Risk Control: Infectious
Process: 1 = never demonstrated, 2 = rarely
demonstrated, 3 = sometimes demonstrated, 4 =
often demonstrated, 5 = consistently demonstrated
Client Outcomes Client Will
• Remain free from symptoms of infection
during contact with health care providers
• State symptoms of infection before initiating
a health care–related procedure
• Demonstrate appropriate care of infection-
prone sites within 48 hours of instruction
• Maintain white blood cell count and
differential within normal limits within 48
hours of treatment initiation
• Demonstrate appropriate hygienic measures
such as handwashing, oral care, and perineal
care within 24 hours of instruction
10
Nursing Interventions and Rationales
• Implement targeted surveillance for
methicillin-resistant Staphylococcus aureus
(MRSA) (screen clients at risk for MRSA on
admission) and other multidrug-resistant
organisms.
• Obtain a travel history from clients presenting
to health care site (e.g., emergency
department, clinic
• Observe and report signs of infection such as
redness, warmth, discharge, and increased
body temperature.
• Oral, rectal, tympanic, temporal artery or
axillary thermometers may be used to assess
temperature in adults and infants.
• Assess skin for color, moisture, texture, and
turgor (elasticity). Keep accurate, ongoing
documentation of changes
• Carefully wash and pat dry skin, including
skinfold areas. Use hydration and
moisturization on all at-risk surfaces.
• Use strategies to prevent health care–
acquired pneumonia ; assess lung sounds
and sputum color and characteristics;
provide daily oral care with chlorhexidine;
use sterile technique when suctioning;
suction secretions above tracheal tube
before suctioning; drain accumulated
condensation in ventilator tubing into a fluid
trap or other collection device before
repositioning the client; assess patency and
placement of nasogastric tubes; elevate the
client’s head to 30 degrees or higher to
prevent gastric reflux of organisms in the
• Encourage fluid intake
• Use appropriate hand hygiene (i.e.,
handwashing or use of alcohol-based hand
rubs). EBN: Meticulous infection prevention
precautions are required to prevent health
care–associated infection, with particular
attention to hand hygiene and standard
precautions
• When using an alcohol-based hand rub,
apply ample amount of product to palm of
one hand and rub hands together, covering
all surfaces of hands and fingers, until hands
are dry. Note that the volume needed to
reduce the number of bacteria on hands
varies by product.
• Follow standard precautions and wear gloves
during any contact with blood, mucous
membranes, nonintact skin, or any
substance except sweat. Use goggles and
gowns when appropriate. Standard
 precautions apply to all clients. You must
assume all clients are carrying blood-borne
pathogens.
• Implement respiratory hygiene/cough
etiquette.
• Follow transmission-based precautions for
airborne-, droplet-, and contact-transmitted
microorganisms:
1. Airborne: Isolate the client in a room with
monitored negative air pressure, with the
room door closed and the client remaining
in the room. Always wear appropriate
respiratory protection when you enter the
room. Limit the movement and transport of
the client from the room to essential
purposes only. Have the client wear a
surgical mask during transport.
2. Droplet: Keep the client in a private room, if
possible. If not possible, maintain a spatial
separation of 3 feet from other beds or
visitors. The door may remain open. Wear a
surgical mask when you must come within
3 feet of the client. Some hospitals may
choose to implement a mask requirement
for droplet precautions for anyone entering
the room. Limit transport to essential
purposes and have the client wear a mask, if
possible.
3. Contact: Place the client in a private room, if
possible, or with someone (cohorting) who
has an active infection from the same
microorganism. Wear clean, nonsterile
gloves when entering the room. When
providing care, change gloves after contact
with any infective material such as wound
drainage. Remove the gloves and clean your
hands before leaving the room and take care
not to touch any potentially infectious items
or surfaces on the way out. Wear a gown if
you anticipate your clothing may have
substantial contact with the client or other
potentially infectious items. Remove the
gown before leaving the room. Limit
transport of the client to essential purposes
and take care that the client does not contact
other environmental surfaces along the way.
Dedicate the use of noncritical client care
equipment to a single client.
If a urinary catheter is necessary, follow catheter
management practices: All indwelling catheters should
be connected to a sterile, closed drainage system (i.e.,
not broken), except for good clinical reasons. Cleanse
11
the perineum and meatus twice daily using soap and
water.
• Use evidence-based practices and educate
personnel in care of peripheral catheters:
use aseptic technique for insertion and
care, label insertion sites and all tubing with
date and time of insertion, inspect every 8
hours for signs of infection, record, and
report.
• Use sterile technique wherever there is a loss
of skin integrity. EBN: Skin and soft tissue
infections arise when skin integrity is broken
by treatments associated with trauma,
surgery, burns.
• Ensure the client’s appropriate hygienic care
with handwashing, bathing, oral care, and
hair, nail, and perineal care performed by
either the nurse or the client
• Recommend responsible use of antibiotics;
use antibiotics sparingly Alteration in tissue
perfusion
ACTIVITY INTOLERANCE
Related Factors (r/t) Bed rest; generalized
weakness; imbalance between oxygen
supply/demand; immobility; sedentary lifestyle
Activity Tolerance as evidenced by the following
indicators: Oxygen saturation with activity/Pulse rate
with activity/ Respiratory rate with activity/Blood
pressure with activity/Electrocardiogram findings/Skin
color/Walking distance.
(Rate the outcome and indicators of Activity
Tolerance: 1 = severely compromised, 2 =
substantially compromised, 3 = moderately
compromised, 4 = mildly compromised, 5 = not
Client Outcomes Client Will
• Participate in prescribed physical activity with
appropriate changes in heart rate, blood
pressure, and breathing rate; maintain
monitor patterns (rhythm and ST segment)
within normal limits
• State symptoms of adverse effects of
exercise and report onset of symptoms
immediately Maintain normal skin color; skin
is warm and dry with activity
• Verbalize an understanding of the need to
gradually increase activity based on testing,
tolerance, and symptoms
• Demonstrate increased tolerance to activity
Nursing Interventions
• Determine cause of Activity intolerance and
determine whether cause is physical,
psychological, or motivational.
• If mainly on bed rest, minimize cardiovascular
deconditioning by positioning the client in an
upright position several times daily if
possible.
• Assess the client daily for appropriateness of
activity and bed rest orders. Mobilize the
client as soon as possible.
• If the client is mostly immobile, consider use
of a transfer chair: a chair that becomes a
stretcher.
• When appropriate, gradually increase activity,
allowing the client to assist with positioning,
transferring, and self-care as able. Progress
the client from sitting in bed to dangling, to
standing, to ambulation. Always have the
client dangle at the bedside before standing
to evaluate for postural hypotension.
• When getting a client up, observe for
symptoms of intolerance such as nausea,
pallor, dizziness, visual dimming, and
impaired consciousness, as well as changes
in vital signs; manual blood pressure
monitoring is best. When an adult rises to
the standing position, blood pools in the
lower extremities; symptoms of central
nervous system hypoperfusion may occur,
including feelings of weakness, nausea,
headache, lightheadedness, dizziness,
blurred vision, fatigue, tremulousness,
palpitations, and impaired cognition.
• If the client has symptoms of postural
hypotension, such as dizziness,
lightheadedness, or pallor, take precautions,
such as dangling the client and applying leg
compression stockings before the client
stands.
• Perform range-of-motion (ROM) exercises if
the client is unable to tolerate activity or is
mostly immobile. See care plan for Risk for
Disuse syndrome
F. Pathophysiologic Mechanisms:
SOLID TUMOR
• An abnormal mass of tissue that usually
does not contain cysts or liquid areas.
• Solid tumors may be benign (not cancer),
or malignant (cancer).
12
• Different types of solid tumors are named
for the type of cells that form them.
Examples of solid tumors are sarcomas,
carcinomas, and lymphomas. Leukemias
(cancers of the blood) generally do not form
solid tumors.
LUNG CANCER
Etiology
• Smoking – 90%
• Asbestos
• radiation for non-lung cancer treatment,
especially non-Hodgkins lymphoma and
breast cancer.
• Exposure to metals, such as chromium,
nickel, and arsenic, and polycyclic aromatic
hydrocarbons also is associated with lung
cancer.
• Lung diseases like idiopathic pulmonary
fibrosis
• It is hypothesized that repeated exposure to
carcinogens, cigarette smoke in-particular,
leads to dysplasia of lung epithelium.
• If the exposure continues, it leads to genetic
mutations and affects protein synthesis.
• This, in turn, disrupts the cell cycle and
promotes carcinogenesis.
• The most common genetic mutations
responsible for lung cancer development are
MYC, BCL2, and p53 for small cell lung
cancer (SCLC) and EGFR, KRAS, and p16
for non-small cell lung cancer (NSCLC).
Signs and symptoms of small cell lung
cancer include coughing and shortness of
breath.
• These and other signs and symptoms may
be caused by small cell lung cancer or by
other conditions. Check with your doctor if
you have any of the following:
• Chest discomfort or pain.
• A cough that doesn’t go away or gets worse
over time.
• Trouble breathing.
• Wheezing.
• Blood in sputum (mucus coughed up from
the lungs).
• Hoarseness.
• Trouble swallowing.
• Loss of appetite.
• Weight loss for no known reason.
• Feeling very tired.
 • Swelling in the face and/or veins in the neck.
Small Cell Lung Cancer- “oat cell”
• Histologically, SCLC is characterized by small
cells with scant cytoplasm and no distinct
nucleoli.
• SCLC is almost usually with smoking.
• It has a higher doubling time and
metastasizes early; therefore, it is always
considered a systemic disease at diagnosis.
The central nervous system, liver, and bone
are the most common sites
• Non-small cell lung cancer is the most
common type of lung cancer. It accounts for
nearly nine out of every 10 cases, and
usually grows at a slower rate than SCLC.
Most often, it develops slowly and causes
few or no symptoms until it has advanced.
Five Types of NSCLC
1. Squamous cell carcinoma is characterized by
the presence of intercellular bridges and
keratinization. These NSCLCs are associated
with smoking and occur predominantly in
men.
Squamous cell cancers can present as Pancoast
tumor and hypercalcemia. Pancoast tumor is the
tumor in the superior sulcus of the lung. The
brain is the most common site of recurrence
postsurgery in cases of Pancoast tumor.
2. Adenocarcinoma is the most common
histologic subtype of NSCLC. It is also the
most common cancer in women and non-
smokers.
Classic histochemical markers include Naps in A,
Cytokeratin-7, and thyroid transcription factor-1.
Lung adenocarcinoma is further subdivided into
acinar, papillary and mixed subtypes.
3. Adenosquamous carcinoma comprises
0.4% to 4% of diagnosed NSCLC. It is
defined as having more than 10% mixed
glandular and squamous components.
It has a poorer prognosis than either squamous and
adenocarcinomas. Molecular testing is recommended
for these cancers.
13
4. Large cell carcinoma lacks the differentiation
of a small cell and glandular or squamous
cell.
5. Carcinoid tumors include two subtypes:
typical and atypical. Typical carcinoid carries
relatively better prognosis and is only
occasionally associated with carcinoid
syndrome.
Treatment of Non- Small Cell Lung Cancer:
Stage 1
• Surgery is the mainstay of treating stage 1
NSCLC.
• The procedure of choice is either lobectomy
or pneumonectomy with mediastinal lymph
node sampling.
• The 5-year survival is 78% for IA and 53%
for IB disease.
• Local postoperative radiation therapy or
adjuvant chemotherapy has not shown to
improve outcomes in stage I disease.
Treatment of Non- Small Cell Lung Cancer:
Stage 2
• The survival of stage IIA and IIB lung is 46%
and 36% respectively. The preferred
treatment is surgery followed by adjuvant
chemotherapy.
• If the tumor has invaded the chest wall, then
an en- bloc resection of the chest wall is
recommended.
• Pancoast tumor is a unique tumor of stage II.
It arises from the superior sulcus and usually
diagnosed at a higher stage, IIB or IIIA. The
treatment of choice in cases of Pancoast
tumor is neoadjuvant chemotherapy usually
with etoposide and cisplatin and concurrent
radiotherapy followed by resection.
Treatment of Non- Small Cell Lung Cancer:
Stage 3
• This is the most heterogeneous group,
consisting of a wide variation of tumor
invasion as well as lymph node involvement.
• Stage IIIA disease with N1 lymph nodes
surgery with curative intent is the treatment
of choice.
Treatment of Non- Small Cell Lung Cancer:
Stage 4
• Stage IV disease is considered incurable,
and therapy is aimed at improving survival
and alleviating symptoms. Only 10% to
 30% of patients respond to chemotherapy,
and only 1% to 3% survive 5 years after
diagnosis.
• Single or double drug-based chemotherapy
is offered to patients with functional
performance status. There is a small survival
benefit from chemotherapy.
Treatment of Non- Small Cell Lung Cancer
Nivolumab: It is an IgG4 monoclonal antibody against
PD-1. It is approved by the FDA for squamous and
non- squamous NSCLC that has progressed after
platinum-based chemotherapy. It can be used in
patients with high or low PD-L1 expression status.
Pembrolizumab: It is also an IgG4 monoclonal
antibody against PD- It is approved for pre-treated
metastatic NSCLC with greater than 50% expression
of PD-L1 and does not harbor EGFR and ALK
mutations. It is also used in combination with
pemetrexed and carboplatin for metastatic non-
squamous NSCLC with less than 50% expression of
PD-L1.
Atezolizumab: It is an IgG1 antibody against PD-L1. It
is approved for use in metastatic, progressive NSCLC
during or following treatment with platinum-based
chemotherapy. It can be used in patients who express
EGFR and ALK mutations and fail targeted therapy.
Bevacizumab: It is not considered immune therapy. It
is an anti- angiogenesis antibody that inhibits vascular
endothelial growth factor A (VEGF-A). It is primarily
used in combination with platinum-based
chemotherapy for the treatment of non-squamous
NSCLC. It is contraindicated in squamous cell NSCLC
due to the risk of severe and often fatal hemoptysis.
It is also used to treat breast, renal, colon, and brain
cancers.
BREAST CANCER
Breast cancer is the most common cancer among
women. The incidence of breast carcinoma continues
to increase partly due to the aging population and
partly due to better diagnostic testing.
• Only about 10% of breast cancers are
inherited, which means that two or more
first-degree relatives have had breast cancer
before the age of 50 years.
• Other risk factors are family history of
bilateral disease, a combination of breast
cancer and another epithelial cancer such as
ovarian cancer, family member with male
breast cancer
14
Etiology
• Excessive amounts of estrogen play a part
such as when a woman gets her period
before the age of 12 years and goes
through menopause after age 55 years. Risk
is also greater in women who have never
been pregnant or have their first child after
age 30 years.
• Postmenopausal hormone replacement
therapy and use of oral contraceptives have
shown that long-term use may show a
higher increase of breast cancer.
• Obesity has been linked to breast cancer as
androgens in fat cells can be converted to
estrogens, thereby increasing estrogens in
the body. Women have a one in eight
chance of developing breast cancer in their
lifetime.
Clinical Manifestations
• Seventy percent of patients present with a
breast lump.
• Less frequent signs are breast pain, nipple
discharge, erosion, retraction, enlargement,
itching of the nipple and redness,
generalized hardness of breast.
• Back or bone pain, jaundice, or weight loss
may be the result of disease that has already
metastasized.
Diagnostic Test
• Sedimentation rate, serum alkaline
phosphatase, CA 125, and CA15-3 or
CA27-29 (for metastasis and recurrent
breast cancer), chest x-ray,
• CT scan of liver; PET scan, biopsy of breast,
ultrasonography of breast, mammography,
MRI, and cytology of nipple discharge or
cyst fluid can confirm diagnoses.
• Mammography
• Breast biopsy
Treatment
• Treatment may be curative or palliative
depending on the type of cancer and stage
at diagnosis.
• Surgery may include resection of the lump
conserving the breast( lumpectomy), to a
mastectomy, and removal of lymph nodes to
determine metastasis.
• Additional treatments are radiation therapy,
chemotherapy, endocrine therapy for
hormone- receptive breast cancers with
 estrogen-receptor antagonists/ agonist
such as tamoxifen, which decrease the risk
of breast cancer in the other breast but can
cause endometrial cancer and
thromboembolic events
• Mastectomy: is a surgery to remove a breast.
Sometimes other tissues near the breast,
such as lymph nodes, are also removed.
This surgery is most often used to treat
breast cancer. In some cases, a mastectomy
is done to help prevent breast cancer in
women who have a high risk for it.
Types of Mastectomy
OVARIAN CANCER
• Ovarian cancer is the ninth most common
cancer in women and the fifth leading cause
of cancer death in women.
• Malignant neoplasms of the ovaries occur at
all ages, including infancy and childhood.
• Ninety percent of ovarian cancer is sporadic
and not inherited, although family history,
increasing age, nulliparity (never having
delivered a child), early menarche, late
menopause, use of hormone replacement
therapy, and a history of breast cancer are
known to add to the risk of developing
ovarian cancer.
• The genes BRCA1 and BRCA2 are inherited
and indicate a high likelihood of developing
ovarian and breast cancer.
Risk factors
• Older age.
• Inherited gene changes.
• Family history of ovarian cancer. Being
overweight or obese. Postmenopausal
hormone replacement therapy. risk of
ovarian cancer.
• Endometriosis.
• Age when menstruation started and ended..
• Never having been pregnant.
15
Early Symptoms
• pain or pressure in the pelvis
• unexpected vaginal bleeding
• pain in the back or abdomen
• bloating
• feeling full rapidly when eating
• changes in urination patterns, such as more
frequent urination
• changes in bowel habits, such as
constipation
Diagnostic Test:
Once a mass is detected, a lab CA 125 test >35 units
indicates that the tumor is probably malignant;
transvaginal ultrasonography; presence of symptoms;
and surgery with biopsy.
• surgical debulking of the tumor,
• an omentectomy ( removal of the
omentum)
• total abdominal hysterectomy (removal of
the uterus), and
• bilateral salpingo-oophorectomy (removal
of the fallopian tubes and both ovaries);
• combination chemotherapy and radiation is
also used.
PROSTATE CANCER
• Cancer of the prostate is a malignant tumor
that is almost always an adenocarcinoma.
• Factors that may affect the development of
prostate cancer are hormonal changes in
testosterone levels.
• It has also been thought that certain viruses,
such as a strain of cytomegalovirus, can
produce malignant changes.
• As the tumor grows, the prostate enlarges,
causing urinary problems, such as difficulty
urinating or urinary obstruction;
• decreased urinary stream; erectile
dysfunction; bloody semen or hematuria;
 and focal nodules or areas of induration
within the prostate (palpated by health care
provider).
• In advanced disease, patients may have
bone pain and lymph node enlargement.
Diagnostic Tests:
PSA levels; blood urea nitrogen (BUN), creatinine
levels, urinalysis, alkaline phosphatase (elevated in
bony metastasis); transrectal ultrasonography–
guided biopsy; MRI; and radionuclide bone scan can
be used to confirm diagnosis.
Treatment:
• Treatment for prostate cancer ranges from
hormone therapy to block testosterone
production, such as leuprolide acetate
(Lupron), goserelin acetate (Zoladex) or
estrogen therapy, to radiation treating local
tumors with either external radiation or
insertion of radioactive seeds, to several
surgical options of prostatectomy or removal
of the prostate.
• When testosterone suppression is necessary
and the hormonal methods do not work,
bilateral orchiectomy may be necessary.
COLORECTAL CANCER
• There is stepwise progression from normal
tissue to cancer in the colon and it is best
described that when adenomatous polyps
are found in the colon, they are at great risk
of changing to cancer unless removed.
These polyps increase with advancing age
and develop in at least 40% of the
population.
• Diets high in fat and red meat have been
linked to colon cancer whereas diets high in
fiber, fruits, and vegetable appears to
protect against colon cancer.
Clinical Manifestation:
• Many patients are asymptomatic.
16
• Some presenting symptoms are abdominal
cramping or pain, change in bowel habits
(constipation, diarrhea, or narrowing of
stool), rectal bleeding, dark stools or
obvious blood in stool, weakness and
fatigue, weight loss, and anemia.
• If metastasis has occurred, there may be
enlarged lymph nodes, pain in liver, and
respiratory problems if in lung.
Diagnostic Test:
• Complete blood count (CBC), liver function
tests, fecal occult blood test, colonoscopy
with biopsy, computed tomographic (CT)
scan to evaluate for metastasis, chest x-ray,
magnetic resonance imaging (MRI), and
endoscopic ultrasonography may be used to
evaluate extent of rectal cancers.
• Treatment Resection of the primary tumor in
the colon or rectum is the treatment of
choice, with regional dissection of at least
12 lymph nodes to determine the staging of
the cancer.
• The stages range from I to IV, with stage I
having best prognosis and stage IV
metastatic disease, which 20% of patients
have at diagnosis. Chemotherapy and
radiation therapy are the course of
treatment
Treatment:
• Treatment for colorectal cancer is surgical
resection of the cancer, which may result in
the person having a colostomy if much of
the colon is removed.
• Chemotherapy may be given even if it is
thought that the cancerous tumor has been
removed, as a prophylactic measurement.
• If the colon cancer has metastasized,
chemotherapy may be given as a palliative
measure as the overall survival rate is 6
months and with best supportive care to 2
years.
Nursing Intervention and Complication
• Prepare patient for abdominal surgery with
bowel cleansing (laxatives, enemas) to
suppress bacterial growth.
• Teach the patients about the planned
surgery and what to expect such as
nasogastric tube, a possible colostomy.
• Support the patient when fearful and
anxious.
 • Postsurgical care includes continued
assessment of close fluid and electrolyte
balance, maintain adequate ventilation,
assess patient for a paralytic ileus, and
support early ambulation.
• If metastasis is discovered during surgery
and prognosis is poor, support the patient
and the family and encourage verbalization
of fears.
• Administer chemotherapy as ordered. If the
patient has a colostomy, teach family about
the care needed and encourage the patient
to assume care as soon as possible.
• Complications may occur because of the
extensive nature of the surgery, such as
infection, bleeding, anastomosis leakage,
and possible fistula development. If
extensive lymph nodes were removed, nerve
pathways may have been affected, causing
urinary lack of control. Long-term
complications are related to disease
recurrence and metastatic disease.
BRAIN CANCER
• Primary brain tumors originate in the brain
itself or in tissues close to it, such as in the
brain-covering membranes (meninges),
cranial nerves, pituitary gland or pineal
gland.
• In adults, primary brain tumors are much less
common than are secondary brain tumors,
in which cancer begins elsewhere and
spreads to the brain.
Manifestation:
Manifestations may be nonspecific and include the
following:
• Headache
• Altered mental status
• Ataxia
• Nausea
17
• Vomiting
• Weakness
• Gait disturbance
CNS neoplasms also may manifest as follows:
• Focal seizures
• Fixed visual changes
• Speech deficits
• Focal sensory abnormalities’
Risk Factors:
• Exposure to radiation. People who have
been exposed to a type of radiation called
ionizing radiation have an increased risk of
brain tumor. Examples of ionizing radiation
include radiation therapy used to treat
cancer and radiation exposure caused by
atomic bombs.
• Family history of brain tumors. A small
portion of brain tumors occurs in people
with a family history of brain tumors or a
family history of genetic syndromes that
increase the risk of brain tumors.
Diagnosis:
• Neurologic exam
• Imaging test
• Collecting and testing a sample of abnormal
tissue (biopsy)
Types:
• Gliomas. These tumors begin in the brain or
spinal cord and include astrocytomas,
ependymomas, glioblastomas,
oligoastrocytomas and oligodendrogliomas.
• Meningiomas. A meningioma is a tumor that
arises from the membranes that surround
your brain and spinal cord (meninges).
Most meningiomas are noncancerous.
• Acoustic neuromas (schwannomas). These
are benign tumors that develop on the
nerves that control balance and hearing
leading from your inner ear to your brain.
• Pituitary adenomas. These are mostly benign
tumors that develop in the pituitary gland at
the base of the brain. These tumors can
affect the pituitary hormones with effects
throughout the body.
• Medulloblastomas. These are the most
common cancerous brain tumors in children.
A medulloblastoma starts in the lower back
part of the brain and tends to spread through
the spinal fluid. These tumors are less
common in adults, but they do occur.
 • Germ cell tumors. Germ cell tumors may
develop during childhood where the
testicles or ovaries will form. But sometimes
germ cell tumors affect other parts of the
body, such as the brain.
• Craniopharyngiomas. These rare,
noncancerous tumors start near the brain's
pituitary gland, which secretes hormones
that control many body functions. As the
craniopharyngioma slowly grows, it can
affect the pituitary gland and other
structures near the brain.
Treatment options and recommendations depend
on several factors:
• The size, type, and grade of the tumor
• Whether the tumor is putting pressure on
vital parts of the brain
• If the tumor has spread to other parts of the
CNS or body
• Possible side effects
• The patient’s preferences and overall health
• For a low-grade brain tumor, surgery may
be the only treatment needed especially if
all of the tumor can be removed. If there is
visible tumor remaining after surgery,
radiation therapy and chemotherapy may be
used. For higher-grade tumors, treatment
usually begins with surgery, followed by
radiation therapy and chemotherapy. Your
exact treatment plan will be made by your
health care team.
Acute treatment for cerebral edema from
intracranial neoplasms is as follows:
• Corticosteroids may dramatically reduce
signs and symptoms, bringing relief within a
few hours
• Dexamethasone is the agent of choice
• Recommended doses generally range from
4-24 mg daily
Definitive treatments
• Generally, care of patients with a brain tumor
is multidisciplinary, requiring assistance from
a neurosurgeon, an oncologist, a radiologist,
and an expert in radiation therapy
• Management varies greatly depending on
tumor location, tissue type, and comorbid
conditions
• Surgery ( craniotomy) is generally only an
option for patients who have a single area
of cancer in the brain. Radiation therapy is
often given afterwards.
18
• Surgical treatment options may include
tumor removal or debulking, installation of a
ventricular shunt, and placement of
radioactive implant, brachytherapy
• Radiation therapy. Whole-brain radiation
therapy (WBRT) Targeted therapy. Some
types of targeted therapy can easily enter the
brain and are able to target specific genetic
changes in the tumor. These include:
o Osimertinib (Tagrisso) for non-
small cell lung cancer (NSCLC)
that has a genetic change on the
EGFR gene
o Alectinib (Alecensa) for NSCLC
with a genetic change on the ALK
gene
o Lapatinib (Tykerb) may be used for
HER2-positive breast cancer
o Dabrafenib (Tafinlar) either by
itself or along with trametinib
(Mekinist) and vemurafenib
(Zelboraf) for melanoma
• Immunotherapy. Some types of
immunotherapy have shown promise in
treating brain metastases from lung cancer
and melanoma. These include ipilimumab
(Yervoy), nivolumab (Opdivo), and
pembrolizumab (Keytruda).
Treatment of leptomeningeal metastases
If cancer spreads to the meninges or the CSF, it is
called leptomeningeal metastases. People with
leptomeningeal metastases may receive
chemotherapy given directly into the CSF of the brain.
This may be done with a lumbar puncture, called
intrathecal chemotherapy. Or it may be given using a
catheter with a reservoir, called an Ommaya reservoir.
Radiation therapy may also be an option.
Liquid Tumor: or cancers present in body fluids
(the blood and bone marrow), and are detectable by
blood laboratory tests or cancers present in body
fluids (the blood and bone marrow), and are
detectable by blood laboratory tests.
A. LYMPHOMAS
Lymphoma is a malignancy of the lymphatic system.
It is commonly divided into Hodgkin’s lymphoma and
non-Hodgkin’s lymphoma.
Epidemiology: Lymphoma accounts for over 10%
of childhood cancers, although childhood cancer is in
itself rare. Lymphoma is seen more commonly in boys
than girls and is much more common in older
children. Just over half of childhood lymphoma cases
are non-Hodgkin’s lymphoma.
Pathophysiology: As with many malignancies, and
particularly malignancies in children, the
pathophysiology of lymphoma is not well understood.
Development is multi-factorial, with infection, genetic
factors and environmental exposures all potentially
involved. In adults, lifestyle factors such as obesity,
smoking and alcohol intake are all associated with
increased lymphoma risk but it is less clear what, if
any, part they play in the development of childhood
disease.
Risk Factors & Clinical Features: History
• Epstein-Barr Virus has been particularly
implicated in the development of lymphoma.
Immunosuppressed patients (eg those who
have had a solid organ transplant) and those
who have been treated for other cancers in
the past are also at increased risk of
lymphoma.
• Lymphoma may present with a visible or
palpable mass. There may be a history of “B
symptoms” such as: Weight loss, Night
sweats, Fevers, Other, more non-specific
symptoms of malignancy, such as lethargy
and anorexia, may also be present.
On Examination: Non-tender lymphadenopathy is
the most common examination finding, however this
may not necessarily be visible or palpable, for
example if mediastinal or intra-abdominal lymph
nodes are involved. Mediastinal lymphadenopathy
may present with cough, wheeze or other difficulty in
breathing, and occasionally superior vena cava
obstruction or airway compromise can occur.
Differential Diagnosis: The most common
differential for a patient presenting with
lymphadenopathy is reactive lymphadenopathy.
There is likely to be a history of recent infection. If the
lymph nodes themselves have become infected
(lymphadenitis) they are likely to be tender and
19
potentially fluctuant if an abscess has formed
• Leukemia can also present with “bulky”
disease and should be considered in
patients with lymphadenopathy associated
with signs and symptoms of anemia and/or
thrombocytopenia
• Lymphadenopathy can also be a sign of
metastatic malignancy from another site, but
this is far more common in adults than
children.
Laboratory tests
Blood tests such as full blood count may be done to
help diagnose differentials such as infection. Urea
and electrolytes are also important as tumour lysis
syndrome can occur before treatment begins in
lymphomas with rapid cell turnover. LDH (lactate
dehydrogenase) levels are usually elevated.
Imaging
• UTZ of the area can help identify other
nodes, and assists with biopsy.
• Chest x-ray may be required if there are
symptoms of mediastinal node involvement.
• A full body CT to determine extent of disease
(and therefore staging) is also required.
Biopsy: Lymph node biopsy is necessary for definitive
diagnosis. Risk scoring
Lymphoma is staged according to how many groups
of lymph nodes or organs are involved:
• Stage 1: Disease is present in a single group
of lymph nodes or a single organ
• Stage 2: Disease is present in 2 or more
groups of lymph nodes or organs on the
same side of the diaphragm
• Stage 3: Disease is present in lymph nodes
or organs on both sides of the diaphragm
• Stage 4: There is diffuse involvement of
lymph nodes and organs such as the liver
and bones
The presence of “B symptoms” is associated with
worse prognosis at all stages and a B is added to any
stage if these are present (eg stage 1B, 2B etc).
Figure
1.Diagramatic
representation of
the staging of
lymphoma
Management
Immediate
• The presence of a mediastinal mass with
potential airway compromise is an
emergency. Treatment is with high dose
steroids and airway support if required.
• Superior vena cava obstruction (SVCO) may
require stenting of veins to keep them
patent, although it will usually resolve with
treatment of the underlying malignancy.
• If there is suggestion of tumour lysis
syndrome, then hyperhydration is important.
Allopurinol or rasburicase are also used.
blood cells. These abnormal white blood
cells are not able to fight infection and
impair the ability of the bone marrow to
produce red blood cells and platelets.
• Leukemia can be either acute or chronic.
Chronic leukemia progresses more slowly
than acute leukemia, which requires
immediate treatment. Leukemia is also
classified as lymphocytic or myelogenous.

Definitive and Long-term

• Treatment is with chemotherapy and

possibly radiotherapy, depending on the
stage of disease.

Prognosis and Complications

• The majority of children and young people

with lymphoma will recover completely, with
Hodgkin’s lymphoma carrying a more
favorable prognosis than non-Hodgkin’s
lymphoma.
• Complications include tumor lysis syndrome,
which is seen when rapid lysis of tumor cells
causes release of large amounts of
phosphorus, potassium and calcium leading
to potential kidney damage. This is most
likely to occur when chemotherapy is first
commenced, but may occur beforehand.
Other complications are more generally
related to cancer treatment and include
neutropenia, alopecia and sub-fertility.
• All children who are treated for cancer will
have life-long follow-up to assess for late-
effects of cancer treatment.
B. LEUKEMIAS
By cell type:
1. Myelogenous or myeloid leukemia affects myeloid
cell. Myeloid cells give rise to RBC, WBC, and platelet
producing cells Lymphocytic leukemia affects the
lymphoid cells ( Lymphocytes ), which form lymphoid
or lymphatic tissue. Lymphatic tissue makes up the
immune system.
Although experts are uncertain about the causes of
leukemia, they have identified several risk factors that
include the following:
• Exposure to high levels of radiation
• Repeated exposure to certain chemicals (for
example, benzene)
• Chemotherapy
• Down Syndrome
• A strong family history of leukemia

• Leukemia is a type of cancer found in the

blood and bone marrow and is caused by
the rapid production of abnormal white

20
Treatment
• complete blood count (CBC)-Abnormal
levels of white blood cells and abnormally
low red blood cell or platelet counts can also
indicate leukemia.
• If test positive for leukemia, bone marrow to
determine the type
• Treatment depends on age, general health,
and type of leukemia.
• Combination :chemotherapy, biological
therapy, radiation therapy, and stem cell
transplantation.
• Patients with acute leukemia often undergo
chemotherapy because this type of
treatment targets fast-dividing cells.
• Many acute leukemia patients have
responded successfully to treatment. On the
other hand, because the cells divide more
slowly in chronic leukemia, it is better
treated with targeted therapies that attack
slowly dividing cells as opposed to
traditional chemotherapy that targets rapidly
dividing cells.
• For some patients, participating in a clinical
trial provides access to experimental
therapies. If you are diagnosed with
leukemia, talk with your doctor about
whether joining a clinical trial is right for you.
PRINCIPLES OF MANAGEMENT
A. Blood component replacement
Blood Transfusions for people with cancer
Why people with cancer might need blood
transfusions? People with cancer might need blood
transfusions because of the cancer itself. For
instance:
• Some cancers (especially digestive system
cancers) cause internal bleeding, which can
lead to anemia
• Blood cells are made in the bone marrow,
the spongy center of certain bones. Cancers
that start in the bone marrow (like
leukemias) or cancers that spread there
from other places may crowd out normal
blood- making cells, leading to low blood
counts.
• People who have had cancer for some time
may develop something called anemia of
chronic disease. This anemia is caused by
certain long-term medical conditions that
affect the production and lifespan of red
blood cells.
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• Cancer can also lower blood counts by
affecting organs such as the kidneys and
spleen, which help keep enough cells in the
blood.
• Surgery to treat cancer
• Most chemotherapy drugs affect cells in the
bone marrow.
• When radiation is used to treat a large area
of the bones, it can affect the bone marrow
• Bone marrow transplant (BMT) or peripheral
blood stem transplant (PBSCT)
patients get large doses of chemotherapy
and/or radiation therapy.
Types of transfusions:
1. Red blood cell transfusions: When red blood
cell transfusions are used (Anemia, Surgery)
2. Plasma transfusions: Plasma basics- Plasma
is the clear, pale-yellow liquid part of blood.
It contains proteins (called clotting factors)
that help make blood clot
3. Platelet transfusions: Platelet basics-
Platelets are fragments of cells in blood and
are another important part of the clotting
process. They work with the clotting factors
in plasma to help stop bleeding.
4. Cryoprecipitate transfusions: Cryoprecipitate
basics Cryoprecipitate, or "cryo," is the name
given to the small fraction of plasma that
separates out (precipitates) when plasma is
frozen and then thawed in the refrigerator.
When cryoprecipitate transfusions are used?
• Cryoprecipitate may be given to replace
several blood clotting factors such as:
• Factor VIII (missing in patients with
hemophilia A)
• Von Willebrand factor (needed to help
platelets work)
• Fibrinogen (a protein needed to form a clot)
• Unless they’re bleeding, people with cancer
rarely need cryoprecipitate.
5. White blood cell (granulocyte) transfusions:
Chemotherapy can damage cells in the bone
marrow, and patients getting chemo often
have low white blood cell (WBC) counts.
(The normal range for WBCs is 4,000 to
10,000 per mcL of blood.)
When white blood cell transfusions are used
• White blood cell transfusions are given rarely.
Research does not show that giving white
blood cell transfusions lowers the risk of
death or infection in people with low white
blood cell counts or white blood cells that
are impaired.
• Instead of transfusing WBCs, doctors now
commonly use drugs called colony-
stimulating factors or growth factors to help
the body make its own. These drugs
stimulate the body to make neutrophils and
other types of granulocytes.
O2 Therapy
Oxygen therapy can be given for a short or long
period of time in the hospital, another medical setting,
or at home.
Another device for use at home is an oxygen
concentrator, which pulls oxygen out of the air for
immediate use. Because oxygen concentrators do not
require refills, they won’t run out of oxygen. Portable
tanks and oxygen concentrators may make it easier
for you to move around while using your therapy.
Hydration Therapy
Hydration therapy is a simple treatment that delivers
fluids directly into your bloodstream through a small
IV inserted into your arm. The fluids may also include
vitamins, electrolytes, antioxidants and even
medication in the mix. By allowing fluids to circulate
quickly through your body, hydration therapy rapidly
replenishes fluids in a way that drinking fluids cannot.
Prevention of Inspection
• Cancer and its treatment can make the
immune system weaker and lower your level
of certain white blood cells. If you have
cancer and are currently in treatment for
cancer, you are more likely to get infections.
• Infections are treatable, but they can be
serious and life-threatening. Talk with your
health care team if you experience signs of
an infection or changes in your symptoms.
Supportive Management
• Care given to improve the quality of life of
patients who have a serious or life-
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threatening disease. The goal of supportive
care is to prevent or treat as early as
possible the symptoms of a disease, side
effects caused by treatment of a disease,
and psychological, social, and spiritual
problems related to a disease or its
treatment. Also called comfort care,
palliative care, and symptom management.
Prevention of complications
1. Don't use tobacco
2. Eat a healthy diet
• Eat plenty of fruits and vegetables.
• Avoid obesity.
• If you choose to drink alcohol, do so only in
moderation
• Limit processed meats.
3. Maintain a healthy weight and be physically active
4. Protect yourself from the sun
• Avoid midday sun.
• Stay in the shade.
• Cover exposed areas.
• Do not skimp on sunscreen.
• Avoid tanning beds and sunlamps.
5. Get vaccinated
• Hepatitis B.
• Human papillomavirus (HPV).
6. Avoid sky behaviors
• Another effective cancer prevention tactic is
to avoid risky behaviors that can lead to
infections that, in turn, might increase the
risk of cancer. For example:
• Practice safe sex. Limit your number of
sexual partners and use a condom when
you have sex. The more sexual partners you
have in your lifetime, the more likely you are
to contract sexually transmitted infection —
such as HIV or HPV. People who have HIV
or AIDS have a higher risk of cancer of the
anu liver and lung. HPV is most often
associated with cervical cancer, but it might
also increase the risk of cancer of the anus,
penis, throat, vulva and vagina.
• Don't share needles. Sharing needles with
people who use intravenous drugs can lead
to HIV, as well as hepatitis B and hepatitis
C — which can increase the risk of liver
 cancer. If you're concerned about drug • Loss of appetite
misuse or addiction, seek professional help. • Lung issues
• Lymphedema
7. Get regular medical care
• Nausea and vomiting
• Regular self-exams and screenings for • Organ damage
various types of cancers — such as cancer • Pain
of the skin, colon, cervix and breast — can • Peripheral Neuropathy
increase your chances of discovering cancer • Premature aging
early, when treatment is most likely to be • Sexual dysfunction
successful. Ask your doctor about the best • Skin problems
cancer screening schedule for you. • Sleep problems

• I.Independent Nursing Care

Rehabilitation
b. Psychosocial Care
• Cancer rehabilitation professionals offer the
c. Spiritual Care
help and expertise that you need to:
• Improve your endurance, strength and 2. Interdependent Care.
mobility
• Increase your confidence and self-esteem A. Pharmacological Anticancer agent
• Make the activities of daily living and caring
• ALKYLATING AGENTS
for yourself easier
• Help you cope with anxiety, distress or other What are Alkylating agents?
emotional issues
• Reduce fatigue, pain and other lingering side There are five traditional categories of alkylating
effects agents:
• Return to work 1. Nitrogen mustards (eg, bendamustine,
• Formulate a long-term plan for cancer chlorambucil, cyclophosphamide, ifosfamide,
survivorship mechlorethamine, melphalan)

2. Nitrosoureas (eg, carmustine, lomustine,

IMPLEMENTATION OF CARE streptozocin)

1. Independent Nursing Care 3. Alkyl sulfonates (eg, busulfan)

a. Physiologic Care 4. Triazines (eg, dacarbazine, temozolomide)

• Anemia: 5. Ethylenimines (eg, altretamine, thiotepa)

• Bleeding and bruising (thrombocytopenia)
• Bone loss (osteoporosis)
• Cancer recurrence • ANTIMETABOLITES
• Constipation:
• Diabetes What are Antimetabolites? Antimetabolites are drugs
• Diarrhea used in cancer chemotherapy.
• Dry mouth Examples of cancer drug antimetabolites include, but
• Eye problems are not limited to the following:
• Fatigue
• Hair loss • 5-Fluorouracil (5-FU)
• Hearing loss • 6-Mercaptopurine (6-MP)
• Heart issues • Capecitabine (Xeloda®)
• Hormonal changes • Cytarabine (Ara-C®)
• Hypothyroidism • Floxuridine.
• Incontinence • Fludarabine.
• Infection • Gemcitabine (Gemzar®)
• Infertility
• Learning and memory problems

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 • NATURAL PRODUCTS (Vinca Alkaloids)

Hormonal Therapy

Medications that block hormones from attaching to

cancer cells

• Tamoxifen. Tamoxifen is usually taken daily in

pill form. It's often used to reduce the risk
of cancer recurrence in women who have
been treated for early-stage breast cancer. In
this situation, it's typically taken for five to
10 years.Tamoxifen may also be used to
treat advanced cancer. Tamoxifen is
appropriate for both premenopausal women
and postmenopausal women.
• Toremifene (Fareston). Toremifene is taken
as a daily pill. It's used to treat breast cancer
that has spread to other areas of the body.
Toremifene is approved for use in
postmenopausal women.
• Fulvestrant (Faslodex). Fulvestrant is
administered as a shot every month after
first getting a dose every two weeks for the
first month. It's used in postmenopausal
women to treat advanced breast cancer.

Medications that stop the body from making estrogen

after menopause- Aromatase inhibitors are a class of
medicines that reduce the amount of estrogen in your
body, depriving breast cancer cells of the hormones
they need to grow.

Aromatase inhibitors used to treat breast cancer

include:

• Anastrozole (Arimidex)-to reduce the risk of

cancer (early-stage breast cancer). It can
also be used to treat advanced breast
cancer.
• Exemestane (Aromasin)-to reduce the risk of
cancer (early-stage breast cancer). It's
sometimes used after taking tamoxifen for
two or three years. It can also be used to
treat advanced breast cancer in women for
whom tamoxifen is no longer working.
• Letrozole (Femara)-to reduce the risk of
cancer (early-stage breast cancer). It can be
used alone or given after completing
tamoxifen treatment. Letrozole is also used
to treat advanced breast cancer.

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