CARE OF THE CLIENTS

WITH
NEOPLASTIC DISORDERS
 What is cancer?
Cancer is a disease of cells. It is an
abnormal growth of cells which tends to
proliferate in an uncontrolled way and,
in some cases, to metastasize.
Cancer also called malignancy. A
cancerous growth or tumor is
sometimes referred to as a malignant
growth or tumor. A non-malignant
growth or tumor is referred to as
benign.
 Pathogenesis of Cancer

• Cellular Transformation and

Derangement Theory

• Failure of the Immune Response

Theory
 Cellular Transformation
Theory
• Cancer cells develop from normal
cells through a complex process
called transformation
• Initiation- 1st step in which a
change in genetic material
prepares the cell to become
cancerous
• Abnormal expression of tumor-
promoting genes may initiate
malignant transformation
• Promotion- 2nd step; initiated cells
proliferate and bear a resemblance
to benign neoplasms
• Benign neoplasms may regress to
normal-appearing tissue through
immune modulating mechanisms
or by removal of the carcinogen
• Progression- transformation of
precancerous cells to malignant
cells
• Several factors such as the
interaction between heredity,
environmental carcinogens, diet,
tobacco use, chemicals, infections
and radiation, are associated with
progression
 Failure of the Immune
Response Theory
• Cancer is more likely to develop
when the immune system is not
functioning normally
 Etiologic Factors

•Virus
•Chemical carcinogens
•Industrial Compounds
•Hormones
•Food, preservatives
•Physical Agents
•Radiation
•Trauma/physical irritation
•Hormones
•Genetics
 Predisposing Factors

•Age
•Sex
•Urban vs rural residence
•Geographic distribution
•Occupation
•Heredity
•Stress
•Precancerous lesions
•Obesity
Warning Signs of Cancer

•C- change in bowel or bladder habits

•A- sore throat that does not heal
•U- unusual bleeding or discharge
•U- unexplained sudden weight loss
•U- unexplained anemia
•T- thickening or lump in the breast or elsewhere
•I- indigestion or difficulty in swallowing
•O- obvious change in warts or moles
•N- nagging cough or hoarse ness of voice
The community nurse is conducting a
health promotion program about risk
factors of cancer. Which of the
following, if identified by the client as
a risk factor, indicates a need for
further instructions?

• A. viral factors
• Stress
• Low-fat and High Fiber Diets
• Exposure to radiation
The community nurse is conducting a
health promotion program about risk
factors of cancer. Which of the
following, if identified by the client as
a risk factor, indicates a need for
further instructions?

• A. viral factors
• Stress
• Low-fat and High Fiber Diets
• Exposure to radiation
 Cancer Detection
Examinations
•Cytologic examination/PAP’s Smear
•Biopsy
•Ultrasound
•MRI
•Radiologic examinations
•Radiodiagnostic techniques
•CT Scan
•Antigen Skin Test
•Laboratory test – AFP, HCG, CEA, PSA
•Endoscopic examination
•Monoclonal antibodies
 Comparison of Benign &
Malignant Neoplasm
Characteristics Benign Malignant
Speed of growth Slow Rapid

Mode of growth Localized Infiltrating

Capsule Encapsulated No capsule

Recurrence Unusual Common

Metastasis None Common

Effect Harmless to host Harmful

Prognosis Very good Poor

 Pathogenesis
Predisposing factors/Etiologic Factors

Cellular Aberration

Ca cell proliferation Ca cells produce Anorexia &

•Pressure Enzymes, hormones Cachexia Synd
•Obstruction & other substances •Tissue wasting
•Pain (Paraneoplastic Synd) •Severe wt loss
•Effusion •Anemia •Severe debilitation
•Ulceration •Hypercalcemia
•Vascular thrombosis, •Edema
Embolus, •DIC
Thrombophlebeitis
Staging and Grading of
Neoplasm

T – tumor
N – node
M - metastasis
 Cancer Prevention

•Skin – avoid overexposure to sunlight

•Oral – annual oral examination
•Breast – monthly BSE, mammogram
•Lungs – avoid cigarette smoking, annual CXR
•Colon – DRE for >40, rectal biopsy,
proctoscopic exam,occult blood stool exam
•Uterus/cervix – annual PAP’s smear
•Basic – annual PE and blood exam
Dietary Recommendation

•Avoid obesity
•Cut down on fats
•High fiber diet
•Food rich in Vit A & C
•Vegetable diet
•Moderation in alcoholic beverage
•Moderation in salty food, preservatives
Therapeutic Modalities

•Surgery
•Chemotherapy
•Radiation therapy
•Immunotherapy
•Bone marrow transplantation
Surgical Interventions

•Preventive
•Diagnostic
•Curative
•Reconstructive
•Palliative
 Classification of Cancer
• Grouped by the tissue which they
originate
• Carcinomas- most common form of
cancer; affects epithelial cells
• Sarcomas- highly malignant
connective tissue tumors that
originate from muscle, fat, bone,
and blood vessels
 Chemotherapy

Objectives
•To destroy Ca cells w/o excessive destruction of normal cells
•To control tumor growth if cure is no longer possible
•Used as adjuvant therapy
Contraindications
•Infection
•Recent surgery
•Impaired renal/hepatic function
•Pregnancy
•Bone marrow depression
•Recent radiation
 Safe Handling of Chemotherapeutic
Agents

1. Wear mask, gloves and back-closing gown

2. Avoid skin contact
3. Sterile/alcohol-wet cotton pledgets should be
used in opening vials
4. Expel air bubbles on wet cottons
5. Vent vials to reduce pressure after mixing
6. Wipe external surface of syringes and IV bottles
• 7. The hanging bottle with
ANTINEOPLASTIC CHEMOTHERAPY
• 8. Clearly label Avoid needle stab
• 9. Contaminated needles should be
disposed in a clearly marked special
container
• 10. Dispose half-empty ampules,
vials, IV bottles in a sealed plastic bag
with label
• 11. Handwashing should be done
before and after removal of gloves
• 12. Trained personnel only should
be involved in the use of drugs
• 13. Ideally preparation of drugs
should be in laminar flow condition
with filtered air
 Nursing Intervention for
Chemotherapeutic Side-effects
1. GI system – nausea, vomiting, diarrhea,
constipation
• Administer antiemetic
• Replace fluid & electrolyte loss, low fiber
diet to relieve diarrhea
• High fiber diet to relieve constipation
• 2. Integumentary system
– Pruritus, urticaria
• Provide good skin care
– Stomatitis
• Provide good oral care, avoid hot &
spicy food
– Alopecia
– Skin pigmentation
– Nail changes
 Nursing Intervention for
Chemotherapeutic Side-effects
3. Hematopoietic system
• Anemia
Provide frequent rest periods
• Neutropenia
Protect from infection
• Thrombocytopenia
Protect from trauma, avoid ASA
• 4. Genito-urinary system
– Hemorrhagic cystitis
– Provide 2-3 L of fluids/day
– Urine color changes
– Reassure client that it is
harmless
• 5. Reproductive system
– Premature menopause or amenorrhea
– Reassure that menstruation will
resume after chemotherapy
 Summary of Effects of
Chemotherapy

Antineoplastic drugs affects both

normal and Ca cells by
disrupting cell function and division
at various points
of cell cycle.
• Most Ca drugs are most effective
against cells that multiply
– rapidly – neoplasm, bone marrow
cells, cells in the GI tract,
– and cells in the skin or hair follicles.
Adverse reaction to
– cancer drugs tend to occur in these
organs.
• Chemotherapeutic agents
should not be used during
pregnancy
–or lactation. Congenital
defects may occur in the
fetus.
 The nurse is caring for a client
experiencing hematologic toxicity as
a result of chemotherapy. The nurse
plans to
• A. restrict all visitors
• B. restrict fluid intake
• C. insert an indwelling foley
catheter to prevent skin
breakdown
• D. restrict fresh fruits and
vegetables in the diet
 The client receiving chemotherapy is
experiencing stomatitis. The nurse advise
the client to use which of the following as
the best substance to rinse the mouth?
• A. hydrogen peroxide mixture
• B. weak salt and bicarbonate
mouth rinse
• C. lemon-flavored mouthwash
• D. alcohol-based mouthwash
 The client receiving chemotherapy is
experiencing stomatitis. The nurse advise
the client to use which of the following as
the best substance to rinse the mouth?
• A. hydrogen peroxide mixture
• B. weak salt and bicarbonate
mouth rinse
• C. lemon-flavored mouthwash
• D. alcohol-based mouthwash
 Antiemetics

•Dronabinol (Marinol)
•Odansetron (Zofran)
•Granisetron (Kytril)
•Alprazolam (Zanax)
•Lorazepam (Ativan)
•Haloperidol (Haldol)
•Prochlorperazine (Compazine)
 Radiation Therapy

•Role in Ca prevention
Primary curative role
Adjunct to other therapy
Palliation
•Sources of Radiation Therapy
External radiation therapy
Internal radiation therapy
•Types:
Sealed source (brachytherapy)
Unsealed source (oral, IV)
 Side Effects of Radiation
Therapy

• Skin reactions • Diarrhea

• Infection • Nausea &
• Hemorrhage vomiting
• Fatigue • Headache
• Weight loss • Hair loss
• Stomatitis • Cystitis
• Social isolation
 Principles of Radiation
Protection

1. Distance
Maintain at least a distance of 3 ft when not
preforming
nursing procedure
2. Time
Limit contact for 5 min each time, 30 min for
whole shift
3. Shielding
Use lead shield during contact with client
 Teaching Guidelines Regarding
Radiation Therapy

1. It is painless
2. Lie very still on a special table
3. Sometimes client may be placed in a special position
4. Each treatment lasts for few minutes
5. Sound will be heard from the machine
6. Client will be alone while procedure is ongoing
7. Personnel will be observing client through a glass
window
8. No residual radioactivity after radiation therapy
9. Client may resume activities of daily living
 The client is receiving external
radiation to the neck for of the
larynx. The most likely side effect to
be expected is

• A. constipation
• Dyspnea
• Sorethroat
• diarrhea
 The client is receiving external
radiation to the neck for of the
larynx. The most likely side effect to
be expected is

• A. constipation
• Dyspnea
• Sorethroat
• diarrhea
 Breast Carcinoma
Risk Factors: Sx & Symptoms
•Menarche at age <11 •Firm, non tender, fixed mass
•Menopause >50 •Solitary, irregularly shaped
•Family Hx of breast Ca mass
•Nulliparity or birth of first •UOQ or nipple periphery
child after 30 involvement
•Hx of uterine Ca •Retraction of nipple
•Presence of benign breast mass •Abnormal discharge from
•Obesity, DM, HPN nipple
•“orange peel” skin
Prevention
•BSE
•Mammogram
Abnormal Breast Findings
1. Retraction Signs
Signs include skin dimpling, creasing, or
changes in the contour of the breast or
nipple
Secondary to fibrosis or scar tissue
formation in the breast
Retraction signs may appear only with
position changes or with breast
palpation.
Breast Retraction
2. Breast Cancer Mass (Malignant Tumor)
Usually occurs as a single mass(lump) n
one breast
Usually nontender
Irregular shape
Firm, hard, embedded in surrounding
tissue
Referral and biopsy indicated for definitive
diagnosis
3. Increased Venous Prominence
Associated with breast cancer if unilateral
Unilateral localized increase in venous
pattern associated with malignant
tumors
Normal with breast enlargement
associated with pregnancy and lactation
of bilateral symmetry
4. Peau d’Orange (edema)
Associated with breast cancer
Caused by interference with lymphatic
drainage
Breast skin has orange peel appearance
Skin pores enlarge
May be noted on the areola
Skin becomes think, hard, immobile
Skin discoloration may occur
Peau d’orange
5. Nipple Inversion
Considered normal if long-standing
Associated with fibrosis and
malignancy if recent development
Nipple Inversion
 Diagnostic Evaluation

• 1. Breast Self Examination

2. Mammography
- is breast-imaging technique that
can detect nonpalpable lesions and
assist in diagnosing palpable
masses that takes about 20mins.
It may detect a breast tumor before it is
clinically palpable.
A baseline mammogram should be obtained
after age 35 years and by the age of 40
Mammography
 3. Galactography

Is a mammographic
diagnostic procedure that
involves injection of less
than 1ml of radiopaque
material through a cannula
inserted into a ductal
opening on the areola,
followed by a mammogram.
It is performed when the
patient has a bloody nipple
discharge on expression,
spontaneous nipple
discharge or solitary dilated
duct noted on
mammography
 4. Ultrasonography

Is used in conjunction with

mammography to distinguish
fluid-filled cysts from other
lesions.
This technique is 85% to 95%
accurate but does not rule
out a malignant lesion.
5. Magnetic Resonance
Imaging
Highly sensitive test and serves as
an adjunct to mammography.
Can be helpful in determining the
exact size of a lesion or the
presence of multiple foci than
mammography
A coil is placed around the breast,
and the patient is placed inside
the MRI machine for about
2mins
 The nurse is preparing a client for
mammography. The nurse tells the
client
• A. that mammography takes about 1
hour
• B. to avoid the use of deodorants,
powders, or creams on the day of the
test
• C. that there is no discomfort
associated with the procedure
• To be on NPO status on the day of the
test
 The nurse is preparing a client for
mammography. The nurse tells the
client
• A. that mammography takes about 1
hour
• B. to avoid the use of deodorants,
powders, or creams on the day of the
test
• C. that there is no discomfort
associated with the procedure
• To be on NPO status on the day of the
test
 Breast Ca Staging

Stage 1: Tumor size is up to 2 cm

Stage 2: Tumor size is up to 5 cm, axillary
lymph node involvement
Stage 3: Tumor size >5cm, axillary + neck
lymph node involvement
Stage 4: Metastasis to distant organs
 Collaborative
Management
1. Surgery
• Lumpectomy
• Simple mastectomy
• Modified Radical Mastectomy (MRM)
• Radical Mastectomy (Halstead Surgery)
2. Chemotherapy
3. Radiation therapy
 Breast Ca Surgery
Preoperative Care: Postoperative Care:
Semifowler’s position
Psychosocial
Arm elevation
support
Monitoring of tissue drainage
Arm exercises
Wound suction Monitoring for signs of bleeding
Affected arm PRECAUTION
drainage
Post mastectomy exercises
Analgesia to promote ambulation &
exercise
Psychological conditioning
Prevention & monitoring for
lymphedema
BSE on remaining breast
 Do’s and Don’t’s

Dont’s
Carry anything heavy Do’s
Wear wristwatch or Wear loose gloves
jewelry Apply lubricating cream
Pick at cuts and cuticle Contact MD if with
Work with thorny plants problem
Reach into hot oven Return for check up
Hold a cigarette Wear tag labeled ARM
Injection, blood PRECAUTION
extraction, BP
taking
 The nurse is caring for a client following a
radical mastectomy. Which of the following
nursing interventions would assist in
preventing lymphedema of the affected
arm?
• A. placing cool compress on the
affected arm
• B. elevating the affected arm on a
pillow above heart level
• C. maintaining an intravenous site
below the antecubital area on the
affected side
• D. avoiding arm exercises in the
immediate postoperative period
 The nurse is caring for a client following a
radical mastectomy. Which of the following
nursing interventions would assist in
preventing lymphedema of the affected
arm?
• A. placing cool compress on the
affected arm
• B. elevating the affected arm on a
pillow above heart level
• C. maintaining an intravenous site
below the antecubital area on the
affected side
• D. avoiding arm exercises in the
immediate postoperative period
 The nurse is caring for a client following a
modified radical mastectomy. Which
assessment finding would indicate that the
client is experiencing a complication related
to the surgery?
• A. sanguineous drainage in the
jackson-pratt drain
• B. pain at the incisional site
• C. complaints of decreased
sensation near the operative site
• D. arm edema on the operative
side
 The nurse is caring for a client following a
modified radical mastectomy. Which
assessment finding would indicate that the
client is experiencing a complication related
to the surgery?
• A. sanguineous drainage in the
jackson-pratt drain
• B. pain at the incisional site
• C. complaints of decreased
sensation near the operative site
• D. arm edema on the operative
side
Fibroadenoma
Gigantomastia
Breast conserving surgery
Total mastectomy: A surgical procedure to remove the whole breast
that contains cancer. This procedure is also called a simple
mastectomy. Some of the lymph nodes under the arm may be
removed for biopsy at the same time as the breast surgery or after.
Modified radical mastectomy: A surgical procedure to remove the
whole breast that contains cancer, many of the lymph nodes under
the arm, the lining over the chest muscles, and sometimes, part of
the chest wall muscles
 Radical mastectomy
• A surgical procedure to remove the breast that contains
cancer, chest wall muscles under the breast, and all of the
lymph nodes under the arm. This procedure is
sometimes called a Halsted radical mastectomy
 Radiation therapy

• a cancer treatment that uses high-energy x-rays or other types of

radiation to kill cancer cells
2 Types of Radiation Therapy

• External radiation therapy - uses a machine outside the body to

send radiation toward the cancer.
• Internal radiation therapy - uses a radioactive substance sealed
in needles, seeds, wires, or catheters that are placed directly into
or near the cancer.
 Chemotherapy
• is a cancer treatment that uses drugs to stop the growth of
cancer cells, either by killing the cells or by stopping the
cells from dividing
 Hormone therapy

• is a cancer treatment that removes hormones or blocks their

action and stops cancer cells from growing
• Tamoxifen -is often given to patients with early stages of breast
cancer and those with metastatis
• However, hormone therapy with tamoxifen or estrogens can act
on cells all over the body and may increase the chance of
developing endometrial cancer
UTERINE CANCER
A tumor in the uterus—the beginning of Uterine Cancer
 Types

• Endometrial Ca. The most

common form which begins in the
lining of the uterus (endometrium)

• Uterine Sarcoma. This is when

the cancer develops in the outer
layer of muscle tissue
(myometrium)
A cross section of a uterus with cancer
 Risk Factors

• When the body produces more

estrogen, stimulating the growth
of the endometrium, the risk for
uterine cancer increases.

• Uterine cancer has several internal

causes usually due to the presence
of extra estrogen.
 Risk Factors
• Women who experience more
years of menstruation are at a
higher risk of uterine cancer.
• If menstruation begins before the
age of 12 and continues into a
woman’s 50’s the risk is higher
(the more years of menstruation a
woman experiences the more
years the endometrium is exposed
 Risk Factors
• Women who have never
experienced pregnancy are at a
higher risk (because the body
produces more progesterone
during pregnancy protecting the
endometrium by lowering estrogen
levels. Women who have never
been pregnant do not receive the
benefit of this protection)
 Risk Factors

• Women who do not experience

regular cycles (Irregular
ovulation or failure to ovulate
increases a woman’s lifetime
exposure to estrogen)
• Women with Type 2 diabetes or
women who are obese (tissues
sometimes change hormones
into estrogen resulting in an
increased level of estrogen)
 Risk Factors
• Women who participate in
Estrogen-only Replacement
Therapy (ERT) (ERT stimulates the
growth of the endometrium,
placing estrogen alone after
menopause)
 Risk Factors
• Uterine cancer is more prevalent in
older women
• 95% of women with uterine cancer
are over the age of 40
• White women are more likely to
develop uterine cancer, but African
American women are more like to
die from it
 Stages of Endometrial Cancer

• Stage I -- Cancer cells are

confined to the uterus.
 Stages of Endometrial Cancer

• Stage II -- Cancer is found in the

uterus and the cervix but has not
spread outside the uterus.
 Stages of Endometrial Cancer
• Stage III -- The cancer has spread
outside the uterus but not beyond the
pelvis.
 Stages of Endometrial Cancer
• Stage IV -- The cancer has spread
beyond the pelvis or has invaded
tissue in the bladder or rectum.
Progression of Uterine Cancer
 Screening

• There are no useful screening

tests and/or pelvic exams that
detect uterine cancer.
• The disease is most often
diagnosed because a woman
shows symptoms of the
disease.
• S/Sx of endometrial cancer include
abnormal bleeding, spotting, or
other discharges from the
vagina. Women who have gone
through menopause are especially
encouraged to consult a physician
if abnormal bleeding, spotting, or
discharges occur.
 Symptoms

• Irregular bleeding
• Postmenopausal bleeding
• Vaginal discharge that does not
contain blood
• Pelvic pain
• Weight loss
 Treatment
• Surgery involves having a
hysterectomy.
• Having a simple hysterectomy
(removal of the entire uterus) or
radical hysterectomy (removal of
the uterus, surrounding tissues,
and cervix) depends on the case.
 Treatment
• The option of radiation therapy
involves using high-energy
radiation to destroy the cancer
cells.
• The procedure is done outside of
the body and is not unlike having
an X-ray for a broken limb.
 Treatment

• Chemotherapy involves taking a

series of drugs (either by mouth or
through a vein) to kill the cancer
cells.
• Chemotherapy is most often used
when the cancer has spread to
other areas of the body.
 Treatment

• Hormone therapy is mainly

used to treat patients with
endometrial stromal
sarcomas
• A progesterone-like hormone drug
or a drug which stops the
production of estrogen can be
used. Hormone therapy, however,
is not often used and is still being
tested
 Prevention

• taking hormone therapy

:

with progestin
• a history of using birth
control pills to regulate
cycles
• and maintaining a healthy
weight.
OVARIAN CANCER
• Ovarian cancer is the fifth leading
cause of cancer death in women
• the leading cause of death from
gynecological malignancy
• and the second most commonly
diagnosed gynecologic
malignancy.
• It is idiopathic.
• The disease is more common in
industrialized nations
 Risk Factors

• Age—Old women
• Carriers of certain mutations of the
BRCA1 or the BRCA2 gene, more
frequent in some populations (e.g.
Ashkenazi Jewish women) are at a
higher risk of both breast cancer
and ovarian cancer
 Risk Factors
• Patients with a personal history of
breast cancer or a family history of
breast and/or ovarian cancer
• The use of fertility medication,
such as Clomiphene citrate
An ultrasound image of ovarian cancer
• Early age at first pregnancy, older
ages of final pregnancy and the
use of low dose hormonal
contraception have also been
shown to have a protective effect
• Recent studies have shown that
women in sunnier countries have a
lower rate of ovarian cancer, which
may have some kind of connection
with exposure to Vitamin D
 History

• Ovarian cancer often is primary,

but can also be secondary, the
result of metastasis from primary
cancers elsewhere in the body. For
example, from breast cancer, or
from gastrointestinal cancer (in
which case the ovarian cancer is a
Krukenberg cancer).
Stages
 Stage 1

• Stage I - limited to one or both

ovaries
 Stage II

• Stage II - pelvic extension or

implants
 Stage III
• Stage III - microscopic peritoneal
implants outside of the pelvis; or
limited to the pelvis with extension to
the small bowel or omentum
 Stage IV

• Stage IV - distant metastases--in

the liver, or outside the peritoneal
cavity
During the admission assessment of a client
with advanced ovarian cancer, the nurse
recognizes which symptom as typical of the
disease?
• A. hypermenorrhea
• B. abdominal distention
• C. diarrhea
• D. abnormal bleeding
During the admission assessment of a client
with advanced ovarian cancer, the nurse
recognizes which symptom as typical of the
disease?
• A. hypermenorrhea
• B. abdominal distention
• C. diarrhea
• D. abnormal bleeding