MEDICAL – SURGICAL NURSING: ONCOLOGIC NURSING

Prepared by: Miss Joya Genzola, RN

CANCER
q Is a ___________________________________ that can involve all body organs with manifestations that vary according to the body system
affected and type of tumor cells.
q Cells lose their normal _______________________________, and the growth of cells is _____________________.

PROLIFERATIVE PATTERNS
DESCRIPTION

Increase in the number of cells in an organ or tissue

Represents a reversible change in which one adult cell type (epithelial or

mesenchymal) is replaced by another adult cell type.
Characterized by deranged cell growth of a specific tissue that results in cells that vary
in size, shape, and organization

Lack of cell differentiation in cancerous tissue

Process of “new growth,” and the new growth is called a ____________

Continues after the stimulus is removed
BENIGN vs
MALIGNANT NEOPLASM
CELL CHARACTERISTICS
MODE OF GROWTH
RATE OF GROWTH
METASTASIS
GENERAL EFFECTS
TISSUE DESTRUCTION
ABILITY TO CAUSE DEATH
BENIGN MALIGNANT BENIGN
TISSUE TISSUE MALIGNANT TUMORS
TUMORS TUMORS TUMORS
Epithelial + “carcinoma” Neural + “toma”
Surface Papilloma Squamous cell Nerve cells Neuroma Neuroblastoma
carcinoma
Glandular Adenoma Adenocarcinoma Glial tissue Glioma Glioblastoma, astrocytoma,
medulloblastoma,
oligodendroglioma
Connective + “sarcoma” Nerve sheath Neurilemmoma Neurilemmal sarcoma
Fibrous Fibroma Fibrosarcoma Meninges Meningioma Meningeal sarcoma
Adipose Lipoma Liposarcoma Hematologic
Cartilage Chondroma Chondrosarcoma Granulocytic Myelocytic leukemia
Bone Osteoma Osteosarcoma Erythrocyte Erythrocytic leukemia
Blood vessels Hemangioma Hemangiosarcoma Plasma cells Multiple myeloma
Lymph vessels Lymphangioma Lymphangiosarcoma Lymphocytic Lymphocytic leukemia or
lymphoma
Lymph tissue Lymphosarcoma Monocytic Monocytic leukemia
Muscle + “sarcoma” Endothelial Tissue
Smooth Leiomyoma Leiomyosarcoma Blood vessels Hemangioma Hemangiosarcoma
Striated Rhabdomyoma Rhabdomyosarcoma Lymph vessels Lymphangioma Lymphangiosarcoma
Endothelial lining Ewing’s sarcoma

growth of the primary tumor into the surrounding host tissues ___________________ or spread of malignant cells from the primary
tumor to distant sites by:
• direct spread of tumor cells to _______________
• through _______________ and ____________ circulation
METASTASIS THROUGH:
1. _______________________ : the transport of tumor cells through the lymphatic circulation
q malignant cells → lymph nodes → lymphatic circulation

2. ____________________________: the dissemination of malignant cells via the bloodstream and is directly related to the vascularity of the tumor
q malignant cells → endothelium → attracts seal → lysosomal enzymes → implantation
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3. ____________________________: growth of new capillaries from the host tissue by the release of growth factors and enzymes such as vascular
endothelial growth factor (VEGF)
Carcinogenesis
2. ______________________ 3. ______________________
1. ______________________
repeated exposure to promoting agents the altered cells exhibit increased
carcinogens escape normal enzymatic
(cocarcinogens) causes the expression of malignant behavior. These cells have a
mechanisms and alter the genetic structure of
abnormal or mutant genetics information. propensity to invade adjacent tissues and
the cellular DNA.
to metastasize.
ETIOLOGY
1. 4.
Burkitt’s Lymphoma Hereditary Breast & Ovarian
Nasopharyngeal cancer Cancer Syndrome
Some type of Hodgkin’s & Non-Hodgkin’s
Gastric cancer Eye Cancer
2. Skin, Mouth , GI tract
Skin cancer 5.
Especially high in: Fats, alcohol, salt-cured or smoked meats, nitrate-containing and
o fair-skinned nitrite-containing foods, and red and processed meats
o blue- or green-eyed people
Pancreas, Gallbladder, Colon
Leukemias Liver
Multiple Myeloma 6.
Lung Vaginal cancer
Bone Endometrial
Breast Hepatocellular
Thyroid Breast
NOTE – INCREASED RISK FOR BREAST CA:
1.
3. 2.
3.
30% Of Cancer
4.
o Lung
o Cervical Continuation of no. 3:
o Bladder Leukemia
Skin cancer
Liver cancer Esophageal cancer
Lung cancer Liver and brain
CANCER GRADING & STAGING
GRADE
Cells differ slightly from normal cells and are _____________________ /
Cells are more abnormal and are __________________________ /
Cells are very abnormal and are _________________________ /
Cells are immature (_________________) and ________________________ / ; cell of origin is difficult to determine.
STAGING

TNM CLASSIFICATION
TUMOR NODE
Primary tumor cannot be assessed Regional lymph nodes cannot be assessed
No evidence of primary tumor No regional lymph node metastasis
Carcinoma in situ
Increasing size and/or local extent of the Increasing involvement of regional lymph nodes
primary tumor
METASTASIS
Mx Mo

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BIOPSY TYPES

1. _________________________ 2. __________________________ 3. __________________________

the surgeon can remove a wedge of tissue from the involves aspirating tissue
the entire tumor as well tumor is removed for fragments through a needle
as the surrounding analysis guided into an area suspected of
marginal tissues bearing disease

1. SURGERY AS A TREATMENT
- primary approach in treating cancer
- the goal is to ________________________________ or as much as is feasible (a procedure sometimes called ____________) and any
involved surrounding tissue, including regional lymph nodes.
1. removal of the mass and a small margin of normal tissue that is easily accessible
* include removal of the primary tumor, lymph nodes, adjacent involved structures, and surrounding tissues that
may be at high risk for tumor spread
2. minimally invasive procedure, an endoscope with intense lighting and an attached multichip
________________________ is inserted into the body through a small incision. The _________________________ are
inserted into the surgical field through one or two additional small incisions, each about 3 cm in length
3. additional treatment option that uses an ________________________________ to treat the local recurrence of a
cancer ______________________________ approach
OTHER TYPES OF SURGERY
4. ___________________ to destroy tumor cells Basal and squamous cell skin cancers
5. liquid nitrogen or a __________________ to freeze tissue and
cause cell destruction
6. _____________________ or chemotherapy applied directly to Intraperitoneal chemotherapy for ovarian
tissue to cause destruction cancer
7. ____________________ aimed at an exact tissue location and Dyspnea associated with endobronchial
depth to vaporize cancer cells (also referred to as obstructions
photocoagulation or photoablation)
8. Intravenous administration of a _____________________ Palliative treatment of dysphagia associated
( ) that is with esophageal and dyspnea associated
taken up by cancer cells, followed by __________ _________within with endobronchial obstructions
24–48 hours; causes cancer cell death
9. Uses localized application of thermal energy that destroys cancer Nonresectable liver tumors, pain control with
cells through heat: ________________________________ bone metastasis
2. PALLIATIVE SURGERY 3. _____________________________________________
• When ______________________ • May follow curative or radical surgery in an attempt to
• To promote _______________________ improve function or obtain a more
• To relieve complications of cancer, such as: ___________________________________
o Obstruction • May be indicated for:
o Hemorrhage o Breast
o Pain o Head and neck
o Malignant effusion o Skin cancers
RADIATION THERAPY
• Destroys cancer cells through ________________
TWO TYPES OF IONIZING RADIATION:
2. ___________________________
• Electrons - Beta particles
1. ___________________________ • Protons - Neutrons
• X-rays • Alpha particles
• Gamma rays
METHODS OF ADMINISTRATION

1. _______________________________________________
• Most commonly used
• Generated from
o Linear accelerator
o Unit that generates energy (ex. GammaKnifeTM)
• Through computerized software programs, both approaches are able to shape an invisible beam of
___________________________________________ and target a tumor with pinpoint accuracy

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2. _____________________________________________
• delivers a high dose of radiation to a localized area
• _______________________________________
• Internal radiation can be implanted by means of needles, seeds, beads, or catheters into body cavities (vagina, abdomen, pleura) or
interstitial compartments
2.1. __________________________ 2.2. ________________________ TO PREVENT DISLODGEMENT:
insertion of catheters or hollow the radioisotopes are inserted (in ____________)
tubes into the lumens of organs into specially positioned applicators after their
ü . placement is verified by
ü . x-ray.
ü . ü For ___________________________

2.3. __________________________ 2. 4. ______________________________

implants usually consist of seeds, needles, wires, or small catheters involves the IV administration of a therapeutic radioactive isotope
positioned to provide a local radiation source and are infrequently targeted to a specific tumor
dislodged
Thyroid
ü .
ü . Bone metastases
ü .
Bone lesions

Malignant ascites a/w ovarian CA

§ Wash _____________ Wear _______________
§ § Do not to _________ the markings
§ ___________ water Avoid wearing _______, __________,
§ § Dry the irradiated area with ______________
§ Mild _________ ___________, or any type of clothing rather than rubbing
§ Use __________ that binds or rubs the skin at the § Avoid heat exposure
§ Rinse well radiation site § Use _____ powders, ointments, lotions, or creams
§ Avoid exposure of the irradiated area to on the skin at the radiation site unless they are
the sun. prescribed by the radiologist
CARE OF CLIENT WITH SEALED RADIATION FOR THE MEDICAL TEAM
1. –
2. .
3.

Advise the client who had a cervical or vaginal implant to notify the HCP DISLODGED IMPLANT
if any of the ff occurs:
§ severe diarrhea
§ frequent urination
§ urethral burning for more than 24 h
§ hematuria
§ heavy vaginal bleeding
§ extreme fatigue
§ abdominal pain
§ fever over 100°F (38°C)

CHEMOTHERAPY

ANTINEOPLASTIC MEDICATIONS - kill or inhibit the reproduction of neoplastic cells

1. used to cure
2. increase survival time
3. decrease life-threatening complications

The effect of antineoplastic medications may not be limited to neoplastic cells; normal cells also are affected by the medication
TYPES OF ANTINEOPLASTIC MEDICATION
1. Cell cycle ________________ 2. Cell cycle __________________
q medications affect cells only during a certain phase of the q medications affect cells in any phase of the reproductive
reproductive cycle cycle

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COMMON ROUTE OF ADMINISTRATION

1. ______________________ 2. ______________________. 3. ______________________. 4. ______________________
SAFE & EFFECTIVE CARE ENVIRONMENT
1. Prepare IV chemotherapy in an ____________________ (_______________________).
2. PPE –
3. Discard in biohazard containers
4. _________________ nurses should avoid the preparation.
5. Administer antineoplastic medication precisely as prescribed.
6. Monitor for ____________ with IV administration.
7. Vesicants should be administered through a ________________ when possible.
8. If a peripheral line is used, ____________ should be checked prior to administration.
9. Reduce IV site pain by altering IV rates or warming the injection site
10. Monitor for _______________ (leakage of medication into surrounding skin and subcutaneous tissue, causes tissue necrosis)
________________________: Agents that, if deposited into the subcutaneous tissue (extravasation), cause tissue necrosis and damage to underlying
tendons, nerves, and blood vessels

_______________________: leakage of medication into surrounding skin and subcutaneous tissue, which causes tissue necrosis
- .
- .
If the nurse suspects extravasation during the IV
- . administration of an antineoplastic medication:
1. S
PREVENTION
2. N
1. Vesicants should not be through peripheral veins.
2. Peripheral is permitted for short-duration infusions only. Forearm only, with 3. I
soft plastic catheter. 4. A
5. T
FOR FREQUENT & PROLONGED ADMINISTRATION:
1. ________________, silastic catheter implanted venous access devices,
2. Peripherally inserted central catheters (PICC)
PSYCHOLOGICAL INTEGRITY:
§ Discuss the purchase of a _______ before treatment starts and consider cutting hair short.
§ Inform the client that _______________ will occur several months after the final treatment
§ Instruct the client about the need for _________________.
§ Discuss the potential effect of ________________, which may be irreversible.
§ Encourage pretreatment counseling and encourage ________________________.
SPECIAL COVERAGE IN CANCER
RISK FOR INFECTION: PRACTICES (Infection):
§ ____________________
ROOM SET-UP § Daily bathing with _______________ soap
• ___________________ isolation § Oral hygiene & good bowel program
• Limit the number of staff § No visitor with any __________________ infection
• ___________________ with the door ____________. § Use strict _________________ technique
• ____________________ filtration or a laminar airflow system § Reduce exposure to environmental organisms by
• Client’s room is cleaned daily Ø ______________________________
• ___________________ supplies & equipment Ø ______________________________
Ø ______________________________
§ Monitor signs of ___________________:
(Infection) HEALTH TEACHING / INSTRUCT CLIENT TO: Avoid immunization with a live virus (vaccines):
§ Avoid ________________ § Measles
§ About a ___________________ § Mumps
§ Avoid exposure to infection § Rubella
Ø ____________________________ § Polio
Ø ____________________________ § Varicella
§ Shingles
§ and some influenza (H1N1 vaccine)
RISK FOR BLEEDING Ø ________________________
- PLATELET BELOW _________ mm3 – _________________ Ø ________________________
- PLATELET BELOW _________ mm3 – ________________ Ø ________________________
§ May need platelet transfusion Ø ________________________
§ Handle the client gently
§ Examine the client for signs and symptoms of bleeding § Use caution when taking blood pressures

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§ Monitor for signs of _____________________ Provide _______________ that are ___________________

PRACTICES (Bleeding): § AVOID!
§ _________________
§ ______ side rails and sharp corners of the bed and § apply ___________ pressure to a needle-stick site for at least ___
furniture minutes, or longer if needed.
§ If the female client is menstruating, ________________ § ________________, rectal suppositories, enemas, and rectal
of pads or tampons used. thermometers.
(Bleeding): INSTRUCT CLIENT TO:
§ Use a __________________ and avoid __________________.
§ Use only an ____________________ for shaving.
§ Avoid ______________ the nose.
§ Avoid engaging in activities involving the use of __________________.
§ Avoid ________________ sports.
§ Avoid using _______________ and products that contain _________________.
BREAST SELF EXAM
GOAL: _______________________________
SCHEDULE (for menstruating): _______________________________
(for menopaused): _________________________
TIME: ______________________________, when the skin is slippery with soap and water

STEPS:
1. Using the pads of the fingers on your left hand, examine the entire right breast.
2. Look at your breasts in a mirror. Stand with your arms at your side.
3. Raise your arms overhead and check for any changes in the breasts.
4. Place your hands on your hips and press down firmly, tightening the pectoral muscles
5. While lying down, feel your breasts as described in step 1.
When examining your right breast, place a folded towel under your right shoulder and put your right hand behind your head.
AGE RECOMMNEDATION Women who are at high risk,
Monthly BSE GET A BREAST MRI AND A MAMMOGRAM ______________,
Clinical breast exam every 3 TYPICALLY STARTING AT AGE _____.
yrs This includes women who:
Annual clinical breast exam 1,
Choice to start annual 2,
mammogram 3,
4,
Annual mammogram
5,
Mammogram every 2 years
CARE OF CLIENT POST MASTECTOMY
1. Avoid overuse of the arm during the first few months.
2. To prevent lymphedema, ___________________________________; consultation with lymphedema specialist may be prescribed.
3. Provide incision care with an __________________ as prescribed, to soften and prevent _______________________.
4. Encourage use of support groups.
5. Encourage the client to perform breast self-examination on the remaining breast and surgical site once healed.
6. Protect the affected hand and arm.
7. Avoid _________________ on the affected arm.
8. Do not let the affected arm ______________________.
9. Do not carry a ___________________________ over the affected arm.
10. Avoid _________, ___________, ___________ OR ______________ to the affected side.
11. Avoid wearing ________________________________ on the affected side.
12. Wear ____________ when gardening.
13. Use ____________________ when cooking.
14. Use a __________________ when sewing.
15. Apply hand cream several times daily.
16. Use cream cuticle remover.
17. Call the health care provider if ______________________ occur in the affected arm.
18. Wear a MedicAlert bracelet stating which arm is at risk for lymphedema.
CAUTION US!!!
C
A
U
T
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I
O
N
U
S
ORGAN CANCER
1. SKIN TYPE
RISK / TUMOR
HALLMARK ASSESSMENT
PRIMARY CAUSE: ________________________ MARKER
RISK FACTORS: 1. epidermis • _______ nodule with pearly
1. chronic skin damage (tanning) borders
2. genetic predisposition • Papule, red, central crater
3. ionizing radiation • Metastasis is rare
4. light-skinned race 2. epidermal • Oozing, bleeding, crusting lesion
5. age older than 60 years keratinocytes + lymph • Potentially ________________
6. an outdoor occupation nodes • Larger tumors associated with a
7. exposure to chemical higher risk for metastasis
carcinogens.
3. birthmarks or new • __________, circular, bordered
ABCDE:
moles lesion with hues of _______,
A__________________________ B________________________
_______, or _________
C__________________________ D ________________________
E__________________________
• Rapid infiltration into tissue
• ____________ metastatic
2. LEUKEMIA - neoplastic proliferation of one particular cell type RISK FOR:
(granulocytes, monocytes, lymphocytes, or infrequently erythrocytes or Ø .
megakaryocytes) Ø .
Leukocytosis - increased level of leukocytes in the circulation Ø .

Mostly ______________ present in bone marrow Mostly _____________________ present in bone marrow
ONSET: ONSET:
Mostly lymphocytes present in bone marrow Mostly __________________ present in bone marrow
ONSET: ONSET:
3. LYMPHOMA: HALLMARK ASSESSMENT:
• abnormal proliferation of lymphocytes • Fever
• Hodgkin’s disease is a malignancy of the ________________ • Malaise, fatigue, and weakness
• Night sweats
• POSSIBLE CAUSE: Viral: _________________________ • Loss of appetite and significant weight loss
• TUMOR MARKER: ____________________________ • Anemia and thrombocytopenia
• Enlarged lymph nodes, spleen, and liver
4. MULTIPLE MYELOMA ADDITIONAL ASSESSMENT:
malignant proliferation of plasma cells within the • ________________________
• ________________________
______
• Bone (skeletal) pain, especially in the ribs, spine, and pelvis
• Osteoporosis & pathological fractures
TUMOR MARKER/DIAGNOSIS:
• Thrombocytopenia and leukopenia
________________________________________________
• Kidney failure
_
• Spinal cord compression and paraplegia
• Bone marrow aspiration shows an abnormal number of ________________________
5. TESTICULAR CANCER TESTICULAR SELF EXAM
arises from germinal epithelium from the sperm-producing germ cells or from
nongerminal epithelium from other structures in the testicles GOAL: _______________________
SCHEDULE _______________________
RISK AGE GROUP: ___________________ TIME: _______________________
CAUSE: _____________________________
HISTORY: 1. ________________________ 1. Gently lift each testicle. Each one should feel like an _______,
2. ________________________ firm but not hard, and smooth with no lumps.
ASSESSMENT: 2. Using both hands, place your ________________ on the
• _________________ testicular swelling occurs. underside of each testicle and your ________________.
• “_________________” or “_________________” sensation. 3. Gently roll the testicle between the thumb and fingers to feel
• METASTASIS: Palpable lymphadenopathy, abdominal masses, and for any lumps, swelling, or mass.
gynecomastia may indicate If you notice any changes from 1 month to the next,
• LATE SIGNS: __________________________________. notify your health care provider.

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6. PROSTATE CANCER ASSESSMENT:

RISK GROUP: _______________________________________________ • Asymptomatic in early stages
CAUSE: • Hard, pea-sized nodule or irregularities palpated on rectal examination
• adenocarcinomas arising from androgen-dependent • Gross, painless hematuria
epithelial cells
• Advancing age LATE SYMPTOMS:
• Heavy metal exposure • weight loss
• Smoking • urinary obstruction
• History of STI • bone pain radiating from the lumbosacral
area down the leg
SPECIAL INTERVENTION
SCREENING:
The PSA test and the DRE should be offered annually, starting at age 50 years, for men who have a life expectancy of at least 10 years.
7. CERVICAL CANCER PAP SMEAR TEST: page 344 (B&S)
RISK FACTORS: Cervical cancer screening should begin approximately ___ years
1. . after a woman begins having vaginal intercourse, but no later than
2. . age ____ years.
3. Reproductive behavior
START
o __________________________________
o __________________________________
Every year – conventional Pap Test
o __________________________________ NEXT
Every 2 years – liquid-based Pap Test

ASSESSMENT: NORMAL TESTS IN A ROW:

1. Painless vaginal postmenstrual and postcoital bleeding Every 2 – 3 years - conventional or liquid-based
30 YEARS
2. Foul-smelling or serosanguineous vaginal discharge Pap test
OLD AND UP
3. Pelvic, lower back, leg, or groin pain Every 3 years – HPV DNA test + cervical
4. Leakage of urine and feces from the vagina cytology
5. Dysuria Ø 10 years of N / more normal tests
70 AND
6. Hematuria previously –
OLDER
7. Cytological changes on Pap test Ø Total hysterectomy –
8. OVARIAN CANCER ASSESSMENT: TREATMENTS:
RISK FACTORS: • Abdominal discomfort or 1. External Radiation
swelling 2. Chemotherapy
HIGH MORTALITY • Gastrointestinal 3. Intraperitoneal chemotherapy involves the instillation
Particularly among: disturbances of chemotherapy into the abdominal cavity.
• White women • Dysfunctional vaginal 4. Total abdominal hysterectomy and bilateral salpingo-
• Between 55 and 65 years of age bleeding oophorectomy
• North American or European descent. • Abdominal mass

TUMOR MARKER: _______________________

9. UTERINE / ENDOMETRIAL CANCER ASSESSMENT:
RISK FACTORS: • Abnormal bleeding, especially in postmenopausal women
• Use Of estrogen replacement therapy (ERT) • Vaginal discharge
• ____________________ • Low back, pelvic, or abdominal pain (pain occurs late in the disease
• Polycystic ovary disease process)
• Increased age • Enlarged uterus (in advanced stages)
• ____________________
• Family history of uterine cancer or hereditary
• Nonpolyposis colorectal cancer
• Obesity , Hypertension, Diabetes mellitus
10. BREAST CANCER ASSESSMENT:

RISK FACTORS: Mass felt during BSE

•
• Age • usually felt in the ________________________
• Family history of breast cancer due to genetic • beneath the nipple
predisposition • in axilla
• ________________ and _________________ • Presence of the lesion on mammography
• Previous cancer of the breast, uterus, or ovaries
• A fixed, irregular nonencapsulated mas
• Nulliparity, late first birth • Typically painless except in the late stages
• Obesity • Asymmetry
• High-dose radiation exposure to chest • Bloody or clear nipple discharge
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• Nipple retraction or elevation

• _______________________, retraction, or ulceration
• Skin edema or ____________ skin
11. GASTRIC CANCER Early: Late:

RISK FACTORS: a. Indigestion a. Weakness and fatigue

• _________________________ infection b. Abdominal discomfort b. Anorexia and weight loss
• diet of smoked, highly salted, processed, or spiced foods c. Full feeling c. Nausea and vomiting
OTHER RISK: d. Epigastric, back, or d. A sensation of pressure in the stomach
• Smoking retrosternal pain e. Dysphagia and obstructive symptoms
• Alcohol f. Iron deficiency anemia
• Nitrate ingestion g. Ascites
• History of gastric ulcers h. Palpable epigastric mass

SURGERY: ___________________________________________ SURGERY: POST GASTRIC SURGERIES

1. Maintain NPO (nothing by mouth) status as prescribed for 1 to 3
days until peristalsis returns; assess for bowel sounds.
2. Monitor nasogastric suction. Following gastrectomy, drainage from
the nasogastric tube is normally bloody for 24 hours
postoperatively, changes to brown-tinged, and is then yellow or
clear.
3. Do not irrigate or remove the nasogastric tube (follow agency
procedures); assist the HCP with irrigation or removal.
12. PANCREATIC CANCER ASSESSMENT:
Endoscopic retrograde
RISK FACTORS: cholangiopancreatography
• Increased age
• History of diabetes mellitus • Nausea and vomiting
• ______________ • Jaundice
• History of previous pancreatitis • Unexplained weight loss
• Smoking • ________________ stools
• Ingestion of a __________________ • Glucose intolerance
• Exposure to environmental chemicals. • Abdominal pain

SURGERY: ____________________________
1. pancreaticoduodenectomy with removal of the distal third of the stomach
2. pancreaticojejunostomy,
3. gastrojejunostomy,
4. choledochojejunostomy

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