UNIT 6 NURSING MANAGEMENT OF

PATIENTS WITH ONCOLOGICAL

CONDITIONS
Structure
6.0 Objectives
6.1 Introduction
6.2 Nursing Implications for Cancers of Various Organs
6.2.1 Cancer of Mouth
6.2.2 Cancer of Larynx
6.2.3 Cancer of Lungs
6.2.4 Cancer of Esophagus
6.2.5 Cancer of Stomach
6.2.6 Cancer of Bowel
6.2.7 Cancer of Breast and Ovary
6.2.8 Cancer of Cervix
6.2.9 Cancer of.Thyroid
6.2.10 Cancer of Skin
6.3 Other Cancers
6.3.1 Lymphomas (Hodgkin's Disease)
6.3.2 Leukaemias
6.3.3 Multiple Myeloma
6.4 Let Us Sum Up
6.5 Key Words
6.6 Answers to Check Your Progress

6.0' OBJECTIVES
After completing this unit, you should be able to:
discuss nursing management of patients with cancer of various body organs;
describe incidence of cancer among various body organs;
discuss their management; and
describe the preventive measures needed for their occurrence.

6.1 INTRODUCTION
Cancer, as you know, presents itself in many ways. If the cancer is detected early
and if it is localized, the prognosis is better and its spread may be brought under
control. However, if it gets advanced, the cure becomes a question. When cure is
not possible, treatment does not stop but new medical and nursing interventions
seek to enable each patient to go on living and growing as positively as he is able
to until he dies. The main objectives of interventions are to cure the persons and
ensure minimal functional and structural i~npairment.
In this unit we shall discuss about nursing management of patients with various Nursing Management of
Patients with Ontological
cancers affecting body organs. The knowledge will enrich you in preventing, Conditions
detecting or rehabilitating and care for the people with cancer.

6.2 NURSING IMPLICATIONS FOR CANCERS OF

VARIOUS ORGANS
6.2.1 Cancer of Mouth
Cancer of the mouth (oral cancer) is more common in men than in women and is
responsible for 3-6 per cent of deaths from cancer. About 40-50 per cent of the
head and neck cancers occur in the oral cavity in Indians.

Etiology
Although the exact cause of mouth cancer is unknown certain predisposing factors
include:
smoking and alcoholism
betel chewing (betel nut mixed with quicklime)
chronic irritation from dental appliances
ionizing radiation may cause cancer of the salivary glands

Pathophysiology a t Oral Cancers

malignant lesions may involve the lips, tongue or mucous membrane lining
of the mouth
cancer of the tongue usually occurs with cancer of the floor of the mouth;
metastasis to the neck is common
malignant turnours of the mouth metastasize early to adjacent structures such
as lymph nodes in the neck and muscle tissue
cancer of the mouth is often associated with leukoplakia (white patches on
the mucous membrane of the tongue or cheek)
cancer of the submaxillary glands are highly malignant and grows rapidly.

Clinical Manifestation
pain may not be an early symptom, but a late symptom
loss. of taste sensation
leukoplakia
ulceration of the area involved

Treatment
Surgery--excision of involved and adjacent areas and reconstruction.
Radiotherapy-includes external radiation and internal radiation by means of
implantation of radioactive materials (radium needles or radon seeds) to arrest
growth of turnour.
Musculoskeletal, Gastrointestinal Nursing Intervention
and Oncology Nursing
While giving nursing care, you should consider the following points:
keep the mouth as clean as possible to prevent'infection
maintain fluid and electrolyte balance
provide for a means of communication
supply a diet containing soft food and free of acids and citrus foods; give
frequent small feedings
relieve pain:
- reassure the patient
- explain to the patient that pain relief is possible with regular'dosage of
analgesics or narcotics
- administer analgesics or narcotics as ordered in the pain clinic
- maintain a pain chart for each patient
provide specific care to the patient undergoing mouth radiation which
includes:
- monitor oral cavity; is redness or desquamation appears and noti@
radiotherapist
- administer prescribed analgesics before meals
- encourage bland diet
- instruct not to smoke and avoid alcohol
- encourage fluid intake
- instruct for good oral hygiene and saline rinses every 2 hours while
awake, to relieve dryness of mouth
- use artificial saliva if needed; suggest sugarless lemon drops or mints to
increase salivation
- avoid food that are dry and thick
provide care to the patient with implanted radioactive materials which
includes:
- caution the patient against any pulling on the threads fastened to outside
of the cheek
- check and count the numbers of threads several times a day and record
on the chart
provide a pad and pencil to communicate
- encourage mouth spray while the needles are in place
- inspect the used articles for radium that may have dislodged
- watch the patient for haemorrhage and edema (see Table 6.1 for other
nursing care measures).
We have so far discussed about the general nursing care of the patients having
oral cancer and also care during external radiation as given in Table 5.6 and
internal radiation. Most of the patients with oral cancer may be treated surgically.
your responsibility is to take care before and after surgery. If you study Table 6.1
you will understand the preoperative and postoperative nursing care of the patient
with oral cancer.
 Nursing Management of
Patients with Ontological
Conditions
Musculoskeletal, Gastrointestinal 6.2.2 Cancer of Larynx
and Oncology Nursing

Cancer of larynx .acc&~ntsfor 2% to 3% of all malignancies. Care of patient with

cancer larynx is a unique challenge to the nurse because of the cosmetic and
functional deformities resulting from this disorder and treatment. If untreated,
cancer of the larynx is inevitably fatal; 90% of untreated people die within 3
years.

Etiology and Risk Factors

The primary etiologic agent is cigarette smoking. Three of four clients who
develop laryngeal cancer have smoked or currently smoking. Alcohol with tobacco
increases the risk of developing laryngeal cancer. Other risk factors are
occupational exposure to asbestos, wood dust, mustard gas and petroleum products
and the inhalation of noxious fumes.

Clinical Warning Signs of Laryngeal Cancer

- Change in voice quality
A lump anywhere in the neck or body
Persistent cough, sore throat, or earache
Haemoptysis
Sores within the throat that does not heal
Difficulty in swallowing or breathing

Diagnosis
Visual examination of the larynx
Computed tomography
Magnetic resonance imaging
Lab. tests including : CBC, serum electrolytes, liver function tests ,
pulmonary assessment and ABG analysis
Biopsy and staging

Medical Management
Tumor Ablation: Radiation therapy is the best treatment with the cure rates of
85% to 95%. The radiation dose depends upon the size and the location of the
tumor.

Chemotherapy: Chemotherapy alone is not considered curative for head and neck
cancers. However, it may be administered pre- operatively to reduce the size of
tumor. Post-operatively it is given to reduce the risk of metastasis.

Surgical Management
The goals of surgical intervention for laryngeal cancer are to : remove the cancer,
maintain adequate physiologic function of the airway, and achieve a personally
acceptable physical appearance.

Laser Surgery
Small tumors can be eradicated with the use of laser. Laser surgery for vocal cord
tumors can preserve much of the glottis,. Sometimes laser surgery is combined
with radiation therapy.
Partial Laryngectomy Nursing Management of
Paticnts with Ontological
Conditions
It involves removal of half or more of the larynx. It is done for cancer involving
one true vocal cord, or one cord plus a portion of the other.

Total Laryngectomy

For large glottic tumors with fixation of the vocal cords, a total laryngectomy is
required. The biggest problem for the client after laryngectomy is loss of voice.
Because the trachea and esophagus are separated by surgery, there is no risk of
aspiration.

Cervical Lymph Node Dissection

Metastasis of the lymph node is common with tumors of the upper aerodigestive
tract.

Complications
r

Possible complications following laryngeal. surgery are:

Airway obstruction occurs due to edema of the surgical site, bleeding into the
airway, or loss of airway from the plugged tracheostomy tube. Airway
obstruction requires immediate intervention for restoration of the airway.

Haemorrhage is usually the result of inadequate heinostasis during surgery. It

must be immediately reported to the physician.
Carotid artery rupture is usually a late complication and is related to poor
condition of the neck tissue. It may be the result of previous radiation
therapy. This condition is a life threatening emergency and has a high
mortality rate.
Fistulae between the hypopharynx and the skin may develop. These may heal
on its own or require surgery.

Nursing Management

1) Risk for aspiration-nurse the patient in semi or high fowler's position to

decrease edema of the airway, facilitate breathing and improve comfort.

2) Ineffective airway clearance--carry out suctioning as needed ,cleaning of the

inner cannula of the tracheostomy. Chest physiotherapy

3) Risk for Impaired Gas Exchange-Pulse oximetry and assessing oxygenation

by ABG analysis and oxygen administration as per need.

4) Altered Nutrition-immediately after surgery NG tube is inserted for removal

of gastric secretions until post-operative ileus subsides. Later on when bowel
sounds return tube feeding is started. Once swallowing is accomplished
without aspiration eating is started with nonpourable pureed diet. The liquids
are with held until the risk for aspiration is minimal.

5) Risk for infection-using universal precautions take care of closed wound

drainage system. Suture lines should be cleaned at least twice with hydrogen
. peroxide followed by saline rinse.

6) Need for communication-For the first few days after surgery , the client
should communicate by writing. Later on client has to learn how to speak
using alternative methods. The techniques used are-artificial larynx,
esophageal speech, and tracheoesophageal puncture.
Musculoskeleta~Gastrointestinal 6.2.3 Cancer of Lungs
and Oncology Nursing
Lung cancer is nlalignmcy in the epithelium of the respiratory tract. There is no
current effective screening test for lung cancer, and the range of treatment options
is limited, resulting 'in poor prognosis. Lung cancer is the leading cause of cancer
deaths worldwide.

Etiology and Risk Factors

Cigarette smoking is the most important risk factor for lung cancer. 90 % of
client's who have lung cancer are, have been, smokers.
Other carcinogens are inhaled toxins, such as asbestos, arsenic, and
pollutants.
Genetic predispcsition also plays a role
TB and low level radiation

Pathophysiology
Tumor cell grow and invade surrounding lung tissue . The cancerous lung tissue
can not exchange oxygen and carbon dioxide. Airways are invaded, obstructing
the flow of air.

Clinical Manifestations
These are the warning signals of lung cancer:
Any change in respiratory patterns
Persistent cough
Sputum streaked with blood
Frank hemoptysis
Rust- colored or purulent sputum
Unexplained weight loss
Chest, shoulder, back or any pain
Recurring episodes of pleural effusion, pneumonia, or bronchitis
Unexplained dyspnea

Diagnostic Findings
Bronchoscopy
Sputum cytologic study
CT scan
MRI
Mediastinoscopy,
Percutaneous transthoracic needle biopsy
Radionuclide scans to detect metastasis to the bone ,liver or brain.
TNM classification for lung cancer staging

Management
Management of the client with lung cancer depends on tumor type and stage as
well as the client's underlying health status. Following diagnosis, primary
treatment modalities are:
 Radiation therapy Nursing Management of
Patients with Ontological
Chemotherapy Conditions

I . Surgery
~ u r s 1 . nmanagement
~

During Diagnostic Phase

I
The client who is undergoing diagnostic tests for lung cancer faces an uncertain
future. If the diagnosis is confirmed, the client can anticipate a variety of physical
I
difficulties and many emotional changes. Nursing mana2ement during this phase
focuses on emotional support and client education. Keep the clients well informed
1 .
about all scheduled tests. Once the diagnosis is confirmed, nursing care must
I
1 incorporate measures designed to help the client cope with anxiety and fear,
family responses , financial considerations, absence from work and social
activities and possible changes in life goals.
Treatment Phase
Nursing care of the client receiving radiation therapy and chemotherapy has
already been described in the beginning in treatment modalities in previous unit
Surgical Management
Surgical treatment is the treatment of choice in early stages of NSLC (non-small
cell lung cancer). Cure is possible if the disease is still localized to the thoracic
cavity and no distant metastasis is present. For patients who successfully undergo
surgical resection , the 5 year survival rate is approximately 35 per cent to 40 per
,-
cent.
In case of SCLC (small cell lung cancer) the role of surgery is limited. Surgery
may be effective for clients with the early stages of SCLC , as a modality of
combined therapy.

Surgical Procedures
Laser surgery-currently laser surgery is used as a palliative measure for relief of
endotracheal obstructions that are not resectable.

Pulmonary Resection
Wedge resection--removal of small, localized area of diseased tissue near the
surface of the lung.
Segmental Resection
Removal of one or more lung segments. The remaining lung tissue over expands
to fill the previously occilpied space.
, Lobectomy
Removal of an entire lobe of the lung. Post-operatively, the remaining lung over
expands to fill the open portion of the thoracic space. -
Pneumonectomy
Removal of the entire lung. Once the lung is removed , the involved side of the
thoracic cavity is an empty space. In order to reduce the size of the cavity, the
surgeon severs the phrenic nerve on the affected side to paralyse the diaphragm in
an elevated position preoperative management-remains same as any other preop
surgery.
Post-operative management remains same except the care of chest drainage tubes
which the patient has after the operation. Care of the patient with chest tube has
already been covered in Practical 3 and 4 of Medical Surgical Nursing (RNSL-
106).
Mu~culorkeletal, Gastrointeqtinal 6.2.4 Cancer of Esophagus
and Oncology NurGng
Cancer of the esophagus takes the f ~ r mof squamous cell carcinoma or adeno
chrcinoma of the esophageal mucosa. The incidence is three times as high in men
as in womcn.

Etiology and Risk Factors

The cause of esophageal cancer is unknown, but evidence suggests heavy
smoking, nutritional deficiencies, habitual ingestion of alcohol, hot foods, and hot
drinks as underlying etiological factors. Chronic irritation from other esophageal
problems, such as achalasia, hiatal hernia, and stricture plays a minor role in the
development of esophageal cancer.
These all are preventable causes which requires change in thc life style of the
people.
Pathophysiology
Cancer of the esophagus begins as slow growing benign tissue changes. Most of
these cancers are squamous epidermoid tumors that are commonly found in the
middle or upper third of the esophagus. Because the esophagus has no serosal
layer to limit its extension, esophageal tumors sprcad locally and very rapidly.
Early spread to the lymph nodes is common. The rich lymphatic supply to thc
mucosa provides an excellent means for the cancer to metastise. The cancers are
typically intralurninal, ulcerating lesions that encircle the esophageal wall and
extend upward and downward.
The diseasc is progressive and almost fatal. As it progresses, most clients
cxperience some pulmonary complications because of the formation of
tracheoesop'hageal fistulae that result in aspiration. If the condition is not treated ,
total esophageal obstruction occurs. Infiltration into blood vessels may predispose
the clicnt to haemorrhage. Metastasis is common because of rich supply of lymph
nodes in the area.

Clinical Manifestations
Dysphagia which is mild and intermittent occurring only after ingestion of
solid food and soon it becomes constant and manifestations of esophageal
obstruction appear.
Increase in salivation and mucus in throat
Nocturnal aspiration
Regurgitation
Inability to swallow even liquids

Diagnosis
Barium swallow, endoscopy, cytological examination, and direct biopsy confirm
the diagnosis, Computed tomography provide information about the size of the
primary lesion and extent of nodal involvement.

Medical Management
Radiation therapy
r Chemotherapy
 Photodynamic therapy-This is a new therapy for palliative treatment of Nursing Management of
Patients with Ontological
esophageal cancer in patients who are not surgical candidates. The client Conditions
receives an injection of a light sensitive drug (photafiin), which is followed
two days later with a special fibroptic probe with a light bearing tip placed
in the esophagus. The light activates the photofrin and kills only cancer cells.

Maintain nutrition-Early in the stage small frequent feedings of soft or semi

soft foods. As the disease progresses tube feedings may be needed. If
necessary gastrostomy or jejunostomy may be created. Short term TPN may
be used to improve the clients nutritional status before surgery. The head of
the bed should be elevated to 30 degrees to prevent regurgitation.

Surgical Management

Surgery may be performed for prophylaxis, cure or palliation depending on

the extent of the disease.

Esophagectomy consists of removal of all part of esophagus and replacing it

with a polyester graft.

Esophago-gastrostomy-involves resection of the lower portion of the

esophagus and anastomosis of the remainder to the stomach.

Gastrostomy-artificial opening made directly into the stomach for feeding.

Successful control of manifestations and prevention of extensive weight loss , as

the client is supported to a peaceful deafh. Few clients survive for 5 years.

6.2.5 Cancer of Stomach

Stomach cancer is twice as common in men than'women and more frequent in
clients who have pernicious anaemia.

Etiology and.Risk Factors

Exact cause is not known but several factors are associated with the
development of the disease.

Presence of Halobacter pylori infec'tion in the stomach which increases the

incidence of gestic cancer.

Chronic atrophic gastritis

People living in urban areasAstress, low socio-economic status, eat smoked

fish or meat and have history of exposure to radiation.

Achlorhydria

Pernicious anaemia

Smoking

Genetic factor as the disease seems to run in families

Metal craft workers, coal miners, bakers, and those working in dusty, smoky,
and sulfur dioxide- containing environments are at increased risk.

Wood or tobacco smoke, nitrite food preservatives, and overheated fat

products may predispose clients to gastric ulcer.
Musculoskeletal, Gastrointestinal Pathophysiology
and Oncology Nursing
Carcinoma of stomach is often not diagnosed until metastasis occurs. The stomach
is able to accommodate to the growth of a tumour and pain occurs late in the
disease. Cancer may develop in any part of the stomach but most oftenly it
develops in its lower half. It may spread directly through the stomach wall in to
adjacent tissues, to the lymphatics, to the regional lymph nodes of the stomach, to
the oesophagus, spleen, pancreas and liver or through blood stream to the bones.

Metastasis occurs by direct extension, lymphatics or blood to the esophagus,

spleen, pancreas, liver or bone.

Signs and Symptoms

anorexia
nausea
belching
heartburn
weight loss
anaemia
occult blood in stool
achlorhydria (absence of HCl) by gastric analysis
cytologic examination using the Papanicolaou technique shows cancer cells
gastroscopic X-rays and fluoroscopic examination of entire GIT reveal the
presence of a turnour.

Treatment
We can say that positive diagnosis of carcinoma of stomach is usually made by
means of gastrointestinal B.M. series. The treatment of choice is surgery which
includes subtotal or total gastrectomy and radiation chemotherapy. If the cancer is
diagnosed at a later stage, surgery is palliative rather than curative may be
effective only for palliation.

Nursing Interventions
correct anaemia and malnutrition preoperatively
0
support patient and family and allow them to verbalize fears of cancer, death,
family problems and self-image

the pre and postoperative care is the same as described in Unit 4 for s@cal
interventions in peptic ulcer

if a total gastrectomy is pefformed, a chest tube may be inserted for drainage

and nursing care may be directed accordingly
patient may require gavage feedings via a nasogastric tube or gastrostomy
tube

dietary regulation is same as for peptic ulcer (see Unit 4 of this block)--
small frequent meals beginning'with tap water, progressing to bland foods, to
eat slowly and chew thoroughly.
a in the absence of the intrinsic factor normally produced by the stomach, Nursing Management of
Patients with Ontological
vitamin B,, cannot be absorbed and so a regular injection of vit B,, is Conditions
necessary to prevent pernicious anaemia.

6.2.6 Cancer of Bowel

Cancer of the colon and rectum are the most prevalent internal cancers in the
developed countries and second to cancer of the lung in men and cancer of the.
breast in women. Two thirds of the malignancies occur in the sigmoid colon and
rectum.

Risk Factors/Etiological/Predisposing Factors

a Family history of colorectal cancer or polyposis
a Premalignant conditions-adenocarcinomas, inflammatory bowel diseases e.g.
ulcerative colitis and Crohn's disease
a Ingestion of food additives, bacteria, stool bulk (roughage) bowel transit time
(bowel stasis)
a A high-fat and low-fiber diet

Pathophysiology
I .

a cancer of the colon affects the middle aged; also there is increase in
incidence in the over-65 year age group
a it may develop as a polyp causing narrowing of the lumen of the colon
a partial or total obstruction may result in the lower colon from formed stool
unable to pass through the narrowed lumen
a ulceration of lesions leads to intestinal bleeding
a the disease may spread by direct extension or through the lymphatic or
circulating systems
a metastasis occurs in the liver, lungs and bones

Signs and Symptoms

a abdominal discomfort-vague, dull, aching
a weakness
a alteration in bowel fuliction (constipationldiarrhoea or alternating both) or
tenesmus (unsuccessful s&aining at stool) or rectal bleeding
a occult blood in stool
a abdominal distension
a altered shape-pencil or ribbon shaped stool
a loss of weight
a secondary anaemia
a digital examination of rectum detects a palpable mass
a proctosigmoidoscopy reveals the presence of abnormalities of the bowel and
colonoscopy (fiberoptic) helps in direct visualization
 . cytologic examination detects malignant cells

.
Musculoskeletal, Gastrointestinal
and Oncology Nursing
barium enema, and turnour biopsy confirms the diagnosis
elevated alkaline phosphatase and SGOT reveals metastasis to the liver

serum carcino-embryonic-antigen (CEA) screen carcinoma of the colon

t
Treatment is always surgical and tumour surrounding colon and lymph nodes are
resected it possible remaining portion of bowel are anastomosed.

Types of surgery include:

.
Transverse colectomy
Temporary colostomy or cecostomy to protect the anastomosis until healing
occurs
Aodomino-perineal resection

Temporary loop colostomy

Permanent,sigmoid colostomy
Radiation in non-surgical situations for palliative purposes

Chemotherapy to reduce the lesion and limit metastasis

Right hemicolectomy: In this entire colon on the right side is removed if the
cancer is found in ascending colon and ileum is anastomosed to the transverse
colon (ileotransverse colostomy). If the cancer is in descending colon or upper
sigmoid, left colectomy is done and the remaining sigmoid is attached to the
transverse colon.

Abdomino perineal resection is done in case of malignant growths in the cancer.

In this two incisions are given:

a) a low midline incision of the abdomen through which sigmoid colon is

divided and proximal end of sigmoid,

b) colon is brought out through a stab wound in the abdominal wall and
becomes permanent colostomy (Fig. 6.1). Through perineal incision rectum
and anus containing growth and distal portion of sigmoid are removed. The
perineal wound is closed around penrose drain study (see Table 6.2) for
nursing intervention.

186 Fig. 6.1: Resecting malignant tumors in rectosigmoid segment of bowel

 Xursing M;~rrauernentcrf
Patients with OncolOgk:11
Preoperative Care Conditioiii

0 prepare the patient as for other bowel surgery

n administer antibiotics as prescribed to reduce bacteria in the bowel
0 correct anaemia by blood tr-nsfusion if ordered
r insert a Miller-Abbot tube with suction to decompress the colon
0 administer vitamin supplements to improve the nutritional status
a prepare the patient for a stoma and for a perineal incision.
Post-operative Care
Provide immediate care as for other bowel surgery prs~entshock
a monltor vital signs, BP and general condition
0 monitor eariy signs of shock and apply shock measures promptly.
Prevent Haemorrhage
check the wound frequently
e reinforce the initial dressing as there will be profuse, sacrosanginous
drainage
0 report if excessive bleeding occurs
Prevent Pulmonary, Embolism and Thrombophlebitis
e promote return circulation by encouraging exercises, e.g., deep breathing
and coughing
0 encourage use of eiastic stockings
a assist in early ambulation.
Promote Healing
a irrigate wound with normal saline
daily sterile dressing to abdominal wound
encourage the use of a T binder
administer standard care for nasogastric decompression, measure daily
abdominal girth
Provide Stoma Care
give consistent, effective care in instill confidence
utilize several approaches or odour control
e carry out colostomy irrigation regularly (refer to a practical procedure
manual)
prevent excoriation around skin by applying karaya powder or a ~ p h o j e l
around the skin
report absence of drainage from ostomy
a encourage self-care for icrlostomy care
Promote Urinary Elimination
a prevent retention, encourage voiding
a check urinary drainage through indwelling catheter
keep an accurate intake-output chart
Promote Comfort
assist patient to assume a comfortable position
e administer analgesics or narcotics as ordered
encourage change of positions
ldent~fypatient problems and plan care accordingly
-- -- -- ...-- - --- -. - -- - -- - -- ---- -. .- --
-
Musculoskeletal, Gastrointestinal Colostomy: A colostomy is an artificial opening (stoma) of the colon, surgically
and Oncology Nursing
created and brought into the abdominal surface for the purpose of bowel
elimination when the rectum or anus is non-functional.

Colostomy may be temporary (loop) or permanent loop (temporary colostomy is

perfonned to divert fecal flow away from the area of operation or any
inflammation and is most commonly created at the mid point of the left colon or
the transverse colon where as a pennanent colostomy is usually performed at
sigmoid colon.

When only one loop of bowel is opened into the abdominal surface it is called
single barreled colostomy and there is only one stoma. A double barreled
colostomy is one in which both loops, distal and proximal, are open on the
abdominal wall. This miy be closed later depending on the disease (see Fig. 6.2)
for single and double barrel colostomy.

Single - barrel Double - barrel Loop

Fig. 6.2: Types of colostomies

Caring for Patients with Cancer

The specific nursing intervention after colostomy includes following:
a watch for fecal spillage through the stoma (see Fig. 6.3). Make sure that
fecal content are kept away from surgical incision.
a provide emotional support till the patient adjusts to the colostomy
a teach the patient colostomy care
For further nursing problems and nursing intervention, study Table 6.3.

Stoma

Adhesive ring

Skin barrier

Fig. 6 3 : Colostomy pouch

 Nursing Management of
Patients with Oncological
Conditions

1) Leakage from stoma care - measure stoma and check that

appliance is of correct size
- apply proper bag (Fig. 5.2)
- adjust diet to altar stool consistency
*
- report if leakage continues

2) Sore skin - apply peristomial wafers to protect skin

- eliminate plastics that cause allergy

3) Constipation - regulate diet pattern

4) Diarrhoea - review diet

- correct electrolyte imbalance
-
I review drugs which may cause
diarrhoea

- take plenty of fluids

5) Depression and anxiety - give pre-operative and post-operative

counselling on understanding of
procedures involve familylpartner for
counselling

6) Health teaching - to take good car of stoma

1 - to avoid foods that cause odour and

-
gas
to avoid overeating, to chew food, to
adjust and correct diet
- to avoid over intake of fruit juices,
tomatoes etc, which may irritate bowel

I1 - to carry disposable bags while

travelling and change pouch
- to report any change in colour,
consistency and odour of stool or
bleeding per stoma, persistent skin
irritation.

6.2.7 Cancer of Breast and Ovary

Breast cancer is the most frequent major malignancy and a leading cause of
cancer deaths. The incidence increases with age and is influenced by heredity and
the past number of menstrual cycles. Multiparas and women with early menopause
have a lower incidence. Recent studies have implicated a high-fat, selenium-
deficient diet as a contributing factor in the development of breast cancer.

Pathophysiology
a often the disease begins as a hard, non-tender relatively fixed nodule found
most often in the upper outer quadrant of the breast (Fig. 6.4).
metastasis occurs by direct extension to the surrounding tissue and via the
lymph and blood to the axillary nodes, lungs, bone, brain and liver.
elim$c~rlo&.r.irtal. G'n~truintrsti~~al
.rnd Oncology 'uurqing

Fig. 6.4: Frequency of occurrence of breast cancer according to location

StagingICrading of Breast Cancer

The staging of a cancer is based upon:

a size of the primary lesion
a extent of the spread of cancer to regional lymph nodes
a presence or absence of metastasis

The conitnonly used classitication system as you have already studied is TNM
staging system i.e. (T) tumor size; (N) reglonal lymph nodes; (M) metastasis. This
TNM staging in case 'of qrcinoma of the breast is given in Table 6.4.

Signs and Symptoms

a painless breast mass

a painful breast mass

nipple discharge

a local oedema
a nipple retraction and crusting

a malaise in early stage.

a dimpling of skin by lesion
a inversion and discharge from nipple
a orange-peel appearance of skin over the affected breast

a enlarged axillary lymph nodes

a positive findings through:

-- mammography

-- therography
-- xerography
-- biopsy--aspiration of tissue by syringe
- excised tissue for frozen section
- estrogen receptor assay
-- elevated carcino embryonic antigen in serum, plasma or CSF.
 Nursing Management of
Patients with Onculogical
Conditions
/Definitions of T N and M Categories for Carcinoma of the Breast

1 T Primary Tumours
I

I
TIS Preinvasive carcinoma (carcinoma in situ), non-infiltrating intraductal
carcinoma, or Paget's disease of nipple with no demonstrable tumor
Note: Paget's disease associated with a demonstrable tumor is classified
according to size of tymor.
TO No demonstrable tumor in breast
ITI* Tumor 2 cm or less in its greatest dimension
TI* T l a With no fixation to underlying pectoral fascia andlor muscle
T l b with fixation to underlying pectoral fascia or muscle
T2* Tumor more man 2 cm but not more than 5 cm in its greatest
dimension
T2a With no fixation to underlying pectoral fascia and/or muscle
T2b With fixation to underlying pectoral facia and/or muscle
/ ~ 3 * Tumor more than 5 crn in its greatest dimension
T3a With no fixation to underlying pectoral fascia and/or muscle
I
T3b With fixation to underlying pectoral fascia and/or muscle

/ ~ 4
Tumor of any sire with direct extension to chest wall or skin
Note: Chest wall includes ribs, intercostal muscles, and serratus anterior
I
muscle but not pectoral muscle.
I

I I
*
T4a With fixation to chest wall
T4b With edema (including peau d'orange), ulceration of skin of breast,
or
Tsatellite skin nodules continued to same breast

I T4c Both of above I

I
NO
N Regional Lymph Nodes
Homolateral axillary nodes not considered to contain growth
I
N1 Movable homolateral axillary nodes considered to contain growth
N2 Homolateral axillary nodes considered to contain growth and fixed to
one another or to other structures
N3 Homolateral supraclavicular or infraclavicular nodes considered to
contain growth or edema of the arm+
Note: Edema of arm may be caused by lymphatic obstruction; lymph
nodes may not then be palpable.
/ M Distant Metastases
II
/ MO NO evidence of distant metastases

lM1 Distant metastases present, including skin involvement beyond breast

area --

Treatment
The intervention depends on the extent of the lesion (TNM staging) and the
physical condition of the patient.
Musculoskeletal, Gastrointe$tinal Surgical intervention includes:
and Oncology Nursing
lumpectomy i.e. removal of the lump
simple mastectomy i.e, removal of breast only
radical mastectomy i.e. removal of breasts, pectoral muscles, pectoral fascia
and nodes
breast reconstruction
cophorectomy, adrenalectomy andor hypophysectomy to control metastasis
through alteration of the endocrine environment
Radiation therapy is given alone or in conjunction with surgery pre-
operatively to reduce lesion or post-operatively to limit metastasis
Hormonal therapy includes cortico steroids, androgens and antiestrogens
(tomaxifen ci~rate)to alter hormonal environment
Chemotherapy is given by using a combination of cancer chemotherapeutic
agents.
alkylating agents: cyclophosphamide (cytoxan), chlorambucil (leukeran) and
triethylene thiophosphoramide (thiotepa)
antimetabolites: 5-fluorouracil (5-Fu) methotrexate (amethopterin)
other drugs: Hadriamycin (doxorubicin, and vincristine (oncovin)

Nursing Intervention
When a patient has been diagnosed as a client of breast cancer you have to assist
the patient and family to cope with the diagnosis of cancer and altered body
image by encouraging them to speak out their fcars and anxieties
We shall further discuss nursing intervention under three main headings:
care following mastectomy
care during radiotherapy
care during chemotherapy

Care following mastectomy:

monitor vital signs, B.P. and haernorrhage from the wound
facilitate drainage from the wound by proper positioning, ensuring patency of
tube. and checking functioning, or by use of portable vacuum
encourage good posture and assist in early ambulation

prevent or reduce lymphoedema by elevating and supporting the patient's

hand above her elbow, and elbow above shoulder:
- apply daily wound dressing using strict aseptic technique
- instruct patient to avoid heavy lifting, cuts and bruises, drawing blood,
injections or blood pressure readings etc. on the affected arm since these
can be led to serious infection due to impaired lymphatic drainage
- encourage active exercises of the affected arm beginning on the day
after surgery (a) wall hand climbing b). brushing hair (c) turning rope
(see Fig. 6.5).
 Nursing Management of
Patients with Oneological
Conditions

Fig. 6.5: Postmastectomy exercises

Care During Radiotherapy

observe for signs of radiation burns (erythema, desquamation)
avoid removal.of skin markings
avoid soap or oil substance on the area

encourage intake of foods rich in immune-stimulating nutrients especially Vit

A, C and E and mineral selenium

encourage low fat diet.

Care During Chemotherapy

For breast cancer refer to general guidelines given in Table 6.6.

Ovarian Cancer
Although not the highest in incidence among reproductive tumors, but is the
leading cause of death fiom genital reproductive malignancies. The death rate
have risen over period, probably because of lack of early detection methods.

Etiology and Risk Factors

The cause of ovarian cancer is unknown. Risk factors include:
Musculoskeletal, Gastrointestinal
and Oncology Nursing LearningITeaching Guide Regarding Arm on Operated Side Following
Mastectomy
Hand Care
After axillary dissection, the arm may salell. Recause lynlph nodes and lymph
vessels were removed, the body is less able to combat infection in this
extremity.
Some "AVOID'S"
Avoid cuts, scratches, primipai-as, hangnails, insect bites, bums, and the use of
strong detergents, since these can lead to serious infection with increased
swelling in this arm.
Some "'DO NOTS"
Do not cany your purse or anything heavy with this am].
Do not wear a wristwatch or other jewellery on this arm. Do not cut or pick at
cuticles or hangnails on this hand. Do not work near thorny plants or dig in
the garden.
Do not reach into a hot oven with this arm. Do not hold a cigarette in this
hand.
Do not permit this arm to be used for rnjections, withdrawing blood, or blood
pressure measurement
Some "D8S"
Do wear a loose nibber glove on this hand when washing dishes. IJo near a
thimble when sewing and take care to a v o ~ dpinpricks, Do apply a good
lanolin hand cream several times daily.
Do wear a "Life-Guard Medical Aid" tag engraved to read "Caution-
Lymphedema [state right or left] Anm- -no Tests--No hypos"
Do contact your physician i!' your arm gets red, warm. or unl~suallyhard or
swollen.
Do return for a check-up and remeasurement for a new gradient elastic sleeve
in two months.
110 show this Hand Care Sheet to your surgeon.
Early postoperative rlrn9 e.xerciscs 011 the operated side are important and
usually are started within 24 hours. Teach the person to perfonn hand and
wrist movements and to flex and extend the elbow homly. Encourage self-care
activities (e.g., feeding, combing hair, washing lace) and other activities that
use the arm, being careful not to abduct the ann. Activities increase mobil~ty.
When wound healing is wel! established. begin abduction and external rotation
of the upper arm with the person iying on-the back. Around the 10th to 12th
postoperative day, the person starts exercises m the erect positioil, including
pzndulun~swings to improve shoulder fi~nction,forward and lateral elevation
of the arms, overhead pulley suspension to obtain hi1 elevation. and \&all
c'linlbing arid rope turning.
- assist the patient in selecting a s~litableprosthesis
- encourage regular fc.,lio~~-up.
 Age above 40 years Nursing Management of
Patients with Ontological
Family history of ovarian or breast cancer Conditions
Family history of hereditary nonpolyposis colorectal cancer
Nulliparity
History of infertility
History of ovulation stim,ulating medications

Prevention
Pregnancy and use of oral contraceptives appear to reduce the risk of ovarian
cancer. Health promotion factors include telling clients that ovarian cancers can be
prevented by anything that interrupts constant ovulatory cycles, such as more than
one full term pregnancy, oral contraceptive use, breast feeding, and bilateral
oophorectomy. Health maintenance activities include routine pelvic exam. and
performance of transvaginal ultrasound combined with bimanual pelvic
examination.

Pathophysiology
Ovarian cancers tend to grow and spread silently until manifestations of pelvic
pressure on adjacent organs or abdominal distention cause he women to seek
medical care. When these pressure elated manifestations appear , the malignancy
has usually spread to the fallopian tubes, uterus, and ligaments. Ovarian cancer
usually spread to the other ovary and associated structures. The cancer may invade
bowel surfaces, the omentum, liver and other organs. When the pelvic blood
vessels become involved, distant metastasis occurs. The usual route of spread are
lymphatic spread, haematogenous spread, local extension, and peritoneal seeding.

Clinical Manifestations
Abdominal distention with increasing abdominal girth
Urinary frequency and urgency
Pleural effusions
Malnutrition with weight loss
Pain from pressure caused by the growing tumor and the effects of urinary or
bowel obstruction
Constipation
Ascitis with dyspnea
Severe general pain

Diagnosis
Identification of pelvic mass on palpation
Pelvic sonogram
IVP
Computed tomography scan
Barium enema

Surgical Management
To find the extent of an ovarian malignancy is determined by exploratory surgery.
Partial or complete omentectomy, and removal of all visible tumor . The less
residual tumor is left, the better the prognosis.
Musculoskeletal, Gastrointestinal Medical Management
and Oncology Nursing
a Radiation therapy

a Chemotherapy

6.2.8 Cancer of Cervix

Cancer of the cervix, the most common form of genital tract, malignancy in
women, has a high rate when diagnosed early. Women who are exposed to diethyl
stilbesteroi (DES) in utero have an increased risk of cervical cancer.

Predisposing Factors for Cervical Cancer

All women are at risk of developing cervical cancer. However, predisposing
factors include:
a - low socio-economic status
a early age at first coitus and frequent coitus

a early marriage
a early age at first pregnancy
a multiparity
a multiple sexual partnefi
a history of venereal disease

a post partum cervical lacerations

a untreated chronic cervicitis

history of genital herpes and indications of a hereditary predisposition.
Other factors include women wh0s.e husbands have prostatic or penile cancer and
those with poor care during and immediately following pregnancy.

Classification of Cancer of Cervix

Cancer of the cervix is divided into stages according to various classification
systems. We shall focus on the World Health Organisation (WHO) classification as
given in Table 6.5.

Pathophysiology
There occurs a slow malignant change in the tissue forming the neck of the
uterus. It tends to spread by direct invasion of surrounding tissues and
metastasizes to the lungs, bones and liver.

Signs and Symptoms

a back pain
a pain in legs due to involvement of lymph glands anterior to the sacrum
which causes pressure on nerves
a spotting of blood after intercourse and in between menstrual periods
vaginal discharge which becomes dark, bloody and foul smelling at later
stage due to infection
 Nursing Management of
Patients with Ontological
Conditiuns

Cervical conization; total

hysterectomy with partial
vaginectomy
layer of cervix
Stage I (invasive Confined to cervix, but has Wertheim's hysterectomy;
stages I to IV) invaded into cervical tissue; irradiation
small lesion may be present
Stage Ha Has extended to vaginal mucosa Irradiation; Wertheim's
but not to lower one-third hysterectomy
Stage Ilb Has extended to parametrial Irradiation

delayed menstruation and necrosis

biopsy and Papanicolaou cytologic findings (Pap smear) confirm the

diagnosis
colposcopic examination locate lesions for biopsy.
Treatment of cancer of cervix depends on stage of tumor, women's age and
general health and the presence of complications and includes surgical intervention
and radiation therapy. .
Surgical intervention includes excisional conization of cervix or cryosurgery of
invasive cancer has been ruled out.
Hystero-salpingo-oophorectomy is the removal of uterus, fallopian tubes and
ovaries, the parametrial tissue and lymph nodes in advanced cases and simple
hysterectomy-when ovarian function is desirable.
Radiation therapy (external and internal) alone or in coinbination with surgery is
also common to reduce the lesion and to limit metastases. Usually, tumours above
Stage I are treated with radiotherapy.

Nursing Interventions
assist the patient and family to express fears and anxieties about changes in
self-image and sexual functioning
provide emotional support to patient and family
care of a patient receiving internal radiation:
- for general care refer to Unit 5 of this block
- explain the need for isolation
- instruct the patient to maintain proper positioning i.e. supine and side
lying
Musculoskeletal, Gastrointestinal - provide a low residue diet to avoid strain on bowel and thus prevent
and Oncology Nursing
displacement of radioactive substance and irradiation of adjacent tissues
- do not' fail to attend to the patient in any sort of emergency
special points in care of patient following surgery:
- - monitor vital signs, BP, watch the wound for haemorrhage and unusual
discharge
- maintain patency of urinary catheter placed prior to surgery, to
decompress the bladder and to reduce stress on operation site
- check bowel sounds
- maintain intake/output chart

Follow Up Care
All women who have been treated for cervical cancer need information about
recurrence. Fear that cancer will recur appears to be highest in women treated
with irradiation.
Encourage women who have been treated for cervical cancer to have frequent
health examinations to diagnose a possible recurrence of the cancer early so it can
be treated before it spreads too far. The following follow-up schedule is
recommended:
Pelvic examination every two months for two years, every four months for
three years, and every six months for flve years.
Pap smear at every pelvic examination.
Chest X-ray every six months.
Intravenous pyelogram every six months for two years.

Preventive Care
Invasive cervical cancer can be prevented by early diagnosis and treatment while
the cancer is still confined to the preinvasive stage. Infofm all women about the
indications of cervical cancer (thin, watery, blood-tinged vaginal discharge,
painless abnormal interenstrural bleeding that begins as spotting, often after
intercourse), leach good personal hygiene, and encourage them to have regular
Pap smears. Poor personal hygiene is considered to be a potential predisposing
factor. Appropriate learningteaching activities include:
Wash perineal area with soap and water regularly, wiping from front to back.
Clean perineal area after voiding and bowel movements.
Change tampons or pads three to four times daily during menstruation-
wash hands before and after. Clean perineal area during each change.
Wear clean undergarments:
- assist the patient in keeping the wound and genital area clean
- help in maintaining personal hygiene
- instruct the patient for follow up care.
- all the mothers should be taught about the preventive measures for
cancer of cervix.
 Nursing Management of
6.2.9 Cancer of Thyroid Patients with Ontological
Conditions
Thyroid cancer accounts for about one per cent of all cancers. It is three times
more common women than men and is more common in areas where goiter is
endemic. Exposure to ionizing radiation is also a causative factor. Thyroid cancer
occurs more frequently among people who have received large doses of radiation
to head and neck.
Signs and Symptoms
The major manifestation of thyroid cancer is appearance of a hard painless nodule
in an enlarged thyroid grand. The nodule is typically solitary, rapidly enlarging
and cold (i.e. it does .not take up radioactive iodine) as opposed to benign
adenomas. The lymph nodes are sometimes palpable if metastasis has occurred. In
later stage there may respiratory difficult and dysphagia.
Classification of Tumours
There are four major types nf thyroid cancer--(papillary adenocarcinoma,
follicular adenocarcinoma, medullary carcinoma, and anaplastic carcinoma. The
incidence, characteristics, intervention, and prognosis of each of these thyroid
cancers are compared in Table 6.6.

Investigations
The patient who is suspected of having carcinoma of the thyroid will have any of
the following investigations:
Thyroxine (T,) estimation
Triiodothyroxin (T,) estimation
Radioactive iodine uptake test, technetium uptake and iodine I"' scan
Chest X-ray and X-rays of the neck may reveal metastasis, if any.
Musculoskeletal, Gastruietestinal Treatment
and Oncology Nursing
The primary treatment for carcinoma of the thyroid is by destruction of the gland
by surgery, radiotherapy or a combination of both. For follicular and medullary
carcinonis, total thyroidectomy is performed followed by use of radioactive II3l to
destroy residual tumour.

Surgery
- .
The preparation is the same as for any other major surgery. Apart from routine post-
operative care, thyroid replacement drugs must be given to prevent myxoedema. The
three main complications following thyroidectomy is given in Table 6.7.

I 0 Respiratory obstruction
I
Bleeding from operation site

Hypoparathyroidism leading
to tetany

Radiotherapy
Patient with well-differentiated tumours of the thyroid such as papillary
adenocarcinoma, follicular adenocarcinoma and medullary carcinoma, receive
radioactive iodine (II3') post-operatively. An initial dose of is given after
thyroidectomy to oblate residual thyroid tissue of tumor. It may be given in a
series of courses until all deposits in lymph nodes locally and all distant
metastases are destroyed. This can be assessed by the scan each time.
The patient receiving II3' will be radioactive and is, therefore, a potential radiation
hazard. The chemical is eliminated from his body via urine, saliva and sweat. It
has a half life of 8 days and both gamma and beta radiation is emitted during
decay. The amount of radioactivity in the patient's secretion depends on the dose
given and the rate of exertion from the body. Table 6.8 describes the nursing care
during 1'" treatment.

6.2.10 Cancer of Skin

Skin cancer is a malignant condition caused by uncontrolled growth and spread of
abnormal cells in a specific layer of the skin. The several kinds of skin cancer are
distinguished by the types of cells involved. The three most common types are:

basal cell carcinoma

squamous cell carcinoma
malignant melanoma
More than 90 per cent of all skin cancers fall into the first two classifications.
Both are slow growing tumors with a cure rate of 95 per cent or greater after
early treatment.

Etiology and Risk Factors

Prolonged or intermittent, repeated exposure to UVL radiation from the sun.
 Nursing Management of
Patients with Ontological
Conditions

Majority of all non-melanoma skin cancers occur on parts of the body

unprotected by clothing (face, neck, forearms, and backs of hands) and
among people who have received considerable exposure to sunlight.
Blacks and Asians are least susceptible, whereas people with light
complexions or freckles are at greater risk.
The most severely affected people usually have a history of long term
occupational (farmers, construction workers, surveyors, sailors) or recreational
(swimmers, skiers, surfers, sunbathers) sun exposure.

Nursing Intervention
All clients should be taught to look for new moles or lesions and to evaluate
them for danger signs of cancer. They are:

I Change in color, especially red, white and blue; sudden darkening; mottled
shades of brown or black.
Change in diameter, especially sudden increase.
1
Change in outline, especially development of irregular margins.

Change in surface characteristics, especially scaliness, erosion, oozing,

crusting, bleeding , ulceration, development of mass on the surface of lesion.
Change in consistency, especially softening or friability.
Change in symptoms especially pruritus.
Musculoskeletal, Gastrointestinal Change in shape, especially irregular elevation from a previous flat condition.
and Oncology Nursing
Change in surrounding skin, especially "leaking" of pigment from the lesion
into surrounding skin or pigmented "satellite" lesions.
Clinical Manifestations
The cardinal feature of melanoma is a change in a skin lesion over a period of
months. If lesion grows so fast that it doubles in size in 10 days, it is usually an
inflammation. If a lesion changes so slowly that neither the client nor the family
is sure of the change, it is usually benign. Changes that may signal melanoma are:
1) doubling size in 3 to 8 months
2) change in diameter
3) bleeding , itching, ulceration, a change in color, or development of a palpable
lymph node
Prognosis depends on the depth of lesion at the time of excision. The more
superficial or "thin" the tumor, the better the prognosis.

Surgical Management
Treatment of all skin cancers require removal of the lesion. The margins of the
resected specimen must be free of tumor to a specific distance to guarantee full
removal.

6.3 OTHER CANCERS

In the previous section you have learnt about cancer of various organs. You will
now study about lymphomas, leukaemias and multiple myeloma in detail.

6.3.1 Lymphomas (Hodgkin's Disease)

Hodgkin's disease, first described by pathologist Thomas Hodgkin's in 1832 is the
most common malignant lymphoma of unknown origin. Although, the disease can
present itself at any age, it is rare in children and incidence peaks occur at 15-35
years and again after 50 years of age. It is generally more common in males than
females.
Hodgkin's disease is a chronic progressive malignant disorder characterized by an
enlargement of lymph glands, spleen and liver as a result there is painless
enlargement of lymphnodes. The first nodes to be involved are in the.cervical
region, followed by the axillary inguinal and mediastinal nodes.

Pathophysiology
There is proliferation of abnormal histiocytes called Reed Sternberg which
are part of tissue macrophage system. As these atypical glial cells multiply
they replace other cellular elements normally found within the lymph node.
All tissues may become eventually involved but chiefly lymph nodes, spleen,
liver, tonsils and bone marrow, get involved.

Signs and Symptoms

Subjective
painless, enlargement of cervical, axillary or inguinal nodes
 dyspnoea and dysphagia due to pressure from enlarged nodes Nursing Management of
Patients with Ontological
Conditions

anorexia

objective
enlarged lymph nodes i.e., cervical nodes are affected first
progressive anaemia
elevated temperature
enlarged spleen and liver
diagnosis is confirmed by lymph node biopsy and histological examination,
full blood count and differential serum biochemistry, chest X-ray, bone
marrow aspiration, lymph angiogram, and computerised axial tomography.
See Fig. 6.6. You will be able to understand the signs and symptoms with related
pathology.

Fig. 6.6: Hodgkin's disease: Signs and Symptoms with related pathology

Treatment.involvqs radiotherapy and surgical intervention:

excision of node for biopsy

excision of masses to relieve pressure in other organs
Musculoskeletal. Gastrointestinal laparotomy or laparoscopy for determination of stage
and Oncology Nursing
chemotherapy

Nursing Interventions
support to the patient and family emotionally
protection- of client from infection
monitoring vital signs, level of jaundice, side-effects of radiation,
chemotherapy
' provision of adequate rest and comfort to the patient
assisting in prevention or correction of anaemia
encourage intake of highly nutritious food

encourage follow-up care.

6.3.2 Leukaemias
Leukaemia is a malignant disorder of white cells (leukocytes) produced in bone
marrow, spleen and the tymphoid system. It is characterised by an extensive and
abnormal production of mature and immature forms of any of the white blood
cells (granulocytes, lymphocytes and monocytes).

Classification of Leukaemias
The different types of leukemia are classified according to the two major criteria
discussed below.
Course and Duration of Disease: Leukemia may be acute, with a short and
deadly course, or chronic, with a more indolent course.
Acute leukaemias have a rapid onset and typically progress to death within days
or months if untreated. The increased numbers of leukocytes produced are very
immature and accumulate within the blood-forming organs, causing organ
malfunction. The French-American-British Cooperative Group has developed a
system of classifying acute leukemias based or morphology and the percentage of
immature cells in the bone marrow. For a leukemic process to be termed acute, at
least 50 per cent of the marrow cells must be immature.

Chronic leukaemia have a gradual onset and a more protracted course than the
acute forms. In some cases the individual lives for five or more years, with or
without intervention. The white cells produced are more mature and thus can
better defend the body against invading microorganisms. Acute leukemia
commonly affects children and young adults. Chronic leukemia afflicts people
between the ages of 25 and 60.
Type of cell and Tissue Involved: Leukemia can involve the committed stern
cell line or a pluripotent stem cell. Tissues involved by leukemia are widespread
and include the spleen, lymph nodes, liver, bone marrow and central nervous
system (CNS). Based on the above criteria we shall now classify leukkmia as
follows.
Acute Nophocytic Leukaemia (ANLL): ANLL was formerly known as acute
myelogenous leukemia (AML). Aberration in the growth of megakaryocytes,
monocytes, granulocytes, and erythrocytes, may be seen in ANLL. Typically,
however, aberrations in one cell type predominate. The most common types of
ANLL involve maturational arrest and proliferation of cells in the myeloblastic Nursing Management of
Patients with Ontological
and monoblastic stages of development. Conditions

Acute Lymphocytic Leukaemia (ALL): A disorder the lymphoid committed stem

line. ALL is characteristic by the proliferation of immature lymphoid cells
(lymphoblasts) in the bone marrow. Lymphadenopathy, hepatosplenomegaly, and
CNS involvement commonly occur with an initial leukocyte count of 100,000/

Chronic Myelogenous Leukaemia (CML): The disorder is thought to originals in

the pluripotent stem cell. Initially, the marrow is hypercellular with a majority of
normal cells. Typically, the peripheral blood smear reveals leukemogenesis and
thrombocytosis (increased platelet count). There is increased production of
granulocytes (neutrophils, cosinophils, basophils). Ninety per cent of the time,
examination of the bone marrow cells during metaphase show a chromosome
translocation called the "Philadelphia chromosome." After a relatively slow course
for a median of four years, the individual invariably enters a "blast crisis which
resembles acute leukaemia.
Chronic Lymphocytic Leukaemia(CLL): This form of leukemia is characterised
by the proliferation of early disorder of white cells.

Lymphocytes
A peripheral blood smear reveals increased number of both mature and slightly
immature lymphocytes (see Fig. 6.7). As the disease progresses, lymphocytes
infiltrate the lymph nodes, liver, spleen and ulti~natelythe bone marrow.

a) Acute non-lymphocytic leukemia (ANLL) b) Acute lymphocytic leukemia (ALL)

Lymphocytes

Myeloblasts Lymphoblasts

Platelets

Lymphocytes
Neutrophil PMN (young form)

Neutrophil PMN (band form)

II
Immature lymphocytes
Neutrophil PMN (mature)

C) Chronic myelogenous leukemia (CNIL) d) Chronic lymphocytic leukedia (CLL)

Fig. 6.7: Types uf leukaemia: A comparison 205

Musculoskeletal, Gastrointestinal Etiology
and Oncology Nursing
The exact cause is unknown. However, there appear to b e several factors which
are associated with the condition.

Exposure to radiation: Low dose irradiation is proved to be a factor;

therapeutic radiation at a particular tumor or organ does not appear to cause
leukaemia.
Familial: There are reports of several cases of leukaemia occurring within
one family and high incidence in identical twins.
Chromosome changes.
Drugs and chemicals: Drugs once used in treatment of Hodgkin's lymphoma
is found to cause leukaemia. Some chemicals have also been found to cause
leukaemia.
Transformation of other disorders: Other bone marrow disorders such as
polycythaenic Vera may transform into acute leukaemia.

Pathophysiology
The white cells are massively overproduced
The white cells never reach proper maturity and so never die, causing
overpopulation of the marrow
The affected white cells are either immature white cells (blasts) causing acute
leukaemia, or abnormal mature cells causing chronic leukaemia. They differ
in appearance from healthy white cells
Due to the presence of vast numbers of leukaemia cells, the bone marrow
becomes unable to reproduce normal quantities of red cells and platelets,
resulting in anaemia and thrombocytopenia.

Signs and Symptoms

Subjective

- malaise

- fatigue, decreased exercise tolerance

- bone pain

Objective
-- anaemia and loss of weight

- thrombocytopenia

- elevated leukocytes

- decreased platelets

- petechiae

-- gingival bleeding or epistaxis.

Study the Fig. 6.8. You will be able to understand the signs and symptoms and
related pathophysiology.
 Nursing Management of
Patients with Oncological
Conditions

Fig. 6.8: Signs and symptoms and related pathophysiology of leukaemia

Treatment
The treatment for acute leukaemias or remission consists of various drug regimes
given orally, intramuscularly, intravenously and intrathecally. These drugs are
either immunosuppressive or cytotoxic agents. Some patients may also receive a
short course of cranial irradiation.
Blood and platelet transhsions and intravenous antibiotics are essential as support
the rapy.
There are three distinct phases of treatment for leukaemia such as induction phase,
consolidation phase and maintenance phase.
Induction phase: In this phase, the cytotoxic therapy is given to decrease the
total count of blast cells in the bone marrow to less than 5 per cent of the
total white cell count. The disease is then said to be in remission
Consolidation phase: Similar regime to that of the induction phase but
consists of 1-2 courses.
Maintenance phase: Intermittent drug therapy to maintain remission.

Nursing Intervention
provide emotional support to the patient and family
isolate the patient in order to minimize infection
encourage the patient to maintain nutritional status
Musculoskeletal, Gastrointestinal a protect the patient from any cuts and injuries
and Oncology Nursing
a monitor vital signs, BP and repeated blood counts
a provide specific nursing care related to particular chemotherapeutic therapy,
blood transfusion or diagnostic tests
discuss the importance of follow up care, with the patient and family.

6.3.3 Multiple Myeloma

Multiple Myeloma is a B-cell neoplastic condition characterized by abnormal
malignant proliferation of plasma cells secreting a monoclonal paraprotein,
accumulation of mature plasma cells in the bone marrow.

Risk factors increased incidence in some families, ionizing radiation, and

occupational chemical exposures.

Pathophysiology

Multiple myeloma is characterized by an abnormal proliferation of plasma cells.

With this overproduction of plasma cells, bone destruction also occurs. There is
also disruption of RBC, leucocytes, and platelet production, which results from
plasma cells crowding the bone marrow. Impaired production of these cells cause
anaemia, increased vulnerability to infection and bleeding tendencies.

Clinical Manifestations
a Involvement of skeletal system , particularly the pelvis, spine, and ribs.
a Backache or bone pain which worsens on movement
a Sudden pathological fractures accompanied by severe pain
a Sternum and rib cage deformities
a Dif'fuse osteoporosis accompanied by negative calcium balance
a Skull shows multiple osteolytic lesions
Loss of calciwn and phosphorus from damaged bones leads to formation of
renal stones, particularly in immobilized clients.

Diagnostic Findings
a Radiographic studies show diffuse lesions in the bone' widespread
demineralization, and osteoporosis
a Bone marrow biopsy shows large number of immature plasma cells.
Normally, normally plasma cells constitute 5 % of the bone marrow cells.
a Blood and urine examination
a Plasma electrophoresis reveals a large number of abnormal immunoglobulins
a Appearance of Bence-jones protein in the urine

Management
Management is aimed at early recognition and treatment of complications of the
disease.
 Chemotherapy is the treatment of choice and palliative radiation should be limited Nursing Management of
Patients with Oncological
to clients with disabling pain from a well defined location that has not been. Conditions
responsive to chemotherapy. Autologous or Allogenic bone marrow transplantation
may also be used in selected cases.

Nursing Interventions
Administer adequate .amount of fluids around 3 litres per day so that urine output
can be maintained to 1.5 to 2.0 litres per day. Monitor intake and output and
*
weigh the cIient daily.
Encourage activity that places stress on the long bones to increase calcium
reabsorption.
Antiemetics may be required for reIief of nausea and vomiting. Small , fiequent
feeds may be better tolerated and stool softeners are given routinely. Closely
monitor the client's mental status. If disorientation occurs than keep the
environment of the patient safe.
Musculoskeletal, Gastrointestinal
and Oncology Nursing

6.4 LET US SUM UP

In this unit, we have discussed about care of the patients with cancers of various
organs of body which include: cancer of head and neck, larynx, lungs, mouth,
esophagus, stomach, intestines, breast and ovary, cervix, thyroid and skin. Finally
we discussed about the other cancers including lymphomas, leukaemias and
multiple myelomas. All these cancer have been dealt separately and special
emphasis has been given to the preventive aspects which includes major life style
changes.
You as an important member of the health team who has a very important role to
play in care and support of the patient and his family. As a nurse you need to .
develop skill to give individualized nursing care to these patients.

6.5 KEY WORDS

Adenocarcinoma : A malignant new growth of glandular epithelial
tissue.
Alkylating agent : A drug that damages the DNA molecule of the
nucleus of malignant tumor cells
Alopecia : Baldness, loss of hair
Cisplatin : A cytotoxic drug containing platinum which has
proved useful in the treatment of ovarian
carcinomas and testicular teratomas
 Nursing Management of
Colonoscope : A fiberoptic irlstrument passed through the anus for
Paticnts with Ontological
examining the intcrior of the colon. Coriditions

Colostomy : The surgical formation of a temporary or

permanent opening between the colon and the
i anterior abdominal wall

Hotlgkin's disease : A progressive i~~alignant co1:dition of the

reticuloendothelial cells

Radioactive isotope : An unstable isotope which decays and einits alpha,

beta or gamma rays

,! 6.6 ANSWERS TO CHECK YOUR PROGRESS

1 1) Clinical warning signs of laryngeal cancer:

Change in voice quality

11 lump anywhere in the neck or body

I'ersistent cough, sore throat, or earache

r

Ilaemoptysis

Sores within the throat that does not heal

1 IPifiiculty in swallowing or brcatliing

2) Airway obstructioni--occurs due to edema of the surgical site, bleeding

i ~ t othe airway, or loss of airway from the plugged tracheostomy tube.
C Airway obstructiori requires immediare intenlention for restoration of the
airway.

hemorrhage is usually the result of inadequate hemostasis during

surgery. Tt must be immediately reported to the physician.

Carotid artery iupt~ireis usually a late complication and is related to

poor condition of the neck tissue. It may be the result of previous
radiation therapy. This conditioii is a life threatening emergency and has
a high mortality rate.

Fistulae between the hypopharynx and the skin may develop. These may
heal on its own or require surgery.

3) Any change in respiratory patterns

Persistent cough
t
rr Sputum streaked with blood
Frank hemoptysis

Rust colored or punilent sputum

t
I Unexplained weight loss

Chest, shoulder, back or any pain

Recurring episodes of pleural effusion, pneumonia, or bronchitis

Unexplained dyspnea
Exact causc is not kn(>wil hi)! !:i'vira1 iji.ti~rsare ass!>ci;ited wi:h tht:
cievelopmenr of :he disc;+c!:.

Presente of Ila!ob'~cre~ pyion : l i f e i t i o n ill the sto!nach \I hit!, :i~rr~:lses

the iccId::;;ce of gastic cancer

Chronic atlophic gastritla

Pcople livltrg 111 urban areas- stre>>. !ow socio-ecenon71c >tatils, ed?
s!iioked fish or !neat and have llistorq '\I exposure to radiatidn.

Pernicious anaemia

Sn~oking

Gcnetis f'actor n. the disc:~scseemi tcb r:!n in farniiies

M e i a l criift workers, coal miners. bakers, and those working in dusty,

smoky; 2nd sulfi!r dioxide- containing environments are at increased risk

FVtjod or tobacco stnoke, nitrite food prz-serkativcs. and ovcrliea!ctl fkt

products may pretlispose clients ti) gastric utcer.

Abdominal distentio~iM !th ItliICilslng ahdom~nalgirib

Ilrinarq frequency and urgency

Ple1:ral eftusic,r:s

Pain from pressure causcd b j tile grciwing tumor and thc effects of
urinary or bou el obstruct ton

Ascitis with dyspnca

Seh ere general pain

I-urnpectomy

Simple mastectomy

Radical mastecton~y

Breast reconstnlction

Oophorectomy

cyclophosphamide

5 FIJ (5- Fluorouracil)

leakage

constipation

depiession and anxiety

sore skin

diirrhoea