NCLEX: Caring for the Client with Cancer

Terms you’ll need to understand:
Anovulation
Dysphagia
Dyspnea
Emaciated
Failure to engraft
Graft versus host disease
Hyperthermia
Nulliparity
Postcoital
Proliferation
Pruritis
Sepsis
Spleenectomy
Veno-occlusive disease

Nursing skills you’ll need to master:
Knowing central line care
Accessing a venous access device
Safely working with radioactive materials
Using patient control analgesia pumps
Caring for the body after death

Cancer
Cancer occurs when an overproliferation of abnormal cells harms the host by growing into a body system or by robbing the body of nutrients.
Metastasis refers to the spread of cancer from a primary site to a secondary site.
Common sites of metastasis are breast cancer (metastatic to the bone and brain) and lung cancer (to the liver and brain).

American Cancer Society’s Seven Warning Signs of Cancer
Malignant, or cancer, cells are initiated by alterations in cell growth patterns.
The warnings that are offered by the American Cancer Society alert the public of occurrences that could indicate a problem. The following are the seven warnings you should know:
- Changes in a wart or mole
- A sore that does not heal
- Changes in bowel or bladder habits
- A new lump or the thickening of an existing lump
- A persistent cough
- Indigestion or difficulty in swallowing
- Unusual bleeding or discharge

The Four Major Categories of Cancer
The different types of cancers are classified according to the tissue from which they originate. The following list identifies the major cancer groups:
- Carcinoma—Cancer arising from epithelial tissue (for example, basal cell carcinoma)
- Sarcoma—Cancer arising from connective tissue, muscle, or bone (for example, osteosarcoma)
- Lymphoma—Cancer arising from lymphoid tissue (for example, Burkitt’s lymphoma)
- Leukemia—Cancer of the blood-forming cells in the bone marrow (for example, acute lymphocytic leukemia)

Risk Factors for Specific Cancers
Some environmental and intrinsic factors are associated with an increased incidence of certain cancers. Included here are risk factors associated with specific cancers:
- Bladder—Risk factors include smoking and environmental carcinogens such as dyes, paint, rubber, ink, and leather.
- Breast—Risk factors include a family history of first-degree relatives, the birth of the first child after age 30, menarche before age 12 and menopause after age 55, obesity, the use of birth control pills and hormonal replacement, alcohol intake, and a diet high in fat.
- Cervical—Risk factors include early sexual activity, early childbearing, multiple partners, human papillomavirus (HPV) or human immunodeficiency (HIV) infection, smoking, the use of DES by the mother during pregnancy, and chronic cervical infections.
- Colon—Risk factors include family history, polyps, chronic inflammato- ry bowel disease, and a diet high in fat and protein and low in fiber. Cancer of the colon is the second most common form of cancer in the United States.
- Esophagus—Risk factors include use of tobacco, use of alcohol, and chronic irritation.
- Larynx—Risk factors include use of tobacco, nutritional deficiencies (riboflavin), chronic laryngitis, use of alcohol, and exposure to carcinogens.
- Liver—Risk factors include cirrhosis, hepatitis B, exposure to certain toxins, smoking, and alcohol use.
- Lung—Risk factors include smoking and secondhand smoke, air pollu- tion, occupational exposure to radon, vitamin A deficiency, and heredity.
- Ovarian—Risk factors include a diet high in fat; alcohol use; a history of cancer of the breast, endometrium, or colon or a family history of ovarian or breast cancer; anovulation; nulliparity; and infertility.
- Pancreas—Risk factors include a diet high in fat, smoking, exposure to industrial chemicals, diabetes mellitus, and chronic pancreatitis.
- Prostate—Risk factors include race (African-Americans) and age (55 and older).
Prostate specific antigen (PSA) is a laboratory test used to monitor response to treatment and to detect recurrence and progression of prostate cancer.

- Renal—Risk factors include tobacco use, exposure to industrial chemi- cals, obesity, and dialysis.
- Skin—Risk factors include exposure to sun, exposure to various chemi- cals (arsenic and coal tar), scarring or chronic irritation of the skin, and ancestry (highest incidence in those of Celtic ancestry with red or blond hair, fair skin, and blue eyes).
Skin cancer is the most common form of cancer in the United States.

Remember the alphabet A B C D when assessing skin lesions. If the answer is yes to any of the questions listed here, it could indicate a possible malignant lesion:

A—Is the lesion asymmetrical in shape?
B—Are the borders of the lesion irregular?
C—Are there different colors within the lesion?
D—Is the diameter of the lesion more than 5mm?

- Stomach—Risk factors include a diet high in smoked foods and lacking in fruits and vegetables, gastric ulcers, Helicobacter pylori bacteria, heredity, pernicious anemia, and chronic gastritis.
- Testes—Risk factors include infections, genetic or endocrine factors, and cryptorchidism.


Cancer Prevention
An early diagnosis can mean a better cure rate for a patient with cancer.
Certain cancers can even be prevented by interventions. The nurse can make a substantial impact by the use of education in preventive teaching and early detection techniques. One way the incidence of cancer can be decreased is by a change in eating habits. For example, with colon cancer the risk is decreased by the avoidance of fatty, fried foods and increasing the intake of fruits, vegetables, and whole grains. Another way to decrease incidence is by staying away from carcinogens such as smoking, alcohol, and toxins. It is important for the nurse candidate to know the importance of patient education when studying for the NCLEX® exam.

Patient Teaching
A part of the early detection process relies on the patient to perform regular exams to find any growths or abnormalities. The following gives information about the best time to perform these exams and the current recommendations by the American Cancer Society:
- Males should be instructed to perform a self-examination of the testes monthly while taking a shower.
- Females should be instructed to perform self breast exams monthly after the menses.
- A baseline mammogram should be done at age 35 and yearly after age 40.
Clients should avoid the use of deodorant or body powder prior to the mammogram because these can produce areas that appear as calcifications.
Malignant breast masses appear most often in the upper outer quadrant of the breast. The most definitive diagnosis is made based on biopsy rather than lab or x-ray.

Management of the Client with Cancer
Treatments for cancer patients are focused on curing the cancer, prolonging survival time, or improving the quality of the patient’s life. Clients with cancer usually die within weeks without treatment. The therapies included here can involve one treatment or a combination of all three:
- Surgery—This procedure is done to remove the tumor or the diseased tissue for a cure. Surgery can also be used to diagnose, as a preventive measure, as a palliative treatment, or for reconstruction. The care of the patient with surgery would be as any patient post-operatively with a focus on the body part involved or removed.
- Radiation—This is performed to shrink the tumor.
- Chemotherapy—This is undertaken to destroy cancer cells by interfer- ing with mitosis or by destroying the cell wall.

Radiation
Radiation therapy is used to destroy cancer cells without destruction of the normal cells. The candidate for the NCLEX® exam should review all aspects of nursing care dealing with radiation. This section focuses on the client with cervical cancer and the use of a sealed radiation source implanted inside the patient. In this case, the radiation is to the patient’s cervix inserted through the vagina.
While the implant is in place, the client emits radiation but the client’s body fluids are not radioactive.

Care of the client with radiation therapy implants requires that the nurse pay attention to time, distance, and shielding when caring for these clients. The nurse should
- Limit the amount of time spent in contact with the client.
- Maximize the distance by standing to the side of the bed and refraining from close contact.
- Shield herself by using a lead-lined apron during patient contact.

This type of radiation therapy is temporary. While the implant is in place, the nursing interventions focus on prevention of dislodgement.
Accomplishment of this outcome is helped by instituting nursing measures, to include
- Bed rest
- Low residue diet (to decrease bowel contents)
- Foley catheter (to prevent collection of urine in the bladder)
In the event the radium implant is dislodged, the nurse should retrieve it with forceps, place it in a lead-lined container, and return it to x-ray.

Clients receiving radiation x-ray treatments can have skin problems that result in drying, rashes, pruritis, and hyperpigmentation of the skin. Clients should be instructed to prevent drying by avoiding
- Soaps
- Alcohol skin preparations
- Hot baths D. not remove the markings placed on the skin by the radiologist.

Chemotherapy
Chemotherapy has detrimental effects on the development of both normal and malignant cells. Chemotherapeutic agents include alkylating agents (which interfere with cell metabolism and growth), plant alkaloids (which react with acids to form salts), antitumor antibiotics (which interfere with the cell wall), and hormones (which suppress hormonal-dependent tumors; an example is progesterone for ovarian cancer and estrogen for prostate or testicular cancer).
There are commonalities in the side effects of chemotherapeutic agents. You should become familiar with these side effects in preparation for the exam.

The common side effects and some measures that are done to relieve them:


Total Parenteral Nutrition
Clients with cancer often have inadequate nutrition due to the side effects of nausea, vomiting, and anorexia. These clients frequently require supplemental nutrition by the use of total parenteral nutrition (TPN).
A central line is required for TPN administration.

Problems Associated with TPN
With TPN, the fluid is delivered directly into the venous system. This fluid has a high level of osmolarity, which can cause a fluid shift as well as electrolyte imbalances. The high dextrose content puts the client at risk for hyperglycemia and infection.

Dressing Changes for TPN
Because of the danger of infection, these clients are at a higher risk of developing sepsis. The following list gives the recommendations for the dressing change on the central line of a client receiving TPN:
- Sterile technique is utilized.
- Recommended dressing is a gauze dressing taped on all four sides.
- Occlusive dressings are not recommended because they collect moisture and allow for growth of microorganisms.

Nursing Implementations
General nursing care for a client with TPN includes the following measures:
- Blood should not be drawn from the TPN port, but it can be drawn from the venous port.
- Avoid air entrance into the central line.
- TPN must be tapered to be discontinued.
- Monitor blood glucose levels.

Bone Marrow Transplantation
Bone marrow transplantation involves the destruction of the client’s bone marrow (this is accomplished by high-dose chemotherapy administration and whole body irradiation). The client then receives a stem cell or bone marrow transplant infusion.
Transplantation of bone marrow can be used to treat
- Aplastic anemia
- Thallassemia
- Sickle cell anemia
- Immunodeficiency disorders
- Certain cancers, such as acute leukemia, chronic myelogenous leukemia,

Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, and testicular cancer

Types of Transplants
The types of bone marrow transplants are based on the source of the donor cells. The three types of transplants available are
- Autologous transplant—Involves the harvesting, cryopreservation, and reinfusion of the client’s own marrow to correct bone marrow hypoplasia resulting from chemotherapeutic drugs.
- Allogenic transplant—Involves the transplantation of bone marrow from a compatible donor. It has the following requirements:
- The prospective donor must be tissue and blood typed.
- The donor should be of the same racial and genetic type to be suc- cessful.
- Syngeneic transplant—Involves the transplantation of bone marrow from an identical twin; this type is rare.

Nursing Care After Transplantation
Until the new bone marrow takes, or engrafts, the client has no immunity or normal bone marrow function. This predisposes the client to infection and decreased thrombocytes. The candidate for the NCLEX® exam must recognize the major risk of bleeding and infection in these clients. Interventions after a transplant focus on the assessment and prevention of complications of the transplant, including failure to engraft, graft versus host disease, and veno-occlusive disease. The nurse also institutes measures to reduce the risk of bleeding and infection, as well as treating these disorders if they occur.
The nurse should
- Use sterile technique when performing care.
- Assess for signs of complications or rejection of transplant, including jaundice, pain in right upper quadrant, weight gain, and hepatomegaly.
- Monitor for bleeding.
- Administer ordered blood transfusion.
- Administer ordered platelets.
- Institute bleeding precautions, including
- Avoid IM injections.
- Avoid venipunctures.
- Avoid flossing of teeth (please refer to depression of platelets for other bleeding precautions)
- Monitor for infection. A. elevation of .5° F. could be significant in these clients.
- Pharmacological interventions include
- Steroids
- Immunosuppressants

Hodgkin’s Lymphoma
Hodgkin’s lymphoma is a malignancy involving the lymph nodes. It is more prevalent in men and tends to peak in the early 20s and after age 50.
Clinical manifestations associated with Hodgkin’s lymphoma include
- Coughing
- Dysphagia
- Dyspnea
- Enlargement of the cervical lymph node
- Fatigue
- Generalized pruritis
- Night sweats
- Pain in cervical lymph nodes when drinking
- Unexplained fever
- Weight loss
A lymphoma client might first note this enlargement while shaving.

Diagnosis of Hodgkin’s Lymphoma
Diagnosis of Hodgkin’s lymphoma is made by assessment of previously mentioned clinical manifestations and by node biopsy results. The staging of involvement listed here becomes important in determining how far the disease has progressed:
- Biopsy confirms presence of Reed-Sternberg cells.
- Staging of the disease by degree of involvement:
- 1—Single node or single site
- 2—More than one node, localized to a single organ on the same side of the diaphragm
- 3—Involvement of lymph nodes on both sides of the diaphragm
- 4—Diffuse involvement with disease disseminated in organs and tissues

Prognosis of Hodgkin’s Lymphoma
Prognosis is dependent on the stage of the disease. If it’s detected in the early stages, the prognosis for survival is good.

Treatment of Hodgkin’s Lymphoma
Treatment of Hodgkin’s depends on the stage of involvement. If the client is in stage 1 or 2, radiation is used alone; with more extensive involvement, though, chemotherapy is used with the radiation. The client might also undergo surgery to remove the spleen to help prevent the pooling of blood in this organ.

Diagnostic Tests for Review
Cancer clients require extensive diagnostic exams to determine the primary site of the cancer or tumor, as well as whether metastasis has occurred.
The tests are also important in determining the treatment options: radiation, chemotherapy, and/or surgery. Laboratory exams such as carcinogenic embryonic acid (CEA) and prostate specific antigen (PSA) are important in determining the disease and its progression. Routine laboratory exams such as chest x-rays, urinalysis, and cell blood counts (CBCs) with differentials also need to be reviewed.
Particularly important when caring for the cancer client receiving chemotherapy is the CBC. This test monitors for the side effects and bone marrow depression that can result from antineoplastic drugs. These diagnostic tests include
- Biopsy
- Bone marrow aspiration
- Bronchoscopy
- CBC
- CEA
- CT scan
- Magnetic resonance imagery (MRI)
- Mammogram
- Mediastinoscopy
- PSA
- Radioactive scan

MRIs use a powerful magnet. Clients with metal in their body cannot take the exam. No metal can be in the room of the client receiving an MRI; therefore, tubings for equipment must be lengthened to accommodate the client on oxygen or other life support equipment. The candidate for the exam must consider the factors in the following list to determine whether an MRI would be contraindicated or whether special accommodations would need to be made for a client who is scheduled for an MRI:
- Pregnancy of client
- Client weight greater than 260 pounds (open MRI would be required due to client size)
- Clients with pacemakers or electronic implants
- Clients who have metal fragments, metal clamps, or aneurysm clips
- The ability of the client to communicate clearly
- Use of life support equipment
- Ability of the client to lie still in a supine position for 30 minutes
- Use of oxygen by the client
- Clients receiving an IV infusion

Pharmacology for Review
The nurse candidate writing for the NCLEX® exam needs to be familiar with agents’ side effects and adverse effects. Although most nurses who administer chemotherapeutic drugs have extensive training, these drugs can be tested on the NCLEX® exam, and the candidate is expected to have knowledge of the drugs. The nurse must be aware of the impact of these drugs on the client’s quality of life and recognize that some of these drugs have lifethreatening, adverse effects. Nurses who administer chemotherapy must also keep in mind the importance of self-protection from the drug agents by wearing appropriate equipment when coming in contact with the agents.
The following list contains the various kinds of chemotherapeutic agents:
- Alkylating agents
- Antiestrogens
- Antimetabolites
- Antineoplastics
- Antitumor antibiotics
- Biologic response modifiers
- Hormones
- Monoclonal antibodies
- Plant alkaloids

Drugs that treat the adverse effects of chemotherapeutic agents include
- Antianxiety
- Antibiotics
- Antiemetics
- Colony stimulating factors
- Erythropoietin
- Immunosuppressants
- Steroids