Chapter 20: Concepts of Care for Patients With Cancer

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Welcome back to the Deep Dive.

Today we're tackling, well, a really complex area, care for patients with cancer.

We're using a core medical surgical text as our guide.

Yeah, it's dense stuff, but essential.

Think of this as a roadmap for coordinating really high quality but also high stakes care.

Okay, so what's the big picture here?

Where do we start?

Right, so the absolute priority concept, the one that connects everything, it's immunity.

When that's compromised, and it often is, then you see the ripple effects.

Ripple effects into?

Into things like cellular regulation, obviously, but also clotting, gas exchange, and even sensory perception.

These are all critically interrelated.

You can't really separate them in cancer care.

Okay, let's unpack that then.

Our goal today really is to distill the core pathophysiology, look at the treatments, which frankly can sometimes seem almost as risky as the disease itself, and most importantly nail down the nursing safety priorities, the interventions that you need to know.

Exactly, turning that textbook knowledge into what you actually do at the bedside.

Right, so let's start with a broad impact.

How do cancer and its treatments affect, you know, just basic physical function?

Well, it's systemic.

A huge factor is the bone marrow.

Chemo, you see, it targets rapidly dividing cells.

Great for cancer, but terrible for bone marrow.

Because the bone marrow is constantly making new cells.

Precisely.

So, chemo often leads to this triad of issues.

Bone marrow suppression causes low white blood cells, which is neutropenia.

Okay, neutropenia, that means massive immunosuppression, right?

High infection risk.

Huge risk.

Then you've got low platelets, thrombocytopenia.

That means impaired clotting.

Big bleeding risk.

Got it.

Neutropenia for infection, thrombocytopenia for bleeding, what's the third part of that triad?

Anemia, low red blood cells, and this ties directly back to that concept of gas exchange.

Ah, okay, so not just feeling tired.

No, no, it's profound fatigue, shortness of breath, sometimes tachycardia because the heart's trying to compensate.

It really impacts their ability to just, you know, function day to day.

The goals of care might even shift depending on whether it's curable versus metastatic disease.

That makes sense.

And beyond the blood counts, what about, say, nutrition,

GI function?

Oh, that's another major area.

Cancer itself increases metabolic demand.

Plus, treatments often wreck appetite, change how food tastes.

Leading to weight loss, obviously.

Yes, but it can progress to something much more severe called cachexia.

This isn't just weight loss, it's significant muscle wasting.

It dramatically weakens the patient and makes it harder for them to tolerate treatment.

That's where nutrition support comes in.

Absolutely critical.

The registered dietitian nutritionist, the RDN, is a key part of the team here.

You need that specialized input.

Okay, shifting gears a bit.

Let's connect to sensory perception.

The text mentions nerve issues, specifically chemotherapy -induced peripheral neuropathy, or CIPN.

Right, CIPN.

It's caused by certain chemo drugs that are just toxic to nerves.

Think agents like Vincristine or cisplatin.

And how does that present?

What would you see?

Typically, it starts with loss of sensation, numbness, tingling, often in the hands and feet.

It's very characteristic.

Which sounds like it would cause problems with walking, balance.

Definitely.

Big fall risk.

Gait instability is common.

And because they lose sensation, they're also at risk for injuries they might not feel, like burns or cuts.

And that's from the chemo itself.

What about the cancer -invading tissues?

Yeah, that's another route to sensory or motor problems.

If a tumor gets into bone, it can cause fractures, pain, or even compress the spinal cord.

Spinal cord compression.

That sounds like an emergency.

It absolutely is.

Spinal cord compression, SCC, is a true oncologic emergency.

Delay in treatment can mean permanent paralysis, so worsening back pain in a cancer patient.

Red flag.

Big red flag.

Got it.

Okay, what about respiratory and cardiac effects?

Well, tumors can physically obstruct airways, obviously.

Decreased lung capacity is common.

But there are two big things the text highlights.

One is superior vena cava syndrome, or SVC syndrome.

SVC syndrome, where the big vein returning blood from the upper body gets compressed.

Exactly.

You see swelling in the face, neck, arms.

It's another oncologic emergency requiring immediate action.

And the other cardiac risk.

It's often a late effect.

Certain chemo drugs like doxorubicin or even radiation to the chest can damage the heart muscle over time.

Patients might develop heart failure years after treatment ends.

Wow.

So survivorship care needs to monitor for that long term.

Absolutely.

It reinforces that cancer care often becomes chronic disease management.

Okay, that gives us a good sense of the systemic impact.

Let's move into the actual treatments.

This is where it gets really interesting, maybe a bit scary.

Surgery, radiation, chemo.

Right, the three main pillars.

Surgery is incredibly versatile.

It can be prophylactic, like removing a breast in someone with a high -risk gene mutation.

Sure, or diagnostic, like a biopsy.

Exactly.

Or curative, trying to remove the whole tumor.

Then there's control, like debulking to reduce tumor size, palliation for symptom relief, even reconstruction.

But surgery always carries risks and potential side effects like loss of function or changes in appearance.

Definitely.

Functional loss or disfigurement can be significant side effects, depending on the surgery.

And that requires a lot of psychosocial support right from the start.

Body image issues are common.

Makes sense.

Okay, next pillar, radiation.

What's the core idea there?

The goal is to use radiation to damage the DNA of cancer cells so they die, ideally while sparing as much normal tissue as possible.

We talk about exposure versus the actual radiation dose, which is measured in units called grays.

And for healthcare workers dealing with radiation, what's the absolute fundamental safety principle?

It boils down to three words, time, distance, and shielding.

Minimize your time near the source.

Maximize your distance and use appropriate shielding like lead aprons.

That's radiation safety 101.

Ruchel.

Now, how is radiation delivered?

I know there are different methods.

Right.

The most common is external beam radiation therapy or EDRT.

Think of it like a targeted x -ray.

After the treatment session, the patient is not radioactive.

Okay, not radioactive with external beam.

But what about internal radiation?

That's brachytherapy.

We place a radioactive source inside the body, close to or within the tumor.

And with brachytherapy, while that source is active and in place, the patient is radioactive.

Right.

And that changes everything for safety protocols,

especially for sealed sources like implants.

Absolutely.

This is critical nursing knowledge.

The patient needs a private room.

There should be a caution, radioactive material sign on the door.

We often use portable lead shields.

Staff must wear a decimeter badge to track their exposure.

And if you have to provide direct care.

Lead apron, definitely.

And always keep the front of the apron facing the radioactive source.

Limit close contact time.

Visitors are restricted usually about 30 minutes per day.

And they need to stay at least six feet away.

And a really key point.

No pregnant women or children allowed as visitors.

Period.

That's intense.

What about waste products?

Are they radioactive too?

Good question.

With sealed implants like seeds, the excreta urine, stool are not radioactive.

But if the patient ingests or receives an unsealed liquid isotope, like radioactive iodine for thyroid cancer, then yes, their waste is radioactive and requires special handling precautions.

Okay, important distinction.

What are the common side effects of radiation itself?

The most common is skin reaction in the treated area, often called radiation dermatitis.

It can range from redness to peeling, kind of like a bad sunburn.

Fatigue is also very common.

And altered taste.

And site -specific things, like head and neck radiation.

Yeah, that can cause dry mouth, xerostomia, which is often permanent, and increases the lifelong risk of tooth decay.

So meticulous oral care is vital.

And you mentioned skin reactions.

Any key teaching points for skin care?

Yes, absolutely.

Gentle washing, patting dry, no rubbing.

Avoid removing any markings the radiation therapist puts on the skin.

Avoid tight clothing or belts that rub.

And this is a big one, an action alert from the text.

Avoid direct sun exposure on the treated area during therapy and for at least a year after.

The skin becomes extremely photosensitive.

A whole year.

Okay, good to know.

Let's move to the third pillar.

Cytotoxic systemic therapy, or what most people just call chemotherapy.

Right.

This is the systemic approach.

Using drugs that kill cancer cells throughout the body.

Very useful for metastatic disease.

It can be given before surgery or radiation that's neoadjuvant chemo.

Or after, which is adjuvant chemo.

And the big safety issue here revolves around handling these drugs.

Huge issue.

These are classified as hazardous drugs, HDs.

Anyone preparing, administering, or handling the patient's bodily fluids within 48 hours of chemo administration must use specific personal protective equipment, or PPE.

What does that PPE involve?

Typically, it's double chemotherapy gloves, a chemotherapy gown, which is usually coated and non -absorbent, and eye protection, like goggles or a face shield.

Strict protocols.

Okay, and what about when giving out a 5E?

There's a specific risk there.

You're thinking of extravasation.

It's when a certain type of chemo drug called a vesicant leaks out of the vein and into the surrounding tissue.

Vesicant.

Meaning it causes blistering and tissue damage.

Severe damage.

Necrosis, sometimes requiring surgery, it's a major complication.

So the nursing priority is constant, close monitoring of that IV site during infusion.

Check for blood return, watch for swelling, redness, pain.

Using central lines or implanted ports is much safer for vesicants whenever possible.

Makes sense.

What about oral chemo?

Are those pills safer?

That's a dangerous misconception.

Oral chemotherapy agents are often just as toxic as IV ones.

They still require careful handlings.

Caregivers might need gloves.

Patients must be taught not to crush, split, or chew them unless specifically told to.

And disposal, can they just flush leftover pills?

Absolutely not.

That contaminates the water supply.

Unused oral chemo should usually be returned to the pharmacy or disposed of according to specific hazardous waste procedures.

Patient teaching on this is vital.

Wow, okay.

Oral chemo is not simpler, just different routes, same hazards.

Got it.

Now let's get into managing the really life -threatening side effects, particularly that bone marrow suppression we talked about earlier.

Right.

This is probably the highest risk period for many patients.

We need to talk about the nadir.

The nadir.

That's a low point, right?

Exactly.

It's the period when the bone marrow is most suppressed after a chemo cycle, usually around 7 to 10 days post -treatment, though it varies.

This is when white counts, platelet counts, red counts are at their lowest.

Maximum vulnerability.

So focusing on neutropenie, the low white count, what's the absolute number one priority?

Infection prevention.

Hand washing, avoiding sick contacts, food safety.

All that teaching is crucial.

But the clinical priority, the critical rescue highlighted in the text, is recognizing a penchal sepsis early.

And how do you do that in someone who might not mount a typical immune response?

That's the key.

They often don't get high fevers or show classic signs like pus.

So any temperature elevation, even a low -grade one, specifically 100 .4 degrees F, 38 degrees Z or higher, is considered a potential emergency.

It needs immediate reporting and workup.

So that low -grade fever is the alarm bell?

It's the critical alarm bell for potential life -threatening infection in a neutropenic patient.

Okay.

What about the bleeding risk from thrombocytopenia?

When does that become critical?

The risk really increases when the platelet count drops below 50 ,000 per cubic millimeter.

Below 20 ,000, there's a significant risk of spontaneous bleeding, meaning bleeding without any obvious injury.

Yikes.

So nursing priority there is safety, preventing injury.

Absolutely.

Provide a safe environment.

Teaching includes using an electric razor, not blades.

Soft toothbrush only.

Avoid aspirin and NSAIs unless approved.

No rectal temps or suppositories.

Avoid forceful nose blowing or straining.

Basically anything that could cause trauma, internal or external.

Got it.

Moving to the GI tract again.

Nausea and vomiting,

CINV.

Chemotherapy -induced nausea and vomiting.

Yeah, it's a major quality of life issue.

There are different types anticipatory happening before chemo even starts.

Acute within the first 24 hours, delayed occurring later, and breakthrough despite preventive meds.

So how do we manage it?

The key is prevention and being proactive.

We have good evidence -based guidelines.

Antimetic drugs should be given before chemo starts on a schedule, not just waiting for nausea to hit.

Because once it starts, it's harder to control.

Much harder.

And there's a drug alert related to some common antimetics, the 5 -HT3 antagonists like Ondansetron or Zofran.

What's the alert?

They can potentially prolong the QT interval on an ECG, which increases the risk of a serious arrhythmia.

So for patients with existing heart issues or other risk factors, ECG monitoring might be necessary.

Good point.

And besides nausea, there's also mouth sores.

Eucocytus.

Right.

Painful inflammation and ulceration anywhere along the GI tract, but often really bad in the mouth.

It makes eating, drinking, even talking incredibly painful.

What can we do about that?

Prevention and supportive care are key.

One interesting intervention, especially for drugs infused quickly, is oral cryotherapy.

Basically having the patient suck on ice chips before, during, and for a short time after the infusion.

Ice chips.

How does that help?

The cold causes vasoconstriction in the mouth, reducing blood flow, and therefore reducing the amount of chemo drug delivered to the oral mucosa.

It can significantly lessen the severity of mucositis for certain drugs.

Frequent, gentle oral hygiene is also vital, avoiding alcohol -based mouthwashes that sting and dry things out.

Cryotherapy and gentle care.

What about other common side effects?

Hair loss?

Alopecia.

Yes.

Very common and often very distressing for patients.

It's usually temporary.

Nursing focuses on helping the patient cope, discussing options like wigs or scarves, and teaching scalp care, protecting it from sun and cold.

Scalp cooling systems are sometimes used to try and reduce hair loss, with varying success.

And this chemo brain I hear patients talk about.

Is that real?

Oh, absolutely.

Patients report issues with concentration, short -term memory, feeling foggy.

We might call it chemotherapy -related cognitive impairment.

It's important for us to validate their experience and offer support and coping strategies, not just in their head.

Right.

And going back to CIPN, that nerve damage, what's the management focus there?

Since we can't always reverse the nerve damage, the focus shifts heavily to safety and preventing injury.

Because they've lost sensation, they need practical strategies, like always wearing well -fitting shoes, even indoors, to protect feet.

Inspecting feet daily for cuts or sores they might not feel.

Testing water temperature with a thermometer, not just fingers, before bathing or washing dishes to prevent burns.

Getting up slowly to prevent falls from orthostatic hypotension, which can also occur.

It's all about adapting to that sensory loss.

That makes sense, adapting to the new reality.

Okay, let's look forward a bit.

Treatments are evolving beyond traditional chemo, right?

Definitely.

We're seeing more immunotherapy and targeted therapies.

Tell me about immunotherapy first.

How does that work?

Basically, it harnesses the patient's own immune system to fight the cancer.

Drugs might, for example, take the brakes off immune cells so they can recognize and attack tumor cells more effectively.

So the side effects wouldn't be the classic chemo ones, like low blood counts?

Generally, no.

The side effects are usually immune -related adverse events, or IRAEs.

Because you've revved up the immune system, it can sometimes mistakenly attack healthy tissues.

Leading to inflammation.

Exactly.

You can get colitis, inflammation of the colon, hepatitis, liver, pneumonitis, lungs, thyroiditis, pretty much any hellitis.

Management often involves suppressing the immune system temporarily with corticosteroids to calm things down.

Interesting.

Okay, and targeted therapies, how are they different?

These drugs are designed to interfere with specific molecules or pathways involved in cancer cell growth and survival.

They might block growth factor receptors, like EGFR, or inhibit blood vessel growth, like VEGF inhibitors, or target specific enzymes inside the cell, like tyrosine kinase inhibitors, TKIs.

So more precise than traditional chemo?

In theory, yes.

They often have different, sometimes unique side effect profiles compared to chemo.

Maybe more skin rashes, diarrhea, blood pressure issues, but less bone marrow suppression.

However, many are oral agents.

And we already covered the safety for oral agents.

Still hazardous.

And it'll carefully take exactly as prescribed.

Precisely.

That drug alert applies here, too.

Adherence is critical for these drugs to work, and safe handling is still essential.

Okay, now for a really critical section.

Oncologic emergencies.

These require immediate recognition and action.

Let's run through the main ones.

Right.

Top of the list, especially for neutropenic patients, is sepsis.

It can progress incredibly rapidly.

And sepsis often triggers DIC, or disseminated intravascular coagulation.

That's the paradoxical clotting and bleeding thing.

Yeah, it's complex.

Widespread micro -clotting uses up all the clotting factors in platelets, which then leads to massive, uncontrolled bleeding.

It's often triggered by sepsis in cancer patients.

Prevention of infection is the best strategy here.

Okay, sepsis and DIC.

What's next?

Syndrome of inappropriate antidiuretic hormone, or SIADH.

Some cancers, or even some treatments, can cause the body to produce too much ADH.

And ADH makes you hold on to water.

Right.

So the patient retains too much water, which dilutes the sodium in their blood, leading to hyponatremia.

This can cause weakness, confusion, muscle cramps, and in severe cases, seizures or coma.

So the nursing priority for SIADH.

Fluid restriction is key.

Plus, frequent monitoring neurochecks, strict intake output, daily weights, and assessing for signs of fluid overload, like that bounding pulse, neck vein distension, crackles in the lungs,

moderate sodium levels closely.

Got it.

Third emergency.

Spinal cord compression, SCC.

We mentioned it earlier.

Tumor growth near the spine or vertebral collapse puts pressure on the spinal cord.

And the key early sign is?

Worsening back pain, especially pain that's different or more severe than usual, baseline pain.

Later signs are weakness, loss of sensation below the level of compression, and bowel or bladder dysfunction, incontinence, or retention.

And treatment has to be immediate.

Immediate.

High -dose corticosteroids are usually given right away to reduce swelling, followed quickly by radiation or possibly surgery to relieve the pressure.

The goal is to prevent permanent paralysis.

Okay.

Fourth.

Hypercalcemia.

High calcium levels in the blood, often seen with bone metastases as the cancer breaks down bone, releasing calcium.

Or some tumors actually secrete a hormone that raises calcium.

What are the signs?

Are they obvious?

Unfortunately, early signs are often vague fatigue, loss of appetite, nausea, constipation, maybe increased urination.

As it gets worse, you see more severe confusion, weakness, dehydration, and potentially kidney stones or cardiac issues.

So how do you manage hypercalcemia?

The priority is aggressive hydration with IV normal saline.

Flushing the kidneys helps excrete the excess calcium.

Medications like bisphosphonates might also be used.

Okay.

Hydration for hypercalcemia.

Last one.

Tumor Lysis Syndrome, or TLS.

This happens when treatment, usually chemo, rapidly kills a large number of cancer cells, especially in bulky tumors like lymphomas or leukemias.

So the cells burst open.

Exactly.

They release massive amounts of their intracellular contents into the bloodstream, particularly potassium, phosphate, and nucleic acids, which break down into uric acid.

Leading to?

Life -threatening hypercalcemia, high potassium, dangerous for the heart,

hyperphosphatemia, which causes low calcium, and hyperuricemia, high uric acid, which can crystallize in the kidneys and cause acute kidney injury.

That sounds like a metabolic catastrophe.

How do you prevent TLS?

Prevention is absolutely key for high -risk patients.

It involves aggressive hydration, usually aiming for about three liters a day or more, starting before chemo begins to keep the kidneys flushed.

And prophylactic medications like allopurinol are often given to block uric acid production.

Frequent lab monitoring during the high -risk period is essential.

Wow.

Okay.

Those five emergencies, sepsis DIC, SIADH, SEC, hypercalcemia, TLS, definitely critical knowledge.

So wrapping up, where does all this leave us?

Well, it highlights that cancer care is complex and constantly evolving, but it also connects back to survivorship.

We're getting better at treating cancer, meaning more people live longer, often viewing cancer as a chronic disease.

This requires ongoing monitoring for those late effects we talked about, cardiac issues, secondary cancers, lymphedema.

So for someone learning this, what are the absolute key takeaways?

I'd say patient safety above all, recognize those subtle signs of infection or bleeding, especially during the nadir, understand the risks associated with each treatment modality, and follow those safety protocols for handling hazardous drugs by V and oral meticulously.

Know the oncologic emergencies cold.

Right.

It's about synthesizing everything, the treatments, the labs, the patient's presentation,

and prioritizing based on risk.

That ability to connect the dots quickly, that's really the core of expert oncology nursing, isn't it?

It really is.

And we haven't even deeply touched on the psychosocial aspects today, but they're interwoven through everything, dealing with body image changes, potential infertility, fear, anxiety.

That support is just as critical as managing the

Absolutely.

A vital point to remember.

It's about the whole person, always.

We hope this deep dive helps you connect those concepts and feel more prepared.

Thank you for joining us from the Last Minute Lecture Team.

We appreciate you tuning in.