NCM 106: CARE OF CLIENTS WITH PROBLEMS

IN CELLULAR ABERRATIONS, ACUTE BIOLOGIC Jaypee A. Bacalso, RN, MN

CRISIS, EMERGENCY AND DISASTER NURSING
EPIDEMIOLOGY
Common in all age group
Most occur in persons older than 65
Higher incidence in men
Higher in industrialized sectors or nations
PATHOPHYSIOLOGY
Cancer is a disease process that begins when an abnormal cell is transformed by
the genetic mutation of the cellular DNA.
The abnormal cell forms a clone and begin to proliferate abnormally
The cells acquire invasive characteristics, and changes occur in surrounding tissues
The cells infiltrate these tissues and gain access to lymph nodes and blood vessels
PROLIFERATIVE CELL GROWTHS
Hyperplasia
Metaplasia
Dysplasia
Anaplasia
Neoplasia
CHARACTERISTICS OF MALIGNANT CELLS
Cancer cells share some common cellular characteristics in relation to the:
cell membrane
special proteins
the nuclei
chromosomal activities
rate of mitosis and growth
CHARACTERISTICS OF BENIGN AND MALIGNANT
NEOPLASMS
Characteristics Benign Malignant
Cell characteristics Well differentiated cells that resemble normal Cells are undifferentiated and often bear little
cells of the tissue from which the tumor originated resemblance to the normal cells

Mode of growth Tumors grow by expansion and does not infiltrate Growth at the periphery and sends out processes
the surrounding tissues that infiltrate and destroy surrounding tissues

Rate of growth Usually slow Variable and depends on level of differentiation

Metastasis Does not spread by metastasis Gains access to blood and lymphatic channels
and metastasize to other areas of the body

General effects Localized unless its location interferes with vital Cause generalized effect like anemia, weakness,
function and weight loss
Tissue destruction Does not case damage unless interferes with Often causes extensive tissue damage; may also
blood flow produce substances that causes tissue damage
Ability to cause death Does not usually cause death unless its location Usually causes death
interferes with vital functions
TUMOR AND TISSUE TYPES
Tissue Type Benign Tumors Malignant Tumors

Epithelial
Surface Papilloma Squamous cell carcinoma
Grandular Ademona Adenocarcinoma

Connective
Fibrous Fibroma Fibrosarcoma
Adipose Lipoma Liposarcoma
Cartilage Chrondoma Chrondosarcoma
Bone Osteoma Osteosarcoma
Blood vessels Hemangioma Hemangiosarcoma
Lymph vessels Lymphangioma Lymphosarcoma
Lymph tissues
Muscle
Smooth Leiomyoma Leiomyosarcoma
Stratiated Rhabdomyoma Rhabdomyosarcoma
TUMOR AND TISSUE TYPES
Tissue Type Benign Tumors Malignant Tumors

Neural Tissue
Nerve Cells Neuroma Neuroblastoma
Glial Cells Glioma Glioblastoma, astrocytoma,
medulloblastoma,
oligodendroglioma
Nerve Sheaths Neurilemmoma Neurilemmal sarcoma
Meninges Meningioma Meningeal sarcoma
Hematologic
Granulocytic Myelocytic leukemia
Erythrocytic Erythrocytic leukemia
Plasma cells Multiple Myeloma
Lymphocytic Lymphocytic leukemia
Monocytic Monocytic leukemia
TUMOR AND TISSUE TYPES
Tissue Type Benign Tumors Malignant Tumors

Endothelial Tissue
Blood Vessels Hemangioma Hemangiosarcoma
Lymph Vessels Lymphagioma Lymphagiosarcoma
Endothelial Lining Ewings sarcoma
INVASION AND METASTASIS
Invasion refers to the growth of the primary tumor into the surrounding host tissues.
Metastasis dissemination of malignant cells from the primary tumor to distant sites
by direct spread of tumor cells to body cavities through lymphatic and blood
circulation
METASTATIC MECHANISM
Lymphatic spread
Hematogenous spread
angiogenesis
LYMPHATIC SPREAD
- transport of tumor cells through the lymphatic circulation.
- tumor emboli enter the lymph channels by way of the interstitial fluid that
communicates with lymphatic fluid
- after entering the lymphatic circulation, malignant cells either lodge in the lymph
nodes or pass between lymphatic and venous circulation
HEMATOGENOUS SPREAD
- malignant cells are disseminated through the blood stream
- few cancer cells can survive the turbulence of arterial circulation, insufficient
oxygenation, and destruction from the bodys immune system
- those cells that survive are able to attach to the endothelium and attract fibrin,
platelets, and clotting factors to seal themselves from immune system surveillance.
ANGIOGENESIS
- the ability to induce the growth of new capillaries from the host tissue to meet their
needs for nutrients and oxygen
CARCINOGENESIS
- malignant transformation
- it is a three-step cellular process
1. Initiation
2. Promotion
3. Progression
INITIATION
the first step
Initiators (carcinogens), such as chemicals, physical factors, biologic agents, escape
normal enzymatic mechanisms and alter the genetic structure of the cellular DNA.
PROMOTION
Repeated exposure to promoting agents (co-carcinogen) causes the expression of
the abnormal or mutant genetic information even after long latency periods
Cellular oncogenes responsible for cellular functions or growth and differentiation
Cellular proto-oncogenes acts as switch on for cellular growth
Cancer suppressor genes acts as turn off or regulate unneeded cellular
proliferation
PROGRESSION
The cellular changes formed during initiation and promotion now exhibit increased
malignant behavior
ETIOLOGY
Viruses and Bacteria
Physical Agents
Chemical Agents
Genetic an Familial Factors
Dietary Factors
Hormonal Agents
VIRUSES AND BACTERIA
Viruses are thought to incorporate themselves in the genetic structure of cells, thus
altering the future generations of the cell population
Example:
Epstein-Barr Virus is highly suspected to cause Burkitts lymphoma, nasopharyngeal cancers, non-
Hodgkins lymphoma and Hodgkins Disease
Herpes Simples, cytomegalovirus, human papilloma virus are associated with dysplasia and
cancer of the cervix
Hepatitis B is implicated in cancer of the liver
HIV is associated with Kaposi's sarcoma
Helicobacter pylori has been associated with increased incidence of gastric cancer
PHYSICAL AGENTS
Exposure to sunlight or radiation
Chronic irritation or inflammation
Tobacco use
CHEMICAL AGENTS
About 75% of cancers are thought to be related to the environment
Pesticides and formaldehyde, arsenic, soot and tars, asbestos, benzene, cadmium,
chromium compound, nickel and zinc ores, wood dust, etc.
GENETIC AND FAMILIAL FACTORS
Approximately 5% to 10% of cancers of adulthood and childhood display a
familial disposition
Cancers associated with familial inheritance include retinoblastomas,
nephroblastomas, malignant neurofibromatosis, and breast, ovarian, endometrial,
colorectal, stomach, prostate, and lung cancers
DIETARY FACTORS
Are thought to be related to 35% of all environmental cancers
Dietary substances associated with an increased cancer risk include fats, alcohol,
salt-cured or smoked meats, foods containing nitrates and nitrites, and a high caloric
dietary intake
Food substances that appear to reduce cancer risk include high fiber foods,
cruciferous vegetables (cabbage, broccoli, cauliflower), carotenoids (carrots,
tomatoes, spinach, dark green and deep yellow vegetables), and possible Vitamins E,
C, zinc and selenium
Obesity is associated with endometrial, postmenopausal breast cancer, colon,
kidney and gallbladder cancers
HORMONAL AGENTS
Diethylstilbesterol (DES) has been recognized as a cause of vaginal carcinomas
Oral contraceptives and prolonged estrogen replacement therapy are associated
with hepatocellular, endometrial, and breast cancers.
ROLE OF THE IMMUNE SYSTEM
T- Lymphocytes, the soldiers of the cellular immune response, are responsible for
recognizing tumor-associated antigens
Interferon, a substance produced by the body in response to viral infection, also
possesses some antitumor properties
Natural Killer (NK) cells, a subpopulation of lymphocytes, act by directly destroying
cancer cells
WHEN THE IMMUNE SYSTEM FAILS.
If the body fails to recognize the malignant cells as different from self (non-self or
foreign, the immune response may not be stimulated.
Tumor antigens may combine may combine with the antibodies produced by the
immune system and hide or disguise themselves from normal immune defense
mechanism
DETECTION AND PREVENTION OF CANCER
Primary Prevention
Secondary Prevention
PRIMARY PREVENTION
concerned with reducing the risks of cancer in healthy people
Assisting patients to avoid known carcinogens
Adopting dietary and various lifestyle changes
SECONDARY PREVENTION
Detection and screening to achieve early diagnosis and prompt intervention to halt
the cancer process
Examples: breast and testicular self-examination, Papanicolaou (Pap) Smear,
mammography, digital rectal exam, prostate specific antigen blood test
TUMOR STAGING AND GRADING
Staging - determines the size of the tumor and he existence of metastasis
Grading refers to the classification of tumor cells
- it seeks to define the type of tissue from which the tumor originated and the
degree to which the tumor cells retain the functional and hislotogic
characteristics of the tissue of origin.
 TNM CLASSIFICATION SYSTEM

T The extent of the primary tumor

N The presence or absence and extent of regional lymph node metastasis
M The presence or absence of distant metastasis
The use of numerical subsets of the TNM components indicates the progressive extent of the malignant disease
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1, T2, T3, T4 Increasing size and /or local extents of the primary tumor
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1, N2, N3 Increasing involvement of lymph nodes
Distant Metastasis
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
MANAGEMENT OF CANCER
Cure complete eradication of the disease
Control containment of cancer growth
Palliation relief of symptoms associated with the disease
MODALITIES IN TREATING CANCER
Surgery
Radiation Therapy
Chemotherapy
Bona Marrow Transplant
Thermal Therapy
Photodynamic Therapy
Gene Therapy
Biologic Response Modifier Therapy
SURGERY
Surgical removal of the entire cancer remains the ideal and most frequently used
treatment method
Reasons for surgery:
Diagnostic
Surgery as primary treatment
Prophylactic surgery
Palliative surgery
Reconstructive surgery
DIAGNOSTIC SURGERY
aka biopsy, is usually performed to obtain a tissue sample for analysis of cells
suspected to be malignant
Biopsy methods:
Excisional biopsy frequently used for easily accessible tumors of the skin, breast, upper
and lower GI tract, and upper respiratory tract
Incisional biopsy is performed if the tumor mass is too large to be removed, a wedge
of tissue from the tumor is removed for analysis
Needle biopsies are performed to sample suspicious masses that are easily accessible,
such as in breast, thyroid, lung, liver and kidney
SURGERY AS PRIMARY TREATMENT
Aka debulking, the removal of the entire tumor
Surgical approaches:
Local excision warranted when the mass is small
Wide or radical incision (en bloc dissection) removal of the primary tumor, lymph
nodes, adjacent involved structures, and surrounding tissues that may be at risk for
tumor spread
Salvage Surgery is an additional treatment option that uses an extensive surgical
approach to treat the local recurrence of the cancer after a less ectensive surgical
approach is used
SURGERY AS PRIMARY TREATMENT
Electrosurgery makes use of electrical current to destroy tumor cells
Cryosurgery uses liquid nitrogen to freeze tissue to case cell destruction
Chemosurgery uses combined topical chemotherapy and layer-by-layer surgical
removal of abnormal tissue
Laser surgery makes use of light and energy aimed at an exact tissue location
and depth to vaporize cancer cells
Stereotactic Radiosurgery is a single and highly precise administration of high-
dose radiation therapy
PROPHYLACTIC SURGERY
Involves removal of nonvital issues or organs that are likely to develop cancer
Factors considered when electing prophylactic surgery:
Family history and genetic disposition
Presence or absence of symptoms
Potential risks and benefits
Ability to detect cancer at an early stage
patient's acceptance of the postoperative outcome
PALLIATIVE SURGERY
When cure is not possible, the goals of treatment are to make the patient as
comfortable as possible and to promote satisfying and productive life for as long as
possible
The major goal is the quality of life as defined by the patient and family
Performed in attempt to relieve complications of cancer, such as ulcerations,
obstructions, hemorrhage, pain, and malignant effusions.
RECONSTRUCTIVE SURGERY
Is carried out to attempt to improve function or obtain a more desirable cosmetic
effect
The nurse must recognize the patients needs and the impact that altered functioning
and altered body image may have on quality of life.