Module 6 - Nursing care of at risk and sick adult clients with

alterations/ problem in Cellular Aberrations.

OVERVIEW
Cancer nursing practice covers all age groups and nursing specialties and is
carried out in a variety of health care settings, including the home, community, acute
care institutions, and rehabilitation centers. The scope, responsibilities, and goals of
cancer nursing, also called oncology nursing, are as diverse and complex as those of
any nursing specialty. Because many people associate cancer with pain and death,
nurses need to identify their own reactions to cancer and set realistic goals to meet the
challenges inherent in caring for patients with cancer.
In addition, the cancer nurse must be prepared to support the patient and family
through a wide range of physical, emotional, social, cultural, and spiritual crises.

LEARNING OBJECTIVES:
On completion of this chapter, the learner will be able to:
1. Compare the structure and function of the normal cell and thecancer cell.
2. Differentiate between benign and malignant tumors.
3. Identify agents and factors that have been found to be carcinogenic.
4. Describe the significance of health education and preventive care in
decreasing the incidence of cancer.
5. Differentiate among the purposes of surgical procedures used in cancer
treatment, diagnosis, prophylaxis, palliation, and reconstruction.
6. Describe the roles of surgery, radiation therapy, chemotherapy, targeted
therapy, hematopoietic stem cell transplantation, and other therapies in
treating cancer.
7. Describe the special nursing needs of patients receiving chemotherapy.
8. Describe nursing care related to common nursing diagnoses associated
with cancer: impaired skin integrity, alopecia, nutritional problems, and
altered body image.
9. Identify potential complications for the patient with cancer and discuss
associated nursing care.
10. Describe the concept of hospice in providing care for patients with
advanced cancer.
11. Identify assessment parameters and nursing management of patients with
oncologic emergencies.
 Lesson 1- ASSESSMENT

CRITICAL THINKING EXERCISES

A. A 33-year-old man has presented to the cancer center for treatment of
colorectal cancer. In reviewing his family history, you note that his father and
grandfather (who are both deceased) had metastatic colon cancer and his
father’s sister had endometrial cancer at age 45.You also note that he has two
younger sisters.
a. What information is important in this family history and why?
b. What type of referral would be appropriate for this man and his family?
c. How would you best advise this man and his family regarding cancer
risks and screening practices?
B. Your 28-year-old patient with acute leukemia, hospitalized for high-dose
chemotherapy, has developed tumor lysis syndrome and acute renal failure.
a. Describe the underlying pathology that can lead to the signs and
symptoms of tumor lysis syndrome.
b. What patient monitoring will be essential during this patient’s care?
c. Describe the medical and nursing management strategies that will be
used for this patient.
C. A 58-year-old patient with bone metastasis from an unknown primary cancer
has been receiving an opioid through a continuous subcutaneous infusion of
analgesia with an infusion pump to relieve his severe pain. His wife tells you
that both she and her husband fear that he will become addicted to the opioid;
his adult children report that his pain remains severe and unrelieved.
a. As a home care nurse, what assessments would be of highest priority to
you during your initial visit to this patient?
b. What nursing interventions would be indicated for the patient and his
wife?

Nursing History
 Health History – chief complaint and history of present illness (onset, course,
duration, location, precipitating and alleviating factors)
 Cancer signs: CAUTION US!

Warning Signs of Cancer

 • CAUTION US!
– Change in bowel or bladder habits
– A sore that does not heal
– Unusual bleeding or discharge
– Thickenings or lumps
– Indigestion or difficulty in swallowing
– Obvious change in a wart or mole
– Nagging or persistent cough or hoarseness
– Unexplained anemia
– Sudden unexplained weight loss

Change in bowel or bladder habits

 A person with colon cancer may have diarrhea or constipation, or he may notice
that the stool has become smaller in diameter
 A person with bladder or kidney cancer may have urinary frequency and urgency

A sore that does not heal

 Small, scaly patches on the skin that bleed or do not heal may be a sign of skin
cancer
 A sore in the mouth that does not heal can indicate oral cancer

Unusual bleeding or discharge

 Blood in the stool is often the first sign of colon cancer
 Similarly, blood in the urine is usually the first sign of bladder or kidney cancer
 Postmenopausal bleeding (bleeding after menopause) may be a sign of uterine
cancer

Thickenings or lumps
 Enlargement of the lymph nodes or glands (such as the thyroid gland) can be an
early sign of cancer
 Breast and testicular cancers may also present as a lump

Indigestion or difficulty in swallowing

 Cancers of the digestive system, including those of the esophagus, stomach, and
pancreas, may cause indigestion, heartburn, or difficulty swallowing

Obvious change in a wart or mole

 Moles or other skin lesions that change in shape, size, or color should be
reported
Nagging or persistent cough or hoarseness
 Cancers of the respiratory tract, including lung cancer and laryngeal cancer, may
cause a cough that does not go away or a hoarse (rough) voice

Unexplained anemia

Sudden unexplained weight loss

 Lesson 2 - PHYSICAL ASSESSMENT

• Inspection – skin and mucus membranes for lesions, bleeding,

petechiae, and irritation
– Assess stools, urine, sputum, vomitus for acute or occult
bleeding
– Scalp noting hair texture and hair loss
• Palpation
– Abdomen for any masses, bulges or abnormalities
– Lymph nodes for enlargement
• Auscultation – of lung sounds, heart sounds and bowel sounds

 Lesson 3 - DIAGNOSTIC STUDIES/ PROCEDURES

 Cancer detection examination

 Laboratory tests
- Complete blood cell count (CBC)
- Tumor markers – identify substance (specific proteins) in the blood that are
made by the tumor
- PSA (Prostatic-specific antigen): prostate cancer
- CEA (Carcinoembryonic antigen): colon cancer
- Alkaline Phosphatase: bone metastasis
 Biopsy

Diagnostic Tests
• Determine location of cancer:
 – X-rays
– Computed tomography
– Ultrasounds
– Magnetic resonance imaging
– Nuclear imaging
– Angiography
• Diagnosis of cell type:
– ▪Tissue samples: from biopsies, shedded cells (e.g. Papanicolaou (PAP)
smear), & washings
– ▪ Cytologic Examination: tissue examined under microscope
• Direct Visualization:
– ▪ Sigmoidoscopy
– ▪ Cystoscopy
– ▪ Endoscopy
– ▪ Bronchoscopy
– ▪ Exploratory surgery; lymph node biopsies to determine metastases

Tumor Staging and Grading

• Staging determines size of tumor and existence of metastasis
• Grading classifies tumor cells by type of tissue
• The TNM system is based on the extent of the tumor (T), the extent of
spread to the lymph nodes (N), and the presence of metastasis (M).
Primary Tumor (T)
TX Primary tumor cannot be evaluated

T0 No evidence of primary tumor

Tis Carcinoma in situ (early cancer that has not spread to neighboring tissue)
T1, T2, T3, T4 Size and/or extent of the primary tumor

Regional Lymph Nodes (N)

NX Regional lymph nodes cannot be evaluated
N0 No regional lymph node involvement (no cancer found in the lymph nodes)

N1, N2, N3 Involvement of regional lymph nodes (number and/or extent of spread)

Distant Metastasis (M)

MX Distant metastasis cannot be evaluated

M0 No distant metastasis (cancer has not spread to other parts of the body)

M1 Distant metastasis (cancer has spread to distant parts of the body)

 Lesson 4 - Analysis/ Nursing Diagnosis

• Acute or chronic pain

• Impaired skin integrity
• Impaired oral mucous membrane
• Risk for injury
• Risk for infection
• Fatigue
• Imbalanced nutrition: less than body requirements
• Risk for imbalanced fluid volume
• Anxiety
• Disturbed body image
• Deficient knowledge
• Ineffective coping
• Social isolation

Lesson 5 – PLANNING

OUTCOME IDENTIFICATION
1. Pain relief
2. Integrity of skin and oral mucosa
3. Absence of injury and infection
4. Fatigue relief
5. Maintenance of nutritional intake and fluid and electrolyte balance
6. Improved body image
7. Absence of complications
8. Knowledge of prevention and cancer treatment
9. Effective coping through recovery and grieving process
10. Optimal social interaction

Lesson 6 – Implementation of Care of clients

NURSING MANAGEMENT
1. Promote measures that relieve pain and discomfort.
 Pharmacologic and non-pharmacologic interventions
2. Promote measures to maintain intact skin integrity
3. Promote measures that maintain oral mucosa
4. Promote measures to prevent injury from abnormal bleeding
5. Promote measures that identify and prevent infection
• Monitor WBC count; encourage frequent handwashing and overall
cleanliness
6. Help decrease the client’s fatigue and increase his activity level
7. Promote measures that ensure adequate nutritional intake
• High protein, high calorie diet
8. Ensure adequate fluid and electrolyte balance
 Monitor platelet count; avoid aspiring products,etc
9. Promote measures to enhance body image.
 Take an honest gentle, caring approach; encourage client to express
and verbalize feelings
10. Promote measures that address preventing complications of cancer therapy
11. Instruct client and family about the disease process and treatments; provide
necessary information for self-care.
12. Help client and family cope effectively
13. Promote measures to reduce social isolation.

Effects of Chemotherapy

• Tissues: (fast growing) frequently affected

• Examples: mucous membranes, hair cells, bone marrow, specific
organs with specific agents, reproductive organs (all are fetal toxic;
impair ability to reproduce)
Chemotherapy Administration
• Routes of administration:
– Oral
– Body cavity (intraperitoneal or intrapleural)
– Intravenous
• Use of vascular access devices because of threat of
extravasation (leakage into tissues) & long-term therapy

Types of vascular access devices:

– PICC lines: (peripherally inserted central catheters)
 – Tunneled catheters: (Hickman, Groshong)
– Surgically implanted ports: (accessed with 90o angle needle- Huber
needles

Lesson 7 – Client education

Prevention and detection

 Primary Prevention
o Reducing modifiable risk factors in the external and internal environment
 Secondary Prevention
o Recognizing early signs and symptoms and seeking prompt treatment
o Prompt intervention to halt cancerous process

Cancer Prevention
1. Avoid Tobacco
2. Protect Yourself From Excessive Sunlight
3. Limit Alcohol and Tobacco
4. Diet: Limit Fats and Calories
5. Diet: Consume Fruits and Vegetables
6. Avoid Cancer Viruses
7. Avoid Carcinogens at Work

Lesson 8 – Evaluation of the outcomes of care

Care of Clients Receiving Chemotherapy

• Classes of Chemotherapy Drugs:

– Alkylating agents:
• Action: create defects in tumor DNA
• Ex: Nitrogen Mustard, Cisplatin
• Toxic Effects: reversible renal tubular necrosis
– Antimetabolites:
• Action: phase specific
• Ex: Methotrexate; 5 fluorouracil
• Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia,
leukopenia
– Antitumor Antibiotics:
• Action: non- phase specific; interfere with DNA
 • Ex: Actinomycin D, Bleomycin, adriamycin (doxorubicin)
• Toxic Effect: damage to cardiac muscle
– Miotic inhibitors:
• Action: Prevent cell division during M phase of cell division
• Ex: Vincristine, Vinblastine
• Toxic Effects: affects neurotransmission, alopecia, bone marrow
depression
– Hormones:
• Action: stage specific G1
• Ex: Corticosteroids
– Hormone Antagonist:
• Action: block hormones on hormone- binding tumors ie: breast,
prostate, endometrium; cause tumor regression
• Ex: Tamoxifen (breast); Flutamide (prostate)
• Toxic Effects: altered secondary sex characteristics

Nursing care of clients receiving chemotherapy

• Assess and manage:
– Toxic effects of drugs (report to physician)
– Side effects of drugs: manage nausea and vomiting,
inflammation and ulceration of mucous membranes, hair loss,
anorexia, nausea and vomiting with specific nursing and
medical interventions
• Monitor lab results (drugs withheld if blood counts seriously low); blood and
blood product administration
• Assess for dehydration, oncologic emergencies
• Teach regarding fatigue, immunosuppression precautions
• Provide emotional and spiritual support to clients and families

Module 7 - Responses To Alterations/ Problems And

Its Pathophysiologic Basis In Cellular Aberrations.

Multiple Choice: choose the letter of the right answer

1. A client who was diagnosed with lung cancer had undergone removal surgery of
the left lung. The best post-op position for this client is
 a. Position on the back or left side only
b. Position on the back or right side only
c. Position on the left side only
d. Position on the right side only
2. The nurse is instructing a premenopausal woman about breast self-examination.
The nurse should tell the client to do her self-examination:
a. At the end of her menstrual cycle.
b. On the same day each month.
c. On the 1st day of the menstrual cycle.
d. Immediately after her menstrual period.
3. The nurse is caring for a client following mastectomy. Which assessment finding
indicates that the client is experiencing a complication related to the surgery?
a. pain at the incisional site
b. arm edema on the operative side
c. sanguineous drainage in the Jackson-Pratt drain
d. complaints of decreased sensation near the operative side
4. Which of the following terms is used to describe removal of the breast tissue and
an axillary lymph node dissection leaving muscular structure intact as surgical
treatment of breast cancer?
a. Modified radical mastectomy
b. Segmental mastectomy
c. Total mastectomy
d. Radical mastectomy

5. The nurse is speaking to a group of women about early detection of breast

cancer. The average age of the women in the group is 47. Following the
American Cancer Society guidelines, the nurse should recommend that the
women:
a. Perform breast self-examination annually.
b. Have a mammogram annually.
c. Have a hormonal receptor assay annually.
d. Have a physician conduct a clinical examination every 2 years.
6. A 52 yr-old female tells the nurse that she has found a painless lump in her right
breast during her monthly self-examination. Which assessment finding would
strongly suggest that this client’s lump is cancerous?
a. eversion of the right nipple and a mobile mass
b. nonmobile mass with irregular edges
c. mobile mass that is oft and easily delineated
d. nonpalpable right axillary lymph nodes
7. A male client should be taught about testicular examinations:
 a. when sexual activity starts
b. after age 60
c. after age 40
d. before age 20
8. For a client newly diagnosed with radiation induced thrombocytopenia, the nurse
should include which intervention in the plan of care?
a. Administer aspirin if the temperature exceeds 38.8º C.
b. Inspect the skin for petechiae once every shift.
c. Provide for frequent periods of rest.
d. Place the client in strict isolation.
9. A 21 year-old male has been seen in the clinic for a thickening in his right
testicle. The physician ordered a human chorionic gonadotropin (HCG) level. The
nurse’s explanation to the client should include the fact that:
a. The test will evaluate prostatic function.
b. The test was ordered to identify the site of a possible infection.
c. The test was ordered because clients who have testicular cancer has
elevated levels of HCG.
d. The test was ordered to evaluate the testosterone level.
10. A client with a solar burn of the chest, back, face, and arms is seen in urgent
care. The nurse’s primary concern should be:
a. Fluid resuscitation
b. Infection
c. body image
d. pain management

 Lesson 1- Lung cancer

• The number 1 cancer killer in men and women

th th
• 6 to 7 decade of life
• 70% involvement of lymphnodes
• 85% caused by inhalation of carcinogenic chemicals

Pathophysiology
Arise from a single transformed epithelial cell in the tracheobronchial
airways.
a. Adenocarcinoma - most prevalent carcinoma of the lung for men and
women, peripherally located and often metastasized
b. Squamous cell Ca – centrally located and arises in the segmental and
subsegmental bronchi
c. Large cell Ca – fast growing tumor that arise peripherally
 d. Bronchioalveolar – slower growing and arises at the alveoli

Classification and staging

Non small cell Ca – 70-75%
a. Adenocarcinoma
- most common (40%)
- slowest growing, metastasize early
b. Squamous cell – 30%
c. Large cell – rarest
- has the worst prognosis
Small cell (25%)
a. Oat cell (90%)
- very aggressive and metastasize at diagnosis.
- 5 year survival rate is 48% if detected early and localize (rare)
- Overall 5 year survival rate is 15%

Risk factors
1. Tobacco smoking
- single most important preventable cause of death
- 10x more common than in non-smoker
- passive smoke exposure increases the risk to 35%
2. Environmental and occupational exposure
- arsenic, asbestos, mustard gas, oil, radiation
3. Genetics
4. Diet

Clinical manifestation
i. Develops insidiously and is assymptomatic until late in the course
ii. s/sx depends on the location and size of the tumor, degree of
obstruction and metastasis
iii. Cough or chronic cough
iv. dry, persistent without sputum production
v. Wheezing
vi. Hemoptysis or blood tinged sputum
vii. Chest and shoulder pain

Common sites of metastasis

• LN
• Bone
• Brain
• Contralateral lung
• Adrenal glands
 • liver

 Screening test: No screening program currently exist.

Assessment:
a. Clients are very rarely symptomatic at the time of diagnosis.
b. Persistent cough and dyspnea
c. Recurrent bronchitis and pneumonia
d. Blood streaked sputum
e. Chest pain

Diagnostics
 Chest xray (solitary peripheral nodule, coin lesion)
 Ct scan of the chest
 Fiberoptic bronchoscopy
 Fine needle biopsy under ct scan

Surgical Management
a. Dependent on whether the tumor is resectable
b. May be cure for non small cell if no metastasis occurred and lung function is
sufficient on removal of all or part of the lungs (50%)
c. Lobectomy – removal of lobe (common)
d. Pneumonectomy – removal of the lung
e. Segmentectomy – partial removal of the lung lobe

Adjuvant therapy
a. Chemotherapy is the primary treatment for small cell
b. Radiation is standard post op for advanced non-small cell
c. Radiation therapy – for localized intrathoracic lung ca and palliation for
hemprtysis, obstruction dysphagia and pain
d. Chemotherapy
e. Immunotherapy

Nursing Intervention
 Assess for signs of superior vena cava syndrome
 Postlobectomy, manage chest tube
 Assess respiration and for presence of pneumothorax or atelectasis
 Position properly post-op
1. Lobectomy – avoid prolonged lying on the operative site
2. Pneumonectomy – position on the back or operative side only
 Instruct the client on deep breathing, coughing and ambulation
 Pain management to promote deep breathing
  Refer client to smoking cessation

 Lesson 2- Breast cancer


 The most common cancer in FEMALES
 Numerous etiologies implicated

RISK FACTORS
1. Genetics- BRCA1 And BRCA 2
2. Increasing age ( > 50yo)
3. Family History of breast cancer
4. Early menarche and late menopause
5. Nulliparity
6. Late age at pregnancy
7. Obesity
8. Hormonal replacement
9. Alcohol
10. Exposure to radiation

PATHOPHYSIOLOGY

PROTECTIVE FACTORS
1. Exercise
2. Breast feeding
3. Pregnancy before 30 yo

ASSESSMENT FINDINGS
 1. MASS- the most common location is the upper outer quadrant
2. Mass is NON-tender. Fixed, hard with irregular borders
3. Skin dimpling
4. Nipple retraction
5. Peau d’ orange

LABORATORY FINDINGS
1. Biopsy procedures
2. Mammography
3. Tumor marker CA 2729

Breast cancer Staging

TNM staging
I - < 2cm
II - 2 to 5 cm, (+) LN
III - > 5 cm, (+) LN
IV- metastasis

Metastatic sites
 Bone
 Liver
 Lung
 Brain

Treatment
• Surgical management is the primary treatment for breast cancer
• Breast conservation (lumpectomy, segmental resection)
- removal of the cancer with margin of healthy tissue
- If followed by radiation therapy has equivalent 5 year survival to mastectomy

1. Simple mastectomy – removal of all breast, nipple and skin

2. Modified radical mastectomy – axillary lymphnodes are removed
3. Radical mastectomy – pectoral muscles are removed

Medical therapy
 External beam radiation therapy 3 weeks after surgery. Most commonly used
 Chemotherapy
 Tamoxifen therapy

NURSING INTERVENTION : PRE-OP

1. Explain breast cancer and treatment options
2. Reduce fear and anxiety and improve coping abilities
3. Promote decision making abilities
 4. Provide routine pre-op care:
Consent, NPO, Meds, Teaching about breathing exercise

NURSING INTERVENTION: Post-OP

1. Position patient:
 Supine
 Affected extremity elevated to reduce edema
2. Relieve pain and discomfort
 Moderate elevation of extremity
 IM/IV injection of pain meds
 Warm shower on 2nd day post-op
3. Maintain skin integrity
 Immediate post-op: snug dressing with drainage
 Maintain patency of drain (JP)
 Monitor for hematoma w/in 12H and apply bandage and ice, refer to
surgeon
 Drainage is removed when the discharge is less than 30 ml in 24 H
 Lotions, Creams are applied ONLY when the incision is healed in 4-6
weeks
4. Promote activity
• Support operative site when moving
• Hand, shoulder exercise done on 2ndday
• Post-op mastectomy exercise 20 mins TID
• NO BP or IV procedure on operative site
• Heavy lifting is avoided
• Elevate the arm at the level of the heart
• On a pillow for 45 minutes TID to relieve transient edema
5. MANAGE COMPLICATIONS
 Lymphedema (10-20% of patients)
 Elevate arms, elbow above shoulder and hand above elbow
 Hand exercise while elevated
 Refer to surgeon and physical therapist
 Hematoma
 Notify the surgeon
 Apply bandage wrap (Ace wrap) and ICE pack
6. TEACH FOLLOW-UP care
- Regular check-up
- Monthly BSE on the other breast
- Annual mammography

 Lesson 2- Prostate cancer

 - a slow growing malignancy of the prostate gland
- Usually an adenocarcinoma
- This usualy spread via blood stream to the vertebrae
- 2nd most common cause of cancer deaths
- 190000 new cases each year and 30,000 deaths annually
- Over 80% are diagnosed in early stages. Allowing an almost 100% 5 year
survival rate.
- Overall for all stages survival is 96%

Predisposing factor
• Age
• Strong family history
• High fat diet may play a role
• Having a vasectomy may play a role

Assessment Findings
1. Digital Rectal Examination: hard, pea-sized nodules on the anterior rectum
2. Hematuria
3. Urinary obstruction
4. Pain on the perineum radiating to the leg

Diagnostic tests
a. DRE
b. Prostatic specific antigen (PSA)
c. Elevated SERUM ACID PHOSPHATASE indicates SPREAD or Metastasis

Surgical Management
• Radical prostatectomy – removal of prostate, capsule, ejaculatory ducts, seminal
vesicles plus lymphnodes
• Watchful waiting without intervention may be appropriate in men over 70 years of
age with small, early stage cancers

Medical and surgical management

1. Prostatectomy
2. TURP
3. Chemotherapy: hormonal therapy to slow the rate of tumor growth
4. Radiation therapy

Nursing Interventions
 1. Prepare patient for chemotherapy
2. Prepare for surgery
Post-prostatectomy
3. Maintain continuous bladder irrigation. Note that drainage is pink tinged w/in 24
hours
4. Monitor urine for the presence of blood clots and hemorrhage
5. Ambulate the patient as soon as urine begins to clear in color
6. Provide for bladder retraining after foley catheter removal
a. Perineal exercises
b. restrict caffeine
c. limit fluid intake at night
7. Education
a. Avoid lifting, straining, and prolonged travel
b. possible impotence

Lesson 3- Ovarian, cervical, uterine cancer

Ovarian Cancer
- Second most common gynecologic cancer after uterine
- Most common cause of gynecologic cancer death
- Industrial countries have higher incidence
- 5 year survival is 30-35%
- 60-70% are diagnosed at stage III

Risk Factors
 Women mid 50-70 (peak 55-59)
 Higher education and socioeconomic status
 History of breast and endometrial cancer
 No pregnancy, infertility, Non use of OCP
 Mutation of BRCA 1 or 2
 Hereditary non polyposis cancer

Assessment
- No early clinical examination
- Abdominal discomfort or enlargement
- Indigestion and flatulence that persist without explanation

Diagnostics
- Pelvic examination
 - Ultrasound and Ct scan
- CA 125
- Barrium enema, cystoscopy IVP

Surgical management
- Peritoneal washing to find cancer cells in fluid
- TAHBSO – primary treatment
- Chemotherapy
- Radiation therapy

Cervical Cancer
- 13,000 new cancers and 4000 deaths
- Very treatable and curable
- 80-90% are squamous carcinoma

Risk factors
- Sexual intercourse before age 17, multiple partners
- Sexual partner who has multiple partners
- Cigarette smoking
- Human papilloma virus
- Lower socioeconomic status

Metastatic sites
- Abdomen and pelvis
- Lung
- Liver
- Bone

Screening
- Pap’s smear beginning at age 18 or sexually active
- should be done annually for 2 consecutive years and at least every 3 years until
age 65 for those with normal findings
- for persons at high risk, it should be done yearly. This include those who are:
sexually active, have multiple partners, commercial sex workers

ASSESSMENT
- Assymptomatic in the early stage
- Watery vaginal discharge
- Late manifestation, postcoital, heavy or intermenstrual bleeding.

DIAGNOSTICS
- Colposcopy – application of acetic acid followed by magnified examination of the
pelvis
 - Biopsy
- Endocervical curettage
- Cone biopsy

Management
- Total abdominal hysterectomy and lymphadenectomy
- Depends on the stage and desire for child bearing
- Radiation therapy
- Chemotherapy for advanced disease
- Laser therapy
- used when all boundaries of the lesion are visible during colposcopic
examination.
- minimal bleeding is associated with the procedure.
- slight vaginal discharge is expected following the procedure and healing occurs
in 6 to 12 weeks.

Conization
- A cone shaped area of the cervix is removed
- Performed in women who desire further childbearing.
- Long term follow up care is needed, as new lesions can develop
- The risk of procedure includes hemorrhage, uterine perforation, incompetent
cervix and preterm labor in future pregnancies.

Hysterectomy
- is the surgical removal of the uterus.
- may be total (removing the body, fundus, and cervix of the uterus; often called
"complete") or partial (removal of the uterine body while leaving the cervix intact;
also called "supracervical")
- radical hysterectomy, a surgeon removes the whole uterus, tissue on the sides of
the uterus, the cervix, and the top part of the vagina. Radical hysterectomy is
generally only done when cancer is present.
- For microinvasive cancer if childbearing is not desired.
- A vaginal approach is most commonly performed.
- A radical hysterectomy and bilateral lymphnode dissection may be performed for
cancer that has spread beyond the cervix but not to the pelvic wall.

Nursing intervention
- Assess for changes in bowel and bladder pattern
- Bladder training
- If laser surgery for early diseases is used, instruct to avoid douching, tampoons
and sexual activity for 2-4 weeks
- Assess for sexual dysfunction, surgical shortening of vagina, vaginal dryness
Endometrial Cancer
- Highest incidence for caucasians
- 90% are adenocarcinoma
- 5 year survival is 96% for early stage and 26% for late

Risk factors
- Female over 50
- High cumulative exposure to endogenous and exogenous estrogen
- Nulliparity
- Family hx of breast or ovarian cancer
- Infertility
- Diabetes
- Hypertention
- Obesity

Assessment
- Abnormal vaginal bleeding
- Pain in later stage

Diagnostics
a. Pelvic examination
b. Pap smear
c. Endometrial biopsy 90% effective
d. D and C

Management
- Used for staging
- TAHBSO and peritoneal washing, omentectomy
- Adjuvant therapy is not required in early stage
- Intravaginal radiation for early stage low grade tumors
- Pelvic external beam for high grade
- Hormonal therapy (progestins) and chemotherapy for advanced disease

Nursing intervention
- Encourage and instruct the importance of regular pelvic examination
- Pain management
- Prevention of postsurgical venous stasis
1. encourage turning and ambulation
2. antiembolic stockings
- Instruct signs of recurrence like vaginal bleeding, pelvic pain and constipation
  Lesson 4- Leukemia

- Malignancy that involves the blood forming tissues on the bone marrow, spleen,
lymphnodes

• Acute lymphoblastic leukemia (ALL) – abnormal proliferation of immature

lymphoblast
- a fast-growing cancer of the white blood cells.

• Acute myeloid leukemia (AML) - proliferation of immature myeloblast

- Predisposing factors, down syndrome, chemotherapy (alkylating agents)
- Peak age 2-5 years old

Assessment
a. Symptomatic anemia
- pallor, fatigue
b. Thrombocytopenia
- petechiae, bleeding
c. Neutropenia
- fever, infection
d. Enlarged LN
e. Hepatosplenomegally
f. Bone pain
g. Neurological symptoms
- increase ICP

Tumor evaluation
 Bone marrow aspiration and biopsy
1. greater than 25% blast indicate leukemia
2. Chest xray to check for mediastinal mass

Management of ALL
Sanctuary chemotherapy
- CNS prophylaxis
- Inthratecal methotrexate
Systemic chemotherapy (2 phases)
- 3 drug: Vincristine, Prednisone, L-asparginase
- 4 drug: + daunorubicin
  Lesson 5 - Colon cancer

- Adenocarcinoma is the most common type

- Metastasis is common to the liver
- 2nd most common site for cancer in men and women
- Ages >50-60
- May be caused by diverticulitis, chronic ulcerative colitis, familial polyposis

Cancer sites
- Sigmoid colon – 33%
- Rectum – 27%
- Ascending Colon – 22%
- Transverse colon – 11%
- Descending colon 6%

Metastatic sites
1. Liver the most common site
2. Peritoneal surface
3. Spread via lymphatics to lung, bone and brain

Risk factors
1. Increasing age
2. Family history
3. Previous colon CA or polyps
4. History of IBD
5. High fat, High protein, LOW fiber
6. Breast Ca and Genital Ca
ASSESSMENT FINDINGS
1. Change in bowel habits- Most common
2. Blood in the stool
 3. Anemia
4. Anorexia and weight loss
5. Fatigue
6. Rectal lesions- tenesmus, alternating D and C
Right sided lesions
- dull abdominal pain, melena
Left sided lesions
- signs of obstruction and bright red stool
Rectal lesion
- tenesmus, rectal pain. Incomplete BM., bloody stool, constipation

Diagnostic findings
1. Fecal occult blood
2. Sigmoidoscopy and colonoscopy
3. BIOPSY
4. CEA- carcino-embryonic antigen

Complications of colorectal CA
1. Obstruction
2. Hemorrhage
3. Peritonitis
4. Sepsis

SURGICAL MANAGEMENT
- Surgery is the primary treatment
- Based on location and tumor size
- Resection, anastomosis, and colostomy (temporary or permanent

Right hemicolectomy
- primary surgery for cancer of the ascending colon
- removal of the terminal ileum, cecum, right transverse colon

Left hemicolectomy
- primary surgery for cancer of descending and sigmoid colon
- removal of the distal transverse, descending and sigmoid colon

Colostomy
- Is a surgical creation of an opening into the colon
a. Single barrel – proximal colon is brought to the surface forming one stoma’
b. Double barrel – two stomas, proximal excretes stool, distal secretes mucus
c. Stool formation depends on
1. Ascending – loose, liquid
2. Transverse – semisolid
 3. descending – soft, formed stool

NURSING INTERVENTION
Pre-Operative care
1. Provide HIGH protein, HIGH calorie and LOW residue diet
2.Provide information about post-op care and stoma care
3. Administer antibiotics 3-5 day prior
4. Enema or colonic irrigation the evening and the morning of surgery
5. NGT is inserted to prevent distention
6. Monitor UO, F and E, Abdomen PE
Post-Operative care
1. Monitor for complications
a. Leakage from the site
b. prolapse of stoma
c. Infection
d. Bowel obstruction
2. Assess the abdomen for return of peristalsis

 Lesson 6 - Gastric cancer

- Approximately 22000 cancers and 13,000 deaths per year

- African americans, japanese, chinese and US have higher incidence
- 95% are adenocarcinomas
- Prognosis is poor, 5 year survival rate is 5-15 %

Risk factors
 Male > 40 years of age
 Low socioeconomic status
 Poor nutritional health habits and vitamin A deficiency
 Family history
 Previous gastric resection
 Pernicious anemia
 H. pylori infection
 Gastric atrophy and chronic gastritis
 Rubber workers and coal miners

Metastatic sites
- Direct extension to the pancreas, liver, esophagus.
- Intraperitoneal dissemination to ovary
 - Nodal spread to the neck
- Bloodstream metastasis to the lung, adrenal, liver, bone and peritoneal cavity

Screening
- Among high risk person’s only
- Barrium x-ray or endoscopy

Assessment
- Early manifestations are non-specific
- Upper epigastrium, retrosternal pain
- Uneasy sense of fullness after meals
- Loss of appetite
- Nausea and vomiting
- Weakness
- Fatigue
- anemia

Diagnostic procedure
- EGD
- Biopsy
- Endoscopic ultrasound
- Double contrast upper GI series
- CT scan

Surgical management
- Only treatment that is potentially curative
- Total gastrectomy
- Radical subtotal gastrectomy
a. Billroth I
b. Billroth II
- Proximal subtotal gastrectomy
- Paliation of symptoms

Adjuvant therapy
 External beam radiation for control of unresectable tumors, palliation and
increased survival.
 Chemotherapy has little impact – 5 FU, doxorubicin, mitomycin

Nursing Intervention
 Goal is control of clinical manifestation and supporting optimal functioning
 Assess the nutritional status
- small frequent feeding low carbohydrate, high fat, high protein.
- restrict fluids 30 minutes after meals reducing risk of dumping syndrome
Postoperative
 Respiratory status: reflux aspiration
 Infection
 Pain – potential anastomotic leak obstruction
 Bezoar (food clumping) formation causing gastric outlet obstruction
 Bleeding
 Dumping syndrome
 anemia

Module 8 - Evidence- Based Practice for the care

of clients with problems/alterations in Cellular
Aberrations.

Nursing Care of Clients

with Cellular Aberration

ASSESSMENT
Environmental Risk Factors
Sun exposure

Most skin cancers are caused by exposure to the sun. This may be long term exposure,
or short periods of intense sun exposure and burning.
The ultraviolet light in sunlight damages the DNA in the skin cells. This damage can
happen years before a cancer develops. The sun’s rays contain 3 types of ultraviolet
light
Being exposed to chemicals and other substances in the environment has been linked
to some cancers:
• Links between air pollution and cancer risk have been found. These include links
between lung cancer and secondhand tobacco smoke, outdoor air pollution, and
asbestos.
• Drinking water that contains a large amount of arsenic has been linked to skin,
bladder, and lung cancers.
Studies have been done to see if pesticides and other pollutants increase the risk of
cancer. The results of those studies have been unclear because other factors can
change the results of the studies.
Cigarette Smoking & Tobacco use
Subjective:
Risk Factors
Tobacco use is strongly linked to an increased risk for many kinds of cancer. Smoking
cigarettes is the leading cause of the following types of cancer:
• Acute myelogenous leukemia (AML).
• Bladder cancer.
• Esophageal cancer.
• Kidney cancer.
• Lung cancer.
• Oral cavity cancer.
• Pancreatic cancer.
• Stomach cancer.
Not smoking or quitting smoking lowers the risk of getting cancer and dying from
cancer. Scientists believe that cigarette smoking causes about 30% of all cancer deaths
in the United States.
Obesity
Recreational Drugs
Obesity is associated with increased risks of the following cancer types, and possibly
others as well:
• Esophagus
• Pancreas
• Colon and rectum
• Breast (after menopause)
• Endometrium (lining of the uterus)
• Kidney
• Thyroid
• Gallbladder
A new study from the University of Southern California (USC) has found a link between
recreational marijuana use and an increased risk of developing subtypes of testicular
cancer that tend to carry a somewhat worse prognosis.
 Hereditary
 Age
 Gender
 Poverty
 Stress
 Diet
 Infections
 Cigarette Smoking and Tobacco Use
 Recreational drugs
 Obesity
 Environmental Risk Factors
 Sun exposure
Subjective:
Health History
Hereditary
Poverty is associated with a huge array of human ills, not the least of which is seriously
undermining the impoverished populations’ health. Due to their limited financial
resources, the poor are recurrently subjected to environmental risks due to unavailability
of suitable housing, are less well nourished, have less knowledge and are less able to
access health care and appropriate insurance.
Stress
Although stress can cause a number of physical health problems, the evidence that it
can cause cancer is weak. Some studies have indicated a link between various
psychological factors and an increased risk of developing cancer, but others have not.
Apparent links between psychological stress and cancer could arise in several ways.
For example, people under stress may develop certain behaviors, such as smoking,
overeating, or drinking alcohol, which increase a person’s risk for cancer. Or someone
who has a relative with cancer may have a higher risk for cancer because of a shared
inherited risk factor, not because of the stress induced by the family member’s
diagnosis.
Espinosa, Madellaine
San Pedro, Eilene
San Pedro, Patrica Mikaela
Tira, Chara Faith
Expected Outcomes
Age
Cancer can take decades to develop. That’s why most people diagnosed with cancer
are 65 or older. While it’s more common in older adults, cancer is not exclusively an
adult disease. Cancer can be diagnosed at any age.
Only a small portion of cancers are due to an inherited condition. If cancer is common in
your family, it’s possible that mutations are being passed from one generation to the
next. You might be a candidate for genetic testing to see whether you have inherited
mutation that might increase your risk of certain cancers. Keep in mind that having an
inherited genetic mutation doesn’t necessarily mean you’ll get cancer.
Poverty
Diet
Gender
Females have a generally lower risk of cancer incidence.
PLANNING
Planning for Health Promotion and Maintenance
Planning for Health Restoration
Primary Prevention - is concerned with reducing the risks of cancer in healthy people
Secondary Prevention - involves detection and screening to achieve early diagnosis
1. Cancer Prevention and Control
1. Surgery
a. Diagnostic
b. Primary Treatment
c. Prophylactic
d. Palliative
c. Reconstructive
2. Prevention, Screening, and Early
Detection
Prophylactic
Diagnostic
Primary Treatment
Involves removing nonvital tissues or organs that are likely to develop cancer.
BIOPSY performed to obtain a tissue sample for analysis of cells suspected to be
malignant
When SURGERY is the primary approach in treating cancer, the goal is to remove the
entire tumor or as much as is feasible and any involved surrounding tissue, including
regional lymph nodes
Factors to consider:
 Family history and genetic predisposition
 Presence or absence of symptoms
 Potential risk or benefits
 Ability to detect cancer at and early stage
 Patient's acceptance of the postoperative outcome
Reconstructive
May follow curative or radical surgery and is carried out in an attempt to improve
function or obtain a more desirable cosmetic effect
May be indicated for: breast, head and neck and skin cancers
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.
Palliative surgery is done in an attempt to relieve complications of cancer such as:
ulcerations, obstructions, hemorrhage, pain, and malignant effusions
Nursing Responsibilities
Before:
 The nurse provided education and emotional support by assessing patient and
family needs and exploring with the patient and family their fears and coping
mechanisms
 It is important that the nurse communicates with the physician and other health
team members to be certain that the information provided to the relatives is
consistent
After:
 Asses patient's responses to surgery and monitors for possible complications
 Provide patient comfort
  Postoperative teaching addresses wound care, activity, nutrition, and medication
info
 Plans for discharge, follow-up, and home care are initiated as early as possible
2. Radiation Therapy
- ionizing radiation is used to interrupt cellular growth
1. External Radiation - one of several delivery methods may be chosen, depending on
the depth of the tumor (Kilovolatge, Linear accelerators, Gamma rays)
2. Internal Radiation - or brachytherapy, delivers a high dose of radiation to a localized
area. Implanted via needles, seeds, beads, or catheters into body cavities or interstitial
compartments
- ionizing radiation breaks the strands of DNA helix = cell death
Nursing Responsibilities
 Protecting the skin and oral mucosa
 Protecting the caregivers
3. Chemotherapy
- antieneoplastic agents are used in an attempt to destroy tumor ells by interfering with
cellular functions and reproduction.
- used primarily to treat systemic disease rather then lesions that are localized and
amenable to surgery or radiation
- GOAL must be realistic because they will define the medications to be used and the
aggressiveness of the treatment plan
Nursing Responsibilities
 Assessing fluid electrolyte status
 Modifying risks for infection and bleeding
 Administering chemotherapy
 Implementing safeguards
NURSING DIAGNOSIS
Risk for trauma as evidenced by high-risk personal behaviors
High Risk Personal Behaviors
Ineffective Protection as evidenced by impaired immunity related to cancer therapy or
HIV disease
Cancer Therapy
HIV
 Altered health maintenance reflects a change in an individual's ability to perform
the functions necessary to maintain health or wellness.
 Patient describes positive health maintenance behaviors such as keeping
scheduled appointments, participating in smoking and substance abuse
programs, making diet and exercise changes, improving home environment, and
following treatment regimen.
 Patient identifies available resources.
 Patient uses available resources.
Infections
Ineffective Heath Management as evidenced by lack of preventive care or health
screening
Risk Factors:
 Assess for physical defining characteristics
 Assess patient's knowledge of health maintenance behaviors
 Assess health history over past 5 years
 Assess to what degree environmental, social, intrafamilial disruptions or changes
have correlated with poor health behaviors
 Determine patient's specific questions related to health maintenance
 Presence of adverse personal habits
 Evidence of impaired perception
 Low income
 Lack of knowledge
 Poor housing conditions
 Risk-taking behaviors
 Inability to communicate needs adequately (e.g., deafness, speech impediment)
 Dramatic change in health status
 Lack of support systems
 Denial of need to change current habits
Physical Characteristics
 Determine patient's motives for failing to report symptoms reflecting changes in
health status
 Discuss noncompliance with instructions or programs with patient to determine
rationale for failure
 Assess the patient's educational preparation and ability to integrate and relate to
information.
 Assess history of other adverse personal habits, including the following: smoking,
obesity, lack of exercise, and alcohol or substance
 abuse
 Determine whether the patient's manual dexterity or lack of mobility is a factor in
patient's altered capacity for health maintenance
• Demonstrated lack of knowledge
• Failure to keep appointments
• Expressed interest in improving behaviors
• Failure to recognize or respond to important symptoms reflective of changing health
state
• Inability to follow instructions or programs for health maintenance
Certain viruses and bacteria are able to cause cancer. Viruses and other infection
-causing agents cause more cases of cancer in the developing world (about 1 in 4
cases of cancer) than in developed nations (less than 1 in 10 cases of cancer).
Examples of cancer-causing viruses and bacteria include:
• Human papillomavirus (HPV) increases the risk for cancers of the cervix, penis,
vagina, anus, andoropharynx.
• Hepatitis B and hepatitis C viruses increase the risk for liver cancer.
• Epstein-Barr virus increases the risk for Burkitt lymphoma.
• Helicobacter pylori increases the risk for gastric cancer.
The foods that you eat on a regular basis make up your diet. Diet is being studied as a
risk factor for cancer. It is hard to study the effects of diet on cancer because a person’s
diet includes foods that may protect against cancer and foods that may increase the risk
of cancer.
It is also hard for people who take part in the studies to keep track of what they eat over
a long period of time. This may explain why studies have different results about how diet
affects the risk of cancer.
Palliative
 TOBACCO USE
 OBESITY: PHYSICAL ACTIVITY AND DIET
 SEXUAL PATTERNS
 DISEASE SCREENING PRACTICES
Behavioral Characteristics
• Body or mouth odor
• Unusual skin color, pallor
• Poor hygiene
• Soiled clothing
• Frequent infections (e.g., URI, UTI)
• Frequent toothaches
• Obesity or anorexia
• Anemia
• Chronic fatigue
• Apathetic attitude
• Substance abuse
 Determine to what degree patient's cultural beliefs and personality contribute to
altered health habits
 Access ramps, motor vehicle modifications, shower bar or chair, and others) are
available to patient.
 Assess whether economic problems present a barrier to maintaining health
behaviors
 Assess hearing, and orientation to time, place, and person to determine the
patient's perceptual abilities
 Make a home visit to determine safety, accessibility, and quality of living
conditions
 Assess patient's experience of stress and disruptors as they relate to health
habits.
Risk for Infection as Evidenced by tissue trauma or impaired immune response
Transmission of Infection
 Infections can be transmitted, either by contact or through airborne transmission,
sexual contact, or sharing of intravenous (IV) drug paraphernalia.
 Being malnourished, having inadequate resources for sanitary living conditions,
and lacking knowledge about disease transmission place individuals at risk for
infection.
 Natural defense mechanisms are inadequate to protect them from the inevitable
injuries and exposures that occur throughout the course of living.
 Infections occur when an organism (bacterium, virus, fungus, or other parasite)
invades a susceptible host.
 If the host's (patient's) immune system cannot combat the invading organism
adequately, an infection occurs.
 Open wounds, traumatic or surgical, can be sites for infection; soft tissues (cells,
fat, muscle) and organs (kidneys, lungs) can also be sites for infection either after
trauma, invasive procedures, or by invasion of pathogens carried through the
bloodstream or lymphatic system.
 Inadequate primary defenses: broken skin, injured tissue, body fluid stasis
 Inadequate secondary defenses: immunosuppression, leukopenia
 Malnutrition
 Intubation
 Indwelling catheters, drains
 Intravenous (IV) devices
 Invasive procedures
 Rupture of amniotic membranes
 Chronic disease
 Failure to avoid pathogens (exposure)
 Inadequate acquired immunity
Assess for presence, existence of, and history of risk factors such as:
Monitor white blood count (WBC).
Assess nutritional status, including weight, history of weight loss, and serum albumin.
Assess for history of drug use or treatment modalities that may cause
immunosuppression
Monitor for the following signs of infection:
• Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, exit
sites of tubes, drains, or catheters.
• Elevated temperature.
• Appearance of urine.
• Color of respiratory secretions.

References
Tira C. (2014, August 4). Nursing care of clients with cellular aberration. Retrieve from
https://prezi.com/zkp_yg7ij9wh/nursing-care-of-clients-with-cellular-aberration/

Module 9 - Relevant Legal, moral And ethical

Standard of care

Ethical Concerns in End-of-Life Care

 In the sick room, ten cents’ worth of human understanding equals ten dollars’
worth of medical science.
-Martin H. Fischer
LEARNING OBJECTIVES
 Define ethics and the role of ethics in medical decision making.
 Identify basic ethical principles and concepts.
 Examine difficult decisions in end-of-life care.

Ethics In Medical Decision Making

 Ethics is a branch of philosophy that is focused on understanding the moral
principles of people and how they make decisions based on what is considered
morally right or wrong (Merriam-Webster, 2014).
 There are often ethical issues that can arise in the context of end-of-life care,
particularly when patients and families make decisions regarding the care they
will accept or not accept.
 As nurses, sometimes our morals and values are in conflict with those that our
patients have, and this can cause some distress for the nurse.
 Patients’ goals of care are what patients place highest value on and would hope
to achieve in regard to their illness. These goals are based on the patient’s moral
principles and values. These are the goals the patient wishes for in terms of their
illness. Often as patients near the end of life, many difficult decisions will have to
be made.
 Example>
o The recent national news story about 13-year old Jahi McMath (Fox News,
2013). In this case, the family wanted to continue to keep their young
daughter on life support which conflicted with what the health care facility
wanted. After several evaluations, the child was determined to be
medically brain dead, and therefore continuation of medical treatments
was considered to be futile.
Basic Ethical Principles And Concepts
 Autonomy, beneficence, nonmaleficence, and justice are four of the basic ethical
principles used to guide nurses and clinicians in the care and decision making of
patients.

Respect for autonomy

- This principle is described as an agreement to respect another’s right to self-
determine a course of action and to support another’s independent decision
making.
- Sometimes it can be difficult to see a patient make a decision about their health
that the nurse does not personally agree with or that the nurse does not feel is
the best decision for that patient’s individual circumstances.
- As nurses, we must support and advocate for our patients’ rights, including their
right to make decisions.
- For example, a nurse has been caring for an elderly gentleman for several
months as he has been receiving treatment for cancer. This patient has decided
to stop his cancer treatments and focus on spending time enjoying his family for
the time he has left. While the nurse has grown fond of this patient and would not
want him to die, they must respect the patient’s wishes and choices for his own
medical care.

Beneficence
- Beneficence is the principle of “doing good” and has been suggested as having
four distinct parts. These include:
 Not to inflict evil or harm.
 To prevent evil or harm.
 To remove evil or harm.
 To do good or promote good.

- Sometimes it might be difficult to differentiate between doing good and doing no

harm, which is nonmaleficence, because it is often easier to determine what is
clearly bad or harmful more than what might be good or a benefit. Kennedy
Swartz recommended that there is a greater obligation to not cause harm than
there is to do something that might benefit the patient. Nurses should keep that in
mind when assisting patients with difficult decisions.

Nonmaleficence
- Nonmaleficence is the principle of refraining from causing unnecessary harm.
- If the act is for a greater good for the patient and is not meant to deliberately
harm them, it is justifiable.
- An example of this is the all too common clinical situation that occurs in end-of-
life care. A patient whose death is imminent is in pain and requires pain
medication to maintain comfort. The patient is very close to death with irregular
respirations around 8 breaths per minute. The nurse needs to administer the pain
 medication but fears that giving it may hasten (or accelerate) death. According
the Code of Ethics for Nurses (ANA, 2015), the nurse may “not act deliberately to
terminate life”; however, the nurse has a moral obligation to provide interventions
“to relieve symptoms in dying patients even if the intervention might hasten
death.”

Justice
- Justice is the principle that governs social fairness.
- It involves determining whether someone should receive or is entitled to receive
a resource.
- The Code of Ethics for Nurses (ANA, 2015) states that nurses’ commitment is to
patients regardless of their “social or economic status.”.
- As with the young Jahi McMath, who was determined to have brain death,
continuing to keep her alive on life support would be futile, as there is little or no
hope for recovery. So this decision was considered just, as discontinuation of life
support was not based on her age, ethnicity or socio-economic status. It was
based on her medical diagnosis.
-
 Informed consent respects a patient’s autonomy and enables him/her to make
an informed decision based on factual and accurate information.
o If a patient is not informed that declining to have a needed surgery would
result in his death, then they cannot make an informed decision. If once
this information is disclosed and the patient decides not to elect the
surgery, it is an informed choice based on the facts.
 Capacity refers to the ability of a patient to understand information and to make
choices or consent to care.
o So using the same example about whether or not to have a life-saving
surgery, if the patient was cognitively impaired because he had
Alzheimer’s disease, he would not have the decisional capacity to make
an informed choice. If he was cognitively intact and decided not to elect
surgery, then that would be his right.

Difficult Decisions In End-Of-Life Care

- Regardless of the intervention or treatment, the nurse should focus on helping
the patient weigh the benefits and burdens of the intervention, rather than focus
on the intervention itself (Kennedy Swartz, 2001).

Withholding/withdrawing of medical interventions

 One of the dilemmas that can occur relates to the cessation of medical
interventions in patients. Sometimes these interventions range from minor, such
as a non-life sustaining medication, to more complex, such as mechanical
ventilation.
 The rationale for stopping these interventions is often based on the fact that the
burdens are outweighing any benefits the patient may get from it.
 Advance directives are documents that enable patients to make their
decisions about medical care known to their family and health care
 providers, in the event that they are unable to make those decisions
themselves (National Cancer Institute, 2013).
 If a family member knows for sure that their loved one would not have wanted a
particular medical intervention done, it may help to alleviate some of the burden
they may feel about making the decision.
 It also helps prevent the initiation of some life sustaining treatments beforehand,
in which case no decision will be need to be made to withdraw that intervention.
 It also can help reduce overall costs of futile medical care (Coyne, Smith, &
Lyckholm, 2010).

Do not attempt resuscitation (DNAR)

 In 2005, the American Heart Association has changed from the more recognized
acronym for do not resuscitate (DNR) to DNAR (Breault, 2011)
 If a patient has an order for a DNR or DNAR, it means that the patient has
elected for cardiopulmonary resuscitation (CPR) to not be initiated or
administered in the event of a cardiac arrest. CPR could include the use of chest
compressions, cardiac drugs, and the placement of a breathing tube.
 . A “do not intubate” (DNI) order often accompanies a DNR order, which states
that the patient elects not to be intubated with a breathing tube if they go into
cardiac arrest. Chest compressions and the use of cardiac medications could still
be used.

Allow natural death (AND)

 Allow natural death is a more recent terminology some health care institutions
have adopted to use instead of the traditional DNR orders. Whereas a DNR order
states that no attempts should be made to start CPR in a patient,
 An AND order states that only comfort measures are taken to manage symptoms
related to comfort.
 An AND order simply allows the patient to remain comfortable while not
interfering with the natural dying process.

Medical order for life sustaining treatment (MOLST)

- Sometimes also referred to as physician order to life-sustaining treatment
(POLST),
- these newer forms of advance directives were developed in order to improve the
communication of a patient’s wishes about life-sustaining treatments among
healthcare providers and settings.

Hastening death (Principle of double effect)

- The principle of “double effect” refers to some decisions that clinicians have that
will produce both desirable and undesirable effects.
- The example for non-maleficence, in which the nurse administers a pain
medication in order to alleviate a patient’s pain and suffering but this same
intervention may also contribute to a hastened death, is also an example of
“double effect.”
 o The medication will reduce the pain but also further reduce the patient’s
respiratory rate to a level that is inconsistent with life. In the case of double
effect, the nurse or clinician should always consider what the intended
effect of the intervention is. Is the pain medication being administered to
reduce pain and suffering, or is it being given to further reduce the
patient’s respirations?

Terminal/palliative sedation
- Terminal sedation (more recently called “palliative sedation”) is an intervention
used in patients at the end of life, usually as a last effort to relieve suffering.
- It involves sedating the patient to a point in which refractory symptoms are
controlled.
- The goal is to control symptoms, and the patient is sedated to varying degrees of
consciousness to achieve this.
- The intent is not to cause or hasten death, but rather to relieve suffering that has
not responded to any other means. Often the patient is sedated to a point at
which they are unconscious.

Four criteria required for a patient to be considered for palliative sedation.

1. Patient has a terminal illness

2. Severe symptoms present are not responsive to treatment and intolerable to patient

3. A “do not resuscitate” order is in effect

4. Death is imminent (hours to days)

 
 The fourth criteria is the most difficult to determine; however, one study
found that the mean time between initiation of terminal sedation and death
ranged from 1.9 to 3.2 days.
 Terminal sedation has been compared with slow euthanasia and assisted
dying; however, they are not the same thing.
 The key difference is based on the intent or purpose of the intervention.
 The intent is not to hasten death but to relieve suffering that cannot be
relieved by any other available method.
 In assisted dying or physician assisted euthanasia, the intent is to produce
death in order to relieve suffering.

Assisted dying
- Assisted dying is defined as “an action in which an individual’s death is
intentionally hastened by the administration of a drug or other lethal substance”.
- Under this general definition, there are two distinct subcategories that include
assisted suicide and active euthanasia.
- In assisted suicide, the patient is provided with the means to carry out suicide,
such as providing a lethal dose of a medication.
 - In active euthanasia, someone other than the patient is the one who carries out
the action that ends the patient’s life.
- The vast majority of ethical codes from the main nurses’ organizations prohibit
the involvement of a nurse in the assisted dying of patients.

WHAT YOU SHOULD KNOW

 Nurses caring for patients at the end of life have a moral and professional
obligation to follow the guidelines depicted in their professional and ethical
standards.
 The absence of an advance directive can make end of life decision-making
difficult for families of dying patients who are no longer able to speak for
themselves.
 Nurses need to advocate to ensure that their patients’ goals of care are met while
following ethical principles.

References

American Nurses Association. (2010). Scope and Standards of Professional Nursing

Practice (2nd Ed.). Silver Spring Maryland: American Nurses Association.

American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive

Statements. Retrieved from http://www.nursingworld.org/MainMenuCategories/-
EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.aspx

Berry, P. & Griffie, J. (2010). Planning for the actual death. In B. R. Ferrell & N.
Coyle (Eds.), Oxford Textbook of Palliative Nursing (pp. 629-644). New York: Oxford
University Press.

Breault, J. L. (2011). DNR, DNAR, or AND? Is language

important? The Ochsner Journal, 11, 302-306.
Coyne, P. J., Smith, T. J., & Lyckholm, L. J. (2010). In B. R. Ferrell & N.
Coyle (Eds.), Oxford Textbook of Palliative Nursing (pp. 487-499). New York: Oxford
University Press.

End of Life Nursing Education Consortium (2010). ELNEC – core curriculum training

program. City of Hope and American Association of Colleges of Nursing. Retrieved
from http://www.aacn.nche.edu/ELNEC

Ethics [Def. 1]. (n.d.). Merriam-Webster Online. In Merriam-Webster.

Retrieved from http://www.merriam-webster.com/dictionary/citation
Fainsinger, R. L., Waller, A., Bercovoci, M, Bengtson, K, Landman, W, Hosking, M.,
DeMossaic, D. (2000). A multicentre international study of sedation for uncontrolled
symptoms in terminally ill patients. Palliative Medicine, 14(4), 267-275.

Fox News. (2013). Jahi McMath’s case: Hospital won’t aid teen’s transfer. Retrieved
from http://www.foxnews.com/health/2013/12/31/family-california-teen-declared-
brain-dead-says-ny-facility-is-last-last-hope/

Hospice and Palliative Nurses Association. (2003). Position statement: Palliative

sedation at the end of life. Retrieved from http://www.hpna.org/pdf/-
positionstatement_palliativesedation.pdf

Kennedy Schwartz, J. (2001). Ethical aspects of palliative care. In M. LaPorte-Matzo &

D. Witt Sherman (Eds.), Palliative Care Nursing: Quality Care to the End of Life (pp.
140-179). New York: Springer.
Knight, P. & Espinosa, L. A. (2010). Sedation for refractory symptoms and terminal
weaning. In B. R. Ferrell & N. Coyle (Eds.), Oxford Textbook of Palliative Nursing (pp.
525-543). New York: Oxford University Press.

National Cancer Institute. (2013). Facts sheets: Advance directives. Retrieved

from http://www.cancer.gov/cancertopics/factsheet/Support/advance-directives

Polst Organization. (2014). About the national Polst program. Retrieved

from http://www.polst.org/
Volker, D. L. (2010). Palliative care and requests for assistance in dying. In B. R. Ferrell
& N. Coyle (Eds.), Oxford Textbook of Palliative Nursing (pp. 1185-1192). New York:
Oxford University Press.

Flexible Teaching Learning Modality (FTLM)

Edmodo, google classroom, module, case study, exercises, problem sets

Assessment Task

C H C H E C K Y O U R U N D E R S TA N D I N G

Multiple Choice: choose the letter of the correct answer

1. A client has an abnormal result on a Papanicolaou test. After admitting
that she read her chart while the nurse was out of the room, the client
asks what dysplasia means. Which definition should the nurse provide?
a. Presence of completely undifferentiated tumor cells
that don't resemble cells of the tissues of their origin.
b. Increase in the number of normal cells in a normal
arrangement in a tissue or an organ.
c. Replacement of one type of fully differentiated cell by
another in tissues where the second type normally isn't
found.
d. Alteration in the size, shape, and organization
of differentiated cells
2. A client with a nagging cough makes an appointment to see the physician
after reading that this symptom is one of the seven warning signs of
cancer. What is another warning sign of cancer?
a. Persistent nausea
b. Rash
c. Indigestion
d. Chronic ache or pain
3. A client has been receiving chemotherapy to treat cancer. Which
assessment finding suggests that the client has developed stomatitis
(inflammation of the mouth)?
a. White, cottage cheese-like patches on the tongue
b. Yellow tooth discoloration
c. Red, open sores on the oral mucosa
d. Rust-colored sputum
4. For a client with newly diagnosed cancer, the nurse formulates a nursing
diagnosis of Anxiety related to the threat of death secondary to cancer
diagnosis. Which expected outcome would be appropriate for this client?
a. "Client verbalizes feelings of anxiety."
b. "Client doesn't guess at prognosis."
c. "Client uses any effective method to reduce tension."
d. "Client stops seeking information."
5. It is based on the extent of the tumor, the extent of spread to the lymph
nodes, and the presence of metastasis.
a. Staging
b. Grading
c. TNM system
d. Proliferating
6. A stage 3 cancer is define in TNM system as
a. T3N0M0
b. T3N1M0
c. T3N2M0
 d. T3N3M0
7. A client who was diagnosed with lung cancer had undergone removal
surgery of the left lung. The best post-op position for this client is
a. Position on the back or left side only
b. Position on the back or right side only
c. Position on the stomach or left side only
d. Position on the stomach or right side only
8. During a breast examination, which finding most strongly suggests that the
client has breast cancer?
a. Slight asymmetry of the breasts
b. A fixed nodular mass with dimpling of the overlying
skin
c. Bloody discharge from the nipple
d. Multiple firm, round, freely movable masses that change
with the menstrual cycle
9. The nurse is interviewing a client about his past medical history. Which
preexisting condition may lead the nurse to suspect that a client has
colorectal cancer?
a. Duodenal ulcers
b. Hemorrhoids
c. Weight gain
d. Polyps
10. The nurse is interviewing a client about his past medical history. Which
statement may the nurse suspect for a contributory risk factor for kidney
cancer
a. I am working as miner for 25 years now
b. I love eating cheese burger
c. Gardening is my habit
d. I drink beer occasionally