Cell Physiology

2 Basic Parts
1. Cytoplasm
 Composed of viscous protoplasm which consists of water, CHON, lipid, CHO, & inorganic solutes.
 Cytosol – fluid inside the cell; make up 55% of the cell’s volume and is composed of water, solutes, and particles
Site of many of the chemical reactions that allow cellular growth
Organelles
 Cytoskeleton – a network of protein filaments that maintains the shape and organization of the cell
 Centrosome – made up of proteins important in cell division
 Cilia and Flagella – cilia are hair-like projections extending from the surface of the cell which propel fluids across the
surface of the cells. Flagella are longer than cilia and can move entire cells
 Ribosomes – the sites of protein formation and they are made up of proteins and nucleic acids
 Endoplasmic Reticulum – a network of folded membranes taking up half of the cytoplasm
Rough ER – studded with ribosomes, and it processes and sorts proteins formed by the ribosomes
Smooth ER – does not contain ribosomes and is responsible for the formation of fatty acids and steroids and it also
plays a part in the inactivation of harmful substances including carcinogens
 Golgi Complex – made up of membranous sacs it stores and packages and exports proteins from the rough ER to other
parts of the cell
 Lysosomes – made up of sacs containing 60 different enzymes that break down the final products of digestion and
allow them to be transported into the cytosol
- Also digest worn out organelles (autophagy) and can destroy themselves (autolysis) which occurs in
some medical conditions and also occurs after death when tissue deteriorates
 Peroxisome and Proteasome – peroxisomes detoxify harmful substances; proteasomes break down unneeded, faulty or
damaged proteins
 Mitochondria – the powerhouse of the cell where energy is produced
- Some cells contain thousands of mitochondria, but others just a hundred, e.g. active cells such as the
liver, kidneys and muscles have large numbers of mitochondria and use up lots of energy
2. Nucleus
 DNA
- deoxyribonucleic acid
- contained in genes which provides instructions for making proteins
- consists of repeating building blocks of nucleotides
 RNA
- Engineers ribosomes

Gene Action and Protein Synthesis

 DNA contained in genes which provides instructions for making proteins

 DNA consists of repeating building blocks of nucleotides
 Each nucleotide is made up of three parts: nitrogenous base, deoxyribose, and phosphate
 The nitrogenous bases consist of one of the following nucleic acids: adenine, guanine, thymine or cytosine
 DNA is made up of two strands, similar to a ladder, which twist around each other, giving it the double helical
structure
 About 1000 rungs of DNA make up a gene
 Humans have between 35000 and 45000 genes
 Any change that occurs in the sequence of nucleotides (known as adenosine or A, guanosine or B, Thymidine or T,
and Cytidine or C) of a gene is known as mutation
 Mutations can result in the death of a cell, cause cancer or produce genetic defects

Cell Division
 Replaces damaged, diseased and worn-out cells
 Each human cell has the same DNA content but only a small number of genes are expressed, giving each cell a distinct
structure and function – termed “differentiation”
2 types
1. Meiosis
- Reproductive cell division produces sperm and eggs, the cells needed to form the next generation of sexually
reproducing organisms
2. Mitosis
- Or somatic cell division produces 2 identical cells after division in all other body cells by replication of the DNA
sequence so that that the same genetic material can be passed on to the newly formed cells

Cellular Adaptation
 Atrophy – refers to the shrinkage of cell size

 Hypertrophy - an increase in size of normal cells

 Hyperplasia – refers to an increase in the number of normal cells

 Metaplasia – refers to a conversion from the normal pattern of differentiation of one type of cell into another type of cell
not normal for that tissue
  Dysplasia – refers to an alteration in the shape, size, appearance, and distribution of cells

 Anaplasia – refers to disorganized, irregular cells that have no structure and have loss of differentiation; the result is almost
always malignant
 Neoplasia – cancer cells

Introduction to Cancer
 There are over 200 different types of cancer that can occur anywhere in the body, all having different causes and
symptoms, and all requiring different treatments
 Refers to the group of diseases characterized by the abnormal growth and spread of cells
 Incidence: as reported by the American Cancer Society on a per year basis
1. Breast cancer has the highest incidence of non-skin cancer among women
2. Prostate cancer has the highest incidence for men
3. For men and women, lung cancer incidence is second and colon and rectal cancer incidence is third
4. More than 1.3 individuals would be diagnosed of cancer in 2006 and that 564, 830 people were expected to die from a
diagnosis of cancer in 2006
5. One in two men and one in three women will develop cancer over a lifetime
6. However, since 1991, death rates fro the majority of cancer types have been continuously dropping
7. In the US, more than 9.8 million individuals are cured of or living with a diagnosis of cancer
8. Cancer is being recognized and managed more as a chronic disease

 Mortality
1. One in four deaths in the US is attributed to cancer (lung and bronchus cancer)

Biology of Cancer
 Cancer is a group of many diseases of multiple causes that can arise in any cell of the body capable of evading regulatory
controls over proliferation and differentiation
 Two major dysfunctions present in the process of cancer are defective cellular proliferation (growth) and defective cellular
differentiation
1. Defect in Cellular Proliferation
 Cell proliferation originates in the stem cell and begins when the stem cell enters the cell cycle
 The time from the birth of a new cell to the time the cell divides into two identical cells is called the generation
time of the cell
 All cells of a tissue are controlled by intracellular mechanism that determines when cellular proliferation is
necessary
 Under normal conditions, a state of dynamic equilibrium is constantly maintained (i.e. cellular proliferation equals
cellular degeneration or death)
 Cellular proliferation will also occur if the body has a physiologic need for more cells (e.g. a normal increase in
white blood cell count occurs in the presence of infection
 Contact inhibition - normal cells respect the boundaries and territory of the cells surrounding them.
 The neighboring cells are thought to inhibit cellular growth through the physical contact of the surrounding cell
membranes
 The rate of cellular proliferation (from the time of cellular birth to the time of cellular death) differs in each body
tissue
 Cancer cells usually proliferate in the manner and at the same rate of the normal cells of the tissue from which
they arise
 Cancer cells divide indiscriminately and haphazardly
 Sometimes they produce more than two cells at the time of mitosis
 The DNA of the stem cell is substituted or permanently rearranged
 In most situations, cancer cells proliferate at the sane rate as normal cells of the tissue from which they originate
 The difference is that proliferation of the cancer cells is indiscriminate and continuous
2. Defect in Cellular Differentiation
 Cellular differentiation is normally orderly process that progresses from a state of immaturity to a state of maturity
 Because all body cells are derived from the fertilized ova, all cells have the potential to perform all body functions
 As cells differentiate this potential is repressed and the mature cell is capable of performing only specific functions
 With cellular differentiation there is a stable and orderly phasing out of cellular potential
 Under normal conditions the differentiated cell is stable and will not differentiate (that is, revert to a previous
undifferentiated state)
 Genes that are important regulators of these normal cellular processes are the cellular oncogenes or
protooncogenes
 Mutations that alter the expression of genes or their products can activate protooncogenes to function as
oncogenes (tumor-inducing genes) by inducing mitosis but inhibiting differentiation of the cell
 The protooncogene has been described as the genetic lock that keeps the cell in its mature functioning state
 When this lock is unlocked, as may occur through exposure to carcinogens or oncogenic viruses, genetic alterations
and mutation occur
PATHOPHYSIOLOGY
CANCER Development
 Carcinogenesis or Oncogenesis – process by which a normal cell is transformed into a malignant or cancerous cell

4 Stages
1. Initiation
- A non reversible event that occurs when a carcinogen (chemical, radiation, viral, bacterial, or familial)
invades and damages the DNA of the cell, causing a change in the DNA structure
- The structural DNA change is evidence by either a gene such as an oncogene (a gene that normally directs
cell growth, and if altered, can promote or allow the uncontrolled growth of cancer) being turned on, or a
gene such a tumor suppressor gene, p53 gene (gene that can block or suppress the development of cancer),
being turned off.
2. Promotion
- Must follow initiation
- A reversible event
- During this stage, prolonged, repeated exposure by a promoter stimulates cellular proliferation of the
initiated cell
- The promoter in a sense potentiates the effects of initiator (e.g. chemical found in tobacco smoke)
- Examples of promoters include but are not limited to hormones, such as estrogen, chemicals such as
chloroform, and certain drugs
3. Progression
- The movement between promotion and progression is not distinct
- During this stage, the transformed cancer or malignant tumor experiences morphological change, growing
in size and malignancy and becoming more anaplastic and less differentiated
- The primary malignant tumor is formed, and its own blood supply is established through a process of
angiogenesis that is the establishment of blood supply through the formation of new blood vessels
- By creating a blood supply, the malignant tumor is able to nourish itself for sustained growth
4. Metastasis
- The spread of malignant tumor to other locations that occurs through the direct invading of nearby
tissues or by spreading to distant sites in the body by penetration into blood and lymph vessels that
circulate the cells throughout the body
- Malignant tumors tend to spread either to adjacent tissues or to tissues and organs that are linked via
lymph and blood channels
- The presence of metastasis is not considered a second cancer
- A person who has been diagnosed with primary colon cancer that has metastasized to the liver through
venous blood supply has colon cancer cells in both the colon and in the liver
- Each specific cancer has its own specific sites of metastasis because of its respective venous circulation
- For example, most common site for metastasis for colon cancer is the liver, whereas pulmonary
metastasis is most common for rectal cancer.
- Angiogenesis is a normal process that occurs in adults whenever new blood vessels are needed, such as
during wound healing or tissue repair
- Angiogenesis also occurs in children at specific times for normal growth and development.
- Tumor angiogenesis is the proliferation of blood vessels to supply nutrients and remove waste products
from malignant tumors and is associated with the process of carcinogenesis
- The new blood supply, stimulated by the angiogenesis-stimulating molecules of the tumor, serves to
nourish the malignant tumor and enhance its growth and spread.
- Without this tumor angiogenesis, tumor growth would be halted because of the lack of nourishment for
growth and cell division.

Classification of Tumors
Benign tumors
 Classified based on their tissues of origin and usually end with the suffix –oma, Greek word for tumor
 e.g. benign tumor of glandular tissue is termed as adenoma
Malignant tumors
 Also classified based on their tissues of origin and usually end with the suffix –sarcoma or carcinoma
 Tumors termed carcinoma arise from epithelial tissues
 E.g. malignant tumor of glandular tissue is termed as adenocarcinoma
 CHARACTERISTICS BENIGN MALIGNANT
Cell characteristics Well-differentiated cells that Cells are undifferentiated and often
resemble normal cells of the tissue bear little resemblance to the
from which the tumor originated normal cells of the tissue from
which they arose
Mode of growth Tumor grows by expansion and does Grows at the periphery and sends
not infiltrate the surrounding out processes that infiltrate and
tissues; usually encapsulated destroy the surrounding tissues
Rate of growth is variable and
Rate of growth Rate of growth is usually slow depends on level of differentiation;
the more anaplastic the tumor, the
faster its growth
Metastasis Does not spread by metastasis Gains access to the blood and
lymphatic channels and
metastasizes to other areas of the
body
General effects Is usually a localized phenomenon Often causes generalized effects,
that does not cause generalized such as anemia, weakness, and
effects unless its location interferes weight loss
with vital functions
Tissue destruction Does not usually cause tissue Often causes extensive tissue
damage unless its location damage as the tumor outgrows its
interferes with blood flow blood supply or encroaches on
blood flow to the area; may also
produce substances that cause cell
damage
Ability to cause death Does not usually cause death unless Usually causes death unless
its location interferes with vital growth can be controlled
functions
Classification of Cancer
1. Anatomic site
 Carcinomas – embryonal ectoderm (skin & glands) and endoderm (mucous membrane linings of the respiratory tract,
GI tract, & GU tract).
 Sarcomas – embryonal mesoderm (connective tissue, muscle, bone, fat)
 Lymphomas/Leukemias – hematopoietic system
2. Histologic analysis
 Grade I: cells differ slightly from normal cells & are well differentiated
 Grade II: cells are more abnormal & moderately differentiated
 Grade III: cells are very abnormal & poorly differentiated
 Grade IV: cells are immature & primitive, & undifferentiated, difficult to determine
3. Extent of disease
Clinical Staging
 Stage 0: Cancer in situ
 Stage I: Tumor limited to the tissue of origin
 Stage II: Limited local spread
 Stage III: Extensive local & regional spread
 Stage IV: Metastasis

TNM Classification System

Primary Tumor (T)
 T0: No evidence of primary tumor
 Tis: Carcinoma in situ
 T1-4: Ascending degrees of increase of nodal involvement

Regional Lymph Nodes (N)

 N0: No evidence of disease in lymph nodes
 N1-4: Ascending degrees of nodal involvement

Distant Metastases (M)

 M0: No evidence of distant metastases
 M1-4: Ascending degrees of metastatic involvement of the host, including distant nodes

Tumor Markers
 protein substances found in the blood or body fluids
 1. Oncofetal antigens
- Present normally in fetal tissue, may indicate an anaplastic process in tumor cells
- E.g. CEA, AFP
2. Hormones
- Are present in large quantities in the human body; however, high levels of hormones mat indicate a
hormone secreting malignancy
- E.g. ADH, calcitonin, HCG, PTH
3. Isoenzymes
- Normally present in a particular tissue may be released into he bloodstream if the tissue is
experiencing rapid, excessive growth as a result of a tumor
- E.g. neuron-specific enolase (NSE) and prostatic acid phosphatise (PAP)
4. Tissue specific proteins
- Identify the type of tissue affected by malignancy
- Prostatic-specific antigen (PSA) utilized to identify prostate cancer

Risk Factors
1. Age
a. Increased risk for people over the age 65
b. Factors attributed to elderly include hormonal changes, altered immune responses, and the accumulation of free
radicals
c. Age has been identified as the single most important factor related to the development of cancer
2. Gender
a. Certain cancer are more commonly seen in specific genders
b. For example, breast cancer occurs more commonly in females, colon cancer occurs more commonly in males
3. Geographic location
a. Risks for cancer vary according to environment and location
b. Rates for specific cancer sites, morbidity, and mortality vary from state to state, nation to nation, and in urban versus
rural living
4. Genetics
a. 15% of cancers may be attributed to a hereditary component
b. Cancers demonstrating a familial relationship include breast, colon, lung, ovarian, and prostate
5. Immune disturbance
a. Some viral infections tend to increase risk
b. Infections associated with cancer include Eipsten-Barr, genital Herpes, papillomavirus, Hepatitis B, and human
cytomegalovirus
6. Chemical agents
a. Over 1000 chemicals are known to be carcinogenic
b. Exposure to chemicals in some occupations heightens this risk over decades
7. Race
a. Cancer can affect any population
b. Nonetheless, African-Americans experience a higher rate of cancer than any other racial or ethnic group
8. Tobacco
a. A strong correlation between smoking and lung cancer exists
b. Other cancer associated with tobacco use include bladder, esophageal, gastric, laryngeal, oropharyngeal, and
pancreatic
c. Smokeless tobacco (snuff and chewing tobacco) increases the risk of oral and esophageal cancers
d. Long-term exposure to secondhand smoke increases the risk for lung and bladder cancers
9. Alcohol
a. Serves as a promoter in cancers of the liver and esophagus
b. When combined with tobacco, the risk for other cancers are even higher
10. Diet
a. Diet has been demonstrated in research to correlate with some cancers
b. Diets high in fat, low fiber, and those containing nitrosamines and nitrosindoles found in preserved meats and pickled
food promote certain cancer such as colon, breast, esophageal
11. Miscellaneous
a. Stress, occupation, viruses

Prevention
 The nurse must assess each patient and determine the types of cancer preventive education and activities and
screening measures are specifically recommended.
Classifications of Prevention
I. Primary – reducing one’s risk for the development of cancer
- Strategies include the use of vaccines and health counselling
- Use of vaccines for cancer prevention is limited
- Currently, a vaccine is available for the hepatitis B virus, which is associated with liver cancer
- At least 2/3 of cancer cases are caused by environmental factors, thus health counselling is more
effective
- All patients should be screened for tobacco behaviours and should be instructed to stop smoking and
avoid second hand smoke
 - Individuals should be taught to protect themselves from sunlight because death from melanoma has
alos risen dramatically
- Individuals should be taught to wear at least SPF 15 sunscreen, to stay out of the sun between 10am
and 4pm, and wear clothing to protect their skin from the sun
- Individuals should be taught to limit drinking of alcohol to less one drink per day for women and less
than two drinks per day for men
- Excessive alcohol intake is related to mouth, throat and esophageal cancers
- Health counselling should include information about diet
- Studies suggest that various vitamins, fiber, and other nutrients may protect against cancer
- Foods containing antioxidants have been identified by a number of researchers as cancer protective
or chemo-protective, a substance or agents that bare used to protect healthy tissues
- Consumption of large amounts of calories and foods high in fat, including red meat products increase
the risk of colon and breast cancer
- Individuals should be taught to exercise regularly, at least 30 mins a da which contributes to overall
body reduction of fat as well as a generalized well being
- Foods that are smoked and preserved with salt have high levels of nitrates and should be limited in
the diet (bacon, ham, hotdogs, lunchmeats)
- People should also be aware that exposure to various viruses and bacteria can lead to the
development of cancer
- Practicing safe sex through the use of condoms and limiting exposure to multiple sex partners
- Individuals should be advised to assess the home and the workplace for known carcinogens and to
develop strategies to avoid those carcinogens
II. Secondary Prevention
- Aimed at screening and early recognition of cancer which then results to early diagnosis, earlier
treatment, and treatment success.
- E.g. treatment success for breast cancer diagnosed in an early stage is over 90% as compared to 26%
diagnosed in a late stage
- The cancer community knows that the best chance for cure or long term management is early
diagnosis

Recommendations of the ACS for early cancer detection:

A. For detection of breast cancer
1. Beginning at age 20, routinely perform monthly BSE’s
2. Women, ages 20-39 should have breast examination by a healthcare provider every 3 years
3. Women, age 40 & older should have a yearly mammogram & BE by a healthcare provider
B. For detection of colon & rectal cancer
1. All persons age 50 & older should have a yearly fecal occult blood test
2. DRG & flexible sigmoidoscopy should be done every 5 years
3. Colonoscopy with barium enema should be done evry 10 years
C. For detection of uterine cancer
1. Yearly Pap Smear for sexually active females & any female over age 18
2. At menopause, high risk women should have an endometrial tissue sample
D. For detection of prostate cancer
1. Beginning at age 50, have a yearly DRE
2. Beginning at age 50, have a yearly PSA test

III. Tertiary Prevention

- Defined as specific activities aimed at prevention of recurrence of cancer
- Two primary strategies to teach patients to prevent recurrence of disease are health counselling and
chemoprevention
- Educating patients early diagnosed with cancer or those who are survivors specifically about actions
that would would reduce their risk of developing the specific cancers
- This activities are centered on diet, exercise, avoidance of exposure, and healthy lifestyles
- Chemoprevention is the incorporation of drugs, foods or other agents into the treatment plan to
reduce the risk of cancer development or cancer reurrence
- Tamoxifen (a form of a synthetic hormone) is an example of drug that that is prescribed to reduce the
risk of breast cancer after breast cancer surgery
- NSAID’s are used for chemoprevention related to decreasing the risk of colon cancer.

Warning Signs of Cancer

C – Change in bowel or bladder habits
- Such as absence of urination or bowel movement or a change may be excessive urination or stool
A – A sore that does not heal
- Within a realistic period of time
U – Unusual bleeding or discharge
- From any body orifice, such as vagina, the nipple or the penis. The unusual discharge can be bloody, purulent, clear, or viscous.
The keywords are unusual, and any body orifice
T – Thickening or lump in breast/elsewhere
I – indigestion or dysphagia
- For a prolonged period of time
O – Obvious change in wart or mole
- Such as color, size, texture
N – Nagging cough or hoarseness
- That is prolonged
U – Unexplained anemia
S – Sudden weight loss

Common Nursing Techniques & Procedures

A. Radiation Therapy
- use to kill a tumor, reduce the tumor size, relieve obstruction, or decrease pain
Classifications
1. Internal Radiation (Brachytherapy)
Sources
a. Implanted into affected tissue or body cavity
b. Ingested as a solution
c. Injected as a solution into the bloodstream or body cavity
d. Introduced through a catheter into the tumor
Side Effects
1. Fatigue
2. Anorexia
3. Immnunosuppression
Health Teachings/Client Education
1. Avoid close contact with others until treatment is completed
2. Maintain daily activities unless contraindicated, allowing for extra rest periods as needed
3. Maintain a balanced diet; may tolerate food better if consumes small frequent meals
4. Maintain fluid intake to ensure adequate hydration
5. If implant is temporary, maintain bed rest to avoid dislodging the implant
6. Excreted body fluids may be radioactive; double-flush toilets after use
Nursing Management
1. Considerations
a. Time: minimize time spent in close proximity to the radiation source—30 minutes total per 8-hr
shift; maximum distance of 6 feet used when possible
b. Distance: maintain the maximum distance possible to the radiation source
c. Shielding: use lead shields & other precautions to reduce exposure to radiation

2. Place client in a private room

3. Instruct visitors to maintain at least a distance of 6 feet from the client and limit visits to 10-30 minutes
4. Ensure proper handling & disposal of body fluids
5. Ensure proper handling of bed linens & clothing
6. In the event of a dislodged implant, use long-handled forceps & place it into a lead container; NEVER
directly touch the implant
7. Do not allow any pregnant women to come into any contact with radiation sources
8. Educate clients in all safety measures
2. External Radiation Therapy
Side effects
a. Tissue damage to target area
b. Ulcerations of oral mucosal membranes
c. GI effects such as nausea, vomiting, & diarrhea
d. Fatigue
e. Alopecia
f. Immunosuppression
Health Teachings/Client Education
1. Wash the marked area of the skin with plain water only and pat skin dry; do not wash off the treatment
marks
2. Avoid rubbing, scratching, or scrubbing the treatment site; when shaving, use only an electric razor
3. Wear soft , loose fitting clothing over the treatment area
4. Protect skin from sun exposure during the treatment
Nursing Management
1. Monitor for adverse side effects of radiation
2. Monitor for significant decreases in WBC counts & platelet
B. Chemotherapy
 involves the use of cytotoxic medications & chemicals to promote tumor cell death
 the intravenous route is the most preferred for administering chemotherapeutic agents, but they may also be
administered by oral, intrathecal, topical, intra-arterial, intracavity, and intravesical route
 disrupts the cell cycle in various phases, interfering with cellular metabolism and reproduction
  according to cell-kill hypothesis, during each cell cycle a fixed percentage of cells are killed by chemotherapy,
leaving some tumor cells remaining; this necessitates the repeated dosages of chemotherapy in order to reduce
the number of cells, allowing the body’s immune system to destroy any remaining tumor cells

Chemotherapeutic Agents
1. Alkylating agents – non-specific; act by interfering with DNA replication
- Examples and Indications:
 Cyclophosphamide (Cytoxan) – Adenocarcinoma of breast and lung, Leukemias, Lymphomas, Multiple
myeloma
 Busulfan (Myleran) – CML
 Meclorethamine (Mustargen) – Chronic Leukemia, Hodgkin’s disease, Lung Cancer, Lymphosarcoma
- Side Effects: Bone marrow suppression, nausea, vomiting, cystitis (cyclophosphamide, ifosfamide), stomatitis,
alopecia, gonadal suppression, renal toxicity (cisplatin)
2. Antimetabolites – interfere with metabolites or nucleic acids necessary for RNA and DNA synthesis
- Examples and Indications:
 5-Fluorouracil (5-FU) – Breast Ca, Colon Ca, Gastric Ca, Pancreatic Ca, Rectal Ca
 Methotrexate – ALL, Gestational trophoblastic carcinoma, possible osteosarcoma
- Side Effects: Nausea, vomiting, diarrhea, bone marrow suppression, proctitis, stomatitis, renal toxicity
(methotrexate), hepatotoxicity
3. Antitumor Antibiotics - Interfere with DNA synthesis by binding DNA; prevent RNA synthesis
- Examples and Indications:
 Bleomycin (Blenoxane) – Hodgkin’s disease, lymphosarcoma, reticulum cell sarcoma, squamous cell
carcinoma. Testicular carcinoma
 Doxorubicin (Adriamycin) – ALL, AML, breast and ovarian cancer, lung Ca, Neuroblastoma, Thyroid Ca,
Wilms’ tumor
- Side effects: Bone marrow suppression, nausea, vomiting, alopecia, anorexia, cardiac toxicity (daunorubicin,
doxorubicin)
4. Hormonal Agents - Bind to hormone receptor sites that alter cellular growth; block binding of estrogens to
receptor sites (antiestrogens); inhibit RNA synthesis; suppress aromatase of P450 system, which decreases
estrogen level
- Examples and Indications:
 Diethylstilbestrol (DES) – Advanced breast Ca, Advanced Prostate Ca
 Tamoxifen (Nolvadex) – Breast Ca
 Prednisone – Leukemia, Lymphoma, Used in combination therapy for several tumors
- Side effects: Hypercalcemia, jaundice, increased appetite, masculinization, feminization, sodium and fluid
retention, nausea, vomiting, hot flashes, vaginal dryness
5. Plant Alkaloids - Arrest metaphase by inhibiting mitotic tubular formation (spindle); inhibit DNA and protein
synthesis
- Examples and Indications:
 Vinblastin (Velban) – used in combination therapy for Breast Ca, Hodgkin’s disease, Kaposi’s sarcoma,
Lymphocytic Lymphoma, Histocytic lymphoma, advanced testicular Ca
 Vincristine (Oncovin) - used in combination therapy for acute leukemia, Hodgkin’s lymphomas, Non-
Hodgkin’s lymphomas, Neuroblastoma, Rhabdomyosarcoma, Wilms’ tumor
- Side effects: Bone marrow suppression (mild with VCR), neuropathies (VCR), stomatitis
6. Miscellaneous Agents - Unknown or too complex to categorize
- Examples and Indications:
 Etoposide (VP-16 or VePesid) – Nonresponsive testicular tumors, small cell lung Ca
 Cisplatin (CDDP) (Platinol) – used in combination and single therapy for bladder Ca, tumor of head
and neck, metastatic testicular Ca, Metastatic ovarian Ca, Non small cell lung carcinoma,
Neuroblastoma, osteogenic sarcoma
- Side effects: Anorexia, nausea, vomiting, bone marrow suppression, hepatotoxicity, anaphylaxis, hypotension,
altered glucose metabolism

Common Side Effects of Chemotherapeutic Agents

A. Bone Marrow Suppression
1. Decreased WBC count (immunosuppression)
Client Education
1. Risk for infection is high when WBC count is low
2. Avoid crowds, people with infections, and small children when WBC is low
3. Use meticulous personal hygiene to avoid infection
4. Wash hands before and after eating, after toileting, and after contact with other people and pets
5. Consume a low bacteria diet; avoid undercooked meat and raw fruits and vegetables
6. Be aware of signs and symptoms of infection and report them immediately to primary care provider
Nursing Management
1. Monitor laboratory values: CBC with differential, platelets, BUN, liver enzymes
2. Assess for infection; monitor vital signs for early indication of infection: fever, tachycardia, and tachypnea
3. WBC suppression, malnutrition and presence of disease increase the risk of infection
4. Utilize neutropenic precautions (low bacteria diet, no fresh plants or flowers in the room, no pets, no visitors with
infections) when WBC level falls below predetermined level (such as 2000 cubic mm)
 B. Thrombocytopenia – Decreased platelet count
Client Education
1. Monitor stools and urine for bleeding
2. For shaving, use electric razor only
3. Avoid contact sports and other activities that may cause trauma
4. If trauma does occur, apply ice to area and seek medical assistance
5. Avoid dental work or other invasive procedures
6. Inform all healthcare providers of chemotherapy and/or radiation treatments
7. Avoid aspirin and aspirin containing products
8. Safety precautions for oral hygiene: use soft toothbrushes and do not floss
Nursing Management
1. There is a high risk for spontaneous hemorrhage when platelet count is <20, 000; precautions are necessary for platelet
count <50, 000
2. Assess for bleeding, monitor stools and urine for occult blood
3. Assess skin for ecchymoses, petechiae, and trauma
4. Educate client about bleeding safety precautions
5. Avoid intramuscular injections and limit venipunctures

C. Stomatitis and Mucositosis

Client Education
1. Use of a soft toothbrush; mouth swabs may be needed during acute episode
2. Avoid mouthwashes containing alcohol; do not use lemon glycerin swabs or dental floss
3. Consider using chlorhexedine mouthwash (Peridex) to decrease risk of hemorrhage and protect gums from trauma
4. Assess daily for lesions, infection, bleeding, or irritation
5. For xerostomia, apply lubricating and moisturizing agents to protect the mucous membranes from trauma and
infection
6. May consider using “artificial saliva” and hard candy or mints to help with dryness
7. Avoid smoking and alcohol, which can further irritate oral mucosa
8. Teach signs and symptoms of oral infection and to report to primary health care provider
9. Drink cool liquids, and avoid irritating foods
Nursing Management – maintaining adequate nutrition and F&E balance
1. Eat frequent small, low fat meals
2. Avoid spicy and fatty foods
3. Avoid extremely hot foods
4. Perform oral hygiene before and after meals
5. Maintain fluid intake as prescribed
6. Take nutritional supplements as prescribed (vitamins, liquid nutrition)
7. Maintain a daily journal of food and fluid intake
8. Assess for adequate hydration; for duration of treatment, encourage fluid intake of 2-3 liters unless contraindicated
9. Administer antiemetics prior to chemotherapy
10. Weigh client routinely, monitor for weight loss
11. Monitor lab values indicative of nutritional status (hemoglobin, hemtocrit, albumin, prealbumin)
12. Monitor for diarrhea or constipation, nausea and vomiting
13. Encourage adequate nutritional intake with meals that are served attractively, and environment free of noxious stimuli
(bedpan, urinal, odors)

D. Fatigue
Nursing Management
1. Assure client that fatigue is a normal response for chemotherapy and it does not indicate progression of disease
2. Encourage client to continue daily as much as possible allowing for rest periods in between
3. Assist client in self-care needs when indicated
4. Allow for periods of rest, cluster activities

E. Alopecia
Nursing Management
1. Chemotherapy and radiation therapy may cause hair loss; the hair loss is temporary and will grow back, usually
beginning about a month after completion of the chemotherapy; the client should know that the texture and color of
the new hair growth may be different; hair loss during radiation therapy to the head may be permanent
2. Encourage the client to choose a wig before hair loss occurs in order to match texture and hair color
3. Care of hair and scalp includes washing hair 2-3 times a week with mild shampoo; pat hair dry, and do not use a blow
dryer
4. Allow client to express feelings concerning body image

Nursing Implications for the Administration of Chemotherapy

1. Intravenous routes may be obtained by subclavian catheters, implanted ports, peripherally inserted catheters
2. Extravasation, the leaking of chemotherapeutic agents into the surrounding tissue, is the major complication of
intravenous chemotherapy; extreme care must be used when administering vesicant agents (chemicals causing
damage to tissue on contact)
3. Physicians and nurses should be specially trained to handle and administer chemotherapeutic agents
4. Vein patency must be assured before administering chemotherapeutic agents
 5. Warning: never test vein patency with chemotherapeutic agents
6. If extravasation occurs, depending on the chemotherapeutic agent, interventions may include the injection of an
antidote, the application of a cold compress, or the application of warm compress
7. Assess respiratory and cardiac status; monitor EKG, assess for heart failure, and monitor vital signs
8. Monitor client closely for anaphylactic reactions or serious side effects; discontinue infusion according to protocol if
reactions occur
9. Monitor intravenous site closely during administration; observe for pain and other symptoms of infiltration
10. Provide a calm, quiet environment for the client during administration
11. Use caution when preparing, administering, or disposing of chemotherapeutic agents; follow practice guidelines and
protective standards for safe handling of chemotherapeutic agents provided by the Occupational Safety and Health
Administration (OSHA) and Oncology Nursing Society

C. Bone Marrow Transplant (BMT)

- Used in the treatment of leukemias, usually in conjunction with radiation or chemotherapy
- Autologous BMT: The client is infused with own bone marrow harvested during remission of disease
- Allogenic BMT: the client is infused with donor bone marrow harvested from a healthy individual
- Syngeneic - (from an identical twin)
- The bone marrow is usually harvested from the iliac crests, then frozen and stored until transfusion
- Before receiving the BMT, the client must first undergo a phase of immunosuppressive therapy to destroy the
immune system; infection, bleeding, and death are major complications that can occur during this
conditioning phase
- After immunosuppression, the bone marrow is transfused intravenously through a central line
- Side Effects: Malnutrition, infection related to immunosuppression, bleeding related to thrombocytopenia

D. Hyperthermia
- the generation of temperatures greater than physiologic fever range (above 41.5°C [106.7°F]), has been used
for many years to destroy tumors in human cancers
- Malignant cells may be more sensitive than normal cells to the harmful effects of high temperatures for
several reasons.
- Malignant cells lack the repair mechanisms necessary to repair cell damage by elevated temperatures.
- Most tumor cells lack an adequate blood supply to provide needed oxygen during periods of increased cellular
demand, such as during hyperthermia
- Cancerous tumors lack blood vessels of adequate size for dissipation of heat. In addition, the body’s immune
system may be indirectly stimulated when hyperthermia is used
- Hyperthermia is most effective when combined with radiation therapy, chemotherapy, or biologic therapy.
Hyperthermia and radiation therapy are thought to work well together because hypoxic tumor cells and cells
in the S phase of the cell cycle are more sensitive to heat than radiation; the addition of heat damages tumor
cells so that they cannot repair themselves after radiation therapy
- Hyperthermia is thought to alter cellular membrane permeability when used with chemotherapy, allowing for
an increased uptake of the chemotherapeutic agent
- Heat can be produced by using radio waves, ultrasound, microwaves, magnetic waves, hot-water baths, or
even hot-wax immersions
- Hyperthermia may be local or regional, or it may include the whole body
- Chemotherapeutic agents, such as melphalan (Alkeran), may also be heated and instilled into the region’s
circulating blood
- Whole body hyperthermia to treat disseminated disease may be achieved by extracorporeal circulation,
immersion of patients in heated water or paraffin, or enclosure in heated suits.
- Side effects of hyperthermic treatments include skin burns and tissue damage, fatigue, hypotension,
peripheral neuropathies, thrombophlebitis, nausea, vomiting, diarrhea, and electrolyte imbalances
Nursing Management
1. Explain the procedure, its goals, and its effects.
2. Assess the patient for adverse effects, and efforts are made to reduce their occurrence and severity.
3. Local skin care at the site of the implanted hyperthermic probes is also required.
E. Biologic Response Modifiers

 a type of treatment that mobilizes the body's immune system to fight cancer
 mainly consists of stimulating the immune system to help it do its job more effectively
 modifiers are substances that are able to trigger the immune system to indirectly affect tumors
- Cytokines, substances produced by cells of the immune system to enhance the production and functioning of
components of the immune system
o Interferons - facilitate the cytolytic or role of macrophages and natural killer cells
o Interleukins - stimulate the production and activation of several different types of lymphocytes
o Colony Stimulating Factor - substances that stimulate the production of blood cells and promote their
ability to function
o Tumor Necrosis Factor - direct tumor-killing activity
E. Gene Therapy
 an experimental treatment that involves introducing genetic material into a person’s cells to fight disease
 involves introducing genetic material (DNA or RNA) into a person’s cells
 replace missing or altered genes with healthy genes which keeps cancer from developing
Oncologic Emergencies
 A. Spinal Cord Compression
1. Occurs secondary to pressure from expanding tumors
2. Early symptoms like back and leg pain, coldness, numbness, tingling, paresthsias; progression leads to bowel and
bladder dysfunction, weakness, and paralysis
3. Early detection is essential: investigate all complaints of back pain or neurological changes
4. Treatment is aimed at reducing tumor size by radiation and/or surgery to relieve compression and to prevent
irreversible paraplegia; may receive corticosteroids to reduce cord edema
5. Nursing interventions include early recognition of symptoms, monitoring vital signs, neurological checks, and
medication administration
B. Superior Vena Cava Syndrome
1. Compression or obstruction of the superior vena cava
2. Usually associated with cancer of lungs and lymphomas
3. Signs and symptoms are the result of blockage of venous circulation of head, neck, and upper trunk
4. Early signs and symptoms are periorbital edema and facial edema
5. Symptoms progress to edema of neck, arms, and hands; difficulty swallowing; shortness of breath
6. Late signs and symptoms are cyanosis, altered mental status, headache, hypotension
7. Death may occur if compression is not relieved
8. Treatment includes high dose radiation to shrink tumor and relieve symptoms
9. Nursing interventions include monitoring vital signs, providing oxygen support, preparing for tracheostomy if
necessary, initiating seizure precautions, and administering corticosteroids to reduce edema
C. Disseminated Intravascular Coagulopathy (DIC)
1. Severe disorder of coagulation, often triggered by sepsis, whereby abnormal clot formation occurs in the
microvasculature; this process depletes the clotting factors and platelets, allowing extensive bleeding to occur, tissue
hypoxia occurs as a result of the blockage of the blood vessels from the clots
2. Signs and symptoms are related to decreased blood flow to major organs (tachycardia, oliguria, dyspnea) and depleted
clotting factors (abnormal bleeding and hemorrhage)
3. Treatment includes anticoagulants to decrease stimulation of coagulation and transfusion of one or more of the
following: fresh frozen plasma, cryoprecipitate, platelets, and packed RBC’s
4. Nursing interventions include assessing client, monitoring for bleeding, applying pressure dressings to venipuncture
sites, and preventing risks of sepsis
5. Mortality for clients experiencing DIC is greater than 70% despite aggressive treatment
D. Cardiac Tamponade
1. Pericardial effusion secondary to metastases or esophageal cancer can lead to compression of the heart, restricting
heart movement and resulting in cardiac tamponade
2. Signs and symptoms are related to cardiogenic shock or circulatory collapse: anxiety, cyanosis, dyspnea, hypotension,
tachycardia, tachypnea, impaired level of consciousness, and increased central venous pressure
3. Pericardiocentesis is performed to remove fluid from pericardial sac
4. Nursing interventions include administering oxygen, maintaining intravenous line, monitoring vital signs, hemodynamic
monitoring, and the administration of vasopressor agents
LEUKEMIA
 is a cancer of the blood or bone marrow and is characterized by an abnormal proliferation (production by
multiplication) of blood cells, usually WBC

 Acute leukemia is characterized by the rapid increase of immature blood cells. Acute forms of leukemia are the most
common forms of leukemia in children.
 Chronic leukemia is distinguished by the excessive build up of relatively mature, but still abnormal, white blood cells.
Typically taking months or years to progress, the cells are produced at a much higher rate than normal cells, resulting in
many abnormal white blood cells in the blood. Chronic leukemia mostly occurs in older people, but can theoretically occur
in any age group.
 In lymphoblastic or lymphocytic leukemias, the cancerous change takes place in a type of marrow cell that normally goes on
to form lymphocytes, which are infection-fighting immune system cells.
 In myeloid or myelogenous leukemias, the cancerous change takes place in a type of marrow cell that normally goes on to
form red blood cells, some other types of white cells, and platelets.
 Acute lymphoblastic leukemia (ALL) is the most common type of leukemia in young children. This disease also affects adults,
especially those age 65 and older. Standard treatments involve chemotherapy and radiation. The survival rates vary by age:
85% in children and 50% in adults.
 Chronic lymphocytic leukemia (CLL) most often affects adults over the age of 55. It sometimes occurs in younger
adults, but it almost never affects children.
 Acute myelogenous leukemia (AML) occurs more commonly in adults than in children, and more commonly in men than
women. AML is treated with chemotherapy.
 Chronic myelogenous leukemia (CML) occurs mainly in adults. A very small number of children also develop this disease.
Treatment is with imatinib (Gleevec) or other drugs.
Signs and Symptoms
 bruises,
 bleeding excessively
 Pinprick bleeds (petechiae).
 frequent infection, ranging from infected tonsils, sores in the mouth, or diarrhea to life-threatening pneumonia or
opportunistic infections.
 dyspnea
 pallor
 Fevers and chills
 Night sweats
 flu-like symptoms
 Fatigue
 Nausea which can result in unintentional weight loss.

 Neurologic symptoms