ONCOLOGY AND PAIN Cancer-malignant neoplasms Ranks as the 3rd leading cause of mortality in the Philippines ONCOLOGY NURSING

PRIMARY GOAL OF CANCER NURSING: a. total quality life b. comfort c. pain management d. Palliation

CANCER PATHOPHYSIOLOGY ETIOLOGY Main cause: Unknown Most common cause: Immunosuppression Risk Factors: Race: Black American Age: 55 y/o and above 65 and above Sex: Male Body Built: Endomorph CARCINOGENS: PHYSICAL AGENTS

Sun Radon Gas Chronic Inflammation Tobacco

CHEMICAL AGENTS

Pesticide Aniline dye Soot Tar Aromatic amines Cadmium Benzene Benzol Beryllium Wood dust

Arsenic Nickel Formaldehyde Chromium Asbestos Polyvinyl Chloride Lime Zinc Ores Betel nut

HORMONAL AGENTS Estrogen replacement Therapy/Pills (single dose) Increases the risk of:

Breast Cancer Endometrium Cancer (decreased when using COC) Liver Cancer Decreases the risk of:

Ovarian Cancer Diethylstilbestrol Risk of the Woman who had taken the DES

Breast, endometrium, liver cancer Risk of the Child of the Pregnant Woman who had taken the DES

MALE: testicular cancer FEMALE: vaginal and cervical cancer

BACTERIAL AND VIRAL CAUSES 1. 2. 3. 4. 1. 2. 3. 4. H. Pylori- Gastric Cancer HIV- Kaposis Sarcoma Human Papilloma Virus- Cervical Cancer EBV- Nasopharyngeal, Burkitts Lymphoma, Hodgkins and Non Hodgkins

PATTERNS OF CELL GROWTH:

Hyperplasia-increase in the number of cells of a tissue; most often associated with periods of rapid body growth Neoplasia-uncontrolled cell growth that follows no physiologic demand Metaplasia-conversion of one type of mature cell into another type of cell Dysplasia-bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same type of tissue Anaplasia-cells that lack normal cellular characteristics and differ in shape and organization with respect to their cells of origin; usually, anaplastic cells are malignant. DIAGNOSIS OF CANCER: CONFIRMATORY: Biopsy Grading- Degree of cellular differentiation Grade 1 75% cells are differentiated (mild dysplasia) Grade 2 50-75% cells are differentiated (moderate dysplasia) Grade 3 25-50% cells are differentiated (severe dysplasia) Grade 4 25% cells are differentiated (anaplasia) Staging: determines the size of tumor and the existence of metastasis STAGE 1: 1 tumor less than 2 cm STAGE 2: 2 or more tumor less than 2 cm or 1 tumor larger than 2 cm but less than 5 cm STAGE 3: 1 tumor larger than 5 cm or involvement of lymph nodes except for breast Cancer (eg. 1 lymph node ipsilateral to 1 breast tumor is still Stage 2; 1 lymph node contralateral to 1 breast tumor is now Stage 3) STAGE 4: With distant metastasis TNM CLASSIFICATION:

The T category describes the original (primary) tumor.

Tx means the tumor can't be measured or found. T0 means there is no evidence of primary tumor. TIS means the cancer is in situ (the tumor has not started growing into the surrounding structures). The numbers T1T4 describe the size and/or level of invasion into nearby structures. The higher the T number, the larger the size of the tumor and/or the further it may have grown into nearby structures.

The N category describes whether or not the cancer has reached nearby lymph nodes.
Nx means the nearby lymph nodes can't be measured or found. N0 means nearby lymph nodes do not contain cancer. The numbers N1N3 describe the size, location, and/or the number of lymph nodes involved. The higher the N number, the more involved the lymph nodes are.

The M category tells whether there are distant metastases.

Mx means metastasis can't be measured or found. M0 means there are no known distant metastases. M1 means that distant metastases are present. It is important to note that each cancer type has its own classification system, so letters and numbers don't always mean the same thing for every kind of cancer. For example, for some cancers, classifications may have subcategories, such as T3a and T3b, while others may not have an N3 category (ACS, 2006).

LEVELS OF PREVENTION PRIMARY 1. CHEMOPREVENTION: MEDICATIONS

Finasteride Aspirin Tamoxifen Beta Carotene Calcium COX 2 inhibitor

CANCER PREVENTED Prostate Cancer Colorectal Cancer Breast Cancer Lung Cancer Colorectal cancer Colorectal Cancer

2.PRIMORDIAL PREVENTION v removal of all modifiable risk factors in the clients lifestyle SECONDARY LEVEL OF PREVENTION SCREENING TESTS 1. COLORECTAL CANCER PRESCRIBED AGE OF COMPLIANCE: 50 y/o 40-45 if High risk a. Guiacs Test annually b. Double contrast Barium enema every 5 years c. Digital Rectal Examination every year d. Anoscopy/proctoscopy/proctosigmoidoscopy every 5 years e. Colonoscopy every 10 years 2. PROSTATE CANCER PRESCRIBED AGE OF COMPLIANCE: 50 y/o 40-45 if High risk A. Digital Rectal Examination annually B. Prostate Specific Antigen- dependent screening test 3. TESTICULAR CANCER PRESCRIBED AGE OF COMPLIANCE: 15 y/o a. Testicular Self Examination-monthly same day each month 4. BREAST CANCER a. Self Breast Examination- monthly, 5-7-10 days after menstruation for irregular menstruation- 1st day of each month

b. Clinical Breast Examination 20-39 y/o every 3 years 40 y/o and above every 1 year c. Mammography 40 y/o and above every year 5. CERVICAL CANCER a. Cervical Pap Smear a.1 Regular Pap Smear every year a.2 Liquid Pap Smear every 2-3 years 6. Oral/ Ovary/ Thyroid/ Lymph Node/ Skin Cancer 20-39 y/o every 3 years

TERTIARY LEVEL OF PREVENTION 1. RADIATION THERAPY A. Brachytherapy- internal therapy -the effects are systemic 2 Forms of Brachytherapy: 1.Sealed- the patient is radioactive but the discharges are not radioactive 2. Unsealed- the patient and the discharges are radioactive (usually the discharges are released from the body 48 hours after the initiation of brachytherapy.) ASSESSMENT: Signs of Bone Marrow Suppression v easy fatigability, anemia, petechiae, oral gingivitis Nx DIAGNOSIS Risk for infection, Fatigue, Risk for Fluid Volume deficit Nursing Interventions: 1. Seclude the patient in a private room. 2. Restrict the following persons in entering the private room: a. Pregnant Clients b. Minors c. Immunosuppressed clients 3. Give care to the patient in the private room guided by the following principles a. Time: health care providers should only stay within the room for 30 minutes per shift b. Distance: health care providers should maintain atleast 6 feet away from the radioactive source c. Shield: health care providers should always use either a concrete barrier or a lead apron. Advisably, the shield should always have a film badge dosimeter) 4. Facilitate a low bacterial diet. 5. Avoid invasive procedures and other sources for infection. 6. Health care providers should be rotated and no health care provider should give care more than 1 patient with internal therapy. 7. Facilitate infection control through the use of Personal Protective Equipment 8. Practice bleeding precaution

2. TELETHERAPY- external therapy -the effects are local - it will utilized an indelible ink to mark the area to be the target an external beam ASSESSMENT ON THE AFFECTED AFTER RADIATION THERAPY 1.Sun Tan Skin- erythematous, moist, caloric -usually it appears 10 to 14 days after the initiation of teletherapy 2. Photosensitive aseptic wound Nx Diagnosis: Impaired Skin Integrity NURSING INTERVENTIONS: 1. Secure consent prior to the initiation of the therapy. 2. Ensure that the radiated site is properly labeled. 3. Wash the area with water and mild soap (not directly after treatment) 4. Pat dry the wound after washing 5. Do not apply lotion, powder, medication, cream without prescription 6. Leave skin markings between treatment 7. Advised the patient to use umbrella rather than sunscreen to address photosensitivity. CHEMOTHERAPY -use of drugs to kill tumor cells by interfering with cellular functions and reproduction -most of these shemotherapeutic agents are vesicants (can cause tissue necrosis) NURSING INTERVENTIONS: 1. Secure consent and validate the following in the doctors order (Identity of the patient/ Type of Chemotherapeutic Agent/ Medical Doctor who ordered such). 2. Choose the most appropriate IV catheter to be used (avoid the use of plastic derivatives because it increases the rick of infection) 3. Choose the most appropriate site taking into consideration the dwelling period of such vascular access device. 4. Perform skin preparation using the following sequence a) Wash the prospective site with bacteriostatic soap and pat dry afterwards b) Apply Betadine 30% 2-6 inches away from the incision site, then Betadine 10%, the finally alcohol 5. During administration, ensure that the line is patent to avoid extravasation. COMPLICATIONS OF CTA ADMINISTRATION: 1. EXTRAVASATION-tissue necrosis at the subcutaneous area. ASSESSMENT:

Signs of inflammation Resistance Absence of backflow Nx INTERVENTIONS: a) Stop the administration b) Leave the needle for the aspiration of residues c) Give antidotes d) Do not give manual compression e) Give cold compress except if the chemotherapeutic agent is Vinca Alkaloids

MEDICATIONS (ANTI DOTES)

Sodium bicarbonate Hyalorunidase Thiosulfate Leucovorin- given only if the causative agent of extravasation is Methotrexate 2. INFECTION ASSESSMENT

Calor Rubor Dolor Tumor Functiolysa Nx INTERVENTIONS: a) Change peripheral vascular access device every 72 hours provided the phlebitis rate in that hospital is less than 5%. If it is greater than 5%, then, changing of IV site should be every 48 hours. b) Always practice aseptic technique when administering chemotherapeutic agents c) Immediately stop CTA administration upon manifestations of either infiltration or phlebitis d) Use warm compress for infiltration and cold compress for phlebitis.

SIDE EFFECTS OF CHEMOTHERAPY: 1. Nausea and Vomiting

The most common side effect of chemotherapy Concentrated blood irritates chemoreceptor trigger zone nausea and vomiting AVOID the ff:

Coffee Carbonated drinks/soda Alcoholic beverage Milk and milk derivatives Smoking Fats Stress Too hot or too cold foods Highly flavored foods

DO the following:

Increase fluid in take to dilute concentrated blood Increase fiber intake

Eat before chemotherapy Take the chemotherapy at night

DRUG OF CHOICE: Ondansetron 2. Nutritional Problem Assessment: a. early satiety b. anorexia c. dysphagia d. nausea e. emaciation Nx INTERVENTIONS: 1. Facilitate a high caloric and protein in take. 2. Give the following foods:

Biscuits and butters Milk in the absence of nausea Egg Puddings Custards Honey Ice cream Yogurt 3. Please be guided that we cannot established eating schedules (every 2 hours) because nausea and vomiting is unpredictable. 4. Refrigerate all left foods within 2 hours and should be consumed within 24 hours. After 24 hours, it should be properly discarded. 3. Alopecia

Usually it develops 2-3 weeks after the initiation of chemotherapy because of the absorption of the CTA in within the roots of hair follicles thus affecting hair mitosis. Nx Interventions: a) Explore feelings of the patient then encourage him to see and touch his head. b) Facilitate purchasing of wig before the start of chemotherapy to facilitate acceptance of the treatment regimen c) Educate the patient that there will be COMPLETE HAIR REGROWTH 8 weeks after the completion of chemotherapy., and PRE TREATMENT HAIR will go back after 1 year d) Educate the patient that alopecia can be reduced or totally be avoided; provided the client have no blood cancer. Through the use of scalp hypothermia, there is no or small absorption of CTA in the roots of hair follicles. 4. BONE MARROW SUPPRESSION 4.1 Erythrocytopenia/ Anemia ASSESSMENT FINDINGS:

Fatigue-most common chief complaint of Cancer patients to their cancer treatments. Episodes of syncope Low oxyhemoglobin v v v v NURSING INTERVENTIONS: 1. 2. 3. 4. 1. 2. 3. 4. Arrange activities of daily living from least oxygen consumption to greatest oxygen consumption. Promote frequent rest periods Use blood transfusion if simple management fails. Advise the patient to eat green leafy vegetables (cabbage family)

4.2 Leukocytopenia ASSESSMENT FINDINGS:

Recurrent infections Fatal infections Oral ulcers/gingivitis Mucositis Mild- expected duration of healing is within 5-7 days Severe- expected duration of healing is within 10-14 days

Nadir (peak of bone marrow)

NURSING INTERVENTIONS: 1. 1. Seclude the patient in a private room using the different filtering machines :

a) High Efficiency Particulate Air Filter-reduces the bacterial infection rate from the usual 85% to 3-5% b) Laminar Flow- reduces the bacterial infection rate form the usual 85% to less than 1 %. c) The best alternative in the absence of the Filtering machines is opening the windows to facilitate 15 gas exchanges; atleast 3 of them are fresh air. 1. 2. 3. 4. 5. 2. To address oral mucositis, facilitate warm saline gurgles, pureed diets and use of toothette. 3. Give insoluble/ whole grain fibers to avoid constipation which can trigger damage in the rectal mucosa which can serve as portal of entry. 4. Avoid invasive procedures. 5. Do not give antipyretic medications when the patient is on the state of Nadir to avoid masking of actual infection. 6. Do not give live attenuated vaccines for it will cause actual infections.

6.

7.

Practice standard precaution

4.3 THROMBOCYTOPENIA ASESSMENT:

Petechiae Echymosis Gastric bleeding Melena Hematochezia Gingivitis DIAGNOSITC CHANGES: v Mild risk for bleeding: 50,000-100,000/mm3 v Moderate risk for bleeding: 20,000-50,000/mm3 v Severe risk for bleeding: 20,000/mm3 NURSING DIAGNOSIS: Risk for fluid volume deficit NURSING INTERVENTIONS: 1. 2. 3. 4. 5. 6. 7. 8. 1. 2. 3. there 4. 5. 6. 7. 8. Use electric razor rather than manual Use soft bristled tootbrush/ toothette Use dental floss rather than tooth pick; provided that the platelet count is greater than 40, 000 or is no pain upon doing such. Remove sharp objects Pad the side rails Avoid shearing forces Avoid invasive procedures Clip hair rather than to shave corporal hair

MULTIPLE MYELOMA An abnormal proliferation of b cells ASSESSMENT:

Bone pain v Rib/costochondral pain v Low back pain

Mild anemia Fatigue Method of Metastasis: Angiogenesis Site of Metastasis: Spinal Cord Nx Interventions:

1. 2. 3. 4.

1. 2. 3. 4.

Use firm bed mattress Use pillows to the affected rib when lying at the side of the bed. Always monitor for reflexes because any alteration on the reflexes controlled within the spinal cord. Facilitate medications

Drug of Choice: Thalidomide Do not give this medication to pregnant clients BECAUSE OF THE DANGER OF HAVING PHOCOMELIA Always monitor for metastasis (severe low back pain) because it maybe a sign of spinal cord compression,

LEUKEMIA v There is an abnormal proliferation of WBC. v There is an increase in the number of immature leukocytes. TYPES OF LEUKEMIA 1. 2. 3. 4. 1. 2. 3. 4. Acute Lymphocytic Leukemia-most common in less than 15 y/o Acute Myelogenous Leukemia-most common in 15-39 y/o Chronic Myelogenous Leukemia-most common in 40 y/o and above Chronic Lymphocytic Leukemia- most common 50 y/o and above

ASSESSMENT FINDINGS: Acute: FATAL infections are more common Chronic: RECURRENT infections are more common Oral ulcers Nosocomial infections NURSING INTERVENTIONS: 1. 2. 3. 1. 2. 3. Seclude the patient in a private room Restrict infectious visitors Assess signs of infection:

a. fever- the most definitive sign of infection b, altered sensorium- earliest manifestation of infection of Geriatric patients 4. Avoid constipating agent and even gas forming foods 5. Avoid sexual intercourse 6. In the suspicion of actual infection, collect for specimen 7. Avoid attenuated viruses. MEDICAL TREATMENT: STAGE 1 AND 2: External Radiation with adjuvant therapy (Biologic Response Modifiers) STAGE 3 AND 4: Bone marrow transplant and Chemotherapy DRUG OF CHOICE: Bususlfan (Myleran)

HODGKINS LYMPHOMA malignant lymphadenopathy more common in early 20s and late 50s a rare malignancy curable cancer ASSESSMENT: painless palpable lymph nodes LYMPH NODES COMMONLY AFFECTED: i. CERVICAL-most commonly affected ii. MEDIASTINAL iii. CLAVICULAR Lymphadenitis B Symptom i. Fever without chills ii. Drenching sweats presence of Reed Sternberg cells during a multimodal biopsy CHEMOTHERAPEUTIC AGENTS: a) Adriamycin always monitor for nephrotoxicity and ototoxicity b) Bleomycin always monitor for dry and productive cough (pulmonary fibrosis) c) Vinblastine Watch for extravasation In case of extravasation, you should give warm compress d) Dacarbazine Monitor for pronounced bone marrow suppression. Monitor for signs of cystitis

[ NURSING INTERVENTIONS are based on the side effects of the medications given. [ Fatigue, risk for infection and bleeding tendencies are addressed in the management of the side effects of Chemotherapy

BREAST CANCER Malignancy involving the breast and the surrounding structures specifically axillary lymph nodes Risk Factors:

Early menarche Use estrogen replacement therapy Colorectal cancer within the family Obesity Sex: Female ASSESSMENT: [ painless, palpable, fixed mass usually at the Upper outer quadrant [ usually the affected breast is the higher breast [ acute nipple discoloration [ acute nipple inversion [ nipple retraction [ long standing erythema [ orange discoloration (peau d orange) TREATMENT MODALITIES: Stage 1 and 2: Breast Conservation- surgery to preserve the physical structure of the breast while treating the cancer without sacrificing the safety of the patient i. Mass removal through the ff measures: 1. 2. ii. 1. 2. a. b. Excisional- removal of the entire mass equal or less than 3 cm Lumpectomy- removal of the entire mass greater than 3cm and additional surrounding structure Radiation therapy Brachyherapy- usually the total duration is about 1-2 months Teletherapy- usually it takes 4-5 months for the treatment completion

iii. Breast Reconstruction Stage 3 and 4: Radical and Modified Radical Mastectomy with Chemotherapy Removed structures Radical Mastectomy Modified Radical Mastectomy Affected Breast removed removed Lymph nodes removed removed Fats removed removed Pectoralis muscle removed retained TYPES OF LYMPH NODE DISSECTION: A. Sentinel Lymph node- removal of the first axillary lymph node that drains the breast. If the succeeding lymph node is found to be malignant, it is also surgically removed -lesser risk of having lymph edema

B. Axillary Lymph node all the axillary lymph nodes are removed simultaneously regardless of its state of malignancy. -greater risk of having lymph edema CHEMOTHERAPEUTIC AGENT OF CHOICE: TAMOXIFEN/ NOVALDEX NURSING INTERVENTIONS AFTER THE SURGERY: [ Wear medic alert bracelet to avoid taking of blood pressure proximal to the surgical site [ Elevate the arms above the level of the heart [ Avoid peripheral injuries [ Facilitate the use of drains CERVICAL CANCER ASSESSMENT: v Metrorrhagia v Post coital bleeding v Urinary obstruction TREATMENT MODALITIES: CONIZATION: a form of cryosurgery

Will no longer use another form of anesthesia because it has utilized liquid nitrate to freeze the affected are Utilize only if the patient would still want to preserve child bearing capacity Only a portion of the cervix is removed HYSTERECTOMY: removal of the entire uterus Nx Interventions post conization and hysterectomy: 1. 2. 3. 4. 5. 6. Advise the patient not to climb stairs for 1 month Lift no more than 20 lbs for 6 weeks Avoid sexual intercourse for 6 weeks Support when ambulating Restrict bending Count the paddings used per hour, ( 1 soaked padding per hour means hemorrhage)

CERVICAL RADIATION IMPLANT:

A form of unsealed brachytherapy which is inserted intracavitary Usually discharges are contaminated 48 to 72 hours after insertion of the Cervical radiation implant Nx Interventions BEFORE INSERTION 1. 2. 3. 4. 5. Secure consent Validate Doctors Order (type of radiation/identity of the patient/MD who ordered) Provide a low residue diet Practice log rolling Secure IFC inserted. Drain before insertion( most vital before insertion of the Radiation Implant

Nx Interventions UPON INSERTION

1. 2. 3.

Raise the head of the bed no more than 20 degrees Advise the patient to logroll when moving Adhere with Guidelines in case of radium implant dislodge:

a) Use long handles forceps (about 6-8 inches) to pick up the dislodged implant b) Put it in a Pb resistant container c) In the absence of a lead resistant container, you may flush it in a water sealed toilet atleast 3 times. d) Document the time of dislodge and notify the physician. Nx Interventions UPON REMOVAL OF IMPLANT 1. Monitor for signs of toxicity:

1. 2. 3. 4. 5. 6. 7. 8. 9.

Nausea Vomiting Diarrhea Frequent urination Hematuria Abdominal distention Abdominal pain Fever Foul smelling vaginal discharge

2. All soiled clothes should be contained within the room. 3. Do all interventions stated for brachytherapy TESTICULAR CANCER Nx History:

Klinefelters Syndrome Cryptorchidism Infertility Prematurity ASSESSMENT: [ Painless swollen testicles [ Dragging/ pulling sensation within the scrotum [ Gynecomastia TREATMENT MODALITIES: Unilateral Orchiectomy- surgical removal of one testicles Pelvic Exanteration-removal of all regional structures surrounding the testicles NURSING INTERVENTIONS POST OP:

1. 2. 3. 4. 5.

a. b. c. d. e.

Do not use warm compress to relieve pain Use cold compress to avoid bleeding Facilitate the use of pressure dressing or orchial support Lift no more than 20 lbs Report the following signs and symptoms:

[ Testicular drains [ Fever [ Intractable testicular pain

CHEMOTHERAPY: v Cisplatin (Platinol)

watch out for hemorrhagic cystitis the earliest manifestation: gross hematuria watch out for nephrotoxicity earliest manifestation: oliguria

COLORECTAL CANCER Nx History: 1. 2. 3. 4. 5. 6. 1. 2. 3. 4. 5. 6. Previously resected colorectal cancer High fat and low residue diet (highly enriched foods) to Western diet Inflammatory Bowel Disease (ulcerative colitis) Gardners Syndrome Turcots Syndrome Hereditary Nonpolyposis Colorectal Cancer

ASSESSMENT:

Changing Bowel habits Alternating diarrhea and constipation Painless palpable Mass at the sigmoid area (most common site) Occult bleeding (rectal bleeding) Abdominal pain Anemia Weakness

Emaciation DIAGNOSTICS: 1. 2. 3. 4. 5. Pelvic MRI Anoscopy Guiacs Test Barium Enema Colonoscopy

MANAGEMENT: SURGICAL RESECTION: a) Colonic J pouch b) Laparotomy c) Abdominoperineal Resection provided the anal sphincter is involved d) Transanal Resection provided the mass is less than 3 cm or 7cm provided it is well differentiated RADIATION THERAPY CHEMOTHERAPY: 1. 2. 3. 4. Irinotecan Levamisole 5 flourouracil Leucovorin

NURSING INTERVENTION: CONSTIPATION

Increase Fluids Use NGT to decompress Mobilize the patient provided it is not contraindicated DIARRHEA

Provide BRATY (banana, rice, applesauce, toast, yogurt) Provide Bland diet Small frequent feedings Avoid the following Alcohol Coffee Pepper Spices Too hot and too cold beverages/foods OSTOMY CARE

Force fluids Avoid the following foods:

GAS FORMING Asparagus Beer Broccoli Brussel Cabbage Carbonated drinks Sprouts Milk ODOR FORMING a) Garlic b) Egg c) Fish d) Onions OBSTRUCTIVE FOODS a) Celery b) Seed c) Nuts a) b) c) d) e) f) g) h)

LUNG CANCER Types of Lung Cancer: 1. 2. 3. 4. 1. 2. 3. 4. Small Cell- proximal alveolar growth Adenocarcinoma Large Cell- peripheral proliferation Epidermoid/ squamous cell- MOST COMMON/ central proliferation

CHEMICAL AGENTS:

Chromium Arsenic Nickel Coal tar Iron Radon Gas Petrleum Oil Mist Asbestos Isopropyl oil ASSESSMENT: v Varying cough v Dyspnea

v v v v

Localized chest pain Copious Sputum Hemoptysis Paraneoplastic Syndrome ( Anasarca/ flank pain)

TREATMENT MODALITIES: SURGERY [ Pneumonectomy [ Lobectomy: a single lobe of lung is removed [ Bilobectomy: two lobes of the lung are removed [ Sleeve resection: cancerous lobe(s) is removed and a segment of the main bronchus is resected [ Pneumonectomy: removal of entire lung [ Segmentectomy: a segment of the lung is removed* [ Wedge resection: removal of a small, pie-shaped area of the segment* [ Chest wall resection with removal of cancerous lung tissue: for [ cancers that have invaded the chest wall RADIATION [ External is preferred CHEMOTHERAPY [ alkylating agents (ifosfamide), [ platinum analogues (cisplatin and carboplatin), [ taxanes (paclitaxel, docetaxel), [ vinca alkaloids (vinblastine and vindesine), [ doxorubicin, gemcitabine, vinorelbine, [ irinotecan (CPT-11), and etoposide (VP-16) PAIN MANAGEMENT PAIN: whatever the patient says it is, then it is. Highly subjective PAIN SCALE: Attempts to measure the severity and intensity of pain. a) Numerical Scale (1-10) b) Ouchers Scale c) Wong-Bakers scale Causes of Cancer pain: v Obstruction v Compression v Massive Lactic Acidosis NURSING INTERVENTIONS: Facilitate distraction Use nonpharmocologic interventions:

guided imagery deep breathing exercise

MEDICAL MANAGEMENTS: a) Using the WHO Ladder System to treat pharmacologically the pain suffered by the patient according to the intensity of pain. b) For intractable pain, Rhizotomy is utilized.