Textbook of Medical-Surgical Nursing 3e

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Unit 3   Applying concepts from the nursing process

which are stimulated by many biological agents (van der Zee & van Rhoon, 2006). Heat can be produced by using radiowaves, 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. Local or regional hyperthermia may be delivered to a cancerous extremity (for malignant melanoma) by regional perfusion, in which the affected extremity is isolated by a tourniquet and an extracorporeal circulator heats the blood flowing through the affected part. Hyperthermia probes may also be inserted around a tumour in a local area and attached to a heat source during treatment. Chemotherapeutic agents, such as melphalan (Alkeran), may also be heated and instilled into the region’s circulating blood. Local or regional hyperthermia may also include infusion of heated solutions into cancerous body organs. 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 (Bruner et al., 2006; van der Zee & van Rhoon, 2006). Side effects of hyperthermic treatments include skin burns and tissue damage, fatigue, hypotension, peripheral neuro­ pathies, thrombophlebitis, nausea, vomiting, diarrhoea and electrolyte imbalances. Resistance to hyperthermia may develop during the treatment because cells adapt to repeated thermal insult. Research into the effectiveness of hyper­ thermia, methods of delivery and side effects is ongoing. Nursing management in hyperthermia Although hyperthermia has been used for many years, many patients and their families are unfamiliar with this cancer treatment. Consequently, they need explanations about the procedure, its goals and its effects. The patient is assessed for adverse effects, and efforts are made to reduce the occurrence and severity. Local skin care at the site of the implanted hyper- Recent scientific advances have led to an improved under- standing of cancer development. Traditional therapies such as chemotherapy and radiation affect all actively proliferating cells. As a result, both healthy cells and malignant cells are subject to harmful systemic effects of treatment. Targeted ther- apies seek to minimise the negative effects on healthy tissues by disrupting specific cancer cell functions such as malignant transformation, cell communication pathways (called signal transduction), processes for growth and metastasis, and genetic coding. Actions of targeted therapies include stimulation or augmentation of immune responses through the use of biolog- ical response modifiers, targeting of cancer cell growth factors, promotion of apoptosis and genetic manipulation through gene therapy (Khoukaz, 2006; Rieger, 2006). Most of the currently available targeted therapies are categorised as either mono­ clonal antibodies or small molecule tyrosine kinase inhibitors. Biological response modifiers Biological response modifier (BRM) therapy involves the use of naturally occurring or recombinant (reproduced through genetic engineering) agents or treatment methods that can alter the immunological relationship between the tumour and the cancer patient (host) to provide a therapeutic benefit. Although the mechanisms of action vary with each type of BRM, the goal is to destroy or stop the malignant growth. BRM treatment thermic probes is also required. Targeted therapies

chemotherapy agents used in the conditioning regime or those used to treat infection (aminoglycosides). Tumour lysis syndrome and acute tubular necrosis are also risks after BMT. GVHD requires skilful nursing assessment to detect early effects on the skin, liver and gastrointestinal tract. VOD result- ing from the conditioning regimes used in BMT can result in fluid retention, jaundice, abdominal pain, ascites, tender and enlarged liver, and encephalopathy. Pulmonary complications, such as pulmonary oedema, interstitial pneumonia, and other pneumonias, often complicate the recovery after BMT (Saria & Gosselin-Acomb, 2007). Providing posttransplantation care Caring for recipients.  Ongoing nursing assessment in follow-up visits is essential to detect late effects of therapy after BMT, which occur 100 days or more after the procedure. Late effects include infections (e.g. varicella zoster infection), restrictive pulmonary abnormalities and recurrent pneumonias. Sterility often results due to total body irradiation as part of the ablative regime. Chronic GVHD involves the skin, liver, intestine, oesophagus, eyes, lungs, joints and vaginal mucosa. Cataracts may also develop after total body irradiation. Psychosocial assessments by nursing staff must be ongoing. In addition to the stressors affecting patients at each phase of the transplantation experience, marrow donors and family members also have needs that must be addressed. Caring for donors.  Like BMT recipients, donors need nursing care. They commonly experience mood alterations, decreased self-esteem and guilt from feelings of failure if the transplanta- tion fails. Family members must be educated and supported to reduce anxiety and promote coping during this difficult time. Family members must also be assisted to maintain realistic expectations of themselves as well as of the patient. As BMT becomes more prevalent, many moral and ethical issues become apparent, including those related to valid (informed) consent, allocation of resources and quality of life. Hyperthermia Hyperthermia (thermal therapy), the generation of tempera- tures greater than physiological fever range (above 41.5°C), has been used for many years to destroy tumours. 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 tumour cells lack an adequate blood supply to provide needed oxygen during periods of increased cellular demand, such as during hyper­ thermia. Cancerous tumours 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 radi- ation therapy, chemotherapy or biological therapy. Hyper­ thermia and radiation therapy are thought to work well together because hypoxic tumour cells and cells in the ‘S’ phase of the cell cycle are more sensitive to heat than radiation; the addition of heat damages tumour 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. Hyperthermia may enhance function of immune system cells, such as macrophages and T cells,