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GENERAL OVERVIEW OF CANCER

Definition of Terms  Aberration – growth which is unusual or expected; the act of departing from the right, normal or usual course.  Cellular aberration – process in the cell departing from the usual course  Cancer – a generic term encompassing a group of disease characterized by: 1. Uncontrolled growth and spread of abnormal cells. 2. Proliferation (rapid reproduction by cell division) 3. Metastasis (spread or transfer of cancer cells from one organ or part to another not directly connected)  Anaplasia – an irreversible change in which the structure of adult cells regress to more primitive levels; these cells lose their capacity for specialized functions, lack normal cellular characteristics and differ in shape and organization with respect to their cell origin; usually anaplastic cells are malignant (a hallmark of cancer).  Carcinoma – a form of cancer composed of epithelial cells; develops in tissue covering or lining the organs of the body, such as the skin, uterus or the breast.  Dysplasia – bizarre cell growth resulting in cells that differ in size, shape or arrangement from other cells of the same tissue type.  Hyperplasia – a reversible increase in the number of cells of a certain tissue type, resulting in increase tissue mass; most often associated with periods of a rapid body growth (e.g., adolescence and pregnancy)  Metaplasia – conversion of one type of mature cell into another type of cell metastasis; spread of one cancer cells from the primary tumors to distant sites.  Neoplasia – uncontrolled cell growth that follows no physiologic demand; neoplasm are characterized by uncontrolled functioning, unregulated division and growth and abnormal motility.  Tumor – an unusual swelling or growth of new cells. Incidence and Prevalence  Incidence rate of cancer – number of new cases occurring in a specified population during a year, expressed as the number of cancer diagnoses per 100,000 populations; it gives perspective on the current magnitude of the problem and provides a source for establishing future properties in cancer control program.  Prevalence of cancer – total number of people alive today whose cancer has been diagnosed in the current year, and those whose cancer has been diagnosed previously.  There is a reported increase incidence of cancer since 1900 because of  More advanced and precise diagnostic tools  Utilization of diagnostic test, which led to earlier diagnosis  Data collections and analysis of cancer statistics have become more sophisticated, which led to more accurate figure for incidence and mortality rates  People are living longer, meaning longer exposure to cancer causing agents Risk Factors of Cancer  Heredity From inheritance of defective genes; people at risk should reduce behaviors that promote cancer; cancer types with familial pattern of incidence include breast and colon cancer.  Age As a person ages, there is an increase in the number of years of potential exposure to carcinogen. There is also immune response alteration with aging, which decreases the immune surveillance against cancer cell proliferation.

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Free radical accumulation within cell also occurs overtime. Free radical damage has been implicated as a major contributor to cancer. Gender Female have a lower general risk of cancer incidence because while most women occasionally smoke and drink, men are more likely to be addicted too smoking and drinking. This increases their chance on having tobacco-related cancers, such as lung and throat cancers. Men make fewer visits to doctors than women do; men tend to wait until they feel that the disorder is severe or life threatening. In most cases, the condition could have been treated if they sought early medical intervention. A hormonal status is another factor. Females have increase incidence risk for Neoplasia in tissue responsive to estrogen such as breast endometrium, and the ovary. Men have increased incidence risk of Neoplasia in tissue responsive to androgens, such as prostrate and testes. Lower socio-economic status Clients with lower socio-economic status usually have inadequate access to healthcare, specifically resources for early detection and promt treatment, due to financial difficulties. Stress Continuous and unmanaged stress causes increased blood levels of epinephrine and cortisol, this result in endocrine system fatigue, impaired immune surveillance and lowered immune system function. Diet Certain preservatives in food, if taken frequently can have a cumulative effect; these are found in certain preservatives in pickled and salted foods. Certain types of diets like fried food, high-fat, low fiber foods promote colon and breast cancer. Food grilled on charcoal has been studied to be a triggering factor of colon cancer. Occupation Certain types of occupation can contribute to exposure to known carcinogens (asbestos), or radiation in workplace. Viruses Viruses are thought to incorporate themselves in the genetic structure of cells, changing the future generations of that cell population. Epstein-Barr virus is suspected as a cause of certain types of cancers like Burkitt’s lymphoma, nasopharyngeal cancers, and some types of Non-Hodgkin’s and Hodgkin’s disease. Herpes simplex virus type II, cytomegalovirus, and Human papillomavirus types16, 18, 31, and 33 are associated with dysplasia and cancer of the cervix. Hepatitis B virus is implicated in the cancer of the liver. Human T-cell lymphotropic virus maybe the cause of some lymphocytic leukemias and lymphomas. HIV is associated with Kapposi’s sarcoma. Bacterium Helicobacter pylori has been associated with an increased incidence of gastric malignancy. Tobacco use The amount of tobacco use and longer use have cumulative effects, this increases the risk for lung cancer. This is computed as pack years (number of pack/s smoked per day multiplied by the number of years of smoking); other forms of cancer with increased risk for smokers include oropharyngeal, esophageal, laryngeal, gastric, pancreatic, and bladder cancer. Alcohol use Alcohol use promotes cancer by enhancing contact between carcinogens in tobacco and the stem cells that line the oral cavity, larynx, and esophagus.

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Sun exposure (ultraviolet radiation) Prolonged exposure to the ultraviolet rays of the sun increases the rate of skin cancer because it causes reduction in the number of immune cells which remove sundamaged cells with malignant potential.

Difference of Normal Cells from Cancer Cells  A primary feature of cancer cell is loss of control over its growth.  For normal cells, the stimulus for cellular proliferation is the need for cell renewal or replacement. The growth of normal cells is rigidly regulated so that normal cells equal the number of cells lost by the cell death or injury. In cancer cells, this normal growth mechanism is lost or altered, causing cancer cells to divide continuously and without regard for the tissue requirement of the host. The number of new cells is greater that the number of cells lost, resulting in a tumor mass.  Most normal cells are limited to a number of divisions before they die (usually about 50). This programmed death is called senescence and is controlled by the cells normal biological clock, the telomere. Cancer cells contain an enzyme that is also found in the testis and the ovary. This enzyme called the telomerase prevents aging by duplicating the telomeres and replaces the segments lost during cell division, enabling the cells replicate indefinitely. Also the process of apoptosis is defective in cancer cells.  In culture, normal cells spread out in a uniform monolayer. If a cut is made through the single layer of the cells, the damaged cells disintegrate and other cells develop to restore the integrity of the monolayer. In contrast, cancer cells, when placed in the same culture medium continue to divide, crowding the space they occupy until the cells are piled on each other in an organized mass. Cancer cells are held less firmly to each other, move about more freely than normal cells to each other, move about more frequently than normal cells and also have fewer requirements of nutrients. Thus they have different density dependence than normal cells.  In normal cells, growth factors produced by one cell type bind to specific receptors of the cell membrane of the target cell, initiating a series of events that lead to mitosis. Cancer cells are able to grow and divide either in the absence of serum growth factors or in serum in which the concentration of growth factors is significantly reduced. This lack of dependence on growth factors means that cancer cells are independent in the body‘s normal control system that keep cell division and cell balance in balance. Some cancer cells even make their own growth factor.

Cell Cycle Cellular proliferations occur as a result of two coordinated events; the duplication of DNA within the cell, and mitosis, the division of the cell into two daughter cells with identical compliments of DNA. Control of the cell cycle resides in the cell‘s nucleus. The phases of the cell cycle are: 1. G0 Phase – a resisting or quiescent state, describes those cells not actively in the cell cycle. This category includes cell that will never divide (ex mature brain cells) and cells that are dormant but are capable of being stimulated to reenter the cell cycle in times of physiologic needs (e.g., hepatocytes) 2. G1 Phase – a period of decreased metabolic activity. During this period, the cell carries out its designated physiologic functions and synthesizes proteins in preparation for copying its DNA and in the S phase of the cell cycle. 3. S Phase – is the portion of the cell cycle in which DNA is duplicated. Normal cellular replication depends on the orderly synthesis of genetic material. Structural damage or disarray of the DNA molecule during its reproduction can result in cell

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death. Cells are most vulnerable to damage in this phase, and it is thought that many cell-cycle-specific chemotherapeutic agents exert their cytotoxic effects during this period. G2 Phase – immediately follows the S Phase and is characterized by another period of decreased activity. Cells entering this stage possess the duplicated genetic material synthesized in the S phase. Although some production of RNA and protein productions occur during this phase, cells in this stage are primarily awaiting entry into the mitotic phase. M Phase – mitosis; is the portion of the cell cycle in which the actual division of the cell occurs. The parent cell segregates the duplicated chromosomes and divides into two daughter cells. After mitosis, the cells either pass into G1 to reenter the cell cycle or enter the resting state of G0.

Pathophysiology of Cancer GENETIC BASIS a. Normal cell growth, differentiation, and division 1. The human body emerges from a single cell in a highly ordered sequence. Germinal cells give rise to specialized stem cells, which become more differentiated with each successive duplication into a variety of specialized cells, organs, and tissues. 2. Cell division occurs in a cell cycle, which is divided into 5 phases. 3. Cells in the body are divided into three groups based on their proliferation. Cells that are constantly renewing are those that must keep up with cell loss (e.g., bone marrow, skin, hair follicles, and mucous membranes). Renewing tissue come from stem cells that operate under various signals that operate under various signals that indicate a need for rapid proliferation. Stem cells must renew themselves as well as generate a large family of descendants. Cells that renew slowly but proliferate in response to injury (e.g., liver, lung, kidney, endocrine glands, and vascular epithelium). Cells that do not divide when they are differentiated (e.g., muscle, brain, bone and cartilage). 4. The decision of a cell to divide is based on a complex series of signals that come from its environment and from other cells. Signals are transmitted to the cell nucleus, which responds to the signals. Abnormal cells appearance and growth, differing from the normal cell cycle 1. The nucleus of the cancer cell is disproportionately larger and shows abnormal mitotic configurations. 2. Abnormal cells are pleomorphic, with a variety of shapes and sizes. 3. The cells surface does not contain normal antigens. Oncogenesis 1. Proto-oncogenes are normal cellular genes found in all species. Proto-oncogenesis control normal growth and proliferation of cells. 2. Oncogenes are mutated proto-oncogenes that produce abnormal growth factors, causing the signals for the cell to proliferate to remain on, resulting in excessive duplication and abnormal cell growth. 3. Oncogenes were discovered in retroviruses that were able to transform normal culture cells into cancer cells. Oncogenes are called dominant because the effects occur when only one of the two inherited proto-oncogenes is damaged.

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Tumor progression – third stage of cancer development. however.. Tumor formation is a multi-step process identified through animal over the past 50 years. thereby acting as a chemical carcinogen. CHEMICAL CARCINOGENESIS a. Apparently DNA viruses need a cofactor in the process (e. or (2) the energy transmitted causes molecules to lose electrons and become electrophilic. Two modes of damage are believed possible: (1) radiation energy causes direct damage to DNA molecules. Tumor-suppressor genes are recessive genes (i. b.e. Cells damaged by carcinogens may suffer lethal damage or maybe repaired by DNA repair mechanisms. The initiated cell by a chemical carcinogen and cannot be differentiated from normal cells. This cell is then initiated. malarial infection in Burkitt‘s lymphoma or Hepatitis B infection in hepatocellular carcinoma). Chemical carcinogens are electrophilic compounds that attach to the electron-rich sites on DNA nucleic acids. RADIATION CARCINOGENESIS a. The process is thought to be short and can occur spontaneously. Tumor suppressor genes are normal cellular genes that suppress the activity of growth promoting genes.g. Initiation – first step in chemical carcinogenesis. VIRAL CARCINOGENESIS a. Promotion – second stage of carcinogenesis. Tumor Biology Tumors are composed of proliferating cells (i. Carcinogenesis caused by radiation s is not as well understood as chemical carcinogenesis. The stages of promotion and progression in radiation carcinogenesis are not well understood.. such as lymphocytes and macrophages. is a process in which the initiated cell undergoes a series of changes under the stimulus of an agent or agents called promoters. at least until the first autonomous tumor cell is formed. Viruses are believed to cause cancer by direct DNA mutations or by inserting genetic material into the cell. causing mutation. They oppose the activity of proto-oncogenes and are often called antioncogenes. The process of viral carcinogenesis is not clear. 2. Damaged cells that have not been repaired and undergo replication. both copies of the gene must be lost mutated for the effects to be seen. Tumor growth varies among types of tumor as well as among individual tumors of the same type. Tumor growth is a function of cell growth being greater than cell loss. Growth depends on three factors: 5|Page . c. The process is reversible. It is an irreversible stage of tumor development in which cellular damage can be detected as the tumor accumulates more malignant characteristics. b. 1. blood vessels and connective tissue) and other cells. has been clinically but only recently studied. b.e.4. and the process is irreversible. d.. an irreversible process in which a permanent change is produced by a chemical carcinogen. pass the detect of the daughter cell.

a smaller percentage of cells are in the replicating pool. The time needed for a tumor to double in size many range from 1 month to 1 year. Tumor invasion and metastasis a. Tumor blood supply a. many do not.g. c. Tumor cell loss – many tumor cells are lost through necrosis and shedding. metastatic colon cancers develop in the liver. b.. Heterogeneity is well established by the time a tumor is clinically detectable. because the ability to prevent metastasis may have great implications for improved survival. Although a malignant tumor begins with transformed cells. Many metastases occur in the lung.a. Although some tumors follow the natural drainage pathways in spreading.. necrosis occurs. Subsequently. A tumor cannot enlarge more than 1 to 2 mm without developing a blood supply. Tumors spread by seeding cells within a body cavity (e. This size is 1000 greater than 1 cm size.. The malignant cell must adhere to and invade the basement membrane of the organ. 6|Page . b. the first capillary drainage bed encountered.g. subsequent mutations produce many subclones. invasion. Breast cancers tend to metastasize to the axillary lymph nodes. The process of metastasis is complex and not well understood. The rate of proliferation – the cell is similar for many tumors. Most cancers metastasize and a few do not. Brain tumors do not metastasize outside the central nervous system. by spread during through lymphatic channels. A tumor measuring 1 cm will have 109 or 1 billion cells. which possess different characteristics (e. the cells will grow if the environment is favorable and the tumor can establish its blood supply to continue growth. ovarian cancer without peritoneal metastases). Tumor cells do not divide more rapidly than their normal counterparts and often divide less frequently. Most cells in a tumor are not actively proliferating. through the blood stream). or by hematogenous mechanism (i. and first two steps are repeated before extravasating into the tissue. The capability to invade surrounding tissue and to establish independent tumors in distant sites is the hallmark of malignancies. Components of this process are being studied intensively. As tumor enlarges. metastasis).e. the tumor size will be 10 12 or 1 kg. b. Tumor doubling time a. The growth function or the number of cells that are dividing. Tumor heterogeneity a. b. intravasate into the bloodstream. b. which is the capillary drainage for all body organs. Tumor secretes angiogenic growth factors capable of inducing formation of blood vessels by which the tumor can support itself. - - c. This size is reached after approximately 30 doublings. As tumor enlarge and some cells outside their blood supply. pass through the extracellular matrix.

7|Page . it is believed only one survives. Tumor cells produce variety enzymes to breakdown membranes.000 cells shed from a tumor that enter the blood stream. In studying breast cancers. The nm 23 (nonmetastatic) gene has been identified in some human tumors. How these gene functions is still unknown. whereas those with low or absent nm 23 levels had metastasis and poorer survival. individuals with high levels of nm 23 had better survival rates and less metastasis.- For every 10.

Rate of growth is variable and depends on level of differentiation. General effects It is usually a localized phenomenon that does not cause generalized effects unless its locations interfere with vital functions. Gains access to the blood and lymphatic channels and metastasizes to other areas of the body. Tissue destruction Often causes extensive tissue damage as the tumor outgrows its blood supply or encroaches on blood flow to the area. Ability to cause death Does not usually cause death unless its location interferes with vital functions. usually encapsulated. such as anemia. weakness. Mode of growth Rate of growth Metastasis Does not spread by metastasis.Differentiating Benign from Malignant tumors CHARACTERISTICS OF BENIGN AND MALIGNANT TUMORS CHARACTERISTICS Cell characteristic BENIGN Well differentiated cells that resemble normal cells of the tissue from which the tumor originated. Rate of growth is usually slow. Tumors grow by expansion and do not infiltrate the surrounding tissues. Usually causes death unless growth can be controlled. Does not usually cause tissue damage unless its locations interfere with blood flow. Grows at the periphery and sends out processes that infiltrate and destroy the surrounding. and weight loss. 8|Page . Often causes generalized effects. may also produce substances that cause cell damage. the more anaplastic the tumor. MALIGNANT Cells are undifferentiated and often bear little resemblance to the normal cells of the tissue from which they arose. the faster its growth.

Hoarseness can be produced when tumor interferes with the vocal cords or when a thoracic tumor impinges on the recurrent laryngeal nerve and indirectly affects the vocal cord function. Many symptoms related to cancer are produced when a tumor impinges on a structure. Infect and fever are produced when an overwhelming number of abnormal white blood cells in leukemia reduced the ability of normal cells to produce immunity and resistance. uterus. extremities. causes jaundice by obstructing the common duct. Inability to swallow occurs when tumors in the esophagus reach a sufficient size to obstruct the lumen. or interferes with the normal function of the organ. Palpable masses located near the body surface are readily detected. Common tumors can manifest themselves by bleeding are cancers of the lung. Tumors in the breast. Tumors within the colon cause changes in the caliber of the stool or cause constipation an diarrhea or both. Bleeding or discharges occurs when tumors have friable surfaces and external egress. colon. nd kidneys.General Assessment for People with Cancer Cancer‘s 9 Warning Signs Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion and difficulty of swallowing Obvious change in a wart or mole Nagging cough or hoarseness Unexplained anemia Sudden weight loss Key Symptoms and their Pathophysiologic Bases Cancer symptoms most often are determined by size and their location of the tumor. and thyroid are often seen of felt by the client. Skin cancers are visible as either a new growth or change in the mole or a wart. partially or totally obstructs the lumen. bladder. Pancreatic tumors located near the sphincter of the Oddi. Most tumors of the oral cavity can be felt or seen. - - 9|Page . Brain tumors manifest themselves with specific symptoms caused by pressure on discrete brain areas or by obstruction of the flow of the cerebrospinal fluid and production of increased intracranial pressure. stomach.

Before the test. Information and instruction in breast. eyeglasses. and skin self examination. Pain is generally a manifestation of advanced cancer. such as hair clip are removed. and recommended screening test can ultimately save lives. Contraindicated to pregnant clients. except possibly from lying on the hard table. 10 | P a g e . and anorexia are systematic symptoms related to cancer and are seen most often in advanced disease states. 3. Health History The standard medical history is used when obtaining information from a symptomatic individual. fluids and medications are not restricted before the procedure. explain the client that: A technician or radiologist will perform it. warning signs of cancer. Attention is given to risk factors that correlate with symptoms and a family history of cancer Nurses have great opportunities to assess cancer risk and teach early detection to all clients Early detection of cancer provided optimal treatment and survival. 3. The area to be examined will be immobilized or the client will be asked to remain still during the procedure. Many cancers produce no symptoms and are found inadvertently during routine tests or other producers. 4. The procedure takes about 15 minutes. Provide a hospital gown if needed. 1. Foods. weight loss. 2. testicular. Views maybe taken by the client in various positions on the x-ray table or in an x-ray chair. - Diagnostic Tests for Cancer X-rays (roeontogenograms) Used to evaluate the bones and soft tissues of the body. Nursing Considerations a. Instruct the client to remain still during the procedure. 7. 2. Prepare the client by: Obtaining a history of known underlying medical conditions or trauma and (for women) date of last menstrual period to determine possibility of pregnancy. No sedation or anesthetic is administered before the procedure. 6. 5. Indicated for suspected neoplasm (benign or malignant). 4. Attention to health habits/lifestyle can provide opportunities to teach cancer prevention. Fatigue. b. jewelry. Ensuring that all dental prostheses.Pain can be produced when tumor invades nerves or when obstruction is caused. or other metal objects. The procedure should not cause discomfort. 1. unless benefits of performing of the test greatly outweighs the risk of the fetus.

chest thickness. ribs and spines. 5. unless benefits of performing the test generally outweigh the risk to the fetus. these high-frequency waves are directed into internal tissues and reflected back to the transducer. Obtaining a history of previous or existing conditions. b. 2. therapeutic regimen. or other abnormality or trauma that can increase the space between the part to be examined and the transducer. Contraindicated to a client who is unable to remain still during the procedure. is imaged with a clarity superior to that of plain films. A disadvantage of tomography is the high level of radiation exposure to the client. perform some neurological tests and vital signs and compare to the baseline data . 11 | P a g e . There are no fluid or food restrictions before the procedure. Prepare the client by: 1. Before the test. Indicated for diagnosing a tumor or solid mass. turn or sit up during the procedure. They are then electronically processed and appear as images on a display screen or oscilloscope for immediate visualization. when combined with computers in computed scans or CTs. and results of previous laboratory tests and procedures.5. a two-dimensional slice. - Nursing Considerations a. Computed Tomography An imaging technique in which a selected body plane is isolated from the tissue on either side. explain to the client that: 1. a few millimeters thick. A gel will be applied on the area to be viewed and a device will be placed and rotated on the area. if desired. A picture is produced on the screen that the client can see. After the test. Indicated for suspected lung tumor when plain chest films are negative. The procedure takes about 30-45 minutes. 4. tomography produces three-dimensional images. 6. - - - Ultrasound A non-invasive instrumentation procedure that uses sound waves to obtain diagnostic information or to perform therapeutic protocols. Nursing considerations is the same with the x-ray. Other contraindications are obesity. 3. There is no pain or risk of complications associated with the procedure. That he/she will be placed in appropriate positions and requested to remain still. as well as for differentiating between a nodule and a solid tumor or a fluid-filled cyst. Contraindicated to pregnant clients. and can affect transmission of waves to and from the chest. as well as suspected tumor involving mediastinal structures. deformity.

Unstable medical conditions. The usual medical regimen can be continued except for those medications containing iron because they will interfere with imaging.2. and all magnetic objects including credit cards are removed and that a hospital gowns without snaps or other metallic closures will be supplied. Offering the client an opportunity to void before the procedure to ensure comfort. especially if blood flow studies are being performed. A special contrast medium maybe given IV before the study to enhance tissue imaging. Primarily used to assist in the diagnosis of conditions affecting blood flow and in the detection of tumors. or heart valves that can be displaced and cause injury to the client during the test. Presence of cardiac pacemaker that can be deactivated by MRI. and a computer that allows visualization of a body region. Nursing Considerations a. c. 2. e. b. Alcohol. depending to the region to be examined. 12 | P a g e . Obtaining vital signs for later comparison of readings. 3. c. 5. unless medications are given before the procedure. d. Produces cross-sectional. 3. Indicated for the diagnosis of benign. infections and any other types of tissue pathology because of its ability to produce images through bone tissue and fluid-filled soft tissues. Extreme obesity. radiologic beams. Magnetic Resonance Imaging A noninvasive procedure that uses magnet. Disadvantages are the cost of the procedure. unless benefits of performing the test greatly outweighs the risk to the fetus. Inform the client that the result will be with the physician one-two days after the test. primary and metastatic tumors in any body organ. a part. Pregnancy. 4. or administration of contrast medium. Clothing. caffeine-containing beverages. c. 4. Place the client on the examination table in a supine position during the test. The procedure requires 30-90 minutes. d. metallic clips or prostheses. radio waves to create a field of energy. Assisting the client to remove clothing and providing a hospital gown. and specific body organs. jewelry. Greatest advantages of MRI are its ability to obtain an excellent detailed image of the region studied without the use of radiopharmaceuticals. Extreme claustrophobic response that prevents the client from remaining still while enclosed in the scanner. ensure that the hospital gown is worn with the opening in front. - Contraindications are: a. the fact that all institutions do not provide this service. Before the test. and the need for immobilization for long periods to perform the procedure. d. a. multiplanar images of the entire body. b. and smoking are restricted for at least 2 hours and that food is withheld for at least an hour before the procedure. explain to the client that: 1.

Indication of the detection of masses. c. After the test: 1. and known or suspected pathology. 4. depending on the radioactive material selected and the organ to be studied. During the test. Claustrophobia is not uncommon and that an anti-anxiety medication can be administered to allay this feeling. 2. There is no discomfort during the procedure except for a venipunctures required when a contrast medium is administered. Note and report redness and swelling at the IV site (signs of phlebitis). Nuclear Imaging A procedure that uses radiopharmaceuticals (radionuclides in compounds that permit entry into the body tissues). Return the client‘s clothing and personal items. if the client is a child. c. Ensuring that dietary. a. Involves the administration of radiopharmaceutical injected intravenously or given orally. Provide more physiological information than the structural types of information gained from radiologic studies. Administering ordered medications for anxiety or sedation. Inquiring about the presence of devices or prostheses in any part of the body. last menstrual period to ascertain possible pregnancy. Advised that he or she can speak to the technician during the study if desired.6. Can be used to complement x-ray procedures or can be used exclusively to study an organ that has no comparable x-ray procedure. Prepare the client by: 1. 5. followed by the measurement of the radiation emitted. 8. 3. A study clanging noise will be heard during the procedure and that earplugs are available. fluid and other restrictions have been followed. 2. the client is: 1. a sedative can be given to ensure immobilization during the procedure unless blood flow studies are to be performed or the care giver could talk or read to the child during the procedure. if applicable. if desired to block out the noise. 3. results of laboratory test and diagnostic procedures. apply ordered warm compress to the site and elevate the arm. b. 4. and presence of claustrophobia. Obtaining a history of allergies or sensitivities to contrast media. Requested to lie very still throughout the entire procedure. and computers to visualize organs and study the dynamic processes that differentiate normal from pathological tissues. d. fluid and medication intake. 3. Providing a hospital gown and ensuring that all metallic objects have been removed from the client and are safely stored. Instructed to take deep breaths if nausea is experienced due to claustrophobia. 2. 7. Advice the client to resume usual food. b. Also advice to keep the eyes closed to promote relaxation and prevent a closed-in feeling common to those undergoing this procedure. Provides clinical information with a much lower dose of radiation than x-ray procedures and are much less expensive than other imaging procedures. radiation detectors with imaging device. or both and antihistamine or steroid (for known sensitivity to iodine) 6. - 13 | P a g e . Have the client void. d.

arteries of the organs and tissues (arteriograms). c. Inform the client that the radioactive substance is eliminated from the body within 624 hours and tat fluid intake should be increased to encourage elimination. Nursing Considerations: a. unless prophylactic medications are administered or non-iodinated contrast medium is used. 3. and known of suspected allergy to iodine. 6. 7. usually in the urine. apply warm compress to the site and elevate arm. These are films taken in rapid sequence after injection of iodinated contrast medium into the vessel or vascular system to be examined. A minute amount of radioactive material will be administered by IV injection and that this will not cause harm to the client or those in contact with him or her. the client is placed on the examining table in a supine position and is reminded to lie very still while the scanner is operating. Before the test. After the test: 1. Angiography Serial radiographs (x-rays) of blood vessels that are used to evaluate the patency. A sedative maybe administered to promote relaxation. A physician will explain and perform the procedure. The radioactive material is exerted by the body. or lymph vessels and nodes (lymphograms). 2. with a machine that moves over the area to be examined. Indicated for suspected benign or malignant tumor and differentiation among tumor types. 2. Instructing the client to void before the test to prevent discomfort or interruption. The only discomfort experienced is the injection of the radiopharmaceutical. depending on the material used. Obtaining a history to ascertain date of last menstrual period date and possible pregnancy in women of childbearing age. Nursing Considerations a. 2. unless benefits of performing the test greatly outweighs the risks to the fetus. During the test. Note and report redness and swelling at the IV site (signs of phlebitis). 3. 5. Advice the client when to return for additional imaging. 14 | P a g e . unless benefits of performing the test greatly overweighs the risk to the fetus. b. d. c. explain the client that: 1. Scanning will take place immediately after the injection or at a later time. - Contraindications are: a. Before the test. size and shapes of the veins (venograms). Allergy to iodinated contrast medium.- Contraindicated for pregnant clients. Pregnancy. if appropriate. Presence of a bleeding disorder. explain to the client that: 1. The procedure takes about an hour. A medication to enhance scanning can be administered before the procedure. 4. b. Prepare the client by: 1.

4. 6. if needed. 9. The client may experience some pressure as the catheter is introduced into the vessel and a feeling of warmth and possible palpitations when the die is injected. fluid and medication restrictions have been followed before the procedure. and bleeding time as well as routine urinalysis and electrolytes. lung or renal condition. 5. 3. 10. and to observe the client for signs of complications although complications are rare. 9. using peripheral pulses on the appropriate extremity. An analgesic. After the test: 1. Transfer the client from x-ray table and place him or her at rest for 8-12 hours after the procedure to prevent bleeding from the puncture site. b. PTT. During the test. Ensuring that dietary. The time required to complete the procedure varies with the type of examination performed for diagnostic or therapeutic purposes but generally. 6. d. platelet count. PT. hearing aids or both. 4. Also. sedative. Foods and fluids are withheld for 4-8 hours before the procedure. 7. 8. Obtaining a history of allergies or sensitivities to the anesthetics or contrast medium. Removing all metallic objects. existing heart. Shaving and cleansing the insertion site. Bed rest is required for about 8-12 hours after the procedure to monitor the insertion site and vital signs. Obtaining and recording baseline vital signs. inform the client that some pain will be felt at the puncture site when the catheter is inserted. or antianxiety agent can administered through injection before the procedure to promote relaxation and alleviate discomfort depending on the physician‘s order. that anticoagulants will be withheld or dosage reduced to prevent excessive bleeding. Ensuring that hematologic status and blood clotting ability have been assessed to include complete blood count.2. the client is placed on a table in a supine position with straps in place to prevent falling and keep the client very still during the procedure. Having the client void. depending on the client and the reason for medication taken. 15 | P a g e . clotting time. 3. The client is requested to stand still throughout the procedure. Some medications can be withheld for 8 hours before the examination. Elevate the head of the bed to 45 degrees and extend the extremity used for the insertion site. it may take 1 to 3 hours. and that aspirin products are withheld for at least a week before the procedure. 7. An IV line is initiated before the procedure to provide access for the administration of fluids and medications when needed. 8. The catheter insertion site will be anesthetized by local injection. c. 2. 5. Administering pre medications subcutaneously or intramuscularly as ordered. 2. but allow client to wear dentures. Marking these sites (peripheral pulses) on the kin to ensure that the same location is used to monitor and compare readings to assess circulatory status after procedure. Prepare the client by: 1. and date of last menstrual period in women of child bearing age to determine the possibility of pregnancy. but last only about 30 seconds.

10. 5. Inspect the insertion site for bleeding or hematoma formation. Note and report the following reactions to anesthetic agent or contrast medium: tachycardia. apply pressure for 15 minutes after the procedure. Malignant cells may show large. A mild analgesic can be administered for pain felt on the site of insertion. darkly stained irregular nuclei. Immobilize the extremity with a sand bag. Cystologic Examination (diagnostic test used to diagnose cell type) Cystology refers to the study of structure. In performing cystologic examinations. Both methods are used primarily to detect cancer. first via IV line and then orally when the client is able to prevent dehydration and promote excretion of the dye. Note and report pain. function and pathology of cells. 8. 6. Assess skin color.3. then every 30 minutes for the next 2 hours. 9. Administer analgesic and antibiotic medications as ordered. Laboratory techniques were developed by George Papanicolaou. Histology deals with the study of structure. 16. dyspnea. Apply ice to the site to relieve discomfort and edema by promoting vasoconstriction of the vessels. 13. The differentiation is based on the changes that occur in the relationships between cytoplasm and the nucleus of the cells. 15. take peripheral pulses of the extremity used. redness. Administer antihistamines and steroids if there is reaction to anesthetic agent or contrast medium. samples of such cells Can be obtained through sputum specimens. who identified characteristic that allowed for differentiation for normal form neoplastic cells. 8 hours for a leg and 3 hours for an arm. The most common site examined through Cystologic methods is the uterine cervix and endometrium (site of Pap smear). Encourage fluid. swelling at the site. sensation and temperature of the extremity to determine circulation status. hyperpnea. and to exercise other body parts. slides with cells are stained with various substances and examined microscopically. from bronchial brushings or washings obtained during bronchoscopic examinations. Monitor site for signs of bleeding or hematoma. function and pathology of tissues. and change the pressure pressing if needed. 14. 12. 11. and the every hour for the next 8 hours or more if needed. 4. or changes in the peripheral pulses. and compare the value obtained with the pulses taken from the same and the other extremity taken before the procedure. or from post bronchoscopy sputum specimens. these should be removed a week after the procedure. Inform client that if statures are used. initiate oxygen therapy and resuscitation if needed. Advice the client to turn from side to side. Cystologic measures are used mainly as screening procedures to detect precancerous and malignant cells. monitor site for changes and apply ordered warm compress. - - 16 | P a g e . apply ice and pressure dressing. Perform pulse assessment every 15 minutes for the first hour. or delayed feeling of itching (urticaria or rash). 7. Cells from the respiratory tract are also frequently examined. note and report excessive bleeding from the insertion site or presence of hematoma.

- Various body fluids can also be examined for abnormal cells. c. Identification of Tumors Used to standardize diagnosis and treatment protocols.g. grading (describing aggressiveness) and staging (describing spread within or beyond tissue of origin). and synovial effusions. Burtkitt‘s lymphoma. peritoneal. Sarcoma – tumors arising from fibrous connective tissues The specific type of the tissue is added to the stem word as a prefix. Incorporates the Latin stem to identify the tissue from which the tumor arises 1. such fluids include urine. pericardial. Carcinoma – tumors arising from epithelial cells. e. cerebrospinal fluid and pleural. myelocytic leukemia).. d. 17 | P a g e . 2.g. Involves naming the tumor according to the tissue or cell of origin. b. Malignancies of the hematopoetic system are named using the predominant immature blood cell type (e. Other names of tumors are derived from the persons who discovered that particular cancer (e. Hodgkin‘s disease). consist of classification (naming).. Classification of Tumors a.

Names of Selected Benign and Malignant Tumors According to Tissue Types Tissue Type Epithelia Surface Glandular Connective Fibrous Adipose Cartilage Bone Blood vessels Lymph vessels Lymph tissue Muscle Smooth Striated Neural Tissue Nerve cell Glial tissue Benign Tumors Malignant Tumors Papiloma Adenoma Squamous cell carcinoma Adenocarcinoma Fibroma Lipoma Chondroma Osteoma Hemangiona Lyphangioma Fibrosarcoma Liposarcoma Chondrosarcoma Osteosarcoma Hemangiosarcoma Lymphangiosarcoma Lymphosarcoma Leiomayoma Rhabdomyoma Leiomyosarcoma Rhabdomyosarcoma Neuroma Glioma Nerve sheats Meninges Hematologic Granulocytic Erythrocytic Plasma cells Lymphocytic Monocytic Endothelial tissue Blood vessels Lymph vesses Neurolemmoma Meningioma Neuroblastoma Glioblastoma. astrocytoma Medulloblastoma. oligodendroglioma Neurilemmal sarcoma Meningeal sarcoma Myelocytic leukemia Erthrocytic Leukemia Multiple myeloma Lymphocytic leukemia or lymphoma Monocytic leukemia Hemangioma Lymphagioma Hemangiosarcoma Lymphangiosarcoma 18 | P a g e .

4. Alpha-fetoprotein (AFP) – hepatocellular carcinoma. 7. 2. 3. embryonal cell tumors of ovary or testis. CA-125 – epithelial ovarian neoplasm. pancreas. liver. b. Grade IV tumors (poorly differentiated or undifferentiated. These are produced by a tumor or by other cells in response to a tumor. N – Refers to lymph node involvement. Carcinoembryonic antigen (CEA) – colon. CA-27-29 – breast. The tumor is assigned a numeric value ranging from I to IV: 1. 6. ovary. Grading evaluates the degree of differentiation and rate of growth: 1. lung. Diagnostic Tests Used to Identify Tumor Markers Tumor markers are protein molecules (biochemical indicators) detectable in serum or other body fluids. teratoma. Human chorionic gonadotropin (HCG) – choriocarcinoma. breast. Staging of Tumors a. choriocarcinoma. Prostate specific antigen (PSA) – prostate. b. colorectal. 5. pancreas. Cells that are most differentiated resemble the parent tissue and therefore least malignant and least aggressive. 8. testicular. Grade I tumors (well differentiated tumors. Commonly used serum tumor markers and malignancies associated with elevation are: 1. most aggressive) are tumors that do not clearly resemble the tissue of origin in structure or function. gastric. absence or presence of distant metastasis. M – Refers to the extent of metastasis. Cells that are least differentiated do not resemble the parent tissue and are therefore most malignant and most aggressive. breast. Most useful in monitoring client‘s response to therapy and for detecting residual disease. absence or presence and extent of regional lymph node metastasis. germ cell. Staging determines the sign of the tumor and the existence of metastasis. rectum. 19 | P a g e . Some tumor markers are not sufficiently sensitive or specific to be used as screening tools because small amounts can also be found in normal body tissue or benign tumors. CA-15-3 – breast. T – Refers to the extent of the primary tumors. least aggressive) closely resemble the tissue of origin in structure and function 2. gastric.Grading of tumors a. High levels of tumor markers are suspicious for malignancy and require follow-up diagnostic studies. CA-19-9 – colorectal. 2. The TNM is the internationally recognized staging system and is frequently used. gastric. hydatidiform mole.

Drapes will be placed to avoid exposure and prevent embarrassment. e. Prepare the Client By: 1. A light meal in the evening before and fluids the morning of the procedure is allowed. d. acute peritonitis. He/she will be place in a knee-chest position for the rigid protoscopic examination or a left lateral position for the flexible fiber optic position. The urge to defecate can be experienced when the scope is inserted. deep breathing through the mouth can help alleviate this feeling. Bowel preparation is always needed before the procedure to clear the rectum and sigmoid colon of feces to enhance visualization. 7. Large abdominal aortic or iliac aneurism Severe bleeding or blood coagulation abnormality. excision of the tissue for cystologic analysis. 5. and that the client will be allowed to practice this breathing technique beforehand. Obtaining a history of bowel disorders. Can be performed using a rigid or flexible fiberoptic endoscope. Contraindicated for: a. 8. the rectum (proctoscopy). 4.Diagnostic Tests Used for Direct Visualization Proctosigmoidoscopy Direct visualization of the mucosa of the anal canal (anoscopy). Severe cardiopulmonary disease. Before the test. A laxative and enema before the procedure can be administered the night before. b. 3. toxic megacolon. The lubricated scope will be inserted into the rectum after the physician performs a digital rectal examination. 20 | P a g e . Advanced pregnancy. and the distal sigmoid colon (sigmoidoscopy). explain to the client that: 1. diverticulitis. Nursing Considerations: a. Suspected bowel perforation. 6. 9. Specimens can be obtained and suctioning performed through the scope to remove excess materials during the examination to enhance visualization. b. or ischemic bowel necrosis. Slight rectal bleeding can be experienced after the procedure if polyps or tissue is excised but what it should not persist for longer than two days. acute fulminant colitis. and blood studies that indicate a coagulation disorder. 2. c. Indicated for cancer screening with identification and polyp removal. that slow. The procedure requires about 15-30 minutes. pregnancy status.

Indicated for: 2.) 3. Monitor for signs of colon perforation. urinary bladder. Ensuring that bowel preparation has been implemented (laxatives or enema or both. in the evening and one or two enemas in the morning before the study) 4. 5. c. fever. During the test: 1. or pain on defecation. Assist the client in cleansing and remaining lubricant from the anal area with commercial wipes or mild soap with warm water. note and report amount of bleeding from the rectum or changes in vital signs for potential hypovolemia. 8. 6. note and report abdominal pain and distention.Ensuring that dietary and fluid restrictions have been followed (light meal in the evening and liquids in the morning before the procedure. After the test: 1. 7. initiate IV line and prepare the client for surgical repair of the colon. and privacy. and repot to the physician any changes from the baselines. Remind the client that slight rectal bleeding or blood in the stool can be noted for up to two days. 5. warmth. Providing the client will a hospital gown. Monitor signs of persistent bleeding.. Instruct the client to report to the physician any abdominal pain or distention. d. Assisting the client on positioning depending on the instrument to be used: (fiber-optic scope) left lateral position with the buttocks at or extending slightly beyond the examination table or bed. if needed. Cystoscopy Direct visualization of the urethra. 21 | P a g e . 4. 3. Take vital signs again. and/or mucopurulent drainage or bleeding from the rectum. and urethral orifices by means of a rigid cystoscope inserted through the urethra. 2. Provide a sitz bath that can soothe and relieve discomfort. Gradually assist the client to a sitting position to avoid possible orthostatic hypotension. or the knee-chest position on a special examination table that tilts the client into the desired position (rigid scope) 2. prepare for procedure to control bleeding at the biopsy or removal site. Instructing the client to void. Assisting the client to the supine position and allow to rest for a few minutes or as needed. Drape the client to provide comfort. Flexible fiber optic cystoscopes are also available and are used in different sizes and varieties depending on the reason for the procedure. 9.

If a local anesthetic is administered. general. explain to the client that: 1.a. a sensation of pressure. A special microscope-like instrument will be inserted into the urethra to visualize the bladder. Administering ordered antibiotic therapy. 3. PTT. 8. 22 | P a g e . The study may take 30 minutes or more. 3. Nursing considerations: a. 7. A burning sensation or discomfort on urination can be experienced during the first few voiding and that the urine will be blood-tinged for the first and second voiding after the procedure. an antibiotic maybe administered before and after the procedure. 9. a need to void. 6. 5. 2. 5. Ensure enough time to practice techniques. or both can be experienced as the procedure is performed. 2. such as local. and urinalysis results for abnormal results. Acute cystitis or urethritis – instrumentation can allow bacteria to enter the blood stream and cause septicemia. Differentiation of benign and malignant lesions involving the bladder through tissue biopsy and laboratory analysis. 4. the nurse should give instructions in breathing technique and other postoperative activities. Obtaining a history of genitourinary infections. To prevent infection. Foods and fluids are withheld for 8 hours before the procedure if general or spinal anesthesia is used and that intake is restricted to clear fluids for 8 hours before the procedure if local anesthesia is used. If the client will undergo general anesthesia. An anesthetic will be administered. b. Bleeding disorders – use of instrumentation can lead to excessive bleeding from the lower urinary tract. b. or spinal. Providing a hospital gown. Removal of polyps and small tumors from the bladder. PT. depending in the age of the client and the procedure to be performed. or other disorders of the urinary tract. Contraindications: a. Vital signs and urinary output will be monitored closely after the procedure. c. Identification of tumors and polyps. 6. Ensuring that hematologic status and blood clotting abilities have been assessedincluding CBC. b. platelet count. Prepare the client by: 1. bleeding disorders. Before the test. Administering enema if ordered. Ensuring that dietary and fluid restrictions have been followed base on the type of anesthesia to be administered. 4.

voiding frequency. the time and amount of voiding. 4. frequency of small amounts of urinary output. and the appearance of the urine. Monitor for signs and symptoms of urinary tract infection. 2. A general or spinal anesthetic is administered before positioning. positive culture results. If a local anesthetic has been administered . Resume foods and fluids withheld before the procedureand. The external genitalia are cleansed with an antiseptic solution. If bladder spasms occur. 8. 5. 4. and then assist him or her to get up from the table. or chills and fever. If a local anesthetic is used. 3. and provide warm sitz or hip baths for adults or tub baths for children. if bacteremia is suspected. allow the client to rest in the supine position for several minutes. After the test: 1. During the test: 1. 6. Assess the resumption of normal voiding patterns. increase fluid intake to 3. persistent blood-tinged or bloody urine. The client is positioned on the special cystoscopy table with the legs placed in stirrups and draped for privacy. note and report dribbling. 5. or bladder distention. 3. 9. 9. administer cholinergic such as bethanechol (urecholine) to stimulate contraction of the bladder. depending on the type of anesthesia to be used. encourage fluid intake. note and report burning on urination. A penile clamp can be used for male clients to aid in the retention of the anestehia. Monitor for signs of hemorrahage. Administer an analgesic such as phenazopyridine (Pyridium) for dysuria caused by edema. c. Such premedications include meperidine (Demerol) to promote relaxation and atropine sulfate to decrease secretions. 7. Obtaining and recording vital signs for later comparison readings. administer antimicrobial therapy as ordered.000 mL within 24 hours of the procedure to dilute urine. or fever and chills. Administering premedications subcutaneously or intramuscularly as ordered. it is instilled in the urethra and retained for 5 minutes. 8. any persistent difficulty or change in urinary pattern. if not medically contraindicate. increase fluid intake to 3. 23 | P a g e . hesitancy. d. cludly or foul smelling urine or both. 2. monitor intake and output for at least 24 hours after the procedure. Having the client void. Monitor for signs of urinary retention. prepare for catheterization to measure residual urine. administer an anticholinergic. Remind the client to report flank or suprapubic pain.7.000 mL if appropriate. note and report hematuria (excessive and persistent) and amount of biopsy was performed. instruct the client as to which foods and medications irritate the bladder and wich fluids promote an acidic urine.

the left hand under the pillow at the head. prepare for surgical repair. gastroscopy.report changes in vitl signs indicating hypovolemia. Nursing Considerations: a. c. duodenoscopy and esophagogastroduodenoscopy (EGD). The client is seated in a semi-reclining position and the oropharynx is sprayed or swabbed with a topical local anesthetic. maintain sterile-closed system. The type of anesthesia is usually local but be general if the client is unduly apprehensive. not endoscopy. 3. His or her history will be obtained including known or suspected gastro intestinal tract disorders. and the knees drawn up at the right angel to the body. Monitor ureteral of urethral catheter obstruction. the neck slightly flexed. 2. stomach and upper duodenum. note and report suprapubic pain or excessive hematuria. b. 3. and provide catheter insertion site care as appropriate. Indicated for diagnosis of tumors of the upper small intestine. maintain bed rest for 4 hours if possible. Inform the client that: 1. Depending on the client‘s condition. 11. Known or suspected prforated viscus. 4. and because endoscopic instrumentation can further aggravate the situation. because mild hypoxemia can be induced by EGD. 10. Endoscopy Dire visualization of the mucosa of the upper gastrointestinal tract which includes the esophagus. Client teaching and physical preparations before the test are the same as those described in cystoscopy. vital signs and cardiac rhythm can be monitored throughout the procedure. 24 | P a g e . Aneurism of the aortic arch because of the risk of rapture. administer ordered medications. Maybe performed for therapeutic as well as diagnostic purposes. and other diagnostic tests and procedure he or she has undergone. 2. The procedure takes at least an hour and that an IV line is initiated to administer fluid and additional medications immediately before the procedure. note and report drainage difficulty. maintain patency and connection to a closed collecting system avoid kinking or tension on catheter. The instrument is inserted in the mouth and passed in the stomach and intestine. d. Any or all the three structures can be included in the examination and can be referred to as esophagoscopy. b. if biopsy was performed. using a fiber-optics endoscope. with the right hand at the side. Unstable cardiac status. Recent gastrointestinal surgery. treatment regimen. because the situation indicated surgery. The client is then assisted on a left-lateral position. During the procedure: 1. c. Contraindications: a. Monitor for bladder perforation.

initiate IV line for fluid replacement. prepare for intervention to repair damaged area. 5. 14. difficulty of breathing. Monitor for reaction to anesthetic agent or medications. back or upper abdomen. and a bite block is also inserted to maintain an open mouth without client effort or control. bloating. A protected guard is inserted into the mouth to cover the teeth. note and report neck pain or pain when swallowing. 6. Restrict activities until the sedative or anesthetic effect has worn off and the client is awake and alert. dyspnea (diaphragm). 13. hemoptysis (bleeding at the cervical level). maintain the client in a side lying position and suction airway. breath sounds and comfort level. 4. note and report hemoptysis. 5. provide resuscitation as needed for immediate interventions. or changes in vital signs for potential hypovolemia if bleeding is ecessive. note and report dyspnea. Instruct the client to report immediately any postprocedural discomfort or pain in the chest. chest pain that increases with breathing (bleeding at the thoracic level). site and degree of pain continuously. note and report pain in the shoulder. 8.4. Provide warm saline gargles or throat lozenges to alleviate throat discomfort. Remind the client that belching. or changes in vital signs for potential hypovolemia. note and report tachycardia. initiate IV line for fluid volume replacement or transfusion of blood or packed RBS as ordered. hematemesis. 7. pain on swallowing. 12. palpitations. cyanosis. Monitor for pulmonary aspirations. substrenal or epigastric pain. if needed. 15. 6. hypoxemia. Monitor vital signs and cardiac rhythm as well as respiratory status. Assist the client to a position of comfort with the head slightly elevated. prepare for intervention to repair damaged area. Advice the client that breathing deeply will help to allay gagging and choking. or blood expectoration. Monitor vital signs. Monitor for perforation of the diaphragm or stomach. or changes in vital sign for potential hypovolemia. or signs and symptoms of aspiration pneumonia or pleural effusion. administer antibiotic therapy if pneumonia is present. Advice the client to withhold food and fluids for 4-6 hours. or flatulence if the result of air insufflations. Maintain the client on a side-lying position for 1-2 hours to prevent aspirations of secretions. black tarry stool. and compare with baselines. 2. Assess swallowing ability. 10. 16. abdominal or back pain (stomach). 11. until swallowing ability returns. provide soft foods and warm soothing fluids. d. hyperpnea. 25 | P a g e . initiate IV line and resuscitation. 9. After the test: 1. and encourage the client to expectorate any accumulated secretions. The client is informed that speaking is not possible but the breathing is not affected. abnormal breath sounds. administer ordered anti histamines. Monitor for perforation of esophagus. 3. When the gag reflex and swallowing ability returns. Monitor for persistent bleeding. neck. or hypertension.

Indicated for therapy though local treatment of known lung cancer through instillation of chemotherapeutic agents. Other non-specific tests to determine involvement of the other organs include CBC. the biopsy is taken from the actual tumor. Monitor for cardiac abnormality. Indicated for diagnosis through: a. and blood chemistries. b. Severe obstructive trachealconditions. In most instances. such as biopsy is usually performed to obtain a tissue sample for analysis of cells suspected to be malignant. differential count. Determination of the cause of unexplained abnormal cystologic findings in sputum. This procedure can be both diagnostic and therapeutic. The three most common biopsy methods are: a. Needle biopsy – involves aspiration tissue fragments through a needle guided into a suspected area of malignancy. or laser palliative therapy. Pulmonary hypertension that can be associated with an increased risk of hemorrhage from the procedure. Determination of the stage of known bronchogenic carcinoma to assist in determining the approach to treatment protocols. e. chest pain or alterations in blood pressure and pulse. 26 | P a g e . c. Nursing considerations: client teaching and physical preparation are the same as those described in ―bronchoscopy‖ Exploratory Surgery Lymph node biopsy to determine metastases. Bleeding disorders. trachea and bronchial tree by means of either a rigidor flexible bronchoscope. Contraindications are: a. Disorders that limit extension of the neck. b. Visualization of pulmonary tumor. implantation of radioisotopes. Incisional biopsy – performed if the tumor mass is too large to be removed. d. c. administer ordered cardiac medications. b.17. c. Excisional biopsy – the surgeon removes the entire tumor and surrounding marginal tissue. d. note and report dysrhythmias. Diagnostic surgery. Bronchoscopy Direct visualization of the larynx. monitor cardiac activity via ECG. electrolytes. Suspected bronchogenic carcinoma to obtain washings or by brushing of biopsy for cystologic analysis.

Instructions for the persons with cancer must be simple. Partial denial either to the parts of the cancer experience is common and can relieve distress for a short time. Some coping strategies can be productive in problem solving.  Denial can only be interfered from the persons observed behavior and statements. Denial allows the person to ignore or explain away unpleasant or threatening matters. Referral to community agencies that may be helpful is important. Abandonment of friends and family can be threatening to the individual. Most people are concerned with the fear f death during the first 100 days after the diagnosis.    Coping is often considered a response to a short-term problem. Faces the prospects of uncomfortable and painful diagnostic procedures. Coping skills are acquired over the person‘s lifetime and are influenced by the personality and life experiences. conscious decision not to thinking about the threat. which is a deliberate. whereas others are counterproductive. Extreme denial leads to poor compliance and block communication. Establishing a trusting relationship with the person who has cancer and the family members provides emotional during the first very stressful period of the diagnosis. if the person believes that lifestyle habits are the cause of the cancer. It involves conscious actions and differs somewhat from psychologic defense mechanisms. Guilt can be predominant emotion. Psychosocial support during the diagnosis is a very important part of the nursing intervention during diagnostic procedures because the client: Experiences extreme anxiety preparing for and waiting for the result of the diagnostic tests.Psychosocial Considerations for Cancer Clients Psychosocial assessment must be ongoing and based on observed statements and behavior of individuals. closing off options and increasing distress. Inappropriate optimism or unconcern on the face of a poor prognosis maybe evidenced of denial. and provided in writing. Denial is a natural defense mechanism that protects the ego against anxiety. Interviews with open-ended statements promote expressions of problems.      Coping is a dynamic process that seeks to restore equilibrium and reduce stress. reinforced. denial also includes suppression. Often they are seeking second opinions and need guidance in choosing appropriate resources.  Family Support 27 | P a g e . or if the person has delayed seeking medical attention. and repression which is unconsciously motivated forgetting. Anxiety decreases perception. where as adaption refers to ongoing adjustment to long-term problems such as chronic disease. disbelief. In cancer literature.  Shock. People with cancer and their family need information during the diagnostic period. which are unconscious. which adds distress to the family. and anxiety are common emotions experience with the diagnosis of cancer. which is often difficult.

Initial role changes in families are required. 28 | P a g e . Major metropolitan areas may have wellness communities or other support programs for people with cancer. Many families do not have adequate insurance to cover a major and longer illness. and then. mental status. year later. 3. Treatment Decisions Tumor-related factors that determine treatment decisions are tumor size. Persons who have a sever cancer phobia will indeed desert friends who are diagnosed with cancer. Community Support People with cancer are concerned over loss of friends. if possible with minimal structural and functional impairment. changes must compensate for the lost of that role. and responsiveness of the tumor to treatment methods. Adjuvant therapy has proven value in breast and colon cancer. Financial concerns may overwhelm the family. Individuals with health maintenance organization coverage may feel frustrated if they are not able to select the best cancer specialist. Whatever the role of the person with cancer in the family. then many roles are changed to provide support and care during treatment. Community resources may vary with geographic location. Person-related factors that influence treatment selection are physical condition. Few cancers can be cured once they have recurred or are metastatic at the time of diagnosis. The basic principle is to cure. resources available. require additional therapy for recurrent disease or palliation of symptoms. 2. Clinical Management for Cancer Goals of Intervention Treatment of cancer is intended to achieve one of three outcomes: 1. stage of disease. Those who live in the rural areas however may have to be more resourceful. Treatment for non-curable tumor is palliative and is directed toward control of tumor growth and relief of symptoms. An individual may undergo treatment for cure. histologic type and grade. and personal preferences. A determination of whether to treat for cure is one of the most critical treatment decisions. Cure is the primary goal for tumors that are localized or have regional lymph nodes metastasis and for hematologic malignancies that can be treated with curative intent. naturally history of the tumor. Adjuvant therapies refer to additional chemotherapy or radiation given after eradication of the tumor to prevent recurrence and therefore improve curability. Cure Prolongation of life Palliation of symptoms Goals can overlap. If a child has cancer.

Burkitt‘s lymphoma. remains investigational. Surgery can be used to debulk the tumor mass and thus enhance the effect of chemotherapy or radiation therapy. with few exceptions. Treatment Planning Throughout the Continuum  Treatment aimed at Cure or Complete Response Curative therapy is often undertaken for localized or early-stage disease. Pharmacologic Interventions for Cancer Chemotherapy Chemotherapy is the only systemic primary treatment method that allows curative or palliative treatment of disseminated or localized disease. Treatment for cure option include the following:  Surgery is often the primary approach  Adjuvant therapy for localized disease (e. Non-Hodgkin‘s lymphoma (children). photodynamic therapy. bone marrow transplantation. Some clients may have long symptom free periods. radiation or chemotherapy) can eliminate micrometastases and can enable a less radical surgery.. testicular cancer.  Chemotherapy or radiation alone or in combination. Biotherapy has become the primary treatment for a few specific cancers. inconvenience. Hodgkin‘s disease.  Palliative Treatment Palliative treatment is used prolonging life is no longer an option. Adjuvant treatment includes hormonal therapy. Most investigational protocols are designed to improve chemotherapy and radiation therapies. Acute lymphoblastic leukemia. Hodgkin‘s disease. and surgery are used to control locally advanced disease.  Primary or neoadjuvant is chemotherapy and radiation sequenced before the surgery. and some types of biotherapy. but some advanced stage cancers can be cured (e. radiation therapy.g. Chemotherapy as cure  Chemotherapy is curative in selective cancers namely: Gestational trophoblastic tumors. and hyperthermia are investigational therapies available in some research centers. osteogenic carcinoma). radiation and chemotherapy are the primary treatment modalities for cancer. Biotherapy. Palliative therapy should minimize cost. Treatment for cure must be aggressive. Testicular tumors Chemotherapy as cure as adjuvant therapy 29 | P a g e . Diffuse large cell lymphoma. Treatment may involve any single or combined modality.  Treatment for Advanced Recurrent Disease Treatment goal is to prolong survival and possible provide cure. Chemotherapy.. and the first treatment is the best and often only opportunity for cure.Surgery. discomfort and risk.g. These are given in addition to or following primary cancer treatments to effect a cure or to prolong disease-free survival. Gene therapy.

ovarian cancer. head and neck cancer. Chemotherapy as complete remission with increased survival  For breast cancer. osteogenic sarcoma. esophageal cancer. prostate cancer. endometrial. cancer of the adrenal cortex. colorectal cancer. laryngeal cancer. Non-Hodgkin‘s lymphoma (indolent). Chemotherapy as a minor response with no demonstrable prolongation of survival  Non-small cell lung cancer. Chemotherapy as response with some prolongation of survival  Multiple myeloma. small cell carcinoma of the lungs. 30 | P a g e . acute myeloblastic leukemia. bladder cancer. pancreatic cancer. neuroblastoma. anus cancer. For Wilm‘s tumor. hairy cell leukemia. melanoma. cervical cancer. chronic granulocytic leukemia. osteogenic sarcoma and rhabdomyosarcoma. soft tissue sarcomas. stomach cancer. soft tissue sarcomas. liver cancer. Chemotherapy as Organ preservation (neoadjuvant therapy)  Breast cancer.

Combination of chemotherapy is the standard for most tumors and is given in protocols with specific dosage and administration intervals.Cytotoxic Drugs Cytotoxic drugs kill only a fixed proportion of cells.and double-stranded DNA break and cross links. 4. Cytotoxic drugs kill normal as well as tumor cells. Cross-resistance to other chemotherapeutic agents occurs even when their mode of action is different. Multiple doses of the drug are therefore required to eradicate tumors. or improvement in performance status. which induce DNA damage and can interfere in DNA repair. These agents cause single. The dose f the drug should be large enough to kill tumor cells while inducing only reversible and tolerable side effects from destruction of normal cells. The efficacy of the chemotherapeutic drug is measured by tumor shrinkage evident by palpation. Each dose kills a constant fraction of the remaining cells. Antitumor antibiotics (cell-cycle nonspecific) Drugs derived from the fungus Streptomyces or made synthetically. Although cytotoxic drugs are usually classified by similar modes of action. Cytotoxic drugs are more effective when they given in combinations as long as each drug is effective against the tumor as a single agent and the toxicities of the drugs do not overlap. imaging techniques. Antimetabolites (cell-cycle specific) 2. Overcoming drug resistance would improve curability. tumor marker measurements. Plant alkaloids (cell-cycle specific) These are drugs derived from Vinca plants or the May apply plant (VP-16). Groups of Cytotoxic Drugs 1. 31 | P a g e . Cell cycle or phase non-specific drugs damage DNA directly and effective during all phases of the cell cycle. excretion and administration. The action of VP-16 is not known. chemotherapy is more effective when the tumor burden is small and greater percentage of cells are proliferating. The Vinca alkaloids affect the structure of the microtubules during mitosis. Many mechanisms of drug resistance are postulated and are under investigation. Development of drug resistance is the major cause chemotherapy failure. They form free radicals. Cytotoxic drugs that interfere with the DNA synthesis (S Phase) or mitosis (M Phase) are cell cycle or phase specific. drugs within each group differ in their metabolism. Chemosensitive tumors may regress to the point of clinically undetectable and then grow while the person is on the same therapy. 3. Alkylating agents (cell-cycle nonspecific) These are drugs that cause alteration in the DNA by forming bonds on electron-rich nucleic acids. Combining drugs with different cell cycle activity exposes more cells to damage. Because cytotoxic drugs are more effective against proliferating or dividing cells.

or intra-arterial instillations. intracavitary. The principle for handling the drugs are:  Protect the client – the client is equally susceptible to the problems of exposure as the nurse administering the drugs. low-dose exposure are not known but the properties of the drugs already stated suggest they may be hazardous. The short-term effects of exposure to the drug can result in irritation of the skin. Most drugs are given at specified intervals to allow for recovery of bone marrow. Preparations. Handling and disposal of drugs Cytotoxic drugs are known to be carcinogenic (cause of cancer). Drugs are administered systemically through oral.  Protect the personnel – it is the nurse‘s responsibility to be aware and to follow policies and procedure in proper handling and disposal of this agents. Antimitotic antibiotics Originates from fungus They insert a ring between adjacent turns of DNA helix. subcutaneous. The dosage for most cytotoxic drugs is based on the body surface area of the person calculated from the height and weight. or physicians. the skin should be protected. specifically trained chemotherapy nurses. If this is not possible.5. They compete for or replace metabolites that are essential for DNA formation. intrathecal. chemotherapy can be given by staff nurse. mutagenic (cause of mutations) and teratogenic (affect embryonic tissue) Personnel can be exposed to cytotoxic drugs through inhalation of aerosols. absorption through the skin. inhibiting replication. - Cytotoxic drugs can be given as single agents or in combination with drugs or hormones. Drugs are given intermittently or by continuous infusion with an external or internal implanted pump device. which distorts the helix. The effects of long-term. All connections between the drug (syringe or container) and the client should be placed away from the client‘s skin. or ingestion of contaminated materials. Accurate measurements are critical to correct dosage.  Use a biochemical safety cabinet for the preparation of all chemotherapeutic agents.  Wear surgical gloves when handling antineoplastic agents and the excretion of clients who received chemotherapy. 32 | P a g e . eye and mucous membranes. Depending on the route of administration and institutional policy. Care should be taken to protect the skin. clinical nurse specialist. Intravenous therapy is the most common route. or intravenous route or regional through topical. Drugs functioning in the S phase of the cell cycle. Exposure to cytotoxic drugs should therefore be avoided by all concerned with their use. intramuscular.

Blood cultures and antibiotic therapy are instituted. Bone marrow suppression Hematopoietic stem cells are destroyed. are replaced for stem cell populations. Since 90% of new fevers in people with cancer are bacterial. Blood counts are monitored at appropriate intervals. On hospital admission. normal replacement and repair are inadequate. esophagus and intestine.  Protect the environment  Dispose of all equipment used in chemotherapy preparation and administration is appropriate. Mucositis Cells of the gastrointestinal lining from the oral cavity to the rectum. Blood counts drop. Effects of Chemotherapy to the Client 1. puncture-proof containers. and to monitor their temperature every 4 hours. Blood count lowest point occurs between the 7th and 14th dayafter drug administration and recover by the 21st day. and localized infections can progress to septicemia without the usual response of fever or inflamation. the person‘s response to bacterial infection is severely compromised. feces.  Dispose of all chemotherapy wastes as hazardous materials. leak-proof. to maintain good hygiene and hand washing. Leukocytes only survive 6 hours in the blood stream.  Client‘s body fluids (urine. The absolute neutrophil count is calculated by multiplying the number of leukocytes by the percentage of Neutrophils and bands. Persons with elevated temperatures or shaking chills are generally advised to contact their physician or return to the hospital immediately or both. 33 | P a g e . 3. which are continuously lost as fluids and foods pass through. Colony stimulating growth factors may be used to argument leukocyte production. Neutrophils function to localize and neutralize bacteria in the body. Individuals with neutropenia without fever can be managed as outpatients and are cautioned to avoid crowds and exposure to infected individuals. As chemotherapy destroys stem cells. a thorough physical examination is performed to determine any source of infection. Mucositis can occur in any portion of the gastrointestinal tract but is most common in the oral cavity.5o F to the physician or oncology nurse. Use luer-lock fittings on all intravenous tubings used to deliver chemotherapy. Rashes. Client are instructed promptly any temperature higher that 100. Delayed bone marrow suppression caused by some agents begins 4 weeks after drug administration. Marrow suppression is greater if active bone marrow sites have been reduced by previous radiation of tumor. fever. When neutropenia occurs. Stomatitis 2. sore throat must be reported. emesis) are considered hazardous for 48 hours after the treatment. a combination of penicillin and an aminoglycoside drugs are administered. they are unable to replace lost cells at the normal rate.

but eventually hair returns to its previous characteristics. Treatment consists of low-residue diet and anti diarrheal medications to control medications without complications. 4. additional interventions are used. Maintain lip moistures with lubricants Reduced irritation with diets that are chemical. 5. Concurrent thrombocytopenia can contribute to mucosal bleeding and neutropenia may decrease resistance to infection. dehydration. - 34 | P a g e . The proliferating cells at the base of the hair follicles are affected. Institution-specific protocols use the same general principles. poor nutrition. because it leads to dehydration and weight loss. mechanical. enteritis subsides in 7 to 10 days. Gonadal Suppression Amenorrhea or azoosphremia due to cytotoxic effects or reproductive cells can be temporary or permanent. Initial regrowth can differ in texture and color. The frequency of oral hygiene measures increases the severity of stomatitis. and thermally nonirritating. Enteritis Loss of intestinal mucosa can diminish absorption and cause diarrhea. Regrowth begins 4 to 6 weeks after discontinuing the treatment. Monitor infection with periodic cultures. Wigs for women are reasonably priced and can improve by styling of a professional hair dresser. Hair loss begins with 2 to 3 weeks following initiation of chemotherapy. causing either total destruction of the atrophy or the bulb. Poor oral hygiene. Hair loss occurs most commonly with doxorubicin. as well as mechanical. Instructions that warm the client of sudden hair loss are imperative to prepare the person for the anticipated assault on body image. Hair loss pronounced psychologic effect. Reduce pain with topical anesthetic. Treat infection with appropriate ordered antimicrobial drug. Following chemotherapy administration. and vincristine. Anti metabolite and antibiotic cytotoxic drugs cause stomatitis more frequently than any other drug groups. Maintaining oral hygiene with mouthwashes that are neutral (saline) or oxidizing (hydrogen peroxide with water). Stomatitis becomes serious problem when it prevents adequate intake of food and liquids. Alopecia Alopecia can range from scalp hair thinning to total body hair loss. dentures are cleansed frequently or removed if stomatitis is severe. clyclophosphamide. and nutritional intake. Drug dosage and duration of treatment affect the degree of stomatitis.Inflamation of the oral cavity ranges to mild discomfort to painful ulceration. as stomatitis progresses. 6. chemical or thermal irritants intensifies stomatitis. clients are instructed to maintain good oral hygiene and adequate fluid. Decrease saliva and chewing reduces the normal mouth cleansing. Reducing mechanical trauma to the tissue by using soft-bristled toothbrush or gauze.

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People with cancer are advised to use some of birth control during chemotherapy as Gonadal cell suppression maybe incomplete and many agents are teratogenic. Sperm banking can be considered for eligible males. Reproductive functioning can recur spontaneously, be delayed for many years, or be lost permanently. Fatigue Causes of fatigue are not clear. Weariness, decreased in strength and weakness are characteristics descriptions of fatigue. Reassurance that fatigue is common during chemotherapy and helping the individual set priorities, redistribute workload, avoid stress, and take frequent rest periods are methods of coping with fatigue. Nausea and Vomiting Nausea is the desire to vomit and is associated with loss of gastric tone and reflux of the duodenal contents into the stomach. Vomiting is the coordinated expulsion of gastric contents. Nausea and vomiting are described as acute if the condition occurs within 1-2 hours after drug administration, delayed if the condition begins more than 24 hours later, anticipatory if it occurs before chemotherapy. Nausea and vomiting are influenced by the drug dosage. Cistplatin, decarbazine, nitrogen mustard, carmustine, lomustine, clyclophosphamide, and streptozotocin are the most ematogenic agents. Most cytotoxic drugs produce acute nausea and vomiting, which subsides within 24 hours. Uncontrolled nausea and vomiting cause 25-50% of people to delay or refuse further treatment. Inadequate nutritional intake, electrolyte imbalances and dehydration can occur. Aspiration pneumonia and mucosal tears are possible complications of uncontrolled nausea and vomiting. Controlling of nausea and vomiting is achieved by the use of antiemetic drugs. Anti emetics must be given ½ hours -24 hours before chemotherapy and should be given on a regular schedule. Other useful measures in reducing nausea and vomiting are reduction of noxious stimuli such as odors, avoidance of spicy and greasy foods, distraction through music or reading or relaxation. Organ Toxicities Some cytotoxic drugs produce toxicities in specific organs. Some effects are temporary, whereas others are permanent. They are not always dose-related. -

Cardiac Toxicities Doxorubicin can produce significant cardiomyopathy, causing congestive heart failure. The toxicity is related to the cumulative doses received. Adults are restricted to cumulative doses of 550 mg/m2; those with previous mediastinal radiation receive only 400 mg/m2. Myocardial biopsies and measurement of cardiac ejection fractions are performed at intervals to assess cardiac functions. The drug is discontinued if myocardial damage is detected or the cumulative dose is achieved. Daunorubicin produces cardiomyopathy.

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Dexrazoxane, a cardioprotective agent has been used effectively in clinical trials of women with metastatic cancer. It permitted higher median doses of doxorubicin, with fewer cases of congestive heart failure. Cardiac toxicities occurring with lesser frequency are cardiac necrosis with higher dose of clyclophosphamide, angina with fluorouracil, and CHF with mitoxantrone.

Pulmonary Toxicity Chronic pneumonitis and fibrosis are the most common pulmonary toxicities related to chemotherapy. With some drugs risk factors are cumulative dose, radiation therapy, oxygen therapy, and age. The drugs associated with pulmonary toxicity are bleomycin, mitomycin, busulfan, carmustine, clyclophosphamide, and methotrexate. Treatment includes discontinuing the drug and managing symptoms. The changes are irreversible. Pulmonary function tests may be obtained before treatment to assess pulmonary function and to determine eligibility for certain drugs.

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Renal Toxicity Nephrotoxicity occurs most commonly with cisplatin, which can produce acute renal failure with necrosis of the renal tubules. High urine flow during cisplatin therapy achieved by intravenous saline or mannitol provides protection against renal damage. Adequate creatinine clearance function is evaluated before the administration of cisplatin. The nitroureas, streptozocin, methotrexate and mitomycin can produce renal damage of varying pathologic features.

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Neurotoxicity Neural damage can occur to central or peripheral nervous system nerves and to cranial nerves as a direct or indirect effect of cytotoxic drugs. Damage can be reversible or permanent. Vincristine cause peripheral neuropathy with sensory and motor components leading to muscle weakness, foot drop and atrophy. Damage to the autonomic nervous system causes ileus, constipation, impotence, and urinary retention. The drug may be withheld until symptoms abate. Cisplatin can cause peripheral neuropathy and ototoxicity. Encephalophaties can occur with high dose methotrexate, cytarabine, and ifosfamide. Cerebellar dysfunction can occur with the use of 5fluororacil.

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Hepatotoxicity

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Hepatic damage is uncommon and can range from mild enzyme elevations to cirrhosis. Agents that can cause hepatotoxicity are methotrexate (high dose), cytarabine (high dose), and 6-mercaptourine.

Bladder Clyclophosphamide causes hemorrhagic cystitis, which can range from dysuria to hemorrhage. Good hydration and frequent urination protect the bladder and mucosa.

Skin Many cytotoxic agent cause a variety of skin changes. Hyoerpigmentation in skin and nail beds, rashes, dermatitis, banding in the nails, erythema, and photosensitivity can be produced by specific agents. Many drugs can produce recall reactions in the skin areas that have been irritated previously.

Long-term effects of Chemotherapy Development of leukemias can occur as secondary to malignancies in 1-10% of people who have been irritated previously. Survivors of Hodgkin‘s disease who have received both chemotherapy and radiation have the highest incidence of secondary malignancies. Alkylating agents, clyclophosphamide, melphalan, carmustine, chlorambucil, and mechlorethamine appear to be the most carcinogenic. Tumors of the bladder, kidney, and ureters have occurred as secondary malignancies.

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Surgical Therapy Surgery is the most frequently used cancer therapy. It offers the greatest hope for cure. Surgery is used alone or in combination with other cancer therapies. Using combinations of surgery, chemotherapy, radiotherapy, and biotherapy has significantly lengthened disease-free intervals, and survival advantages have been realized. Surgery can be used for cancer prevention, diagnosis, definitive treatment, rehabilitation and palliation.

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Factors Influencing Treatment Decisions  Tumor Cell Kinetics Knowledge of tumor cell kinetics has helped clinicians identify tumors that are best treated with surgery. The goal is to eradicate tumor with the least amount of disruption to normal

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tissue. Decisions about the extent of the surgical resection are guided by characteristics of tumor cells.  Growth Rate – slow-growing tumors lend themselves best to surgical treatment because they are more likely to be confined locally.  Invasiveness – a surgical procedure intended to be curative must include resection of the entire tumor mass and a margin of safety that includes normal tissue surrounding the tumor. Less radical procedures are indicted with invasive disease, for which radical surgery has not been proved to enhance results.  Metastatic Potential – the initial surgical procedure has a better chance of success than any subsequent surgery performed for recurrence. Knowledge of metastatic patterns of individual tumors is crucial for planning the most effective therapy. Some tumor metastases late or not at all and may respond well to aggressive primary surgical resection. For tumors known to metastasize early, surgery may not be appropriate. Surgery may be used to remove a tumor mass either in preparation for adjuvant systemic therapy or after chemotherapy to respect any remaining disease. Tumor Location  The location and extent of tumor determine the structural and functional changes after surgery.  Superficial and encapsulated tumors are more easily resected than are those embedded in an inaccessible or delicate tissue or those that have invaded tissues in multiple directions. Physical Status – perioperative assessment is initiated to identify factors that may increase the risk factor or surgical morbidity and mor tality. The client‘s rehabilitation potential is assessed before surgery. Quality of Life – the goal of surgical therapy varies with the state of the disease. Selection of treatment approach takes into consideration the quality of the individual‘s life when treatment is complete.

Surgery for Treatment of Cancer a. Curative Surgery Primary tumors are potentially curable by surgical resection for people with local or regional disease. The goal is adequate removal of the tumor with minimal structural and functional impairment. The extent of the excision is based on the type of the tumor. Superficial tumors can be treated by a wide local excision. Other that may spread to the regional lymph nodes are removed with and bloc excision in which the tumor and the lymph nodes are removed in continuity. Techniques are used to prevent dissemination of the tumor into the operative field. Glove changing, instrument cleaning, and wound irrigation with cytotoxic agents are used to prevent cell shedding. Previous concepts in tumor biology, which presumed cancer to spread in an orderly fashion from tumor to lymph node and then to distant sites, dictated a radical excision as the logical treatment to remove all tumors. Current concepts favor less radical approaches with adjuvant chemotherapy and radiation to eradicate micrometastatic tumors. Locally recurrent tumors occasionally can be resected to effect a cure, although to a lesser degree. Sarcomas and colon, breast, and skin cancers have been successfully reexcised locally, with resulting cure.

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cancer clients may experience a set of complex responsespresipitated by concominant therapies or underlying disease process itself. 39 | P a g e . Solitary metastatic lesions in the lungs. Autologous donation may be done 42-72 hours before surgery. infection. Palliative surgery is aimed at controlling cancer and improves quality of life. e. Surgery may remove nonvital benign tissue that predisposes individuals to a higher risk of cancer such as prophylactic removal of the breast in women with a high risk of breast cancer. people with cancer have form and function improved with reconstructive surgery. melanomas. - Special Considerations for Nursing Care Surgical setting and length of stay – the greatest challenge concerning the short length of stay for the surgical procedure is to ensure that adequate information is given to clients and families. or liver can be removed to effect a surgical cure. length of disease-free interval. Reconstruction in head and neck procedures can be extensive but offer the person with cancer improved cosmesis and quality of life. producing cures or prolonged survival times. remove infected or ulcerating tumors. relieve obstructions in the respiratory. d. and colon carcinomas have been removed in selected persons. pain control. Metastatic cell sarcomas. c. so that they are well educated in regard to the procedure and the care afterward.  Blood product administration. Decisions to resect metastatic lesions are based on tumor type and natural history. General Surgical Care and Oncological Emergencies  In addition to the typical surgical complications. brain. Reconstructive Surgery Following radical curative surgical procedures. nutritional support. and hemostas are common surgical challenges. and unresponsiveness of the tumor to chemotherapy and radiation. Prophylactic Surgery People who are at risk for developing specific cancers may be considered for the excision of the target organ. stability of the lesion.  Autologous Blood Donation – clients may donate one or more units of their own blood to bank before their surgery.b. relieve pressure on the brain or spinal cord. Palliative procedures can be done to reduce pain. or urinary tract. and drain abscesses. Adjuvant Surgery Debulking procedures are performed in large sarcomas or ovarian cancers to reduce the tumor burden and to make the tumor more responsive to chemotherapy and radiation. and stomatitis. bleeding. poor wound healing. Removal of precancerous polyps is commonly done as a measure to prevent colon cancer. aspiration pneumonia. These can include acute respiratory distress syndrome (ARDS). Palliative Surgery Palliative surgical procedures are considered if risk-to0benefit ratio to the person with cancer is positive. gastrointestinal. prevent hemorrhage. Skin and muscles flaps can be used to cover anatomic defects.

protein calorie malnutrition should be reversed. Before surgery. 40 | P a g e . Early postoperative ambulation is instituted. Radiotherapy and chemotherapy can compromise wound healing and may increase postoperative complications. Hemostatis – the person with cancer is highly susceptible to postoperative thrombophlebitis. Combination Therapy Synergistic augmentation effects of combined therapies can produce postoperative reactions and complications that may be difficult to manage. Clients may receive aggressive preoperative nutritional status. Nutritional Support – the nutritionally deliberated person with cancer is a poor surgical risk.    Anxiety and Pain Control – teaching about pain control begins preoperatively and includes expectations of pain and relief measure pain. and nonpharmacological methods to decrease pain and anxiety.

whereas gamma rays are emitted from radioactive materials such as cobalt. The electrons acquiring energy from the photons are rejected from their orbits.. neutrons. ionization is believed either to damage the DNA molecule directly or to react with water in the cell. negative pi mesons.e. The rad. It is also effective in destroying tumor in known sanctuaries (i. which diffuse and cause damage to critical structures. whereas others are emitted from natural radioactive sources. relieve obstructions of the gastrointestinal. 41 | P a g e . Hodgkin‘s disease. X-ray are produced in electrical devices. intestinal and urinary systems. headache or nerve palsies. which was the standard unit before 1985 is equal to 1cGY. causing production of free radicals. o Although not completely understood. can die a reproductive death if damage to the DNA renders the cell unable to replicate. o Radiation must produce cell death to be effective. Postoperatively. brain and spinal cord) that may not penetrated by chemotherapy.  The radiation dose measures the average energy deposited per unit mass tissue.  Ionizing radiation energy is absorbed as it passes through matter. Cells can die immediately if a sufficient dose is given. The gray (GY) is the standard unit of measurement and represent the energy absorption of 1 joule per kilogram. o Palliative radiation can be used to relieve pain from bony metastases. o Preoperatively. o Radiation in combination with chemotherapy can be used to reduce a large tumor burden. causing brakage of chemical bonds. o Electromagnetic x-rays or gamma rays are photons of energy that are the shortest wavelengths of the electromagnetic spectrum. o The GY equals 100 centogray (cGY).  Adjuvant radiation therapy is used combination with other treatment methods to improve survival. causing ionization. o Radiation is chosen for surgically inaccessible tumor and for individuals who are poor candidates for surgery. It interacts with cellular molecules. carcinoma of the cervix. Cells that are damaged. o Most therapeutic radiation uses gama rays or x-rays or electrons.Radiation Therapy  Curative Radiation can be used to treat local or regional cancers is the tumor is sensitive to radiation. differing only in their source. o Several factors increased the radiosensitivity of cells. tumor cells left in surgical margin can be destroyed. prevent paralysis from spinal cord compression and relieve neurologic symptoms of seizure. protons. X-rays and gamma rays are the same in the physical and biologic function.  Therapeutic radiation uses ionizing radiation. skin and eye. o Electrons. thus making chemotherapy more effective. Most particulate radiation generally requires expensive and complicated machinery and is used in investigational studies.  Oxygen – the radiation dosage required to kill hypoxic cells is three times that of normal cells. alpha particles. and head and neck cancers can often be cured by radiation therapy. o Early-stage lymphomas. adjuvant radiation can reduce tumor bulk and destroy malignant cells peripheral to the tumor. Some of these forms of particulate matter are produced in electrical devices. however. and high-energy heavy particles are forms of ionizing radiation.

connective tissue and small blood vessels are immediate in sensitivity. Some examples of teletherapy equipment available are fast neurons. Consultation For treatment   The radiation oncologist evaluates the physical condition of the person. o The amount of radiation required to eradicate a tumor depends on the cell type of the tumor. and bone tumors.  Teletherapy is a radiation technique in which the radiation source is external to the person. and the ear accelerator are the most commonly used in therapeutic radiation. during treatment. and less tissue damage occurs.    Treatment Planning 42 | P a g e . o Midvoltage machines.  The basic treatment principle allows a greater total radiation dose. The distance allows the more uniform dose distribution. head. and non renewing cells are most resistant to radiation. the cobalt machine. and the goals of therapy. increasing the ability of the beam to penetrate the tissue. Te diagnosis and the stage of the tumor are confirmed. The client is then oriented to the facility. as opposed to a single dose to be tolerated and is based on the four concepts of radiation biology:  Repair – cells that have sublethal damage have time to recover. The total radiation dosage. risk and benefits and side effects of radiation are discussed with the client with cancer. The maximum dosage is deposited beneath the skin. or fractionated.  Individuals with metastatic disease undergoing palliative radiation are usually treated with higher daily dosage in a shorter time interval.  Redistribution – cells that are in the sensitive portions of the cell cycle will be destroyed by the initial radiation treatment. and the resources available during the treatment. neck. and negative pi-mesons. protons and helium ions. o Equipment differs in the type of photon or particle produced the energy of the photon that determines the depth of tissue that can be penetrated. other cells are then recruited into the replicating pool and will be subjected to radiation at the next dose. as opposed to a single dose is divided. the personnel.  The usual fractioned dosage in curative therapy is 180 to 200 cGY 5 times per week.  Repopulation – normal cells that have repaired sublethal damage are able to duplicate in the intervening time interval. the shield is removed and the radiation emitted. Cobalt units have enough penetrating abilities to treat brain.Cells in G2 or M Phase of the cell cycle are more radiosensitive.  Reoxygenation – hypoxic tumor cells that are radioresistant become oxygenated as the tumor shrinks and there is less demand for oxygen.  The cobalt machine houses a radioactive cobalt source in the head of the mahine. Self-renewing cells are the most sensitive to radiation.  The linear accelerator produces x-rays with electricity and is capable of producing very high energy photons.

Skin markings are down with tattoo or ink to ensure exactly placement of the radiation beam. The client is seen weekly by the radiation oncologist to monitor progress. Delayed reactions occur in related organs secondary to destruction of the endothelial linings of the small blood vessels. and treat side effects and reactions. fatigue. inflamation. 5 days a week. Therefore the person is seen 2-3 months during the first post-treatment year. A computer simulation is constructed to demonstrate the tumor volume and dosage to ensure precise treatment. Some reactions considered acute may occur within a few months of treatment. and x-rays.   Post Treatment Follow-up   The person with cancer is seen frequently until all acute reactions have subsided. Wedges to compensate for tissue differences.     43 | P a g e . and immobilization casts are created. Effects of Radiation Therapy  Local reactions to radiation occur only in the irradiated tissue and are classified as early reactions if they occur during treatment or within several months following and as late or delayed effects if they occur any time after 6 months. the person with cancer is seen annually to monitor late treatment complications. skin. A weekly complete blood count and weight measurement are taken. and weakness) occur only during treatment. Systemic reactions to radiation (nausea. Additional time is required if several treatment is required if several treatment ports are used and the client needs to repositioned. The severity of the reaction depends on the total dosage received and the tissue composition. which become damaged over time. and mucosal membranes are most responsive to radiation. scans. Treatment  The client is usually treated with 180-300 cGY per day. The radiation oncologist. Acute reactions are self-limiting and relate to edema. A simulator (a diagnostic x-ray unit with the same geometry of the radiation therapy unit) is used to design the radiation ports and tumor volume. Acute reactions occur days to weeks after the initiation of the therapy. Dose calculations are frequently checked by the radiation physicist. and technologist determine optimal position and treatment portals. Self-renewing cell-systems. If radiation was primary curative treatment. The treatment volume is defined and localized using physical palpations of the tumor (if possible). bone marrow. Actual radiation time is only few minutes. make assessment. radiation physicist. and parenchymal cell death. lead blocks to shield normal tissues adjacent to the tumor.

Avoid thermal irritation with the following precautions: 1. Use only mild soap. Pat the skin dry. 2. Use lukewarm water. creams. Protect the skin from the sun. Hair loss is temporary if the total radiation dose is less than 3000 rads. necrosis. Individuals are advised to pace their activities. 4. Notify the physician or nurse whenever skin changes causes discomfort or if any blistering or weeping occurs. b. a. Reactions can progress from erythema to dry desquamation characterized by dryness. curlers. Radiation-induced stimulation of melanocytes causes hyper pigmentation (tanning). f. or fibrosis of the affected tissue. Avoid chemical irritation with the following precautions: 1. scaling. Instructions to routine care. and nausea are the most frequent occurring symptoms of systemic reactions to radiation. Rinse skin thoroughly. 3. The cause of these symptoms of systemic reactions to radiation. Do not rub. Avoid chemical irritation with the following precautions: 1.  Skin Reactions – skin erythema begins 2 to 3 weeks after treatment initiation. powders. Wear loose clothing. 3. Protect the skin from friction and rubbing of clothing. and rest frequently. 6. but thickness may be diminished. Delayed effects are permanent and irreversible during treatment can have delayed reactions. Do not use lotions. e. Hair growth recurs in 6 to 8 weeks. Do not remove skin markings. Acute Effects of Radiation  Systemic Reactions – fatigue. d. leading to occlusion. Do not use tape in the affected area. not hot or cold water. Diminish function in affected sweat and sebaceous glands may produce dryness and anhidrosis. Do not use hot-water bottles or heating pads on the affected skin. and itching to moist desquamation (loss of epidermis). Wash the skin gently with lukewarm water. Do not shave skin in the affected area. people receiving brain radiation must be cautioned to avoid use of electric hair dryers. with blistering and weeping of tissue. avoid exertion. 2. infarction. or perfumes on the affected area unless prescribed by the physician. 3. Skin reactions can be minimized by proper sin care during treatment. weakness. The cause of these symptoms is unknown. 4. Avoid extreme cold or wind. 44 | P a g e . c. and curling rods. 5. 2.

sugarless gums. use of a humidifier during the night. alcohol. food such as popcorn) or thermal (e. cigarette and cigar smoke) stimulus. Gastritis with decreased in production of gastric secretions can cause anorexia. citrus juices. bland meals high in calories and proteins frequently and avoiding sweet and greasy foods to minimize nausea. moist.. Saliva becomes thick and acidic. partial dentures.400 cGY are employed.   Head and Neck Radiation Reactions Curative treatment of head and neck tumors requires high doses of radiation. Abdominal Radiation Reactions The radiosensitivity of the epithelium of the small intestine causes diarrhea. Thoracic Radiation Reactions Esophagitis with dysphagia can occur if the esophagus is in the radiation port. Nausea can be managed by encouraging the client to eat small. facilitating bacterial growth and tooth decay. Clients are advised to eat soft. adequate fluid intake. chewing tobacco.g. diarrhea can be managed by encouraging the client to increase fluid intake and calories to compensate for losses. but pericarditis can occur with dose higher than 400 cGY.. chewing sugarless gum or candy. The heart is radioresistant. candy. Commercial preparations of artificial saliva are available. mouthwashes.. bleeding. Dental consultation for prophylaxis or tooth decay is obtained before radiation therapy and fluoride treatments can be given. and artificial saliva and frequent rinsing with prescribed solutions. A dry or soar throat and a dry persistent cough usually occur. and dysphagia. moist foods and avoid irritants such as alcohol and tobacco smoke. Dysphagia can be minimized by eating a bland diet with soft. nausea and vomiting. Drink clear liquids in between meals as tolerated. Radiation hepatitis can occur when doses higher than 25. Decreased saliva production causes xerostomia. Dry mouth symptoms are relieved by humidity. inflamation. highly seasoned foods. cough syrups with an alcohol base). or pureed foods and to keep their mouth clean by rinsing with tepid solutions and using a soft tooth brush. Mouth dryness can be relieved by frequent gargling with warm water.g. hot or cold liquids and foods. and cramping as the absorptive capacity of the small intestine is diminished. hard toothbrushes.g. Oral Mucositis causes pain. Antacids may be used. Radiation pneumonitis can occur 1-2 months after the therapy. Symptoms of oral Mucositis can be minimized by reducing irritation to the mucosa from any chemical (e. and eating moist foods with sauces and gravies. mechanical (e. Eating a low 45 | P a g e .

and sprays should not be used. gold. and vaginitis with dryness and dysparenuria. Douches. depending on the mode of administration. brain. Pelvic Radiation Reactions Irradiation of the bladder. urgency. Vaginitis may cause painful intercourse. Diarrhea is symptomatically treated. Antidiarrheal medications may be ordered. Loose cotton underwear. iodine. and prostrate tumors. An oral solution of radioactive iodine will be taken up selectively by the thyroid to produce the effect. caffeine.. strong herbs and spices. This mode is often used in breast.  An applicator is placed within the organ in the operating room.   46 | P a g e . Interstitial Administration – wire. frequent meals and avoiding raw foods. and spices). radioactive seeds are inserted. burning and hematuria. vagina.  Radiation sources used in brachytherapy are radioactive isotopes (e. and rectum produces irritation and inflamation causing cystitis with frequency. needles. thus limiting exposure to others. lotions. frequent baths. Systemic therapy – thyroid cancer is often treated by systemic therapy based on the affinity of the thyroid tissue for iodine. alcohol. tobacco products. and exposing the perineum to air whenever possible are recommended. and avoiding substances that irritate the bladder (e. neck. Cystitis can be minimized by increasing fluid intake. and cobalt)..g. bloody stools.g. and the radiation source is inserted after loaded when the person is returned to the room. and tenesmus. fatty foods. especially cranberry juice.  Intracavitary radiation is now used to reduce obstructive lung and esophageal tumors that have been radiated previously. brachytherapy is generally given in addition to teletherapy as a booster dose to increase radiation to the tumor without additional radiation to the surrounding tissue. head. These sources have low energy and limited tissue penetration. but intracavitary radiation is mainly used for cervical and endometrial cancers. creams. proctitis with diarrhea. radium. When placement is deemed satisfactory. milk and milk products minimize stimulation of the small intestine. caffeine. which may need to be avoided until soreness decreases. or ribbons are placed within the tumor. iridium.  The principle of inverse square law – the dose of a point is inversely related to the square of the distance between that point and the radiation sources is the basis for brachytherapy. residue diet of small. cesium. Sitz bath may be recommended. Sources can be temporary or permanent.  Intracavitary administration – application of radiation can be done for any hollow organ. Brachytherapy  A radiation technique in which radiation sources are placed directly into an organ or tumor. as in abdominal radiation. Difficulty in voiding should be reported to radiotherapist. The rectal area should be cleaned after bowel movements.

androgens.. Alpha and beta particles do not penetrate in the tissue. Gamma rays have sufficient penetrating ability to provide a radiation hazard to individuals near the client.e. using antihormones. Anti hormones or synthetic anti-estrogens and antiandrogens are hormone antagonists that interfere with the normal hormone-hormone receptor-binding process.Procedure to minimize radiation exposure to personnel:  The amount of radiation exposure depends on the radiation source. bone marrow transplantation allows administration of high dosed chemotherapy to destroy the tumor cells of the target organ while preventing the potentially fatal bone marrow destruction associated with high doses. Hormonal manipulation can be achieved by adding hormones. RNA. but it is thought to affect secretions of the tumor growth factors. leukemia and lymphomas) it restore bone marrow function after eradication of the person‘s bone marrow through the use of high-dose chemotherapy and radiation. Radiation exposure is minimized by reducing the time spent with the person. Long term remissions and cure can be achieved in some people. It is believed that tumors probably contain hormone-dependent and hormone-independent clones. which as tumor growth progress and cell become more anaplastic. Appropriate procedures should be developed with radiation personnel to prevent inadvertent environmental contamination of radioactive materials. and endometrial cancers and hematologic malignancies. Although hormone manipulation can cause tumor regressions.. their dependence on hormones is lost. progestins and glucocorticoids) carried through the blood while bound to plasma proteins. and eventually the tumor becomes refractory to other manipulations.    Adjunctive Therapies Hormone-responsive tumors have been managed empirically for many years by hormone manipulation. and increasing the distance between the person and the others. protein synthesis. Bone Marrow Transplantation Bone marrow transplantation is supportive therapy used in hematologic malignancies (i. Drugs that suppress hormone production by suppressing gonadotropins can also be used. The precise mechanism of hormone action is unknown. and cell division. Surgical removal of hormone-producing organs also affects hormonal production. estrogens. prostate. the duration of the effect is limited.g. In the treatment of solid tumors. bind with cell specific receptors that convey them to the cell nucleus where they affect DNA. Hormone manipulation is used primarily in the treatment of metastatic breast. Steroid hormones (e. The person who conveys radiation risk should be isolated in a clearly marked private room. suppressing hormones. and surgically removing hormone producing organs. interposing shielding materials between the person and the personnel. 47 | P a g e . Pregnant personnel and visitors should not be exposed to the client.

Peripheral blood progenitor cells have been harvested from people with hypoplastic marrow. renal. mortality. A match is based on human leukocyte antigen (HLA) testing. arduous and prolonged survival following failure of standard chemotherapy. Autologous marrow can also be treated to remove any residual malignant cells. Synergenic – bone marrow is obtained from an identical twin. melphalan. Radiation is used to destroy malignant cells in the marrow. People receiving allogenic transplant must be immunosupressed to prevent rejection. Marrow rejection is avoided with autologous transplantation. Physical evaluation must determine ability to withstand aggressive chemotherapy and includes pulmonary. Alternative scheduling of radiation and chemotherapeutic agents (busulfan. especially those that may be sanctuaries in the central nervous system. Conditioning renders the persons immunosupressed and involves allogenic transplant rejection. etoposide. Autologous – bone marrow is obtained from the person during periods of disease remission. Multiple aspirations (150-200) are required to obtain sufficient bone marrow. The procedure involves apheresis following marrow stimulation with hematopoietic growth factors. Risk of morbidity. The ability of the person and family to cope with long-term treatment is evaluated.Sources of Bone Marrow  Allogenic – bone marrow is obtained from family member or unrelated individual whose marrow is compatible with the person who has cancer. marrow is screened to remove bone spicules and fat. The marrow is cryopresserved until use. The client and family are given detailed information of the transplantation process. cytosine. Bone marrow is harvested from the posterior iliac crest under general anesthesia. and long-term physical disability are high. and cardiac assessment.   48 | P a g e . Pretrasplantation Preparation Bone marrow transplantation is an aggressive. complications and long-term effects. Following harvest. Transplantation Process Pretreatment Total body irradiation and high dose clyclophosphamide have been the standard conditioning preparation. arabinoside. and carmustine) is used to minimize the side effects. Erythrocytes are removed from allogenic marrow if the recipient and donor are ABO incompatible. long.

Increasingly. these marrow recipients are managed as out patients is they reside close to the hospital. the client is at high risk for infection and bleeding and must be supported with blood products. fluids. Transplant rejection and acute graft-versus-host disease prolong the recovery period. Virtually all clients become infected. but thrombocytes may take months. chemotherapy regime. Mucositis. diarrhea. whereas those with autologous transplantation. reducing ingestion of bacteria through blood preparation (cooked food only) and reducing endogenous microbes (prophylactic antibacterial). Acute Complications – occurs within the first 3 months following transplant. bleeding. as are specific organ toxicities. High dose chemotherapy and radiation can produce all the side effects of those treatments. During this time. Autologous transplantation can invoke recovery within 30 days or less. Neutrophils may recover in 5 weeks. Complications The marrow source. and physical condition of the person determine the severity of complications following bone marrow transplantation. Toxicities related to renewing cell populations (infection. A germ-free environment is established by preventing inhalation of microbes (laminar-flow rooms and isolation). and hyperalimentation. and alopecia) and general systemic effects (fatigue. nausea and vomiting) are intensified by the combination of radiation and high-dose chemotherapy. Recovery Allogenic marrow transplantation requires approximately 35 days of hospitalization. Strict aseptic technique is used by all personnel. Engraftment Transplanted marrow requires 15-20 days to become engrafted. radiation dosage. The transfused cells fine their way to the recipient‘s marrow.Transplantation Bone marrow is transplanted by intravenous infusion 48-72 hours after the last chemotherapy dose. Those with Allogenic transplants can develop graft-versus-host disease and graft rejection.    Veno-occlusive disease Renal Failure Graft Rejection 49 | P a g e .

nausea. Kaposi‘s sarcoma. myalgias.is approved for use in hairy cell leukemia. Interferon.. skin and gut. Immunotherapy can be active or passive.Chronic Complications – most chronic complications develop with the first year following transplantation. viral. anorexia. vaccines) to stimulate a general response. Individuals are usually taught to self-administer interferon.    Bacterial. and arrhythmias. intramuscularly. Toxicities include diffuse rash. anorexia. weight loss. myocardial infarction. beta. Active Immunotherapy – uses nonspecific agents (e. tachycardia. interleukins) or specific agents (e. eyes. Interleukin-2 has a wide range of toxicities. and fungal infections Cytomegalovirus. gamma. and diarrhea. chills. hypertension. They have no cytotoxic effect. are proteis produced by activatedblymphcytes or macrophages. interferons also modulate the immune response.g. esophagus. and headache.. affecting joints.  50 | P a g e . lungs liver. and most people are treated in intensive care units. Cardiac arrhythmias. lethargy. The toxicities are revisable after discontinuing the drug. Cytokine therapy uses specific cytokines that either are cytotoxic or are growth factors involved in cell production and differentiation. fatigue. enhance the expressions of cell surface antigens. They have widespread effects in all phases of T-cell activity. vomiting. destroy tumors through the use of cytotoxic cytokines. and dizziness. The severity and frequency of toxicities and related to the dosage and age of the person. interferon. or intravenously in daily doses ranging from 2 to 9 million units. Biotherapy This encompasses therapies that augment or manipulate the immune system against cancers (biologic response modifiers). Toxicities of interferon are an acute flulike syndrome of fever. Interleukin-2 is administered intravenously as a bolus or continuous infusion in dosages ranging from 6 to 42 million units per 24 hours. and decrease proliferation by lengthening the cell cycle of both normal and tumor cells.  Interferon – are a family of proteins with 3 major groups: alpha. and depression. and renal cell sarcoma. The antitumor activity is dose and schedule dependent. Interferon is administered subcutaneously. Interleukins – 12 are known interleukins. A capillary leak syndrome of intravascular volume depletion with fluid retention and interstitial edema occurs. Pneumocystis carinii Collagen vascular disorder. Most biotherapy remains investigational. or enhance cell maturation and differentiation by administration of cytokines. Originally discovered by their antiviral activity.g.

its use has been investigated extensively in colon. anemia. used to treat the reduced erythrocyte count of myelosupressed individuals. Systemic side effects include fever. although the latter route can produce severe inflamation. Anaphylactic reactions occur in those with high levels of human anti-mouse antibodies. disorientation. and weakness. also known as Human papillomavirus or HPV vaccine. headache. chills.        Cytotoxic Cytokines – tumor necrosis factor (TNF) shows dramatic necrosis in established tumors in animals. and renal cancers and in malignant melanomas. fatigue. differentiation. and vomiting. or radio nuclides that can deliver cytotoxic cells in the immune system. rigors. breast. Cells (i. and maturation of blood cells. nausea. and thrombocytopenia are other side effects. These lymphokine-activated cells are capable of lysing tumor cells but not destroy normal cells.e. It is 51 | P a g e . TNF can be administered intravenously or subcutaneously. Side effects are fevers.. Local side effects are bladder irritability. urticaria. urgency. malaise.  Passive immunotherapy – involves transfer of immunologic cells or antibodies that have the ability to mediate antitumor responses. Monoclonal antibodies – unconjugated or ‗‘naked‘‘ monoclonal antibodies can produce antitumor effect either by direct cytotoxicity or by activating cytotoxic cells in the immune system.  Cytokines (growth factors) – hematopoietic colony-stimulating factors essential for the proliferation.  Bacille Calmette-Guerin (BCG) – a strain or M. frequency. chills. BCG is administered intravesically in dosages ranging from 10 to 100 million bacilli in a weekly basis for 6 months.  Erythropoietin is a cytokine produced in the kidneys in response to hypoxemia. adoptive immunotherapy) – lymphokine-activated cells are produced by exposing peripheral blood mononuclear cells to high concentrations of interleukin-2.hallucinations. Side effects of this therapy are fever. Vaccines – one vaccine that has been developed is the vaccine against cervical cancer. bovis. toxins. flushing. Monoclonal antibodies. bladder. People receiving BCG must have a small tumor and be immunocompetent. chills. hypertension. and dysuria. although treatment of bladder cancer is not its sole use. headache. but this activity has not been demonstrated in human tumors unless TNF is injected directly into the tumor.can be conjugated to drug molecules. and thrombocytopenia. TNF is used in combination with chemotherapy and biologic response modifiers to eradicate tumors.

Complications of Cancer Cancer Pain The experience of anticipation of pain is the most feared and dreaded complication of cancer. Moderate to severe pain occurs in 40% to 50% of clients with early. and concentration and irritability are prominent. myalgia. Side effects are mild hypotension. nerves. but changes in mood. Causes of pain are the following:  Tissue damage causing necrosis. Chronic pain is caused by tumor progression or syndromes related to cancer therapies. radiation therapy. Used to shorten periods of neutropenia but shows no effect in thrombocytopenia. myalgia. pressure sores. Fear of death and hopelessness are related psychologic factors. 52 | P a g e . and soft tissue adjacent to the tumor. ulceration. basophils. and skin rash. Administered subcutaneously. bone pain. Pain related to tumor progression increases in severity with tumor infiltration of bone. Chronic cancer-related pain persists for more than 3 months. or both. Signs of sympathetic stimulation are absent. Granulocyte colony-stimulating factor influences maturation of granulocytes. and facial expression are seen. its mild side effects are bone pain. Sources of Pain  Approximately 75% of pain is tumor related. Administered intravenously or subcutaneously in varying dosage.or intermediate-stage cancer. and is associated with symptoms of sympathetic stimulation. for use in case of neutropenia associated with chemotherapy. Pain unrelated to cancer accounts for 5% of pain reported by people with cancer. peptic ulcers. with infiltration of nerves  Obstructions of hollow organs  Pressure from tumor growth in tight compartments Cancer therapies account for 20% of cancer pain through injuries to nerves or painsensitive structures from chemotherapy. Granulocyte-macrophage colony-stimulating factor is produced by T cell stimulating the production of Neutrophils.  administered 3 times weekly by subcutaneous injection. it causes such transient side effects as fever. with a defined onset. and nausea. sleep. It is of limited duration. erythrocytes. eosinophils. It has been demonstrated to shorten periods of neutropenia to people receiving various cytotoxic drugs. or surgery. monocytes. Temporal Classifications of Pain Acute cancer-related pain can be caused by tumor or tumor-related therapies. and megakaryocytes. The cause of acute pain can usually be determined easily and managed by treatment of the underlying cancer or the use of analgesics. Persistent pain occurs in 70% to 90% of terminally ill cancer clients. compromising the quality of life for most people with cancer. and osteoarthritis are other causes of pain. Alterations in appetite. gait. constipation. and infection  Tumor erosion.

Side effects of opioid use are constipation. Client‘s reports of pain should always be believed.Pain Assessment Determining the source of pain is accomplished through a detailed medical history with a physical examination and a thorough neurologic examination. Discontinuation of opioids should be done gradually to avoid withdrawal symptoms. and drug absorption is not reliable. 53 | P a g e . Occasionally. and transcutaneous electrical nerve stimulation). and respiratory depression. Anticipation and prevention of pain is most effective. Pain is intensified by many psychologic states such as anxiety and depression. use of pain assessment tools. 90% of superior vena cava syndrome cases are caused by malignant tumors. physical. Pain assessment should occur regularly and systematically. chemotherapy. and maintaining mobility and function (through recreational. Physical dependence and opioid tolerance are expected with longterm treatment and should not be confused with psychologic addiction. and intracerebral ventricular routes) should be used only if maximal doses of systemic drugs fail to control pain. Adjuvant medications may or may not be added An opioid is added if pain persists or if pain is moderate at initial assessment. Removing the cause of pain is limited in treatment-related syndromes. an emergency arises. intrathecal. Pain control requires multimodal treatment with analgesics and other approaches. All medications must be individualized for the client with cancer Routes of administration The simplest and least invasive methods should be used. Determining the nature of the pain is accomplished through a detailed pain history. If the process occurs slowly. especially lung cancers. Additional measures of pain control are added as pain assessment dictates. heat and cold applications (if not contraindicated). stronger opioids are added to the treatment regimen. Analgesic ladder – mild pain is treated with nonopioid analgesic or NSAID. It is painful and inconvenient. vibration. Venous return from the head. Pain management is difficult and complicated in clients with cancer who have had preexisting chronic pain syndromes related to noncancer causes or a history of drug abuse.. or radiation should begin simultaneously whenever possible. the potency or dosage of the opioid should be increased. Intraspinal system (epidural. Diagnostic tests may be ordered. or occupational therapy). Intramuscular administration should be avoided.. Superior Vena Cava Syndrome The superior vena cava is a thin-walled structure with low intravascular pressure. the least invasive routes (i. sedation. Treatment of the cause of pain by surgery. Cancer pain can be treated with anesthetic procedures or with neuroablative and neurostimulatory procedures in selected situations. If the oral route cannot be used. and a psychologic evaluation of the person with cancer. aAddiction rarely occurs with people with cancer who have chronic pain.e. massage. transdermal and rectal) should be considered. Pain management begins with the analgesic ladder— as pain increases.g. collateral circulation develops. this syndrome is the presenting sign of lung cancer. and upper extremities can be impeded by extrinsic tumor growth or lymph node enlargement. Nonivasive pain management include cutaneous stimulation (e. nausea and vomiting. The oral route is preferred for is convenience and cost effectiveness. Short-term psychotherapy often can be helpful in providing the person with coping strategies. If these are ineffective. If tumor growth has been rapid. chest. then intravenous or subcutaneous routes with portable or implanted pumps should be considered. Medications should be administered round the clock and not on as necessary basis. If pain is severe or persists. acupressure.

shaking chills. tumor. Cultures are drawn. tachycardia. Symptoms depend on the severity of the obstruction.Symptoms of superior vena cava syndrome are chest pain.g. the person‘s microbacterial flora) or exogenous (e. Cardiac Tamponade Impairment of heart filling during diastole can occur when pericardial fluid produced by tumor cells accumulates in the pericardial sac or when the pericardium becomes fibrotic or constricted following radiation therapy. and head and neck tumors most often cause bleeding problems. poor nutrition. This condition also occurs as sequelae of sepsis. Radiation therapy to the obstructing tumor is the usual therapy.g. tachypnea. Radiation therapy to the obstructed area with initial high doses can be given. Symptoms of cardiac tamponade are anxiety. tumors invade blood vessels and cause profuse bleeding. pelvic.. bladder. A pericardial window. dyspnea. depending on how sensitive the primary tumor is to these treatments. head and neck. occasionally. Early signs of sepsis — fever. catheters). Hemorrhage Bleeding can occur from any tumor surface. Septic Shock Septic shock causes circulatory collapse. Sources of infection can be endogenous (e. Facial swelling and distention of veins over the neck and chest wall are physical signs. Chemotherapy may be used in small-cell lung cancers or lymphomas that are chemoresponsive. Pericardiocentesis is done as an emergency therapeutic procedure. Lung. and thyroid tumors and lymphomas most commonly cause airway obstructions. Disseminated Intravascular Coagulation (DIC) DIC can occur during intensive chemotherapy in leukemia and is thought to be related to the release of tissue thromboplastins. and hoarseness. proteases. Treatment is specific to the site. Maintaining high Fowler‘s position and using oxygen therapy. Treatment of cardiac tamponade depends on its severity. and cough. cyanosis. irreversible organ damage. circulatory collapse can result. and antibiotic treatment is instituted promptly. prednisone and diuretic medications may be prescribed and the client‘s status is carefully monitored. Gastrointestinal. and esophageal tumors can invade the pericardium directly. and pericardial rub are frequent signs. breast.. or scleroses of the pericardium are other treatment options. Lung. and advanced disease are factors in the development of bacteremia. Typical changes are also seen on chest radiograph and electrocardiogram. pulsus paradoxus. or decreased sensorium — must be recognized in the neutropenic client. Signs of cardiac tamponade related to rapidity of fluid accumulation. Intraluminal obstruction to the bronchus can be relieved by bronchoscopic laser treatment or photodynamic 54 | P a g e . diuretic. In mild effusions. Radiation therapy or antineoplastic agents. or interleukins from blast cells. Hypotension. and death unless bacteremia and sepsis are recognized and treated promptly. If the pericardial fluid accumulates rapidly. Upper Airway Obstruction Obstruction of the trachea or bronchus can occur at any point. Echocardiography is the most specific and sensitive diagnostic tool. cough. and corticosteroids may be helpful in supportive treatment. pericardiectomy. chest pain. Myelosuppression from treatment.

Brain metastases or treatment with clyclophosphamide and vincristine can produce this syndrome by distributing hypothalamic and pituitary function. pharmacologic intervention of urea and furosemide may be ordered. Elevated serum ionized calcium levels are diagnostic of hypercalcemia. vomiting.therapy. hyperphosphatemia. 55 | P a g e . nausea. Acute Tumor Lysis Syndrome Hyperuricemia. hydration. breast. and calcium imbalances. kidney. Malignant pleural effusions (usually confirmed by cytologic studies) are treated by thoracentesis. and polydipsia. and frequent monitoring and correction of electrolyte imbalance can prevent development of acute tumor lysis syndrome and renal dysfunction. Pleural Effusions The quantity of fluid accumulation produced by tumor implants on the visceral and parietal pleura or impairment of fluid drainage by mediastinal tumor varies. pancreas. Hypercalcemia High levels of serum calcium (above 13 mg/dL) can arise when the calcium mobilization from bone exceeds the capacity of the kidneys to excrete it.000 ml per day to increase the serum sodium level and decrease fluid overload. Chest radiographs reveal most pleural effusions. especially leukemia and lymphomas. who are undergoing chemotherapy or radiation that produces a highly volume of destroyed cells can develop this syndrome. Untreated hypercalcemia can progress to altered mental status. polyuria. hyperkalemia. coma. calcitonin. alkalinization of urine..g. Democlocycline is often prescribed to interfere with the antidiuretic action of antidiuretic hormone and atrial natriuretic factor. or diphosphonates depends on the person‘s condition and underlying disease. If water excess continues despite treatment. lymphomas and small-lung cancers). Chest tube drainage and pleural sclerosing may be necessary if fluid reaccumulates. potassium. Some tumors that produce peptides that function as parathormone also produce hypercalcemia without bone metastasis. Clients with hypercalcemia experience fatigue. Prophylactic treatment with allopurinol to increase uric acid excretion. plicamycin (mithramycin). Long-term control of hypercalcemia is achieved by treatment of the underlying tumor. seizures. Individuals with highly proliferative tumors. Malignant pleural effusions most often result from metastatic breast and lung cancers and lymphomas. Treatment depends on the severity of the condition. as well as squamous cell head and neck cancers most often produce hypercalcemia. the underlying cancer is treated. Parenteral sodium replacement and diuretic therapy are indicated when neurologic symptoms are severe. Bone metastasis is present in 80% of clients with hypercalcemia. Hydration with normal saline. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) (SIADH) most often occurs in small-cell lung cancers. Dyspnea and unproductive cough are common symptoms. corticosteroids. Additional chemotherapy is given to responsive tumors (e. and ovary. Monitor electrolyte levels to detect secondary magnesium. constipation. Aggressive fluid hydration is initiated 48 hours and after the initiation of cytotoxic therapy to increase urine volume and eliminate uric acid and electrolytes. and hypocalcemia occur in acute tumor lysis syndrome. Tumors of the lung. They can be asymptomatic or sufficiently large to produce respiratory insufficiency. After the symptoms are controlled. anorexia. and death. Management includes fluid intake range limited to 500 to 1.

to treat hyperphosphatemia by promoting phosphate excretion in the feces. Lung. Administration of hypertonic dextrose and regular insulin temporarily shifts potassium into cells and lowers serum potassium levels. weight loss. and loss of bowel and bladder control signal progressive compression. resulting in ascites. Ascites Ascites can be caused by obstruction of the subdiaphragmatic lymphatics or by fluid production of metastatic peritoneal tumors. such as sodium polystryrene sulfonate (Kayexalate) to treat hyperkalemia by binding and eliminating potassium through bowel. and kidney cancers and lymphoma are the most frequent tumors associated with spinal cord compression. 56 | P a g e . Bowel Obstruction and Perforation Peritoneal carcinomas can produce single or multiple bowel obstructions with an associated risk of perforation. numbness. Sudden. Administration of a cation-exchange resin.Urine is alkalinized by adding sodium bicarbonate to IV fluid to maintain a urine pH of 7 or more. Treatment depends on the extent of the disease and the size of the obstructing tumor. breast. unusual pain in the back or neck. Ovarian. such as aluminum hydroxide. is most often caused by advanced genitourinary tumors (cervical. but may be excluded if extensive abdominal carcinomatosis exists. to alkalinize the urine. Obstructions can be relieved by percutaneous nephrostomy followed by ureteral stent placement. bladder. In advanced disease. but mediastinal lymphomas and lung cancers can obstruct the lumen by external compression. Administration of phosphate-binding gels. and aspiration of oral secretions are symptomatic of obstruction. paresthesias. Hemodialysis when clients are unresponsive to the standard approaches for managing uric acid and electrolyte abnormalities. Diuretic therapy with a carbonic anhydrase inhibitor or acetazolamide. Esophageal Obstruction Obstruction of the lumen of the esophagus most often is caused by primary esophageal cancers. prostate. Treatment depends on the extent of disease and the condition of the person. radiation. Increasing dysphagia. which can progress to renal failure. Surgery. Pain is described as constant and is increased by coughing or straining. Obstruction is easily identified by esophagogram and esophagoscopy. gastrointestinal. Hepatic metastases can cause portal hypertension and hypoalbuminemia. which can be described as local or radicular pain is the most common symptom. and breast cancers are associated with obstructions. or prostate) or by large retroperitoneal tumors. this prevents renal failure secondary to uric acid precipitation in the kidneys. Ureteral Obstruction Bilateral ureteral obstruction. and chemotherapy may be used. partial tumor ablation with laser therapy or stent placement can provide temporary patency. Surgical correction is preferred if possible. Spinal Cord Compression Metastasis to a vertebral body or pedicle with erosion into the anterior or anterolateral epidural space or direct extension by paraspinal tumor can cause spinal cord compression with irreversible damage if untreated. Leg weakness. Allopurinol therapy to inhibit the conversion of nucleic acids to uric acid.

Depression is a major factor in 50% of suicides. The diagnosis of depression in peoples with cancer is particularly difficult because some of the somatic symptoms of depression are also the symptoms of cancer. People with risk factors should be assessed for suicide risk and referred for psychiatric consultation. anxiety. Altered Nutrition and Cancer Cachexia People with cancer vary greatly in nutritional problems. Some clients can maintain their food intake and weight throughout their illness. and psychomotor retardation or agitation.e.Prompt diagnosis is important to prevent irreversible nerve damage. 57 | P a g e . whereas others experience anorexia and weight loss as presenting symptoms. Treating pain. Diagnosing depression is important in people with cancer because it hinders coping and increases morbidity and overall disability. indecisiveness. cachexia is believed to be caused by peptides and cytokines that are released from normal cells in response to the tumor. Currently. People with depression are at 25 ti me‘s greater risk for committing suicide. Likewise. fistulas. People with depressive symptoms should be referred to a psychiatrist for diagnosis and antidepressant therapy when appropriate. diarrhea. prior suicide attempt. fatigue. Cancer cachexia Is a paraneoplastic syndrome characterized by anorexia. dysphagia. interleukin-1. hopelessness. Laminectomy and chemotherapy are also therapeutic options for some people. xerostomia. Many of the medications used in treatment (i. stomatitis. surgical resection of the tongue. poor prognosis. poor concentration. The diagnosis of depression is difficult in people with cancer because feelings of sadness are normal responses to losses common with this illness. MRI has replaced myelography as best diagnostic technique. The criteria for the diagnosis of major depression are dysphoria and anhedonia. the relative risk is twice that of the general population. or surgical procedures that decrease the absorptive surface of the small intestine. Weight loss and malnutrition can be related to either decreased nutrient intake secondary to cancer treatment or its sequelae or to cancer cachexia.. and muscle wasting. and interleukin-6 may be involved in cachexia development. and family history of suicide are other factors. pharynx. Steroids are given to reduce edema. early satiety. Tumor necrosis factor. interferon-y. and suicidal ideation. or stomach or loss of nutrients through vomiting. guilt. Decreased nutrient intake related to cancer treatment can be the result of the inability to take in food caused by such conditions such as nausea. Suicide Although suicide is rare in people with cancer. Any four of the physical or psychological symptoms in combination with dysphoria and anhydonia lasting more than 2 weeks are diagnostic of major depression. physical signs such as sleep disorder. appetite change. anxiety. and depression and providing social support to help the person cope may prevent suicide and the devastating sequelae on family and friends. steroids) can also cause depression. and stress) can also decrease appetite and food intake. and psychologic symptoms such as low self-esteem. Psychologic factors (depression. Radiation therapy is used if the person has not been irradiated previously. it is a major factor in suicide. weight loss. uncontrolled pain. Severe Depression Person with pancreatic and head and neck cancers have the highest incidence of depression. Advanced illness. weakness.

Weight loss in cachexia results from decreased nutrient intake and altered metabolism. Paraneoplastic Syndromes Paraneoplastic syndromes are symptom complexes that are not produced directly by the tumor or its metastases. Endocrinopathies – Cushing‘s syndrome. Parenteral therapy is indicated for those in whom the gastrointestinal tract cannot provide nutrient intake (e. History – weight change over time. type of tumor. Abnormalities in taste and aversion to red meat are common. Enteral therapy is indicated for those who are unable to maintain adequate oral intake but have a functioning gastrointestinal system. change in functional capacity. but in people with cancer. Short-term therapy can be accomplished with a smallbore feeding tube. weight loss is greater than 10% is considered cachexia. polycythemia Nerve and muscle syndrome – disorders of the central and peripheral nervous systems.. it is elevated. or severe malnourishment). hyponatremia. More commonly seen in advanced disease. Long-term management requires a gastrostomy or jejunostomy tube. paraneoplastic syndromes can be caused by production of hormones by the tumor affecting the target organ. and megestrol acetate can be used empirically to improve nutritional intake. decreases in body fat and protein catabolism. dexamethasone. Decreased nutrient intake is affected by anorexia and early satiety. severely malnourished The goal of nutritional support must be determined before intervention to determine the extent of therapy. change in dietary intake relative to normal. and serum albumin less than 3. articular. Oral nutrition may suffice for those who are nourished or mildly malnourished but are undergoing temporary impairment of nutritional intake or increased nutrient losses. cachexia also occurs in localized cancers. proteins secreted by the tumor 58 | P a g e . evidence of muscle wasting. Antidepressant therapy can reduce anorexia caused by depression. Often called remote or systemic effects of malignancy. Malnutrition can be determined if the person exhibits unexplained weight loss of 10% or more of body weight. The subjective global assessment gives a clinical determination of malnutrition. Assessment of nutritional status is important to determine the need and extent of nutritional support. or extent of disease. concurrent diseases or stress Physical examination – evidence of loss of subcutaneous fat stores. minimally malnourished. Chemotherapy and radiation therapy produce a large range of side effects that impair nutrition. Peripheral or central venous access can be used to provide parenteral nutrition. The severity of cachexia is not correlated to tumor size. carbohydrate. presence of ankle or sacral edema Diagnostic categories – well nourished. and muscle wasting. resulting in increased glucose production. myasthenia gravis Osseous. presence of ascites. Metoclopramide can be used to improve gastric emptying. Adequate nutrition is vital for maintaining immunocompetence and resisting infection. presence of gastrointestinal symptoms for over 2 weeks. Meeting 2 of the 3 criteria indicates a need for nutritional support. Generally. and fat metabolism are altered. serum transferrin less than 150 mg/dL. malabsorptions. Protein. In normal malnutrition.Diagnosis of cachexia is based on symptoms. hypercalcemia. Symptomatic treatment of stomatitis and mucositis also improves intake. cases of fistulas.g. the body reduces its basal metabolic rate. paraneoplastic syndromes represent a diverse group of symptoms affecting many body systems. obstructions. nonbacterial thrombotic endocarditis Occurring in 10% to 15% of cancer clients. carcinoid syndrome. and soft tissue changes – hypertrophic osteoarthropathy and clubbing of fingers Vascular and hematologic changes – venous thrombosis (Trousseau‘s phenomenon).4 gm/dL. Hydrazine. Increased energy expenditure has been demonstrated in some studies.

and malaise. they can mimic metastatic disease and confuse treatment. Surgical removal of metastatic lesions in the lung and liver can improve survival. Cancer recurrence at the original site of the tumor can be treated. in a small percentage of cases. neuromuscular.Lung metastases are often asymptomatic masses found in the periphery or outer 3rd of the lung parenchyma. Colon cancer most frequently metastasized to the liver. The standard diagnostic test in defining pulmonary metastases is the CT scan. and jaundice are late signs. radiation therapy is used to treat local recurrence. hematologic.. the lesions are resectable. colony-stimulating factors). Most metastatic lesions are usually treated if they are symptomatic or potentially disabling. Although limited hepatic metastases are usually asymptomatic. although they can occur with any cancer. Lung. Ascites. TNF). Metastatic Disease Most people with cancer die of metastatic disease. extensive liver metastasis causes anorexia. Breast cancer can recur locally and be re-excised. People with increasing dyspnea without any findings on the radiograph may have diffuse lymphangitic metastases throughout the lungs. Between 15 to 25% of clients have liver metastases at the time of diagnosis. causing metastasis. metastatic disease can be treated with curative intent. proteins produced by normal cells in response to tumors (e. gastrointestinal.g. Recurrent hematologic malignancies can be treated with chemotherapy and subsequent cure. bone. Some can be fatal if not recognized and treated. Dyspnea may occur with airway obstruction or pleural effusions. Chemotherapy may be used in responsive tumors. Paraneoplastic syndromes occur most frequently with lung tumors. The most common sites of metastasis are the lungs. and antibodies produced in response to the cancer. Radiation may be used to reduce obstructing lesions. Liver 59 | P a g e . Liver metastasis. Survival rates of 25 to 40% have been reported. Surgical resection of liver metastases from colon cancer can be curative in selected clients who have good liver function and a limited number of metastatic lesions. Pulmonary metastases appear as nodular densities on chest radiograph. Occasionally. Occasionally. Paraneoplastic syndromes can be the first manifestation of malignancy.g. and breast cancers also metastasize to the liver. the type of tumor. Treatment of pulmonary metastases depends on the person‘s physical condition. Recurrent Cancer Cancer can recur locally at the site of the primary tumor or at a distant site. nausea. and the extent of the disease. cutaneous. liver. fever. kidney. Resection of non-colonic tumors does not improve survival. Unusual metastatic sites have become more frequent as the length of survival has improved in many cancers. Recognition is important. CT scanning provides the best diagnostic technology for the detection of liver metastases. and the person has had a reasonable diseasefree survival..(e. no other metastatic lesions are detected. Improving the quality of life and minimizing the sideeffects of treatment are treatment goals for peoples with metastatic disease. bladder. treatment leads to subsequent cures. An additional 20 to 25% will develop metastases after curative resections. or connective tissue disorders. which also controls the symptoms of the syndrome. and brain. pain. Surgical resection of a limited number of pulmonary metastases is considered if the primary disease is controlled. Treatment is aimed at tumor control. Lung metastasis. renal. Paraneoplastic effects can be manifested as endocrine.

whereas lung cancer. Relief of pain and prevention of fractures and disability are treatment goals. Emergency evaluation is needed to prevent irreversible neurologic damage. the number of people with bone metastases is large. MRI is the most sensitive diagnostic tool to detect brain metastases. aching. although extensive bone metastasis can exists without pain. osteogenic sarcoma. focal weakness. which is extremely sensitive to changes in the bone. Selected clients with single lesions may benefit from surgical excision.0 to 1. CT scan and MRI may be useful in equivocal situations. but bone metastases occur in the three most common tumors: breast. The presenting signs and symptoms of brain metastases are headache. physical symptoms increase and require constant evaluation and new treatment strategies. Lesions that are primarily osteolytic will show as cold spots. and seminomas tend to develop multiple metastatic lesions. pelvis. As the disease advances. Radiographs can detect bone changes after 30 to 50% of the bone is destroyed and the lesion is 1. and lung. Internal fixation of the bone with rods and plates and use of bone cement provide stability in weight-bearing bones. Approximately 60 to 90% of clients have moderate to severe pain. 60 | P a g e . When treatment options have been exhausted and tumor growth is uncontrolled. Brain metastases generally develop multiple metastatic lesions. and seizures. The most common sites are vertebrae. Brain metastasis. breast cancer. or new metastatic lesions occur in locations that have received maximum radiation dosages. however. and skull. mental disturbances. Described as insidious. Chemotherapy and hormonal therapy (in breast and prostate) are used to treat the underlying cancer. Not all people with metastatic cancer become terminally ill. Terminal Cancer Palliative treatment refers to the use of treatment modalities (chemotherapy.Brain metastasis occurs in approximately 13% of cancer clients. but CT scanning can also be utilized. pain is usually localized to the area of the tumor. Brain metastases generally arise after secondary metastases to the lungs and liver. Some die of complications related to treatment or of other causes. Maintaining maximum neurologic functioning is the treatment goal in brain metastases. surgery) in incurable cancer to alleviate symptoms caused by persistent tumor growth. Surgical interventions are needed for impending fractures. functioning in their usual roles. Chemotherapy is limited to the few tumors that respond. Either the tumor is refractory to chemotherapy and radiation. and the side effects of treatment. prostate. Pain is the most common symptom. Bone metastasis. and renal cancer. new metastatic lesions. Thus. For people with certain types of cancer. and increasing in intensity over time. Metastatic lesions can be osteolytic through destruction of bone by osteoclasts or osteoblastic through development of new bone in response to tumor invasion. The treatment goals then become symptom management. The person might also choose to terminate treatment. whereas osteoblastic lesions will appear as hot spots. Palliative care is frequently referred to as the chronic phase of cancer. Single metastatic lesions are associated with ovarian cancer. the terminal phase of cancer begins. Specificity. Many remain working and productive. melanomas.metastases can be treated by systematic chemotherapy or regional hepatic artery infusion with implanted or portable infusion pumps. it can extend for many years. Supportive care with steroids can be helpful. Increasing back pain can represent external compression of the spinal cord or cauda equine by metastatic lesions. Local treatment to bony metastasis with radiation therapy is effective to relive pain and improve function.Bone is the third most common site of metastasis. Bony metastases are diagnosed by bone scan. is poor. radiation. detecting changes of as little as 5%.5 cm in diameter. Radiation therapy is the primary mode of treatment. femur.

pleural effusion. Counseling may be appropriate for some family members. Losses predominates the psychologic concerns of the terminally ill. anorexia. if they know they can obtain help when they need it. no matter how physically exhausting. providing opportunities and resources for them to talk and reconcile their life. Fatigue is major limitation to activity but good pain control and proper timing of activities can be helpful. confusion. and fatigue are common problems resulting either from tumor growth or from side effects of medications. but some interventions may be helpful. Nurses can help the dying people cope by enhancing their autonomy. relationships. and oral hygiene are ways to promote comfort and simple physical care (e. and requires constant evaluation and collaboration of the client. dysphagia. and the ability to enjoy simple pleasures. and changes in consciousness level occur. Good control of nausea and vomiting will enable the person to eat. In the declining client. Terminally ill people may feel angry. In the final days. lonely. Constant attention to pain control is critical as tumor growth may change the nature and source of pain. Families may need guidance and resources for resolution of conflicts or expression of feelings with the dying person. cardiac. but many cannot maintain unrealistic hope until their death. They need constant reassurance that they are providing good care.Families need to be taught on the physical care of the dying person. anxious. families need direction with procedures like death certification and burial. Losses include independence. The immediate causes of death in people with cancer are infection (pneumonia and septicemia). good skin care. The physical stress of caring for the dying person often leaves family members with little energy to cope with emotions and psychologic issues.g. Allowing family members to express feelings and problems as they arise and facilitate problem solving promotes coping for family members. roles. carcinomatosis (widespread metastatic disease). on-call nursing coverage also reduces anxiety. edema. vomiting. physician. 61 | P a g e . hepatic. depressed.. and cachexia. and family in discerning the true cause of symptoms and appropriate interventions. The beneficial aspects of dehydration are reduced urinary output (less incontinence). Anorexia and dysphagia limit the ability to maintain adequate nutrition. cognitive ability is also lost. reduced gastric secretions (less vomiting). emphasis on food and hydration is futile. Maintaining optimal bowel and bladder function. weakness. nausea. Most families are able to manage care of the dying person. The essence of nursing the dying person is care and compassion. Information on physical changes occurring during the dying process reduces anxiety of facing unexpected changes. Respiratory symptoms occur near death. and reduced pulmonary secretions. physical attractiveness. and hemorrhage. Those who have reconciled their situation may be peaceful and serene. and weight loss. Many people with cancer can reconcile these losses as they become resigned to accept their fate. Drowsiness. Dying people tolerate dehydration and often are less symptomatic. Other physical symptoms vary and relate to organs involved with tumors. organ failure (respiratory. constipation. allowing them to express their feelings and thoughts. and maintaining their respect and dignity.immobility.Symptom management is the key to quality of life in the terminally ill. These measures can provide distinct comfort for the dying person. function. As people decline. and renal). isolated. infarction (heart and lung). nurse. and fearful. The psychologic needs of the family are extremely important. Maintaining optimal functioning is important within the person‘s limitations. People who are declining with imminent death (less than 4 weeks) experience significant anorexia. dehydration. Supporting the family.Pain. and ascites. Information and access to 24-hours. Supporting the dying person. bathing and massage).

dyspnea. is initially performed to visually evaluate the pharynx. paint fumes. and underlying medical conditions in the assessment. PET scan may also be used to detect recurrence of laryngeal tumorafter treatment. and lower in pitch o Complains of cough or sore throat that does not go away o Pain and burning in the throat especially when consuming hot liquids or citrus juices o A lump may be felt in the neck o Later symptoms include dysphagia. nutritional deficiencies (riboflavin). a general debilitated state. combined effects of alcohol and tobacco. Risk factors for laryngeal cancer are: Carcinogens – tobacco (smoke. if normal movement is limited. Clinical Manifestations o Hoarseness of more than 2 weeks‘ duration (tumor impedes the action of the vocal cords during speech) o Voice may sound harsh. race (more prevalent in African Americans). unplanned weight loss. asbestos. raspy. weakened immune system A malignant growth may occur in three different areas of the larynx: the glottis area (vocal cords). smokeless).Cancers of the Respiratory System Cancer of the Larynx Cancer of the larynx is a malignant tumor in the larynx. mustard gas. using a flexible endoscope. include risk factors.  Indirect laryngoscopy. age (higher than incidence after 60 years of age). persistent hoarseness. the growth may affect muscle. and subglottic (area below the glottis or vocal cords to the cricoids).  Assess the mobility of vocal cords. family history.  CT scan and MRI are used to assess regional adenopathy and soft tissue. second-hand smoke. 62 | P a g e . It is potentially curable if detected early Occurs four times more frequently in men than in women. history of alcohol abuse. and most commonly in persons 50 to 70 years of age. unilateral nasal obstruction or discharge. persistent ulceration. and foul breath o Cervical lymph adenopathy. chronic laryngitis. larynx. and possible tumor. and pain radiating to the ear may occur with metastasis Assessment and Diagnostic Findings  Initial assessment includes a complete history and physical examination of the head and neck. gender (more common in men). supraglottic area (area above the glottis or vocal cords including epiglottis and false cords). or even the airway.  Direct laryngoscopic examination is performed when a tumor is suspected on initial examination. chemical. leather and metals Other factors – straining the voice. tar products. cement dust. familial predisposition. other tissue. Glottis tumors seldom spread if found early due to the limited lymph vessels found in the vocal cords.  Samples of tissue are obtained for histologic evaluation. wood dust.  Palpate the lymph nodes of the neck and thyroid gland to determine spread of malignancy. and help stage and determine the extent of the tumor.

total laryngectomy requires a permanent tracheal stoma because the larynx that provides the sphincter is no longer present Postoperatively. the client‘s gender and age. pharyngeal walls. Thyroid cartilage of the larynx is split in the midline of the neck and the portion of the vocal cord (one true cord and one false cord) is removed with the tumor.  Treatment options include surgery. speech therapy is required before and after surgery Major disadvantage is the high risk for recurrence of cancer Hemilaryngectomy Performed when the tumor extends beyond the vocal cord but is less than 1 cm in size and is limited to the subglottic area. size. chemotherapy. may also be used in conjunction with either radiation therapy to avoid a total laryngectomy or preoperative to shrink a tumor before surgery. and two or three rings of the trachea.  Treatment plan depends on whether this is an initial diagnosis or recurrence.  Surgery and radiation therapy are both effective methods in the early stages of cancer of the larynx. or for recurrent or persistent cancer following radiation therapy Laryngeal structures are removed. may also be performed for a recurrence when a high-dose radiation has failed A portion of the larynx is removed. and pathologic features of the tumor. cricoids cartilage. though the quality of voice may change. arytenoids cartilage and half of the thyroid are removed. the client will have no voice but will have normal swallowing. and trachea remain intact. glottis. Prognosis depends on the tumor stage. usually removed after a few days and the stoma is allowed to close. and histology of the tumor and the presence and the extent of cervical lymph node involvement. Associated with a very high cure rate. which includes the location. tongue. raspy. airway and swallowing remain intact Total laryngectomy Performed in the most advance stage IV laryngeal cancer. cricoid cartilages. and false cords are removed.Medical Management  Treatment depends on the staging of the tumor. nutrition is provided through a nasogastric tube until there is healing followed by a semisolid diet.  Chemotherapy traditionally has been used for recurrence or metastatic disease. and hoarse and have limited projection. Complications 63 | P a g e . Airway of the client remains intact and no difficulty in swallowing is expected. Postoperatively. along with one vocal cord and the tumor. including the hyoid bone. voice may be rough. and radiation. epiglottis. voice quality may change or the client may be hoarse Supraglottic laryngectomy Indicated in the management of early stage (stage I) supraglottic and stage II lesions Hyoid bone. including the grade and depth of infiltration. Surgical Management Partial laryngectomy (laryngofissure thyrotomy) Recommended in the early stages of cancer in the glottis area when only one vocal cord is involved. Client will have a tracheostomy tube and nasogastric tube in place for 10 to 14 days following surgery. the client may experience some difficulty swallowing for the first 2 weeks. aspiration is a potential complication. client is at risk for aspiration postoperatively Some changes may occur with voice quality. An advantage of this procedure is that it preserves the voice. when tumor extends beyond the vocal cords. may be used in stage I glottis lesions. true vocal cords. all other structures remain. A tracheostomy tube is left in the trachea until the glottis airway is established. A radical neck dissection is performed during surgery. and trachea are preserved This procedure will result in permanent loss of the voice and a change in the airway.

and dysphagia secondary to pharyngeal and cervical esophageal stricture Radiation Therapy The goal is to eradicate the cancer and preserve the function of the larynx. setting off a vibration of the pharyngeal esophageal segment This technique can be taught once the client begins oral feedings (a week after surgery): 1) The client learns to belch and is reminded to do so an hour after eating. and it is easily learned. stomal stenosis.include a salivary leak. moving the tongue and lips form the sound into words produces speech  64 | P a g e . voice prosthesis is fitted over the puncture site. Complications may be a result if external radiation to the head and neck area. Voice produced sounds mechanical and some words may be difficult to distinguish. A benefit of this therapy is that clients retain a near-normal voice. and fibrosis. when the mouth forms the words. xerostomia. once the puncture is surgically created and has healed. symptoms include acute mucositis. radiation therapy may be an alternative to total laryngectomy. and personal preference are factors considered in making the treatment decision. To prevent airway obstruction. May also be used preoperatively to reduce the tumor size. pain. and as a palliative measure. dysphagia. the sounds from the electric larynx becomes audible words. A few may develop chondritis or stenosis. A speech therapist teaches the client how to produce sounds. Tracheoesophageal puncture Most widely used technique because the speech associated with it resembles normal speech (sound produced is a combination of esophageal speech and voice). wound infection from the development of a pharyngocutaneous fistula. an advantage is that the client is able tocommunicate with relative ease while working to become proficient with other techniques. the prosthesis is removed and cleaned when mucus builds up. Later complications may include laryngeal necrosis. lifestyle. ulceration of the mucous membranes. a small number may later require laryngectomy. A valve is placed in the tracheal stoma to divert air into the esophagus and out of the mouth. Combine with chemotherapy. fatigue. Speech Therapy  Esophageal speech Primary method of a laryngeal speech. and the client‘s overall health status. loss of taste. The staging of the tumor (usually used for stage I and II tumors as a standard treatment option). or until the client masters the technique This is a battery-powered apparatus that projects sound into the oral cavity. client needs the ability to compress air into the esophagus and expel it. combined with surgery in advanced (stages II and IV) laryngeal cancer as adjunctive therapy to surgery or chemotherapy. and skin reactions. then the technique is practice repeatedly 2) The conscious belching action is transformed into simple explosions of air from the esophagus for speech purpose 3) The speech therapist works with the client in an attempt to make speech intelligible and as close as normal as possible Electric larynx An electric larynx may be used if esophageal speech is unsuccessful. which may also include the parotid gland responsible for mucus production. edema.

a preoperative evaluation of the speech therapist is indicated. Potential complications that may develop include respiratory distress (hypoxia. remove the crusts with sterile tweezers and apply additional ointment. to remove secretions.and postoperative period. Suction as necessary. If treatment includes surgery and the client is expected to have no voice postoperatively. clean the stoma daily with saline solution. and the special training that can provide a means of communicating. see. Answer client‘s question about the nature of the surgery. o Encourage the client to turn. and discuss perceptions about the treatment. the loss of the natural voice. apprehension. teach coughing and deep-breathing exercises. cough. If crusting appears around the stoma. o Wipe clean and clear mucus from the tracheostomy opening. o Reduce anxiety and depression o Provide the client and the family to ask questions. 65 | P a g e . related to inability to ingest food secondary to swallowing difficulties  Disturbed body image and low self-esteem secondary to major neck surgery. and deep breath. Assess the client‘s ability to hear. and increased pulse rate to identify possible respiratory or circulatory problems. Apply none—oil-based antibiotic ointment around the stoma and suture line. infection. and wound breakdown. Encourage and assist the client with early ambulation to prevent atelectasis and pneumonia. labored breathing. read. Nursing Diagnosis  Deficient knowledge about the surgical procedure and the postoperative course  Deficient knowledge about the surgical procedure and postoperative course  Anxiety and depression related to the diagnosis of cancer and impending surgery  Ineffective airway clearance related to excess mucus production secondary to surgical alterations in the airway  Impaired verbal communication related to anatomic deficit secondary to removal of the larynx and to edema  Imbalanced nutrition: less than body requirements.Position the client in the semi-Fowler‘s or Fowler‘s position after recovery from anesthesia. dyspnea. o Allow visits for the client during the pre. tracheal edema). o Review equipment and treatments for postoperative care with client and family. hemorrhage. fatigue. or pain and burning in the throat. measure. change in the structure and function of the larynx  Self-care deficit related to pain. airway obstruction. Reassure the client that frequent coughing episodes will diminish in time as the tracheobronchial mucosa adapts to the altered physiology. Determine the psychological readiness and evaluate the coping methods of the client and family. dysphagia. musculoskeletal impairment related to surgical procedure and postoperative course Nursing Interventions Teach the client preoperatively o Provide information materials about the surgery to the client and family for review and reinforcement. Palpate the neck for swelling. o Maintain a patent airway . weakness. o Observe for restlessness. o Care for the laryngectomy tube. sore throat. and record drainage from wound drains and suction. o Observe. and clarify the client‘s roles in the postoperative and rehabilitation periods.Nursing Care of the Client Undergoing Laryngectomy Assessment Assess the client for hoarseness. verbalize feelings. and write.

o Observe the client for any difficulty swallowing. and rapid deep breathing. and report significant changes to the surgeon. o Monitor for vital signs changes: increased pulse rate. o Promote positive body image and self-esteem o Encourage the client to express any feelings brought about by the surgery. and report the occurrence to the physician. notepad and pen. particularly when eating resumes. If wound breakdown occurs. Monitor and manage potential complications o Monitor the client for signs and symptoms of respiratory distress and hypoxia. o Observe the stoma area for wound breakdown. o Have a positive approach when caring for the client by promoting self-care activities. apply direct pressure over the artery. o Collaborate with the speech therapist and encourage the client and family to use alternative communication methods. Teach clients self-care o Provide specific instructions to the client and family about the tracheostomy and its management. o Observe for signs of postoperative infection and report any significant changes to the surgeon. the client must be monitored carefully and identified as being high risk for carotid hemorrhage. hematoma. and crusting around the stoma.o o Provide adequate humidification to decrease cough.phrase board. o If rupture to the carotid artery is the cause of bleeding. and pale skin are signs of active bleeding. o Teach the client and family to perform suctioning and emergency measures and tracheostomy and stoma care. Promote adequate nutrition o Thick liquids will be used first for feedings once the client is ready to start oral feedings. mucus production. and bleeding. a Magic Stale. call for assistance. Rule out obstructions by suctioning and having the client cough and deep breath. Explain the importance of humidification and instruct the family to set up a humidification system before the client returns home. o Introduce solid foods as tolerated. Promote alternative communication methods o Establish and consistently use alternative modes of communication such as a call bell. clammy. 66 | P a g e . Instruct the client to rinse mouth with warm water or mouthwash and to brush the teeth frequently. which increases salivation and suppresses appetite. or hand signals. o Notify the surgeon for any active bleeding at the surgical site. cold. pictureword. decreased blood pressure. o Teach the client and family about special precautions needed in the shower to prevent water from entering the stoma. Instruct the client to avoid sweet foods. and provide emotional support to the client until the veins are ligated. Teach the client how to clean and change the laryngectomy tube and how to remove secretions.

Clinical Manifestations o Develops insidiously and is asymptomatic until late in its course o Signs and symptoms depend on the location and size of the tumor. bone. recurring fever. abnormal cell growth. genetics. The damage results in ce llular changes. Large cell carcinoma (undifferentiated carcinoma) is a fast growing tumor that tends to arise peripherally. Bronchioalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing as compared to other bronchogenic carcinoma. symptoms or pleural or pericardial effusion are present if the tumor spreads to adjacent structures and lymph nodes o Most common sites for metastases are lymph nodes. the cough may be productive due to infection o Wheezing. and liver o Weakness. head and neck edema. 67 | P a g e . gender. persistent cough. A carcinogen binds to a cell‘s DNA and damages it. Adenocarcinoma is the most prevalent carcinoma of the lung for both men and women. hemoptysis or blood-tinged sputum. the pulmonary epithelium undergoes malignant transformation from normal epithelium to eventual invasive carcinoma. Small cell carcinomas arise primarily as a proximal lesions or lesions but may arise in part of the tracheobronchial tree. the degree of obstruction. cough starts as a dry. when obstruction of airways occurs. hoarseness. Instruct the client to avoid strenuous exercise and fatigue because when tired. Squamous cell carcinoma is more centrally located and arises more commonly in the segmental and subsegmental bronchi in response to repetitive carcinogenic exposures. it presents more peripherally as peripheral masses or nodules and often metastasizes. contralateral lung. he or she will have more difficulty speaking. With the accumulation of genetic changes. the DNA undergoes further changes and becomes unstable. dysphagia. a solitary peripheral nodule (coin lesion). and eventually a malignant cell. anorexia and weight loss though nonspecific may also be diagnostic Assessment and Diagnostic Findings  If pulmonary symptoms occur in a heavy smoker.  Chest x-ray is performed to search for pulmonary density.o o o Remind the client that swimming is not recommended. As the damage DNA is passed on daughter‘s cells. Risk factors associated with the development of lung cancer include tobacco smoke. Lung Cancer (Bronchogenic Carcinoma) Pathophysiology Lung cancers arise from a single transformed epithelial cell in the tracheobronchial airways. without sputum production. cancer of the lung is suspected. Instruct and encourage the client to perform oral hygiene regularly to prevent halitosis and infection. environmental and occupational exposures. and infection. second-hand (passive) smoke. adrenal glands. dyspnea. and dietary deficits. Encourage the client to wear a medical identification to alert medical personnel for special requirements for resuscitation should the need arise. and the existence of metastases to regional or distant sites o Most frequent symptom is cough or change in a chronic cough. atelectasis. brain. chest or shoulder pain are also manifestations o Chest pain and tightness.

       CT scans of the chest are used to identify small nodules and to examine areas of the thoracic cage. PET scans. and exercise testing may be used as part of preoperative assessment. 68 | P a g e . and biopsies. Fiberoptic bronchoscopy is more commonly used and provides a detailed study of the tracheobronchial tree and allows for brushings. pulmonary function tests. gemcitabine. platinum analogues. and bone and liver pain. A variety of chemotherapeutic agents are used including. hemoptysis. no evidence of metastatic spread. A transthoracic fine-needle aspiration may be performed under CT or fluoroscopic guidance to aspirate cells from a suspicious area. pulmonary insufficiency. and prolonged mechanical ventilation is a potential outcome. Radiation may help relieve cough. Sputum cytology is rarely used to make a diagnosis. Contraindications to this intervention are coronary artery disease. It can control symptoms of spinal cord metastasis and superior vena cava compression. vinorelbine. ventilation-perfusion scans. or to relieve the pressure of the tumor on vital structures. Pulmonary toxicity is potential side effect of chemotherapy. and other comorbidities. Prophylactic brain irradiation is used in certain clients to treat microscopic metastases to the brain. If surgery is a potential treatment. Chemotherapy Used to alter tumor growth patterns. washings. and adequate cardiopulmonary function. alkylating agents. Several types of lung resections may be performed:  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  Chest wall resection with removal of cancerous lung tissue – for cancers that have invaded the chest wall Surgical resection may result in respiratory failure. irinotecan. doxorubicin. pericarditis. and radiation lung fibrosis. pneumonitis. Bone scans. and etoposide. to make an inoperable tumor operable. or liver ultrasound or scans can be used to assess for metastasis. Esophageal ultrasound (EUS) may be used to obtain a transesophageal biopsy of enlarged subcarinal lymph nodes. ABG analysis. chest pain. dyspnea. Radiation Therapy Useful in controlling neoplasms that cannot be surgically resected but are responsive to radiation. to treat clients with distant metastases or small cell cancer of the lung. myelitis. and as an adjunct to surgery or radiation therapy. May result in diminished cardiopulmonary functions and other complications such as pulmonary fibrosis. vinca alkaloids. abdominal scans. corpulmonale. Surgical Management Surgical resection is the preferred method for treating clients with localized non-small cell tumors. esophagitis. may also be used to reduce the size of a tumor. taxanes.

Teach client and family about strategies to manage symptoms of dyspnea.Palliative Therapy May include radiation therapy to shrink the tumor to provide pain relief. and pain management and other comfort measures Nursing Management Instruct the client and family about the potential side effects of the specific treatments and strategies to manage them. and end -of-life treatment options. Administer chest physiotherapy and suctioning as necessary to maintain airway patency. methods to maintain the client‘s quality of life during the course of the disease. a variety of bronchoscopic interventions to open the narrowed bronchus or airway. 69 | P a g e . or pulmonary rehabilitation program as preferred by the client. Administer supplementary oxygen. Refer the client to a physical therapy. Support the client and family in making decisions reading the possible treatment options. Encourage the client to assume positions that promote lung expansion and to do breathing exercises for lung expansion and relaxation. Teach client to cough and deep breath. Assess the client‘s level of fatigue a nd educate him/her on energy conservation techniques. fatigue. and anorexia. Administer bronchodilators as prescribed to promote bronchial dilation. occupational therapy. nausea and vomiting.

 Prognosis is highly variable and is not consistently based on client or disease variables. and bone pain from expansion of marrow are caused by the proliferation of leukemic cells within organs Assessment and Diagnostic Findings CBC results show a decrease in both erythrocyte and platelets.  AML is the most common nonlymphocytic leukemia. hyperplasia of the gums. erythrocytes. myeloid).  All age groups are affected. based on cytogenetics.Cancers of the Blood Leukemia Any of several malignant diseases where an unusual number of leucocytes form in the blood Uncontrolled proliferation of white blood cells (leukocytosis) which is often immature (therefore will be non-functional). percentage of normal cells is usually greatly decreased Bone marrow analysis shows an excess of immature blasts. clients who are older or have a more undifferentiated form of the disease tend to have worse prognosis. However.  Clients with AML have a potentially curable disease. Classification of the disease is according to the stem cell line involved (lymphoid. and according to the time it takes for symptoms to evolve and phase of cell development that is halted: Acute – abrupt onset. granulocytes. rapid progression. Chronic – symptoms evolve slowly. - 70 | P a g e . AML can be further classified into seven different subgroups. Acute Myeloid Leukemia (AML)  AML results from a defect in the hematopoietic stem cell that differentiates into all myeloid cells: monocytes. death usually occurring within weeks to months if no aggressive treatment is initiated. histology. the incidence arises with age. and platelets. total leukocyte count can be low. white blood cell development halted at the blast phase. genetic influence and viral pathogenesis may be involved Bone marrow damage from radiation exposure or from chemicals is a risk factor of the disease. this leaves little room for normal cell production in the bone marrow There can also be a proliferation of cells in the liver and spleen (extramedullary hematopoiesis) Cause of leukemia is not fully known. with a peak incidence at age 60 years. and morphology of the blasts. normal or high. Clinical Manifestations o Most signs and symptoms evolve from insufficient production of normal blood cells o Fever and infection result from neutropenia o Weakness and fatigue from anemia o Bleeding tendencies from thrombocytopenia o Pain from an enlarged liver or spleen.

Low platelet count can result in ecchymoses and petechiae Major hemorrhages may also develop when the platelet count drops to less than 10. nausea. the client becomes severely neutropenic. as severe neutropenia is prolonged Complications o o o o o Medical Management Objective of treatment is to achieve complete remission. also called peripheral blood stem cell transplantation (PBCT). severe mucositis. Complications of treatment include tumor lysis syndrome. During this time. neutrophils counts that persist at less than 100/mm3 make the chances of systemic infection extremely high Client‘s risk for developing fungal infection increases.000/mm3. if not identical. Supportive care is another option for the client to consider. Aggressive chemotherapy is not used. When a suitable tissue match can be obtained. thereby diminishing the change of recurrence. with the treatment goal of destroying hematopoietic function of the client‘s bone marrow. and occasionally viral infections. the client is typically very ill. hyperkalemia and hypocalcemia. which usually requires hospitalization for several weeks. and severe mucositis. to the induction treatment but uses lower dosages resulting in less toxicity. and a marked decline in the ability to maintain adequate nutrition. This may be the only option if the client has significant comorbidity. The client is then rescued with the infusion of the donor stem cells to reinitiate blood cell production. bleeding. pulmonary. The goal is to eliminate any residual leukemia cells that are not clinically detectable. Thus. with bacterial. Clients are more commonly supported with antimicrobial therapy and transfusion as needed. vomiting. anorexia.  Induction therapy is attempts made to achieve remission by aggressive administration of chemotherapy. gastrointestinal problems. fungal. Frequently. Supportive care consists of administering blood products and promptly treating infections. anemic. and thrombocytopenic. in which there is no detectable evidence of residual leukemia remaining in the bone marrow. Bone marrow transplantation (BMT) is another aggressive treatment. Consolidation therapy is administered to the client after he/she has recovered from the induction therapy. also the major causes of death.   71 | P a g e .- Clients may have significant problems with bleeding. risk of bleeding correlates with the level of platelet deficiency. they have higher underlying coagulopathy and a higher incidence of disseminated intravascular coagulation (DIC) Bleeding and infection. but this is often accompanied by the eradication of normal types of myeloid cells. diarrhea. gastrointestinal. the client embarks on an even more aggressive regimen of chemotherapy sometimes in combination with radiation therapy. which causes diarrhea. and intracranial are the most common sites of bleeding Fever and infection also increases the chances of bleeding Clients with leukemia are always threatened by infection due to the lack of mature and normal granulocytes. The aim of induction therapy is to eradicate the leukemic cells. hydroxyurea may be used to briefly to control the increase of blast cells. the client receives one cycle of treatment that is almost the same.

resulting in enlargement of these organs that is sometimes painful.000/mm3  Clients may complain of an enlarged. therapy is not benign. Chronic phase – expected outcome is correction of the chromosomal abnormality. into the cavities of the long bones. a less aggressive approach but does not alter cytogenetic changes Anthracycline chemotherapeutic agent may also be used to bring the white blood cell count down quickly to a safer lever Transformation phase – can be insidious. Conventional therapy depends on the stage of the disease. anorexia. agents that have been used successfully are interferon-alfa and cytosine. treatment may resemble induction therapy for acute leukemia. clients have more symptoms and complications as the disease progresses Medical Management o Oral formulation of a tyrosine kinase inhibitor. Clinical Manifestations Clinical picture of CML varies. depression. mucositis. but there is a preference for immature (blast) forms. 72 | P a g e . Normal myeloid cells continue to be produced. and accelerated or blast crisis. liver may also be enlarged  Malaise. resulting in production of tyrosine kinase that causes white blood cells to divide rapidly. imatinib mesylate (Gleevec) works by blocking signals within the leukemia cells that express the BCRABL protein. once the disease transforms to the acute phase (blast crisis). lymphadenopathy is rare  CML has three stages: chronic. Clients diagnosed with CML in the chronic phase have an overall median life expectancy of 3 to 5 years. from blast forms through mature neutrophils. Because there is an uncontrolled proliferation of cells. often in combination. thus preventing a series of chemical reactions that cause the cell to grow and divide. BCR gene of chromosome 22 is translocated onto ABL gene of chromosome 9. and weight loss are some insidious symptoms. anorexia. However. and cells are also formed in the liver and spleen. but it marks the process of evolution to the acute form of leukemia.Chronic Myeloid Leukemia (CML) CML arises from a mutation in the myeloid stem cell. Agents are administered daily in subcutaneous injections. many clients are symptomatic and leukocytosis is detected by a CBC performed for other reasons  WBC count commonly exceeds 100. client may complain of bone pain and may report fevers and weight loss. tender spleen. the marrow expands. using the same medications for AML and Acute Lymphocytic Leukemia (ALL) CML is a disease that can be potentially treated with bone marrow transplantation. Thus. many clients cannot tolerate profound fatigue. the overall survival time rarely exceeds several months. client may become more anemic and thrombocytopenic. a wide spectrum of cell types exists within the blood. Problems with bleeding and infections are rare. spleen may continue to enlarge even with chemotherapy. transformation to the acute phase can be gradual or rapid In the more acute form of leukemia. transformation. and inability to concentrate Hydroxyurea or busulfan can be used to reduce the white blood cell count to a more normal level.

resulting in reduced numbers of leukocytes. and platelets. Because of improvements in therapy. and platelets. Lymphadenopathy occurs as the lymphocytes are trapped within the lymph nodes. an elevated lymphocyte count is seen and can exceed 100. Clinical Manifestations Reduced number of leukocytes. These lymphocytes are small and can easily travel through the small capillaries within the circulation.Acute Lymphocytic Leukemia (ALL) ALL results from uncontrolled proliferation of immature cells (lymphoblasts) derived from the lymphoid stem cell. In the early stage. normal hematopoiesis is inhibited. Most common in young children. a maintenance phase is often included (lower disease of medications are given for up to 3 years) o Treatment can be provided in outpatient setting o Bone marrow transplant offers a chance for prolonged remission or even cure if the illness recurs after therapy Chronic Lymphocytic Leukemia (CLL) CLL is a common malignancy of older adults. the peak incidence is 4 years of age. The disease is classified into three or four stages. These mature cells appear to escape apoptosis. leukocyte counts may be either low or high. but there is always a high proportion of immature cells. with result being an excessive accumulation of the cells in the marrow and circulation. more than 80% of children survive at least 5 years. The antigen CD52 is prevalent on the surface of many of these leukemic B cells. Anemia and thrombocytopenia occur in later stages. early treatment does not appear to increase survival. The nodes can become very large and are sometimes painful. Bone marrow transplant may be successful even after a second relapse. 2/3 of all clients are older than 60 years of age at diagnosis. erythrocytes. and headache and vomiting (because of meningeal involvement) Medical Management o Expected outcome of treatment is complete remission o Corticosteroids and vinca alkaloids are integral part of induction therapy o Prophylaxis with cranial irradiation or intrathecal chemotherapy or both is included in the treatment plan o Treatment protocols for ALL are complex and involves using a wide variety of chemotherapeutic agents. Pathophysiology CLL typically derives from a malignant clone of B lymphocytes. ALL is relatively uncommon.000/mm3. most of the leukemia cells are fully mature. After 15 years. 73 | P a g e . Immature lymphocytes proliferate in the marrow and crowd the development of normal myeloid cells. Treatment is typically initiated in the later stages. resumption of induction therapy can often achieve a second complete remission. with boys affected more often than girls. erythrocytes. Hepatomegaly and splenomegaly may develop. Even if relapse occurs. bone pain. and the pulmonary and cerebral complications of leukocytosis typically are not found in CLL. Increasing age appears to be associated with diminished survival. Pain from an enlarged liver or spleen.

drenching sweat (especially at night). Herpes zoster) can become widely disseminated Medical Management o Early stages may require no treatment. such as infection. and electrolyte levels. anemia or idiopathic Clinical Manifestations  Many clients are asymptomatic  Increased lymphocyte count is always present  RBC and platelet counts may be normal. viral infections (e. the assessment should be performed daily. and unintentional weight loss.  Culture results need to be reported immediately so that appropriate antimicrobial therapy can begin or be modified. hepatic function tests. Nursing Diagnosis The following are major diagnosis for clients with acute leukemia:  Risk for infection and bleeding  risk for impaired skin integrity related to toxic effects of chemotherapy. alteration in nutrition.Autoimmune complications (either hemolytic thrombocytopenic purpura) can also occur at any stage. in late stages. infections are common  Anergy – a defect in cellular immunity as evidenced by absent or decreased reaction to skin sensitivity tests  Life-threatening infections are common to these clients. o Chemotherapy with corticosteroids and chlorambucil is often used in later stages or when symptoms are severe.g. often used in combination with other chemotherapeutic agents o Intravenous treatment with immunoglobulin may be given to selected clients due to occurrence of bacterial infections Nursing Care for the Client with Acute Leukemia Assessment  Assessment of health history may reveal a range of subtle symptoms reported by the client before the problem is manifested by findings on physical examination. o Monoclonal antibody rituximab (Rituxan) also has efficacy in CLL therapy. nutritional depletion. and impaired mobility  Impaired gas exchange 74 | P a g e . and creatinine levels.  Closely monitor the results of laboratory studies. o Fludarabine (Fludara) is being used as a front-line therapy. absolute neutrophil count. or more frequently as needed. decreased  Enlargement of lymph nodes can be severe and painful  Spleen may also be enlarged  Clients may develop ―B symptoms‖ – a constellation of symptoms including fevers. hematocrit.  Flow sheets and spreadsheets are particularly useful in tracking the WBC count.. bleeding. platelet. or. renal dysfunction.  If the client is hospitalized. tumor lysis syndrome. and mucositis.  Assess for potential complications.  Systematic assessment incorporating all body systems must be done thoroughly.

bleeding. need for multiple intravenous medications and blood products Diarrhea due to altered gastrointestinal flora.  For epistaxis. and increased metabolic rate Self-care deficit due to fatigue.  Saline rinses are used to clean and moisten oral mucosa. mucositis.  Manage mucositis  Instruct client to practice meticulous oral hygiene. related to hypermetabolic state.  Do not give intramuscular injections. and nausea Acute pain and discomfort related to mucositis.  Take no rectal temperatures. 75 | P a g e .  Allow no one with cold or sore throat to care for the client or to enter room. if unavoidable.  Use stool softeners.  Notify physician for prolonged bleeding. anorexia. Prevent falls by ambulating with client as necessary.  Avoid suctioning if at all possible. or come in contact with the client at home. fever.  Administer chlorhexidine rinses or clotrimazole troches to prevent yeast or fungal infections in the mouth. if possible. Apply pressure to venipunctures sites for 5 minutes or until bleeding has stopped.  Provide low microbial diet. use only gentle suctioning. packed red blood cells as prescribed. Administer platelets. do not give suppositories. apply ice pack to the back of the neck and direct pressure to the nose. treatment. pain. function. position client in high Fowler‘s position. hypoproteinemia. infection. and infection Hyperthermia related to tumor lysis and infection Fatigue and activity intolerance related to anemia and infection Impaired physical mobility due to anemia and protective isolation Risk for excess fluid volume related to renal dysfunction. frozen plasma. and self-care measures Nursing Interventions  Prevent infection and bleeding  Thorough hand hygiene must be done by everyone before entering the client‘s room.  Avoid aspirin and aspirin-containing medications or other medications known to inhibit platelet function.  Use only electric razor for shaving. oral laxatives to prevent constipation. less than body requirements.  Permit no flossing of teeth and no commercial mouthwashes. mucosal denudation Risk for deficient fluid volume related to potential for diarrhea.  Do not insert indwelling catheters.  Use smallest possible needles when performing venipuncture. malaise. WBC infiltration of systemic tissues.  Discourage vigorous coughing or blowing of the nose. complication management. enemas.  Pad side rails as needed. and protective isolation Anxiety due to knowledge deficit and uncertain future Disturbed body image related to change in appearance. and roles Grieving related to anticipatory loss and altered role functioning Potential for spiritual distress Deficient knowledge about disease process.               Impaired mucous membranes due to changes in epithelial lining of the gastrointestinal tract from chemotherapy or prolonged use of antimicrobial medications Imbalanced nutrition. Use only softbristled toothbrush for mouth care. Eliminate fresh salads and unpeeled fresh fruits or vegetables.

Sitz bath may be administered. Daily body weights. Assist client with activity and exercise to prevent deconditioning that results from inactivity. frequent feeding of foods that are soft in texture and moderate in temperature are better tolerated. its treatment. Parenteral nutrition may be administered to maintain adequate nutrition. Assist the client to resume self-care as he or she recovers. Replace electrolytes as necessary. Small. Monitor laboratory tests results (electrolytes. Maintain fluid and electrolyte balance Assess client for signs of dehydration as well as fluid overload. Encourage client to sit up in a chair while awake rather than stay in bed. with particular attention to pulmonary status and the development of edema. Reassure clients by providing open lines of communication even in home care management of the disease. Initiate strategies to permit uninterrupted sleep during acute hospitalizations. blood urea nitrogen. Encourage spiritual well-being 76 | P a g e .                              Remind client to cleanse perineal-rectal area thoroughly after each bowel movement. warn the client to chew with extreme care to avoid accidentally biting the tongue or buccal mucosa. and hematocrit) and compare with previous results. Low-microbial diets are typically prescribed. If oral anesthetics are used. Improve self-care Encourage client to do self-care activities to preserve mobility and function. and provide gentle shoulder and back massage for comfort. intake and output measurements are used in monitoring fluid status. frequently change bed clothes. Assess how much information the client wants to have regarding the illness. Decrease fatigue and deconditioning Assist the client to establish a balance between activity and rest. Referral to a physical therapist can also be beneficial. sponge cool water but avoid using cold water or ice packs. Listen to clients verbalization of feelings empathetically. and potential complications. creatinine. Improve nutritional intake Instruct client to do mouth care before and after each meal. Patient-controlled analgesia may be ordered for controlling pain. Assist the client in identifying the source of grief. For clients discharged with central venous access device. provide instructions for catheter care. as well as selfesteem. Nutritional supplements may be administered. Ease pain and discomfort For recurrent fevers. Manage anxiety and grief Provide emotional support for the client and family.

tonsils. 15% are below the diaphragm. the spleen. commonly in the neck and chest. It may appear in several forms: acute. Pathophysiology and Etiology  The exact cause of Hodgkin‘s disease is unknown.  Reed-Sternberg cells are nearly immortal. can develop in areas other than lymph nodes (e. spreads downward from initial site  More orderly growth from one node to adjacent nodes  More curable  Common in abdomen. creating a malignant cell type known as ReedSternberg cells. and lymphogranulomatosis (multiple granular tumors or growths composed of lymphoid cells). lymphocytes. localized.Cancers of the Lymphatic System Lymphomas    Lymphoma is a term that applies to a group of cancer that affect the lymphatic system. appears to cause mutations in some. Comparison of Lymphomas Hodgkin’s Non-Hodgkin’s  Four subtypes  Two peaks of onset: ages 15 to 40 and older than age 55 years  Reed-Sternberg cells  40% of affected clients test positive for Epstein-Barr virus B-cell origin  Thirty subtypes  Peaks after age 50 years  No Reed-Sternberg cells  More common in industrial countries.and T-cell origin  Usually starts in lymph nodes above the clavicle. but not all.. with invasion of other tissues such as the bone marrow and lungs. and are somehow shielded from being destroyed by killer T-cells. continue to reproduce prolifically. nasal passages)  Less predictable growth. Lymphoma is classified by the microscopic appearance of the malignant cells and how quickly the malignancy spreads. and the liver. spreads to extranodal sites  Less curable  Acquired immunodeficiency syndrome-related lymphoma occurs in those who have been infected with the human immunodeficiency virus. splenomegaly.  The virus also appears to inactivate the immune system‘s ability to suppress tumor growth. brain. Two of the most common forms of lymphoma are Hodgkin‘s disease and non Hodgkin‘s lymphoma. 77 | P a g e . common among clients with immunosuppression  B. Epstein-Barr virus.  A virus.g. Hodgkin’s Disease   This disease is a malignancy that produces enlargement of lymphoid tissue. latent with relapsing pyrexia.

chest radiography. the disease is staged from I to IV. such as the esophagus or bronchi.  Marked weight loss. and weakness occur. Clients who receive treatment usually have remission that last for months or years. Assessment Findings  Early symptoms of Hodgkin‘s disease include painless enlargement of one or more lymph nodes. computed tomography.  Results of blood chemistry tests such as erythrocyte sedimentation rate are elevated.  After diagnosis.  Resistance to infection is poor. magnetic resonance imaging. fatigue. others die in four to five years. Death results from respiratory obstruction.  Cervical lymph nodes are the first to be affected. characterized as giant multinucleated B lymphocytes are microscopically identifiable in lymph node biopsies.  As retroperitoneal nodes enlarge there is a sense of fullness in the stomach and epigastric pain. A cure is possible when the disease is localized to one section of the body.  Liver enzymes such as alkaline phosphatase are elevated.  Lymphangiography. causing inflammatory symptoms such as pain and fever. malnutrition.  As nodes enlarge. or secondary infections. and night sweats are common. gastrointestinal structures. pruritus.  A bone marrow aspiration biopsy indicates abnormalities of other blood cells. or other sites 78 | P a g e .  Reed-Sternberg cells. Some clients survive 10 or more years. Stages of Hodgkin’s Disease Stage Involvement  Single lymph node region  Two or more lymph node regions on one side of the diaphragm  Lymph node regions on both sides of the diaphragm but extension is limited to the spleen  Bilateral lymph nodes affected and extension includes spleen plus one or more of the following: bones.  A complete blood count demonstrates low red blood cell count. causing a tendency to bleed. or laparotomy to obtain abdominal nodes for biopsy demonstrate size of lymph nodes and spread of the disease in the thorax. and staphylococcal skin infections and respiratory tract infections often complicate the illness. cachexia (state of ill health. abdomen. The disease is more common in men than in women and most frequently occurs during the late adolescence and young adulthood. based on the number of positive lymph nodes and the involvement of other organs. or pelvis. and decreased lymphocytes. lungs.       The malignant cells release chemicals known as cytokines. skin. liver. elevated leukocytes. anorexia. Some clients develop generalized itching and a skin rash because of the release of histamine from an atypical allergic/immune response.  Sometimes marked anemia and thrombocytopenia develop. and wasting). suggesting a current inflammatory process. bone marrow.  Low-grade fever. they press on adjacent structures.

thyroid cancer.  A transplant is performed after separating normal stem cells from malignant cells in the harvested specimen. such as whether they are fixed or mobile. and IV adult Hodgkin‘s disease are sub -classified into A and B categories: B for those with defined general symptoms and A for those without B symptoms. and/or dental caries. Night sweats alone do not confer an adverse prognosis) Medical Management  Treatment includes localized radiation to affected lymph nodes and chemotherapy with combinations of antineoplastic drugs. pericarditis (acute or chronic). herpes infections. pneumococcal sepsis. dacarbazine (DTIC) mechlorethamine (Mustargen).  Assess for location. solid tumors.  Potential long-term complications of therapy for Hodgkin‘s disease include immune dysfunction.  Ask about fever. The B designation is given to clients with any of the following symptoms: Unexplained loss of more than 10% of body weight in six months before diagnosis Unexplained fever with temperatures above 38ºC Drenching night sweats (The most significant B symptoms are fever and weight loss.     Stages I. chills. melphalan (Alkeran)  Antibiotics are given to fight secondary infections. growth retardation. myelodysplastic syndrome. etoposide (VePesid) carmustine (BICNU). vinblastine (Velban). cytosine arabinoside-e (Cytosar-U). nonHodgkin‘s lymphoma. impotence. 79 | P a g e . procarbazine (Matulane) Alternation of drugs from both regimens For partial remission or relapse within 1 year  CBV  BEAM  cyclophosphamide (Cytoxan).  Chemotherapy Regimens for Hodgkin’s Disease Regimen Drugs  ABVD  MOPP  MOPP/ABVD  doxorubicin (Adriamycin).  If resistance to treatment develops. bleomycin (Blenoxane). and characteristics of enlarged lymph nodes. avascular necrosis.  Transfusions are prescribed to control anemia. II. autologous bone marrow or peripheral stem cells are harvested. carmustine (BICNU). Nursing Care for Client with Hodgkin’s Disease Assessment  Look for history of infection mononucleosis or symptoms resembling this disorder. vincristine (Oncovin). or night sweats. III. hypothyroidism.  Ask how long the client has noticed the enlarged lymph nodes and check for presence and extent of tenderness in the area of lymph node enlargement. size. infertility. acute myeloid leukemia. followed by high doses of chemotherapy that destroy the bone marrow. thymic hyperplasia. prednisone (Meticorten). etoposide (VePesid).

 Avoid oral contact with germ-laden objects.  Perform priority activities first.  Check the client‘s current weight and deviation from usual weight. Diagnosis. coughing. breathlessness. Inspect the appearance of the skin.g.  Take prescribed medications as directed. Administer oxygen per physician‘s orders if blood saturation is consistently less than 90%. Report side effects to the physician. rate. depth. pattern.  Avoid crowds or people who have infectious disease. Planning. and Interventions  Client and family teaching include the following:  Keep appointments for medical follow-up.  Contact physician if breathing becomes labored. vomiting). Place an endotracheal tube.  Provide rest periods between activities.  80 | P a g e . Note quality. and position for breathing..   Risk for Ineffective Airway Clearance and Risk for Impaired Gas exchange related to compression of trachea secondary to enlarged cervical lymph nodes       Expected Outcome: Breathing will remain adequate to maintain blood oxygen saturation of 90% or greater Assess respiratory status each shift and PRN (as needed). flaring of nostrils. ask about any itching. and discuss any additional symptoms caused by lymph node enlargement (e.  Eat small amounts frequently or include a liquid nutritional supplement between meals and at bedtime. Keep the neck in midline and place the client in high Fowler‘s position i f respiratory distress develops.  Wash hands frequently. enlargement of the liver and spleen. evidence of splinting.  Reduce work schedule and rest frequently to avoid exhaustion.  Institute infectious disease precautions if normal white blood cells are suppressed to dangerous limits. and level of energy and appetite. nausea. laryngoscope. use of accessory muscles. dyspnea on exertion. Activity Intolerance and Self-Care Deficit related to anemia and generalized weakness from disease Expected Outcome: Client will tolerate essential activities as evidence by heart and respiratory rates within normal limits  Divide care into manageable amounts. and bag-valve mask at the bedside for (emergency) intubation.  Practice conscientious hand washing and follow other principles of medical and surgical asepsis. Risk for Infection related to immunosuppression secondary to impaired lymphocytes and drug or radiation therapy  Expected Outcome: Client will remain free of infection as evidenced by no fever and symptoms of secondary infection  Restrict visitors or personnel with infections from contact with client.  Assist client with whatever activities of daily living are independently unmanageable.

 Additional tests are performed to determine the stage of the lymphoma. or hair dye.  Diagnosis and differentiation of the subtypes of non.  Aggressive because the condition has a shorter onset with acute symptoms. The mice make lymphocytes that produce - - - 81 | P a g e . Burkitt‘s lymphoma.  Lymph node enlargement. Pathophysiology and Etiology  There is no single definitive cause for non-Hodgkin‘s lymphomas. chemotherapy. human cancer cells are injected into laboratory animals such as mice. although a genetic link is strongly implicated in some types. Medical Management Non-Hodgkin‘s lymphoma is treated with radiation. such as a viral agent. Research continues on the use of biologic therapy (immunotherapy) with MABs to eliminate malignant cells and induce remission. axillary. which usually is diffuse rather than localized. choosing to treat the client once the disease accelerates. could induce the disease. pesticides. and reticulum cell sarcoma. Assessment Findings  Symptoms of non-Hodgkin‘s lymphoma depend on site of lymph node involvement. The physician may adopt a ―watch and wait‖ approach for clients with indolent forms of non.  An environmental ―trigger‖.  In non-Hodgkin‘s lymphoma. and the number of cases continues to rise.Hodgkin‘s lymphoma from Hodgkin‘s disease depend on microscopic examination of lymphoid tissue biopsies. chromosomal changes occur in affected lymphocytes. 30% to 60% of aggressive forms of non-Hodgkin‘s lymphoma are curable with intensive treatment. the client is relatively asymptomatic at diagnosis and the disorder is relatively responsive to radiation and chemotherapy.  Administration of immunosuppressive drugs to prevent transplant rejection also is correlated with cases of non-Hodgkin‘s lymphoma. and lymphoid tissue enlarges to accumulate proliferative production of malignant cells. The incidence of non-Hodgkin‘s lymphomas is size to seven times that of Hodgkin‘s disease.Hodgkin‘s lymphoma. occurs in cervical. Immunotherapy with monoclonal antibodies (MABs) and bone marrow transplants is being used to cure lymphomas or extend the lives of clients with these diseases. chemical herbicides. Examples include lymphosarcoma. and inguinal regions. With MABs.Non-Hodgkin’s Lymphoma    These are a group of 30 sub-classifications of malignant disease that originate in lymph glands and other lymphoid tissues. Non-Hodgkin‘s lymphoma is classified as either:  Indolent. or both.

continue to produce tumorfighting antibodies. The mouse lymphocytes are harvested and fused with a laboratory-grown cell. The advantage of combining MABs with drugs or radiation is that they target and destroy cancer cells while sparing normal cells. 82 | P a g e . The MABs are used alone or are bound to a chemotherapeutic or radioactive agent. whether they have non-Hodgkin‘s lymphoma or Hodgkin‘s disease. when administered to a client with cancer.- antibodies against cancer cells.  Because chemotherapy and radiation kill many cells. Rituximab (Rituxan) is an MAB drug approved for treating nonHodgkin‘s lymphoma. Nursing Management  Nursing care is similar for all clients with lymphoma. encourage clients to drink extra fluids (equivalent to 2500 ml/day) to facilitate excretion of the cells destroyed by therapy. creating clones that.

dietary deficiency.  Surgical resection. Pathophysiology  Malignancies of the oral cavity are usually squamous cell cancers.Cancers of the Gastrointestinal System Cancer of the Oral Cavity Cancers of the oral cavity can occur in any part of the mouth or throat. Assessment and Diagnostic Findings  Diagnostic evaluation consists of an oral examination as well as an assessment of the cervical lymph nodes to detect possible metastases. chemotherapy. radiation therapy. Predisposing factors for other oral cancers are exposure to tobacco (including smokeless tobacco).  High-risk areas include the buccal mucosa and gingival for people who use snuffs or smoke cigars or pipes. the preference of the physician.  Small lesions in cancer of the lip are usually excised liberally. Medical Management  Management varies with the nature of the lesion. the ventrolateral tongue.  Biopsies are performed on suspicious lesions (those that have not healed in two weeks).  For those who smoke cigarettes and drink alcohol. or enlarged cervical lymph nodes. high-risk areas include the floor of the mouth. difficulty in chewing. uvula. Chronic irritation by a warm pipestem or prolonged exposure to the sun and wind may predispose a person to lip cancer. These cancers are associated with the use of alcohol and tobacco. A typical lesion in oral cancer is painless indurated (hardened) ulcer with raised edges. As the disease progresses. and the soft palate complex (soft palate. and ingestion of smoked meats. the lateral aspects of the tongue. The most frequent symptom seen in late stages is a painless sore or mass that will not heal. the client may complain of tenderness. and the floor of the mouth are most commonly affected. anterior and posterior tonsillar area. are curable if discovered early.  Cancer of the tongue may be treated with radiation therapy and chemotherapy to preserve organ function and maintain quality of life. or a combination of these therapies may be effective. swallowing. and the area behind the molar and the tongue junction).  Tumors larger than 4 cm often recur. larger lesions involving more than one-third may be more appropriately treated by radiation therapy because of superior cosmetic results. but the lips. Tissue from any ulcer of the oral cavity that does not heal in two weeks should be examined through biopsy.  The choice depends on the extent of the lesion and what is necessary to cure the client while preserving the best appearance. coughing of blood-tinged sputum.  Any area of the oropharynx can be a site for malignant growth. ingestion of alcohol. Clinical Manifestations A number of oral cancers produce few or no symptoms in the early stages. 83 | P a g e . and client choice. or speaking.

Nursing diagnoses for a client with oral cancer may include the following:  Fear related to diagnosis and long-term prognosis  Imbalanced Nutrition: Less than body requirements related to oral surgery or radical neck dissection  Disturbed Body Image related to disfiguring surgery Cancer of the Esophagus Chronic irritation is a risk factor for esophageal cancer. if required. have a higher incidence of esophageal cancer. The palm will be pale. Also. 1) The Allen test is performed by asking the client to make a fist and then manually compressing the ulnar artery. A common reconstructive technique involves the use of a radial forearm free flap (a thin layer of skin from the forearm along with the radial artery). Pathophysiology  Esophageal cancer is usually of squamous cell epidermoid type. suctioning must be performed with care to prevent damage to the graft. the palm will flush within about three to five seconds. Pressure on the ulnar artery is released. slightly flexed position. Suction as necessary to help the client manage oral secretions. Nursing Management  Assess the client‘s nutritional status preoperatively. enteral or parenteral feedings before and after surgery to maintain adequate nutrition. Assess the graft postoperatively for viability. If grafting was included in the surgery. People with Barrett‘s esophagus.  If a radial graft is to be performed. 2) The client is then asked to open the hand into a relaxed. Locate the radial pulse at the graft site and assess graft perfusion using a Doppler ultrasound device. Surgical treatments leave a less functional tongue.     A combination of radioactive interstitial implants and external beam radiation may be used. the incidence of adenocarcinoma is increasing.  Administer. 3) If the ulnar artery is patent. surgical procedures include hemiglossectomy (surgical removal of half of the tongue) and total glossectomy (removal of the tongue).     Assess for a patent airway postoperatively. a dietary consultation may be necessary. the surgeon may perform a neck dissection. If the cancer has spread to the lymph nodes. which is caused by chronic irritation of mucous membranes due to reflux of gastric and duodenal contents. there seems to be an association between gastroesophageal reflux disease (GERD) and adenocarcinoma of the esophagus. Often cancer of the oral cavity has metastasized through the extensive lymphatic channel in the neck region. requiring a neck dissection and reconstructive surgery of the oral cavity. Cancer of the esophagus has been associated with ingestion of alcohol and with the use of tobacco. 84 | P a g e . carry out an Allen tests on the donor arm to ensure that the ulnar artery is patent and can provide blood flow to the hand after removal of the radial artery. however.

Clinical Manifestations Clients may have an advanced ulcerated lesion of the esophagus before symptoms are manifested. The delay between the onset of early symptoms and the time when the client seeks medical advice is often 12 to 18 months. and beyond the muscle layers into the lymphatics.  Tumors of the lower thoracic esophagus are more amenable to surgery than tumors located in the esophagus. depending on the location of the tumor. and. The client first becomes aware of intermittent and increasing difficulty in swallowing. radiation. with possible perforation into the mediastinum and erosion into the great vessels. through. in which the tumor is removed and the area is replace with a portion of the jejunum.  Standard surgical management includes a total resection of the esophagus (esophagectomy) with removal of the tumor plus a wide tumor-free margin of the esophagus and the lymph nodes in the area. In the latter stages.  Tumor cells may spread beneath the esophageal mucosa or directly into. Anyone with swallowing difficulties should be encouraged to consult a physician immediately. substernal pain or fullness. painful swallowing. hemorrhage may take place. Assessment and Diagnostic Findings  Diagnosis is confirmed most often by esophagogastroduodenoscopy (EGD) with biopsy and brushings. depending on the extent of the disease. if it is often found in late stages making relief of symptoms is the only reasonable goal for therapy. chemotherapy. As the tumor progresses and the obstruction become more complete. and progressive loss of weight and strength occurs from starvation.  Cancer of the lower end of the esophagus may be caused by adenocarcinoma of the stomach that extends upward into the esophagus. even liquids cannot pass into the stomach. or the stomach can be elevated into the chest and the proximal section of the esophagus anastomosed to the stomach. esophageal continuity may be maintained by free jejuna graft transfer. however. a sensation of a mass in the throat. and gastrointestinal tract integrity is maintained by anastomosing the lower esophagus to the stomach. and foul breath. Symptoms include dysphagia. or a combination of the modalities. Medical Management  Treatment goals may be directed toward cure if esophageal cancer is found at an early stage. persistent hiccup.  Treatment may include surgery. initially with solid foods and eventually with liquids.  The surgical approach may be through the thorax or the abdomen.  Bronchoscopy is usually performed.  A segment of the colon may be used.  Endoscopic ultrasound or mediastinoscopy is used to determine whether the cancer has spread to the nodes and other mediastinal structures. to determine whether the trachea has been affected and to help determine whether the lesion can be removed. especially in tumors of the middle and the upper third of the esophagus. Regurgitation of food and saliva occurs.  When tumors occurs in the cervical or upper thoracic area. respiratory difficulty. 85 | P a g e . later regurgitation of undigested food with foul breath and hiccups. obstruction of the esophagus is noted. Later symptoms include substernal pain.

Later. Perform a barium swallow to asses for any anastomotic leak before the client is allowed to eat.  Monitor temperature to detect any elevation that may indicate aspiration or seepage of fluid through the operative site into the mediastinum.  Check for the graft viability hourly for at least the first 12 hours if jejunal grafting has been performed. position the client in a Fowler‘s position to assist in preventing reflux of gastric secretions. placement of an endoprosthesis (stent).  Remind the client with endoprosthesis to chew food sufficiently to prevent obstruction. small amounts of pureed food once feeding begins. Nursing Management  Intervention is directed toward improving the client‘s nutritional and physical condition in preparation for surgery. including the required for closed chest drainage.  Placed the client in a low Fowler‘s position a fter recovering from the effects of anesthesia. and to control saliva. or chemotherapy. radiation.  Encourage the client with poor appetite to eat by involving the family to prepare home-cooked favourite foods. to assist with nutrition.  Remove the nasogastric tube five to seven days after surgery. Postoperatively.       Surgical resection of the esophagus has a relatively high mortality rate because of infection. treatment is based on type of cell. radiation therapy. Preoperative radiation therapy or chemotherapy. or both. Palliative treatment may be necessary to keep the esophagus open. The client is given nothing by mouth until x-ray studies confirm that the anastomosis is secure and not leaking. tumor spread.  Encourage the client to swallow small sips of water. may be used.  Provide immediate postoperative care that is similar to that provided to clients undergoing thoracic surgery.  If an endoprosthesis has been placed or an anastomosis has been performed. laser therapy. however.  Inform the client about the nature of the postoperative equipment that will be used. and gastric intubation. mark the nasogastric tube for position immediately after surgery.  Initiate parenteral or enteral nutrition if the client is unable to eat by mouth.  Allow the client to remain upright for at least two hours after each meal to allow the food to move through the gastrointestinal tract. and client condition. or chemotherapy. pulmonary complications.  Do not attempt to reinsert a displaced nasogastric tube because damage to the anastomosis may occur. later.  Assess the graft for color.  If adequate food can be taken by mouth.  Discontinue parenteral fluids once the client is able to increase food intake to an adequate amount. 86 | P a g e . Treatment is individually determined since the ideal method of treating esophageal cancer has not yet been found.  Monitor nutritional status throughout treatment. Palliation may be accomplished with dilation of the esophagus. Presence of a pulse may be assessed using a doppler sonography. or leakage through the anastomosis. parenteral fluid therapy. the client will have a nasogastric tube in place that should not be manipulated. and notify the physician if displacement occurs. nasogastric suction. promote weight gain based on a high-calorie and high-protein diet in liquid or in soft form. and.Carefully observe the client for regurgitation and dyspnea (a common postoperative complication is aspiration pneumonia).

 Ascites and hepatomegaly (enlarged liver) may be apparent if the cancer cells have metastasized to the liver. Clinical Manifestations Symptoms of early disease.  Esophagogastroduodenoscopy for biopsy and cytologic washings is the diagnostic study of choice. smoking. penetrating the wall of the stomach and adjacent organs and stomach. called Sister Mary Joseph’s nodules are a sign of a GI malignancy. Pathophysiology  Most gastric cancers are adenocarcinomas.  Palpable nodules around the umbilicus.    Administer antacids to relieve gastric distress. where they cause little disturbance of gastric function. A diet high in smoked. measures to take if complications occur. usually a gastric cancer. The incidence of gastric cancer is much greater in Japan. such as pain relieved by antacids. Administer oral suction if the client is unable to handle secretions. Most case of gastric cancers are discovered only after local invasion has advanced or metastases are present. or wick-type gauze may be placed at the corner of the mouth to direct secretions to a dressing or emesis basin. 87 | P a g e . and how to obtain needed physical and emotional support. Symptoms of progressive disease include dyspepsia (indigestion).  The tumor infiltrates the surrounding mucosa.  Metastasis through lymph to the peritoneal cavity occurs later in the disease. they can occur anywhere in the stomach. abdominal pain just above the umbilicus. weight loss. The prognosis is generally poor. resemble those of benign ulcers and are seldom definitive. During discharge planning. which has instituted mass screening programs for earlier diagnosis. Provide liquid supplements. and duodenum are often already affected at the time of diagnosis. what observations to make. and genetics. which are more easily tolerated by clients undergoing radiation and experiencing esophagitis. but gastric can occur in people younger than 40 years of age.  The liver. Assessment and Diagnostic Findings  The physical examination is usually not helpful in detecting the cancer because most early gastric tumors are not palpable. nausea and vomiting. esophagus. or pickled foods and low in fruits and vegetables may increase the risk of gastric cancer. bloating after meals.  Advance gastric cancer may be palpable as a mass. instruct the family about promotion of adequate nutrition. H. salted. and a barium x-ray examination of the upper GI tract may also be performed. because most gastric tumors begin on the lesser curvature of the stomach. pancreas. Men have a higher incidence of gastric cancer than women. loss or decrease in appetite. the diagnosis is during the early stages of the disease. Gastric Cancer The typical client with gastric cancer is between 40 and 70 years of age. and symptoms similar to those of peptic ulcer disease. Diet appears to be a significant factor. achlorhydria. Other factors related to the incidence of gastric cancer include chronic inflammation of the stomach. how to keep the client comfortable. pylori infection. early satiety. gastric ulcers. previous subtotal gastrectomy (more than 20 years ago). pernicious anemia.

effective palliation to prevent discomfort caused by obstruction or dysphagia may be obtained by resection of the tumor. etoposide (Etopophos). such as the liver. The Billroth I involves a limited resection and offers a lower cure rate than Billroth II.  The client with a tumor that is deemed resectable undergoes an open surgical procedure to resect the tumor and appropriate lymph nodes.  A gastric resection may be the most effective palliative procedure for advanced gastric cancer.  The client with an unresectable tumor and an advanced disease undergoes chemotherapy. treatment with chemotherapy may offer further control of the disease or palliation.  Palliative procedures such as gastric or esophageal bypass. Computed tomography completes the diagnostic studies. abdomen. bleeding. doxorubicin (Adriamycin). obtain tissue for pathologic diagnosis.  In many clients. the lower portion of the esophagus.  If the tumor has spread beyond the area that can be excised.  Reconstruction of the GI tract is performed by anastomosing the end of the jejunum to the end of the esophagus (esophagojejunostomy). cure is less likely. CT scan of the chest.  Commonly used single-agent chemotherapeutic medications include 5-fluorouracil (5-FU).   Endoscopic ultrasound is an important tool to assess tumor depth and any lymph node involvement.  Common problems of advanced gastric cancer that often requires surgery include pyloric obstruction. Medical Management  There is no successful treatment for gastric carcinoma except removal of the tumor. or to achieve a better quality of life. The Billroth II procedure is a wider resection and involves removing approximately 75% of the stomach and decreases the possibility of lymph node spread or metastatic recurrence. the client may be cured. and mitomycin-C (Mutamycin).  A proximal subtotal gastrectomy may be performed for a resectable tumor located in the proximal portion of the stomach or cardia. and lymph nodes.  A diagnostic laparoscopy may be the initial surgical approach to evaluate the gastric tumor. Radiation Therapy  Radiation therapy is mainly used for palliation in clients with obstruction. Chemotherapy  If surgical treatment does not affect cure. and detect metastasis. Surgical Treatment  A total gastrectomy may be performed for a resectable cancer in the midportion or body of the stomach. GI bleeding secondary to tumor.  If the tumor can be removed while it is still localized to the stomach.  A Billroth I or a Billroth II operation is performed.  A radical subtotal gastrectomy is performed for a resectable tumor in the middle and distal portion of the stomach. and severe pain. and significant pain.  Gastric perforation is an emergency situation requiring surgical intervention. 88 | P a g e . or jejunostomy may temporarily alleviate symptoms such as nausea and vomiting. cisplatin (Platinol). supporting mesentery. and pelvis is valuable in staging gastric cancer. The entire stomach is removed along with the duodenum.  A total gastrectomy or an esophagogastrectomy is usually performed in place of proximal subtotal gastrectomy to achieve a more extensive resection.  Palliative rather than radical surgery may be preformed if there is metastasis to other vitalorgans. gastrostomy. particularly to assess for surgical respectability of the tumor before surgery is scheduled.

 Assessment of tumor markers (blood analysis for antigens indicative of cancer) such as carcinoembryonic antigen (CEA). and daily weight to ensure that the client is maintaining or gaining weight. relaxation exercises. Anxiety related to the disease and anticipated treatment Imbalanced nutrition.  Routinely assess the frequency.  Monitor the IV therapy and nutritional status and record intake.  Advise the client about any procedures and treatments so that the client is aware of what to expect.  Encourage the family or significant other to support the client. back rubs. and iron to enhance tissue repair. less than body requirements. and financial resources. Perform psychosocial assessment. 89 | P a g e . Perform a complete physical examination. and palpate and percuss the abdomen to detect ascites. focusing on recent nutritional intake and status.  Administer vitamin B12 it is necessary for life if the client underwent total gastrectomy. Fluids between meals rather than with meals  Inform the client that dumping syndrome often resolves after several months. imagery. Provide food supplements high in calories.  Administer continuous IV infusion of an opioid for postoperative or severe pain. such as: Six small feedings daily that are low in carbohydrates and sugar. nonthreatening atmosphere so that the client can express fears. and family history.  Suggest nonpharmacologic methods for pain relief. include questions about social support. and possibly anger about the diagnosis and prognosis. Obtain other health information about the client‘s smoking and alcohol history. frequent portions on nonirritating foods to decrease gastric irritation. concerns. and duration of the pain to determine the effectiveness of the analgesic agent. Carefully assess the client‘s a bdomen for tenderness or masses. Nursing Management Assessment Obtain a dietary history from the client. distraction. massages.  Administer parenteral nutrition to a client who is unable to eat adequately prior to surgery to meet nutritional requirements. output.  Assess for signs of dehydration and review the results of daily laboratory studies to note any metabolic abnormalities. Relieve pain  Administer analgesic agents as prescribed. Promote optimal nutrition  Encourage the client to eat small. offer reassurance. and support positive coping measures.  Explain ways to prevent and manage dumping syndrome when enteral feeding resumes after gastric resection. and CA 50 may help determine the effectiveness of treatment. such as position changes. individual and family coping skills. carbohydrate antigen (CA 19-9). vitamin C and A. related to early satiety or anorexia Pain related to tumor mass Anticipatory grieving related to the diagnosis of cancer  Deficient knowledge regarding self-care activities Planning and Nursing Interventions Reduce anxiety  Provide a relaxed.  Administer antiemetics as prescribed. and periods of rest and relaxation. intensity.

or any symptoms that become progressively worse. If the disease is detected in an early stage. Arrange for psychological counseling. activity and lifestyle changes. sigmoid colon – 33%. psychologist. Early diagnosis and prompt treatment could save almost three of every four people with colorectal cancer. such as bleeding.  Provide time and support to a client that undergo mourning for the loss of a body part and who perceives surgery as a type of mutilation.year survival rate is 90% but only 34% of colorectal cancers are found at an early stage. perforation.  Project an empathetic attitude and spend time with the client. if necessary. transverse colon – 11%.  Teach the client or caregiver to recognize and report sign and symptoms of complications that require immediate attention. The incidence of cancer in the sigmoid and rectal areas has decreased. low-fiber diet.  Assist the client. obstruction.  Explain the care needed during and after treatments to the client and family or significant other.Provide psychosocial support  Help the client express fears. and significant others that emotional responses are normal and expected. including detection and prevention of untoward complications related to feedings. family. and reassure the client. psychiatric clinical nurse specialist. Promote home and community-based care  Client and family teaching include information about diet and nutrition.  Make the services of clergy. if needed. concerns. and psychiatrist available.  Offer emotional support and involve the family members and significant others whenever possible. high-fat. Pathophysiology  Cancer of the colon and rectum are predominantly adenocarcinoma. ascending. social workers. and descending colon has increased. descending colon – 6%. 90 | P a g e . and grief about the diagnosis. rectum – 27% Changes in the distribution have occurred in recent years. Most people are asymptomatic for long periods and seek health care only when they notice a change in bowel habits or rectal bleeding.  Answer the client‘s questions honestly and encourage him or her to participate in treatment decisions. previous colon cancer or adenomatous polyps.  Provide explanation about chemotherapy and radiation therapy. The exact cause of colon and rectal cancer is still unknown but risk factors have been identified: Increasing age. high-protein (with high intake of beef). treatment regimen. genital cancer or breast cancer (in women) The distribution of cancer sites throughout the colon are: ascending colon – 22%. Survival rates after late diagnosis are very low. whereas the incidence of cancer in the cecum. family history of colon cancer or polyps. or significant other with decisions regarding end-of-life care and make referrals as warranted. family members.  Recognize mood swings and defense mechanisms. arising from the epithelial lining of the intestine. Colorectal Cancer Tumors of the colon and rectum are relatively common. pain management.  Teach the client and caregiver about administration of enteral or parenteral nutrition. and possible complications. The incidence increases with age (the incidence is highest for people older than 85 years of age) and is higher for people with a family history of colon cancer and those with inflammatory bowel disease or polyps. the 5. history of inflammatory bowel disease.

 Carcinoembryonic antigen (CEA) studies may also be performed.  Although CEA may not be highly reliable indicator in diagnosing colon cancer because not all lesions secrete CEA. invade and destroy normal tissue. tarry stools). The most common presenting symptom is a change in bowel habits. and shock may occur. 91 | P a g e . Gerontologic Considerations  The incidence of carcinoma of the colon and rectum increases with age. and colonoscopy.  It may start as a benign polyp but may become malignant. the stage of the disease. anorexia. Medical Management  The client with symptoms of intestinal obstruction is treated with intravenous fluids and nasogastric suction. narrowing stools.  Lack of fiber is a major causative factor because the passage of feces through the intestinal tract is prolonged.  Elevation of CEA at a later date suggests recurrence. Assessment and Diagnostic Findings  Along with an abdominal and rectal examination. These cancers are considered common malignancies in advanced age. the elevated levels of CEA should return to normal within 48 hours. the feeling of incomplete evacuation after a bowel movement. and extend into surrounding structures.  Perforation. and distention). as well as bright red blood in the stool. blood component therapy may be required. peritonitis. abscess formation. Cancer cells may break away from the primary tumor and spread to other parts of the body. rectal pain. Clinical Manifestations The symptoms are greatly determined by the location of the cancer. barium enema. alternating constipation and diarrhea. and bloody stool. Complications  Tumor growth may cause partial to complete bowel obstruction. The symptom most commonly associated with leftside lesions are those associated with obstruction (abdominal pain and cramping.  Colon cancer in the elderly has been closely associated with dietary carcinogens. proctosigmoidoscopy. The symptoms most commonly associated with rightsided lesions are dull abdominal pain and melena (black. weight loss.  With complete excision of the tumor. the most important diagnostic procedures for cancer of the colon are fecal occult blood testing. Symptoms may also include unexplained anemia.  Extension of the tumor and ulceration into the surrounding blood vessels results in hemorrhage. and the function of the intestinal segment in which it is located. most often to the liver. Symptoms associated with rectal lesions are tenesmus (ineffective. The passage of blood in the stools is the second most common symptom. and fatigue.  Excess fat is believed to alter bacterial flora and convert steroids into compounds that have carcinogenic properties. painful straining at stool). studies show that CEA levels are reliable in predicting prognosis. which extends exposure to possible carcinogens.  If there has been significant bleeding. sepsis. constipation.

to achieve better results from surgery. tumor is limited to bowel wall Class C2: Positive nodes. supportive therapy. during. and to reduce the risk of recurrence. allowing initial bowel decompression and bowel preparation before resection Permanent colostomy or ileostomy for palliation of unresectable obstructing lesions Construction of a coloanal reservoir called a colonic J pouch is performed in two steps. the tumor mass is then excised. irradiation is used to provide significant relief from symptoms.  The response to adjuvant therapy varies.  Clients with Dukes‘ class B or C rectal cancer are given 5-fluourouracil and high disease of pelvic irradiation. The type of surgery recommended depends on the location and size of the tumor. it is considered nonresectable. if the tumor has spread and involves surrounding vital structures. Mitomycin is also used. tumor extends through entire bowel wall Class D: Advanced and metastasis to liver.. no nodal involvement  Class C1: Positive nodes.  For inoperative or unresectable tumors.  Radiation therapy is used before.e. Cancers limited to one side can be removed through colonoscope. as well as the blood vessels and lymphatic nodes) Abdominoperitoneal resection with permanent sigmoid colostomy (i.  Intracavity and implantable devices are used to deliver radiation to the site. removal of the tumor and a portion of the sigmoid and all of the rectum and anal sphincter) Temporary colostomy followed by the segmental resection and anastomosis and subsequent reanastomosis of the colostomy.e. but the goal of surgery in this instance is palliative. It may be curative or palliative.fluourouracil plus levamisole regimen. and after surgery to shrink the tumor. Bowel resection is indicated for most class A lesions and all class B and C lesions. Surgical Management          Surgery is the primary treatment for most colon and rectal cancers. Laparoscopic colotomy with polypectomy minimizes the extent of surgery needed in some cases. lung. Treatment of colorectal cancer depends on the stage of the disease and consists of surgery to remove the tumor. and adjuvant therapy. Use of the neodymium/yttrium-aluminum-garnet (Nd:YAG) laser has proved effective with some lesions as well. Surgery is sometimes recommended for class D colon cancer. or bone Adjuvant Therapy  The standard adjuvant therapy administered to clients with Dukes‘ Class C colon cancer is the 5. Staging of Colorectal Cancer: Dukes’ Classification – Modified Staging System  Class A: Tumor limited to muscular mucosa and submucosa  Class B1: Tumor extends into mucosa  Class B2: Tumor extends through entire bowel wall into serosa or pericolic fat. removal of the tumor and portions of the bowel on either side of the growth.  92 | P a g e . Surgical procedures include the following: Segmental resection with anastomosis (i. A laparoscope is used as a guide in making an incision into the colon..

abdominal or rectal pain. Nursing Diagnosis  Imbalanced nutrition. 2) About three months after the initial stage. Nursing Management Assessment  Complete a health history to obtain information about fatigue. as well as amounts of alcohol consumed. and solid mass. distention. and minerals if the client is hospitalized in the days preceding surgery. The anal sphincter and therefore continence are preserved.  Prescribe a full-liquid diet 24 to 48 hours before surgery to decrease bulk. including stoma care if a colostomy is to be created.  Parenteral nutrition may be required to replace depleted nutrients. a family history of colorectal disease. to provide adequate nutrition and minimize cramping by decreasing excessive peristalsis.  Build the client‘s stamina in the days preceding surgery and cleans e and sterilize the bowel the day before the surgery. abscess. 93 | P a g e . and self-care after discharge  Impaired skin integrity related to the surgical incisions (abdominal and perianal). and sepsis Planning and Interventions  Prepare the client for surgery  Prepare the client physically for surgery. less than body requirements. and characteristics of stool.  Obtain additional information about history of inflammatory bowel disease or colorectal polyps. provideinformation about postoperative care. vitamins. the formation of a stoma. and current medication therapy. related to nausea and anorexia  Risk for deficient fluid volume related to vomiting and dehydration  Anxiety related to impending surgery and the diagnosis of cancer  Risk for ineffective therapeutic regimen management related to knowledge deficit concerning the diagnosis. and frequent fecal contamination of peristomal skin  Disturbed body image related to colostomy  Ineffective sexuality patterns related to presence of ostomy and changes in body image and self-concept Collaborative Problems Intraperitoneal infection Complete large bowel obstruction GI bleeding Bowel perforation Peritonitis.  Inspect stool specimens for character and presence of blood.  Recommend a diet high in calories. and support the client and family emotionally. including fat and fiber intake. the surgical procedure. and the newly constructed J pouch (made from 6 to 10 cm of the colon) is reattached to the anal stump.1) A temporary loop ileostomy is constructed to divert intestinal flow. if client‘s condition permits.  Describe and document a history of weight loss. and carbohydrates and low in residue for several days before surgery. protein.  Identify dietary habits. past and present elimination patterns. and intestinal continuity is restored. the ileostomy is reversed.  Assessment includes auscultating the abdomen for bowel sounds and palpating the abdomen for areas of tenderness.

and expected level of functioning after surgery. stoma retraction.  Arrange a meeting with a spiritual advisor if the client desires or with the physician if the client wishes to discuss the treatment or prognosis. and appliance to explain and clarify. and medication management.  Set aside time to listen to the client who wishes to talk. professional. as necessary. skin irritation. prolapse of the stoma. or colonic irrigation the evening before and the morning of surgery. Consultation with an enterostomal therapist during the preoperative period or with a person who is successfully managing an ostomy can be helpful.  Monitor the client for complications. which may indicate obstruction or perforation. Monitor serum electrolyte levels to detect hypokalemia and hyponatremia that occur with GI fluid loss. Monitor intravenous fluids and electrolytes.  Complete a nutritional assessment for clients with a colostomy. such as leakage from the site of the anastomosis. dietary restrictions. and concentrated urine. Measure and record intake and output. Provide postoperative care  Postoperative care for clients undergoing colon resection or colostomy is similar to nursing care for any abdominal surgery client.. sulfonamides. Allow the client to have full or clear liquids as tolerated or to have nothing by mouth. perforation.  Present facts about the surgical procedure and the creation and management of ostomy to reduce the fear related to changes in body image. neomycin.  Project a relaxed. Provide emotional support  Assess the client‘s anxiety level and coping mechanism.  Assess the abdomen for returning peristalsis and assess the initial stool characteristics. cry. prognosis. Maintain optimal nutrition  Teach all clients undergoing surgery for colorectal cancer about the health benefits to be derived from consuming a healthy diet.  Include pain management during immediate postoperative period. Observe for signs of hypovolemia.  Help the client with ostomy out of bed on the first operative day and encourage him or her to begin participating in managing the colostomy. or ask questions. 94 | P a g e . enemas. and pulmonary complications associated with abdominal surgery. the expected appearance and care of the wound. assess hydration status. loss of bowel sounds. and pain or rigidity. photographs. and report decreased skin turgor. and cephalexin) the day before the surgery to reduce intestinal bacteria. the technique of ostomy care (if applicable). dry mucous membranes.  Use diagrams. for the client who is very ill and hospitalized to provide an accurate record of fluid balance. fecal impaction. Allow the client and family to ask questions or voice out concerns. Include in the teaching plan information about the physical preparation for surgery. Assess the client‘s knowledge about the diagnosis. Insert a nasogastric tube to drain accumulated fluids and prevent abdominal distention. and suggest methods for reducing anxiety. surgical procedure. Restrict the client‘s oral food and fluid intake to prevent vomiting. Monitor the abdomen for increasing distention.  Provide privacy and teach relaxation techniques. Administer antiemetics as prescribed. including vomitus. Cleanse the bowel using laxatives. and empathetic attitude to promote client comfort.g.           Administer antibiotics (e. pain control.

     

Teach the client to avoid foods that causes excessive odor and gas, including foods in the cabbage family, eggs, fish, beans, and highcellulose products (e.g., peanuts). Substitute nonirritating foods for those that are restricted to be able to correct nutritional deficiencies. Advise the client to experiment with an irritating food for several times before restricting it, because an initial sensitivity may decrease with time. Help the client identify any foods or fluids that may be causing diarrhea, such as fruits, highfiber foods, soda, coffee, tea, or carbonated beverages. Help control diarrhea by administering paregoric, bismuth subgallate, bismuth subcarbonate, or diphenoxylate with atropine (Lomotil). Suggest fluid intake of at least two liters of fluid per day.

Provide wound care  Examine the abdominal dressing frequently during the first 24 hours after surgery to detect signs of hemorrhage.  Help the client splint the abdominal incision during coughing and deep breathing to lessen tension on the edges of the incision.  Monitor temperature, pulse, and respiratory rates for elevations, which may indicate an infectious process.  If the client has a colostomy, examine the stoma for swelling (slight edema from surgical manipulation is normal), color (a healthy stomach is pink or red), discharge (a small amount of oozing is normal), and bleeding (an abnormal sign).  If the malignancy has been removed using the perineal route, observe for signs of hemorrhage. Remove the wound packing or drain gradually.  Hasten the process of tissue sloughing off by performing mechanical irrigation of the wound or with sitz baths two to three times a day for a week. Document the condition of the perineal wound and any bleeding, infection, or necrosis. Monitor and manage complications  Observe the client for signs and symptoms of complications.  Assess the abdomen frequently, including decreasing or changing bowel sounds and increasing abdominal girth, to detect bowel obstruction.  Monitor vital signs for increased temperature, pulse, and respirations and for decreased blood pressure, which may indicate an intra-abdominal infectious process.  Report rectal, which indicates hemorrhage, immediately.  Monitor hematocrit and hemoglobin levels and administer blood component therapy as prescribed.  Promptly report any change in abdominal pain.  Report elevated white blood cell counts and temperature or symptoms of shock because these may indicate sepsis.  Encourage frequent activity (i.e., turning the client from side to side every 2 hours); deep breathing, coughing, and early ambulation can reduce the risks for pneumonia and atelectasis. Potential complications and nursing interventions after intestinal surgery  Paralytic ileus  Initiate or continue nasogastric intubation as prescribed.  Prepare client for x-ray study.  Ensure adequate fluid and electrolyte replacement.  Administer prescribed antibiotics if client has symptoms of peritonitis.  Mechanical obstruction  Assess client for intermittent colicky pain, nausea, and vomiting.

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 Peritonitis  Evaluate client for nausea, hiccups, chills, spiking fever, and tachycardia.  Administer antibiotics as prescribed.  Prepare client for drainage procedure.  Administer parenteral fluid and electrolyte therapy as prescribed.  Prepare client for surgery if condition deteriorates.  Abscess formation  Administer antibiotics as prescribed.  Apply warm compresses as prescribed.  Prepare for surgical drainage.  Infection (surgical wound complication)  Monitor temperature, report temperature deviation.  Observe for redness, tenderness, and pain around the wound.  Assist in establishing local drainage.  Obtain specimen of drainage material for culture and sensitivity studies.  Wound disruption  Observe for sudden appearance of profuse serous drainage from wound.  Cover wound area with sterile towels held in place with binder.  Prepare client immediately for surgery.  Intraperitoneal infection and abdominal wound infection  Monitor for evidence of constant or generalized abdominal pain, rapid pulse, and elevation of temperature.  Prepare for tube decompression of bowel. Administer fluids and electrolytes by IV route as prescribed.  Administer antibiotics as prescribed.  Dehiscence of anastomosis  Prepare client for surgery.  Fistulas (anastomotic complication)  Assist in bowel decompression.  Administer parenteral fluids as prescribed to correct fluid and electrolyte deficits.        Remove and apply the colostomy appliance The colostomy begins to function three to six days after surgery. Manage and teach the client about colostomy care until the client can take over. Differentiate ostomy appliances available for the client‘s use. One-piece appliance consists of a pouch with an integral adhesive section that adheres to the client‘s skin. Two -piece appliance consists of a separate pouch that fastens to the barrier backing. Teach skin care and how to apply and remove the drainage pouch. Care of the peristomal skin is an ongoing concern because excoriation or ulceration can develop quickly. Presence of skin irritation makes adhering the ostomy appliance difficult, and adhering the ostomy appliance to irritated skin can worsen the skin condition. The effluent discharge and the degree to which it is irritating vary with the type of ostomy. Transverse colostomy – stool is soft and mushy and irritating to the skin Descending or sigmoid colostomy – stool is fairly solid and less irritating to the skin.Other skin problems associated with a colostomy are yeast infections and allergic dermatitis. If the client wants to bathe or shower before putting on the clean appliance, apply micropore tape to the sides of the pouch to secure it during bathing.

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1) To remove the appliance, the client assumes a comfortable sitting or standing position and gently pushes the skin down from the faceplate while pulling the pouch up and away from the stoma. (Gentle pressure prevents the skin from being traumatized and any liquid fecal contents from spilling out.) 2) Advise the client to protect the peristomal skin by washing the area gently with a moist, soft cloth and a mild soap. 3) Instruct the client to remove any excess skin barrier. 4) Cover the stoma with gauze or insert a vaginal tampon to absorb excessive drainage while the skin is being cleansed. 5) Pat the skin dry, take care not to rub the area. 6) Nystatin powder can be dusted lightly on the peristomal skin if irritation or yeast growth is present.  Smooth application of the drainage appliance for a secure fit requires practice and a well-fitting appliance. 1) Allow the client to choose from a wide variety of appliances, depending on what he or she needs. 2) Measure the stoma to determine the correct size for the pouch; the pouch opening should be about 0.3 cm (1/8 inch) larger than the stoma. 3) After the skin is cleansed, apply the peristomal skin barrier (i.e., wafer, paste, or powder). 4) Dust the skin with karaya or Stomahesive powder before attaching the pouch (for mildly irritated skin). 5) Remove the backing from the adherent surface of the appliance, and place the bag down over the stoma for 30 seconds. 6) Empty or change the appliance when it is 1/3 to ¼ full so that the weight of its contents does not cause the appliance to separate from the adhesive disk and spill the contents. For some clients, colostomy appliances are not always needed. As soon as the client has learned a routine for evacuation, bags may be dispensed with, and a closed ostomy appliance or a simple dressing of disposable tissue (often covered with plastic wrap) is used, held in place by an elastic belt. Nothing escapes from the colostomy opening between irrigations, except for gas and a slight amount of mucous. Colostomy plugs that expand on insertion to prevent passage of flatus and feces are also available. Irrigate the colostomy Irrigation of the colostomy is done to empty the colon of gas, mucus, and feces so that the client can go about social and business activities without fear of fecal drainage. A stoma does not have voluntary muscle control and may empty at irregular intervals. Regulating the passage of fecal material is achieved by irrigating the colostomy or allowing the bowel to evacuate naturally without irrigations. By irrigating the stoma at a regular time, there is less gas and retention of the irrigant. The time for irrigating the colostomy should be consistent with the schedule the person will follow after leaving the hospital. Support a positive image Encourage the client to verbalize feelings and concerns about altered body image and to discuss the surgery and the stoma (if one was created). Provide a supportive environment and a supportive attitude to be able to promote the client‘s adaptation to the changes brought about by the surgery.

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Help the client overcome aversion to the stoma or fear of self-injury by providing care and teaching in an open, accepting manner and by encouraging the client to talk about his or her feelings about the stoma. Discuss sexuality issues Encourage the client to discuss feelings about sexuality and sexual function. Assess the client‘s needs and attempt to identity specific concerns. Seek assistance from an enterostomal therapy nurse, sex counselor or therapist, or advanced practice nurse of the client‘s concern seem complex.

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Management  Complete excision of these carcinomas is followed by reconstruction with skin grafting if the surgical excision is extensive. It spreads to the surrounding tissues and metastasizes to other organs. Squamous cell carcinoma is also rare but invasive. especially the parents of a pediatric client. Malignant eyelid tumors occur more frequently among people with fair complexion who have a history of chronic exposure to the sun. Malignant Tumors of the Conjunctiva Conjunctival carcinoma most often grows in the exposed areas of the conjunctiva. Some benign tumors and most malignant tumors recur. and is useful in estimating the field for radiation therapy if needed. Basal cell carcinoma appears as a painless nodule that may ulcerate. The degree of orbital destruction is important in planning the surgical approach. It usually appears on the lower lid margin near the inner canthus with a pearly white margin. Malignant melanoma may not be pigmented and can arise from nevi. the thigh.  Donor graft sites may include the buccal mucosa.  Emotional support and reassurance are important aspects of nursing management.  The ocular postoperative site and the graft donor site are monitored for bleeding. spreads to the surrounding tissues. but it can metastasize to the regional lymph nodes. and stage of the disease. The most common site of metastasis is the lung. and adjuvant chemotherapy. but it can also develop in elderly persons. The symptoms include sudden painless proptosis of one eye followed by eyelid swelling. and surgical excisions may result in facial disfigurement. They grow gradually. resection often involves removal of the globe. Management of primary malignant orbital tumors involves three major therapeutic modalities: surgery. are vital in planning the management approach. Squamous cell carcinoma may resemble basal cell carcinoma initially because it also grows slowly and painlessly.  The client is referred to an oncologist for evaluation for the need for radiation therapy treatment and monitoring for metastasis. and grows slowly but does not metastasize. or the abdomen. It tends to ulcerate and invade the surrounding tissues. radiation therapy.Cancers of the Special Senses Malignant Tumors of the Orbit Rhabdomyosarcoma is the most common malignant primary orbital tumor in childhood. The management is surgical incision. Squamous cell carcinoma occurs less frequently but is considered the second most common malignant tumor. Imaging of these tumors establishes the size. The psychological needs of the client and family. 99 | P a g e . In the orbit. Malignant Tumors of the Eyelid Basal cell carcinoma is the most common malignant tumor of the eyelid. Malignant melanoma is rare but may arise from a preexisting nevus or acquired melanosis during middle age. and deep invasion and metastasis are rare. delineates the degree of bone destruction. configuration. and impairment of ocular motility.  Early diagnosis and surgical management are the basis of a good prognosis. conjunctival chemosis. location.  These conditions have life-threatening consequences. The lesion is invasive. The typical lesions are usually gelatinous and whitish due to keratin formation.

 Asymmetry in audiovestibular test results should be identified so that further workup can be performed to rule out an acoustic neuroma. Tumors are classified according to size (i. a suboccipital or middle cranial fossa approach to removing the tumor may be used. Malignant Tumors of the Globe (Ocular Melanoma) A malignant tumor of the retina. the surgery is performed using a translabyrinthine approach.  Multidisciplinary treatment approach involves a neurotologist and a neurosurgeon. Very small tumors are generally monitored. The diagnosis is confirmed at biopsy after enucleation. 100 | P a g e . medium. In addition to a complete physical examination to discover any evidence of metastasis. small. clients usually undergo radiation therapy and cryotherapy after the excision of malignant tumors.. This rare. Radiation therapy is achieved by external beam performed in repeated doses over several days or through the surgical implantation of a radioactive plaque. usually arising from the Schwann cells of the vestibular portion of the nerve. although most occur during middle age.e. fluorescein angiography. which is removed after several days. Most acoustic tumors arise within the internal auditory canal and extend into the cerebellopontine angle to press on the brain stem.To avoid recurrences.  The objective of surgery is to remove the tumor while preserving facial nerve function. CT scan with contrast dye may also be performed for claustrophobic clients. Many clients do not have symptoms in the early stages though some clients may complain of blurred vision or a change in eye color. Ocular melanoma is another cancer that primarily occurs in adults. it could be mistaken for a nevus. malignant choroidal tumor is often discovered on a retinal examination. in which bilateral tumors occur. retinal fundus photography. and intraoperative monitoring of cranial nerve VIII is performed to save the hearing. enucleation. occurs in childhood.  MRI with a paramagnetic contrast agent is the imaging study of choice. In its early stages. A number of such tumors have been found in people with blindness that has painful eyes. and the hearing mechanism is destroyed.  Most acoustic tumors have damaged the cochlear portion of cranial nerve VIII. or both. is hereditary. retinoblastoma. and no serviceable hearing exists before surgery. and ultrasonography are performed. Cosmetic disfigurement may result from extensive excision when deep invasion by the malignant tumor is involved. Acoustic Neuroma An acoustic neuroma is a slow-growing benign tumor of cranial nerve VIII. whereas medium and large tumors require treatment. except in von Recklinghausen‘s disease. and requires complete enucleation if there is to be a chance for successful outcome. Management  Surgical removal of acoustic tumors is the treatment of choice because these tumors do not respond well to irradiation or chemotherapy. large). Assessment and Diagnostic Findings  The most common findings of assessment of clients with an acoustic neuroma are unilateral tinnitus and hearing loss with or without vertigo or balance disturbance. Treatment consists of radiation therapy. Most acoustic neuromas are unilateral.  If hearing is still good before surgery. Acoustic neuroma occurs with equal frequency in men and women at any age.  In these clients.

 Complications of surgery for acoustic neuroma include facial nerve paralysis. 101 | P a g e . and cerebral edema. Death from acoustic neuroma surgery is rare. cerebrospinal fluid leak. meningitis.

pancreas. and appearance. These pressure effects produce headache. but metastatic lesions to the brain occur commonly from the lung. Functioning pituitary tumors can produce one or more hormones normally produced by the anterior pituitary. as recent research shows that these tumors are more sensitive to chemotherapy than astrocytomas. astrocytomas. causing any or all of the following pathophysiologic events: Increased intracranial pressure (ICP) and cerebral edema. brain tumors develop from structures outside the brain and occur in 20% to 40% of all clients with cancer. kidney. are divided into categories (i. The effects of neoplasms occur from the compression and infiltration of tissue. the histologic distinction between astrocytomas and oligodendrogliomas is difficult to make but important. but they can grow diffusely and infiltrate tissue. Secondary. Brain tumors rarely metastasize outside the CNS. The grade is based on cellular density. or metastatic. and enlargement and erosion of the sella turcica. visual dysfunction.The most common type of glioma and are graded from I to IV. The cause of primary brain tumors is unknown. Meningiomas Represents 20% of all primary brain tumors. lower gastrointestinal tract. The only known risk factor is exposure to ionizing radiation. glioblastoma multiforme. Seizure activity and focal neurologic signs. Meningiomas most often occur in areas proximal to the venous sinuses. Pathophysiology  Gliomas – glial tumors. Different physiologic changes result. Hydrocephalus. These tumors are categorized as low-grade and high-grade (anaplastic). Pressure from a pituitary adenoma may be exerted on the optic nerves. indicating the degree of malignancy. optic chiasm.e. Standard treatment is surgery with complete removal or partial dissection. cell mitosis. are common benign encapsulated tumors of arachnoid cells on the meninges. breast. Oligodendroglial Tumors Represents 20% of gliomas. and skin (melanomas).. Tumors usually grow as a spherical mass. increased ICP. or optic tracts or on the hypothalamus or the third ventricle when the tumor invades the cavernous sinuses or explains into the sphenoid bone. medulloblastoma):  Astrocytomas . Primary brain tumors originate from cells and structures within the brain. Manifestations depend on the area involved and are the result of compression rather than invasion of brain tissue. Altered pituitary function. They are slow growing and occur most often in middle-aged adults (more often in women). These tumors usually spread by infiltrating into the surrounding neural connective tissue and therefore cannot be totally removed without causing considerable damage to vital structures. hypothalamic disorders. the most common type of neoplasm.Cancers of the Nervous System Primary Brain Tumors A brain tumor is a localized intracranial lesion that occupies space within the skull. oligodendrocytoma. Acoustic Neuromas Pituitary Adenomas – represent about 8% to 12% of all brain tumors and cause symptoms as a result of pressure on adjacent structures or hormonal changes (hyperfunction or hypofunction of the pituitary). These hormones may cause prolactinsecreting pituitary adenomas 102 | P a g e .

compensatory adjustments may occur through compression of intracranial veins. An occipital lobe tumor produces visual manifestations: contralateral homonymous hemianopsia and visual hallucinations. seizures. the client develops signs and symptoms of increased ICP. compressing. and language disturbances (aphasia). The three most common signs of increased ICP are headache. pituitary gland tumors produce pain radiating between the two temples (bitemporal). seldom related to food intake.(prolactinomas). these clients are at risk for a cerebral vascular accident (stroke). marked muscle incoordination. sensory. others cause symptoms of a brain tumor. or sudden movement. in cerebral tumors. Clinical Manifestations Increasing ICP . the cerebrospinal fluid (CSF). and nystagmus. Headaches are usually described as deep or expanding or as dull but unrelenting. Headache. alterations in cognition. Adenomas that secrete thyroid-stimulating hormone occur infrequently. the headache may be located in the suboccipital region at the back of the head. Some tumors are not easily localized because they lied in so-called silent areas of the brain. such as sensory and motor abnormalities. visual alterations. an ataxic or staggering gait with a tendency to fall toward the side of the lesion. They occur in the cerebellum in 83% of cases. and cranial nerve dysfunction. is most common in the early morning and is made worse by coughing. all located within the skull. 103 | P a g e . The effect is a disruption of the equilibrium that exists between the brain. diplopia. growth hormone-secreting pituitary adenomas that produce acromegaly in adults. It is thought to be caused by the tumor invading. Personality changes and a variety of focal deficits. Frontal tumors usually produce a bilateral frontal headache. Occasionally. nausea. a modest decrease of cerebral blood flow. although not always present. Localized Symptoms The most common focal or localized symptoms are hemiparesis. and reduction of intracellular and extracellular brain tissue mass.Symptoms of ICP result from a gradual compression of the brain by the enlarging tumor. many tumors can be localized by correlating the signs and symptoms to known areas of the brain: A motor cortex tumor produces seizure-like movements localized on one side of the body (Jacksonian seizures). A cerebellar tumor causes dizziness. and the cerebral blood. When specific regions of the brain are affected. As the tumor grows. Because the walls of the blood vessels in angiomas are thin. Some persist throughout life without causing symptoms. additional local signs and symptoms occur. including motor. Vomiting. Papilledema is present in 70% to 75% of clients and is associated with visual disturbances such as decreased visual acuity. whereas adenomas that produce both growth hormone and prolactin are relatively common. reduction of CSF volume. are also common. straining. and visual field deficits. If the vomiting is of the forceful type. is usually due to irritation of the vagal centers in the medulla. Cerebral hemorrhage in people younger than 40 years of age should suggest the possibility of an angioma. When these compensatory mechanisms fail. it is described as projectile vomiting. The progression of the signs and symptoms is important because it indicates tumor growth and expansion. or distorting painsensitive structures or by edema that accompanies the tumor. and mental status change. sixth-nerve palsy. and adrenocorticotropic hormone (ACTH)-producing pituitary adenomas that result in Cushing‘s disease. and vomiting. the diagnosis is suggested by the presence of another angioma somewhere in the head or by a bruit audible over the skull. Angiomas Brain angiomas (masses composed of largely abnormal blood vessels) are found either in or on the surface of the brain.

The client often becomes extremely untidy and careless and may use obscene language.  MRI is the most helpful diagnostic tool for detecting brain tumors.  IV autologous bone marrow transplantation is used in some clients who will receive chemotherapy or radiation therapy because it has the potential to ―rescue‖ the client from the bone marrow toxicity associated with high doses of chemotherapy and radiation. and tumors in the brain stem and pituitary regions. enhanced by a contrast agent. because the enlarging tumor presses on the cerebellum.  Electroencephalogram (EEG) can detect an abnormal brain wave in regions occupied by a tumor and is used to evaluate temporal lobe seizures and assist in ruling out other disorders. lowgrade tumors are associated with hypometabolism and high-grade tumors show hypermetabolism (this information is useful in treatment decisions).  PET scan is used to supplement MRI. on PET. Surgical management 104 | P a g e . can give specific information concerning the number. Medical Management  Radiation therapy (cornerstone of treatment of many brain tumors) decreases the incidence of recurrence of incompletely resected tumors. size. Assessment and Diagnostic Findings  History of the illness and the manner and time frame in which the symptoms evolved are key components in the diagnosis of brain tumors.- - usually in the horizontal direction. and an uninterested mental attitude.  Cytologic studies of the CSF may be performed to detect malignant cells because CNS tumors can shed cells into the CSF. abnormalities in motor function may be present.  Corticosteroids may be used before and after treatment to reduce cerebral edema and promote a smoother. Numbness and tingling of the face and the tongue occur (involvement of cranial nerve V). particularly smaller lesions.  A neurologic examination indicates the areas of the CNS involved. Later. more rapid recovery. A cerebellopontine angle tumor usually originates in the sheath of the acoustic nerve and gives rise to a characteristic sequence of symptoms.  Gene-transfer therapy uses retroviral vectors to carry genes to the tumor.  CT scans. Tinnitus and vertigo appear first. and density of the lesions and the extent of secondary cerebral edema.  Photodynamic therapy (new technique) is a treatment of primary malignant brain tumors that delivers a targeted therapy while conserving healthy brain tissue.  Computer-assisted stereotactic (three-dimensional) biopsy is being used to diagnose deep-seated brain tumors. and to provide a basis for treatment and prognosis. reprogramming the tumor tissue for susceptibility to treatment (this is being tested). where bone interferes with CT. A frontal lobe tumor frequently produces personality disorders. weakness or paralysis of the face develops (cranial nerve VII involvement). generally used as an adjunct to conventional radiation therapy or as a rescue measure for recurrent disease.  Cerebral angiography provides visualization of cerebral blood vessels and can localize most cerebral tumors.  Brachytherapy has had promising results for primary malignancies. changes in emotional state and behavior. Finally. soon followed by progressive nerve deafness (cranial nerve VIII dysfunction).

surgery (usually for a single intracranial metastasis).  Reassess function postoperatively. which theoretically leaves behind fewer cells to become resistant to radiation or chemotherapy. time.  Check eye movement and papillary size and reaction which may be affected by cranial nerve involvement.  Check motor functions at intervals because specific motor deficits may occur depending on the tumor‘s location. colloid cysts of the third ventricle. gait disturbances. perform neurologic checks. altered mentation. Neurologic signs and symptoms include headache. acoustic neuromas. Conventional surgical approaches require an incision into the skull (craniotomy).  The median survival for clients with no treatment for brain metastases is 1 month. removing any necrotic tissue.  Carefully monitor and protect clients with seizures from injury.  Clients with changes in cognition caused by the lesion require frequent reorientation and the use of orienting devices. monitor vital signs. but the rationale for resection includes relieving ICP. 105 | P a g e . and reorient the client when necessary to person. visual impairment. Medical Management  Treatment is palliative and involves eliminating or reducing serious symptoms. cystic astrocytomas of the cerebellum.  Assess sensory disturbances. having the client sit upright to eat. space nursing interventions to prevent rapid increase in ICP.  Evaluate the gag reflex and the ability to swallow preoperatively. offering a semisoft diet. Cerebral Metastases Metastatic lesions to the brain constitute the most common neurologic complication. paralysis. and ongoing monitoring and intervention for prevention of injury. Stereotactic approaches involve the use of a three-dimensional frame that allows very precise localization of the tumor. a stereotactic frame and multiple imaging studies are used to localize the tumor and verify its position. and place. and seizures. complete removal of the tumor and cure are not possible. and some of the granulomas. personality changes. The use of gamma knife to perform radiosurgery allows deep. radiation therapy extends the median survival to 3 to 6 months. more often some combination of these treatments is the optimal method.  Evaluate speech. For clients with malignant glioma. Gamma knife radiosurgery is considered when three or fewer lesions are present. occurring in 20% to 30% of clients with cancer.  Teach the client who has diminished gag response to direct food and fluids toward the unaffected side. often in a single session.  The therapeutic approach includes radiation therapy (the foundation of treatment).  For clients with increased ICP. with corticosteroid treatment alone is 2 months. and chemotherapy. inaccessible tumors to be treated. supervision of and assistance with self-care. maintain a neurologic flow chart. focal weakness. congenital tumors.    The objective is to remove or destroy the entire tumor without increasing the neurologic deficit or to relieve symptoms by partial removal. Nursing Management  The client with a brain tumor may be at an increased risk for aspiration due to cranial nerve dysfunction. and reducing the bulk of the tumor. aphasia. and having suction readily available. This approach is used in clients with meningiomas.

Nursing Diagnoses  Self-care deficit (feeding. and reactions to medications  Sleep pattern disturbances related to discomfort and fear of dying  Impaired skin integrity related to cachexia.  Refer to home or hospice care if necessary. Review biochemical measures to assess the degree of malnutrition. less than body requirements. adapting to weakness or paralysis and to visual and speech loss. Explore changes associated with poor nutritional status. and low fluid intake  Ineffective thermoregulation related to hypothalamic involvement. weakness. and range of motion. and compensations in solving problems that arise to help the client maintain some sense of control.  Increase assistance with self-care activities. and preferences. and decreased mobility  Deficient fluid volume related to fever. vomiting. uncertainty. moving. decreased nutritional intake. and walking.  Encourage the client and the family to plan for each day and to make the most of each day.  Address symptoms that cause distress to the client. time pressures. and focus on how the client is functioning. impaired cellular immunity. and ask the client about altered taste sensations that may be secondary to dysphagia. and electrolyte balance. adaptations. respiratory problems. fever. endurance. poor tissue perfusion. including pain. altered relationships. and impairment of skin integrity.  Improve nutrition 106 | P a g e . and chills Planning and Interventions  Compensate for self-care deficits  Encourage the family to keep the client as independent for as long as possible.  Assess (together with other members of the health care team) the impact of illness on the family in terms of home care. and about distortions and impaired sense of smell (anosmia). fluid balance. and family problems. Calculate body mass index that can confirm the loss of subcutaneous fat and lean body mass. Take a dietary history to assess food intake.  Assist the client to find useful coping mechanisms. and depression. bowel and bladder disorders. and altered lifestyle  Interrupted family process related to anticipatory grief and the burdens imposed by the care of the person with a terminal illness  Acute pain related to tumor compression  Impaired gas exchange related to dyspnea  Constipation related to decreased fluid and dietary intake and medications  Impaired urinary elimination relayed to reduced fluid intake. financial problems. sleep disturbances. and malabsorption  Anxiety related to fear of dying.  Assess nutritional status because cachexia is common in clients with metastases.  Assist with an individualize exercise program to help maintain strength. vomiting. change in appearance. toileting) related to loss or impairment of motor and sensory function and decreased cognitive abilities  Imbalanced nutrition. related to cachexia due to treatment and tumor effects. bathing. and dealing with seizures.Nursing Process for the Client with Cerebral Metastases or Incurable Brain Tumor Assessment  Assessment includes baseline neurologic examination. Ask assistance from a dietitian in determining the caloric needs of the client. and temperature regulation. intolerance.

and inform them about resources and services early to assist them to deal with changes in the client‘s condition. comfortable. and care. Teach the family how to position the client for comfort during meals. and change IV tubing and dressing. Enhance family processes Reassure the family that their loved one is receiving optimal care and that attention will be paid to the client‘s changing symptoms and to their concerns. if acceptable to the client. For a client with nutritional support: assess the patency of the central and IV line or feeding tube. provide enough fluids. Use creative strategies to make food more palatable. and pain through assessment. Nutritional support may be indicated (if consistent with the client‘s end -of-life preferences) when the client shows marked deterioration as a result of tumor growth and effects. Provide dietary supplement. Plan meals for the times the client is rested and in less distress from pain or the effects of treatment. and free of pain for meals. Instruct the family members about maintaining nutritional support if they will be providing care at home. if he/she is not interested in most usual foods. Additional help from a spiritual advisor. breathlessness. and increase opportunities for socialization during meals. monitor intake and output. A nursing goal is to keep anxiety at a manageable level. Ask the family to keep a daily weight chart and to record the quantity of food eaten to determine the daily calorie count. and health professionals to convey support. The family and additional support systems may be needed when the client can no longer carry out self-care. planning. monitor the insertion site for infection. Reassure client that continuing care will be provided and that they will not be abandoned. vomiting. Promote home and community-based care Teach the client and the family strategies of pain management.                Manage and control nausea. and methods to ensure adequate food and fluid intake. Provide an environment that is attractive as possible since the client needs to be clean. diarrhea. a spiritual advisors. social worker. friends. check the infusion rate. Spend time with the client and allow him/her to talk and to communicate their fears and concerns. Relieve anxiety Be sensitive to the client‘s concerns and needs. Evaluation o Expected client outcomes include the following (Theclient…) o Engages in self-care activities as long as possible o Maintains as optimal a nutritional status as possible o Reports being less anxious o Family members seek help as needed 107 | P a g e . or mental health professional may be indicated if a client‘s emotional reactions are very intense or prolonged. prevention of complications related to treatment strategies. to meet increased caloric needs Offer food preferred by the client. Assess the changing needs of the client and the family. Refer to support groups if client prefers/wishes to be a part of one. as the disease progresses. Encourage the presence of family. Provide parenteral nutrition at home if indicated. Make home care nursing and hospice services available to the client and the family early in the course of a terminal illness.

and management of altered activities of daily living due to sensory and motor deficits and bowel and bladder dysfunction. Nursing Management  Provide preoperative care  Preoperative care objectives include recognition of neurologic changes through ongoing assessment. chemotherapy. and extramedullary-extradural lesions (outside the dural membrane). decompression of the spinal cord.  Includes assessment of pain. loss of reflexes. bowel and bladder dysfunction. especially if cervical tumor is present.  Helpful diagnostic studies include x-rays. Sharp pain occurs in the area innervated by the spinal roots that arise from the cord in the region of the tumor (usually). loss of sensation or motor function.  Discuss postoperative pain management strategies with the client.  The goal is to remove as much tumor as possible while sparing uninvolved portions of the spinal cord.  Epidural spinal cord compression occurs in approximately 5% of clients who die of cancer and is considered a neurologic emergency. radionuclide bone scans. Assessment and Diagnostic Findings  Neurologic examination and diagnostic studies are used to make the diagnosis.  Surgical intervention is the primary treatment for most spinal cord tumors. They include intramedullary lesions (within the spinal cord). pain control. and radiation therapy.  Clients with extensive neurologic deficits before surgery usually do not make significant functional recovery even after successful tumor removal.  Assess the client after surgery 108 | P a g e .  Evaluate the client for coagulation deficiencies. Tumors occurring within the spinal cord or exerting pressure on it cause symptoms ranging from localized or shooting pains and weakness and loss of reflexes above the tumor level to progressive loss of motor function and paralysis. Medical Management  Treatment of specific intraspinal tumors depends on the type and location of the tumor and the presenting symptoms and physical status of the client. particularly for intramedullary tumors and metastatic lesions.  In clients with this condition resulting from metastatic cancer.  Other treatment modalities include partial removal of the tumor.  Assess for weakness. high-dose dexamethasone combined with radiation therapy is effective in relieving pain. and the tumor origin. muscle wasting. sensory changes. the speed with which symptom occurred. MRI is the most sensitive diagnostic tool and is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases. spasticity. and potential respiratory problems.  Tumor removal is desirable but is not always possible. extramedullary-intradural lesions (within or under the spinal dura). Increasing deficits also develop below the level of the lesion.  Prognosis is related to the degree of neurologic impairment at the time of surgery.Spinal Cord Tumors Tumors within the spine are classified according to their anatomic relation to the spinal cord.  Teach and demonstrate breathing exercises.  Microsurgical techniques have improved the prognosis for clients with intramedullary tumors. and MRI. Obtain and report a history of aspirin intake because the use of aspirin may impede hemostasis postoperatively. and the presence of weakness and paralysis.

Turn the client as a unit. Assess sensory function by pinching the skin of the arms. Caution clients with residual sensory involvement about the dangers of extremes in temperature. determine the level.g. Teach the client to check skin integrity daily. and sensation of the upper and lower extremities. and abnormal breath sounds. legs. Manage pain Administer the prescribed pain medication in adequate amounts and at appropriate intervals to relieve pain and prevent its recurrence. Monitor vital signs at regular intervals. Keep in mind that pain is the hallmark of spinal metastasis. if there is. which may lead to serious infection or to an inflammatory reaction in the surrounding tissues that can cause severe pain in the postoperative period. Maintain a record of intake and output. Bone Tumors 109 | P a g e . keeping shoulders and hips aligned and the back straight. in activities of daily living and safe use of assistive devices. Refer to home care if indicated. Place a pillow between the knees of the client in a side-lying position to help prevent extreme knee flexion. Auscultate the abdomen for bowel sounds. and assessment for signs and symptoms that should be reported promptly.. Instruct the client and family about pain management strategies. Promote home and community-based care Assess the client for their ability to function independently in the home and for the availability of resources (e. family members to assist in care giving) in preparation for discharge. Carry out frequent neurologic checks with emphasis on movement. Keep the bed flat initially. abdominal breathing. Monitor and manage potential complications Monitor the client for asymmetric chest movement. Monitor for incontinence because urinary dysfunction usually implies significant decompensation of spinal cord function. Place the client in a side-lying position which is usually the most comfortable because this position imposes the least pressure on the surgical site. Refer the client to inpatient or outpatient rehabilitation to improve self-care abilities. and trunk to determine if there is loss of feeling and. strength. bowel and bladder management. with impaired motor function related to motor weakness or paralysis.                        Monitor for deterioration in neurologic status. Monitor for staining of the dressing which may indicate leakage of CSF from the surgical site. Assess for urinary retention by palpating the area over the bladder or by performing a bladder scan. Train clients. Encourage the client to perform deep-breathing and coughing exercises. A sudden onset of neurologic deficit is an ominous signs and may be due to vertebral collapse associated with spinal cord infarction.

scapula. and fixed. Osteochondroma is the most common benign tumor. Prognosis depends on whether the tumor has metastasized to the lungs at the time the client seek health care. and fibroma. The bony mass may be palpable. Giant cell tumors (osteoclastomas) are benign for long periods but may invade local tissue and cause destruction. humerus. bone cyst. giant cell tumors) have the potential to become malignant. fibrosarcoma of soft tissue. Benign primary neoplasms of the musculoskeletal system include osteochondroma. with an increase in skin temperature over the mass and venous distention. or humerus. A painful tumor that occurs in children and young adults is the osteoid osteoma. and rhabdomyosarcoma. large bloc excision or amputation of the affected extremity results in increased survival rates.Benign Bone Tumors Benign tumors of the bone and soft tissue are more common than malignant primary bone tumors. Malignant Bone Tumors Primary malignant musculoskeletal tumors are relatively rare and arise from connective and supportive tissue cells (sarcomas) or bone marrow elements. The primary lesion may involve any bone. chondrosarcoma. Usually. tibia. giant cell tumors may undergo malignant transformation and metastasize. in older people with Paget‘s disease.. Develops during growth and then becomes a static by bony mass. enchondroma. Eventually. and a chondrosarcoma or osteosarcoma may develop. Pathologic fractures may occur. They occur in young adults and are soft and hemorrhagic. The usual tumor sites include the pelvis. limited motion. who present with a painful. and tibia. Malignant tumors of the hyaline cartilage are called chondrosarcomas. Malignant primary musculoskeletal tumor includes osteosarcoma. rhabdomyoma. and the proximal humerus. Ewing‘s sarcoma. Soft tissue sarcomas include liposarcoma. They are large.g. and are not a cause of death. Aneurysmal (widening) bone cysts are seen in young adults. slow-growing tumors that affect adults. Benign bone tumors generally are slow growing and well circumscribed. spine. femur. Metastatic Bone Disease 110 | P a g e . the only symptom is a mild ache. osteoid osteoma. Usually occurs as a large projection of the bone at the end of lone bones (at the knee or shoulder). When these tumors are well differentiated. Osteogenic sarcoma (osteosarcoma) is the most common and most often fatal primary malignant bone tumor. Bone tumor metastasis to the lungs is common. bulky. Enchondroma is a common tumor of the hyaline cartilage that develops in the hand. present few symptoms. and weight loss (which is considered and ominous finding). swelling. Metastasis to the lungs occur fewer than half of clients. Bone cysts are expanding lesions within the bone. Appears most frequently in males between the ages of 10 and 25 years (in bones that grow rapidly). palpable mass of the long bones. tender. The neoplastic tissue is surrounded by reactive bone formation that assists in its identification by x-ray. Some benign tumors (e. These tumors are the second most common primary malignant bone tumor. femur. the proximal tibia. but the most common sites are the distal femur. and as a result of radiation exposure. Unicameral (single cavity) bone cysts occur in children and cause mild discomfort and possible pathologic fractures of the upper humerus and femur. vertebrae. Clinical manifestations include pain. and fibrosarcoma. These tumors may recur. which may heal spontaneously. or flat bone. The cartilage cap of the osteochondroma may undergo malignant transformation after trauma.

 With spinal metastasis. or kidney cancer bone metastases. and diagnostic studies (i. in contrast.  Neurologic deficits must be identified early and treated with decompressive laminectomy to prevent permanent spinal cord injury. bone scan. malaise.  This may be accomplished by surgical excision (ranging from local excision to amputation and disarticulation). MRI.  It can progress rapidly or slowly. lung. or bone tissue from the client (autograft) or from a cadaver donor (allograft) replaces the resected tissue. and humerus and involve more than one bone (polyostotic). breast. and adjunctive for possible micrometastases). 111 | P a g e . and thyroid.  Chest x-rays are performed to determine the presence of lung metastasis.  They may be symptom free or have pain (mild and occasional to constant and severe).  Hypercalcemia is present with breast. prostate.  Limb-sparing (salvage) procedures are used to remove the tumor and adjacent tissue. resulting in bone fractures. serum acid phosphatase levels are elevated.  Weight loss. Metastatic tumors most frequently attack the skull. radiation therapy if the tumor is radiosensitive. intraoperative. Assessment and Diagnostic Findings  The differential diagnosis is based on the history. has a symmetric.Metastatic bone disease (secondary bone tumor) is more common than any primary bone tumor.  Serum alkaline phosphatase levels are frequently elevated with osteogenic sarcoma.  Malignant bone tumors invade and destroy adjacent bone tissue. varying degrees of disability. spinal cord compression may occur. controlled growth pattern and place pressure on the adjacent bone tissue. lung. postoperative. at times.e. and fever may be present.  Surgical staging of musculoskeletal tumors is based on tumor grade and site. The most common primary sites for tumors that metastasize to the bone are the kidney. ovary. pelvis. Pathophysiology  A tumor in the bone causes the normal bone tissue to react by osteolytic response (bone destruction) or osteoblastic response (bone formation). which weakens the bone. Medical Management  Primary Bone Tumors  The goal of primary bone tumor treatment is to destroy or remove the tumor.  A benign bone tumor. physical examination. biopsy. pathologic fracture commonly results.  A customized prosthesis. myelography.  With metastatic carcinoma of the prostate. as well as on metastasis. arteriography. femur. total joint arthroplasty. spine.  Malignant invading bone tumors weaken the structure of the bone until it can no longer withstand the stress of ordinary use. Clinical Manifestations  Clients with metastatic bone tumor may have a wide range of associated clinical manifestations.  The bone‘s surface changes and the contours enlarge in the tumor area. and. obvious bone growth. and chemotherapy (preoperative..  The tumor may be diagnosed only after pathologic fracture has occurred. Tumors arising from tissues elsewhere in the body may invade the bone and produce localized bone destruction (lytic lesions) or bone overgrowth (blastic lesions).  Adjacent normal bone responds to the tumor by altering its normal pattern of remodeling. CT scan. and biochemical assays of the blood and urine).  Primary tumors cause bone destruction.

 If metastatic disease weakens the bone. mobilization. and calcitonin). chemotherapy or radiation side effects. loosening or dislocation of the prosthesis. Complications may include infection. devitalization of the skin and soft tissue.  Hematopoiesis is frequently disrupted by tumor invasion of the bone marrow or by treatment (chemotherapy or radiation).  Radiation and hormonal therapy may be effective in promoting healing of osteolytic lesions. Nursing Process for the Client with a Bone Tumor Assessment  Ask the client about the onset and course of symptoms. large bones with metastatic lesions are strengthened by prophylactic internal fixation. fracture.g. Surgical removal of the tumor may require amputation of the affected extremity. and hemorrhage than other clients after orthopedic surgery. limbsparing excision.  Hypercalcemia results from breakdown of bone. joint fibrosis. and arthritis. surgery. pain. with the amputation extending well above the tumor to achieve local control of the primary lesion.  Note the client‘s understanding of the disease process.  Pain can result from multiple factors..  Chemotherapy is used to control the primary disease. structural support and stabilization are needed to prevent pathologic fractures.  External beam radiation to involved metastasis sites may be used.  Evaluate the client‘s mobility and ability to perform activities of the daily living. diuresis. hypoxemia.  Treatment includes hydration with IV administration of normal saline solution. and nonpharmaceutical interventions. The goal of combined chemotherapy is greater therapeutic effect at a lower toxicity rate with reduced resistance to the medications.  Assess the neurovascular status and range of motion of the extremity to provide a baseline data for future comparisons.  On physical examination. deep vein thrombosis.  Clients with metastatic disease are at a higher risk for pulmonary congestion. and adjuvant chemotherapy. and medications (e.  At times. Soft-tissue sarcomas are treated with radiation. bisphosphanates. and recurrence of the tumor. The therapeutic goal is to relieve the client‘s pain and discomfort while promoting quality of life. how the client and the family have been coping.  Assess pain accurately and manage with adequate and appropriate opioid. pamidronate. allograft nonunion.       Soft tissue and blood vessels may need grafting because of the extent of the excision. gently palpate the mass and note its size and associated soft tissue swelling. 112 | P a g e . Metastatic Bone Disease  The treatment is palliative. Blood product transfusions restore hematologic factors. and tenderness.  Clients with multiple bony metastases may achieve pain control with systematically administered ―bone-seeking‖ isotopes. nonopioid. Combine chemotherapy is started before and continued after surgery in an effort to eradicate micrometastatic lesions. including the osseous metastasis. and how the client has managed the pain.

 Promote coping skills  Encourage the client and the family to verbalize their fears. perception of disease process.  Support the client and family as they deal with the impact of the malignant bone tumor.  Prevent pathologic fracture  Support and handle affected extremities gently during nursing care. counselor. 113 | P a g e .  Follow prescribed weight-bearing restrictions after a surgery (open reduction with internal fixation or joint replacement).  External radiation or systemic radioisotopes may be used to control pain.  Work with the client in designing the most effective pain management regimen to increase his/her control over the pain. and expected results to help the client to deal with the procedures and changes.  Relieve pain  Assess pain accurately. and grief.  Assist the client in dealing with changes in body image due to surgery and possible amputation.  Used prescribed IV or epidural analgesics during the early postoperative period.  Use pharmacologic and nonpharmacologic pain management techniques to relieve pain and increase the client‘s comfort level. restoration of self-concept. and inadequate support system  Risk for situational low self-esteem related to loss of body part or alteration in role performance Planning and Interventions  Promote understanding of the disease process and treatment regimen  Teach the client and the family about the disease process and diagnostic and management regimens. Oral or transdermal opioid or nonopioid analgesics are usually used later to adequately relieve pain.Nursing Diagnoses  Deficient knowledge related to the disease process and the therapeutic regimen  Acute and chronic pain related to pathologic process and surgery  Risk for injury: pathologic fracture related to tumor and metastasis  Ineffective coping related to fear of the unknown. treatments.  Prepare the client and give support during painful procedures.  Use external supports for additional protection.  Promote self-esteem  Support the family in working through the adjustments that must be made. despair. and a sense of being in control of one‘s life.  Teach the client how to use assistive devices safely and how to strengthen unaffected extremities. Refer to a psychiatric nurse liaison.  Reinforce and clarify information provided by the physician by being present during discussions. concerns. and feelings.  Explain the diagnostic tests. psychologist.  Involve the client and the family all throughout the treatment to encourage confidence. or spiritual advisor for specific psychological help and emotional support. Expect feelings of shock.  Provide realistic reassurance about the future and resumption of role-related activities and encourage self-care and socialization.  Encourage the client to participate in planning daily activities and to be independent as possible.

Osteomyelitis and wound infections Use prophylactic antibiotics and strict aseptic dressing techniques to diminish the occurrence of osteomyelitis and wound infections. Administer antiemetics and encourage use of relaxation techniques to reduce gastrointestinal reaction. Hypercalcemia Symptoms of hypercalcemia must be recognized and treatment should be initiated promptly. Nutritional supplements or total parenteral nutrition may be prescribed to achieve adequate nutrition. Control stomatitis with anesthetic or antifungal mouthwash. Special therapeutic beds may be needed to prevent skin breakdown and to promote wound healing after extensive surgical reconstruction and skin grafting. 114 | P a g e . Monitor and report laboratory findings to facilitate initiation of interventions to promote homeostasis and wound healing. Reposition the client at frequent intervals to reduce the incidence of skin breakdown due to pressure. Evaluation  The following are expected outcomes for a client with a bone tumor (The client…):  Describes the disease process and treatment regimen  Achieves control of pain  Experiences no pathologic fracture  Demonstrates effective coping patterns  Demonstrates positive self-concept  Exhibits absence of complications  Participates in continuing health care at home Breast Cancer Malignant Conditions of the Breast Carcinoma in Situ (Noninvasive) . Inadequate nutrition. nontraumatic wound dressing to promote healing. Use an aseptic.In situ carcinoma of the breast is being detected more frequently with the widespread use of screening mammography.     Monitor and manage potential complications Delayed wound healing Minimize pressure on the wound site to promote circulation to the tissues. Monitor the white blood cell count for a client receiving chemotherapy and instruct him/her to avoid contact with people who have colds or other infections. Provide adequate hydration. Prevent the occurrence of other infections during healing so that hematogenous spread does not result in osteomyelitis.

The symptoms mentioned rapidly grow more severe and usually prompt the woman to seek health care sooner than the woman with small breast mass. A mucin producer. it is also slow-growing and thus has a more favorable prognosis than many other types. Edema and nipple retraction often occur. Grows in a capsule inside a duct. Tamoxifen as a chemopreventive agent prescribed for five years for women at high risk. Because DCIS has the capacity to progress to invasive cancer. These tumors typically occur as an area of illdefined thickening in the breast. Lumpectomy alone is also a treatment option. making biopsy of the lesion the only definitive test. whereas lobular carcinomas may metastasize to meningeal surfaces or other unusual sites. the localized tumor is tender and painful. without invasion into the surrounding tissues. but the prognosis is often favorable. The disease can spread to other parts of the body rapidly. prognosis is poorer than for other types of cancer. Lobular Carcinoma in Situ (LCIS). More common of the two types. There are two types: Ductal Carcinoma in Situ (DCIS). Use of tamoxifen for women with DCIS after treatment with surgery and radiation is usually prescribed for five years. Mucinous Cancer. Mammography may be the only diagnostic test that detects the tumor. The breast is abnormally firm and large.The neoplasm is ductal and may be in situ alone or may also have invasive cancer cells. this type of tumor can become larger. it is a noninvasive form of cancer and is considered stage 0 breast cancer. This is characterized by proliferation within the breast lobules. Etiology 115 | P a g e . chemotherapeutic agents play a major role in attempting to control the progression of this disease. Long-term surveillance is an appropriate option of treatment rather than bilateral total mastectomy. lung. Paget’s Disease A scale lesion and burning and itching around he nipple-areola complex are frequent symptoms. Medullary Carcinoma. the most traditional treatment is total or simple mastectomy. comedo and noncomedo. divided histologically into two major subtypes. Radiation and surgery are also used to control spread. It is commonly associated with multicentric disease and is rarely associated with invasive cancer. Tubular Ductal Cancer. therefore. these tumors are notable because of their hardness on palpation. Usually metastasize to the axillary nodes. or brain. and the skin over it is red and dusky. liver. Another option is a bilateral prophylactic mastectomy to decrease risk. Often. LCIS is usually an incidental finding discovered on pathologic evaluation of a breast biopsy for a breast change noted during physical examination or on screening mammography. Prognosis is usually excellent with this type because axillary metastases are uncommon with this histology. Infiltrating ductal and infiltrating lobular carcinoma usually spread to bone. The most common histologic type of breast cancer. A rare type of breast cancer with symptoms different from those of other breast cancers. a tumor mass cannot be palpated underneath the nipple where this disease arises. but results of the mammogram are often negative. Invasive Carcinoma Infiltrating Ductal Carcinoma. Are most often multicentric (several areas of thickening may occur in one or both breasts).This disease is characterized by the proliferation of malignant cells within the ducts and lobules. Breast-conservation therapy (limited surgery followed by radiation) is an option appropriate for localized lesions for clients with DCIS. Inflammatory Carcinoma. as compared with the infiltrating ductal types. but this is decided on a case-to-case basis. Infiltrating Lobular Carcinoma.

Marked pain at presentation may be associated with breast cancer in the later stages. Complaints of diffuse breast pain and tenderness with menstruation are usually associated with benign breast disease. nulliparity. Genetic alterations may be somatic (acquired) or germline (inherited). menarche. Abnormalities in either of the two genes can be identified by blood tests. increasing the chance for cancer to develop. where most breast tissue is located. hormones. Hormones produced by the ovaries have an important role in breast cancer. Genetic alterations include changes or mutations in normal genes and the influence of proteins that either promote or suppress the development of breast cancer. Research suggests that a relationship between estrogen exposure and the development of breast cancer. and environmental events may contribute to its development. Estradiol and progesterone (two key ovarian hormones) are altered in the cellular environment by a variety of factors. provides the cells of the breast another chance to mutate. They may seek attention for: Dimpling or a peau d’ orange (orange-peel) appearance of the skin. Many women with advanced disease seek initial treatment only after ignoring symptoms. but most are found in the upper outer quadrant. Genetics. A mutation in the BRCA-1 gene has been linked to the development of breast and ovarian cancer. and these may affect growth factors for breast cancer. fixed rather than mobile.  There is no single specific cause of breast cancer. women should be counseled about the risks and benefits before actually undergoing genetic testing. which has high levels of endogenous estrogen. Estrogen itself does not cause breast cancer. and late menopause are assumed to be associated with prolonged exposure to estrogen because of menstruation. Increasing evidence indicates that genetic alterations are associated with the development of breast cancer. a condition caused by swelling that results from obstructed lymphatic circulation in the dermal layer Nipple retraction and lesions fixed to the chest wall may also be evident Involvement of the skin is manifested by ulcerating and fungating lesions 116 | P a g e . childbirth after 30 years of age. but are detected on mammography. whereas a mutation in the BRCA-2 gene identifies risk for breast cancer.  Risk Factors  BRCA-1 and BRCA-2 genetic mutation  Increasing age (genetic risks for breast cancer occurs after age 50)  Personal or family history of breast cancer  Early menarche (menses beginning before 12 years of age)  Nulliparity and late maternal age at first birth  Late menopause  History of benign proliferative breast disease  Exposure to ionizing radiation between puberty and 30 years  Obesity  Hormone replacement therapy  Alcohol intake Clinical Manifestations Breast cancer occurs anywhere in the breast. and hard with irregular borders rather than encapsulated and smooth (generally). but less so for ovarian cancer. Lesions are nontender rather than painful. but. Women seeking treatment at an earlier stage of disease have no symptoms and no palpable lump. The theory is that each cycle. but it is associated with its development. Hormones. genetic.

along with axillary lymph nodes. standard treatment is a completion or salvage mastectomy. or with supraclavicular or intraclavicular nodal involvement.  The goal of breast conservation is to remove the tumor completely with clear margins while achieving an acceptable cosmetic result.  The risk for local recurrence. incisional biopsy. or tumors are smaller with mobile axillary lymph node involvement. ulceration.Assessment and Diagnostic Findings  Fine-needle aspiration biopsy.  If reconstructive surgery is planned. excisional biopsy. a consultation is made with a plastic surgeon before the mastectomy is performed. is greater  than 1% per year after surgery. and stereotactic biopsy are techniques used to determine the histology and tissue diagnosis of breast cancer.  Survival rates after breast-conserving surgery are equivalent to those after modified radical mastectomy.  The breast cancer is staged according to the TNM system after the diagnostic workup and definitive surgical treatment. needle localization. If the client experiences a local recurrence. bone scans.  Stage IV: All tumors with distant metastasis. edema. microscopic disease.  This treatment includes both surgery and radiation. Breast-Conserving Surgery  Consists of lumpectomy.  Stage IIIa: Tumors are greater than 5 cm. wide excision. and shoulder girdle on the affected side. fixation to the skin or chest wall. partial or segmental mastectomy.  Stage II: Tumors are less than 5 cm. Contraindications to this treatment include: Absolute contraindications o First or second trimester of pregnancy  Presence of multicentric disease in the beast  Prior radiation to the breast or chest region Relative contraindications 117 | P a g e . or tumors are accompanied by enlarged axillary lymph nodes fixed to one another or to adjacent tissue. in which the rest of the breast tissue is removed.  Stage IIIb: More advanced lesions with satellite nodules. pectoralis major and pectoralis minor muscles remain intact. Breast Cancer Staging  Stage I: Tumors are less than 2 cm in diameter and are confined to breast. and liver function tests are diagnostic tests and procedures performed in the staging of the disease. core biopsy. arm. however.  An objective of surgical treatment is to maintain or restore normal function to the hand. Medical Management Surgical Management Modified Radical Mastectomy (MRM)  Removal of the entire breast tissue.  Clinical staging involves the physician‘s estimate of the size of the breast tumor and the extent of axillary node involvement by physical examination and mammography. or quadrantectomy (resection of the involved breast quadrant) and removal of the axillary nodes (axillary lymph node dissection) for tumors with an invasive component followed by a course of radiation therapy to treat residual.  Chest x-rays.

A radiocolloid and/or blue dye is injected into the tumor site.  Occasionally.  Postoperative radiation after mastectomy is not common today but is still used in certain cases: when tumors have spread regionally (chest wall involvement. and it is examined by the pathologist. clients who have had a mastectomy require radiation treatment to the chest wall. with paclitaxel (Taxol) (T) as an addition.  Another approach is the use of intraoperative radiation therapy (IORT). radiation therapy usually begins after completion of the chemotherapy. ACT (AC given first followed by T). is being used more frequently but research on its difference is still limited. and doxorubicin (D). and ATC. thus sparing the client the sequelae of the procedure.   History of collagen vascular disease Large tumor-to-breast ratio Tumor beneath nipple Lymphatic Mapping and Sentinel Node Biopsy  The use of this technique is changing the way clients are treated because it provides the same prognostic information as the axillary dissection. a standard axillary dissection is not needed. Docetaxel (T). If the sentinel node is positive.  If systemic chemotherapy is indicated. generally after completion of systemic chemotherapy. or tumorslarger than 5 cm). mastectomy is the client‘s option. the client undergoes the standard axillary dissection. If radiation therapy is contraindicated. Radiation Therapy  With breast-conserving surgery. a course of externalbeam radiation therapy usually follows excision of the tumor mass to decrease the chance of local recurrence and to eradicate any residual microscopic cancer cells.  Nursing interventions for this procedure focus on informing the client about the expectations and possible complications.  Chemotherapeutic agents most often used in combination are cyclophosphamide (Cytoxan) (C). four or more positive nodes. in which a single dose of radiation is delivered to the lumpectomy site immediately after the surgeon has performed the lumpectomy.  The combination regimen CMF or CAF is a common treatment protocol.  If the sentinel node is negative for metastatic breast cancer. methotrexate (M). Chemotherapy  Chemotherapy regimens for breast cancer combine several agents to increase tumor cell destruction and to minimize medication resistance. are other regimens that may be used. fluorouracil (F). with all three agents given together.  The surgeon uses a hand-held probe to locate the sentinel node (the primary drainage from the breast) and excises it.  Radiation treatment typically begins about 6 weeks after the surgery to allow the incision to heal. a newer taxane.  treatment is necessary to obtain results equal to those of removal of the breast. the client then undergoes the surgical procedure. AC. 118 | P a g e .  External-beam irradiation provided by a linear accelerator using photons is delivered on a daily basis over 5 to 7 weeks to the entire breast region.

peripheral stem cell transplants. body image changes. oncogenes. Investigational Therapy  Research in breast cancer treatment includes the following areas: bone marrow transplantation.g. or possible death  Risk for ineffective coping (individual or family) related to the diagnosis of breast cancer and related treatment options  Decisional conflict related to treatment options  Postperative nursing diagnoses  Acute pain related to surgical procedure  Impaired skin integrity due to surgical incision  Risk for infection related to surgical incision and presence of surgical drain  Disturbed body image related to loss or alteration of the breast related to the surgical procedure  Risk for impaired adjustment related to the diagnosis of cancer. and this protein regulates cell growth. Herceptin binds with the HER2 protein. and fear of death  Self-care deficit related to partial immobility of upper extremity on operative side 119 | P a g e . letrozole (Femara). surgical treatment.. or friend available to assist her in making treatment choices?  What are the most important areas of information she needs?  Is the client experiencing any discomfort? Nursing Diagnoses Preoperative nursing diagnoses  Deficient knowledge about breast cancer and treatment options  Anxiety related to cancer diagnosis  Fear related to specific treatments. mportant questions to ask include the following:  How is the client responding to the diagnosis?  What coping mechanisms does she find the most helpful?  What psychological or emotional supporter does she have and use?  Is there a partner. megestrol and aminoglutethimide (Cytadren) are other hormonal agents used to suppress hormone-dependent tumors. family member. leuprolide (Lupron).  Another treatment modality that has shown promise is trastuzumab (Herceptin). Hormonal therapy may include surgery to remove endocrine glands (e. and vaccine studies. monoclonal antibodies. thus inhibiting tumor cell growth. ovaries. pituitary. Nursing Process for the Client with Breast Cancer Assessment  The health history includes an assessment of the client‘s reaction to the diagnosis and her ability to cope with it. or adrenal glands) with the goal of suppressing hormone secretion. Oopherectomy is one treatment option for premenopausal women with estrogen-dependent tumors. Anastrozole (Arimidex). biologic response modifiers. Tamoxifen is the primary hormonal agent used. growth factors.     Hormonal Therapy Decisions about hormonal therapy for breast cancer are based on the outcome of an estrogen and progesterone receptor assay of tumor tissue taken during the initial biopsy.

g.  Provide information about the surgery. oncology nurse. management of side effects.  Discuss and plan with the client methods to compensate for physical changes related to mastectomy (e. medical oncologist. prostheses and plastic surgery). psychological.  Discuss fears and concerns with the client. change in selfimage. and postoperative treatments involving radiation therapy and chemotherapy to enable the client make informed decisions.. and treatment goals.  Discuss with the client medications. possible reactions after treatment.  Promote decision-making ability  Careful guide and provide supportive counselling to help the client make a decision about her treatment. frequency and duration of treatment..  Be knowledgeable about current treatment and be able to discuss them with the client. extent of treatment. the location and extent of the tumor. and social worker) and acquaint her with the role of each in her care. or chest wall  Risk for sexual dysfunction related to loss of body part.g.  Reduce fear and anxiety and improve coping ability  Start the client‘s emotional preparation when the tentative diagnosis of cancer is made. psychologist. Disturbed sensory perception (kinesthesia) related to sensations in affected arm. and nutritional wellbeing after the treatment plan has been established. or psychiatric clinical nurse specialist if necessary.  Be aware of the information that has been given by the physician to the client. Initiate a referral to the psychiatrist. social.  Introduce the client to other members of the oncology team (e.  Encourage the client to talk with a breast cancer survivor for reassurance.  Encourage the client to take one step of the treatment process at a time. radiation oncologist. breast.  Promote preoperative physical.  Discuss the implications of each treatment option and how it may affect various aspects of the client‘s treatment course and lifestyle. Postoperative Nursing Interventions 120 | P a g e . and fear of partner‘s responses  Deficient knowledge: drain management after breast surgery  Deficient knowledge: arm exercises to regain mobility of affected extremity  Deficient knowledge: hand and arm care after an axillary lymph node dissection Planning and Interventions Preoperative Nursing Interventions  Explain breast cancer and treatment options time for the client to absorb the significance of the diagnosis and any information that will help her evaluate treatment options.  Provide anticipatory teaching and counseling at each stage of the process and identify the sensations that can be expected during additional diagnostic procedures.  Refer client to the advanced practice nurse or oncology social worker to help the client and family discuss some of the personal issues that may arise in relation to treatment.  Evaluate if the client needs a mental health consultation before surgery to assist her in coping with the diagnosis and impending treatment.

Provide privacy and consideration when assisting the client to view her incision fully for the first time. She may again use deodorant on the affected side.                        Relieve pain and discomfort Have an ongoing assessment of pain and discomfort. Explain that her feelings are normal response to breast cancer surgery to reassure the client. Encourage the client to take analgesic agents before exercises or at bedtime. and allow her to express her emotions. Teach the client that she may shower on the second post-op day and wash the incision and drain site with soap and water to prevent infection. how it looks and feels. Notify the physician if a hematoma. lotions or creams may be applied to the area to increase skin elasticity. occurs. and prevent venous congestion in the affected extremity). Leave the drain in place for 7 to 10 days and then remove it after the output is less than 30 ml in a 24-hour period. Initially. that could cause necrosis of the surgical flaps. and the possible signs and symptoms of an infection. Moderately elevate the involved extremity to relieve pain (decreases tension on the surgical incision. and to take warm shower twice daily (usually allowed on the second postoperative day) to alleviate the discomfort that comes from referred muscle pain. Inspect the dressings and drains for bleeding and monitor the extent of drainage regularly. Discuss the incision. Administer intravenous or intramuscular opioid analgesic agents to manage the pain in the initial postoperative phase. Explain the care of the incision. Teach the client that after the incision is completely healed (usually 4 to 6 weeks). Administer oral analgesics after the anesthesia has cleared sufficiently and the client is able to take in fluids and food per orem. Promote positive body image Address the client‘s perc eption of the body image changes and physical alterations of the breast during teaching sessions. the consequences of surgical treatment. but it gradually changes to serosanguineous and then a serous fluid during the next several days. sensations to expect. Promote positive adjustment and coping Have an ongoing assessment of the client‘s concerns related to the diagnosis of cancer. promote circulation. and the progressive changes in its appearance with the client during dressing changes. Maintain skin integrity and prevent infection Prevent fluid from accumulating under the chest wall incision or in the axillary by maintaining the patency of the surgical drains. Monitor the incision if hematoma develops within the first 12 hours after surgery. Note the characteristics of fluid from the drain. the fluid in the surgical drain appears blood. Remind her that a dry dressing should be applied to the incision each day for 7 days. Inform the client that sensation is decreased in the operative area because the nerves were disrupted during surgery and gentle care is needed to avoid injury. which 121 | P a g e . Teach the client and family the importance of ensuring correct management of the drainage system prior to discharge. Place an Ace wrap (elastic bandage) around the incision and apply an ice pack. and fear of death.

swelling. Encourage self-care activities (e. Counseling or consultation with a mental health practitioner may be indicated for a client who displays ineffective coping. If transient edema develops in the affected extremity. Support the client on the nonoperative side. Instruct clients about activity limitations while healing postoperatively (e. Use cooking mitt for removing objects from the oven. If a client has skin grafts. wash the area with soap and water. and respiratory) in the second postop day.g. brushing the teeth. Focus on the hand and arm care after an axillary lymph node dissection to prevent injury or trauma to the affected extremity to decrease the likelihood of developing lymphedema. and combing/brushing the hair) because they aid in restoring arm function and provides a sense of normalcy for the client. Wear gloves for gardening. Assist the client in identifying mobilizing her support systems. and apply an over-the-counter antibacterial ointment. Use sunscreen higher than 15 SPF for extended exposure to the sun. Use electric razor for shaving armpit. If a trauma of break in the skin occurs. Observe the area and extremity for 24 hours. tight surgical incision. Manage postoperative sensations Explain to the client that tightness.                   are important in determining her progress in adjusting and the effectiveness of her coping strategies. Avoid lifting objects greater than 5 to 10 pounds. Be knowledgeable about the client‘s plan of care and encourage her to ask questions to the appropriate members of the health care team to help promote coping during recovery. burning. call the surgeon or nurse. Avoid blood pressures. shoulder. injections. Promote the use of the muscles in both arms and to maintain proper posture. Initiate exercises (hand. or immediate reconstruction.. Avoid cutting cuticles. Previous activities should be introduced when fully healed. Perform post-mastectomy exercises three times daily for 20 minutes at a time until full range of motion is restored in 4 to 6 weeks.g. and to take an analgesic agent 30 minutes before beginning the regimen. Encourage the client to discuss issues and concerns with other clients who have had breast cancer to help her understand that her feelings are normal and that other women who have had breast cancer can provide invaluable support and understanding. and along the inside aspect of the upper arm are 122 | P a g e . Refocus the client on the recovery from surgery. and tingling along the chest wall. or a fever occurs. exercises may need to be prescribed specifically and introduced gradually. if redness. a tense. arm. Instructions should be provided on the first postop day. Apply insect repellant to avoid bug bites.. instruct the client to elevate the arm above the level of the heart on a pillow for 45 minutes at a time three times daily to promote circulation. Answer questions and concerns about the treatment options that may follow after surgery. and blood draws in affected extremity. pulling. avoid heavy lifting). in the axilla. washing the face. and checking with the physician regarding this is usually indicated. Encourage the client to shower before performing post-mastectomy exercises to loosen stiff muscles. Promote participation in care Encourage the client to ambulate when she is free of postanesthesia nausea and is able to tolerate fluids. while addressing her concerns and answering questions. push them back during manicures.

other options for expressing affection can also be helpful. and to contact her health care provider for evaluation. Assist in taking specimen for cultures on any foulsmelling discharge. if present. or a special pump to decrease swelling. Manage lymphedema by elevating the arm with the elbow above the shoulder and the hand higher than the elbow. such as hand pumps. Infection  Teach the client to monitor for signs and symptoms of infection preoperatively and before discharge. manual lymph drainage. Notify the surgeon for gross swelling or output from the drain that may indicate hematoma formation. Monitor and manage potential complications Lymphedema Reassure client that transient edema is not lymphedema. the swelling can become painful and difficult to reverse. Assist in performing exercises to decrease sensations. along with specific exercises. Refer the client to a physical therapist or rehabilitation specialist for a custom-made elastic sleeve. Emphasize that need for early intervention because lymphedema can be manageable if treated early. Refer the client and her partner to a psychosocial source if problems develop or persist. Educate the client how to prevent lymphedema and how to do hand and arm care after axillary dissection. if allowed to progress without treatment. Instruct the client to contact her health care provider if lymphedema occurs to discuss management because she may need a course of antibiotics or specific exercises to decrease the swelling. Be calm to help prevent anxiety and panic on the part of the client. Evaluation  Expected preoperative outcomes may include the following: (The client…)  Exhibits knowledge about diagnosis and treatment options  Verbalizes willingness to deal with anxiety and fears related to the diagnosis and the effects of surgery on self-image and sexual functioning  Demonstrates ability to cope with diagnosis and treatment  Demonstrates ability to make decisions regarding treatment options in timely fashion  Expected postoperative outcomes may include the following: (The client…) Reports the pain has decreased and states pain and discomfort management strategies are effective 123 | P a g e . Hematoma formation  Monitor the surgical site for excessive swelling and monitor the drainage device. and desires to reduce the couple‘s stress Suggest varying the time of day for sexual activity (when the client is less tired) or assume positions that are more comfortable. however. Monitor the site and reassure the client that this complication is rare but does occur and that she will be assisted through its management. needs. exercises. Improve sexual function Encourage discussion about fears. acetaminophen as needed to assist managing discomforts.        common and that these are normal parts of healing to help reassure her that these sensations are not indicative of a problem. Administer oral or intravenous antibiotics depending on the severity of the infection.

surgical treatment.        Exhibits clean. dry. and intact surgical incisions without signs of inflammation or infection Lists the signs and symptoms of infection to be reported to the nurse or surgeon Verbalizes feelings regarding change in body image Discusses meaning of the diagnosis. and fears appropriately Participates actively in self-care activities Recognizes that postoperative sensations are normal and identifies management strategies Discusses issues of sexuality and resumption of sexual relations Demonstrates knowledge of postdischarge recommendations and restrictions Experiences no complications 124 | P a g e .

perineal and rectal discomfort. Prostate cancer can metastasize to bone and lymph nodes. Symptoms related to metastases include backache. or transrectal needle biopsy.Cancer of the Prostate Clinical Manifestations Rarely produces symptoms in the early stages.  Capromab Pendetide with Indium-111 (ProstaScint) is an antibody that is attracted to the prostate-specific antigen found on prostate cancer cells. This type of cancer tends to vary in its course. open prostatectomy. weakness.  PSA testing is routinely used to monitor the client‘s response to cancer therapy and to detect local progression and early recurrence of prostate cancer. is important because early cancer may be detected as a nodule within the substance of the gland or as an extensive hardening in the posterior lobe. allowing detection of disease spread. urinary retention.  The radioactive element attached to the antibody is then visible with scanning. weight loss. hip pain.  TRUS studies help in detecting nonpalpable prostate cancers and assist with staging localized prostate cancer. The following signs and symptoms of urinary obstruction occur if the neoplasm is larger enough to encroach on the bladder neck: difficulty and frequency of urination. Medical Management Surgical Management 125 | P a g e . decrease in size and force of urine stream.  Diagnosis of prostate cancer is confirmed by a histologic examination of tissue removed surgically by transurethral resection.  This study is used to detect spread of prostate cancer in the lymph nodes or other parts of the body in newly diagnosed men who have apparently localized prostate cancer who are thought to be at high risk for metastasis.  Every man older than 40 years of age should have a digital rectal exam (DRE) as part of his regular health checkup.  The more advanced lesion is ―stony hard‖ and fixed. preferably by the same examiner.  Needle biopsies of the prostate are commonly guided by TRUS.  Most prostate cancers are diagnosed when a man seeks medical attention for symptoms of urinary obstruction or after abnormalities are found by DRE. renal function tests.  Other tests include bone scans to detect metastatic bone disease. skeletal x-rays to identify bone metastases. excretory urography to detect changes caused by ureteral obstruction.  Routine repeated rectal palpation of the gland. and CT scans or lymphangiography to identify metastases in the pelvic lymph nodes. anemia. Fine-needle aspiration is helpful for determining the stage of disease as well. Symptoms that develop from urinary obstruction occur late in the disease. Assessment and Diagnostic Findings  The likelihood of cure is high if prostate cancer is detected early. Hematuria may result if the cancer invades the urethra or bladder.  Prostate-specific antigen (PSA) together with DRE appears to be a cost-effective method for detecting prostate cancer. and oliguria. Other symptoms may include blood in the urine or semen and painful ejaculation. or both.  Transrectal ultrasound (TRUS) studies are indicated for men who have elevated PSA levels and abnormal DRE findings. nausea.

cause adrenal androgen suppression.  If prostate cancer metastasizes to the bones. If antiandrogen therapies are not effective. has long been used to inhibit gonadotropins responsible for testicular androgenic activity.  Hormonal therapy for advanced prostate cancer suppresses androgenic stimuli to the prostate by decreasing the circulating plasma testosterone levels or interrupting the conversion to or binding of dihydrotestosterone.. Nursing Process for the Client Undergoing Prostactectomy Assessment o Assess how the prostate cancer has affected the client‘s lifestyle (e.  Antiandrogen therapies are used in an effort to reduce the circulating androgens. Hormonal Therapy  This is one method to control rather than cure prostate cancer. potentially curable disease and a life expectancy of ten years or more. palliative measures are indicated. Other Therapies  Cryosurgery of the prostate is used to ablate prostate cancer in clients who could not physically tolerate surgery or in those with recurrent prostate cancer. As a result. Diagnosis 126 | P a g e . the prostatic epithelium atrophies. o Ask the client additional questions that will help determine how soon he will be able to return to normal activities after prostatectomy. Sexual impotence follow radical prostatectomy and 5% to 10% of clients have varying degrees of urinary incontinence. including hypertension.   Radical prostatectomy remains the standard surgical procedure for clients who have earlystage.  For men with advanced prostate cancer.  Luteinizing hormone-releasing hormone (LH-RH) agonists suppress testicular androgen while antiandrogen agents. such as flutamide. medications such as prednisone and mitoxantrone have been effective in reducing pain and improving quality of life. External beam radiation therapy can be delivered to skeletal lesions to relieve pain.  The above effect is accomplished either by orchiectomy or by administration of medications. Opioid and nonopioid medications are used to control pain. these bone lesions can be very painful. perineal Radiation Therapy  The treatment may be curative radiation therapy if prostate cancer is detected in its early stage— either teletherapy with a linear accelerator or interstitial irradiation (brachytherapy). usually in the form of diethylstilbestrol (DES).g. Has he been reasonably active for his age? What are his presenting urinary problems?). Several approaches can be used to remove the hypertrophied portion of the prostate gland: transurethral resection of the prostate (TURP). o Obtain further information about the client‘s history of cancer and heart or kidney disease.  Estrogen therapy. thereby removing the androgenic hormone that promotes the growth of the malignancy. suprapubic prostactectomy.

Insert an indwelling catheter if the client has continuing urinary retention or if laboratory test results indicate azotemia.Review the anatomy of the affected parts and their function in relation to urinary and reproductive systems using diagrams and other teaching aids with the client. and assist him to ambulate the next morning.Monitor the urine output and the amount of fluid used for irrigation to determine if irrigation fluid is being retained and to ensure an adequate urine output.  Provide instruction. Document and report signs and symptoms of fluid imbalance to the surgeon. if the client is hospitalized.  Prepare the client for surgery Apply elastic compression stockings before surgery to prevent deep vein thrombosis if the client is placed in a lithotomy position during surgery.Assist the client to sit and dangle his legs over the side of the bed on the day of surgery. which varies with the type of surgical approach.g. Clarify the nature of the surgery and expected postoperative outcomes. flavoxate and oxybutynin) that can relax smooth muscles to ease bladder spasms. Determine the cause and location if pain occurs. Familiarize the client with the pre. which can induce bleeding.. catheter placement. and the recovery room procedure. inform the client about the type of urinary drainage system that is expected. watch for bladder distention. rising blood pressure. Encourage the client to verbalize his feelings and concerns. Instruct the client about postoperative use of medications for pain management.Preoperative Nursing Diagnoses  Anxiety about surgery and its outcome  Acute pain related to bladder distention  Deficient knowledge about factors related to the disorder and the treatment protocol Postoperative Nursing Diagnoses  Acute pain related to the surgical incision.Establish communication with the client to assess his understanding of the diagnosis and of the planned surgical procedure. Monitor voiding patterns.and postoperative routines and initiates measures to reduce anxiety. administer analgesic agents. Warm 127 | P a g e . and bladder spasms  Deficient knowledge about postoperative care and management Collaborative Problems  Hemorrhage and shock  Infection  Deep vein thrombosis  Catheter obstruction  Sexual dysfunction Planning and Interventions Preoperative Nursing Interventions  Reduce anxiety. Administer an enema at home the evening before surgery or the morning of the surgery to prevent postoperative straining. Monitor the client for electrolyte imbalances. and initiate measures to relieve anxiety if discomfort is present before the day of the surgery.Place the client on bed rest. Explain what will take place as the client is prepared for diagnostic tests and then for surgery. Describe the type of incision. Postoperative Nursing Interventions  Maintain fluid balance.  Relieve discomfort. and assist with catheterization if indicated. Administer medications (e.  Relieve pain. and respiratory distress. Provide privacy and establish a trusting and professional relationship when discussing problems related to genitalia and sexuality. the type of anesthesia. confusion. Prepare the client for a cystostomy if he cannot tolerate urinary catheter.

Irrigate the catheter with 50 ml of irrigating fluid at a time. Administer fluid and blood component therapy if blood loss is extensive. if indicated and prescribed. and carefully monitor drainage to ensure adequate urine flow and patency of the drainage system.                 compress and sitz baths may also relieve spasms. pallor. maintain an accurate record of intake and output. and enemas because of the risk for injury to and bleeding in the prostatic fossa. and an increasing pulse rate. saturated or improperly placed drainage. Check if discomfort is caused by dressings that are too snug. Administer analgesic agents asprescribed. Direct a heat lamp to the perineal area to promote healing. Avoid rectal thermometers. Administer enema with caution (if prescribed) to avoid rectal perforation.Closely monitor vital signs. Examine the drainage bag. administer medications. Secure the catheter drainage tubing to the leg or abdomen to help decrease tension on the catheter and prevent bladder irritation. and blood component therapy as prescribed. Assess for the presence of sexual dysfunction after surgery. Protect the scrotum with a towel while a heat lamp is used. Monitor and manage complications Initiate strategies to stop bleeding and to prevent or reverse hemorrhagic shock. Observe the lower abdomen to ensure that the catheter has not become blocked. dressing. Assess frequently for manifestations of deep vein thrombosis (DVT) and apply elastic compression stockings to reduce the risk for DVT and pulmonary embolism. Irrigate the drainage system. to clear any obstruction if the client complains of pain. cold sweats. any drop in blood pressure. Use aseptic technique when changing dressings to prevent infection. Provide prune juice and stool softeners to ease bowel movements and to prevent excessive straining. Monitor blood pressure. pulse. Monitor the drainage tubing and irrigate the system as prescribed. Note the color of the urine. intravenous fluids. Provide a private and confidential environment to discuss issues of sexuality. Instruct the client and the family to monitor for signs and symptoms of infection after discharge. Administer furosemide to promote urination and initiate postoperative diuresis to help keep the catheter patent. Observe the client for restlessness. Clean the perineum as indicated after the perineal sutures are removed. Administer antibiotics as prescribed if they occur. and incision site for bleeding. Encourage the ambulatory client to walk but not to sit for prolonged periods since this may increase intra-abdominal pressure and the possibility of discomfort and bleeding. rectal tubes. Testicular Cancer 128 | P a g e . to relieve any obstruction that may cause discomfort. and respirations and compare with baseline preoperative vital signs to detect hypotension. Assess for the occurrence of urinary tract infections and epididymitis.

o Risk factors include a family history of testicular cancer and cancer of one testicle. of the testicles. occupational hazards including exposure to chemicals encountered in mining. oil and gas production. The client may complain of heaviness in the scrotum. and general weakness may result from metastasis.  The two main types of stromal tumors are Leydig cell tumors and Sertoli cell tumors. while nonseminomatous tumors grow quickly. inguinal area. and leather processing. abdominal pain. secondary testicular cancers may also occur. Nongerminal Tumors  Testicular cancer may also develop in the supportive and hormonal producing tissues. Enlargement of the testis without pain is significant diagnostic finding.  Cancers may also spread to the testicles from the prostate gland. skin (melanoma).  Seminomas tend to remain localized. it can occur in males of any age. or lower abdomen. or stroma. nonseminomas tend to develop earlier in life than seminomas (usually occurring in men in their 20s). although these tumors spread beyond the testicle. and embryonal carcinomas. and. ultrasound to determine the presence and size of testicular 129 | P a g e . lymphangiography to assess the extent of tumor spread to the lymphatic system.  Examples of nonseminomas include teratocarcinomas.  Lymphoma is the most common cause of secondary testicular cancer. although it occurs most often between the ages of 15 to 40. weight loss. Backache (from retroperitoneal node extensions).  Seminomas are tumors that develop from the sperm-producing cells of the testes. Clinical Manifestations Symptoms appear gradually. Secondary Testicular Tumors  These tumors are those that have metastasized to the testicle from other organs. lung. with a mass or lump on the testicle and generally painless enlargement of the testis. and other organs.  Other diagnostic tests include intravenous urography to detect any ureteral deviation caused by a tumor mass.  Prognosis for these cancers is usually poor because these cancers generally also spread to other organs. yolk sac carcinomas. choriocarcinomas. Testicular cancers are classified as germinal or nongerminal (stromal). Testicular tumors tend to metastasize early.Most common cancer in men 15 to 35 years of age.  A small number of these tumors metastasize and tend to be resistant to chemotherapy and radiation therapy. spreading from the testis to the lymph nodes in the retroperitoneum and to the lungs. Risk Factor o Risk for testicular cancer is several times greater in men with any type of undescended testis than in the general population. Germinal Tumors  Germinal tumors may be further classified as seminomas or nonseminomas. kidney. Assessment and Diagnostic Findings  Monthly testicular self-examinations (TSEs) are effective in detecting testicular cancer. race and ethnicity.  Human chorionic gonadotropin and alpha-fetoprotein are tumor markers that may be elevated in clients with testicular cancer.

Since most penile cancers occur in uncircumcised men.  Postoperative irradiation of the lymph nodes from the diaphragm to the iliac region is used in treating seminomas. It can involve the glans.  Encourage the client to participate in health promotion and health screening activities. the urethra. Personal hygiene is an important preventive measure in uncircumcised men. retroperitoneum. it has been suggested that the etiology of this cancer may be the irritative effect of smegma and poor hygiene. the other testis is shielded from radiation to preserve fertility. chemotherapy. mass.  Testicular cancers are highly responsive to chemotherapy. Bowen’s disease is a form of squamous cell carcinoma in situ of the penile shaft. circumcision that occurs at puberty or after does not present the same benefit. and CT scan of the chest. Prevention Circumcision in infancy almost eliminates the possibility of penile cancer because chronic irritation and inflammation of the glans penis predispose to penile tumors. and regional or distant lymph nodes. and radiation therapy. Radiation is also used for clients whose disease does not respond to chemotherapy or for whom lymph node surgery is not recommended. the coronal sulcus under the prepuce. wart-like growth or ulcer. Nursing Management  Assess the client‘s physical and psychological status and monitor the client for response to and possible effects of surgery. Cancer of the Penis Penile cancer occurs in men older than 60.  Inform the client that radiation therapy will not necessarily prevent him from fathering children. A gel-filled prosthesis can be implanted.  Encourage the client to maintain positive attitude during the long course of therapy. However. the corporal bodies. Medical Management  Testicular cancer is one of the most curable solid tumors. 130 | P a g e . and pelvis to determine the extent of the disease in the lungs. the protective effect of circumcision is seen only in males who are circumcised in the neonatal period.  Radiation is delivered only to the affected side.  The testis is removed by orchidectomy through an inguinal incision with a high ligation of the spermatic cord.  Address issues related to body image and sexuality. Medical Management  Smaller lesions involving only the skin may be controlled by excision. nor does unilateral excision of a testis necessarily decrease virility.  Chemotherapy with cisplatin-based regimens results in a high percentage of complete remissions.  Topical chemotherapy with 5-fluorouracil cream is an option in selected clients. abdomen.  Remind the client about the importance of performing TSE and keeping follow-up appointments with the physician. Cancer of the penis appears on the skin of the penis as a painless.  Treatment selection is based on the cell type and the anatomic extent of the disease. Microscopic analysis of tissue is the only definitive way to determine if cancer is present but is usually performed at the time of surgery rather than as part of the diagnostic workup to reduce the risk of promoting spread of cancer.  The goals of management are to eradicate the disease and achieve a cure. and pelvis.  Retroperitoneal lymph node dissection to prevent lymphatic spread of the cancer may be performed after orchiectomy.

blue-eyed people. Squamous cell carcinoma (SCC) A malignant proliferation arising from the epidermis. fair-haired. leukoplakia. Usually begins as a small. arising on the skin and mucous membranes. or they may develop from a precancerous condition (such as actinic keratosis. and it is inversely proportional to the amount of melanin in the skin. translucent. Risk Factors  Exposure to the sun is the leading cause of skin cancer. Skin Cancer  Ask the students the possible causes which may increase an individual‘s risk for skin cancer. pearly borders. or a lip. gray. It undergoes central ulceration and sometimes crusting as it grows. Radiation therapy is used to treat small squamous cell carcinomas of the penis or for palliation in advanced tumors or lymph node metastasis. construction workers)  Exposure to chemical pollutants (industrial workers in arsenic. It is of greater concern than BCC because it is a truly invasive carcinoma. usually appears on sundamaged skin but may also arise from normal skin or from preexisting skin lesions. Incidence is proportional to the age of the client (average of 60 years) and the total amount of sun exposure. rarely metastasizes but recurrence is common. particularly those of Celtic origin. incidence is related to the total amount of exposure to the sun  Fair-skinned. or scarred or ulcerated lesions). flat. Tumors appear most frequently on the face. Other variants of BCC may appear as a shiny. characterized by invasion and erosion of adjoining tissues.  Total penectomy is indicated when the tumor is not amenable to conservative treatment. waxy nodule with rolled. telangiectatic vessels may be present. The third most common type is the malignant melanoma. nitrates. with insufficient skin pigmentation to protect underlying skin tissues  People who sustain sunburn and who do not tan  Long-time sun exposure (farmers. metastasizing by the blood or lymphatic system. an ear. or yellowish plaque.  Partial penectomy is preferred to total penectomy if possible. a neglected lesion can result in the loss of a nose. coal. 131 | P a g e . The lesions may be primary. fishermen. tar and pitch. oils and paraffin)  Sun-damaged skin (elderly people)  History of x-ray therapy for acne or benign lesions  Scars from severe burns  Chronic skin irritations  Immunosuppression  Genetic factors Basal Cell and Squamous Cell Carcinoma The most common types of skin cancer are basal cell carcinoma (BCC) and squamous cell (epidermoid) carcinoma (SCC). Clinical Manifestations Basal cell carcinoma (BCC) Generally appears on the sun-exposed areas of the body and is more prevalent in regions where the population is subjected to intense and extensive exposure to the sun.

with cure rate for BCC and SCC approaching 99%.  Mohs surgery is the recommended tissuesparing procedure. thickened. ears. nose.  The adequacy of the surgical excision is verified by microscopic evaluation of sections of the specimen. which ―feels‖ the extent of the tumor.  Regional lymph nodes should be evaluated for metastases. Electrodesiccation is then implemented to achieve hemostasis and to destroy any viable malignant cells at the base of the wound or along its edges. which is related to the histologic type and the level or depth of invasion.  Prognosis for SCC depends on the incidence of metastases. the risk for death from this tumor is low. lower lip. and more inflammatory than that of a BCC lesion. When the tumor is large. Common sites are exposed areas. additional layers of tissue are shaved and examined until all tissue margins are tumor-free. Prognosis  Prognosis for BCC is usually good. Secondary infection can occur.- - It appears as rough.  The best way to maintain cosmetic appearance is to place the incision properly along natural skin tension lines and natural anatomic body lines.  Usually. upper lip. The first layer excised includes all evident tumors and a small margin of normalappearing tissue.  It is the treatment of choice and the most effective for tumors around the eyes. With this. Tumors remain localized. This method takes advantage of the fact that the tumor in each instance is softer than surroundings skin and therefore can be outlined by a curette. The boarder of an SCC lesion may be wider.  The specimen is frozen and analyzed by section to determine if the entire tumor has been removed.  Electrosurgery may be preceded by curettage. and though some require wide excision with resultant disfigurement.  The current is converted to heat. and auricular and preauricular areas. A pressure dressing applied over the wound provides support. and forehead. Electrosurgery  This is the destruction or removal of tissue by electrical energy. nose. which then passes to the tissue from a cold electrode. tumors arising in sun-damaged areas are less invasive and rarely cause death. more infiltrated. If not. especially of the upper extremities and of the face. The incision is closed in layers to enhance cosmetic effect. whereas SCC that arises without a history of sun or arsenic exposure or scar formation appears to have a greater chance for spread. only the tumor and a safe. scaly tumor that may be asymptomatic or may involve bleeding. Medical Management Surgical Management  Primary goal is to remove the tumor entirely. Mohs Micrographic Surgery  This technique is most accurate and best conserves normal tissue. reconstructive surgery with the use of a skin flap or skin grafting may be required. The tumor is removed 132 | P a g e . normaltissue margin are removed. performed without the initial chemosurgery component (application of zinc chloride paste to the tumor).  The size of the incision depends on the tumor size and location but usually involves a length-towidth ratio of 3:1.  The procedure removes the tumor layer by layer.

Risk Factors  Fair-skinned or freckled.and the base cauterized. occurs faster with a good blood supply. blue-eyed. Generally. The margins of the lesion may be flat or elevated and palpable. The appearance of the lesion varies. It usually affects middle-aged people and occurs most frequently on the trunk and lower extremities. if the lesion is in the perioral area. reserved for older clients. including the type of dressing to purchase..g. with irregular outer portions.  Instruct the client to seek treatment for any moles that are subject to repeated friction and irritation. how to remove dressings and apply fresh ones. facial nerve).  Advise the client to apply sunscreen over the wound to prevent postoperative hyperpigmentation if he/she spends time outdoors. The lesion tends to be circular. which may take 4 to 6 weeks.  Advise the client when to report for a dressing change or provide a written and verbal information on how to change dressings. and then refrozen. Cryosurgery  This method destroys the tumor by deep freezing the tissue. and to watch for indications of potential malignancy. and malignant changes in scars may be induced by irradiation 15 to 30 years later.  A thermocouple needle apparatus is inserted into the skin.  Instruct the client to drink liquids through straw and limit talking and facial movement. tip of the nose and areas in or near vital structures (e. 133 | P a g e . The site thaws naturally and then becomes gelatinous and heals spontaneously. Normal healing. Nursing Management  Teach client about prevention of skin cancer and about self-care after treatment.  Apply an emollient cream to help reduce dryness after the sutures have been removed. light-haired people of Celtic or Scandinavian origin  People who burn and do not tan or who have a significant history of severe burn  Environmental exposure to intense sunlight  History of melanoma (personal or family)  Skin with giant congenital nevi Clinical Manifestations Superficial spreading melanoma occurs anywhere on the body and is the most common form of melanoma. since x-ray changes may be seen after 5 to 10 years. Radiation Therapy  Frequently performed for cancer of the eyelid. allowed to thaw. healing occurs within a month.  Advise the client to watch for excessive bleeding and tight dressing that compromise circulation. and liquid nitrogen is directed to the center of the tumor until the tumor base is -40ºC to -60ºC. Swelling and edema follow the freezing. Malignant Melanoma A malignant melanoma is a cancerous neoplasm in which atypical melanocytes are present in the epidermis and the dermis. The process is repeated twice.  The tumor tissue is frozen. and the importance of hand washing before and after the procedure. Dental work should also be avoided until the area is completely healed.

134 | P a g e . biologic response modifiers (e.  A thorough history and physical examination should include a meticulous skin examination and palpation of regional lymph nodes that drain the lesional area. curettage. after which skin grafting may be needed. superficial lesions. although new surgical approaches call only for sentinel node biopsy. the head. a chest x-ray.  Regional lymph node dissection is commonly performed to rule out metastasis. It may be dome-shaped with a smooth surface. These melanomas appear as irregular. especially the dorsum of the hand. or needle aspiration are not considered reliable histologic proof of disease. level of invasion. or scalp have a better prognosis. flat lesions. and thickness of the lesion.  After the diagnosis of melanoma has been confirmed. interleukin-2). or white. levamisole). BCG vaccine. A nodular melanoma invades directly into adjacent dermis and therefore has poorer prognosis. those with lesions on the torso have an increased chance of metastases to the bone. on the soles. brown.5 mm thick or there is regional lymph node involvement. foot.  Clients with melanoma on the hand. These melanomas may appear as irregularly shaped plaques. sometimes. It is found on the palms of the hands. Lentigo-maligna melanoma are slowly evolving. they undergo changes in size and color. or purple. and the neck in elderly people. Corynebacterium parvum.  Men and elderly clients also have poor prognoses. Acral lentiginous melanoma occurs in areas not excessively exposed to sunlight and where hair follicles are absent. blue-black. and central nervous system. It may have other shadings of red.  An excisional biopsy specimen provides histologic information on the type. lungs. pigmented lesions that occur on exposed skin areas. blue-black color.g. Nodular melanoma is a spherical. and black mixed with gray.g. They may become invasive early. pigmented macules that develop nodules. interferon-alpha. Medical Management  Treatment depends on the level of invasion and the depth of the lesion. and radionuclide or CT scans are usually ordered to stage the extent of disease. complete blood cell count. with hues of tan.  Incisional biopsy should be performed when the suspicious lesion is too large to be removed safely without extensive scarring. spleen. Assessment and Diagnostic Findings  Biopsy results confirm the diagnosis of melanoma. A dull pin rose color can be seen in a small area within the lesion.  Deeper lesions require wide local excision.  Biopsy specimens obtained by shaving.  Several forms of immunotherapy (e. liver. They first appear as tan. in the nail beds. but in time.. liver function tests.- - - - This type of melanoma may appear in a combination of colors. Lesions are often present for many years before they are examined by a physician.. blueberry-like nodule with a relatively smooth surface and a relatively uniform. and in the mucous membranes in dark-skinned people. gray. The client may describe this as a blood blister that fails to resolve. Prognosis  The prognosis for long-term (5-year) survival is considered poor when the lesion is more than 1.  Surgical excision is the treatment of choice for small.

bluish-red).  Question the client about changes in pre-existing moles or the development of new. Some malignant melanomas. The border is fuzzy or indistinct. and extent of tumor to help clarify information and misconceptions. White areas within a pigmented lesion are suspicious. This approach delivers a high concentration of cytotoxic agents while avoiding systemic. Common sites of melanomas are the skin of the back. Some nodular melanomas have a smooth surface. Nursing Diagnoses  Acute pain related to surgical excision and grafting  Anxiety and depression related to possible lifethreatening consequences of melanoma and disfigurement  Deficient knowledge about early signs of melanoma Planning and Interventions  Relieve pain and discomfort. and blue. Regional perfusion may be used when the melanoma is located in an extremity then chemotherapeutic agent is perfused directly into the area that contains melanoma. If an imaginary line were drawn down the middle. and pain which are not features of a benign nevus. the two halves would not look alike. lymphokine-activated killer cells). Chemotherapy may also be used. pigmented lesions. Melanomas are most likely to occur in less pigmented sites: palms. and monoclonal antibodies are some of the investigational therapies available. and mucous membranes of dark-skinned people.. although this finding without other sign is not significant.  Signs that suggest malignant changes are referred to as the ABCDs of moles: A – Asymmetry . toxic effects.  adaptive immunotherapy (i. bluish-gray. Many benign skin growths are larger than 6 mm. shades of blue are ominous. Further surgical intervention may be performed to debulk the tumor or to remove part of the organ involved for metastatic melanoma.Promote comfort and administer appropriate medications.The lesion does appear balanced on both sides. face. between the toes. Colors that may indicate malignancy if found together within a single lesion are shades of red. The lesion has an irregular surface with uneven elevations (irregular topography) either palpable or visible. as if rubbed with an eraser. scalp. 135 | P a g e . Nursing Process for the Client with Malignant Melanoma Assessment  Assessment is based on the client‘s history and symptoms. tenderness.Satellite lesions (those situated near the mole) are inspected.  Ask the client specifically about pruritus. understand their anger and depression. and convey understanding of these feelings. however. B – Irregular Border Angular indentations or multiple notches appear in the border. A change in the surface may be noted from smooth to scaly. whereas some early melanomas may be smaller. C – Variegated Color Normal moles are usually a uniform light to medium brown. fingernails. white.e.  Answer questions about the diagnostic workup and staging of the depth type. are not variegated but are uniformly colored (bluish-black. the legs. Darker coloration indicates that the melanocytes have penetrated to a deeper layer of the dermis.  Reduce anxiety and depression  Allow clients to express feelings about the seriousness of this cutaneous neoplasm. subungual areas. soles. and backs of hands. D – Diameter A diameter exceeding 6 mm is considered more suspicious. and on the feet.

sudden in onset. decreased blood viscosity. major intracranial vessels. PTT is utilized for heparin therapy and INR is utilized for oral warfarin (Coumadin) therapy. CT angiography. MRA. past effective coping mechanisms. treatment. perioral numbness Carotid bruit History of headaches of duration of days before ischemia Assessment/Diagnostic Evaluation Cerebral angiography. and provide emotional support. increased PCO2. and Doppler ultrasound provide information about carotid and intracranial circulation. Carotid arteries. ataxia. decreased PO2. digital subtraction angiography. infectious endocarditis. Deliver supportive care and provide and clarify information about the therapy and the rationale for its use. Monitor and manage potential complications Be knowledgeable about the most effective current therapies to manage metastasis. unilateral weakness. with maximal deficit within five minutes. and lasting less than 24 hours Carotid system involvement: amaurosis fugax (loss of vision in one eye due to a temporary lack of blood flow to the retina). and instruct the client to and family about the expected outcomes of the treat Cerebrovascular Disease    Cerebrovascular insufficiency is an interruption or inadequate blood flow to a focal area of the brain resulting in transient or permanent neurologic dysfunction. unilateral numbness or paresthesias. Symptoms persisting longer than 24 hours are classified as stroke (also known as brain attack). homonymous hemianopsia (loss of half of the field of view on the same side in both eyes). Pathophysiology and Etiology Cerebrovascular insufficiency is caused by atherosclerotic plaque or thrombosis. dysphagia. in that the pathogenesis is loss of blood supply to the tissue. increased intracranial pressure. ask questions that the client may be reluctant to ask.Point out resource. dysarthria Vertebrobasilar system involvement: vertigo. Cardiac causes of emboli include atrial fibrillation. Transient ischemic attack (TIA) lasts less than 24 hours. vertebral arteries. mitral valve prolapse. and continuing follow-up. Blood levels are monitored to document therapeutic ranges and determine dosing. homonymous hemianopsia. weakness that is bilateral or alternate sides. Partial prothrombin time (PTT) or International Normalized Ratio (INR) if anticoagulation is considered. and social support systems to help them cope with the problems associated with diagnosis. possibly up to 24 hours. Event may be classified as TIA—transient episode of cerebral dysfunction with associated clinical manifestations lasting usually minutes to an hour. Include the client‘s family in all the discussions to clarify th e information presented.     o         136 | P a g e . dysarthria. Ischemic stroke is similar to myocardial. identify potential side effects of therapy and ways to manage them. Transient Ischemic Attacks (TIA) Clinical Manifestations History of intermittent neurologic deficit. which can result in irreversible damage if blood flow is not restored quickly. or microcirculation may be affected. diplopia. and prosthetic heart valve. aphasia. hyperthermia/hypothermia.

Transesophageal echocardiography to rule out emboli from heart. and clopidogrel (Plavix). such as atrial fibrillation. A tiny balloon at the end of the catheter is inflated to open the narrowed area and a metal stent (wire-mesh tubular scaffolding) is inserted to keep the artery from narrowing again. hollow tube) is inserted in the groin artery and threaded up to the narrowed carotid artery. a catheter (long. Transarterial (Carotid) Angioplasty withStenting In carotid angioplasty. ticlopidine (Ticlid). Assess client for history of headache and. cardiac. Medical Management Platelet aggregation inhibitors. such as aspirin. to reduce risk of stroke Reduction of other risk factors to prevent stroke. The purpose of extracranial to intracranial (EC-IC) bypass is to augment cerebral blood flow. and hyperlipidemia. Advantages: Local instead of general anesthesia Fewer surgical complications such asnerve injury. to a branch of the middle cerebral artery (MCA). and are usually discharged from the hospital the following day. smoking. Extracranial/Intracranial Anastomosis This procedure entails connection of the superficial temporal artery (STA). diabetes. Perform physical examination. or a venous conduit.             137 | P a g e . including neurologic. hyperlipidemia. Clients are awake during the procedure. Indicated for clients with symptoms of TIA or mild stroke found to be due to severe (70% to 99%) carotid artery stenosis or moderate (50% to 69%) stenosis with other significant risk factors. and smoking cessation Treatment of arrhythmias Treatment of isolated systolic hypertension Anticoagulation agents for clients who continue to have symptoms despite antiplatelet therapy and those with major source of cardiac emboli Surgical Management Surgical or endovascular intervention to increase blood flow to brain Carotid Endarterectomy   The removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke. cardiovascular disease. such as control of hypertension. hypertensive and diabetic control.      Diffusion-weighted MRI may be done to rule out stroke. hematoma (bruising) and wound infection Shorter operation Less discomfort Smaller incision Shorter recovery time Ability to treat narrowed arteries that arehard to reach or difficult to treat withsurgery Nursing Process Assessment Obtain history of possible TIA. for duration of headache. be sure to listen for carotid bruit. Most clients are able to resume normal activities when they get home. dipyridamole/aspirin 200/25 (Aggrenox). if positive. and circulatory systems.

Notify the health care provider of any deficits immediately. which indicate cranial nerve injury. Following carotid endarterectomy:   Monitor for hoarseness. lowsodium diet as indicated. Mild swelling is expected. risk 138 | P a g e . Reinforce with client and family importance of accessing the medical system. monitoring for adverse effects and therapeutic effect.Nursing Diagnoses  Ineffective tissue perfusion (cerebral) related to underlying arteriosclerosis  Risk for injury related to surgical procedure  Readiness for enhanced knowledge of risk factors and therapeutic lifestyle changes Interventions  Improve cerebral perfusion Teach client signs and symptoms of TIA and need to notify health care provider immediately. how to read labels. sensation. administer medications as directed: Heparin – bolus given intraprocedure then continuous IV drip post-procedure to maintain PTT within ordered range. which could affect blood pressure. handgrip and plantar flexion strength. when symptoms first occur. discuss its causes. monitor PTT every six hours Clopidogrel (Plavix) before procedure. closely monitor vital signs and administer medication as prescribed to avoid hypotension (which can cause cerebral ischemia) or hypertension (which may precipitate cerebral hemorrhage). and how to follow a low-fat. monitor drainage. Observe operative area closely for swelling. Aspirin 81 mg daily as directed. Elevate head of bed when vital signs are stable. reports relief of pain Expresses readiness to quit smoking and adhere to a low-fat diet menu 2. including pupil size. Encourage lifestyle changes to reduce risk Help client begin to formulate a plan for smoking cessation Teach client and family members the basics of the food pyramid. Administer or teach self-administration of anticoagulants. Following transcranial stenting. If the client wears glasses. prepare client for immediate surgery. the difference between ischemic and hemorrhagic stroke. Prepare client for surgical or endovascular intervention as indicated.  Expected Outcomes    Alert without neurologic deficits Respirations unlabored. Obtain physical therapy referral for endurance training and monitoring as indicated      Client education and health maintenance Encourage client receiving long-term oral anticoagulants to comply with follow-up monitoring of INR and to report any signs of bleeding. Encourage the use of electric razors and toothbrushes toprevent bleeding. and reaction. Following EC-IC anastomosis. and other medication. or difficulty swallowing and facial weakness. Describe what CVA is. Medicate for pain and avoid agitation or sudden changes in position. remove the eyeglass arm on the operative side to avoid this possible pressure point. no swelling of neck. by calling emergency numbers. Keep tracheostomy tube at bedside and assess for stridor. antiplatelet agents. Perform frequent neurologic checks. equality. vital signs stable. as ordered. impaired gag reflex. and particularly a low-saturated fat diet Obtain a referral to a nutritionist for help with weight management and low-fat. but if hematoma formation is suspected. avoid pressure over the anastomosis of the superior temporal artery (extracranial) and the middle cerebral artery (intracranial) to prevent rupture or ischemia of the site. and speech. Keep head in neutral position to relieve stress on surgical site.  Provide care and prevent complications after surgical procedure After surgery. hematoma formation can cause airway obstruction. antihypertensives. Encourage daily activity for 30 minutes if possible. mental status. dosing is physician-dependent. Encourage client receiving anti agents to report any signs of bleeding.

defined as the interruption of normal blood flow in one or more of the blood vessels that supply the brain as a result.  Strokes are classified as ischemic (more common) and hemorrhagic (greater morbidity and mortality).  Reduction in the flow of blood to any part of the brain first causes ischemia.     139 | P a g e . and hemorrhage are the primary causes of CVA  Ischemic Stroke  Results from cerebral vessels becoming occluded. Reversible ischemic neurologic deficits Signs and symptoms are consistent with but more pronounced than a TIA and last more than 24 hours.  Sudden loss of function occurs. assessment/diagnostic procedures. which has its greatest incidence in the first month after the first attack. Causes  A CVA is an acute neurological injury that occurs because of changes in the blood vessels of the brain. Dilation of the vessel Weakening of the vessel Obstruction of the vessel (thrombosis) Most common cause:  Extrinsic cause Embolism from the heart Thrombosis. if the reduction is severe or prolonged.Neurologic signs and symptoms stabilize which indicates no further progression of the hypoxic insult to the brain. This is a progressing stroke. as well as the nursing process for a client who had CVA.factors. pathophysiology. Depending on the area involved. significantly reducing the blood and oxygen supply to the brain. Symptoms resolve in days with no permanent neurologic deficit. and then.  Stroke clients may present to the acute care facility atany point along a continuum of neurologic involvement  May be classified according to the time course into: Transient ischemic attack (TIA) May serve as a warning of impending stroke. a reversible loss of function. leading to hypoxia or anoxia. the tissues become ischemic. Lack or delay in evaluation and treatment of a client who has experienced previous TIAs may result in a stroke and irreversible deficits.  Onset and persistence of neurologic dysfunction last onger than 24 hours. There is leakage of blood from a blood vessel and hemorrhage into brain tissue. with destruction or necrosis of the neurons. embolism. causing edema. Stroke in evolution Worsening of neurologic signs and symptoms over several minutes or hours.  The changes can be intrinsic or extrinsic to the vessel:  Intrinsic causes Atherosclerosis Inflammation Arterial dissection.  Stroke  Also known as cerebrovascular accident (CVA) or brain attack.  Hemorrhagic Stroke Account for 15% of cerebrovascular disorders.    Completed stroke . infarction with irreversible cell death. medical management of CVA. support structures (glia). compression of brain tissue. and vasculature. it may occur: outside the dura (extradural). clinical manifestations. and spasm of adjacent blood vessels.

diabetes mellitus. the greater the risk of hemorrhagic conversion. but as blood flow decreases focal areas of ischemia occur. Subtle decrease in blood flow may allow brain cells to maintain minimal function. occurs over several days  Embolus – a moving clot of cardiac origin (frequently due to atrial fibrillation) or from a carotid artery that travels quickly to the brain and lodges in a small artery. occurs suddenly with immediate maximum deficits  Area of brain affected is related to the vessel that was occluded supplying a particular part of the brain. resulting to loss of function specifically controlled by the affected area. usually at bifurcation of larger arteries. it may even occur at rest. in the subarachnoid space (SAS or subarachnoid). tissue breakdown. followed by infarction of that area.           beneath the dura mater (subdural). and small arterial vessel damage.  Ischemic strokes are not activity dependent. hormone replacement therapy or contraceptive use. the goal is: LDL is less than 160 mg/dL if one or no risk factor less than 130 if two or fewer risk factors or 10-year CHD risk is less than 20% less than 100 if two or fewer risk factors and 10-year CHD risk greater than 20% Carotid stenosis Prior history of TIA or stroke Elevated homocysteine level in blood Behaviors/lifestyle Cigarette smoking Alcohol abuse Physical inactivity Cocaine use (hemorrhagic stroke) Nonmodifiable factors Increasing age – risk doubles for each decade over age 50 Gender – men are at greater risk than women Heredity – increased risk with family history of stroke There have been reports of increased risk due to childbirth. valvular conditions. the goal is less than 130/80 mm Hg Treatment that achieve adequate BP control decreases the risk by 30% to 40% Cardiac disorders – congenital heart disease. within the brain substance (intracerebral) Risk Factors Medical conditions Hypertension The goal is to for the client to have a BP lower than 140/90 mm Hg If there is renal insufficiency or heart failure. The small arterial vessel damage poses a risk of hemorrhage. endocarditis Atrial fibrillation – oral anticoagulant therapy reduces the risk by 68% Diabetes mellitus – 44% risk reduction in hypertensive diabetics with controlled BP Hyperlipidemia – 20% to 30% risk reduction with those with known coronary heart disease on statin therapy. or cocaine use 140 | P a g e .  An area of injury includes edema. The larger the area of infarction. the goal is less than 130/85 mm Hg If the client is diabetic.               Pathophysiology Ischemic Stroke  Partial or complete occlusion of a cerebral blood flow to an area of the brain due to:  Thrombus (most common) – due to arteriosclerotic plaque in a cerebral artery.  Pathophysiology Hemorrhagic Stroke  Causes include the following:  Increased pressure due to hypertension  Head trauma causing dissection or rupture or vessel  Deterioration of vessel wall from chronic hypertension. and migraine headaches.

9 mg/kg within 3 hours of onset of symptoms. oxygenation. Headache may be a sign of impending cerebral hemorrhage or infarction. leading to hydrocephalus. double vision. breathing. MRI with diffusion-weighted images to localize ischemic damage. Clinical Manifestation Clinical manifestations vary depending on the vessel affected and the cerebral territories it supplies/perfuses. Cerebral angiography to determine extent of cerebrovascular insufficiency and to evaluate for structural abnormalities. Reperfusion and hemodilution with colloids and volume expanders (albumin). loss of half of a visual field (hemianopsia). transarterially within\ 6 hours of onset of symptoms Advantages of transarterial therapy: Higher concentration delivered to clot Allows gentle mechanical disruption of clot Provides precise imaging of pathology and evaluation of collateral circulation Defines extent of injury and recanalization  Additional transarterial treatment options:  Abciximab – antiplatelet agent delivered intra-arterially  Verapamil – potent vasodilator injected into intracranial vessel to treat acute spasm 141 | P a g e . photophobia Altered cognitive abilities and psychological effect Self-care deficits Assessment/Diagnostic Procedures Carotid ultrasound to detect carotid stenosis. Hemorrhage commonly occurs suddenly while a person is active-spontaneous (nontraumatic) intracranial hemorrhage. weakness (paresis).                             Congenital weakening of blood vessel wall with aneurysm or arteriovenous malformation (AVM) Intracranial hemorrhage becomes a space-occupying lesion within the skull. further compromising brain function. often associated with damage to the left frontal lobe (Broca‘s) area Receptive – inability to understand what someone else is saying. Medical Management Acute Treatment Support of vital functions: maintain airway. often associated with damage to the temporal lobe (Wernicke‘s) area Global – an extreme impairment or loss of language ability in all input and output modalities. however. meaning the individual has very poor language comprehension as well as the inability to speak or write Visual difficulties of inattention or neglect (lack of acknowledgment of one side of the sensory field). Subarachnoid hemorrhage (SAH) or hemorrhage into a ventricle can block normal CSF flow. Common clinical manifestations: Numbness (paresthesia). Mass effect (caused by a rapidly growing tumor) causes pressure on brain tissue. and circulation. MRA or CT angiogram for noninvasive evaluation of cerebrovascular structures. CT scan to determine cause and location of stroke. or loss of motor ability (plegia) on one side of the body Difficulty in swallowing (dysphagia) Aphasia Expressive – inability to express oneself. Hemorrhage irritates local brain tissue leading to surrounding focal edema. PET. it is not always present. Thrombolytic therapy – recombinant tissue plasminogen (tPA) given IV 0.

       Clot retrieval Balloon angioplasty to treat acute spasm Disadvantages of transarterial therapy: Risk of hemorrhage related to catheter manipulation Delay in thrombolytic therapy due to access delays Limited facility based accessibility Management of increased intracranial pressure (ICP). nimodipine (Nimotop). to reduce BP. Maintain BP within prescribed parameters.  Subsequent Treatment             Anticoagulation after hemorrhage is ruled out. Treatment of post-stroke depression with antidepressants such as selective serotonin reuptake inhibitors. Dipyridamole/aspirin 200/25 (Aggrenox). and counseling as needed. and clopidogrel (Plavix). occupational therapy.  Calcium channel blockers. Antispasmodic agents for spastic paralysis. which peaks 3 to 5 days after infarction. pulmonary embolism Brain stem herniation Post-stroke depression (PSD) 142 | P a g e . while promoting adequate cerebral perfusion to prevent further ischemia. Management of systemic hypertension with nitroprusside (Nipride) or alternative IV antihypertensive agents Vasopressor agents to maintain Diuretic treatment to reduce cerebral edema. promote vasodilatation. Antiplatelet agents such as ticlopidine (Ticlid). or aspirin. may be used. Complications Aspiration pneumonia Dysphagia in 25% to 50% of clients after stroke Spasticity. A rehabilitation program. although this is controversial. contractures Deep vein thrombosis. and prevent cerebral vasospasm. including physical therapy. Limit hypertensive fluctuations and keep systolic BP (SBP) less than 200 mm Hg to reduce vessel wall stressors to prevent rebleed in hemorrhagic stroke or potentiate hemorrhagic conversion of ischemic stroke. speech therapy as soon as stable).

Administer oxygen as ordered during acute phase to maximize cerebral oxygenation. swallowing Impaired urinary elimination related to motor/sensory deficits Disabled family coping related to catastrophic illness. Assess for voluntary or involuntary movements.Apply splints and braces as indicated to support flaccid extremities or on spasticextremities to decrease stretch stimulationand reduce spasticity. toileting related to hemiparesis/paralysis Imbalanced nutrition: less than body requirements related to impaired self-feeding. maintain frequent vigilance and interactions aimed at orienting. Maintain functional position of all extremities. Encourage neutral positioning of affected limbs to promote relaxation and to limit abnormal increases in muscular tone to enhance functional recovery . Frequently assess level of function and psychosocial response to condition. Also assess mental status. When client becomes more alert after acute phase. Place a pillow in the axilla of the affected side when there is limited external rotation to keep arm away from chest and prevent adduction of the affectedshoulder. dressing. heart rate and rhythm. cranial nerve function. and avoid sitting up in chair for long periods to prevent knee and hip flexion contractures. chewing. contractures. alternate elbowextension. Do not allow top bedding to pull affected foot into plantar flexion. Assess for skin breakdown. Assess client for risk for fall status. Apply a trochanter roll from the crest of the ilium to the mid thigh to prevent external rotation of the hip. Place the hand in slight supination with fingers slightly flexion. Avoid excessive pressure on ball of foot after spasticity develops. Place the affected upper extremity slightly flexed on pillow supports with each joint positioned higher than the preceding one to prevent edema and resultant fibrosis. and other complications of immobility. and urine output to maintain and support vital functions. Monitor effectiveness of anticoagulation therapy. and presence of deep tendon reflexes. Monitor bowel and bladder function/control. vital signs. may use tennis shoes in bed. and sensation/proprioception. and meeting the needs of the client. Frequently assess respiratory status. Nursing Process                Assessment Maintain neurologic flow sheet. assessing. Place the client in a prone position for 15 to 30 minutes daily. cognitive and behavioral sequelae of stroke.          Prevent complications of immobility Interventions to improve functional recovery require active participation of the client and repetitive training. and caregiving burden  Intervention  Prevent falls and other injuries Maintain bed rest during acute phase (24 to 48 hours after onset of stroke) with head of bed slightly elevated and side rails in place. Try to allay confusion and agitation with calm reassurance and presence. tone of muscles. 143 | P a g e . Nursing Diagnoses Risk for injury related to neurologic deficits Impaired physical mobility related to motor deficits Disturbed thought processes related to brain injury Impaired verbal vommunication related to brain injury Self-care deficit: bathing.

Provide rest periods as client will tire easily. and allow plenty of time to chew and swallow. calendar. Be aware that clients usually have clear goals in relation to functional abilities. strengthening effort to swallow while chin is tucked down. cueing procedures—as outlined by rehabilitation nurse or therapist. Teach the client to scan environment if visual deficits are present. Facilitate communication Speak slowly. and reinforce attempts as well as correct responses. with front closures. Have client wear walking shoes or tennis shoes. and stretch fabric.. Velcro. Be aware that ADLs require anticipatory (automatic coordination of multiple muscle groups in anticipation of a specific movement) and reactive (adjustment of posture to stimuli) postural adjustments. Make sure personal care items. or speech difficulties. Participate in cognitive retraining program — reality orientation. against which all success and forward progress will be measured. Assess standing balance. Use alternative methods of communication other than verbal. Encourage family to provide clothing a size larger than client wears. and commode are nearby and that client obtains assistance with transfers and other activities as needed. Be aware that depression is common and therapy should include psychotherapy and pharmacological agents. such as written words. tray) to side of awareness if spatial neglect or visual field cuts are present. Inspect mouth for food collection and pocketing before entry of each new bolus of food. Assist with ambulation as needed with help of physical therapy as indicated. Foster independence Teach client to use non-affected side for activities of daily living (ADLs) but not to neglect affected side. Encourage small. Make sure mechanical soft or pureed diet is provided.                Volar splint to support functional position of wrist. based on ability to chew. Teach client to use unaffected extremity to move affected one. Minimize distractions. Optimize cognitive abilities Be aware of the client's cognitive alterations. Adjust the environment (e. Give plenty of time for response. Inspect oral mucosa for injury from biting tongue or cheek.g. approach client from uninvolved side. ensure safety with a client waist belt. using visual cues and gestures. Help client begin ambulating as soon as standing balance is achieved. gestures. and have client practice standing. and adjust interaction and environment accordingly. Sling to prevent shoulder subluxation of flaccid arm. Encourage frequent oral hygiene. Remind client to chew on unaffected side. call light. be consistent. clock. frequent meals. and dangles legs at the bedside before transferring out of bed or ambulating. Dietary consults can be helpful for selection of food preferences. Place ice on tongue and encourage sucking. High-top sneaker for ankle and foot support. post schedule of daily activities where client can see it. urinal. Exercise the affected extremities passively through ROM four to five times daily to maintain joint mobility and enhance circulation. to evaluate swallowing function at bedside or radiographically to demonstrate safe and functional swallowing mechanisms before initiation of oral diet. use pictures of family members. and repeat as necessary. or pictures. Teach the family how to assist the client with meals to facilitate chewing and swallowing. visual imagery. Check for orthostatic hypotension when dangling and standing. 144 | P a g e . Encourage client to drink small sips from a straw with chin tucked to the chest. Graduate the client from a reclining position to head elevated. teach client to dress while sitting to maintain balance. and give positive feedback. Speak directly to the client while facing him/her. Focus on client's strengths. Assess the client for excessive exertion. assess sitting balance in bed. In clients with increased awareness. dyspraxic speech. encourage active ROM exercise as able. Promote adequate oral intake Initiate referral for a speech therapist for individuals with compromised LOC. Help client relearn swallowing sequence using compensatory techniques. help them set realistic shortand long-term goals.

Encourage participation in support group for family respite program for caregivers. Teach family that stroke survivors do show depression in the first three months of recovery. Provide information about stroke and expected outcome. 145 | P a g e . feelings of guilt or sadness. Use pillows to achieve correct position. use of community and faith-based support networks. treatment can be given. remove as soon as status stabilizes. Attain bladder control Insert indwelling bladder catheterization during acute stage for accurate fluid management. Reinforce that these muscle and ligament deformities resulting from stroke can be prevented with daily stretching and strengthening exercises. Assist with standing or sitting to void (especially males). Involve as many family and friends in care as possible. external rotation of the hip with flexion of the knee and plantar flexion of the ankle. Notify health care provider for possible medication therapy. correlated with fluid intake—when bladder tone returns. such as relaxation exercises. such as difficulty sleeping. Perform ROM exercises. Establish regular voiding schedule—every 2 to 3 hours. anorexia. Instruct the client of the need for rest periods throughout day. and fingers. Community and home care considerations Hemiplegic complications resulting from stroke commonly include frozen• shoulder. Position the client so he is sitting with 90 degrees of flexion at the hips and 45 degrees of flexion at the neck.          Reduce environmental distractions to improve client concentration. Encourage consistency in the environment without distraction. Depression after stroke is a major problem because it can increase the morbidity. Reassure the family that it is common for post-stroke clients to experience emotional ability and depression. Maintain position for 30 to 45 minutes after meals to prevent regurgitation and aspiration. frequent crying. wrist. or other available resources in area. Teach stress management techniques. If client is unable to void. Educate those at risk for stroke about lifestyle modifications and medication therapy that can lower risk. adduction and internal rotation of arm with flexion of elbow. Strengthen family coping Encourage the family to maintain outside interests. Assist family to obtain self-help aids for the client. Monitor for signs of depression. Client education and health maintenance Teach the client and family to adapt home environment for safety and ease of use. Provide oral care before eating to improve aesthetics and afterward to remove food debris. intermittent catheterization can be used to empty bladder and prevent overstretching of bladder. Instruct the family in management of aphasia. The bladder scan device is useful in monitoring bladder capacity and identifying individuals at risk. Continue to support family who may be caring for a hemiplegic or aphasic person at home or in long-term care for a long time. and instruct the client and family on these as well as proper positioning.

lesions. About 125 to 150 ml circulates throughout the ventricular system and the SAS in the following ratio: 25 ml in the ventricles. and Increased ICP constitutes an emergency and requires prompt treatment. Increased ICP is defined as CSF pressure greater than 15 mm Hg. no contractures Oriented to person. place. Normally. The brain contents must be kept in equilibrium. Definition Intracranial pressure (ICP) is the pressure exerted by the contents inside the cranial vault—the brain tissue (gray and white matter). principles of management of increased ICP. physical activity) Regional cerebral vasospasm Oxygen saturation and hematocrit Inability to maintain a steady state. Pathophysiology ICP is comprised of the following components and volume ratio: brain tissue. blood volume. putting on shirt and pants independently Feeds self two-thirds of meal Voids on commode at 2-hour intervals Family seeks help and assistance from others  Increased Intracranial Pressure       Define intracranial pressure (ICP). Intracranial compliance is tightness• of the brain. complications. As ICP increases. compliance decreases. When this volumepressure relationship becomes unbalanced.Expected Outcomes         No falls. results in increased Traumatic brain injury. The Monro-Kellie doctrine states that the pressure relationship of these elements constantly adjusts to achieve an acceptable steady state or equilibrium between the components of the intracranial system. Increased CSF absorption. and 35 ml in the cisterns and surroundingSAS. and the ratio between volume and pressure must remain constant. Increased ICP will ultimately occur if the volume of the intracranial mass exceeds the volume compensated. Compensatory measures are finite. vital signs stable Maintains body alignment. clinical manifestations. and nursing process for a client with increased ICP.                  146 | P a g e . Factors that influence the ability of the body to achieve this steady state include: Ventilation and oxygenation Metabolic rate and oxygen consumption (fever. abscess and infection. Compliance is the relationship between intracranial volume and ICP. about 500 ml of CSF are produced and absorbed in 24 hours. 10%. intracranial surgery. Discuss the pathophysiology. 80%. and time Communicates appropriately Brushing teeth. cerebrospinal fluid. CSF. 90 ml in the lumbar SAS. shivering. cerebral edema. The brain attempts to compensate for rises in ICP by: Displacement/shunting of CSF from the intracranial compartment to the lumbar subarachnoid space (SAS). and the blood volume. ICP increases. Any increase in the volume of one component must be accompanied by a reciprocal decrease in one of the other components. Clinical Manifestations Changes in LOC caused by increased cerebral pressure. Decreased cerebral blood volume by displacement of cerebral venous blood into the venous sinuses. 10%.

 Midbrain involvement – fixed and dilated  Pontine involvement – pinpoint pupils  Uncal herniation Unilaterally dilating pupil ipsilateral to lesion Anisocoria (unequal) with sluggish light reaction in dilated pupil If treatment is delayed or unsuccessful.  Inability to abduct or adduct: deviation of one or both eyes. This may be followed by hypotension and labile vital signs. blurred vision. up. indicating further brain stem compromise. particularly pupillary changes related to location and progression of brain stem herniation. contusion.  Assess for the following:  Rising BP or widening pulse pressure. configuration. random eye movements  Nystagmus on horizontal/vertical gaze  Oculocephalic reflex (doll's eyes): brisk turning of the head left. working together) or dysconjugate (eye deviates or movement is asymmetrical). deep breathing)  Apneuistic (sustained inspiratory effort) breathing  Ataxic (uncoordinated and spasmodic) breathing  Hyperthermia followed by hypothermia  Be alert for respiratory irregularities may not be apparent of client is mechanically ventilated  Pupillary changes caused by increased pressure on optic and oculomotor nerves. Reaction to light is brisk but with small range of constriction. contralateral pupil becomes dilated and fixed to light When herniation of brainstem occurs. both pupils assume midposition and remain fixed to light  Central transtentorial herniation Pupils are small bilaterally (1 to 3 mm).  Perform fundoscopic examination to inspect the retina and optic nerve for hemorrhage and papilledema.  Inspect the pupils with a flashlight to evaluate size.  Compare both eyes for similarities or differences. small pupils dilate moderately (3 to 5 mm) to fix irregularly at midposition. When herniation of brainstem occurs.  Alteration in vision (e. and apathy Falling score on the Glasgow Coma Scale (GCS) Change in orientation: disorientation to time.  Extraocular movements  Evaluate gaze to determine if it is conjugate (paired. irritability.  Evaluate movement of eyes. and reaction to light. both pupils dilate widely and remain fixed to light. field cut)  Spontaneous roving.Treatment is delayed or unsuccessful. or person Difficulty or inability to follow commands Difficulty or inability in verbalization or in responsiveness to auditory stimuli Change in response to painful stimuli (e.  Respiratory irregularities:  Tachypnea (early sign of increased ICP)  Slowing of rate with lengthening periods of apnea  Cheyne-Stokes (rhythmic pattern of increasing and decreasing depth of respirations with periods of apnea) or Kussmaul (paroxysms of difficulty breathing) breathing  Central neurogenic hyperventilation (prolonged.         Assess for the following: Change in LOC (awareness): drowsiness. or down with observation of eye movements in response to the stimulus. purposeful to inappropriate or absent responses) Changes in vital signs caused by pressure on brain stem. right.. 147 | P a g e . lethargy Early behavioral changes: restlessness..  Pulse changes with bradycardia changing to tachycardia as ICP rises. diplopia. place.g.g.

This is performed by physician as part of brain death examination. or clients with known cervical spine injuries unless part of the brain death exam. receptive. Promote normal PCO2. purposeless movements. e. chewing. and mental cloudiness Contralateral hemiparesis progressing to complete hemiplegia Speech impairment (expressive. grasp. clients in a cervical collar. Oculovestibular reflex (ice water calorics): 30 to 60 ml of ice water instilled into the ear with the head of the bed elevated to 30 degrees. this should not be performed on clients with suspected cervical spine injury. response preserved longer than the doll's eyes maneuver.. Hyperventilation is not recommended for prophylactic treatment of increased ICP as cerebral circulation is reduced by 50% the first 24 hours after injury. corneal. also connected to pressure transducer system.  Nursing Diagnosis: Decreased intracranial adaptivecapacity      Interventions (to decrease intracranial pressure) Establish and maintain airway. so does not measurepressure directly.            Tests brain stem pathways between cranial nerves III. and swallow) Pathologic reflexes: Babinski. or brain death. allows ventricular drainage. and VIII. headache. Hyperventilation causes cerebral vasoconstriction and decreases cerebral blood volume and results in decreased ICP.g. Subarachnoid (bolt) hollow screw inserted into SAS beneath skull and dura through drill hole. VI. IV. connected to fluid-filled transducer. Parenchymal device is inserted directly into brain tissue. such as restlessness. fiber-optic cable is connected directly to monitor. or an epidural pressure-recording device. gag. IV. especially in early morning. VI. Other changes to be alert for: Headache increasing in intensity and aggravated by movement and straining Vomiting recurrent with little or no nausea. a subarachnoid screw or bolt. which converts mechanical pressure to electrical impulses and waveform. this can potentiate secondary injury to the brain. Tests brain stem pathways between cranial nerves III. may be projectile Papilledema from optic nerve compression Subtle changes.  Monitoring  The purposes of ICP monitoring are to: Identify increased pressure early in its course (before cerebral damage occurs) Quantify the degree of elevation Initiate appropriate treatment Provide access to CSF for sampling and drainage Evaluate the effectiveness of treatment  Different ways for ICP monitoring: Intraventricular catheter inserted into lateral ventricle using a drill or burr hole opening.  Alterations or compromise in cerebral blood flow can be measured noninvasively by a transcranial Doppler (TCD). andcirculation. sucking  Nursing Process  Assessment  ICP can be monitored by means of an intraventricular catheter. Increased velocities indicate vasospasm. or global aphasia) when dominant hemisphere involved Seizure activity. and absent velocities are consistent with no flow. diminished velocities indicate low blood flow. Epidural sensor inserted beneath skull butnot through dura. breathing. either focal or generalized Decreased brain stem reflexes (cranial nerve deficits. and VIII. forced breathing. 148 | P a g e .

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Hyperventilation should be used only after all other treatment options have been exhausted or in an acute crisis. Avoid hypoxia. Decreased PO2 (less than 60) alsocauses cerebral vasodilation, thus increasing ICP. Maintain adequate cerebral perfusion pressure (CPP). CPP is determined by subtracting the ICP from the mean arterial pressure (MAP): MAP – ICP Administer mannitol (Osmitrol), an osmotic diuretic, ifordered. Osmotic diuretics act by establishing an osmoticgradient across the blood-brain barrier that depletes the intracellular and extracellular fluid volume within the brain and throughout the body. The mannitol will be ineffective if the blood-brain barrier is not intact. Administer hypertonic saline, as ordered. It creates an osmotic gradient that pulls extra fluid from the brain with an intact bloodbrain barrier, lowers ICP, improves cerebral blow flow, and delivers oxygen. Insert an indwelling urinary catheter for management of diuresis. Administer corticosteroids, such as dexamethasone (Decadron), as ordered, to reduce edema surrounding brain tumor, if present. Corticosteroids are used to reduce inflammation and decrease vasogenic (extracellular) cerebral edema. Corticosteroids are useful in the treatment of vasogenic edema associated with brain tumors but are not recommended in the treatment of cytoxic (intracellular) cerebral edema related to trauma. Maintain balanced fluids and electrolytes. Diabetes insipidus (DI) results from the absence of antidiuretic hormone (ADH); this is reflected by increased urine output with elevation of serum osmolarity and sodium. The syndrome of inappropriate antidiuretic hormone (SIADH) results from the secretion of ADH in the absence of changes in serum osmolarity. This is reflected by decreased urine output with decreased serum sodium and increased free water. Either extreme may occur with ICP. Monitor effects of neuromuscular paralyzing agents, such as pancuronium (Pavulon), anesthetic agents, such as propofol (Diprivan), and sedatives, such as midazolam (Versed) or lorazepam (Ativan), which may be given along with mechanical ventilation to prevent sudden changes in ICP due to coughing, straining, or fighting• the ventilator. Neuromuscular paralyzing agents, such as pancuronium (Pavulon) or vecuronium (Norcuron), or high-dose barbiturates may be used in cases that are difficult to manage. High-dose barbiturates induce a comatose state and suppress brain metabolism, which, in turn, reduces cerebral blood flow and ICP (not recommended unless all other treatments failed). Be alert to the high level of nursing support required. All responses to environmental and noxious stimuli (suctioning, turning) are abolished as well as all protective reflexes. Cough or gag reflex will be absent and the client will be unable to protect the airway, increasing susceptibility to pneumonia. Monitor ICP, arterial pressure, and serum barbiturate levels as indicated. Perform continuous EEG monitoring to document burst suppression (suppression of cortical activity) and ensure adequate dosing of barbiturates, if used. Monitor temperature because barbiturate coma causes hypothermia. Treat fever aggressively because fever increases cerebral blood flow and cerebral blood volume; acute increases in ICP occur with fever spikes. Cerebral temperature is 4 to 5 degrees higher then body core temperature; therefore, small increases in body core temperature can create drastic increases in the core temperature of the brain. Also, infection is a common complication of ICP. Avoid positions or activities that may increase ICP.

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Keep head in alignment with shoulders; neckflexion or rotation increases ICP by impeding venous return. Keep head of bed elevated 30 degrees to reduce jugular venous pressure and decrease ICP. Minimize suctioning, keep procedure less than 15 seconds, and, if ordered, instill lidocaine via endotracheal (ET) tube before suctioning. Coughing and suctioning are associated with increased intrathoracic pressure, which is associated with ICP spikes. Lidocaine 5 to 10 ml injected into ET tube before suctioning dampens the cough response. Minimize other stimuli, such as alarms, television, radio, and bedside conversations that may precipitously increase ICP (stimuli are clientdependent). Avoid hyperglycemia. Treat with sliding scale insulin or insulin drip as ordered. Initiate treatment modalities as ordered for sustainedincreased ICP (above 20 mm Hg persisting 15minutes or more or if there is a significant shift inpressure). Avoid taking pressure readings immediately after a procedure. Allow client to rest for approximately 5 minutes. Record ICP readings every hour, and correlate withsignificant clinical events or treatments (e.g.,suctioning, turning). Outcome Criteria ICP and vital signs stable Client is alert and responsive

Complications of Increased ICP Brain stem herniation Results from an excessive increase in ICP when the pressure builds in the cranial vault and the braintissue presses down on the brain stem.  This increasing pressure on the brain stem results in the cessation of blood flow to the brain, causing irreversible brain anoxia and brain death.  Diabetes insipidus (DI)  DI is the result of decreased secretion of antidiuretic hormone.  The client has excessive urine output, and hyperosmolarity results.  Therapy consists of administration of fluid volume,electrolyte replacement, and vasopressin (desmopressin, DDAVP) therapy.  Syndrome of inappropriate antidiuretic hormone (SIADH)  SIADH is the result of increased secretion ofantidiuretic hormone.  The client becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute resulting in hyponatremia (dilutional).  Treatment of SIADH includes fluid restriction, which is usually sufficient to correct the hyponatremia; severe cases call for judicious administration of a 3% hypertonic saline solution.  Principles of Management           Surgical Management Craniotomy is the surgical opening of the skull to gain access to intracranial structures to: remove a tumor relieve increased intracranial pressure (ICP) evacuate a blood clot stop hemorrhage or remove brain tissue acting as the source of seizures Surgical approach is based on location of lesion and may be: Supratentorial (above the tentorium or dural covering that divides the cerebrum from cerebellum); or, Infratentorial (below the tentorium, including thebrain stem). Craniotomy may be performed by means of burr holes (made with a drill or hand tools) or by making a bony flap.

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Craniectomy is excision of a portion of the skull. Cranioplasty is repair of a cranial defect by means ofa plastic or metal plate. Transsphenoidal surgery is an approach that gains access to the pituitary gland through the nasal cavity and sphenoid sinus. Nursing Management of the Client Undergoing Intracranial Surgery Preoperative Management Diagnostic findings, surgical procedure, and expectations are reviewed with the client. Presurgical shampoo with an antimicrobial agent may be ordered. Shave and prep are performed in the operating room. Depending on primary diagnosis, corticosteroids may be ordered preoperatively to reduce cerebral edema. Depending on the type and location of lesion, anticonvulsants may be ordered to reduce risk of seizures. The client is prepared for the use of intraoperative antibiotics to reduce risk of infection, and urinary catheterization to assessurinary volume during operative period. If cerebral edema develops, intraoperative or postoperative osmotic diuretic (mannitol [Osmitrol]) or corticosteroids may be ordered for its treatment. Neurologic assessment is performed to evaluate and record the client's neurologic baseline and vital signs for postoperative comparison. Family and client are made aware of the immediate postoperative care and where the physician will contact the family after surgery. Supportive care is given as needed for neurologic deficits. Postoperative Management Respiratory status is assessed by monitoring rate, depth, and pattern of respirations. A patent airway is maintained. Vital signs and neurologic status are monitored, using GCS; findings are documented. Arterial and central venous pressures (CVP) are monitored, possibly with a pulmonary Swan- Ganz catheter for accurate assessment of hemodynamic status. Pharmacologic agents may be prescribed to control increased ICP. Incisional and headache pain may be controlled with mild analgesic (codeine and acetaminophen) or low dose opioids (morphine sulfate or fentanyl/Duragesic), as prescribed. Monitor response to medications. Position head of bed at 15 to 30 degrees, or per clinical status of client, to promote venous drainage. Determining appropriate position of head of bed is client-dependent and should be adjusted based on observed changes in the client's clinical response and ICP to positioning. A decrease in CPP is observed with raising the head of the bed to lower ICP. Turn side-to-side every 2 hours; positioning restrictions will be ordered by the physician. CT scan of the brain is performed if client's status deteriorates. Oral fluids are provided after swallow reflex and bowel sounds have returned. Intake and output are monitored. Speech therapy may be ordered for bedside swallow study or radiographic swallow study. Signs of infection are monitored by checking craniotomy site, ventricular drainage, nuchal rigidity, or presence of CSF (fluid collection at surgical site). Periorbital edema is controlled by such measures as elevation of head of bed and cold compresses. Removal of surgical dressing and increase in activity will assist in the resolution of periorbital edema. Complications of surgery Intracranial hemorrhage/hematoma Cerebral edema Infections (e.g., postoperative meningitis, pulmonary, wound) Seizures

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Cranial nerve dysfunction Decreased CPP causing cerebral ischemia Nursing Diagnoses of Client Undergoing Surgery Ineffective tissue perfusion (cerebral) related to increased ICP Risk for aspiration related to decreased swallow reflex and postoperative positioning Risk for infection related to invasive procedure Acute pain related to physiologic changes produced due to invasive procedure Constipation related to use of opioid medication and immobility Nursing Interventions

-Maintain ICP within normal range Closely monitor LOC, vital signs, papillary response, and ICP, if indicated. Notify health care provider if ICP greater than 20 mm Hg or CCP less than 70 mm Hg. Teach client to avoid activities that can raise ICP, such as excessive flexion or rotation of the head and Valsalva maneuver (coughing, straining with defecation). Administer medications as prescribed to reduce ICP. Eliminate noxious tactile stimuli, such as suctioning, prolonged physical assessment, turning, and providing ROM exercises (based on client response).  Prevent aspiration Offer fluids only when client is alert and swallow reflex has returned. Have suction equipment available at bedside. Suction only if indicated. Pre-treatwith sedation or endotracheal lidocaine to prevent elevation of ICP. Elevate head of bed to maximum of order, or per clinical status, and client comfort.  Prevent nosocomial infections Use sterile technique for dressing changes, catheter care, and ventricular drain management. Be aware of clients at higher risk of infection —those undergoing lengthy operations, those with ventricular drains left in longer than 72 hours, and those with operations of the third ventricle. Assess surgical site for redness, tenderness, and drainage. Watch for leakage of CSF, which increases the danger of meningitis.  Watch for sudden discharge of fluid from wound; a large leak usually requires surgical repair.  Warn against coughing, sneezing, or nose blowing, which may aggravate CSF leakage.  Assess for moderate elevation of temperature and neck rigidity.  Note patency of ventricular catheter system. Institute measures to prevent respiratory infection or UTI postoperatively.  Relieve pain Medicate client as prescribed and according to assessment findings. Elevate head of bed per protocol to relieve headache. Provide distractive measures for pain management. Darken room if client is photophobic.  Avoid constipation Encourage fluids when client is able to manage liquids. Ambulate as soon as possible. Change to non-opioid agents for pain control as soon as possible .Avoid Valsalva-like maneuvers. Use stool softeners and laxatives, as ordered.  Educate and support family/support system Keep client and family aware of progress and plans to transfer to step-down unit, general nursing unit, subacute care, or rehabilitation facility. Encourage frequent visiting and interaction of family for stimulation of client as care allows. Begin discharge planning early, and obtain referral for home care nursing, social work, physical and occupational therapy as needed.  Expected Outcomes  Decreased ICP and CPP maintained greater than 70 mm Hg  Gag reflex present; breath sounds clear  Afebrile without signs of infection  Verbalization of decreased pain Passed soft stool  Discharge Planning  Be sure the client understands all medications, including the dosage, route, action, adverse effects, and the need for routine laboratory monitoring.

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restlessness Tachycardia. The result of inadequate cardiac output (CO) is poor organ perfusion and vascular congestion in the pulmonary or systemic circulation. CHD leading to MI. alcohol consumption and/or use of cardiotoxic drugs. dyspnea on exertion. transfusions or infusions. paroxysmal nocturnal dyspnea (due to re absorption of dependent edema that has developed during day). CAD. physical and emotional stress.and right-sided heart failure is common. there may be isolated left-sided heart failure. and heart enlargement) occur to assist the struggling heart. arteriovenous fistula). pregnancy. catabolic effect of chronic failure Insomnia. hemorrhage and anemia. Caused by disorders of heart muscle resulting in decreased contractile properties of the heart. Heart failure is a clinical syndrome that results from the progressive process of remodeling. smoking. sodium and water retention. nocturia. and function of the ventricle's ability to pump enough oxygenated blood to meet the metabolic demands of the body. Other causes include pulmonary embolism.  Teach the client and caregiver the signs and symptoms that necessitate a return to the hospital. orthopnea. Cardiac Failure Definition Heart failure (HF) occurs when the heart is unable to pump sufficient blood to meet the metabolic needs of the body. The compensatory mechanisms may hasten the onset of failure because they increase afterload and cardiac work. chronic lung disease. infection) may cause these mechanisms to fail and precipitate the clinical syndrome• associated with a failing heart (elevated ventricular/atrial pressures. hyperlipidemia. unproductive. or. valvular heart disease. diabetes. excessive sodium intake. decreased CO. increased body demands (fever. family history. Left-Sided Heart Failure (Forward Failure)                    Congestion occurs mainly in the lungs from blood backing up into pulmonary veins and capillaries Shortness of breath. in which mechanical and biochemical forces alter the size. dysrhythmias. Clinical Manifestations Initially. infection. but eventually the right ventricle fails because of the additional workload. Stress the importance of follow-up visits to the physician‘s office. dyspnea. congenital heart disease. shape. cardiomyopathies. insomnia. drug-induced. circulatory and pulmonary congestion). These mechanisms are able to compensate• for the heart's inability to pump effectively and maintain sufficient blood flow to organs and tissue at rest. anesthesia and surgery. Combined left. vasoconstriction. Pathophysiology Cardiac compensatory mechanisms (increases in heart rate. pulmonary edema Cough may be dry. Risk factors include hypertension. hypertension. S3 ventricular gallo Right-Sided Heart Failure (Backward Failure) Signs and symptoms of elevated pressures and congestion in systemic veins and capillaries: 153 | P a g e . usually occurs at night Fatigability from low CO. Physiologic stressors that increase the workload of the heart (exercise.

5 kg] of fluid) Liver congestion may produce upper abdominal pain Distended jugular veins Abnormal fluid in body cavities (pleural space – pleural effusion. Radionuclide ventriculogram              Principles of Management Pharmacotherapy Diuretics Eliminate excess body water and decrease ventricular pressures. By relaxing capacitance vessels (veins and venules). abdominal cavity [ascites]) Anorexia and nausea from hepatic and visceral engorgement Nocturia diuresis occurs at night with rest and improved CO Weakness Cardiovascular Findings in Both Types Cardiomegaly (enlargement of the heart) – detected by physical examination and chest Xray Ventricular gallop – S3 evident on auscultation Rapid heart rate Development of pulsus alternans (alternation in strength of beat) Assessment Echocardiography two-dimensional with Doppler flow studies may show ventricular hypertrophy. This test aids in the diagnosis of heart failure. Digoxin (Lanoxin) may only be effective in severe cases of failure Dopamine (Intropin) improves renal blood flow in low dose range Dobutamine (Dobutrex) Milrinone (Primacor) and amrinone (Inocor) are potent vasodilators Vasodilator therapy decreases the workload of the heart by dilating peripheral vessels. A level greater than 100/ml is diagnostic for heart failure. dilation of chambers. such as nitroglycerin (Tridil). vasodilators can reduce impedance to left ventricular ejection and improve stroke volume. BNP is used in emergency department to quickly diagnose and start treatment. isosorbide (Isordil).                        Edema of ankles. Positive inotropic agents increase the heart's ability to pump more effectively by improving the contractile force of the muscle. the higher the BNP. pleural effusion. A low-sodium diet and fluid restriction complement this therapy. reduces arteriolar tone 154 | P a g e . By relaxing resistance vessels (arterioles). unexplained weight gain (pitting edema is obvious only after retention of at least 10 lb [4. triage BNP. Nterminal probrain NP. nitroglycerin ointment (NitroBid) predominantly dilate systemic veins Hydralazine (Apresoline) predominantly affects arterioles. Nitrates. In addition. the more severe the heart failure. vasodilators reduce ventricular filling pressures (preload) and volumes. cardiac cells produce and released more BNP. Some diuretics may have slight venodilator properties. and abnormal wall motion ECG (resting and exercise) may show ventricular hypertrophy and ischemia Chest X-ray may show cardiomegaly. or proBNP) As volume and pressure in the cardiac chambers rise. and vascular congestion Cardiac catheterization to rule out CAD ABG studies may show hypoxemia due to pulmonary vascular congestion Liver function studies may be altered because of hepatic congestion Human B-type natriuretic peptide (BNP.

Captopril (Capoten) and enalapril (Vasotec) are commonly used. and buttocks and inflated in rhythm with the client's ECG. The balloon catheter is attached to an external console. Aldosterone antagonists decrease sodium retention. Spironolactone (Aldactone) is most commonly used. It produces smooth muscle cell relaxation. Used in clients who cannot tolerate ACE inhibitors due to cough or angioedema. A balloon catheter is introduced into the femoral artery percutaneously or surgically. thereby reducing the workload of the heart and increasing CO. counterpulsation devices pump while the heart muscle relaxes (diastole) and relax when the heart muscle contracts (systole). Enhanced external counterpulsation pneumatic cuffs are wrapped around the calves. which increases blood flow through the coronary arteries. the external console integrates the inflation and deflation sequence with the mechanical events of the cardiac cycle (systole-diastole) by triggering• gas delivery in synchronization with the client's ECG and timing• the duration of inflation and point of deflation in conjunction with the client's arterial pressure waveform. and a reduction in afterload. Decreases left ventricular afterload with a subsequent decrease in heart rate associated with heart failure. Beta-adrenergic blockers decrease myocardial workload and protect against fatal dysrhythmias by blocking norepinephrine effects of the sympathetic nervous system. Eases the workload of a damaged heart by increasing coronary blood flow and decreasing the resistance in the arterial vessels against which the heart must pump (reduces the afterload) This results in an increase in CO and a reduction in myocardial oxygen demand. The cuffs push venous blood back to the heart during diastole and decrease afterload. Metoprolol (Lopressor) or metoprolol CR or XL (Toprol XL) are commonly used. The balloon is inflated at the onset of diastole. Diet Therapy: Restricted sodium and restricted fluids  Mechanical Circulatory Support / Surgical Management   Intra-aortic balloon pump counterpulsation Counterpulsation is a method of assisting the failing heart and circulation by mechanical support when the myocardium is unable to generate adequate CO. The mechanism of counterpulsation therapy is opposite to the normal pumping action of the heart.to 3-week period while they adjust to the medication.            Prazosin (Minipress) balanced effects on both arterial and venous circulation Sodium nitroprusside (Nipride) predominantly affects arterioles Morphine (Duramorph) decreases venous return. May decrease remodeling of the ventricle. Angiotensin II-receptor blockers (ARBs) similar to ACE inhibitors. Clients may actually experience increase in general malaise for a 2.and alpha-adrenergic blocker. allowing for inflation and deflation of the balloon with gas such as carbon dioxide. and positioned distal to the subclavian artery. this results in an increase in diastolic pressure (diastolic augmentation). Human B-type natriuretic peptide (Nesiritide) used in clients with decompensated heart failure. threaded to the descending thoracic aorta. diuresis. Carvedilol (Coreg) is a nonselective beta. decreases pain and anxiety and thus cardiac work Angiotensin-converting enzyme (ACE) inhibitors inhibit the adverse effects of angiotensin II (potent vasoconstriction/sodium retention). thighs. The balloon is deflated just before the onset of systole. facilitating the emptying of blood from the left ventricle. sympathetic nervous system activation and cardiac remodeling.       155 | P a g e .

Assess weight and ask about baseline weight. it decreases or halts remodeling. Obtain hemodynamic measurements as indicated and note change from baseline. Identify sleep patterns and sleep aids commonly used by client. response to rest. improves hemodynamics. it's more likelyyou'll develop blood clots. The mechanism of action is unknown. which makes it more difficult for your liver to function properly. can become damaged from the blood and fluid buildup from heart failure. which can increase your risk of having a heart attack or stroke. and improves CO. Unlike a total artificial heart. which keep blood flowing in the proper direction through your heart. thus providing a more normal shape and size of the heart. Acorn cardiac support device a polyester mesh. which can eventually cause kidney failure if left untreated. is a mechanical pump that is implanted inside a person's chest to help a weakened heart ventricle pump blood throughout the body. Nursing Process       Assessment Obtain history of symptoms.Cardiac resynchronization therapy or biventricular pacing helps to restore synchronous ventricular contractions.         Continuous positive airway pressure decreases sleep apnea (which worsens heart failure). assess edema. Heart transplant is a procedure that removes a damaged or diseased heart and replaces it with a healthy one. It just helps it do its job.  Heart valve problems  The valves of your heart.  Complications  Kidney damage or failure  Heart failure can reduce the blood flow to your kidneys. providing diastolic support. or LVAD. Endoventricular circular patch-plasty or the Dorprocedure removal of diseased portion of septum or left ventricle with a synthetic or autologous tissue patch. Left ventricular assist device (LVAD) The left ventricular assist device. Nursing Diagnosis 156 | P a g e . slows ventricular remodeling.  Liver damage  Heart failure can lead to a buildup of fluid that puts too much pressure on the liver. which improves hemodynamics. Kidney damage from heart failure can require dialysis for treatment. custom-fitted jacket is surgically placed on the epicardial surface.  Heart attack and stroke  Because blood flow through the heart is slower in heart failure than in a normal heart. This procedure is not commonly used. improves ventricular left ventricle filling. Over time. andreduces ventricular irritability. Partial left ventriculectomy (reduction ventriculoplasty or Batista procedure) a triangular section of the weakened heart muscle is removed to reduce ventricular wall tension. Assess peripheral arterial pulses. and history of response to drug therapy. assess heart rhythm and rate and BP. the LVAD doesn't replace the heart. limits of activity. Note results of serum electrolyte levels and other laboratory tests. note quality. The healthy heart comes from a donor who has died. This fluid backup can lead to scarring. It is the last resort for people with heart failure when all other treatments have failed. character. Inspect and palpate precordium for lateral displacement of PMI.

       Decreased cardiac output related to impaired contractility and increased preload and afterload Impaired gas exchange related to alveolar edema due to elevated ventricular pressures Excess fluid volume related to sodium and water retention Activity intolerance related to oxygen supply and demand imbalance Nursing Interventions Maintain adequate cardiac output Place client at physical and emotional rest to reduce work of heart. Observe for lowering of systolic pressure. reduces BP. Improve oxygenation Raise head of bed 8 to 10 inches (20 to 30 cm) reduces venous return to heart and lungs. Be alert and watch for sudden unexpected hypotension. Provide bedside commode to reduce work of getting to bathroom and for defecation. elevates arterial pressure. and speeds the heart. and poor capillary refill of nail beds. Monitor clinical response of client with respect to relief of symptoms (lessening dyspnea and orthopnea. Promote physical comfort. Administer oxygen as directed. Note narrowing of pulse pressure. Restore fluid balance                              157 | P a g e . Mark. Auscultate heart sounds frequently and monitorcardiac rhythm. Provide for psychological rest emotional stress produces vasoconstriction. Offer careful explanations and answers to the client's questions. frequent feedings to avoid excessive gastric filling and abdominal distention with subsequent elevation of diaphragm that causes decrease in lung capacity. with ink that does not easily rub off. Administer pharmacotherapy as directed. relief of peripheral edema). Observe for signs and symptoms of reduced peripheral tissue perfusion: cool temperature o fskin. Evaluate frequently for progression of left-sided heart failure. facial pallor. Encourage deep-breathing exercises every 1 to 2 hours to avoid atelectasis. Observe for Cheyne-Stokes respirations (may occur in elderly clients because of a decrease in cerebral perfusion stimulating a neurogenic response). increases heart reserve. Avoid situations that tend to promote anxiety and agitation. Position the client every 2 hours (or encourage the client to change position frequently) to help prevent atelectasis and pneumonia. which can cause myocardial ischemia and decrease perfusion to vital organs. recumbence promotes diuresis by improving renal perfusion. Sit orthopneic client on side of bed with feet supported by a chair. Take frequent BP readings. alleviates pulmonary congestion. Monitor for premature ventricular beats. Offer small. the level on the client's back where adventitious breath sounds are heard. head and arms resting on an over-the-bed table. Auscultate lung fields at least every 4 hours for crackles and wheezes in dependent lung fields (fluid accumulates in areas affected by gravity). Support lower arms with pillows to eliminate pull of their weight on shoulder muscles. Provide rest in semi-recumbent position or in armchair in air-conditioned environment reduces work of heart. and lumbosacral area supported with pillows. Note presence of S3 or S4 gallop (S3 gallop is asignificant indicator of heart failure). decrease in crackles. Note alternating strong and weak pulsations(pulsus alternans). improves efficiency of heart contraction. decreases work of respiratory muscles and oxygen utilization. Use markings for comparative assessment over time and among different care Observe for increased rate of respirations (could be indicative of falling arterial pH).

Alter or modify client's activities to keep within the limits of his cardiac reserve. Monitor client's diet. Client education and health maintenance Explain the disease process to the client. which may cause weakening of cardiac contractions and may precipitate digoxin toxicity in the form of dysrhythmias. Improve activity tolerance Increase client's activities gradually. weigh at same time daily to 158 | P a g e . Observe for the complications of bed rest pressure ulcers (especially in edematous clients). Explain the pumping action of the heart to move blood through the body to provide nutrients and aid in the removal of waste material. Administer I. Keep input and output record client may lose large volume of fluid after a single dose of diuretic. Be aware of disorders that may be worsened by diuretic therapy including hyperuricemia. or eliminate edema.0 kg) per day. Explain the difference between heart attack and heart failure.V. muscle weakness and cramps. may also be limited in calories. Document time lapse and revise client care plan as appropriate (progressive increase Relieve nighttime anxiety and provide for rest and sleep clients with heart failure have a tendency to be restless at night because of cerebral hypoxia with superimposed nitrogen retention. control. Observe the pulse. Teach the signs and symptoms of recurrence Watch for: Gain in weight report weight gain of more than 2 to 3 lb (0. vomiting. Be alert to complaints of chest pain or skeletal pain during or after activities. Note time lapse between cessation of activity and decrease in heart rate (decreased stroke volume causes immediate rise in heart rate). Use convoluted foam mattress and sheepskin to prevent pressure ulcers (poor blood flow and edema increase susceptibility). weak. confusion. decreased urine output. Assist client with self-care activities early in the day (fatigue sets in as day progresses). abdominal distention.4 kg) in a few days. magnesium depletion. nausea. phlebothrombosis. fluids carefully through an intermittent access device to prevent fluid overload. and behavioural response to increased activity. Watch for signs of bladder distention in elderly male clients with prostatic hyperplasia.9 to 1. paralytic ileus. Diet may be limited in sodium to prevent. nausea.5 to 1. Allow heart rate to decrease to preactivity level before initiating a new activity. Caution clients to avoid added salt in food and foods with high sodium content. gout. Give diuretic early in the morning nighttime diuresis disturbs sleep. orthostatic hypotension. and abdominal distention (may indicate hepatic and visceral engorgement). note that some clients allergic to sulfa drugs may also be allergic to thiazide diuretics. and/or pulmonary embolism. poor appetite. and increased urine specific gravity.                             Administer prescribed diuretic as ordered. Give potassium supplements as prescribed. symptoms. anorexia. hyperglycemia. thready pulse. paresthesias. Weigh client daily to determine if edema is being controlled: weight loss should not exceed 1 to 2 lb (0. Monitor client's heart rate during self-care activities. and diabetes mellitus. Monitor for pitting edema of lower extremities and sacral area. volume depletion. increased serum osmolarity. Also. Assess for signs of hypovolemia caused by diuretic therapy thirst. Be alert to complaints of right upper quadrant abdominal pain. Give appropriate sedation to relieve insomnia and restlessness. Be alert for signs of hypokalemia. the term failure may have terrifying implications. hyponatremia.

herbs. adverse effects. If the client is taking oral potassium solution. pain relievers.  Restrict sodium as directed. loss of appetite Frequent urination at night Review medication regimen. and so forth). and lemon juice. rests between activities  Discharge Planning        Prevention To prevent exacerbations.  Give client a written diet plan with lists of permitted and restricted foods.  Advice client to look at all labels to ascertain sodium content (antacids. Inform the client of adverse drug effects. including effect. humid environment. and other drugs.5 L per day and restrict sodium intake as prescribed. cough remedies. Teach the client to monitor daily weights and report weight gain of more than 4 pounds in 2 days. which increase the work of the heart. ABG levels within normal limits. some of these contain large amounts of sodium. 159 | P a g e . Tell the client to restrict fluid intake to 2 to 2. cough remedies. Weight decrease of 2. continue at whatever activity level can be maintained without the appearance of symptoms. Ask whether client is taking Coenzyme Q10 or other supplements. and the need for routine laboratory monitoring for drugs such as digoxin. provided they do not cause fatigue and dyspnea. Be sure the client and family understand all medications.  Outcome Criteria    Normal BP and heart rate Respiratory rate 16 to 20.it may be diluted with juice and taken after a meal. Make sure the client has a check-off system that will show that he has taken medications.  Avoid salt substitutes with renal disease.  Teach the client that sodium is present in alkalizers.  Avoid excesses in eating and drinking. Label all medications. Teach the client to take and record pulse rate and BP. In general. teach the client and family to monitor for an increase in shortness of breath or edema. laxatives.  Teach the client to rinse the mouth well after using tooth cleansers and mouthwashes. air conditioning may be essential in a hot.  Review activity program. Water softeners should be checked for salt content. Undertake a weight reduction program until optimal weight is reached. spices.  Encourage use of flavorings. estrogens.  Teach restricted sodium diet and the DASH (dietary approaches to stop hypertension) diet. Give written instructions. laxatives. Instruct the client as follows:  Increase walking and other activities gradually. should discuss with health care provider. feet. Tell the client to weigh self daily and log weight if on diuretic therapy. dosage. no pitting edema of lower extremities and sacral area Heart rate within normal limits.2 lb (1 kg) daily.  Avoid extremes in heat and cold. detect any tendency toward fluid retention Swelling of ankles. route. or abdomen Persistent cough Tiredness.  Keep regular appointment with health care provider or clinic. Complications of heart failure Tell the client to call for emergency assistance for acute shortness of breath or chest discomfort that is not alleviated with rest.

Encourage the client to have hope in the therapy employed while maintaining a realistic perspective about the disease and ultimate outcome. Monitor and document symptoms that may indicate metastasis: lung. bone. Nursing care should be based on the client‘s symptoms. and liver. Offer information about support groups and contact people. and arrange for palliative hospice care if appropriate. ment. Provide time for the client to express fears and concerns. Evaluation  Expected client outcomes may include the following: (The client…)  Experiences relief of pain and discomfort Is less anxious  Demonstrates understanding of the means for detecting and preventing melanoma Experiences absence of complications CANCERS of the RESPIRATORY SYSTEM 160 | P a g e .

combined effects of alcohol and tobacco. familial predisposition. and most commonly in persons 50 to 70 years of age. supraglottic area (area above the glottis or vocal cords including epiglottis and false cords). raspy. tar products. and lower in pitch 161 | P a g e . asbestos. weakened immune system A malignant growth may occur in three different areas of the larynx: the glottis area (vocal cords). Glottis tumors seldom spread if found early due to the limited lymph vessels found in the vocal cords. wood dust. mustard gas. gender (more common in men).Cancer of the Larynx Cancer of the larynx is a malignant tumor in the larynx. leather and metals Other factors – straining the voice. paint fumes. history of alcohol abuse. race (more prevalent in African Americans). cement dust. second-hand smoke. chronic laryngitis. chemical. Clinical Manifestations o Hoarseness of more than 2 weeks‘ duration (tumor impedes the action of the vocal cords during speech) o Voice may sound harsh. smokeless). Risk factors for laryngeal cancer are: Carcinogens – tobacco (smoke. nutritional deficiencies (riboflavin). It is potentially curable if detected early Occurs four times more frequently in men than in women. and subglottic (area below the glottis or vocal cords to the cricoids). age (higher than incidence after 60 years of age).

chemotherapy. including the grade and depth of infiltration.  Treatment options include surgery.  Palpate the lymph nodes of the neck and thyroid gland to determine spread of malignancy. and foul breath Cervical lymph adenopathy.  CT scan and MRI are used to assess regional adenopathy and soft tissue. persistent hoarseness. and underlying medical conditions in the assessment. and false cords are removed.  Treatment plan depends on whether this is an initial diagnosis or recurrence. cricoid cartilages. other tissue. and pain radiating to the ear may occur with metastasis Assessment and Diagnostic Findings  Initial assessment includes a complete history and physical examination of the head and neck. and pathologic features of the tumor. is initially performed to visually evaluate the pharynx. the growth may affect muscle. unilateral nasal obstruction or discharge. glottis. true vocal cords. may also be used in conjunction with either radiation therapy to avoid a total laryngectomy or preoperative to shrink a tumor before surgery.o o o o o Complains of cough or sore throat that does not go away Pain and burning in the throat especially when consuming hot liquids or citrus juices A lump may be felt in the neck Later symptoms include dysphagia. along with one vocal cord and the tumor. Associated with a very high cure rate. larynx. family history.  Chemotherapy traditionally has been used for recurrence or metastatic disease. which includes the location. size. Airway of the client remains intact and no difficulty in swallowing is expected.  Samples of tissue are obtained for histologic evaluation.  Direct laryngoscopic examination is performed when a tumor is suspected on initial examination. Prognosis depends on the tumor stage. may also be performed for a recurrence when a high-dose radiation has failed A portion of the larynx is removed. or even the airway. the client‘s gender and age. unplanned weight loss. and radiation.  Assess the mobility of vocal cords. and possible tumor. using a flexible endoscope. and help stage and determine the extent of the tumor. if normal movement is limited. include risk factors. Medical Management  Treatment depends on the staging of the tumor. and trachea remain intact. PET scan may also be used to detect recurrence of laryngeal tumorafter treatment. Surgical Management Partial laryngectomy (laryngofissure thyrotomy) Recommended in the early stages of cancer in the glottis area when only one vocal cord is involved. A radical neck dissection is performed during surgery. persistent ulceration.  Indirect laryngoscopy. voice quality may change or the client may be hoarse Supraglottic laryngectomy Indicated in the management of early stage (stage I) supraglottic and stage II lesions Hyoid bone.  Surgery and radiation therapy are both effective methods in the early stages of cancer of the larynx. dyspnea. and histology of the tumor and the presence and the extent of cervical lymph node involvement. A tracheostomy tube is left 162 | P a g e . a general debilitated state. all other structures remain.

May also be used preoperatively to reduce the tumor size. symptoms include acute mucositis. Combine with chemotherapy. usually removed after a few days and the stoma is allowed to close. wound infection from the development of a pharyngocutaneous fistula. and the client‘s overall health status. combined with surgery in advanced (stages II and IV) laryngeal cancer as adjunctive therapy to surgery or chemotherapy. the client will have no voice but will have normal swallowing. loss of taste. The staging of the tumor (usually used for stage I and II tumors as a standard treatment option). total laryngectomy requires a permanent tracheal stoma because the larynx that provides the sphincter is no longer present Postoperatively. airway and swallowing remain intact Total laryngectomy Performed in the most advance stage IV laryngeal cancer. or for recurrent or persistent cancer following radiation therapy Laryngeal structures are removed. and dysphagia secondary to pharyngeal and cervical esophageal stricture Radiation Therapy The goal is to eradicate the cancer and preserve the function of the larynx. and trachea are preserved This procedure will result in permanent loss of the voice and a change in the airway. arytenoids cartilage and half of the thyroid are removed. voice may be rough. pain. may be used in stage I glottis lesions. and fibrosis. lifestyle. Later complications may include laryngeal necrosis. speech therapy is required before and after surgery Major disadvantage is the high risk for recurrence of cancer Hemilaryngectomy Performed when the tumor extends beyond the vocal cord but is less than 1 cm in size and is limited to the subglottic area. which may also include the parotid gland responsible for mucus production. A benefit of this therapy is that clients retain a near-normal voice. Complications include a salivary leak. though the quality of voice may change. and two or three rings of the trachea. a small number may later require laryngectomy. Thyroid cartilage of the larynx is split in the midline of the neck and the portion of the vocal cord (one true cord and one false cord) is removed with the tumor. ulceration of the mucous membranes. Client will have a tracheostomy tube and nasogastric tube in place for 10 to 14 days following surgery. xerostomia. epiglottis. fatigue. radiation therapy may be an alternative to total laryngectomy. raspy. the client may experience some difficulty swallowing for the first 2 weeks. client needs the ability to compress air into the esophagus and expel it. and as a palliative measure. edema. dysphagia. client is at risk for aspiration postoperatively Some changes may occur with voice quality. stomal stenosis. pharyngeal walls. and hoarse and have limited projection. Postoperatively. when tumor extends beyond the vocal cords. then the technique is practice repeatedly 163 | P a g e . Complications may be a result if external radiation to the head and neck area.in the trachea until the glottis airway is established. aspiration is a potential complication. nutrition is provided through a nasogastric tube until there is healing followed by a semisolid diet. setting off a vibration of the pharyngeal esophageal segment This technique can be taught once the client begins oral feedings (a week after surgery): 1) The client learns to belch and is reminded to do so an hour after eating. including the hyoid bone. and personal preference are factors considered in making the treatment decision. and skin reactions. A few may develop chondritis or stenosis. cricoids cartilage. An advantage of this procedure is that it preserves the voice. Speech Therapy  Esophageal speech Primary method of a laryngeal speech. tongue.

dysphagia. or until the client masters the technique This is a battery-powered apparatus that projects sound into the oral cavity. Assess the client‘s ability to hear. or pain and burning in the throat. Nursing Diagnosis  Deficient knowledge about the surgical procedure and the postoperative course  Deficient knowledge about the surgical procedure and postoperative course  Anxiety and depression related to the diagnosis of cancer and impending surgery  Ineffective airway clearance related to excess mucus production secondary to surgical alterations in the airway  Impaired verbal communication related to anatomic deficit secondary to removal of the larynx and to edema  Imbalanced nutrition: less than body requirements. the sounds from the electric larynx becomes audible words. dyspnea. weakness.2) The conscious belching action is transformed into simple explosions of air from the esophagus for speech purpose 3) The speech therapist works with the client in an attempt to make speech intelligible and as close as normal as possible Electric larynx An electric larynx may be used if esophageal speech is unsuccessful. Answer client‘s question about the nature of the 164 | P a g e . A speech therapist teaches the client how to produce sounds. fatigue. voice prosthesis is fitted over the puncture site. A valve is placed in the tracheal stoma to divert air into the esophagus and out of the mouth. musculoskeletal impairment related to surgical procedure and postoperative course Nursing Interventions Teach the client preoperatively o Provide information materials about the surgery to the client and family for review and reinforcement. Voice produced sounds mechanical and some words may be difficult to distinguish. and write. when the mouth forms the words. a preoperative evaluation of the speech therapist is indicated. hemorrhage. tracheal edema). the prosthesis is removed and cleaned when mucus builds up. Tracheoesophageal puncture Most widely used technique because the speech associated with it resembles normal speech (sound produced is a combination of esophageal speech and voice). once the puncture is surgically created and has healed. infection. and it is easily learned. airway obstruction. see. Potential complications that may develop include respiratory distress (hypoxia. sore throat. Palpate the neck for swelling. related to inability to ingest food secondary to swallowing difficulties  Disturbed body image and low self-esteem secondary to major neck surgery. Determine the psychological readiness and evaluate the coping methods of the client and family. To prevent airway obstruction. read. If treatment includes surgery and the client is expected to have no voice postoperatively. moving the tongue and lips form the sound into words produces speech  Nursing Care of the Client Undergoing Laryngectomy Assessment Assess the client for hoarseness. change in the structure and function of the larynx  Self-care deficit related to pain. an advantage is that the client is able tocommunicate with relative ease while working to become proficient with other techniques. and wound breakdown.

teach coughing and deep-breathing exercises. and crusting around the stoma. and report the occurrence to the physician. Promote alternative communication methods o Establish and consistently use alternative modes of communication such as a call bell. Rule out obstructions by suctioning and having the client cough and deep breath. measure. Suction as necessary.o o o o o o o o o o o o surgery. cough. a Magic Stale. labored breathing. Reassure the client that frequent coughing episodes will diminish in time as the tracheobronchial mucosa adapts to the altered physiology. o Promote positive body image and self-esteem o Encourage the client to express any feelings brought about by the surgery. and deep breath. Instruct the client to avoid sweet foods. and discuss perceptions about the treatment. and increased pulse rate to identify possible respiratory or circulatory problems.and postoperative period. verbalize feelings. the loss of the natural voice. Allow visits for the client during the pre. Teach the client how to clean and change the laryngectomy tube and how to remove secretions. Instruct the client to rinse mouth with warm water or mouthwash and to brush the teeth frequently. o Collaborate with the speech therapist and encourage the client and family to use alternative communication methods. Observe for restlessness. Maintain a patent airway . 165 | P a g e . mucus production. pictureword. apprehension. which increases salivation and suppresses appetite. Care for the laryngectomy tube. remove the crusts with sterile tweezers and apply additional ointment. o Observe the client for any difficulty swallowing. Apply none—oil-based antibiotic ointment around the stoma and suture line. Monitor and manage potential complications o Monitor the client for signs and symptoms of respiratory distress and hypoxia. Observe. Encourage and assist the client with early ambulation to prevent atelectasis and pneumonia. to remove secretions. Promote adequate nutrition o Thick liquids will be used first for feedings once the client is ready to start oral feedings. clean the stoma daily with saline solution. o Have a positive approach when caring for the client by promoting self-care activities. Provide adequate humidification to decrease cough.phrase board. and the special training that can provide a means of communicating. notepad and pen. Encourage the client to turn. o Introduce solid foods as tolerated. and record drainage from wound drains and suction. Wipe clean and clear mucus from the tracheostomy opening. If crusting appears around the stoma. Review equipment and treatments for postoperative care with client and family. or hand signals. particularly when eating resumes. Reduce anxiety and depression Provide the client and the family to ask questions. and clarify the client‘s roles in the postoperative and rehabilitation periods.Position the client in the semi-Fowler‘s or Fowler‘s position after recovery from anesthesia.

As the damage DNA is passed on daughter‘s cells. o Instruct the client to avoid strenuous exercise and fatigue because when tired. o Encourage the client to wear a medical identification to alert medical personnel for special requirements for resuscitation should the need arise. If wound breakdown occurs. A carcinogen binds to a cell‘s DNA and damages it. the client must be monitored carefully and identified as being high risk for carotid hemorrhage. The damage results in cellular changes. Teach clients self-care o Provide specific instructions to the client and family about the tracheostomy and its management. and report significant changes to the surgeon. and rapid deep breathing. and pale skin are signs of active bleeding. it presents more peripherally as peripheral masses or nodules and often metastasizes. and bleeding. hematoma. he or she will have more difficulty speaking. decreased blood pressure. Squamous cell carcinoma is more centrally located and arises more commonly in the segmental and subsegmental bronchi in response to repetitive carcinogenic exposures. 166 | P a g e . Lung Cancer (Bronchogenic Carcinoma) Pathophysiology Lung cancers arise from a single transformed epithelial cell in the tracheobronchial airways. abnormal cell growth. If rupture to the carotid artery is the cause of bleeding.o o o o o Notify the surgeon for any active bleeding at the surgical site. and eventually a malignant cell. Observe for signs of postoperative infection and report any significant changes to the surgeon. o Teach the client and family about special precautions needed in the shower to prevent water from entering the stoma. Monitor for vital signs changes: increased pulse rate. Observe the stoma area for wound breakdown. the pulmonary epithelium undergoes malignant transformation from normal epithelium to eventual invasive carcinoma. With the accumulation of genetic changes. and provide emotional support to the client until the veins are ligated. Explain the importance of humidification and instruct the family to set up a humidification system before the client returns home. apply direct pressure over the artery. Adenocarcinoma is the most prevalent carcinoma of the lung for both men and women. Instruct and encourage the client to perform oral hygiene regularly to prevent halitosis and infection. call for assistance. cold. clammy. Bronchioalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing as compared to other bronchogenic carcinoma. Large cell carcinoma (undifferentiated carcinoma) is a fast growing tumor that tends to arise peripherally. the DNA undergoes further changes and becomes unstable. o Teach the client and family to perform suctioning and emergency measures and tracheostomy and stoma care. o Remind the client that swimming is not recommended.

dysphagia. bone. cancer of the lung is suspected. and biopsies. cough starts as a dry. the degree of obstruction. contralateral lung.  A transthoracic fine-needle aspiration may be performed under CT or fluoroscopic guidance to aspirate cells from a suspicious area.  Sputum cytology is rarely used to make a diagnosis. ABG analysis. PET scans. without sputum production. and liver o Weakness. pulmonary insufficiency. Contraindications to this intervention are coronary artery disease. the cough may be productive due to infection o Wheezing.  CT scans of the chest are used to identify small nodules and to examine areas of the thoracic cage. brain. persistent cough.  Chest x-ray is performed to search for pulmonary density. head and neck edema. atelectasis.Small cell carcinomas arise primarily as a proximal lesions or lesions but may arise in part of the tracheobronchial tree. Risk factors associated with the development of lung cancer include tobacco smoke. abdominal scans.  Esophageal ultrasound (EUS) may be used to obtain a transesophageal biopsy of enlarged subcarinal lymph nodes. washings. dyspnea. and adequate cardiopulmonary function. hoarseness. hemoptysis or blood-tinged sputum. second-hand (passive) smoke. when obstruction of airways occurs. Surgical Management Surgical resection is the preferred method for treating clients with localized non-small cell tumors. Clinical Manifestations o Develops insidiously and is asymptomatic until late in its course o Signs and symptoms depend on the location and size of the tumor. environmental and occupational exposures. gender.  If surgery is a potential treatment.  Fiberoptic bronchoscopy is more commonly used and provides a detailed study of the tracheobronchial tree and allows for brushings. recurring fever. and exercise testing may be used as part of preoperative assessment. and infection. anorexia and weight loss though nonspecific may also be diagnostic Assessment and Diagnostic Findings  If pulmonary symptoms occur in a heavy smoker. and dietary deficits. symptoms or pleural or pericardial effusion are present if the tumor spreads to adjacent structures and lymph nodes o Most common sites for metastases are lymph nodes. Several types of lung resections may be performed:  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 167 | P a g e . chest or shoulder pain are also manifestations o Chest pain and tightness. adrenal glands. and the existence of metastases to regional or distant sites o Most frequent symptom is cough or change in a chronic cough. and other comorbidities. ventilation-perfusion scans. genetics. no evidence of metastatic spread. a solitary peripheral nodule (coin lesion).  Bone scans. or liver ultrasound or scans can be used to assess for metastasis. pulmonary function tests.

Teach client and family about strategies to manage symptoms of dyspnea. alkylating agents. Support the client and family in making decisions reading the possible treatment options.Chest wall resection with removal of cancerous lung tissue – for cancers that have invaded the chest wall Surgical resection may result in respiratory failure. It can control symptoms of spinal cord metastasis and superior vena cava compression. vinca alkaloids. Assess the client‘s level of fatigue and educate him/her on energy conservation techniques. and prolonged mechanical ventilation is a potential outcome. pericarditis. or pulmonary rehabilitation program as preferred by the client. Administer bronchodilators as prescribed to promote bronchial dilation. and bone and liver pain. taxanes. Prophylactic brain irradiation is used in certain clients to treat microscopic metastases to the brain. Administer supplementary oxygen. methods to maintain the client‘s quality of life dur ing the course of the disease. fatigue. 168 | P a g e . and etoposide. vinorelbine. a variety of bronchoscopic interventions to open the narrowed bronchus or airway. and radiation lung fibrosis. irinotecan. Radiation may help relieve cough. may also be used to reduce the size of a tumor. A variety of chemotherapeutic agents are used including. to treat clients with distant metastases or small cell cancer of the lung. platinum analogues. chest pain. corpulmonale. Teach client to cough and deep breath. Administer chest physiotherapy and suctioning as necessary to maintain airway patency. myelitis. Encourage the client to assume positions that promote lung expansion and to do breathing exercises for lung expansion and relaxation. nausea and vomiting. hemoptysis. esophagitis. occupational therapy. to make an inoperable tumor operable. dyspnea. and anorexia.  Palliative Therapy May include radiation therapy to shrink the tumor to provide pain relief. Chemotherapy Used to alter tumor growth patterns. and end-of-life treatment options. Radiation Therapy Useful in controlling neoplasms that cannot be surgically resected but are responsive to radiation. Refer the client to a physical therapy. or to relieve the pressure of the tumor on vital structures. gemcitabine. and as an adjunct to surgery or radiation therapy. Pulmonary toxicity is potential side effect of chemotherapy. May result in diminished cardiopulmonary functions and other complications such as pulmonary fibrosis. and pain management and other comfort measures Nursing Management Instruct the client and family about the potential side effects of the specific treatments and strategies to manage them. pneumonitis. doxorubicin.

CANCERS of the BLOOD 169 | P a g e .

 Clients with AML have a potentially curable disease. Acute Myeloid Leukemia (AML)  AML results from a defect in the hematopoietic stem cell that differentiates into all myeloid cells: monocytes. white blood cell development halted at the blast phase. granulocytes. with a peak incidence at age 60 years. and platelets.  AML is the most common nonlymphocytic leukemia. this leaves little room for normal cell production in the bone marrow There can also be a proliferation of cells in the liver and spleen (extramedullary hematopoiesis) Cause of leukemia is not fully known. the incidence arises with age. hyperplasia of the gums. erythrocytes. However. and bone pain from expansion of marrow are caused by the proliferation of leukemic cells within organs 170 | P a g e .Leukemia Any of several malignant diseases where an unusual number of leucocytes form in the blood Uncontrolled proliferation of white blood cells (leukocytosis) which is often immature (therefore will be non-functional). Classification of the disease is according to the stem cell line involved (lymphoid. clients who are older or have a more undifferentiated form of the disease tend to have worse prognosis. death usually occurring within weeks to months if no aggressive treatment is initiated. Chronic – symptoms evolve slowly. Clinical Manifestations o Most signs and symptoms evolve from insufficient production of normal blood cells o Fever and infection result from neutropenia o Weakness and fatigue from anemia o Bleeding tendencies from thrombocytopenia o Pain from an enlarged liver or spleen. myeloid). genetic influence and viral pathogenesis may be involved Bone marrow damage from radiation exposure or from chemicals is a risk factor of the disease. rapid progression.  Prognosis is highly variable and is not consistently based on client or disease variables. and according to the time it takes for symptoms to evolve and phase of cell development that is halted: Acute – abrupt onset.  All age groups are affected.

fungal. if not identical. and intracranial are the most common sites of bleeding o Fever and infection also increases the chances of bleeding o Clients with leukemia are always threatened by infection due to the lack of mature and normal granulocytes. gastrointestinal. anemic. percentage of normal cells is usually greatly decreased . total leukocyte count can be low. Aggressive chemotherapy is not used.Bone marrow analysis shows an excess of immature blasts. AML can be further classified into seven different subgroups. with the treatment goal of destroying hematopoietic function of the client‘s bone marrow. and occasionally viral infections. and morphology of the blasts.CBC results show a decrease in both erythrocyte and platelets. Consolidation therapy is administered to the client after he/she has recovered from the induction therapy. to the induction treatment but uses lower dosages resulting in less toxicity. The aim of induction therapy is to eradicate the leukemic cells. the client receives one cycle of treatment that is almost the same. The client is then rescued with the infusion of the donor stem cells to reinitiate blood cell production. in which there is no detectable evidence of residual leukemia remaining in the bone marrow. the client embarks on an even more aggressive regimen of chemotherapy sometimes in combination with radiation therapy.  Induction therapy is attempts made to achieve remission by aggressive administration of chemotherapy.Assessment and Diagnostic Findings .Clients may have significant problems with bleeding. neutrophils counts that persist at less than 100/mm3 make the chances of systemic infection extremely high o Client‘s risk for developing fungal infection increases. the client becomes severely neutropenic. as severe neutropenia is prolonged Medical Management Objective of treatment is to achieve complete remission. risk of bleeding correlates with the level of platelet deficiency. and a marked decline in the ability to maintain adequate nutrition. During this time. Supportive care is another option for the client to consider. Low platelet count can result in ecchymoses and petechiae o Major hemorrhages may also develop when the platelet count drops to less than 10. Supportive care consists of administering blood products and promptly treating infections. thereby diminishing the change of recurrence. pulmonary. normal or high. and thrombocytopenic. also called peripheral blood stem cell transplantation (PBCT). severe mucositis. bleeding. which causes diarrhea. but this is often accompanied by the eradication of normal types of myeloid cells. Bone marrow transplantation (BMT) is another aggressive treatment.000/mm3. they have higher underlying coagulopathy and a higher incidence of disseminated intravascular coagulation (DIC) Complications o Bleeding and infection. also the major causes of death. Clients are more commonly supported with   171 | P a g e . Thus. based on cytogenetics. hydroxyurea may be used to briefly to control the increase of blast cells. the client is typically very ill. histology. When a suitable tissue match can be obtained. This may be the only option if the client has significant comorbidity. which usually requires hospitalization for several weeks. Frequently. with bacterial. . The goal is to eliminate any residual leukemia cells that are not clinically detectable.

a less aggressive approach but does not alter cytogenetic changes Anthracycline chemotherapeutic agent may also be used to bring the white blood cell count down quickly to a safer lever Transformation phase – can be insidious. and inability to concentrate Hydroxyurea or busulfan can be used to reduce the white blood cell count to a more normal level. many clients cannot tolerate profound fatigue. diarrhea. depression. thus preventing a series of chemical reactions that cause the cell to grow and divide. and severe mucositis. from blast forms through mature neutrophils. Chronic Myeloid Leukemia (CML) CML arises from a mutation in the myeloid stem cell. Conventional therapy depends on the stage of the disease. therapy is not benign. many clients are symptomatic and leukocytosis is detected by a CBC performed for other reasons  WBC count commonly exceeds 100. client may become more anemic and thrombocytopenic. However. client may complain of bone pain and may report fevers and weight loss. often in combination. tender spleen. Problems with bleeding and infections are rare. but there is a preference for immature (blast) forms. but it marks the process of evolution to the acute form of leukemia. Chronic phase – expected outcome is correction of the chromosomal abnormality. Because there is an uncontrolled proliferation of cells. spleen may continue to enlarge even with chemotherapy. hyperkalemia and hypocalcemia. transformation to the acute phase can be gradual or rapid In the more acute form of leukemia. Normal myeloid cells continue to be produced. liver may also be enlarged  Malaise. using the same medications for AML and Acute Lymphocytic Leukemia (ALL) 172 | P a g e . anorexia. treatment may resemble induction therapy for acute leukemia. Clinical Manifestations Clinical picture of CML varies. clients have more symptoms and complications as the disease progresses Medical Management o Oral formulation of a tyrosine kinase inhibitor. a wide spectrum of cell types exists within the blood. once the disease transforms to the acute phase (blast crisis). agents that have been used successfully are interferon-alfa and cytosine. the marrow expands. and accelerated or blast crisis. Clients diagnosed with CML in the chronic phase have an overall median life expectancy of 3 to 5 years. and weight loss are some insidious symptoms. Agents are administered daily in subcutaneous injections. Thus. Complications of treatment include tumor lysis syndrome. imatinib mesylate (Gleevec) works by blocking signals within the leukemia cells that express the BCRABL protein. mucositis. into the cavities of the long bones. nausea. resulting in production of tyrosine kinase that causes white blood cells to divide rapidly. anorexia.antimicrobial therapy and transfusion as needed. anorexia. vomiting. BCR gene of chromosome 22 is translocated onto ABL gene of chromosome 9. resulting in enlargement of these organs that is sometimes painful.000/mm3  Clients may complain of an enlarged. transformation. lymphadenopathy is rare  CML has three stages: chronic. and cells are also formed in the liver and spleen. gastrointestinal problems. the overall survival time rarely exceeds several months.

and the pulmonary and cerebral complications of leukocytosis typically are not found in CLL. Because of improvements in therapy.000/mm3. The disease is classified into three or four stages. Even if relapse occurs. more than 80% of children survive at least 5 years. the peak incidence is 4 years of age. resulting in reduced numbers of leukocytes. a maintenance phase is often included (lower disease of medications are given for up to 3 years) o Treatment can be provided in outpatient setting o Bone marrow transplant offers a chance for prolonged remission or even cure if the illness recurs after therapy Chronic Lymphocytic Leukemia (CLL) CLL is a common malignancy of older adults. erythrocytes. Clinical Manifestations Reduced number of leukocytes. In the early stage. with result being an excessive accumulation of the cells in the marrow and circulation. but there is always a high proportion of immature cells. and headache and vomiting (because of meningeal involvement) Medical Management o Expected outcome of treatment is complete remission o Corticosteroids and vinca alkaloids are integral part of induction therapy o Prophylaxis with cranial irradiation or intrathecal chemotherapy or both is included in the treatment plan o Treatment protocols for ALL are complex and involves using a wide variety of chemotherapeutic agents. Bone marrow transplant may be successful even after a second relapse. leukocyte counts may be either low or high. Immature lymphocytes proliferate in the marrow and crowd the development of normal myeloid cells. an elevated lymphocyte count is seen and can exceed 100. The antigen CD52 is prevalent on the surface of many of these leukemic B cells. most of the leukemia cells are fully mature. bone pain. resumption of induction therapy can often achieve a second complete remission. Acute Lymphocytic Leukemia (ALL) ALL results from uncontrolled proliferation of immature cells (lymphoblasts) derived from the lymphoid stem cell. These lymphocytes are small and can easily travel through the small capillaries within the circulation. Most common in young children. and platelets. Pathophysiology CLL typically derives from a malignant clone of B lymphocytes. with boys affected more often than girls. normal hematopoiesis is inhibited. and platelets. After 15 years. Increasing age appears to be associated with diminished survival. Pain from an enlarged liver or spleen.CML is a disease that can be potentially treated with bone marrow transplantation. These mature cells appear to escape apoptosis. erythrocytes. 173 | P a g e . 2/3 of all clients are older than 60 years of age at diagnosis. ALL is relatively uncommon.

Treatment is typically initiated in the later stages. decreased  Enlargement of lymph nodes can be severe and painful  Spleen may also be enlarged  Clients may develop ―B symptoms‖ – a constellation of symptoms including fevers. often used in combination with other chemotherapeutic agents o Intravenous treatment with immunoglobulin may be given to selected clients due to occurrence of bacterial infections Nursing Care for the Client with Acute Leukemia Assessment  Assessment of health history may reveal a range of subtle symptoms reported by the client before the problem is manifested by findings on physical examination. early treatment does not appear to increase survival. or. o Fludarabine (Fludara) is being used as a front-line therapy.  Culture results need to be reported immediately so that appropriate antimicrobial therapy can begin or be modified. the assessment should be performed daily. Anemia and thrombocytopenia occur in later stages. such as infection. infections are common  Anergy – a defect in cellular immunity as evidenced by absent or decreased reaction to skin sensitivity tests  Life-threatening infections are common to these clients. o Chemotherapy with corticosteroids and chlorambucil is often used in later stages or when symptoms are severe.. o Monoclonal antibody rituximab (Rituxan) also has efficacy in CLL therapy. hematocrit. Herpes zoster) can become widely disseminated Medical Management o Early stages may require no treatment. renal dysfunction. Hepatomegaly and splenomegaly may develop. and unintentional weight loss.Lymphadenopathy occurs as the lymphocytes are trapped within the lymph nodes. in late stages. or more frequently as needed.  Closely monitor the results of laboratory studies. Nursing Diagnosis The following are major diagnosis for clients with acute leukemia:  Risk for infection and bleeding 174 | P a g e . platelet.  Assess for potential complications. absolute neutrophil count. and mucositis.g. and creatinine levels. viral infections (e. hepatic function tests. tumor lysis syndrome. Clinical Manifestations  Many clients are asymptomatic  Increased lymphocyte count is always present  RBC and platelet counts may be normal. bleeding.  Systematic assessment incorporating all body systems must be done thoroughly. Autoimmune complications (either hemolytic anemia or idiopathic thrombocytopenic purpura) can also occur at any stage. drenching sweat (especially at night). nutritional depletion. The nodes can become very large and are sometimes painful. and electrolyte levels.  If the client is hospitalized.  Flow sheets and spreadsheets are particularly useful in tracking the WBC count.

 Take no rectal temperatures. hypoproteinemia. pain. mucosal denudation Risk for deficient fluid volume related to potential for diarrhea. apply ice pack to the back of the neck and direct pressure to the nose. frozen plasma. less than body requirements. alteration in nutrition. treatment.                 risk for impaired skin integrity related to toxic effects of chemotherapy. and nausea Acute pain and discomfort related to mucositis.  Permit no flossing of teeth and no commercial mouthwashes. Prevent falls by ambulating with client as necessary. use only gentle suctioning. position client in high Fowler‘s position. or come in contact with the client at home. and impaired mobility Impaired gas exchange Impaired mucous membranes due to changes in epithelial lining of the gastrointestinal tract from chemotherapy or prolonged use of antimicrobial medications Imbalanced nutrition. packed red blood cells as prescribed.  Allow no one with cold or sore throat to care for the client or to enter room.  For epistaxis. if unavoidable. and roles Grieving related to anticipatory loss and altered role functioning Potential for spiritual distress Deficient knowledge about disease process. fever. function. bleeding. and self-care measures Nursing Interventions  Prevent infection and bleeding  Thorough hand hygiene must be done by everyone before entering the client‘s room. enemas.  Pad side rails as needed. infection.  Do not give intramuscular injections.  Provide low microbial diet.  Use smallest possible needles when performing venipuncture. anorexia. need for multiple intravenous medications and blood products Diarrhea due to altered gastrointestinal flora. malaise. Use only softbristled toothbrush for mouth care. Administer platelets.  Discourage vigorous coughing or blowing of the nose. mucositis.  Do not insert indwelling catheters.  Manage mucositis  Instruct client to practice meticulous oral hygiene.  Use stool softeners. related to hypermetabolic state.  Use only electric razor for shaving. Eliminate fresh salads and unpeeled fresh fruits or vegetables. Apply pressure to venipunctures sites for 5 minutes or until bleeding has stopped.  Avoid aspirin and aspirin-containing medications or other medications known to inhibit platelet function. and increased metabolic rate Self-care deficit due to fatigue. and protective isolation Anxiety due to knowledge deficit and uncertain future Disturbed body image related to change in appearance. if possible.  Notify physician for prolonged bleeding. oral laxatives to prevent constipation.  Avoid suctioning if at all possible. complication management. 175 | P a g e . do not give suppositories. and infection Hyperthermia related to tumor lysis and infection Fatigue and activity intolerance related to anemia and infection Impaired physical mobility due to anemia and protective isolation Risk for excess fluid volume related to renal dysfunction. WBC infiltration of systemic tissues.

Assist the client to resume self-care as he or she recovers. Encourage spiritual well-being 176 | P a g e . provide instructions for catheter care. Small. and provide gentle shoulder and back massage for comfort. frequently change bed clothes. Assess how much information the client wants to have regarding the illness. Sitz bath may be administered. Encourage client to sit up in a chair while awake rather than stay in bed. intake and output measurements are used in monitoring fluid status. Decrease fatigue and deconditioning Assist the client to establish a balance between activity and rest. Administer chlorhexidine rinses or clotrimazole troches to prevent yeast or fungal infections in the mouth. Low-microbial diets are typically prescribed. as well as selfesteem. sponge cool water but avoid using cold water or ice packs.                                Saline rinses are used to clean and moisten oral mucosa. and potential complications. Referral to a physical therapist can also be beneficial. Monitor laboratory tests results (electrolytes. For clients discharged with central venous access device. Assist client with activity and exercise to prevent deconditioning that results from inactivity. Reassure clients by providing open lines of communication even in home care management of the disease. and hematocrit) and compare with previous results. Remind client to cleanse perineal-rectal area thoroughly after each bowel movement. with particular attention to pulmonary status and the development of edema. Assist the client in identifying the source of grief. creatinine. warn the client to chew with extreme care to avoid accidentally biting the tongue or buccal mucosa. frequent feeding of foods that are soft in texture and moderate in temperature are better tolerated. Manage anxiety and grief Provide emotional support for the client and family. Parenteral nutrition may be administered to maintain adequate nutrition. Nutritional supplements may be administered. Improve self-care Encourage client to do self-care activities to preserve mobility and function. Improve nutritional intake Instruct client to do mouth care before and after each meal. Daily body weights. If oral anesthetics are used. Patient-controlled analgesia may be ordered for controlling pain. Replace electrolytes as necessary. Initiate strategies to permit uninterrupted sleep during acute hospitalizations. blood urea nitrogen. Ease pain and discomfort For recurrent fevers. Listen to clients verbalization of feelings empathetically. its treatment. Maintain fluid and electrolyte balance Assess client for signs of dehydration as well as fluid overload.

Cancers of the Lymphatic System

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Lymphomas Lymphoma is a term that applies to a group of cancer that affect the lymphatic system.  Lymphoma is classified by the microscopic appearance of the malignant cells and how quickly the malignancy spreads.  Two of the most common forms of lymphoma are Hodgkin‘s disease and non Hodgkin‘s lymphoma. Comparison of Lymphomas Hodgkin’s Non-Hodgkin’s  Four subtypes  Two peaks of onset: ages 15 to 40 and older than age 55 years  Reed-Sternberg cells  40% of affected clients test positive for Epstein-Barr virus B-cell origin  Thirty subtypes  Peaks after age 50 years  No Reed-Sternberg cells  More common in industrial countries; common among clients with immunosuppression  B- and T-cell origin  Usually starts in lymph nodes above the clavicle, commonly in the neck and chest; 15% are below the diaphragm; spreads downward from initial site  More orderly growth from one node to adjacent nodes  More curable  Common in abdomen, tonsils; can develop in areas other than lymph nodes (e.g., brain, nasal passages)  Less predictable growth; spreads to extranodal sites  Less curable 

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Acquired immunodeficiency syndrome-related lymphoma occurs in those who have been infected with the human immunodeficiency virus. Hodgkin’s Disease   This disease is a malignancy that produces enlargement of lymphoid tissue, the spleen, and the liver, with invasion of other tissues such as the bone marrow and lungs. It may appear in several forms: acute, localized, latent with relapsing pyrexia, splenomegaly, and lymphogranulomatosis (multiple granular tumors or growths composed of lymphoid cells).

Pathophysiology and Etiology  The exact cause of Hodgkin‘s disease is unknown.  A virus, Epstein-Barr virus, appears to cause mutations in some, but not all, lymphocytes, creating a malignant cell type known as ReedSternberg cells.  Reed-Sternberg cells are nearly immortal, continue to reproduce prolifically, and are somehow shielded from being destroyed by killer T-cells.  The virus also appears to inactivate the immune system‘s ability to suppress tumor growth.  The malignant cells release chemicals known as cytokines, causing inflammatory symptoms such as pain and fever.  Some clients develop generalized itching and a skin rash because of the release of histamine from an atypical allergic/immune response.  The disease is more common in men than in women and most frequently occurs during the late adolescence and young adulthood.  Some clients survive 10 or more years; others die in four to five years.  A cure is possible when the disease is localized to one section of the body.  Clients who receive treatment usually have remission that last for months or years.  Death results from respiratory obstruction, cachexia (state of ill health, malnutrition, and wasting), or secondary infections. Assessment Findings  Early symptoms of Hodgkin‘s disease include painless enlargement of one or more lymph nodes.  Cervical lymph nodes are the first to be affected.  As nodes enlarge, they press on adjacent structures, such as the esophagus or bronchi.  As retroperitoneal nodes enlarge there is a sense of fullness in the stomach and epigastric pain.  Marked weight loss, anorexia, fatigue, and weakness occur.  Low-grade fever, pruritus, and night sweats are common.  Sometimes marked anemia and thrombocytopenia develop, causing a tendency to bleed.  Resistance to infection is poor, and staphylococcal skin infections and respiratory tract infections often complicate the illness.  A complete blood count demonstrates low red blood cell count, elevated leukocytes, and decreased lymphocytes.  Reed-Sternberg cells, characterized as giant multinucleated B lymphocytes are microscopically identifiable in lymph node biopsies.  Results of blood chemistry tests such as erythrocyte sedimentation rate are elevated, suggesting a current inflammatory process.

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Liver enzymes such as alkaline phosphatase are elevated. Lymphangiography, chest radiography, computed tomography, magnetic resonance imaging, or laparotomy to obtain abdominal nodes for biopsy demonstrate size of lymph nodes and spread of the disease in the thorax, abdomen, or pelvis. A bone marrow aspiration biopsy indicates abnormalities of other blood cells. After diagnosis, the disease is staged from I to IV, based on the number of positive lymph nodes and the involvement of other organs.

Stages of Hodgkin’s Disease Stage Involvement  Single lymph node region  Two or more lymph node regions on one side of the diaphragm  Lymph node regions on both sides of the diaphragm but extension is limited to the spleen  Bilateral lymph nodes affected and extension includes spleen plus one or more of the following: bones, bone marrow, lungs, liver, skin, gastrointestinal structures, or other sites  Stages I, II, III, and IV adult Hodgkin‘s disease are sub -classified into A and B categories: B for those with defined general symptoms and A for those without B symptoms.  The B designation is given to clients with any of the following symptoms:  Unexplained loss of more than 10% of body weight in six months before diagnosis  Unexplained fever with temperatures above 38ºC  Drenching night sweats (The most significant B symptoms are fever and weight loss. Night sweats alone do not confer an adverse prognosis) Medical Management  Treatment includes localized radiation to affected lymph nodes and chemotherapy with combinations of antineoplastic drugs.  Chemotherapy Regimens for Hodgkin’s Disease Regimen Drugs  ABVD  MOPP  MOPP/ABVD  doxorubicin (Adriamycin), bleomycin (Blenoxane), vinblastine (Velban), dacarbazine (DTIC) mechlorethamine (Mustargen), vincristine (Oncovin), prednisone (Meticorten), procarbazine (Matulane) Alternation of drugs from both regimens For partial remission or relapse within 1 year  CBV  BEAM  cyclophosphamide (Cytoxan), carmustine (BICNU), etoposide (VePesid) carmustine (BICNU), etoposide (VePesid), cytosine arabinoside-e (Cytosar-U), melphalan (Alkeran)  Antibiotics are given to fight secondary infections.  Transfusions are prescribed to control anemia.  If resistance to treatment develops, autologous bone marrow or peripheral stem cells are harvested, followed by high doses of chemotherapy that destroy the bone marrow.

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and discuss any additional symptoms caused by lymph node enlargement (e.  Inspect the appearance of the skin.  Take prescribed medications as directed. evidence of splinting. and bag-valve mask at the bedside for (emergency) intubation. herpes infections. or night sweats. and/or dental caries. infertility. enlargement of the liver and spleen.  Check the client‘s current weight and deviation from usual weight. thymic hyperplasia. use of accessory muscles. avascular necrosis. and level of energy and appetite. pattern. coughing.  Reduce work schedule and rest frequently to avoid exhaustion.   Risk for Ineffective Airway Clearance and Risk for Impaired Gas exchange related to compression of trachea secondary to enlarged cervical lymph nodes  Expected Outcome: Breathing will remain adequate to maintain blood oxygen saturation of 90% or greater  Assess respiratory status each shift and PRN (as needed).  Ask how long the client has noticed the enlarged lymph nodes and check for presence and extent of tenderness in the area of lymph node enlargement. and position for breathing. Nursing Care for Client with Hodgkin’s Disease Assessment  Look for history of infection mononucleosis or symptoms resembling this disorder.  Wash hands frequently.  Keep the neck in midline and place the client in high Fowler‘s position if respiratory distress develops.  Place an endotracheal tube.  Avoid crowds or people who have infectious disease. impotence. nonHodgkin‘s lymphoma.  Assess for location. Report side effects to the physician. nausea.  Eat small amounts frequently or include a liquid nutritional supplement between meals and at bedtime. acute myeloid leukemia. myelodysplastic syndrome.  Avoid oral contact with germ-laden objects. laryngoscope. growth retardation. and characteristics of enlarged lymph nodes. vomiting).  Ask about fever. rate. solid tumors. flaring of nostrils. Diagnosis. thyroid cancer.  A transplant is performed after separating normal stem cells from malignant cells in the harvested specimen.  Contact physician if breathing becomes labored. breathlessness.. Note quality. pericarditis (acute or chronic). size. Planning. ask about any itching. dyspnea on exertion. chills.g.  Administer oxygen per physician‘s orders if blood saturation is consistently less than 90%. such as whether they are fixed or mobile. Risk for Infection related to immunosuppression secondary to impaired lymphocytes and drug or radiation therapy  181 | P a g e . hypothyroidism. and Interventions  Client and family teaching include the following:  Keep appointments for medical follow-up. pneumococcal sepsis. depth. Potential long-term complications of therapy for Hodgkin‘s disease include immune dysfunction.

 Assist client with whatever activities of daily living are independently unmanageable. Activity Intolerance and Self-Care Deficit related to anemia and generalized weakness from disease Expected Outcome: Client will tolerate essential activities as evidence by heart and respiratory rates within normal limits  Divide care into manageable amounts. 182 | P a g e .  Perform priority activities first. Institute infectious disease precautions if normal white blood cells are suppressed to dangerous limits.  Provide rest periods between activities.     Expected Outcome: Client will remain free of infection as evidenced by no fever and symptoms of secondary infection Restrict visitors or personnel with infections from contact with client. Practice conscientious hand washing and follow other principles of medical and surgical asepsis.

 An environmental ―trigger‖.  Lymph node enlargement. 30% to 60% of aggressive forms of non-Hodgkin‘s lymphoma are curable with intensive treatment. and inguinal regions. although a genetic link is strongly implicated in some types.  Aggressive because the condition has a shorter onset with acute symptoms. Pathophysiology and Etiology  There is no single definitive cause for non-Hodgkin‘s lymphomas.Hodgkin‘s lymphoma from Hodgkin‘s disease depend on microscopic examination of lymphoid tissue biopsies. Burkitt‘s lymphoma. could induce the disease. the client is relatively asymptomatic at diagnosis and the disorder is relatively responsive to radiation and chemotherapy. chemical herbicides. and reticulum cell sarcoma. chromosomal changes occur in affected lymphocytes.  Examples include lymphosarcoma. or hair dye. Non-Hodgkin‘s lymphoma is classified as either:  Indolent.  Administration of immunosuppressive drugs to prevent transplant rejection also is correlated with cases of non-Hodgkin‘s lymphoma. pesticides. Assessment Findings  Symptoms of non-Hodgkin‘s lymphoma depend on site of lymph node involvement.  Additional tests are performed to determine the stage of the lymphoma. which usually is diffuse rather than localized. axillary.  In non-Hodgkin‘s lymphoma.Non-Hodgkin’s Lymphoma  These are a group of 30 sub-classifications of malignant disease that originate in lymph glands and other lymphoid tissues.  Diagnosis and differentiation of the subtypes of non. such as a viral agent.  The incidence of non-Hodgkin‘s lymphomas is size to seven times that of Hodgkin‘s disease. occurs in cervical. and the number of cases continues to ris e. and lymphoid tissue enlarges to accumulate proliferative production of malignant cells. 183 | P a g e .

The physician may adopt a ―watch and wait‖ approach for clients with indolent forms of non. With MABs. creating clones that. whether they have non-Hodgkin‘s lymphoma or Hodgkin‘s disease. The advantage of combining MABs with drugs or radiation is that they target and destroy cancer cells while sparing normal cells. chemotherapy. The MABs are used alone or are bound to a chemotherapeutic or radioactive agent.Hodgkin‘s lymphoma. continue to produce tumorfighting antibodies. choosing to treat the client once the disease accelerates. Nursing Management  Nursing care is similar for all clients with lymphoma. The mice make lymphocytes that produce antibodies against cancer cells. The mouse lymphocytes are harvested and fused with a laboratory-grown cell. Research continues on the use of biologic therapy (immunotherapy) with MABs to eliminate malignant cells and induce remission. Rituximab (Rituxan) is an MAB drug approved for treating nonHodgkin‘s lymphoma. Cancers of the Gastrointestinal System 184 | P a g e . Immunotherapy with monoclonal antibodies (MABs) and bone marrow transplants is being used to cure lymphomas or extend the lives of clients with these diseases.  Because chemotherapy and radiation kill many cells. encourage clients to drink extra fluids (equivalent to 2500 ml/day) to facilitate excretion of the cells destroyed by therapy. or both. when administered to a client with cancer. human cancer cells are injected into laboratory animals such as mice.Medical Management Non-Hodgkin‘s lymphoma is treated with radiation.

185 | P a g e . are curable if discovered early. dietary deficiency.Cancer of the Oral Cavity Cancers of the oral cavity can occur in any part of the mouth or throat. and ingestion of smoked meats. Predisposing factors for other oral cancers are exposure to tobacco (including smokeless tobacco). These cancers are associated with the use of alcohol and tobacco. Chronic irritation by a warm pipestem or prolonged exposure to the sun and wind may predispose a person to lip cancer. ingestion of alcohol.

 The choice depends on the extent of the lesion and what is necessary to cure the client while preserving the best appearance. the surgeon may perform a neck dissection.  For those who smoke cigarettes and drink alcohol. high-risk areas include the floor of the mouth.  Surgical resection. A typical lesion in oral cancer is painless indurated (hardened) ulcer with raised edges. The most frequent symptom seen in late stages is a painless sore or mass that will not heal. 186 | P a g e . difficulty in chewing. Assessment and Diagnostic Findings  Diagnostic evaluation consists of an oral examination as well as an assessment of the cervical lymph nodes to detect possible metastases. but the lips.  Surgical treatments leave a less functional tongue. and the area behind the molar and the tongue junction). the lateral aspects of the tongue. or speaking. Clinical Manifestations A number of oral cancers produce few or no symptoms in the early stages. anterior and posterior tonsillar area.  Tumors larger than 4 cm often recur. chemotherapy. the preference of the physician. radiation therapy.  Any area of the oropharynx can be a site for malignant growth.  Small lesions in cancer of the lip are usually excised liberally. Medical Management  Management varies with the nature of the lesion.  Biopsies are performed on suspicious lesions (those that have not healed in two weeks). and client choice.  A combination of radioactive interstitial implants and external beam radiation may be used. or enlarged cervical lymph nodes. and the soft palate complex (soft palate. swallowing. or a combination of these therapies may be effective.  Cancer of the tongue may be treated with radiation therapy and chemotherapy to preserve organ function and maintain quality of life. and the floor of the mouth are most commonly affected. the client may complain of tenderness. Tissue from any ulcer of the oral cavity that does not heal in two weeks should be examined through biopsy. As the disease progresses. surgical procedures include hemiglossectomy (surgical removal of half of the tongue) and total glossectomy (removal of the tongue).Pathophysiology  Malignancies of the oral cavity are usually squamous cell cancers. larger lesions involving more than one-third may be more appropriately treated by radiation therapy because of superior cosmetic results. uvula. coughing of blood-tinged sputum.  High-risk areas include the buccal mucosa and gingival for people who use snuffs or smoke cigars or pipes. the ventrolateral tongue.  If the cancer has spread to the lymph nodes.

1) The Allen test is performed by asking the client to make a fist and then manually compressing the ulnar artery. 2) The client is then asked to open the hand into a relaxed. requiring a neck dissection and reconstructive surgery of the oral cavity. through. The palm will be pale. the incidence of adenocarcinoma is increasing. enteral or parenteral feedings before and after surgery to maintain adequate nutrition. Also. 3) If the ulnar artery is patent. however. there seems to be an association between gastroesophageal reflux disease (GERD) and adenocarcinoma of the esophagus.  If a radial graft is to be performed. 187 | P a g e . Assess the graft postoperatively for viability. Clinical Manifestations Clients may have an advanced ulcerated lesion of the esophagus before symptoms are manifested. have a higher incidence of esophageal cancer. Cancer of the esophagus has been associated with ingestion of alcohol and with the use of tobacco. and beyond the muscle layers into the lymphatics. a dietary consultation may be necessary. the palm will flush within about three to five seconds.  Often cancer of the oral cavity has metastasized through the extensive lymphatic channel in the neck region. Pathophysiology  Esophageal cancer is usually of squamous cell epidermoid type.     Assess for a patent airway postoperatively. suctioning must be performed with care to prevent damage to the graft. Suction as necessary to help the client manage oral secretions. which is caused by chronic irritation of muco us membranes due to reflux of gastric and duodenal contents. carry out an Allen tests on the donor arm to ensure that the ulnar artery is patent and can provide blood flow to the hand after removal of the radial artery. Pressure on the ulnar artery is released.  In the latter stages. if required. obstruction of the esophagus is noted. with possible perforation into the mediastinum and erosion into the great vessels.  Tumor cells may spread beneath the esophageal mucosa or directly into. slightly flexed position.  Administer. Nursing Management  Assess the client‘s nutritional status preoperatively. People with Barrett‘s esophagus. Locate the radial pulse at the graft site and assess graft perfusion using a Doppler ultrasound device. Nursing diagnoses for a client with oral cancer may include the following:  Fear related to diagnosis and long-term prognosis  Imbalanced Nutrition: Less than body requirements related to oral surgery or radical neck dissection  Disturbed Body Image related to disfiguring surgery Cancer of the Esophagus Chronic irritation is a risk factor for esophageal cancer. If grafting was included in the surgery. A common reconstructive technique involves the use of a radial forearm free flap (a thin layer of skin from the forearm along with the radial artery).

The delay between the onset of early symptoms and the time when the client seeks medical advice is often 12 to 18 months.  Bronchoscopy is usually performed. a sensation of a mass in the throat. persistent hiccup. treatment is based on type of cell. initially with solid foods and eventually with liquids.  Standard surgical management includes a total resection of the esophagus (esophagectomy) with removal of the tumor plus a wide tumor-free margin of the esophagus and the lymph nodes in the area. especially in tumors of the middle and the upper third of the esophagus. Medical Management  Treatment goals may be directed toward cure if esophageal cancer is found at an early stage. even liquids cannot pass into the stomach.- - Symptoms include dysphagia. and client condition. Anyone with swallowing difficulties should be encouraged to consult a physician immediately. and progressive loss of weight and strength occurs from starvation. however. Assessment and Diagnostic Findings  Diagnosis is confirmed most often by esophagogastroduodenoscopy (EGD) with biopsy and brushings.  Preoperative radiation therapy or chemotherapy. or the stomach can be elevated into the chest and the proximal section of the esophagus anastomosed to the stomach. painful swallowing. depending on the location of the tumor. respiratory difficulty.  Endoscopic ultrasound or mediastinoscopy is used to determine whether the cancer has spread to the nodes and other mediastinal structures. or leakage through the anastomosis. in which the tumor is removed and the area is replace with a portion of the jejunum.  Tumors of the lower thoracic esophagus are more amenable to surgery than tumors located in the esophagus. and foul breath. and gastrointestinal tract integrity is maintained by anastomosing the lower esophagus to the stomach. The client first becomes aware of intermittent and increasing difficulty in swallowing. may be used.  The client is given nothing by mouth until x-ray studies confirm that the anastomosis is secure and not leaking. and. to determine whether the trachea has been affected and to help determine whether the lesion can be removed. later regurgitation of undigested food with foul breath and hiccups. substernal pain or fullness. esophageal continuity may be maintained by free jejuna graft transfer.  Surgical resection of the esophagus has a relatively high mortality rate because of infection. Regurgitation of food and saliva occurs. however. tumor spread. if it is often found in late stages making relief of symptoms is the only reasonable goal for therapy.  Treatment may include surgery. pulmonary complications. or a combination of the modalities. Later symptoms include substernal pain. 188 | P a g e .  Cancer of the lower end of the esophagus may be caused by adenocarcinoma of the stomach that extends upward into the esophagus. depending on the extent of the disease. hemorrhage may take place. As the tumor progresses and the obstruction become more complete.  When tumors occurs in the cervical or upper thoracic area. or both.  Postoperatively.  The surgical approach may be through the thorax or the abdomen.  A segment of the colon may be used. the client will have a nasogastric tube in place that should not be manipulated. chemotherapy. radiation.

 Provide immediate postoperative care that is similar to that provided to clients undergoing thoracic surgery. what observations to make.  Placed the client in a low Fowler‘s position after recovering from the effects of anesthesia.  Initiate parenteral or enteral nutrition if the client is unable to eat by mouth.  Do not attempt to reinsert a displaced nasogastric tube because damage to the anastomosis may occur. Nursing Management  Intervention is directed toward improving the client‘s nutritional and physical condition in preparation for surgery. small amounts of pureed food once feeding begins. and gastric intubation.  Monitor nutritional status throughout treatment. parenteral fluid therapy. placement of an endoprosthesis (stent).  Encourage the client to swallow small sips of water. Treatment is individually determined since the ideal method of treating esophageal cancer has not yet been found.  Discontinue parenteral fluids once the client is able to increase food intake to an adequate amount.  Remind the client with endoprosthesis to chew food sufficiently to prevent obstruction.  Provide liquid supplements.  Administer oral suction if the client is unable to handle secretions. how 189 | P a g e . or chemotherapy.  During discharge planning. Later. instruct the family about promotion of adequate nutrition.Carefully observe the client for regurgitation and dyspnea (a common postoperative complication is aspiration pneumonia). or wick-type gauze may be placed at the corner of the mouth to direct secretions to a dressing or emesis basin.  Allow the client to remain upright for at least two hours after each meal to allow the food to move through the gastrointestinal tract. promote weight gain based on a high-calorie and high-protein diet in liquid or in soft form. measures to take if complications occur. and notify the physician if displacement occurs. radiation therapy.  If an endoprosthesis has been placed or an anastomosis has been performed. Perform a barium swallow to asses for any anastomotic leak before the client is allowed to eat. Palliation may be accomplished with dilation of the esophagus.  Inform the client about the nature of the postoperative equipment that will be used.   Palliative treatment may be necessary to keep the esophagus open. laser therapy. or chemotherapy. including the required for closed chest drainage. later. to assist with nutrition. and.  If adequate food can be taken by mouth.  Check for the graft viability hourly for at least the first 12 hours if jejunal grafting has been performed. radiation. Presence of a pulse may be assessed using a doppler sonography.  Administer antacids to relieve gastric distress. which are more easily tolerated by clients undergoing radiation and experiencing esophagitis.  Remove the nasogastric tube five to seven days after surgery.  Monitor temperature to detect any elevation that may indicate aspiration or seepage of fluid through the operative site into the mediastinum.  Assess the graft for color.  Encourage the client with poor appetite to eat by involving the family to prepare home-cooked favourite foods. mark the nasogastric tube for position immediately after surgery. nasogastric suction. position the client in a Fowler‘s position to assist in preventing reflux of gastric secretions. and to control saliva.

the client may be cured. Diet appears to be a significant factor.  The tumor infiltrates the surrounding mucosa. The prognosis is generally poor. achlorhydria. particularly to assess for surgical respectability of the tumor before surgery is scheduled.  The liver. abdominal pain just above the umbilicus. called Sister Mary Joseph’s nodules are a sign of a GI malignancy. gastric ulcers. smoking. or pickled foods and low in fruits and vegetables may increase the risk of gastric cancer.  If the tumor can be removed while it is still localized to the stomach.  Advance gastric cancer may be palpable as a mass. Other factors related to the incidence of gastric cancer include chronic inflammation of the stomach.  Ascites and hepatomegaly (enlarged liver) may be apparent if the cancer cells have metastasized to the liver. abdomen. where they cause little disturbance of gastric function.  CT scan of the chest. pancreas. the diagnosis is during the early stages of the disease. A diet high in smoked. 190 | P a g e . bloating after meals. Pathophysiology  Most gastric cancers are adenocarcinomas. and pelvis is valuable in staging gastric cancer.  Palpable nodules around the umbilicus. Most case of gastric cancers are discovered only after local invasion has advanced or metastases are present. and a barium x-ray examination of the upper GI tract may also be performed. and duodenum are often already affected at the time of diagnosis. Symptoms of progressive disease include dyspepsia (indigestion). Medical Management  There is no successful treatment for gastric carcinoma except removal of the tumor. usually a gastric cancer. salted. The incidence of gastric cancer is much greater in Japan. cure is less likely. because most gastric tumors begin on the lesser curvature of the stomach. but gastric can occur in people younger than 40 years of age. and genetics. weight loss. and how to obtain needed physical and emotional support.  Esophagogastroduodenoscopy for biopsy and cytologic washings is the diagnostic study of choice. which has instituted mass screening programs for earlier diagnosis. esophagus. nausea and vomiting.  Metastasis through lymph to the peritoneal cavity occurs later in the disease. loss or decrease in appetite. pernicious anemia. Assessment and Diagnostic Findings  The physical examination is usually not helpful in detecting the cancer because most early gastric tumors are not palpable.to keep the client comfortable.  Endoscopic ultrasound is an important tool to assess tumor depth and any lymph node involvement. Men have a higher incidence of gastric cancer than women. Clinical Manifestations Symptoms of early disease. such as pain relieved by antacids. penetrating the wall of the stomach and adjacent organs and stomach. pylori infection. and symptoms similar to those of peptic ulcer disease.  If the tumor has spread beyond the area that can be excised. H. Gastric Cancer The typical client with gastric cancer is between 40 and 70 years of age.  Computed tomography completes the diagnostic studies. they can occur anywhere in the stomach. early satiety. resemble those of benign ulcers and are seldom definitive. previous subtotal gastrectomy (more than 20 years ago).

 Assessment of tumor markers (blood analysis for antigens indicative of cancer) such as carcinoembryonic antigen (CEA).  A total gastrectomy or an esophagogastrectomy is usually performed in place of proximal subtotal gastrectomy to achieve a more extensive resection. The client with an unresectable tumor and an advanced disease undergoes chemotherapy. and CA 50 may help determine the effectiveness of treatment. include questions about social support. GI bleeding secondary to tumor. etoposide (Etopophos). The entire stomach is removed along with the duodenum. effective palliation to prevent discomfort caused by obstruction or dysphagia may be obtained by resection of the tumor.  Palliative procedures such as gastric or esophageal bypass. the lower portion of the esophagus. The Billroth I involves a limited resection and offers a lower cure rate than Billroth II.    In many clients. and significant pain. treatment with chemotherapy may offer further control of the disease or palliation. focusing on recent nutritional intake and status.  Commonly used single-agent chemotherapeutic medications include 5-fluorouracil (5-FU). and family history. Nursing Management Assessment Obtain a dietary history from the client. individual and family coping skills. carbohydrate antigen (CA 19-9). Radiation Therapy  Radiation therapy is mainly used for palliation in clients with obstruction. 191 | P a g e . Surgical Treatment  A total gastrectomy may be performed for a resectable cancer in the midportion or body of the stomach.  Common problems of advanced gastric cancer that often requires surgery include pyloric obstruction. gastrostomy. and lymph nodes. or to achieve a better quality of life.  A proximal subtotal gastrectomy may be performed for a resectable tumor located in the proximal portion of the stomach or cardia. obtain tissue for pathologic diagnosis. Obtain other health information about the client‘s smoking and alcohol history.  A gastric resection may be the most effective palliative procedure for advanced gastric cancer. A diagnostic laparoscopy may be the initial surgical approach to evaluate the gastric tumor.  A Billroth I or a Billroth II operation is performed. and detect metastasis. cisplatin (Platinol). doxorubicin (Adriamycin). The client with a tumor that is deemed resectable undergoes an open surgical procedure to resect the tumor and appropriate lymph nodes. and mitomycin-C (Mutamycin). Perform psychosocial assessment. and financial resources. supporting mesentery.  Gastric perforation is an emergency situation requiring surgical intervention. such as the liver.  A radical subtotal gastrectomy is performed for a resectable tumor in the middle and distal portion of the stomach. bleeding.  Palliative rather than radical surgery may be preformed if there is metastasis to other vitalorgans. or jejunostomy may temporarily alleviate symptoms such as nausea and vomiting. The Billroth II procedure is a wider resection and involves removing approximately 75% of the stomach and decreases the possibility of lymph node spread or metastatic recurrence. ] Chemotherapy  If surgical treatment does not affect cure. and severe pain.  Reconstruction of the GI tract is performed by anastomosing the end of the jejunum to the end of the esophagus (esophagojejunostomy).

and iron to enhance tissue repair. related to early satiety or anorexia Pain related to tumor mass Anticipatory grieving related to the diagnosis of cancer  Deficient knowledge regarding self-care activities Planning and Nursing Interventions Reduce anxiety  Provide a relaxed.  Recognize mood swings and defense mechanisms. social workers. back rubs. less than body requirements. psychiatric clinical nurse specialist. and psychiatrist available. Relieve pain  Administer analgesic agents as prescribed.  Advise the client about any procedures and treatments so that the client is aware of what to expect. and support positive coping measures.  Monitor the IV therapy and nutritional status and record intake.  Encourage the family or significant other to support the client. psychologist. intensity. nonthreatening atmosphere so that the client can express fears.Perform a complete physical examination. Provide psychosocial support  Help the client express fears. and grief about the diagnosis. such as position changes. and daily weight to ensure that the client is maintaining or gaining weight. massages. Anxiety related to the disease and anticipated treatment Imbalanced nutrition. imagery.  Administer antiemetics as prescribed. and duration of the pain to determine the effectiveness of the analgesic agent. Carefully assess the client‘s abdomen for tenderness or masses.  Administer continuous IV infusion of an opioid for postoperative or severe pain. and palpate and percuss the abdomen to detect ascites. Provide food supplements high in calories. and reassure the client. such as: Six small feedings daily that are low in carbohydrates and sugar.  Explain ways to prevent and manage dumping syndrome when enteral feeding resumes after gastric resection. and possibly anger about the diagnosis and prognosis. 192 | P a g e . Promote optimal nutrition  Encourage the client to eat small. concerns. vitamin C and A. and periods of rest and relaxation.  Make the services of clergy.  Answer the client‘s questions honestly and encourage him or her to participate in treatment decisions. output.  Administer vitamin B12 it is necessary for life if the client underwent total gastrectomy.  Suggest nonpharmacologic methods for pain relief. concerns. and significant others that emotional responses are normal and expected. frequent portions on nonirritating foods to decrease gastric irritation.  Administer parenteral nutrition to a client who is unable to eat adequately prior to surgery to meet nutritional requirements. distraction.  Provide time and support to a client that undergo mourning for the loss of a body part and who perceives surgery as a type of mutilation. relaxation exercises. if needed. offer reassurance.  Assess for signs of dehydration and review the results of daily laboratory studies to note any metabolic abnormalities. Fluids between meals rather than with meals  Inform the client that dumping syndrome often resolves after several months. family members.  Offer emotional support and involve the family members and significant others whenever possible.  Routinely assess the frequency.

perforation. anorexia. The passage of blood in the stools is the second most common symptom. high-protein (with high intake of beef). low-fiber diet. Promote home and community-based care  Client and family teaching include information about diet and nutrition. Colorectal Cancer Tumors of the colon and rectum are relatively common. if necessary. Survival rates after late diagnosis are very low. Early diagnosis and prompt treatment could save almost three of every four people with colorectal cancer. genital cancer or breast cancer (in women) The distribution of cancer sites throughout the colon are: ascending colon – 22%.  Provide explanation about chemotherapy and radiation therapy.  Cancer cells may break away from the primary tumor and spread to other parts of the body. whereas the incidence of cancer in the cecum. the 5. Symptoms may also include unexplained anemia. the stage of the disease. family history of colon cancer or polyps. previous colon cancer or adenomatous polyps. The most common presenting symptom is a change in bowel habits. and the function of the intestinal segment in which it is located. The exact cause of colon and rectal cancer is still unknown but risk factors have been identified: Increasing age.  Teach the client and caregiver about administration of enteral or parenteral nutrition. such as bleeding. rectum – 27% Changes in the distribution have occurred in recent years. Arrange for psychological counseling. or significant other with decisions regarding end-of-life care and make referrals as warranted. Pathophysiology  Cancer of the colon and rectum are predominantly adenocarcinoma. tarry stools). obstruction. and fatigue. 193 | P a g e . invade and destroy normal tissue. sigmoid colon – 33%. The incidence increases with age (the incidence is highest for people older than 85 years of age) and is higher for people with a family history of colon cancer and those with inflammatory bowel disease or polyps. Project an empathetic attitude and spend time with the client.  Teach the client or caregiver to recognize and report sign and symptoms of complications that require immediate attention. including detection and prevention of untoward complications related to feedings. most often to the liver. Clinical Manifestations The symptoms are greatly determined by the location of the cancer. If the disease is detected in an early stage. transverse colon – 11%. high-fat. weight loss.  Assist the client.  It may start as a benign polyp but may become malignant. and descending colon has increased.  Explain the care needed during and after treatments to the client and family or significant other. and extend into surrounding structures. ascending. or any symptoms that become progressively worse. arising from the epithelial lining of the intestine. history of inflammatory bowel disease. activity and lifestyle changes. pain management.year survival rate is 90% but only 34% of colorectal cancers are found at an early stage. descending colon – 6%. The symptoms most commonly associated with rightsided lesions are dull abdominal pain and melena (black. and possible complications. treatment regimen. The incidence of cancer in the sigmoid and rectal areas has decreased. family. Most people are asymptomatic for long periods and seek health care only when they notice a change in bowel habits or rectal bleeding.

and colonoscopy. as well as bright red blood in the stool. Assessment and Diagnostic Findings  Along with an abdominal and rectal examination. barium enema. tumor extends through entire bowel wall Class D: Advanced and metastasis to liver. Symptoms associated with rectal lesions are tenesmus (ineffective. narrowing stools. peritonitis.  Extension of the tumor and ulceration into the surrounding blood vessels results in hemorrhage. supportive therapy. and bloody stool.  Although CEA may not be highly reliable indicator in diagnosing colon cancer because not all lesions secrete CEA.  Treatment of colorectal cancer depends on the stage of the disease and consists of surgery to remove the tumor. Medical Management  The client with symptoms of intestinal obstruction is treated with intravenous fluids and nasogastric suction. These cancers are considered common malignancies in advanced age. sepsis. tumor is limited to bowel wall Class C2: Positive nodes.  Elevation of CEA at a later date suggests recurrence. and distention).  Lack of fiber is a major causative factor because the passage of feces through the intestinal tract is prolonged. the elevated levels of CEA should return to normal within 48 hours. Complications  Tumor growth may cause partial to complete bowel obstruction. painful straining at stool).  Excess fat is believed to alter bacterial flora and convert steroids into compounds that have carcinogenic properties.  With complete excision of the tumor. studies show that CEA levels are reliable in predicting prognosis. proctosigmoidoscopy.- - The symptom most commonly associated with leftside lesions are those associated with obstruction (abdominal pain and cramping. alternating constipation and diarrhea. which extends exposure to possible carcinogens. the feeling of incomplete evacuation after a bowel movement. abscess formation.  Perforation. no nodal involvement  Class C1: Positive nodes. rectal pain.  Carcinoembryonic antigen (CEA) studies may also be performed. and adjuvant therapy. or bone Adjuvant Therapy 194 | P a g e . blood component therapy may be required. Staging of Colorectal Cancer: Dukes’ Classification – Modified Staging System  Class A: Tumor limited to muscular mucosa and submucosa  Class B1: Tumor extends into mucosa  Class B2: Tumor extends through entire bowel wall into serosa or pericolic fat. lung. and shock may occur. Gerontologic Considerations  The incidence of carcinoma of the colon and rectum increases with age.  If there has been significant bleeding. constipation. the most important diagnostic procedures for cancer of the colon are fecal occult blood testing.  Colon cancer in the elderly has been closely associated with dietary carcinogens.

allowing initial bowel decompression and bowel preparation before resection Permanent colostomy or ileostomy for palliation of unresectable obstructing lesions  Construction of a coloanal reservoir called a colonic J pouch is performed in two steps.  Laparoscopic colotomy with polypectomy minimizes the extent of surgery needed in some cases. and to reduce the risk of recurrence. 2) About three months after the initial stage. and intestinal continuity is restored. the ileostomy is reversed.  Obtain additional information about history of inflammatory bowel disease or colorectal polyps.. and the newly constructed J pouch (made from 6 to 10 cm of the colon) is reattached to the anal stump. removal of the tumor and a portion of the sigmoid and all of the rectum and anal sphincter) Temporary colostomy followed by the segmental resection and anastomosis and subsequent reanastomosis of the colostomy. during. including fat and fiber intake.  Surgical procedures include the following: Segmental resection with anastomosis (i. Nursing Management Assessment  Complete a health history to obtain information about fatigue. It may be curative or palliative. 1) A temporary loop ileostomy is constructed to divert intestinal flow.  The type of surgery recommended depends on the location and size of the tumor. Mitomycin is also used.fluourouracil plus levamisole regimen. For inoperative or unresectable tumors. and after surgery to shrink the tumor.  Use of the neodymium/yttrium-aluminum-garnet (Nd:YAG) laser has proved effective with some lesions as well. and current medication therapy. if the tumor has spread and involves surrounding vital structures. but the goal of surgery in this instance is palliative. 195 | P a g e . a family history of colorectal disease. and characteristics of stool. The anal sphincter and therefore continence are preserved. the tumor mass is then excised.  Describe and document a history of weight loss. it is considered nonresectable.  A laparoscope is used as a guide in making an incision into the colon. removal of the tumor and portions of the bowel on either side of the growth. irradiation is used to provide significant relief from symptoms. Surgical Management  Surgery is the primary treatment for most colon and rectal cancers. Intracavity and implantable devices are used to deliver radiation to the site. abdominal or rectal pain.  Identify dietary habits. Clients with Dukes‘ class B or C rectal cancer are given 5-fluourouracil and high disease of pelvic irradiation. past and present elimination patterns. The response to adjuvant therapy varies. Radiation therapy is used before.      The standard adjuvant therapy administered to clients with Dukes‘ Class C colon cancer is the 5. to achieve better results from surgery. as well as the blood vessels and lymphatic nodes) Abdominoperitoneal resection with permanent sigmoid colostomy (i.e.  Bowel resection is indicated for most class A lesions and all class B and C lesions. as well as amounts of alcohol consumed.  Cancers limited to one side can be removed through colonoscope.  Surgery is sometimes recommended for class D colon cancer..e.

if client‘s condition permits. less than body requirements. assess hydration status. and cephalexin) the day before the surgery to reduce intestinal bacteria.  Recommend a diet high in calories. loss of bowel sounds. and self-care after discharge  Impaired skin integrity related to the surgical incisions (abdominal and perianal).  Build the client‘s stamina in the days preceding surgery and cleanse and sterilize the bowel the day before the surgery. abscess. and frequent fecal contamination of peristomal skin  Disturbed body image related to colostomy  Ineffective sexuality patterns related to presence of ostomy and changes in body image and self-concept Collaborative Problems Intraperitoneal infection Complete large bowel obstruction GI bleeding Bowel perforation Peritonitis. and concentrated urine. and pain or rigidity.  Cleanse the bowel using laxatives. and solid mass. vitamins. sulfonamides. to provide adequate nutrition and minimize cramping by decreasing excessive peristalsis.  Administer antiemetics as prescribed.g. Inspect stool specimens for character and presence of blood. and minerals if the client is hospitalized in the days preceding surgery. neomycin. or colonic irrigation the evening before and the morning of surgery. and report decreased skin turgor.. which may indicate obstruction or perforation. distention. protein. enemas. and carbohydrates and low in residue for several days before surgery.  Prescribe a full-liquid diet 24 to 48 hours before surgery to decrease bulk.  Parenteral nutrition may be required to replace depleted nutrients. including stoma care if a colostomy is to be created.  Monitor the abdomen for increasing distention. the surgical procedure.  Monitor intravenous fluids and electrolytes.  Restrict the client‘s oral food and fluid intake to prevent vomiting. dry mucous membranes.  Observe for signs of hypovolemia.  Measure and record intake and output. Insert a nasogastric tube to drain accumulated fluids and prevent abdominal distention.  Assessment includes auscultating the abdomen for bowel sounds and palpating the abdomen for areas of tenderness.  Monitor serum electrolyte levels to detect hypokalemia and hyponatremia that occur with GI fluid loss. for the client who is very ill and hospitalized to provide an accurate record of fluid balance. Allow the client to have full or clear liquids as tolerated or to have nothing by mouth. as necessary. Nursing Diagnosis  Imbalanced nutrition. the formation of a stoma.  Administer antibiotics (e. and support the client and family emotionally. provideinformation about postoperative care. 196 | P a g e . related to nausea and anorexia  Risk for deficient fluid volume related to vomiting and dehydration  Anxiety related to impending surgery and the diagnosis of cancer  Risk for ineffective therapeutic regimen management related to knowledge deficit concerning the diagnosis. and sepsis Planning and Interventions  Prepare the client for surgery  Prepare the client physically for surgery. including vomitus.

 Provide privacy and teach relaxation techniques. or ask questions. and pulmonary complications associated with abdominal surgery. skin irritation. and empathetic attitude to promote client comfort. Provide wound care  Examine the abdominal dressing frequently during the first 24 hours after surgery to detect signs of hemorrhage.  Use diagrams.g.  Help the client with ostomy out of bed on the first operative day and encourage him or her to begin participating in managing the colostomy. dietary restrictions.  Include pain management during immediate postoperative period. surgical procedure.  Help control diarrhea by administering paregoric. because an initial sensitivity may decrease with time.  Substitute nonirritating foods for those that are restricted to be able to correct nutritional deficiencies. or carbonated beverages. tea.  Advise the client to experiment with an irritating food for several times before restricting it. peanuts).  Suggest fluid intake of at least two liters of fluid per day. and expected level of functioning after surgery. the expected appearance and care of the wound. and suggest methods for reducing anxiety. professional. and highcellulose products (e. beans. soda. fish.  Assess the abdomen for returning peristalsis and assess the initial stool characteristics. fecal impaction. Provide emotional support  Assess the client‘s anxiety level and coping mechanism.  Help the client identify any foods or fluids that may be causing diarrhea. highfiber foods.  Present facts about the surgical procedure and the creation and management of ostomy to reduce the fear related to changes in body image.  Project a relaxed. including foods in the cabbage family. bismuth subcarbonate. coffee. eggs. Include in the teaching plan information about the physical preparation for surgery. stoma retraction. Consultation with an enterostomal therapist during the preoperative period or with a person who is successfully managing an ostomy can be helpful.  Help the client splint the abdominal incision during coughing and deep breathing to lessen tension on the edges of the incision. Allow the client and family to ask questions or voice out concerns. and medication management.  Teach the client to avoid foods that causes excessive odor and gas. Maintain optimal nutrition  Teach all clients undergoing surgery for colorectal cancer about the health benefits to be derived from consuming a healthy diet. such as leakage from the site of the anastomosis.  Monitor the client for complications. prolapse of the stoma. such as fruits. 197 | P a g e . or diphenoxylate with atropine (Lomotil). cry. prognosis. the technique of ostomy care (if applicable).  Arrange a meeting with a spiritual advisor if the client desires or with the physician if the client wishes to discuss the treatment or prognosis. bismuth subgallate. photographs.. and appliance to explain and clarify. perforation.  Set aside time to listen to the client who wishes to talk.  Assess the client‘s knowledge about the diagnosis. pain control. Provide postoperative care  Postoperative care for clients undergoing colon resection or colostomy is similar to nursing care for any abdominal surgery client.  Complete a nutritional assessment for clients with a colostomy.

 Administer antibiotics as prescribed. Document the condition of the perineal wound and any bleeding.  Assist in establishing local drainage. Hasten the process of tissue sloughing off by performing mechanical irrigation of the wound or with sitz baths two to three times a day for a week. spiking fever.  Mechanical obstruction  Assess client for intermittent colicky pain.  Ensure adequate fluid and electrolyte replacement. coughing. color (a healthy stomach is pink or red). and bleeding (an abnormal sign).e. immediately.  Apply warm compresses as prescribed.  Prepare client for surgery if condition deteriorates.  Peritonitis  Evaluate client for nausea. which may indicate an infectious process.  Encourage frequent activity (i.  Administer parenteral fluid and electrolyte therapy as prescribed. pulse.  Monitor vital signs for increased temperature.  Prepare client for drainage procedure.  Prepare client for x-ray study. which may indicate an intra-abdominal infectious process. deep breathing. or necrosis.    Monitor temperature.  Obtain specimen of drainage material for culture and sensitivity studies. pulse. and respirations and for decreased blood pressure. including decreasing or changing bowel sounds and increasing abdominal girth. report temperature deviation. Remove the wound packing or drain gradually. tenderness.  Prepare for surgical drainage.  Abscess formation  Administer antibiotics as prescribed.  Infection (surgical wound complication)  Monitor temperature. to detect bowel obstruction.  Observe for redness.  Assess the abdomen frequently. 198 | P a g e . and vomiting. and early ambulation can reduce the risks for pneumonia and atelectasis. If the malignancy has been removed using the perineal route. examine the stoma for swelling (slight edema from surgical manipulation is normal). infection. nausea. and tachycardia.  Promptly report any change in abdominal pain. Potential complications and nursing interventions after intestinal surgery  Paralytic ileus  Initiate or continue nasogastric intubation as prescribed. which indicates hemorrhage. discharge (a small amount of oozing is normal).  Report rectal.  Administer prescribed antibiotics if client has symptoms of peritonitis. hiccups. If the client has a colostomy. Monitor and manage complications  Observe the client for signs and symptoms of complications.  Monitor hematocrit and hemoglobin levels and administer blood component therapy as prescribed. turning the client from side to side every 2 hours). and respiratory rates for elevations. observe for signs of hemorrhage. chills..  Report elevated white blood cell counts and temperature or symptoms of shock because these may indicate sepsis. and pain around the wound.

 Administer antibiotics as prescribed.  Prepare for tube decompression of bowel. the client assumes a comfortable sitting or standing position and gently pushes the skin down from the faceplate while pulling the pouch up and away from the stoma.Other skin problems associated with a colostomy are yeast infections and allergic dermatitis.  Dehiscence of anastomosis  Prepare client for surgery. Transverse colostomy – stool is soft and mushy and irritating to the skin Descending or sigmoid colostomy – stool is fairly solid and less irritating to the skin. Teach skin care and how to apply and remove the drainage pouch. and elevation of temperature. and adhering the ostomy appliance to irritated skin can worsen the skin condition. The effluent discharge and the degree to which it is irritating vary with the type of ostomy. 6) Nystatin powder can be dusted lightly on the peristomal skin if irritation or yeast growth is present.  Intraperitoneal infection and abdominal wound infection  Monitor for evidence of constant or generalized abdominal pain. 3) Instruct the client to remove any excess skin barrier. 4) Cover the stoma with gauze or insert a vaginal tampon to absorb excessive drainage while the skin is being cleansed. Presence of skin irritation makes adhering the ostomy appliance difficult. Care of the peristomal skin is an ongoing concern because excoriation or ulceration can develop quickly. 5) Pat the skin dry.  Administer parenteral fluids as prescribed to correct fluid and electrolyte deficits.  Prepare client immediately for surgery. Administer fluids and electrolytes by IV route as prescribed. (Gentle pressure prevents the skin from being traumatized and any liquid fecal contents from spilling out.        Remove and apply the colostomy appliance The colostomy begins to function three to six days after surgery. 199 | P a g e . If the client wants to bathe or shower before putting on the clean appliance. o o o 1) To remove the appliance. Differentiate ostomy appliances available for the client‘s use.  Smooth application of the drainage appliance for a secure fit requires practice and a well-fitting appliance. One-piece appliance consists of a pouch with an integral adhesive section that adheres to the client‘s skin. soft cloth and a mild soap. Manage and teach the client about colostomy care until the client can take over.) 2) Advise the client to protect the peristomal skin by washing the area gently with a moist. Two -piece appliance consists of a separate pouch that fastens to the barrier backing.  Fistulas (anastomotic complication)  Assist in bowel decompression. take care not to rub the area. apply micropore tape to the sides of the pouch to secure it during bathing. rapid pulse.  Cover wound area with sterile towels held in place with binder. Wound disruption  Observe for sudden appearance of profuse serous drainage from wound.

5) Remove the backing from the adherent surface of the appliance. Assess the client‘s needs and attempt to identity specific concerns. and feces so that the client can go about social and business activities without fear of fecal drainage.e. bags may be dispensed with. 3) After the skin is cleansed. apply the peristomal skin barrier (i. paste. accepting manner and by encouraging the client to talk about his or her feelings about the stoma. or advanced practice nurse of the client‘s concern seem complex. or powder). By irrigating the stoma at a regular time. Regulating the passage of fecal material is achieved by irrigating the colostomy or allowing the bowel to evacuate naturally without irrigations. Nothing escapes from the colostomy opening between irrigations. held in place by an elastic belt. wafer. and a closed ostomy appliance or a simple dressing of disposable tissue (often covered with plastic wrap) is used. the pouch opening should be about 0. colostomy appliances are not always needed. Provide a supportive environment and a supportive attitude to be able to promote the client‘s adaptation to the changes brought about by the surgery. Seek assistance from an enterostomal therapy nurse. As soon as the client has learned a routine for evacuation. and place the bag down over the stoma for 30 seconds. Colostomy plugs that expand on insertion to prevent passage of flatus and feces are also available.3 cm (1/8 inch) larger than the stoma. except for gas and a slight amount of mucous. Irrigate the colostomy Irrigation of the colostomy is done to empty the colon of gas. Discuss sexuality issues Encourage the client to discuss feelings about sexuality and sexual function. A stoma does not have voluntary muscle control and may empty at irregular intervals. there is less gas and retention of the irrigant. 4) Dust the skin with karaya or Stomahesive powder before attaching the pouch (for mildly irritated skin). 200 | P a g e . mucus. 2) Measure the stoma to determine the correct size for the pouch. sex counselor or therapist. 6) Empty or change the appliance when it is 1/3 to ¼ full so that the weight of its contents does not cause the appliance to separate from the adhesive disk and spill the contents. The time for irrigating the colostomy should be consistent with the schedule the person will follow after leaving the hospital. Help the client overcome aversion to the stoma or fear of self-injury by providing care and teaching in an open. Support a positive image Encourage the client to verbalize feelings and concerns about altered body image and to discuss the surgery and the stoma (if one was created).1) Allow the client to choose from a wide variety of appliances.. For some clients. depending on what he or she needs.

Cancers of the Special Senses 201 | P a g e .

In the orbit. and grows slowly but does not metastasize. The psychological needs of the client and family.  Donor graft sites may include the buccal mucosa. The most common site of metastasis is the lung. location. Squamous cell carcinoma may resemble basal cell carcinoma initially because it also grows slowly and painlessly. configuration. conjunctival chemosis. are vital in planning the management approach. It spreads to the surrounding tissues and metastasizes to other organs. The lesion is invasive. The degree of orbital destruction is important in planning the surgical approach. and is useful in estimating the field for radiation therapy if needed. resection often involves removal of the globe. spreads to the surrounding tissues. but it can also develop in elderly persons.  The client is referred to an oncologist for evaluation for the need for radiation therapy treatment and monitoring for metastasis. It tends to ulcerate and invade the surrounding tissues. Basal cell carcinoma appears as a painless nodule that may ulcerate. Management of primary malignant orbital tumors involves three major therapeutic modalities: surgery. and impairment of ocular motility. Squamous cell carcinoma occurs less frequently but is considered the second most common malignant tumor. Imaging of these tumors establishes the size. The symptoms include sudden painless proptosis of one eye followed by eyelid swelling. and adjuvant chemotherapy. or the abdomen.  Early diagnosis and surgical management are the basis of a good prognosis. Malignant melanoma may not be pigmented and can arise from nevi. Malignant Tumors of the Eyelid Basal cell carcinoma is the most common malignant tumor of the eyelid. and stage of the disease. especially the parents of a pediatric client.Malignant Tumors of the Orbit Rhabdomyosarcoma is the most common malignant primary orbital tumor in childhood. 202 | P a g e . radiation therapy. It usually appears on the lower lid margin near the inner canthus with a pearly white margin. delineates the degree of bone destruction. the thigh. Malignant eyelid tumors occur more frequently among people with fair complexion who have a history of chronic exposure to the sun. but it can metastasize to the regional lymph nodes. Management  Complete excision of these carcinomas is followed by reconstruction with skin grafting if the surgical excision is extensive.  The ocular postoperative site and the graft donor site are monitored for bleeding.

retinoblastoma. although most occur during middle age. The diagnosis is confirmed at biopsy after enucleation. Emotional support and reassurance are important aspects of nursing management. Cosmetic disfigurement may result from extensive excision when deep invasion by the malignant tumor is involved. Most acoustic neuromas are unilateral. Malignant Tumors of the Globe (Ocular Melanoma) A malignant tumor of the retina. Malignant melanoma is rare but may arise from a preexisting nevus or acquired melanosis during middle age. whereas medium and large tumors require treatment. enucleation. Acoustic Neuroma An acoustic neuroma is a slow-growing benign tumor of cranial nerve VIII. and ultrasonography are performed. is hereditary.. except in von Recklinghausen‘s disease. malignant choroidal tumor is often discovered on a retinal examination. 203 | P a g e . CT scan with contrast dye may also be performed for claustrophobic clients. usually arising from the Schwann cells of the vestibular portion of the nerve. retinal fundus photography. Some benign tumors and most malignant tumors recur. In its early stages. Acoustic neuroma occurs with equal frequency in men and women at any age. Tumors are classified according to size (i. To avoid recurrences.  MRI with a paramagnetic contrast agent is the imaging study of choice. They grow gradually. A number of such tumors have been found in people with blindness that has painful eyes. Treatment consists of radiation therapy. Many clients do not have symptoms in the early stages though some clients may complain of blurred vision or a change in eye color. Management  Surgical removal of acoustic tumors is the treatment of choice because these tumors do not respond well to irradiation or chemotherapy. which is removed after several days. or both. Squamous cell carcinoma is also rare but invasive. This rare. and surgical excisions may result in facial disfigurement. The typical lesions are usually gelatinous and whitish due to keratin formation. Ocular melanoma is another cancer that primarily occurs in adults. medium. clients usually undergo radiation therapy and cryotherapy after the excision of malignant tumors.  Asymmetry in audiovestibular test results should be identified so that further workup can be performed to rule out an acoustic neuroma. small. Very small tumors are generally monitored. large). Radiation therapy is achieved by external beam performed in repeated doses over several days or through the surgical implantation of a radioactive plaque. In addition to a complete physical examination to discover any evidence of metastasis. and requires complete enucleation if there is to be a chance for successful outcome. Most acoustic tumors arise within the internal auditory canal and extend into the cerebellopontine angle to press on the brain stem. it could be mistaken for a nevus. Malignant Tumors of the Conjunctiva Conjunctival carcinoma most often grows in the exposed areas of the conjunctiva. fluorescein angiography. in which bilateral tumors occur. Assessment and Diagnostic Findings  The most common findings of assessment of clients with an acoustic neuroma are unilateral tinnitus and hearing loss with or without vertigo or balance disturbance. occurs in childhood.e. The management is surgical incision.  These conditions have life-threatening consequences. and deep invasion and metastasis are rare.

      Multidisciplinary treatment approach involves a neurotologist and a neurosurgeon. Death from acoustic neuroma surgery is rare. a suboccipital or middle cranial fossa approach to removing the tumor may be used. cerebrospinal fluid leak. 204 | P a g e . In these clients. the surgery is performed using a translabyrinthine approach. Most acoustic tumors have damaged the cochlear portion of cranial nerve VIII. meningitis. and cerebral edema. Complications of surgery for acoustic neuroma include facial nerve paralysis. If hearing is still good before surgery. The objective of surgery is to remove the tumor while preserving facial nerve function. and intraoperative monitoring of cranial nerve VIII is performed to save the hearing. and the hearing mechanism is destroyed. and no serviceable hearing exists before surgery.

Cancers of the Nervous System Primary Brain Tumors 205 | P a g e .

pancreas. The cause of primary brain tumors is unknown.The most common type of glioma and are graded from I to IV. Seizure activity and focal neurologic signs. Primary brain tumors originate from cells and structures within the brain. breast. oligodendrocytoma. These tumors are categorized as low-grade and high-grade (anaplastic). These hormones may cause prolactinsecreting pituitary adenomas (prolactinomas). are divided into categories (i. Hydrocephalus. Meningiomas Represents 20% of all primary brain tumors. Manifestations depend on the area involved and are the result of compression rather than invasion of brain tissue.. Secondary. visual dysfunction.A brain tumor is a localized intracranial lesion that occupies space within the skull. The only known risk factor is exposure to ionizing radiation. cell mitosis. Oligodendroglial Tumors Represents 20% of gliomas. indicating the degree of malignancy. kidney. They are slow growing and occur most often in middle-aged adults (more often in women). Acoustic Neuromas Pituitary Adenomas – represent about 8% to 12% of all brain tumors and cause symptoms as a result of pressure on adjacent structures or hormonal changes (hyperfunction or hypofunction of the pituitary). but metastatic lesions to the brain occur commonly from the lung. and appearance. hypothalamic disorders. These tumors usually spread by infiltrating into the surrounding neural connective tissue and therefore cannot be totally removed without causing considerable damage to vital structures. The effects of neoplasms occur from the compression and infiltration of tissue. medulloblastoma):  Astrocytomas . These pressure effects produce headache. or optic tracts or on the hypothalamus or the third ventricle when the tumor invades the cavernous sinuses or explains into the sphenoid bone. brain tumors develop from structures outside the brain and occur in 20% to 40% of all clients with cancer. Pressure from a pituitary adenoma may be exerted on the optic nerves. and skin (melanomas). Pathophysiology  Gliomas – glial tumors. the most common type of neoplasm. growth hormone-secreting pituitary adenomas that produce acromegaly in adults. or metastatic. The grade is based on cellular density. whereas adenomas that produce both growth hormone and prolactin are relatively common. lower gastrointestinal tract. and adrenocorticotropic hormone (ACTH)-producing pituitary adenomas that result in Cushing‘s disease. Meningiomas most often occur in areas proximal to the venous sinuses. Functioning pituitary tumors can produce one or more hormones normally produced by the anterior pituitary. Brain tumors rarely metastasize outside the CNS. Altered pituitary function. causing any or all of the following pathophysiologic events: Increased intracranial pressure (ICP) and cerebral edema. and enlargement and erosion of the sella turcica. optic chiasm. as recent research shows that these tumors are more sensitive to chemotherapy than astrocytomas. Adenomas that secrete thyroid-stimulating hormone occur infrequently. Tumors usually grow as a spherical mass. glioblastoma multiforme. increased ICP. Standard treatment is surgery with complete removal or partial dissection. are common benign encapsulated tumors of arachnoid cells on the meninges. the histologic distinction between astrocytomas and oligodendrogliomas is difficult to make but important.e. Angiomas 206 | P a g e . Different physiologic changes result. astrocytomas. but they can grow diffusely and infiltrate tissue.

diplopia. such as sensory and motor abnormalities. the client develops signs and symptoms of increased ICP. nausea. these clients are at risk for a cerebral vascular accident (stroke). The effect is a disruption of the equilibrium that exists between the brain. compressing. including motor. it is described as projectile vomiting. Frontal tumors usually produce a bilateral frontal headache. A cerebellar tumor causes dizziness. many tumors can be localized by correlating the signs and symptoms to known areas of the brain: A motor cortex tumor produces seizure-like movements localized on one side of the body (Jacksonian seizures). It is thought to be caused by the tumor invading. Because the walls of the blood vessels in angiomas are thin. an ataxic or staggering gait with a tendency to fall toward the side of the lesion. in cerebral tumors. An occipital lobe tumor produces visual manifestations: contralateral homonymous hemianopsia and visual hallucinations. Cerebral hemorrhage in people younger than 40 years of age should suggest the possibility of an angioma. Occasionally. Papilledema is present in 70% to 75% of clients and is associated with visual disturbances such as decreased visual acuity. Some tumors are not easily localized because they lied in so-called silent areas of the brain. marked muscle incoordination. and visual field deficits. the diagnosis is suggested by the presence of another angioma somewhere in the head or by a bruit audible over the skull. 207 | P a g e . alterations in cognition. As the tumor grows. and reduction of intracellular and extracellular brain tissue mass. Vomiting. Clinical Manifestations Increasing ICP . seldom related to food intake. A frontal lobe tumor frequently produces personality disorders. are also common. Headaches are usually described as deep or expanding or as dull but unrelenting. and the cerebral blood. additional local signs and symptoms occur. Localized Symptoms The most common focal or localized symptoms are hemiparesis. usually in the horizontal direction. visual alterations. compensatory adjustments may occur through compression of intracranial veins. reduction of CSF volume. or sudden movement. The progression of the signs and symptoms is important because it indicates tumor growth and expansion. and language disturbances (aphasia). and an uninterested mental attitude. and nystagmus.Symptoms of ICP result from a gradual compression of the brain by the enlarging tumor. pituitary gland tumors produce pain radiating between the two temples (bitemporal). Headache. all located within the skull. the headache may be located in the suboccipital region at the back of the head. others cause symptoms of a brain tumor. Some persist throughout life without causing symptoms. and vomiting. although not always present. and cranial nerve dysfunction. the cerebrospinal fluid (CSF). is most common in the early morning and is made worse by coughing. When specific regions of the brain are affected. or distorting painsensitive structures or by edema that accompanies the tumor. Personality changes and a variety of focal deficits. changes in emotional state and behavior. sixth-nerve palsy. The client often becomes extremely untidy and careless and may use obscene language. sensory. straining. a modest decrease of cerebral blood flow. When these compensatory mechanisms fail. seizures. If the vomiting is of the forceful type. and mental status change. The three most common signs of increased ICP are headache.Brain angiomas (masses composed of largely abnormal blood vessels) are found either in or on the surface of the brain. is usually due to irritation of the vagal centers in the medulla. They occur in the cerebellum in 83% of cases.

and density of the lesions and the extent of secondary cerebral edema. reprogramming the tumor tissue for susceptibility to treatment (this is being tested). size.  A neurologic examination indicates the areas of the CNS involved. Assessment and Diagnostic Findings  History of the illness and the manner and time frame in which the symptoms evolved are key components in the diagnosis of brain tumors. This approach is used in clients with meningiomas.  CT scans.  Cytologic studies of the CSF may be performed to detect malignant cells because CNS tumors can shed cells into the CSF. can give specific information concerning the number. Later. Surgical management  The objective is to remove or destroy the entire tumor without increasing the neurologic deficit or to relieve symptoms by partial removal.  Photodynamic therapy (new technique) is a treatment of primary malignant brain tumors that delivers a targeted therapy while conserving healthy brain tissue. where bone interferes with CT.  PET scan is used to supplement MRI. generally used as an adjunct to conventional radiation therapy or as a rescue measure for recurrent disease.  Corticosteroids may be used before and after treatment to reduce cerebral edema and promote a smoother. Finally. and to provide a basis for treatment and prognosis. particularly smaller lesions. weakness or paralysis of the face develops (cranial nerve VII involvement).  IV autologous bone marrow transplantation is used in some clients who will receive chemotherapy or radiation therapy because it has the potential to ―rescue‖ the client from the bone marrow toxicity associated with high doses of chemotherapy and radiation. enhanced by a contrast agent. and tumors in the brain stem and pituitary regions. congenital 208 | P a g e . Numbness and tingling of the face and the tongue occur (involvement of cranial nerve V).A cerebellopontine angle tumor usually originates in the sheath of the acoustic nerve and gives rise to a characteristic sequence of symptoms. lowgrade tumors are associated with hypometabolism and high-grade tumors show hypermetabolism (this information is useful in treatment decisions). Medical Management  Radiation therapy (cornerstone of treatment of many brain tumors) decreases the incidence of recurrence of incompletely resected tumors. cystic astrocytomas of the cerebellum.  MRI is the most helpful diagnostic tool for detecting brain tumors.  Gene-transfer therapy uses retroviral vectors to carry genes to the tumor.  Computer-assisted stereotactic (three-dimensional) biopsy is being used to diagnose deep-seated brain tumors. colloid cysts of the third ventricle. on PET. more rapid recovery.  Conventional surgical approaches require an incision into the skull (craniotomy). acoustic neuromas. because the enlarging tumor presses on the cerebellum.  Electroencephalogram (EEG) can detect an abnormal brain wave in regions occupied by a tumor and is used to evaluate temporal lobe seizures and assist in ruling out other disorders.  Cerebral angiography provides visualization of cerebral blood vessels and can localize most cerebral tumors. Tinnitus and vertigo appear first.  Brachytherapy has had promising results for primary malignancies. soon followed by progressive nerve deafness (cranial nerve VIII dysfunction). abnormalities in motor function may be present.

radiation therapy extends the median survival to 3 to 6 months. Neurologic signs and symptoms include headache.  Teach the client who has diminished gag response to direct food and fluids toward the unaffected side. and ongoing monitoring and intervention for prevention of injury. and place. inaccessible tumors to be treated. visual impairment. adapting to weakness or paralysis and to visual and speech loss. complete removal of the tumor and cure are not possible. and dealing with seizures. offering a semisoft diet. and reducing the bulk of the tumor.  Check motor functions at intervals because specific motor deficits may occur depending on the tumor‘s location. altered mentation. space nursing interventions to prevent rapid increase in ICP. but the rationale for resection includes relieving ICP. supervision of and assistance with self-care. aphasia. maintain a neurologic flow chart. and having suction readily available. and walking. perform neurologic checks. and reorient the client when necessary to person. and some of the granulomas. and chemotherapy.  The median survival for clients with no treatment for brain metastases is 1 month. and focus on how the client is functioning. gait disturbances. occurring in 20% to 30% of clients with cancer. Gamma knife radiosurgery is considered when three or fewer lesions are present.  The therapeutic approach includes radiation therapy (the foundation of treatment). 209 | P a g e . moving.  The use of gamma knife to perform radiosurgery allows deep. For clients with malignant glioma. more often some combination of these treatments is the optimal method.  Assess sensory disturbances.  Evaluate the gag reflex and the ability to swallow preoperatively. paralysis. time.  For clients with increased ICP.  Clients with changes in cognition caused by the lesion require frequent reorientation and the use of orienting devices.  Carefully monitor and protect clients with seizures from injury. monitor vital signs. Nursing Process for the Client with Cerebral Metastases or Incurable Brain Tumor Assessment  Assessment includes baseline neurologic examination.  Reassess function postoperatively. and seizures.tumors. personality changes.  Stereotactic approaches involve the use of a three-dimensional frame that allows very precise localization of the tumor. often in a single session.  Evaluate speech. a stereotactic frame and multiple imaging studies are used to localize the tumor and verify its position. which theoretically leaves behind fewer cells to become resistant to radiation or chemotherapy. Cerebral Metastases Metastatic lesions to the brain constitute the most common neurologic complication.  Check eye movement and papillary size and reaction which may be affected by cranial nerve involvement. removing any necrotic tissue. Medical Management  Treatment is palliative and involves eliminating or reducing serious symptoms. having the client sit upright to eat. Nursing Management  The client with a brain tumor may be at an increased risk for aspiration due to cranial nerve dysfunction. surgery (usually for a single intracranial metastasis). with corticosteroid treatment alone is 2 months. focal weakness.

weakness. adaptations. Take a dietary history to assess food intake. Ask assistance from a dietitian in determining the caloric needs of the client. diarrhea. planning. and about distortions and impaired sense of smell (anosmia). fluid balance.  Assess (together with other members of the health care team) the impact of illness on the family in terms of home care. vomiting. less than body requirements.  Encourage the client and the family to plan for each day and to make the most of each day. and temperature regulation. and impairment of skin integrity. vomiting. bathing. fever. and family problems. vomiting. intolerance. and decreased mobility  Deficient fluid volume related to fever. and altered lifestyle  Interrupted family process related to anticipatory grief and the burdens imposed by the care of the person with a terminal illness  Acute pain related to tumor compression  Impaired gas exchange related to dyspnea  Constipation related to decreased fluid and dietary intake and medications  Impaired urinary elimination relayed to reduced fluid intake. breathlessness. Address symptoms that cause distress to the client. Calculate body mass index that can confirm the loss of subcutaneous fat and lean body mass. and ask the client about altered taste sensations that may be secondary to dysphagia.  Assist the client to find useful coping mechanisms. respiratory problems. altered relationships.  Increase assistance with self-care activities. financial problems. and preferences. change in appearance. and electrolyte balance. poor tissue perfusion. and malabsorption  Anxiety related to fear of dying. 210 | P a g e . and chills Planning and Interventions  Compensate for self-care deficits  Encourage the family to keep the client as independent for as long as possible. Review biochemical measures to assess the degree of malnutrition. toileting) related to loss or impairment of motor and sensory function and decreased cognitive abilities  Imbalanced nutrition. and low fluid intake  Ineffective thermoregulation related to hypothalamic involvement. time pressures.  Refer to home or hospice care if necessary. and care. endurance.     Improve nutrition Manage and control nausea. and range of motion. sleep disturbances. decreased nutritional intake. Explore changes associated with poor nutritional status. uncertainty.  Assist with an individualize exercise program to help maintain strength. Teach the family how to position the client for comfort during meals. impaired cellular immunity.  Assess nutritional status because cachexia is common in clients with metastases. and pain through assessment. and depression. and reactions to medications  Sleep pattern disturbances related to discomfort and fear of dying  Impaired skin integrity related to cachexia. related to cachexia due to treatment and tumor effects. including pain. Plan meals for the times the client is rested and in less distress from pain or the effects of treatment. and compensations in solving problems that arise to help the client maintain some sense of control. Nursing Diagnoses  Self-care deficit (feeding. bowel and bladder disorders.

Make home care nursing and hospice services available to the client and the family early in the course of a terminal illness. Instruct the family members about maintaining nutritional support if they will be providing care at home. Spend time with the client and allow him/her to talk and to communicate their fears and concerns. For a client with nutritional support: assess the patency of the central and IV line or feeding tube. 211 | P a g e . They include intramedullary lesions (within the spinal cord). social worker. and change IV tubing and dressing.             Provide an environment that is attractive as possible since the client needs to be clean. and extramedullary-extradural lesions (outside the dural membrane). comfortable. Evaluation o Expected client outcomes include the following (Theclient…) o Engages in self-care activities as long as possible o Maintains as optimal a nutritional status as possible o Reports being less anxious o Family members seek help as needed Spinal Cord Tumors Tumors within the spine are classified according to their anatomic relation to the spinal cord. and inform them about resources and services early to assist them to deal with changes in the client‘s condition. Refer to support groups if client prefers/wishes to be a part of one. monitor intake and output. Encourage the presence of family. Use creative strategies to make food more palatable. to meet increased caloric needs Offer food preferred by the client. Promote home and community-based care Teach the client and the family strategies of pain management. provide enough fluids. Enhance family processes Reassure the family that their loved one is receiving optimal care and that attention will be paid to the client‘s changing symptoms and to their concerns. Provide parenteral nutrition at home if indicated. extramedullary-intradural lesions (within or under the spinal dura). Ask the family to keep a daily weight chart and to record the quantity of food eaten to determine the daily calorie count. monitor the insertion site for infection. as the disease progresses. and health professionals to convey support. Reassure client that continuing care will be provided and that they will not be abandoned. and methods to ensure adequate food and fluid intake. if acceptable to the client. Provide dietary supplement. Nutritional support may be indicated (if consistent with the client‘s end -of-life preferences) when the client shows marked deterioration as a result of tumor growth and effects. and increase opportunities for socialization during meals. check the infusion rate. if he/she is not interested in most usual foods. Relieve anxiety Be sensitive to the client‘s concerns and needs. A nursing goal is to keep anxiety at a manageable level. or mental health professional may be indicated if a client‘s emotional reactions are very intense or prolonged. Additional help from a spiritual advisor. Assess the changing needs of the client and the family. The family and additional support systems may be needed when the client can no longer carry out self-care. friends. prevention of complications related to treatment strategies. and free of pain for meals. a spiritual advisors.

 Includes assessment of pain. Obtain and report a history of aspirin intake because the use of aspirin may impede hemostasis postoperatively. strength.  Surgical intervention is the primary treatment for most spinal cord tumors. and the tumor origin. Sharp pain occurs in the area innervated by the spinal roots that arise from the cord in the region of the tumor (usually).  The goal is to remove as much tumor as possible while sparing uninvolved portions of the spinal cord. bowel and bladder dysfunction.  In clients with this condition resulting from metastatic cancer.  Evaluate the client for coagulation deficiencies.  Epidural spinal cord compression occurs in approximately 5% of clients who die of cancer and is considered a neurologic emergency. Medical Management  Treatment of specific intraspinal tumors depends on the type and location of the tumor and the presenting symptoms and physical status of the client. particularly for intramedullary tumors and metastatic lesions. and management of altered activities of daily living due to sensory and motor deficits and bowel and bladder dysfunction.  Tumor removal is desirable but is not always possible.  Other treatment modalities include partial removal of the tumor. legs. loss of reflexes.  Carry out frequent neurologic checks with emphasis on movement.Tumors occurring within the spinal cord or exerting pressure on it cause symptoms ranging from localized or shooting pains and weakness and loss of reflexes above the tumor level to progressive loss of motor function and paralysis.  Assess for weakness. decompression of the spinal cord. and MRI. Assessment and Diagnostic Findings  Neurologic examination and diagnostic studies are used to make the diagnosis. 212 | P a g e .  Clients with extensive neurologic deficits before surgery usually do not make significant functional recovery even after successful tumor removal. especially if cervical tumor is present.  Assess the client after surgery  Monitor for deterioration in neurologic status. and sensation of the upper and lower extremities. Nursing Management  Provide preoperative care  Preoperative care objectives include recognition of neurologic changes through ongoing assessment. spasticity. if there is. muscle wasting.  Microsurgical techniques have improved the prognosis for clients with intramedullary tumors.  Assess sensory function by pinching the skin of the arms. A sudden onset of neurologic deficit is an ominous signs and may be due to vertebral collapse associated with spinal cord infarction. and trunk to determine if there is loss of feeling and. determine the level.  Helpful diagnostic studies include x-rays. and the presence of weakness and paralysis.  Teach and demonstrate breathing exercises. chemotherapy. pain control.  Prognosis is related to the degree of neurologic impairment at the time of surgery. and radiation therapy. sensory changes.  Discuss postoperative pain management strategies with the client. and potential respiratory problems. Increasing deficits also develop below the level of the lesion. loss of sensation or motor function. MRI is the most sensitive diagnostic tool and is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases. the speed with which symptom occurred. high-dose dexamethasone combined with radiation therapy is effective in relieving pain. radionuclide bone scans.

Manage pain Administer the prescribed pain medication in adequate amounts and at appropriate intervals to relieve pain and prevent its recurrence. Teach the client to check skin integrity daily. Assess for urinary retention by palpating the area over the bladder or by performing a bladder scan. Caution clients with residual sensory involvement about the dangers of extremes in temperature. which may lead to serious infection or to an inflammatory reaction in the surrounding tissues that can cause severe pain in the postoperative period. in activities of daily living and safe use of assistive devices. Encourage the client to perform deep-breathing and coughing exercises. Refer the client to inpatient or outpatient rehabilitation to improve self-care abilities. keeping shoulders and hips aligned and the back straight. Monitor for staining of the dressing which may indicate leakage of CSF from the surgical site. and abnormal breath sounds. Monitor for incontinence because urinary dysfunction usually implies significant decompensation of spinal cord function. with impaired motor function related to motor weakness or paralysis..                     Monitor vital signs at regular intervals. Keep in mind that pain is the hallmark of spinal metastasis. abdominal breathing. Promote home and community-based care Assess the client for their ability to function independently in the home and for the availability of resources (e. Place a pillow between the knees of the client in a side-lying position to help prevent extreme knee flexion. and assessment for signs and symptoms that should be reported promptly. Refer to home care if indicated. Place the client in a side-lying position which is usually the most comfortable because this position imposes the least pressure on the surgical site. Monitor and manage potential complications Monitor the client for asymmetric chest movement. bowel and bladder management. Instruct the client and family about pain management strategies. Train clients. Maintain a record of intake and output. family members to assist in care giving) in preparation for discharge. Auscultate the abdomen for bowel sounds. 213 | P a g e . Turn the client as a unit.g. Keep the bed flat initially.

Bone Tumors 214 | P a g e .

vertebrae. The neoplastic tissue is surrounded by reactive bone formation that assists in its identification by x-ray. Clinical manifestations include pain. and fibrosarcoma. the only symptom is a mild ache. Appears most frequently in males between the ages of 10 and 25 years (in bones that grow rapidly). and fibroma. and rhabdomyosarcoma. and as a result of radiation exposure.Benign Bone Tumors Benign tumors of the bone and soft tissue are more common than malignant primary bone tumors. Bone cysts are expanding lesions within the bone. Benign bone tumors generally are slow growing and well circumscribed. Soft tissue sarcomas include liposarcoma. or flat bone. Giant cell tumors (osteoclastomas) are benign for long periods but may invade local tissue and cause destruction. Usually.. Usually occurs as a large projection of the bone at the end of lone bones (at the knee or shoulder). Unicameral (single cavity) bone cysts occur in children and cause mild discomfort and possible pathologic fractures of the upper humerus and femur. Malignant Bone Tumors Primary malignant musculoskeletal tumors are relatively rare and arise from connective and supportive tissue cells (sarcomas) or bone marrow elements. Pathologic fractures may occur. osteoid osteoma. Prognosis depends on whether the tumor has metastasized to the lungs at the time the client seek health care. fibrosarcoma of soft tissue. femur. swelling. limited motion. enchondroma. Osteogenic sarcoma (osteosarcoma) is the most common and most often fatal primary malignant bone tumor. Malignant primary musculoskeletal tumor includes osteosarcoma. present few symptoms. Ewing‘s sarcoma. rhabdomyoma. and are not a cause of death. Eventually. A painful tumor that occurs in children and young adults is the osteoid osteoma. who present with a painful. bone cyst.g. and weight loss (which is considered and ominous finding). Aneurysmal (widening) bone cysts are seen in young adults. giant cell tumors) have the potential to become malignant. Bone tumor metastasis to the lungs is common. Develops during growth and then becomes a static by bony mass. in older people with Paget‘s disease. Osteochondroma is the most common benign tumor. Enchondroma is a common tumor of the hyaline cartilage that develops in the hand. tibia. Benign primary neoplasms of the musculoskeletal system include osteochondroma. giant cell tumors may undergo malignant transformation and metastasize. or humerus. palpable mass of the long bones. chondrosarcoma. Some benign tumors (e. and a chondrosarcoma or osteosarcoma may develop. 215 | P a g e . which may heal spontaneously. The cartilage cap of the osteochondroma may undergo malignant transformation after trauma. They occur in young adults and are soft and hemorrhagic.

bone scan. The most common primary sites for tumors that metastasize to the bone are the kidney. CT scan. tender. MRI.  The tumor may be diagnosed only after pathologic fracture has occurred.  Neurologic deficits must be identified early and treated with decompressive laminectomy to prevent permanent spinal cord injury. femur.  Primary tumors cause bone destruction. and biochemical assays of the blood and urine). resulting in bone fractures. and humerus and involve more than one bone (polyostotic). These tumors are the second most common primary malignant bone tumor. in contrast. and tibia. with an increase in skin temperature over the mass and venous distention. but the most common sites are the distal femur. large bloc excision or amputation of the affected extremity results in increased survival rates. serum acid phosphatase levels are elevated. femur. lung. at times. These tumors may recur.  A benign bone tumor. controlled growth pattern and place pressure on the adjacent bone tissue. spinal cord compression may occur. slow-growing tumors that affect adults. myelography. Metastatic tumors most frequently attack the skull. ovary. and thyroid.  Serum alkaline phosphatase levels are frequently elevated with osteogenic sarcoma. has a symmetric. the proximal tibia. Pathophysiology  A tumor in the bone causes the normal bone tissue to react by osteolytic response (bone destruction) or osteoblastic response (bone formation).. humerus. 216 | P a g e .  Weight loss. prostate. which weakens the bone. The primary lesion may involve any bone. or kidney cancer bone metastases. bulky. varying degrees of disability. Metastatic Bone Disease Metastatic bone disease (secondary bone tumor) is more common than any primary bone tumor. lung. biopsy. Tumors arising from tissues elsewhere in the body may invade the bone and produce localized bone destruction (lytic lesions) or bone overgrowth (blastic lesions).  They may be symptom free or have pain (mild and occasional to constant and severe).  Chest x-rays are performed to determine the presence of lung metastasis.  It can progress rapidly or slowly.  Hypercalcemia is present with breast. The usual tumor sites include the pelvis. They are large. scapula. and fever may be present. pelvis.  The bone‘s surface changes and the contours enlarge in the tumo r area. Clinical Manifestations  Clients with metastatic bone tumor may have a wide range of associated clinical manifestations. When these tumors are well differentiated. and diagnostic studies (i.  With metastatic carcinoma of the prostate. malaise. Metastasis to the lungs occur fewer than half of clients. breast. Malignant tumors of the hyaline cartilage are called chondrosarcomas. spine.  With spinal metastasis.  Malignant invading bone tumors weaken the structure of the bone until it can no longer withstand the stress of ordinary use. and. arteriography.  Adjacent normal bone responds to the tumor by altering its normal pattern of remodeling. Assessment and Diagnostic Findings  The differential diagnosis is based on the history. spine.  Malignant bone tumors invade and destroy adjacent bone tissue. physical examination. and fixed. pathologic fracture commonly results. and the proximal humerus. obvious bone growth.e.The bony mass may be palpable.

 Hypercalcemia results from breakdown of bone. total joint arthroplasty. structural support and stabilization are needed to prevent pathologic fractures. pamidronate.  Soft-tissue sarcomas are treated with radiation. with the amputation extending well above the tumor to achieve local control of the primary lesion. surgery. joint fibrosis.  A customized prosthesis. intraoperative. The therapeutic goal is to relieve the client‘s pain and discomfort while promoting quality of life. Surgical staging of musculoskeletal tumors is based on tumor grade and site.  Clients with multiple bony metastases may achieve pain control with systematically administered ―bone-seeking‖ isotopes. including the osseous metastasis. and arthritis. and calcitonin).  Metastatic Bone Disease  The treatment is palliative. Blood product transfusions restore hematologic factors.  Hematopoiesis is frequently disrupted by tumor invasion of the bone marrow or by treatment (chemotherapy or radiation). and medications (e. large bones with metastatic lesions are strengthened by prophylactic internal fixation. as well as on metastasis. chemotherapy or radiation side effects.  Soft tissue and blood vessels may need grafting because of the extent of the excision. 217 | P a g e . diuresis. and hemorrhage than other clients after orthopedic surgery. and adjunctive for possible micrometastases).  Limb-sparing (salvage) procedures are used to remove the tumor and adjacent tissue. Medical Management  Primary Bone Tumors  The goal of primary bone tumor treatment is to destroy or remove the tumor. deep vein thrombosis.  The goal of combined chemotherapy is greater therapeutic effect at a lower toxicity rate with reduced resistance to the medications. devitalization of the skin and soft tissue. nonopioid.  At times. loosening or dislocation of the prosthesis.  Chemotherapy is used to control the primary disease. limbsparing excision.  Combine chemotherapy is started before and continued after surgery in an effort to eradicate micrometastatic lesions.  Surgical removal of the tumor may require amputation of the affected extremity. mobilization. postoperative.  Treatment includes hydration with IV administration of normal saline solution. allograft nonunion. hypoxemia. radiation therapy if the tumor is radiosensitive. and recurrence of the tumor. bisphosphanates.  This may be accomplished by surgical excision (ranging from local excision to amputation and disarticulation).  Radiation and hormonal therapy may be effective in promoting healing of osteolytic lesions.  External beam radiation to involved metastasis sites may be used.  Clients with metastatic disease are at a higher risk for pulmonary congestion. fracture. or bone tissue from the client (autograft) or from a cadaver donor (allograft) replaces the resected tissue. and chemotherapy (preoperative.  Complications may include infection.  If metastatic disease weakens the bone..  Assess pain accurately and manage with adequate and appropriate opioid.g.  Pain can result from multiple factors. and adjuvant chemotherapy. and nonpharmaceutical interventions.

 Prepare the client and give support during painful procedures. how the client and the family have been coping.  Promote coping skills  Encourage the client and the family to verbalize their fears. 218 | P a g e . perception of disease process. and how the client has managed the pain.  Prevent pathologic fracture  Support and handle affected extremities gently during nursing care.  Explain the diagnostic tests.  Use pharmacologic and nonpharmacologic pain management techniques to relieve pain and increase the client‘s comfort level.  Work with the client in designing the most effective pain management regimen to increase his/her control over the pain. Oral or transdermal opioid or nonopioid analgesics are usually used later to adequately relieve pain.Nursing Process for the Client with a Bone Tumor Assessment  Ask the client about the onset and course of symptoms. and feelings.  Note the client‘s understanding of the disease process. and tenderness.  Follow prescribed weight-bearing restrictions after a surgery (open reduction with internal fixation or joint replacement).  Teach the client how to use assistive devices safely and how to strengthen unaffected extremities.  Used prescribed IV or epidural analgesics during the early postoperative period.  Reinforce and clarify information provided by the physician by being present during discussions. Nursing Diagnoses  Deficient knowledge related to the disease process and the therapeutic regimen  Acute and chronic pain related to pathologic process and surgery  Risk for injury: pathologic fracture related to tumor and metastasis  Ineffective coping related to fear of the unknown.  On physical examination. gently palpate the mass and note its size and associated soft tissue swelling.  Evaluate the client‘s mobility and ability to perform activities of the daily living.  External radiation or systemic radioisotopes may be used to control pain.  Relieve pain  Assess pain accurately. concerns.  Assess the neurovascular status and range of motion of the extremity to provide a baseline data for future comparisons. treatments. and expected results to help the client to deal with the procedures and changes.  Use external supports for additional protection. pain. and inadequate support system  Risk for situational low self-esteem related to loss of body part or alteration in role performance Planning and Interventions  Promote understanding of the disease process and treatment regimen  Teach the client and the family about the disease process and diagnostic and management regimens.

Monitor the white blood cell count for a client receiving chemotherapy and instruct him/her to avoid contact with people who have colds or other infections. and grief. Expect feelings of shock. Provide adequate hydration.            Support the client and family as they deal with the impact of the malignant bone tumor. Nutritional supplements or total parenteral nutrition may be prescribed to achieve adequate nutrition. psychologist. Provide realistic reassurance about the future and resumption of role-related activities and encourage self-care and socialization. Prevent the occurrence of other infections during healing so that hematogenous spread does not result in osteomyelitis. despair. Encourage the client to participate in planning daily activities and to be independent as possible. Use an aseptic. Involve the client and the family all throughout the treatment to encourage confidence. or spiritual advisor for specific psychological help and emotional support. Evaluation  The following are expected outcomes for a client with a bone tumor (The client…):  Describes the disease process and treatment regimen  Achieves control of pain  Experiences no pathologic fracture  Demonstrates effective coping patterns  Demonstrates positive self-concept  Exhibits absence of complications  Participates in continuing health care at home 219 | P a g e . Assist the client in dealing with changes in body image due to surgery and possible amputation. Monitor and report laboratory findings to facilitate initiation of interventions to promote homeostasis and wound healing. Promote self-esteem Support the family in working through the adjustments that must be made. Hypercalcemia Symptoms of hypercalcemia must be recognized and treatment should be initiated promptly. Osteomyelitis and wound infections Use prophylactic antibiotics and strict aseptic dressing techniques to diminish the occurrence of osteomyelitis and wound infections. Control stomatitis with anesthetic or antifungal mouthwash. restoration of self-concept. Monitor and manage potential complications Delayed wound healing Minimize pressure on the wound site to promote circulation to the tissues. counselor. Special therapeutic beds may be needed to prevent skin breakdown and to promote wound healing after extensive surgical reconstruction and skin grafting. Reposition the client at frequent intervals to reduce the incidence of skin breakdown due to pressure. Refer to a psychiatric nurse liaison. and a sense of being in control of one‘s life. nontraumatic wound dressing to promote healing. Inadequate nutrition. Administer antiemetics and encourage use of relaxation techniques to reduce gastrointestinal reaction.

There are two types: Ductal Carcinoma in Situ (DCIS). divided histologically into two major subtypes. 220 | P a g e . comedo and noncomedo. Use of tamoxifen for women with DCIS after treatment with surgery and radiation is usually prescribed for five years. without invasion into the surrounding tissues. but this is decided on a case-to-case basis.In situ carcinoma of the breast is being detected more frequently with the widespread use of screening mammography. the most traditional treatment is total or simple mastectomy. it is a noninvasive form of cancer and is considered stage 0 breast cancer. Breast-conservation therapy (limited surgery followed by radiation) is an option appropriate for localized lesions for clients with DCIS. Lumpectomy alone is also a treatment option. More common of the two types.Breast Cancer Malignant Conditions of the Breast Carcinoma in Situ (Noninvasive) . therefore. Because DCIS has the capacity to progress to invasive cancer. This disease is characterized by the proliferation of malignant cells within the ducts and lobules.

lung. a tumor mass cannot be palpated underneath the nipple where this disease arises. making biopsy of the lesion the only definitive test. and the skin over it is red and dusky. or brain.The neoplasm is ductal and may be in situ alone or may also have invasive cancer cells. Infiltrating ductal and infiltrating lobular carcinoma usually spread to bone. Invasive Carcinoma Infiltrating Ductal Carcinoma. it is also slow-growing and thus has a more favorable prognosis than many other types. The symptoms mentioned rapidly grow more severe and usually prompt the woman to seek health care sooner than the woman with small breast mass. nulliparity.  Hormones. Edema and nipple retraction often occur. hormones. Often. childbirth after 30 years of age. Long-term surveillance is an appropriate option of treatment rather than bilateral total mastectomy. Mammography may be the only diagnostic test that detects the tumor. Prognosis is usually excellent with this type because axillary metastases are uncommon with this histology. Are most often multicentric (several areas of thickening may occur in one or both breasts). Hormones produced by the ovaries have an important role in breast cancer. chemotherapeutic agents play a major role in attempting to control the progression of this disease. increasing the chance for cancer to develop. Inflammatory Carcinoma. These tumors typically occur as an area of illdefined thickening in the breast. Estrogen itself does not cause breast cancer. liver. A rare type of breast cancer with symptoms different from those of other breast cancers. but it is associated with its development. and these may affect growth factors for breast cancer. as compared with the infiltrating ductal types. provides the cells of the breast another chance to mutate. The disease can spread to other parts of the body rapidly. but results of the mammogram are often negative. prognosis is poorer than for other types of cancer.Lobular Carcinoma in Situ (LCIS). Tubular Ductal Cancer. menarche. The most common histologic type of breast cancer. Tamoxifen as a chemopreventive agent prescribed for five years for women at high risk. Another option is a bilateral prophylactic mastectomy to decrease risk. A mucin producer. which has high levels of endogenous estrogen. Radiation and surgery are also used to control spread. but the prognosis is often favorable. LCIS is usually an incidental finding discovered on pathologic evaluation of a breast biopsy for a breast change noted during physical examination or on screening mammography. The breast is abnormally firm and large. whereas lobular carcinomas may metastasize to meningeal surfaces or other unusual sites. Grows in a capsule inside a duct. and environmental events may contribute to its development. Paget’s Disease A scale lesion and burning and itching around he nipple-areola complex are frequent symptoms. Research suggests that a relationship between estrogen exposure and the development of breast cancer. The theory is that each cycle. this type of tumor can become larger. Mucinous Cancer. Infiltrating Lobular Carcinoma. Medullary Carcinoma. these tumors are notable because of their hardness on palpation. the localized tumor is tender and painful. 221 | P a g e . It is commonly associated with multicentric disease and is rarely associated with invasive cancer. Estradiol and progesterone (two key ovarian hormones) are altered in the cellular environment by a variety of factors. Usually metastasize to the axillary nodes. This is characterized by proliferation within the breast lobules. genetic. and late menopause are assumed to be associated with prolonged exposure to estrogen because of menstruation. Etiology  There is no single specific cause of breast cancer.

where most breast tissue is located. Genetic alterations include changes or mutations in normal genes and the influence of proteins that either promote or suppress the development of breast cancer. but less so for ovarian cancer. excisional biopsy. Marked pain at presentation may be associated with breast cancer in the later stages. but. bone scans. Lesions are nontender rather than painful. but are detected on mammography. They may seek attention for: Dimpling or a peau d’ orange (orange-peel) appearance of the skin. Breast Cancer Staging  Stage I: Tumors are less than 2 cm in diameter and are confined to breast. 222 | P a g e . Genetic alterations may be somatic (acquired) or germline (inherited). Risk Factors  BRCA-1 and BRCA-2 genetic mutation  Increasing age (genetic risks for breast cancer occurs after age 50)  Personal or family history of breast cancer  Early menarche (menses beginning before 12 years of age)  Nulliparity and late maternal age at first birth  Late menopause  History of benign proliferative breast disease  Exposure to ionizing radiation between puberty and 30 years  Obesity  Hormone replacement therapy  Alcohol intake Clinical Manifestations Breast cancer occurs anywhere in the breast. and stereotactic biopsy are techniques used to determine the histology and tissue diagnosis of breast cancer. Abnormalities in either of the two genes can be identified by blood tests. and liver function tests are diagnostic tests and procedures performed in the staging of the disease. incisional biopsy. Many women with advanced disease seek initial treatment only after ignoring symptoms. whereas a mutation in the BRCA-2 gene identifies risk for breast cancer. and hard with irregular borders rather than encapsulated and smooth (generally). Genetics. fixed rather than mobile.  Clinical staging involves the physician‘s estimate of the size of the breast tumor and the extent of axillary node involvement by physical examination and mammography. A mutation in the BRCA-1 gene has been linked to the development of breast and ovarian cancer. but most are found in the upper outer quadrant. a condition caused by swelling that results from obstructed lymphatic circulation in the dermal layer Nipple retraction and lesions fixed to the chest wall may also be evident Involvement of the skin is manifested by ulcerating and fungating lesions Assessment and Diagnostic Findings  Fine-needle aspiration biopsy. needle localization. Complaints of diffuse breast pain and tenderness with menstruation are usually associated with benign breast disease.  Chest x-rays. Women seeking treatment at an earlier stage of disease have no symptoms and no palpable lump.  The breast cancer is staged according to the TNM system after the diagnostic workup and definitive surgical treatment. women should be counseled about the risks and benefits before actually undergoing genetic testing. Increasing evidence indicates that genetic alterations are associated with the development of breast cancer. core biopsy.

or tumors are accompanied by enlarged axillary lymph nodes fixed to one another or to adjacent tissue. wide excision. edema. Breast-Conserving Surgery  Consists of lumpectomy. ulceration. or quadrantectomy (resection of the involved breast quadrant) and removal of the axillary nodes (axillary lymph node dissection) for tumors with an invasive component followed by a course of radiation therapy to treat residual.  An objective of surgical treatment is to maintain or restore normal function to the hand. and it is examined by the pathologist. partial or segmental mastectomy.  The surgeon uses a hand-held probe to locate the sentinel node (the primary drainage from the breast) and excises it. microscopic disease. A radiocolloid and/or blue dye is injected into the tumor site.  The risk for local recurrence. in which the rest of the breast tissue is removed. is greater  than 1% per year after surgery.  Survival rates after breast-conserving surgery are equivalent to those after modified radical mastectomy.  This treatment includes both surgery and radiation. or tumors are smaller with mobile axillary lymph node involvement. a standard axillary dissection is not needed. arm. along with axillary lymph nodes. standard treatment is a completion or salvage mastectomy. Stage IV: All tumors with distant metastasis. a consultation is made with a plastic surgeon before the mastectomy is performed. Stage IIIa: Tumors are greater than 5 cm. Contraindications to this treatment include: Absolute contraindications o First or second trimester of pregnancy  Presence of multicentric disease in the beast  Prior radiation to the breast or chest region Relative contraindications  History of collagen vascular disease  Large tumor-to-breast ratio  Tumor beneath nipple Lymphatic Mapping and Sentinel Node Biopsy  The use of this technique is changing the way clients are treated because it provides the same prognostic information as the axillary dissection. and shoulder girdle on the affected side. Medical Management Surgical Management Modified Radical Mastectomy (MRM)  Removal of the entire breast tissue.  If the sentinel node is negative for metastatic breast cancer. Stage IIIb: More advanced lesions with satellite nodules. thus sparing the client the sequelae of the 223 | P a g e . fixation to the skin or chest wall. If the client experiences a local recurrence. pectoralis major and pectoralis minor muscles remain intact.    Stage II: Tumors are less than 5 cm.  If reconstructive surgery is planned.  The goal of breast conservation is to remove the tumor completely with clear margins while achieving an acceptable cosmetic result. or with supraclavicular or intraclavicular nodal involvement. however. the client then undergoes the surgical procedure.

fluorouracil (F). If the sentinel node is positive. or tumorslarger than 5 cm). in which a single dose of radiation is delivered to the lumpectomy site immediately after the surgeon has performed the lumpectomy. Docetaxel (T). or adrenal glands) with the goal of suppressing hormone secretion.  Oopherectomy is one treatment option for premenopausal women with estrogen-dependent tumors. Radiation Therapy  With breast-conserving surgery. is being used more frequently but research on its difference is still limited. leuprolide (Lupron).  If systemic chemotherapy is indicated.  treatment is necessary to obtain results equal to those of removal of the breast. four or more positive nodes.  Anastrozole (Arimidex).  Postoperative radiation after mastectomy is not common today but is still used in certain cases: when tumors have spread regionally (chest wall involvement. ovaries. the client undergoes the standard axillary dissection.  External-beam irradiation provided by a linear accelerator using photons is delivered on a daily basis over 5 to 7 weeks to the entire breast region. and doxorubicin (D). ACT (AC given first followed by T)..  Tamoxifen is the primary hormonal agent used.g. mastectomy is the client‘s option. radiation therapy usually begins after completion of the chemotherapy.  Radiation treatment typically begins about 6 weeks after the surgery to allow the incision to heal.  Hormonal therapy may include surgery to remove endocrine glands (e. procedure. letrozole (Femara). Chemotherapy  Chemotherapy regimens for breast cancer combine several agents to increase tumor cell destruction and to minimize medication resistance. with paclitaxel (Taxol) (T) as an addition. If radiation therapy is contraindicated. are other regimens that may be used. AC. generally after completion of systemic chemotherapy. clients who have had a mastectomy require radiation treatment to the chest wall.  Chemotherapeutic agents most often used in combination are cyclophosphamide (Cytoxan) (C).  Another approach is the use of intraoperative radiation therapy (IORT).  Occasionally. pituitary.  The combination regimen CMF or CAF is a common treatment protocol. Hormonal Therapy Decisions about hormonal therapy for breast cancer are based on the outcome of an estrogen and progesterone receptor assay of tumor tissue taken during the initial biopsy. and ATC. Nursing interventions for this procedure focus on informing the client about the expectations and possible complications. a course of externalbeam radiation therapy usually follows excision of the tumor mass to decrease the chance of local recurrence and to eradicate any residual microscopic cancer cells. methotrexate (M). Investigational Therapy  224 | P a g e . with all three agents given together. megestrol and aminoglutethimide (Cytadren) are other hormonal agents used to suppress hormone-dependent tumors. a newer taxane.

  Research in breast cancer treatment includes the following areas: bone marrow transplantation. growth factors. body image changes. Nursing Process for the Client with Breast Cancer Assessment  The health history includes an assessment of the client‘s reaction to the diagnosis and her ability to cope with it. 225 | P a g e . thus inhibiting tumor cell growth. surgical treatment. and fear of partner‘s responses  Deficient knowledge: drain management after breast surgery  Deficient knowledge: arm exercises to regain mobility of affected extremity  Deficient knowledge: hand and arm care after an axillary lymph node dissection Planning and Interventions Preoperative Nursing Interventions  Explain breast cancer and treatment options time for the client to absorb the significance of the diagnosis and any information that will help her evaluate treatment options. monoclonal antibodies. or friend available to assist her in making treatment choices?  What are the most important areas of information she needs?  Is the client experiencing any discomfort? Nursing Diagnoses Preoperative nursing diagnoses  Deficient knowledge about breast cancer and treatment options  Anxiety related to cancer diagnosis  Fear related to specific treatments. mportant questions to ask include the following:  How is the client responding to the diagnosis?  What coping mechanisms does she find the most helpful?  What psychological or emotional supporter does she have and use?  Is there a partner. breast. Herceptin binds with the HER2 protein. family member. change in selfimage. or chest wall  Risk for sexual dysfunction related to loss of body part. and fear of death  Self-care deficit related to partial immobility of upper extremity on operative side  Disturbed sensory perception (kinesthesia) related to sensations in affected arm. and this protein regulates cell growth. Another treatment modality that has shown promise is trastuzumab (Herceptin). oncogenes. biologic response modifiers. and vaccine studies. or possible death  Risk for ineffective coping (individual or family) related to the diagnosis of breast cancer and related treatment options  Decisional conflict related to treatment options  Postperative nursing diagnoses  Acute pain related to surgical procedure  Impaired skin integrity due to surgical incision  Risk for infection related to surgical incision and presence of surgical drain  Disturbed body image related to loss or alteration of the breast related to the surgical procedure  Risk for impaired adjustment related to the diagnosis of cancer. peripheral stem cell transplants.

Discuss the implications of each treatment option and how it may affect various aspects of the client‘s treatment course and lifestyle. management of side effects.. Refer client to the advanced practice nurse or oncology social worker to help the client and family discuss some of the personal issues that may arise in relation to treatment. prostheses and plastic surgery). psychologist. Discuss and plan with the client methods to compensate for physical changes related to mastectomy (e. the location and extent of the tumor. and postoperative treatments involving radiation therapy and chemotherapy to enable the client make informed decisions. and to take warm shower twice daily (usually allowed on the second postoperative day) to alleviate the discomfort that comes from referred muscle pain. Discuss with the client medications.  Encourage the client to take analgesic agents before exercises or at bedtime.  Maintain skin integrity and prevent infection 226 | P a g e . Promote decision-making ability Careful guide and provide supportive counselling to help the client make a decision about her treatment. Provide anticipatory teaching and counseling at each stage of the process and identify the sensations that can be expected during additional diagnostic procedures. Be aware of the information that has been given by the physician to the client. Evaluate if the client needs a mental health consultation before surgery to assist her in coping with the diagnosis and impending treatment. social. Provide information about the surgery. Encourage the client to take one step of the treatment process at a time.  Administer intravenous or intramuscular opioid analgesic agents to manage the pain in the initial postoperative phase. and social worker) and acquaint her with the role of each in her care. Encourage the client to talk with a breast cancer survivor for reassurance. and prevent venous congestion in the affected extremity).  Moderately elevate the involved extremity to relieve pain (decreases tension on the surgical incision.  Administer oral analgesics after the anesthesia has cleared sufficiently and the client is able to take in fluids and food per orem. radiation oncologist.                  Be knowledgeable about current treatment and be able to discuss them with the client.g. frequency and duration of treatment. extent of treatment. and treatment goals. Discuss fears and concerns with the client. psychological. oncology nurse.g. Reduce fear and anxiety and improve coping ability Start the client‘s emotional preparation when the tentative diagnosis of cancer is made. Postoperative Nursing Interventions  Relieve pain and discomfort  Have an ongoing assessment of pain and discomfort. medical oncologist. or psychiatric clinical nurse specialist if necessary. possible reactions after treatment. promote circulation.. Promote preoperative physical. and nutritional wellbeing after the treatment plan has been established. Initiate a referral to the psychiatrist. Introduce the client to other members of the oncology team (e.

while addressing her concerns and answering questions. Teach the client that she may shower on the second post-op day and wash the incision and drain site with soap and water to prevent infection. and fear of death. Promote positive adjustment and coping Have an ongoing assessment of the client‘s concerns related to the diagnosis of cancer. sensations to expect. Initially. Note the characteristics of fluid from the drain. and the possible signs and symptoms of an infection. Be knowledgeable about the client‘s plan of care and encourage her to ask questions to the appropriate members of the health care team to help promote coping during recovery. Assist the client in identifying mobilizing her support systems. which are important in determining her progress in adjusting and the effectiveness of her coping strategies. Place an Ace wrap (elastic bandage) around the incision and apply an ice pack. Encourage the client to discuss issues and concerns with other clients who have had breast cancer to help her understand that her feelings are normal and that other women who have had breast cancer can provide invaluable support and understanding. Remind her that a dry dressing should be applied to the incision each day for 7 days. Explain the care of the incision. Notify the physician if a hematoma. occurs. the fluid in the surgical drain appears blood. Inform the client that sensation is decreased in the operative area because the nerves were disrupted during surgery and gentle care is needed to avoid injury. Inspect the dressings and drains for bleeding and monitor the extent of drainage regularly. 227 | P a g e . Discuss the incision.                      Prevent fluid from accumulating under the chest wall incision or in the axillary by maintaining the patency of the surgical drains. and the progressive changes in its appearance with the client during dressing changes. Teach the client that after the incision is completely healed (usually 4 to 6 weeks). lotions or creams may be applied to the area to increase skin elasticity. Leave the drain in place for 7 to 10 days and then remove it after the output is less than 30 ml in a 24-hour period. and allow her to express her emotions. the consequences of surgical treatment. Monitor the incision if hematoma develops within the first 12 hours after surgery. that could cause necrosis of the surgical flaps. Refocus the client on the recovery from surgery. Teach the client and family the importance of ensuring correct management of the drainage system prior to discharge. Explain that her feelings are normal response to breast cancer surgery to reassure the client. Provide privacy and consideration when assisting the client to view her incision fully for the first time. Promote positive body image Address the client‘s perception of the body image changes and physical alterations of the breast during teaching sessions. how it looks and feels. She may again use deodorant on the affected side. Answer questions and concerns about the treatment options that may follow after surgery. but it gradually changes to serosanguineous and then a serous fluid during the next several days.

. Observe the area and extremity for 24 hours.g. Apply insect repellant to avoid bug bites. call the surgeon or nurse. Assist in performing exercises to decrease sensations. Encourage self-care activities (e. Encourage the client to shower before performing post-mastectomy exercises to loosen stiff muscles. Previous activities should be introduced when fully healed. Promote the use of the muscles in both arms and to maintain proper posture. instruct the client to elevate the arm above the level of the heart on a pillow for 45 minutes at a time three times daily to promote circulation. Support the client on the nonoperative side. arm. and along the inside aspect of the upper arm are common and that these are normal parts of healing to help reassure her that these sensations are not indicative of a problem. Use cooking mitt for removing objects from the oven. If transient edema develops in the affected extremity. pulling. tight surgical incision. Wear gloves for gardening. Avoid blood pressures. Manage postoperative sensations Explain to the client that tightness. washing the face.g. avoid heavy lifting). Refer the client and her partner to a psychosocial source if problems develop or persist. and tingling along the chest wall. Focus on the hand and arm care after an axillary lymph node dissection to prevent injury or trauma to the affected extremity to decrease the likelihood of developing lymphedema. and apply an over-the-counter antibacterial ointment..                     Counseling or consultation with a mental health practitioner may be indicated for a client who displays ineffective coping. Initiate exercises (hand. Avoid lifting objects greater than 5 to 10 pounds. or immediate reconstruction. Use electric razor for shaving armpit. If a trauma of break in the skin occurs. and checking with the physician regarding this is usually indicated. if redness. Improve sexual function Encourage discussion about fears. injections. shoulder. swelling. exercises may need to be prescribed specifically and introduced gradually. other options for expressing affection can also be helpful. in the axilla. brushing the teeth. Instruct clients about activity limitations while healing postoperatively (e. Monitor and manage potential complications 228 | P a g e . needs. Use sunscreen higher than 15 SPF for extended exposure to the sun. Perform post-mastectomy exercises three times daily for 20 minutes at a time until full range of motion is restored in 4 to 6 weeks. and combing/brushing the hair) because they aid in restoring arm function and provides a sense of normalcy for the client. If a client has skin grafts. a tense. Avoid cutting cuticles. wash the area with soap and water. and desires to reduce the couple‘s stress Suggest varying the time of day for sexual activity (when the client is less tired) or assume positions that are more comfortable. burning. Instructions should be provided on the first postop day. push them back during manicures. or a fever occurs. and blood draws in affected extremity. and to take an analgesic agent 30 minutes before beginning the regimen. Promote participation in care Encourage the client to ambulate when she is free of postanesthesia nausea and is able to tolerate fluids. and respiratory) in the second postop day. acetaminophen as needed to assist managing discomforts.

 Lymphedema Reassure client that transient edema is not lymphedema. Notify the surgeon for gross swelling or output from the drain that may indicate hematoma formation. Be calm to help prevent anxiety and panic on the part of the client. surgical treatment. if allowed to progress without treatment. along with specific exercises. and fears appropriately  Participates actively in self-care activities  Recognizes that postoperative sensations are normal and identifies management strategies  Discusses issues of sexuality and resumption of sexual relations  Demonstrates knowledge of postdischarge recommendations and restrictions Experiences no complications 229 | P a g e . and intact surgical incisions without signs of inflammation or infection  Lists the signs and symptoms of infection to be reported to the nurse or surgeon  Verbalizes feelings regarding change in body image  Discusses meaning of the diagnosis. Educate the client how to prevent lymphedema and how to do hand and arm care after axillary dissection. Manage lymphedema by elevating the arm with the elbow above the shoulder and the hand higher than the elbow. manual lymph drainage. Evaluation  Expected preoperative outcomes may include the following: (The cli ent…)  Exhibits knowledge about diagnosis and treatment options  Verbalizes willingness to deal with anxiety and fears related to the diagnosis and the effects of surgery on self-image and sexual functioning  Demonstrates ability to cope with diagnosis and treatment  Demonstrates ability to make decisions regarding treatment options in timely fashion  Expected postoperative outcomes may include the following: (The client…) Reports the pain has decreased and states pain and discomfort management strategies are effective  Exhibits clean. Instruct the client to contact her health care provider if lymphedema occurs to discuss management because she may need a course of antibiotics or specific exercises to decrease the swelling. Assist in taking specimen for cultures on any foulsmelling discharge. however. or a special pump to decrease swelling. dry. exercises. Monitor the site and reassure the client that this complication is rare but does occur and that she will be assisted through its management. if present. Emphasize that need for early intervention because lymphedema can be manageable if treated early. Refer the client to a physical therapist or rehabilitation specialist for a custom-made elastic sleeve. Administer oral or intravenous antibiotics depending on the severity of the infection. and to contact her health care provider for evaluation. Infection  Teach the client to monitor for signs and symptoms of infection preoperatively and before discharge. Hematoma formation  Monitor the surgical site for excessive swelling and monitor the drainage device. the swelling can become painful and difficult to reverse. such as hand pumps.

Cancer of the Prostate Clinical Manifestations Rarely produces symptoms in the early stages. urinary retention.  This study is used to detect spread of prostate cancer in the lymph nodes or other parts of the body in newly diagnosed men who have apparently localized prostate cancer who are thought to be at high risk for metastasis.  Transrectal ultrasound (TRUS) studies are indicated for men who have elevated PSA levels and abnormal DRE findings. hip pain. weight loss. renal function tests. and oliguria. preferably by the same examiner. allowing detection of disease spread.  PSA testing is routinely used to monitor the client‘s response to cancer therapy and to detect local progression and early recurrence of prostate cancer. and CT scans or lymphangiography to identify metastases in the pelvic lymph nodes.  The more advanced lesion is ―stony hard‖ and fixed. Medical Management Surgical Management 230 | P a g e . This type of cancer tends to vary in its course. The following signs and symptoms of urinary obstruction occur if the neoplasm is larger enough to encroach on the bladder neck: difficulty and frequency of urination.  Most prostate cancers are diagnosed when a man seeks medical attention for symptoms of urinary obstruction or after abnormalities are found by DRE. Assessment and Diagnostic Findings  The likelihood of cure is high if prostate cancer is detected early. nausea.  TRUS studies help in detecting nonpalpable prostate cancers and assist with staging localized prostate cancer. open prostatectomy. Symptoms that develop from urinary obstruction occur late in the disease.  Capromab Pendetide with Indium-111 (ProstaScint) is an antibody that is attracted to the prostate-specific antigen found on prostate cancer cells.  Prostate-specific antigen (PSA) together with DRE appears to be a cost-effective method for detecting prostate cancer. skeletal x-rays to identify bone metastases. weakness. or transrectal needle biopsy. Symptoms related to metastases include backache. perineal and rectal discomfort. Fine-needle aspiration is helpful for determining the stage of disease as well.  Routine repeated rectal palpation of the gland.  Diagnosis of prostate cancer is confirmed by a histologic examination of tissue removed surgically by transurethral resection. Prostate cancer can metastasize to bone and lymph nodes. decrease in size and force of urine stream. is important because early cancer may be detected as a nodule within the substance of the gland or as an extensive hardening in the posterior lobe. or both. Other symptoms may include blood in the urine or semen and painful ejaculation.  Every man older than 40 years of age should have a digital rectal exam (DRE) as part of his regular health checkup. Hematuria may result if the cancer invades the urethra or bladder.  Needle biopsies of the prostate are commonly guided by TRUS. excretory urography to detect changes caused by ureteral obstruction.  The radioactive element attached to the antibody is then visible with scanning.  Other tests include bone scans to detect metastatic bone disease. anemia.

the prostatic epithelium atrophies. Hormonal Therapy  This is one method to control rather than cure prostate cancer.  Luteinizing hormone-releasing hormone (LH-RH) agonists suppress testicular androgen while antiandrogen agents. palliative measures are indicated. thereby removing the androgenic hormone that promotes the growth of the malignancy. has long been used to inhibit gonadotropins responsible for testicular androgenic activity.  For men with advanced prostate cancer. o Obtain further information about the client‘s history of cancer and heart or kidney disease. Several approaches can be used to remove the hypertrophied portion of the prostate gland: transurethral resection of the prostate (TURP).  Hormonal therapy for advanced prostate cancer suppresses androgenic stimuli to the prostate by decreasing the circulating plasma testosterone levels or interrupting the conversion to or binding of dihydrotestosterone. Sexual impotence follow radical prostatectomy and 5% to 10% of clients have varying degrees of urinary incontinence. Opioid and nonopioid medications are used to control pain. usually in the form of diethylstilbestrol (DES). 231 | P a g e .. these bone lesions can be very painful. As a result. Nursing Process for the Client Undergoing Prostactectomy Assessment o Assess how the prostate cancer has affected the client‘s lifestyle (e. medications such as prednisone and mitoxantrone have been effective in reducing pain and improving quality of life. Other Therapies  Cryosurgery of the prostate is used to ablate prostate cancer in clients who could not physically tolerate surgery or in those with recurrent prostate cancer.  Estrogen therapy.g.  Antiandrogen therapies are used in an effort to reduce the circulating androgens. o Ask the client additional questions that will help determine how soon he will be able to return to normal activities after prostatectomy. perineal Radiation Therapy  The treatment may be curative radiation therapy if prostate cancer is detected in its early stage— either teletherapy with a linear accelerator or interstitial irradiation (brachytherapy). such as flutamide. suprapubic prostactectomy.  If prostate cancer metastasizes to the bones. including hypertension. If antiandrogen therapies are not effective. External beam radiation therapy can be delivered to skeletal lesions to relieve pain.  The above effect is accomplished either by orchiectomy or by administration of medications. cause adrenal androgen suppression.   Radical prostatectomy remains the standard surgical procedure for clients who have earlystage. potentially curable disease and a life expectancy of ten years or more. Has he been reasonably active for his age? What are his presenting urinary problems?).

Insert an indwelling catheter if the client has continuing urinary retention or if laboratory test results indicate azotemia. Familiarize the client with the pre. Monitor the client for electrolyte imbalances. which varies with the type of surgical approach.Place the client on bed rest. Instruct the client about postoperative use of medications for pain management. Administer an enema at home the evening before surgery or the morning of the surgery to prevent postoperative straining. the type of anesthesia. Monitor voiding patterns. Document and report signs and symptoms of fluid imbalance to the surgeon. confusion. Provide privacy and establish a trusting and professional relationship when discussing problems related to genitalia and sexuality.and postoperative routines and initiates measures to reduce anxiety. which can induce bleeding. and bladder spasms  Deficient knowledge about postoperative care and management Collaborative Problems  Hemorrhage and shock  Infection  Deep vein thrombosis  Catheter obstruction  Sexual dysfunction Planning and Interventions Preoperative Nursing Interventions  Reduce anxiety.Diagnosis Preoperative Nursing Diagnoses  Anxiety about surgery and its outcome  Acute pain related to bladder distention  Deficient knowledge about factors related to the disorder and the treatment protocol Postoperative Nursing Diagnoses  Acute pain related to the surgical incision. if the client is hospitalized. inform the client about the type of urinary drainage system that is expected.Monitor the urine output and the amount of fluid used for irrigation to determine if irrigation fluid is being retained and to ensure an adequate urine output. watch for bladder distention. and the recovery room procedure. 232 | P a g e .  Prepare the client for surgery Apply elastic compression stockings before surgery to prevent deep vein thrombosis if the client is placed in a lithotomy position during surgery. Clarify the nature of the surgery and expected postoperative outcomes. Encourage the client to verbalize his feelings and concerns. rising blood pressure.  Provide instruction.  Relieve discomfort. Explain what will take place as the client is prepared for diagnostic tests and then for surgery. Describe the type of incision. and assist with catheterization if indicated. administer analgesic agents.Establish communication with the client to assess his understanding of the diagnosis and of the planned surgical procedure. and respiratory distress. Postoperative Nursing Interventions  Maintain fluid balance. Prepare the client for a cystostomy if he cannot tolerate urinary catheter. catheter placement. and initiate measures to relieve anxiety if discomfort is present before the day of the surgery.Review the anatomy of the affected parts and their function in relation to urinary and reproductive systems using diagrams and other teaching aids with the client.

Use aseptic technique when changing dressings to prevent infection. to clear any obstruction if the client complains of pain. intravenous fluids. pallor. Note the color of the urine. Direct a heat lamp to the perineal area to promote healing. Administer enema with caution (if prescribed) to avoid rectal perforation. Irrigate the catheter with 50 ml of irrigating fluid at a time. and incision site for bleeding. and an increasing pulse rate. Observe the client for restlessness. Protect the scrotum with a towel while a heat lamp is used. Check if discomfort is caused by dressings that are too snug. Administer furosemide to promote urination and initiate postoperative diuresis to help keep the catheter patent. and assist him to ambulate the next morning. Encourage the ambulatory client to walk but not to sit for prolonged periods since this may increase intra-abdominal pressure and the possibility of discomfort and bleeding. maintain an accurate record of intake and output. Instruct the client and the family to monitor for signs and symptoms of infection after discharge. if indicated and prescribed. saturated or improperly placed drainage.Assist the client to sit and dangle his legs over the side of the bed on the day of surgery. to relieve any obstruction that may cause discomfort. and carefully monitor drainage to ensure adequate urine flow and patency of the drainage system. Administer medications (e. Secure the catheter drainage tubing to the leg or abdomen to help decrease tension on the catheter and prevent bladder irritation. Administer fluid and blood component therapy if blood loss is extensive. dressing. Provide prune juice and stool softeners to ease bowel movements and to prevent excessive straining.Closely monitor vital signs. and blood component therapy as prescribed. Assess for the presence of sexual dysfunction after surgery. any drop in blood pressure. Assess for the occurrence of urinary tract infections and epididymitis.. cold sweats.                  Relieve pain. and respirations and compare with baseline preoperative vital signs to detect hypotension. Clean the perineum as indicated after the perineal sutures are removed. Assess frequently for manifestations of deep vein thrombosis (DVT) and apply elastic compression stockings to reduce the risk for DVT and pulmonary embolism. Warm compress and sitz baths may also relieve spasms. and enemas because of the risk for injury to and bleeding in the prostatic fossa. flavoxate and oxybutynin) that can relax smooth muscles to ease bladder spasms. Monitor the drainage tubing and irrigate the system as prescribed. Irrigate the drainage system. Monitor and manage complications Initiate strategies to stop bleeding and to prevent or reverse hemorrhagic shock. Determine the cause and location if pain occurs. Examine the drainage bag. Administer antibiotics as prescribed if they occur. Observe the lower abdomen to ensure that the catheter has not become blocked. rectal tubes. Provide a private and confidential environment to discuss issues of sexuality. Administer analgesic agents asprescribed.g. administer medications. pulse. Monitor blood pressure. Avoid rectal thermometers. Testicular Cancer 233 | P a g e .

or lower abdomen. with a mass or lump on the testicle and generally painless enlargement of the testis. spreading from the testis to the lymph nodes in the retroperitoneum and to the lungs. occupational hazards including exposure to chemicals encountered in mining. ultrasound to determine the presence and size of testicular 234 | P a g e . Secondary Testicular Tumors  These tumors are those that have metastasized to the testicle from other organs. and other organs.  Cancers may also spread to the testicles from the prostate gland. Testicular cancers are classified as germinal or nongerminal (stromal). and leather processing. Germinal Tumors  Germinal tumors may be further classified as seminomas or nonseminomas.Most common cancer in men 15 to 35 years of age. secondary testicular cancers may also occur. inguinal area.  Other diagnostic tests include intravenous urography to detect any ureteral deviation caused by a tumor mass. weight loss. lymphangiography to assess the extent of tumor spread to the lymphatic system. choriocarcinomas.  A small number of these tumors metastasize and tend to be resistant to chemotherapy and radiation therapy. Backache (from retroperitoneal node extensions). skin (melanoma). while nonseminomatous tumors grow quickly. o Risk factors include a family history of testicular cancer and cancer of one testicle. and general weakness may result from metastasis. and. of the testicles. Testicular tumors tend to metastasize early. nonseminomas tend to develop earlier in life than seminomas (usually occurring in men in their 20s). and embryonal carcinomas. although these tumors spread beyond the testicle. Risk Factor o Risk for testicular cancer is several times greater in men with any type of undescended testis than in the general population. abdominal pain.  Lymphoma is the most common cause of secondary testicular cancer. or stroma. Clinical Manifestations Symptoms appear gradually. it can occur in males of any age.  Seminomas tend to remain localized. oil and gas production. lung.  The two main types of stromal tumors are Leydig cell tumors and Sertoli cell tumors. Enlargement of the testis without pain is significant diagnostic finding. race and ethnicity.  Seminomas are tumors that develop from the sperm-producing cells of the testes.  Prognosis for these cancers is usually poor because these cancers generally also spread to other organs. Nongerminal Tumors  Testicular cancer may also develop in the supportive and hormonal producing tissues.  Examples of nonseminomas include teratocarcinomas. kidney. The client may complain of heaviness in the scrotum. although it occurs most often between the ages of 15 to 40. yolk sac carcinomas. Assessment and Diagnostic Findings  Monthly testicular self-examinations (TSEs) are effective in detecting testicular cancer.  Human chorionic gonadotropin and alpha-fetoprotein are tumor markers that may be elevated in clients with testicular cancer.

 The goals of management are to eradicate the disease and achieve a cure. mass.  Topical chemotherapy with 5-fluorouracil cream is an option in selected clients. the protective effect of circumcision is seen only in males who are circumcised in the neonatal period. Medical Management  Testicular cancer is one of the most curable solid tumors.  Chemotherapy with cisplatin-based regimens results in a high percentage of complete remissions. it has been suggested that the etiology of this cancer may be the irritative effect of smegma and poor hygiene. the corporal bodies. and CT scan of the chest. Radiation is also used for clients whose disease does not respond to chemotherapy or for whom lymph node surgery is not recommended. and pelvis.  Treatment selection is based on the cell type and the anatomic extent of the disease.  Postoperative irradiation of the lymph nodes from the diaphragm to the iliac region is used in treating seminomas. nor does unilateral excision of a testis necessarily decrease virility. Since most penile cancers occur in uncircumcised men. Cancer of the Penis Penile cancer occurs in men older than 60. chemotherapy.  Address issues related to body image and sexuality. Bowen’s disease is a form of squamous cell carcinoma in situ of the penile shaft. 235 | P a g e . Personal hygiene is an important preventive measure in uncircumcised men. retroperitoneum.  Encourage the client to maintain positive attitude during the long course of therapy. Cancer of the penis appears on the skin of the penis as a painless. circumcision that occurs at puberty or after does not present the same benefit.  The testis is removed by orchidectomy through an inguinal incision with a high ligation of the spermatic cord. and regional or distant lymph nodes. A gel-filled prosthesis can be implanted.  Remind the client about the importance of performing TSE and keeping follow-up appointments with the physician. Microscopic analysis of tissue is the only definitive way to determine if cancer is present but is usually performed at the time of surgery rather than as part of the diagnostic workup to reduce the risk of promoting spread of cancer.  Radiation is delivered only to the affected side. the coronal sulcus under the prepuce. Prevention Circumcision in infancy almost eliminates the possibility of penile cancer because chronic irritation and inflammation of the glans penis predispose to penile tumors. However. wart-like growth or ulcer. and pelvis to determine the extent of the disease in the lungs.  Encourage the client to participate in health promotion and health screening activities. the other testis is shielded from radiation to preserve fertility.  Testicular cancers are highly responsive to chemotherapy. the urethra. It can involve the glans. Nursing Management  Assess the client‘s physical and psychological status and monitor the client for response to and possible effects of surgery.  Inform the client that radiation therapy will not necessarily prevent him from fathering children. abdomen. and radiation therapy. Medical Management  Smaller lesions involving only the skin may be controlled by excision.  Retroperitoneal lymph node dissection to prevent lymphatic spread of the cancer may be performed after orchiectomy.

nitrates. tar and pitch. It undergoes central ulceration and sometimes crusting as it grows. fair-haired. or yellowish plaque. The lesions may be primary. characterized by invasion and erosion of adjoining tissues. Squamous cell carcinoma (SCC) A malignant proliferation arising from the epidermis. gray. an ear. translucent. blue-eyed people. leukoplakia.  Partial penectomy is preferred to total penectomy if possible. Usually begins as a small. Other variants of BCC may appear as a shiny. with insufficient skin pigmentation to protect underlying skin tissues  People who sustain sunburn and who do not tan  Long-time sun exposure (farmers. or scarred or ulcerated lesions). oils and paraffin)  Sun-damaged skin (elderly people)  History of x-ray therapy for acne or benign lesions  Scars from severe burns  Chronic skin irritations  Immunosuppression  Genetic factors Basal Cell and Squamous Cell Carcinoma The most common types of skin cancer are basal cell carcinoma (BCC) and squamous cell (epidermoid) carcinoma (SCC). rarely metastasizes but recurrence is common. arising on the skin and mucous membranes. or a lip. It is of greater concern than BCC because it is a truly invasive carcinoma. flat. fishermen. construction workers)  Exposure to chemical pollutants (industrial workers in arsenic. waxy nodule with rolled. a neglected lesion can result in the loss of a nose. Risk Factors  Exposure to the sun is the leading cause of skin cancer. Skin Cancer  Ask the students the possible causes which may increase an individual‘s risk for skin cancer. particularly those of Celtic origin. telangiectatic vessels may be present. coal. metastasizing by the blood or lymphatic system. Tumors appear most frequently on the face. pearly borders. The third most common type is the malignant melanoma. Radiation therapy is used to treat small squamous cell carcinomas of the penis or for palliation in advanced tumors or lymph node metastasis. 236 | P a g e . incidence is related to the total amount of exposure to the sun  Fair-skinned. Incidence is proportional to the age of the client (average of 60 years) and the total amount of sun exposure.  Total penectomy is indicated when the tumor is not amenable to conservative treatment. or they may develop from a precancerous condition (such as actinic keratosis. usually appears on sundamaged skin but may also arise from normal skin or from preexisting skin lesions. Clinical Manifestations Basal cell carcinoma (BCC) Generally appears on the sun-exposed areas of the body and is more prevalent in regions where the population is subjected to intense and extensive exposure to the sun. and it is inversely proportional to the amount of melanin in the skin.

A pressure dressing applied over the wound provides support. upper lip. Secondary infection can occur. with cure rate for BCC and SCC approaching 99%.  The size of the incision depends on the tumor size and location but usually involves a length-towidth ratio of 3:1. When the tumor is large. Electrosurgery  This is the destruction or removal of tissue by electrical energy.  Mohs surgery is the recommended tissuesparing procedure. and auricular and preauricular areas. nose. more infiltrated.  The adequacy of the surgical excision is verified by microscopic evaluation of sections of the specimen. performed without the initial chemosurgery component (application of zinc chloride paste to the tumor).  The specimen is frozen and analyzed by section to determine if the entire tumor has been removed. whereas SCC that arises without a history of sun or arsenic exposure or scar formation appears to have a greater chance for spread. and forehead. and more inflammatory than that of a BCC lesion. and though some require wide excision with resultant disfigurement. ears.  Usually. With this. tumors arising in sun-damaged areas are less invasive and rarely cause death. This method takes advantage of the fact that the tumor in each instance is softer than surroundings skin and therefore can be outlined by a curette. which is related to the histologic type and the level or depth of invasion. especially of the upper extremities and of the face. The first layer excised includes all evident tumors and a small margin of normalappearing tissue. normaltissue margin are removed. Mohs Micrographic Surgery  This technique is most accurate and best conserves normal tissue. Medical Management Surgical Management  Primary goal is to remove the tumor entirely.- - It appears as rough. thickened.  It is the treatment of choice and the most effective for tumors around the eyes.  Prognosis for SCC depends on the incidence of metastases.  The best way to maintain cosmetic appearance is to place the incision properly along natural skin tension lines and natural anatomic body lines. Electrodesiccation is then implemented to achieve hemostasis and to destroy any viable malignant cells at the base of the wound or along its edges. which ―feels‖ the extent of the tumor. Tumors remain localized.  The current is converted to heat. reconstructive surgery with the use of a skin flap or skin grafting may be required. If not.  Regional lymph nodes should be evaluated for metastases. which then passes to the tissue from a cold electrode. the risk for death from this tumor is low. The boarder of an SCC lesion may be wider. The incision is closed in layers to enhance cosmetic effect. scaly tumor that may be asymptomatic or may involve bleeding. additional layers of tissue are shaved and examined until all tissue margins are tumor-free.  The procedure removes the tumor layer by layer. Prognosis  Prognosis for BCC is usually good. lower lip. The tumor is removed 237 | P a g e .  Electrosurgery may be preceded by curettage. Common sites are exposed areas. nose. only the tumor and a safe.

since x-ray changes may be seen after 5 to 10 years. with irregular outer portions. reserved for older clients. Risk Factors  Fair-skinned or freckled. and malignant changes in scars may be induced by irradiation 15 to 30 years later. and liquid nitrogen is directed to the center of the tumor until the tumor base is -40ºC to -60ºC. blue-eyed.. which may take 4 to 6 weeks. Swelling and edema follow the freezing.  Apply an emollient cream to help reduce dryness after the sutures have been removed. tip of the nose and areas in or near vital structures (e. The lesion tends to be circular. It usually affects middle-aged people and occurs most frequently on the trunk and lower extremities. Malignant Melanoma A malignant melanoma is a cancerous neoplasm in which atypical melanocytes are present in the epidermis and the dermis. Generally. Nursing Management  Teach client about prevention of skin cancer and about self-care after treatment. and the importance of hand washing before and after the procedure. Normal healing.  Advise the client when to report for a dressing change or provide a written and verbal information on how to change dressings. occurs faster with a good blood supply. Radiation Therapy  Frequently performed for cancer of the eyelid.  The tumor tissue is frozen. including the type of dressing to purchase. allowed to thaw. and then refrozen.  Instruct the client to drink liquids through straw and limit talking and facial movement.  Advise the client to watch for excessive bleeding and tight dressing that compromise circulation. healing occurs within a month. facial nerve). light-haired people of Celtic or Scandinavian origin  People who burn and do not tan or who have a significant history of severe burn  Environmental exposure to intense sunlight  History of melanoma (personal or family)  Skin with giant congenital nevi Clinical Manifestations Superficial spreading melanoma occurs anywhere on the body and is the most common form of melanoma. Cryosurgery  This method destroys the tumor by deep freezing the tissue.and the base cauterized.  Instruct the client to seek treatment for any moles that are subject to repeated friction and irritation. if the lesion is in the perioral area. The site thaws naturally and then becomes gelatinous and heals spontaneously. The process is repeated twice. 238 | P a g e . The appearance of the lesion varies. and to watch for indications of potential malignancy. Dental work should also be avoided until the area is completely healed.  Advise the client to apply sunscreen over the wound to prevent postoperative hyperpigmentation if he/she spends time outdoors. how to remove dressings and apply fresh ones. The margins of the lesion may be flat or elevated and palpable.g.  A thermocouple needle apparatus is inserted into the skin.

a chest x-ray. blue-black. interferon-alpha. A dull pin rose color can be seen in a small area within the lesion. with hues of tan.g. 239 | P a g e . Lentigo-maligna melanoma are slowly evolving.  Incisional biopsy should be performed when the suspicious lesion is too large to be removed safely without extensive scarring. after which skin grafting may be needed. flat lesions. gray.g. or white... These melanomas may appear as irregularly shaped plaques. or scalp have a better prognosis. It may be dome-shaped with a smooth surface.  Several forms of immunotherapy (e. Prognosis  The prognosis for long-term (5-year) survival is considered poor when the lesion is more than 1. interleukin-2).  Regional lymph node dissection is commonly performed to rule out metastasis. lymphokine-activated killer cells).e. but in time. the head. and thickness of the lesion. The client may describe this as a blood blister that fails to resolve.  Surgical excision is the treatment of choice for small. Assessment and Diagnostic Findings  Biopsy results confirm the diagnosis of melanoma. Corynebacterium parvum. and in the mucous membranes in dark-skinned people. although new surgical approaches call only for sentinel node biopsy. sometimes. spleen. Acral lentiginous melanoma occurs in areas not excessively exposed to sunlight and where hair follicles are absent. BCG vaccine. curettage.. It is found on the palms of the hands. Nodular melanoma is a spherical.  A thorough history and physical examination should include a meticulous skin examination and palpation of regional lymph nodes that drain the lesional area. blue-black color. level of invasion. especially the dorsum of the hand.  Deeper lesions require wide local excision. These melanomas appear as irregular. and radionuclide or CT scans are usually ordered to stage the extent of disease. pigmented lesions that occur on exposed skin areas. A nodular melanoma invades directly into adjacent dermis and therefore has poorer prognosis.  Biopsy specimens obtained by shaving. lungs. superficial lesions. It may have other shadings of red. Lesions are often present for many years before they are examined by a physician.  An excisional biopsy specimen provides histologic information on the type. levamisole). or needle aspiration are not considered reliable histologic proof of disease. brown. They first appear as tan. and black mixed with gray.- - - - This type of melanoma may appear in a combination of colors. pigmented macules that develop nodules. in the nail beds. liver function tests. liver. adaptive immunotherapy (i. or purple. and central nervous system. They may become invasive early. on the soles. foot. Medical Management  Treatment depends on the level of invasion and the depth of the lesion. biologic response modifiers (e. and the neck in elderly people. complete blood cell count. blueberry-like nodule with a relatively smooth surface and a relatively uniform.  After the diagnosis of melanoma has been confirmed.  Clients with melanoma on the hand.  Men and elderly clients also have poor prognoses.5 mm thick or there is regional lymph node involvement. and monoclonal antibodies are some of the investigational therapies available. those with lesions on the torso have an increased chance of metastases to the bone. they undergo changes in size and color.

D – Diameter A diameter exceeding 6 mm is considered more suspicious.  Further surgical intervention may be performed to debulk the tumor or to remove part of the organ involved for metastatic melanoma. Include the client‘s family in all the discussions to clarify the 240 | P a g e .  Question the client about changes in pre-existing moles or the development of new. are not variegated but are uniformly colored (bluish-black. Some nodular melanomas have a smooth surface. bluish-red). as if rubbed with an eraser. pigmented lesions. The lesion has an irregular surface with uneven elevations (irregular topography) either palpable or visible. and extent of tumor to help clarify information and misconceptions. the two halves would not look alike. tenderness. Some malignant melanomas. and continuing follow-up. White areas within a pigmented lesion are suspicious. If an imaginary line were drawn down the middle. Nursing Process for the Client with Malignant Melanoma Assessment  Assessment is based on the client‘s history and symptoms. however. Regional perfusion may be used when the melanoma is located in an extremity then chemotherapeutic agent is perfused directly into the area that contains melanoma. bluish-gray. whereas some early melanomas may be smaller. Many benign skin growths are larger than 6 mm. and pain which are not features of a benign nevus. This approach delivers a high concentration of cytotoxic agents while avoiding systemic.Promote comfort and administer appropriate medications. subungual areas. Chemotherapy may also be used. white. B – Irregular Border Angular indentations or multiple notches appear in the border. fingernails. and blue. the legs. soles. understand their anger and depression. Colors that may indicate malignancy if found together within a single lesion are shades of red.The lesion does appear balanced on both sides. The border is fuzzy or indistinct. face. between the toes.  Answer questions about the diagnostic workup and staging of the depth type. although this finding without other sign is not significant. C – Variegated Color Normal moles are usually a uniform light to medium brown. and backs of hands.  Signs that suggest malignant changes are referred to as the ABCDs of moles: A – Asymmetry .  Ask the client specifically about pruritus.  Reduce anxiety and depression  Allow clients to express feelings about the seriousness of this cutaneous neoplasm.  Point out resource. Nursing Diagnoses  Acute pain related to surgical excision and grafting  Anxiety and depression related to possible lifethreatening consequences of melanoma and disfigurement  Deficient knowledge about early signs of melanoma Planning and Interventions  Relieve pain and discomfort. shades of blue are ominous.Satellite lesions (those situated near the mole) are inspected. and mucous membranes of dark-skinned people. toxic effects. and social support systems to help them cope with the problems associated with diagnosis. Darker coloration indicates that the melanocytes have penetrated to a deeper layer of the dermis. Common sites of melanomas are the skin of the back. A change in the surface may be noted from smooth to scaly. and convey understanding of these feelings. scalp. Melanomas are most likely to occur in less pigmented sites: palms. and on the feet. past effective coping mechanisms. treatment.

information presented. ask questions that the client may be reluctant to ask. Deliver supportive care and provide and clarify information about the therapy and the rationale for its use. identify potential side effects of therapy and ways to manage them. Offer information about support groups and contact people. and arrange for palliative hospice care if appropriate.  Monitor and manage potential complications Be knowledgeable about the most effective current therapies to manage metastasis. Monitor and document symptoms that may indicate metastasis: lung. bone. and instruct the client to and family about the expected outcomes of the treatment. Encourage the client to have hope in the therapy employed while maintaining a realistic perspective about the disease and ultimate outcome. and liver. Nursing care should be based on the client‘s symptoms. and provide emotional support. Evaluation  Expected client outcomes may include the following: (The client…)  Experiences relief of pain and discomfort Is less anxious  Demonstrates understanding of the means for detecting and preventing melanoma Experiences absence of complications 241 | P a g e . Provide time for the client to express fears and concerns.