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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 Burkitts lymphoma, nasopharyngeal cancers, and some types of Non-Hodgkins and Hodgkins 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 Kapposis 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 bodys 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 cells 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 suppressor genes are normal cellular genes that suppress the activity of growth promoting genes. They oppose the activity of proto-oncogenes and are often called antioncogenes. Tumor-suppressor genes are recessive genes (i.e., both copies of the gene must be lost mutated for the effects to be seen.

CHEMICAL CARCINOGENESIS a. b. Tumor formation is a multi-step process identified through animal over the past 50 years. Initiation first step in chemical carcinogenesis; an irreversible process in which a permanent change is produced by a chemical carcinogen. The process is thought to be short and can occur spontaneously. The initiated cell by a chemical carcinogen and cannot be differentiated from normal cells. 1. Chemical carcinogens are electrophilic compounds that attach to the electron-rich sites on DNA nucleic acids. 2. Cells damaged by carcinogens may suffer lethal damage or maybe repaired by DNA repair mechanisms. Damaged cells that have not been repaired and undergo replication, however, pass the detect of the daughter cell. This cell is then initiated, and the process is irreversible. Promotion second stage of carcinogenesis; is a process in which the initiated cell undergoes a series of changes under the stimulus of an agent or agents called promoters. The process is reversible; at least until the first autonomous tumor cell is formed. Tumor progression third stage of cancer development; has been clinically but only recently studied. It is an irreversible stage of tumor development in which cellular damage can be detected as the tumor accumulates more malignant characteristics.

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RADIATION CARCINOGENESIS a. Carcinogenesis caused by radiation s is not as well understood as chemical carcinogenesis. Two modes of damage are believed possible: (1) radiation energy causes direct damage to DNA molecules, or (2) the energy transmitted causes molecules to lose electrons and become electrophilic, thereby acting as a chemical carcinogen. The stages of promotion and progression in radiation carcinogenesis are not well understood.

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VIRAL CARCINOGENESIS a. b. Viruses are believed to cause cancer by direct DNA mutations or by inserting genetic material into the cell, causing mutation. The process of viral carcinogenesis is not clear. Apparently DNA viruses need a cofactor in the process (e.g., malarial infection in Burkitts lymphoma or Hepatitis B infection in hepatocellular carcinoma).

Tumor Biology Tumors are composed of proliferating cells (i.e., blood vessels and connective tissue) and other cells, such as lymphocytes and macrophages. 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:

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The growth function or the number of cells that are dividing. As tumor enlarges, a smaller percentage of cells are in the replicating pool. Most cells in a tumor are not actively proliferating. The rate of proliferation the cell is similar for many tumors. Tumor cells do not divide more rapidly than their normal counterparts and often divide less frequently. Tumor cell loss many tumor cells are lost through necrosis and shedding.

Tumor doubling time a. b. The time needed for a tumor to double in size many range from 1 month to 1 year. A tumor measuring 1 cm will have 109 or 1 billion cells. This size is reached after approximately 30 doublings; the tumor size will be 10 12 or 1 kg. This size is 1000 greater than 1 cm size.

Tumor blood supply a. b. Tumor secretes angiogenic growth factors capable of inducing formation of blood vessels by which the tumor can support itself. A tumor cannot enlarge more than 1 to 2 mm without developing a blood supply. As tumor enlarge and some cells outside their blood supply, necrosis occurs.

Tumor heterogeneity a. Although a malignant tumor begins with transformed cells, subsequent mutations produce many subclones, which possess different characteristics (e.g., invasion, metastasis). Heterogeneity is well established by the time a tumor is clinically detectable.

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Tumor invasion and metastasis a. The capability to invade surrounding tissue and to establish independent tumors in distant sites is the hallmark of malignancies. Most cancers metastasize and a few do not. Tumors spread by seeding cells within a body cavity (e.g., ovarian cancer without peritoneal metastases), by spread during through lymphatic channels, or by hematogenous mechanism (i.e., through the blood stream). Although some tumors follow the natural drainage pathways in spreading, many do not. Breast cancers tend to metastasize to the axillary lymph nodes; metastatic colon cancers develop in the liver, the first capillary drainage bed encountered. Many metastases occur in the lung, which is the capillary drainage for all body organs. Brain tumors do not metastasize outside the central nervous system. The malignant cell must adhere to and invade the basement membrane of the organ, pass through the extracellular matrix, intravasate into the bloodstream, and first two steps are repeated before extravasating into the tissue. Subsequently, the cells will grow if the environment is favorable and the tumor can establish its blood supply to continue growth. The process of metastasis is complex and not well understood. Components of this process are being studied intensively, because the ability to prevent metastasis may have great implications for improved survival.

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

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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. Tumors grow by expansion and do not infiltrate the surrounding tissues; usually encapsulated. Rate of growth is usually slow. MALIGNANT Cells are undifferentiated and often bear little resemblance to the normal cells of the tissue from which they arose. Grows at the periphery and sends out processes that infiltrate and destroy the surrounding. Rate of growth is variable and depends on level of differentiation; the more anaplastic the tumor, the faster its growth. Gains access to the blood and lymphatic channels and metastasizes to other areas of the body. Often causes generalized effects, such as anemia, weakness, and weight loss.

Mode of growth

Rate of growth

Metastasis

Does not spread by metastasis.

General effects

It is usually a localized phenomenon that does not cause generalized effects unless its locations interfere with vital functions. Does not usually cause tissue damage unless its locations interfere with blood flow.

Tissue destruction

Often causes extensive tissue damage as the tumor outgrows its blood supply or encroaches on blood flow to the area; may also produce substances that cause cell damage. Usually causes death unless growth can be controlled.

Ability to cause death

Does not usually cause death unless its location interferes with vital functions.

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General Assessment for People with Cancer Cancers 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. Palpable masses located near the body surface are readily detected. Tumors in the breast, extremities, 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. Most tumors of the oral cavity can be felt or seen. Bleeding or discharges occurs when tumors have friable surfaces and external egress. Common tumors can manifest themselves by bleeding are cancers of the lung, colon, uterus, stomach, bladder, nd kidneys. Many symptoms related to cancer are produced when a tumor impinges on a structure, partially or totally obstructs the lumen, or interferes with the normal function of the organ. 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. Pancreatic tumors located near the sphincter of the Oddi, causes jaundice by obstructing the common duct. Tumors within the colon cause changes in the caliber of the stool or cause constipation an diarrhea or both. Inability to swallow occurs when tumors in the esophagus reach a sufficient size to obstruct the lumen. 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. 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.

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Pain can be produced when tumor invades nerves or when obstruction is caused. Pain is generally a manifestation of advanced cancer. Fatigue, weight loss, and anorexia are systematic symptoms related to cancer and are seen most often in advanced disease states. Many cancers produce no symptoms and are found inadvertently during routine tests or other producers. Health History The standard medical history is used when obtaining information from a symptomatic individual. 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. Attention to health habits/lifestyle can provide opportunities to teach cancer prevention. Information and instruction in breast, testicular, and skin self examination; warning signs of cancer; and recommended screening test can ultimately save lives.

Diagnostic Tests for Cancer X-rays (roeontogenograms) Used to evaluate the bones and soft tissues of the body. Indicated for suspected neoplasm (benign or malignant). Contraindicated to pregnant clients, unless benefits of performing of the test greatly outweighs the risk of the fetus.

Nursing Considerations a. 1. 2. 3. 4. 5. 6. 7. b. 1. 2. 3. 4. Before the test, explain the client that: A technician or radiologist will perform it. The procedure takes about 15 minutes. Foods, fluids and medications are not restricted before the procedure. No sedation or anesthetic is administered before the procedure. Views maybe taken by the client in various positions on the x-ray table or in an x-ray chair. The area to be examined will be immobilized or the client will be asked to remain still during the procedure. The procedure should not cause discomfort, except possibly from lying on the hard table. 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. Ensuring that all dental prostheses, jewelry, eyeglasses, or other metal objects, such as hair clip are removed. Provide a hospital gown if needed. Instruct the client to remain still during the procedure.

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After the test, perform some neurological tests and vital signs and compare to the baseline data

Computed Tomography An imaging technique in which a selected body plane is isolated from the tissue on either side, a two-dimensional slice, a few millimeters thick, is imaged with a clarity superior to that of plain films, when combined with computers in computed scans or CTs, tomography produces three-dimensional images. A disadvantage of tomography is the high level of radiation exposure to the client. Indicated for suspected lung tumor when plain chest films are negative, as well as suspected tumor involving mediastinal structures, ribs and spines. Contraindicated to pregnant clients, unless benefits of performing the test generally outweigh the risk to the fetus. Nursing considerations is the same with the x-ray.

Ultrasound A non-invasive instrumentation procedure that uses sound waves to obtain diagnostic information or to perform therapeutic protocols; these high-frequency waves are directed into internal tissues and reflected back to the transducer. They are then electronically processed and appear as images on a display screen or oscilloscope for immediate visualization. Indicated for diagnosing a tumor or solid mass, as well as for differentiating between a nodule and a solid tumor or a fluid-filled cyst. Contraindicated to a client who is unable to remain still during the procedure. Other contraindications are obesity, chest thickness, deformity, or other abnormality or trauma that can increase the space between the part to be examined and the transducer, and can affect transmission of waves to and from the chest.

Nursing Considerations a. Before the test, explain to the client that: 1. The procedure takes about 30-45 minutes. 2. There are no fluid or food restrictions before the procedure. 3. That he/she will be placed in appropriate positions and requested to remain still, turn or sit up during the procedure. 4. A gel will be applied on the area to be viewed and a device will be placed and rotated on the area. 5. A picture is produced on the screen that the client can see, if desired. 6. There is no pain or risk of complications associated with the procedure. Prepare the client by: 1. Obtaining a history of previous or existing conditions, therapeutic regimen, and results of previous laboratory tests and procedures.

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Assisting the client to remove clothing and providing a hospital gown; ensure that the hospital gown is worn with the opening in front. 3. Obtaining vital signs for later comparison of readings. 4. Offering the client an opportunity to void before the procedure to ensure comfort. Place the client on the examination table in a supine position during the test. Inform the client that the result will be with the physician one-two days after the test.

Magnetic Resonance Imaging A noninvasive procedure that uses magnet, radio waves to create a field of energy, and a computer that allows visualization of a body region. a. Produces cross-sectional, multiplanar images of the entire body, a part, and specific body organs. b. Primarily used to assist in the diagnosis of conditions affecting blood flow and in the detection of tumors, infections and any other types of tissue pathology because of its ability to produce images through bone tissue and fluid-filled soft tissues. c. Greatest advantages of MRI are its ability to obtain an excellent detailed image of the region studied without the use of radiopharmaceuticals, radiologic beams, or administration of contrast medium. d. Disadvantages are the cost of the procedure, the fact that all institutions do not provide this service, and the need for immobilization for long periods to perform the procedure. Indicated for the diagnosis of benign, primary and metastatic tumors in any body organ.

Contraindications are: a. b. c. d. e. Pregnancy, unless benefits of performing the test greatly outweighs the risk to the fetus. Extreme obesity. Unstable medical conditions. Extreme claustrophobic response that prevents the client from remaining still while enclosed in the scanner, unless medications are given before the procedure. Presence of cardiac pacemaker that can be deactivated by MRI, metallic clips or prostheses, or heart valves that can be displaced and cause injury to the client during the test.

Nursing Considerations a. Before the test, explain to the client that: 1. The procedure requires 30-90 minutes, depending to the region to be examined. 2. Alcohol, caffeine-containing beverages, and smoking are restricted for at least 2 hours and that food is withheld for at least an hour before the procedure, especially if blood flow studies are being performed. 3. The usual medical regimen can be continued except for those medications containing iron because they will interfere with imaging. 4. Clothing, jewelry, and all magnetic objects including credit cards are removed and that a hospital gowns without snaps or other metallic closures will be supplied. 5. A special contrast medium maybe given IV before the study to enhance tissue imaging.

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A study clanging noise will be heard during the procedure and that earplugs are available, if desired to block out the noise. 7. Claustrophobia is not uncommon and that an anti-anxiety medication can be administered to allay this feeling; if the client is a child, 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. 8. There is no discomfort during the procedure except for a venipunctures required when a contrast medium is administered. Prepare the client by: 1. Ensuring that dietary, fluid and other restrictions have been followed. 2. Obtaining a history of allergies or sensitivities to contrast media, last menstrual period to ascertain possible pregnancy, and known or suspected pathology. 3. Inquiring about the presence of devices or prostheses in any part of the body, results of laboratory test and diagnostic procedures, and presence of claustrophobia. 4. Providing a hospital gown and ensuring that all metallic objects have been removed from the client and are safely stored. 5. Administering ordered medications for anxiety or sedation, or both and antihistamine or steroid (for known sensitivity to iodine) 6. Have the client void. During the test, the client is: 1. Requested to lie very still throughout the entire procedure. 2. Advised that he or she can speak to the technician during the study if desired. 3. Also advice to keep the eyes closed to promote relaxation and prevent a closed-in feeling common to those undergoing this procedure. 4. Instructed to take deep breaths if nausea is experienced due to claustrophobia. After the test: 1. Return the clients clothing and personal items. 2. Advice the client to resume usual food, fluid and medication intake, if applicable. 3. Note and report redness and swelling at the IV site (signs of phlebitis); apply ordered warm compress to the site and elevate the arm.

Nuclear Imaging A procedure that uses radiopharmaceuticals (radionuclides in compounds that permit entry into the body tissues), radiation detectors with imaging device, and computers to visualize organs and study the dynamic processes that differentiate normal from pathological tissues. a. Provide more physiological information than the structural types of information gained from radiologic studies. b. Can be used to complement x-ray procedures or can be used exclusively to study an organ that has no comparable x-ray procedure. c. Provides clinical information with a much lower dose of radiation than x-ray procedures and are much less expensive than other imaging procedures. d. Involves the administration of radiopharmaceutical injected intravenously or given orally, depending on the radioactive material selected and the organ to be studied, followed by the measurement of the radiation emitted. Indication of the detection of masses.

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Contraindicated for pregnant clients, unless benefits of performing the test greatly outweighs the risks to the fetus.

Nursing Considerations a. Before the test, explain the client that: 1. The procedure takes about an hour. 2. A sedative maybe administered to promote relaxation. 3. 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. 4. The radioactive material is exerted by the body, usually in the urine. 5. Scanning will take place immediately after the injection or at a later time, depending on the material used, with a machine that moves over the area to be examined. 6. A medication to enhance scanning can be administered before the procedure. 7. The only discomfort experienced is the injection of the radiopharmaceutical. Prepare the client by: 1. Obtaining a history to ascertain date of last menstrual period date and possible pregnancy in women of childbearing age, and known of suspected allergy to iodine. 2. Instructing the client to void before the test to prevent discomfort or interruption. During the test, the client is placed on the examining table in a supine position and is reminded to lie very still while the scanner is operating. After the test: 1. Advice the client when to return for additional imaging, if appropriate. 2. 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. 3. Note and report redness and swelling at the IV site (signs of phlebitis); apply warm compress to the site and elevate arm.

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Angiography Serial radiographs (x-rays) of blood vessels that are used to evaluate the patency, size and shapes of the veins (venograms); arteries of the organs and tissues (arteriograms); or lymph vessels and nodes (lymphograms). These are films taken in rapid sequence after injection of iodinated contrast medium into the vessel or vascular system to be examined. Indicated for suspected benign or malignant tumor and differentiation among tumor types.

Contraindications are: a. b. c. Pregnancy, unless benefits of performing the test greatly overweighs the risk to the fetus. Allergy to iodinated contrast medium, unless prophylactic medications are administered or non-iodinated contrast medium is used. Presence of a bleeding disorder.

Nursing Considerations: a. Before the test, explain to the client that: 1. A physician will explain and perform the procedure.

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The time required to complete the procedure varies with the type of examination performed for diagnostic or therapeutic purposes but generally, it may take 1 to 3 hours. 3. Foods and fluids are withheld for 4-8 hours before the procedure. 4. Some medications can be withheld for 8 hours before the examination, depending on the client and the reason for medication taken; that anticoagulants will be withheld or dosage reduced to prevent excessive bleeding; and that aspirin products are withheld for at least a week before the procedure. 5. An analgesic, sedative, or antianxiety agent can administered through injection before the procedure to promote relaxation and alleviate discomfort depending on the physicians order. 6. The client is requested to stand still throughout 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. 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, but last only about 30 seconds. 10. Bed rest is required for about 8-12 hours after the procedure to monitor the insertion site and vital signs, and to observe the client for signs of complications although complications are rare. Prepare the client by: 1. Ensuring that dietary, fluid and medication restrictions have been followed before the procedure. 2. Obtaining a history of allergies or sensitivities to the anesthetics or contrast medium; existing heart, lung or renal condition; and date of last menstrual period in women of child bearing age to determine the possibility of pregnancy. 3. Ensuring that hematologic status and blood clotting ability have been assessed to include complete blood count, platelet count, PT, PTT, clotting time, and bleeding time as well as routine urinalysis and electrolytes. 4. Removing all metallic objects, but allow client to wear dentures, hearing aids or both. 5. Obtaining and recording baseline vital signs, using peripheral pulses on the appropriate extremity. 6. 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. 7. Having the client void. 8. Shaving and cleansing the insertion site, if needed. 9. Administering pre medications subcutaneously or intramuscularly as ordered. During the test, 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. Also, inform the client that some pain will be felt at the puncture site when the catheter is inserted. 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. 2. Elevate the head of the bed to 45 degrees and extend the extremity used for the insertion site.

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3. 4. 5. 6. 7.

8. 9. 10. 11. 12. 13. 14. 15. 16.

Immobilize the extremity with a sand bag, 8 hours for a leg and 3 hours for an arm. Inspect the insertion site for bleeding or hematoma formation, and change the pressure pressing if needed. Apply ice to the site to relieve discomfort and edema by promoting vasoconstriction of the vessels. A mild analgesic can be administered for pain felt on the site of insertion. Assess skin color, sensation and temperature of the extremity to determine circulation status; take peripheral pulses of the extremity used, and compare the value obtained with the pulses taken from the same and the other extremity taken before the procedure. Perform pulse assessment every 15 minutes for the first hour, then every 30 minutes for the next 2 hours, and the every hour for the next 8 hours or more if needed. Advice the client to turn from side to side, and to exercise other body parts. Encourage fluid, first via IV line and then orally when the client is able to prevent dehydration and promote excretion of the dye. Inform client that if statures are used, these should be removed a week after the procedure. Note and report the following reactions to anesthetic agent or contrast medium: tachycardia, dyspnea, hyperpnea, or delayed feeling of itching (urticaria or rash). Administer antihistamines and steroids if there is reaction to anesthetic agent or contrast medium; initiate oxygen therapy and resuscitation if needed. Note and report pain, redness, swelling at the site, or changes in the peripheral pulses; monitor site for changes and apply ordered warm compress. Administer analgesic and antibiotic medications as ordered. Monitor site for signs of bleeding or hematoma; note and report excessive bleeding from the insertion site or presence of hematoma; apply pressure for 15 minutes after the procedure; apply ice and pressure dressing.

Cystologic Examination (diagnostic test used to diagnose cell type) Cystology refers to the study of structure, function and pathology of cells. Histology deals with the study of structure, function and pathology of tissues. Both methods are used primarily to detect cancer. Cystologic measures are used mainly as screening procedures to detect precancerous and malignant cells. Laboratory techniques were developed by George Papanicolaou, who identified characteristic that allowed for differentiation for normal form neoplastic cells. The differentiation is based on the changes that occur in the relationships between cytoplasm and the nucleus of the cells. In performing cystologic examinations, slides with cells are stained with various substances and examined microscopically. Malignant cells may show large, darkly stained irregular nuclei. The most common site examined through Cystologic methods is the uterine cervix and endometrium (site of Pap smear). Cells from the respiratory tract are also frequently examined, samples of such cells Can be obtained through sputum specimens, from bronchial brushings or washings obtained during bronchoscopic examinations, or from post bronchoscopy sputum specimens.

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Various body fluids can also be examined for abnormal cells; such fluids include urine, cerebrospinal fluid and pleural, peritoneal, pericardial, and synovial effusions.

Identification of Tumors Used to standardize diagnosis and treatment protocols; consist of classification (naming), grading (describing aggressiveness) and staging (describing spread within or beyond tissue of origin).

Classification of Tumors a. b. Involves naming the tumor according to the tissue or cell of origin. Incorporates the Latin stem to identify the tissue from which the tumor arises 1. Carcinoma tumors arising from epithelial cells. 2. Sarcoma tumors arising from fibrous connective tissues The specific type of the tissue is added to the stem word as a prefix. Other names of tumors are derived from the persons who discovered that particular cancer (e.g., Burtkitts lymphoma, Hodgkins disease). Malignancies of the hematopoetic system are named using the predominant immature blood cell type (e.g., myelocytic leukemia).

c. d. e.

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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

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Grading of tumors a. Grading evaluates the degree of differentiation and rate of growth: 1. Cells that are most differentiated resemble the parent tissue and therefore least malignant and least aggressive. 2. Cells that are least differentiated do not resemble the parent tissue and are therefore most malignant and most aggressive. The tumor is assigned a numeric value ranging from I to IV: 1. Grade I tumors (well differentiated tumors; least aggressive) closely resemble the tissue of origin in structure and function 2. Grade IV tumors (poorly differentiated or undifferentiated; most aggressive) are tumors that do not clearly resemble the tissue of origin in structure or function.

b.

Staging of Tumors a. b. Staging determines the sign of the tumor and the existence of metastasis. The TNM is the internationally recognized staging system and is frequently used. T Refers to the extent of the primary tumors. N Refers to lymph node involvement; absence or presence and extent of regional lymph node metastasis. M Refers to the extent of metastasis; absence or presence of distant metastasis.

Diagnostic Tests Used to Identify Tumor Markers Tumor markers are protein molecules (biochemical indicators) detectable in serum or other body fluids. These are produced by a tumor or by other cells in response to a tumor. 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. High levels of tumor markers are suspicious for malignancy and require follow-up diagnostic studies. Most useful in monitoring clients response to therapy and for detecting residual disease. Commonly used serum tumor markers and malignancies associated with elevation are: 1. Alpha-fetoprotein (AFP) hepatocellular carcinoma; choriocarcinoma, teratoma, embryonal cell tumors of ovary or testis. 2. Carcinoembryonic antigen (CEA) colon, rectum, pancreas, gastric, lung, breast, ovary. 3. CA-125 epithelial ovarian neoplasm, breast, colorectal, gastric. 4. CA-15-3 breast. 5. CA-19-9 colorectal, pancreas, gastric, liver. 6. CA-27-29 breast. 7. Human chorionic gonadotropin (HCG) choriocarcinoma, germ cell, testicular, hydatidiform mole. 8. Prostate specific antigen (PSA) prostate.

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Diagnostic Tests Used for Direct Visualization Proctosigmoidoscopy Direct visualization of the mucosa of the anal canal (anoscopy), the rectum (proctoscopy), and the distal sigmoid colon (sigmoidoscopy). Can be performed using a rigid or flexible fiberoptic endoscope. Bowel preparation is always needed before the procedure to clear the rectum and sigmoid colon of feces to enhance visualization. Indicated for cancer screening with identification and polyp removal; excision of the tissue for cystologic analysis. Contraindicated for: a. b. c. d. e. Suspected bowel perforation, acute peritonitis, acute fulminant colitis, diverticulitis, toxic megacolon, or ischemic bowel necrosis. Severe cardiopulmonary disease. Large abdominal aortic or iliac aneurism Severe bleeding or blood coagulation abnormality. Advanced pregnancy.

Nursing Considerations: a. Before the test, explain to the client that: 1. The procedure requires about 15-30 minutes. 2. A light meal in the evening before and fluids the morning of the procedure is allowed. 3. A laxative and enema before the procedure can be administered the night before. 4. 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. 5. Drapes will be placed to avoid exposure and prevent embarrassment. 6. The lubricated scope will be inserted into the rectum after the physician performs a digital rectal examination. 7. The urge to defecate can be experienced when the scope is inserted; that slow, deep breathing through the mouth can help alleviate this feeling; and that the client will be allowed to practice this breathing technique beforehand. 8. Specimens can be obtained and suctioning performed through the scope to remove excess materials during the examination to enhance visualization. 9. 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. b. Prepare the Client By: 1. Obtaining a history of bowel disorders, pregnancy status, and blood studies that indicate a coagulation disorder.

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

2.

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a. b. c.

Differentiation of benign and malignant lesions involving the bladder through tissue biopsy and laboratory analysis. Identification of tumors and polyps. Removal of polyps and small tumors from the bladder.

Contraindications: a. b. Bleeding disorders use of instrumentation can lead to excessive bleeding from the lower urinary tract. Acute cystitis or urethritis instrumentation can allow bacteria to enter the blood stream and cause septicemia.

Nursing considerations: a. Before the test, explain to the client that: 1. The study may take 30 minutes or more. 2. 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. 3. An anesthetic will be administered, such as local, general, or spinal, depending in the age of the client and the procedure to be performed. 4. To prevent infection, an antibiotic maybe administered before and after the procedure. 5. A special microscope-like instrument will be inserted into the urethra to visualize the bladder. 6. If a local anesthetic is administered, a sensation of pressure, a need to void, or both can be experienced as the procedure is performed. 7. If the client will undergo general anesthesia, the nurse should give instructions in breathing technique and other postoperative activities. Ensure enough time to practice techniques. 8. Vital signs and urinary output will be monitored closely after the procedure. 9. 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. Prepare the client by: 1. Obtaining a history of genitourinary infections, bleeding disorders, or other disorders of the urinary tract. 2. Ensuring that hematologic status and blood clotting abilities have been assessedincluding CBC, platelet count, PT, PTT, and urinalysis results for abnormal results. 3. Ensuring that dietary and fluid restrictions have been followed base on the type of anesthesia to be administered. 4. Administering enema if ordered. 5. Providing a hospital gown. 6. Administering ordered antibiotic therapy.

b.

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7. 8. 9.

c.

d.

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

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report changes in vitl signs indicating hypovolemia; if biopsy was performed, maintain bed rest for 4 hours if possible. 10. Monitor for bladder perforation; note and report suprapubic pain or excessive hematuria; administer ordered medications; prepare for surgical repair. 11. Monitor ureteral of urethral catheter obstruction; note and report drainage difficulty; maintain patency and connection to a closed collecting system avoid kinking or tension on catheter, maintain sterile-closed system, and provide catheter insertion site care as appropriate. Endoscopy Dire visualization of the mucosa of the upper gastrointestinal tract which includes the esophagus, stomach and upper duodenum, using a fiber-optics endoscope. Any or all the three structures can be included in the examination and can be referred to as esophagoscopy, gastroscopy, duodenoscopy and esophagogastroduodenoscopy (EGD). Maybe performed for therapeutic as well as diagnostic purposes. Indicated for diagnosis of tumors of the upper small intestine.

Contraindications: a. b. c. d. Aneurism of the aortic arch because of the risk of rapture. Unstable cardiac status, because mild hypoxemia can be induced by EGD. Known or suspected prforated viscus, because the situation indicated surgery, not endoscopy, and because endoscopic instrumentation can further aggravate the situation. Recent gastrointestinal surgery.

Nursing Considerations: a. b. Client teaching and physical preparations before the test are the same as those described in cystoscopy. Inform the client that: 1. The procedure takes at least an hour and that an IV line is initiated to administer fluid and additional medications immediately before the procedure. 2. The type of anesthesia is usually local but be general if the client is unduly apprehensive. 3. The instrument is inserted in the mouth and passed in the stomach and intestine. 4. His or her history will be obtained including known or suspected gastro intestinal tract disorders, treatment regimen, and other diagnostic tests and procedure he or she has undergone. During the procedure: 1. The client is seated in a semi-reclining position and the oropharynx is sprayed or swabbed with a topical local anesthetic. 2. The client is then assisted on a left-lateral position, with the right hand at the side, the left hand under the pillow at the head, the neck slightly flexed, and the knees drawn up at the right angel to the body. 3. Depending on the clients condition, vital signs and cardiac rhythm can be monitored throughout the procedure.

c.

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4.

d.

A protected guard is inserted into the mouth to cover the teeth, and a bite block is also inserted to maintain an open mouth without client effort or control. 5. The client is informed that speaking is not possible but the breathing is not affected. 6. Advice the client that breathing deeply will help to allay gagging and choking. After the test: 1. Monitor vital signs, breath sounds and comfort level. 2. Assist the client to a position of comfort with the head slightly elevated, and encourage the client to expectorate any accumulated secretions. 3. Maintain the client on a side-lying position for 1-2 hours to prevent aspirations of secretions. 4. Monitor vital signs and cardiac rhythm as well as respiratory status, and compare with baselines. 5. Assess swallowing ability, site and degree of pain continuously. 6. Advice the client to withhold food and fluids for 4-6 hours, until swallowing ability returns. 7. Restrict activities until the sedative or anesthetic effect has worn off and the client is awake and alert. 8. Provide warm saline gargles or throat lozenges to alleviate throat discomfort. 9. When the gag reflex and swallowing ability returns, provide soft foods and warm soothing fluids. 10. Remind the client that belching, bloating, or flatulence if the result of air insufflations. 11. Instruct the client to report immediately any postprocedural discomfort or pain in the chest, neck, back or upper abdomen; pain on swallowing; difficulty of breathing; or blood expectoration. 12. Monitor for reaction to anesthetic agent or medications; note and report tachycardia, palpitations, hyperpnea, or hypertension; administer ordered anti histamines; initiate IV line and resuscitation, if needed. 13. Monitor for perforation of esophagus; note and report neck pain or pain when swallowing, hemoptysis (bleeding at the cervical level), substrenal or epigastric pain, chest pain that increases with breathing (bleeding at the thoracic level), or changes in vital signs for potential hypovolemia; initiate IV line for fluid replacement; prepare for intervention to repair damaged area. 14. Monitor for perforation of the diaphragm or stomach; note and report pain in the shoulder, dyspnea (diaphragm), abdominal or back pain (stomach), or changes in vital sign for potential hypovolemia; prepare for intervention to repair damaged area. 15. Monitor for persistent bleeding; note and report hemoptysis; hematemesis, black tarry stool, or changes in vital signs for potential hypovolemia if bleeding is ecessive; initiate IV line for fluid volume replacement or transfusion of blood or packed RBS as ordered. 16. Monitor for pulmonary aspirations; note and report dyspnea, cyanosis, abnormal breath sounds, hypoxemia, or signs and symptoms of aspiration pneumonia or pleural effusion, maintain the client in a side lying position and suction airway; provide resuscitation as needed for immediate interventions; administer antibiotic therapy if pneumonia is present.

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17. Monitor for cardiac abnormality; note and report dysrhythmias, chest pain or alterations in blood pressure and pulse; administer ordered cardiac medications; monitor cardiac activity via ECG. Bronchoscopy Direct visualization of the larynx, trachea and bronchial tree by means of either a rigidor flexible bronchoscope. This procedure can be both diagnostic and therapeutic.

Indicated for diagnosis through: a. b. c. d. e. Visualization of pulmonary tumor. Determination of the cause of unexplained abnormal cystologic findings in sputum. Suspected bronchogenic carcinoma to obtain washings or by brushing of biopsy for cystologic analysis. Determination of the stage of known bronchogenic carcinoma to assist in determining the approach to treatment protocols. Indicated for therapy though local treatment of known lung cancer through instillation of chemotherapeutic agents, implantation of radioisotopes, or laser palliative therapy.

Contraindications are: a. b. c. d. Bleeding disorders. Pulmonary hypertension that can be associated with an increased risk of hemorrhage from the procedure. Disorders that limit extension of the neck. Severe obstructive trachealconditions.

Nursing considerations: client teaching and physical preparation are the same as those described in bronchoscopy

Exploratory Surgery Lymph node biopsy to determine metastases. Diagnostic surgery, such as biopsy is usually performed to obtain a tissue sample for analysis of cells suspected to be malignant. In most instances, the biopsy is taken from the actual tumor. The three most common biopsy methods are: a. Excisional biopsy the surgeon removes the entire tumor and surrounding marginal tissue. b. Incisional biopsy performed if the tumor mass is too large to be removed. c. Needle biopsy involves aspiration tissue fragments through a needle guided into a suspected area of malignancy.

Other non-specific tests to determine involvement of the other organs include CBC, differential count; electrolytes; and blood chemistries.

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Psychosocial Considerations for Cancer Clients Psychosocial assessment must be ongoing and based on observed statements and behavior of individuals. Interviews with open-ended statements promote expressions of problems, which is often difficult. Shock, disbelief, and anxiety are common emotions experience with the diagnosis of cancer. Anxiety decreases perception. Instructions for the persons with cancer must be simple, reinforced, and provided in writing. Most people are concerned with the fear f death during the first 100 days after the diagnosis. 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. 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. Faces the prospects of uncomfortable and painful diagnostic procedures. Guilt can be predominant emotion, if the person believes that lifestyle habits are the cause of the cancer, or if the person has delayed seeking medical attention. Abandonment of friends and family can be threatening to the individual. Referral to community agencies that may be helpful is important. People with cancer and their family need information during the diagnostic period. Often they are seeking second opinions and need guidance in choosing appropriate resources.

Coping is a dynamic process that seeks to restore equilibrium and reduce stress. It involves conscious actions and differs somewhat from psychologic defense mechanisms, which are unconscious. Coping is often considered a response to a short-term problem, where as adaption refers to ongoing adjustment to long-term problems such as chronic disease. Coping skills are acquired over the persons lifetime and are influenced by the personality and life experiences. Some coping strategies can be productive in problem solving, whereas others are counterproductive, closing off options and increasing distress.

Denial is a natural defense mechanism that protects the ego against anxiety. Denial allows the person to ignore or explain away unpleasant or threatening matters. In cancer literature, denial also includes suppression, which is a deliberate, conscious decision not to thinking about the threat, and repression which is unconsciously motivated forgetting. Denial can only be interfered from the persons observed behavior and statements. Inappropriate optimism or unconcern on the face of a poor prognosis maybe evidenced of denial. Extreme denial leads to poor compliance and block communication, which adds distress to the family. Partial denial either to the parts of the cancer experience is common and can relieve distress for a short time.

Family Support

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Initial role changes in families are required. Whatever the role of the person with cancer in the family, changes must compensate for the lost of that role. If a child has cancer, then many roles are changed to provide support and care during treatment. Financial concerns may overwhelm the family. Many families do not have adequate insurance to cover a major and longer illness. Individuals with health maintenance organization coverage may feel frustrated if they are not able to select the best cancer specialist. Community Support People with cancer are concerned over loss of friends. Persons who have a sever cancer phobia will indeed desert friends who are diagnosed with cancer. Community resources may vary with geographic location. Major metropolitan areas may have wellness communities or other support programs for people with cancer. Those who live in the rural areas however may have to be more resourceful. Clinical Management for Cancer Goals of Intervention Treatment of cancer is intended to achieve one of three outcomes: 1. 2. 3. Cure Prolongation of life Palliation of symptoms

Goals can overlap. An individual may undergo treatment for cure, and then, year later, require additional therapy for recurrent disease or palliation of symptoms. A determination of whether to treat for cure is one of the most critical treatment decisions. The basic principle is to cure, if possible with minimal structural and functional impairment. 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. Few cancers can be cured once they have recurred or are metastatic at the time of diagnosis. Adjuvant therapies refer to additional chemotherapy or radiation given after eradication of the tumor to prevent recurrence and therefore improve curability. Adjuvant therapy has proven value in breast and colon cancer. Treatment for non-curable tumor is palliative and is directed toward control of tumor growth and relief of symptoms. Treatment Decisions Tumor-related factors that determine treatment decisions are tumor size, stage of disease, histologic type and grade, naturally history of the tumor, and responsiveness of the tumor to treatment methods. Person-related factors that influence treatment selection are physical condition, mental status, resources available, and personal preferences.

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

Chemotherapy as cure as adjuvant therapy

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For Wilms tumor, osteogenic sarcoma and rhabdomyosarcoma.

Chemotherapy as complete remission with increased survival For breast cancer, small cell carcinoma of the lungs, acute myeloblastic leukemia, Non-Hodgkins lymphoma (indolent), prostate cancer, hairy cell leukemia, chronic granulocytic leukemia.

Chemotherapy as response with some prolongation of survival Multiple myeloma, ovarian cancer, endometrial, neuroblastoma, colorectal cancer, liver cancer.

Chemotherapy as a minor response with no demonstrable prolongation of survival Non-small cell lung cancer, head and neck cancer, stomach cancer, pancreatic cancer, cervical cancer, melanoma, cancer of the adrenal cortex, soft tissue sarcomas.

Chemotherapy as Organ preservation (neoadjuvant therapy) Breast cancer, laryngeal cancer, bladder cancer, osteogenic sarcoma, soft tissue sarcomas, anus cancer, esophageal cancer.

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

2.

3.

4.

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5.

Drugs functioning in the S phase of the cell cycle. They compete for or replace metabolites that are essential for DNA formation. Antimitotic antibiotics Originates from fungus They insert a ring between adjacent turns of DNA helix, which distorts the helix, inhibiting replication. -

Cytotoxic drugs can be given as single agents or in combination with drugs or hormones. Most drugs are given at specified intervals to allow for recovery of bone marrow. Depending on the route of administration and institutional policy, chemotherapy can be given by staff nurse, clinical nurse specialist, specifically trained chemotherapy nurses, or physicians. Drugs are administered systemically through oral, subcutaneous, intramuscular, or intravenous route or regional through topical, intrathecal, intracavitary, or intra-arterial instillations. The dosage for most cytotoxic drugs is based on the body surface area of the person calculated from the height and weight. Accurate measurements are critical to correct dosage. Intravenous therapy is the most common route. Drugs are given intermittently or by continuous infusion with an external or internal implanted pump device. Preparations, Handling and disposal of drugs Cytotoxic drugs are known to be carcinogenic (cause of cancer), mutagenic (cause of mutations) and teratogenic (affect embryonic tissue) Personnel can be exposed to cytotoxic drugs through inhalation of aerosols, absorption through the skin, or ingestion of contaminated materials. The effects of long-term, 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, eye and mucous membranes. Exposure to cytotoxic drugs should therefore be avoided by all concerned with their use. 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. Care should be taken to protect the skin. All connections between the drug (syringe or container) and the client should be placed away from the clients skin. If this is not possible, the skin should be protected. Protect the personnel it is the nurses responsibility to be aware and to follow policies and procedure in proper handling and disposal of this agents. 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.

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Use luer-lock fittings on all intravenous tubings used to deliver chemotherapy. Protect the environment Dispose of all equipment used in chemotherapy preparation and administration is appropriate, leak-proof, puncture-proof containers. Dispose of all chemotherapy wastes as hazardous materials. Clients body fluids (urine, feces, emesis) are considered hazardous for 48 hours after the treatment. Effects of Chemotherapy to the Client 1. Bone marrow suppression Hematopoietic stem cells are destroyed; they are unable to replace lost cells at the normal rate. Blood counts drop. Blood count lowest point occurs between the 7th and 14th dayafter drug administration and recover by the 21st day. 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. Leukocytes only survive 6 hours in the blood stream. Neutrophils function to localize and neutralize bacteria in the body. When neutropenia occurs, the persons response to bacterial infection is severely compromised, and localized infections can progress to septicemia without the usual response of fever or inflamation. Blood counts are monitored at appropriate intervals. The absolute neutrophil count is calculated by multiplying the number of leukocytes by the percentage of Neutrophils and bands. Client are instructed promptly any temperature higher that 100.5o F to the physician or oncology nurse. Individuals with neutropenia without fever can be managed as outpatients and are cautioned to avoid crowds and exposure to infected individuals, to maintain good hygiene and hand washing, and to monitor their temperature every 4 hours. Rashes, fever, sore throat must be reported. Persons with elevated temperatures or shaking chills are generally advised to contact their physician or return to the hospital immediately or both. On hospital admission, a thorough physical examination is performed to determine any source of infection. Blood cultures and antibiotic therapy are instituted. Since 90% of new fevers in people with cancer are bacterial, a combination of penicillin and an aminoglycoside drugs are administered. Colony stimulating growth factors may be used to argument leukocyte production. Mucositis Cells of the gastrointestinal lining from the oral cavity to the rectum, which are continuously lost as fluids and foods pass through, are replaced for stem cell populations. As chemotherapy destroys stem cells, normal replacement and repair are inadequate. Mucositis can occur in any portion of the gastrointestinal tract but is most common in the oral cavity, esophagus and intestine. Stomatitis

2.

3.

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

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7.

8.

9.

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 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.

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.

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.

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 Hodgkins 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.

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.

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 clients 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 individuals 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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b.

c.

d.

e.

Solitary metastatic lesions in the lungs, brain, or liver can be removed to effect a surgical cure. Decisions to resect metastatic lesions are based on tumor type and natural history, length of disease-free interval, stability of the lesion, and unresponsiveness of the tumor to chemotherapy and radiation. Metastatic cell sarcomas, melanomas, and colon carcinomas have been removed in selected persons, producing cures or prolonged survival times. Palliative Surgery Palliative surgical procedures are considered if risk-to0benefit ratio to the person with cancer is positive. Palliative procedures can be done to reduce pain; relieve obstructions in the respiratory, gastrointestinal, or urinary tract; relieve pressure on the brain or spinal cord; prevent hemorrhage; remove infected or ulcerating tumors; and drain abscesses. Palliative surgery is aimed at controlling cancer and improves quality of life. 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. Reconstructive Surgery Following radical curative surgical procedures, people with cancer have form and function improved with reconstructive surgery. Skin and muscles flaps can be used to cover anatomic defects. Reconstruction in head and neck procedures can be extensive but offer the person with cancer improved cosmesis and quality of life. Prophylactic Surgery People who are at risk for developing specific cancers may be considered for the excision of the target organ. 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. Removal of precancerous polyps is commonly done as a measure to prevent colon cancer. -

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, so that they are well educated in regard to the procedure and the care afterward. General Surgical Care and Oncological Emergencies In addition to the typical surgical complications, cancer clients may experience a set of complex responsespresipitated by concominant therapies or underlying disease process itself. These can include acute respiratory distress syndrome (ARDS), aspiration pneumonia, infection, bleeding, poor wound healing, and stomatitis. Blood product administration, pain control, nutritional support, and hemostas are common surgical challenges. Autologous Blood Donation clients may donate one or more units of their own blood to bank before their surgery. Autologous donation may be done 42-72 hours before surgery.

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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. Nutritional Support the nutritionally deliberated person with cancer is a poor surgical risk. Before surgery, protein calorie malnutrition should be reversed. Clients may receive aggressive preoperative nutritional status. Hemostatis the person with cancer is highly susceptible to postoperative thrombophlebitis. Early postoperative ambulation is instituted. Combination Therapy Synergistic augmentation effects of combined therapies can produce postoperative reactions and complications that may be difficult to manage. Radiotherapy and chemotherapy can compromise wound healing and may increase postoperative complications.

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

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

Treatment Planning

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The treatment volume is defined and localized using physical palpations of the tumor (if possible), scans, and x-rays. 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. The radiation oncologist, radiation physicist, and technologist determine optimal position and treatment portals. Wedges to compensate for tissue differences, lead blocks to shield normal tissues adjacent to the tumor, and immobilization casts are created. Skin markings are down with tattoo or ink to ensure exactly placement of the radiation beam. A computer simulation is constructed to demonstrate the tumor volume and dosage to ensure precise treatment.

Treatment The client is usually treated with 180-300 cGY per day, 5 days a week. Actual radiation time is only few minutes. Additional time is required if several treatment is required if several treatment ports are used and the client needs to repositioned. The client is seen weekly by the radiation oncologist to monitor progress, make assessment, and treat side effects and reactions. A weekly complete blood count and weight measurement are taken. Dose calculations are frequently checked by the radiation physicist.

Post Treatment Follow-up The person with cancer is seen frequently until all acute reactions have subsided. Therefore the person is seen 2-3 months during the first post-treatment year. If radiation was primary curative treatment, the person with cancer is seen annually to monitor late treatment complications.

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. Systemic reactions to radiation (nausea, fatigue, and weakness) occur only during treatment. The severity of the reaction depends on the total dosage received and the tissue composition. Self-renewing cell-systems, skin, bone marrow, and mucosal membranes are most responsive to radiation. Acute reactions are self-limiting and relate to edema, inflamation, and parenchymal cell death. Acute reactions occur days to weeks after the initiation of the therapy. Some reactions considered acute may occur within a few months of treatment. Delayed reactions occur in related organs secondary to destruction of the endothelial linings of the small blood vessels, which become damaged over time,

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

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

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residue diet of small, frequent meals and avoiding raw foods, caffeine, strong herbs and spices, fatty foods, milk and milk products minimize stimulation of the small intestine. Antidiarrheal medications may be ordered. Pelvic Radiation Reactions Irradiation of the bladder, vagina, and rectum produces irritation and inflamation causing cystitis with frequency, urgency, burning and hematuria; proctitis with diarrhea, bloody stools, and tenesmus; and vaginitis with dryness and dysparenuria. Diarrhea is symptomatically treated, as in abdominal radiation. The rectal area should be cleaned after bowel movements. Sitz bath may be recommended. Cystitis can be minimized by increasing fluid intake, especially cranberry juice, and avoiding substances that irritate the bladder (e.g., caffeine, tobacco products, alcohol, and spices). Difficulty in voiding should be reported to radiotherapist. Vaginitis may cause painful intercourse, which may need to be avoided until soreness decreases. Loose cotton underwear, frequent baths, and exposing the perineum to air whenever possible are recommended. Douches, creams, lotions, and sprays should not be used.

Brachytherapy A radiation technique in which radiation sources are placed directly into an organ or tumor, 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. 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. Radiation sources used in brachytherapy are radioactive isotopes (e.g., radium, cesium, iodine, gold, iridium, and cobalt). These sources have low energy and limited tissue penetration. Sources can be temporary or permanent, depending on the mode of administration. Intracavitary administration application of radiation can be done for any hollow organ, but intracavitary radiation is mainly used for cervical and endometrial cancers. An applicator is placed within the organ in the operating room, and the radiation source is inserted after loaded when the person is returned to the room, thus limiting exposure to others. Intracavitary radiation is now used to reduce obstructive lung and esophageal tumors that have been radiated previously. Interstitial Administration wire, needles, or ribbons are placed within the tumor. When placement is deemed satisfactory, radioactive seeds are inserted. This mode is often used in breast, brain, head, neck, and prostrate tumors. Systemic therapy thyroid cancer is often treated by systemic therapy based on the affinity of the thyroid tissue for iodine. An oral solution of radioactive iodine will be taken up selectively by the thyroid to produce the effect.

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Procedure to minimize radiation exposure to personnel: The amount of radiation exposure depends on the radiation source. Gamma rays have sufficient penetrating ability to provide a radiation hazard to individuals near the client. Alpha and beta particles do not penetrate in the tissue. The person who conveys radiation risk should be isolated in a clearly marked private room. Radiation exposure is minimized by reducing the time spent with the person, interposing shielding materials between the person and the personnel, and increasing the distance between the person and the others. Pregnant personnel and visitors should not be exposed to the client. Appropriate procedures should be developed with radiation personnel to prevent inadvertent environmental contamination of radioactive materials.

Adjunctive Therapies Hormone-responsive tumors have been managed empirically for many years by hormone manipulation. Hormone manipulation is used primarily in the treatment of metastatic breast, prostate, and endometrial cancers and hematologic malignancies. Although hormone manipulation can cause tumor regressions, the duration of the effect is limited, and eventually the tumor becomes refractory to other manipulations. It is believed that tumors probably contain hormone-dependent and hormone-independent clones, which as tumor growth progress and cell become more anaplastic; their dependence on hormones is lost. Hormonal manipulation can be achieved by adding hormones, suppressing hormones, using antihormones, and surgically removing hormone producing organs. Steroid hormones (e.g., estrogens, androgens, progestins and glucocorticoids) carried through the blood while bound to plasma proteins, bind with cell specific receptors that convey them to the cell nucleus where they affect DNA, RNA, protein synthesis, and cell division. The precise mechanism of hormone action is unknown, but it is thought to affect secretions of the tumor growth factors. Anti hormones or synthetic anti-estrogens and antiandrogens are hormone antagonists that interfere with the normal hormone-hormone receptor-binding process. Surgical removal of hormone-producing organs also affects hormonal production. Drugs that suppress hormone production by suppressing gonadotropins can also be used. Bone Marrow Transplantation Bone marrow transplantation is supportive therapy used in hematologic malignancies (i.e., leukemia and lymphomas) it restore bone marrow function after eradication of the persons bone marrow through the use of high-dose chemotherapy and radiation. Long term remissions and cure can be achieved in some people. In the treatment of solid tumors, 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.

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

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

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Chronic Complications most chronic complications develop with the first year following transplantation. Bacterial, viral, and fungal infections Cytomegalovirus, Pneumocystis carinii Collagen vascular disorder, affecting joints, esophagus, eyes, lungs liver, skin and gut.

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

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hallucinations, disorientation, anemia, and thrombocytopenia are other side effects. Bacille Calmette-Guerin (BCG) a strain or M. bovis; its use has been investigated extensively in colon, breast, bladder, and renal cancers and in malignant melanomas, although treatment of bladder cancer is not its sole use. BCG is administered intravesically in dosages ranging from 10 to 100 million bacilli in a weekly basis for 6 months. People receiving BCG must have a small tumor and be immunocompetent. Systemic side effects include fever, chills, malaise, headache, and weakness. Local side effects are bladder irritability, frequency, urgency, and dysuria. Vaccines one vaccine that has been developed is the vaccine against cervical cancer, also known as Human papillomavirus or HPV vaccine. 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. Monoclonal antibodies- can be conjugated to drug molecules, toxins, or radio nuclides that can deliver cytotoxic cells in the immune system. Side effects of this therapy are fever, chills, flushing, urticaria, nausea, and vomiting. Anaphylactic reactions occur in those with high levels of human anti-mouse antibodies. Cells (i.e., adoptive immunotherapy) lymphokine-activated cells are produced by exposing peripheral blood mononuclear cells to high concentrations of interleukin-2. These lymphokine-activated cells are capable of lysing tumor cells but not destroy normal cells.

Cytotoxic Cytokines tumor necrosis factor (TNF) shows dramatic necrosis in established tumors in animals, but this activity has not been demonstrated in human tumors unless TNF is injected directly into the tumor. TNF is used in combination with chemotherapy and biologic response modifiers to eradicate tumors. TNF can be administered intravenously or subcutaneously, although the latter route can produce severe inflamation. Side effects are fevers, chills, rigors, headache, fatigue, hypertension, and thrombocytopenia. Cytokines (growth factors) hematopoietic colony-stimulating factors essential for the proliferation, differentiation, and maturation of blood cells. Erythropoietin is a cytokine produced in the kidneys in response to hypoxemia; used to treat the reduced erythrocyte count of myelosupressed individuals. It is

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administered 3 times weekly by subcutaneous injection. Side effects are mild hypotension. Granulocyte-macrophage colony-stimulating factor is produced by T cell stimulating the production of Neutrophils, basophils, eosinophils, monocytes, erythrocytes, and megakaryocytes. Used to shorten periods of neutropenia but shows no effect in thrombocytopenia. Administered intravenously or subcutaneously in varying dosage, it causes such transient side effects as fever, myalgia, bone pain, and nausea. Granulocyte colony-stimulating factor influences maturation of granulocytes. It has been demonstrated to shorten periods of neutropenia to people receiving various cytotoxic drugs; for use in case of neutropenia associated with chemotherapy. Administered subcutaneously, its mild side effects are bone pain, myalgia, and skin rash.

Complications of Cancer Cancer Pain The experience of anticipation of pain is the most feared and dreaded complication of cancer, compromising the quality of life for most people with cancer. Persistent pain occurs in 70% to 90% of terminally ill cancer clients. Moderate to severe pain occurs in 40% to 50% of clients with early- or intermediate-stage cancer. Sources of Pain Approximately 75% of pain is tumor related. Causes of pain are the following: Tissue damage causing necrosis, ulceration, and infection Tumor erosion, 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, radiation therapy, or surgery. Pain unrelated to cancer accounts for 5% of pain reported by people with cancer; pressure sores, peptic ulcers, constipation, and osteoarthritis are other causes of pain. Temporal Classifications of Pain Acute cancer-related pain can be caused by tumor or tumor-related therapies. It is of limited duration, with a defined onset, and is associated with symptoms of sympathetic stimulation. The cause of acute pain can usually be determined easily and managed by treatment of the underlying cancer or the use of analgesics, or both. Chronic cancer-related pain persists for more than 3 months. Signs of sympathetic stimulation are absent, but changes in mood, gait, and facial expression are seen. Alterations in appetite, sleep, and concentration and irritability are prominent. Chronic pain is caused by tumor progression or syndromes related to cancer therapies. Pain related to tumor progression increases in severity with tumor infiltration of bone, nerves, and soft tissue adjacent to the tumor. Fear of death and hopelessness are related psychologic factors.

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

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

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

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

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

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Diagnosis of cachexia is based on symptoms. Generally, weight loss is greater than 10% is considered cachexia. The severity of cachexia is not correlated to tumor size, type of tumor, or extent of disease. More commonly seen in advanced disease, cachexia also occurs in localized cancers. Weight loss in cachexia results from decreased nutrient intake and altered metabolism. Decreased nutrient intake is affected by anorexia and early satiety. Abnormalities in taste and aversion to red meat are common. Increased energy expenditure has been demonstrated in some studies. In normal malnutrition, the body reduces its basal metabolic rate, but in people with cancer, it is elevated. Protein, carbohydrate, and fat metabolism are altered; resulting in increased glucose production, decreases in body fat and protein catabolism, and muscle wasting. Adequate nutrition is vital for maintaining immunocompetence and resisting infection. Assessment of nutritional status is important to determine the need and extent of nutritional support. Malnutrition can be determined if the person exhibits unexplained weight loss of 10% or more of body weight, serum transferrin less than 150 mg/dL, and serum albumin less than 3.4 gm/dL. Meeting 2 of the 3 criteria indicates a need for nutritional support. The subjective global assessment gives a clinical determination of malnutrition. History weight change over time; change in dietary intake relative to normal; presence of gastrointestinal symptoms for over 2 weeks; change in functional capacity; concurrent diseases or stress Physical examination evidence of loss of subcutaneous fat stores; evidence of muscle wasting; presence of ascites; presence of ankle or sacral edema Diagnostic categories well nourished; minimally malnourished; severely malnourished The goal of nutritional support must be determined before intervention to determine the extent of therapy. Oral nutrition may suffice for those who are nourished or mildly malnourished but are undergoing temporary impairment of nutritional intake or increased nutrient losses. Chemotherapy and radiation therapy produce a large range of side effects that impair nutrition. Antidepressant therapy can reduce anorexia caused by depression. Symptomatic treatment of stomatitis and mucositis also improves intake. Metoclopramide can be used to improve gastric emptying. Hydrazine, dexamethasone, and megestrol acetate can be used empirically to improve nutritional intake. Enteral therapy is indicated for those who are unable to maintain adequate oral intake but have a functioning gastrointestinal system. Short-term therapy can be accomplished with a smallbore feeding tube. Long-term management requires a gastrostomy or jejunostomy tube. Parenteral therapy is indicated for those in whom the gastrointestinal tract cannot provide nutrient intake (e.g., cases of fistulas, obstructions, malabsorptions, or severe malnourishment). Peripheral or central venous access can be used to provide parenteral nutrition. Paraneoplastic Syndromes Paraneoplastic syndromes are symptom complexes that are not produced directly by the tumor or its metastases. Often called remote or systemic effects of malignancy, paraneoplastic syndromes represent a diverse group of symptoms affecting many body systems. Endocrinopathies Cushings syndrome, hyponatremia, hypercalcemia, carcinoid syndrome, polycythemia Nerve and muscle syndrome disorders of the central and peripheral nervous systems, myasthenia gravis Osseous, articular, and soft tissue changes hypertrophic osteoarthropathy and clubbing of fingers Vascular and hematologic changes venous thrombosis (Trousseaus phenomenon), nonbacterial thrombotic endocarditis Occurring in 10% to 15% of cancer clients, paraneoplastic syndromes can be caused by production of hormones by the tumor affecting the target organ, proteins secreted by the tumor

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

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metastases can be treated by systematic chemotherapy or regional hepatic artery infusion with implanted or portable infusion pumps. Bone metastasis- Bone is the third most common site of metastasis, but bone metastases occur in the three most common tumors: breast, prostate, and lung. Thus, the number of people with bone metastases is large. The most common sites are vertebrae, pelvis, femur, and skull. Metastatic lesions can be osteolytic through destruction of bone by osteoclasts or osteoblastic through development of new bone in response to tumor invasion. Pain is the most common symptom. Described as insidious, aching, and increasing in intensity over time, pain is usually localized to the area of the tumor, although extensive bone metastasis can exists without pain. Increasing back pain can represent external compression of the spinal cord or cauda equine by metastatic lesions. Emergency evaluation is needed to prevent irreversible neurologic damage. Bony metastases are diagnosed by bone scan, which is extremely sensitive to changes in the bone, detecting changes of as little as 5%. Specificity, however, is poor. Lesions that are primarily osteolytic will show as cold spots, whereas osteoblastic lesions will appear as hot spots. Radiographs can detect bone changes after 30 to 50% of the bone is destroyed and the lesion is 1.0 to 1.5 cm in diameter. CT scan and MRI may be useful in equivocal situations. Relief of pain and prevention of fractures and disability are treatment goals. Local treatment to bony metastasis with radiation therapy is effective to relive pain and improve function. Approximately 60 to 90% of clients have moderate to severe pain. Chemotherapy and hormonal therapy (in breast and prostate) are used to treat the underlying cancer. Surgical interventions are needed for impending fractures. Internal fixation of the bone with rods and plates and use of bone cement provide stability in weight-bearing bones. Brain metastasis- Brain metastasis occurs in approximately 13% of cancer clients. Single metastatic lesions are associated with ovarian cancer, osteogenic sarcoma, breast cancer, and renal cancer, whereas lung cancer, melanomas, and seminomas tend to develop multiple metastatic lesions. Brain metastases generally develop multiple metastatic lesions. Brain metastases generally arise after secondary metastases to the lungs and liver. The presenting signs and symptoms of brain metastases are headache, focal weakness, mental disturbances, and seizures. MRI is the most sensitive diagnostic tool to detect brain metastases, but CT scanning can also be utilized. Maintaining maximum neurologic functioning is the treatment goal in brain metastases. Radiation therapy is the primary mode of treatment. Selected clients with single lesions may benefit from surgical excision. Supportive care with steroids can be helpful. Chemotherapy is limited to the few tumors that respond. Terminal Cancer Palliative treatment refers to the use of treatment modalities (chemotherapy, radiation, surgery) in incurable cancer to alleviate symptoms caused by persistent tumor growth, new metastatic lesions, and the side effects of treatment. Palliative care is frequently referred to as the chronic phase of cancer. For people with certain types of cancer, it can extend for many years. Many remain working and productive, functioning in their usual roles. When treatment options have been exhausted and tumor growth is uncontrolled, the terminal phase of cancer begins. Either the tumor is refractory to chemotherapy and radiation, or new metastatic lesions occur in locations that have received maximum radiation dosages. The person might also choose to terminate treatment. The treatment goals then become symptom management. Not all people with metastatic cancer become terminally ill. Some die of complications related to treatment or of other causes. As the disease advances, physical symptoms increase and require constant evaluation and new treatment strategies.

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

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Cancers of the Respiratory System


Cancer of the Larynx Cancer of the larynx is a malignant tumor in the larynx. It is potentially curable if detected early Occurs four times more frequently in men than in women, and most commonly in persons 50 to 70 years of age. Risk factors for laryngeal cancer are: Carcinogens tobacco (smoke, smokeless), combined effects of alcohol and tobacco, asbestos, second-hand smoke, paint fumes, wood dust, cement dust, chemical, tar products, mustard gas, leather and metals Other factors straining the voice, chronic laryngitis, nutritional deficiencies (riboflavin), history of alcohol abuse, familial predisposition, age (higher than incidence after 60 years of age), gender (more common in men), race (more prevalent in African Americans), weakened immune system A malignant growth may occur in three different areas of the larynx: the glottis area (vocal cords), supraglottic area (area above the glottis or vocal cords including epiglottis and false cords), and subglottic (area below the glottis or vocal cords to the cricoids). Glottis tumors seldom spread if found early due to the limited lymph vessels found in the vocal cords. 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, raspy, 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, dyspnea, unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath o Cervical lymph adenopathy, unplanned weight loss, a general debilitated state, 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; include risk factors, family history, and underlying medical conditions in the assessment. Indirect laryngoscopy, using a flexible endoscope, is initially performed to visually evaluate the pharynx, larynx, and possible tumor. Assess the mobility of vocal cords; if normal movement is limited, the growth may affect muscle, other tissue, or even the airway. Palpate the lymph nodes of the neck and thyroid gland to determine spread of malignancy. Direct laryngoscopic examination is performed when a tumor is suspected on initial examination. Samples of tissue are obtained for histologic evaluation. CT scan and MRI are used to assess regional adenopathy and soft tissue, and help stage and determine the extent of the tumor. PET scan may also be used to detect recurrence of laryngeal tumorafter treatment.

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

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include a salivary leak, wound infection from the development of a pharyngocutaneous fistula, stomal stenosis, 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. The staging of the tumor (usually used for stage I and II tumors as a standard treatment option), and the clients overall health status, lifestyle, and personal preference are factors considered in making the treatment decision. A benefit of this therapy is that clients retain a near-normal voice. A few may develop chondritis or stenosis; a small number may later require laryngectomy. May also be used preoperatively to reduce the tumor size; combined with surgery in advanced (stages II and IV) laryngeal cancer as adjunctive therapy to surgery or chemotherapy, and as a palliative measure. Combine with chemotherapy, radiation therapy may be an alternative to total laryngectomy. Complications may be a result if external radiation to the head and neck area, which may also include the parotid gland responsible for mucus production; symptoms include acute mucositis, ulceration of the mucous membranes, pain, xerostomia, loss of taste, dysphagia, fatigue, and skin reactions. Later complications may include laryngeal necrosis, edema, and fibrosis. Speech Therapy Esophageal speech Primary method of a laryngeal speech; client needs the ability to compress air into the esophagus and expel it, 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, 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, or until the client masters the technique This is a battery-powered apparatus that projects sound into the oral cavity; when the mouth forms the words, the sounds from the electric larynx becomes audible words. Voice produced sounds mechanical and some words may be difficult to distinguish; an advantage is that the client is able tocommunicate with relative ease while working to become proficient with other techniques. 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), and it is easily learned. A valve is placed in the tracheal stoma to divert air into the esophagus and out of the mouth; once the puncture is surgically created and has healed, voice prosthesis is fitted over the puncture site. To prevent airway obstruction, the prosthesis is removed and cleaned when mucus builds up. A speech therapist teaches the client how to produce sounds; moving the tongue and lips form the sound into words produces speech

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Nursing Care of the Client Undergoing Laryngectomy Assessment Assess the client for hoarseness, sore throat, dyspnea, dysphagia, or pain and burning in the throat. Palpate the neck for swelling. If treatment includes surgery and the client is expected to have no voice postoperatively, a preoperative evaluation of the speech therapist is indicated. Assess the clients ability to hear, see, read, and write. Determine the psychological readiness and evaluate the coping methods of the client and family. Potential complications that may develop include respiratory distress (hypoxia, airway obstruction, tracheal edema), hemorrhage, infection, and wound breakdown. 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, related to inability to ingest food secondary to swallowing difficulties Disturbed body image and low self-esteem secondary to major neck surgery, change in the structure and function of the larynx Self-care deficit related to pain, weakness, fatigue, 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. Answer clients question about the nature of the surgery, the loss of the natural voice, and the special training that can provide a means of communicating. o Review equipment and treatments for postoperative care with client and family, teach coughing and deep-breathing exercises, and clarify the clients roles in the postoperative and rehabilitation periods. o Reduce anxiety and depression o Provide the client and the family to ask questions, verbalize feelings, and discuss perceptions about the treatment. o Allow visits for the client during the pre- and postoperative period. o Maintain a patent airway - Position the client in the semi-Fowlers or Fowlers position after recovery from anesthesia. o Observe for restlessness, labored breathing, apprehension, and increased pulse rate to identify possible respiratory or circulatory problems. o Encourage the client to turn, cough, and deep breath. Suction as necessary, to remove secretions. Encourage and assist the client with early ambulation to prevent atelectasis and pneumonia. o Care for the laryngectomy tube; clean the stoma daily with saline solution. Apply noneoil-based antibiotic ointment around the stoma and suture line. If crusting appears around the stoma, remove the crusts with sterile tweezers and apply additional ointment. o Observe, measure, and record drainage from wound drains and suction. Reassure the client that frequent coughing episodes will diminish in time as the tracheobronchial mucosa adapts to the altered physiology. o Wipe clean and clear mucus from the tracheostomy opening.

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o o

Provide adequate humidification to decrease cough, mucus production, and crusting around the stoma. Teach the client how to clean and change the laryngectomy tube and how to remove secretions.

Promote alternative communication methods o Establish and consistently use alternative modes of communication such as a call bell, a Magic Stale, notepad and pen, pictureword- phrase board, or hand signals. o Collaborate with the speech therapist and encourage the client and family to use alternative communication methods. Promote adequate nutrition o Thick liquids will be used first for feedings once the client is ready to start oral feedings. Instruct the client to avoid sweet foods, which increases salivation and suppresses appetite. o Introduce solid foods as tolerated. Instruct the client to rinse mouth with warm water or mouthwash and to brush the teeth frequently. o Observe the client for any difficulty swallowing, particularly when eating resumes, and report the occurrence to the physician. o Promote positive body image and self-esteem o Encourage the client to express any feelings brought about by the surgery. o Have a positive approach when caring for the client by promoting self-care activities, Monitor and manage potential complications o Monitor the client for signs and symptoms of respiratory distress and hypoxia. Rule out obstructions by suctioning and having the client cough and deep breath. o Notify the surgeon for any active bleeding at the surgical site. o If rupture to the carotid artery is the cause of bleeding, apply direct pressure over the artery, call for assistance, and provide emotional support to the client until the veins are ligated. o Monitor for vital signs changes: increased pulse rate, decreased blood pressure, and rapid deep breathing; cold, clammy, and pale skin are signs of active bleeding. o Observe for signs of postoperative infection and report any significant changes to the surgeon. o Observe the stoma area for wound breakdown, hematoma, and bleeding, and report significant changes to the surgeon. If wound breakdown occurs, the client must be monitored carefully and identified as being high risk for carotid hemorrhage.

Teach clients self-care o Provide specific instructions to the client and family about the tracheostomy and its management. o Teach the client and family to perform suctioning and emergency measures and tracheostomy and stoma care. Explain the importance of humidification and instruct the family to set up a humidification system before the client returns home. o Teach the client and family about special precautions needed in the shower to prevent water from entering the stoma.

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o o o

Remind the client that swimming is not recommended. Instruct the client to avoid strenuous exercise and fatigue because when tired, he or she will have more difficulty speaking. Encourage the client to wear a medical identification to alert medical personnel for special requirements for resuscitation should the need arise. Instruct and encourage the client to perform oral hygiene regularly to prevent halitosis and infection.

Lung Cancer (Bronchogenic Carcinoma) Pathophysiology Lung cancers arise from a single transformed epithelial cell in the tracheobronchial airways. A carcinogen binds to a cells DNA and damages it. The damage results in ce llular changes, abnormal cell growth, and eventually a malignant cell. As the damage DNA is passed on daughters cells, the DNA undergoes further changes and becomes unstable. With the accumulation of genetic changes, the pulmonary epithelium undergoes malignant transformation from normal epithelium to eventual invasive carcinoma. Squamous cell carcinoma is more centrally located and arises more commonly in the segmental and subsegmental bronchi in response to repetitive carcinogenic exposures. Adenocarcinoma is the most prevalent carcinoma of the lung for both men and women; it presents more peripherally as peripheral masses or nodules and often metastasizes. 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. 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, second-hand (passive) smoke, environmental and occupational exposures, gender, genetics, and dietary deficits. 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, the degree of obstruction, and the existence of metastases to regional or distant sites o Most frequent symptom is cough or change in a chronic cough; cough starts as a dry, persistent cough, without sputum production; when obstruction of airways occurs, the cough may be productive due to infection o Wheezing, dyspnea, hemoptysis or blood-tinged sputum, recurring fever, chest or shoulder pain are also manifestations o Chest pain and tightness, hoarseness, dysphagia, head and neck edema, 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, bone, brain, contralateral lung, adrenal glands, and liver o Weakness, anorexia and weight loss though nonspecific may also be diagnostic Assessment and Diagnostic Findings If pulmonary symptoms occur in a heavy smoker, cancer of the lung is suspected. Chest x-ray is performed to search for pulmonary density, a solitary peripheral nodule (coin lesion), atelectasis, and infection.

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CT scans of the chest are used to identify small nodules and to examine areas of the thoracic cage. Sputum cytology is rarely used to make a diagnosis. Fiberoptic bronchoscopy is more commonly used and provides a detailed study of the tracheobronchial tree and allows for brushings, washings, and biopsies. A transthoracic fine-needle aspiration may be performed under CT or fluoroscopic guidance to aspirate cells from a suspicious area. Esophageal ultrasound (EUS) may be used to obtain a transesophageal biopsy of enlarged subcarinal lymph nodes. Bone scans, abdominal scans, PET scans, or liver ultrasound or scans can be used to assess for metastasis. If surgery is a potential treatment, pulmonary function tests, ABG analysis, ventilation-perfusion scans, and exercise testing may be used as part of preoperative assessment.

Surgical Management Surgical resection is the preferred method for treating clients with localized non-small cell tumors, no evidence of metastatic spread, and adequate cardiopulmonary function. Contraindications to this intervention are coronary artery disease, pulmonary insufficiency, and other comorbidities. 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, and prolonged mechanical ventilation is a potential outcome. Radiation Therapy Useful in controlling neoplasms that cannot be surgically resected but are responsive to radiation; may also be used to reduce the size of a tumor, to make an inoperable tumor operable, or to relieve the pressure of the tumor on vital structures. It can control symptoms of spinal cord metastasis and superior vena cava compression, Prophylactic brain irradiation is used in certain clients to treat microscopic metastases to the brain. Radiation may help relieve cough, chest pain, dyspnea, hemoptysis, and bone and liver pain. May result in diminished cardiopulmonary functions and other complications such as pulmonary fibrosis, pericarditis, myelitis, corpulmonale, esophagitis, pneumonitis, and radiation lung fibrosis. Chemotherapy Used to alter tumor growth patterns, to treat clients with distant metastases or small cell cancer of the lung, and as an adjunct to surgery or radiation therapy. A variety of chemotherapeutic agents are used including, alkylating agents, platinum analogues, taxanes, vinca alkaloids, doxorubicin, gemcitabine, vinorelbine, irinotecan, and etoposide. Pulmonary toxicity is potential side effect of chemotherapy.

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

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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); 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, genetic influence and viral pathogenesis may be involved Bone marrow damage from radiation exposure or from chemicals is a risk factor of the disease. Classification of the disease is according to the stem cell line involved (lymphoid, myeloid), and according to the time it takes for symptoms to evolve and phase of cell development that is halted: Acute abrupt onset, white blood cell development halted at the blast phase, rapid progression, death usually occurring within weeks to months if no aggressive treatment is initiated. Chronic symptoms evolve slowly. Acute Myeloid Leukemia (AML) AML results from a defect in the hematopoietic stem cell that differentiates into all myeloid cells: monocytes, granulocytes, erythrocytes, and platelets. All age groups are affected; the incidence arises with age, with a peak incidence at age 60 years. AML is the most common nonlymphocytic leukemia. Prognosis is highly variable and is not consistently based on client or disease variables. Clients with AML have a potentially curable disease. However, clients who are older or have a more undifferentiated form of the disease tend to have worse prognosis. 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, hyperplasia of the gums, 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; total leukocyte count can be low, normal or high; percentage of normal cells is usually greatly decreased Bone marrow analysis shows an excess of immature blasts; AML can be further classified into seven different subgroups, based on cytogenetics, histology, and morphology of the blasts.

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Clients may have significant problems with bleeding, they have higher underlying coagulopathy and a higher incidence of disseminated intravascular coagulation (DIC) Bleeding and infection, also the major causes of death; risk of bleeding correlates with the level of platelet deficiency. Low platelet count can result in ecchymoses and petechiae Major hemorrhages may also develop when the platelet count drops to less than 10,000/mm3; gastrointestinal, pulmonary, 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; neutrophils counts that persist at less than 100/mm3 make the chances of systemic infection extremely high Clients risk for developing fungal infection increases, as severe neutropenia is prolonged

Complications o o o o

Medical Management Objective of treatment is to achieve complete remission, in which there is no detectable evidence of residual leukemia remaining in the bone marrow. Induction therapy is attempts made to achieve remission by aggressive administration of chemotherapy, which usually requires hospitalization for several weeks. The aim of induction therapy is to eradicate the leukemic cells, but this is often accompanied by the eradication of normal types of myeloid cells. Thus, the client becomes severely neutropenic, anemic, and thrombocytopenic. During this time, the client is typically very ill, with bacterial, fungal, and occasionally viral infections, bleeding, severe mucositis, which causes diarrhea, and a marked decline in the ability to maintain adequate nutrition. Supportive care consists of administering blood products and promptly treating infections. Consolidation therapy is administered to the client after he/she has recovered from the induction therapy. The goal is to eliminate any residual leukemia cells that are not clinically detectable, thereby diminishing the change of recurrence. Frequently, the client receives one cycle of treatment that is almost the same, if not identical, to the induction treatment but uses lower dosages resulting in less toxicity. Bone marrow transplantation (BMT) is another aggressive treatment; also called peripheral blood stem cell transplantation (PBCT). When a suitable tissue match can be obtained, the client embarks on an even more aggressive regimen of chemotherapy sometimes in combination with radiation therapy, with the treatment goal of destroying hematopoietic function of the clients bone marrow. The client is then rescued with the infusion of the donor stem cells to reinitiate blood cell production. Supportive care is another option for the client to consider. This may be the only option if the client has significant comorbidity. Aggressive chemotherapy is not used; hydroxyurea may be used to briefly to control the increase of blast cells. Clients are more commonly supported with antimicrobial therapy and transfusion as needed. Complications of treatment include tumor lysis syndrome, hyperkalemia and hypocalcemia, gastrointestinal problems, anorexia, nausea, vomiting, diarrhea, and severe mucositis.

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

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Acute Lymphocytic Leukemia (ALL) ALL results from uncontrolled proliferation of immature cells (lymphoblasts) derived from the lymphoid stem cell. Immature lymphocytes proliferate in the marrow and crowd the development of normal myeloid cells; normal hematopoiesis is inhibited, resulting in reduced numbers of leukocytes, erythrocytes, and platelets. Most common in young children, with boys affected more often than girls; the peak incidence is 4 years of age. After 15 years, ALL is relatively uncommon. Increasing age appears to be associated with diminished survival. Because of improvements in therapy, more than 80% of children survive at least 5 years. Even if relapse occurs, resumption of induction therapy can often achieve a second complete remission. Bone marrow transplant may be successful even after a second relapse. Clinical Manifestations Reduced number of leukocytes, erythrocytes, and platelets; leukocyte counts may be either low or high, but there is always a high proportion of immature cells. Pain from an enlarged liver or spleen, bone pain, 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; 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; 2/3 of all clients are older than 60 years of age at diagnosis.

Pathophysiology CLL typically derives from a malignant clone of B lymphocytes; most of the leukemia cells are fully mature. These mature cells appear to escape apoptosis, with result being an excessive accumulation of the cells in the marrow and circulation. The antigen CD52 is prevalent on the surface of many of these leukemic B cells. The disease is classified into three or four stages. In the early stage, an elevated lymphocyte count is seen and can exceed 100,000/mm3. These lymphocytes are small and can easily travel through the small capillaries within the circulation, and the pulmonary and cerebral complications of leukocytosis typically are not found in CLL. Lymphadenopathy occurs as the lymphocytes are trapped within the lymph nodes. The nodes can become very large and are sometimes painful. Hepatomegaly and splenomegaly may develop. Anemia and thrombocytopenia occur in later stages. Treatment is typically initiated in the later stages; early treatment does not appear to increase survival.

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Autoimmune complications (either hemolytic thrombocytopenic purpura) can also occur at any stage.

anemia

or

idiopathic

Clinical Manifestations Many clients are asymptomatic Increased lymphocyte count is always present RBC and platelet counts may be normal, or, in late 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, drenching sweat (especially at night), and unintentional weight loss; 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; viral infections (e.g., Herpes zoster) can become widely disseminated Medical Management o Early stages may require no treatment. o Chemotherapy with corticosteroids and chlorambucil is often used in later stages or when symptoms are severe. o Fludarabine (Fludara) is being used as a front-line therapy. o Monoclonal antibody rituximab (Rituxan) also has efficacy in CLL therapy; 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. If the client is hospitalized, the assessment should be performed daily, or more frequently as needed. Systematic assessment incorporating all body systems must be done thoroughly. Closely monitor the results of laboratory studies. Flow sheets and spreadsheets are particularly useful in tracking the WBC count, absolute neutrophil count, hematocrit, platelet, and creatinine levels, hepatic function tests, and electrolyte levels. Culture results need to be reported immediately so that appropriate antimicrobial therapy can begin or be modified. Assess for potential complications, such as infection, bleeding, renal dysfunction, tumor lysis syndrome, nutritional depletion, and mucositis. 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, and impaired mobility Impaired gas exchange

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Impaired mucous membranes due to changes in epithelial lining of the gastrointestinal tract from chemotherapy or prolonged use of antimicrobial medications Imbalanced nutrition, less than body requirements, related to hypermetabolic state, anorexia, mucositis, pain, and nausea Acute pain and discomfort related to mucositis, WBC infiltration of systemic tissues, fever, 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, hypoproteinemia, need for multiple intravenous medications and blood products Diarrhea due to altered gastrointestinal flora, mucosal denudation Risk for deficient fluid volume related to potential for diarrhea, bleeding, infection, and increased metabolic rate Self-care deficit due to fatigue, malaise, and protective isolation Anxiety due to knowledge deficit and uncertain future Disturbed body image related to change in appearance, function, and roles Grieving related to anticipatory loss and altered role functioning Potential for spiritual distress Deficient knowledge about disease process, treatment, complication management, and self-care measures

Nursing Interventions Prevent infection and bleeding Thorough hand hygiene must be done by everyone before entering the clients room. Allow no one with cold or sore throat to care for the client or to enter room, or come in contact with the client at home. Provide low microbial diet. Eliminate fresh salads and unpeeled fresh fruits or vegetables. Avoid aspirin and aspirin-containing medications or other medications known to inhibit platelet function, if possible. Do not give intramuscular injections. Do not insert indwelling catheters. Take no rectal temperatures; do not give suppositories, enemas. Use stool softeners, oral laxatives to prevent constipation. Use smallest possible needles when performing venipuncture. Apply pressure to venipunctures sites for 5 minutes or until bleeding has stopped. Permit no flossing of teeth and no commercial mouthwashes. Use only softbristled toothbrush for mouth care. Avoid suctioning if at all possible; if unavoidable, use only gentle suctioning. Discourage vigorous coughing or blowing of the nose. Use only electric razor for shaving. Pad side rails as needed. Prevent falls by ambulating with client as necessary. For epistaxis, position client in high Fowlers position; apply ice pack to the back of the neck and direct pressure to the nose. Notify physician for prolonged bleeding. Administer platelets, frozen plasma, packed red blood cells as prescribed. Manage mucositis Instruct client to practice meticulous oral hygiene. Saline rinses are used to clean and moisten oral mucosa. Administer chlorhexidine rinses or clotrimazole troches to prevent yeast or fungal infections in the mouth.

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

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Cancers of the Lymphatic System 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 Hodgkins disease and non Hodgkins lymphoma.

Comparison of Lymphomas Hodgkins Non-Hodgkins 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 Acquired immunodeficiency syndrome-related lymphoma occurs in those who have been infected with the human immunodeficiency virus. Hodgkins 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 Hodgkins 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 systems ability to suppress tumor growth.

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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 Hodgkins 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. 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 Hodgkins 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

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Stages I, II, III, and IV adult Hodgkins 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 38C 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 Hodgkins 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. A transplant is performed after separating normal stem cells from malignant cells in the harvested specimen. Potential long-term complications of therapy for Hodgkins disease include immune dysfunction, herpes infections, pneumococcal sepsis, acute myeloid leukemia, myelodysplastic syndrome, nonHodgkins lymphoma, solid tumors, thyroid cancer, thymic hyperplasia, hypothyroidism, pericarditis (acute or chronic), avascular necrosis, growth retardation, infertility, impotence, and/or dental caries. Nursing Care for Client with Hodgkins Disease Assessment Look for history of infection mononucleosis or symptoms resembling this disorder. Assess for location, size, and characteristics of enlarged lymph nodes, such as whether they are fixed or mobile. 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. Ask about fever, chills, or night sweats.

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Check the clients current weight and deviation from usual weight, enlargement of the liver and spleen, and level of energy and appetite. Inspect the appearance of the skin, ask about any itching, and discuss any additional symptoms caused by lymph node enlargement (e.g., coughing, breathlessness, nausea, vomiting).

Diagnosis, Planning, and Interventions Client and family teaching include the following: Keep appointments for medical follow-up. Take prescribed medications as directed, Report side effects to the physician. Avoid crowds or people who have infectious disease. Wash hands frequently. Avoid oral contact with germ-laden objects. Contact physician if breathing becomes labored. Eat small amounts frequently or include a liquid nutritional supplement between meals and at bedtime. 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). Note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing. Keep the neck in midline and place the client in high Fowlers position i f respiratory distress develops. Administer oxygen per physicians orders if blood saturation is consistently less than 90%. Place an endotracheal tube, laryngoscope, and bag-valve mask at the bedside for (emergency) intubation.

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. Practice conscientious hand washing and follow other principles of medical and surgical asepsis. Institute infectious disease precautions if normal white blood cells are suppressed to dangerous limits. 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. Provide rest periods between activities. Perform priority activities first. Assist client with whatever activities of daily living are independently unmanageable.

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Non-Hodgkins Lymphoma These are a group of 30 sub-classifications of malignant disease that originate in lymph glands and other lymphoid tissues. Examples include lymphosarcoma, Burkitts lymphoma, and reticulum cell sarcoma. The incidence of non-Hodgkins lymphomas is size to seven times that of Hodgkins disease, and the number of cases continues to rise.

Pathophysiology and Etiology There is no single definitive cause for non-Hodgkins lymphomas, although a genetic link is strongly implicated in some types. An environmental trigger, such as a viral agent, chemical herbicides, pesticides, or hair dye, could induce the disease. Administration of immunosuppressive drugs to prevent transplant rejection also is correlated with cases of non-Hodgkins lymphoma. In non-Hodgkins lymphoma, chromosomal changes occur in affected lymphocytes, and lymphoid tissue enlarges to accumulate proliferative production of malignant cells. Non-Hodgkins lymphoma is classified as either: Indolent, the client is relatively asymptomatic at diagnosis and the disorder is relatively responsive to radiation and chemotherapy. Aggressive because the condition has a shorter onset with acute symptoms; 30% to 60% of aggressive forms of non-Hodgkins lymphoma are curable with intensive treatment. Assessment Findings Symptoms of non-Hodgkins lymphoma depend on site of lymph node involvement. Lymph node enlargement, which usually is diffuse rather than localized, occurs in cervical, axillary, and inguinal regions. Diagnosis and differentiation of the subtypes of non- Hodgkins lymphoma from Hodgkins disease depend on microscopic examination of lymphoid tissue biopsies. Additional tests are performed to determine the stage of the lymphoma.

Medical Management Non-Hodgkins lymphoma is treated with radiation, chemotherapy, or both. The physician may adopt a watch and wait approach for clients with indolent forms of non- Hodgkins lymphoma, choosing to treat the client once the disease accelerates. Immunotherapy with monoclonal antibodies (MABs) and bone marrow transplants is being used to cure lymphomas or extend the lives of clients with these diseases. Research continues on the use of biologic therapy (immunotherapy) with MABs to eliminate malignant cells and induce remission. With MABs, human cancer cells are injected into laboratory animals such as mice. The mice make lymphocytes that produce

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antibodies against cancer cells. The mouse lymphocytes are harvested and fused with a laboratory-grown cell, creating clones that, when administered to a client with cancer, continue to produce tumorfighting antibodies. The MABs are used alone or are bound to a chemotherapeutic or radioactive agent. The advantage of combining MABs with drugs or radiation is that they target and destroy cancer cells while sparing normal cells. Rituximab (Rituxan) is an MAB drug approved for treating nonHodgkins lymphoma.

Nursing Management Nursing care is similar for all clients with lymphoma, whether they have non-Hodgkins lymphoma or Hodgkins disease. 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.

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

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A combination of radioactive interstitial implants and external beam radiation may be used. If the cancer has spread to the lymph nodes, the surgeon may perform a neck dissection. Surgical treatments leave a less functional tongue; surgical procedures include hemiglossectomy (surgical removal of half of the tongue) and total glossectomy (removal of the tongue). 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. 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).

Nursing Management Assess the clients nutritional status preoperatively; a dietary consultation may be necessary. Administer, if required, enteral or parenteral feedings before and after surgery to maintain adequate nutrition. If a radial graft is to be performed, 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. 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, slightly flexed position. The palm will be pale. Pressure on the ulnar artery is released. 3) If the ulnar artery is patent, the palm will flush within about three to five seconds. Assess for a patent airway postoperatively. Suction as necessary to help the client manage oral secretions. If grafting was included in the surgery, suctioning must be performed with care to prevent damage to the graft. Assess the graft postoperatively for viability. 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. Cancer of the esophagus has been associated with ingestion of alcohol and with the use of tobacco. Also, there seems to be an association between gastroesophageal reflux disease (GERD) and adenocarcinoma of the esophagus. People with Barretts esophagus, which is caused by chronic irritation of mucous membranes due to reflux of gastric and duodenal contents, have a higher incidence of esophageal cancer. Pathophysiology Esophageal cancer is usually of squamous cell epidermoid type; however, the incidence of adenocarcinoma is increasing.

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Tumor cells may spread beneath the esophageal mucosa or directly into, through, and beyond the muscle layers into the lymphatics. In the latter stages, obstruction of the esophagus is noted, with possible perforation into the mediastinum and erosion into the great vessels.

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

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Surgical resection of the esophagus has a relatively high mortality rate because of infection, pulmonary complications, or leakage through the anastomosis. Postoperatively, the client will have a nasogastric tube in place that should not be manipulated. The client is given nothing by mouth until x-ray studies confirm that the anastomosis is secure and not leaking. Preoperative radiation therapy or chemotherapy, or both, may be used; however, treatment is based on type of cell, tumor spread, and client condition. Palliative treatment may be necessary to keep the esophagus open, to assist with nutrition, and to control saliva. Palliation may be accomplished with dilation of the esophagus, laser therapy, placement of an endoprosthesis (stent), radiation, or chemotherapy. Treatment is individually determined since the ideal method of treating esophageal cancer has not yet been found.

Nursing Management Intervention is directed toward improving the clients nutritional and physical condition in preparation for surgery, radiation therapy, or chemotherapy. If adequate food can be taken by mouth, promote weight gain based on a high-calorie and high-protein diet in liquid or in soft form. Initiate parenteral or enteral nutrition if the client is unable to eat by mouth. Monitor nutritional status throughout treatment. Inform the client about the nature of the postoperative equipment that will be used, including the required for closed chest drainage, nasogastric suction, parenteral fluid therapy, and gastric intubation. Provide immediate postoperative care that is similar to that provided to clients undergoing thoracic surgery. Placed the client in a low Fowlers position a fter recovering from the effects of anesthesia. Later, position the client in a Fowlers position to assist in preventing reflux of gastric secretions.Carefully observe the client for regurgitation and dyspnea (a common postoperative complication is aspiration pneumonia). 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. Assess the graft for color. Presence of a pulse may be assessed using a doppler sonography. If an endoprosthesis has been placed or an anastomosis has been performed, mark the nasogastric tube for position immediately after surgery, and notify the physician if displacement occurs. Do not attempt to reinsert a displaced nasogastric tube because damage to the anastomosis may occur. Remove the nasogastric tube five to seven days after surgery. Perform a barium swallow to asses for any anastomotic leak before the client is allowed to eat. Encourage the client to swallow small sips of water, and, later, small amounts of pureed food once feeding begins. 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. Allow the client to remain upright for at least two hours after each meal to allow the food to move through the gastrointestinal tract. Encourage the client with poor appetite to eat by involving the family to prepare home-cooked favourite foods.

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Administer antacids to relieve gastric distress. Provide liquid supplements, which are more easily tolerated by clients undergoing radiation and experiencing esophagitis. Administer oral suction if the client is unable to handle secretions, or wick-type gauze may be placed at the corner of the mouth to direct secretions to a dressing or emesis basin. During discharge planning, instruct the family about promotion of adequate nutrition, what observations to make, measures to take if complications occur, how to keep the client comfortable, and how to obtain needed physical and emotional support.

Gastric Cancer The typical client with gastric cancer is between 40 and 70 years of age, but gastric can occur in people younger than 40 years of age. Men have a higher incidence of gastric cancer than women. The incidence of gastric cancer is much greater in Japan, which has instituted mass screening programs for earlier diagnosis. Diet appears to be a significant factor. A diet high in smoked, salted, or pickled foods and low in fruits and vegetables may increase the risk of gastric cancer. Other factors related to the incidence of gastric cancer include chronic inflammation of the stomach, H. pylori infection, pernicious anemia, smoking, achlorhydria, gastric ulcers, previous subtotal gastrectomy (more than 20 years ago), and genetics. The prognosis is generally poor; the diagnosis is during the early stages of the disease. Most case of gastric cancers are discovered only after local invasion has advanced or metastases are present. Pathophysiology Most gastric cancers are adenocarcinomas; they can occur anywhere in the stomach. The tumor infiltrates the surrounding mucosa, penetrating the wall of the stomach and adjacent organs and stomach. The liver, pancreas, esophagus, and duodenum are often already affected at the time of diagnosis. Metastasis through lymph to the peritoneal cavity occurs later in the disease. Clinical Manifestations Symptoms of early disease, such as pain relieved by antacids, resemble those of benign ulcers and are seldom definitive, because most gastric tumors begin on the lesser curvature of the stomach, where they cause little disturbance of gastric function. Symptoms of progressive disease include dyspepsia (indigestion), early satiety, weight loss, abdominal pain just above the umbilicus, loss or decrease in appetite, bloating after meals, nausea and vomiting, and symptoms similar to those of peptic ulcer disease. Assessment and Diagnostic Findings The physical examination is usually not helpful in detecting the cancer because most early gastric tumors are not palpable. Advance gastric cancer may be palpable as a mass. Ascites and hepatomegaly (enlarged liver) may be apparent if the cancer cells have metastasized to the liver. Palpable nodules around the umbilicus, called Sister Mary Josephs nodules are a sign of a GI malignancy, usually a gastric cancer. Esophagogastroduodenoscopy for biopsy and cytologic washings is the diagnostic study of choice, and a barium x-ray examination of the upper GI tract may also be performed.

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Endoscopic ultrasound is an important tool to assess tumor depth and any lymph node involvement. Computed tomography completes the diagnostic studies, particularly to assess for surgical respectability of the tumor before surgery is scheduled. CT scan of the chest, abdomen, and pelvis is valuable in staging gastric cancer.

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

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Assessment of tumor markers (blood analysis for antigens indicative of cancer) such as carcinoembryonic antigen (CEA), carbohydrate antigen (CA 19-9), and CA 50 may help determine the effectiveness of treatment.

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

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Provide psychosocial support Help the client express fears, concerns, and grief about the diagnosis. Answer the clients questions honestly and encourage him or her to participate in treatment decisions. 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. Offer emotional support and involve the family members and significant others whenever possible. Recognize mood swings and defense mechanisms, and reassure the client, family members, and significant others that emotional responses are normal and expected. Make the services of clergy, psychiatric clinical nurse specialist, psychologist, social workers, and psychiatrist available, if needed. Project an empathetic attitude and spend time with the client. Promote home and community-based care Client and family teaching include information about diet and nutrition, treatment regimen, activity and lifestyle changes, pain management, and possible complications. Teach the client and caregiver about administration of enteral or parenteral nutrition, including detection and prevention of untoward complications related to feedings. Provide explanation about chemotherapy and radiation therapy. Arrange for psychological counseling, if necessary. Teach the client or caregiver to recognize and report sign and symptoms of complications that require immediate attention, such as bleeding, obstruction, perforation, or any symptoms that become progressively worse. Explain the care needed during and after treatments to the client and family or significant other. Assist the client, family, or significant other with decisions regarding end-of-life care and make referrals as warranted.

Colorectal Cancer Tumors of the colon and rectum are relatively common. 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 exact cause of colon and rectal cancer is still unknown but risk factors have been identified: Increasing age, family history of colon cancer or polyps, previous colon cancer or adenomatous polyps, history of inflammatory bowel disease, high-fat, high-protein (with high intake of beef), low-fiber diet, genital cancer or breast cancer (in women) The distribution of cancer sites throughout the colon are: ascending colon 22%, transverse colon 11%, descending colon 6%, sigmoid colon 33%, rectum 27% Changes in the distribution have occurred in recent years. The incidence of cancer in the sigmoid and rectal areas has decreased, whereas the incidence of cancer in the cecum, ascending, and descending colon has increased. Early diagnosis and prompt treatment could save almost three of every four people with colorectal cancer. If the disease is detected in an early stage, the 5- year survival rate is 90% but only 34% of colorectal cancers are found at an early stage. Survival rates after late diagnosis are very low. Most people are asymptomatic for long periods and seek health care only when they notice a change in bowel habits or rectal bleeding. Pathophysiology Cancer of the colon and rectum are predominantly adenocarcinoma, arising from the epithelial lining of the intestine.

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It may start as a benign polyp but may become malignant, invade and destroy normal tissue, and extend into surrounding structures. Cancer cells may break away from the primary tumor and spread to other parts of the body, most often to the liver.

Clinical Manifestations The symptoms are greatly determined by the location of the cancer, the stage of the disease, and the function of the intestinal segment in which it is located. The most common presenting symptom is a change in bowel habits. The passage of blood in the stools is the second most common symptom. Symptoms may also include unexplained anemia, anorexia, weight loss, and fatigue. The symptoms most commonly associated with rightsided lesions are dull abdominal pain and melena (black, tarry stools). The symptom most commonly associated with leftside lesions are those associated with obstruction (abdominal pain and cramping, narrowing stools, constipation, and distention), as well as bright red blood in the stool. Symptoms associated with rectal lesions are tenesmus (ineffective, painful straining at stool), rectal pain, the feeling of incomplete evacuation after a bowel movement, alternating constipation and diarrhea, and bloody stool. Assessment and Diagnostic Findings Along with an abdominal and rectal examination, the most important diagnostic procedures for cancer of the colon are fecal occult blood testing, barium enema, proctosigmoidoscopy, and colonoscopy. 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, studies show that CEA levels are reliable in predicting prognosis. With complete excision of the tumor, the elevated levels of CEA should return to normal within 48 hours. Elevation of CEA at a later date suggests recurrence. Complications Tumor growth may cause partial to complete bowel obstruction. Extension of the tumor and ulceration into the surrounding blood vessels results in hemorrhage. Perforation, abscess formation, peritonitis, sepsis, and shock may occur. Gerontologic Considerations The incidence of carcinoma of the colon and rectum increases with age. These cancers are considered common malignancies in advanced age. Colon cancer in the elderly has been closely associated with dietary carcinogens. Lack of fiber is a major causative factor because the passage of feces through the intestinal tract is prolonged, which extends exposure to possible carcinogens. Excess fat is believed to alter bacterial flora and convert steroids into compounds that have carcinogenic properties.

Medical Management The client with symptoms of intestinal obstruction is treated with intravenous fluids and nasogastric suction. If there has been significant bleeding, blood component therapy may be required.

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Treatment of colorectal cancer depends on the stage of the disease and consists of surgery to remove the tumor, supportive therapy, and adjuvant therapy.

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, no nodal involvement Class C1: Positive nodes, tumor is limited to bowel wall Class C2: Positive nodes, tumor extends through entire bowel wall Class D: Advanced and metastasis to liver, lung, or bone Adjuvant Therapy The standard adjuvant therapy administered to clients with Dukes Class C colon cancer is the 5- fluourouracil plus levamisole regimen. Clients with Dukes class B or C rectal cancer are given 5-fluourouracil and high disease of pelvic irradiation. Mitomycin is also used. Radiation therapy is used before, during, and after surgery to shrink the tumor, to achieve better results from surgery, and to reduce the risk of recurrence. For inoperative or unresectable tumors, irradiation is used to provide significant relief from symptoms. Intracavity and implantable devices are used to deliver radiation to the site. The response to adjuvant therapy varies. Surgical Management Surgery is the primary treatment for most colon and rectal cancers. It may be curative or palliative. The type of surgery recommended depends on the location and size of the tumor. Cancers limited to one side can be removed through colonoscope. Laparoscopic colotomy with polypectomy minimizes the extent of surgery needed in some cases. A laparoscope is used as a guide in making an incision into the colon; the tumor mass is then excised. Use of the neodymium/yttrium-aluminum-garnet (Nd:YAG) laser has proved effective with some lesions as well. Bowel resection is indicated for most class A lesions and all class B and C lesions. Surgery is sometimes recommended for class D colon cancer, but the goal of surgery in this instance is palliative; if the tumor has spread and involves surrounding vital structures, it is considered nonresectable. Surgical procedures include the following: Segmental resection with anastomosis (i.e., removal of the tumor and portions of the bowel on either side of the growth, as well as the blood vessels and lymphatic nodes) Abdominoperitoneal resection with permanent sigmoid colostomy (i.e., 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, 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.

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1) A temporary loop ileostomy is constructed to divert intestinal flow, and the newly constructed J pouch (made from 6 to 10 cm of the colon) is reattached to the anal stump. 2) About three months after the initial stage, the ileostomy is reversed, and intestinal continuity is restored. The anal sphincter and therefore continence are preserved.

Nursing Management Assessment Complete a health history to obtain information about fatigue, abdominal or rectal pain, past and present elimination patterns, and characteristics of stool. Obtain additional information about history of inflammatory bowel disease or colorectal polyps, a family history of colorectal disease, and current medication therapy. Identify dietary habits, including fat and fiber intake, as well as amounts of alcohol consumed. Describe and document a history of weight loss. Assessment includes auscultating the abdomen for bowel sounds and palpating the abdomen for areas of tenderness, distention, and solid mass. Inspect stool specimens for character and presence of blood. Nursing Diagnosis Imbalanced nutrition, less than body requirements, 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, the surgical procedure, and self-care after discharge Impaired skin integrity related to the surgical incisions (abdominal and perianal), the formation of a stoma, 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, abscess, and sepsis Planning and Interventions Prepare the client for surgery Prepare the client physically for surgery, provideinformation about postoperative care, including stoma care if a colostomy is to be created, and support the client and family emotionally. Build the clients stamina in the days preceding surgery and cleans e and sterilize the bowel the day before the surgery. Recommend a diet high in calories, protein, and carbohydrates and low in residue for several days before surgery, if clients condition permits, to provide adequate nutrition and minimize cramping by decreasing excessive peristalsis. Prescribe a full-liquid diet 24 to 48 hours before surgery to decrease bulk. Parenteral nutrition may be required to replace depleted nutrients, vitamins, and minerals if the client is hospitalized in the days preceding surgery.

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Administer antibiotics (e.g., sulfonamides, neomycin, and cephalexin) the day before the surgery to reduce intestinal bacteria. Cleanse the bowel using laxatives, enemas, or colonic irrigation the evening before and the morning of surgery. Measure and record intake and output, including vomitus, for the client who is very ill and hospitalized to provide an accurate record of fluid balance. Restrict the clients oral food and fluid intake to prevent vomiting. Administer antiemetics as prescribed. Allow the client to have full or clear liquids as tolerated or to have nothing by mouth. Insert a nasogastric tube to drain accumulated fluids and prevent abdominal distention, as necessary. Monitor the abdomen for increasing distention, loss of bowel sounds, and pain or rigidity, which may indicate obstruction or perforation. Monitor intravenous fluids and electrolytes. Monitor serum electrolyte levels to detect hypokalemia and hyponatremia that occur with GI fluid loss. Observe for signs of hypovolemia, assess hydration status, and report decreased skin turgor, dry mucous membranes, and concentrated urine. Assess the clients knowledge about the diagnosis, prognosis, surgical procedure, and expected level of functioning after surgery. Include in the teaching plan information about the physical preparation for surgery, the expected appearance and care of the wound, the technique of ostomy care (if applicable), dietary restrictions, pain control, and medication management.

Provide emotional support Assess the clients anxiety level and coping mechanism, and suggest methods for reducing anxiety. Provide privacy and teach relaxation techniques. Set aside time to listen to the client who wishes to talk, cry, or ask questions. 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. Project a relaxed, professional, and empathetic attitude to promote client comfort. Present facts about the surgical procedure and the creation and management of ostomy to reduce the fear related to changes in body image. Use diagrams, photographs, and appliance to explain and clarify. Allow the client and family to ask questions or voice out concerns. Consultation with an enterostomal therapist during the preoperative period or with a person who is successfully managing an ostomy can be helpful. Provide postoperative care Postoperative care for clients undergoing colon resection or colostomy is similar to nursing care for any abdominal surgery client. Include pain management during immediate postoperative period. Monitor the client for complications, such as leakage from the site of the anastomosis, prolapse of the stoma, perforation, stoma retraction, fecal impaction, skin irritation, and pulmonary complications associated with abdominal surgery. Assess the abdomen for returning peristalsis and assess the initial stool characteristics. 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. Maintain optimal nutrition Teach all clients undergoing surgery for colorectal cancer about the health benefits to be derived from consuming a healthy diet. Complete a nutritional assessment for clients with a colostomy.

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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 clients use. One-piece appliance consists of a pouch with an integral adhesive section that adheres to the clients 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 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 clients 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 clients needs and attempt to identity specific concerns. Seek assistance from an enterostomal therapy nurse, sex counselor or therapist, or advanced practice nurse of the clients concern seem complex.

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Cancers of the Special Senses

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

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To avoid recurrences, clients usually undergo radiation therapy and cryotherapy after the excision of malignant tumors. Cosmetic disfigurement may result from extensive excision when deep invasion by the malignant tumor is involved.

Malignant Tumors of the Globe (Ocular Melanoma) A malignant tumor of the retina, retinoblastoma, occurs in childhood, is hereditary, and requires complete enucleation if there is to be a chance for successful outcome. Ocular melanoma is another cancer that primarily occurs in adults. This rare, malignant choroidal tumor is often discovered on a retinal examination. In its early stages, it could be mistaken for a nevus. Many clients do not have symptoms in the early stages though some clients may complain of blurred vision or a change in eye color. A number of such tumors have been found in people with blindness that has painful eyes. In addition to a complete physical examination to discover any evidence of metastasis, retinal fundus photography, fluorescein angiography, and ultrasonography are performed. The diagnosis is confirmed at biopsy after enucleation.

Tumors are classified according to size (i.e., small, medium, large). Very small tumors are generally monitored, whereas medium and large tumors require treatment. Treatment consists of radiation therapy, enucleation, or both. Radiation therapy is achieved by external beam performed in repeated doses over several days or through the surgical implantation of a radioactive plaque, which is removed after several days. Acoustic Neuroma An acoustic neuroma is a slow-growing benign tumor of cranial nerve VIII, usually arising from the Schwann cells of the vestibular portion of the nerve. Most acoustic tumors arise within the internal auditory canal and extend into the cerebellopontine angle to press on the brain stem. Acoustic neuroma occurs with equal frequency in men and women at any age, although most occur during middle age. Most acoustic neuromas are unilateral, except in von Recklinghausens disease, 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. Asymmetry in audiovestibular test results should be identified so that further workup can be performed to rule out an acoustic neuroma. MRI with a paramagnetic contrast agent is the imaging study of choice. CT scan with contrast dye may also be performed for claustrophobic clients. Management Surgical removal of acoustic tumors is the treatment of choice because these tumors do not respond well to irradiation or chemotherapy. Multidisciplinary treatment approach involves a neurotologist and a neurosurgeon. The objective of surgery is to remove the tumor while preserving facial nerve function. Most acoustic tumors have damaged the cochlear portion of cranial nerve VIII, and no serviceable hearing exists before surgery. In these clients, the surgery is performed using a translabyrinthine approach, and the hearing mechanism is destroyed. If hearing is still good before surgery, a suboccipital or middle cranial fossa approach to removing the tumor may be used, and intraoperative monitoring of cranial nerve VIII is performed to save the hearing.

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Complications of surgery for acoustic neuroma include facial nerve paralysis, cerebrospinal fluid leak, meningitis, and cerebral edema. Death from acoustic neuroma surgery is rare.

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Cancers of the Nervous System

Primary Brain Tumors A brain tumor is a localized intracranial lesion that occupies space within the skull. Tumors usually grow as a spherical mass, but they can grow diffusely and infiltrate tissue. The effects of neoplasms occur from the compression and infiltration of tissue. Different physiologic changes result, causing any or all of the following pathophysiologic events: Increased intracranial pressure (ICP) and cerebral edema; Seizure activity and focal neurologic signs; Hydrocephalus; Altered pituitary function. Primary brain tumors originate from cells and structures within the brain. Secondary, or metastatic, brain tumors develop from structures outside the brain and occur in 20% to 40% of all clients with cancer. Brain tumors rarely metastasize outside the CNS, but metastatic lesions to the brain occur commonly from the lung, breast, lower gastrointestinal tract, pancreas, kidney, and skin (melanomas). The cause of primary brain tumors is unknown. The only known risk factor is exposure to ionizing radiation. Pathophysiology Gliomas glial tumors, the most common type of neoplasm, are divided into categories (i.e., astrocytomas, glioblastoma multiforme, oligodendrocytoma, medulloblastoma): Astrocytomas - The most common type of glioma and are graded from I to IV, indicating the degree of malignancy. The grade is based on cellular density, cell mitosis, and appearance. 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. Oligodendroglial Tumors Represents 20% of gliomas; the histologic distinction between astrocytomas and oligodendrogliomas is difficult to make but important, as recent research shows that these tumors are more sensitive to chemotherapy than astrocytomas. These tumors are categorized as low-grade and high-grade (anaplastic). Meningiomas Represents 20% of all primary brain tumors; are common benign encapsulated tumors of arachnoid cells on the meninges. They are slow growing and occur most often in middle-aged adults (more often in women). Meningiomas most often occur in areas proximal to the venous sinuses. Manifestations depend on the area involved and are the result of compression rather than invasion of brain tissue. Standard treatment is surgery with complete removal or partial dissection. 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). Pressure from a pituitary adenoma may be exerted on the optic nerves, optic chiasm, or optic tracts or on the hypothalamus or the third ventricle when the tumor invades the cavernous sinuses or explains into the sphenoid bone. These pressure effects produce headache, visual dysfunction, hypothalamic disorders, increased ICP, and enlargement and erosion of the sella turcica. Functioning pituitary tumors can produce one or more hormones normally produced by the anterior pituitary. These hormones may cause prolactinsecreting pituitary adenomas

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

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usually in the horizontal direction. A frontal lobe tumor frequently produces personality disorders, changes in emotional state and behavior, and an uninterested mental attitude. The client often becomes extremely untidy and careless and may use obscene language. A cerebellopontine angle tumor usually originates in the sheath of the acoustic nerve and gives rise to a characteristic sequence of symptoms. Tinnitus and vertigo appear first, soon followed by progressive nerve deafness (cranial nerve VIII dysfunction). Numbness and tingling of the face and the tongue occur (involvement of cranial nerve V). Later, weakness or paralysis of the face develops (cranial nerve VII involvement). Finally, because the enlarging tumor presses on the cerebellum, abnormalities in motor function may be present.

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. A neurologic examination indicates the areas of the CNS involved. CT scans, enhanced by a contrast agent, can give specific information concerning the number, size, and density of the lesions and the extent of secondary cerebral edema. MRI is the most helpful diagnostic tool for detecting brain tumors, particularly smaller lesions, and tumors in the brain stem and pituitary regions, where bone interferes with CT. PET scan is used to supplement MRI; on PET, lowgrade tumors are associated with hypometabolism and high-grade tumors show hypermetabolism (this information is useful in treatment decisions). Computer-assisted stereotactic (three-dimensional) biopsy is being used to diagnose deep-seated brain tumors, and to provide a basis for treatment and prognosis. Cerebral angiography provides visualization of cerebral blood vessels and can localize most cerebral tumors. 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. Cytologic studies of the CSF may be performed to detect malignant cells because CNS tumors can shed cells into the CSF. Medical Management Radiation therapy (cornerstone of treatment of many brain tumors) decreases the incidence of recurrence of incompletely resected tumors. Brachytherapy has had promising results for primary malignancies; generally used as an adjunct to conventional radiation therapy or as a rescue measure for recurrent disease. 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. Corticosteroids may be used before and after treatment to reduce cerebral edema and promote a smoother, more rapid recovery. Gene-transfer therapy uses retroviral vectors to carry genes to the tumor; reprogramming the tumor tissue for susceptibility to treatment (this is being tested). Photodynamic therapy (new technique) is a treatment of primary malignant brain tumors that delivers a targeted therapy while conserving healthy brain tissue. Surgical management

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The objective is to remove or destroy the entire tumor without increasing the neurologic deficit or to relieve symptoms by partial removal. Conventional surgical approaches require an incision into the skull (craniotomy). This approach is used in clients with meningiomas, acoustic neuromas, cystic astrocytomas of the cerebellum, colloid cysts of the third ventricle, congenital tumors, and some of the granulomas. For clients with malignant glioma, complete removal of the tumor and cure are not possible, but the rationale for resection includes relieving ICP, removing any necrotic tissue, and reducing the bulk of the tumor, which theoretically leaves behind fewer cells to become resistant to radiation or chemotherapy. 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. The use of gamma knife to perform radiosurgery allows deep, inaccessible tumors to be treated, often in a single session.

Nursing Management The client with a brain tumor may be at an increased risk for aspiration due to cranial nerve dysfunction. Evaluate the gag reflex and the ability to swallow preoperatively. Teach the client who has diminished gag response to direct food and fluids toward the unaffected side, having the client sit upright to eat, offering a semisoft diet, and having suction readily available. Reassess function postoperatively. For clients with increased ICP, perform neurologic checks, monitor vital signs, maintain a neurologic flow chart, space nursing interventions to prevent rapid increase in ICP, and reorient the client when necessary to person, time, and place. Clients with changes in cognition caused by the lesion require frequent reorientation and the use of orienting devices, supervision of and assistance with self-care, and ongoing monitoring and intervention for prevention of injury. Carefully monitor and protect clients with seizures from injury. Check motor functions at intervals because specific motor deficits may occur depending on the tumors location. Assess sensory disturbances. Evaluate speech. Check eye movement and papillary size and reaction which may be affected by cranial nerve involvement. Cerebral Metastases Metastatic lesions to the brain constitute the most common neurologic complication, occurring in 20% to 30% of clients with cancer. Neurologic signs and symptoms include headache, gait disturbances, visual impairment, personality changes, altered mentation, focal weakness, paralysis, aphasia, and seizures. Medical Management Treatment is palliative and involves eliminating or reducing serious symptoms. The median survival for clients with no treatment for brain metastases is 1 month; with corticosteroid treatment alone is 2 months; radiation therapy extends the median survival to 3 to 6 months. The therapeutic approach includes radiation therapy (the foundation of treatment), surgery (usually for a single intracranial metastasis), and chemotherapy; more often some combination of these treatments is the optimal method. Gamma knife radiosurgery is considered when three or fewer lesions are present.

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

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

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

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

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

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

Metastatic Bone Disease

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

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Soft tissue and blood vessels may need grafting because of the extent of the excision. Complications may include infection, loosening or dislocation of the prosthesis, allograft nonunion, fracture, devitalization of the skin and soft tissue, joint fibrosis, and recurrence of the tumor. Surgical removal of the tumor may require amputation of the affected extremity, with the amputation extending well above the tumor to achieve local control of the primary lesion. Combine chemotherapy is started before and continued after surgery in an effort to eradicate micrometastatic lesions. The goal of combined chemotherapy is greater therapeutic effect at a lower toxicity rate with reduced resistance to the medications. Soft-tissue sarcomas are treated with radiation, limbsparing excision, and adjuvant chemotherapy.

Metastatic Bone Disease The treatment is palliative. The therapeutic goal is to relieve the clients pain and discomfort while promoting quality of life. If metastatic disease weakens the bone, structural support and stabilization are needed to prevent pathologic fractures. At times, large bones with metastatic lesions are strengthened by prophylactic internal fixation. Clients with metastatic disease are at a higher risk for pulmonary congestion, hypoxemia, deep vein thrombosis, and hemorrhage than other clients after orthopedic surgery. Hypercalcemia results from breakdown of bone. Treatment includes hydration with IV administration of normal saline solution, diuresis, mobilization, and medications (e.g., bisphosphanates, pamidronate, and calcitonin). Hematopoiesis is frequently disrupted by tumor invasion of the bone marrow or by treatment (chemotherapy or radiation). Blood product transfusions restore hematologic factors. Pain can result from multiple factors, including the osseous metastasis, surgery, chemotherapy or radiation side effects, and arthritis. Assess pain accurately and manage with adequate and appropriate opioid, nonopioid, and nonpharmaceutical interventions. External beam radiation to involved metastasis sites may be used. Clients with multiple bony metastases may achieve pain control with systematically administered bone-seeking isotopes. Radiation and hormonal therapy may be effective in promoting healing of osteolytic lesions. Chemotherapy is used to control the primary disease.

Nursing Process for the Client with a Bone Tumor Assessment Ask the client about the onset and course of symptoms. Note the clients understanding of the disease process, how the client and the family have been coping, and how the client has managed the pain. On physical examination, gently palpate the mass and note its size and associated soft tissue swelling, pain, and tenderness. Assess the neurovascular status and range of motion of the extremity to provide a baseline data for future comparisons. Evaluate the clients mobility and ability to perform activities of the daily living.

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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, perception of disease process, 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. Explain the diagnostic tests, treatments, and expected results to help the client to deal with the procedures and changes. Reinforce and clarify information provided by the physician by being present during discussions. Relieve pain Assess pain accurately. Use pharmacologic and nonpharmacologic pain management techniques to relieve pain and increase the clients comfort level. Work with the client in designing the most effective pain management regimen to increase his/her control over the pain. Prepare the client and give support during painful procedures. Used prescribed IV or epidural analgesics during the early postoperative period. Oral or transdermal opioid or nonopioid analgesics are usually used later to adequately relieve pain. External radiation or systemic radioisotopes may be used to control pain. Prevent pathologic fracture Support and handle affected extremities gently during nursing care. Use external supports for additional protection. 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. Promote coping skills Encourage the client and the family to verbalize their fears, concerns, and feelings. Support the client and family as they deal with the impact of the malignant bone tumor. Expect feelings of shock, despair, and grief. Refer to a psychiatric nurse liaison, psychologist, counselor, or spiritual advisor for specific psychological help and emotional support. Promote self-esteem Support the family in working through the adjustments that must be made. Assist the client in dealing with changes in body image due to surgery and possible amputation. 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. Involve the client and the family all throughout the treatment to encourage confidence, restoration of self-concept, and a sense of being in control of ones life.

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Monitor and manage potential complications Delayed wound healing Minimize pressure on the wound site to promote circulation to the tissues. Use an aseptic, nontraumatic wound dressing to promote healing. 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. Special therapeutic beds may be needed to prevent skin breakdown and to promote wound healing after extensive surgical reconstruction and skin grafting. Inadequate nutrition. Administer antiemetics and encourage use of relaxation techniques to reduce gastrointestinal reaction. Control stomatitis with anesthetic or antifungal mouthwash. Provide adequate hydration. Nutritional supplements or total parenteral nutrition may be prescribed to achieve adequate nutrition. Osteomyelitis and wound infections Use prophylactic antibiotics and strict aseptic dressing techniques to diminish the occurrence of osteomyelitis and wound infections. Prevent the occurrence of other infections during healing so that hematogenous spread does not result in osteomyelitis. 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. Hypercalcemia Symptoms of hypercalcemia must be recognized and treatment should be initiated promptly.

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) - In situ carcinoma of the breast is being detected more frequently with the widespread use of screening mammography.

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

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There is no single specific cause of breast cancer; hormones, genetic, and environmental events may contribute to its development. Hormones. Hormones produced by the ovaries have an important role in breast cancer. Estradiol and progesterone (two key ovarian hormones) are altered in the cellular environment by a variety of factors, and these may affect growth factors for breast cancer. Research suggests that a relationship between estrogen exposure and the development of breast cancer. menarche, nulliparity, childbirth after 30 years of age, and late menopause are assumed to be associated with prolonged exposure to estrogen because of menstruation. The theory is that each cycle, which has high levels of endogenous estrogen, provides the cells of the breast another chance to mutate, increasing the chance for cancer to develop. Estrogen itself does not cause breast cancer, but it is associated with its development. Genetics. Increasing evidence indicates that genetic alterations are associated with the development of 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. Genetic alterations may be somatic (acquired) or germline (inherited). A mutation in the BRCA-1 gene has been linked to the development of breast and ovarian cancer, whereas a mutation in the BRCA-2 gene identifies risk for breast cancer, but less so for ovarian cancer. Abnormalities in either of the two genes can be identified by blood tests; but, women should be counseled about the risks and benefits before actually undergoing genetic testing.

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, but most are found in the upper outer quadrant, where most breast tissue is located. Lesions are nontender rather than painful, fixed rather than mobile, and hard with irregular borders rather than encapsulated and smooth (generally). Complaints of diffuse breast pain and tenderness with menstruation are usually associated with benign breast disease. Marked pain at presentation may be associated with breast cancer in the later stages. Women seeking treatment at an earlier stage of disease have no symptoms and no palpable lump, but are detected on mammography. Many women with advanced disease seek initial treatment only after ignoring symptoms. They may seek attention for: Dimpling or a peau d orange (orange-peel) appearance of the skin, 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

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

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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 radiocolloid and/or blue dye is injected into the tumor site; the client then undergoes the surgical procedure. The surgeon uses a hand-held probe to locate the sentinel node (the primary drainage from the breast) and excises it, and it is examined by the pathologist. If the sentinel node is negative for metastatic breast cancer, a standard axillary dissection is not needed, thus sparing the client the sequelae of the procedure. If the sentinel node is positive, the client undergoes the standard axillary dissection. Nursing interventions for this procedure focus on informing the client about the expectations and possible complications. 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. treatment is necessary to obtain results equal to those of removal of the breast. If radiation therapy is contraindicated, mastectomy is the clients option. Radiation treatment typically begins about 6 weeks after the surgery to allow the incision to heal. If systemic chemotherapy is indicated, radiation therapy usually begins after completion of the chemotherapy. 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. Postoperative radiation after mastectomy is not common today but is still used in certain cases: when tumors have spread regionally (chest wall involvement, four or more positive nodes, or tumorslarger than 5 cm). Occasionally, clients who have had a mastectomy require radiation treatment to the chest wall, generally after completion of systemic chemotherapy. Another approach is the use of intraoperative radiation therapy (IORT), in which a single dose of radiation is delivered to the lumpectomy site immediately after the surgeon has performed the lumpectomy. Chemotherapy Chemotherapy regimens for breast cancer combine several agents to increase tumor cell destruction and to minimize medication resistance. Chemotherapeutic agents most often used in combination are cyclophosphamide (Cytoxan) (C), methotrexate (M), fluorouracil (F), and doxorubicin (D), with paclitaxel (Taxol) (T) as an addition. Docetaxel (T), a newer taxane, is being used more frequently but research on its difference is still limited. The combination regimen CMF or CAF is a common treatment protocol. AC, ACT (AC given first followed by T), and ATC, with all three agents given together, are other regimens that may be used.

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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. Hormonal therapy may include surgery to remove endocrine glands (e.g., ovaries, pituitary, or adrenal glands) with the goal of suppressing hormone secretion. Oopherectomy is one treatment option for premenopausal women with estrogen-dependent tumors. Tamoxifen is the primary hormonal agent used. Anastrozole (Arimidex), letrozole (Femara), leuprolide (Lupron), megestrol and aminoglutethimide (Cytadren) are other hormonal agents used to suppress hormone-dependent tumors.

Investigational Therapy Research in breast cancer treatment includes the following areas: bone marrow transplantation, peripheral stem cell transplants, oncogenes, growth factors, monoclonal antibodies, biologic response modifiers, and vaccine studies. Another treatment modality that has shown promise is trastuzumab (Herceptin). Herceptin binds with the HER2 protein, and this protein regulates cell growth, thus inhibiting tumor cell growth. Nursing Process for the Client with Breast Cancer Assessment The health history includes an assessment of the clients reaction to the diagnosis and her ability to cope with it. 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, family member, 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, body image changes, 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, surgical treatment, and fear of death Self-care deficit related to partial immobility of upper extremity on operative side

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Disturbed sensory perception (kinesthesia) related to sensations in affected arm, breast, or chest wall Risk for sexual dysfunction related to loss of body part, change in selfimage, and fear of partners 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. Be knowledgeable about current treatment and be able to discuss them with the client. Be aware of the information that has been given by the physician to the client. Provide information about the surgery, the location and extent of the tumor, and postoperative treatments involving radiation therapy and chemotherapy to enable the client make informed decisions. Discuss with the client medications, extent of treatment, management of side effects, possible reactions after treatment, frequency and duration of treatment, and treatment goals. Discuss and plan with the client methods to compensate for physical changes related to mastectomy (e.g., prostheses and plastic surgery). Reduce fear and anxiety and improve coping ability Start the clients emotional preparation when the tentative diagnosis of cancer is made. Discuss fears and concerns with the client. Provide anticipatory teaching and counseling at each stage of the process and identify the sensations that can be expected during additional diagnostic procedures. Discuss the implications of each treatment option and how it may affect various aspects of the clients treatment course and lifestyle. Introduce the client to other members of the oncology team (e.g., radiation oncologist, medical oncologist, oncology nurse, and social worker) and acquaint her with the role of each in her care. Promote preoperative physical, psychological, social, and nutritional wellbeing after the treatment plan has been established. Encourage the client to talk with a breast cancer survivor for reassurance. Promote decision-making ability Careful guide and provide supportive counselling to help the client make a decision about her treatment. Encourage the client to take one step of the treatment process at a time. 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. Initiate a referral to the psychiatrist, psychologist, or psychiatric clinical nurse specialist if necessary. Postoperative Nursing Interventions

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Relieve pain and discomfort Have an ongoing assessment of pain and discomfort. Moderately elevate the involved extremity to relieve pain (decreases tension on the surgical incision, promote circulation, and prevent venous congestion in the affected extremity). Administer intravenous or intramuscular opioid analgesic agents to manage the pain in the initial postoperative phase. Administer oral analgesics after the anesthesia has cleared sufficiently and the client is able to take in fluids and food per orem. Encourage the client to take analgesic agents before exercises or at bedtime, and to take warm shower twice daily (usually allowed on the second postoperative day) to alleviate the discomfort that comes from referred muscle pain. 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. Inspect the dressings and drains for bleeding and monitor the extent of drainage regularly. Monitor the incision if hematoma develops within the first 12 hours after surgery. Notify the physician if a hematoma, that could cause necrosis of the surgical flaps, occurs. Place an Ace wrap (elastic bandage) around the incision and apply an ice pack. Note the characteristics of fluid from the drain. Initially, the fluid in the surgical drain appears blood, but it gradually changes to serosanguineous and then a serous fluid during the next several days. 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. Teach the client and family the importance of ensuring correct management of the drainage system prior to discharge. Discuss the incision, how it looks and feels, and the progressive changes in its appearance with the client during dressing changes. Explain the care of the incision, sensations to expect, and the possible signs and symptoms of an infection. 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. 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. 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. She may again use deodorant on the affected side. Promote positive body image Address the clients perc eption of the body image changes and physical alterations of the breast during teaching sessions. Provide privacy and consideration when assisting the client to view her incision fully for the first time, and allow her to express her emotions. Explain that her feelings are normal response to breast cancer surgery to reassure the client. Promote positive adjustment and coping Have an ongoing assessment of the clients concerns related to the diagnosis of cancer, the consequences of surgical treatment, and fear of death, which

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

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common and that these are normal parts of healing to help reassure her that these sensations are not indicative of a problem. Assist in performing exercises to decrease sensations. acetaminophen as needed to assist managing discomforts. Improve sexual function Encourage discussion about fears, needs, and desires to reduce the couples stress Suggest varying the time of day for sexual activity (when the client is less tired) or assume positions that are more comfortable, other options for expressing affection can also be helpful. Refer the client and her partner to a psychosocial source if problems develop or persist. Monitor and manage potential complications Lymphedema Reassure client that transient edema is not lymphedema. Educate the client how to prevent lymphedema and how to do hand and arm care after axillary dissection. 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. Emphasize that need for early intervention because lymphedema can be manageable if treated early; however, if allowed to progress without treatment, the swelling can become painful and difficult to reverse. Manage lymphedema by elevating the arm with the elbow above the shoulder and the hand higher than the elbow, along with specific exercises, such as hand pumps. Refer the client to a physical therapist or rehabilitation specialist for a custom-made elastic sleeve, exercises, manual lymph drainage, or a special pump to decrease swelling.

Hematoma formation Monitor the surgical site for excessive swelling and monitor the drainage device, if present. Notify the surgeon for gross swelling or output from the drain that may indicate hematoma formation. Monitor the site and reassure the client that this complication is rare but does occur and that she will be assisted through its management. Be calm to help prevent anxiety and panic on the part of the client. Infection Teach the client to monitor for signs and symptoms of infection preoperatively and before discharge, and to contact her health care provider for evaluation. Administer oral or intravenous antibiotics depending on the severity of the infection. Assist in taking specimen for cultures on any foulsmelling discharge. 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

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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, surgical treatment, 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

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Cancer of the Prostate Clinical Manifestations Rarely produces symptoms in the early stages. Symptoms that develop from urinary obstruction occur late in the disease. 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, urinary retention, decrease in size and force of urine stream. Other symptoms may include blood in the urine or semen and painful ejaculation. Hematuria may result if the cancer invades the urethra or bladder, or both. Prostate cancer can metastasize to bone and lymph nodes. Symptoms related to metastases include backache, hip pain, perineal and rectal discomfort, anemia, weight loss, weakness, nausea, and oliguria. Assessment and Diagnostic Findings The likelihood of cure is high if prostate cancer is detected early. Every man older than 40 years of age should have a digital rectal exam (DRE) as part of his regular health checkup. Routine repeated rectal palpation of the gland, preferably by the same examiner, 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. The more advanced lesion is stony hard and fixed. Diagnosis of prostate cancer is confirmed by a histologic examination of tissue removed surgically by transurethral resection, open prostatectomy, or transrectal needle biopsy. Fine-needle aspiration is helpful for determining the stage of disease as well. Most prostate cancers are diagnosed when a man seeks medical attention for symptoms of urinary obstruction or after abnormalities are found by DRE. Prostate-specific antigen (PSA) together with DRE appears to be a cost-effective method for detecting prostate cancer. PSA testing is routinely used to monitor the clients response to cancer therapy and to detect local progression and early recurrence of prostate cancer. Transrectal ultrasound (TRUS) studies are indicated for men who have elevated PSA levels and abnormal DRE findings. TRUS studies help in detecting nonpalpable prostate cancers and assist with staging localized prostate cancer. Needle biopsies of the prostate are commonly guided by TRUS. 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, renal function tests, and CT scans or lymphangiography to identify metastases in the pelvic lymph nodes. Capromab Pendetide with Indium-111 (ProstaScint) is an antibody that is attracted to the prostate-specific antigen found on prostate cancer cells. The radioactive element attached to the antibody is then visible with scanning, allowing detection of disease spread. 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.

Medical Management Surgical Management

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

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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, catheter placement, 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- Establish communication with the client to assess his understanding of the diagnosis and of the planned surgical procedure. Clarify the nature of the surgery and expected postoperative outcomes. Familiarize the client with the pre- and postoperative routines and initiates measures to reduce anxiety. Provide privacy and establish a trusting and professional relationship when discussing problems related to genitalia and sexuality. Encourage the client to verbalize his feelings and concerns. Relieve discomfort- Place the client on bed rest, administer analgesic agents, and initiate measures to relieve anxiety if discomfort is present before the day of the surgery. Monitor voiding patterns, watch for bladder distention, and assist with catheterization if indicated, if the client is hospitalized. Insert an indwelling catheter if the client has continuing urinary retention or if laboratory test results indicate azotemia. Prepare the client for a cystostomy if he cannot tolerate urinary catheter. Provide instruction- 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. Explain what will take place as the client is prepared for diagnostic tests and then for surgery. Describe the type of incision, which varies with the type of surgical approach; inform the client about the type of urinary drainage system that is expected, the type of anesthesia, and the recovery room procedure. Instruct the client about postoperative use of medications for pain management. 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. Administer an enema at home the evening before surgery or the morning of the surgery to prevent postoperative straining, which can induce bleeding. Postoperative Nursing Interventions Maintain fluid balance- 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. Monitor the client for electrolyte imbalances, rising blood pressure, confusion, and respiratory distress. Document and report signs and symptoms of fluid imbalance to the surgeon. Relieve pain- Assist the client to sit and dangle his legs over the side of the bed on the day of surgery, and assist him to ambulate the next morning. Determine the cause and location if pain occurs. Administer medications (e.g., flavoxate and oxybutynin) that can relax smooth muscles to ease bladder spasms. Warm

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

Testicular Cancer

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

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mass; and CT scan of the chest, abdomen, and pelvis to determine the extent of the disease in the lungs, retroperitoneum, and pelvis. 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.

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

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Radiation therapy is used to treat small squamous cell carcinomas of the penis or for palliation in advanced tumors or lymph node metastasis. Partial penectomy is preferred to total penectomy if possible. Total penectomy is indicated when the tumor is not amenable to conservative treatment. Skin Cancer Ask the students the possible causes which may increase an individuals risk for skin cancer. Risk Factors Exposure to the sun is the leading cause of skin cancer; incidence is related to the total amount of exposure to the sun Fair-skinned, fair-haired, blue-eyed people, particularly those of Celtic origin, with insufficient skin pigmentation to protect underlying skin tissues People who sustain sunburn and who do not tan Long-time sun exposure (farmers, fishermen, construction workers) Exposure to chemical pollutants (industrial workers in arsenic, nitrates, coal, 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). The third most common type is the malignant melanoma. 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. Incidence is proportional to the age of the client (average of 60 years) and the total amount of sun exposure, and it is inversely proportional to the amount of melanin in the skin. Usually begins as a small, waxy nodule with rolled, translucent, pearly borders; telangiectatic vessels may be present. It undergoes central ulceration and sometimes crusting as it grows. Tumors appear most frequently on the face; characterized by invasion and erosion of adjoining tissues; rarely metastasizes but recurrence is common; a neglected lesion can result in the loss of a nose, an ear, or a lip. Other variants of BCC may appear as a shiny, flat, gray, or yellowish plaque. Squamous cell carcinoma (SCC) A malignant proliferation arising from the epidermis; usually appears on sundamaged skin but may also arise from normal skin or from preexisting skin lesions. It is of greater concern than BCC because it is a truly invasive carcinoma, metastasizing by the blood or lymphatic system. The lesions may be primary, arising on the skin and mucous membranes, or they may develop from a precancerous condition (such as actinic keratosis, leukoplakia, or scarred or ulcerated lesions).

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It appears as rough, thickened, scaly tumor that may be asymptomatic or may involve bleeding. The boarder of an SCC lesion may be wider, more infiltrated, and more inflammatory than that of a BCC lesion. Secondary infection can occur. Common sites are exposed areas, especially of the upper extremities and of the face, lower lip, ears, nose, and forehead.

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

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and the base cauterized. The process is repeated twice. Generally, healing occurs within a month. Cryosurgery This method destroys the tumor by deep freezing the tissue. A thermocouple needle apparatus is inserted into the skin, and liquid nitrogen is directed to the center of the tumor until the tumor base is -40C to -60C. The tumor tissue is frozen, allowed to thaw, and then refrozen. The site thaws naturally and then becomes gelatinous and heals spontaneously. Swelling and edema follow the freezing. The appearance of the lesion varies. Normal healing, which may take 4 to 6 weeks, occurs faster with a good blood supply. Radiation Therapy Frequently performed for cancer of the eyelid, tip of the nose and areas in or near vital structures (e.g., facial nerve); reserved for older clients, since x-ray changes may be seen after 5 to 10 years, and malignant changes in scars may be induced by irradiation 15 to 30 years later. Nursing Management Teach client about prevention of skin cancer and about self-care after treatment. Advise the client when to report for a dressing change or provide a written and verbal information on how to change dressings, including the type of dressing to purchase, how to remove dressings and apply fresh ones, and the importance of hand washing before and after the procedure. Advise the client to watch for excessive bleeding and tight dressing that compromise circulation. Instruct the client to drink liquids through straw and limit talking and facial movement, if the lesion is in the perioral area. Dental work should also be avoided until the area is completely healed. Apply an emollient cream to help reduce dryness after the sutures have been removed. Advise the client to apply sunscreen over the wound to prevent postoperative hyperpigmentation if he/she spends time outdoors. Instruct the client to seek treatment for any moles that are subject to repeated friction and irritation, and to watch for indications of potential malignancy. Malignant Melanoma A malignant melanoma is a cancerous neoplasm in which atypical melanocytes are present in the epidermis and the dermis. Risk Factors Fair-skinned or freckled, blue-eyed, 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. It usually affects middle-aged people and occurs most frequently on the trunk and lower extremities. The lesion tends to be circular, with irregular outer portions. The margins of the lesion may be flat or elevated and palpable.

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This type of melanoma may appear in a combination of colors, with hues of tan, brown, and black mixed with gray, blue-black, or white. A dull pin rose color can be seen in a small area within the lesion, sometimes. Lentigo-maligna melanoma are slowly evolving, pigmented lesions that occur on exposed skin areas, especially the dorsum of the hand, the head, and the neck in elderly people. Lesions are often present for many years before they are examined by a physician. They first appear as tan, flat lesions, but in time, they undergo changes in size and color. Nodular melanoma is a spherical, blueberry-like nodule with a relatively smooth surface and a relatively uniform, blue-black color. It may be dome-shaped with a smooth surface. It may have other shadings of red, gray, or purple. These melanomas may appear as irregularly shaped plaques. The client may describe this as a blood blister that fails to resolve. A nodular melanoma invades directly into adjacent dermis and therefore has poorer prognosis. Acral lentiginous melanoma occurs in areas not excessively exposed to sunlight and where hair follicles are absent. It is found on the palms of the hands, on the soles, in the nail beds, and in the mucous membranes in dark-skinned people. These melanomas appear as irregular, pigmented macules that develop nodules. They may become invasive early.

Assessment and Diagnostic Findings Biopsy results confirm the diagnosis of melanoma. An excisional biopsy specimen provides histologic information on the type, level of invasion, and thickness of the lesion. Incisional biopsy should be performed when the suspicious lesion is too large to be removed safely without extensive scarring. Biopsy specimens obtained by shaving, curettage, or needle aspiration are not considered reliable histologic proof of disease. A thorough history and physical examination should include a meticulous skin examination and palpation of regional lymph nodes that drain the lesional area. After the diagnosis of melanoma has been confirmed, a chest x-ray, complete blood cell count, liver function tests, and radionuclide or CT scans are usually ordered to stage the extent of disease. Prognosis The prognosis for long-term (5-year) survival is considered poor when the lesion is more than 1.5 mm thick or there is regional lymph node involvement. Clients with melanoma on the hand, foot, or scalp have a better prognosis; those with lesions on the torso have an increased chance of metastases to the bone, liver, lungs, spleen, and central nervous system. Men and elderly clients also have poor prognoses. Medical Management Treatment depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, after which skin grafting may be needed. Regional lymph node dissection is commonly performed to rule out metastasis, although new surgical approaches call only for sentinel node biopsy. Several forms of immunotherapy (e.g., BCG vaccine, Corynebacterium parvum, levamisole), biologic response modifiers (e.g., interferon-alpha, interleukin-2),

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adaptive immunotherapy (i.e., lymphokine-activated killer cells), and monoclonal antibodies are some of the investigational therapies available. Further surgical intervention may be performed to debulk the tumor or to remove part of the organ involved for metastatic melanoma. Chemotherapy may also be used. 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. This approach delivers a high concentration of cytotoxic agents while avoiding systemic, toxic effects.

Nursing Process for the Client with Malignant Melanoma Assessment Assessment is based on the clients history and symptoms. Ask the client specifically about pruritus, tenderness, and pain which are not features of a benign nevus. Question the client about changes in pre-existing moles or the development of new, pigmented lesions. Signs that suggest malignant changes are referred to as the ABCDs of moles: A Asymmetry - The lesion does appear balanced on both sides. If an imaginary line were drawn down the middle, the two halves would not look alike. The lesion has an irregular surface with uneven elevations (irregular topography) either palpable or visible. A change in the surface may be noted from smooth to scaly. Some nodular melanomas have a smooth surface. B Irregular Border Angular indentations or multiple notches appear in the border. The border is fuzzy or indistinct, as if rubbed with an eraser. C Variegated Color Normal moles are usually a uniform light to medium brown. Darker coloration indicates that the melanocytes have penetrated to a deeper layer of the dermis. Colors that may indicate malignancy if found together within a single lesion are shades of red, white, and blue; shades of blue are ominous. White areas within a pigmented lesion are suspicious. Some malignant melanomas, however, are not variegated but are uniformly colored (bluish-black, bluish-gray, bluish-red). D Diameter A diameter exceeding 6 mm is considered more suspicious, although this finding without other sign is not significant. Many benign skin growths are larger than 6 mm, whereas some early melanomas may be smaller. Common sites of melanomas are the skin of the back, the legs, between the toes, and on the feet, face, scalp, fingernails, and backs of hands. Melanomas are most likely to occur in less pigmented sites: palms, soles, subungual areas, and mucous membranes of dark-skinned people.Satellite lesions (those situated near the mole) are inspected. 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- Promote comfort and administer appropriate medications. Reduce anxiety and depression Allow clients to express feelings about the seriousness of this cutaneous neoplasm, understand their anger and depression, and convey understanding of these feelings. Answer questions about the diagnostic workup and staging of the depth type, and extent of tumor to help clarify information and misconceptions.

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

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Diffusion-weighted MRI may be done to rule out stroke. Transesophageal echocardiography to rule out emboli from heart. Medical Management Platelet aggregation inhibitors, such as aspirin, ticlopidine (Ticlid), dipyridamole/aspirin 200/25 (Aggrenox), and clopidogrel (Plavix), to reduce risk of stroke Reduction of other risk factors to prevent stroke, such as control of hypertension, diabetes, and hyperlipidemia, 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. 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. Extracranial/Intracranial Anastomosis This procedure entails connection of the superficial temporal artery (STA), or a venous conduit, to a branch of the middle cerebral artery (MCA). The purpose of extracranial to intracranial (EC-IC) bypass is to augment cerebral blood flow. Transarterial (Carotid) Angioplasty withStenting In carotid angioplasty, a catheter (long, hollow tube) is inserted in the groin artery and threaded up to the narrowed carotid artery. 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. Clients are awake during the procedure, and are usually discharged from the hospital the following day. Most clients are able to resume normal activities when they get home. Advantages: Local instead of general anesthesia Fewer surgical complications such asnerve injury, 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; hypertensive and diabetic control; hyperlipidemia; cardiovascular disease, such as atrial fibrillation; smoking. Perform physical examination, including neurologic, cardiac, and circulatory systems; be sure to listen for carotid bruit. Assess client for history of headache and, if positive, for duration of headache.

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

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factors, pathophysiology, clinical manifestations, assessment/diagnostic procedures, medical management of CVA, as well as the nursing process for a client who had CVA. Stroke Also known as cerebrovascular accident (CVA) or brain attack; defined as the interruption of normal blood flow in one or more of the blood vessels that supply the brain as a result, the tissues become ischemic, leading to hypoxia or anoxia, with destruction or necrosis of the neurons, support structures (glia), and vasculature. Onset and persistence of neurologic dysfunction last onger than 24 hours. Strokes are classified as ischemic (more common) and hemorrhagic (greater morbidity and mortality). Causes A CVA is an acute neurological injury that occurs because of changes in the blood vessels of the brain. The changes can be intrinsic or extrinsic to the vessel: Intrinsic causes Atherosclerosis Inflammation Arterial dissection, Dilation of the vessel Weakening of the vessel Obstruction of the vessel (thrombosis) Most common cause: Extrinsic cause Embolism from the heart Thrombosis, embolism, and hemorrhage are the primary causes of CVA Ischemic Stroke Results from cerebral vessels becoming occluded, significantly reducing the blood and oxygen supply to the brain. Sudden loss of function occurs. Reduction in the flow of blood to any part of the brain first causes ischemia, a reversible loss of function, and then, if the reduction is severe or prolonged, infarction with irreversible cell death. 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, which has its greatest incidence in the first month after the first attack. Lack or delay in evaluation and treatment of a client who has experienced previous TIAs may result in a stroke and irreversible deficits. Reversible ischemic neurologic deficits Signs and symptoms are consistent with but more pronounced than a TIA and last more than 24 hours. Symptoms resolve in days with no permanent neurologic deficit. Stroke in evolution Worsening of neurologic signs and symptoms over several minutes or hours. This is a progressing stroke.

Completed stroke - Neurologic signs and symptoms stabilize which indicates no further progression of the hypoxic insult to the brain. Hemorrhagic Stroke Account for 15% of cerebrovascular disorders. There is leakage of blood from a blood vessel and hemorrhage into brain tissue, causing edema, compression of brain tissue, and spasm of adjacent blood vessels. Depending on the area involved, it may occur: outside the dura (extradural),

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beneath the dura mater (subdural), in the subarachnoid space (SAS or subarachnoid), 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 goal is less than 130/85 mm Hg If the client is diabetic, 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, valvular conditions, 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; 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, hormone replacement therapy or contraceptive use, and migraine headaches.

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, usually at bifurcation of larger arteries; 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. Subtle decrease in blood flow may allow brain cells to maintain minimal function, but as blood flow decreases focal areas of ischemia occur, followed by infarction of that area, resulting to loss of function specifically controlled by the affected area. An area of injury includes edema, tissue breakdown, and small arterial vessel damage. The small arterial vessel damage poses a risk of hemorrhage. The larger the area of infarction, the greater the risk of hemorrhagic conversion. Ischemic strokes are not activity dependent, it may even occur at rest. 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, diabetes mellitus, or cocaine use

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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. Mass effect (caused by a rapidly growing tumor) causes pressure on brain tissue. Hemorrhage irritates local brain tissue leading to surrounding focal edema. Subarachnoid hemorrhage (SAH) or hemorrhage into a ventricle can block normal CSF flow, leading to hydrocephalus. Hemorrhage commonly occurs suddenly while a person is active-spontaneous (nontraumatic) intracranial hemorrhage. Clinical Manifestation Clinical manifestations vary depending on the vessel affected and the cerebral territories it supplies/perfuses. Headache may be a sign of impending cerebral hemorrhage or infarction; however, it is not always present. Common clinical manifestations: Numbness (paresthesia), weakness (paresis), or loss of motor ability (plegia) on one side of the body Difficulty in swallowing (dysphagia) Aphasia Expressive inability to express oneself; often associated with damage to the left frontal lobe (Brocas) area Receptive inability to understand what someone else is saying; often associated with damage to the temporal lobe (Wernickes) area Global an extreme impairment or loss of language ability in all input and output modalities, 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), loss of half of a visual field (hemianopsia), double vision, photophobia Altered cognitive abilities and psychological effect Self-care deficits Assessment/Diagnostic Procedures Carotid ultrasound to detect carotid stenosis. CT scan to determine cause and location of stroke. MRA or CT angiogram for noninvasive evaluation of cerebrovascular structures. Cerebral angiography to determine extent of cerebrovascular insufficiency and to evaluate for structural abnormalities. PET, MRI with diffusion-weighted images to localize ischemic damage. Medical Management Acute Treatment Support of vital functions: maintain airway, breathing, oxygenation, and circulation. Reperfusion and hemodilution with colloids and volume expanders (albumin). Thrombolytic therapy recombinant tissue plasminogen (tPA) given IV 0.9 mg/kg within 3 hours of onset of symptoms; 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

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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).

Maintain BP within prescribed parameters. 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, 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, which peaks 3 to 5 days after infarction, may be used, although this is controversial. Calcium channel blockers, nimodipine (Nimotop), to reduce BP, promote vasodilatation, and prevent cerebral vasospasm. Subsequent Treatment Anticoagulation after hemorrhage is ruled out. Antiplatelet agents such as ticlopidine (Ticlid), Dipyridamole/aspirin 200/25 (Aggrenox), and clopidogrel (Plavix), or aspirin. Antispasmodic agents for spastic paralysis. A rehabilitation program, including physical therapy, occupational therapy, speech therapy as soon as stable), and counseling as needed. Treatment of post-stroke depression with antidepressants such as selective serotonin reuptake inhibitors. Complications Aspiration pneumonia Dysphagia in 25% to 50% of clients after stroke Spasticity, contractures Deep vein thrombosis, pulmonary embolism Brain stem herniation Post-stroke depression (PSD)

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Nursing Process Assessment Maintain neurologic flow sheet. Assess for voluntary or involuntary movements, tone of muscles, and presence of deep tendon reflexes. Also assess mental status, cranial nerve function, and sensation/proprioception. Monitor bowel and bladder function/control. Monitor effectiveness of anticoagulation therapy. Frequently assess level of function and psychosocial response to condition. Assess for skin breakdown, contractures, and other complications of immobility. 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, dressing, toileting related to hemiparesis/paralysis Imbalanced nutrition: less than body requirements related to impaired self-feeding, chewing, swallowing Impaired urinary elimination related to motor/sensory deficits Disabled family coping related to catastrophic illness, cognitive and behavioral sequelae of stroke, 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.Administer oxygen as ordered during acute phase to maximize cerebral oxygenation. Frequently assess respiratory status, vital signs, heart rate and rhythm, and urine output to maintain and support vital functions. When client becomes more alert after acute phase, maintain frequent vigilance and interactions aimed at orienting, assessing, and meeting the needs of the client. Try to allay confusion and agitation with calm reassurance and presence. Assess client for risk for fall status. Prevent complications of immobility Interventions to improve functional recovery require active participation of the client and repetitive training. Maintain functional position of all extremities. Apply a trochanter roll from the crest of the ilium to the mid thigh to prevent external rotation of the hip. 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. 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; alternate elbowextension. Place the hand in slight supination with fingers slightly flexion. Avoid excessive pressure on ball of foot after spasticity develops. Do not allow top bedding to pull affected foot into plantar flexion; may use tennis shoes in bed. Place the client in a prone position for 15 to 30 minutes daily, and avoid sitting up in chair for long periods to prevent knee and hip flexion contractures. Encourage neutral positioning of affected limbs to promote relaxation and to limit abnormal increases in muscular tone to enhance functional recovery .Apply splints and braces as indicated to support flaccid extremities or on spasticextremities to decrease stretch stimulationand reduce spasticity.

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

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

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

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Assess for the following: Change in LOC (awareness): drowsiness, lethargy Early behavioral changes: restlessness, irritability, contusion, and apathy Falling score on the Glasgow Coma Scale (GCS) Change in orientation: disorientation to time, place, 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.g., purposeful to inappropriate or absent responses) Changes in vital signs caused by pressure on brain stem.

Assess for the following: Rising BP or widening pulse pressure. This may be followed by hypotension and labile vital signs, indicating further brain stem compromise. Pulse changes with bradycardia changing to tachycardia as ICP rises. 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, 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. Inspect the pupils with a flashlight to evaluate size, configuration, and reaction to light. Compare both eyes for similarities or differences, particularly pupillary changes related to location and progression of brain stem herniation. 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, 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). Reaction to light is brisk but with small range of constriction.Treatment is delayed or unsuccessful; small pupils dilate moderately (3 to 5 mm) to fix irregularly at midposition. When herniation of brainstem occurs, both pupils dilate widely and remain fixed to light. Perform fundoscopic examination to inspect the retina and optic nerve for hemorrhage and papilledema. Extraocular movements Evaluate gaze to determine if it is conjugate (paired, working together) or dysconjugate (eye deviates or movement is asymmetrical). Evaluate movement of eyes. Inability to abduct or adduct: deviation of one or both eyes. Alteration in vision (e.g., blurred vision, diplopia, field cut) Spontaneous roving, random eye movements Nystagmus on horizontal/vertical gaze Oculocephalic reflex (doll's eyes): brisk turning of the head left, right, up, or down with observation of eye movements in response to the stimulus.

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Tests brain stem pathways between cranial nerves III, IV, VI, and VIII; this should not be performed on clients with suspected cervical spine injury, clients in a cervical collar, or clients with known cervical spine injuries unless part of the brain death exam. 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. Tests brain stem pathways between cranial nerves III, IV, VI, and VIII; response preserved longer than the doll's eyes maneuver. This is performed by physician as part of brain death examination. Other changes to be alert for: Headache increasing in intensity and aggravated by movement and straining Vomiting recurrent with little or no nausea; especially in early morning; may be projectile Papilledema from optic nerve compression Subtle changes, such as restlessness, headache, forced breathing, purposeless movements, and mental cloudiness Contralateral hemiparesis progressing to complete hemiplegia Speech impairment (expressive, receptive, or global aphasia) when dominant hemisphere involved Seizure activity, either focal or generalized Decreased brain stem reflexes (cranial nerve deficits; e.g., corneal, gag, and swallow) Pathologic reflexes: Babinski, grasp, chewing, sucking

Nursing Process Assessment ICP can be monitored by means of an intraventricular catheter, a subarachnoid screw or bolt, or an epidural pressure-recording device. Alterations or compromise in cerebral blood flow can be measured noninvasively by a transcranial Doppler (TCD). Increased velocities indicate vasospasm, diminished velocities indicate low blood flow, and absent velocities are consistent with no flow, or brain death. 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; connected to fluid-filled transducer, which converts mechanical pressure to electrical impulses and waveform; allows ventricular drainage. Subarachnoid (bolt) hollow screw inserted into SAS beneath skull and dura through drill hole; also connected to pressure transducer system. Epidural sensor inserted beneath skull butnot through dura, so does not measurepressure directly; fiber-optic cable is connected directly to monitor. Parenchymal device is inserted directly into brain tissue. Nursing Diagnosis: Decreased intracranial adaptivecapacity Interventions (to decrease intracranial pressure) Establish and maintain airway, breathing, andcirculation. Promote normal PCO2. Hyperventilation is not recommended for prophylactic treatment of increased ICP as cerebral circulation is reduced by 50% the first 24 hours after injury. Hyperventilation causes cerebral vasoconstriction and decreases cerebral blood volume and results in decreased ICP; this can potentiate secondary injury to the brain.

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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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Teach the client and caregiver the signs and symptoms that necessitate a return to the hospital. Stress the importance of follow-up visits to the physicians office. 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 result of inadequate cardiac output (CO) is poor organ perfusion and vascular congestion in the pulmonary or systemic circulation. Heart failure is a clinical syndrome that results from the progressive process of remodeling, in which mechanical and biochemical forces alter the size, shape, and function of the ventricle's ability to pump enough oxygenated blood to meet the metabolic demands of the body. Pathophysiology Cardiac compensatory mechanisms (increases in heart rate, vasoconstriction, and heart enlargement) occur to assist the struggling heart. 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. Physiologic stressors that increase the workload of the heart (exercise, infection) may cause these mechanisms to fail and precipitate the clinical syndrome associated with a failing heart (elevated ventricular/atrial pressures, sodium and water retention, decreased CO, circulatory and pulmonary congestion). The compensatory mechanisms may hasten the onset of failure because they increase afterload and cardiac work. Caused by disorders of heart muscle resulting in decreased contractile properties of the heart; CHD leading to MI; hypertension; valvular heart disease; congenital heart disease; cardiomyopathies; dysrhythmias. Other causes include pulmonary embolism; chronic lung disease; hemorrhage and anemia; anesthesia and surgery; transfusions or infusions; increased body demands (fever, infection, pregnancy, arteriovenous fistula); drug-induced; physical and emotional stress; or, excessive sodium intake. Risk factors include hypertension, hyperlipidemia, diabetes, CAD, family history, smoking, alcohol consumption and/or use of cardiotoxic drugs. Clinical Manifestations Initially, there may be isolated left-sided heart failure, but eventually the right ventricle fails because of the additional workload. Combined left- and right-sided heart failure is common. Left-Sided Heart Failure (Forward Failure)

Congestion occurs mainly in the lungs from blood backing up into pulmonary veins and capillaries Shortness of breath, dyspnea on exertion, paroxysmal nocturnal dyspnea (due to re absorption of dependent edema that has developed during day), orthopnea, pulmonary edema Cough may be dry, unproductive; usually occurs at night Fatigability from low CO, nocturia, insomnia, dyspnea, catabolic effect of chronic failure Insomnia, restlessness Tachycardia, S3 ventricular gallo Right-Sided Heart Failure (Backward Failure) Signs and symptoms of elevated pressures and congestion in systemic veins and capillaries:

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Edema of ankles; unexplained weight gain (pitting edema is obvious only after retention of at least 10 lb [4.5 kg] of fluid) Liver congestion may produce upper abdominal pain Distended jugular veins Abnormal fluid in body cavities (pleural space pleural effusion, 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, dilation of chambers, and abnormal wall motion ECG (resting and exercise) may show ventricular hypertrophy and ischemia Chest X-ray may show cardiomegaly, pleural effusion, 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, triage BNP, Nterminal probrain NP, or proBNP) As volume and pressure in the cardiac chambers rise, cardiac cells produce and released more BNP. This test aids in the diagnosis of heart failure. A level greater than 100/ml is diagnostic for heart failure. In addition, the higher the BNP, the more severe the heart failure. BNP is used in emergency department to quickly diagnose and start treatment. Radionuclide ventriculogram

Principles of Management Pharmacotherapy Diuretics Eliminate excess body water and decrease ventricular pressures. A low-sodium diet and fluid restriction complement this therapy. Some diuretics may have slight venodilator properties. Positive inotropic agents increase the heart's ability to pump more effectively by improving the contractile force of the muscle. 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. By relaxing capacitance vessels (veins and venules), vasodilators reduce ventricular filling pressures (preload) and volumes. By relaxing resistance vessels (arterioles), vasodilators can reduce impedance to left ventricular ejection and improve stroke volume. Nitrates, such as nitroglycerin (Tridil), isosorbide (Isordil), nitroglycerin ointment (NitroBid) predominantly dilate systemic veins Hydralazine (Apresoline) predominantly affects arterioles; reduces arteriolar tone

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Prazosin (Minipress) balanced effects on both arterial and venous circulation Sodium nitroprusside (Nipride) predominantly affects arterioles Morphine (Duramorph) decreases venous return, decreases pain and anxiety and thus cardiac work Angiotensin-converting enzyme (ACE) inhibitors inhibit the adverse effects of angiotensin II (potent vasoconstriction/sodium retention). Decreases left ventricular afterload with a subsequent decrease in heart rate associated with heart failure, thereby reducing the workload of the heart and increasing CO. May decrease remodeling of the ventricle. Captopril (Capoten) and enalapril (Vasotec) are commonly used. Beta-adrenergic blockers decrease myocardial workload and protect against fatal dysrhythmias by blocking norepinephrine effects of the sympathetic nervous system. Metoprolol (Lopressor) or metoprolol CR or XL (Toprol XL) are commonly used. Carvedilol (Coreg) is a nonselective beta- and alpha-adrenergic blocker. Clients may actually experience increase in general malaise for a 2- to 3-week period while they adjust to the medication. Angiotensin II-receptor blockers (ARBs) similar to ACE inhibitors. Used in clients who cannot tolerate ACE inhibitors due to cough or angioedema. Aldosterone antagonists decrease sodium retention, sympathetic nervous system activation and cardiac remodeling. Spironolactone (Aldactone) is most commonly used. Human B-type natriuretic peptide (Nesiritide) used in clients with decompensated heart failure. It produces smooth muscle cell relaxation, diuresis, and a reduction in afterload. 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; counterpulsation devices pump while the heart muscle relaxes (diastole) and relax when the heart muscle contracts (systole). A balloon catheter is introduced into the femoral artery percutaneously or surgically, threaded to the descending thoracic aorta, and positioned distal to the subclavian artery. The balloon catheter is attached to an external console, allowing for inflation and deflation of the balloon with gas such as carbon dioxide. 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. 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 balloon is inflated at the onset of diastole; this results in an increase in diastolic pressure (diastolic augmentation), which increases blood flow through the coronary arteries. The balloon is deflated just before the onset of systole, facilitating the emptying of blood from the left ventricle. Enhanced external counterpulsation pneumatic cuffs are wrapped around the calves, thighs, and buttocks and inflated in rhythm with the client's ECG. The cuffs push venous blood back to the heart during diastole and decrease afterload.

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Continuous positive airway pressure decreases sleep apnea (which worsens heart failure), slows ventricular remodeling, improves hemodynamics, andreduces ventricular irritability. The mechanism of action is unknown.Cardiac resynchronization therapy or biventricular pacing helps to restore synchronous ventricular contractions, improves ventricular left ventricle filling, and improves CO. Left ventricular assist device (LVAD) The left ventricular assist device, or LVAD, is a mechanical pump that is implanted inside a person's chest to help a weakened heart ventricle pump blood throughout the body. Unlike a total artificial heart, the LVAD doesn't replace the heart. It just helps it do its job. Partial left ventriculectomy (reduction ventriculoplasty or Batista procedure) a triangular section of the weakened heart muscle is removed to reduce ventricular wall tension. This procedure is not commonly used. Endoventricular circular patch-plasty or the Dorprocedure removal of diseased portion of septum or left ventricle with a synthetic or autologous tissue patch, thus providing a more normal shape and size of the heart, which improves hemodynamics. Acorn cardiac support device a polyester mesh, custom-fitted jacket is surgically placed on the epicardial surface, providing diastolic support. Over time, it decreases or halts remodeling. Heart transplant is a procedure that removes a damaged or diseased heart and replaces it with a healthy one. The healthy heart comes from a donor who has died. It is the last resort for people with heart failure when all other treatments have failed.

Complications Kidney damage or failure Heart failure can reduce the blood flow to your kidneys, which can eventually cause kidney failure if left untreated. Kidney damage from heart failure can require dialysis for treatment. Heart valve problems The valves of your heart, which keep blood flowing in the proper direction through your heart, can become damaged from the blood and fluid buildup from heart failure. Liver damage Heart failure can lead to a buildup of fluid that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it more difficult for your liver to function properly. Heart attack and stroke Because blood flow through the heart is slower in heart failure than in a normal heart, it's more likelyyou'll develop blood clots, which can increase your risk of having a heart attack or stroke. Nursing Process Assessment Obtain history of symptoms, limits of activity, response to rest, and history of response to drug therapy. Assess peripheral arterial pulses; note quality, character; assess heart rhythm and rate and BP; assess edema. Inspect and palpate precordium for lateral displacement of PMI. Obtain hemodynamic measurements as indicated and note change from baseline. Assess weight and ask about baseline weight. Note results of serum electrolyte levels and other laboratory tests. Identify sleep patterns and sleep aids commonly used by client. Nursing Diagnosis

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

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Administer prescribed diuretic as ordered. Give diuretic early in the morning nighttime diuresis disturbs sleep. Keep input and output record client may lose large volume of fluid after a single dose of diuretic. Weigh client daily to determine if edema is being controlled: weight loss should not exceed 1 to 2 lb (0.5 to 1.0 kg) per day. Assess for signs of hypovolemia caused by diuretic therapy thirst; decreased urine output; orthostatic hypotension; weak, thready pulse; increased serum osmolarity; and increased urine specific gravity. Be alert for signs of hypokalemia, which may cause weakening of cardiac contractions and may precipitate digoxin toxicity in the form of dysrhythmias, anorexia, nausea, vomiting, abdominal distention, paralytic ileus, paresthesias, muscle weakness and cramps, confusion. Give potassium supplements as prescribed. Be aware of disorders that may be worsened by diuretic therapy including hyperuricemia, gout, volume depletion, hyponatremia, magnesium depletion, hyperglycemia, and diabetes mellitus. Also, note that some clients allergic to sulfa drugs may also be allergic to thiazide diuretics. Watch for signs of bladder distention in elderly male clients with prostatic hyperplasia. Administer I.V. fluids carefully through an intermittent access device to prevent fluid overload. Monitor for pitting edema of lower extremities and sacral area. Use convoluted foam mattress and sheepskin to prevent pressure ulcers (poor blood flow and edema increase susceptibility). Observe for the complications of bed rest pressure ulcers (especially in edematous clients), phlebothrombosis, and/or pulmonary embolism. Be alert to complaints of right upper quadrant abdominal pain, poor appetite, nausea, and abdominal distention (may indicate hepatic and visceral engorgement). Monitor client's diet. Diet may be limited in sodium to prevent, control, or eliminate edema; may also be limited in calories. Caution clients to avoid added salt in food and foods with high sodium content. Improve activity tolerance Increase client's activities gradually. Alter or modify client's activities to keep within the limits of his cardiac reserve. Assist client with self-care activities early in the day (fatigue sets in as day progresses). Be alert to complaints of chest pain or skeletal pain during or after activities. Observe the pulse, symptoms, and behavioural response to increased activity. Monitor client's heart rate during self-care activities. Allow heart rate to decrease to preactivity level before initiating a new activity. Note time lapse between cessation of activity and decrease in heart rate (decreased stroke volume causes immediate rise in heart rate). 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. Give appropriate sedation to relieve insomnia and restlessness. Client education and health maintenance Explain the disease process to the client; the term failure may have terrifying implications. Explain the pumping action of the heart to move blood through the body to provide nutrients and aid in the removal of waste material. Explain the difference between heart attack and heart failure. Teach the signs and symptoms of recurrence Watch for: Gain in weight report weight gain of more than 2 to 3 lb (0.9 to 1.4 kg) in a few days; weigh at same time daily to

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detect any tendency toward fluid retention Swelling of ankles, feet, or abdomen Persistent cough Tiredness, loss of appetite Frequent urination at night Review medication regimen. Label all medications. Give written instructions. Make sure the client has a check-off system that will show that he has taken medications. Teach the client to take and record pulse rate and BP. Inform the client of adverse drug effects. If the client is taking oral potassium solution,it may be diluted with juice and taken after a meal. Tell the client to weigh self daily and log weight if on diuretic therapy. Ask whether client is taking Coenzyme Q10 or other supplements; should discuss with health care provider.

Review activity program. Instruct the client as follows: Increase walking and other activities gradually, provided they do not cause fatigue and dyspnea. In general, continue at whatever activity level can be maintained without the appearance of symptoms. Avoid excesses in eating and drinking. Undertake a weight reduction program until optimal weight is reached. Avoid extremes in heat and cold, which increase the work of the heart; air conditioning may be essential in a hot, humid environment. Keep regular appointment with health care provider or clinic. Restrict sodium as directed. Teach restricted sodium diet and the DASH (dietary approaches to stop hypertension) diet. 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, laxatives, cough remedies, and so forth). Teach the client to rinse the mouth well after using tooth cleansers and mouthwashes, some of these contain large amounts of sodium. Water softeners should be checked for salt content. Teach the client that sodium is present in alkalizers, cough remedies, laxatives, pain relievers, estrogens, and other drugs. Encourage use of flavorings, spices, herbs, and lemon juice. Avoid salt substitutes with renal disease. Outcome Criteria Normal BP and heart rate Respiratory rate 16 to 20, ABG levels within normal limits, Weight decrease of 2.2 lb (1 kg) daily, no pitting edema of lower extremities and sacral area Heart rate within normal limits, rests between activities

Discharge Planning Prevention To prevent exacerbations, teach the client and family to monitor for an increase in shortness of breath or edema. Tell the client to restrict fluid intake to 2 to 2.5 L per day and restrict sodium intake as prescribed. Teach the client to monitor daily weights and report weight gain of more than 4 pounds in 2 days. Be sure the client and family understand all medications, including effect, dosage, route, adverse effects, and the need for routine laboratory monitoring for drugs such as digoxin. 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.

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ment. Monitor and document symptoms that may indicate metastasis: lung, bone, and liver. Nursing care should be based on the clients symptoms. Encourage the client to have hope in the therapy employed while maintaining a realistic perspective about the disease and ultimate outcome. Provide time for the client to express fears and concerns. Offer information about support groups and contact people, and arrange for palliative hospice care if appropriate. 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

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

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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, dyspnea, unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath Cervical lymph adenopathy, unplanned weight loss, a general debilitated state, 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; include risk factors, family history, and underlying medical conditions in the assessment. Indirect laryngoscopy, using a flexible endoscope, is initially performed to visually evaluate the pharynx, larynx, and possible tumor. Assess the mobility of vocal cords; if normal movement is limited, the growth may affect muscle, other tissue, or even the airway. Palpate the lymph nodes of the neck and thyroid gland to determine spread of malignancy. Direct laryngoscopic examination is performed when a tumor is suspected on initial examination. Samples of tissue are obtained for histologic evaluation. CT scan and MRI are used to assess regional adenopathy and soft tissue, and help stage and determine the extent of the tumor. PET scan may also be used to detect recurrence of laryngeal tumorafter treatment. Medical Management Treatment depends on the staging of the tumor, which includes the location, size, and histology of the tumor and the presence and the extent of cervical lymph node involvement. Treatment plan depends on whether this is an initial diagnosis or recurrence. Treatment options include surgery, chemotherapy, and radiation. Surgery and radiation therapy are both effective methods in the early stages of cancer of the larynx. Chemotherapy traditionally has been used for recurrence or metastatic disease; may also be used in conjunction with either radiation therapy to avoid a total laryngectomy or preoperative to shrink a tumor before surgery. Prognosis depends on the tumor stage, the clients gender and age, and pathologic features of the tumor, 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. Associated with a very high cure rate; may also be performed for a recurrence when a high-dose radiation has failed A portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. Airway of the client remains intact and no difficulty in swallowing is expected; 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, glottis, and false cords are removed; true vocal cords, cricoid cartilages, and trachea remain intact. A radical neck dissection is performed during surgery. A tracheostomy tube is left

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

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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, or until the client masters the technique This is a battery-powered apparatus that projects sound into the oral cavity; when the mouth forms the words, the sounds from the electric larynx becomes audible words. Voice produced sounds mechanical and some words may be difficult to distinguish; an advantage is that the client is able tocommunicate with relative ease while working to become proficient with other techniques. 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), and it is easily learned. A valve is placed in the tracheal stoma to divert air into the esophagus and out of the mouth; once the puncture is surgically created and has healed, voice prosthesis is fitted over the puncture site. To prevent airway obstruction, the prosthesis is removed and cleaned when mucus builds up. A speech therapist teaches the client how to produce sounds; 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, sore throat, dyspnea, dysphagia, or pain and burning in the throat. Palpate the neck for swelling. If treatment includes surgery and the client is expected to have no voice postoperatively, a preoperative evaluation of the speech therapist is indicated. Assess the clients ability to hear, see, read, and write. Determine the psychological readiness and evaluate the coping methods of the client and family. Potential complications that may develop include respiratory distress (hypoxia, airway obstruction, tracheal edema), hemorrhage, infection, and wound breakdown. 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, related to inability to ingest food secondary to swallowing difficulties Disturbed body image and low self-esteem secondary to major neck surgery, change in the structure and function of the larynx Self-care deficit related to pain, weakness, fatigue, 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. Answer clients question about the nature of the

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surgery, the loss of the natural voice, and the special training that can provide a means of communicating. Review equipment and treatments for postoperative care with client and family, teach coughing and deep-breathing exercises, and clarify the clients roles in the postoperative and rehabilitation periods. Reduce anxiety and depression Provide the client and the family to ask questions, verbalize feelings, and discuss perceptions about the treatment. Allow visits for the client during the pre- and postoperative period. Maintain a patent airway - Position the client in the semi-Fowlers or Fowlers position after recovery from anesthesia. Observe for restlessness, labored breathing, apprehension, and increased pulse rate to identify possible respiratory or circulatory problems. Encourage the client to turn, cough, and deep breath. Suction as necessary, to remove secretions. Encourage and assist the client with early ambulation to prevent atelectasis and pneumonia. Care for the laryngectomy tube; clean the stoma daily with saline solution. Apply noneoil-based antibiotic ointment around the stoma and suture line. If crusting appears around the stoma, remove the crusts with sterile tweezers and apply additional ointment. Observe, measure, and record drainage from wound drains and suction. Reassure the client that frequent coughing episodes will diminish in time as the tracheobronchial mucosa adapts to the altered physiology. Wipe clean and clear mucus from the tracheostomy opening. Provide adequate humidification to decrease cough, mucus production, and crusting around the stoma. Teach the client how to clean and change the laryngectomy tube and how to remove secretions.

Promote alternative communication methods o Establish and consistently use alternative modes of communication such as a call bell, a Magic Stale, notepad and pen, pictureword- phrase board, or hand signals. o Collaborate with the speech therapist and encourage the client and family to use alternative communication methods. Promote adequate nutrition o Thick liquids will be used first for feedings once the client is ready to start oral feedings. Instruct the client to avoid sweet foods, which increases salivation and suppresses appetite. o Introduce solid foods as tolerated. Instruct the client to rinse mouth with warm water or mouthwash and to brush the teeth frequently. o Observe the client for any difficulty swallowing, particularly when eating resumes, and report the occurrence to the physician. o Promote positive body image and self-esteem o Encourage the client to express any feelings brought about by the surgery. o Have a positive approach when caring for the client by promoting self-care activities, Monitor and manage potential complications o Monitor the client for signs and symptoms of respiratory distress and hypoxia. Rule out obstructions by suctioning and having the client cough and deep breath.

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o o o o o

Notify the surgeon for any active bleeding at the surgical site. If rupture to the carotid artery is the cause of bleeding, apply direct pressure over the artery, call for assistance, and provide emotional support to the client until the veins are ligated. Monitor for vital signs changes: increased pulse rate, decreased blood pressure, and rapid deep breathing; cold, clammy, and pale skin are signs of active bleeding. Observe for signs of postoperative infection and report any significant changes to the surgeon. Observe the stoma area for wound breakdown, hematoma, and bleeding, and report significant changes to the surgeon. If wound breakdown occurs, the client must be monitored carefully and identified as being high risk for carotid hemorrhage.

Teach clients self-care o Provide specific instructions to the client and family about the tracheostomy and its management. o Teach the client and family to perform suctioning and emergency measures and tracheostomy and stoma care. Explain the importance of humidification and instruct the family to set up a humidification system before the client returns home. o Teach the client and family about special precautions needed in the shower to prevent water from entering the stoma. o Remind the client that swimming is not recommended. o Instruct the client to avoid strenuous exercise and fatigue because when tired, he or she will have more difficulty speaking. o Encourage the client to wear a medical identification to alert medical personnel for special requirements for resuscitation should the need arise. Instruct and encourage the client to perform oral hygiene regularly to prevent halitosis and infection. Lung Cancer (Bronchogenic Carcinoma) Pathophysiology Lung cancers arise from a single transformed epithelial cell in the tracheobronchial airways. A carcinogen binds to a cells DNA and damages it. The damage results in cellular changes, abnormal cell growth, and eventually a malignant cell. As the damage DNA is passed on daughters cells, the DNA undergoes further changes and becomes unstable. With the accumulation of genetic changes, the pulmonary epithelium undergoes malignant transformation from normal epithelium to eventual invasive carcinoma. Squamous cell carcinoma is more centrally located and arises more commonly in the segmental and subsegmental bronchi in response to repetitive carcinogenic exposures. Adenocarcinoma is the most prevalent carcinoma of the lung for both men and women; it presents more peripherally as peripheral masses or nodules and often metastasizes. 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.

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

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Chest wall resection with removal of cancerous lung tissue for cancers that have invaded the chest wall Surgical resection may result in respiratory failure, and prolonged mechanical ventilation is a potential outcome. Radiation Therapy Useful in controlling neoplasms that cannot be surgically resected but are responsive to radiation; may also be used to reduce the size of a tumor, to make an inoperable tumor operable, or to relieve the pressure of the tumor on vital structures. It can control symptoms of spinal cord metastasis and superior vena cava compression, Prophylactic brain irradiation is used in certain clients to treat microscopic metastases to the brain. Radiation may help relieve cough, chest pain, dyspnea, hemoptysis, and bone and liver pain. May result in diminished cardiopulmonary functions and other complications such as pulmonary fibrosis, pericarditis, myelitis, corpulmonale, esophagitis, pneumonitis, and radiation lung fibrosis. Chemotherapy Used to alter tumor growth patterns, to treat clients with distant metastases or small cell cancer of the lung, and as an adjunct to surgery or radiation therapy. A variety of chemotherapeutic agents are used including, alkylating agents, platinum analogues, taxanes, vinca alkaloids, doxorubicin, gemcitabine, vinorelbine, irinotecan, and etoposide. Pulmonary toxicity is potential side effect of chemotherapy.

Palliative Therapy May include radiation therapy to shrink the tumor to provide pain relief, a variety of bronchoscopic interventions to open the narrowed bronchus or airway, 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. Teach client and family about strategies to manage symptoms of dyspnea, fatigue, nausea and vomiting, and anorexia. Administer chest physiotherapy and suctioning as necessary to maintain airway patency. Teach client to cough and deep breath. Administer bronchodilators as prescribed to promote bronchial dilation. Administer supplementary oxygen. Encourage the client to assume positions that promote lung expansion and to do breathing exercises for lung expansion and relaxation. Assess the clients level of fatigue and educate him/her on energy conservation techniques. Refer the client to a physical therapy, occupational therapy, or pulmonary rehabilitation program as preferred by the client. Support the client and family in making decisions reading the possible treatment options, methods to maintain the clients quality of life dur ing the course of the disease, and end-of-life treatment options.

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CANCERS of the BLOOD

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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); 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, genetic influence and viral pathogenesis may be involved Bone marrow damage from radiation exposure or from chemicals is a risk factor of the disease. Classification of the disease is according to the stem cell line involved (lymphoid, myeloid), and according to the time it takes for symptoms to evolve and phase of cell development that is halted: Acute abrupt onset, white blood cell development halted at the blast phase, rapid progression, death usually occurring within weeks to months if no aggressive treatment is initiated. Chronic symptoms evolve slowly. Acute Myeloid Leukemia (AML) AML results from a defect in the hematopoietic stem cell that differentiates into all myeloid cells: monocytes, granulocytes, erythrocytes, and platelets. All age groups are affected; the incidence arises with age, with a peak incidence at age 60 years. AML is the most common nonlymphocytic leukemia. Prognosis is highly variable and is not consistently based on client or disease variables. Clients with AML have a potentially curable disease. However, clients who are older or have a more undifferentiated form of the disease tend to have worse prognosis. 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, hyperplasia of the gums, and bone pain from expansion of marrow are caused by the proliferation of leukemic cells within organs

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

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antimicrobial therapy and transfusion as needed. Complications of treatment include tumor lysis syndrome, hyperkalemia and hypocalcemia, gastrointestinal problems, anorexia, nausea, vomiting, diarrhea, and severe mucositis. Chronic Myeloid Leukemia (CML) CML arises from a mutation in the myeloid stem cell. Normal myeloid cells continue to be produced, but there is a preference for immature (blast) forms. Thus, a wide spectrum of cell types exists within the blood, from blast forms through mature neutrophils. Because there is an uncontrolled proliferation of cells, the marrow expands, into the cavities of the long bones, and cells are also formed in the liver and spleen, resulting in enlargement of these organs that is sometimes painful. BCR gene of chromosome 22 is translocated onto ABL gene of chromosome 9, resulting in production of tyrosine kinase that causes white blood cells to divide rapidly. Clients diagnosed with CML in the chronic phase have an overall median life expectancy of 3 to 5 years. Problems with bleeding and infections are rare. However, once the disease transforms to the acute phase (blast crisis), the overall survival time rarely exceeds several months.

Clinical Manifestations Clinical picture of CML varies; many clients are symptomatic and leukocytosis is detected by a CBC performed for other reasons WBC count commonly exceeds 100,000/mm3 Clients may complain of an enlarged, tender spleen; liver may also be enlarged Malaise, anorexia, and weight loss are some insidious symptoms; lymphadenopathy is rare CML has three stages: chronic, transformation, and accelerated or blast crisis; clients have more symptoms and complications as the disease progresses Medical Management o Oral formulation of a tyrosine kinase inhibitor, imatinib mesylate (Gleevec) works by blocking signals within the leukemia cells that express the BCRABL protein, thus preventing a series of chemical reactions that cause the cell to grow and divide. Conventional therapy depends on the stage of the disease. Chronic phase expected outcome is correction of the chromosomal abnormality; agents that have been used successfully are interferon-alfa and cytosine, often in combination. Agents are administered daily in subcutaneous injections; therapy is not benign; many clients cannot tolerate profound fatigue, depression, anorexia, mucositis, and inability to concentrate Hydroxyurea or busulfan can be used to reduce the white blood cell count to a more normal level; 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, but it marks the process of evolution to the acute form of leukemia; client may complain of bone pain and may report fevers and weight loss; spleen may continue to enlarge even with chemotherapy; client may become more anemic and thrombocytopenic; transformation to the acute phase can be gradual or rapid In the more acute form of leukemia, treatment may resemble induction therapy for acute leukemia, using the same medications for AML and Acute Lymphocytic Leukemia (ALL)

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CML is a disease that can be potentially treated with bone marrow transplantation.

Acute Lymphocytic Leukemia (ALL) ALL results from uncontrolled proliferation of immature cells (lymphoblasts) derived from the lymphoid stem cell. Immature lymphocytes proliferate in the marrow and crowd the development of normal myeloid cells; normal hematopoiesis is inhibited, resulting in reduced numbers of leukocytes, erythrocytes, and platelets. Most common in young children, with boys affected more often than girls; the peak incidence is 4 years of age. After 15 years, ALL is relatively uncommon. Increasing age appears to be associated with diminished survival. Because of improvements in therapy, more than 80% of children survive at least 5 years. Even if relapse occurs, resumption of induction therapy can often achieve a second complete remission. Bone marrow transplant may be successful even after a second relapse. Clinical Manifestations Reduced number of leukocytes, erythrocytes, and platelets; leukocyte counts may be either low or high, but there is always a high proportion of immature cells. Pain from an enlarged liver or spleen, bone pain, 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; 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; 2/3 of all clients are older than 60 years of age at diagnosis.

Pathophysiology CLL typically derives from a malignant clone of B lymphocytes; most of the leukemia cells are fully mature. These mature cells appear to escape apoptosis, with result being an excessive accumulation of the cells in the marrow and circulation. The antigen CD52 is prevalent on the surface of many of these leukemic B cells. The disease is classified into three or four stages. In the early stage, an elevated lymphocyte count is seen and can exceed 100,000/mm3. These lymphocytes are small and can easily travel through the small capillaries within the circulation, and the pulmonary and cerebral complications of leukocytosis typically are not found in CLL.

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Lymphadenopathy occurs as the lymphocytes are trapped within the lymph nodes. The nodes can become very large and are sometimes painful. Hepatomegaly and splenomegaly may develop. Anemia and thrombocytopenia occur in later stages. Treatment is typically initiated in the later stages; early treatment does not appear to increase survival. Autoimmune complications (either hemolytic anemia or idiopathic thrombocytopenic purpura) can also occur at any stage. Clinical Manifestations Many clients are asymptomatic Increased lymphocyte count is always present RBC and platelet counts may be normal, or, in late 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, drenching sweat (especially at night), and unintentional weight loss; 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; viral infections (e.g., Herpes zoster) can become widely disseminated Medical Management o Early stages may require no treatment. o Chemotherapy with corticosteroids and chlorambucil is often used in later stages or when symptoms are severe. o Fludarabine (Fludara) is being used as a front-line therapy. o Monoclonal antibody rituximab (Rituxan) also has efficacy in CLL therapy; 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. If the client is hospitalized, the assessment should be performed daily, or more frequently as needed. Systematic assessment incorporating all body systems must be done thoroughly. Closely monitor the results of laboratory studies. Flow sheets and spreadsheets are particularly useful in tracking the WBC count, absolute neutrophil count, hematocrit, platelet, and creatinine levels, hepatic function tests, and electrolyte levels. Culture results need to be reported immediately so that appropriate antimicrobial therapy can begin or be modified. Assess for potential complications, such as infection, bleeding, renal dysfunction, tumor lysis syndrome, nutritional depletion, and mucositis. Nursing Diagnosis The following are major diagnosis for clients with acute leukemia: Risk for infection and bleeding

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risk for impaired skin integrity related to toxic effects of chemotherapy, alteration in nutrition, 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, less than body requirements, related to hypermetabolic state, anorexia, mucositis, pain, and nausea Acute pain and discomfort related to mucositis, WBC infiltration of systemic tissues, fever, 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, hypoproteinemia, need for multiple intravenous medications and blood products Diarrhea due to altered gastrointestinal flora, mucosal denudation Risk for deficient fluid volume related to potential for diarrhea, bleeding, infection, and increased metabolic rate Self-care deficit due to fatigue, malaise, and protective isolation Anxiety due to knowledge deficit and uncertain future Disturbed body image related to change in appearance, function, and roles Grieving related to anticipatory loss and altered role functioning Potential for spiritual distress Deficient knowledge about disease process, treatment, complication management, and self-care measures

Nursing Interventions Prevent infection and bleeding Thorough hand hygiene must be done by everyone before entering the clients room. Allow no one with cold or sore throat to care for the client or to enter room, or come in contact with the client at home. Provide low microbial diet. Eliminate fresh salads and unpeeled fresh fruits or vegetables. Avoid aspirin and aspirin-containing medications or other medications known to inhibit platelet function, if possible. Do not give intramuscular injections. Do not insert indwelling catheters. Take no rectal temperatures; do not give suppositories, enemas. Use stool softeners, oral laxatives to prevent constipation. Use smallest possible needles when performing venipuncture. Apply pressure to venipunctures sites for 5 minutes or until bleeding has stopped. Permit no flossing of teeth and no commercial mouthwashes. Use only softbristled toothbrush for mouth care. Avoid suctioning if at all possible; if unavoidable, use only gentle suctioning. Discourage vigorous coughing or blowing of the nose. Use only electric razor for shaving. Pad side rails as needed. Prevent falls by ambulating with client as necessary. For epistaxis, position client in high Fowlers position; apply ice pack to the back of the neck and direct pressure to the nose. Notify physician for prolonged bleeding. Administer platelets, frozen plasma, packed red blood cells as prescribed. Manage mucositis Instruct client to practice meticulous oral hygiene.

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

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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 Hodgkins disease and non Hodgkins lymphoma. Comparison of Lymphomas Hodgkins Non-Hodgkins 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. Hodgkins 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 Hodgkins 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 systems 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 Hodgkins 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 Hodgkins 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 Hodgkins 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 38C 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 Hodgkins 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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A transplant is performed after separating normal stem cells from malignant cells in the harvested specimen. Potential long-term complications of therapy for Hodgkins disease include immune dysfunction, herpes infections, pneumococcal sepsis, acute myeloid leukemia, myelodysplastic syndrome, nonHodgkins lymphoma, solid tumors, thyroid cancer, thymic hyperplasia, hypothyroidism, pericarditis (acute or chronic), avascular necrosis, growth retardation, infertility, impotence, and/or dental caries.

Nursing Care for Client with Hodgkins Disease Assessment Look for history of infection mononucleosis or symptoms resembling this disorder. Assess for location, size, and characteristics of enlarged lymph nodes, such as whether they are fixed or mobile. 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. Ask about fever, chills, or night sweats. Check the clients current weight and deviation from usual weight, enlargement of the liver and spleen, and level of energy and appetite. Inspect the appearance of the skin, ask about any itching, and discuss any additional symptoms caused by lymph node enlargement (e.g., coughing, breathlessness, nausea, vomiting). Diagnosis, Planning, and Interventions Client and family teaching include the following: Keep appointments for medical follow-up. Take prescribed medications as directed, Report side effects to the physician. Avoid crowds or people who have infectious disease. Wash hands frequently. Avoid oral contact with germ-laden objects. Contact physician if breathing becomes labored. Eat small amounts frequently or include a liquid nutritional supplement between meals and at bedtime. 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). Note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing. Keep the neck in midline and place the client in high Fowlers position if respiratory distress develops. Administer oxygen per physicians orders if blood saturation is consistently less than 90%. Place an endotracheal tube, laryngoscope, and bag-valve mask at the bedside for (emergency) intubation. Risk for Infection related to immunosuppression secondary to impaired lymphocytes and drug or radiation therapy

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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. Institute infectious disease precautions if normal white blood cells are suppressed to dangerous limits.

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. Provide rest periods between activities. Perform priority activities first. Assist client with whatever activities of daily living are independently unmanageable.

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

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Medical Management Non-Hodgkins lymphoma is treated with radiation, chemotherapy, or both. The physician may adopt a watch and wait approach for clients with indolent forms of non- Hodgkins lymphoma, choosing to treat the client once the disease accelerates. Immunotherapy with monoclonal antibodies (MABs) and bone marrow transplants is being used to cure lymphomas or extend the lives of clients with these diseases. Research continues on the use of biologic therapy (immunotherapy) with MABs to eliminate malignant cells and induce remission. With MABs, human cancer cells are injected into laboratory animals such as mice. The mice make lymphocytes that produce antibodies against cancer cells. The mouse lymphocytes are harvested and fused with a laboratory-grown cell, creating clones that, when administered to a client with cancer, continue to produce tumorfighting antibodies. The MABs are used alone or are bound to a chemotherapeutic or radioactive agent. The advantage of combining MABs with drugs or radiation is that they target and destroy cancer cells while sparing normal cells. Rituximab (Rituxan) is an MAB drug approved for treating nonHodgkins lymphoma. Nursing Management Nursing care is similar for all clients with lymphoma, whether they have non-Hodgkins lymphoma or Hodgkins disease. 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.

Cancers of the Gastrointestinal System

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Cancer of the Oral Cavity Cancers of the oral cavity can occur in any part of the mouth or throat; are curable if discovered early. 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. Predisposing factors for other oral cancers are exposure to tobacco (including smokeless tobacco), ingestion of alcohol, dietary deficiency, and ingestion of smoked meats.

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Pathophysiology Malignancies of the oral cavity are usually squamous cell cancers. Any area of the oropharynx can be a site for malignant growth, but the lips, the lateral aspects of the tongue, and the floor of the mouth are most commonly affected. Clinical Manifestations A number of oral cancers produce few or no symptoms in the early stages. The most frequent symptom seen in late stages is a painless sore or mass that will not heal. A typical lesion in oral cancer is painless indurated (hardened) ulcer with raised edges. Tissue from any ulcer of the oral cavity that does not heal in two weeks should be examined through biopsy. As the disease progresses, the client may complain of tenderness; difficulty in chewing, swallowing, or speaking; coughing of blood-tinged sputum; or enlarged cervical lymph nodes. 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. Biopsies are performed on suspicious lesions (those that have not healed in two weeks). High-risk areas include the buccal mucosa and gingival for people who use snuffs or smoke cigars or pipes. For those who smoke cigarettes and drink alcohol, high-risk areas include the floor of the mouth, the ventrolateral tongue, and the soft palate complex (soft palate, anterior and posterior tonsillar area, uvula, and the area behind the molar and the tongue junction).

Medical Management Management varies with the nature of the lesion, the preference of the physician, and client choice. Surgical resection, radiation therapy, chemotherapy, or a combination of these therapies may be effective. Small lesions in cancer of the lip are usually excised liberally; larger lesions involving more than one-third may be more appropriately treated by radiation therapy because of superior cosmetic results. The choice depends on the extent of the lesion and what is necessary to cure the client while preserving the best appearance. Tumors larger than 4 cm often recur. Cancer of the tongue may be treated with radiation therapy and chemotherapy to preserve organ function and maintain quality of life. A combination of radioactive interstitial implants and external beam radiation may be used. If the cancer has spread to the lymph nodes, the surgeon may perform a neck dissection. Surgical treatments leave a less functional tongue; surgical procedures include hemiglossectomy (surgical removal of half of the tongue) and total glossectomy (removal of the tongue).

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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. 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).

Nursing Management Assess the clients nutritional status preoperatively; a dietary consultation may be necessary. Administer, if required, enteral or parenteral feedings before and after surgery to maintain adequate nutrition. If a radial graft is to be performed, 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. 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, slightly flexed position. The palm will be pale. Pressure on the ulnar artery is released. 3) If the ulnar artery is patent, the palm will flush within about three to five seconds. Assess for a patent airway postoperatively. Suction as necessary to help the client manage oral secretions. If grafting was included in the surgery, suctioning must be performed with care to prevent damage to the graft. Assess the graft postoperatively for viability. 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. Cancer of the esophagus has been associated with ingestion of alcohol and with the use of tobacco. Also, there seems to be an association between gastroesophageal reflux disease (GERD) and adenocarcinoma of the esophagus. People with Barretts esophagus, which is caused by chronic irritation of muco us membranes due to reflux of gastric and duodenal contents, have a higher incidence of esophageal cancer. Pathophysiology Esophageal cancer is usually of squamous cell epidermoid type; however, the incidence of adenocarcinoma is increasing. Tumor cells may spread beneath the esophageal mucosa or directly into, through, and beyond the muscle layers into the lymphatics. In the latter stages, obstruction of the esophagus is noted, with possible perforation into the mediastinum and erosion into the great vessels. Clinical Manifestations Clients may have an advanced ulcerated lesion of the esophagus before symptoms are manifested.

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Symptoms include dysphagia, initially with solid foods and eventually with liquids; a sensation of a mass in the throat; painful swallowing; substernal pain or fullness; and, later regurgitation of undigested food with foul breath and hiccups. The client first becomes aware of intermittent and increasing difficulty in swallowing. As the tumor progresses and the obstruction become more complete, even liquids cannot pass into the stomach. Regurgitation of food and saliva occurs, hemorrhage may take place, and progressive loss of weight and strength occurs from starvation. Later symptoms include substernal pain, persistent hiccup, respiratory difficulty, and foul breath. The delay between the onset of early symptoms and the time when the client seeks medical advice is often 12 to 18 months. Anyone with swallowing difficulties should be encouraged to consult a physician immediately.

Assessment and Diagnostic Findings Diagnosis is confirmed most often by esophagogastroduodenoscopy (EGD) with biopsy and brushings. Bronchoscopy is usually performed, especially in tumors of the middle and the upper third of the esophagus, to determine whether the trachea has been affected and to help determine whether the lesion can be removed. Endoscopic ultrasound or mediastinoscopy is used to determine whether the cancer has spread to the nodes and other mediastinal structures. Cancer of the lower end of the esophagus may be caused by adenocarcinoma of the stomach that extends upward into the esophagus. Medical Management Treatment goals may be directed toward cure if esophageal cancer is found at an early stage; however, if it is often found in late stages making relief of symptoms is the only reasonable goal for therapy. Treatment may include surgery, radiation, chemotherapy, or a combination of the modalities, depending on the extent of the disease. 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. The surgical approach may be through the thorax or the abdomen, depending on the location of the tumor. When tumors occurs in the cervical or upper thoracic area, esophageal continuity may be maintained by free jejuna graft transfer, in which the tumor is removed and the area is replace with a portion of the jejunum. A segment of the colon may be used, or the stomach can be elevated into the chest and the proximal section of the esophagus anastomosed to the stomach. Tumors of the lower thoracic esophagus are more amenable to surgery than tumors located in the esophagus, and gastrointestinal tract integrity is maintained by anastomosing the lower esophagus to the stomach. Surgical resection of the esophagus has a relatively high mortality rate because of infection, pulmonary complications, or leakage through the anastomosis. Postoperatively, the client will have a nasogastric tube in place that should not be manipulated. The client is given nothing by mouth until x-ray studies confirm that the anastomosis is secure and not leaking. Preoperative radiation therapy or chemotherapy, or both, may be used; however, treatment is based on type of cell, tumor spread, and client condition.

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Palliative treatment may be necessary to keep the esophagus open, to assist with nutrition, and to control saliva. Palliation may be accomplished with dilation of the esophagus, laser therapy, placement of an endoprosthesis (stent), radiation, or chemotherapy. Treatment is individually determined since the ideal method of treating esophageal cancer has not yet been found.

Nursing Management Intervention is directed toward improving the clients nutritional and physical condition in preparation for surgery, radiation therapy, or chemotherapy. If adequate food can be taken by mouth, promote weight gain based on a high-calorie and high-protein diet in liquid or in soft form. Initiate parenteral or enteral nutrition if the client is unable to eat by mouth. Monitor nutritional status throughout treatment. Inform the client about the nature of the postoperative equipment that will be used, including the required for closed chest drainage, nasogastric suction, parenteral fluid therapy, and gastric intubation. Provide immediate postoperative care that is similar to that provided to clients undergoing thoracic surgery. Placed the client in a low Fowlers position after recovering from the effects of anesthesia. Later, position the client in a Fowlers position to assist in preventing reflux of gastric secretions.Carefully observe the client for regurgitation and dyspnea (a common postoperative complication is aspiration pneumonia). 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. Assess the graft for color. Presence of a pulse may be assessed using a doppler sonography. If an endoprosthesis has been placed or an anastomosis has been performed, mark the nasogastric tube for position immediately after surgery, and notify the physician if displacement occurs. Do not attempt to reinsert a displaced nasogastric tube because damage to the anastomosis may occur. Remove the nasogastric tube five to seven days after surgery. Perform a barium swallow to asses for any anastomotic leak before the client is allowed to eat. Encourage the client to swallow small sips of water, and, later, small amounts of pureed food once feeding begins. 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. Allow the client to remain upright for at least two hours after each meal to allow the food to move through the gastrointestinal tract. Encourage the client with poor appetite to eat by involving the family to prepare home-cooked favourite foods. Administer antacids to relieve gastric distress. Provide liquid supplements, which are more easily tolerated by clients undergoing radiation and experiencing esophagitis. Administer oral suction if the client is unable to handle secretions, or wick-type gauze may be placed at the corner of the mouth to direct secretions to a dressing or emesis basin. During discharge planning, instruct the family about promotion of adequate nutrition, what observations to make, measures to take if complications occur, how

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

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In many clients, effective palliation to prevent discomfort caused by obstruction or dysphagia may be obtained by resection of the tumor. A diagnostic laparoscopy may be the initial surgical approach to evaluate the gastric tumor, obtain tissue for pathologic diagnosis, and detect metastasis. The client with a tumor that is deemed resectable undergoes an open surgical procedure to resect the tumor and appropriate lymph nodes. The client with an unresectable tumor and an advanced disease undergoes chemotherapy.

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

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

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Project an empathetic attitude and spend time with the client.

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

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The symptom most commonly associated with leftside lesions are those associated with obstruction (abdominal pain and cramping, narrowing stools, constipation, and distention), as well as bright red blood in the stool. Symptoms associated with rectal lesions are tenesmus (ineffective, painful straining at stool), rectal pain, the feeling of incomplete evacuation after a bowel movement, alternating constipation and diarrhea, and bloody stool.

Assessment and Diagnostic Findings Along with an abdominal and rectal examination, the most important diagnostic procedures for cancer of the colon are fecal occult blood testing, barium enema, proctosigmoidoscopy, and colonoscopy. 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, studies show that CEA levels are reliable in predicting prognosis. With complete excision of the tumor, the elevated levels of CEA should return to normal within 48 hours. Elevation of CEA at a later date suggests recurrence. Complications Tumor growth may cause partial to complete bowel obstruction. Extension of the tumor and ulceration into the surrounding blood vessels results in hemorrhage. Perforation, abscess formation, peritonitis, sepsis, and shock may occur. Gerontologic Considerations The incidence of carcinoma of the colon and rectum increases with age. These cancers are considered common malignancies in advanced age. Colon cancer in the elderly has been closely associated with dietary carcinogens. Lack of fiber is a major causative factor because the passage of feces through the intestinal tract is prolonged, which extends exposure to possible carcinogens. Excess fat is believed to alter bacterial flora and convert steroids into compounds that have carcinogenic properties. Medical Management The client with symptoms of intestinal obstruction is treated with intravenous fluids and nasogastric suction. If there has been significant bleeding, blood component therapy may be required. Treatment of colorectal cancer depends on the stage of the disease and consists of surgery to remove the tumor, supportive therapy, and adjuvant therapy. 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, no nodal involvement Class C1: Positive nodes, tumor is limited to bowel wall Class C2: Positive nodes, tumor extends through entire bowel wall Class D: Advanced and metastasis to liver, lung, or bone Adjuvant Therapy

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The standard adjuvant therapy administered to clients with Dukes Class C colon cancer is the 5- fluourouracil plus levamisole regimen. Clients with Dukes class B or C rectal cancer are given 5-fluourouracil and high disease of pelvic irradiation. Mitomycin is also used. Radiation therapy is used before, during, and after surgery to shrink the tumor, to achieve better results from surgery, and to reduce the risk of recurrence. For inoperative or unresectable tumors, irradiation is used to provide significant relief from symptoms. Intracavity and implantable devices are used to deliver radiation to the site. The response to adjuvant therapy varies.

Surgical Management Surgery is the primary treatment for most colon and rectal cancers. It may be curative or palliative. The type of surgery recommended depends on the location and size of the tumor. Cancers limited to one side can be removed through colonoscope. Laparoscopic colotomy with polypectomy minimizes the extent of surgery needed in some cases. A laparoscope is used as a guide in making an incision into the colon; the tumor mass is then excised. Use of the neodymium/yttrium-aluminum-garnet (Nd:YAG) laser has proved effective with some lesions as well. Bowel resection is indicated for most class A lesions and all class B and C lesions. Surgery is sometimes recommended for class D colon cancer, but the goal of surgery in this instance is palliative; if the tumor has spread and involves surrounding vital structures, it is considered nonresectable. Surgical procedures include the following: Segmental resection with anastomosis (i.e., removal of the tumor and portions of the bowel on either side of the growth, as well as the blood vessels and lymphatic nodes) Abdominoperitoneal resection with permanent sigmoid colostomy (i.e., 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, 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. 1) A temporary loop ileostomy is constructed to divert intestinal flow, and the newly constructed J pouch (made from 6 to 10 cm of the colon) is reattached to the anal stump. 2) About three months after the initial stage, the ileostomy is reversed, and intestinal continuity is restored. The anal sphincter and therefore continence are preserved. Nursing Management Assessment Complete a health history to obtain information about fatigue, abdominal or rectal pain, past and present elimination patterns, and characteristics of stool. Obtain additional information about history of inflammatory bowel disease or colorectal polyps, a family history of colorectal disease, and current medication therapy. Identify dietary habits, including fat and fiber intake, as well as amounts of alcohol consumed. Describe and document a history of weight loss.

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Assessment includes auscultating the abdomen for bowel sounds and palpating the abdomen for areas of tenderness, distention, and solid mass. Inspect stool specimens for character and presence of blood.

Nursing Diagnosis Imbalanced nutrition, less than body requirements, 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, the surgical procedure, and self-care after discharge Impaired skin integrity related to the surgical incisions (abdominal and perianal), the formation of a stoma, 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, abscess, and sepsis Planning and Interventions Prepare the client for surgery Prepare the client physically for surgery, provideinformation about postoperative care, including stoma care if a colostomy is to be created, and support the client and family emotionally. Build the clients stamina in the days preceding surgery and cleanse and sterilize the bowel the day before the surgery. Recommend a diet high in calories, protein, and carbohydrates and low in residue for several days before surgery, if clients condition permits, to provide adequate nutrition and minimize cramping by decreasing excessive peristalsis. Prescribe a full-liquid diet 24 to 48 hours before surgery to decrease bulk. Parenteral nutrition may be required to replace depleted nutrients, vitamins, and minerals if the client is hospitalized in the days preceding surgery. Administer antibiotics (e.g., sulfonamides, neomycin, and cephalexin) the day before the surgery to reduce intestinal bacteria. Cleanse the bowel using laxatives, enemas, or colonic irrigation the evening before and the morning of surgery. Measure and record intake and output, including vomitus, for the client who is very ill and hospitalized to provide an accurate record of fluid balance. Restrict the clients oral food and fluid intake to prevent vomiting. Administer antiemetics as prescribed. Allow the client to have full or clear liquids as tolerated or to have nothing by mouth. Insert a nasogastric tube to drain accumulated fluids and prevent abdominal distention, as necessary. Monitor the abdomen for increasing distention, loss of bowel sounds, and pain or rigidity, which may indicate obstruction or perforation. Monitor intravenous fluids and electrolytes. Monitor serum electrolyte levels to detect hypokalemia and hyponatremia that occur with GI fluid loss. Observe for signs of hypovolemia, assess hydration status, and report decreased skin turgor, dry mucous membranes, and concentrated urine.

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Assess the clients knowledge about the diagnosis, prognosis, surgical procedure, and expected level of functioning after surgery. Include in the teaching plan information about the physical preparation for surgery, the expected appearance and care of the wound, the technique of ostomy care (if applicable), dietary restrictions, pain control, and medication management.

Provide emotional support Assess the clients anxiety level and coping mechanism, and suggest methods for reducing anxiety. Provide privacy and teach relaxation techniques. Set aside time to listen to the client who wishes to talk, cry, or ask questions. 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. Project a relaxed, professional, and empathetic attitude to promote client comfort. Present facts about the surgical procedure and the creation and management of ostomy to reduce the fear related to changes in body image. Use diagrams, photographs, and appliance to explain and clarify. Allow the client and family to ask questions or voice out concerns. Consultation with an enterostomal therapist during the preoperative period or with a person who is successfully managing an ostomy can be helpful. Provide postoperative care Postoperative care for clients undergoing colon resection or colostomy is similar to nursing care for any abdominal surgery client. Include pain management during immediate postoperative period. Monitor the client for complications, such as leakage from the site of the anastomosis, prolapse of the stoma, perforation, stoma retraction, fecal impaction, skin irritation, and pulmonary complications associated with abdominal surgery. Assess the abdomen for returning peristalsis and assess the initial stool characteristics. 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. Maintain optimal nutrition Teach all clients undergoing surgery for colorectal cancer about the health benefits to be derived from consuming a healthy diet. Complete a nutritional assessment for clients with a colostomy. 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.

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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. 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.

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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 clients use. One-piece appliance consists of a pouch with an integral adhesive section that adheres to the clients 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.

o o o

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.

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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 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 clients adaptation to the changes brought about by the surgery. 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 clients needs and attempt to identity specific concerns. Seek assistance from an enterostomal therapy nurse, sex counselor or therapist, or advanced practice nurse of the clients concern seem complex.

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Cancers of the Special Senses

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

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These conditions have life-threatening consequences, and surgical excisions may result in facial disfigurement. Emotional support and reassurance are important aspects of nursing management.

Malignant Tumors of the Conjunctiva Conjunctival carcinoma most often grows in the exposed areas of the conjunctiva. The typical lesions are usually gelatinous and whitish due to keratin formation. They grow gradually, and deep invasion and metastasis are rare. Malignant melanoma is rare but may arise from a preexisting nevus or acquired melanosis during middle age. Squamous cell carcinoma is also rare but invasive, The management is surgical incision. Some benign tumors and most malignant tumors recur. To avoid recurrences, clients usually undergo radiation therapy and cryotherapy after the excision of malignant tumors. Cosmetic disfigurement may result from extensive excision when deep invasion by the malignant tumor is involved. Malignant Tumors of the Globe (Ocular Melanoma) A malignant tumor of the retina, retinoblastoma, occurs in childhood, is hereditary, and requires complete enucleation if there is to be a chance for successful outcome. Ocular melanoma is another cancer that primarily occurs in adults. This rare, malignant choroidal tumor is often discovered on a retinal examination. In its early stages, it could be mistaken for a nevus. Many clients do not have symptoms in the early stages though some clients may complain of blurred vision or a change in eye color. A number of such tumors have been found in people with blindness that has painful eyes. In addition to a complete physical examination to discover any evidence of metastasis, retinal fundus photography, fluorescein angiography, and ultrasonography are performed. The diagnosis is confirmed at biopsy after enucleation.

Tumors are classified according to size (i.e., small, medium, large). Very small tumors are generally monitored, whereas medium and large tumors require treatment. Treatment consists of radiation therapy, enucleation, or both. Radiation therapy is achieved by external beam performed in repeated doses over several days or through the surgical implantation of a radioactive plaque, which is removed after several days. Acoustic Neuroma An acoustic neuroma is a slow-growing benign tumor of cranial nerve VIII, usually arising from the Schwann cells of the vestibular portion of the nerve. Most acoustic tumors arise within the internal auditory canal and extend into the cerebellopontine angle to press on the brain stem. Acoustic neuroma occurs with equal frequency in men and women at any age, although most occur during middle age. Most acoustic neuromas are unilateral, except in von Recklinghausens disease, 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. Asymmetry in audiovestibular test results should be identified so that further workup can be performed to rule out an acoustic neuroma. MRI with a paramagnetic contrast agent is the imaging study of choice. CT scan with contrast dye may also be performed for claustrophobic clients. Management Surgical removal of acoustic tumors is the treatment of choice because these tumors do not respond well to irradiation or chemotherapy.

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

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Cancers of the Nervous System

Primary Brain Tumors

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A brain tumor is a localized intracranial lesion that occupies space within the skull. Tumors usually grow as a spherical mass, but they can grow diffusely and infiltrate tissue. The effects of neoplasms occur from the compression and infiltration of tissue. Different physiologic changes result, causing any or all of the following pathophysiologic events: Increased intracranial pressure (ICP) and cerebral edema; Seizure activity and focal neurologic signs; Hydrocephalus; Altered pituitary function. Primary brain tumors originate from cells and structures within the brain. Secondary, or metastatic, brain tumors develop from structures outside the brain and occur in 20% to 40% of all clients with cancer. Brain tumors rarely metastasize outside the CNS, but metastatic lesions to the brain occur commonly from the lung, breast, lower gastrointestinal tract, pancreas, kidney, and skin (melanomas). The cause of primary brain tumors is unknown. The only known risk factor is exposure to ionizing radiation. Pathophysiology Gliomas glial tumors, the most common type of neoplasm, are divided into categories (i.e., astrocytomas, glioblastoma multiforme, oligodendrocytoma, medulloblastoma): Astrocytomas - The most common type of glioma and are graded from I to IV, indicating the degree of malignancy. The grade is based on cellular density, cell mitosis, and appearance. 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. Oligodendroglial Tumors Represents 20% of gliomas; the histologic distinction between astrocytomas and oligodendrogliomas is difficult to make but important, as recent research shows that these tumors are more sensitive to chemotherapy than astrocytomas. These tumors are categorized as low-grade and high-grade (anaplastic). Meningiomas Represents 20% of all primary brain tumors; are common benign encapsulated tumors of arachnoid cells on the meninges. They are slow growing and occur most often in middle-aged adults (more often in women). Meningiomas most often occur in areas proximal to the venous sinuses. Manifestations depend on the area involved and are the result of compression rather than invasion of brain tissue. Standard treatment is surgery with complete removal or partial dissection. 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). Pressure from a pituitary adenoma may be exerted on the optic nerves, optic chiasm, or optic tracts or on the hypothalamus or the third ventricle when the tumor invades the cavernous sinuses or explains into the sphenoid bone. These pressure effects produce headache, visual dysfunction, hypothalamic disorders, increased ICP, and enlargement and erosion of the sella turcica. Functioning pituitary tumors can produce one or more hormones normally produced by the anterior pituitary. These hormones may cause prolactinsecreting pituitary adenomas (prolactinomas), growth hormone-secreting pituitary adenomas that produce acromegaly in adults, and adrenocorticotropic hormone (ACTH)-producing pituitary adenomas that result in Cushings disease. Adenomas that secrete thyroid-stimulating hormone occur infrequently, whereas adenomas that produce both growth hormone and prolactin are relatively common. Angiomas

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Brain angiomas (masses composed of largely abnormal blood vessels) are found either in or on the surface of the brain. They occur in the cerebellum in 83% of cases. Some persist throughout life without causing symptoms; others cause symptoms of a brain tumor. Occasionally, the diagnosis is suggested by the presence of another angioma somewhere in the head or by a bruit audible over the skull. Because the walls of the blood vessels in angiomas are thin, these clients are at risk for a cerebral vascular accident (stroke). Cerebral hemorrhage in people younger than 40 years of age should suggest the possibility of an angioma. Clinical Manifestations Increasing ICP - Symptoms of ICP result from a gradual compression of the brain by the enlarging tumor. The effect is a disruption of the equilibrium that exists between the brain, the cerebrospinal fluid (CSF), and the cerebral blood, all located within the skull. As the tumor grows, compensatory adjustments may occur through compression of intracranial veins, reduction of CSF volume, a modest decrease of cerebral blood flow, and reduction of intracellular and extracellular brain tissue mass. When these compensatory mechanisms fail, the client develops signs and symptoms of increased ICP. The three most common signs of increased ICP are headache, nausea, and vomiting, sixth-nerve palsy. Personality changes and a variety of focal deficits, including motor, sensory, and cranial nerve dysfunction, are also common. Headache, although not always present, is most common in the early morning and is made worse by coughing, straining, or sudden movement. It is thought to be caused by the tumor invading, compressing, or distorting painsensitive structures or by edema that accompanies the tumor. Headaches are usually described as deep or expanding or as dull but unrelenting. Frontal tumors usually produce a bilateral frontal headache; pituitary gland tumors produce pain radiating between the two temples (bitemporal); in cerebral tumors, the headache may be located in the suboccipital region at the back of the head. Vomiting, seldom related to food intake, is usually due to irritation of the vagal centers in the medulla. If the vomiting is of the forceful type, it is described as projectile vomiting. Papilledema is present in 70% to 75% of clients and is associated with visual disturbances such as decreased visual acuity, diplopia, and visual field deficits.

Localized Symptoms The most common focal or localized symptoms are hemiparesis, seizures, and mental status change. When specific regions of the brain are affected, additional local signs and symptoms occur, such as sensory and motor abnormalities, visual alterations, alterations in cognition, and language disturbances (aphasia). The progression of the signs and symptoms is important because it indicates tumor growth and expansion. Some tumors are not easily localized because they lied in so-called silent areas of the brain, 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). An occipital lobe tumor produces visual manifestations: contralateral homonymous hemianopsia and visual hallucinations. A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, marked muscle incoordination, and nystagmus, usually in the horizontal direction. A frontal lobe tumor frequently produces personality disorders, changes in emotional state and behavior, and an uninterested mental attitude. The client often becomes extremely untidy and careless and may use obscene language.

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

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

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

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

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. They include intramedullary lesions (within the spinal cord), extramedullary-intradural lesions (within or under the spinal dura), and extramedullary-extradural lesions (outside the dural membrane).

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

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

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Bone Tumors

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

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

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Surgical staging of musculoskeletal tumors is based on tumor grade and site, as well as on metastasis.

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

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Nursing Process for the Client with a Bone Tumor Assessment Ask the client about the onset and course of symptoms. Note the clients understanding of the disease process, how the client and the family have been coping, and how the client has managed the pain. On physical examination, gently palpate the mass and note its size and associated soft tissue swelling, pain, and tenderness. Assess the neurovascular status and range of motion of the extremity to provide a baseline data for future comparisons. Evaluate the clients mobility and ability to perform activities of the daily living. 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, perception of disease process, 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. Explain the diagnostic tests, treatments, and expected results to help the client to deal with the procedures and changes. Reinforce and clarify information provided by the physician by being present during discussions. Relieve pain Assess pain accurately. Use pharmacologic and nonpharmacologic pain management techniques to relieve pain and increase the clients comfort level. Work with the client in designing the most effective pain management regimen to increase his/her control over the pain. Prepare the client and give support during painful procedures. Used prescribed IV or epidural analgesics during the early postoperative period. Oral or transdermal opioid or nonopioid analgesics are usually used later to adequately relieve pain. External radiation or systemic radioisotopes may be used to control pain. Prevent pathologic fracture Support and handle affected extremities gently during nursing care. Use external supports for additional protection. 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. Promote coping skills Encourage the client and the family to verbalize their fears, concerns, and feelings.

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Support the client and family as they deal with the impact of the malignant bone tumor. Expect feelings of shock, despair, and grief. Refer to a psychiatric nurse liaison, psychologist, counselor, or spiritual advisor for specific psychological help and emotional support. Promote self-esteem Support the family in working through the adjustments that must be made. Assist the client in dealing with changes in body image due to surgery and possible amputation. 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. Involve the client and the family all throughout the treatment to encourage confidence, restoration of self-concept, and a sense of being in control of ones life. Monitor and manage potential complications Delayed wound healing Minimize pressure on the wound site to promote circulation to the tissues. Use an aseptic, nontraumatic wound dressing to promote healing. 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. Special therapeutic beds may be needed to prevent skin breakdown and to promote wound healing after extensive surgical reconstruction and skin grafting. Inadequate nutrition. Administer antiemetics and encourage use of relaxation techniques to reduce gastrointestinal reaction. Control stomatitis with anesthetic or antifungal mouthwash. Provide adequate hydration. Nutritional supplements or total parenteral nutrition may be prescribed to achieve adequate nutrition. Osteomyelitis and wound infections Use prophylactic antibiotics and strict aseptic dressing techniques to diminish the occurrence of osteomyelitis and wound infections. Prevent the occurrence of other infections during healing so that hematogenous spread does not result in osteomyelitis. 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. Hypercalcemia Symptoms of hypercalcemia must be recognized and treatment should be initiated promptly.

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

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

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

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Genetics. Increasing evidence indicates that genetic alterations are associated with the development of 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. Genetic alterations may be somatic (acquired) or germline (inherited). A mutation in the BRCA-1 gene has been linked to the development of breast and ovarian cancer, whereas a mutation in the BRCA-2 gene identifies risk for breast cancer, but less so for ovarian cancer. Abnormalities in either of the two genes can be identified by blood tests; but, women should be counseled about the risks and benefits before actually undergoing genetic testing.

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, but most are found in the upper outer quadrant, where most breast tissue is located. Lesions are nontender rather than painful, fixed rather than mobile, and hard with irregular borders rather than encapsulated and smooth (generally). Complaints of diffuse breast pain and tenderness with menstruation are usually associated with benign breast disease. Marked pain at presentation may be associated with breast cancer in the later stages. Women seeking treatment at an earlier stage of disease have no symptoms and no palpable lump, but are detected on mammography. Many women with advanced disease seek initial treatment only after ignoring symptoms. They may seek attention for: Dimpling or a peau d orange (orange-peel) appearance of the skin, 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, excisional biopsy, incisional biopsy, needle localization, core biopsy, and stereotactic biopsy are techniques used to determine the histology and tissue diagnosis of breast cancer. Chest x-rays, bone scans, and liver function tests are diagnostic tests and procedures performed in the staging of the disease. Clinical staging involves the physicians estimate of the size of the breast tumor and the extent of axillary node involvement by physical examination and mammography. The breast cancer is staged according to the TNM system after the diagnostic workup and definitive surgical treatment. Breast Cancer Staging Stage I: Tumors are less than 2 cm in diameter and are confined to breast.

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Stage II: Tumors are less than 5 cm, or tumors are smaller with mobile axillary lymph node involvement. Stage IIIa: Tumors are greater than 5 cm, or tumors are accompanied by enlarged axillary lymph nodes fixed to one another or to adjacent tissue. Stage IIIb: More advanced lesions with satellite nodules, fixation to the skin or chest wall, ulceration, edema, or with supraclavicular or intraclavicular nodal involvement. Stage IV: All tumors with distant metastasis.

Medical Management Surgical Management Modified Radical Mastectomy (MRM) Removal of the entire breast tissue, along with axillary lymph nodes; pectoralis major and pectoralis minor muscles remain intact. An objective of surgical treatment is to maintain or restore normal function to the hand, arm, and shoulder girdle on the affected side. If reconstructive surgery is planned, a consultation is made with a plastic surgeon before the mastectomy is performed. Breast-Conserving Surgery Consists of lumpectomy, wide excision, partial or segmental mastectomy, 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, microscopic disease. The goal of breast conservation is to remove the tumor completely with clear margins while achieving an acceptable cosmetic result. This treatment includes both surgery and radiation. Survival rates after breast-conserving surgery are equivalent to those after modified radical mastectomy. The risk for local recurrence, however, is greater than 1% per year after surgery. If the client experiences a local recurrence, standard treatment is a completion or salvage mastectomy, in which the rest of the breast tissue is removed. 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. A radiocolloid and/or blue dye is injected into the tumor site; the client then undergoes the surgical procedure. The surgeon uses a hand-held probe to locate the sentinel node (the primary drainage from the breast) and excises it, and it is examined by the pathologist. If the sentinel node is negative for metastatic breast cancer, a standard axillary dissection is not needed, thus sparing the client the sequelae of the

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procedure. If the sentinel node is positive, the client undergoes the standard axillary dissection. Nursing interventions for this procedure focus on informing the client about the expectations and possible complications.

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. treatment is necessary to obtain results equal to those of removal of the breast. If radiation therapy is contraindicated, mastectomy is the clients option. Radiation treatment typically begins about 6 weeks after the surgery to allow the incision to heal. If systemic chemotherapy is indicated, radiation therapy usually begins after completion of the chemotherapy. 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. Postoperative radiation after mastectomy is not common today but is still used in certain cases: when tumors have spread regionally (chest wall involvement, four or more positive nodes, or tumorslarger than 5 cm). Occasionally, clients who have had a mastectomy require radiation treatment to the chest wall, generally after completion of systemic chemotherapy. Another approach is the use of intraoperative radiation therapy (IORT), in which a single dose of radiation is delivered to the lumpectomy site immediately after the surgeon has performed the lumpectomy. Chemotherapy Chemotherapy regimens for breast cancer combine several agents to increase tumor cell destruction and to minimize medication resistance. Chemotherapeutic agents most often used in combination are cyclophosphamide (Cytoxan) (C), methotrexate (M), fluorouracil (F), and doxorubicin (D), with paclitaxel (Taxol) (T) as an addition. Docetaxel (T), a newer taxane, is being used more frequently but research on its difference is still limited. The combination regimen CMF or CAF is a common treatment protocol. AC, ACT (AC given first followed by T), and ATC, with all three agents given together, are other regimens that may be used. 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. Hormonal therapy may include surgery to remove endocrine glands (e.g., ovaries, pituitary, or adrenal glands) with the goal of suppressing hormone secretion. Oopherectomy is one treatment option for premenopausal women with estrogen-dependent tumors. Tamoxifen is the primary hormonal agent used. Anastrozole (Arimidex), letrozole (Femara), leuprolide (Lupron), megestrol and aminoglutethimide (Cytadren) are other hormonal agents used to suppress hormone-dependent tumors. Investigational Therapy

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Research in breast cancer treatment includes the following areas: bone marrow transplantation, peripheral stem cell transplants, oncogenes, growth factors, monoclonal antibodies, biologic response modifiers, and vaccine studies. Another treatment modality that has shown promise is trastuzumab (Herceptin). Herceptin binds with the HER2 protein, and this protein regulates cell growth, thus inhibiting tumor cell growth.

Nursing Process for the Client with Breast Cancer Assessment The health history includes an assessment of the clients reaction to the diagnosis and her ability to cope with it. 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, family member, 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, body image changes, 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, surgical treatment, 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, breast, or chest wall Risk for sexual dysfunction related to loss of body part, change in selfimage, and fear of partners 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.

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Be knowledgeable about current treatment and be able to discuss them with the client. Be aware of the information that has been given by the physician to the client. Provide information about the surgery, the location and extent of the tumor, and postoperative treatments involving radiation therapy and chemotherapy to enable the client make informed decisions. Discuss with the client medications, extent of treatment, management of side effects, possible reactions after treatment, frequency and duration of treatment, and treatment goals. Discuss and plan with the client methods to compensate for physical changes related to mastectomy (e.g., prostheses and plastic surgery). Reduce fear and anxiety and improve coping ability Start the clients emotional preparation when the tentative diagnosis of cancer is made. Discuss fears and concerns with the client. Provide anticipatory teaching and counseling at each stage of the process and identify the sensations that can be expected during additional diagnostic procedures. Discuss the implications of each treatment option and how it may affect various aspects of the clients treatment course and lifestyle. Introduce the client to other members of the oncology team (e.g., radiation oncologist, medical oncologist, oncology nurse, and social worker) and acquaint her with the role of each in her care. Promote preoperative physical, psychological, social, and nutritional wellbeing after the treatment plan has been established. Encourage the client to talk with a breast cancer survivor for reassurance. Promote decision-making ability Careful guide and provide supportive counselling to help the client make a decision about her treatment. Encourage the client to take one step of the treatment process at a time. 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. Initiate a referral to the psychiatrist, psychologist, or psychiatric clinical nurse specialist if necessary.

Postoperative Nursing Interventions Relieve pain and discomfort Have an ongoing assessment of pain and discomfort. Moderately elevate the involved extremity to relieve pain (decreases tension on the surgical incision, promote circulation, and prevent venous congestion in the affected extremity). Administer intravenous or intramuscular opioid analgesic agents to manage the pain in the initial postoperative phase. Administer oral analgesics after the anesthesia has cleared sufficiently and the client is able to take in fluids and food per orem. Encourage the client to take analgesic agents before exercises or at bedtime, and to take warm shower twice daily (usually allowed on the second postoperative day) to alleviate the discomfort that comes from referred muscle pain. Maintain skin integrity and prevent infection

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Prevent fluid from accumulating under the chest wall incision or in the axillary by maintaining the patency of the surgical drains. Inspect the dressings and drains for bleeding and monitor the extent of drainage regularly. Monitor the incision if hematoma develops within the first 12 hours after surgery. Notify the physician if a hematoma, that could cause necrosis of the surgical flaps, occurs. Place an Ace wrap (elastic bandage) around the incision and apply an ice pack. Note the characteristics of fluid from the drain. Initially, the fluid in the surgical drain appears blood, but it gradually changes to serosanguineous and then a serous fluid during the next several days. 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. Teach the client and family the importance of ensuring correct management of the drainage system prior to discharge. Discuss the incision, how it looks and feels, and the progressive changes in its appearance with the client during dressing changes. Explain the care of the incision, sensations to expect, and the possible signs and symptoms of an infection. 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. 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. 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. She may again use deodorant on the affected side. Promote positive body image Address the clients perception of the body image changes and physical alterations of the breast during teaching sessions. Provide privacy and consideration when assisting the client to view her incision fully for the first time, and allow her to express her emotions. Explain that her feelings are normal response to breast cancer surgery to reassure the client. Promote positive adjustment and coping Have an ongoing assessment of the clients concerns related to the diagnosis of cancer, the consequences of surgical treatment, and fear of death, which are important in determining her progress in adjusting and the effectiveness of her coping strategies. Assist the client in identifying mobilizing her support systems. 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. Answer questions and concerns about the treatment options that may follow after surgery. Refocus the client on the recovery from surgery, while addressing her concerns and answering questions, Be knowledgeable about the clients plan of care and encourage her to ask questions to the appropriate members of the health care team to help promote coping during recovery.

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Counseling or consultation with a mental health practitioner may be indicated for a client who displays ineffective coping. Promote participation in care Encourage the client to ambulate when she is free of postanesthesia nausea and is able to tolerate fluids. Support the client on the nonoperative side. Initiate exercises (hand, shoulder, arm, and respiratory) in the second postop day. Instructions should be provided on the first postop day. 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. Encourage the client to shower before performing post-mastectomy exercises to loosen stiff muscles, and to take an analgesic agent 30 minutes before beginning the regimen. Encourage self-care activities (e.g., brushing the teeth, washing the face, and combing/brushing the hair) because they aid in restoring arm function and provides a sense of normalcy for the client. Promote the use of the muscles in both arms and to maintain proper posture. If a client has skin grafts, a tense, tight surgical incision, or immediate reconstruction, exercises may need to be prescribed specifically and introduced gradually. Instruct clients about activity limitations while healing postoperatively (e.g., avoid heavy lifting). Previous activities should be introduced when fully healed, and checking with the physician regarding this is usually indicated. If transient edema develops in the affected extremity, 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. 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. Avoid blood pressures, injections, and blood draws in affected extremity. Use sunscreen higher than 15 SPF for extended exposure to the sun. Apply insect repellant to avoid bug bites. Wear gloves for gardening. Use cooking mitt for removing objects from the oven. Avoid cutting cuticles; push them back during manicures. Use electric razor for shaving armpit. Avoid lifting objects greater than 5 to 10 pounds. If a trauma of break in the skin occurs, wash the area with soap and water, and apply an over-the-counter antibacterial ointment. Observe the area and extremity for 24 hours; if redness, swelling, or a fever occurs, call the surgeon or nurse. Manage postoperative sensations Explain to the client that tightness, pulling, burning, and tingling along the chest wall, in the axilla, 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. Assist in performing exercises to decrease sensations. acetaminophen as needed to assist managing discomforts. Improve sexual function Encourage discussion about fears, needs, and desires to reduce the couples stress Suggest varying the time of day for sexual activity (when the client is less tired) or assume positions that are more comfortable, other options for expressing affection can also be helpful. Refer the client and her partner to a psychosocial source if problems develop or persist. Monitor and manage potential complications

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Lymphedema Reassure client that transient edema is not lymphedema. Educate the client how to prevent lymphedema and how to do hand and arm care after axillary dissection. 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. Emphasize that need for early intervention because lymphedema can be manageable if treated early; however, if allowed to progress without treatment, the swelling can become painful and difficult to reverse. Manage lymphedema by elevating the arm with the elbow above the shoulder and the hand higher than the elbow, along with specific exercises, such as hand pumps. Refer the client to a physical therapist or rehabilitation specialist for a custom-made elastic sleeve, exercises, manual lymph drainage, or a special pump to decrease swelling.

Hematoma formation Monitor the surgical site for excessive swelling and monitor the drainage device, if present. Notify the surgeon for gross swelling or output from the drain that may indicate hematoma formation. Monitor the site and reassure the client that this complication is rare but does occur and that she will be assisted through its management. Be calm to help prevent anxiety and panic on the part of the client. Infection Teach the client to monitor for signs and symptoms of infection preoperatively and before discharge, and to contact her health care provider for evaluation. Administer oral or intravenous antibiotics depending on the severity of the infection. Assist in taking specimen for cultures on any foulsmelling discharge. 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, 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, surgical treatment, 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

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Cancer of the Prostate Clinical Manifestations Rarely produces symptoms in the early stages. Symptoms that develop from urinary obstruction occur late in the disease. 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, urinary retention, decrease in size and force of urine stream. Other symptoms may include blood in the urine or semen and painful ejaculation. Hematuria may result if the cancer invades the urethra or bladder, or both. Prostate cancer can metastasize to bone and lymph nodes. Symptoms related to metastases include backache, hip pain, perineal and rectal discomfort, anemia, weight loss, weakness, nausea, and oliguria. Assessment and Diagnostic Findings The likelihood of cure is high if prostate cancer is detected early. Every man older than 40 years of age should have a digital rectal exam (DRE) as part of his regular health checkup. Routine repeated rectal palpation of the gland, preferably by the same examiner, 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. The more advanced lesion is stony hard and fixed. Diagnosis of prostate cancer is confirmed by a histologic examination of tissue removed surgically by transurethral resection, open prostatectomy, or transrectal needle biopsy. Fine-needle aspiration is helpful for determining the stage of disease as well. Most prostate cancers are diagnosed when a man seeks medical attention for symptoms of urinary obstruction or after abnormalities are found by DRE. Prostate-specific antigen (PSA) together with DRE appears to be a cost-effective method for detecting prostate cancer. PSA testing is routinely used to monitor the clients response to cancer therapy and to detect local progression and early recurrence of prostate cancer. Transrectal ultrasound (TRUS) studies are indicated for men who have elevated PSA levels and abnormal DRE findings. TRUS studies help in detecting nonpalpable prostate cancers and assist with staging localized prostate cancer. Needle biopsies of the prostate are commonly guided by TRUS. 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, renal function tests, and CT scans or lymphangiography to identify metastases in the pelvic lymph nodes. Capromab Pendetide with Indium-111 (ProstaScint) is an antibody that is attracted to the prostate-specific antigen found on prostate cancer cells. The radioactive element attached to the antibody is then visible with scanning, allowing detection of disease spread. 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.

Medical Management Surgical Management

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

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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, catheter placement, 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- Establish communication with the client to assess his understanding of the diagnosis and of the planned surgical procedure. Clarify the nature of the surgery and expected postoperative outcomes. Familiarize the client with the pre- and postoperative routines and initiates measures to reduce anxiety. Provide privacy and establish a trusting and professional relationship when discussing problems related to genitalia and sexuality. Encourage the client to verbalize his feelings and concerns. Relieve discomfort- Place the client on bed rest, administer analgesic agents, and initiate measures to relieve anxiety if discomfort is present before the day of the surgery. Monitor voiding patterns, watch for bladder distention, and assist with catheterization if indicated, if the client is hospitalized. Insert an indwelling catheter if the client has continuing urinary retention or if laboratory test results indicate azotemia. Prepare the client for a cystostomy if he cannot tolerate urinary catheter. Provide instruction- 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. Explain what will take place as the client is prepared for diagnostic tests and then for surgery. Describe the type of incision, which varies with the type of surgical approach; inform the client about the type of urinary drainage system that is expected, the type of anesthesia, and the recovery room procedure. Instruct the client about postoperative use of medications for pain management. 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. Administer an enema at home the evening before surgery or the morning of the surgery to prevent postoperative straining, which can induce bleeding. Postoperative Nursing Interventions Maintain fluid balance- 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. Monitor the client for electrolyte imbalances, rising blood pressure, confusion, and respiratory distress. Document and report signs and symptoms of fluid imbalance to the surgeon.

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

Testicular Cancer

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

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mass; and CT scan of the chest, abdomen, and pelvis to determine the extent of the disease in the lungs, retroperitoneum, and pelvis. 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.

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

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Radiation therapy is used to treat small squamous cell carcinomas of the penis or for palliation in advanced tumors or lymph node metastasis. Partial penectomy is preferred to total penectomy if possible. Total penectomy is indicated when the tumor is not amenable to conservative treatment. Skin Cancer Ask the students the possible causes which may increase an individuals risk for skin cancer.

Risk Factors Exposure to the sun is the leading cause of skin cancer; incidence is related to the total amount of exposure to the sun Fair-skinned, fair-haired, blue-eyed people, particularly those of Celtic origin, with insufficient skin pigmentation to protect underlying skin tissues People who sustain sunburn and who do not tan Long-time sun exposure (farmers, fishermen, construction workers) Exposure to chemical pollutants (industrial workers in arsenic, nitrates, coal, 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). The third most common type is the malignant melanoma. 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. Incidence is proportional to the age of the client (average of 60 years) and the total amount of sun exposure, and it is inversely proportional to the amount of melanin in the skin. Usually begins as a small, waxy nodule with rolled, translucent, pearly borders; telangiectatic vessels may be present. It undergoes central ulceration and sometimes crusting as it grows. Tumors appear most frequently on the face; characterized by invasion and erosion of adjoining tissues; rarely metastasizes but recurrence is common; a neglected lesion can result in the loss of a nose, an ear, or a lip. Other variants of BCC may appear as a shiny, flat, gray, or yellowish plaque. Squamous cell carcinoma (SCC) A malignant proliferation arising from the epidermis; usually appears on sundamaged skin but may also arise from normal skin or from preexisting skin lesions. It is of greater concern than BCC because it is a truly invasive carcinoma, metastasizing by the blood or lymphatic system. The lesions may be primary, arising on the skin and mucous membranes, or they may develop from a precancerous condition (such as actinic keratosis, leukoplakia, or scarred or ulcerated lesions).

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It appears as rough, thickened, scaly tumor that may be asymptomatic or may involve bleeding. The boarder of an SCC lesion may be wider, more infiltrated, and more inflammatory than that of a BCC lesion. Secondary infection can occur. Common sites are exposed areas, especially of the upper extremities and of the face, lower lip, ears, nose, and forehead.

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

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and the base cauterized. The process is repeated twice. Generally, healing occurs within a month. Cryosurgery This method destroys the tumor by deep freezing the tissue. A thermocouple needle apparatus is inserted into the skin, and liquid nitrogen is directed to the center of the tumor until the tumor base is -40C to -60C. The tumor tissue is frozen, allowed to thaw, and then refrozen. The site thaws naturally and then becomes gelatinous and heals spontaneously. Swelling and edema follow the freezing. The appearance of the lesion varies. Normal healing, which may take 4 to 6 weeks, occurs faster with a good blood supply. Radiation Therapy Frequently performed for cancer of the eyelid, tip of the nose and areas in or near vital structures (e.g., facial nerve); reserved for older clients, since x-ray changes may be seen after 5 to 10 years, and malignant changes in scars may be induced by irradiation 15 to 30 years later. Nursing Management Teach client about prevention of skin cancer and about self-care after treatment. Advise the client when to report for a dressing change or provide a written and verbal information on how to change dressings, including the type of dressing to purchase, how to remove dressings and apply fresh ones, and the importance of hand washing before and after the procedure. Advise the client to watch for excessive bleeding and tight dressing that compromise circulation. Instruct the client to drink liquids through straw and limit talking and facial movement, if the lesion is in the perioral area. Dental work should also be avoided until the area is completely healed. Apply an emollient cream to help reduce dryness after the sutures have been removed. Advise the client to apply sunscreen over the wound to prevent postoperative hyperpigmentation if he/she spends time outdoors. Instruct the client to seek treatment for any moles that are subject to repeated friction and irritation, and to watch for indications of potential malignancy. Malignant Melanoma A malignant melanoma is a cancerous neoplasm in which atypical melanocytes are present in the epidermis and the dermis. Risk Factors Fair-skinned or freckled, blue-eyed, 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. It usually affects middle-aged people and occurs most frequently on the trunk and lower extremities. The lesion tends to be circular, with irregular outer portions. The margins of the lesion may be flat or elevated and palpable.

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This type of melanoma may appear in a combination of colors, with hues of tan, brown, and black mixed with gray, blue-black, or white. A dull pin rose color can be seen in a small area within the lesion, sometimes. Lentigo-maligna melanoma are slowly evolving, pigmented lesions that occur on exposed skin areas, especially the dorsum of the hand, the head, and the neck in elderly people. Lesions are often present for many years before they are examined by a physician. They first appear as tan, flat lesions, but in time, they undergo changes in size and color. Nodular melanoma is a spherical, blueberry-like nodule with a relatively smooth surface and a relatively uniform, blue-black color. It may be dome-shaped with a smooth surface. It may have other shadings of red, gray, or purple. These melanomas may appear as irregularly shaped plaques. The client may describe this as a blood blister that fails to resolve. A nodular melanoma invades directly into adjacent dermis and therefore has poorer prognosis. Acral lentiginous melanoma occurs in areas not excessively exposed to sunlight and where hair follicles are absent. It is found on the palms of the hands, on the soles, in the nail beds, and in the mucous membranes in dark-skinned people. These melanomas appear as irregular, pigmented macules that develop nodules. They may become invasive early.

Assessment and Diagnostic Findings Biopsy results confirm the diagnosis of melanoma. An excisional biopsy specimen provides histologic information on the type, level of invasion, and thickness of the lesion. Incisional biopsy should be performed when the suspicious lesion is too large to be removed safely without extensive scarring. Biopsy specimens obtained by shaving, curettage, or needle aspiration are not considered reliable histologic proof of disease. A thorough history and physical examination should include a meticulous skin examination and palpation of regional lymph nodes that drain the lesional area. After the diagnosis of melanoma has been confirmed, a chest x-ray, complete blood cell count, liver function tests, and radionuclide or CT scans are usually ordered to stage the extent of disease. Prognosis The prognosis for long-term (5-year) survival is considered poor when the lesion is more than 1.5 mm thick or there is regional lymph node involvement. Clients with melanoma on the hand, foot, or scalp have a better prognosis; those with lesions on the torso have an increased chance of metastases to the bone, liver, lungs, spleen, and central nervous system. Men and elderly clients also have poor prognoses. Medical Management Treatment depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, after which skin grafting may be needed. Regional lymph node dissection is commonly performed to rule out metastasis, although new surgical approaches call only for sentinel node biopsy. Several forms of immunotherapy (e.g., BCG vaccine, Corynebacterium parvum, levamisole), biologic response modifiers (e.g., interferon-alpha, interleukin-2), adaptive immunotherapy (i.e., lymphokine-activated killer cells), and monoclonal antibodies are some of the investigational therapies available.

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Further surgical intervention may be performed to debulk the tumor or to remove part of the organ involved for metastatic melanoma. Chemotherapy may also be used. 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. This approach delivers a high concentration of cytotoxic agents while avoiding systemic, toxic effects.

Nursing Process for the Client with Malignant Melanoma Assessment Assessment is based on the clients history and symptoms. Ask the client specifically about pruritus, tenderness, and pain which are not features of a benign nevus. Question the client about changes in pre-existing moles or the development of new, pigmented lesions. Signs that suggest malignant changes are referred to as the ABCDs of moles: A Asymmetry - The lesion does appear balanced on both sides. If an imaginary line were drawn down the middle, the two halves would not look alike. The lesion has an irregular surface with uneven elevations (irregular topography) either palpable or visible. A change in the surface may be noted from smooth to scaly. Some nodular melanomas have a smooth surface. B Irregular Border Angular indentations or multiple notches appear in the border. The border is fuzzy or indistinct, as if rubbed with an eraser. C Variegated Color Normal moles are usually a uniform light to medium brown. Darker coloration indicates that the melanocytes have penetrated to a deeper layer of the dermis. Colors that may indicate malignancy if found together within a single lesion are shades of red, white, and blue; shades of blue are ominous. White areas within a pigmented lesion are suspicious. Some malignant melanomas, however, are not variegated but are uniformly colored (bluish-black, bluish-gray, bluish-red). D Diameter A diameter exceeding 6 mm is considered more suspicious, although this finding without other sign is not significant. Many benign skin growths are larger than 6 mm, whereas some early melanomas may be smaller. Common sites of melanomas are the skin of the back, the legs, between the toes, and on the feet, face, scalp, fingernails, and backs of hands. Melanomas are most likely to occur in less pigmented sites: palms, soles, subungual areas, and mucous membranes of dark-skinned people.Satellite lesions (those situated near the mole) are inspected. 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- Promote comfort and administer appropriate medications. Reduce anxiety and depression Allow clients to express feelings about the seriousness of this cutaneous neoplasm, understand their anger and depression, and convey understanding of these feelings. Answer questions about the diagnostic workup and staging of the depth type, and extent of tumor to help clarify information and misconceptions. Point out resource, past effective coping mechanisms, and social support systems to help them cope with the problems associated with diagnosis, treatment, and continuing follow-up. Include the clients family in all the discussions to clarify the

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information presented, ask questions that the client may be reluctant to ask, and provide emotional support. Monitor and manage potential complications Be knowledgeable about the most effective current therapies to manage metastasis. 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, and instruct the client to and family about the expected outcomes of the treatment. Monitor and document symptoms that may indicate metastasis: lung, bone, and liver. Nursing care should be based on the clients symptoms. Encourage the client to have hope in the therapy employed while maintaining a realistic perspective about the disease and ultimate outcome. Provide time for the client to express fears and concerns. Offer information about support groups and contact people, and arrange for palliative hospice care if appropriate. 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

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