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GERIATRIC NURSING

GERIATRIC NURSING

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  • 1. CANCER OF BLADDER AND KIDNEY
  • 2. BLADDER CANCER • It is the carcinoma of the bladder
  • 3. INCIDENCE • About 73,510 new cases of bladder cancer diagnosed (about 55,600 in men and 17,910 in women). • Bladder cancer occurs mainly in older people. About 9 out of 10 people with this cancer are over the age of 55. The average age at the time of diagnosis is 73.
  • 4. ETIOLOGY AND RISK FACTORS • • • • • • • Smoking Workplace exposures Race and ethnicity Age Gender Chronic bladder irritation and infections Personal history of bladder or other urothelial cancer
  • 5. Contd… • • • • • Bladder birth defects Genetics and family history Chemotherapy and radiation therapy Arsenic Low fluid consumption
  • 6. TYPES OF BLADDER CANCER
  • 7. Transitional cell (urothelial) carcinoma • About 95% of bladder cancers are this type. • The cells from transitional cell carcinomas look like the urothelial cells that line the inside of the bladder. • Urothelial cells also line other parts of the urinary tract, such as the lining of the kidneys (called the renal pelvis), the ureters, and the urethra, so transitional cell cancers can also occur in these places
  • 8. • Non-invasive bladder cancers are still in the inner layer of cells (the transitional epithelium) but have not grown into the deeper layers • Invasive cancers grow into the lamina propria or even deeper into the muscle layer.
  • 9. Papillary carcinomas • Grow in slender, finger-like projections from the inner surface of the bladder toward the hollow center.
  • 10. Flat carcinomas • Do not grow toward the hollow part of the bladder at all. If a flat tumor is only in the inner layer of bladder cells, it is known as a non-invasive flat carcinoma or a flat carcinoma in situ (CIS).
  • 11. STAGING OF BLADDER TUMER • • • • • • • • Tis-flat carcinoma insitu Ta-papillary ,confined to mucosa T1-invasion of lamina propria T2-invasion of superficial muscle T3a-invasion of deep muscle T3b-invasion of perivesical tissue T4a-tumour fixed to prostate T4b-tumour fixed to other pelvic organs
  • 12. • • • • • M0-no evidence of metastatic disease M1-metastasis present MX-metastatic state unknown N0-no regional lymph node metastasis N1-metastasis in a single lymph node 2cm or less in greatest dimension • N2-metastasis in a single lymph node more than 2 cm but not more than 5 cm in greatest dimension or multiple lymph nodes more than 5 cm in great dimension • N3-metastasis in a lymph node morethan 5 cm in greatest dimension
  • 13. PATHOPHYSIOLOGY OF BLADDER CANCER Due to the etiological factors Activation of oncogenes and inactivation or loss of tumor suppressor genes. • Loss of genetic material on chromosome 9
  • 14. That leads to bladder cancer
  • 15. Exposure of the bladder wall to a carcinogen Premalignant proliferative changes are found in the transitional cell layer. These changes are called dysplasia and refers to abnormal cell configuration found in several degrees of sevearity. The invasion progress through the pelvic lymph nodes and spreads to liver, bones and lungs ,rectum, vagina, and other pelvic soft tissues
  • 16. CLINICAL FEATURES • • • • • Blood in the urine Frequency Dysuria Urgency Lower back pain or being unable to urinate
  • 17. DIAGNOSTIC MEASURES • Medical history and physical exam • Cystoscopy • LAB TESTS 1. Urine cytology 2. Urine culture 3. Urine tumor marker tests(tests for NMP22 and BTA) •Bladder biopsies
  • 18. • • • • • Intravenous pyelogram Computed tomography (CT) scan CT-guided needle biopsy Magnetic resonance imaging (MRI) scan Ultrasound
  • 19. MANAGEMENT • The main types of treatment for cancer of the bladder are: Surgery Intravesical therapy Chemotherapy Radiation therapy
  • 20. SURGERIES FOR BLADDER CANCER 1. Transurethral surgery  TURBT 2. CYSTECTOMY Partial cystectomy Radical cystectomy
  • 21. RECONSTRUCTIVE SURGERY • Urinary Diversions Urinary diversion procedures are performed to divert urine from the bladder to a new exit site, usually through a surgically created opening (stoma) in the skin. The main types are: 1. Cutaneous Urinary Diversions 2. Continent Urinary Diversions
  • 22. 1.Cutaneous Urinary Diversions cutaneous urinary diversion, in which urine drains through an opening created in the abdominal wall and skin,
  • 23. A. Continent Urinary Diversions . In an ileal conduit, the urine is diverted by implanting the ureter into a 12-cm loop of ileum that is led out through the abdominal wall.
  • 24. B. Cutaneous Ureterostomy A cutaneous ureterostomy, in which the ureters are directed through the abdominal wall and attached to an opening in the skin, is used for selected patients with ureteral obstruction
  • 25. C. Vesicostomy. The surgeon sutures the bladder to the abdominal wall and creates an opening (stoma) through the abdominal and bladder walls for urinary drainage.
  • 26. D. Nephrostomy The surgeon inserts a catheter into the renal pelvis via an incision into the flank or, by percutaneous catheter placement, into the kidney.
  • 27. 2.Continent Urinary Diversions • continent urinary diversion, in which a portion of the intestine is used to create a new reservoir for urine.
  • 28. A.Continent Ileal Urinary Reservoir 1.Indiana Pouch The Indiana pouch uses a segment of the ileum and cecum to form the reservoir for urine. The ureters are tunneled through the muscular bands of the intestinal pouch and anastomosed
  • 29. 2.Kock pouch U-shaped pouch constructed of ileum, with a nipplelike one-way valve.With both of these methods, the pouch must be drained at regular intervals by a catheter
  • 30. B. Ureterosigmoidostomy Implantation of the ureters into the sigmoid colon
  • 31. NURSING MANAGEMENT 1.PREOPERATIVE MANAGEMENT • • • • • Functional assessment psychosocial resources Bowel preparation Adequate hydration The procedure is explained
  • 32. • For ileal or colon conduit, the stoma site is planned preoperatively • Stoma site may also be marked
  • 33. Postoperative Management • Assessed for immediate postoperative complications; wound or UTI, urinary or fecal anastomotic leakage, small bowel obstruction, paralytic ileus, pelvic thrombophlebitis, pulmonary embolism, and necrosis of stoma. • Intake and output are monitored including amount • Suction drains are evaluated sudden increase in drainage suggests an anastomotic leak • Ureteral stents are used to protect ureterointestinal anastomoses
  • 34. Nursing Diagnoses • Impaired Urinary Elimination related to urinary diversion • Acute Pain related to surgery • Disturbed Body Image related to urinary diversion • Sexual Dysfunction related to reconstructive surgery and impotence (in men) • Risk for impaired skin integrity related to problems in managing the urine collection appliance • Risk for complications related to complexity of surgery
  • 35. 1.Achieving Urinary Elimination For ileal or colon conduit patients • Maintain a transparent urostomy pouch • Inspect the stoma for color and size 1. Stoma should be red, wet with mucus, soft, and slightly rubbery to the touch (stoma lacks nerve ending, so feeling in stoma is absent). 2. Cyanotic stoma indicates poor circulation. 3. Necrotic stoma is blue-black or tan-brown.
  • 36. • Connect pouches to drainage bag when patient is in bed, and record urine volume hourly. • Initial urostomy pouch remains in place for several days postoperatively; it is changed every 3 to 5 days when patient teaching begins. • Report bleeding, necrosis, sloughing, suture separation. • Check patency of ureteral stents. • Keep the pouch on at all times, and observe normal urine
  • 37. • • • • • • • • • • For continent urinary diversion patients Irrigate with 30 mL saline every 2 to 4 hours Assess stoma Record urine output and character of urine irrigate with 30 mL saline every 2 to 4 hours Assess stoma Monitor output of pelvic drain Record urine output and character of urine Controlling Pain Resolving Body Image Issues Coping with Sexual Dysfunction
  • 38. • Providing stoma and skin care • Monitoring And Managing Potential Complications
  • 39. Patient Education and Health Maintenance For Ileal or Colon Conduit Patients • Obtain and familiarize the patient with the appropriate equipment • Assist the patient to determine stoma size • The inside diameter of the skin barrier should not be more than 1/16 to 1/8 inch larger than the diameter of the stoma.
  • 40. DISPOSABLE UROSTOMY POUCH
  • 41. • Teach how to change the pouch. • Pastes or cements, are not usually necessary with a well-fitting pouch. • Pouches should be changed every 3 days • Emptying the pouch when it is a third to half full to prevent weight of urine from loosening adhesive seal open drain valve
  • 42. For Continent Ileal Urinary Reservoir Patients • Teach irrigation of catheter • Teach how to change stoma dressing • Instruct in use of leg bag or bedside urinary drainage
  • 43. Teach how to catheterize continent urinary diversion when healing is verified • Red rubber or plastic, straight or coud catheters are used. • Apply a small amount of water-soluble lubricant to the tip of the catheter. • Use clean technique, wash hands before each catheterization. • Maintain schedule of catheterizations • After training period, catheterize four to five times per day; pouch should not hold more than 400 to 500 mL. • Irrigate pouch with saline through catheter once per day to clear it of accumulated mucus.
  • 44. INTRAVESICAL THERAPY • With intravesical therapy, the doctor puts the drug directly into the bladder 1. INTRAVESICAL IMMUNOTHERAPY A.Bacillus Calmette-Guerin therapy • The body’s immune system cells are attracted to the bladder and activated by BCG, which in turn affects the bladder cancer cells • Started a few weeks after a transurethral resection of the tumor and is given once a week for 6 weeks.
  • 45. B. Interferon • Stimulate the immune system • Interferon-alpha is the type most often used to treat cancer. C. Intravesical chemotherapy • Mitomycin and thiotepa are the drugs used most often for intravesical chemotherapy. Other drugs that are used include valrubicin, doxorubicin, and gemcitabine.
  • 46. CHEMOTHERAPY FOR BLADDER CANCER • Cisplatin 50 to 70 mg/m2 intravenously once every 3 to 4 weeks • Cisplatin plus fluorouracil (5-FU) This consisted of cisplatin 15 mg/m(2) i.v. and 5fluorouracil (5-FU) 400 mg/m(2) i.v. in the mornings
  • 47. • Mitomycin with 5-FU 12mg/m2 IV Bolus (DAY 1 ONLY) • Gemcitabine and cisplatin gemcitabine dose of 1000 mg/m(2) and cisplatin dose and schedule varied, with total doses ranging from 70 to 105 mg/m(2) • Methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (called M-VAC) • paclitaxel or docetaxel (for patients with poor kidney function) Paclitaxel was given at a dose of 250 mg/m2 by 24hour continuous infusion
  • 48. RADIATION THERAPY FOR BLADDER CANCER • External beam radiation therapy
  • 49. PHOTODYNAMIC THERAPY • A special light-sensitive drug is injected into the blood and allowed to collect in the tumor cells for a few days. Then a special type of laser light is focused on the inner lining of the bladder through a cystoscope. The light changes the drug in the cancer cells into a new chemical that can kill them.
  • 50. TARGETED THERAPIES Medication that blocks the growth of cancer cells by interfering with specific targeted molecules needed for carcinogenesis and tumor growth rather than by simply interfering with all rapidly dividing cells • Eg-sunitinib,lapatinib ,Erlotinib, trastuzumab
  • 51. GENE THERAPY • The modified virus is put into the bladder and infects the bladder cancer cells • When this infection occurs, the virus injects a gene into the cells for GM-CSF, an immune system hormone (cytokine) that may help activate immune system cells to attack the cancer
  • 52. PROGNOSIS • • • • Stage 0 -- 98%. For stage I -- 88%. For stage II -- 63%. For stage III -- 46%, depending on the size of the cancer deposits present in the tissues next to the bladder and whether the cancer has spread to nearby organs. • For stage IV -- 15%
  • 53. • Renal cell carcinoma (RCC), also known as renal cell cancer • Adenocarcinoma, is by far the most common type of kidney cancer. About 9 out of 10 kidney cancers are renal cell carcinomas
  • 54. INCIDENCE • As per the Indian cancer registry data in men, it is the ninth most common cancer accounting for 3.9% of all cancer cases • It is three times more common in men than in women, and 90% of the bladder tumors are transitional cell carcinoma (TCC)
  • 55. TYPES OF KIDNEY CANCER 1. Papillary renal cell carcinoma • These cancers form little finger-like projections (called papillae) • Sometimes it is called chromophilic because the cells take in certain dyes and look pink under the microscope.
  • 56. 2. Chromophobe renal cell carcinoma • This subtype accounts for about 5% • The cells of these cancers are also pale, like the clear cells, but are much larger 3. Collecting duct renal cell carcinoma This subtype is very rare. The major feature is that the cancer cells can form irregular tubes.
  • 57. 4.Transitional cell carcinoma • Transitional cell carcinomas don't start in the kidney itself, but instead begin in the lining of the renal pelvis • 5-10 % OF TOTAL RCC 5. Wilms tumor (nephroblastoma) • Nephroblastomas, more commonly called Wilms tumors, almost always occur in children. This type of cancer is very rare among adults
  • 58. 6. Renal sarcoma • That begin in the blood vessels or connective tissue of the kidney.TOTAL 1%
  • 59. STAGING/TNM CLASSIFICATION • • • • • Primary Tumor (T) Tx-Primary tumor can not be assessed T0-No evidence of primary tumor T1a-Tumor 4 cm, confined to the kidney T1b-Tumor 4 cm to < 7 cm, confined to the kidney • T2a-Tumor ≥ 7 cm to < 10 cm, confined to the kidney • T2b-Tumor ≥ 10 cm, confined to the kidney
  • 60. • T3a-Tumor extends into the renal vein or its segmental branches or invades adrenal gland or perinephric fat but not beyond Gerota’s fascia • T3b-Tumor extends into the vena cava below diaphragm • T3c-Tumor extends into the vena cava above the diaphragm or invades the wall of vena cava • T4-Tumor invades beyond Gerota’s fascia • Regional Lymph Nodes (N) • N1-Metastasis in 1 regional lymph node • N2-Metastasis in > 1 regional lymph node • Distant Metastases (M) • M1-Distant metastasis present
  • 61. ETIOLOGY AND RISK FACTORS • Smoking • Obesity • Workplace exposures • Genetic and hereditary risk factors
  • 62. von Hippel-Lindau disease • People with this condition often develop several kinds of tumors and cysts (fluid-filled sacs) in different parts of the body
  • 63. ETIOL … • • • • • • Hereditary papillary renal cell carcinoma Hereditary leiomyoma-renal cell carcinoma (FH) gene. Hereditary renal oncocytoma Family history of kidney cancer High blood pressure
  • 64. • Certain medicines Phenacetin, Diuretics • Advanced kidney disease • Gender • Race
  • 65. PATHOPHYSIOLOGY Due to etiology Loss of VHL protein(von-Hippel-Lindeau)tumour suppressor gene Accumulate hypoxia-induced factor (HIF) Transcriptional activation of multiple downstream targets
  • 66. RCC
  • 67. CLINICAL FEATURES • Blood in the urine (hematuria) • Low back pain on one side (not caused by injury) • A mass (lump) on the side or lower back • Fatigue (tiredness) • Weight loss not caused by dieting • Fever that is not caused by an infection and that doesn't go away after a few weeks • Anemia (low red blood cell counts)
  • 68. Paraneoplastic Syndromes 1. Erythrocytosis promoting erythropoietin production from nonneoplastic renal tissue. 2. Hypercalcemia Due to production of a parathyroid hormone. 3. Hypertension Due to excess rennin production
  • 69. 4. Non metastatic hepatic dysfunction Elevation of alkaline phosphatase and bilirubin, hypoalbuminemia, prolonged prothrombin time, and hypergammaglobulinemia. It is known as Stauffer syndrome
  • 70. DIAGNOSTIC MEASURES • • • • • • • • • Urine analysis Complete blood count Blood chemistry tests CT scan MRI scan Ultrasound Positron emission tomography (PET) scan Intravenous pyelogram Fine needle aspiration and needle core biopsy
  • 71. MANAGEMENT –Surgery –Radiation therapy –Chemotherapy
  • 72. SURGERY • Radical nephrectomy • Partial nephrectomy (nephron-sparing surgery) • Cryotherapy (cryoablation) • Radiofrequency ablation • Arterial embolization
  • 73. RADIATION THERAPY FOR KIDNEY CANCER • External beam therapy focuses radiation from outside the body on the cancer
  • 74. CHEMOTHERAPY FOR KIDNEY CANCER • Unfortunately, kidney cancer cells are usually resistant to chemo, and so chemo is not a standard treatment for kidney cancer. • Some chemo drugs, such as vinblastine,floxuridine, 5-fluorouracil (5-FU), capecitabine, and gemcitabine
  • 75. Targeted therapies • Targeted drugs are proving to be especially important in diseases such as kidney cancer, where chemotherapy has not been shown to be very effective. • These include drugs that stop angiogenesis (growth of the new blood vessels that nourish cancers) and drugs that target other important cell growth factors. • EXAMPLES-Sorafenib ,Sunitinib Temsirolimus ,Everolimus ,evacizumab ,Pazopanib
  • 76. Biologic therapy (immunotherapy) • The goal of biologic therapy is to boost the body's immune system to fight off or destroy cancer cells more effectively. • The main immunotherapy drugs used in kidney cancer are cytokines. The 2 cytokines most often used are interleukin-2 (IL-2) and interferon-alpha.
  • 77. New approaches to local treatment • High-intensity focused ultrasound is a fairly new technique that is now being studied for use in kidney cancer. It involves pointing very focused ultrasound beams from outside the body to destroy the tumor
  • 78. NURSING MANAGEMENT • • • • ASSESSMENT Nursing Diagnosis Preoperative nursing diagnosis Anxiety related to diagnosis of cancer and possibility of metastatic disease • Acute Pain and Hyperthermia related to postinfarction syndrome • Anticipatory grieving related to loss; altered role functioning • Disturbed body image and situational low selfesteem related to changes in appearance, function,and roles
  • 79. Nursing Interventions • Reducing Anxiety  Explain each diagnostic test, its purpose, and possible adverse reactions  Answer questions, and encourage more thorough discussion with health care  Assess patient's understanding about diagnosis and treatment options
  • 80. Controlling Symptoms of Postinfarction Syndrome • • • • • Administer analgesics as prescribed Encourage rest, and assist with positioning Administer antiemetics as ordered Restrict oral intake and provide Obtain temperature every 4 hours,
  • 81. • Post operative nursing diagnosis • Ineffective airway clearance related to the location of the surgical incision • Ineffective breathing pattern related to surgical incision and general anesthesia • Acute pain related to the location of the surgical incision, the position the patient assumed on the operating table during surgery, and abdominal distention • Urine retention related to pain, immobility, and anesthesia • Risk for complications related to major surgical procedure
  • 82. Nursing interventions Monitoring And Managing Potential Complications Promoting Urinary Elimination Maintaining Airway Clearance And Breathing Patterns