Oncologic Nursing

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Oncologic Nursing

  1. 1. ONCOLOGIC NURSING Ma. Victoria J. Recinto RN, USRN University of the Philippines Manila Philippine General Hospital
  2. 2. NEOPLASIA DIFFERENCES BENIGN (Tumor) MALIGNANT (CA) Differentiation Well Poor Encapsulation (+) (-) Metastasis (-) (+) Prognosis Good Poor Tx Modalities Surgery Surgery, Irradiation, Chemotx, BM transplant
  3. 3. Predisposing Factors: Carcinogenesis <ul><li>G-enetic </li></ul><ul><li>I-mmunosuppression </li></ul><ul><li>V-iral (Human Papilloma, Epstein-Barr, Hepa B) </li></ul><ul><li>E-nv’tal </li></ul><ul><ul><li>Physical </li></ul></ul><ul><ul><ul><li>Radiation, UV rays, nuclear explosion </li></ul></ul></ul><ul><ul><ul><li>Chronic irritation, direct trauma </li></ul></ul></ul><ul><ul><li>Chemical </li></ul></ul><ul><ul><ul><li>Acids, alkalis, hydrocarbons, dye </li></ul></ul></ul><ul><ul><ul><li>Food (  fat,  fiber) & Food additives (Nitrites) </li></ul></ul></ul><ul><ul><ul><li>Drugs (Stillbestrol, urethane) </li></ul></ul></ul><ul><ul><ul><li>Hormones </li></ul></ul></ul><ul><ul><ul><li>Smoking </li></ul></ul></ul>
  4. 4. Grading of Cancer <ul><li>Classifies the cellular aspects of CA </li></ul><ul><li>Grade I: cells differ slightly from N cells, well-differentiated (mild dysplasia) </li></ul><ul><li>Grade II: cells are more abN, mod. differentiated (mod. dysplasia) </li></ul><ul><li>Grade III: cells are very abN, poorly differentiated (severe dysplasia) </li></ul><ul><li>Grade IV: cells are immature (anaplasia), undifferentiated </li></ul>
  5. 5. Staging of Cancer <ul><li>Classifies the clinical aspects of CA </li></ul><ul><li>Stage O: carcinoma in situ </li></ul><ul><li>Stage I: tumor limited to the tissue of origin, localized tissue growth </li></ul><ul><li>Stage II: limited local spread </li></ul><ul><li>Stage III: extensive local & regional spread </li></ul><ul><li>Stage IV: metastatis </li></ul>
  6. 6. WARNING/DANGER SIGNS OF CANCER <ul><li>C-hange in bowel/bladder habits </li></ul><ul><li>A- sore that does not heal </li></ul><ul><li>U-nusual bleeding/discharge </li></ul><ul><li>T-hickening of a lump in breast or elsewhere </li></ul><ul><li>I-ndigestion/dysphagia </li></ul><ul><li>O-bvious change in a wart or mole </li></ul><ul><li>N-agging cough/hoarseness </li></ul><ul><li>U-nexplained anemia </li></ul><ul><li>S-udden wt loss </li></ul>
  7. 7. EARLY DETECTION OF CANCER <ul><li>Mammography </li></ul><ul><li>Pap smear </li></ul><ul><li>Stool for occult blood </li></ul><ul><li>Sigmoidoscopy, colonoscopy </li></ul><ul><li>Breast self-examination </li></ul><ul><li>Testicular self-examination </li></ul><ul><li>Skin inspection </li></ul>
  8. 8. Breast Self-Examination (BSE) <ul><li>Done 7-10 days after menses </li></ul><ul><li>Postmenopausal or s/p hysterectomy: specific day of the month </li></ul><ul><li>Inspection: In front of the mirror with arms at sides, arms overhead & arms at hips (WOF changes in shape, dimpling of skin or any changes in nipple) </li></ul>
  9. 9. Breast Self-Examination (BSE) <ul><li>Palpation: While in shower/bath or lying down with folded towel under breast being examined </li></ul><ul><li>Use the R hand to examine L breast & vice versa </li></ul><ul><li>Use the pads of 2 nd , 3 rd & 4 th fingers </li></ul><ul><li>Use small, circular motions in spiral or in an up-and-down motion to examine entire breast & under the arm (WOF lump, hard knot or thickened tissue) </li></ul>
  10. 10. Testicular Self-Examination (TSE) <ul><li>Same day, q month, right after a warm shower (scrotal skin is moist & relaxed) </li></ul><ul><li>Gently lift each testicle, each one should feel like an egg, firm but not hard & smooth without lumps </li></ul><ul><li>Using both hands, place middle fingers underside of each testicle & thumbs on top & gently roll the testicles (WOF lumps, swelling or mass) </li></ul>
  11. 11. CANCER TX MODALITIES: Surgery <ul><li>Prophylactic </li></ul><ul><ul><li>With premalignant condition or with strong family hx of CA </li></ul></ul><ul><li>Curative </li></ul><ul><ul><li>Removal of all gross & microscopic tumor </li></ul></ul><ul><li>Control (cytoreductive) </li></ul><ul><ul><li>“ debulking” procedure,  the no. of CA cells,  the chance of other tx will be successful </li></ul></ul>
  12. 12. CANCER TX MODALITIES: Surgery <ul><li>Palliative </li></ul><ul><ul><li>Improves quality of life during survival time </li></ul></ul><ul><ul><li> pain; relieve obstruction (airway, GI or GU), relieve pressure on brain & spinal cord, prevent hemorrhage, remove infected or ulcerated tumors or drain abscesses </li></ul></ul><ul><li>Reconstructive or rehabilitative </li></ul><ul><ul><li>Improves quality of life by restoring maximal function & appearance (breast reconstruction s/p mastectomy) </li></ul></ul>
  13. 13. CANCER TX MODALITIES: Chemotherapy <ul><li>Kills CA cells & rapidly producing cells (skin, hair, BM, Reproductive tract, GIT,) </li></ul><ul><ul><li>Antimetabolites: N2 mustard </li></ul></ul><ul><ul><li>Plant alkaloid: Vincristine & Vinblastine </li></ul></ul><ul><ul><li>Alkylating: Methotrexate </li></ul></ul><ul><ul><li>Hormones (DES)/ steroids </li></ul></ul><ul><ul><li>Antineoplastic antibiotics </li></ul></ul>
  14. 14. CANCER TX MODALITIES: Chemotherapy <ul><li>Major S/E & Nursing Interventions </li></ul><ul><li>Hair: alopecia </li></ul><ul><ul><li>Encourage pt to wear wigs, cap </li></ul></ul><ul><ul><li>Temporary, hair will regrow in 3-6 mos. after chemo with new color & texture </li></ul></ul><ul><li>BM: depression </li></ul><ul><ul><li>Anemia: CBR, O2 as ordered </li></ul></ul><ul><ul><li>Leukemia: reverse isolation, strict HW, asepsis </li></ul></ul><ul><ul><li>Thrombocytopenia: Bleeding precautions </li></ul></ul>
  15. 15. CANCER TX MODALITIES: Chemotherapy <ul><li>Major S/E & Nursing Interventions </li></ul><ul><li>GIT: N/V </li></ul><ul><ul><li>Antiemetics 4-6 hrs. pre-chemo & post chemo as ordered </li></ul></ul><ul><ul><li>NPO temporarily </li></ul></ul><ul><ul><li>Bland diet post chemo </li></ul></ul><ul><li>Stomatitis </li></ul><ul><ul><li>Oral care </li></ul></ul><ul><ul><li>Ice chips/popsicles </li></ul></ul><ul><li>Diarrhea </li></ul><ul><ul><li>Antidiarrheals </li></ul></ul><ul><ul><li>Monitor VS, I/O, WOF dehydration </li></ul></ul><ul><li>WOF paralytic ileus (with Vincristine) </li></ul>
  16. 16. CANCER TX MODALITIES: Chemotherapy <ul><li>Major S/E & Nursing Interventions </li></ul><ul><li>Reproductive tract: sterility </li></ul><ul><ul><li>Encourage sperm banking for M </li></ul></ul><ul><li>Renal damage:  uric acid </li></ul><ul><ul><li>Allopurinol as ordered </li></ul></ul><ul><li>Neuro disturbance: peripheral neuropathy </li></ul><ul><ul><li>Skin, hand & foot care (like in PVD & DM) </li></ul></ul>
  17. 17. Alkylating Meds <ul><li>Cell-cycle nonspecific </li></ul><ul><li>Nitrogen Mustards </li></ul><ul><ul><li>Chlorambucil (Leukeran) & Mechlorethamine (Mustargen): hyperuricemia </li></ul></ul><ul><ul><li>Cyclophosphamide (Cytoxan): taken without food, S/E: alopecia, hemorrhagic cystitis (hematuria, dysuria) </li></ul></ul><ul><ul><li>Ifosfamide (Ifex) </li></ul></ul><ul><ul><li>Melphalan (Alkeran) </li></ul></ul><ul><ul><li>Uracil mustard </li></ul></ul>
  18. 18. Alkylating Meds <ul><li>Nitrosoureas </li></ul><ul><ul><li>Carmustine (BiCNU) </li></ul></ul><ul><ul><li>Lomustine (CeeNU) </li></ul></ul><ul><ul><li>Streptozocin (Zanosar) </li></ul></ul><ul><li>Alkylating-like Meds </li></ul><ul><ul><li>Altretamine (Hexalen) </li></ul></ul><ul><ul><li>Busulfan (Myleran): hyperuricemia </li></ul></ul><ul><ul><li>Cisplatin (Platinol): ototoxicity & nephrotoxicity (given amifostine [Ethyol] prior to  risk), hypoK, hypoCa, hypoMg </li></ul></ul><ul><ul><li>Dacarbazine (DTIC-Dome) </li></ul></ul><ul><ul><li>Thiotepa (Thioplex) </li></ul></ul>
  19. 19. Anti-tumor Antibiotics <ul><li>Cell-cycle nonspecific </li></ul><ul><li>Bleomycin SO4 (Blenoxane): pulmonary toxicity </li></ul><ul><li>Dactinomycin (Actinomycin D, Cosmegan) </li></ul><ul><li>Daunorubicin (Cerubidine, DaunoXome): causes CHF & dysrhythmias </li></ul><ul><li>Doxorubicin (Adriamycin) & Idarubicin (Idamycin): cardiotoxicity (given Dexraxozane [Zinecard] to prevent cardiomyopathy) </li></ul>
  20. 20. Anti-tumor Antibiotics <ul><li>Mitomycin (Mutamycin) </li></ul><ul><li>Mitoxantrone (Novantrone) </li></ul><ul><li>Pentostatin (Nipent) </li></ul><ul><li>Plicamycin (Mithracin): affects bleeding time </li></ul><ul><li>Valrubicin (Valstar) </li></ul>
  21. 21. Antimetabolites <ul><li>Cell-cycle phase-specific (S phase) </li></ul><ul><li>Capecitabine (Xeloda) </li></ul><ul><li>Cladribine (Leustatin) </li></ul><ul><li>Cytarabine (ara-C, Cytosar-U): alopecia, stomatitis, hyperuricemia, hepatotoxicity </li></ul><ul><li>Floxuridine (FUDR) </li></ul><ul><li>Fludarabine (Fludara) </li></ul>
  22. 22. Antimetabolites <ul><li>Methotrexate (Folex) & 5-Fluorouracil (Adrucil): alopecia, stomatitis, hyperuricemia, photosensitivity, hepatotoxicity, hema, GI & skin toxicity </li></ul><ul><ul><li>Leucovorin rescue (given leucovorin [folinic acid or citrovorum factor) to prevent toxicity r/t Methotrexate </li></ul></ul><ul><li>Hydroxyurea (Hydrea) </li></ul><ul><li>6-Mercaptopurine (Purinethol): hyperuricemia, hepatotoxicity </li></ul><ul><li>Procarbazine (Matulane) </li></ul><ul><li>Thioguanide </li></ul>
  23. 23. Mitotic Inhibitors (Vinca Alkaloids) <ul><li>Cell-cycle phase-specific: M phase </li></ul><ul><li>Docetaxel (Taxotere) </li></ul><ul><li>Etoposide (VePesid) </li></ul><ul><li>Teniposide (Vumon) </li></ul><ul><li>Vinblastine SO4 (Velban) </li></ul><ul><li>Vincristine SO4 (Oncovin): neurotoxicity (numbness & tingling of fingers & toes), peripheral neuropathy, ptosis </li></ul><ul><li>Vinorelbine (Navelbine) </li></ul>
  24. 24. Immunomodulator Agents <ul><li>Stimulate immune system to recognize CA cells & destroy them (Interleukins) </li></ul><ul><li>Slow down tumor cell division, causes CA cells to differentiate into non-proliferative forms (Interferons) </li></ul>
  25. 25. Immunomodulator Agents <ul><li>Aldesleukin (Proleukin, Interleukin-2) </li></ul><ul><li>Interferon alfa-2a </li></ul><ul><li>Interferon alfa-2b </li></ul><ul><li>Interferon alfa-n3 (Alferon N) Levamisole (Ergamisole) </li></ul><ul><li>Recombinant interferon-  (Intron A, Roferon A) </li></ul><ul><li>Rituximab (Rituxan) </li></ul>
  26. 26. Colony-Stimulating Factors <ul><li>Induce rapid BM recovery after chemotherapy </li></ul><ul><li>Granulocyte-Macrophage: Sargramostim (Leukin, Prokine) </li></ul><ul><li>Granulocyte: Filgrastim (Neupogen) </li></ul><ul><li>Erythropoetin: Epoetin alfa (Epogen) </li></ul>
  27. 27. CANCER TX MODALITIES: Radiation <ul><li>Use of ionizing radiation that kills CA & rapidly growing cells & inhibit their growth </li></ul><ul><li>Types of energy </li></ul><ul><ul><li>Alpha rays: don’t penetrate skin tissue </li></ul></ul><ul><ul><li>Beta rays: penetrate skin (e.g. internal radiation) </li></ul></ul><ul><ul><li>Gamma rays: penetrate deeper, underlying tissues (e.g. external radiation) </li></ul></ul>
  28. 28. CANCER TX MODALITIES: Radiation <ul><li>Factors Affecting Delivery </li></ul><ul><ul><li>Half-life: time required for the ½ of the radioisotope to decay </li></ul></ul><ul><ul><li>Time: less time, less exposure </li></ul></ul><ul><ul><li>Distance: the farther the source, the lesser the exposure </li></ul></ul><ul><ul><li>Shielding: Alpha & Beta rays can be blocked by gloves, Gamma rays can be blocked by thick, lead gown & concrete </li></ul></ul>
  29. 29. CANCER TX MODALITIES: Radiation <ul><li>Methods of Delivery </li></ul><ul><ul><li>Internal: utilizes injection/ implantation of radioactive isotopes proximal to CA sites for specified period of time </li></ul></ul><ul><ul><ul><li>Sealed: within a container, don’t contaminate with body fluids </li></ul></ul></ul><ul><ul><ul><li>Unsealed: e.g. Phosphorus 32 </li></ul></ul></ul><ul><ul><li>External: uses electromagnetic waves e.g. Cobalt </li></ul></ul>
  30. 30. CANCER TX MODALITIES: Teletherapy/Beam Radiation <ul><li>Source: external radiation </li></ul><ul><li>Pt does not emit radiation & does not pose a hazard to anyone else </li></ul><ul><li>Wash area with water & mild soap, using the hand than a washcloth, rinse & pat dry with soft towel </li></ul><ul><li>Don’t remove radiation markings from the skin </li></ul>
  31. 31. CANCER TX MODALITIES: Teletherapy/Beam Radiation <ul><li>No powder, ointment, lotion or cream on area unless ordered </li></ul><ul><li>Wear soft clothing over the area, avoid constrictive garments </li></ul><ul><li>Avoid sun & heat exposure </li></ul><ul><li>WOF weeping of skin (moist desquamation) & if noted, cleanse the area with warm water & pat dry, apply antibiotic or steroid cream as ordered & expose the site to air </li></ul>
  32. 32. CANCER TX MODALITIES: Brachytherapy Radiation <ul><li>Source: internal radiation (sealed or unsealed) </li></ul><ul><li>For a pd. of time the pt emits radiation & pose a hazard to others </li></ul>
  33. 33. CANCER TX MODALITIES: Brachytherapy Radiation <ul><li>Unsealed Radiation Source </li></ul><ul><ul><li>Administered PO or IV or instillation into body cavities </li></ul></ul><ul><ul><li>It enters body fluids, eliminated via various excreta (radioactive & harmful to others esp. the 1 st 48 hrs) </li></ul></ul>
  34. 34. CANCER TX MODALITIES: Brachytherapy Radiation <ul><li>Sealed Radiation Source </li></ul><ul><ul><li>Temporary or permanent solid implant within tumor target tissues </li></ul></ul><ul><ul><li>The pt emits radiation while the implant is in place, but the excreta is not radioactive </li></ul></ul><ul><ul><li>Place the pt in a private room with private bath </li></ul></ul><ul><ul><li>Place a caution sign on the pt’s door </li></ul></ul>
  35. 35. CANCER TX MODALITIES: Brachytherapy Radiation <ul><li>Sealed Radiation Source </li></ul><ul><ul><li>Organize nursing tasks to minimize exposure to radiation source </li></ul></ul><ul><ul><li>Nursing staff assignments should be rotated, a nurse should never care for more than 1 pt with radiation implant at a time, avoid assigning a pregnant nurse </li></ul></ul><ul><ul><li>Limit time to 30 mins per care provider/shift </li></ul></ul>
  36. 36. CANCER TX MODALITIES: Brachytherapy Radiation <ul><li>Sealed Radiation Source </li></ul><ul><ul><li>Wear a dosimeter film badge to measure radiation exposure </li></ul></ul><ul><ul><li>Wear a lead shield </li></ul></ul><ul><ul><li>Do not allow children <16 y/o or pregnant woman to visit the pt </li></ul></ul><ul><ul><li>Limit visitors to 30 min./day, at least 6 ft from the pt </li></ul></ul><ul><ul><li>Save bed linens & dressings until the source is removed then dispose </li></ul></ul><ul><ul><li>Other equipments can be removed from the room at any time </li></ul></ul>
  37. 37. CANCER TX MODALITIES: Brachytherapy Radiation <ul><li>Dislodged Sealed Radiation Source </li></ul><ul><ul><li>Don’t touch it with bare hands, use a long-handled forceps to place the source in a lead container kept in the pt’s room & notify MD </li></ul></ul><ul><ul><li>If unable to locate the radiation source, bar visitors & notify MD </li></ul></ul>
  38. 38. CANCER TX MODALITIES: Brachytherapy Radiation <ul><li>Sealed Radiation Source Removal </li></ul><ul><ul><li>Pt is no longer radioactive </li></ul></ul><ul><ul><li>Inform the pt that sexual partner cannot “catch” CA </li></ul></ul><ul><ul><li>Pt may resume sexual intercourse after 7-10 days for cervical or vaginal implant </li></ul></ul><ul><ul><li>Perform povidone-iodine douche as ordered for cervical implant </li></ul></ul><ul><ul><li>Administer Fleet enema as ordered </li></ul></ul><ul><ul><li>Notify MD if N/V/D, frequent urination, vaginal or rectal bleeding, hematuria, foul-smelling vaginal discharge, abdominal pain/distention or fever occurs </li></ul></ul>
  39. 39. CANCER TX MODALITIES: Radiation <ul><li>Major S/E & Nursing Interventions </li></ul><ul><ul><li>Skin erythema, redness, irritation & sloughing of tissue </li></ul></ul><ul><ul><ul><li>Assist in bathing the pt </li></ul></ul></ul><ul><ul><ul><li>Force fluids </li></ul></ul></ul><ul><ul><ul><li>Avoid lotion, talcum powder; may use cornstarch or olive oil </li></ul></ul></ul><ul><ul><li>BM depression (same as in chemo) </li></ul></ul><ul><ul><li>GIT disturbance: Dysgeusia-  taste sensation esp. with internal implant </li></ul></ul><ul><ul><ul><li>Oral care, avoid hot & cold foods </li></ul></ul></ul>
  40. 40. LEUKEMIA <ul><li>Group of malignant disease </li></ul><ul><li>Rapid  immature WBC, competes nutrition with mature WBC and production of RBC and platelets </li></ul><ul><li>N= 500 RBC: 1 WBC </li></ul>
  41. 41. LEUKEMIA
  42. 42. CLASSIFICATION OF LEUKEMIA <ul><li>Lympho- affects lymphocytes </li></ul><ul><li>Myelo- affects myeloblasts </li></ul><ul><li>Acute/Blastic- affects immature cells </li></ul><ul><li>Chronic/Cystic- affects mature cells </li></ul><ul><li>Most common in children: Acute Lymphocytic Leukemia (ALL), peak onset 2-6 y/o, M>F </li></ul><ul><li>Acute Myelogenous Leukemia (AML): peak onset 15-39 y/o </li></ul>
  43. 43. Signs and Symptoms: LEUKEMIA <ul><li>From invasion of BM (“Nadir”) </li></ul><ul><ul><li>Infection:  T, poor wound healing, sore throat, bone weakens  fracture, bone & joint pains, lymphadenopathy </li></ul></ul><ul><ul><li>Bleeding: hemorrhage, petechiae, epistaxis, hematoma, hematuria, hematemesis, hepatosplenomegaly </li></ul></ul><ul><ul><li>Anemia: pallor, fatigue, anorexia, constipation </li></ul></ul>
  44. 44. Signs and Symptoms: LEUKEMIA <ul><li>From invasion of CNS </li></ul><ul><ul><li> ICP:  LOC, severe HA, vomiting, papilledema, seizures </li></ul></ul><ul><ul><li>CN VII or spinal nerve involvement </li></ul></ul><ul><li>From invasion of kidneys, testes, prostate, ovaries, GI and lungs </li></ul>
  45. 45. LEUKEMIA <ul><li>Diagnostic Tests </li></ul><ul><ul><li>PBS- (+) immature WBC </li></ul></ul><ul><ul><li>CBC-  immature WBC,  RBC,  platelets </li></ul></ul><ul><ul><ul><li>Done weekly during maintenance phase of chemotherapy </li></ul></ul></ul><ul><ul><li>Lumbar Puncture- CNS affectation </li></ul></ul><ul><ul><ul><li>Shrimp/fetal/C-position, avoid neck flexion may occlude airway of infants and children </li></ul></ul></ul>
  46. 46. LEUKEMIA <ul><li>Diagnostic Tests </li></ul><ul><ul><li>Bone Marrow Aspiration- (+) blast cells (immature WBC), common site: iliac crest </li></ul></ul><ul><ul><ul><li>Post op: apply direct pressure, lie on affected side to stop bleeding </li></ul></ul></ul><ul><ul><li>Bone Scan- to determine bone involvement (fractures) </li></ul></ul><ul><ul><li>CT Scan: to determine organ involvement </li></ul></ul>
  47. 47. LEUKEMIA <ul><li>Triad Management </li></ul><ul><ul><li>Surgery (most preferred) </li></ul></ul><ul><ul><li>(Cranial) Irradiation </li></ul></ul><ul><ul><li>Chemotherapy </li></ul></ul><ul><li>BM transplant </li></ul>
  48. 48. Nursing Management: LEUKEMIA <ul><ul><li>Assess for common side effects: anorexia, nausea and vomiting (give antiemetics 30mins prior to chemo and continue until 1 day post chemo), WOF dehydration </li></ul></ul>
  49. 49. Nursing Management: LEUKEMIA <ul><ul><li>Assure pt that alopecia and hirsutism are temporary side effects, hair will regrow in 3-6 mos. With new color & texture </li></ul></ul>
  50. 50. Nursing Management: LEUKEMIA <ul><ul><li>Assess for stomatitis (oral ulcers) </li></ul></ul><ul><ul><ul><li>Oral care: alcohol-free mouthwash, pNSS with or without NaHCO3 </li></ul></ul></ul><ul><ul><ul><li>Use soft-bristled toothbrush, cotton plegets </li></ul></ul></ul><ul><ul><ul><li>Apply Xylocaine (topical anesthetic) on mouth before meals </li></ul></ul></ul><ul><ul><ul><li>Diet: soft and bland according to child’s preference, small frequent feedings </li></ul></ul></ul>
  51. 51. Nursing Management: LEUKEMIA <ul><ul><li>Protect pt from infection </li></ul></ul><ul><ul><ul><li>Strict hand washing </li></ul></ul></ul><ul><ul><ul><li>Reverse isolation </li></ul></ul></ul><ul><ul><li>Protect pt from additional fatigue </li></ul></ul><ul><ul><ul><li>Bed rest </li></ul></ul></ul><ul><ul><ul><li>Activities balanced with rest </li></ul></ul></ul>
  52. 52. Nursing Management: LEUKEMIA <ul><ul><li>Protect pt from bleeding </li></ul></ul><ul><ul><ul><li>Minimize parenteral injections </li></ul></ul></ul><ul><ul><ul><li>Apply pressure on venipuncture sites </li></ul></ul></ul><ul><ul><ul><li>Use electric razor in shaving </li></ul></ul></ul>
  53. 53. Nursing Management: LEUKEMIA <ul><ul><li>Encourage verbalization of feelings & concerns </li></ul></ul><ul><ul><li>Introduce the family to other families of children with CA </li></ul></ul><ul><ul><li>Consult social services & chaplains as necessary </li></ul></ul>
  54. 54. HODGKIN’S DISEASE/LYMPHOMA <ul><li>Involves lymph nodes, tonsils, spleen & BM </li></ul><ul><li>(+) Reed-Sternberg cell in the nodes </li></ul><ul><li>S/Sx </li></ul><ul><li> T, A/, malaise, fatigue & weakness, wt loss </li></ul><ul><li>Anemia, thrombocytopenia </li></ul><ul><li>Enlarged lymph nodes, spleen & liver </li></ul><ul><li>(+) bx of cervical lymph nodes (affected 1 st ) </li></ul><ul><li>(+) CT scan of liver & spleen </li></ul>
  55. 55. HODGKIN’S DISEASE/LYMPHOMA <ul><li>Management </li></ul><ul><li>External radiation (tx of choice) </li></ul><ul><li>Multiagent chemotx (if extensive) </li></ul><ul><li>WOF S/E: infection, bleeding </li></ul><ul><li>Sperm banking (possibility of sterility for M) </li></ul>
  56. 56. MULTIPLE MYELOMA <ul><li>Malignant proliferation of plasma cells and tumors within the bone, destroying the bone & invading the lymph nodes, spleen & liver </li></ul><ul><li>abN plasma cells produce an abN Ab (myeloma protein or Bence Jones protein) found in blood & urine </li></ul><ul><li> production of Ig & Ab,  uric acid & Ca  RF </li></ul>
  57. 57. S/Sx: MULTIPLE MYELOMA <ul><li>Bone pain (pelvis, spine, ribs) </li></ul><ul><li>Osteoporesis (bone loss, pathological fractures) </li></ul><ul><li>Spinal cord compression & paraplegia </li></ul><ul><li>Weakness & fatigue </li></ul><ul><li>Recurrent infections </li></ul><ul><li>Anemia </li></ul><ul><li>Bence Jones proteinuria,  total serum protein, Ca & uric acid levels </li></ul><ul><li>RF </li></ul><ul><li>Thrombocytopenia, granulocytopenia </li></ul>
  58. 58. Nursing Interventions: MULTIPLE MYELOMA <ul><li>Administer as ordered </li></ul><ul><ul><li>Chemotherapy </li></ul></ul><ul><ul><li>IVF & diuretics (to eliminate Ca) </li></ul></ul><ul><ul><li>BT for anemia </li></ul></ul><ul><ul><li>Analgesics, antibiotics </li></ul></ul><ul><li>WOF bleeding, infection, fractures, RF </li></ul><ul><li>Force fluids </li></ul><ul><li>Encourage ambulation </li></ul><ul><li>Provide skeletal support during moving, turning & ambulating </li></ul><ul><li>Maintain hazard-free env’t </li></ul>
  59. 59. TESTICULAR CANCER <ul><li>Occurs between ages 15-40 </li></ul><ul><li>Common sites of mets: lymph nodes, bone, lungs, adrenal glands & liver </li></ul><ul><li>Types </li></ul><ul><ul><li>Germinal tumors (Seminomas, Nonseminomas) </li></ul></ul><ul><ul><li>Nongerminal tumors (Interstitial cell tumors, Androblastoma) </li></ul></ul>
  60. 60. S/Sx: TESTICULAR CANCER <ul><li>Painless testicular swelling </li></ul><ul><li>Dragging sensation in the scrotum </li></ul><ul><li>S/Sx of mets: palpable lymphadenopathy, abdominal masses, gynecomastia </li></ul><ul><li>Late S/Sx: back or bone pain & respiratory Sx </li></ul>
  61. 61. Tx: TESTICULAR CANCER <ul><li>Chemotherapy </li></ul><ul><li>Radiation </li></ul><ul><li>Surgery </li></ul><ul><ul><li>Unilateral orchiectomy- for dx & primary surgical mgt. </li></ul></ul><ul><ul><li>Radical retroperitoneal lymph node dissection- to stage the CA &  tumor vol. </li></ul></ul><ul><li>Reproductive options: sperm storage, donor insemination & adoption </li></ul>
  62. 62. Nursing Interventions: s/p Testicular Surgery <ul><li>Suture removal: 7-10 days post-op </li></ul><ul><li>May resume N activities within 1 week except for lifting heavy objects > 20 lbs or stair climbing </li></ul><ul><li>Perform monthly testicular self-exam on the remaining testicle </li></ul>
  63. 63. BREAST CANCER <ul><li>Common sites of mets: lymph nodes, bone, lungs, brain & liver </li></ul><ul><li>Precipitating factors </li></ul><ul><ul><li>Genetics </li></ul></ul><ul><ul><li>Early menarche & late menopause </li></ul></ul><ul><ul><li>Nulliparity </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>High-dose radiation exposure to chest </li></ul></ul>
  64. 64. S/Sx: BREAST CANCER <ul><li>Mass felt during BSE (usually in the upper outer quadrant or beneath the nipple) </li></ul><ul><li>Fixed, irregular, nonencapsulated mass </li></ul><ul><li>Painless (early stage) or painful (late stage) mass </li></ul><ul><li>Nipple retraction or elevation </li></ul><ul><li>Assymetrical breast (affected breast higher) </li></ul><ul><li>Bloody or clear nipple d/c </li></ul>
  65. 65. S/Sx: BREAST CANCER <ul><li>Skin dimpling, retraction or ulceration </li></ul><ul><li>Skin edema or peau d’orange skin </li></ul><ul><li>Axillary lymphadenopathy </li></ul><ul><li>Lymphedema of affected arm </li></ul><ul><li>Presence of lesion on mammography </li></ul><ul><li>S/Sx of lung/bone mets </li></ul>
  66. 66. Nonsurgical Tx: BREAST CANCER <ul><li>Chemotx </li></ul><ul><li>Radiation tx </li></ul><ul><li>Hormonal manipulation in post menopausal women </li></ul><ul><li>Meds: Tamoxifen (Nolvadex) for estrogen receptor-positive tumors </li></ul>
  67. 67. Surgical Tx: BREAST CANCER <ul><li>Lumpectomy: removal of tumor with lymph node dissection </li></ul><ul><li>Simple Mastectomy: removal of breast tissue & nipple, lymph nodes left intact </li></ul><ul><li>Modified Radical Mastectomy: removal of breast tissue, nipple & lymph nodes, muscles left intact </li></ul><ul><li>Halsted Radical Mastectomy: removal of breast tissue, nipple, lymph nodes & underlying muscles </li></ul>
  68. 68. Surgical Tx: BREAST CANCER <ul><li>Oophorectomy: for estrogen receptor-positive tumors </li></ul><ul><li>Ablative therapy with adrenalectomy or chemical ablation which blocks cortisol, androstenedione & aldosterone production </li></ul>
  69. 69. Nursing Interventions: s/p Breast Surgery <ul><li>Semi-Fowlers’ position, turn from back to unaffected side, with affected arm elevated above the heart level to promote drainage & prevent lymphedema </li></ul><ul><li>Use a pressure sleeve if edema is severe </li></ul><ul><li>Maintain Jackson-Pratt suction, record the amount & characteristic of draiange </li></ul><ul><li>No IV, injections, BP, venipunctures in affected arm </li></ul><ul><li>Low Na-diet, diuretics for severe lymphedema </li></ul><ul><li>Refer to MD & PT for appropriate exercise program </li></ul>
  70. 70. Health Teaching: s/p Breast Surgery <ul><li>Protect & avoid overuse of the hand & arm during the 1 st few months </li></ul><ul><li>Keep the affected arm elevated to prevent lymphedema </li></ul><ul><li>Incision care with lanolin to soften & prevent wound contractures </li></ul><ul><li>BSE on the remaining breast </li></ul><ul><li>Avoid strong sunlight or heat to the affected arm </li></ul><ul><li>Don’t carry anything heavy over the affected arm </li></ul>
  71. 71. Health Teaching: s/p Breast Surgery <ul><li>Avoid constrictive clothing/jewelry, trauma, cuts, bruises or burns to the affected arm </li></ul><ul><li>Wear gloves when gardening, washing dishes/clothes </li></ul><ul><li>Use thick oven mitten mitts when cooking </li></ul><ul><li>Use a thimble when sewing </li></ul><ul><li>Apply lanolin hand cream several times daily </li></ul><ul><li>Use cream cuticle remover </li></ul><ul><li>Notify MD if S/ of inflammation occur in the affected arm </li></ul><ul><li>Wear a Medic-Alert bracelet stating lymphedema arm </li></ul>
  72. 72. CERVICAL CANCER <ul><li>Premalignant changes: (Stage I) mild dysplasia to (Stage II) mod. dysplasia to (Stage III) severe dysplasia to carcinoma in situ </li></ul><ul><li>Common sites of mets: pelvis & lymphatics </li></ul><ul><li>Precipitating factors </li></ul><ul><ul><li>Low socioeconomic groups </li></ul></ul><ul><ul><li>Early 1 st marriage </li></ul></ul><ul><ul><li>Early & frequent intercourse </li></ul></ul><ul><ul><li>Multiple sex partners </li></ul></ul><ul><ul><li>High parity </li></ul></ul><ul><ul><li>Poor hygiene </li></ul></ul>
  73. 73. S/Sx: CERVICAL CANCER <ul><li>Painless vaginal bleeding postmenstrually & postcoitally </li></ul><ul><li>Foul-smelling or serosanguinous vaginal d/c </li></ul><ul><li>Leakage of urine or feces from the vagina </li></ul><ul><li>Dysuria, hematuria </li></ul><ul><li>Pelvic, lower back, leg or groin pain </li></ul><ul><li>A/, wt loss </li></ul><ul><li>Changes on Pap smear </li></ul>
  74. 74. Tx: CERVICAL CANCER <ul><li>Nonsurgical </li></ul><ul><ul><li>Chemotherapy </li></ul></ul><ul><ul><li>Cryosurgery </li></ul></ul><ul><ul><li>External radiation </li></ul></ul><ul><ul><li>Internal radiation (intracavitary) </li></ul></ul><ul><ul><li>Laser therapy </li></ul></ul><ul><li>Surgical </li></ul><ul><ul><li>Conization </li></ul></ul><ul><ul><li>Hysterectomy </li></ul></ul><ul><ul><li>Pelvic exenteration </li></ul></ul>
  75. 75. CERVICAL CA: Laser Therapy <ul><li>Energy from the beam is absorbed by fluid in the tissues, causing them to vaporize </li></ul><ul><li>Minimal bleeding & slight vaginal d/c is expected after the procedure, healing occurs in 6-12 wks </li></ul>
  76. 76. CERVICAL CA: Cryosurgery <ul><li>Involves freezing of the tissues by a probe with subsequent necrosis </li></ul><ul><li>No anesthesia required </li></ul><ul><li>Cramping may occur during the procedure </li></ul><ul><li>A heavy, watery d/c is expected several wks after the procedure, use tampons </li></ul><ul><li>Avoid sexual intercourse </li></ul>
  77. 77. CERVICAL CA: Conization <ul><li>A cone-shaped area of the cervix is removed </li></ul><ul><li>For women who want further child bearing </li></ul><ul><li>Long-term follow-up is needed (new lesions may develop) </li></ul><ul><li>Cx: hemorrhage, uterine perforation, incompetent cervix, cervical stenosis & preterm labor </li></ul>
  78. 78. CERVICAL CA: Hysterectomy <ul><li>Vaginal approach for microinvasive CA if childbearing is not desired </li></ul><ul><li>Radical hysterectomy & bilateral lymph node dissection for CA that spread beyond the cervix but not to the pelvic wall </li></ul>
  79. 79. Nursing Interventions: s/p Hysterectomy <ul><li>Monitor vaginal bleeding (>1 saturated pad/hr) </li></ul><ul><li>Avoid stair climbing for 1 mo. </li></ul><ul><li>Avoid tub baths & sitting for long periods </li></ul><ul><li>Avoid strenous activity or lifting >20 lbs </li></ul><ul><li>Avoid sexual intercourse for 3-6 wks </li></ul>
  80. 80. CERVICAL CA: Pelvic exenteration <ul><li>Radical surgical procedure for recurrent CA </li></ul><ul><li>When the bladder is removed, an ileal conduit is created & located at the R side of the abdomen to divert urine </li></ul><ul><li>A colostomy is created on the L side of the abdomen for the passage of feces </li></ul>
  81. 81. CERVICAL CA: Types of Pelvic Exenteration <ul><li>Anterior </li></ul><ul><ul><li>Removal of uterus, ovaries, fallopian tubes, vagina, bladder, urethra & pelvic lymph nodes </li></ul></ul><ul><li>Posterior </li></ul><ul><ul><li>Removal of uterus, ovaries, fallopian tubes, descending colon, rectum & anal cnal </li></ul></ul><ul><li>Total </li></ul><ul><ul><li>Combo of anterior & posterior </li></ul></ul>
  82. 82. Nursing Interventions: s/p Pelvic exenteration <ul><li>Administer perineal irrigation with half-strength H2O2 & NS </li></ul><ul><li>Avoid strenous activity for 6 mos. </li></ul><ul><li>Perineal opening may drain for several mos. </li></ul><ul><li>Ileal conduit & colostomy care </li></ul><ul><li>Sexual counseling: vaginal intercourse is not possible s/p anterior & total pelvic exenteration </li></ul>
  83. 83. OVARIAN CANCER <ul><li>Grows rapidly, spreads fast, often bilateral </li></ul><ul><li>Common sites of mets: pelvis, lymphatics & peritoneum </li></ul><ul><li>Usually detected late: Poor prognosis </li></ul><ul><li>Exploratory laparotomy: to dx & stage the tumor </li></ul>
  84. 84. S/Sx: OVARIAN CANCER <ul><li>Abdominal discomfort or swelling </li></ul><ul><li>GI disturbance </li></ul><ul><li>Dysfunctional vaginal bleeding </li></ul><ul><li>Abdominal mass </li></ul>
  85. 85. Tx: OVARIAN CANCER <ul><li>External radiation: if with mets </li></ul><ul><li>Chemotherapy: done post-op for all stages of CA </li></ul><ul><li>Intraperitoneal chemotx: instillation into abdominal cavity </li></ul><ul><li>Immunotherapy: promotes tumor resistance </li></ul><ul><li>Surgery: TAHBSO </li></ul>
  86. 86. ENDOMETRIAL CANCER <ul><li>Slow-growing tumor asso. with menopausal years </li></ul><ul><li>Common sites of mets: ovaries, pelvis, peritoneum, lymphatics & via blood to the lungs, liver & bone </li></ul><ul><li>Precipitating Factors </li></ul><ul><ul><li>Hx of uterine polyps </li></ul></ul><ul><ul><li>Nulliparity </li></ul></ul><ul><ul><li>Polycystic ovary disease </li></ul></ul><ul><ul><li>Estrogen stimulation </li></ul></ul><ul><ul><li>Late menopause </li></ul></ul><ul><ul><li>Family hx </li></ul></ul>
  87. 87. S/Sx: ENDOMETRIAL CANCER <ul><li>Postmenopausal bleeding </li></ul><ul><li>Watery, serosanguinous discharge </li></ul><ul><li>Low back, pelvic or abdominal pain </li></ul><ul><li>Enlarged uterus in advanced stages </li></ul>
  88. 88. Tx: ENDOMETRIAL CANCER <ul><li>External or internal radiation </li></ul><ul><li>Chemotherapy for advanced or recurrent CA </li></ul><ul><li>Medroxyprogesterone (Depo-Provera) or Megestrol) Megace for estrogen-dependent tumors </li></ul><ul><li>Tamoxifen (Nolvadex): antiestrogen </li></ul><ul><li>Surgery: TAHBSO </li></ul>
  89. 89. GASTRIC CANCER <ul><li>Predisposing Factors </li></ul><ul><ul><li>Diet: high in complex CHO, grains & salt, low in fresh green, leafy vegetables & fruits </li></ul></ul><ul><ul><li>Use of nitrates </li></ul></ul><ul><ul><li>Smoking, alcoholism </li></ul></ul><ul><ul><li>Hx of gastric ulcers </li></ul></ul><ul><li>Cx: hemorrhage, obstruction, mets & dumping syndrome </li></ul><ul><li>Goal of Tx: remove the tumor & provide nutritional support </li></ul>
  90. 90. S/Sx: GASTRIC CANCER <ul><li>A/N/V, wt loss </li></ul><ul><li>Fatigue, anemia </li></ul><ul><li>Indigestion, epigastric discomfort </li></ul><ul><li>A sensation of pressure in the stomach </li></ul><ul><li>Dysphagia </li></ul><ul><li>Ascites </li></ul><ul><li>Palpable mass </li></ul>
  91. 91. Tx: GASTRIC CANCER <ul><li>Chemotx </li></ul><ul><li>Radiation </li></ul><ul><li>Surgery </li></ul><ul><ul><li>Subtotal gastrectomy </li></ul></ul><ul><ul><ul><li>Bilroth I: Gastroduodenostomy </li></ul></ul></ul><ul><ul><ul><li>Bilroth II: Gastrojejunostomy </li></ul></ul></ul><ul><ul><li>Total gastrectomy </li></ul></ul><ul><ul><ul><li>Esophagojejunostomy </li></ul></ul></ul>
  92. 92. Nursing Interventions: GASTRIC CANCER <ul><li>Fowler’s position for comfort: Pain meds as ordered </li></ul><ul><li>Monitor Hgb, Hct: BT as ordered </li></ul><ul><li>NPO for 1-3 days post-op until peristalsis returns </li></ul><ul><li>Monitor I/O: IVF & e+ as ordered </li></ul><ul><li>Monitor NGT suction, don’t irrigate or remove NGT </li></ul>
  93. 93. Nursing Interventions: GASTRIC CANCER <ul><li>Progressive diet to 6 small bland meals/day </li></ul><ul><li>Monitor wt, nutritional status: Small, bland, easy digestible meals with vit & mineral supplements </li></ul><ul><li>WOF Cx: hemorrhage, dumping syndrome, diarrhea, hypoglycemia, Vit B12 deficiency </li></ul>
  94. 94. PANCREATIC CANCER <ul><li>More common in blacks than in whites, in smokers & in men </li></ul><ul><li>Linked with DM, alcohol use, hx of pancreatitis, high fat diet, env’tal chemicals </li></ul><ul><li>With poor prognosis </li></ul>
  95. 95. S/Sx: PANCREATIC CANCER <ul><li>N/V </li></ul><ul><li>Jaundice </li></ul><ul><li>Unexplained wt. loss </li></ul><ul><li>Clay-colored stool </li></ul><ul><li>Glucose intolerance </li></ul><ul><li>Abdominal pain </li></ul>
  96. 96. Tx: PANCREATIC CANCER <ul><li>Radiation </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Whipple’s procedure: pancreaticoduodenectomy with removal of distal third of the stomach, pancreaticojejunostomy, gastrojejunostomy & choledochojejunostomy </li></ul>
  97. 97. INTESTINAL TUMORS <ul><li>Develop in the cells lining the bowel wall or develop as polyps in the colon or rectum </li></ul><ul><li>Cx: bowel perforation with peritonitis, abscess & fistula formation, hemorrhage & complete gut obstruction </li></ul><ul><li>Common sites of mets: via lymphatics & blood, colon & other organs </li></ul>
  98. 98. S/Sx: INTESTINAL TUMORS <ul><li>A/V, malaise, wt loss </li></ul><ul><li>Blood in stools, anemia </li></ul><ul><li>AbN stools </li></ul><ul><ul><li>Ascending colon tumor: diarrhea </li></ul></ul><ul><ul><li>Descending colon tumor: constipation with some diarrhea, ribbon-like stool </li></ul></ul><ul><ul><li>Rectal tumor: alternating constipation & diarrhea </li></ul></ul><ul><li>Guarding or abdominal distention </li></ul><ul><li>Abdominal mass & cachexia (late signs) </li></ul>
  99. 99. Nursing Interventions: INTESTINAL TUMORS <ul><li>WOF bowel perforation:  BP,  HR,  T, weak pulse, distended abdomen </li></ul><ul><li>WOF intestinal obstruction: (EARLY S/Sx-  peristalsis,  to  bowel sounds) fecal vomiting, pain, constipation, distended abdomen </li></ul><ul><li>Radiation pre-op </li></ul><ul><li>Chemotherapy post-op </li></ul><ul><li>Surgery: bowel resection & creation of colo or ileostomy </li></ul>
  100. 100. COLO/ILEOSTOMY PRE-OP CARE <ul><li>Consult with enterostomal therapist to identify optimal placement of ostomy </li></ul><ul><li>Low-residue diet for 1-2 days pre-op </li></ul><ul><li>Give intestinal antiseptics & antibiotics, laxatives & enemas as ordered </li></ul>
  101. 101. COLOSTOMY POST-OP CARE <ul><li>Apply petroleum jelly over the stoma to keep it moist followed by dry sterile gauze if pouch system is not yet in place </li></ul><ul><li>Monitor the stoma for size, unusual bleeding or necrotic tissue </li></ul><ul><li>Monitor the stoma for color </li></ul><ul><ul><li>N: pink or red indicating  vascularity </li></ul></ul><ul><ul><li>Pale: anemia, Violet/Blue/Black: compromised circulation </li></ul></ul>
  102. 102. COLOSTOMY POST-OP CARE <ul><li>Check pouch system for proper fit & leakage </li></ul><ul><li>Ascending colon colostomy: expect liquid stool </li></ul><ul><li>Transverse colon colostomy: expect loose to semiformed stool </li></ul><ul><li>Descending colon: expect close to N stool </li></ul><ul><li>Empty pouch when 1/3 full, remove feces from the skin </li></ul><ul><li>Avoid gas/odor-forming foods </li></ul>
  103. 103. COLOSTOMY POST-OP CARE <ul><li>WOF perineal wound infection (if present) </li></ul><ul><li>Administer as ordered </li></ul><ul><ul><li>Analgesics & antibiotics </li></ul></ul><ul><ul><li>Stoma irrigation </li></ul></ul>
  104. 104. ILEOSTOMY POST-OP CARE <ul><li>Post-op drainage: dark green to yellow (as the pt begins to eat) </li></ul><ul><li>Expect liquid stool </li></ul><ul><li>WOF dehydration & e+ imbalance </li></ul><ul><li>Avoid suppositories through ileostomy </li></ul>
  105. 105. LUNG CANCER <ul><li>Lungs: common target for mets from other organs </li></ul><ul><li>Bronchiogenic carcinoma: direct extension & via lymphatics </li></ul><ul><li>4 Major Types </li></ul><ul><ul><li>Small (Oat) Cell </li></ul></ul><ul><ul><li>Epidermal (Squamous Cell) </li></ul></ul><ul><ul><li>Adenocarcinoma </li></ul></ul><ul><ul><li>Large cell anaplastic carcinoma </li></ul></ul>
  106. 106. LUNG CANCER <ul><li>Causes </li></ul><ul><ul><li>Cigarette smoking </li></ul></ul><ul><ul><li>Env’tal & occupational pollutants </li></ul></ul><ul><li>Dx: CXR (lesion or mass), bronchoscopy & sputum cytological studies </li></ul>
  107. 107. S/Sx: LUNG CANCER <ul><li>Cough </li></ul><ul><li>Dyspnea </li></ul><ul><li>Hoarseness </li></ul><ul><li>Hemoptysis </li></ul><ul><li>Chest pain </li></ul><ul><li>A/ wt loss </li></ul><ul><li>Weakness </li></ul>
  108. 108. Nursing Interventions: LUNG CANCER <ul><li>Monitor VS, pulse oximetry </li></ul><ul><li>Fowler’s position </li></ul><ul><li>WOF RR distress, tracheal deviation, bleeding, infection & e+ imbalance </li></ul><ul><li>Activity as tolerated, rest periods, active/passive ROM </li></ul><ul><li>Diet:  calorie, high CHON,  Vit </li></ul><ul><li>Administer as ordered </li></ul><ul><ul><li>O2, bronchodilators, steroids </li></ul></ul><ul><ul><li>Analgesics </li></ul></ul><ul><ul><li>CPT </li></ul></ul>
  109. 109. Tx: LUNG CANCER <ul><li>Radiation </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Immunotherapy </li></ul><ul><li>Surgery </li></ul><ul><ul><li>Laser therapy: to relieve endobronchial obstruction </li></ul></ul><ul><ul><li>Thoracentesis & pleurodesis: to remove pleural fluid & relieve hypoxia </li></ul></ul><ul><ul><li>Thoracotomy with pneumonectomy or lobectomy or segmental resection </li></ul></ul>
  110. 110. Pre-op Care: LUNG CANCER <ul><li>Explain the potential post-op need for chest tubes </li></ul><ul><li>Closed chest drainage is not used for pneumonectomy & the serum fluid that accumulates in the empty thoracic cavity will consolidate, preventing mediastinal shift </li></ul>
  111. 111. Post-op Care: LUNG CANCER <ul><li>Monitor VS, breath sounds </li></ul><ul><li>Maintain chest tube drainage system, WOF SQ emphysema </li></ul><ul><li>Avoid complete lateral turning </li></ul><ul><li>Activity as tolerated, active ROM of the operative shoulder </li></ul><ul><li>Administer O2 as ordered </li></ul>
  112. 112. PROSTATE CANCER <ul><li>Slow-growing, androgen type of adenocarcinoma in M >50 y/o </li></ul><ul><li>Common sites of mets: bloodstream, lymphatics, pelvis, spine, bone </li></ul>
  113. 113. S/Sx: PROSTATE CANCER <ul><li>(-) in early stages </li></ul><ul><li>Hard, pea-sized nodule on rectal exam </li></ul><ul><li>Hematuria </li></ul><ul><li>Late S/Sx: wt loss, urinary obstruction, pain radiating from the lumbosacral area down the leg </li></ul><ul><li>Prostate-specific Ag test: monitors the pt’s response to tx </li></ul><ul><li> serum acid phosphatase: indicates spread & mets </li></ul>
  114. 114. Tx: PROSTATE CANCER <ul><li>Hormonal manipulation </li></ul><ul><ul><li>LT: leuprolide acetate (Lupron), flutamide (Eulexin) or DES </li></ul></ul><ul><ul><li>Goserelin acetate (Zoladex) when orchiectomy or estrogen administration is not acceptable for the pt </li></ul></ul><ul><li>Radiation & Chemotx for hormone-resistant tumors </li></ul>
  115. 115. Tx: PROSTATE CANCER <ul><li>Palliative surgery: Orchiectomy (to  testosterone production) </li></ul><ul><li>Cryosurgical ablation (liquid nitrogen freezes the prostate, dead cells are absorbed by the body) </li></ul><ul><li>Transurethral resection of the prostate (TURP) or prostatectomy </li></ul>
  116. 116. PROSTATE CA: TURP <ul><li>Insertion of a scope into the urethra to excise prostatic tissue </li></ul><ul><li>Bleeding is common post-op, WOF hemorrhage </li></ul><ul><li>Continuous bladder irrigation (CBI) post-op to maintain the urine at a pink color </li></ul><ul><li>Bladder spasms are common post-op, give antispasmodics as ordered </li></ul><ul><li>WOF dribbling & incontinence </li></ul><ul><li>Sterility may or may not occur post-op </li></ul>
  117. 117. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal Technique Via abdominal & bladder incision Via low abdominal incision without opening the bladder Via incision bet. scrotum & anus Hemorrhage Yes No No Bladder spasms Yes Yes but less Urinary incontinence common
  118. 118. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal CBI Yes Yes - Sterility Yes Yes Yes Remarks Abdominal dressing soaked frequently with urine, Longer healing time than TURP Minimal abdominal drainage WOF infection, (No rectal tubes, rectal temp. taking & enema) Teach perineal exercises
  119. 119. Nursing Interventions: s/p TURP <ul><li>Monitor VS, U.O., hematuria & clots, Hgb & Hct levels </li></ul><ul><li>Force fluids </li></ul><ul><li>Expect red to light pink urine for 24 hrs, turning to amber in 3 days (then encourage ambulation) </li></ul><ul><li>WOF arterial bleeding (bright red urine with clots):  CBI & notify MD </li></ul><ul><li>WOF venous bleeding (burgundy-colored urine): notify MD who will apply traction on the catheter </li></ul><ul><li>Continuous urge to void is N but not encouraged to prevent bladder spasms </li></ul><ul><li>Antibiotics, analgesics, stool softeners & antispasmodics as ordered </li></ul>
  120. 120. Nursing Interventions: s/p TURP <ul><li>Monitor 3-way foley catheter (for the balloon (30-45 cc), inflow & outflow) </li></ul><ul><li>Use pNSS only to prevent water intoxication or hypoNa (  LOC,  HR,  BP) </li></ul><ul><li>Maintain infusion rate as ordered, if (+) clots:  rate </li></ul><ul><li>For obstructed catheter: turn off CBI, irrigate with 30-50 ml pNSS, notify MD if it does not resolve </li></ul><ul><li>CBI is d/c usually after 1-2 days, WOF continence & urinary retention </li></ul>
  121. 121. Discharge Health Teaching: s/p TURP <ul><li>Avoid heavy lifting, stressful exercise, driving, Valsalva maneuver & sexual intercourse for 2-6 wks </li></ul><ul><li>Drink 2.4-3L fluids/day before 8 pm </li></ul><ul><li>Avoid alcohol, caffeine & spicy foods to prevent overstimulation of the bladder </li></ul><ul><li>Pt may pass small clots & tissue debris for several days </li></ul><ul><li>If urine becomes less in amount & bloody, rest & force fluids, notify MD if persistent </li></ul>
  122. 122. Nursing Interventions: s/p Suprapubic Prostatectomy <ul><li>Monitor foley catheter & suprapubic catheter drainage </li></ul><ul><li>As ordered, clamp the suprapubic cath after foley cath is removed (2-4 days post-op) & instruct the pt to void, measure residual urine by unclamping the cath & measuring the U.O. </li></ul><ul><li>Prepare for removal of suprapubic cath if pt consistently empties bladder & residual urine is <75 ml </li></ul>

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