0133427269 Module02 CellularReg LectureOutline

Module 2 Cellular Regulation  The Concept of Cellular Regulation Cell ( basic unit of life, working unit of all living systems Life starts as single cell Developed human body ( trillions of cells Common features Specialized cells Body regulates reproduction, proliferation, growth of cell Normal cellular regulation Physiology review Cell membrane Defined boundary, definite shape, holds cell contents together Protective covering Allows materials in and out of cell See Table 21 METHODS OF CELLULAR TRANSPORTATION, p. 30 Cytoplasm ( watery soup of proteins, nucleic acids, gases, salts, other substances Nucleus and nucleolus Regulates and directs activities of the organelles in the cell Nucleus surrounded by double-walled nuclear membrane Membrane has large pores to allow certain materials in and out Chromosomes Nucleolus within nucleus Centrosomes Ribosomes ( organelles found in endoplasmic reticulum, made of RNA, assist in production of enzymes, other proteins needed for cell repair, reproduction Endoplasmic reticulum Series of channels in cytoplasm Folded membranes Two forms ( rough, smooth Synthesizes protein, synthesizes lipids Mitochondria Tiny bean-shaped organelles Cells power plant 95 of bodys energy needs for cellular repair, movement, and reproduction Enzymes help to take in oxygen ( use it to produce energy Golgi apparatus Looks like flattened, membranous sac Protein received from endoplasmic reticulum ( portion of Golgi apparatus envelops the protein Cells of organs with high level of secretion, storage (digestive system) contain larger Golgi apparatus Lysosomes Vesicles containing enzymes Clean up intracellular debris, other waste Assist with phagocytosis Genetic and lifespan considerations DNA and genes All human cells except red blood cells Complete set of DNA molecules All of DNA referred to as human genome complete set of inheritance for an individual Cell nucleus contains about 6 feet of DNA Cell cycle Human cells divide in two ways Mitosis is process of making new cells ( takes place in somatic cells (tissue) Meiosis ( reduction division of cell Only in sex cells of testes, ovaries Controlled by cyclins ( ensure cell cycle proceeds in correct order Differentiation ( normal process occurring over many cell cycles Allows cells to specialize in certain tasks Alterations to cellular regulation Hyperplasia ( increase in number or density of normal cells In response to stress Increased metabolic demands Elevated levels of hormones Under normal DNA control Reversible Metaplasia ( change in normal pattern of differentiation ( dividing cells differentiate into cell types not normally found at that location in body Metaplastic cell normal for particular type but not in normal location Some cells less functional than cells they replace In response to stressor ( reversible Under normal DNA control Dysplasia ( loss of DNA control over differentiation occurring in response to adverse conditions Anaplasia ( regression of a cell to an immature or undifferentiated cell type Any of differences in cellular regulation have potential to become cancerous, compromise client health Prevalence Cancer ( 41.24 of men and women born today will be diagnosed with cancer at some point in their lives Anemia ( prevalence depends on cause see exemplar on Anemia Sickle cell disease ( estimated 70,000 100,000 people in the U.S. affected greater prevalence among Black/African American population Genetic considerations and nonmodifiable risk factors Cancer Certain forms of cancer have a genetic component such as breast, ovarian, prostate, and colon Low socioeconomic status and lack of healthcare coverage are associated with increased risk of developing cancer Anemia ( depend on underlying cause of the disorder see exemplar on Anemia Sickle cell disease ( development depends entirely on genetics see exemplar on Sickle Cell Disease See CONCEPTS RELATED TO CELLULAR REGULATION, p. 33 Case Study, Part 1 ( Andrew, an 8-year-old Native American male, is brought to the emergency department by his mother Prevention Modifiable risk factors Increase intake of fruits and vegetables Encourage use of sunscreen Discourage smoking Test homes for radon Screenings For families with history of cancer ( encourage family to learn more and increase surveillance For all families ( inform adolescent and adults about appropriate screenings such as Pap tests and testicular self-examination Assessment Highly dependent on specific alterations and organ system involved Ongoing assessment includes stress and coping abilities of client and family members Assessment also includes nutrition and hydration of client Nursing assessment Assess all clients for early warning signs of cancer Teach clients to watch for signs Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Obvious change in wart or mole nagging cough or hoarseness Developmental assessment of children Assessment of physical and neurological development establishes a baseline and helps track progress of treatment Should be performed regularly during treatment for cancer Children under age 6 should receive developmental assessment using a standardized tool Observe developmental milestones and refer for further assessment if regression occurs Monitor performance in school and social activities in older children to assess developmental milestones Diagnostic tests ( use tests include Biopsy Bone marrow aspiration CT scan MRI PET Radiograph Scans Ultrasound CBC Red blood indices Serum chemistry panel Tumor markers Urinalysis Lumbar puncture Case Study, Part 2 ( Andrew is admitted to the ED Interventions and therapies Nursing interventions focus on reducing complications and maintaining optimal homeostasis Independent interventions and therapies Educating client and family about the disease, treatments, and preventing complications Providing psychosocial support Help families through the initial shock of diagnosis Help families of pediatric clients to plan how to tell the child Provide additional education as needed both verbally and in writing Help family to identify support services Provide opportunities for clients to express their thoughts and feelings Promote healthy grieving Listen attentively to expressions of grief Explain to clients that it is normal to have periods of depression, anger, and denial Involve the partner in helping client to cope if the partner wishes Considerations for the pediatric client and family Consider the impact on siblings who may feel resentment and guilt about their siblings diagnosis Offer support appropriate to the clients developmental level Younger children need support through painful procedures and separation from parents Older children need assistance in working through their feelings related to diagnosis and treatment Adolescents should be empowered as much as possible Help with the transition back to school by talking with school personnel or classmates, or arranging for tutors Promote balanced nutrition, activity, and rest Teach clients about a well-rounded diet including all macro- and micronutrients Teach clients to seek balance between activity and rest Collaborative interventions and therapies Provide appropriate pain management, both pharmacologic and nonpharmacologic Promote good nutrition to Prevent or reverse nutritional deficits Preserve lean body mass Minimize side effects Allow for growth for pediatric clients Manage hydration Offer frequent small amounts of fluid Children are at particular risk for dehydration Manage treatment side effects Teach clients that some side effects appear after therapy has ended Suppression of blood cell production can occur Neutropenia is present when absolute neutrophil count is less than 500 cells/mm3 or between 500 and 1000 cells/mm3 when chemotherapy is being given and fallen levels are anticipated At these levels, clients will be given a broad-spectrum antibiotic Granulocyte colony-stimulating factor (G-CSF) may be given Take clients temperature, isolate from other clients, and perform serum laboratory studies as ordered Protect clients from bruises and be alert for hemorrhage and signs of bleeding Pharmacologic therapy Play an important role in treating alterations of cellular regulation Administration of chemotherapy requires nurses to obtain advanced training See MEDICATONS CELLULAR REGULATION on p. 40 for an overview of pharmacologic therapies Review The Concept of Cellular Regulation Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Student Nursing Resources Reflect Case Study, Part 3 Andrews lab results are available Exemplar 2.1 Cancer Overview Group of complex diseases ( manifestations depend on which body system is affected, type of cells involved Results when normal cells mutate into abnormal, deviant cells Can affect any body tissue Oncology study of cancer See FOCUS ON DIVERSITY AND CULTURE Variations in incidence and mortality, p. 42 Pathophysiology and etiology Neoplasm ( mass of new tissue ( grows independently of surrounding structures, no physiological purpose Grows at rate uncoordinated with needs of body Share some properties of parent cells, with altered shape and size Does not benefit the host and may be actively harmful See Table 23 COMPARISON OF BENIGN AND MALIGNANT NEOPLASMS, p. 53 Benign neoplasms Localized growths Solid mass, well-defined borders, frequently encapsulated May be destructive if they crowd surrounding tissue, obstruct function of organs Malignant neoplasms Grows aggressively Does not respond to bodys homeostatic controls Cells from primary tumor may travel through blood, lymph to invade other tissues, organs ( form secondary tumor ( metastasis Vary in degree of differentiation Highly differentiated ( try to mimic function of parent tissue Undifferentiated ( immature cells, almost no resemblance to parent tissue Rob body of energy, nutrition as they grow Characteristics of malignant cells Loss of regulation of rate of mitosis Loss of specializations, differentiation Loss of contact inhibition Progressive acquisition of cancerous phenotype Irreversibility Altered cell structure Simplified metabolic activities Transplantability Ability to promote their own survival See Box 21 CHARACTERISTICS OF MALIGNANT CELLS, p. 43 Tumor invasion and metastasis Invasion ( overtakes adjacent tissues Ability to cause pressure atrophy Ability to disrupt basement membrane of normal cells Motility Response to chemical signals from adjacent tissues Chemotaxis ( movement of cells in response to a chemical stimulus ( draws tumor cells into normal tissues Metastasis ( occurs by one or more mechanisms Embolism in blood or lymph or spread by way of body cavities Tumors ability to metastasize requires three steps Intravasation of malignant cells through blood or lymphatic vessel walls into the circulation Survival of malignant cells in blood Extravasation from the circulation ( implantation in a new tissue Tumor cells tend to clump together Metastatic lesions tend to follow blood, lymph circulation Some target specific organs Malignant cells that gain access to lymph channels may travel to a preferred organ ( then move into it the same way they emigrate through blood vessels May become trapped in lymph node and continue to grow Malignant tumor may break through walls of primary organ ( shed cells into nearby body cavity Metastatic lesions differ from primary neoplasms ( do not resemble tissue in which they reside To metastasize, cancer cells must escape detection by immune system Aggressive cells may compile a large mass so rapidly that immune system unable to overcome tumor before it takes hold in new tissue To be recognized as foreign by immune system ( must display tumor-associated antigen ( marks tumor for destruction If persons immune system weakened, altered ( metastatic tumor may take hold with little opposition 5060 of all cancers metastasized by time primary tumor identified Client education necessary for early diagnosis Immune system response ( tries to destroy neoplasms using the resources of the body Chemical mediators Hormones and enzymes Blood cells Antibodies Proteins Inflammatory and immune responses Etiology Carcinogenesis ( theories of the origin of cancer include two important concepts Damaged DNA (inherited or from external sources) sets up the initial step for cancer to occur Impairment of the immune system lessens its ability to destroy abnormal cells Three theories of carcinogenesis include Cellular mutation ( carcinogens cause mutations in cellular DNA Oncogenes ( Genes that promote cell proliferation are capable of triggering cancerous characteristics Tumor suppressor genes (Normally suppress oncogenes but can become inactive by deletion or mutation Causative agents Number of agents are known to cause cancer External ( chemicals, radiation, viruses Internal ( hormones, immune conditions, inherited mutations Carcinogens can be categorized in two groups Genotoxic ( directly alter DNA and cause mutations Promotor substances ( which cause other biological effects such as cytotoxicity, hormonal imbalances, altered immunity, or chronic tissue damage Several viruses are associated with development of cancer Viruses play a significant role in weakening immunological defenses against neoplasms See Box 2-2 CANCERS ASSOCIATED WITH VIRAL ETIOLOGY on p. 45 Risk factorscontrollable and not controllable Heredityfamilial pattern, predisposition Age77 of cancer diagnoses occur after age 55 Five cycles of genetic mutations necessary to cause permanent damage Hormonal changes occur with aging, male and female Severe, cumulative losses implicated in promoting cancer ( repeated stressors to immune system Gender Poverty Stress Keeps hormones at high levels General adaptation syndrome Personality Depression ( tend to shut down energizing chemicals in body, depress immune responses Dietsome foods considered genotoxic Nitrosamines High-fat, low-fiber foods Occupationmight be considered controllable or uncontrollable Education ( may limit choices Risks vary according to occupation Infectionviruses linked to cancer Some unavoidable Others avoidable with safe sex practices Tobacco use Relationship to lung cancer well known Related to increased risk of oropharyngeal, esophageal, laryngeal, gastric, pancreatic, bladder cancers Effects of second-hand smoke Alcohol useenhances contact between carcinogens, stem cells in oral cavity, larynx, esophagus Recreational drug useoften promotes unhealthy lifestyle Nutrition Immunosuppressive Obesityincreased risk for hormone-dependent cancers Sun exposure Prevention ( centers around making healthy lifestyle choices Avoiding smoking Limiting alcohol intake Eating a balanced diet Exercising regularly Avoiding sun exposure Following safety protocols in the workplace Clinical manifestations Disruption of function Obstruction of pressure Liver ( primary hepatocellular cancer or metastatic lesions Impair multiple life-sustaining functions of liver Obstruction of blood flow in liver via portal vein ( portal hypertension Hematological alterations Impair normal function of blood cells Leukemia ( proliferative disease of hematopoietic system ( immature leukocytes cannot perform phagocytic functions GI tumors disrupt absorption of vitamin B12, iron Growing tumors need purines, folate ( accumulate and store, depriving bone marrow Renal cell carcinoma ( erythropoietin hormone produces large number of RBCs ( polycythemia Infection Tumor may invade, connect two organs ( bladder, bowel fistula ( infection Necrotic tissue from or in tumor Immune response impaired ( involve liver, bone marrow, spleen, lymph nodes Hemorrhage Erosion through blood vessels Anemia to hypovolemic shock Anorexiacachexia syndrome Neoplastic cells divert nutrition to own use, reduce appetite at same time Glucose metabolism altered Alter taste, smell Pain, infection, depression contribute to anorexia Catabolism of bodys tissue and muscle proteins Paraneoplastic syndromes Result from chemicals secreted by tumor immune systems response Breast, ovarian, renal cancers ( may set up ectopic parathyroid hormone sites ( severe hypercalcemia Oat cell, other lung cancers ( ectopic secretions of insulin, parathyroid hormone, antidiuretic hormone, adrenocorticotropic hormone Other paraneoplastic syndromes ( hematological abnormalities, nephritic, cutaneous, neurological syndromes Pain Ranked as one of most serious concerns of clients families Types of cancer pain Acute ( well-defined pattern of onset Chronic pain ( lacks objective manifestations Can result in personality changes Alterations in functional abilities Lifestyle disruptions Clients who cite acute pain as primary symptom that led to diagnosis ( often perceive pain as introduction to another cancer, recurrence Clients who report pain as component of therapy ( often able to endure in anticipation of successful outcome Chronic ( related to treatment, or indicate progression of disease Preexisting pain, history of drug abuse ( perceptions of pain may be altered Dying client with cancer pain ( strongly associated with confrontation of issues of hopelessness, death Causes of cancer pain Direct tumor involvement primary cause Side effects, toxic effects of cancer therapies Psychological stress Diagnosis of cancer provokes variety of psychological, emotional responses Client may see cancer as death sentence ( give up Client may feel guilt ( punishment for past behaviors Client may experience anger ( Ive been practicing healthy lifestyle, feelings of powerlessness Fear ( the outcome of illness, effects of treatment, pain, death Body image concerns Oncological emergencies ( may result from the cancer itself or as a side effect of treatment Metabolic emergencies Tumor lysis syndrome Septic shock Hypercalcemia Hematological emergencies (result from bone marrow suppression or from hyperleukocytosis Bone marrow suppression results in anemia and thrombocytopenia Idiopathic bleeding may be a sign Disseminated intravascular coagulation (DIC) may occur Space-occupying lesions ( extensive tumor growth may result in Spinal cord compression Increased intracranial pressure Brain herniation Seizures Massive hepatomegaly Gastrointestinal obstruction Cardiac and respiratory complications Superior vena cava syndrome Lifespan and cultural considerations Children and adolescents Nurses caring for children and adolescents with cancer provide care for the entire family Psychosocial needs Parents must cope with diagnosis, gather resources, make treatment decisions, adjust family they may have to travel great distances for treatments, have financial concerns, have issues with their work or employment, and have other children to parent Infants and toddlers do not understand the severity of their condition and must cope with pain and separation from parents Preschoolers may understand that they are ill, but cant understand why parents cant make them better School-age children can understand a diagnosis of cancer and benefit from talking about it Adolescents find contact with others who have cancer to be reassuring and supportive Cancer survival Treatments are increasingly successful From 1969 to 2008, mortality rates declined by 66 Survivors may have special healthcare needs Treatment of cancer in children Surgery ( short- and long-term effects Radiation ( short- and long-term effects Impairment of the growth of bones and teeth Cause chronic pain from skeletal toxicity Hypothyroidism from head and neck radiation Cardiotoxicity and pulmonary toxicity Delayed puberty and sterility Impairment of neurocognitive performance Possible lowered behavioral and social competence, and higher rates of PTSD Chemotherapy ( wide variety of short- and long-term effects Cardiomyopathy Temporary or permanent pulmonary toxicity Renal complications Hearing loss Cataracts and other eye problems Learning disabilities Infertility Secondary cancers, most commonly solid tumors, occur in some survivors Survivors at higher risk of developing cancers commonly seen in adults such as breast, colon, or prostate Barriers to optimal care for cancer survivors include Lack of knowledge about survivorship by healthcare professionals Lack of knowledge about risks and care recommendations by the cancer survivor Limitations to follow-up care due to issues related to healthcare coverage and insurability Inadequate access to psychological services geared toward promoting the transition to independent in adulthood Pregnant women 1 out 1000 pregnant women will be treated for cancer Most do not spread to the fetus Cancer symptoms mimic pregnancy symptoms, so diagnosis is often delayed Surgery is considered the safest treatment for pregnant women with cancer Certain types of chemotherapy may be administered second and third trimesters Radiation is usually avoided Collaboration Team approach, early detection essential Three treatment approaches used surgery, radiation therapy, drug therapy Diagnostic tests and classification Several procedures used to diagnose cancer X-ray imaging Computed tomography Ultrasonography Magnetic resonance imaging Microscopic histological examination of tissue reveals type of cell, structural difference from parent cell Tissue sample ( biopsy, shed cells, collections of secretions Simple screening procedures ( pick up substances secreted by tumor, increases in enzymes or hormones released by normal tissues Studies have noted communication between chemical mediators and emotional centers of the brain Identification system developed to standardize diagnosis, treatment protocols Classification ( name the tumor Classified, named by tissue of origin See Table 23 NOMENCLATURE FOR BENIGN AND MALIGNANT NEOPLASMS, p. 53 Named for discoverer of particular cancer Hematopoietic malignancies usually named by type of immature blood cell that predominates Grade ( describes aggressiveness Evaluates amount of differentiation, estimates rate of growth based on mitotic rate Staging ( spread within or beyond tissue of origin Used to classify solid tumors, refers to relative size of tumor, extent of disease TNM staging system internationally recognized T relative tumor size, depth of invasion, surface spread N presence, extent of lymph node involvement M presence or absence of distant metastases See Table 24 THE TNM STAGING SYSTEM, p. 53 Cytological examination( to be identified, malignant tissues must be subjected to histological, cytological examination Specimen collection Exfoliation from epithelial surface Aspiration of fluid from body cavities, blood Needle aspiration of solid tumors Specimens spread across slide, fixed, stained if necessary Tumor markers ( protein molecule detectable in serum or other body fluids Most useful for monitoring clients response to therapy, detecting residual disease Two categories ( derived from tumor itself, associated with host (immune) response to tumor Examples Antigens Hormones Proteins Enzymes Oncological imaging X-ray imaging ( least expensive, least invasive Method of choice for screening areas such as breast, lung, bone Computed tomography Application of computers and mathematics to diagnostic imaging ( allows visualization of cross-sections of anatomy Magnetic resonance imaging also involves computerized mathematical technology Diagnostic imaging machine may cause claustrophobic reaction Ultrasonography ( safe, noninvasive Nuclear imaging ( involve the use of special scintillation scanner in conjunction with the ingestion, injection of specific radioactive isotopes Principle underlying technology is certain isotopes have affinity for specific tissues Procedure usually minimally distressing for client Angiography ( expensive, invasive performed when precise location of tumor cannot be identified, or tumors extent needs to be seen before surgery Procedure involves injecting radiopaque dye into major blood vessel proximal to organ to be examined Requires preparation similar to that for minor surgery Direct visualization Sigmoidoscopy Cystoscopy Endoscopy Bronchoscopy Allow visual identification of organs, usually permit biopsy of suspicious lesions or masses All require some client preparation, moderate to considerable discomfort, may require sedation or anesthesia Radical method of direct visualization ( exploratory surgery with biopsy Laboratory tests Most laboratory tests of blood, urine, body fluids used to rule out nutritional disorders, other noncancerous conditions that may be causing clients symptoms In conjunction with other diagnostic studies, some laboratory tests can be useful for screening, validating cancer diagnosis Surgery ( perform to remove tumor that is localized or that is pressing on nerves, airways, other vital tissues Pharmacologic therapies Referred to as chemotherapy, antineoplastic drug therapy Three general purposes ( cure, palliation, prophylaxis Classified into six categories Alkylating agents Nitrogen mustards Nitrosoureas Antimetabolites Folic acid antagonist Pyrimidine analogs Purine analogs Antitumor antibiotics Natural products Vinca alkaloids Taxanes Topoisomerase inhibitors Camptothecins Hormone and hormone antagonists Glucocorticoids Androgens and androgen antagonists Estrogens and estrogen antagonists Progestins Biological response modifiers, immune therapies Radiation therapy Effective way to kill tumor cells through nonsurgical means Approximately 50 of clients with cancer received radiation therapy May follow surgery to kill cancer cells left behind May be used as palliation for inoperable cancers to shrink the size of tumor Nursing Process Assessment Begins with focused assessment of organ systems involved, then full assessment Focused interview ( see ASSESSMENT INTERVIEW CANCER on p. 57 Data collection History of clients disease Other concurrent diseases Current physical, common psychological problems resulting from cancer Understanding of treatment plan Expectations of treatment plan Functional limitations due to illness or treatment Effect of disease on current lifestyle Reliable support systems Coping strategies Physical assessment Establish a baseline against which to evaluate changes Document nutritional status of client Assess client hydration status Diagnosis Risk for Infection Risk for Injury Imbalanced Nutrition Less Than Body Requirements Impaired Tissue Integrity Anxiety Disturbed Body Image Anticipatory Grieving Planning Client and family will verbalize feelings related to cancer diagnosis, seek support Client will relate potential side effects of chosen therapies, list strategies for minimizing or coping with symptoms Client will demonstrate no signs or symptoms of infection Client will sustain no injuries Client will maintain weight within normal range based on height and body type Client will remain hydrated Implementation Caring intervention could potentially include any skill, intervention Prevent infection Malnutrition, impaired skin integrity, tumor necrosis, suppression of WBCs, radiation therapy contribute to risk for infection Monitor vital signs Monitor WBC counts frequently Teach client to avoid crowds, small children, people with infections, practice scrupulous personal hygiene Protect skin and mucous membranes from injury Encourage client to consume diet high in protein, minerals, and vitamins, especially C. Prevent injury Assess frequently for signs, symptoms indicating problem with organ obstruction Teach client ( differentiate minor problems from those a serious nature Monitor laboratory values that may indicate presence of ectopic functioning, report abnormal findings to physician Promote balanced nutrition Anorexia-cachexia syndrome common cause of malnutrition in clients with cancer Assess current patterns, including likes and dislikes, identify factors that impair food intake Evaluate degree of malnutrition Check laboratory values Calculate nitrogen balance, creatinine-height index, calculate skeletal muscle mass ( compare findings to normal ranges Take anthropometric measurements and compare to standards Teach principles of maintaining good nutrition using the federal governments MyPlate recommendations, adapt diet to medical restrictions and current preferences Manage problems that interfere with eating Encourage eating whatever is appealing Eat small, frequent meals Encourage client to try icy cold foods, or those highly seasoned if food has no taste Encourage cold and bland, semisoft and liquid foods for clients with oropharyngeal ulcers use an anesthetic, alcohol-free mouthwash before eating Manage nausea, vomiting by administering antiemetic drugs Teach client to supplement meals with nutritional supplements, take multivitamin and mineral tablets with meals Teach client to keep food diary to document daily intake Teach client to administer parenteral nutrition via central line Protect tissue integrity Most common impairment occurs in oral-pharyngeal-esophageal mucous membranes Carefully assess and evaluate type of tissue impairment presence Implement and teach measures for preventing oropharyngeal infection Observe for systemic sign of infection Encourage cleaning teeth gently, using nonalcohol mouthwash several times a day Culture any oral lesions Implement and teach measures for reducing trauma to delicate tissues Counteract dry mouth with lubricating and moisturizing agents Avoid putting sharp instruments in the mouth Brush teeth with very soft toothbrush Administer specific medications as ordered to control infection and/or pain Acyclovir often used to treat viral infections Systemic antibiotics retrieved bacterial infections Nystatin or clotrimazole solution or lozenges used for fungal infections Use viscous Xylocaine or various combinations of mouthwashes before meals and as needed Promote healthy coping Threats to or changes in health status, comfort, role functioning, anticipation of pain, disfigurement, threat of death may cause anxiety Assess clients level of anxiety and reality of threats Establish a therapeutic relationship Encourage client to acknowledge and express feelings Review coping strategies client used in the past, introducing new strategies as appropriate Provide safe, calm, quiet environment for client in panic Promote healthy body image Cancer treatments frequently result in nature physiological, psychological changes in body image due to loss of body part, hair loss, disfigurement of body part, creation of unnatural opening Discuss meaning of loss or change with client Observe and evaluate clients interaction with significant others Allow denial, but do not participate in denial Assist client and significant others in coping with changes in appearance Provide supportive environment Encourage client and significant others to express feelings Give matter-of-fact responses to questions and concerns Identify new coping strategies Enlist family and friends in reaffirming clients worth Teach client or significant others to participate in care of affected body area Teach strategies for minimizing physical changes Teach ways to reduce alopecia Promote healthy grief responses Use therapeutic communication skills of active listening, silence, nonverbal support to provide open environment for client, significant others to discuss feelings realistically and express anger, negative feelings appropriately Answer questions about illness and prognosis honestly, encourage hope Encourage dying client to make funeral, burial plans ahead of time Encourage client to continue taking part in activities he or she enjoys Evaluation Important to remember outcomes may not include recovery, absence of complications May include client acceptance and preparedness for death Other outcomes Client demonstrates no evidence of infection Client reports pain level of 3 or less, allowing adequate rest, performance of ADLs Client reports reduction in side effects of treatment regimen Client demonstrates appropriate dietary choices to increase caloric intake Review Cancer Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 2.2 Anemia Overview Abnormally low number of circulating red blood cells, low hemoglobin concentration, or both Caused by blood loss, inadequate RBC production, increased RBC destruction Pathophysiology and etiology Anemia reduces oxygen-carrying capacity of the blood If anemia develops gradually ( compensatory mechanisms may mask, prevent appearance of symptoms Symptoms develop as RBCs, hemoglobin levels further reduced Rapid blood loss ( volume decreased, as is oxygen-carrying capacity of blood See Box 25 PATHOPHYSIOLOGICAL MECHANISMS OF ANEMIA, p. 65 Etiology Iron deficiency anemia most common form Usually result of chronic bleeding Common in older adults, women of childbearing age Most common nutritional deficiency in children Risk factors Clients who do not eat a well-balanced diet Childbearing years Prevention Several forms of anemia are genetic and cannot be prevented Consuming a well-balanced diet will help prevent deficiencies of iron and vitamin B12 Clinical manifestations See MULTISYSTEM EFFECTS OF ANEMIA, p. 67 Blood loss anemia RBCs and other blood components lost from body Circulating volume decreases Cardiac output falls Compensatory mechanisms activated Acute blood loss ( circulating RBCs normal size, shape Chronic blood loss ( depletes iron stores Nutritional anemias Nutrients required for erythropoiesis Iron deficiency anemia Supply of iron inadequate for optimal RBC formation Body cannot synthesize hemoglobin without iron Results in fewer RBCs microcytic, hypochromic RBCs malformed RBCs (poikilocytosis) See Figure 27 A BLOOD SMEAR SHOWING RBCS Vitamin B12 deficiency anemia B12 is required for DNA synthesis deficiency impairs cell division and maturation of the nucleus, especially in RBCs Found almost exclusively in foods derived from animals Deficiency occurs When not enough B12 is consumed When B12 is poorly absorbed from the gastrointestinal tract As a result of other malabsorption disorders Failure to absorb B12 results in pernicious anemia Manifestations develop gradually Folic acid deficiency anemia Folic acid required for DNA synthesis, normal maturation of RBCs Chronically undernourished client ( older adult, alcoholism, addicted to drugs Pregnant women at risk for anemia due to increased folic acid needs Manifestations develop gradually as folic acid stores depleted See Box 26 CAUSES OF FOLIC ACID DEFICIENCY ANEMIA, p. 68 Hemolytic anemias Characterized by premature destruction of RBCs Intrinsic and extrinsic causes See Box 27 CAUSES OF HEMOLYTIC ANEMIA, p. 68 Thalassemia ( inherited disorders of hemoglobin (Hgb) synthesis in which alpha or beta chains of Hgb molecule missing or defective Usually affects certain populations Mediterranean decent ( beta-defect thalassemia Asian descent ( alpha-defect thalassemia Children with thalassemia major rarely reach adulthood Thalassemia minor often asymptomatic Manifestations Mild to moderate anemia, mild splenomegaly, bronze skin coloring, bone marrow hyperplasia Major form of disease ( severe anemia, heart failure, liver, spleen enlargement, bone fractures Acquired hemolytic anemia Hemolysis resulting from factors outside RBC such as Mechanical trauma to RBCs Autoimmune disorders Bacterial, protozoal infection Immune systemmediated responses Drugs, toxins, chemical agents, venoms Manifestations depend on extent of hemolysis and bodys ability to replace destroyed RBCs Glucose-6-phosphate dehydrogenase (G6PD) anemia Caused by hereditary defect in RBC metabolism Common in African, Mediterranean descent Enzyme that catalyzes glycolysis Hemolysis usually occurs when affected person exposed to stressors When exposed to stressors ( symptoms develop within several days As new RBCs develop ( counts return to normal Aplastic Anemia Bone marrow fails to produce all three types of blood cells ( leading to pancytopenia (deficiency in red, white blood cells) Rare form of aplastic anemia (Fanconi anemia) caused by defects of DNA repair Most causes unknown Number of stem cells in bone marrow significantly reduced Manifestations vary with severity of pancytopenia Onset may be insidious or sudden Lifespan and cultural considerations Neonatal anemia may be caused by blood loss, hemolysis/erythrocyte destruction, impaired RBC production Excessive hemolysis usually a result of blood group incompatibilities May be caused by infection Physiological anemia of infancy ( result of normal, gradual drop in hemoglobin for first 612 weeks of life Collaboration Ensure adequate tissue oxygenation ( priority care Specific care determined by underlying cause Diagnostic tests CBC Hemoglobin electrophoresis Serum iron Serum ferritin Iron-binding capacity Microscopic analysis Schilling test Bone marrow examination Quantitative assay of G6PD Surgery For anemia due to blood loss, treatment focuses on identifying the source of the bleeding and repairing the damaged organ or tissues if possible Treatment of aplastic anemia may include a stem cell transplant Pernicious anemia may require exploratory surgery to assess for disorders that may be the cause Splenectomy may be indicated for clients with thalassemia major Pharmacologic therapy Depends on underlying cause Drugs include the following Ferrous sulfate, other sources of iron Folic acid Vitamin B12 Erythropoietin Immunosuppressive therapy Nonpharmacologic therapy Nutrition Dietary modification for nutritional deficiency anemia See Box 28 DIETARY SOURCES OF IRON, FOLIC ACID, AND VITAMIN B12, p. 71 Blood transfusions May be indicated to treat anemias resulting from major blood loss Complementary and alternative therapy May include enzymes to treat nutritional anemias Check for potential interactions with prescribed medications Nursing process Assessment Health history Physical examination Diagnosis Impaired Gas Exchange Risk for Decreased Cardiac Output Risk for Ineffective Cerebral Tissue Perfusion Acute Pain Fatigue Activity Intolerance Self-Neglect Planning Client makes appropriate dietary choices to increase iron intake Client demonstrates appropriate self-administration of supplements Clients RBC count (or Hgb) improves Client reports an absence of dyspnea Client will verbalize awareness of signs and symptoms associated with exacerbations of conditions related to anemia Client will describe a plan for balancing activity with rest Implementation Promote optimal cardiorespiratory function Monitor vital signs Assess client for pallor, cyanosis, and dependent edema Closely monitor client for manifestations of anaphylaxis Should signs appear, discontinue administration of iron Notify physician Be prepared to administer medications such as diphenhydramine or epinephrine Institute CPR as necessary Promote balance between oxygen supply and demand Help identify ways to conserve energy when performing necessary or desired activities Help client and family establish priorities for tasks and activities Assist to develop schedule of alternating periods of activity, rest throughout the day Encourage 810 hours of sleep at night Monitor vital signs before and after activity Discontinue activity if any of the following occur Chest pain, breathlessness, vertigo Palpitations, tachycardia does not return to normal within 4 minutes of rest Bradycardia Tachypnea, dyspnea Decreased systolic blood pressure Instruct client not to smoke Facilitate Enhanced Self-Care Glossitis and cheilosis Monitor condition of lips and tongue daily Use mouthwash of saline, saltwater, or half-strength peroxide to rinse mouth every 24 hours Avoid alcohol-based mouthwashes Provide frequent oral hygiene with soft-bristle toothbrush or sponge Apply petroleum-based lubricating jelly or ointment to lips after oral care Instruct to avoid hot, spicy, or acidic foods Encourage soft, cool, bland foods Encourage client to eat four to six small meals with high protein, vitamin content each day Report signs and symptoms of decreased cardiac output to the healthcare provider Evaluation Clients laboratory results manifest normal RBC level Client and/or family verbalizes understanding of treatment regimen Client consumes the recommended dietary intake Client is free of side effects of oral iron therapy Client is active and able to maintain normal activity levels Pediatric client achieves appropriate growth and development milestones Review Anemia Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 2.3 Breast Cancer Overview Breast cancer is unregulated growth of abnormal cells in breast tissue Pathophysiology and etiology Begins as a single, transformed cell, often hormone dependent Invasive or noninvasive (in situ) May remain noninvasive, without spreading (metastasizing) for long periods of time Categories Carcinoma of mammary ducts Carcinoma of mammary lobules Sarcoma of the breast Most adenocarcinomas Appear to arise in terminal section of breast ductal tissue Many histological types Can metastasize to other sites ( bloodstream or lymphatic system Common sites Bone Brain Lung Liver Skin Lymph nodes Staging ( system of classifying according to Size of tumor, Involvement of lymph nodes Metastasis to distant sites Presence/absence of distant metastasis Provides important information for decision making about treatment options Used as basis for prognosis See Table 27 STAGING OF BREAST CANCER, p. 77 Etiology Possible causes of breast cancer include Environmental factors Hormones Reproductive factors Hereditary factors Two breast cancer susceptibility genes have been identified BRCA1 on chromosome 17 and BRCA2 on chromosome 13 Both are known as tumor suppressor genes May be responsible for 10 of women with hereditary breast cancer, with genetic mutations causing up to 80 of breast cancer in women Risk factors Nonmodifiable Age and gender Genetic risk factors Family history of breast cancer Personal history of breast cancer Previous breast biopsy Previous chest irradiation Menstrual history Modifiable (lifestyle-related) factors Oral contraceptives Not having children, or having after age 30 Using hormone replacement therapy for more than 5 years Not breastfeeding Drinking alcohol Obesity High-fat diets Physical inactivity Prevention Actively limiting exposure to risk factors linked to development of breast cancer Limiting alcohol to one drink per day Maintaining body weight within normal limits Engaging in physical activities Refraining from smoking Avoiding exposure to environmental pollution and radiation Limiting hormone therapy Early detection cannot prevent breast cancer, but it is essential to reducing clients risk of mortality and promoting positive outcomes Clinical manifestations Nontender lump in breast Most often upper outer quadrant Area with most glandular tissue Abnormal nipple discharge Rash around the nipple area Nipple retraction Dimpling of the skin Change in position of the nipple Nipple pain, scaliness, ulceration, skin irritation, discharge Usually painless, some women report a burning or stinging sensation Many women have no manifestations ( tumors detected by mammography Most breast cancers found by women (breast self-examination BSE or in a shower) or by partners See CLINICAL MANIFESTATIONS AND THERAPIES Breast Cancer, p. 81 Collaboration Diagnosis begins with detection Screening Monthly self-examination Diagnostic tests Clinical breast examination Mammography ACS recommends mammograms begin at age 40 Percutaneous needle biopsy Breast biopsy See Figure 28 TYPES OF BREAST BIOPSY, Surgery Mastectomy Radical mastectomy Simple mastectomy Segmental mastectomy or lumpectomy Modified radical mastectomy Axillary node dissection Stages the tumor Possible complications Lymphedema Nerve damage Adhesions Sentinel node biopsy See Figure 29 TYPES OF MASTECTOMY, p. 79 Lumpectomy Breast conservation surgery Excision of primary tumor and adjacent breast tissue followed by radiation Breast reconstruction Individual preference Prosthesis ( removable Timing of reconstruction ( womans preference Several procedures See Figure 210 TYPES OF BREAST RECONSTRUCTION SURGERIES, p. 80 Pharmacologic therapies Tamoxifen citrate (Nolvadex) Oral medication Interferes with estrogen activity Trastuzumab (Herceptin) Immunotherapy, used to stop growth of tumors that express the HER2/neu receptor Chemotherapy Standard of care for majority of cases with axillary node involvement In late metastatic cancer, chemotherapy becomes primary treatment Adjuvant systemic therapy combining other pharmacologic agents with chemotherapy has extended cancer-free survival Radiation therapy Typically follows surgery to destroy remaining cancer cells May be used to treat metastases Intraoperative radiotherapy ( single, concentrated dose of radiation Nursing process Assessment Health history Family history Signs Physical assessment Diagnosis Risk for Infection Risk for Injury Anxiety Decisional Conflict Grief Disturbed Body Image over loss of a breast Acute Pain Planning Client will not experience infection Client will make informed treatment decisions Client will express feelings regarding diagnosis, treatment, and prognosis Family and significant others will provide appropriate support for client Implementation Prevent infection Assess surgical dressings ( bleeding, drainage, color, odor every 4 hours for 24 hours ( document findings Circle any bleeding, drainage on the dressing as baseline for subsequent assessment Observe incision and IV sites for pain, redness, swelling, and drainage Assess the drainage system for patency, adequate suction Note color and amount of drainage IV catheters on uninvolved side only Change dressings and IV tubing using aseptic technique Encourage a protein-rich diet ( discuss nutritional status with dietitian, request consultation for the woman Teach woman how to care for drainage system if present Teach woman to watch for, report manifestations of infection Explain that she may experience scaling, flaking, dryness, itching, rash, or dry desquamation, particularly after radiation therapy Tell the woman to avoid deodorants, talcum powder on the affected side until incision completely healed Promote optimal circulation When obtaining blood pressure and starting IVs, use nonsurgical side Elevate affected arm higher than shoulder on pillow without abduction ( hand higher than elbow Encourage range-of-motion exercises in the affected arm Explain that lymphedema massage and elastic compression bandage may help control swelling after recovery from surgery Promote psychosocial well-being Re diagnosis, surgery, outcome of surgery, possible changes in sexual and family relationships Discuss the womans knowledge of breast cancer Encourage discussion relating to immediate concerns about resuming life at home and changes she must make Explain the surgical procedure, including information about preoperative medications, anesthesia, and recovery Explain that it is normal to have decreased sensations in the surgical area Promote a healthybody image Surgical changes may be compounded by weight gain, side effects of chemotherapy or hormone therapy Assess how the woman views her body ( discuss image of herself before surgery Explain that redness and swelling in scar will fade with time Include partner and family if possible when discussing plan of care and ADLs ( request consultation with psychologist, other professional if woman interested Offer pamphlets, suggest books, videos that might increase knowledge about what lies ahead Encourage woman to look at incision when she feels ready often reality not as frightening as imagined If woman interested in breast reconstruction, provide material and encourage her to talk with a plastic surgeon and with women who have had reconstruction Evaluation Client experiences no complications resulting from treatment Side effects from medications are minimized Pain is managed to allow the client to rest and perform essential ADLs Review Breast Cancer Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 2.4 Colorectal Cancer Overview Colon cancer ( cancer of third segment of large bowel, may or may not include anus Colorectal cancer ( involves both colon, rectum Regular colonoscopies greatly reduce risk ( remove polyps before malignant Pathophysiology and etiology Colorectal cancers ( most begin as adenomatous polyps, are adenocarcinomas Tumor typically produces few manifestations until disease spreads into deeper layers of bowel tissue, adjacent organs Metastasis to regional lymph nodes most common May also spread by way of lymphatic system, circulatory system to secondary sites Seeding of tumor ( when tumor extends through serosa or during surgical resection See Figure 211 DISTRIBUTION AND FREQUENCY OF CANCER OF THE COLON AND RECTUM, p. 85 See Table 28 THE TNM STAGING SYSTEM FOR COLORECTAL CANCER, p. 86 Etiology Third most common cancer diagnosed in the United States Earlier diagnosis, improved treatment ( improved survival rate for colorectal cancer Risk factors Genetic factors strongly linked to risk for colorectal cancer Diet plays a role ( diets high in calories, meat proteins, fats Thought to increase population of anaerobic bacteria in gut ( anaerobes convert bile acids into carcinogens Diets high in fruits, vegetables, folic acid, calcium appear to reduce risk Prevention American Cancer Society recommends using one of the following testing schedules starting at age 50 Yearly fecal occult blood test or fecal immunochemical test Stool DNA test (interval uncertain) Flexible sigmoidoscopy every 5 years Double-contrast barium enema every 5 years Colonoscopy every 10 years CT colonography every 5 years Clinical manifestations Depend on location, type, extent, complications Slow growing ( may be present for 515 years Rectal bleeding may be initial manifestation Early manifestations ( change in bowel habits, diarrhea or constipation Late manifestations ( pain, anorexia, weight loss See CLINICAL MANIFESTATIONS AND THERAPIES COLORECTAL CANCER, p. 87 Collaboration Diagnostic tests Include sigmoidoscopy, colonoscopy ( obtain tissue for biopsy Radiological examinations to detect metastases, assess tumor depth Laboratory tests Fecal occult blood CBC to detect anemia Carcinoembryonic antigen (CEA) level Surgery Surgical resection of tumor, adjacent colon, regional lymph nodes treatment of choice Laser photocoagulation during endoscopy Abdominoperineal resection with permanent colostomy ( tumors of the rectum Local excision Fulguration electrocoagulation used to reduce size of large tumors in clients who are poor surgical risk Resection of colon with anastomosis of remaining bowel as curative procedure Colostomy Ostomy made in colon for diversion of fecal contents May be temporary or permanent See Figure 212 VARIOUS OSTOMY LEVELS AND SITES, p. 88 Sigmoid colostomy most common permanent colostomy ( removal of sigmoid colon, rectum, anus through abdominal and perineal incisions Double-barrel colostomy ( two stomas created, distal colon not removed May be temporary, for healing, or permanent Trauma, tumor, inflammation See Figure 2-13 A DOUBLE-BARREL COLOSTOMY, p. 88 Transverse loop colostomy used to relieve intestinal obstruction, perforation 12 weeks Temporary Hartmann procedure ( temporary colostomy, distal portion of colon left in place and oversewn Done for bowel rest, healing Anastomosis delayed Colostomy closed 36 months following temporary colostomy Laser photocoagulation Uses a very small, intense beam of light to generate heat in tissues Heat is used to destroy small tumors Also used as palliative treatment of advanced tumors to remove obstructions Can be performed endoscopically Pharmacologic therapy Fluorouracil (5-FU) and folinic acid (leucovorin) Used postoperatively as adjunctive therapy for colorectal cancer Combined with radiation therapy ( reduces rate of recurrence, prolongs survival for clients with stage II and III rectal tumors Radiation therapy Not primary treatment Used with surgical resection for treating rectal tumors Nursing process Assessment Health history Bowel patterns, changes Family history Pain History of inflammatory bowel disease, polyps Physical examination Diagnosis Risk of Infection Acute Pain Imbalanced Nutrition Less Than Body Requirements Anticipatory Grieving Risk for Ineffective Sexuality Pattern Planning Client will not demonstrate evidence of infection Client will consistently rate her pain at 3 or less on a pain rating scale of 0 to 10 Client will demonstrate proper ostomy care and management Client will verbalize feelings related to diagnosis and prognosis Family and/or significant others will provide adequate emotional and physical support for the client upon discharge Client will make informed choice related to treatment options Implementation Include emotional support, teaching, direct care before/after diagnostic procedures, surgery, as well as during adjunctive treatments Manage pain Related to preparations for surgery, diagnostic examinations, surgery, phantom rectal pain, tumor and metastatic tumors impinge on nerves, other organs Monitor for adequate pain relief Ask client to rate pain using scale of 010 Monitor analgesic effectiveness 30 minutes after administration Assess incision for inflammation, swelling assess drainage tubes, catheters Assess abdomen for distention, tenderness, bowel sounds Administer analgesia before activity or procedure Assist with adjunctive comfort measures Splint incision with pillow, teach client to self-splint when coughing, deep breathing Promote balanced nutrition Bowel prep, surgery, radiation, and chemotherapy place client at risk for nutritional deficiencies Assess nutritional status refer to dietitian or nutritionist Assess readiness for resumption of oral intake after surgery, procedures Statements of hunger Presence of bowel sounds Passage of flatus Minimal abdominal distention Monitor and document food and fluid intake Weigh client daily Maintain total parenteral nutrition and central IV lines as ordered When oral intake resumes, help client develop meal plan Promote healthy coping Client needs to adjust to loss of major body part, as well as diagnosis Work to develop trusting relationship with client and family Listen actively, encouraging client and family to express fears, concerns Demonstrate respect for cultural, spiritual, religious values, beliefs encourage use of resources Encourage discussion of potential impact of loss on individual family members, family structure, family function Refer to cancer support groups, social services counseling as appropriate Reduce risk for sexual dysfunction Physical and psychological factors can lead to sexual dysfunction Disruption of nerves, blood vessels, radiation therapy, chemotherapy, other medication Altered body image ( feel undesirable, fear rejection, concern about odors, pouch leakage Provide opportunities for client and family to express feelings about cancer diagnosis, ostomy, effects of treatments Provide consistent colostomy care Encourage expression of sexual concerns Reassure client and significant other that effect on sexuality is temporary Refer client and partner to social services, family counselor for further interventions Arrange for visit from member of United Ostomy Association Evaluation Client does not demonstrate any signs or symptoms of infection Client will maintain adequate hydration Client will report pain level of 3 or less, be able to rest, perform essential ADLs Review Colorectal Cancer Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 2.5 Leukemia Overview Group of chronic malignant disorders of WBCs and WBC precursors Usual ratio of RBCs to WBCs is reversed Pathophysiology and etiology Classified by acuity and predominant cell type involved Acute leukemias Acute onset Rapid disease progression Immature, undifferentiated blast cells Chronic leukemias Gradual onset Prolonged course Abnormal mature-appearing cells Lymphocytic leukemias Involve immature lymphocytes and precursor cells in bone marrow Infiltrate spleen, lymph nodes, CNS Myeloid leukemias Involve myeloid stem cells in bone marrow Interfere with maturation of all types of cells Most common Children ( acute lymphocytic leukemia Adults ( acute myeloid leukemia Chronic lymphocytic leukemia See Table 29 PRIMARY FORMS OF LEUKEMIA. p. 93 Acute myeloid leukemia (AML) ( uncontrolled proliferation of myeloblasts, hyperplasia of bone marrow and spleen Manifestations of AML result from neutropenia, thrombocytopenia Bone infarctions, subperiosteal infiltrates may case bone pain Bone marrow aspiration shows proliferation of immature WBCs CBC shows thrombocytopenia, normocytic normochromic anemia Chronic myeloid leukemia (CML) ( abnormal proliferation of all bone marrow elements Men more than women Associated with chromosome abnormality called Philadelphia chromosome Often asymptomatic in early stages, diagnosed through routine blood tests Within 34 years disease progresses ( more aggressive Evolves to acute leukemia with blast cell proliferation Acute lymphocytic leukemia (ALL) ( most common type in children, young adults Rarely seen in adults until middle age Most cases result from malignant transformation of B cells Malignant cells resemble immature lymphocytes ( do not function effectively Onset is usually rapid ( lymphoblasts proliferating in bone marrow, peripheral tissues crowd growth of normal cells CBC shows elevated WBC count with increased lymphocytes on differential Combination therapies produce complete remission in 8090 of adults Chronic lymphocytic leukemia (CLL) proliferation, accumulation of small, abnormal, mature lymphocytes in bone marrow, peripheral blood, body tissues Has slow onset, often diagnosed during routine physical Symptoms may be vague, if present May be years before treatment required Average 7-year survival Etiology Leukemia diagnosed 10 times more often in adults than children Causes not well understood ( infectious agents, genetic factors, other immunodeficiency states Ionizing radiation in utero, chemical agents used for treatment of earlier cancer Malignant WBCs fill bone marrow, replacing stem cells that produce RBCs, other blood products ( ( amount of these products in circulation Risk factors Men affected more than women Environmental factors ( cigarette smoking, chemicals such as benzenes Radiation, previous cancer treatment Clinical manifestations General manifestations result from anemia, infection, bleeding Other manifestations result from leukemic cell infiltration, increased metabolism, increased leukocyte destruction See MULTISYSTEM EFFECTS OF LEUKEMIA, p. 96 See CLINICAL MANIFESTATIONS AND THERAPIES Leukemia, p. 97 Collaboration Treatment focuses on achieving remission or cure, relieving symptoms Diagnostic tests Complete blood count with differential (CBC) Platelet count Bone marrow examination See Table 210 DIAGNOSTIC FINDINGS BY TYPE OF LEUKEMIA, p. 98 Surgery Bone marrow transplant (BMT) BMT is treatment of choice for some types of leukemia Often in conjunction with, following chemotherapy Allogenic bone marrow transplant ( uses bone marrow cells from donor Autologous bone marrow transplant (uses clients own bone marrow to restore function after chemotherapy or radiation Bone marrow aspirated during period of remission Client critically ill, at risk for infection, bleeding Stem cell transplant (SCT) SCT alternative to BMT Results in complete, sustained replacement of recipients blood cell lines Donors must have tissue that is closely matched Before harvesting, hematopoietic growth factors administered to donor Graft-versus-host disease (GVHD) Allogenic BMT or SCT may precipitate GVHD ( 60 of clients Immune cells identify recipients body tissue as foreign Acute ( within days Chronic ( (100 days after transplant Pharmacologic therapy Chemotherapy Single agent or combination chemotherapy ( eradicate leukemic cells, produce remission See Table 211 CHEMOTHERAPEUTIC REGIMENS USED TO TREAT LEUKEMIA, p. 99 Combination therapy interrupts cell growth at various stages of cell cycle Generally divided into two phases Induction phase ( high drug doses to eradicate leukemic cells Damage stem cells, production of normal blood cells Colony stimulating factors (CSF)hematopoietic growth factorsadministered to rescue bone marrow following induction chemotherapy Client may experience bone pain with CSFs Postremission chemotherapy ( eradicate additional leukemic cells, prevent relapse, prolong survival Biological therapy Cytokines (interferons, interleukins) ( modify bodys response to cancer cells Radiation therapy Damages cellular DNA ( cell cannot divide and multiply Rapidly dividing cells respond ( bone marrow cells, cancer cells Complementary and alternative therapy Not shown to have sustained benefit in treating leukemia Coping skills training, hypnosis shown to significantly reduce oral discomfort Nursing process Assessment Health history Fatigue, weakness, dyspnea on exertion, frequent infections, weight loss Physical examination Skin and mucous membranes ( bruising, purpura Vital signs, including orthostatic vitals Diagnosis Risk for Infection Risk for Bleeding Imbalanced Nutrition Less Than Body Requirements Impaired Oral Mucous Membrane Anticipatory Grieving Planning Client, family members/significant others describe strategies to reduce risk of infection Client remains infection free Pediatric client meets developmental milestones Client expresses feelings related to diagnosis Client meets nutritional needs to maintain growth and/or weight Client reports symptoms of complications in a timely manner Implementation Prevent and manage adverse medication effects Many clients treated in oncology clinic ( outpatient Drug side effects may necessitate infusion of platelets or packed RBCs Chemotherapeutic drugs Hydration ( IV fluids Check drug references before administration Evaluate infusion site before, during, after infusion Intake and output, urine specific gravity Daily weights Bone marrow suppression ( transmission-based precautions Prevent infection Promptly report manifestations of infection Institute infection protection measures Maintain protective isolation as indicated Ensure meticulous hand washing among all people in contact with client Assist as needed with appropriate hygiene measures Restrict visitors with colds, flu, infections Provide oral hygiene after every meal Avoid invasive procedures when possible Monitor vital signs, including temperature, oxygen saturation every 4 hours Monitor neutrophil levels for relative risk for infection No risk ( 2,0002,500/mm3 Minimal risk ( 1,0002,000/mm3 Moderate risk (5001,000/mm3 Severe risk ( 500/mm3 Protect from injury related to bleeding Bleeding second most common cause of leukemia deaths Assess vital signs every 4 hours and body systems every shift for bleeding Skin and mucous membranes for petechiae, ecchymoses, purpura Gums, nasal membranes, conjunctiva for bleeding Vomitus, stool, urine for visible or occult blood Vaginal bleeding Prolonged bleeding from puncture sites Neurological changes, such as headache, visual changes, altered mentation, decreased level of consciousness seizures Abdomen for complaints of epigastric pain, diminished bowel sounds, increasing abdominal girth, rigidity or guarding Avoid invasive procedures, such as rectal temperatures, suppositories, vaginal douches, tampons, urinary catheterization, parenteral injections Apply pressure to injection sites for 35 minutes, arterial punctures for 1520 minutes Instruct client to avoid forceful blowing, picking the nose, forceful coughing or sneezing, straining to have bowel movement Monitor and promptly report abnormal blood levels of electrolytes, uric acid, urea nitrogen, creatinine, or manifestations of tumor lysis syndrome Maintain adequate hydration, administer prescribed medications as ordered Protect mucous membrane integrity Inspect buccal region, gums, sublingual area, and throat daily for swelling or lesions Culture any oral lesions Assist with mouth care, oral rises with saline or solution of hydrogen peroxide and water (11 or 13 hydrogen peroxide and water) every 24 hours Encourage use of soft-bristle toothbrush or sponge to clean teeth and gums Administer medications as ordered to treat infection or relieve pain Instruct client to avoid alcohol-based mouthwashes, citrus fruit juices, spicy foods, very hot or very cold foods, alcohol, crusty foods Promote balanced nutrition Weigh regularly, evaluate weight loss over time Address causative or contributing factors to inadequate food, fluid intake Provide mouth care before and after meals Provide liquids with different textures, tastes Increase liquid intake with meals Reduce intake of milk, milk products Assist to a sitting position for eating Ensure that environment is clean and odor free Provide medications for pain, nausea 30 minutes before meals, if prescribed Provide rest periods before meals Offer small, frequent meals, including low-fat, high-kilocalorie foods throughout the day Provide commercial supplements Avoid painful or unpleasant procedures immediately before or after meals Suggest measures to improve food tolerance, such as eating dry foods when arising, consuming salty foods if allowed, avoiding very sweet, rich, or greasy foods Promote healthy grief response Discuss roles of the client and family and ways in which they managed stressful situations in the past Use therapeutic communication skills to facilitate open discussion of losses, provide permission to grieve Evaluation Client remains free from infection Client maintains normal urinary output Client is adequately hydrated to allow elimination of drugs and cell components Clients electrolyte values are maintained within normal limits Client rates pain as absent or at a level that is tolerable Client demonstrates adequate knowledge related to disease process and treatment regimens Review Leukemia Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 2.6 Lung Cancer Overview Leading cause of cancer deaths among all racial groups in United States Most people with lung cancer die within 1 year of initial diagnosis Pathophysiology and etiology Majority are bronchogenic carcinomas ( tumors of airway epithelium Further differentiated Small-cell carcinoma ( grow rapidly, spread early 25 of lung cancers Non-small-cell carcinoma(75 of lung cancers Adenocarcinoma Squamous cell carcinoma Large-cell carcinoma Each cell type differs in incidence, presentation, manner of spread See Table 212 COMPARISON OF LUNG CANCER CELL TYPES, p. 105 Bronchogenic cancer tends to be aggressive, locally invasive, widespread metastatic lesions Etiology Develops as damaged bronchial epithelial cells mutate, over time become neoplastic Risk factors Incidence increases with age, commonly over age 50 Cigarette smoke most significant cause of lung cancer More than 80 related to smoking, disease 10 times more common in smokers Exposure to ionizing radiation, inhaled irritants, exposure to radon also risk factors Prevention Highly dependent on refraining from or stopping smoking For smokers who quit before the age of 40, the risk of death due to conditions associated with continued smoking decreases by 90 Prevention of lung cancer also includes preventing environmental exposure to known carcinogens such as asbestos and radon Clinical manifestations Manifestations related to location, spread of tumor Initial symptoms often attributed to smoking or chronic bronchitis Systemic, paraneoplastic manifestations ( weight loss, anorexia, fatigue, weakness, bone pain, tenderness, clubbing of fingers and toes, various endocrine, neuromuscular, cardiovascular, hematological symptoms See MULTISYSTEM EFFECTS OF LUNG CANCER, p. 106 Confusion, impaired gait and balance, headache, personality changes may indicate brain metastases Bone pain, pathological fractures, possible spinal cord compression, thrombocytopenia, anemia may indicate bone metastases See CLINICAL MANISFESTATIONS AND THERAPIES Lung Cancer, p. 107 Collaboration Prevention must be primary goal for healthcare providers ( disease typically advanced when diagnosed, prognosis generally poor Accurate diagnosis first step in treating lung cancer ( treatment based on tumor location, type of cancer cell, staging of tumor, clients ability to tolerate treatment See Table 213 THE TNM STAGING SYSTEM FOR LUNG CANCER, p. 107 Diagnostic tests Chest x-ray Sputum specimen Bronchoscopy Computed tomography (CT) Cytological examination and biopsy CBC, liver function studies, serum electrolytes Tuberculin test Pulmonary function test and arterial blood gas Surgery Only real chance to cure non-small-cell lung cancer Most inoperable, partially resectable at time of diagnosis Pharmacologic therapy Combination chemotherapy treatment of choice for small-cell lung cancer ( due to rapid growth, dissemination, sensitivity to cytotoxic drugs Also used as adjunct to surgery, radiation therapy may be used to reduce size of advanced tumor Bronchodilators may be prescribed to reduce airway obstruction Analgesics, pain management strategies Radiation therapy Used alone or in combination with surgery or chemotherapy May be either cure or symptom relief May be delivered by external beam, intraluminal radiation, or brachytherapy Nursing process Assessment Focus on identifying risk factors, early manifestations, respiratory function Health history Current symptoms Smoking history Occupational exposures Physical examination Diagnosis Impaired Gas Exchange Ineffective Breathing Pattern Risk for Decreased Cardiac Tissue Perfusion secondary to impaired oxygenation Activity Intolerance Pain Anticipatory Grieving Planning Client expresses feelings related to diagnosis and/or terminal condition Client makes informed decision related to treatment options Client maintains adequate oxygenation Client reports pain at acceptable level to allow for rest Implementation Promote effective cardiorespiratory function Assess and document respiratory rate, depth, lung sounds at least every 4 hours Frequently assess and document pain level provide analgesics as needed Elevate head of the bed 60 Assist client to turn, cough, deep breathe, use incentive spirometry Suction airway as needed Provide chest physiotherapy with percussion and postural drainage as needed If mechanical ventilation instituted, work with respiratory therapy, use analgesia or sedation to synchronize respirations with ventilator Provide reassurance and emotional support Manage pain effectively Assess and document pain using standardized pain scale and objective data Provide analgesics as needed to maintain comfort For cancer pain, maintain around-the-clock medication schedule Provide or assist with comfort measures, such as massage, positioning, distraction, relaxation techniques Assist client and family plan and engage in activities that distract from pain Spend as much time with client as possible allow family members to remain with client Manage fatigue and activity intolerance Plan rest periods between activities and procedures Assist postoperative client to increase activities gradually Teach measures to conserve energy while performing ADLs Keep frequently used objects within easy reach Administer oxygen as prescribed Encourage maintenance of physical activity to tolerance Allow family members to provide assistance as needed Promote healthy grieving Spend time with clients and family Answer questions honestly do not deny the probable outcome of the disease Encourage clients and family to express their feelings, fears, concerns Encourage use of other support systems Discuss advance directives, such as DNR orders, powers of attorney Evaluation Client maintains an oxygen saturation of greater than 90 at rest and with activity Clients respiratory rate ranges between 12 and 24 breathes per minute Client denies dyspnea at rest and during appropriate levels of activity Clients heart rate is maintained within 10 of the upper and lower limits of his normal range. Client makes informed decisions regarding all treatments Client reports maintenance of pain at tolerable levels Client verbalizes grief and fears related to his diagnosis and treatment Review Lung cancer Relate Link the Concepts and Exemplars Ready Go To Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 2.7 Prostate Cancer Overview Abnormal growth of prostate tissue may be related to benign prostatic hypertrophy or maybe indication of prostate cancer Prostate cancer is curable when diagnosed early Prostate cancer found on autopsy ( no manifestations or complications Pathophysiology and etiology Prostate gland consists of primarily glandular epithelial cells Androgens believed to have role in its development Almost all primary prostate cancers are adenocarcinomas Develop in peripheral zones of prostate gland May compress urethra ( obstructing urinary flow Metastasis by lymph and venous channels is common Etiology Most common cancer type, second-leading cause of death among men in North America Disease of older men death rates decreasing due to advances in diagnosis, treatment Risk factors Greatest risk factor is age Genetic and hereditary factors Having a vasectomy believed to increase levels of circulating free testosterone Dietary factors, including diet high in animal fat See FOCUS OF DIVERSITY AND CULTURE Risk and Incidence of Prostate Cancer, p. 113 Early-stage often asymptomatic Pain from metastases to bones often initial manifestation Urinary manifestations depend on size, location of tumor Prevention Medications to prevent prostate cancer are the topic of research Certain hormones used to treat benign prostatic hyperplasia have shown at 25 reduction of risk for developing prostate cancer Screening recommendations center around the discussion and timing of available tests For men at average risk with life expectancy of at least 10 years ( initiate discussion at age 50 For men at high risk (African Americans and any whose close relative was diagnosed before age 65 ( initiate discussion at age 45 For men at even higher risk (those with several close relatives diagnosed at an early age) ( initiate discussion at age 40 Clinical manifestations Early-stage prostate cancer is usually asymptomatic Urinary manifestations depend on size and location of the tumor and stage of malignancy Urgency Frequency Hesitancy Dysuria Nocturia Men may notice hematuria in the ejaculate Pain from metastasis to bones is often the initial manifestation See CLINICAL MANIFESTATIONS AND THERAPIES PROSTATE CANCER on p. 114 Collaboration Focuses on diagnosis, elimination or containment, and prevention or treatment of complications Treatment is complex, depends on grade and stage of cancer as well as age, health, preference of client Diagnostic tests Definitive diagnosis made only by biopsy Digital rectal examination (DRE) ( prostate gland nodular, fixed Prostate-specific antigen (PSA) ( used to diagnose, stage prostate cancer and monitor response to treatment PSA used with DRE Ultrasonography used to guide needle biopsy Urinalysis Cystoscopy Bone scan, MRI, CT ( to determine presence of metastases Grade and stage help determine prognosis, guide treatment decisions See Table 215 PROSTATE CANCER STAGING AND TREATMENT, p. 114 Surgery Prostatectomy Simple prostatectomy Radical prostatectomy Retropubic prostatectomy Perineal prostatectomy Suprapubic prostatectomy Clients with stage III locally advanced ( surgery is controversial, may be used to relieve obstruction Surgical intervention available for men with postprostatectomy incontinence due to urinary sphincter insufficiency See Figure 219 OPERATION OF AN ARTIFICIAL URINARY SPHINCTER, p. 115 Pharmacologic therapy Androgen deprivation therapy ( used to treat advanced prostate cancer Strategies to induce androgen deprivation include orchiectomy, administration of hormonal agents See Table 217 SURGICAL AND HORMONE THERAPY IN THE MANAGEMENT OF ADVANCED PROSTATE CANCER, p. 116 Radiation therapy May be used as primary treatment ( reduces risk of long-term problems of impotence, urinary incontinence associated with surgery Also in palliative role for clients with metastatic cancer See Table 216 POTENTIAL COMPLICATIONS RELATED TO RADICAL PROSTATECTOMY AND RADIATION THERAPY, p. 115 Complementary and alternative therapy Men may lower their risk of prostate cancer by consuming a diet low in dairy and processed meats and high in fruits and vegetables Nurses should question clients about their use of nutritional supplements Clients should be urged to check with their healthcare provider regarding complementary and alternative therapies Nursing process Assessment Health history Risk factors Urinary elimination patterns and manifestations Hematuria Pain Physical assessment Digital rectal examination (DRE) ( advanced nursing assessment Diagnosis Impaired Urinary Elimination Risk for Urinary Retention Risk for Stress Urinary Incontinence Sexual Dysfunction Pain Planning Client verbalizes concerns about, symptoms of sexual dysfunction without discomfort Client maintains adequate urinary output Client lists strategies for reducing and coping with urinary incontinence Client receives adequate pain management to control pain within tolerable levels Implementation Promote urinary elimination Assess the degree of incontinence and its effects on lifestyle Teach Kegel exercises to help restore continence Teach methods to control dampness and odor from stress incontinence Do not attempt to prevent accidental voiding by restricting fluids Manage occasional episodes with absorbent pads worn inside underwear and changed as needed Refer to physical therapy or a continence specialist for additional measures Explore options such as an external collection device Encourage verbalizing feelings about impact of incontinence on quality of life Promote communication related to sexual function Surgical treatment may cause erectile dysfunction Assess mans pretreatment sexual function Teach the man about actual or potential effects of therapy on sexual function Provide an opportunity for the man and his partner to discuss implications of and concerns about the diagnosis and treatment of sexual function Discuss medical and surgical treatments for erectile dysfunction Refer for sexual counseling as appropriate Promote effective pain management Assess intensity, location, and quality of pain provide optimal pain relief Teach the man and his family noninvasive methods of pain control Evaluation Client rates and reports pain before it becomes intolerable Client discusses sexual function without anxiety or discomfort Client list strategies for managing urinary incontinence Client maintains adequate urine output without complications related to altered urinary illumination Review Prostate cancer Relate Link the Concepts and Exemplars Ready Go Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 2.8 Sickle Cell Disease Overview Hereditary hemoglobinopathy ( characterized by replacement of normal hemoglobin with abnormal hemoglobin S (Hgb S) Sickle cell anemia most common sickle cell disorder See Table 218 FORMS OF SICKLE CELL DISEASE, p. 120 Pathophysiology and etiology When percentage of hemoglobin replaced by Hgb S increases ( called sickling RBCs become abnormally crescent shaped ( causes occlusion of small blood vessels, ischemia, damage to affected organs Abnormally shaped RBCs unable to circulate freely Repeated, prolonged ischemia causes damage to tissues and organs, causing scarring, impaired function Stroke is a significant risk to children with sickle cell disease ( can lead to developmental delay, mental retardation, other neurological outcomes Other complications ( pulmonary, bone marrow, priapism, gallstone formation Sickle cell crisis( term used to describe periods when the percentage of Hgb S increases, resulting in appearance of symptoms Precipitating factors include dehydration, hypoxia Sickled cells can resume normal shape when rehydrated and reoxygenated Membrane of cells becomes more fragile ( cell life is shortened Etiology Disease transmitted as autosomal recessive genetic defect Risk factors Most common among people of African descent In United States 713 of African Americans carry defective gene, have sickle cell trait Likely to remain asymptomatic unless stressed by severe hypoxia Less than 1 of African Americans are homozygous for the disease ( have sickle cell disease At risk for sickle cell crisis Condition likely to trigger sickling include hypoxia, low environmental or body temperature, excessive exercise, anesthesia, dehydration, infections, acidosis See Table 219 OVERVIEW OF SICKLE CELL CRISIS, p. 121 Clinical manifestations Acute and chronic manifestations arise from episodes of RBC sickling Sickling causes general manifestations of hemolytic anemia ( pallor, fatigue, jaundice, irritability Repeated infarcts associated with sickling may cause Enlarged liver and spleen renal insufficiency Gallstones Priapism Abdominal pain Skin ulcers Pain Intensity and duration vary depending on individual and location Pain may require opioid analgesics and use of a PCA Stroke ( significant risk for all clients with SCD Other complications include aplastic crisis or temporary cessation of bone marrow blood cell production Extensive sickling can precipitate crisis Vaso-occlusive or thrombotic crisis occurs when sickling develops in microcirculation Thrombotic crisis painful, last an average of 46 days Infarction of small vessels in extremities causes painful swelling Abdominal pain may signal infarction of abdominal organs, structures Infarction may also affect bone marrow Acute chest syndrome may develop Other complications include pneumonia, pulmonary infarction, pulmonary embolism, death Lifespan considerations Pediatric clients Affected children usually asymptomatic until 4 to 6 months of age because sickling inhibited by high levels of fetal hemoglobin Children experience chest tightness and shortness of breath 10 will experience a stroke Children with sickle cell trait may develop symptoms when in low oxygen situations, such when flying in an unpressurized airplane or when anesthesia is administered Pregnant clients Pregnant women with SCD often experience more frequent pain crises and more intense symptoms At higher risk for complications including miscarriage, premature birth, and low birth weight Collaboration Neonatal screening, early intervention, prophylactic antibiotics, parent education ( allow children with sickle cell disease to live into adulthood Diagnostic tests Newborn screening ( mandatory in the U.S. Initial diagnosis is made by testing a few drops of blood from a heelstick Prenatal diagnosis is possible through amniocentesis Adult testing is done from venous blood sample Blood samples evaluated for presence of Hb S Positive samples are further evaluated for number of sickle genes present Those with two Hb S genes are further evaluated for anemia For pediatric clients Further testing may be indicated for prevention of stroke At age 2, children should have routine ultrasound of the head to assess cerebral blood flow Surgery Bone marrow or hematopoietic stem cell transplantation may be considered Splenectomy may be necessary for clients experiencing splenic sequestration of RBCs Pharmacologic therapy Oxygen ( administered to reduce risk of hypoxemia Parenteral analgesics generally administered around the clock, or via PCA Oral, IV fluid replacement also promote pain relief Hydroxyurea is helpful in adult clients, and is now being used more often in children as well Pneumococcal and influenza vaccines recommended for all clients with SCD For children ( prevention and treatment of infection Those between 2 months and 5 years often receive daily prophylactic penicillin Children who are functionally asplenic, have had splenectomy ( decreased capability to fight infection When infection suspected ( cultures obtained, aggressive antibiotic therapy implemented Nonpharmacologic therapy Blood transfusions ( core component of treatment Benefits include improved blood and tissue oxygenation, reduction in sickling, temporary suppression production of RBCs containing Hgb S Complication with frequent transfusions ( overload of the iron in body Hemosiderosis may require iron-chelating therapy Alloimmunization is another complication of multiple transfusions Chronic transfusion proven to be effective treatment for stroke complications related to sickle cell disease Complementary and alternative therapy Massage reduces pain associated with SCD Nutritional supplement to relieve the inflammatory process are being studied Nursing process Assessment History Past crises, precipitating events, medical treatment, home management Chronic, acute pain Height and weight Multisystem assessment Fever, neurological changes, respiratory symptoms ( emergency conditions ADLs, developmental status Family psychosocial assessment Diagnosis Impaired Gas Exchange Risk for Ineffective Breathing Pattern Risk for Decreased Cardiac Tissue Perfusion Risk for Imbalanced Fluid Volume Risk for Impaired Cerebral Tissue Perfusion Risk for Infection Acute Pain Caregiver Role Strain Interrupted Family Processes Delayed Growth and Development Impaired Physical Mobility Planning Clients oxygen saturation will be maintained at greater than 90 Clients respiratory rate will range between 12 and 20 breathes per minute Client will deny shortness of breath Client will deny manifestations of acute cardiac syndrome Client will demonstrate no signs or symptoms of stroke Client will demonstrate urine output of at least 0.5 mL/kg/hr Client will demonstrate no signs or symptoms of infection Adult client will consistently rate is pain level at 3 or less pediatric client will rate her pain as being tolerable or absent Client will meet criteria for normal growth and development Caregiver will provide report in assistance as needed Client will meet growth and development needs Client will optimize physical mobility as tolerated Implementation Promote optimal oxygenation and circulation Administer blood transfusions, oxygen as ordered Monitor for transfusion reactions Encourage child to rest Schedule caregiving activities and play to allow for optimal rest Maintain fluid volume balance Dehydration can lead to life-threatening consequences Administer IV fluids as ordered Teach clients to monitor intake and output Prevent and manage infection Teach parents how to administer antibiotics for prophylaxis or treatment Assess resources to obtain antibiotics Encourage use of vaccines Manage pain Administer prescribed analgesics around the clock during crises PCA education for parent or child Reposition for comfort Facilitate growth and development Emphasize the importance of nutrition and hydration Encourage child to eat high-protein, high-calorie diet Emphasize the importance of folic acid and vitamin C supplements Perform regular growth measurements Calculate childs fluid maintenance requirements Monitor childs oral fluid intake teach clients, parents to monitor intake, output ( see CLIENT TEACHING, p. 125 Reduce risk for caregiver role strain Explore resources in home and community Assess knowledge of signs of infection, sickle cell crisis, when to seek medical care Refer for genetic counseling, support groups Collaborate with family members, provide ongoing support Evaluation Client demonstrates no signs and symptoms of hypoxia Client denies dyspnea Client experiences no complications of SCD Client demonstrates indicators of adequate hydration Client demonstrates no signs or symptoms of infection Client is current and up todate with all recommended vaccinations Client reports absence of pain or pain at level she finds tolerable Family and healthcare personnel promptly recognize and treat complications of the disease Pediatric client meets normal growth and developmental milestones Family, healthcare personnel promptly recognize and treat complications of the disease Parents, other family members referred for and receive information to manage and understand disease Family demonstrates adequate knowledge of the disease in treatment regimens Review Sickle cell disease Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 2.9 Skin Cancer Overview Skin is fragile, subject to damage from ultraviolet radiation and chemicals Common site for malignant lesions Melanomas most common of all cancers Nonmelanoma skin cancers ( basal cell cancer and squamous cell cancer Pathophysiology and etiology Melanoma Arise from melanocytes ( cells located at or near basal layer, where there is pigment Initially develop within epidermis over a long period Start flat, and relatively benign ( penetrate dermis, mingle with blood, lymph vessels ( capable of metastasizing Prognosis for survival determined by several variables Tumor thickness Ulceration Metastasis Site ( hands, feet, scalp ( poorer prognosis Age Gender Precursor lesions Congenital nevi ( present at birth Lentigo maligna ( tan or black patch on skin that looks like a freckle, grows slowly Classifications of malignant melanomas Four types superficial spreading melanoma, lentigo maligna melanoma, nodular melanoma, and acral lentiginous melanoma Phases Radial ( melanoma grows parallel to skin surface Rarely metastasizes, often curable by surgical excision Vertical growth phase ( atypical melanocytes rapidly penetrate into dermis, subcutaneous tissue, greatly increasing risk for metastasis and death Superficial spreading melanoma Most common50 of all melanomas Flat, scaly or crusty lesions approximately 2 cm in diameter Trunk, back of men, legs of women Median age of occurrence is in the 50s Radial growth phase lasts 15 years ( grows rapidly when enters vertical growth phase Develops irregular borders, raised nodules, ulcerations See Figure -21 MALIGNANT MELANOMA, p. 129 Lentigo maligna melanoma ( often from precursor lesion Large, tan, different shades of brown Affects women more than men, typically in the 60s or 70s Proliferation of atypical melanocytes parallel to basal layer of epidermis Radial growth phase from 10 to 25 years Nodular melanoma ( raised, dome-shaped, blue-black or red nodules Head, neck, trunk ( may look like blood blister, may ulcerate and bleed Vertical growth phase only ( aggressive growth Acral lentiginous melanoma ( more common in people with dark skin Tan, brown, black flat lesions to elevated nodules Found on palms of the hands and soles of the feet Radial phase 25 years Nonmelanoma skin cancer Basal cell cancer ( epithelial tumor Most common, least aggressive, rarely metastasizing Tends to recur Nodular basal cell cancer ( most common type, appears on face, neck, head Superficial basal cell cancer ( second most common type of basal cell cancer Proliferating tissue that attaches to undersurface of epithelium Pigmented basal cell cancer ( found on head, neck, face Less common Morpheaform basal cell cancer ( rarest form of basal cell cancer Finger-like projections that extend in any direction along dermal tissue planes Keratotic basal cell cancer ( found on preauricular and postauricular groove Tends to recur locally, most likely to metastasize See Table 220 TYPES AND CHARACTERISTICS OF BASAL CELL CANCERS, p. 130 Squamous cell cancer ( malignant tumor of squamous epithelium Most often on areas of skin exposed to UV rays More aggressive than basal cell cancer Arises when keratinizing cells of squamous epithelium proliferate Begins as small firm red nodule May ulcerate, bleed, become painful Recurrent squamous cell cancer can be invasive Actinic keratosis ( epidermal skin lesion directly related to chronic sun exposure, photodamage May progress to squamous cell carcinoma Erythematous, rough macules, may be shiny, scaly Etiology Leading cause is exposure to sun Tanning beds among most dangerous forms of UV exposure Other factors ( age, skin type, skin color, genetic predisposition Risk factors Melanoma skin cancer Light-colored eyes, freckling, fair skin, blond or red hair, family history, blistering sunburns before age 12, frequent sun exposure, melanocytic nevi, immunosuppression Nonmelanoma skin cancer Environmental factors UV radiation, pollutants, chemicals, ionizing radiation, viruses, physical trauma UV radiation from sun Geographic, environmental, lifestyle factors Chemical ( polycyclic hydrocarbons Other factors( radiation, viruses, physical trauma Host factors ( skin pigmentation ( more melanin, more protection Major risk is change in existing lesion, presence of premalignant lesion Organ transplant recipients Actinic keratosis ( highest prevalence in light-colored skin Prevention Primary prevention ( avoid prolonged sun exposure Avoid artificial tanning machines Apply sunscreen daily Wear broad-brimmed hats and sunglasses Newborns should not be exposed to direct sunlight Apply sunscreen to children over 6 months of age Clinical manifestations Differs with each type of skin cancer See CLINICAL MANIFESTATIONS AND THERAPIES Skin Cancer, pp. 132 - 133 Collaboration Promote early detection Treatment of nonmelanoma ( removal of malignant tissue Surgery, curettage, electrodesiccation, cryotherapy, or radiotherapy Treatment of melanoma ( begins with identification, diagnosis, tumor staging Removed through surgical excision Chemotherapy, immunotherapy, radiation therapy Diagnostic tests Biopsy of suspicious lesion Tests to determine if tumor has metastasized Microscopic examination Tests for metastasis ( liver function, CT of liver, CBC, serum blood chemistry profile, chest x-ray, bone scan, CT or MRI of brain Microstaging ( assessment of level of invasion of a malignant melanoma and maximum tumor thickness After thickness, depth determined, clinical stage assigned See Figure 225 CLARKS LEVELS FOR STAGING, p. 134 Surgery Surgical excision of lesions includes full thickness of skin, subcutaneous tissue Surgical excision of clinically significant lymph nodes ( most common site for metastasis of malignant melanoma Elective lymph node dissection (ELND) remains controversial Surgery indicated for palliative management of isolated metastasis Pharmacologic therapy Immunotherapy Tumor-specific antigen-antibodies identified with melanoma Agents include interferons, interleukins, monoclonal antibodies, more Emerging treatments Gene therapy Melanoma DNA research Immune therapy Staging Radiation therapy Melanoma responds to higher-dose radiation, if tumor small Palliation of symptoms related to metastasis to brain, bone, lymph nodes, gastrointestinal tract, skin, subcutaneous tissue Nursing process Assessment Skin assessment Health questionnaire See ASSESSMENT INTERVIEW Skin Cancer, p. 135 Diagnosis Impaired Skin Integrity Deficient Knowledge related to risk factors for skin cancer Risk for Infection Hopelessness Anxiety Planning Client describes treatment options, pros and cons of each Client will demonstrate no signs or symptoms of infection postoperatively Client reports need to examine all skin lesions for changes or unusual appearance Client avoids sun exposure and does not use tanning beds Client expresses feelings related to diagnosis of skin cancer Implementation Prevent infection Monitor for manifestations of infection Keep incision line clean and dry by changing dressing as necessary Follow principles of medical and surgical asepsis when caring for the clients incision Encourage and maintain adequate caloric and protein intake in the diet Address feelings of hopelessness Provide an environment that encourages client to identify and express feelings, concerns, goals Use active listening, ask open-ended questions, reflect on clients statements Acknowledge and respect feelings of apathy, anger as expressions of distress Convey empathetic understanding of fears and concerns Provide opportunities to express positive emotions Explore clients perceptions, modify or clarify them if necessary Encourage the client to identify support systems, sources of strength, coping Encourage participation in self-care, mutual decision making, goal setting Encourage focus not only on present, but also on future Reduce anxiety Provide reassurance and comfort Set aside time to sit quietly with the client, speaking slowly and calmly Convey empathetic understanding by touch, supporting coping mechanisms Do not make demands or expect client to make decisions Decrease sensory stimuli by using short, simple, sentences Provide interventions that decrease anxiety levels and increase coping Evaluation Client demonstrates no signs or symptoms of infection Clients postoperative wound demonstrates signs of adequate healing Client consistently rates his pain at a level he considers to be tolerable or denies pain Client verbalizes awareness of the need to examine all skin lesions for changes or unusual appearance Client describes indications for reporting integumentary changes to healthcare provider Client makes informed decision regarding treatment options Client avoids sun exposure and use of tanning bed Client copes with alterations in body image in a constructive way Review Skin cancer Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. Lecture Outline for Nursing A Concept-Based Approach to Learning, 2e, Volume 1 PAGE MERGEFORMAT 84 Y, dXiJ(x(I_TS1EZBmU/xYy5g/GMGeD3Vqq8K)fw9 xrxwrTZaGy8IjbRcXI u3KGnD1NIBs RuKV.ELM2fiVvlu8zH (W uV4(Tn 7_m-UBww_8(/0hFL)7iAs),Qg20ppf DU4p MDBJlC5 2FhsFYn3E6945Z5k8Fmw-dznZxJZp/P,)KQk5qpN8KGbe Sd17 paSR 6Q