Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Colorectal Cancer Brunner, pp. 1098-1107 Colorectal Cancer Statistics and Risk Second leading cause of death from cancer Most are adenocarcinoma Approximately 70-75% occur in colon; 25-30% in rectum with ½ occurring in the rectosigmoid area Over ¾ of cancers come from polyps that spread into mucosal lining and into lymph system and then to liver*,lungs, bone, brain Risk factors p. 1099, Chart 38-9 Manifestations Maybe none for 5-15 years Hematochezia or melena Abdominal pain/cramping Weakness, fatigue, anemia, weight loss Change in bowel habits Change in stool caliber Fullness in lower abdomen or rectum or palpable mass Complications Intestinal obstruction (pain, vomiting, distention, unusual bowel sounds, no stool) Iron-deficiency anemia from blood loss Perforation with peritonitis (sudden pain, distention, fever, sepsis) Fistula formation Diagnostics Colonoscopy is gold standard—polyps or tumors may be seen, but bx is confirmation. Starting at 50, then depending on findings, family hx—may be q 5 or q 10yr Hemoccult or guaiac (FOB) Barium enema Labs: CBC, coag studies, liver functions, CEA—initial and to monitor treatment and recurrence CT or MRI Collaborative Care: Surgery Treatment depends on Dukes or TNM classification Polypectomy during colonoscopy for in-situ Colon resection (right or left hemicolectomy) with endto-end anastomosis with lymph removal (lap procedures decrease recovery time) Abdominal-perineal resection with ostomy A-P resection with temporary ostomy to preserve anal sphincter. May include construction of rectal pouch. If metastasized, surgery may be palliative to control bleeding or obstructive sx Chemo and Radiation Therapy Treatment is highly individualized, but combo platters are usually used. Most common drugs: – – – – 5-FU Leucovorin Xeloda Mitomycin Radiation as adjuvant or for metastasis to reduce tumor size & provide symptomatic relief Nursing Management: History Colon, breast, ovarian cancer, familial or hereditary polyposis, inflammatory bowel dz, meds affecting bowel function High-fat, low-fiber diet Weakness, fatigue, anorexia, wt loss, N/V Bowel changes: urgency, bleeding, mucoid, black, gas, decrease in caliber, pain Nursing Management: Objective Data Pallor, cachexia, lymphadenopathy Abd mass, distention, ascites, hepatomegaly Hemoccult + stools, anemia + DRE, + scopes, + radiography Preop Nursing Management Preop teaching—may need ostomy teaching by wound care or ostomy care nurse, preferably Dietary modifications may be done several days before surgery Need info about bowel prep procedure Bowel cleansing and or antibiotics to decrease contamination Maybe need TPN before surgery Need a lot of emotional support Postop Nursing Management If reanastamosis is done, then postop care is routine abdominal surgery. Incision may be large, but closed with staples. Remember to check incision, dressing, and drainage. Lap procedures will only have small midline incision and lap sites covered with Tegaderm Pt may have NGT or TPN. May be NPO, ice chips, or clear liqs depending on type of surgery Surgical Nsg Care cont’d Monitor for infection in any skin break Provide adequate pain control and give prophylacticly Monitor for signals of readiness to resume oral intake If abdominal-perineal surgery is done for extensive metastasis, care of both an abdominal and an open perineal wound and drain management is necessary. Ostomy care if indicated Probs with sexual dysfunction Patient Education For screening: – FOB q yr – Patients > 50 to have routine colonoscopy; 45 in blacks—repeat q 10 y unless + hx – Teaching regarding colonoscopy prep – Teach patients how to recognize early warning signs For postop: – Home instruction on sitz baths, wound & ostomy care, dietary management – Don’t forget psychosocial issues, sexual concerns & Prostate Cancer Brunner, pp. 1516-1530 Prostate Cancer Most common cancer in men and 2nd leading cause of death from cancer. 2/3 are over 65 y.o. Almost 30,000 die each year. Interestingly, early dx leads to cure. 5-year survival rate is 98% Risk Factors >50 y.o. African American (twice as likely) Family hx (father or brother twice as likely) High fat diet, high red meat intake, Vitamin A supplements, low intake of fruits and vegs Positive HPC1, BRCA1 and BRCA2 gene mutations Manifestations of Prostate Cancer Asymptomatic at 1st Dysuria, urgency, frequency, hesitancy, dribbling, nocturia, retention, interrupted stream, inability to urinate, hematuria, oliguria Painful ejaculation, back, hip, leg pain and weakness, and perineal or rectal discomfort Anemia, nausea, wt loss Complications Metastasis to lymph nodes, bones, bladder, lungs, and liver Bone mets are especially painful because of spinal cord compression and destruction of pelvic bone, femoral head, or lumbosacral spine. Pain control is important aspect of care. Diagnostics DRE reveals hard, nodular, asymmetrical gland PSA>4 (not all elevations are cancer). For screening and monitoring success of tx UA, CBC, Alkaline phosphatase Transrectal US with needle bx CT, MRI, bone scan Medical Management of Prostate Cancer Depends on stage Pharmacologic: androgen deprivation therapy or androgen antagonist therapy. Accomplished by giving meds such as Lupron (testicular suppression of androgen), or Eulexin (adrenal suppression). External beam or brachytherapy (internal radiation with seed implants)—with or without surgery Cryotherapy—liquid nitrogen placed into prostate Watchful waiting—more common in elderly Surgical Management Surgical tx includes radical prostatectomy (prostate, seminal vesicles, part of bladder neck and lymphs are removed) by one of three methods: suprapubic, retropubic, perineal—see p. 1525, Figure 49-4 May also be done laproscopically and with nerve-sparing procedure Orchiectomy may also be done if late stage (produces androgen suppression) Complications Urinary incontinence Erectile dysfunction Hemorrhage Urinary retention Infection Dehiscence DVT and PE Nursing Management: Health Promotion Teach importance of PSA and DRE beginning at age 50 and 45 for African Americans If risk factors are present, screening may need to be done earlier Teach symptoms of enlarged prostate and to seek help when it happens Stress high success rate with early detection Postop Nursing Management Monitor for return of sensation from spinal anesthesia and protect from injury Monitor 3-way Foley and CBI if used Keep CBI running at rate that keeps urine pink without clots Watch for hemorrhage FF, keep strict I&O (subtract CBI) Monitor surgical incision Postop Nursing Care cont’d After CBI is d/c, urine will be cranberry Monitor for clots—call MD for irrigation order Usually go home with cath; After cath is out, urine is racked (monitored by comparison samples) Push fluids! Clots must be prevented Expect bladder spasms and discomfort with first voiding which will be small Give analgesics and also antispasmodics (if ordered), stool softeners Emotional support Patient/Family Education after Surgery • • • • Catheter care and bag-switching Kegel exercises Wearing pad up to one year Avoid intraabdominal pressure: Valsalva, lifting, long trips, strenuous activity, sitting or walking for long periods • Caffeine restriction, FF, urine will be cloudy • Watch for bright red bleeding, infection, decreased UOP, incision, calf tenderness • Management of ED—Viagra and penile implants Breast Cancer Brunner, pp. 1481-1503 Overview * Factors used to help differentiate benign from malignant tumors include age, number of lumps, shape, consistency, mobility, tenderness, retraction. • BSE qmo beginning at age 20, but malignant lesions may not be palpable for 10 years; therefore mammography baseline 35-40 and qyr after 40. • Mutated cell doubles q30d; 30 doubling times for lump to get to 1 cm when it can become apparent Breast Cancer Statistics Most common 2nd to skin cancer Highest death rate 2nd to lung cancer Over 200,000 new cases; almost 41,000 deaths each year Incidence is increasing; deaths decreasing especially among young women Localized cancers without node involvement have 5-yr survival rate of 98% Etiology and Risk Factors Table 48-3 on p. 1483 shows gender, age, fa hx, personal hx, hormonal influences, parity, obesity, dietary factors, radiation exposure, and complicated benign disease as risk factors Mutations in genes BRCA 1 and 2 increase risk, but can be reduced by having ovaries removed. Protective Factors and Prevention Strategies Full-term pregnancy before age 30 Breastfeeding (delays exposure to estrogen) Exercise after menopause Close surveillance with high risk patients using MRI Tamoxifen or Evista for high risk patients Prophylactic mastectomy Types of Breast Cancer Ductal Carcinoma in Situ (noninvasive) – Confined to ducts – Mostly treated by simple mastectomy with radiation – Tamoxifen x 5 yrs for prophylaxis Types cont’d Invasive Carcinoma—Most serious: – Infiltrating ductal –80% of all breast cancers; very hard on palpation; more likely to metastasize to lung, bone, liver, brain; poorest prognosis. – Infiltrating lobular—10-15%; arise from thickened areas and may occur at several sites; may spread to above areas and meninges; poor prognosis. Types cont’d Invasive Carcinoma—Better outcomes: – Medullary—5%; encapsulated and large; fair prognosis. – Mucinous—3%; slow growing; good prognosis – Tubular—2%; metastasis rare; excellent prognosis Types cont’d Invasive Carcinoma—Rare, serious types: – Inflammatory—1-3%; causes pain, redness, enlarged and firm breast, edema, nipple retraction; attention is sought early; spreads quickly; chemo, radiation, surgery – Paget’s Disease—1%; ductal type; scaly lesion, burning, itching around nipple-areola area; bx is needed for dx; tx as above Assessment (Chart 48-1, p. 1474) Nontender Fixed Hard Irregular border Retraction Dimpling Usually upper outer quad Lymphs, bone, lung sites most common sites of metastasis Diagnostics BSE: includes inspection & palpation Mammography US MRI (for women at high risk) Biopsy: definitive; can reveal type and stage and whether tumor is estrogen dependent Breast Self-Exam (BSE), p. 1475-6 Examine monthly , preferably after period, beginning at age 20 Clinical exam q3yr 20-40; qyr after 40 Examine in shower with soap and water Look at breasts in mirror, then raise arms Put hands on hips; then lean forward Use a method to palpate entire breast tissue, including tail of Spence Mammography Detects tumors using x-ray even before they are palpable (usually 1 cm-10 years) Can show early cancer tissue changes if compared to previous x-rays Yearly mammography starting at 40 (talk with MD if high-risk) Staging Most women are Stage 2 @ time of dx Survival Rates depend on: – Hormone receptors – Growth factor receptors (HER-2) – Tumor differentiation, size – Proliferation (number) – DNA content – Axillary node involvement 100 90 80 70 60 50 40 30 20 10 0 Stages 1 2 3 4 Management Surgical Treatment Breast Conserving Lumpectomy Partial mastectomies Node Dissection Sentinel Node Axil ary Node Mastectomy Total Modified Radical/Radical Other Management Hormone suppression by oophrectomy, removal of pituitary gland, or adrenal glands Radiation (internal and external)—only in breast conserving procedures or with chest wall involvement Pharmacologic—Hormones if tumor is hormone dependent; Antineoplastics—3 of 5 drugs being used Preop Nursing Management Education about dx procedures, meds, postop wound care, managing chemo SEs, prosthetics Physician will discuss treatment options and reconstruction Emotional support—Use therapeutic communication and education to address many fears and anxieties r/t death, reoccurrence, txs, relationships, and finances Postop Nursing Management Pain management (paresthesia is common) Meds Arm elevation Drain management Management of incision and dressing Arm exercises (1491) Emotional support Education for home management Preventing Postop Complications Hematoma—indicates internal hemorrhage. Monitor x 12h—if forms, call MD immediately External hemorrhage Infection—incision, etc. Lymphedema—occurs more often in pts who have had axillary node dissection compared to sentinel node dissection Injury and trauma to arm Radiation External beam—most common Brachytherapy with implant into lumpectomy site Intraoperative radiation therapy (IORT)—intense radiation to surgical site after lump is removed Chemotherapy Cytoxan, methotrexate, and fluorouracil regimen is most common Taxol may be added for axillary node involvement Hormonal therapy with Tamoxifen (estrogen blocker) for premenopausal women; Arimidex (enzyme inhibitor that prevents estrogen from forming) for postmenopausal Targeted therapy using Herceptin which inactivates the HER-2 protein that makes tumor grow Reconstruction Enables women to maintain a sense of wholeness and to balance other breast Some women prefer prosthetics In most cases, can be done immediately or within one year of mastectomy Done in stages More successful if women have realistic expectations and have reconstruction done as soon as possible Types of Reconstructive Surgery Saline implant: – Temporary implant placed inside pectoralis muscle with port attached for injecting saline over a period of weeks. When tissue is stretched enough, permanent one is placed. – Advantages—office visits and OP surgery, less complications. – Disadvantages—less natural looking, synthetic material used Types cont’d Flap procedures—muscle flap, vessels, fat, and skin are transferred to operative site – TRAM—transverse rectus abdominis musculocutaneous flap (Figure 48-7, p. 1498). Most common type. – Gluteal muscle – Latissimus dorsi muscle (Figure 48-8) – Advantages—more natural appearance, no synthetic material – Disadvantages—longer inpatient surgery, more risk of complications (infection, bleeding, abdominal tension, and flap necrosis) Ovarian Cancer Brunner, pp. 1462-1464 Detection Leading cause of gynecological cancer deaths Hard to detect—bimanual exam still makes diagnosis difficult. No current screening test. Transvaginal US and other imaging techniques are not always reliable By the time it is diagnosed, it is advanced Most originate on the outside of the ovary (epithelial) Risk Factors Hx breast or colon cancer Mutations in BRCA-1 or BRCA-2 genes 50-60 years old Middle to upper class Nulliparous (increased # of ovulatory cycles) HRT Never used BCP Assessment Pelvic discomfort Low back pain Undx GI sx in women >40 such as wt change, abd pain, distention, NV, constipation Urinary frequency Early menopause Postmenopausal bleeding Premenarchial precocious breast development Virilization Diagnostics Bimanual exam—palpable ovaries in pre or postmenopausal females is abnormal. In menopausal females ovaries are hard or irregular and fixed US (abd or transvaginal) CA-125 (also + in fibroids and endometriosis Laparotomy with bx is definitive—prognosis is determined by histologic differentiation Management Prevention is best—annual pelvic exam Because of the difficulty of the dx, the disease is usually extensive at the time of dx. TAH-BSO with radiation and/or chemo because surgery alone does not cure. Chemotherapy Taxol + Paraplatin are most common Encapsulated chemotherapy delivers high dose in a liposome that decreases side effects. Combination IV and intraperitoneal chemotherapy is sometimes used Nursing Management Encourage women to get annual bimanual exams. Give emotional support and information Ascites and pleural effusion must be assessed for and reported so that para or thoracentesis can be done it pt condition warrants.