Transcript Gall Bladder Disease

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:
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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
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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.