Grading and Staging

of Cancer

Grading

Grade I: Cells differ slightly from normal cells and are well differentiated (mild dysplasia).

Grade II: Cells are more abnormal and are moderately differentiated (moderate dysplasia).

Grade III: Cells are very abnormal and are poorly differentiated (severe dysplasia).

Grade IV: Cells are immature (anaplasia) and undifferentiated; cell of origin is difficult to

determine.

Staging

Stage 0: Carcinoma in situ

Stage I: Tumor limited to the tissue of origin; localized tumor growth

Stage II: Limited local spread

Stage III: Extensive local and regional spread

Stage IV: Distant metastasis

■ Any sore that does not heal

■ Change in bowel or bladder habits

■ Indigestion

■ Nagging cough or hoarseness

■ Obvious change in wart or mole

■ Thickening or lump in breast or elsewhere

■ Unusual bleeding or discharge

A. Description

1. Chemotherapy kills or inhibits the reproduction of neoplastic cells and kills normal cells.

2. The effects are systemic because chemotherapy is usually administered systemically.

3. Normal cells most profoundly affected include those of the skin, hair, and lining of the

gastrointestinal tract, spermatocytes, and hematopoietic cells.

4. Usually, several chemotherapy and biotherapy agents are used in combination (combination

therapy) to increase the therapeutic response.

5. Combination chemotherapy is planned by the health care provider (HCP) so that medications

with overlapping toxicities and nadirs (the time during which bone marrow activity and white

blood cell counts are at their lowest) are not administered at or near the same time; this will

minimize immunosuppression.

6. Chemotherapy may be combined with other treatments, such as surgery and radiation.

B. Common side effects include fatigue, alopecia, nausea and vomiting, mucositis, skin changes, and

myelosuppression (neutropenia, anemia, and thrombocytopenia).

C. See Chapter 53 for information regarding the care of the client receiving chemotherapy.

A. Description

1. Radiation therapy destroys cancer cells, with minimal exposure of normal cells to the damaging

effects of radiation; the damaged cells die or become unable to divide.

2. Radiation therapy is effective on tissues directly within the path of the radiation beam.

3. Side effects include local skin changes and irritation, alopecia (hair loss), fatigue (most

common side effect of radiation), and altered taste sensation; the effects vary according to the

site of treatment.

4. External beam radiation (also called teletherapy) and brachytherapy are the types of radiation

therapy most commonly used to treat cancer.

B. External beam radiation (teletherapy): The actual radiation source is external to the client.

1. Instruct the client regarding self-care of the skin

2. The client does not emit radiation and does not pose a hazard to anyone else.

1. The radiation source comes into direct, continuous contact with tumor tissues for a specific

time.

2. The radiation source is within the client; for a period of time, the client emits radiation and can

pose a hazard to others.

3. Brachytherapy includes an unsealed source or a sealed source of radiation.

4. Unsealed radiation source

a. Administration is via the oral or IV route or by instillation into body cavities.

b. The source is not confined completely to one body area, and it enters body fluids and

eventually is eliminated via various excreta, which are radioactive and harmful to others.

Most of the source is eliminated from the body within 48 hours; then neither the client nor the

excreta is radioactive or harmful.

5. Sealed radiation source

a. A sealed, temporary or permanent radiation source (solid implant) is implanted within the

tumor target tissues.

b. The client emits radiation while the implant is in place, but the excreta are not radioactive.

6. Removal of sealed radiation sources

a. The client is no longer radioactive.

b. Inform the client that cancer is not contagious.

c. Inform the female client that she may resume sexual intercourse after 7 to 10 days if the

implant was cervical or vaginal.

d. Provide a douche, as prescribed, if the implant was placed into the cervix.

e. Administer a ready-to-use saline enema if prescribed.

f. Advise the client who had a cervical or vaginal implant to notify the HCP if nausea, vomiting,

diarrhea, frequent urination, vaginal or rectal bleeding, hematuria, foul-smelling vaginal

discharge, abdominal pain or distention, or fever occurs.

Wash the irradiated area gently each day with warm water alone or with mild soap and water.

Use the hand rather than a washcloth to wash the area.

Rinse soap thoroughly from the skin.

Take care not to remove the markings that indicate exactly where the beam of radiation is to be

focused.

Dry the irradiated area with patting motions rather than rubbing motions; use a clean, soft towel or

cloth.

Use no powders, ointments, lotions, or creams on the skin at the radiation site unless they are

prescribed by the radiologist.

Wear soft clothing over the skin at the radiation site.

Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at the

radiation site.

Avoid exposure of the irradiated area to the sun.

Avoid heat exposure.

1. Encourage the client to lie still.

2. Use a long-handled forceps to retrieve the radioactive source.

3. Deposit the radioactive source in a lead container.

4. Contact the radiation oncologist.

5. Document the occurrence and the actions taken.

The client with a sealed radiation implant can emit radiation. Therefore the nurse and any other

person who is in contact with the client needs to take special precautions to protect himself or

herself from radiation exposure. In the event that a radiation source becomes dislodged, the nurse

would first encourage the client to lie still until the radioactive source has been placed in a safe,

closed lead container. The nurse would never touch the dislodged radiation source with his or her

hands and would use a long-handled forceps to place the source in the lead container that should

be kept in the client’s room. The nurse calls the radiation oncologist and then documents the

occurrence and the actions taken. In the event that the radiation source cannot be located, the nurse

ensures that no linens or other articles in the client’s room are disposed of, prohibits visitors, and

notifies the radiation oncologist.

Place the client in a private room with a private bath.

Place a caution sign on the client’s door.

Organize nursing tasks to minimize exposure to the radiation source.

Nursing assignments to a client with a radiation implant should be rotated.

Limit time to 30 minutes per care provider per shift.

Wear a dosimeter film badge to measure radiation exposure.

Wear a lead shield to reduce the transmission of radiation.

The nurse should never care for more than one client with a radiation implant at one time.

Do not allow a pregnant nurse to care for the client.

Do not allow children younger than 16 years or a pregnant woman to visit the client.

Limit visitors to 30 minutes per day; visitors should be at least 6 feet from the source.

Save bed linens and dressings until the source is removed; then dispose of the linens and dressings

in the usual manner.

Other equipment can be removed from the room at any time.

A. Description

1. Bone marrow transplantation (BMT) and peripheral blood stem cell transplantation (PBSCT)

are procedures that replace stem cells that have been destroyed by high doses of chemotherapy

and/or radiation therapy.

2. BMT and PBSCT are most commonly used in the treatment of leukemia and lymphoma, but are

also used to treat other cancers, such as neuroblastoma and multiple myeloma.

3. The goal of treatment is to rid the client of all leukemic or other malignant cells through

treatment with high doses of chemotherapy and whole-body irradiation.

4. Because these treatments are damaging to bone marrow cells, without the replacement of bloodforming

stem cell function through transplantation, the client would die of infection or

hemorrhage.

B. Types of donor stem cells

1. Allogeneic: Stem cell donor is usually a sibling, parent with a similar tissue type, or a person

who is not related to the client (unrelated donor).

2. Syngeneic: Stem cells are from an identical twin.

3. Autologous

a. Autologous donation is the most common type.

b. The client receives his or her own stem cells.

c. Stem cells are harvested during disease remission and are stored frozen to be reinfused later.

C. Procedure

1. Harvest

a. The stem cells used in PBSCT come from the bloodstream in a 4- to 6-hour process called

apheresis or leukapheresis (the blood is removed through a central venous catheter and an

apheresis machine removes the stem cells and returns the remainder of the blood to the

donor).

b. In BMT, marrow is harvested through multiple aspirations from the iliac crest to retrieve

sufficient bone marrow for the transplant.

c. Marrow from the client is filtered for residual cancer cells.

d. Allogeneic marrow is transfused immediately; autologous marrow is frozen for later use

(cryopreservation).

e. Harvesting is done before the initiation of the conditioning regimen.

2. Conditioning refers to an immunosuppression therapy regimen used to eradicate all malignant

cells, provide a state of immunosuppression, and create space in the bone marrow for the

engraftment of the new marrow.

3. Transplantation

a. Stem cells are administered through the client’s central line in a manner similar to that for a

blood transfusion.

b. Stem cells may be administered by IV infusion or by IV push directly into the central line.

4. Engraftment

a. The transfused stem cells move to the marrow-forming sites of the recipient’s bones.

b. Engraftment occurs when the white blood cell, erythrocyte, and platelet counts begin to rise.

c. When successful, the engraftment process takes 2 to 5 weeks.

D. Posttransplantation period: Infection, bleeding, or neutropenia and thrombocytopenia are major

concerns until engraftment occurs.

During the posttransplantation period, the client remains without any natural immunity

until the donor stem cells begin to proliferate and engraftment occurs.

E. Complications

1. Failure to engraft: If the transplanted stem cells fail to engraft, the client will die unless another

transplantation is attempted and is successful.

2. Graft-versus-host disease in allogeneic transplants

a. Although the recipient cannot recognize the donated stem cells as foreign or non-self because

of the total immunosuppression, the immune-competent cells of the donor recognize the

recipient’s cells as foreign and mount an immune offense against them.

b. Graft-versus-host disease is managed cautiously with immunosuppressive agents to avoid

suppressing the new immune system to such an extent that the client becomes more

susceptible to infection, or the transplanted cells stop engrafting.

3. Veno-occlusive disease

a. The disease involves occlusion of the hepatic venules by thrombosis or phlebitis.

b. Signs include right upper quadrant abdominal pain, jaundice, ascites, weight gain, and

hepatomegaly.

c. Early detection is critical because there is no known way to open the hepatic vessels.

d. The client will be treated with fluids and supportive therapy.

Acute Lymphocytic Leukemia

■ Mostly lymphoblasts present in bone marrow

■ Age of onset is younger than 15 years.

Acute Myelogenous Leukemia

■ Mostly myeloblasts present in bone marrow

■ Age of onset is between 15 and 39 years.

Chronic Myelogenous Leukemia

■ Mostly granulocytes present in bone marrow

■ Age of onset is in the fourth decade.

Chronic Lymphocytic Leukemia

■ Mostly lymphocytes present in bone marrow

■ Age of onset is after 50 years.

A. Description

1. leukemias are a group of hematological malignancies involving abnormal overproduction of

leukocytes, usually at an immature stage, in the bone marrow.

2. The two major types of leukemia are lymphocytic (involving abnormal cells from the lymphoid

pathway) and myelocytic or myelogenous (involving abnormal cells from the myeloid

pathways).

3. Leukemia may be acute, with a sudden onset, or chronic, with a slow onset and persistent

symptoms over a period of years.

4. Leukemia affects the bone marrow, causing anemia, leukopenia, the production of immature

cells, thrombocytopenia, and a decline in immunity.

5. The cause is unknown and appears to involve genetically damaged cells, leading to the

transformation of cells from a normal state to a malignant state.

6. Risk factors include genetic, viral, immunological, and environmental factors and exposure to

radiation, chemicals, and medications, such as previous chemotherapy.

B. Assessment

1. Anorexia, fatigue, weakness, weight loss

2. Anemia

3. Overt bleeding (nosebleeds, gum bleeding, rectal bleeding, hematuria, increased menstrual

flow) and occult bleeding (e.g., as detected in a fecal occult blood test)

4. Ecchymoses, petechiae

5. Prolonged bleeding after minor abrasions or lacerations

6. Elevated temperature

7. Enlarged lymph nodes, spleen, liver

8. Palpitations, tachycardia, orthostatic hypotension

9. Pallor and dyspnea on exertion

10. Headache

11. Bone pain and joint swelling

12. Normal, elevated, or reduced white blood cell count

13. Decreased hemoglobin and hematocrit levels

14. Decreased platelet count

15. Positive bone marrow biopsy identifying leukemic blast–phase cells

C. Infection

1. Infection can occur through autocontamination or cross-contamination. The white blood cell

(WBC) count may be extremely low during the period of greatest bone marrow depression,

known as the nadir.

2. Common sites of infection are the skin, respiratory tract, and gastrointestinal tract.

3. Initiate protective isolation procedures.

4. Ensure frequent and thorough hand washing by the client, family, and health care providers.

5. Staff and visitors with known infections or exposure to communicable diseases should avoid

contact with the client until risk of infectious spread has passed.

6. Use strict aseptic technique for all procedures.

7. Keep supplies for the client separate from supplies for other clients; keep frequently used

equipment in the room for the client’s use only.

8. Limit the number of staff entering the client’s room to reduce the risk of cross-infection.

9. Maintain the client in a private room with the door closed.

10. Place the client in a room with high-efficiency particulate air filtration or a laminar airflow

system if possible.

11. Rduce exposure to environmental organisms by eliminating fresh or raw fruits and vegetables

(low-bacteria diet) from the diet; eliminate fresh flowers and live plants from the client’s room

and avoid leaving standing water in the client’s room.

12. Be sure that the client’s room is cleaned daily.

13. Assist the client with daily bathing, using an antimicrobial soap.

14. Assist the client to perform oral hygiene frequently.

15. Initiate a bowel program to prevent constipation and prevent rectal trauma.

16. Avoid invasive procedures such as injections, insertion of rectal thermometers, and urinary

catheterization.

17. Change wound dressings daily, and inspect the wounds for redness, swelling, or drainage.

18. Assess the urine for cloudiness and other characteristics of infection.

19. Assess skin and oral mucous membranes for signs of infection

20. Auscultate lung sounds, and encourage the client to cough and deep-breathe.

21. Monitor temperature, pulse, respirations, blood pressure, and for pain.

22. Monitor white blood cell and neutrophil counts.

23. Notify the HCP if signs of infection are present, and prepare to obtain specimens for culture of

the blood, open lesions, urine, and sputum; chest radiograph may also be prescribed.

24. Administer prescribed antibiotic, antifungal, and antiviral medications.

25. Instruct the client to avoid crowds and those with infections.

26. Instruct the client about a low-bacteria diet.

27. Instruct the client to avoid activities that expose the client to infection, such as changing a pet’s

litter box or working with house plants or in the garden.

28. Instruct the client that neither they nor their household contacts should receive immunization

with a live virus such as measles, mumps, rubella, polio, varicella, shingles, and some

influenza, including the H1N1 vaccine.

Infection is a major cause of death in the immunosuppressed client.

D. Bleeding

1. During the period of greatest bone marrow suppression (the nadir), the platelet count may be

extremely low.

2. The client is at risk for bleeding when the platelet count falls below 50,000 cells/mm3, and

spontaneous bleeding frequently occurs when the platelet count is lower than 20,000 cells/mm3.

3. Clients with platelet counts lower than 20,000 cells/mm3 may need a platelet transfusion.

4. For clients with anemia and fatigue, packed red blood cells may be prescribed.

5. Monitor laboratory values.

6. Examine the client for signs and symptoms of bleeding; examine all body fluids and excrement

for the presence of blood.

7. Handle the client gently; use caution when taking blood pressures to prevent skin injury.

8. Monitor for signs of internal hemorrhage (e.g., pain, rapid and weak pulse, increased abdominal

girth, and abdomen guarding).

9. Provide soft foods that are cool to warm to avoid oral mucosa damage.

10. Avoid injections, if possible, to prevent trauma to the skin and bleeding; apply firm and gentle

pressure to a needle stick site for at least 5 minutes, or longer if needed.

11. Pad side rails and sharp corners of the bed and furniture.

12. Avoid rectal suppositories, enemas, and thermometers.

13. If the female client is menstruating, count the number of pads or tampons used.

14. Administer blood products as prescribed.

15. Instruct the client to use a soft toothbrush and avoid dental floss.

16. Instruct the client to use only an electric razor for shaving.

17. Instruct the client to avoid blowing the nose.

18. Discourage the client from engaging in activities involving the use of sharp objects; contact

sports also need to be avoided.

19. Instruct the client to avoid using nonsteroidal antiinflammatory drugs and products that contain

aspirin.

E. Fatigue and nutrition

1. Assist the client in selecting a well-balanced diet.

2. Provide small, frequent meals (high calorie, high protein, high carbohydrate) that require little

chewing to reduce energy expenditure at mealtimes.

3. Assist the client in self-care and mobility activities.

4. Allow adequate rest periods during care.

5. Do not perform activities unless they are essential; assist the client in scheduling important or

pleasurable activities during periods of highest energy.

6. Administer blood products for anemia as prescribed.

F. Additional interventions

1. Chemotherapy

a. Induction therapy is aimed at achieving a rapid, complete remission of all manifestations of

the disease.

b. Consolidation therapy is administered early in remission with the aim of curing.

c. Maintenance therapy may be prescribed for months or years following successful induction

and consolidation therapy; the aim is to maintain remission.

2. Administer antibiotic, antibacterial, antiviral, and antifungal medications as prescribed.

3. Administer colony-stimulating factors as prescribed.

4. Administer blood replacements as prescribed.

5. Maintain infection and bleeding precautions.

6. Prepare the client for transplantation if indicated.

7. Instruct the client in appropriate home care measures.

8. Provide psychosocial support and support services for home care.

Inspect the mouth daily.

Offer complete mouth care before and after every meal and at bedtime.

Brush the teeth and tongue with a soft-bristled toothbrush or sponges.

Provide mouth rinses every 12 hours with the prescribed solution.

Administer topical anesthetic agents to mouth sores as prescribed.

Avoid the use of alcohol- or glycerin-based mouthwashes or swabs because they are irritating to

the mucosa.

Offer soft foods that are cool to warm in temperature rather than foods that are hard or spicy.

A. Description

1. Lymphomas, classified as Hodgkin’s and non-Hodgkin’s depending on the cell type, are

characterized by abnormal proliferation of lymphocytes.

2. Hodgkin’s disease is a malignancy of the lymph nodes that originates in a single lymph node or

a chain of nodes.

3. Metastasis occurs to other, adjacent lymph structures and eventually invades nonlymphoid

tissue.

4. The disease usually involves lymph nodes, tonsils, spleen, and bone marrow and is

characterized by the presence of Reed-Sternberg cells in the nodes.

5. Possible causes include viral infections; clients treated with combination chemotherapy for

Hodgkin’s disease have a greater risk of developing acute leukemia and non-Hodgkin’s

lymphoma, among other secondary malignancies.

6. Prognosis depends on the stage of the disease.

B. Assessment

1. Fever

2. Malaise, fatigue, and weakness

3. Night sweats

4. Loss of appetite and significant weight loss

5. Anemia and thrombocytopenia

6. Enlarged lymph nodes, spleen, and liver

7. Positive biopsy of lymph nodes, with cervical nodes most often affected first

8. Presence of Reed-Sternberg cells in nodes

9. Positive computed tomography (CT) scan of the liver and spleen

C. Interventions

1. For earlier stages (stages I and II), without mediastinal node involvement, the treatment of

choice is extensive external radiation of the involved lymph node regions.

2. With more extensive disease, radiation and multiagent chemotherapy are used.

3. Monitor for side effects related to chemotherapy or radiation therapy.

4. Monitor for signs of infection and bleeding.

5. Maintain infection and bleeding precautions.

6. Discuss the possibility of sterility with the male client receiving radiation, and inform the client

of fertility options such as sperm banking.

A. Description

1. A malignant proliferation of plasma cells within the bone

2. Excessive numbers of abnormal plasma cells invade the bone marrow and ultimately destroy

bone; invasion of the lymph nodes, spleen, and liver occurs.

3. The abnormal plasma cells produce an abnormal antibody (myeloma protein or the Bence Jones

protein) found in the blood and urine.

4. Multiple myeloma causes decreased production of immunoglobulin and antibodies and

increased levels of uric acid and calcium, which can lead to kidney failure.

5. The disease typically develops slowly and the cause is unknown.

B. Assessment

1. Bone (skeletal) pain, especially in the ribs, spine, and pelvis

2. Weakness and fatigue

3. Recurrent infections

4. Anemia

5. Urinalysis shows Bence Jones proteinuria and elevated total serum protein level.

6. Osteoporosis (bone loss and the development of pathological fractures)

7. Thrombocytopenia and leukopenia

8. Elevated calcium and uric acid levels

9. Kidney failure

10. Spinal cord compression and paraplegia

11. Bone marrow aspiration shows an abnormal number of immature plasma cells.

The client with multiple myeloma is at risk for pathological fractures. Therefore, provide

skeletal support during moving, turning, and ambulating and provide a hazard-free

environment.

C. Interventions

1. Administer chemotherapy as prescribed.

2. Provide supportive care to control symptoms and prevent complications, especially bone

fractures, hypercalcemia, kidney failure, and infections.

3. Maintain neutropenic and bleeding precautions as necessary.

4. Monitor for signs of bleeding, infection, and skeletal fractures.

5. Encourage the consumption of at least 2 L of fluids per day to offset potential problems

associated with hypercalcemia, hyperuricemia, and proteinuria, and encourage additional fluid

as indicated and tolerated.

6. Monitor for signs of kidney failure.

7. Encourage ambulation to prevent renal problems and to slow down bone resorption.

8. Administer IV fluids and diuretics as prescribed to increase renal excretion of calcium.

9. Administer blood transfusions as prescribed for anemia.

10. Administer analgesics as prescribed and provide nonpharmacological therapies to control pain.

11. Administer antibiotics as prescribed for infection.

12. Prepare the client for local radiation therapy if prescribed.

13. Instruct the client in home care measures and the signs and symptoms of infection.

14. Administer bisphosphonate medications as prescribed to slow bone damage and reduce pain

and risk of fractures.

A. Description

1. Testicular cancer arises from germinal epithelium from the sperm-producing germ cells or from

nongerminal epithelium from other structures in the testicles.

2. Testicular cancer most often occurs between the ages of 15 and 40 years.

3. The cause of testicular cancer is unknown, but a history of undescended testicle

(cryptorchidism) and genetic predisposition have been associated with testicular tumor

development.

4. Metastasis occurs to the lung, liver, bone, and adrenal glands via the blood, and to the

retroperitoneal lymph nodes via lymphatic channels.

B. Early detection: Perform monthly testicular self-examination

1. Performing testicular self-examination: Perform monthly; a day of the month is selected and the

examination is performed on the same day each month.

2. Client instructions (see Fig. 52-1)

C. Assessment

1. Painless testicular swelling occurs.

2. “Dragging” or “pulling” sensation is experienced in the scrotum.

3. Palpable lymphadenopathy, abdominal masses, and gynecomastia may indicate metastasis.

4. Late signs include back or bone pain and respiratory symptoms.

D. Interventions

1. Administer chemotherapy as prescribed.

2. Prepare the client for radiation therapy as prescribed.

3. Prepare the client for unilateral orchiectomy, if prescribed, for diagnosis and primary surgical

management or radical orchiectomy (surgical removal of the affected testis, spermatic cord,

and regional lymph nodes).

4. Prepare the client for retroperitoneal lymph node dissection, if prescribed, to stage the disease

and reduce tumor volume so that chemotherapy and radiation therapy are more effective.

5. Discuss reproduction, sexuality, and fertility information and options with the client.

6. Identify reproductive options such as sperm storage, donor insemination, and adoption.

E. Postoperative interventions

1. Monitor for signs of bleeding and wound infection; antibiotics may be administered to prevent

wound infection.

2. Monitor intake and output.

3. Provide and explain pain management methods; to reduce swelling in the first 48 hours, apply

an ice pack with an intervening protective layer of cloth.

4. Notify the HCP if chills, fever, increasing pain or tenderness at the incision site, or drainage

from the incision occurs.

5. After the orchiectomy, instruct the client to avoid heavy lifting and strenuous activity for the

length of time prescribed by the HCP.

6. Instruct the client to perform a monthly testicular self-examination on the remaining testicle (see

Fig. 52-1).

7. Inform the client that sutures will be removed approximately 7 to 10 days after surgery.

The best time to perform this examination is right after

a shower when your scrotal skin is moist and relaxed, making the testicles easy to feel. First, gently

lift each testicle. Each one should feel like an egg, firm but not hard, and smooth with no lumps.

Then, using both hands, place your middle fingers on the underside of each testicle and your thumbs

on top. Gently roll the testicle between the thumb and fingers to feel for any lumps, swelling, or

mass. If you notice any changes from one month to the next, notify your health care provider.

Stage I: Mild dysplasia

Stage II: Moderate dysplasia

Stage III: Severe dysplasia to carcinoma in situ

A. Description

1. Preinvasive cancer is limited to the cervix

2. Invasive cancer is in the cervix and other pelvic structures.

3. Metastasis usually is confined to the pelvis, but distant metastasis occurs through lymphatic

spread.

4. Premalignant changes are described on a continuum from dysplasia, which is the earliest

premalignancy change, to carcinoma in situ, the most advanced premalignant change.

B. Risk factors

1. Human papillomavirus (HPV) infection (vaccination against HPV is effective to avoid HPV

infection, and thus cervical cancer)

2. Cigarette smoking, both active and passive

3. Reproductive behavior including early first intercourse (before age 17), multiple sex partners,

or male partners with multiple sex partners.

4. Screening via regular gynecological examinations and Papanicolaou smear (Pap test), with

treatment of precancerous abnormalities, decreases the incidence and mortality of cervical

cancer.

C. Assessment

1. Painless vaginal postmenstrual and postcoital bleeding

2. Foul-smelling or serosanguineous vaginal discharge

3. Pelvic, lower back, leg, or groin pain

4. Anorexia and weight loss

5. Leakage of urine and feces from the vagina

6. Dysuria

7. Hematuria

8. Cytological changes on Pap test

D. Interventions

Nonsurgical

■ Chemotherapy

■ Cryosurgery

■ External radiation

■ Internal radiation implants (intracavitary)

■ Laser therapy

Surgical

■ Conization

■ Hysterectomy

■ Pelvic exenteration

E. Laser therapy

1. Laser therapy is used when all boundaries of the lesion are visible during colposcopic

examination.

2. Energy from the beam is absorbed by fluid in the tissues, causing them to vaporize.

3. Minimal bleeding is associated with the procedure.

4. Slight vaginal discharge is expected following the procedure, and healing occurs in 6 to 12

weeks.

F. Cryosurgery

1. Cryosurgery involves freezing of the tissues, using a probe, with subsequent necrosis and

sloughing.

2. No anesthesia is required, although cramping may occur during the procedure.

3. A heavy watery discharge will occur for several weeks following the procedure.

4. Instruct the client to avoid intercourse and the use of tampons while the discharge is present.

G. Conization

1. A cone-shaped area of the cervix is removed.

2. Conization allows the woman to retain reproductive capacity.

3. Long-term follow-up care is needed because new lesions can develop.

4. The risks of the procedure include hemorrhage, uterine perforation, incompetent cervix,

cervical stenosis, and preterm labor in future pregnancies.

H. Hysterectomy

1. Description

a. Hysterectomy is performed for microinvasive cancer if childbearing is not desired.

b. A vaginal approach is most commonly used.

c. A radical hysterectomy and bilateral lymph node dissection may be performed for cancer that

has spread beyond the cervix but not to the pelvic wall.

2. Postoperative interventions

a. Monitor vital signs

b. Assist with coughing and deep-breathing exercises.

c. Assist with range-of-motion exercises and provide early ambulation.

d. Apply antiembolism stockings or sequential compression devices as prescribed.

e. Monitor intake and output, Foley catheter drainage, and hydration status.

f. Monitor bowel sounds.

g. Assess incision site for signs of infection.

h. Administer pain medication as prescribed.

i. Instruct the client to limit stair climbing for 1 month as prescribed and to avoid tub baths and

sitting for long periods.

j. Avoid strenuous activity or lifting anything weighing more than 20 pounds.

k. Instruct the client to consume foods that promote tissue healing.

l. Instruct the client to avoid sexual intercourse for 3 to 6 weeks as prescribed.

m. Instruct the client in the signs associated with complications.

Monitor vaginal bleeding following hysterectomy. More than one saturated pad per hour

may indicate excessive bleeding.

I. Pelvic exenteration

1. Description

a. Pelvic exenteration, the removal of all pelvic contents, including bowel, vagina, and bladder,

is a radical surgical procedure performed for recurrent cancer if no evidence of tumor

outside the pelvis and no lymph node involvement exist.

b. When the bladder is removed, an ileal conduit is created and located on the right side of the

abdomen to divert urine.

c. A colostomy may need to be created on the left side of the abdomen for the passage of feces.

2. Postoperative interventions

a. Similar to postoperative interventions following hysterectomy.

b. Monitor for signs of altered respiratory status.

c. Monitor incision site for infection.

d. Monitor intake and output and for signs of dehydration.

e. Monitor for hemorrhage, shock, and deep vein thrombosis.

f. Apply antiembolism stockings or sequential compression devices as prescribed.

g. Administer prophylactic heparin as prescribed.

h. Administer perineal irrigations and sitz baths as prescribed.

i. Instruct the client to avoid strenuous activity for 6 months.

j. Instruct the client that the perineal opening, if present, may drain for several months.

k. Instruct the client in the care of the ileal conduit and colostomy, if created.

l. Provide sexual counseling because vaginal intercourse is not possible after anterior and total

pelvic exenteration.

A. Description

1. Ovarian cancer grows rapidly, spreads fast, and is often bilateral.

2. Metastasis occurs by direct spread to the organs in the pelvis, by distal spread through

lymphatic drainage, or by peritoneal seeding.

3. In its early stages, ovarian cancer is often asymptomatic; because most women are diagnosed in

advanced stages, ovarian cancer has a higher mortality rate than any other cancer of the female

reproductive system, particularly among white women between 55 and 65 years of age of North

American or European descent.

4. An exploratory laparotomy is performed to diagnose and stage the tumor.

B. Assessment

1. Abdominal discomfort or swelling

2. Gastrointestinal disturbances

3. Dysfunctional vaginal bleeding

4. Abdominal mass

5. Elevated tumor marker (i.e., CA-125)

C. Interventions

1. External radiation may be used if the tumor has invaded other organs; intraperitoneal

radioisotopes may be instilled for stage I disease.

2. Chemotherapy is used postoperatively for most stages of ovarian cancer.

3. Intraperitoneal chemotherapy involves the instillation of chemotherapy into the abdominal

cavity.

4. Total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor debulking may

be necessary.

A. Description

1. Endometrial cancer is a slow-growing tumor arising from the endometrial mucosa of the uterus,

associated with the menopausal years.

2. Metastasis occurs through the lymphatic system to the ovaries and pelvis; via the blood to the

lungs, liver, and bone; or intraabdominally to the peritoneal cavity.

B. Risk factors

1. Use of estrogen replacement therapy (ERT)

2. Nulliparity

3. Polycystic ovary disease

4. Increased age

5. Late menopause

6. Family history of uterine cancer or hereditary nonpolyposis colorectal cancer

7. Obesity

8. Hypertension

9. Diabetes mellitus

C. Assessment

1. Abnormal bleeding, especially in postmenopausal women

2. Vaginal discharge

3. Low back, pelvic, or abdominal pain (pain occurs late in the disease process)

4. Enlarged uterus (in advanced stages)

D. Nonsurgical interventions

1. External or internal radiation is used alone or in combination with surgery, depending on the

stage of cancer.

2. Chemotherapy is used to treat advanced or recurrent disease.

3. Progesterone therapy with medication may be prescribed for estrogen-dependent tumors.

4. Tamoxifen, an antiestrogen medication, also may be prescribed.

E. Surgical interventions: Total abdominal hysterectomy and bilateral salpingo-oophorectomy

A. Description

1. Breast cancer is classified as invasive when it penetrates the tissue surrounding the mammary

duct and grows in an irregular pattern.

2. Metastasis occurs via lymph nodes.

3. Common sites of metastasis are the bone and lungs; metastasis may also occur to the brain and

liver.

4. Diagnosis is made by breast biopsy through a needle aspiration or by surgical removal of the

tumor with microscopic examination for malignant cells.

B. Risk factors

1. Age

2. Family history of breast cancer

3. Early menarche and late menopause

4. Previous cancer of the breast, uterus, or ovaries

5. Nulliparity, late first birth

6. Obesity

7. High-dose radiation exposure to chest

C. Assessment

1. Mass felt during breast self-examination (BSE) (usually felt in the upper outer quadrant, beneath

the nipple, or in axilla)

2. Presence of the lesion on mammography

3. A fixed, irregular nonencapsulated mass; typically painless except in the late stages

4. Asymmetry, with the affected breast being higher

5. Bloody or clear nipple discharge

6. Nipple retraction or elevation

7. Skin dimpling, retraction, or ulceration

8. Skin edema or peau d’orange skin

9. Axillary lymphadenopathy

10. Lymphedema of the affected arm

11. Symptoms of bone or lung metastasis in late stage

D. Early detection: Monthly BSE

1. Performing BSE

a. Perform monthly 7 to 10 days after menses.

b. Postmenopausal clients or clients who have had a hysterectomy should select a specific day

of the month and perform BSE monthly on that day.

2. Client instructions

E. Nonsurgical interventions

1. Chemotherapy

2. Radiation therapy

3. Hormonal manipulation via the use of medication in postmenopausal women or other

medications for estrogen receptor–positive tumors

F. Surgical interventions: Surgical breast procedures, with possible breast reconstruction

Lumpectomy

■ Tumor is excised and removed.

■ Lymph node dissection may also be performed.

Simple Mastectomy

■ Breast tissue and the nipple are removed.

■ Lymph nodes are usually left intact.

Modified Radical Mastectomy

■ Breast tissue, nipple, and lymph nodes are removed.

■ Muscles are left intact.

G. Postoperative interventions

1. Monitor vital signs.

2. Position the client in a semi-Fowler’s position; turn from the back to the unaffected side, with

the affected arm elevated above the level of the heart to promote drainage and prevent

lymphedema.

3. Encourage coughing and deep breathing.

4. If a drain (usually a Jackson-Pratt) is in place, maintain suction and record the amount of

drainage and drainage characteristics; teach the client about home management of the drain

5. Assess operative site for infection, swelling, or the presence of fluid collection under the skin

flaps or in the arm.

6. Monitor incision site for restriction of dressing, impaired sensation, or color changes of the

skin.

7. If breast reconstruction was performed, the client will return from surgery usually with a

surgical brassiere and a prosthesis in place.

8. Provide the use of a pressure sleeve as prescribed if edema is severe.

9. Maintain fluid and electrolyte balance; administer diuretics and provide a low-salt diet as

prescribed for severe lymphedema.

10. Consult with the HCP and physical therapist regarding the appropriate exercise program and

assist client with prescribed exercise.

11. Instruct the client about home care measures

While in the shower or bath, when the skin is slippery with soap and water, examine your breasts. Use the pads of your second, third, and fourth fingers to press every part of the breast firmly. Use your right hand to examine your left breast, and use your left hand to examine your right breast. Using the pads of the fingers on your left hand, examine the entire right breast using small circular motions in a spiral or up-anddown motion so that the entire breast area is examined. Repeat the procedure using your right hand to examine your left breast. Repeat the pattern of palpation under the arm. Check for any lump, hard knot, or thickening of the tissue. 2,  Look at your breasts in a mirror. Stand with your arms at your side. 3, Raise your arms overhead and check for any changes in the shape of your breasts, dimpling of the skin, or any changes in the nipple. 4, Next, place your hands on your hips and press down firmly, tightening the pectoral muscles. Observe for asymmetry or changes, keeping in mind that your breasts probably do not match exactly. 5, While lying down, feel your breasts as described in step 1. When examining your right breast, place a folded towel under your right shoulder and put your right hand behind your head. Repeat the procedure while examining your left breast. Mark your calendar that you have completed your breast self-examination; note any changes or unique characteristics you want to check with your health care provider.

Avoid overuse of the arm during the first few months.

To prevent lymphedema, keep the affected arm elevated; consultation with lymphedema specialist

may be prescribed.

Provide incision care with an emollient as prescribed, to soften and prevent wound contracture.

Encourage use of Reach to Recovery volunteers.

Encourage the client to perform breast self-examination on the remaining breast.

Protect the affected hand and arm.

Avoid strong sunlight on the affected arm.

Do not let the affected arm hang dependent.

Do not carry a pocketbook or anything heavy over the affected arm.

Avoid trauma, cuts, bruises, or burns to the affected side.

Avoid wearing constricting clothing or jewelry on the affected side.

Wear gloves when gardening.

Use thick oven mitts when cooking.

Use a thimble when sewing.

Apply hand cream several times daily.

Use cream cuticle remover.

Call the health care provider if signs of inflammation occur in the affected arm.

Wear a Medic-Alert bracelet stating which arm is lymphedematous.

No IVs, no injections, no blood pressure measurements, and no venipunctures should be done in the arm on the side of the mastectomy. The arm on the side of the mastectomy is protected, and any intervention that could traumatize the affected arm is avoided.

A. Description

1. Esophageal cancer is a malignancy found in the esophageal mucosa, formed by squamous cell

carcinoma (SCC) or adenocarcinoma.

2. The cause is unknown but major risk factors include cigarette smoking, alcohol consumption,

and chronic reflux.

3. Complications include dysphagia, painful swallowing, loss of appetite, and malaise.

4. The goal of treatment is to inhibit tumor growth and maintain nutrition.

B. Assessment

1. Dysphagia

2. Odynophagia

3. Epigastric pain or sternal pain

C. Interventions

1. Monitor nutritional status, including daily weight, intake and output, and calories consumed.

2. Instruct the client about diet changes that make eating easier.

3. Surgical interventions may be prescribed.

A. Description

1. Gastric cancer is a malignant growth of the mucosal cells in the inner lining of the stomach, with

invasion to the muscle and beyond in advanced disease.

2. No single causative agent has been identified but it is believed that Helicobacter pylori

infection and a diet of smoked, highly salted, processed, or spiced foods have carcinogenic

effects; other risk factors include smoking, alcohol and nitrate ingestion, and a history of gastric

ulcers.

3. Complications include hemorrhage, obstruction, metastasis, and dumping syndrome.

4. The goal of treatment is to remove the tumor and provide a nutritional program.

B. Assessment

1. Early:

a. Indigestion

b. Abdominal discomfort

c. Full feeling

d. Epigastric, back, or retrosternal pain

2. Late:

a. Weakness and fatigue

b. Anorexia and weight loss

c. Nausea and vomiting

d. A sensation of pressure in the stomach

e. Dysphagia and obstructive symptoms

f. Iron deficiency anemia

g. Ascites

h. Palpable epigastric mass

C. Interventions

1. Monitor vital signs.

2. Monitor hemoglobin and hematocrit and administer blood transfusions as prescribed.

3. Monitor weight.

4. Assess nutritional status; encourage small, bland, easily digestible meals with vitamin and

mineral supplements.

5. Administer pain medication as prescribed.

6. Prepare the client for chemotherapy or radiation therapy as prescribed.

7. Prepare the client for surgical resection of the tumor as prescribed

D. Postoperative interventions

1. Monitor vital signs.

2. Place in Fowler’s position for comfort.

3. Administer analgesics, antiemetics, as prescribed.

4. Monitor intake and output; administer fluids and electrolyte replacement by IV as prescribed;

administer parenteral nutrition as indicated.

5. Maintain NPO status as prescribed for 1 to 3 days until peristalsis returns; assess for bowel

sounds.

6. Monitor nasogastric suction.

7. Do not irrigate or remove the nasogastric tube (follow agency procedures); assist the HCP with

irrigation or removal.

8. Advance the diet from NPO to sips of clear water to six small bland meals a day, as prescribed.

9. Monitor for complications such as hemorrhage, dumping syndrome, diarrhea, hypoglycemia,

and vitamin B12 deficiency.

A. Description

1. Most pancreatic tumors are highly malignant, rapidly growing adenocarcinomas originating

from the epithelium of the ductal system.

2. Pancreatic cancer is associated with increased age, a history of diabetes mellitus, alcohol use,

history of previous pancreatitis, smoking, ingestion of a high-fat diet, and exposure to

environmental chemicals.

3. Symptoms usually do not occur until the tumor is large; therefore, the prognosis is poor.

4. Endoscopic retrograde cholangiopancreatography for visualization of the pancreatic duct and

biliary system and collection of tissue and secretions may be done.

B. Assessment

1. Nausea and vomiting

2. Jaundice

3. Unexplained weight loss

4. Clay-colored stools

5. Glucose intolerance

6. Abdominal pain

C. Interventions

1. Radiation

2. Chemotherapy

3. Whipple procedure, which involves a pancreaticoduodenectomy with removal of the distal

third of the stomach, pancreaticojejunostomy, gastrojejunostomy, and choledochojejunostomy

4. Postoperative care measures and complications are similar to those for the care of a client with

pancreatitis and the client following gastric surgery; monitor blood glucose levels for transient

hyperglycemia or hypoglycemia resulting from surgical manipulation of the pancreas

A. Description

1. Intestinal tumors are malignant lesions that develop in the cells lining the bowel wall or

develop as adenomatous polyps in the colon or rectum.

2. Tumor spread is by direct invasion and through the lymphatic and circulatory systems.

3. Complications include bowel perforation with peritonitis, abscess and fistula formation,

hemorrhage, and complete intestinal obstruction.

B. Risk factors for colorectal cancer

1. Age older than 50 years

2. Familial polyposis, family history of colorectal cancer

3. Previous colorectal polyps, history of colorectal cancer

4. History of chronic inflammatory bowel disease

5. History of ovarian or breast cancer

C. Assessment

1. Blood in stool (most common manifestation)

2. Anorexia, vomiting, and weight loss

3. Anemia

4. Abnormal stools

a. Ascending colon tumor: Diarrhea

b. Descending colon tumor: Constipation or some diarrhea, or flat, ribbon-like stool caused by a

partial obstruction

c. Rectal tumor: Alternating constipation and diarrhea

5. Guarding or abdominal distention, abdominal mass (late sign)

6. Cachexia (late sign)

7. Masses noted on barium enema, colonoscopy, CT scan, sigmoidoscopy

D. General interventions

1. Monitor for signs of complications, which include bowel perforation with peritonitis, abscess

or fistula formation (fever associated with pain), hemorrhage (signs of shock), and complete

intestinal obstruction.

2. Monitor for signs of bowel perforation, which include low blood pressure, rapid and weak

pulse, distended abdomen, and elevated temperature.

3. Monitor for signs of intestinal obstruction, which include vomiting (may be fecal contents),

pain, constipation, and abdominal distention; provide comfort measures.

4. Note that an early sign of intestinal obstruction is increased peristaltic activity, which produces

an increase in bowel sounds; as the obstruction progresses, hypoactive bowel sounds may be

heard.

5. Prepare for radiation preoperatively to facilitate surgical resection, and postoperatively to

decrease the risk of recurrence or to reduce pain, hemorrhage, bowel obstruction, or

metastasis.

E. Nonsurgical interventions

1. Preoperative radiation for local control and postoperative radiation for palliation may be

prescribed.

2. Postoperative chemotherapy to control symptoms and the spread of disease

F. Surgical interventions: Bowel, local lymph node resection, and creation of a colostomy or

ileostomy

G. Colostomy, ileostomy

1. Preoperative interventions

a. Consult with the enterostomal therapist to assist in identifying optimal placement of the

ostomy.

b. Instruct the client in prescribed preoperative diet; bowel preparation (laxatives and enemas),

may be prescribed.

c. Intestinal antiseptics and antibiotics may be prescribed, to decrease the bacterial content of

the colon and to reduce the risk of infection from the surgical procedure.

2. Postoperative: Colostomy

a. If a pouch system is not in place, apply a petroleum jelly gauze over the stoma to keep it

moist, covered with a dry sterile dressing; place a pouch system on the stoma as soon as

possible.

b. Monitor the pouch system for proper fit and signs of leakage; empty the pouch when one-third

full.

c. Monitor the stoma for size, unusual bleeding, color changes, or necrotic tissue.

d. Note that the normal stoma color is red or pink, indicating high vascularity.

e. Note that a pale pink stoma indicates low hemoglobin and hematocrit levels.

f. Assess the functioning of the colostomy.

g. Expect that stool will be liquid postoperatively but will become more solid, depending on the

area of the colostomy.

h. Expect liquid stool from an ascending colon colostomy, loose to semiformed stool from a

transverse colon colostomy, or close to normal stool from a descending colon colostomy.

i. Fecal matter should not be allowed to remain on the skin.

j. Administer analgesics and antibiotics as prescribed.

k. Irrigate perineal wound if present and if prescribed, and monitor for signs of infection;

provide comfort measures for perineal itching and pain.

l. Instruct the client to avoid foods that cause excessive gas formation and odor.

m. Instruct the client in stoma care and irrigations as prescribed.

n. Instruct the client on how to resume normal activities, including work, travel, and sexual

intercourse, as prescribed; provide psychosocial support.

3. Postoperative: Ileostomy

a. Healthy stoma is red in color.

b. Postoperative drainage will be dark green and progress to yellow as the client begins to eat.

c. Stool is liquid.

d. Risk for dehydration and electrolyte imbalance exists.

Monitor stoma color. A dark blue, purple, or black stoma indicates compromised

circulation, requiring HCP notification.

A. Description

1. Lung cancer is a malignant tumor of the bronchi and peripheral lung tissue.

2. The lungs are a common target for metastasis from other organs.

3. Bronchogenic cancer (tumors originate in the epithelium of the bronchus) spreads through direct

extension and lymphatic dissemination.

4. Classified according to histological cell type; types include: small cell lung cancer (SCLC) and

non–small cell lung cancer (NSCLC); epidermal (squamous cell), adenocarcinoma, and large

cell anaplastic carcinoma are classified as NSCLC because of their similar responses to

treatment.

5. Diagnosis is made by a chest x-ray study, CT scan, or magnetic resonance imaging (MRI),

which shows a lesion or mass, and by bronchoscopy and sputum studies, which demonstrate a

positive cytological study for cancer cells.

B. Causes

1. Cigarette smoking; also exposure to “passive” tobacco smoke

2. Exposure to environmental and occupational pollutants

C. Assessment

1. Cough

2. Wheezing, dyspnea

3. Hoarseness

4. Hemoptysis, blood-tinged or purulent sputum

5. Chest pain

6. Anorexia and weight loss

7. Weakness

8. Diminished or absent breath sounds, respiratory changes

D. Interventions

1. Monitor vital signs.

2. Monitor breathing patterns and breath sounds and for signs of respiratory impairment; monitor

for hemoptysis.

3. Assess for tracheal deviation.

4. Administer analgesics as prescribed for pain management.

5. Place in a Fowler’s position to help ease breathing.

6. Administer oxygen as prescribed and humidification to moisten and loosen secretions.

7. Monitor pulse oximetry.

8. Provide respiratory treatments as prescribed.

9. Administer bronchodilators and corticosteroids as prescribed to decrease bronchospasm,

inflammation, and edema.

10. Provide a high-calorie, high-protein, high-vitamin diet.

11. Provide activity as tolerated, rest periods, and active and passive range-of-motion exercises.

E. Nonsurgical interventions

1. Radiation therapy may be prescribed for localized intrathoracic lung cancer and for palliation

of hemoptysis, obstructions, dysphagia, superior vena cava syndrome, and pain.

2. Chemotherapy may be prescribed for treatment of nonresectable tumors or as adjuvant therapy.

F. Surgical interventions

1. Laser therapy: To relieve endobronchial obstruction

2. Thoracentesis and pleurodesis: To remove pleural fluid and relieve hypoxia

3. Thoracotomy (opening into the thoracic cavity) with pneumonectomy: Surgical removal of one

entire lung

4. Thoracotomy with lobectomy: Surgical removal of one lobe of the lung for tumors confined to a

single lobe

5. Thoracotomy with segmental resection: Surgical removal of a lobe segment

G. Preoperative interventions

1. Explain the potential postoperative need for chest tubes.

2. Note that closed chest drainage usually is not used for a pneumonectomy and the serous fluid

that accumulates in the empty thoracic cavity eventually consolidates, preventing shifts of the

mediastinum, heart, and remaining lung.

H. Postoperative interventions

1. Monitor vital signs.

2. Assess cardiac and respiratory status; monitor lung sounds.

3. Maintain the chest tube drainage system, which drains air and blood that accumulates in the

pleural space; monitor for excess bleeding. (See Chapter 21 for care of the client with a chest

tube.)

4. Administer oxygen as prescribed.

5. Check the HCP’s prescriptions regarding client positioning; avoid complete lateral turning.

6. Monitor pulse oximetry.

7. Provide activity as tolerated.

8. Encourage active range-of-motion exercises of the operative shoulder as prescribed.

The airway is the priority for a client with lung or laryngeal cancer.

A. Description

1. Laryngeal cancer is a malignant tumor of the larynx

2. Laryngeal cancer presents as malignant ulcerations with underlying infiltration and is spread by

local extension to adjacent structures in the throat and neck, and by the lymphatic system.

3. Diagnosis is made by laryngoscopy and biopsy showing a positive cytological study for cancer

cells.

4. Laryngoscopy allows for evaluation of the throat and biopsy of tissues; chest radiography, CT,

and MRI are used for staging.

B. Risk factors

1. Cigarette smoking

2. Heavy alcohol use and the combined use of tobacco and alcohol

3. Exposure to environmental pollutants (e.g., asbestos, wood dust)

4. Exposure to radiation

C. Assessment

1. Persistent hoarseness or sore throat

2. Painless neck mass

3. Feeling of a lump in the throat

4. Burning sensation in the throat

5. Dysphagia

6. Change in voice quality

7. Dyspnea

8. Weakness and weight loss

9. Hemoptysis

10. Foul breath odor

D. Interventions

1. Place in Fowler’s position to promote optimal air exchange.

2. Monitor respiratory status.

3. Monitor for signs of aspiration of food and fluid.

4. Administer oxygen as prescribed.

5. Provide respiratory treatments as prescribed.

6. Provide activity as tolerated.

7. Provide a high-calorie and high-protein diet.

8. Provide nutritional support via parenteral nutrition, nasogastric tube feedings, or gastrostomy or

jejunostomy tube, as prescribed.

9. Administer analgesics as prescribed for pain.

E. Nonsurgical interventions

1. Radiation therapy if the cancer is limited to a small area in one vocal cord

2. Chemotherapy, which may be given in combination with radiation and surgery

F. Surgical interventions

1. The goal is to remove the cancer while preserving as much normal function as possible.

2. Surgical intervention depends on the tumor size, location, and amount of tissue to be resected.

3. Types of resection include cordal stripping, cordectomy, partial laryngectomy, and total

laryngectomy.

4. A tracheostomy is performed with a total laryngectomy; this airway opening is permanent and is

referred to as a laryngectomy stoma.

G. Preoperative interventions

1. Discuss self-care of the airway, alternative methods of communication, suctioning, pain control

methods, the critical care environment, and nutritional support.

2. Encourage the client to express feelings about changes in body image and loss of voice.

3. Describe the rehabilitation program and information about the tracheostomy and suctioning.

H. Postoperative interventions

1. Monitor vital signs.

2. Monitor respiratory status; monitor airway patency and provide frequent suctioning to remove

bloody secretions.

3. Place the client in a high Fowler’s position.

4. Maintain mechanical ventilator support or a tracheostomy collar with humidification, as

prescribed.

5. Monitor pulse oximetry.

6. Maintain surgical drains in the neck area if present.

7. Observe for hemorrhage and edema in the neck.

8. Monitor IV fluids or parenteral nutrition until nutrition is administered via a nasogastric,

gastrostomy, or jejunostomy tube.

9. Provide oral hygiene.

10. Assess gag and cough reflexes and the ability to swallow.

11. Increase activity as tolerated.

12. Assess the color, amount, and consistency of sputum.

13. Provide stoma and laryngectomy care

14. Provide consultation with speech and language pathologist as prescribed.

15. Reinforce method of communication established preoperatively.

16. Prepare the client for rehabilitation and speech therapy

Protect the neck from injury.

Instruct the client in how to clean the incision and provide stoma care.

Instruct the client to wear a stoma guard to shield the stoma.

Demonstrate ways to prevent debris from entering the stoma.

Advise the client to wear loose-fitting, high-collared clothing to cover the stoma.

Avoid swimming, showering, and using aerosol sprays.

Teach the client clean suctioning technique.

Advise the client to increase humidity in the home.

Increase fluid intake to 3000 mL/day as prescribed.

Avoid exposure to persons with infections.

Alternate rest periods with activity.

Instruct the client in range-of-motion exercises for the arms, shoulders, and neck as prescribed.

Advise the client to wear a Medic-Alert bracelet.

Esophageal Speech

The client produces esophageal speech by “burping” the air swallowed.

The voice produced is monotone, cannot be raised or lowered, and carries no pitch.

The client must have adequate hearing because his or her mouth shapes words as they are heard.

Mechanical Devices

One device, the electrolarynx, is placed against the side of the neck; the air inside the neck and

pharynx is vibrated, and the client articulates.

Another device consists of a plastic tube that is placed inside the client’s mouth and vibrates on

articulation.

Tracheoesophageal Fistula

A fistula is created surgically between the trachea and the esophagus, with eventual placement of a

prosthesis to produce speech.

The prosthesis provides the client with a means to divert air from the trachea into the esophagus,

and out of the mouth.

Lip and tongue movement produce the speech.

A. Description

1. Prostate cancer, a slow-growing malignancy of the prostate gland, is a common cancer in

American men; most prostate tumors are adenocarcinomas arising from androgen-dependent

epithelial cells.

2. The risk increases in men with each decade after the age of 50 years.

3. Prostate cancer can spread via direct invasion of surrounding tissues or by metastasis through

the bloodstream and lymphatics, to the bony pelvis and spine.

4. Bone metastasis is a concern, as is spread to the lungs, liver, and kidneys.

5. The cause of prostate cancer is unclear, but advancing age, heavy metal exposure, smoking, and

history of sexually transmitted infection are contributing factors.

B. Assessment

1. Asymptomatic in early stages

2. Hard, pea-sized nodule or irregularities palpated on rectal examination

3. Gross, painless hematuria

4. Late symptoms such as weight loss, urinary obstruction, and bone pain radiating from the

lumbosacral area down the leg

5. The prostate-specific antigen level is elevated in various noncancerous conditions; therefore, it

should not be used as a screening test without a digital rectal examination. It is routinely used

to monitor response to therapy.

6. Diagnosis is made through biopsy of the prostate gland.

C. Nonsurgical interventions

1. Prepare the client for hormone manipulation therapy as prescribed.

2. Luteinizing hormone may be prescribed to slow the rate of growth of the tumor.

3. Pain medication, radiation therapy, corticosteroids, and bisphosphonates may be prescribed for

palliation of advanced prostate cancer.

4. Prepare the client for external beam radiation or brachytherapy, which may be prescribed alone

or with surgery, preoperatively or postoperatively, to reduce the lesion and limit metastasis.

5. Prepare the client for the administration of chemotherapy in cases of hormone-resistant tumors.

D. Surgical interventions

1. Prepare the client for orchiectomy (palliative), if prescribed, which will limit the production of

testosterone.

2. Prepare the client for prostatectomy, if prescribed.

3. The radical prostatectomy can be performed via a retropubic, perineal, or suprapubic approach.

4. Cryosurgical ablation is a minimally invasive procedure that may be an alternative to radical

prostatectomy; liquid nitrogen freezes the gland, and the dead cells are absorbed by the body.

E. Transurethral resection of the prostate (TURP) may be performed for palliation in prostate cancer

clients.

1. The procedure involves insertion of a scope into the urethra to excise prostatic tissue.

2. Monitor for hemorrhage; bleeding is common following TURP.

3. Postoperative continuous bladder irrigation (CBI) may be prescribed, which prevents catheter

obstruction from clots.

4. Assess for signs of transurethral resection syndrome, which include signs of cerebral edema

and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion,

disorientation, muscle twitching, visual disturbances, and nausea and vomiting.

5. Antispasmodics may be prescribed for bladder spasm.

6. Instruct the client to monitor and report dribbling or incontinence postoperatively and teach

perineal exercises.

7. Sterility is possible following the surgical procedure.

F. Suprapubic prostatectomy

1. Suprapubic prostatectomy is removal of the prostate gland by an abdominal incision with a

bladder incision.

2. The client will have an abdominal dressing that may drain copious amounts of urine, and the

abdominal dressing will need to be changed frequently.

3. Severe hemorrhage is possible, and monitoring for blood loss is an important nursing

intervention.

4. Antispasmodics may be prescribed for bladder spasms.

5. CBI is prescribed and carried out to maintain pink-colored urine.

6. Sterility occurs with this procedure.

G. Retropubic prostatectomy

1. Retropubic prostatectomy is removal of the prostate gland by a low abdominal incision without

opening the bladder.

2. Less bleeding occurs with this procedure compared with the suprapubic procedure, and the

client experiences fewer bladder spasms.

3. Abdominal drainage is minimal.

4. CBI may be used.

5. Sterility occurs with this procedure.

H. Perineal prostatectomy

1. The prostate gland is removed through an incision made between the scrotum and anus.

2. Minimal bleeding occurs with this procedure.

3. The client needs to be monitored closely for infection, because the risk of infection is increased

with this type of prostatectomy.

4. Urinary incontinence is common.

5. The procedure causes sterility.

6. Teach the client how to perform perineal exercises.

I. Postoperative interventions

1. Monitor vital signs.

2. Monitor urinary output and urine for hemorrhage or clots.

3. Increase fluids to 2400 to 3000 mL/day, unless contraindicated.

4. Monitor for arterial bleeding as evidenced by bright red urine with numerous clots; if it occurs,

increase CBI and notify the HCP immediately.

5. Monitor for venous bleeding as evidenced by burgundy-colored urine output; if it occurs, inform

the HCP, who may apply traction on the catheter.

6. Monitor hemoglobin and hematocrit levels.

7. Expect red to light pink urine for 24 hours, turning to amber in 3 days.

8. Ambulate the client as early as possible and as soon as urine begins to clear in color.

9. Inform the client that a continuous feeling of an urge to void is normal.

10. Instruct the client to avoid attempts to void around the catheter because this will cause bladder

spasms.

11. Administer antibiotics, analgesics, stool softeners, and antispasmodics as prescribed.

12. Monitor the three-way Foley catheter, which usually has a 30- to 45-mL retention balloon.

13. Maintain CBI with sterile bladder irrigation solution as prescribed to keep the catheter free of

obstruction and keep the urine pink in color

J. Postoperative interventions: Suprapubic prostatectomy

1. Monitor suprapubic and Foley catheter drainage.

2. Monitor CBI if prescribed.

3. Note that the Foley catheter will be removed 2 to 4 days postoperatively if the client has a

suprapubic catheter.

4. If prescribed, clamp the suprapubic catheter after the Foley catheter is removed, and instruct the

client to attempt to void; after the client has voided, assess the residual urine in the bladder by

unclamping the suprapubic catheter and measuring the output.

5. Prepare for removal of the suprapubic catheter when the client consistently empties the bladder

and residual urine is 75 mL or less.

6. Monitor the suprapubic incision dressing, which may become saturated with urine, until the

incision heals; dressing may need to be changed frequently.

K. Postoperative interventions: Retropubic prostatectomy

1. Note that because the bladder is not entered, there is no urinary drainage on the abdominal

dressing; if urinary or purulent drainage is noted on the dressing, notify the HCP.

2. Monitor for fever and increased pain, which may indicate an infection.

L. Postoperative interventions: Perineal prostatectomy

1. Note that the client will have an incision, which may or may not have a drain.

2. Avoid the use of rectal thermometers, rectal tubes, and enemas because they may cause trauma

and bleeding.

Description

A three-way (lumen) irrigation is used to decrease bleeding and to keep the bladder free from clots

—one lumen is for inflating the balloon (30 mL); one lumen is for instillation (inflow); one

lumen is for outflow.

Interventions

Maintain traction on the catheter, if applied, to prevent bleeding by pulling the catheter taut and

taping it to the abdomen or thigh.

Instruct the client to keep the leg straight if traction is applied to the catheter and it is taped to the

thigh.

Catheter traction is not released without a health care provider’s (HCP’s) prescription; it usually

is released after any bright red drainage has diminished.

Use only sterile bladder irrigation solution or prescribed solution to prevent water intoxication.

Run the solution at a rate, as prescribed, to keep the urine pink. Run the solution rapidly if bright

red drainage or clots are present; monitor output closely. Run the solution at about 40 drops

(gtt)/minute when the bright red drainage clears.

If the urinary catheter becomes obstructed, turn off the CBI and irrigate the catheter with 30 to

50 mL of normal saline, if prescribed; notify the HCP if obstruction does not resolve.

Discontinue CBI and the Foley catheter as prescribed, usually 24 to 48 hours after surgery.

Monitor for continence and urinary retention when the catheter is removed. Inform the client that

some burning, frequency, and dribbling may occur following catheter removal.

Inform the client that he should be voiding 150 to 200 mL of clear yellow urine every 3 to 4 hours

by 3 days after surgery.

Inform the client that he may pass small clots and tissue debris for several days.

Teach the client to avoid heavy lifting, stressful exercise, driving, the Valsalva maneuver, and

sexual intercourse for 2 to 6 weeks to prevent strain, and to call the HCP if bleeding occurs or if

there is a decrease in urinary stream.

Instruct the client to drink 2400 to 3000 mL of fluid each day, preferably before 8 PM to avoid

nocturia.

Instruct the client to avoid alcohol, caffeinated beverages, and spicy foods, and overstimulation of

the bladder.

Instruct the client that if the urine becomes bloody, to rest and increase fluid intake and, if the

bleeding does not subside, to notify the HCP.

Following TURP, monitor for transurethral resection syndrome or severe hyponatremia (water intoxication) caused by the excessive absorption of bladder irrigation during surgery. (Signs include altered mental status, bradycardia, increased blood pressure, and confusion.)

A. Description

1. Bladder cancer is a papillomatous growth in the bladder urothelium that undergoes malignant

changes and that may infiltrate the bladder wall.

2. Predisposing factors include cigarette smoking, exposure to industrial chemicals, and exposure

to radiation.

3. Common sites of metastasis include the liver, bones, and lungs.

4. As the tumor progresses, it can extend into the rectum, vagina, other pelvic soft tissues, and

retroperitoneal structures.

B. Assessment

1. Gross or microscopic, painless hematuria

2. Frequency, urgency, dysuria

3. Clot-induced obstruction

4. Bladder wash specimens and biopsy confirm diagnosis

C. Radiation

1. Radiation therapy is indicated for advanced disease that cannot be eradicated by surgery;

palliative radiation may be used to relieve pain and bowel obstruction and control potential

hemorrhage and leg edema caused by venous or lymphatic obstruction.

2. Intracavitary radiation may be prescribed, which protects adjacent tissue.

3. External beam radiation combined with chemotherapy or surgery may be prescribed to improve

survival.

4. Complications of radiation

a. Abacterial cystitis

b. Proctitis

c. Fistula formation

d. Ileitis or colitis

e. Bladder ulceration and hemorrhage

D. Chemotherapy

1. Intravesical instillation

a. An alkylating chemotherapeutic agent is instilled into the bladder.

b. This method provides a concentrated topical treatment with little systemic absorption.

c. The medication is injected into a urethral catheter and retained for 2 hours.

d. Following instillation, the client’s position is rotated every 15 to 30 minutes, starting in the

supine position, to avoid lying on a full bladder.

e. After 2 hours, the client voids in a sitting position and is instructed to increase fluids to flush

the bladder.

f. Treat the urine as a biohazard and send to the radioisotope laboratory for monitoring.

g. For 6 hours following intravesical chemotherapy, disinfect the toilet with household bleach

after the client has voided.

2. Systemic chemotherapy: Used to treat inoperable tumors or distant metastasis.

3. Complications of chemotherapy

a. Bladder irritation

b. Hemorrhagic cystitis

E. Surgical interventions

1. Transurethral resection of bladder tumor

a. Local resection and fulguration (destruction of tissue by electrical current through electrodes

placed in direct contact with the tissue)

b. Performed for early tumors for cure or for inoperable tumors for palliation

2. Partial cystectomy

a. Partial cystectomy is the removal of up to half the bladder.

b. The procedure is done for early-stage tumors and for clients who cannot tolerate a radical

cystectomy.

c. During the initial postoperative period, bladder capacity is reduced greatly to about 60 mL;

however, as the bladder tissue expands, the capacity increases to 200 to 400 mL.

d. Maintenance of a continuous output of urine following surgery is critical to prevent bladder

distention and stress on the suture line.

e. A urethral catheter and a suprapubic catheter may be in place, and the suprapubic catheter

may be left in place for 2 weeks until healing occurs.

3. Cystectomy and urinary diversion

a. Various surgical procedures performed to create alternative pathways for urine collection and

excretion

b. Urinary diversion may be performed with or without cystectomy (bladder removal).

c. The surgery may be performed in two stages if the tumor is extensive, with the creation of the

urinary diversion first and the cystectomy several weeks later.

d. If a radical cystectomy is performed, lower extremity lymphedema may occur as a result of

lymph node dissection, and male impotence may occur.

4. Ileal conduit

a. The ileal conduit is also called a ureteroileostomy, or Bricker’s procedure.

b. Ureters are implanted into a segment of the ileum, with the formation of an abdominal stoma.

c. The urine flows into the conduit and is propelled continuously out through the stoma by

peristalsis.

d. The client is required to wear an appliance over the stoma to collect the urine

e. Complications include obstruction, pyelonephritis, leakage at the anastomosis site, stenosis,

hydronephrosis, calculi, skin irritation and ulceration, and stomal defects.

5. Kock pouch

a. The Kock pouch is a continent internal ileal reservoir created from a segment of the ileum

and ascending colon.

b. The ureters are implanted into the side of the reservoir, and a special nipple valve is

constructed to attach the reservoir to the skin.

c. Postoperatively, the client will have a Foley catheter in place to drain urine continuously until

the pouch has healed.

d. The Foley catheter is irrigated gently with normal saline to prevent obstruction from mucus or

clots.

e. Following removal of the Foley catheter, the client is instructed in how to self-catheterize and

to drain the reservoir at 4- to 6-hour intervals

6. Indiana pouch

a. A continent reservoir is created from the ascending colon and terminal ileum, making a pouch

larger than the Kock pouch (additional continent reservoirs include the Mainz and Florida

pouch systems).

b. Postoperatively, care is similar as with the Kock pouch.

7. Creation of a neobladder

a. Creation of a neobladder is similar to the creation of an internal reservoir, with the difference

being that instead of emptying through an abdominal stoma, the bladder empties through a

pelvic outlet into the urethra.

b. The client empties the neobladder by relaxing the external sphincter and creating abdominal

pressure or by intermittent self-catheterization.

8. Percutaneous nephrostomy or pyelostomy

a. These procedures are used to prevent or treat obstruction.

b. The procedures involve a percutaneous or surgical insertion of a nephrostomy tube into the

kidney for drainage.

c. Nursing interventions involve stabilizing the tube to prevent dislodgment and monitoring

output.

9. Ureterostomy

a. Ureterostomy may be performed as a palliative procedure if the ureters are obstructed by the

tumor.

b. The ureters are attached to the surface of the abdomen, where the urine flows directly into a

drainage appliance without a conduit.

c. Potential problems include infection, skin irritation, and obstruction to urinary flow as a

result of strictures at the opening.

10. Vesicostomy

a. The bladder is sutured to the abdomen, and a stoma is created in the bladder wall.

b. The bladder empties through the stoma.

F. Preoperative interventions

1. Instruct the client in preoperative, operative, and postoperative management including diet,

medications, nasogastric tube placement, IV lines, NPO status, pain control, coughing and deep

breathing, leg exercises, and postoperative activity.

2. Demonstrate appliance application and use for those clients who will have a stoma.

3. Arrange an enterostomal nurse consult and for a visit with a person who has had urinary

diversion.

4. Administer antimicrobials for bowel preparation as prescribed.

5. Encourage discussion of feelings including the effects on sexual activities.

G. Postoperative interventions

Monitor urinary output closely following bladder surgery. Irrigate the ureteral catheter (if

present and if prescribed) gently to prevent obstruction. Follow the HCP’s prescriptions and

agency policy regarding irrigation.

1. Monitor vital signs.

2. Assess incision site.

3. Assess stoma (should be red and moist) every hour for the first 24 hours.

4. Monitor for edema in the stoma, which may be present in the immediate postoperative period.

5. Notify the HCP if the stoma appears dark and dusky (indicates necrosis).

6. Monitor for prolapse or retraction of the stoma.

7. Assess bowel function; monitor for expected return of peristalsis in 3 to 4 days.

8. Maintain NPO status as prescribed until bowel sounds return.

9. Monitor for continuous urine flow (30 to 60 mL/hour).

10. Notify the HCP if the urine output is less than 30 mL/hour or if no urine output occurs for more

than 15 minutes.

11. Ureteral stents or catheters, if present, may be in place for 2 to 3 weeks or until healing occurs;

maintain stability with catheters to prevent dislodgment.

12. Monitor for hematuria.

13. Monitor for signs of peritonitis.

14. Monitor for bladder distention following a partial cystectomy.

15. Monitor for shock, hemorrhage, thrombophlebitis, and lower extremity lymphedema after a

radical cystectomy.

16. Monitor the urinary drainage pouch for leaks, and check skin integrity (see Box 52-19).

17. Monitor the pH of the urine (do not place the dipstick in the stoma) because highly alkaline or

acidic urine can cause skin irritation and facilitate crystal formation.

18. Instruct the client regarding the potential for urinary tract infection or the development of

calculi.

19. Instruct the client to assess the skin for irritation, monitor the urinary drainage pouch, and report

any leakage.

20. Encourage the client to express feelings about changes in body image, embarrassment, and

sexual dysfunction.

Instruct the client to change the appliance in the morning, when urinary production is slowest.

Collect equipment, remove collection bag, and use water or commercial solvent to loosen

adhesive.

Hold a rolled gauze pad against the stoma to collect and absorb urine during the procedure.

Cleanse the skin around stoma and under the drainage bag with mild nonresidue soap and water.

Inspect the skin for excoriation, and instruct the client to prevent urine from coming into contact

with the skin.

After the skin is dry, apply skin adhesive around the appliance.

Instruct the client to cut the stoma opening of the skin barrier just large enough to fit over the stoma

(no more than 3 mm larger than the stoma).

Instruct the client that the stoma will begin to shrink, requiring a smaller stoma opening on the skin

barrier.

Apply skin barrier before attaching the pouch or face plate.

Place the appliance over the stoma and secure in place.

Encourage self-care; teach the client to use a mirror.

Instruct the client that the pouch may be drained by a bedside bag or leg bag, especially at night.

Instruct the client to empty the urinary collection bag when it is one-third full to prevent pulling of

the appliance and leakage.

Instruct the client to check the appliance seal if perspiring occurs.

Instruct the client to leave the urinary pouch in place as long as it is not leaking and to change it

every 5 to 7 days.

During appliance changes, leave the skin open to air as long as possible.

Use a nonkaraya gum product, because urine erodes karaya gum.

To control odor, instruct the client to drink adequate fluids, wash the appliance thoroughly with

soap and lukewarm water, and soak the collection pouch in dilute white vinegar for 20 to 30

minutes; a special deodorant tablet can also be placed into the pouch while it is being worn.

Instruct the client who takes baths to keep the level of the water below the stoma and to avoid oily

soaps.

If the client plans to shower, instruct the client to direct the flow of water away from the stoma.

Irrigation

Instruct the client to wash hands and use clean technique.

Instruct the client to use a catheter and syringe, instill 60 mL of normal saline or water into the

reservoir, and aspirate gently or allow to drain.

Instruct the client to irrigate until the drainage remains free of mucus but to be careful not to

overirrigate.

Catheterization

Instruct the client to wash hands and use clean technique.

Initially, instruct the client to insert a catheter every 2 to 3 hours to drain the reservoir; during each

week thereafter, increase the interval by 1 hour until catheterization is done every 4 to 6 hours.

Lubricate the catheter well with water-soluble lubricant, and instruct the client never to force the

catheter into the reservoir.

If resistance is met, instruct the client to pause, rotate the catheter, and apply gentle pressure to

insert.

Instruct the client to notify the health care provider if the client is unable to insert the catheter.

When urine has stopped, instruct the client to take several deep breaths and move the catheter in

and out 2 to 3 inches to ensure that the pouch is empty.

Instruct the client to withdraw the catheter slowly and pinch the catheter when withdrawn so that it

does not leak urine.

Instruct the client to carry catheterization supplies with him or her.

A. Sepsis and disseminated intravascular coagulation (DIC)

1. Description: The client with cancer is at increased risk for infection, particularly gram-negative

organisms, in the bloodstream (sepsis or septicemia) and DIC, a life-threatening problem

frequently associated with sepsis.

2. Interventions

a. Prevent the complication through early identification of clients at high risk for sepsis and

DIC.

b. Maintain strict aseptic technique with the immunocompromised client and monitor closely for

infection.

c. Administer antibiotics intravenously as prescribed.

d. Administer anticoagulants as prescribed during the early phase of DIC.

e. Administer cryoprecipitated clotting factors, as prescribed, when DIC progresses and

hemorrhage is the primary problem.

Notify the HCP immediately if signs of an oncological emergency occur.

B. Syndrome of inappropriate antidiuretic hormone (SIADH)

1. Description

a. Tumors can produce, secrete, or stimulate substances that mimic antidiuretic hormone.

b. Mild symptoms include weakness, muscle cramps, loss of appetite, and fatigue; serum sodium

levels range from 115 to 120 mEq/L.

c. More serious signs and symptoms relate to water intoxication and include weight gain,

personality changes, confusion, and extreme muscle weakness.

d. As the serum sodium level approaches 110 mEq/L, seizures, coma, and eventually death will

occur, unless the condition is treated rapidly.

2. Interventions

a. Initiate fluid restriction and increased sodium intake as prescribed.

b. As prescribed, administer an antagonist to antidiuretic hormone.

c. Monitor serum sodium levels.

d. Treat the underlying cause with chemotherapy or radiation to reduce the tumor.

C. Spinal cord compression

1. Description

a. Spinal cord compression occurs when a tumor directly enters the spinal cord or when the

vertebral column collapses from tumor entry, impinging on the spinal cord.

b. Spinal cord compression causes back pain, usually before neurological deficits occur.

c. Neurological deficits relate to the spinal level of compression and include numbness;

tingling; loss of urethral, vaginal, and rectal sensation; and muscle weakness.

2. Interventions

a. Early recognition: Assess for back pain and neurological deficits.

b. Administer high-dose corticosteroids to reduce swelling around the spinal cord and relieve

symptoms.

c. Prepare the client for immediate radiation and/or chemotherapy to reduce the size of the

tumor and relieve compression.

d. Surgery may need to be performed to remove the tumor and relieve the pressure on the spinal

cord.

e. Instruct the client in the use of neck or back braces if they are prescribed.

D. Hypercalcemia

1. Description

a. Hypercalcemia is a late manifestation of extensive malignancy that occurs most often with

bone metastasis, when the bone releases calcium into the bloodstream.

b. Decreased physical mobility contributes to or worsens hypercalcemia.

c. Early signs include fatigue, anorexia, nausea, vomiting, constipation, and polyuria.

d. More serious signs and symptoms include severe muscle weakness, diminished deep tendon

reflexes, paralytic ileus, dehydration, and changes in the electrocardiogram.

2. Interventions

a. Monitor serum calcium level and electrocardiographic changes.

b. Administer oral or parenteral fluids as prescribed.

c. Administer medications that lower the calcium level as prescribed.

d. Prepare the client for dialysis if the condition becomes life-threatening or is accompanied by

renal impairment.

E. Superior vena cava syndrome

1. Description

a. Superior vena cava (SVC) syndrome occurs when the SVC is compressed or obstructed by

tumor growth (commonly associated with lung cancer and lymphoma).

b. Signs and symptoms result from blockage of blood flow in the venous system of the head,

neck, and upper trunk.

c. Early signs and symptoms generally occur in the morning and include edema of the face,

especially around the eyes, and tightness of the shirt or blouse collar (Stokes’ sign).

d. As the condition worsens, edema in the arms and hands, dyspnea, erythema of the upper body,

and epistaxis occur.

e. Life-threatening signs and symptoms include airway obstruction, hemorrhage, cyanosis,

mental status changes, decreased cardiac output, and hypotension.

2. Interventions

a. Assess for early signs and symptoms of superior vena cava syndrome.

b. Prepare the client for high-dose radiation therapy to the mediastinal area, and possible

surgery to insert a metal stent in the vena cava.

F. Tumor lysis syndrome

1. Description

a. Tumor lysis syndrome occurs when large quantities of tumor cells are destroyed rapidly and

intracellular components such as potassium and uric acid are released into the bloodstream

faster than the body can eliminate them.

b. Tumor lysis syndrome can indicate that cancer treatment is destroying tumor cells; however,

if left untreated, it can cause severe tissue damage and death.

c. Hyperkalemia, hyperphosphatemia with resultant hypocalcemia, and hyperuricemia occur;

hyperuricemia can lead to acute kidney injury.

2. Interventions

a. Encourage oral hydration; IV hydration may be prescribed for the client experiencing nausea;

monitor renal function.

b. Administer diuretics to increase the urine flow through the kidneys as prescribed.

c. Administer medications that increase the excretion of purines, such as allopurinol (Zyloprim),

as prescribed.

d. Prepare to administer IV infusion of glucose and insulin to treat hyperkalemia.

e. Prepare the client for dialysis if hyperkalemia and hyperuricemia persist despite treatment.