Acute Exam 4 (Ch.57: Female Reproductive Disorders; Ch. 58: Assessment and Management of Patients with Breast Disorders; Ch.59: Assessment and Management of Patients with Male Reproductive Disorders )

Prostatic Disorders: Prostatitis Manifestations

***Acute prostatitis is characterized by the sudden onset of fever, dysuria, perineal prostatic pain, and severe lower urinary tract symptoms: dysuria, frequency, urgency, hesitancy, and nocturia. Approximately 5% of cases of type I prostatitis (acute bacterial prostatitis) progress to type II prostatitis (chronic bacterial prostatitis) (McDougal et al., 2016). ***Patients with type II disease are typically asymptomatic between episodes. Patients with type III prostatitis often have no bacteria in the urine in the presence of genitourinary pain. Patients with type IV prostatitis are usually diagnosed incidentally during a workup for infertility, an elevated PSA test, or other disorders. ACUTE •Sudden onset of fever •Dysuria •Perineal prostatic pain •Sever lower urinary tract symptoms •Dysuria •Frequency •Urgency •Hesitancy •Nocturia CHRONIC •Asymptomatic between episodes CP/CPPS •No bacteria in urine in presence of genitourinary pain ASYMPTOMATIC INFLAMMATION Diagnosed by accident

Cancer of the Prostate Assessment and Diagnosis

***If prostate cancer is detected early, the likelihood of cure is high (Itano et al., 2016). It can be diagnosed through an abnormal finding with the DRE, serum PSA, and ultrasound-guided TRUS with biopsy. Detection is more likely with the use of combined diagnostic procedures. Routine repeated DRE (preferably by the same examiner) is important because early cancer may be detected as a nodule within the gland or as an extensive hardening in the posterior lobe. The more advanced lesion is "stony hard" and fixed. DRE also provides useful clinical information about the rectum, anal sphincter, and quality of stool. The diagnosis of prostate cancer is confirmed by a histologic examination of tissue removed surgically by TURP, open prostatectomy, or ultrasound-guided transrectal needle biopsy. Fine-needle aspiration is a quick, painless method of obtaining prostate cells for cytologic examination and determining the stage of disease. Most prostate cancers are detected when a man seeks medical attention for symptoms of urinary obstruction or are found by routine DRE and PSA testing. Cancer detected incidentally when TURP is performed for clinically benign disease and lower urinary tract symptoms occurs in about 1 of 10 cases.TRUS helps detect nonpalpable prostate cancers and assists with staging of localized prostate cancer. Needle biopsies of the prostate are commonly guided by TRUS. The biopsies are examined by a pathologist to both determine if cancer is present and to grade the tumor. The most commonly used tumor grading system is the Gleason score. This system assigns a grade of 1 to 5 for the most predominant architectural pattern of the glands of the prostate and a secondary grade of 1 to 5 to the second most predominant pattern. ***The Gleason score is then reported as, for example, 2 + 4; the combined value can range from 2 to 10. With each increase in Gleason score, there is an increase in tumor aggressiveness. Lower Gleason scores indicate well-differentiated and less aggressive tumor cells; higher Gleason scores indicate undifferentiated cells and more aggressive cancer. A total score of 8 to 10 indicates a high-grade cancer (Keane & Graham, 2016). ***Categorization of low-, intermediate-, and high-risk prostate cancer is determined by the extent of cancer in the prostate gland, whether or not the cancer is localized to the prostate, the aggressiveness of the cells, and the spread to the lymph nodes and beyond. Level of risk, in turn, is used to determine treatment options. Bone scans, skeletal x-rays, and magnetic resonance imaging (MRI) may be used to identify metastatic bone disease. Pelvic computed tomography (CT) scans may be performed to determine if the cancer has spread to the lymph nodes. The radiolabeled monoclonal antibody capromab pendetide with indium 111 (ProstaScint) is an antibody that can be used to detect either recurrent prostate cancer at low PSA levels or metastatic disease

Prostatic Disorders: Prostatitis Pathophysiology

***Prostatitis is an inflammation of the prostate gland that is often associated with lower urinary tract symptoms and symptoms of sexual discomfort and dysfunction. The condition affects 5% to 10% of men. It is the most common urologic diagnosis in men younger than 50 years and the third most common such diagnosis in men older than 50 years (McDougal et al., 2016). ***vProstatitis may be caused by infectious agents (bacteria, fungi, mycoplasma) or other conditions (e.g., urethral stricture, BPH). Escherichia coli is the most commonly isolated organism, although Klebsiella and Proteus species are also found (Chen, Hu, Peng, et al., 2015). The microorganisms colonize the urinary tract and ascend to the prostate, ultimately causing infection. The causal pathogen is usually the same in recurrent infections. ***There are four types of prostatitis: acute bacterial prostatitis (type I), chronic bacterial prostatitis (type II), chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) (type III), and asymptomatic inflammatory prostatitis (type IV). Type III, which occurs in more than 90% of cases, is further classified as type IIIA or type IIIB, depending on the presence (type IIIA) or absence (type IIIB) of white blood cells in semen after prostate massage •Acute bacterial •Chronic bacterial •Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) •Asymptomatic inflammatory

Prostatic Disorders: Prostatitis Medical Management

***The goal of treatment is to eradicate the causal organisms. Hospital admission may be necessary for patients with unstable vital signs, sepsis, or intractable pelvic pain; those who are frail or immunosuppressed; or those who have diabetes or renal insufficiency. ***Specific treatment is based on the type of prostatitis and on the results of culture and sensitivity testing of the urine (Wagenlehner, Weidner, Pilatz, et al., 2014). ***If bacteria are cultured from the urine, antibiotic agents, including trimethoprim-sulfamethoxazole (Bactrim) or a fluoroquinolone (e.g., ciprofloxacin [Cipro]), may be prescribed, and continuous therapy with low-dose antibiotic agents may be used. If the patient is afebrile and has a normal urinalysis, anti-inflammatory agents may be used. Alpha-adrenergic blocker therapy (e.g., tamsulosin [Flomax]), may be prescribed to promote bladder and prostate relaxation. Factors contributing to prostatitis, including stress, neuromuscular factors, and myofascial pain, are also addressed. Supportive, nonpharmacologic therapies may be prescribed. ***These include biofeedback, pelvic floor training, physical therapy, reduction of prostatic fluid retention by ejaculation through sexual intercourse or masturbation, sitz baths, stool softeners, and evaluation of sexual partners to reduce the possibility of cross-infection. Eradicate organisms •Urine C&S +Trimethoprim-sulfamethoxazole +Fluoroquinolone Hospital admission •Unstable VS •Sepsis •Intractable pelvic pain •Frail/immunosuppressed •DM •Renal insufficiency Anti-inflammatory medications Alpha-adrenergic blocker therapy •Tamsulosin Contributing Factors •Stress •Neuromuscular factors •Myofascial pain

Cancer of the Uterus (Endometrium) Risk Factors

+Age—usually >50 years; average age, 63 years +Obesity that results in increased estrone levels (related to excess weight) resulting from conversion of androstenedione to estrone in body fat, which exposes the uterus to unopposed estrogen +Unopposed estrogen therapy (estrogen used without progesterone, which offsets the risk of unopposed estrogen) +Other—nulliparity, truncal obesity, early menarche, late menopause (after 52 years of age) and the use of tamoxifen

Hysterectomy Nursing Interventions: PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE

+Educating Patients About Self-Care. The information provided to the patient is tailored to her needs. She must know what limitations or restrictions, if any, to expect. She is instructed to check the surgical incision daily and to contact her primary provider if redness or purulent drainage or discharge occurs. She is informed that her periods are now over but that she may have a slightly bloody discharge for a few days; if bleeding recurs after this time, it should be reported immediately. The patient is instructed about the importance of an adequate oral intake and of maintaining bowel and urinary tract function. The patient is informed that she is likely to recover quickly but that postoperative fatigue is not unusual. The patient should resume activities gradually. This does not mean sitting for long periods, because doing so may cause blood to pool in the pelvis, increasing the risk of VTE. The nurse explains that showers are preferable to tub baths to reduce the possibility of infection and to avoid the dangers of injury that may occur when getting in and out of the bathtub. The patient is instructed to avoid straining, lifting, having sexual intercourse, or driving until permitted. Vaginal discharge, foul odor, excessive bleeding, any leg redness or pain, or an elevated temperature should be reported, and the nurse reinforces education regarding activities and restrictions. +Continuing and Transitional Care. Follow-up telephone contact provides the nurse with the opportunity to determine whether the patient is recovering without problems and to answer any questions that may have arisen. The patient is reminded about postoperative follow-up appointments. If the patient's ovaries were removed and she finds vasomotor symptoms troublesome, hormone therapy may be considered at a low dose for a short amount of time. The patient is reminded to discuss risks and benefits of hormone therapy and alternative therapies with her primary provider and gynecologic care provider. Decisions about use of hormone therapy need to be made individually in consultation with these providers.

Physical Assessment: Female Breast INSPECTION

-American Cancer Society (ACS) screening guidelines for early detection of cancer state that an annual clinical breast examination for women 40 years and older is preferable. -A clinical breast examination every 1 to 3 years for women between the ages of 20 and 39 years is preferable as part of a periodic health examination (ACS, 2012). -A thorough breast examination, including instruction in breast awareness and BSE, takes at least 10 minutes. INSPECTION -Examination begins with inspection. -The breasts are inspected for size and symmetry. +A slight variation in the size of each breast is common and generally normal. -The skin is inspected for color, venous pattern, thickening, or edema. +Erythema (redness) may indicate benign local inflammation or superficial lymphatic invasion by a neoplasm. +A prominent venous pattern can signal increased blood supply required by a tumor. +Edema and pitting of the skin may result from a neoplasm blocking lymphatic drainage, giving the skin an orange peel appearance (peau d'orange)—a classic sign of advanced breast cancer.

Endometriosis Nursing Assessment and Diagnosis

-Health History +an account of the menstrual pattern, is necessary to elicit specific symptoms. -Bimanual Pelvic Examination +fixed tender nodules are sometimes palpated, and uterine mobility may be limited, indicating adhesions. -Laparoscopic Examination +confirms the diagnosis and helps stage the disease. In stage 1, patients have superficial or minimal lesions; stage 2, mild involvement; stage 3, moderate involvement; and stage 4, extensive involvement and dense adhesions, with obliteration of the cul-de-sac. -Ultrasonography, magnetic resonance imaging (MRI), and CT scans may also be useful to visualize endometriosis

Endometriosis Risk Factors

-There also appears to be a familial predisposition to endometriosis; it is more common in women whose close female relatives are affected. -Other factors that may suggest increased risk include a shorter menstrual cycle (less than every 27 days), flow longer than 7 days, outflow obstruction, and younger age at menarche •Factors suggestive of endometriosis +Late childbearing +Relative +Shorter menstrual cycles +Longer flow +Younger onset of menses

Endometriosis Pathophysiology

-benign lesion(s) of endometrial tissue in pelvic cavity outside the uterus -a chronic disease -occurring more frequently in women who have never had children -extensive endometriosis may cause few symptoms, or an isolated lesion may produce severe symptoms -a major cause of chronic pelvic pain and infertility During menstruation, this ectopic tissue bleeds, mostly into areas having no outlet, which causes pain and adhesions. The lesions are typically small and puckered, with a blue/brown/gray powder-burn appearance and brown or blue-black appearance, indicating concealed bleeding. Endometrial tissue contained within an ovarian cyst has no outlet for the bleeding; this formation is referred to as a pseudocyst or chocolate cyst. Adhesions, cysts, and scar tissue may result, causing pain and infertility (Beckmann et al., 2014). Endometriosis may increase the risk of ovarian cancer. Currently, the best-accepted theory regarding the origin of endometrial lesions is the transplantation theory, which suggests that a backflow of menses (retrograde menstruation) transports endometrial tissue to ectopic sites through the fallopian tubes. Why some women with retrograde menstruation develop endometriosis and others do not is unknown. Endometrial tissue can also be spread by lymphatic or venous channels. •Bleeding ectopic tissue •Adhesions •Pain •Cysts •Scar tissue

Endometriosis Manifestations

-dysmenorrhea -dyspareunia -pelvic discomfort -pain -Dyschezia (pain with bowel movements) -radiation of pain to the back or leg may occur. -Depression, loss of work due to pain, and relationship difficulties may result. -Infertility may occur because of fibrosis and adhesions or because of a variety of substances (prostaglandins, cytokines, other factors) produced by the implants of endometriosis and scar tissue on anatomical sites. •Dysmenorrhea •Dyspareunia •Pelvic discomfort •Pain •Dyschezia (pain with bowel movements)

Benign Disorders: Polycystic Ovary Syndrome (PCOS) Pathophysiology

-is a type of hormonal imbalance or cystic disorder that affects the ovaries -involves a disorder in the hypothalamic-pituitary and ovarian network or axis, resulting in chronic anovulation and hyperandrogenism, often along with multiple small ovarian cysts

Diagnostic Evaluation of Breasts: Contrast Mammography

A contrast mammography (i.e., ductogram, galactogram) is a diagnostic procedure that involves injection of less than 1 mL of radiopaque material through a cannula inserted into a ductal opening on the areola, which is followed by a mammogram (Fischbach & Dunning, 2015). It is performed to evaluate an abnormality within the duct when the patient has bloody nipple discharge on expression, spontaneous nipple discharge, or a solitary dilated duct noted on mammography.

Prostatic Disorders: Prostatitis Nursing Management

ACUTE •IV antibiotic administration •Comfort measures +Analgesics +Sitz baths •Avoid sexual arousal and intercourse CHRONIC •Antibiotic regimen adherence •S/SX to report Promoting Home, Community-Based, and Transitional Care •Educating Patients about Self Care +Complete entire course of antibiotics +Home IV administration +Sitz baths +Encourage fluids +Avoid alcohol, coffee, tea, chocolate, cola, and spices +Suprapubic catheter +Don't sit for long periods •Keep follow-up appointments If the patient experiences symptoms of acute prostatitis (fever, severe pain and discomfort, inability to urinate, malaise), he may be hospitalized for intravenous (IV) antibiotic therapy. Nursing management includes administration of prescribed antibiotic agents and provision of comfort measures, including prescribed analgesic agents and sitz baths. The patient with chronic prostatitis is usually treated on an outpatient basis and needs to be educated about the importance of continuing antibiotic therapy and recognizing recurrent signs and symptoms of prostatitis. The nurse educates the patient about the importance of completing the prescribed course of antibiotic therapy. If IV antibiotic agents are to be given at home, the nurse educates the patient and family about correct and safe administration. Arrangements for a home care nurse to oversee administration may be needed. Warm sitz baths (10 to 20 minutes) may be taken several times daily. Fluids are encouraged to satisfy thirst but are not "forced," because an effective medication level must be maintained in the urine. Foods and liquids with diuretic action or that increase prostatic secretions, such as alcohol, coffee, tea, chocolate, cola, and spices, should be avoided. A suprapubic catheter may be necessary for severe urinary retention. During periods of acute inflammation, sexual arousal and intercourse should be avoided. To minimize discomfort, the patient should avoid sitting for long periods. Medical follow-up is necessary for at least 6 months to 1 year, because prostatitis caused by the same or different organisms can recur. The patient is advised that the UTI may recur and is educated to recognize its symptoms.

Breast Cancer Systemic Treatments (Chemotherapy)

Adjuvant chemotherapy involves the use of anticancer agents in addition to other treatments (i.e., surgery, radiation) to delay or prevent a recurrence of breast cancer. It is recommended for patients who have positive lymph nodes or who have invasive tumors greater than 1 cm in size, regardless of nodal status. It is considered in patients with tumors that are 0.6 to 1 cm, are moderately to poorly differentiated, or have unfavorable features (NCCN, 2015). Table 58-6 outlines general indications for adjuvant chemotherapy. A survival benefit has been shown in both women who are pre- and postmenopausal and who have received chemotherapy, although data are limited in women older than 70 years. Chemotherapy is most commonly initiated after breast surgery and before radiation. Patients who delay initiation of chemotherapy beyond 90 days postsurgery have an increased risk of adverse outcomes (Chavez-McGregor, Clarke, Lichtensztajn, et al., 2016). Nurses encourage and assist in facilitating timely treatment to optimize outcomes. Chemotherapy regimens for breast cancer combine several agents (polychemotherapy), generally given over a period of 3 to 6 months. Decisions regarding the optimal regimen are based on a variety of factors, including tumor characteristics (i.e., tumor size, lymph node status, hormone receptor status, HER-2/neu status) and the patient's age, physical status, and existing comorbid conditions. A regimen that includes cyclophosphamide (Cytoxan), methotrexate (Trexall), and fluorouracil (Fluoroplex) (collectively referred to as CMF) has been the most widely used adjuvant therapy. It is usually well tolerated and may be considered for patients with a low risk of recurrence. CMF also may be considered for use in patients who have a high risk of cardiac toxicity or who have other limiting comorbidities. Anthracycline-based regimens (e.g., doxorubicin [Adriamycin], epirubicin [Ellence]) have shown longer survival in patients. However, the benefit relative to CMF is modest and is accompanied by increased toxicity (Meneses & Walker, 2014). Selection of patients most likely to benefit from anthracycline therapy would allow better use of current cytotoxic agents and reduce the risk of patients receiving toxicity with little or no effect. Identifying biomarkers that can accurately predict benefit from anthracyclines will also highlight key resistance/susceptibility pathways that can then be exploited clinically to further increase efficacy (Meneses & Walker, 2014). Cyclophosphamide, doxorubicin, and fluorouracil (CAF) and doxorubicin and cyclophosphamide (AC) are examples of combination regimens often given to patients who are at high risk. The taxanes (paclitaxel [Taxol], docetaxel [Taxotere]) are generally incorporated into treatment regimens for patients with larger, node-negative cancers and for those with positive axillary lymph nodes. The addition of four cycles of paclitaxel after a standard course of AC (regimen known as ACT) has been found to increase the disease-free period and improve overall survival in patients with operable breast cancer and positive lymph nodes (Meneses & Walker, 2014). Much attention has been focused on dose-dense chemotherapy, which is the administration of chemotherapeutic agents at standard doses with shorter time intervals between each cycle of treatment. A systematic review and meta-analysis of existing data from randomized controlled trials that compared dose-dense chemotherapy with a standard chemotherapy schedule in women with nonmetastatic breast cancer demonstrated that dose-dense chemotherapy results in better overall and disease-free survival, particularly in women with hormone receptor-negative breast cancer (Bonilla, Ben-Aharon, Vidal, et al., 2010). However, additional data from randomized controlled trials are needed before dose-dense chemotherapy can be considered the standard of care (Bardia & Baselga, 2014).

Pelvic Organ Prolapse: Cystocele, Rectocele, Enterocele Risk Factors

Age and parity can put strain on the ligaments and structures that make up the female pelvis and pelvic floor. Childbirth can result in tears of the levator sling musculature, resulting in structural weakness. Hormone deficiency also may play a role. Some degree of prolapse (weakening of the vaginal walls allowing the pelvic organs to descend and protrude into the vaginal canal) may be found in older women. Risk factors include: -age -parity (particularly vaginal delivery) -menopause -previous pelvic surgery -possibly a genetic predisposition

Anatomic and Physiologic Overview of Male Reproductive System: Gerontologic Considerations

As men age, the *prostate gland enlarges; prostate secretion decreases; the scrotum hangs lower; the testes decrease in weight, atrophy, and become softer; and pubic hair becomes sparser and stiffer. Changes in gonadal function include a decline in plasma testosterone levels and reduced production of progesterone

Abnormal Assessment Findings During Inspection of the Breasts: Peau d'Orange (Edema)

Associated with inflammatory breast cancer Caused by interference with lymphatic drainage Breast skin has orange peel appearance Skin pores enlarge May be noted on the areola Skin becomes thick, hard, and immobile

Abnormal Assessment Findings During Inspection of the Breasts: Acute Mastitis (Inflammation of the Breasts)

Associated with lactation but may occur at any age Nipple cracks or abrasions noted Breast skin reddened and warm to touch Tenderness Systemic signs include fever and increased pulse

Benign Prostatic Hyperplasia (Enlarged Prostate) Manifestations

BPH may or may not lead to lower urinary tract symptoms; if symptoms occur, they may range from mild to severe. Severity of symptoms increases with age, and half of men with BPH report having moderate to severe symptoms. Obstructive and irritative symptoms may include urinary frequency, urgency, nocturia, hesitancy in starting urination, decreased and intermittent force of stream and the sensation of incomplete bladder emptying, abdominal straining with urination, a decrease in the volume and force of the urinary stream, dribbling (urine dribbles out after urination), and complications of acute urinary retention and recurrent UTIs. Normally, residual urine amounts to no more than 50 mL in the middle-aged adult and less than 50 to 100 mL in the older adult (Weber & Kelley, 2014). Ultimately, chronic urinary retention and large residual volumes can lead to azotemia (accumulation of nitrogenous waste products) and kidney failure. Generalized symptoms may also be noted, including fatigue, anorexia, nausea, vomiting, and pelvic discomfort. Other disorders that produce similar symptoms include urethral stricture, prostate cancer, neurogenic bladder, and urinary bladder stones. •Lower urinary tract symptoms •Obstructive and irritative symptoms +Urinary frequency +Urgency +Nocturia +Hesitancy in starting urination +Decreased and intermittent force of stream +Sensation of incomplete bladder emptying +Abdominal straining with urination +Decrease in volume and force of stream +Dribbling +Complication of acute urinary retention +Recurrent UTIs •Generalized symptoms +Fatigue +Anorexia +N/V +Pelvic discomfort

Cystocele Manifestations

Because a cystocele causes the anterior vaginal wall to bulge downward, the patient may report a sense of pelvic pressure and urinary problems such as incontinence, frequency, and urgency. Back pain and pelvic pain may occur as well. •Pelvic pressure +Urinary problems +Incontinence +Frequency +Urgency •Pain +Back +Pelvic

Benign Prostatic Hyperplasia (Enlarged Prostate) Pathophysiology

Benign prostatic hyperplasia (BPH), a noncancerous enlargement or hypertrophy of the prostate, is one of the most common diseases in aging men. It can cause bothersome lower urinary tract symptoms that affect quality of life by interfering with normal daily activities and sleep patterns (McDougal et al., 2016). BPH typically occurs in men older than 40 years. By the time they reach 60 years, 50% of men have BPH. It affects as many as 90% of men by 85 years of age. BPH is the second most common cause of surgical intervention in men older than 60 years. Pathophysiology The cause of BPH is not well understood, but testicular androgens have been implicated. Dihydrotestosterone (DHT), a metabolite of testosterone, is a critical mediator of prostatic growth. Estrogens may also play a role in the cause of BPH; BPH generally occurs when men have elevated estrogen levels and when prostate tissue becomes more sensitive to estrogens and less responsive to DHT. Smoking, heavy alcohol consumption, obesity, reduced activity level, hypertension, heart disease, diabetes, and a Western diet (high in animal fat and protein and refined carbohydrates, low in fiber) are risk factors for BPH (McDougal et al., 2016; Tantamango-Bartley, Knutsen, Knutsen, et al., 2016). BPH develops over a prolonged period; changes in the urinary tract are slow and insidious. BPH is a result of complex interactions involving resistance in the prostatic urethra to mechanical and spastic effects, bladder pressure during voiding, detrusor muscle strength, neurologic functioning, and general physical health (McCance et al., 2013). The hypertrophied lobes of the prostate may obstruct the bladder neck or urethra, causing incomplete emptying of the bladder and urinary retention. As a result, a gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis) can occur. Urinary retention may result in UTIs because urine that remains in the urinary tract serves as a medium for infective organisms.

Breast Surgical Management: Breast Conservation Therapy

Breast Conservation Treatment +Lumpectomy +Wide excision +Partial/segmental mastectomy +Quadranectomy The goal of breast conservation treatment (i.e., lumpectomy, wide excision, partial or segmental mastectomy, quadrantectomy) is to excise the tumor in the breast completely and obtain clear margins while achieving an acceptable cosmetic result. If the procedure is being performed to treat a noninvasive breast cancer, lymph node removal is not necessary. For an invasive breast cancer, lymph node removal (SLNB or ALND) is indicated. The lymph nodes are removed through a separate semicircular incision in the axilla

Physical Assessment: Male Breast

Breast cancer can occur in men. Assessment of the male breast and axilla is brief but important and should be included in a physical examination. The nipple and areola are inspected for swelling, nodules, ulcerations, and nipple discharge. The flat disc of undeveloped breast tissue under the nipple is palpated. The same procedure for palpating the female axilla is used when assessing the male axilla (Weber & Kelley, 2014). Gynecomastia is the firm enlargement of glandular tissue beneath and immediately surrounding the areola of the male (see later discussion). This is different from the enlargement of soft, fatty tissue, which is caused by obesity.

Hysterectomy Potential Complications

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: Hemorrhage VTE Bladder dysfunction Infection •Hemorrhage •VTE •Bladder dysfunction •Infection

Pathophysiology of the Malignant Process

Cancer is a disease process that begins when a cell is transformed by genetic mutations of the cellular deoxyribonucleic acid (DNA). Genetic mutations may be inherited and/or acquired, leading to abnormal cell behavior (Grossman & Porth, 2014). The initial genetically altered cell forms a clone and begins to proliferate abnormally, evading normal intracellular and extracellular growth-regulating processes or signals as well as the immune system defense mechanisms of the body. Genetic mutations may lead to abnormalities in cell signaling transduction processes (signals from outside and within cells that turn cell activities either on or off) that can in turn lead to cancer development. Ultimately cells acquire a variety of capabilities that allow them to invade surrounding tissues and/or gain access to lymph and blood vessels, which carry the cells to other areas of the body resulting in metastasis or spread of the cancer (Acharyya, Matrisian, Welch, et al., 2015). •Malignant transformation resulting from a carcinogen 1. Initiation •Carcinogen causes mutations to the cellular DNA 2. Promotion •Proliferation and expansion of initiated (abnormal) cells 3. Progression •Altered cells exhibit increased malignant behavior •Angiogenesis - growth of blood vessels to further enhance abnormal cellular growth (when a tumor develops its own blood and lymph supply) •Viruses/Bacteria (H. pylori, HPV-so gardisel was the vaccine created to prevent it) •Physical Agents (Sunlight) •Chemical Agents (Tobacco) •Genetics (Broncha 1 and 2) •Lifestyle (obesisty) •Hormonal Agents (woman who never give birth to a child, nullparity, are at an increased risk for breast cancer)

Protective Factors of Breast Cancer

Certain factors may be protective against the development of breast cancer. Breast feeding for at least 1 year, regular or moderate physical activity and maintaining a healthy body weight are cited as protective (ACS, 2015). Some research suggests that the use of extra virgin olive oil regularly in one's diet may be preventive

Cancer of the Cervix Risk Factors

Chronic cervical infection Early childbearing Exposure to diethylstilbestrol in utero Exposure to human papillomavirus, types 16 and 18 Family history of cervical cancer HIV infection and other causes of immune deficiency Low socioeconomic status (may be related to early marriage and early childbearing) Nutritional deficiencies (folate, beta-carotene, and vitamin C levels are lower in women with cervical cancer than in women without it) Overweight status Prolonged use of oral contraceptives Sexual activity: Multiple sex partners Early age (<20 years) at first coitus (exposes the vulnerable young cervix to potential viruses from a partner) Sexual contact with men whose partners have had cervical cancer Sex with uncircumcised men Smoking and exposure to secondhand smoke

Abnormal Assessment Findings During Inspection of the Breasts: Nipple Inversion

Considered normal if long-standing Associated with fibrosis and malignancy if recent development

Ductal Carcinoma in Situ Medical Management

Current management takes into account (1) assurance of an accurate diagnosis, (2) assessment of DCIS size and grade, and (3) careful margin evaluation. The pathologist analyzes the piece of breast tissue removed to determine the type and grade of the DCIS or how abnormal the cells look when compared with normal breast cells and how fast they are growing. Grade III (high-grade DCIS) cells tend to grow more quickly than grade I (low-grade) and grade II (moderate-grade) cells and look much different from normal breast cells. Accurate grading of DCIS is critical, because high nuclear grade and the presence of necrosis (the premature death of cells in living tissue) are highly predictive of the inability to achieve adequate margins or borders of healthy tissue around the cancer, of local recurrence, and of the probability of missed areas of invasion. The pros and cons of irradiating patients with DCIS who are treated conservatively should be carefully weighed on a case-by-case basis, considering recent trials have shown that radiation has a beneficial effect on distant recurrence, breast cancer-specific mortality, and overall survival. Breast conservation (treatment of a breast cancer without the loss of the breast) can be curative for well-defined subsets of women with DCIS (ACS, 2015).

Benign Conditions of the Breast: Cysts

Cysts are fluid-filled sacs that develop as breast ducts dilate. Cysts occur most commonly in women 30 to 55 years of age and may be exacerbated during perimenopause. Although their cause is unknown, cysts usually disappear after menopause, suggesting that estrogen is a factor. Cystic areas often fluctuate in size and are usually larger premenstrually. They may be painless or may become very tender premenstrually. Occasionally, a patient may report an intermittent shooting sensation or a dull ache. Various breast masses are compared in Table 58-2. Cysts that are confirmed on an ultrasound and are not bothersome can often be left alone. To confirm a diagnosis or to relieve pain, FNA can be performed. Cysts do not increase the risk of breast cancer (ACS, 2015). Fibrocystic breast changes, often incorrectly called fibrocystic breast disease, is a nonspecific term used to describe an array of benign findings including palpable nodularity, lumpiness, swelling, or pain. The changes do not necessarily indicate a cystic or disease process.

Benign Disorders: Polycystic Ovary Syndrome (PCOS) Manifestations

Cysts form in the ovaries because the hormonal milieu cannot cause ovulation on a regular basis. •Obesity •Insulin resistance •Glucose intolerance •Dyslipidemia •Sleep apnea •Infertility •Irregular cycles •Hirsutism

Male Reproductive Assessment: Physical Assessment

DIGITAL RECTAL EXAMINATION Digital Rectal Examination The DRE is used to screen for prostate cancer and is recommended annually for every man older than 50 years (45 years for men at high risk [African American men and men with a family history of prostate cancer in first-degree relatives]) (American Cancer Society [ACS], 2015). The DRE enables the skilled examiner, using a lubricated, gloved finger placed in the rectum, to assess the size, symmetry, shape, and consistency of the posterior surface of the prostate gland (see Fig. 59-2). The clinician assesses for tenderness of the prostate gland on palpation and for the presence and consistency of any nodules. The DRE may be performed with the patient leaning over an examination table or positioning the man in a side-lying position with legs flexed toward the abdomen or supine with legs resting in stirrups. To minimize discomfort and relax the anal sphincter during the rectal examination, the patient is instructed to take a deep breath and exhale slowly as the practitioner inserts a finger. If possible, he should turn his feet inward so his toes are touching. Although this examination may be uncomfortable and embarrassing for the patient, it is an important screening tool. TESTICULAR EXAMINATION The male genitalia are inspected for abnormalities and palpated for masses. The scrotum is palpated carefully for nodules, masses, or inflammation. Examination of the scrotum can reveal such disorders as hydrocele, inguinal hernia, testicular torsion, orchitis, epididymitis, or a tumor of the testis. The penis is inspected and palpated for ulcerations, nodules, inflammation, discharge, and curvature. If the patient is uncircumcised, the foreskin should be retracted for visualization of the glans penis. The testicular examination provides an excellent opportunity to instruct the patient on how to perform a testicular self-examination (TSE) and its importance in early detection of testicular cancer. TSE should begin during adolescence. For more details on TSE, see later discussion in the chapter and Chart 59-6.

Ductal Carcinoma in Situ

Ductal carcinoma in situ (DCIS) is characterized by the proliferation of malignant cells inside the milk ducts without invasion into the surrounding tissue. Unlike invasive breast cancer, DCIS does not metastasize and a woman generally does not die of DCIS unless it develops into invasive breast cancer. DCIS can develop into invasive breast cancer if left untreated. The best estimates are that 14% to 53% of untreated DCIS progresses to invasive breast cancer over a period of 10 years or more. However, the natural history of DCIS is not well understood, and it is currently not possible to accurately predict which women with DCIS will go on to develop invasive breast cancer (ACS, 2015). DCIS is frequently manifested on a mammogram with the appearance of calcifications and is considered breast cancer stage 0.

Abnormal Assessment Findings During Inspection of the Breasts: Paget Disease (Malignancy of Mammary Ducts)

Early signs—erythema of nipple and areola Late signs—thickening, scaling, and erosion of the nipple and areola

Testicular Cancer Assessment and Diagnostic Findings

Educating young men about testicular cancer and the need for urgent evaluation of any mass or enlargement or unexplained testicular pain is key to early detection (Fuller, 2014). Education about TSE, starting in adolescence, alerts men to the importance of seeking medical attention if a testicle becomes indurated, enlarged, atrophied, nodular, or painful (see Chart 59-6). TSE should be performed monthly. Testicular cancers generally grow rapidly and are easily detected against a typically smooth and homogeneous texture. Annual testicular examination by a clinician can reveal signs and lead to early diagnosis and treatment of testicular cancer. Promoting awareness of this disease is an important health promotion intervention; men should seek medical evaluation for signs or symptoms of testicular cancer without delay (Akar & Bebis, 2014). Any suspicious testicular mass warrants prompt evaluation with a thorough history and physical examination, focusing on palpation of the affected testicle. The tumor markers alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-hCG) may be elevated in patients with testicular cancer. Tumor marker levels in the blood are used for diagnosis, staging, and monitoring the response to treatment. Blood chemistry, including lactate dehydrogenase, is also necessary. A chest x-ray to assess for metastasis in the lungs and a transscrotal testicular ultrasound will be performed. Microscopic analysis of tissue is the only definitive way to determine if cancer is present, but it is usually performed at the time of surgery rather than as a part of the diagnostic workup to reduce the risk of promoting spread of the cancer (ACS, 2015). Inguinal orchiectomy is the standard way to establish the diagnosis of testicular cancer. Other staging tests to determine the extent of the disease in the retroperitoneum, pelvis, and chest include an abdominal/pelvic CT scan and chest CT scan (if the abdominal CT or chest x-ray is abnormal). A brain MRI and bone scan may be obtained if indicated (NCCN, 2016c). Discussion of the option to bank sperm should take place prior to orchiectomy and treatment.

Erectile Dysfunction

Erectile dysfunction, also called impotence, is the inability to achieve or maintain an erect penis

Erythropoiesis

Erythroblasts arise from the primitive myeloid stem cells in bone marrow. The erythroblast is an immature nucleated cell that gradually loses its nucleus. At this stage, the cell is known as a reticulocyte. Further maturation into an erythrocyte entails the loss of the dark-staining material within the cell and slight shrinkage. The mature erythrocyte is then released into the circulation. Under conditions of rapid erythropoiesis (i.e., erythrocyte production), reticulocytes and other immature cells (e.g., nucleated RBCs) may be released prematurely into the circulation. This is often seen when the liver or spleen takes over as the site of erythropoiesis and more nucleated red cells appear within the circulation. Differentiation of the primitive myeloid stem cell into an erythroblast is stimulated by erythropoietin, a hormone produced primarily by the kidney. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), or with people living at high altitudes with lower atmospheric oxygen concentrations, erythropoietin levels increase. The increased erythropoietin then stimulates the marrow to increase the production of erythrocytes. The entire process of erythropoiesis typically takes less than 5 days (Papayannopoulou & Migliaccio, 2013). For normal erythrocyte production, the bone marrow also requires iron, vitamin B12, folate, pyridoxine (vitamin B6), protein, and other factors. A deficiency of these factors during erythropoiesis can result in decreased red cell production and anemia. +Iron Stores and Metabolism The average daily diet in the United States contains 10 to 15 mg of elemental iron, but only 1 to 2.5 mg of ingested iron is normally absorbed from the small intestine (Adamson, 2015). The rate of iron absorption is regulated by the amount of iron already stored in the body and by the rate of erythrocyte production. Additional amounts of iron, up to 2 mg daily, must be absorbed by women of childbearing age to replace that lost during menstruation. Total body iron content in the average adult is approximately 3 g, most of which is present in hemoglobin or in one of its breakdown products. Iron is stored as ferritin and when required, the iron is released into the plasma, binds to transferrin, and is transported into the membranes of the normoblasts (erythrocyte precursor cells) within the marrow, where it is incorporated into hemoglobin. Iron is lost in the feces, either in bile, blood, or mucosal cells from the intestine. The concentration of iron in blood is normally about 50 to 150 µg/dL (Adamson & Longo, 2015). With iron deficiency, bone marrow iron stores are rapidly depleted; hemoglobin synthesis is depressed, and the erythrocytes produced by the marrow are small and low in hemoglobin. Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Lack of dietary iron is rarely the sole cause of iron deficiency anemia in adults. The source of iron deficiency should be investigated promptly, because iron deficiency in an adult may be a sign of bleeding in the GI tract or colon cancer. +Vitamin B12 and Folate Metabolism Vitamin B12 and folate are required for the synthesis of deoxyribonucleic acid (DNA) in RBCs. Both vitamin B12 and folate are derived from the diet. Folate is absorbed in the proximal small intestine, but only small amounts are stored within the body. If the diet is deficient in folate, stores within the body quickly become depleted. Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12-intrinsic factor complex is absorbed in the distal ileum. People who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished. The effects of either decreased absorption or decreased intake of vitamin B12 are not apparent for 2 to 4 years. Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes called megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. This results in megaloblastic anemia.

Hysterectomy Nursing Evaluation

Expected patient outcomes may include: 1. Experiences decreased anxiety 2. Has improved body image -Discusses changes resulting from surgery with her partner -Verbalizes understanding of her disorder and the treatment plan -Displays minimal depression or anxiety 3. Experiences minimal pain and discomfort -Reports relief of abdominal pain and discomfort -Ambulates without pain 4. Verbalizes knowledge and understanding of self-care -Practices deep-breathing, turning, and leg exercises as instructed -Increases activity and ambulation daily -Reports adequate fluid intake and adequate urinary output -Identifies reportable symptoms -Schedules and keeps follow-up appointments 5. Absence of complications -Has minimal vaginal bleeding and exhibits normal vital signs -Ambulates early -Notes no chest or calf pain and no redness, tenderness, or swelling in the extremities -Reports no urinary problems or abdominal distention

Benign Conditions of the Breast: Fibroadenomas

Fibroadenomas are firm, round, movable, benign tumors. They can occur from puberty to menopause with a peak incidence at 30 years of age. These masses are nontender and are sometimes biopsied or removed for definitive diagnosis.

Benign Tumors of the Uterus: Fibroids (Leiomyomas, Myomas) Pathophysiology

Fibroids arise from the muscle tissue of the uterus and can be solitary or multiple, in the lining (intracavitary), muscle wall (intramural), and outside surface (serosal) of the uterus. They usually develop slowly in women between 25 and 40 years of age and may become quite large. A growth spurt with enlargement of the fibroid tumor may occur in the decade before menopause, possibly related to anovulatory cycles and high levels of unopposed estrogen. Fibroids are a common reason for hysterectomy because they often result in menorrhagia, which can be difficult to control.

DISEASES OF THE MALE BREAST

Gynecomastia +Adolescents - R/T hormones - Benign - Resolves spontaneously in 1-2 years +Adults -Firm/tender mass -Medication related -Disease/disorder related +Treatment -Surgery -Liposuction

•The nurse is caring for a client who has a radiation implant to treat cervical cancer. During morning care, the nurse turns the client to the side and sees the radiation device lying under the client. What actions should the nurse take?

Have the client lie still Use long handled forceps to retrieve the radioactive source Deposit the source into a lead box Contact the radiation oncologist Do not allow others to enter the room until the source is secured. Document occurrence and actions.

Hysterectomy Nursing Interventions: Improving Body Image

IMPROVING BODY IMAGE The patient may have strong emotional reactions to having a hysterectomy and personal feelings related to the diagnosis, views of significant others who may be involved (family, partner), religious beliefs, and fears about prognosis. Concerns such as the inability to have children and the effect on femininity may surface, as may questions about the effects of surgery on sexual relationships, function, and satisfaction. The patient needs reassurance that she will still have a vagina and that she can experience sexual activity after temporary postoperative abstinence while tissues heal. Information that sexual satisfaction and orgasm arise from clitoral stimulation rather than from the uterus reassures many women. Most women note some change in sexual feelings after hysterectomy, but they vary in intensity. In some cases, the vagina is shortened by surgery, and this may affect sensitivity or comfort. When hormonal balance is upset, as often occurs with reproductive system disorders, the patient may experience depressed mood and heightened emotional sensitivity to people and situations. The nurse needs to approach and evaluate each patient individually in light of these factors. A nurse who exhibits interest, concern, and willingness to listen to the patient's fears will help the patient progress through the surgical experience.

Special Issues in Breast Cancer Management

Implications of Genetic Testing Pregnancy and Breast Cancer +QOL and Survivorship Realistic expectations Informed decisions Gerontologic Considerations Breast Health of Women with Disabilities +Lower rate of mammograms

Breast Cancer Radiation Therapy Side Effects

In general, radiation therapy is well tolerated. Acute side effects consist of mild to moderate erythema, breast edema, and fatigue. Occasionally, skin breakdown may occur in the inframammary fold or near the axilla toward the end of treatment. Fatigue can be depressing, as can the frequent trips to the radiation oncology unit for treatment. The patient needs to be reassured that the fatigue is normal and not a sign of recurrence. Side effects usually resolve within a few weeks to a few months after treatment is completed. Rare long-term effects of radiation therapy include pneumonitis, rib fracture, heart disease, breast fibrosis or necrosis (Harris & Morrow, 2014). •Mild/moderate erythema •Breast edema •Fatigue •Skin breakdown •Rare long-term effects +Pneumonitis +Rib fracture +Heart disease +Breast fibrosis/necrosis

Invasive Breast Cancers

Infiltrating Ductal Carcinoma +Infiltrating ductal carcinoma—the most common histologic type of breast cancer—accounts for 80% of all cases. The tumors arise from the duct system and invade the surrounding tissues. They often form a solid irregular mass in the breast. Infiltrating Lobular Carcinoma +Infiltrating lobular carcinoma accounts for 10% to 15% of breast cancers. The tumors arise from the lobular epithelium and typically occur as an area of ill-defined thickening in the breast. They are often multicentric and can be bilateral. Medullary Carcinoma +Medullary carcinoma accounts for about 5% of breast cancers, and it tends to be diagnosed more often in women younger than 50 years. The tumors grow in a capsule inside a duct. They can become large and may be mistaken for a fibroadenoma. The prognosis is often favorable. Mucinous Carcinoma +Mucinous carcinoma accounts for about 3% of breast cancers and often presents in women who are postmenopausal and are 75 years and older. A mucin producer, the tumor is also slow growing; thus, the prognosis is more favorable than in many other types. Tubular Ductal Carcinoma +Tubular ductal carcinoma accounts for about 2% of breast cancers. Because axillary metastases are uncommon with this histology, prognosis is usually excellent. Micropapillary invasive ductal carcinoma is a rare type of aggressive ductal cancer characterized by a high rate of axillary node metastasis and skin involvement. Inflammatory Carcinoma +Inflammatory carcinoma is a rare (1% to 3%) and aggressive type of breast cancer that has unique symptoms. The cancer is characterized by diffuse edema and erythema of the skin, often referred to as peau d'orange (resembling an orange peel). This is caused by malignant cells blocking the lymph channels in the skin. An associated mass may or may not be present; if there is a mass, it is often a large area of indiscrete thickening. Inflammatory carcinoma can be confused with an infection because of its presentation. The disease can spread to other parts of the body rapidly. Chemotherapy often plays an initial role in controlling disease progression, but radiation and surgery may also follow. Paget Disease +Paget disease of the breast accounts for 1% of diagnosed cases of breast cancer (Grossman & Porth, 2014). Symptoms typically include a scaly, erythematous, pruritic lesion of the nipple. Paget disease often represents DCIS of the nipple but may have an invasive component. If no lump can be felt in the breast tissue and the biopsy shows DCIS without invasion, the prognosis is very favorable.

Cystocele, Rectocele, and Enterocele Medical Management

Kegel exercises, which involve contracting or tightening the vaginal muscles, are prescribed to help strengthen these weakened muscles. The exercises are more effective in the early stages of a cystocele. Kegel exercises are easy to perform and are recommended for all women, including those with strong pelvic floor muscles A pessary can be used alone or in conjunction with other treatments to avoid surgery. This device is inserted into the vagina and positioned to keep an organ, such as the bladder, uterus, or intestine, properly aligned when a cystocele, rectocele, or prolapse has occurred. Pessaries are usually ring- or doughnut shaped and are made of various materials, such as rubber or plastic (see Fig. 57-4). Rubber pessaries must be avoided in women with latex allergy. The size and type of pessary are selected and fitted by a gynecologic health care provider. The patient should have the pessary removed, examined, and cleaned by her health care provider at prescribed intervals. At these checkups, vaginal walls should be examined for pressure points or signs of irritation. Normally, the patient experiences no pain, discomfort, or discharge with a pessary, but if chronic irritation, excessive discharge, or bleeding occurs, alternative measures may be needed. A Colpexin Sphere is another nonsurgical device used to treat pelvic organ prolapse. This intravaginal device is similar to a pessary, but it supports the pelvic floor muscles and facilitates exercise of these muscles. It is removed daily for cleaning. •Kegel exercises (10 second intervals; can be done up to 80 times a day) •Pessary (have to be fitted for one by the doctor and there has to be a follow up to make sure there is no skin breakdown/infection) •Colpexin Sphere

Leukocytes (White Blood Cells)

Leukocytes are divided into two general categories: granulocytes and lymphocytes. In normal blood, the total leukocyte count is 4000 to 11,000 cells/mm3. Of these, approximately 60% to 80% are granulocytes and 20% to 40% are lymphocytes. Both of these types of leukocytes primarily protect the body against infection and tissue injury.Function of Leukocytes Leukocytes protect the body from invasion by bacteria and other foreign entities. The major function of neutrophils is phagocytosis. Neutrophils arrive at a given site within 1 hour after the onset of an inflammatory reaction and initiate phagocytosis, but they are short-lived. An influx of monocytes follows; these cells continue their phagocytic activities for long periods as macrophages. This process constitutes a second line of defense for the body against inflammation and infection. Although neutrophils can often work adequately against bacteria without the help of macrophages, macrophages are particularly effective against fungi and viruses. Macrophages also digest senescent (aging or aged) blood cells, primarily within the spleen. The primary function of lymphocytes is to attack foreign material. One group of lymphocytes (T lymphocytes) kills foreign cells directly or releases lymphokines, substances that enhance the activity of phagocytic cells. T lymphocytes are responsible for delayed allergic reactions, rejection of foreign tissue (e.g., transplanted organs), and destruction of tumor cells. This process is known as cellular immunity. The other group of lymphocytes (B lymphocytes) is capable of differentiating into plasma cells. Plasma cells, in turn, produce antibodies called immunoglobulins (Igs), which are protein molecules that destroy foreign material by several mechanisms. This process is known as humoral immunity. Eosinophils and basophils function in hypersensitivity reactions. Eosinophils are important in the phagocytosis of parasites. The increase in eosinophil levels in allergic states indicates that these cells are involved in the hypersensitivity reaction; they neutralize histamine. Basophils produce and store histamine as well as other substances involved in hypersensitivity reactions. The release of these substances provokes allergic reactions. See Chapter 35 for further information on the immune response. Granulocytes +Eosinophils +Basophils +Neutrophils Granulocytes are defined by the presence of granules in the cytoplasm of the cell. Granulocytes are divided into three main subgroups—eosinophils, basophils, and neutrophils—that are characterized by the staining properties of these granules (see Fig. 32-2). Eosinophils have bright-red granules in their cytoplasm, whereas the granules in basophils stain deep blue. The third and most numerous cell in this class is the neutrophil, with granules that stain a pink to violet hue. Neutrophils are also called polymorphonuclear neutrophils (PMNs, or polys) or segmented neutrophils (segs). The nucleus of the mature neutrophil has multiple lobes (usually two to five) that are connected by thin filaments of nuclear material, or a "segmented" nucleus; it is usually two times the size of an erythrocyte. The somewhat less mature granulocyte has a single-lobed, elongated nucleus and is called a band cell. Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. The increased number of band cells is sometimes called a left shift or shift to the left. (Traditionally, the diagram of neutrophil maturation showed the myeloid stem cell on the left with progressive maturation stages toward the right, ending with a fully mature neutrophil on the far right side. A shift to the left indicates that more immature cells are present in the blood than normal.) Fully mature neutrophils result from the gradual differentiation of myeloid stem cells, specifically myeloid blast cells. The process, called myelopoiesis, is highly complex and depends on many factors. These factors, including specific cytokines such as growth factors, are normally present within the marrow itself. As the blast cell matures, the cytoplasm of the cell changes in color (from blue to violet) and granules begin to form with the cytoplasm. The shape of the nucleus also changes. The entire process of maturation and differentiation takes about 10 days (see Fig. 32-1). Once the neutrophil is released into the circulation from the marrow, it stays there for only about 6 hours before it migrates into the body tissues to perform its function of phagocytosis (ingestion and digestion of bacteria and particles). Neutrophils die here within 1 to 2 days. The number of circulating granulocytes found in the healthy person is relatively constant; however, in infection, large numbers of these cells are rapidly released into the circulation. Agranulocytes +Monocytes +Lymphocytes Monocytes Monocytes (also called mononuclear leukocytes) are leukocytes with a single-lobed nucleus and a granule-free cytoplasm—hence the term agranulocyte (see Fig. 32-2). In normal adult blood, monocytes account for approximately 5% of the total leukocytes. Monocytes are the largest of the leukocytes. Produced by the bone marrow, they remain in the circulation for a short time before entering the tissues and transforming into macrophages. Macrophages are particularly active in the spleen, liver, peritoneum, and alveoli; they remove debris from these areas and phagocytize bacteria within the tissues. Lymphocytes Mature lymphocytes are small cells with scanty cytoplasm (see Fig. 32-2). Immature lymphocytes are produced in the marrow from the lymphoid stem cells. A second major source of production is the thymus. Cells derived from the thymus are known as T lymphocytes (or T cells); those derived from the marrow can also be T cells but are more commonly B lymphocytes (or B cells). Lymphocytes complete their differentiation and maturation primarily in the lymph nodes and in the lymphoid tissue of the intestine and spleen after exposure to a specific antigen. Mature lymphocytes are the principal cells of the immune system, producing antibodies and identifying other cells and organisms as "foreign." Natural killer (NK) cells serve an important role in the body's immune defense system. Like other lymphocytes, NK cells accumulate in the lymphoid tissues (especially spleen, lymph nodes, and tonsils), where they mature. When activated, they serve as potent killers of virus-infected and cancer cells. They also secrete chemical messenger proteins, called cytokines, to mobilize the T and B cells into action. •Bands •Immature granulocyte •Shift to the left

Breast Cancer Prevention Strategies in the Patient Who Is at High Risk

Long-Term Surveillance •CBE •Mammogram •MRI Long-term surveillance focuses on early detection. As recommended by the ACS (2012), women at high risk for breast cancer benefit from additional screening using MRI along with a yearly mammogram. Clinical breast examinations may be performed twice a year starting as early as 25 years of age. Mammograms may also be performed as early as 25 years of age. Data concerning the effectiveness of BSE are limited. In addition to yearly mammography and MRI, other screening tests, including ultrasonography, may be useful. Chemoprevention •Tamoxifen •Raloxifene •Anastrozole •Exemestane Chemoprevention is the main modality that aims to prevent the disease. Several national, randomized clinical trials in the past two decades have led to FDA approval of tamoxifen and raloxifene (Evista) as effective chemopreventive agents for use in women who are at high risk (Cummings, Eckert, Krueger, et al., 1999; Fisher, Constantino, Wickerham, et al., 1998; Vogel, Costantino, Wickerham, et al., 2006). In addition, anastrozole (Arimidex) and exemestane (Aromasin) are now used for chemoprevention (Comerford, 2015). Nurses can help women who are considering chemoprevention by providing them with information about the benefits, risks, and possible side effects of these medications. Prophylactic Mastectomy Prophylactic mastectomy is another primary prevention modality that can reduce the risk of breast cancer by 90% (National Cancer Institute [NCI], 2013) and is sometimes referred to as a "risk-reducing" mastectomy. The procedure consists of a total mastectomy (removal of breast tissue) and is usually accompanied by immediate breast reconstruction. Possible candidates include women with a strong family history of breast cancer, a diagnosis of LCIS or atypical hyperplasia, a mutation in a BRCA gene, and previous cancer in one breast. Because of physical and psychological ramifications including anxiety, depression, and altered body image, this procedure should be undertaken only after extensive counseling related to its risks and benefits. The procedure does not confer 100% protection against the development of breast cancer (NCI, 2013). A multidisciplinary approach should be used to help the patient arrive at a decision that is best for her. Consultation with a genetic counselor, plastic surgeon, medical oncologist, and psychiatrist can be invaluable. The patient needs to understand that this surgery is elective and not emergent. The nurse can play a valuable role in providing the patient with information, clarification, and support during the decision-making process.

Prostectomy Postoperative Nursing Interventions

MAINTAINING FLUID BALANCE During the postoperative period, the patient is at risk for imbalanced fluid volume because of the irrigation of the surgical site during and after surgery. With irrigation of the urinary catheter to prevent its obstruction by blood clots, fluid may be absorbed through the open surgical site and retained, increasing the risk of excessive fluid retention, fluid imbalance, and water intoxication. The urine output and the amount of fluid used for irrigation must be closely monitored to determine whether irrigation fluid is being retained and to ensure an adequate urine output. An intake and output record, including the amount of fluid used for irrigation, must be maintained. The patient is also monitored for electrolyte imbalances (e.g., hyponatremia), increasing blood pressure, confusion, and respiratory distress. These signs and symptoms are documented and reported to the surgeon. The risk of fluid and electrolyte imbalance is greater in older patients with pre-existing cardiovascular or respiratory disease. RELIEVING PAIN After a prostatectomy, the patient is assisted to sit and dangle his legs over the side of the bed on the day of surgery. The next morning, he is assisted to ambulate. If pain is present, the cause and location are determined, and the severity of pain and discomfort is assessed (Carter, Miller, Murphy, et al., 2014). The pain may be related to the incision or may be the result of excoriation of the skin at the catheter site. It may be in the flank area, indicating a kidney problem, or it may be caused by bladder spasms. Bladder irritability can initiate bleeding and result in clot formation, leading to urinary retention. Patients experiencing bladder spasms may report urgency to void, a feeling of pressure or fullness in the bladder, and bleeding from the urethra around the catheter. Medications that relax the smooth muscles can help ease the spasms, which can be intermittent and severe; these medications include flavoxate (Urispas) and oxybutynin (Ditropan). Warm compresses to the pubis or sitz baths may also relieve the spasms. The nurse monitors the drainage tubing and irrigates the system as prescribed to relieve any obstruction that may cause discomfort. Usually, the catheter is irrigated with 50 mL of irrigating fluid at a time. It is important to make sure that the same amount is recovered in the drainage receptacle. Securing the catheter drainage tubing to the leg or abdomen can help decrease tension on the catheter and prevent bladder irritation. Discomfort may be caused by dressings that are too snug, saturated with drainage, or improperly placed. Analgesic agents are given as prescribed. The nurse notifies the primary provider if the analgesic medications do not relieve the patient's pain and obtains a prescription for new doses or different medications. After the patient is ambulatory, he is encouraged to walk but not to sit for prolonged periods, because this increases intra-abdominal pressure and the possibility of discomfort and bleeding. Prune juice and stool softeners are provided to ease bowel movements and to prevent excessive straining. An enema, if prescribed, is given with caution to avoid rectal perforation. MONITORING AND MANAGING POTENTIAL COMPLICATIONS After prostatectomy, the patient is monitored for major complications such as hemorrhage, infection, VTE, catheter problems, and sexual dysfunction. Hemorrhage. Although patients are advised to discontinue all aspirin, nonsteroidal anti-inflammatory drugs, and platelet inhibitors 10 to 14 days before the surgery to prevent excessive bleeding, bleeding and hemorrhagic shock remain risks. The risk is increased with BPH because a hyperplastic prostate gland is very vascular. Bleeding may occur from the prostatic bed. Bleeding may also result in the formation of clots, which then obstruct urine flow. The drainage normally begins as reddish-pink and then clears to a light pink within 24 hours after surgery. Bright red bleeding with increased viscosity and numerous clots usually indicates arterial bleeding. Venous blood appears darker and less viscous. Arterial hemorrhage usually requires surgical intervention (e.g., suturing or transurethral coagulation of bleeding vessels), whereas venous bleeding may be controlled by applying prescribed traction to the catheter so that the balloon holding the catheter in place applies pressure to the prostatic fossa. The surgeon applies traction by securely taping the catheter to the patient's thigh if hemorrhage occurs. Less blood loss (150 mL) is expected with robotic-assisted laparoscopic radical prostatectomy, compared to the 500 to 900 mL loss that may occur with open prostatectomy. Nursing management includes assistance in implementing strategies to stop the bleeding and to prevent or reverse hemorrhagic shock. If blood loss is extensive, fluids and blood component therapy may be given. If hemorrhagic shock occurs, treatments described in Chapter 14 are initiated. Nursing interventions include closely monitoring vital signs; administering medications, IV fluids, and blood component therapy as prescribed; maintaining an accurate record of intake and output; and carefully monitoring drainage to ensure adequate urine flow and patency of the drainage system. The patient who experiences hemorrhage and his family are often anxious and benefit from explanations and reassurance about the event and the procedures that are performed. Infection. After perineal prostatectomy, the surgeon usually changes the dressing on the first postoperative day. Further dressing changes may become the responsibility of the nurse in the inpatient setting or the home care nurse upon discharge. Careful aseptic technique is used because the potential for infection is great. Dressings can be held in place by a double-tailed, T-binder bandage or a padded athletic supporter. The tails cross over the incision to give double thickness and then each tail is drawn up on either side of the scrotum to the waistline and fastened. Rectal thermometers, rectal tubes, and enemas are avoided because of the risk of injury and bleeding in the prostatic fossa. After the perineal sutures are removed, the perineum is cleansed as indicated. A heat lamp may be directed to the perineal area to promote healing. The scrotum is protected with a towel while the heat lamp is in use. Sitz baths are also used to promote healing. UTIs and epididymitis are possible complications after prostatectomy. The patient is assessed for their occurrence; if they occur, the nurse administers antibiotic agents as prescribed. Because the risk of infection continues after discharge from the hospital, the patient and family need to be educated to monitor for signs and symptoms of infection (fever, chills, sweating, myalgia, dysuria, urinary frequency, and urgency). The patient and family are instructed to contact the urologist if these symptoms occur. Venous Thromboembolism. Patients undergoing prostatectomy are at risk for VTE, including deep vein thrombosis and pulmonary embolism; therefore, the nurse assesses the patient frequently after surgery for manifestations of VTE. Early postoperative ambulation is essential to reduce the risk of VTE. Medical and nursing management of VTE are described in Chapters 23 and 30, respectively. In addition, if the patient is at high risk for clot formation, additional antithrombotic interventions may be prescribed (Goodman, 2013). Potential Catheter Problems. After TURP, the catheter must drain well; an obstructed catheter produces distention of the prostatic capsule and resultant hemorrhage. Furosemide (Lasix) may be prescribed to promote urination and initiate postoperative diuresis, thereby helping to keep the catheter patent. The nurse observes the lower abdomen to ensure that the catheter has not become blocked. A distinct, rounded swelling above the pubis is a manifestation of an overdistended bladder. If the nurse ascertains that the client's bladder is distended, a portable bladder scanner may be used to determine if urine retention is a problem (see Chapter 53). The drainage bag is monitored for bloody urine, and the dressings and surgical incision are examined for bleeding. The color of the urine is carefully noted and documented; a change in color from pink to amber indicates reduced bleeding. Blood pressure, pulse, and respirations are monitored and compared with baseline preoperative vital signs to detect hypotension. The nurse also observes the patient for restlessness, diaphoresis, pallor, any drop in blood pressure, and an increasing pulse rate. Figure 59.5 • A three-way system for bladder irrigation. Drainage of the bladder may be accomplished by gravity through a closed sterile drainage system. A three-way drainage system is useful in irrigating the bladder and preventing clot formation (see Fig. 59-5). Continuous irrigation may be used with TURP. Some urologists leave an indwelling catheter attached to a dependent drainage system. Gentle irrigation of the catheter may be prescribed to remove any obstructing clots. If the patient complains of pain, the tubing is examined. The drainage system is irrigated with irrigating fluid (usually 50 mL), if indicated and prescribed, to clear any obstruction. Quality and Safety Nursing Alert The amount of fluid recovered in the drainage bag must equal the amount of fluid instilled. Overdistention of the bladder should be avoided because it can induce secondary hemorrhage by stretching the coagulated blood vessels in the prostatic capsule. To prevent traction on the bladder, the drainage tube (not the catheter) is secured to the inner thigh. If a cystostomy catheter is in place, it is secured to the abdomen. The nurse explains the purpose of the catheter to the patient and assures him that the urge to void results from the presence of the catheter and from bladder spasms. Reassurance is given to the patient that medication (anticholinergics) will be given to control his bladder spasms. He is cautioned not to pull on the catheter, because this causes bleeding and subsequent catheter blockage, which leads to urinary retention. p. 1776 p. 1777 After the catheter is removed (usually when the urine appears clear), urine may leak around the wound for several days in the patient who has undergone perineal, suprapubic, or retropubic surgery. The cystostomy tube may be removed before or after the urethral catheter is removed. Some urinary incontinence may occur after catheter removal, and the patient is informed that this is likely to subside over time. Urinary Incontinence. Postoperative urinary incontinence is a complication that can be reduced through the use of a surgical technique called puboprostatic ligament-sparing, or through the use of a male sling (Sandhu, 2015). Even without these techniques, current surgical procedures have decreased the incidence of urinary incontinence following surgery. Factors associated with postoperative continence are younger age, preservation of both neurovascular bundles, absence of an anastomotic stricture, eversion of the bladder neck, and a smaller prostate volume. The nurse can encourage the patient who experiences incontinence to take steps to prevent incontinence, improve continence, anticipate leakage, and cope with lack of complete control (Dorey, 2013). Preventing incontinence involves increasing voiding frequency, avoiding positions that encourage the urge to void, and decreasing fluid intake prior to activities. Promoting continence involves pelvic floor exercises (see the Educating Patients About Self-Care section that follows), biofeedback, and electrical stimulation. Anticipating leakage may entail lifestyle modifications such as using absorbent pads and carrying extra clothes to prevent urinary accidents; this can improve confidence when bathroom access is limited. It also helps to know the location of public bathrooms. Coping long term with complete lack of control may involve collagen injections, artificial sphincter implants, medications, and leg bags (Dorey, 2013; McDougal et al., 2016). Sexual Dysfunction. Depending on the type of surgery, the patient may experience sexual dysfunction related to erectile dysfunction, decreased libido, and fatigue. These issues may become a concern to the patient soon after surgery or in the weeks to months of rehabilitation. With nerve-sparing radical prostatectomy, the likelihood of recovering the ability to have erections is better for men who are younger and men in whom both neurovascular bundles are spared. A decrease in libido is usually related to the impact of the surgery on the body. Reassurance that the usual level of libido will return after recuperation from surgery is often helpful to the patient and his partner. The patient should be aware that he may experience fatigue during rehabilitation from surgery. This fatigue may also decrease his libido and alter his enjoyment of usual activities. Several options to restore erectile function are discussed with the patient by the surgeon or urologist. These options may include medications, surgically placed implants, or negative-pressure devices. PDE-5 inhibitors (see Table 59-3) may be effective for treatment of erectile dysfunction in men after radical prostatectomy, especially if the neurovascular bundles have been preserved. They may also improve erectile function in men with partial or moderate erectile dysfunction after radiation therapy for localized prostate cancer. Nursing interventions include assessing for sexual dysfunction after surgery. Providing a private and confidential environment to discuss issues of sexuality is important. The emotional challenges of prostate surgery and its consequences need to be carefully explored with the patient and his partner. Providing the opportunity to discuss these issues can be very beneficial to the patient. For patients who have significant difficulty adjusting to sexual dysfunction, a referral to a sex therapist may be indicated.

Hysterectomy Nursing Interventions: Monitoring and Managing Potential Complications

MONITORING AND MANAGING POTENTIAL COMPLICATIONS +Hemorrhage. Vaginal bleeding and hemorrhage may occur after hysterectomy. To detect these complications early, the nurse counts the perineal pads used or checks the incision site, assesses the extent of saturation with blood, and monitors vital signs. Abdominal dressings are monitored for drainage if an abdominal surgical approach has been used. In preparation for hospital discharge, the nurse gives prescribed guidelines for activity restrictions to promote healing and to prevent postoperative bleeding. Because many women may go home the day of surgery or within a day or two, they are instructed to contact the nurse or surgeon if bleeding is beyond what is expected, which should be minimal. +Venous Thromboembolism. Because of positioning during surgery, postoperative edema, and decreased activity postoperatively, the patient is at risk for DVT and PE. To minimize the risk, antiembolism stockings are applied. In addition, the patient is encouraged and assisted to change positions frequently, although pressure under the knees is avoided, and to exercise her legs and feet while in bed. The nurse helps the patient ambulate early in the postoperative period. The nurse also assesses for DVT (leg pain, redness, warmth, edema) and PE (chest pain, tachycardia, dyspnea). If the patient is being discharged home soon after surgery, she is instructed to avoid prolonged sitting in a chair with pressure at the knees, sitting with crossed legs, and inactivity. Furthermore, she is instructed to contact her primary provider if symptoms of DVT or PE occur. +Bladder Dysfunction. Because of possible difficulty in voiding postoperatively, occasionally an indwelling catheter may be inserted before or during surgery and is left in place in the immediate postoperative period. If a catheter is in place, it is usually removed shortly after the patient begins to ambulate. After the catheter is removed, urinary output is monitored; additionally, the abdomen is assessed for distention. If the patient does not void within a prescribed time, measures are initiated to encourage voiding (e.g., assisting the patient to the bathroom, pouring warm water over the perineum). If the patient cannot void, catheterization may be necessary. On rare occasions, the patient may be discharged home with the catheter in place and is instructed in its management.

Diagnostic Evaluation of Breasts: MRI

Magnetic resonance imaging (MRI) of the breast is a highly sensitive test that has become a useful diagnostic adjunct to mammography. A magnet is linked to a computer that creates detailed images of the breast without exposure to radiation. An intravenous (IV) injection of gadolinium, a contrast dye, is given to improve visibility. The patient lies face down, and the breast is placed through a depression in the table. A coil is placed around the breast, and the patient is placed inside the MRI machine. The entire procedure takes about 30 to 40 minutes. p. 1725 p. 1726 Breast MRI is useful for evaluation of contralateral disease, invasive lobular carcinoma, and assessment of chemotherapeutic response. The ACS recommends an annual MRI scan in addition to mammography in women at high risk for breast cancer (i.e., those with greater than 20% lifetime risk). Candidates include women who have a BRCA1 or BRCA2 mutation, a first-degree relative with either of these mutations, certain rare genetic syndromes, or radiation to the chest between 10 and 30 years of age (ACS, 2012). MRI should be used in addition to mammography, not instead of it. Some disadvantages of MRI include high cost, variations in technique and interpretation, and the potential for patient claustrophobia. The procedure cannot always accurately distinguish between malignant and benign breast conditions, so false positive results may occur. MRI is contraindicated in patients with implantable metal devices (e.g., aneurysm clips, pacemakers, ports of tissue expanders) because of the metallic force. Foil-backed medication patches (e.g., nicotine, nitroglycerin, fentanyl) must be removed prior to MRI to avoid burns to the skin.

Breast Cancer Surgical Management Main Goal

Main goal of surgery +Gain control of disease

Patient Undergoing Surgery for Breast Cancer: Nursing Planning and Goals

Major goals +Increased Knowledge +Increased Self-care abilities +Reduced Fear +Reduced Anxiety +Reduced Emotional stress +Improved Decision-making +Improved Coping abilities +Improved Sexual function Pain management Neurovascular function management Positive body image No complications

Breast Assessment: Anatomy and Physiology

Male and female breasts mature comparably until puberty, when estrogen and other hormones initiate breast development in females. This development usually occurs from 10 to 16 years of age, although the range can vary from 9 to 18 years. Stages of breast development are described as Tanner stages 1 through 5: +Stage 1 describes a prepubertal breast. +Stage 2 is breast budding, the first sign of puberty in a female. +Stage 3 involves further enlargement of breast tissue and the areola (a darker tissue ring around the nipple). +Stage 4 occurs when the nipple and areola form a secondary mound on top of the breast tissue. +Stage 5 is the continued development of a larger breast with a single contour. The breasts are located between the second and sixth ribs over the pectoralis muscle from the sternum to the midaxillary line. An area of breast tissue, called the tail of Spence, extends into the axilla Fascial bands, called Cooper ligaments, support the breast on the chest wall. The inframammary fold (or crease) is a ridge of fat at the bottom of the breast. Each breast contains 12 to 20 cone-shaped lobes, which are made up of glandular elements (lobules and ducts) and separated by fat and fibrous tissue that binds the lobes together. Milk is produced in the lobules and then carried through the ducts to the nipple.

Diagnostic Evaluation of Breasts: Mammography

Mammography is a breast imaging technique used to visualize the breast to detect small abnormalities that could suggest malignant or benign disease (Fischbach & Dunning, 2015). The procedure takes about 15 minutes and can be performed in a hospital radiology department or independent imaging center. Two views are taken of each breast. The breast is mechanically compressed from top to bottom (craniocaudal view) and side to side (mediolateral oblique view) (see Fig. 58-4). Women may experience some discomfort because maximum compression is necessary for proper visualization. The new mammogram is compared with previous mammograms, and any changes may indicate a need for further investigation. Mammography may detect a breast tumor before it is clinically palpable (i.e., smaller than 1 cm); however, it has limitations (Fischbach & Dunning, 2015). The false-negative rate ranges between 5% and 10% (Helvie & Patterson, 2014). Younger women, or those taking HTs, may have dense breast tissue, making it more difficult to detect lesions with mammography. Patients scheduled for a mammogram may voice concern about exposure to radiation. The radiation exposure is equivalent to about 1 hour of exposure to sunlight, so patients would have to have many mammograms in a year to increase their cancer risk. To ensure that a mammogram is reliable, it is important that a woman find a reputable facility. Mammographic facilities are certified by the U.S. Food and Drug Administration (FDA), and the machines are accredited by the American College of Radiology (Fischbach & Dunning, 2015). In 2015, the ACS changed the mammography recommendations to state that healthy women should have mammography every year beginning at age 45 years (ACS, 2015). Women 55 and older may continue yearly screening or transition to every 2 years. This change was based on calculations that starting annual screening mammography later and getting it less often would cause less harm and be as safe as starting it earlier and getting it more often. Screening every other year may, however, result in a missed diagnosis and a small increase in the probability of being diagnosed with later-stage cancer (Kerlikowske, 2015). The ACS, however, continues to recommend that women 45 years and older have a mammogram every year and that they continue to do so for as long as they do not have serious, chronic health problems such as congestive heart failure, end-stage kidney disease, chronic obstructive pulmonary disease, and moderate to severe dementia. Age alone should not be the reason to stop having regular mammograms (ACS, 2012). Newer techniques for breast screening include digital mammography and 3D mammography. Digital mammography records x-ray images on a computer instead of on film, thus allowing radiologists to adjust the contrast and focus on an image without having to take additional x-rays. Although the accuracy of both film and digital screening mammography is similar for most women, digital mammography has been shown to be better at detecting estrogen receptor-negative tumors and cancer in extremely dense breasts. Both of these subgroups are more common in younger women, who may therefore choose digital mammography if they wish to have screening mammography. The 3D mammography obtains multiple projections of the compressed breast and results in fewer call backs for additional imaging (Jochelson, 2014). Computer-aided detection (CAD) is an option for radiologists and can be helpful in finding abnormal areas that should be checked more closely for early cancers. Refinements and improvements have been made to CAD software with a focus on increasing sensitivity for masses and reducing false-positive rates.

Benign Conditions of the Breast: Breast Pain (Mastalgia)

Mastalgia (breast pain) may be cyclical or noncyclical. Cyclical pain is usually related to hormonal fluctuations, usually during the menstrual cycle, and accounts for the majority of complaints. Noncyclical pain is far less common and does not vary with the menstrual cycle. Women who experience injury or trauma to the breast or those who have had a breast biopsy may experience noncyclical pain. Patients should be reassured that breast pain is rarely indicative of cancer. However, if the pain persists after menses begin, the patient should see her primary provider. Nursing Management The nurse may recommend that the patient wear a supportive bra both day and night for a week, decrease her salt and caffeine intake, and take ibuprofen (Advil) as needed for its anti-inflammatory actions. Vitamin E supplements may also be helpful. •Support bra •Decrease salt and caffeine intake •Ibuprofen •Vit E

Breast Assessment: Health History

Medical disorders Previous Surgeries Family history (particularly cancer) Gynecologic and obstetric history Medications (including prescriptions, vitamins, and herbals) Fertility treatments (past and present use of hormonal contraceptives, hormone therapy (HT) (formerly referred to as hormone replacement therapy [HRT]), or fertility treatments) Social habits (e.g., smoking, drinking alcohol, illicit drug use) Psychosocial information (patient's marital status, occupation, and availability of resources and support people, is obtained) BSE (Focused questions pertaining to the breast disorder are asked concerning the onset of the disorder and the length of time it has been present. In addition, the patient is asked if any masses are palpable and if there is any associated pain, swelling, redness, nipple discharge, or change in the skin. Knowledge and comfort related to breast self-awareness, which can include breast self-examination (BSE), should also be ascertained from the patient.) * Any recent x-rays or other diagnostic tests are noted.

Radiation Therapy

Methods of Radiation Therapy •External Radiation Therapy -Skin surface •Intraoperative Radiation Therapy -Directly to affected area during surgery •Internal/intracavitary Irradiation (given an anesthetic) -Inserted applicator •Nursing Considerations for Radiation Safety -Follow radiation safety

Breast Cancer Surgical Management: Radical Mastectomy

Modified radical mastectomy is performed to treat invasive breast cancer. The procedure involves removal of breast tissue, including the nipple-areola complex. In addition, a portion of the axillary lymph nodes are also removed in axillary lymph node dissection (ALND). If immediate breast reconstruction is desired, the patient is referred to a plastic surgeon prior to the mastectomy so that she has the opportunity to explore all available options. In modified radical mastectomy, the pectoralis major and pectoralis minor muscles are left intact, unlike in radical mastectomy, in which the muscles are removed. Modified Radical Mastectomy +Breast tissue +Nipple-areola complex +Axillary lymph node dissection (ALND)

Breast Cancer Surgical Management: Sentinel Lymph Node Biopsy

Sentinel Lymph Node Biopsy +sentinel node breast - - Video Search Results (yahoo.com) The status of the lymph nodes is the most important prognostic factor in breast cancer. The SLNB is a less invasive alternative to ALND and is considered a standard of care for the treatment of early-stage breast cancer. ALND is associated with potential morbidity, including lymphedema, cellulitis, decreased arm mobility, and sensory changes. Studies suggest that SLNB is highly accurate and is associated with a local recurrence rate similar to that of ALND (Chung & Giuliano, 2014). Table 58-5 compares SLNB and ALND. The sentinel lymph node, which is the first node (or nodes) in the lymphatic basin that receives drainage from the primary tumor in the breast, is identified by injecting a radioisotope and/or blue dye into the breast; the radioisotope or dye then travels via the lymphatic pathways to the node. In SLNB, the surgeon uses a handheld probe to locate the sentinel lymph node, excises it, and sends it for pathologic analysis, which is often performed immediately during the surgery using frozen-section analysis. If the sentinel lymph node is positive, the surgeon can proceed with an immediate ALND, thus sparing the patient a return trip to the operating room and additional anesthesia. (The patient could also return for additional surgery at a later time.) If the sentinel lymph node is negative, a standard ALND is not needed, thus sparing the patient the possible complications of the procedure. After the procedure is complete, all specimens are sent to pathology for more thorough analysis. +Nursing Management -Discolored urine and stool Patients who undergo SLNB in conjunction with breast conservation treatments are generally discharged the same day. Patients who undergo SLNB with total mastectomy usually stay in the hospital overnight, possibly longer if breast reconstruction is being performed. The patient must be informed that although frozen-section analysis is highly accurate, false-negative results can occur. A negative sentinel lymph node on frozen-section analysis may show metastatic disease on subsequent analysis, indicating that ALND is still necessary. The patient should also be reassured that the radioisotope and blue dye are generally safe. The nurse informs patients that they may notice a blue-green discoloration in the urine or stool for the first 24 hours as the blue dye is excreted. The incidence of lymphedema, decreased arm mobility, and seroma formation (collection of serous fluid) in the axilla is generally low, but the patient should be prepared for these possibilities. Women who have SLNB alone have neuropathic sensations similar to those who undergo ALND, although the prevalence and severity of these sensations and the resulting distress are lower with SLNB (Chung & Giuliano, 2014). The nurse must not overlook the psychosocial needs of the patient who has undergone SLNB. Although SLNB is a less invasive procedure than ALND and results in a shorter recovery period, a patient who has undergone SLNB also has many difficult issues surrounding her breast cancer diagnosis and treatment. The nurse must listen, provide emotional support, and refer the patient to appropriate specialists when indicated.

Carcinogenesis

Molecular Process Malignant transformation, or carcinogenesis, is thought to be at least a three-step cellular process, involving initiation, promotion, and progression. Agents that initiate or promote malignant transformation are referred to as carcinogens.During initiation, carcinogens (substances that can cause cancer), such as chemicals, physical factors, or biologic agents, cause mutations in the cellular DNA. Normally, these alterations are reversed by DNA repair mechanisms or the changes initiate programmed cellular death (apoptosis) or cell senescence. Cells can escape these protective mechanisms with permanent cellular mutations occurring, but these mutations usually are not significant to cells until the second step of carcinogenesis. During promotion, repeated exposure to promoting agents (co-carcinogens) causes proliferation and expansion of initiated cells with increased expression or manifestations of abnormal genetic information, even after long latency periods. Promoting agents are not mutagenic and do not need to interact with the DNA. Latency periods for the promotion of cellular mutations vary with the type of agent, the dosage of the promoter, and the innate characteristics and genetic stability of the target cell. The promotion phase generally leads to the formation of a preneoplastic or benign (noncancerous) lesion. During progression, the altered cells exhibit increasingly malignant behavior. These cells acquire the ability to stimulate angiogenesis (growth of new blood vessels that allow cancer cells to grow), to invade adjacent tissues, and to metastasize. Cellular oncogenes are responsible for vital cell functions, including proliferation and differentiation. Cellular proto-oncogenes, such as those for the epidermal growth factor receptor (EGFR), transcription factors such as c-Myc, or cell signaling proteins such as Kirsten ras (KRAS), act as "on switches" for cellular growth. Amplification of proto-oncogenes or overexpression of growth factors, such as epidermal growth factor (EGF), can lead to uncontrolled cell proliferation. Mutations that increase the activity of oncogenes also deregulate cell proliferation. Genetic alterations in the gene for KRAS have been associated with pancreatic, lung, and colorectal cancers (http://www.mycancergenome.org/content/disease/lung-cancer/kras/Lovly, Horn, & Pao, 2015). Just as proto-oncogenes "turn on" cellular growth, cancer suppressor genes "turn off," or regulate, unneeded cellular proliferation. When suppressor genes are mutated, resulting in loss of function or expression, the cells begin to produce mutant cell populations that are different from their original cellular ancestors. See Chart 15-1 for further discussion of genetics concepts and cancer.

Patient Undergoing Surgery for Breast Cancer: Postoperative Nursing Interventions CONT 3

Monitoring and Managing Potential Complications +Infection -S/SX: Redness, warmth, tenderness, foul-smelling drainage, increased temperature, chills -Treatment Cultures Antibiotics Infection. Although infection is rare, it is a risk after any surgical procedure. This risk may be higher in patients with conditions such as diabetes, immune disorders, and advanced age, as well as in those with poor hygiene. Patients are taught to monitor for signs and symptoms of infection (redness, warmth around incision, tenderness, foul-smelling drainage, temperature greater than 40°C [100.4°F], chills) and to contact the surgeon or nurse for evaluation. Treatment consists of oral or IV antibiotics (for more severe infections) for 1 or 2 weeks. Cultures are taken of any foul-smelling discharge.

Patient Undergoing Surgery for Breast Cancer: Postoperative Nursing Interventions CONT

Monitoring and Managing Potential Complications +Lymphedema -Painful swelling of arm -Weakness -Shoulder pain -Tingling sensations -Treatment Antibiotics OT/PT Compression device Exercises Manual lymph drainage Lymphedema. Lymphedema is a complication characterized by a chronic swelling of an extremity due to interrupted lymphatic circulation. The swelling is due to the accumulation of protein-rich fluid in the interstitial space and is a somewhat common postoperative complication after ALND. It often affects both the breast and ipsilateral limb. It is associated with a painful swelling of the arm as well as weakness, shoulder pain, and tingling sensations in the arm and shoulder. Research results suggest that within 5 years of ALND, there is a 20% risk of lymphedema. Because sentinel lymph node dissection (SLND) involves more focused surgery and less disruption of the axilla, the risk is only up to 7% within 5 years. Risk factors for lymphedema in mixed-age groups include ALND, concomitant radiation therapy, increased age, presence of a concomitant infection, pre-existing cardiovascular conditions, and obesity. Lymphedema results if functioning lymphatic channels are inadequate to ensure a return flow of lymph fluid to the general circulation. After axillary lymph nodes are removed, collateral circulation must assume this function. Transient edema in the postoperative period occurs until collateral circulation has completely taken over this function, which generally occurs within a month. Performing prescribed exercises, elevating the arm above the heart several times a day, and gentle muscle pumping (making a fist and releasing) can help reduce the transient edema. The patient needs reassurance that this transient swelling is not lymphedema. Once lymphedema develops, it tends to be chronic, so preventive strategies are vital. After ALND, the patient is taught hand and arm care to prevent injury or trauma to the affected extremity, thus decreasing the likelihood for development of lymphedema (see Chart 58-5). The patient is instructed to follow these guidelines for the rest of her life. She is also instructed to contact her primary provider immediately if she suspects that she has lymphedema, because early intervention provides the best chance for control. If allowed to progress without treatment, the swelling can become more difficult to manage. Treatment may consist of a course of antibiotic agents if an infection is present. A referral to a rehabilitation specialist (e.g., occupational or physical therapist) may be necessary for a compression sleeve or glove, exercises, manual lymph drainage, and a discussion of ways to modify daily activities to avoid worsening lymphedema. Ongoing research is seeking to identify which lymph nodes drain the arm before surgery so that they can be preserved when possible, helping to prevent the development of lymphedema.

Patient Undergoing Surgery for Breast Cancer: Postoperative Nursing Interventions CONT 2

Monitoring and Managing Potential Complications Hematoma/Seroma Formation +Hematoma -Swelling -Tightness -Pain -Bruising -Treatment Compression Surgical exploration Heat applications Hematoma or Seroma Formation. Hematoma formation (collection of blood inside a cavity) may occur after either mastectomy or breast conservation and usually develops within the first 12 hours after surgery. The nurse assesses for signs and symptoms of hematoma at the surgical site, which may include swelling, tightness, pain, and bruising of the skin. The surgeon should be notified immediately if there is gross swelling or increased bloody output from the drain. Depending on the surgeon's assessment, a compression wrap may be applied to the incision for approximately 12 hours, or the patient may be returned to the operating room so that the incision may be reopened to identify the source of bleeding. Some hematomas are small, and the body absorbs the blood naturally. The patient may take warm showers (if permitted by the surgeon) or apply warm compresses to help increase the absorption. A hematoma usually resolves in 4 to 5 weeks. +Seroma -Swelling -Heaviness -Discomfort -Sloshing of fluid -Treatment Unclog drain Needle aspiration A seroma, a collection of serous fluid, may accumulate under the breast incision after mastectomy or breast conservation or in the axilla. Signs and symptoms may include swelling, heaviness, discomfort, and a sloshing of fluid. Seromas may develop temporarily after the drain is removed or if the drain is in place and becomes obstructed. Seromas rarely pose a threat and may be treated by unclogging the drain or manually aspirating the fluid with a needle and syringe. Large, long-standing seromas that have not been aspirated may lead to infection. Small seromas that are not bothersome to the patient usually resolve on their own.

Cancer of the Uterus (Endometrium) Pathophysiology

Most uterine cancers are endometrioid (i.e., originating in the lining of the uterus). There are two types. +Type 1, which accounts for about 90% of cases, is estrogen dependent. It is usually low grade with a favorable prognosis. -estrogen DEPENDENT + Type 2, which occurs in about 10% of cases, is high grade and usually serous cell or clear cell. Type 2 is considered to be estrogen independent. Older and African-American women are at higher risk for type 2 -estrogen INDEPENDENT

Breast Cancer Systemic Treatments (Chemotherapy) Side Effects

N/V Bone marrow suppression Taste changes Alopecia Mucositis Neuropathy Skin changes Fatigue Many of the side effects of adjuvant chemotherapy can be managed well, allowing patients to maintain their daily routines and work schedules. In large part, this is the a result of the meticulous educational and psychological preparation provided to patients and their families by oncology nurses, oncologists, social workers, and other members of the health care team. In addition, strides have been made in the effectiveness of antiemetic agents used to alleviate nausea and vomiting and the use of hematopoietic growth factors to treat neutropenia and anemia. Common physical side effects of chemotherapy for breast cancer may include nausea, vomiting, bone marrow suppression, taste changes, alopecia (hair loss), mucositis, neuropathy, skin changes, and fatigue. A weight gain of more than 10 pounds occurs in about half of all patients; the cause is unknown. Women who are premenopausal may also experience temporary or permanent amenorrhea. Specific side effects vary with the type of chemotherapeutic agent used. In general, CMF and the taxanes are better tolerated than the anthracyclines. However, the taxanes can cause peripheral neuropathy, arthralgias, and myalgias, particularly at high doses. During taxane administration, hypersensitivity reactions may occur; therefore, the patient must be premedicated. Alopecia is also common. The side effects of the anthracyclines may be severe and include cardiotoxicity in addition to nausea and vomiting, bone marrow suppression, and alopecia. Their vesicant properties can lead to tissue necrosis if infiltration of the medication infusion occurs.

Hysterectomy Nursing Diagnosis

NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses may include the following: Anxiety related to the diagnosis of cancer, fear of pain, possible perception of loss of femininity or childbearing potential Disturbed body image related to altered fertility and fears about sexuality and relationships with partner and family Acute pain related to surgery and other adjuvant therapy Deficient knowledge of the perioperative aspects of hysterectomy and postoperative self-care •Nursing Diagnoses •Anxiety •Disturbed body image •Acute pain •Knowledge deficit

Erectile Dysfunction Medical Management: Negative Pressure Devices

Negative-pressure (vacuum) devices may also be used to induce an erection. A plastic cylinder is placed over the flaccid penis, and negative pressure is applied. When an erection is attained, a constriction band is placed around the base of the penis to maintain the erection. To avoid penile injury, the patient is instructed not to leave the constricting band in place for longer than 1 hour. Only devices with a vacuum limiter are recommended for use (Mulhall & Hsiao, 2014). Although many men find this method satisfactory, others experience premature loss of penile rigidity or pain when applying suction or during intercourse.

Surgical Treatment Options for Noninvasive and Invasive Breast Cancer

Noninvasive Breast Cancer Breast conservation alone Total mastectomy alone Invasive Breast Cancer Breast conservationa with one of the following: Sentinel lymph node biopsy Axillary lymph node dissection Total mastectomy with sentinel lymph node biopsy or Modified radical mastectomy

Breast Cancer Radiation Therapy Nursing Management

Nurses play a significant role in supporting patients throughout their treatment with radiation therapy. See Chapter 15 for discussion of radiation therapy. Self-care instructions for patients receiving radiation are provided to assist in the maintenance of skin integrity during the treatments and for several weeks after completion. They pertain only to the area being treated and not to the rest of the body. Instructions include: Use mild soap with minimal rubbing. Avoid perfumed soaps or deodorants. Use hydrophilic lotions (Lubriderm, Eucerin, Aquaphor) for dryness. Use a nondrying, antipruritic soap (Aveeno) if pruritus occurs. Avoid tight clothes, underwire bras, excessive temperatures, and ultraviolet light. Follow-up care includes educating the patient to minimize sun exposure to the treated area (i.e., using sunblock with sun protection factor [SPF] of 15 or higher) and reassuring the patient that short-term minor twinges and pain in the breast are normal after radiation treatment. Maintain skin integrity

Breast Cancer Systemic Treatments (Chemotherapy) Nursing Management

Nurses play an important role in helping patients manage the physical and psychosocial sequelae of chemotherapy. (Chapter 15 provides an in-depth discussion of side effect management.) Instructing the patient about the use of antiemetic agents and reviewing the optimal dosage schedule can help minimize nausea and vomiting. The different classes of antiemetic agents include serotonin (5-HT-3) receptor antagonists (palonosetron [Aloxi], granisetron [Kytril], ondansetron [Zofran]); neurokinin-1 receptor antagonists (aprepitant [Emend]); dopamine receptor antagonists (prochlorperazine [Compazine], metoclopramide [Reglan]); benzodiazepines (lorazepam [Ativan]); and corticosteroids (dexamethasone [Decadron]). Measures to ease the symptoms of mucositis may include rinsing with normal saline or sodium bicarbonate solution, avoiding hot and spicy foods, and using a soft toothbrush. Some patients may require hematopoietic growth factors to minimize the effects of chemotherapy-induced neutropenia and anemia. Granulocyte colony-stimulating factors boost the white blood cell count, helping to reduce the incidence of neutropenic fever and infection. The short-acting form, filgrastim (Neupogen), is injected subcutaneously or IV for 7 to 10 days after chemotherapy administration. The long-acting form, pegfilgrastim (Neulasta), is injected once, no earlier than 24 hours after chemotherapy (Comerford, 2015). Erythropoietin growth factor increases the production of red blood cells, thus decreasing the symptoms of anemia. The short-acting form, epoetin alfa (Epogen) is usually given weekly. The long-acting form, darbepoetin alfa (Aranesp), can be given every 2 to 3 weeks. The nurse instructs the patient and family on proper injection technique of hematopoietic growth factors and about symptoms that require follow-up with a primary provider (see Chart 58-9).To prevent some of the emotional trauma associated with alopecia, it often helps to have a patient obtain a wig before hair loss begins to occur. The nurse may provide a list of wig suppliers in the patient's geographic region. Familiarity with creative ways to use scarves and turbans may also help minimize the patient's distress. The patient needs reassurance that new hair will grow back when treatment is completed, although the color and texture may be different. The ACS offers the Look Good Feel Better program, which provides useful tips for applying cosmetics during the period a patient is receiving chemotherapy (see Resources section). Chemotherapy may negatively affect the patient's self-esteem, sexuality, and sense of well-being. This, combined with the stress of a potentially life-threatening disease, can be acute. Providing support and promoting open communication are important aspects of nursing care. Referring the patient to the dietitian, social worker, psychiatrist, or spiritual advisor can provide additional support. Numerous community support and advocacy groups are available for patients and their families. Complementary therapies, such as guided imagery, meditation, and relaxation exercises, can also be used in conjunction with conventional treatments. Antiemetics NS or HCO3 rinse solutions Avoid hot/spicy foods Soft toothbrush Hematopoietic growth factor injections Wigs

Nursing Management to Reduce Mucositis/Stomatitis

ORAL CARE •Inspect Daily •Oral care before and after every meal •Soft bristled toothbrush •Oral rinses with lidocaine •Avoid alcohol and glycerin based oral washes and swabs •Soft foods •Avoid "Cold" or "Hot" foods (cool to warm)

Diagnostic Evaluation of Breasts: Procedures for Tissue Analysis (Percutaneous Biopsy)

Percutaneous biopsy is performed on an outpatient basis to sample palpable and nonpalpable lesions. Less invasive than a surgical biopsy, percutaneous biopsy is a needle or core biopsy that obtains tissue by making a small puncture in the skin. Table 58-1 outlines the different types of biopsies that can be performed to obtain a tissue diagnosis. Fine-Needle Aspiration +Fine-needle aspiration (FNA) is a biopsy technique that is generally well tolerated by most women. A local anesthetic may or may not be used. A small-gauge needle (25 or 22 gauge) attached to a syringe is inserted into the mass or area of nodularity. Suction is applied to the syringe, and multiple passes are made through the mass. A simple cyst often disappears on aspiration, and the fluid is usually discarded. If no fluid is obtained, any cellular material obtained in the hub of the needle is spread on a glass slide or placed in a preservative and sent to the laboratory for analysis (CancerQuest, 2015). For nonpalpable masses, the same procedure can be performed by a radiologist using ultrasound guidance (ultrasound-guided FNA). FNA is less expensive than other diagnostic methods, and results are usually available quickly. However, false-negative or false-positive results are possible, and appropriate follow-up depends on the clinical judgment of the treating physician. Core Needle Biopsy +Core needle biopsy is similar to FNA, except a larger-gauge needle is used (usually 14 gauge). A local anesthetic is applied, and tissue cores are removed via a spring-loaded device. This procedure allows for a more definitive diagnosis than FNA, because actual tissue, not just cells, is removed. It is often performed for relatively large tumors that are close to the skin surface, but is also utilized for smaller, deeper lesions that are visible on ultrasound. Stereotactic Core Biopsy +Stereotactic core biopsy is performed on nonpalpable lesions detected by mammography. The patient lies prone on the stereotactic table. The breast is suspended through an opening in the table and compressed between two x-ray plates. Images are then obtained using digital mammography. The exact coordinates of the lesion to be sampled are located with the aid of a computer. Next, a local anesthetic is injected into the entry site on the breast. A small nick is made in the skin, a core needle is inserted, and samples of the tissue are taken for pathologic examination. Often, several passes are taken to ensure that the lesion is well sampled. Post-biopsy images are then taken to check that sampling has been adequate. A small titanium clip is almost always placed at the biopsy site so that the site can easily be located if further treatment is indicated.Stereotactic biopsy is quite accurate and often allows the patient to avoid a surgical biopsy. However, there is a small false-negative rate. Appropriate follow-up depends on the final pathologic diagnosis and the clinical judgment of the primary provider. The use of a titanium clip does not preclude subsequent MRIs. US-Guided Core Biopsy +The principles for ultrasound-guided core biopsy are similar to those of stereotactic core biopsy, but by using ultrasound guidance, computer coordination and mammographic compression are not necessary. An ultrasound-guided core biopsy does not use radiation and is also usually faster and less expensive than stereotactic core biopsy. MRI-Guided Core Biopsy +MRI-guided core biopsy can be performed by a radiologist and technologist when the abnormal area in the breast is too small to be felt but is visible on MRI.

Erectile Dysfunction Nursing Management

Personal satisfaction and the ability to sexually satisfy a partner are common concerns of patients. Men with illnesses and disabilities may need the assistance of a ***sex therapist to identify, implement, and integrate their sexual beliefs and behaviors into a healthy and satisfying lifestyle. The nurse can inform patients about support groups for men with erectile dysfunction and their partners.

Thrombocytes (Platelets)

Platelets, or thrombocytes, are not technically cells; rather, they are granular fragments of giant cells in the bone marrow called megakaryocytes (see Fig. 32-2). Platelet production in the marrow is regulated in part by the hormone thrombopoietin, which stimulates the production and differentiation of megakaryocytes from the myeloid stem cell. Platelets play an essential role in the control of bleeding. They circulate freely in the blood in an inactive state, where they nurture the endothelium of the blood vessels, maintaining the integrity of the vessel. When vascular injury occurs, platelets collect at the site and are activated. They adhere to the site of injury and to each other, forming a platelet plug that temporarily stops bleeding. Substances released from platelet granules activate coagulation factors in the blood plasma and initiate the formation of a stable clot composed of fibrin, a filamentous protein. Platelets have a normal lifespan of 7 to 10 days (Konkle, 2015). Recently, researchers have discovered an additional role for platelets that is related to inflammatory function. Receptors on the surface of platelets permit them to interact with leukocytes, inflamed endothelium of the vessel, and pathogens (Weyrich, 2014). Through a complex process, activated platelets adhere to neutrophils and monocytes, amplifying the immune response. This process is beneficial in the context of exposure to various pathogens (e.g., bacteria). However, this process is also thought to contribute to the inflammatory injury that may be involved in the development of arthritis, cardiovascular and cerebrovascular diseases, cancer, and progression to sepsis.

Patient Undergoing Surgery for Breast Cancer: Nursing Diagnosis

Preoperative ND •Knowledge deficit •Anxiety •Fear •Defensive/ineffective coping •Decisional conflict PREOPERATIVE NURSING DIAGNOSES Based on the assessment data, major preoperative nursing diagnoses may include the following: Deficient knowledge about the planned surgical treatments Anxiety related to the diagnosis of cancer Fear related to specific treatments and body image changes Risk for defensive or ineffective coping related to the diagnosis of breast cancer and related treatment options Decisional conflict related to treatment options Postoperative ND •Acute pain •Peripheral neurovascular dysfunction •Disturbed body image •Ineffective coping •Self-care deficit •Sexual dysfunction •Knowledge deficit POSTOPERATIVE NURSING DIAGNOSES Based on the assessment data, major postoperative nursing diagnoses may include the following: Acute pain and discomfort related to surgical procedure Peripheral neurovascular dysfunction related to nerve irritation in affected arm, breast, or chest wall Disturbed body image related to loss or alteration of the breast Risk for ineffective coping related to the diagnosis of cancer and surgical treatment Self-care deficit related to partial immobility of upper extremity on operative side Risk for sexual dysfunction related to loss of body part, change in self-image, and fear of partner's responses Deficient knowledge: drain management after breast surgery, arm exercises to regain mobility of affected extremity, hand and arm care after ALND Collaborative Problems/Potential Complications •Lymphedema •Hematoma/seroma •Infection COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: Lymphedema Hematoma/seroma formation Infection

Transfusion of Packed Red Blood Cells

Preprocedure 1. Confirm that the transfusion has been prescribed. 2. Check that patient's blood has been typed and cross-matched. 3. Verify that patient has signed a written consent form per institution or agency policy and agrees to procedure. 4. Explain procedure to patient. Instruct patient in signs and symptoms of transfusion reaction (itching, hives, swelling, shortness of breath, fever, chills). 5. Take patient's temperature, pulse, respiration, blood pressure and assess fluid volume status (e.g., auscultate lungs, assess for jugular venous distention) to serve as a baseline for comparison during transfusion. 6. Note if signs of increased fluid overload present (e.g., heart failure, see Chapter 29), contact primary provider to discuss potential need for a prescription for diuretic, as warranted. 7. Use hand hygiene and wear gloves in accordance with standard precautions. 8.Use appropriately sized needle for insertion in a peripheral vein.a Use special tubing that contains a blood filter to screen out fibrin clots and other particulate matter. Do not vent blood container. Procedure 1. Obtain packed red blood cells (PRBCs) from the blood bank after the IV line is started. (Institution policy may limit release to only 1 unit at a time.) 2. Double-check labels with another nurse or physician to ensure that the ABO group and Rh type agree with the compatibility record. 3 Check to see that number and type on donor blood label and on patient's medical record are correct. Confirm patient's identification by asking the patient's name and checking the identification wristband. Check blood for gas bubbles and any unusual color or cloudiness. (Gas bubbles may indicate bacterial growth. Abnormal color or cloudiness may be a sign of hemolysis.) 4. Make sure that PRBC transfusion is initiated within 30 minutes after removal of PRBCs from blood bank refrigerator. 5. For the first 15 minutes, run the transfusion slowly—no faster than 5 mL/min. Observe patient carefully for adverse effects. If no adverse effects occur during the first 15 minutes, increase the flow rate unless patient is at high risk for circulatory overload. 6.Monitor closely for 15-30 minutes to detect signs of reaction. Monitor vital signs at regular intervals per institution or agency policy; compare results with baseline measurements. Increase frequency of measurements based on patient's condition. Observe patient frequently throughout the transfusion for any signs of adverse reaction, including restlessness, hives, nausea, vomiting, torso or back pain, shortness of breath, flushing, hematuria, fever, or chills. Should any adverse reaction occur, stop infusion immediately, notify primary provider, and follow the agency's transfusion reaction standard. 7. Note that administration time does not exceed 4 hours because of increased risk of bacterial proliferation. 8.Be alert for signs of adverse reactions: circulatory overload, sepsis, febrile reaction, allergic reaction, and acute hemolytic reaction. 9. Change blood tubing after every 2 units transfused to decrease chance of bacterial contamination. Postprocedure 1. Obtain vital signs and breath sounds; compare with baseline measurements. If signs of increased fluid overload present (e.g., heart failure, see Chapter 29), consider obtaining prescription for diuretic as warranted. 2. Dispose of used materials properly. 3. Document procedure in patient's medical record, including patient assessment findings and tolerance to procedure. 4. Monitor patient for response to and effectiveness of procedure. If patient is at risk, monitor for at least 6 hours for signs of transfusion-associated circulatory overload (TACO); also monitor for signs of delayed hemolytic reaction.

Detection and Prevention of Cancer

Primary Prevention Primary prevention is about reducing the risks of disease through health promotion and risk reduction strategies. Guidelines on nutrition and physical activity for cancer prevention can be found in Chart 15-2. An example of primary prevention is the use of immunization to reduce the risk of cancer through prevention of infections associated with cancer. The HPV vaccine is recommended to prevent cervical and head and neck cancers (Chen et al., 2014). The vaccine to prevent HBV infection is recommended by the CDC (2015) to reduce the risk of hepatitis and subsequent development of liver cancer. •Primary •Healthy Weight •Physical Activity •Avoid carcinogens (tobacco, radiation, chemical hazards) •Avoid high risk behaviors •Sunscreen/Sunglasses Includes vaccines Secondary Prevention Secondary prevention involves screening and early detection activities that seek to identify precancerous lesions and early-stage cancer in individuals who lack signs and symptoms of cancer. ACS screening is advocated for many types of cancer (See Table 15-3) (ACS, 2016b). Detection of cancer at an early stage may reduce costs, use of resources, and the morbidity associated with advanced stages of cancer and their associated complex treatment approaches. Many screening and detection programs target people who do not regularly practice health-promoting behaviors or lack access to health care. Nurses continue to develop community-based screening and detection programs that address barriers to health care or reflect the socioeconomic and cultural beliefs of the target population (Benito, Binefa, Lluch, et al., 2014; Brittain & Murphy, 2015; Shackelford, Weyhenmeyer, & Mabus, 2015). The evolving understanding of the role of genetics in cancer cell development has contributed to prevention and screening efforts. Many centers offer cancer risk evaluation programs that provide interdisciplinary in-depth assessment, screening, education, and counseling as well as follow-up monitoring for people at high risk for cancer (National Comprehensive Cancer Network [NCCN] 2015a; NCCN 2015b). The NCI provides guidance for cancer risk assessment, counseling, education, and genetic testing (NCI, 2016). •Secondary •Mammogram •Pap Smear •Colonoscopy •PSA •Skin exams Secondary prevention is screening and early detection methods Instruct clients to discuss benefits and risks for each screening exam with their provider to determine if and when screening should take place. Clients at increased risk for specific cancer types might need to start screenings earlier or have them more frequently. Mammogram: Annually for female clients 45 to 54 years. At 55 years, clients can transition to every two years. Clients in good health should continue screening as long as there is at least 10 years continued life expectancy. Clinical breast exam: Every 3 years for clients 20 to 39 years. Annually for clients older than 40 years. Colonoscopy: At age 50 and then every 10 years Fecal testing: Guaiac-based fecal occult blood test or fecal immunochemical test annually; or stool DNA test every 3 years. Prostate screening: Prostate-specific antigen testing annually for males 70 years and older. Clients younger than 70 years should make an individual decision with the provider when to initiate screening. Screening for gene mutations: For clients who have a strong family history of breast or colon cancer Pap test: Clients age 21 to 29, every 3 years. Clients age 30 to 65, every 5 years with an HPV DNA test, or every 3 years with Pap test alone. Low-dose helical (chest) CT: For healthy adults who are current or former smokers aged 55 to 74 years with a 30-year pack history, either currently smoking or abstained within the last 15 years. Tertiary Prevention Improved screening, diagnosis, and treatment approaches have led to an estimated 14.5 million cancer survivors in the United States (ACS, 2014). Tertiary prevention efforts focus on monitoring for and preventing recurrence of the primary cancer as well as screening for the development of second malignancies in cancer survivors. Survivors are assessed for the development of second malignancies such as lymphoma and leukemia, which have been associated with certain chemotherapy agents and the use of radiation therapy (ACS, 2014). Survivors may also develop second malignancies not related to treatment but genetic mutations related to inherited cancer syndromes, environmental exposures, and lifestyle factors.

Patient Undergoing Surgery for Breast Cancer: Postoperative Nursing Interventions CONT 4

Promoting Home, Community-Based, and Transitional Care +Educating Patients About Self-Care -Written and oral discharge instructions Continuing and Transitional Care +Home health +Follow-up visits PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Educating Patients About Self-Care. Patients who undergo breast cancer surgery receive a tremendous amount of information both pre- and postoperatively. It is often difficult for the patient to absorb all of the information, partly because of the emotional distress that often accompanies the diagnosis and treatment. Prior to discharge, the nurse must assess the patient's readiness to assume self-care responsibilities and identify any gaps in knowledge. A review of education provided in written and oral forms, with reinforcement, may be required to ensure that the patient and family are prepared to manage the necessary care at home. The nurse reiterates symptoms that the patient should report, such as infection, seroma, hematoma, or arm swelling. All instruction should be reinforced during office visits and by telephone. Most patients are discharged 1 or 2 days after ALND or mastectomy (possibly later if they have had immediate reconstruction) with surgical drains in place. Initially, the drainage fluid appears bloody, but it gradually changes to a serosanguineous and then a serous fluid over the next several days. The patient is given instructions about drainage management at home (see Chart 58-6). If the patient lives alone and drainage management is difficult, a referral for a home care nurse should be made. The drains are usually removed when the output is less than 30 mL in a 24-hour period (approximately 7 to 10 days). The home care nurse also reviews pain management and incision care. In general, the patient may shower on the second postoperative day and wash the incision and drain site with soap and water to prevent infection. Some surgeons do not permit showers until 48 hours after drains are removed. If immediate reconstruction has been performed, showering may be contraindicated until the drain is removed. A dry dressing may be applied to the incision each day for 7 days. The patient should realize that sensation may be decreased in the operative area because the nerves were disrupted during surgery, and she should be informed that gentle care is needed to avoid injury. After the incision has completely healed (usually after 4 to 6 weeks), lotions or creams may be applied to the area to increase skin elasticity. The patient can begin to use deodorant on the affected side, although many women note that they no longer perspire as much as before the surgery.After ALND, patients are taught arm exercises on the affected side to restore range of motion (see Chart 58-7). After SLNB, patients may also benefit from these exercises, although they are less likely to have decreased range of motion than those who have undergone ALND. Range-of-motion exercises are initiated on the second postoperative day; however, instruction often occurs on the first postoperative day. The goals of the exercise regimen are to increase circulation and muscle strength, prevent joint stiffness and contractures, and restore full range of motion. The patient is instructed to perform range-of-motion exercises at home three times a day for 20 minutes at a time until full range of motion is restored (generally 4 to 6 weeks). Most patients find that after the drain is removed, range of motion returns quickly if they have adhered to their exercise program.If the patient is having any discomfort, taking an analgesic agent 30 minutes before beginning the exercises can be helpful. Taking a warm shower before exercising can also loosen stiff muscles and provide comfort. When exercising, the patient is encouraged to use the muscles in both arms and to maintain proper posture. Specific exercises may need to be prescribed and introduced gradually if the patient has had skin grafts; has a tense, tight surgical incision; or has had immediate reconstruction. Self-care activities, such as brushing the teeth, washing the face, and brushing the hair, are physically and emotionally therapeutic because they aid in restoring arm function and provide a sense of normalcy for the patient. The patient is instructed about postoperative activity limitation. In general, heavy lifting (more than 5 to 10 pounds) is avoided for about 4 to 6 weeks, although normal household and work-related activities are promoted to maintain muscle tone. Brisk walking, the use of stationary bikes and stepping machines, and stretching exercises may begin as soon as the patient feels comfortable. Once the drain is removed, the patient may begin to drive if she has full arm range of motion and is no longer taking opioid analgesic agents. General guidelines for activity focus on the gradual introduction of previous activities (e.g., bowling, weight training) once fully healed. Continuing and Transitional Care. Patients who have difficulty managing their postoperative care at home may benefit from a referral for home health, transitional, or community-based care. The nurse making a home visit assesses the patient's incision and surgical drain(s), adequacy of pain management, adherence to the exercise plan, and overall physical and psychological functioning. In addition, the home care nurse reinforces previous education and communicates important physiologic findings and psychosocial issues to the patient's primary provider, nurse, or surgeon. The frequency of follow-up visits after surgery may vary but generally should occur every 3 to 6 months for the first several years. The patient may alternate visits with the surgeon, medical oncologist, or radiation oncologist, depending on the treatment regimen. The ambulatory care nurse can also be a great source of education for the patient and family and should encourage them to telephone if they have any questions or concerns. It is common for people to ignore routine health care when a major health issue arises, so women who have been treated for breast cancer should be reminded of the importance of participating in routine health screening.

Patient Undergoing Surgery for Breast Cancer: Preoperative Nursing Interventions

Providing Education and Preparation About Surgical Treatments +Reinforce information +Answer questions +Expectations pre/during/post surgery PROVIDING EDUCATION AND PREPARATION ABOUT SURGICAL TREATMENTS Patients with newly diagnosed breast cancer are expected to absorb an abundance of new information during a very emotionally difficult time, and this may lead to difficulty in making treatment decisions. The nurse plays a key role in reviewing treatment options by reinforcing information provided to the patient and answering any questions. The nurse fully prepares the patient for what to expect before, during, and after surgery. Patients undergoing breast conservation with ALND, or a total or modified radical mastectomy, generally remain in the hospital overnight (or longer if they have immediate reconstruction). Surgical drains will be inserted in the mastectomy incision and in the axilla if the patient undergoes ALND. A surgical drain is generally not needed after SLNB. The patient should be informed that she will go home with the drain(s) and that complete instructions about drain care will be provided prior to discharge. In addition, the patient should be informed that she will often have decreased arm and shoulder mobility after ALND and that she will be shown range-of-motion exercises prior to discharge. The patient should also be reassured that appropriate analgesia and comfort measures will be provided to alleviate any postoperative discomfort. Reducing Fear and Anxiety and Improving Coping Ability +Physical +Emotional REDUCING FEAR AND ANXIETY AND IMPROVING COPING ABILITY The nurse helps the patient cope with the physical and emotional effects of surgery. Many fears may emerge during the preoperative phase. These can include fear of pain, mutilation (after mastectomy), and loss of sexual attractiveness; concern about inability to care for oneself and one's family; concern about taking time off from work; and coping with an uncertain future. Providing the patient with realistic expectations about the healing process and expected recovery can help alleviate fears. Maintaining open communication and assuring the patient that she can contact the nurse at any time with questions or concerns can be a source of comfort. The patient should also be made aware of available resources at the treatment facility as well as in the breast cancer community such as social workers, psychiatrists, and support groups. Some women find it helpful and reassuring to talk to a survivor of breast cancer who has undergone similar treatments. Promoting Decision-Making Ability +Understanding options PROMOTING DECISION-MAKING ABILITY The patient may be eligible for more than one therapeutic approach; she may be presented with treatment options and then asked to make a choice. This can be very frightening for some patients, and they may prefer to have someone else make the decision for them (e.g., surgeon, family member). The nurse can be instrumental in ensuring that the patient and family members truly understand their options. The nurse can then help the patient weigh the risks and benefits of each option. The patient may be presented with the option of having breast conservation treatment followed by radiation or a mastectomy. The nurse can explore the issues with the patient by asking questions such as the following: How do you think you might feel about losing your breast? Are you considering breast reconstruction? If you choose to retain your breast, would you consider undergoing radiation treatments 5 days a week for 5 to 6 weeks? Questions such as these can help the patient focus. Once the patient's decision is made, it is very important to support it.

Hysterectomy Nursing Interventions: Relieving Anxiety

RELIEVING ANXIETY Anxiety stems from several factors: unfamiliar environment; the effects of surgery on body image and reproductive ability; fear of pain and other discomfort; and, possibly, feelings of embarrassment about exposure in the perioperative period. The nurse determines what the experience means to the patient and encourages her to verbalize her concerns. Throughout the preoperative, postoperative, and recovery periods, explanations are given about physical preparations and procedures that are performed. Patient education addresses the outcomes of surgery, possible feelings of loss, and options for management of any symptoms that occur. Women vary in their preferences for information and participation in decision making, including choice of treatment options, accurate and useful information at the appropriate time, support from their health care providers, and access to professional and lay support systems.

Hysterectomy Nursing Interventions: Relieving Pain

RELIEVING PAIN Postoperative pain and discomfort are common. Therefore, the nurse assesses the intensity of the patient's pain and assists the patient with analgesia as prescribed. If the patient has abdominal distention or flatus, a rectal tube and application of heat to the abdomen may be prescribed. When abdominal auscultation reveals return of bowel sounds and peristalsis, additional fluids and a soft diet are permitted. Early ambulation facilitates the return of normal peristalsis.

Breast Cancer Radiation Therapy

Radiation therapy is used to decrease the chance of a local recurrence in the breast by eradicating residual microscopic cancer cells. Breast conservation treatment followed by radiation therapy for stages I and II breast cancer results in a survival rate equal to that of a modified radical mastectomy (NCCN, 2015). If radiation therapy, which is part of breast conservation treatment (see Chart 58-8), is contraindicated, a mastectomy would then be indicated. External-beam radiation (the most common type) typically begins about 6 weeks after breast conservation to allow the surgical site to heal. If systemic chemotherapy is indicated, radiation therapy usually begins after its completion. Before radiation begins, the patient undergoes a planning session called a simulation, in which the anatomic areas to be treated are mapped out and then identified with small permanent ink markings. External-beam radiation, which delivers high-energy photons from a linear accelerator, is given to the entire breast region (whole breast radiation). Each treatment lasts only a few minutes and is generally given 5 days a week for 5 to 6 weeks. After completion of radiation to the entire breast, many patients receive a "boost"—a dose of radiation to the lumpectomy site where the cancer cells were located. The boost consists of the same dose of radiation but is less penetrating and directed to a smaller area. The treatments are not painful.Because most breast cancer recurrences appear at or near the lumpectomy site, the need for whole breast radiation has been questioned. Partial breast radiation (radiation to the lumpectomy site alone) continues be evaluated at some institutions in patients who have been carefully selected. One approach is brachytherapy, in which radiation is delivered by an internal device that is placed close to the tumor within the breast. This technique can lead to an improved quality of life because the treatments are given over 4 to 5 days instead of 5 to 6 weeks. After mastectomy, postoperative radiation may be indicated for women at high risk for cancer recurrence (i.e., chest wall involvement, four or more positive lymph nodes, tumors larger than 5 cm, positive surgical margins). •External-beam radiation •Permanent ink markings •Brachytherapy

Cancer of the Cervix Preventative Measures

Regular pelvic examinations and Pap tests for all women, especially older women past childbearing age. Preventive counseling should encourage delaying first intercourse, avoiding HPV infection, engaging only in safer sex, ceasing smoking, and receiving HPV immunization.

Patient Undergoing Surgery for Breast Cancer: Postoperative Nursing Interventions

Relieving Pain and Discomfort Managing Postoperative Sensations +Tenderness +Soreness +Numbness +Tightness +Pulling +Twinges RELIEVING PAIN AND DISCOMFORT Many patients tolerate breast surgery well and have minimal pain during the postoperative period. This is particularly true of less invasive procedures such as breast conservation treatment with SLNB. However, all patients must be carefully assessed, because individual patients can have varying degrees of pain. Patients who have had more invasive procedures, such as a modified radical mastectomy with immediate reconstruction, may have considerably more pain. All patients are discharged home with analgesic medication (e.g., oxycodone and acetaminophen [Percocet]) and are encouraged to take it if needed. An over-the-counter analgesic agent such as acetaminophen may provide sufficient relief. Patients sometimes complain of a slight increase in pain after the first few days of surgery; this may occur as patients regain sensation around the surgical site and become more active. However, patients who report more than moderate pain must be evaluated to rule out any potential complications such as infection or hematoma. Postoperative pain may be more common in patients who have had axillary dissection and correlates with the number of nodes removed (Cherny & Truong, 2014). Alternative methods of pain management, such as taking warm showers (if permitted by the surgeon) and using distraction methods (e.g., guided imagery), may also be helpful. See Chapter 12 for further discussion of methods that relieve pain. MANAGING POSTOPERATIVE SENSATIONS Because nerves in the skin and axilla are often ligated or injured during breast surgery, patients experience a variety of sensations. Common sensations include tenderness, soreness, numbness, tightness, pulling, and twinges. These sensations may occur along the chest wall, in the axilla, and along the inside aspect of the upper arm. After mastectomy, some patients experience phantom sensations and report a feeling that the breast or nipple is still present. Overall, patients do not find these sensations severe or distressing. Sensations usually persist for several months and then begin to diminish, although some may persist for as long as 5 years and possibly longer. Patients should be reassured that this is a normal part of healing and that these sensations are not indicative of a problem. Promoting Positive Body Image +View surgical site first time with a healthcare professional PROMOTING POSITIVE BODY IMAGE Patients who have undergone mastectomy may find it difficult to view the surgical site for the first time. No matter how prepared the patient may think she is, the appearance of an absent breast can be very emotionally distressing. Ideally, the patient sees the incision for the first time when she is with the nurse or another health care provider who is available for support. The nurse first assesses the patient's readiness and provides gentle encouragement. It is important to maintain the patient's privacy while assisting her as she views the incision; this allows her to express feelings safely to the nurse. Asking the patient what she perceives, acknowledging her feelings, and allowing her to express her emotions are important nursing actions. Reassuring the patient that her feelings are a normal response to breast cancer surgery may be comforting. If the patient has not had immediate reconstruction, providing her with a temporary breast form or soft padding to place in her bra on discharge can help alleviate feelings of embarrassment or self-consciousness. Promoting Positive Adjustment and Coping +Support systems PROMOTING POSITIVE ADJUSTMENT AND COPING Providing ongoing assessment of how the patient is coping with her diagnosis of breast cancer and her surgical treatment is important in determining her overall adjustment. Assisting the patient in identifying and mobilizing her support systems can be beneficial to her well-being. The patient's spouse or partner may also need guidance, support, and education. The patient and partner may benefit from a wide network of available community resources, including the Reach to Recovery program of the ACS, advocacy groups, social worker, or a spiritual advisor. Encouraging the patient to discuss issues and concerns with other patients who have had breast cancer may help her to understand that her feelings are normal and that other women who have had breast cancer can provide invaluable support and understanding. The patient may also have considerable anxiety about the treatments that will follow surgery (i.e., chemotherapy and radiation) and their implications. Providing her with information about the plan of care and referring her to the appropriate members of the health care team also promote coping during recovery. Some women require additional support to adjust to their diagnosis and the changes that it brings. If a woman displays ineffective coping, consultation with a mental health provider may be indicated. Research suggests that nurse navigators can help those undergoing breast biopsy to cope (Harding, 2015) (see Chart 58-4). Improving Sexual Function Openly discuss IMPROVING SEXUAL FUNCTION Once discharged from the hospital and feeling well, most patients are physically allowed to engage in sexual activity, if interested. However, any change in the patient's body image, self-esteem, or the response of her partner may increase her anxiety level and affect sexual function. Some partners may have difficulty looking at the incision, whereas others may be completely unaffected. Encouraging the patient to openly discuss how she feels about herself and about possible reasons for a decrease in libido (e.g., fatigue, anxiety, self-consciousness) may help clarify issues for her. Helpful suggestions for the patient may include varying the time of day for sexual activity (when the patient is less tired), assuming positions that are more comfortable, and expressing affection using alternative measures (e.g., hugging, kissing, manual stimulation). Most patients and their partners adjust with minimal difficulty if they openly discuss their concerns. However, if issues cannot be resolved, a referral for counseling (e.g., psychologist, psychiatrist, psychiatric clinical nurse specialist, social worker, sex therapist) may be helpful. The ambulatory care nurse in the outpatient clinic or hospital should inquire whether the patient who was sexually active prior to surgery has resumed activities, because many patients are reluctant or embarrassed to bring this topic up themselves.

Abnormal Assessment Findings During Inspection of the Breasts: Retraction Signs

Signs include skin dimpling, creasing, or changes in the contour of the breast or nipple They may be secondary to contraction of fibrotic tissue that can occur with underlying malignancy They may be secondary to scar tissue formation after breast surgery Retraction signs may appear only with position changes

Cancer of the Prostate Medical Management

Surgical Management -Radical prostatectomy Radical prostatectomy is considered first-line treatment for prostate cancer and is used with patients whose tumor is confined to the prostate (McDougal et al., 2016). It is the complete surgical removal of the prostate, seminal vesicles, tips of the vas deferens, and often the surrounding fat, nerves, and blood vessels. Laparoscopic radical prostatectomy and robotic-assisted laparoscopic radical prostatectomy have become the standard surgical approaches for localized cancer of the prostate. Although sexual impotence is a common side effect, these laparoscopic radical prostatectomy approaches result in low morbidity and more favorable postoperative outcomes, including improved quality of life and less sexual dysfunction if the nerves are spared. Surgical approaches are discussed in detail later in this chapter. Radiation Management - Teletherapy - Brachytherapy Two major forms of radiation therapy are used to treat cancer of the prostate: teletherapy (external) and brachytherapy (internal). Teletherapy (external-beam radiation therapy [EBRT]) is prescribed by the radiation oncologist for a total dose over a certain time frame—for example, 28 treatments over 5½ weeks (Itano et al., 2016). It is a treatment option for patients with low-risk prostate cancer; progression-free survival is similar to that of low-risk patients treated with radical prostatectomy. Patients with intermediate- and high-risk cancers receive higher doses of EBRT. They may also be candidates both pelvic lymph node irradiation and androgen deprivation therapy (ADT) that entails surgical (orchiectomy) or medical castration (e.g., with luteinizinghormone-releasing hormone agonists) (NCCN, 2016b). Intensity-modulated radiation therapy (IMRT) is one method of delivery of EBRT. IMRT sets a dose for the target volume and restricts the dose to surrounding tissue. Another approach to delivery of radiation uses a computer-controlled robotic arm to deliver a course of radiotherapy (i.e., stereotactic radiosurgery) to localized prostate cancer. This method, referred to as the CyberKnife®, is now considered a safe and reliable method of delivering radiation to treat prostate cancer Brachytherapy involves the implantation of interstitial radioactive seeds under anesthesia. It has become a commonly used monotherapy treatment option for early, clinically organ-confined prostate cancer. The surgeon uses ultrasound guidance to place 80 to 100 seeds (depending on the prostate volume), and the patient returns home after the procedure. Exposure of others to radiation is minimal, but the patient should avoid close contact with pregnant women and infants for up to 2 months. Radiation safety guidelines include straining urine for seeds and using a condom during sexual intercourse for 2 weeks after implantation to catch any seeds that pass through the urethra. This approach can be completed in 1 day, with little lost time from normal activities. Brachytherapy may be combined with EBRT with or without neoadjuvant ADT for patients considered at intermediate risk. High-risk patients are considered poor candidates for permanent brachytherapy (Itano et al., 2016). Although cure rates with radiation are comparable to those of radical prostatectomy, radiation therapy possesses its own unique set of side effects, which differ depending on the method of radiation administration. Patients receiving EBRT or brachytherapy may experience inflammation of the rectum, bowel, and bladder (proctitis, enteritis, and cystitis) because of the proximity of these structures to the prostate and the radiation doses. Inflammation and mucosal loss at the bladder neck, prostate, and urethra can cause acute urinary dysfunction. Both irritative and obstructive urinary symptoms can cause pain with urination and ejaculation until the irritation subsides. Rectal urgency, diarrhea, and tenesmus may occur as a result of radiation of the anterior rectal wall. Late side effects include rectal proctitis, bleeding, and rectal fistula; painless hematuria; chronic interstitial cystitis; urethral stricture erectile dysfunction; and, rarely, secondary cancers of the rectum and bladder (Thakur, 2016). Hormonal Strategies - Androgen Deprivation Therapy (ADT) +Castration - Chemotherapy The number of survivors of prostate cancer in the United States is estimated at 2 million; approximately one third of these men currently receive ADT (Simpson, 2015). ADT is commonly used to suppress androgenic stimuli to the prostate by decreasing the level of circulating plasma testosterone or interrupting the conversion to or binding of DHT. As a result, the prostatic epithelium atrophies (decreases in size). This effect is accomplished either by surgical castration (bilateral orchiectomy, removal of one or both of the testes), which has traditionally been the mainstay of hormonal treatment, or by medical castration with the administration of medications, such as luteinizing hormone-releasing hormone (LHRH) agonists. Bilateral orchiectomy decreases plasma testosterone levels significantly because approximately 93% of circulating testosterone is of testicular origin (7% is from the adrenal glands). Thus, the testicular stimulus required for continued prostatic growth is removed, resulting in prostatic atrophy. However, orchiectomy often results in significant morbidity. Although the procedure does not cause the side effects associated with other hormonal therapies (described later), it is associated with considerable emotional impact. Because patients who have prostate cancer are living longer with the disease, health care providers are focusing on effective therapeutic modalities that promote an acceptable quality of life. Patients may be given the option for testicular prostheses to be placed during surgery. LHRH agonists include leuprolide (Lupron) and goserelin (Zoladex). Additional hormonal manipulation with antiandrogens may be prescribed for patients who do not show adequate serum testosterone suppression (less than 50 ng/mL) with medical or surgical castration. Antiandrogen receptor antagonists include flutamide (Eulexin), bicalutamide (Casodex), and nilutamide (Nilandron). LHRH agonists suppress testicular androgen, whereas antiandrogen receptor antagonists cause adrenal androgen suppression. When LHRH agonists are initiated, a testosterone flare may occur, causing pain in bony metastatic disease. Antiandrogens given for the first 7 days may reduce this uncomfortable symptom. The most common uses of LHRH agonists are as follows: (1) in the adjuvant and neoadjuvant setting in combination with radiation therapy, (2) after radical prostatectomy, and (3) in the treatment of recurrence indicated by an elevation in the PSA but without clinical or x-ray evidence. Medical and surgical castration causes hot flushing because these treatment modalities increase hypothalamic activity, which stimulates the thermoregulatory centers of the body (Baker, 2014; Jones, 2016; Scher, 2016). The management of hormone-refractory prostate cancer remains somewhat controversial. Another category of medication used as a second-line hormonal intervention is the adrenal ablating drugs. Ketoconazole (Nizoral) is used to inhibit cytochrome P450 enzymes, which are required for the synthesis of androgens and other steroids. High-dose ketoconazole lowers testosterone by decreasing both testicular and endocrine production of androgen. Administration of this medication requires steroid supplementation to prevent adrenal insufficiency. Hypogonadism is responsible for the adverse effects of ADT, which include vasomotor flushing, loss of libido, decreased bone density (resulting in osteoporosis and fractures), anemia, fatigue, increased fat mass, lipid alterations, decreased muscle mass, gynecomastia (increased breast tissue), and mastodynia (breast/nipple tenderness). Hypogonadism is associated with an increased risk of diabetes, resulting from insulin resistance, metabolic syndrome, and cardiovascular disease (McDougal et al., 2016). Recent studies have shown clear benefits in terms of survival with chemotherapy treatment that includes a docetaxel-based regimen for non-androgen-dependent prostate cancer (NCCN, 2016b). Other studies are under way to determine the importance of the vascular endothelial growth factor system. Tumor angiogenesis is essential for tumor growth, including growth of prostate carcinomas and other high-grade cancers. Therefore, antiangiogenic treatment in combination with conventional therapies may play a future role in treatment. Gene-based therapy in prostate cancer is an emerging and promising adjuvant to conventional treatment strategies. Possible complications related to chemotherapy are specific to the type of chemotherapy given (see Chapter 15, Chart 15-3). Other Therapies - Cryosurgery - Suprapubic or transurethral catheter - Palliative care Cryosurgery of the prostate is used to ablate prostate cancer in patients who cannot tolerate surgery and in those with recurrent prostate cancer. Transperineal probes are inserted into the prostate under ultrasound guidance to freeze the tissue directly. Keeping the urethral passage patent may require repeated TURPs. If this is impractical, catheter drainage is instituted by way of the suprapubic or transurethral route. For men with advanced prostate cancer, palliative measures are indicated. Although cure is unlikely with advanced prostate cancer, many men survive for long periods, free of debilitating symptoms. Bone lesions that result from metastasis of prostate cancer can be very painful and result in pathologic fractures. Opioid and nonopioid medications are used to control bone pain. EBRT can be delivered to skeletal lesions to relieve pain. Radiopharmaceuticals, such as strontium or samarium, can be injected IV to treat multiple sites of bone metastasis. Antiandrogen therapies are used in an effort to reduce the circulating androgens. If antiandrogen therapies are not effective, medications such as prednisone have been effective in reducing pain and improving quality of life (Lycken, Garmo, Adolfsson, et al., 2013; Rathkopf & Scher, 2013). Bisphosphonate therapy with pamidronate (Aredia) can be given to reduce the risk of pathologic fracture. In advanced prostate cancer, blood transfusions are given to maintain adequate hemoglobin levels when bone marrow is replaced by tumor. p. 1770 p. 1771 More than one third of men with a diagnosis of prostate cancer elect to use some form of complementary and integrative health. Acupuncture has been used to treat both PE and erectile dysfunction with some limited, anecdotal success (Tsai, Liu, Chang, et al., 2014). Because research on many forms of complementary, alternative, and integrative health is lacking, patients often rely on anecdotal information to make decisions about its use. Nurses and other health care professionals play a vital role in assisting patients to locate and evaluate available information about these practices to ensure that harmful forms are avoided (Braun, Gupta, Birdsall, et al., 2013). The National Center for Complementary and Integrative Health (NCCIH) website can assist nurses in providing patients with evidence-based information (see the Resources section at the end of the chapter). ***Treatment is based on the patient's life expectancy, symptoms, risk of recurrence after definitive treatment, size of the tumor, Gleason score, PSA level, likelihood of complications, and patient preference. Therapy is often guided by the use of a nomogram or risk stratification scheme suggested by the NCCN (2016b) clinical practice guidelines. A multidisciplinary team approach is essential for the development of appropriate treatment. Management may be nonsurgical and involve watchful waiting or be surgical and entail prostatectomy. Nursing care of the patient with cancer of the prostate is summarized in Chart 59-3. ****For patients with prostate cancer who choose nonsurgical watchful waiting, this approach involves actively monitoring the course of disease and intervening only if the cancer progresses or if symptoms warrant other intervention. It is an option for patients with life expectancy of less than 5 years and low-risk cancers. Advantages include absence of side effects of more aggressive treatment, improved quality of life, avoidance of unnecessary treatment, and decreased initial costs. Disadvantages include missed chance at cure, risk of metastasis, subsequent need for more aggressive treatment, anxiety about living with untreated cancer, and need for frequent monitoring (NCCN, 2016b; Thakur, 2016). Therapeutic vaccines kill existing cancer cells and provide long-lasting immunity against further cancer development. In 2010, the U.S. Food and Drug Administration (FDA) approved the first therapeutic cancer vaccine, sipuleucel-T (Provenge), for use in men with metastatic prostate cancer that is no longer responding to hormone therapy. In addition, two other medications, abiraterone acetate (Zytiga) and cabazitaxel (Jevtana injection) are treatments options for patients requiring care for the management of metastatic castration-resistant prostate cancer, which does not respond to sipuleucel-T or the usual treatment options (Simondsen & Kolesar, 2013).

Diagnostic Evaluation of Breasts: Procedures for Tissue Analysis (Surgical Biopsy)

Surgical biopsy is usually performed using local anesthesia and intravenous (IV) sedation. After an incision is made, the lesion is excised and sent to a laboratory for pathologic examination. Surgical biopsy is usually preceded by a core biopsy or stereotactic biopsy for pathologic determination. Excisional Biopsy Excisional biopsy is the standard procedure for complete pathologic assessment of a palpable breast mass. The entire mass, plus a margin of surrounding tissue, is removed. This type of biopsy may also be referred to as a lumpectomy. Depending on the clinical situation, a frozen-section analysis of the specimen may be performed at the time of the biopsy by the pathologist, who does an immediate reading intraoperatively and provides a provisional diagnosis. This can help confirm a diagnosis in a patient who has had no previous tissue analysis performed. Incisional Biopsy +Incisional biopsy surgically removes a portion of a mass. This is performed to confirm a diagnosis and to conduct special studies (e.g., ER/PR, HER-2/neu [also referred to as ERBB2]; see later discussion for explanation of these terms) that will aid in determining treatment, which is discussed later in this chapter. Complete excision of the area may not be possible or immediately beneficial to the patient, depending on the clinical situation. This procedure is often performed on women with locally advanced breast cancer or on women with suspected cancer recurrence, whose treatment may depend on the results of these special studies. However, pathologic information may be easily obtained from core needle biopsy, and incisional biopsy is becoming less common. Wire Needle Localization +Wire needle localization is a technique used to locate nonpalpable masses or suspicious calcium deposits detected on a mammogram, ultrasound, or MRI that require an excisional biopsy. The radiologist inserts a long, thin wire through a needle, which is then inserted into the area of abnormality using x-ray or ultrasound guidance (whichever imaging technique originally identified the abnormality). The wire remains in place after the needle is withdrawn to ensure the precise location. The patient is then taken to the operating room, where the surgeon follows the wire to the tip and excises the area.

Fistulas of the Vagina Manifestations

Symptoms depend on the specific defect. For example, in a patient with a vesicovaginal fistula, urine escapes continuously into the vagina. With a rectovaginal fistula, there is fecal incontinence, and flatus is discharged through the vagina. The combination of fecal discharge with leukorrhea results in malodor that is difficult to control.

Cancer of the Ovary Manifestations

Symptoms of ovarian cancer are nonspecific and may include increased abdominal girth, pelvic pressure, bloating, back pain, constipation, abdominal pain, urinary urgency, indigestion, flatulence, increased waist size, leg pain, and pelvic pain. Symptoms are often vague, so many women tend to ignore them. Ovarian cancer is often silent, but enlargement of the abdomen from an accumulation of fluid is a common sign. All women with gastrointestinal symptoms without a known cause must be evaluated for potential ovarian cancer. Vague, undiagnosed, persistent gastrointestinal symptoms should alert the nurse to the possibility of an early ovarian malignancy. A palpable ovary in a woman who has gone through menopause is investigated immediately, because ovaries normally become smaller and less palpable after menopause. •Nonspecific •Increased abdominal girth •Increased waist size •Pelvic pressure •Pain +Back +Abdominal +Leg +Pelvic •Bloating •Constipation •Indigestion •Flatulence •Urinary urgency

Breast Cancer Systemic Treatments (Targeted Therapy)

Targeted Therapy +HER-2/neu protein +Medication adverse reactions Fever Chills N/V/D Headache An exciting area of research in the systemic treatment of breast cancer involves the use of targeted therapies. Trastuzumab (Herceptin) is a monoclonal antibody that binds specifically to the HER-2/neu protein. This protein, which regulates cell growth, is present in small amounts on the surface of normal breast cells and in most breast cancers. Approximately 25% to 30% of tumors overexpress (overproduce) the HER-2/neu protein and are associated with rapid growth and poor prognosis. Trastuzumab targets and inactivates the HER-2/neu protein, thus slowing tumor growth. Unlike chemotherapy, trastuzumab spares the normal cells and has limited adverse reactions, which may include fever, chills, nausea, vomiting, diarrhea, and headache. However, when trastuzumab is given to patients who have previously been treated with an anthracycline, the risk of cardiac toxicity is increased. The medication has been shown to improve survival rates in women with HER-2/neu-positive metastatic breast cancer and is now regarded as standard therapy. It may be given as a single agent or in combination with chemotherapy. More recently, trastuzumab has been shown to be effective in treating early-stage breast cancer that is HER-2/neu positive. Assessing the benefits and risks of trastuzumab is complex, and medical oncologists often use a variety of aids in their decision making (Kimmick, Hughes, & Muss, 2014).

Red Blood Cell Destruction

The average lifespan of a normal circulating erythrocyte is 120 days. Aged erythrocytes lose their elasticity and become trapped in small blood vessels and the spleen. They are removed from the blood by the reticuloendothelial cells, particularly in the liver and the spleen. As the erythrocytes are destroyed, most of their hemoglobin is recycled. Some hemoglobin also breaks down to form bilirubin and is secreted in the bile. Most of the iron is recycled to form new hemoglobin molecules within the bone marrow; small amounts are lost daily in the feces and urine and monthly in menstrual flow.

Physical Assessment: Female Breast PALPITATION

The breasts are palpated with the patient sitting up (upright) and lying down (supine). In the supine position, the patient's shoulder is first elevated with a small pillow to help balance the breast on the chest wall. Failure to do this allows the breast tissue to slip laterally, and a breast mass may be missed. The entire surface of the breast and the axillary tail is systematically palpated using the flat part (pads) of the second, third, and fourth fingertips, held together, making dime-size circles. The examiner may choose to proceed in a clockwise direction, following imaginary concentric circles from the outer limits of the breast toward the nipple. Other acceptable methods are to palpate from each number on the face of the clock toward the nipple in a clockwise fashion or along imaginary vertical lines on the breast. Palpation of the axillary and clavicular areas is easily performed with the patient seated (see Fig. 58-3). To examine the axillary lymph nodes, the examiner gently abducts the patient's arm from the thorax. With the left hand, the patient's right forearm is grasped and supported. The right hand is then free to palpate the axilla. Any lymph nodes that may be lying against the thoracic wall are noted. Normally, these lymph nodes are not palpable, but if they are enlarged, their location, size, mobility, and consistency are noted. During palpation, the examiner notes any patient-reported tenderness or masses. If a mass is detected, it is described by its location (e.g., right breast, 2 cm from the nipple at 2 o'clock position). Size, shape, consistency, border delineation, and mobility are included in the description (Morrow, 2014). The examiner then modifies these steps to use the right hand to grasp the patient's left forearm, and then uses the left hand to palpate the axilla of the left breast. The breast tissue of the adolescent is usually firm and lobular, whereas that of the postmenopausal woman is more likely to feel thinner and fattier. During pregnancy and lactation, the breasts are firmer and larger with lobules that are more distinct. Hormonal changes cause the areola to darken.Obesity may have a proinflammatory effect on the breast that can contribute to increased rates of atypia. Atypia in breast ductal lavage and C-reactive protein levels in the nipple are significantly correlated with body mass index (BMI). Excessive body weight, as reflected by a BMI of 25 kg/m2 or higher, is associated with postmenopausal breast cancer and increases the risk of dying of this disease (Gucalp, Morris, Hudis, et al., 2014). Cysts are commonly found in women who are menstruating and are usually well defined and freely movable. In the premenstrual period, cysts may be larger and more tender. Malignant tumors, on the other hand, tend to be hard, poorly defined, and nontender. A clinician should further evaluate any abnormalities detected during inspection and palpation.

Structure of Hematological System (Blood)

The cellular component of blood consists of three primary cell types (see Table 32-1): erythrocytes (red blood cells [RBCs], red cells), leukocytes (white blood cells [WBCs]), and thrombocytes (platelets). These cellular components of blood normally make up 40% to 45% of the blood volume. Because most blood cells have a short lifespan, the need for the body to replenish its supply of cells is continuous; this process is termed hematopoiesis. The primary site for hematopoiesis is the bone marrow. During embryonic development and in other conditions, the liver and spleen may also be involved.Under normal conditions, the adult bone marrow produces about 175 billion erythrocytes, 70 billion neutrophils (a mature type of WBC), and 175 billion platelets each day. When the body needs more blood cells, as in infection (when neutrophils are needed to fight the invading pathogen) or in bleeding (when more RBCs are required), the marrow increases its production of the cells required. Thus, under normal conditions, the marrow responds to increased demand and releases adequate numbers of cells into the circulation. Blood makes up approximately 7% to 10% of the normal body weight and amounts to 5 to 6 L of volume. Circulating through the vascular system and serving as a link between body organs, blood carries oxygen absorbed from the lungs and nutrients absorbed from the gastrointestinal (GI) tract to the body cells for cellular metabolism. Blood also carries hormones, antibodies, and other substances to their sites of action or use. In addition, blood carries waste products produced by cellular metabolism to the lungs, skin, liver, and kidneys, where they are transformed and eliminated from the body. The danger that trauma can lead to excess blood loss always exists. To prevent this, an intricate clotting mechanism is activated when necessary to seal any leak in the blood vessels. Excessive clotting is equally dangerous, because it can obstruct blood flow to vital tissues. To prevent this, the body has a fibrinolytic mechanism that eventually dissolves clots (thrombi) formed within blood vessels. The balance between these two systems—clot (thrombus) formation and clot dissolution or fibrinolysis—is called hemostasis. •Plasma •Erythrocytes (Red Blood Cells) •Leukocytes (White Blood Cells) •Thrombocytes (Platelets)

Erectile Dysfunction Assessment and Diagnostics

The diagnosis of erectile dysfunction requires a sexual and medical history; an analysis of presenting symptoms; a physical examination, including a neurologic examination; a detailed assessment of all medications, alcohol, and drugs used; and various laboratory studies. Nocturnal penile tumescence tests are conducted to monitor changes in penile circumference. This test can help to determine if erectile impotence has an organic or a psychological cause. In healthy men, nocturnal penile erections closely parallel rapid eye movement (REM) sleep in occurrence and duration. Organically impotent men show inadequate sleep-related erections that correspond to their waking performance. Arterial blood flow to the penis is measured using a Doppler probe. In addition, nerve conduction tests and extensive psychological evaluations may be carried out. Figure 59-3 describes the evaluation and treatment of erectile dysfunction.

Erectile Dysfunction Medical Management: Penile Transplants

The first successful penis transplant was performed in 2014 in Cape Town, South Africa. In the United States, a few medical centers have protocols for penis transplants. ***Candidates for transplantation include military veterans and other men who have suffered traumatic penile injuries. It is believed that men undergoing this surgery will have their ability to urinate and their sexual functioning restored

Structure of Hematological System

The hematologic system consists of the blood and the sites where blood is produced, including the bone marrow and the reticuloendothelial system (RES). Blood is a specialized organ that differs from other organs in that it exists in a fluid state. Blood is composed of plasma and various types of cells. Plasma is the fluid portion of blood; it contains various proteins, such as albumin, globulin, fibrinogen, and other factors necessary for clotting, as well as electrolytes, waste products, and nutrients. About 55% of blood volume is plasma (Mescher, 2013).

Hysterectomy Nursing Planning and Goals

The major goals may include relief of anxiety, acceptance of loss of the uterus, absence of pain or discomfort, increased knowledge of self-care requirements, and absence of complications. •Relief of anxiety •Acceptance of loss of uterus •Absence of pain/discomfort •Increased knowledge of self-care requirements •Absence of complications

Diagnostic Evaluation of Breasts: BSE

The nurse plays a critical role in breast awareness education—a modality used for the early detection of breast cancer. BSE can be taught in a variety of settings, either on a one-to-one basis or in a group. It can also be initiated by a health care provider during a patient's routine physical examination. Regular self-examinations may result in early identification of problems and may also result in more diagnostic work-ups for benign or malignant problems. Variations in breast tissue occur during the menstrual cycle, pregnancy, and the onset of menopause. Women on HT can also experience fluctuations. Normal changes must be distinguished from those that may signal disease. Most women notice increased tenderness and lumpiness before their menstrual periods; therefore, BSE is best performed after menses (day 5 to day 7, counting the first day of menses as day 1). In addition, many women have grainy-textured breast tissue, but such areas are usually less nodular after menses. Younger women may find BSE particularly difficult because of the density of their breast tissue. As women age, their breasts become fattier and may be easier to examine.Current practice is shifting from educating about BSE to promoting breast self-awareness, which is a woman's attentiveness to the normal appearance and feel of her breasts. However, self-examination still may be appropriate for some women who are at high risk and for those who prefer it. Breast self-awareness can include self-examination. For every woman, knowing how her breasts normally feel helps detect any changes or signs of a problem. BSE may play an important role in screening, especially for women who develop cancer in the interval after a negative result on mammography or clinical breast examination or who have a false-negative imaging or clinical examination result. It can also promote detection in women who have not been screened. The goal, with or without BSE, is to report any breast changes to a primary provider. Family history can increase the risk of breast cancer in men, particularly if other men in the family have had breast cancer. The risk is also higher if there is a breast cancer gene abnormality in the family. An abnormal BRCA2 gene accounts for up to 40% of male breast cancers (Jain & Gradishar, 2014). Instructions about BSE should be provided to men if they have a family history of breast cancer. Patients who elect to perform BSE should receive proper instruction on technique (see Chart 58-2). They should be informed that routine, monthly BSE will help them become familiar with their "normal abnormalities." If a change is detected, they should seek medical attention. Patients should be instructed about optimal timing for BSE (5 to 7 days after menses begin for women who are premenopausal and once monthly for women who are postmenopausal). When demonstrating examination techniques, the feel of normal breast tissue should be reviewed and ways to identify breast changes discussed. Patients should then perform a BSE demonstration on themselves or on a breast model. Patients who have had breast cancer surgery should be instructed to examine their breast or chest wall for any new changes or nodules that may indicate a recurrence of the disease.

Hysterectomy Postoperative Care

The principles of general postoperative care for abdominal surgery apply. Major risks are infection and hemorrhage. In addition, because the surgical site is close to the bladder, voiding problems may occur, particularly after a vaginal hysterectomy. Edema or nerve trauma may cause temporary loss of bladder tone (bladder atony), and an indwelling catheter may be inserted. •Risk for infection •Risk for hemorrhage (decrease BP, and H&H, increased HR) •Voiding problems +Edema +Nerve Trauma +Catheter

Rectocele Manifestations

The symptoms of rectocele resemble those of cystocele, with one exception: Instead of urinary symptoms, patients may experience rectal pressure. Constipation, uncontrollable gas, and fecal incontinence may occur in patients with complete tears. Prolapse can result in feelings of pressure and ulcerations and bleeding. Dyspareunia may occur with these disorders. •Rectal pressure •Constipation •Uncontrollable gas •Fecal incontinence

Benign Conditions of the Breast: Benign Proliferative Breast Disease

The two most common types of benign proliferative breast disease (atypical, yet noncancerous, breast tissue) found on biopsy are atypical hyperplasia and lobular carcinoma in situ (LCIS). These diagnoses increase a woman's risk of breast cancer. Atypical Hyperplasia Atypical hyperplasia can be ductal or lobular and is a premalignant lesion of the breast. It is recognized as a precursor lesion to both noninvasive and invasive breast cancer. Imbalance in the normal regulation of cell proliferation is a defining feature. Women with atypical hyperplasia have a fourfold increased risk of breast cancer compared to women in the general population, with a cumulative incidence approaching 30% at 25 years of age (Collins & Schnitt, 2014). Lobular Carcinoma in Situ Lobular carcinoma in situ (LCIS) is an incidental microscopic finding of abnormal tissue growth in the lobules of the breast. LCIS is a risk indicator and some studies describe half of affected women will develop breast cancer within 15 to 30 years (King & Reis-Filho, 2014). Affected women should undergo rigorous breast cancer surveillance that consists of annual mammography and clinical breast examination every 6 months (National Comprehensive Cancer Network [NCCN], 2015). Patients should be offered information about chemoprevention with selective estrogen receptor modulators (SERMs), such as tamoxifen (Soltamox, Nolvadex). See the discussion of chemoprevention later in this chapter.

Breast Cancer Systemic Treatments (Hormonal Therapy)

The use of adjuvant hormonal therapy, with or without the addition of chemotherapy, is considered in women who have hormone receptor-positive tumors. Its use can be determined by the results of an estrogen and progesterone receptor assay (a test to determine whether the breast tumor is nourished by hormones). About two thirds of breast cancers depend on estrogen for growth and express a nuclear receptor that binds to the estrogen; thus, they are estrogen receptor positive (ER+). Similarly, tumors that express the progesterone receptor are progesterone receptor positive (PR+). Hormonal therapy involves the use of synthetic hormones or other medications that compete with estrogen by binding to the receptor sites (SERMs), or the use of aromatase inhibitors, which block estrogen production by the adrenal glands. In general, tumors that are ER+/PR+ have the greatest likelihood of responding to hormonal therapy and have a more favorable prognosis than those that are ER-/PR-. Women who are pre- and perimenopausal are more likely to have non-hormone-dependent lesions, whereas women who are postmenopausal are more likely to have hormone-dependent lesions. Traditionally, the SERM tamoxifen has been the main hormonal agent used in treatment of pre- and postmenopausal breast cancer and remains the mainstay in women who are premenopausal. As an SERM, tamoxifen has estrogen antagonistic (estrogen-blocking) and agonistic (estrogenlike) effects on certain tissues. Its antagonistic effects in the breast prevent estrogen from binding to the receptor sites, thus preventing tumor growth. Tamoxifen has positive agonistic effects on blood lipid profiles and bone mineral density in women who are postmenopausal. It also has agonistic effects on endometrial tissue and blood coagulation processes, leading to an increased incidence of endometrial cancer and thromboembolic events (e.g., deep vein thrombosis, superficial phlebitis, pulmonary embolism). Nevertheless, the benefits in most women with breast cancer outweigh the risks. The aromatase inhibitors anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin) are important components in the hormonal management of women who are postmenopausal. Most of the circulating estrogens in women who are postmenopausal are derived from the conversion of the adrenal androgen androstenedione to estrone and the conversion of testosterone to estradiol. Aromatase inhibitors work by blocking the enzyme aromatase from performing the conversion, thereby decreasing the level of circulating estrogen in peripheral tissues. Clinical trials have demonstrated that the aromatase inhibitors are superior to tamoxifen in terms of overall response rate and clinical benefit and that inhibitors appear to be effective and feasible compared with tamoxifen as first-line hormonal therapy in women who are postmenopausal with advanced breast cancer (Rimawi & Osborne, 2014). These data ensure that aromatase inhibitors will play an increasingly central role in the long-term management of breast cancer. Trials are ongoing to determine the optimal treatment regimen and the timing of the treatment. Table 58-7 outlines the adverse effects of adjuvant hormonal therapy. Chart 58-10 outlines appropriate patient education to manage the adverse effects. Hormone receptor-positive tumors +ER+ +PR+ -SERM Tamoxifen -Aromatase inhibitors

Reconstructive Procedures After Mastectomy

Tissue Expander Followed by Permanent Implant Tissue Transfer Procedures +TRAM flap Nipple-Areola Reconstruction +Skin graft/flap +Micropigmentation/tattooing

How to inspect for skin dimpling and retractions of the female breasts

To elicit skin dimpling or retraction that may otherwise go undetected, the examiner instructs the patient to raise both arms overhead. This maneuver normally elevates both breasts equally. The patient is then instructed to place her hands on her waist and push in. These movements, which cause contraction of the pectoral muscles, do not normally alter the breast contour or nipple direction. Any dimpling or retraction during these position changes suggests an underlying mass. The clavicular and axillary regions are inspected for swelling, discoloration, lesions, or enlarged lymph nodes

Breast Cancer Surgical Management: Total Mastectomy

Total Mastectomy +Breast tissue +Nipple-areola complex Like modified radical mastectomy, total mastectomy (i.e., simple mastectomy) also involves removal of the breast and nipple-areola complex but does not include ALND. Total mastectomy may be performed in patients with noninvasive breast cancer (e.g., DCIS), which does not have a tendency to spread to the lymph nodes. It may also be performed prophylactically in patients who are at high risk for breast cancer (e.g., LCIS, BRCA mutation). A total mastectomy may also be performed in conjunction with sentinel lymph node biopsy (SLNB) for patients with invasive breast cancer.

True or False: A rectovaginal fistula heals faster when the patient eats a low-residue diet and when the affected tissue drains properly.

True

True or False: Fibroids usually shrink after menopause because of the decreased estrogen.

True

Erectile Dysfunction Medical Management: Penile Implants

Two general types of penile implants are available: the malleable, noninflatable, nonhydraulic prosthesis (also called the semirigid rod) and the inflatable, hydraulic prostheses (Keane & Graham, 2016). The semirigid rod (e.g., the Small-Carrion prosthesis) results in a permanent semierection but can be bent into an unnoticeable position when appropriate. The inflatable prosthesis simulates natural erections and natural flaccidity. ***Complications after implantation include infection, erosion of the prosthesis through the skin (more common with the semirigid rod than with the inflatable prosthesis), and persistent pain, which may require removal of the implant. Subsequent cystoscopic surgery is more difficult with a semirigid rod than with the inflatable prosthesis. Factors to consider in choosing a penile prosthesis are the patient's activities of daily living, social activities, and the expectations of the patient and his partner. Ongoing counseling for the patient and his partner is usually necessary to help them adapt to the prosthesis.

Male Reproductive System Assessment: Health History

URINARY FUNCTION AND SYMPTOMS Any symptoms or changes in function are explored fully and described in detail. Symptoms related to bladder function and urination, collectively referred to as prostatism, are explored further. They may occur with an obstruction caused by an enlarged prostate gland: increased urinary frequency, decreased force of urine stream, and "double" or "triple" voiding (the patient needs to urinate two or three times over a period of several minutes to completely empty his bladder). The patient is also assessed for dysuria (painful urination), hematuria (blood in the urine), nocturia (urination during the night), and hematospermia (blood in the ejaculate). SEXUAL DYSFUNCTION Assessment also involves addressing sexual function, including manifestations of sexual dysfunction. The extent of the history depends on the patient's presenting symptoms and the presence of factors that may affect sexual function such as chronic illnesses or disability (e.g., diabetes, multiple sclerosis, stroke, cardiac disease), the use of medications that affect sexual function (e.g., antihypertensive and anticholesterolemic medications, psychotropic agents), stress, the use of alcohol, and the patient's willingness to discuss sexual issues.

Diagnostic Evaluation of Breasts: Ultrasonography

Ultrasonography (ultrasound) is used as a diagnostic adjunct to mammography to help distinguish fluid-filled cysts from other lesions. A thin coating of lubricating jelly is spread over the area to be imaged. A transducer is then placed on the breast. The transducer transmits high-frequency sound waves through the skin toward the area of concern. The sound waves that are reflected back form a two-dimensional image, which is then displayed on a computer screen. No radiation is emitted during the procedure. Ultrasound is also used as an adjunct to mammography in women with dense breast tissue. Ultrasonography has advantages and disadvantages. Although it can diagnose cysts with great accuracy, it cannot definitively rule out malignant lesions. Microcalcifications, which are detectable on mammography, cannot be identified on ultrasonography. Finally, examination techniques and interpretation criteria are not standardized.

Abnormal Assessment Findings During Inspection of the Breasts: Increased Venous Prominence

Unilateral localized increase in venous pattern associated with malignant tumors Normal with bilateral and symmetrical breast enlargement associated with pregnancy and lactation

Breast Cancer Manifestations

Upper outer quadrant Nontender Fixed Hard Irregular Advanced +Dimpling +Nipple retraction +Skin ulceration Breast cancers can occur anywhere in the breast but are usually found in the upper outer quadrant, where the most breast tissue is located. In general, the lesions are nontender, fixed rather than mobile, and hard with irregular borders. Complaints of diffuse breast pain and tenderness with menstruation are usually associated with benign breast disease. With the increased use of mammography, more women are seeking treatment at earlier stages of the disease. These women often have no signs or symptoms other than a mammographic abnormality. Some women with advanced disease seek initial treatment after ignoring symptoms. Advanced signs may include skin dimpling, nipple retraction, or skin ulceration.

When should oral ED medications be taken?

When PDE-5 inhibitors are taken about 1 hour before sexual activity, they are effective in producing an erection with sexual stimulation; the erection can last about 1 to 2 hours.

Rectovaginal Fistula

abnormal opening between the rectum and the vagina-feces

Fistulas of the Vagina

an abnormal opening between two internal hollow organs or between an internal hollow organ and the exterior of the body

Vesicovaginal Fistula

an opening between the bladder and the vagina-urine

Organic Causes of Erectile Dysfunction

cardiovascular disease, endocrine disease (diabetes, pituitary tumors, testosterone deficiency, hyperthyroidism, and hypothyroidism), cirrhosis, chronic kidney injury, genitourinary conditions (radical pelvic surgery), hematologic conditions (Hodgkin lymphoma, leukemia), neurologic disorders (neuropathies, parkinsonism, spinal cord injury [SCI], multiple sclerosis), trauma to the pelvic or genital area, alcohol, smoking, medications (see Chart 59-1), and drug abuse.

Gynecomastia

development of breast tissue in males

LEEP procedure

loop electrical excision procedure; uses a thin, low-voltage electrified wire loop to cut out abnormal tissue of the cervix; not done during pregnancy

Medications Associated with Erectile Dysfunction

mainly HTN medications! Antiadrenergics and antihypertensives: guanethidine (Ismelin), clonidine (Catapres), hydralazine (Apresoline) Anticholinergics and phenothiazines: prochlorperazine (Compazine), trihexyphenidyl (Artane) Antidepressants: tricyclic antidepressants: amitriptyline (Elavil), desipramine (Norpramin); selective serotonin reuptake inhibitors: fluoxetine (Prozac), sertraline (Zoloft) Antifungals: ketoconazole (Nizoral) Antihistamines: diphenhydramine (Benadryl), dimenhydrinate (Dramamine) Antihormone (prostate cancer treatment): flutamide (Eulexin), leuprolide (Lupron) Antipsychotics: haloperidol (Haldol), chlorpromazine (Thorazine) Anticonvulsant agents: carbamazepine (Tegretol) Antispasmodics: oxybutynin (Ditropan) Anxiolytics, sedative-hypnotics, tranquilizers: lorazepam (Ativan), triazolam (Halcion) Beta-blockers: nadolol (Corgard), metoprolol (Lopressor) Calcium channel blockers: nifedipine (Adalat, Procardia) Carbonic anhydrase inhibitors: acetazolamide (Diamox) Chemotherapeutic agents: busulfan (Myleran), cyclophosphamide (Cytoxan) Diuretics: hydrochlorothiazide (HydroDIURIL), furosemide (Lasix), spironolactone (Aldactone), verapamil (Calan) Histamine-2 antagonists: nizatidine (Axid), ranitidine (Zantac) Nonsteroidal anti-inflammatory drugs: naproxen (Naprosyn), indomethacin (Indocin) Other substances: alcohol, amphetamines, barbiturates, cocaine, marijuana, methadone, nicotine, opioids Parkinson disease medications: carbidopa/levodopa (Sinemet), benztropine (Cogentin)

Peu d'orange

orange peel appearance of breast

Prostectomy

surgical removal of the prostatep

Anatomic and Physiologic Overview of Male Reproductive System

the (1) external male genitalia, consisting of the testes, epididymis, scrotum, and penis, and the (2) internal male genitalia, consisting of the vas deferens (ductus deferens), ejaculatory duct, and prostatic and membranous sections of the urethra, seminal vesicles, and certain accessory glands, such as the prostate gland and Cowper glands (bulbourethral glands) The testes have a dual function: spermatogenesis (production of sperm) and secretion of the male sex hormone testosterone, which induces and preserves the male sex characteristics.

Cancer of the Cervix Nursing Assessment and Diagnostics

•Abnormal Pap smear results •Biopsy •Colposcopy •D&C •CT •MRI •IV urography •Cystography •PET scan •Barium xray In its very early stages, cervical cancer is found microscopically by Pap smear. In later stages, pelvic examination may reveal a large, reddish growth or a deep, ulcerating lesion. The patient may report spotting or bloody discharge. When the patient has been diagnosed with invasive cervical cancer, clinical staging estimates the extent of the disease so that treatment can be planned more specifically and prognosis reasonably predicted. Staging is based on the International Federation of Gynecology and Obstetrics (FIGO) Staging Classification (Beckmann et al., 2014): -Stage I, the carcinoma is strictly confined to the cervix. -Stage II, the carcinoma invades beyond the uterus but not the pelvic wall or vagina. -Stage III, the tumor spreads to the pelvic wall and/or the vagina, and/or causes hydronephrosis of the kidneys. -Stage IV, the tumor has extended beyond the pelvis and involves the bladder or rectum. Signs and symptoms are evaluated, and x-rays, laboratory tests, and special examinations, such as biopsy and colposcopy, are performed (Beckmann et al., 2014). Depending on the stage of the cancer, other tests and procedures may be performed to determine the extent of disease and appropriate treatment. These tests may include dilation and curettage (D&C), CT scan, MRI scan, IV urography, cystography, positron emission tomography (PET) scan, and barium x-ray studies. Treatment depends on the stage of the disease.

Benign Disorders: Ovarian Cysts

•Acute/chronic pain +The patient may or may not report acute or chronic abdominal pain. Symptoms of a ruptured cyst mimic various acute abdominal emergencies, such as appendicitis or ectopic pregnancy. Larger cysts may produce abdominal swelling and exert pressure on adjacent abdominal organs. •Ruptured cyst symptoms resemble appendicitis or ectopic pregnancy (pain, distention, etc.) •Postoperative care +Abdominal binder (make sure it is not too tight) +Postoperative nursing care after surgery to remove an ovarian cyst is similar to that after abdominal surgery, with one exception. The marked decrease in intra-abdominal pressure resulting from removal of a very large cyst usually leads to considerable abdominal distention. This may be prevented to some extent by applying a snug-fitting abdominal binder. The ovary is a common site for cysts, which may be simple enlargements of normal ovarian constituents, the graafian follicle, or the corpus luteum, or they may arise from abnormal growth of the ovarian epithelium. Ovarian cysts are often detected on routine pelvic examination. Although these cysts are typically benign, they nevertheless should be evaluated to exclude ovarian cancer, particularly in women who are postmenopausal. Some surgeons discuss the option of a hysterectomy when a woman is undergoing bilateral ovary removal because of a suspicious mass; it may increase life expectancy and avoid a later second surgery. Patient preference is a priority in determining its appropriateness.

Patient Undergoing Surgery for Breast Cancer: Nursing Assessment

•Reaction to diagnosis •Ability to cope The health history is a valuable tool to assess the patient's reaction to the diagnosis and her ability to cope with it. Pertinent questions include the following: How is the patient responding to the diagnosis? What coping mechanisms does she find most helpful? What psychological or emotional supports does she have and use? Is there a partner, family member, or friend available to assist her in making treatment choices? What are her educational needs? Is she experiencing any discomfort?

Chemotherapy

•Administration of systemic or local cytotoxic medications that damage a cell's DNA or destroy rapidly dividing cells •Cytotoxic •Administration of chemotherapeutic medications is limited to certified individuals •Complications of Chemotherapy •Immunosuppression/Neutropenia •Nausea/Vomiting/Anorexia •Alopecia •Mucus Membrane and Oral Cavity irritation •Anemia/Thrombocytopenia The cells in the mouth proliferative fast so when we kill them with chemotherapy, they have significant oral pain EX: Mrs. Aultaman's dad would only eat cold food for 3 years *usually given through a central line Chemotherapy involves the use of antineoplastic drugs in an attempt to destroy cancer cells by interfering with cellular functions, including replication and DNA repair (Grossman & Porth, 2014). Chemotherapy is used primarily to treat systemic disease rather than localized lesions that are amenable to surgery or radiation. Chemotherapy may be combined with surgery, radiation therapy, or both to reduce tumor size preoperatively (neoadjuvant), to destroy any remaining tumor cells postoperatively (adjuvant), or to treat some forms of leukemia or lymphoma (primary). The goals of chemotherapy (cure, control, or palliation) must be realistic because they will determine the medications that are used and the aggressiveness of the treatment plan.

Cancer of the Uterus Nursing Assessment and Diagnostics

•Annual checkups •Gynecologic examination •Endometrial aspiration or biopsy •US: transvaginal All women should be encouraged to have annual checkups, including a gynecologic examination. Any woman who is experiencing irregular bleeding should be evaluated promptly. If a menopausal woman experiences bleeding, an endometrial aspiration or biopsy is performed to rule out hyperplasia, which is a possible precursor of endometrial cancer. The procedure is quick and usually not painful. Transvaginal ultrasound can also be used to measure the thickness of the endometrium (ACOG, 2015d). (Women who are postmenopausal should have a very thin endometrium due to low levels of estrogen; a thicker lining warrants further investigation.) A biopsy or aspiration for tissue pathology is diagnostic.

Cystocele, Rectocele, and Enterocele Surgical Management

•Anterior colporrhaphy +Anterior vaginal wall repair •Posterior colporrhaphy +Rectocele repair •Perineorrhaphy +Perineal laceration repair In many cases, surgery helps correct structural abnormalities. The procedure to repair the anterior vaginal wall is called anterior colporrhaphy, repair of a rectocele is referred to as a posterior colporrhaphy, and repair of perineal lacerations is called a perineorrhaphy. These repairs are frequently performed laparoscopically, resulting in short hospital lengths of stay and good outcomes. A laparoscope is inserted through a small abdominal incision, the pelvis is visualized, and surgical repairs are performed. Transvaginal surgical mesh as a treatment option has been associated with the complications of vaginal erosion, pain and infection leading to recommendations from the U.S. Food and Drug Administration (FDA) for regulatory solutions and close monitoring of adverse outcomes Follow up, post op care (stool softeners, ambulation), etc.

Benign Tumors of the Uterus: Fibroids (Leiomyomas, Myomas) Manifestations

•Asymptomatic •Abnormal vaginal bleeding +Menorrhagia +Metrorrhagia •Pressure •Pain •Backache •Bloating •Constipation •Urinary problems Fibroids may cause no symptoms, or they may produce abnormal vaginal bleeding. Other symptoms result from pressure on the surrounding organs and include pain, backache, pressure, bloating, constipation, and urinary problems. Menorrhagia (excessive bleeding) and metrorrhagia (irregular bleeding) may occur because fibroids may distort the uterine lining. Fibroids may interfere with fertility.

Erythrocytes (Red Blood Cells)

•Bi-Concave •Contain hemoglobin which contains iron •Transports oxygen between lungs and tissues •Reticulocytes are immature erythrocytes •Erythropoietin (from the kidneys) stimulate marrow to increase release of erythrocytes •Liver and spleen traps decayed and destroyed RBCs, recycle the iron and macrophages engulf to "used" erythrocytes The normal erythrocyte is a biconcave disc that resembles a soft ball compressed between two fingers (see Fig. 32-2). It has a diameter of about 8 mcm and is so flexible that it can pass easily through capillaries that may be as small as 2.8 mcm in diameter. The membrane of the red cell is very thin so that gases, such as oxygen and carbon dioxide, can easily diffuse across it; the disc shape provides a large surface area that facilitates the absorption and release of oxygen molecules. Mature erythrocytes consist primarily of hemoglobin, which contains iron and makes up 95% of the cell mass. Mature erythrocytes have no nuclei, and they have many fewer metabolic enzymes than do most other cells. The presence of a large amount of hemoglobin enables the red cell to perform its principal function, which is the transport of oxygen between the lungs and tissues. Occasionally, the marrow releases slightly immature forms of erythrocytes, called reticulocytes, into the circulation. This occurs as a normal response to an increased demand for erythrocytes (as in bleeding) or in some disease states.The oxygen-carrying hemoglobin molecule is made up of four subunits, each containing a heme portion attached to a globin chain. Iron is present in the heme component of the molecule. An important property of heme is its ability to bind to oxygen loosely and reversibly. Oxygen readily binds to hemoglobin in the lungs and is carried as oxyhemoglobin in arterial blood. Oxyhemoglobin is a brighter red than hemoglobin that does not contain oxygen (reduced hemoglobin); thus, arterial blood is a brighter red than venous blood. The oxygen readily dissociates (detaches) from hemoglobin in the tissues, where the oxygen is needed for cellular metabolism. In venous blood, hemoglobin combines with hydrogen ions produced by cellular metabolism and thus buffers excessive acid. Whole blood normally contains about 15 g of hemoglobin per 100 mL of blood (Fischbach & Dunning, 2015).

Cancer of the Ovary Pharmacological Management

•Chemotherapy +Paclitaxel +Carboplatin Chemotherapy is usually administered IV on an outpatient basis using a combination of platinum and taxane agents. Paclitaxel (Taxol) plus carboplatin (Paraplatin) are most often used because of their excellent clinical benefits and manageable toxicity. Leukopenia, neurotoxicity, and fever may occur. Because paclitaxel often causes leukopenia, patients may need to take granulocyte colony-stimulating factor as well. Paclitaxel is contraindicated in patients with hypersensitivity to medications formulated in polyoxyethylated castor oil and in patients with baseline neutropenia. Because of possible adverse cardiac effects, paclitaxel is not used in patients with cardiac disorders. Hypotension, dyspnea, angioedema, and urticaria indicate severe reactions that usually occur soon after the first and second doses are given. Nurses who administer chemotherapy are prepared to assist in treating anaphylaxis. Patients should be prepared for inevitable hair loss. Carboplatin may be used in the initial treatment and in patients with recurrence. It is used with caution in patients with renal impairment. Usually, six cycles are given. A positive clinical response is normalization of the tumor marker CA-125, negative CT results, and a normal physical and gynecologic examination. Liposomal therapy, delivery of chemotherapy in a liposome, allows the highest possible dose of chemotherapy to the tumor target with a reduction in adverse effects. Liposomes are used as drug carriers because they are nontoxic, biodegradable, easily available, and relatively inexpensive. This encapsulated chemotherapy allows increased duration of action and better targeting. The encapsulation of doxorubicin (Doxil) lessens the incidence of nausea, vomiting, and alopecia. Patients must be monitored for bone marrow suppression and gastrointestinal and cardiac effects. Combination IV and intraperitoneal chemotherapy is an option for some patients. However, this treatment is more toxic and side effects are more severe than regular chemotherapy (ACS, 2015c). Intraperitoneal chemotherapy is reserved for women with good kidney function (ACS, 2015c). Genetic engineering and identification of cancer genes may make gene therapy a future possibility; gene therapy is under investigation. Emerging proteomic technologies (tissue-based protein analysis) look promising; they may allow earlier diagnosis and treatment decision making. New biomarkers need further validation, but protein signature patterns are now being tested. These technologies may result in individualized treatment strategies for epithelial ovarian cancer (ACS, 2105c). Recurrence of ovarian cancer is common, and many patients may require treatment with multiple agents. Treatment is directed toward control of the cancer, maintenance of quality of life, and palliation. Liposomal preparations, intraperitoneal drug administration, anticancer vaccines, monoclonal antibodies directed against cancer antigens, gene therapy, and antiangiogenic treatments (to prevent formation of new blood vessels in an effort to halt growth of ovarian cancer) may be used in the treatment for recurrence.

Treatment of Recurrent and Metastatic Breast Cancer

•Chest wall •Remaining breast •Regionally: lymph nodes •Systemically: distant organs •Metastasis +Bone -Hips -Spine -Ribs -Skull •Pelvis •Lungs •Liver •Pleura •Brain Despite the advances made in the treatment of breast cancer, it may recur locally (on the chest wall or in the conserved breast), regionally (in the remaining lymph nodes), or systemically (in distant organs). In metastatic disease, the bone, usually the hips, spine, ribs, skull, or pelvis, is the most common site of spread. Other sites of metastasis include the lungs, liver, pleura, and brain. The overall prognosis and optimal treatment are determined by a variety of factors such as the site and extent of recurrence, the time to recurrence from the original diagnosis, history of prior treatments, the patient's performance status, and any existing comorbid conditions. Patients with bone metastases generally have a longer overall survival compared with metastases in visceral organs. Local recurrence in the absence of systemic disease is treated aggressively with surgery, radiation, and hormonal therapy. Chemotherapy may also be used for tumors that are not hormonally sensitive. Local recurrence may be an indicator that systemic disease will develop in the future, particularly if it occurs within 2 years of the original diagnosis (NCCN, 2015). Metastatic breast cancer involves control of the disease rather than cure (NCCN, 2015). Treatment includes hormonal therapy, chemotherapy, and targeted therapy. Surgery or radiation may be indicated in select situations. Women who are premenopausal and who have hormonally dependent tumors may eliminate the production of estrogen by the ovaries through oophorectomy (removal of the ovaries) or suppression of estrogen production by medications such as leuprolide (Lupron) or goserelin (Zoladex). Patients with advanced breast cancer are monitored closely for signs of disease progression. Baseline studies are obtained at the time of recurrence. These may include complete blood count; comprehensive metabolic panel; tumor markers (i.e., carcinoembryonic antigen, cancer antigen 15-3); bone scan; CT of the chest, abdomen, and pelvis; and MRI of symptomatic areas. Additional x-rays may be performed to evaluate areas of pain or abnormal areas seen on bone scan (e.g., long bones, pelvis). These studies are repeated at regular intervals to assess for effectiveness of treatment and to monitor progression of disease. •Nursing Management +Education +Symptom management +Emotional support +Palliative care Nurses play an important role in not only educating patients and managing their symptoms but also in providing emotional support. Many patients find that recurrence of the disease is more distressing than the initial cancer diagnosis. They not only have to contend with another round of treatments but are also faced with a greater uncertainty about their future and long-term survival. The nurse can help the patient identify coping strategies and set priorities to optimize quality of life. Family members and significant others should be included in the treatment plan and follow-up care. Referrals to support groups, as well as psychiatry or psychiatric clinical nurse specialist, social work, and complementary medicine programs (e.g., guided imagery, meditation, yoga), should be made as indicated. Nurses can also be instrumental in providing palliative care, if indicated. The highest priorities include alleviating pain and providing comfort measures. A frank discussion with the patient and family regarding their preferences for end-of-life care should occur before the need arises to ensure a smooth transition without disruption of care. Referrals to hospice and home health care should be initiated as necessary (see Chapters 15 and 16).

Fistulas of the Vagina Causes

•Congenital •Obstructed labor complications (several births, traumatic births) •Pelvic surgery injury •Vaginal delivery •Radiation •Carcinoma •Chrohn's disease •Lymphogranuloma venereum

Uterine Prolapse Aggravating Factors

•Coughing •Lifting heavy objects •Standing long lengths of time •Climbing stairs The symptoms are aggravated when a woman coughs, lifts a heavy object, or stands for a long time. Normal activities, even walking up stairs, may aggravate the symptoms.

Radiation Therapy

•Cure: Thyroid, Head/Neck. Cervix (b/c we can get the radiation close to the source) •Control: nonsurgical local tumors •Palliation: Reduce tumor size to facilitate removal or quality of life •High energy radiation destroys/weakens/prevents division of cells •Adverse effects on tissues within the radiation path include skin changes, hair loss, and debilitating fatigue. •EBRT, Internal, Systemic, Contact forms available

Hysterectomy

•Removal of uterus •Treatment +Cancer +Dysfunctional uterine bleeding +Endometriosis +Nonmalignant growths +Persistent pain +Pelvic relaxation/prolapse +Injury •Performed +Through vagina +Abdominal incision +Laparoscopically

Other Benign Conditions

•Cystosarcoma •Fat necrosis •Intraductal papilloma •Superficial thrombophlebitis Cystosarcoma phyllodes is a rare fibroepithelial tumor that tends to grow rapidly. It is rarely malignant and is treated with surgical excision. If it is malignant, mastectomy may follow. Lymph node removal is usually not performed, because metastasis is rare. Fat necrosis is a condition of the breast that is often associated with a history of trauma. Surgical procedures such as a breast biopsy, lumpectomy or mastectomy can cause fat necrosis. It may be indistinguishable from carcinoma, and the entire mass may be excised or biopsied. If excision is not indicated, it is followed with regular breast imaging. p. 1729 p. 1730 Intraductal papilloma is a wartlike growth that often involves the large milk ducts near the nipple, causing bloody nipple discharge. Surgery usually involves removal of the papilloma and a segment of the duct where the papilloma is found. Superficial thrombophlebitis of the breast (Mondor disease) is an uncommon condition that is usually associated with pregnancy, trauma, or breast surgery. Pain and redness occur as a result of a superficial thrombophlebitis in the vein that drains the outer part of the breast. The mass is usually linear, tender, and erythematous. Treatment consists of analgesic agents and heat.

Nursing Management: Preoperative

•DC medications •NPO The nurse instructs the patient to discontinue any agents that can increase the risk of bleeding, including products containing aspirin, nonsteroidal anti-inflammatory drugs, vitamin E supplements, herbal substances (such as ginkgo biloba and garlic supplements). Patients on prescription anticoagulants may need to check with the prescriber prior to temporary cessation for the procedure, as biopsies done without cessation of these drugs can result in prolonged bleeding and hematomas. The patient may be instructed not to eat or drink for several hours prior to the procedure or after midnight the night before the procedure, depending on the type of biopsy and anesthesia planned. Most breast biopsy procedures are performed with the use of moderate sedation and local anesthesia.

Endometriosis Medical Management

•Dependent on symptoms •Dependent on desire for children •Routine examinations •NSAIDS •Oral contraceptives •GnRH agonist •Surgery •Pregnancy Treatment depends on the symptoms, the patient's desire for pregnancy, and the extent of the disease. If the woman does not have symptoms, routine examination may be all that is required. Other therapy for varying degrees of symptoms may be NSAIDs, oral contraceptive agents, GnRH agonists, or surgery. Pregnancy often alleviates symptoms, because neither ovulation nor menstruation occurs.

Cancer of the Ovary Pathophysiology

•Difficult to detect •No early screenings available •Epidemiology +Family history •Pathophysiology +Germ cell tumors +Stromal cell tumors +Epithelial tumors Family history is the most significant risk factor. Most cases are random, but 5% to 10% of ovarian cancers are familial (Beckmann et al., 2014). In most cases, the mutations are in the BRCA1 gene and sometimes in the BRCA2 gene. A family history in a first-degree relative (mother, daughter, or sister), older age, early menarche, late menopause, and obesity may increase the risk of ovarian cancer. However, most women who develop ovarian cancer have no known risk factors, and no definitive causative factors have been determined. Patients with concerns about their family history should be referred to a cancer genetics center to obtain information and testing, if indicated (see Chapter 8). Women with inherited types of ovarian cancer tend to be younger when the diagnosis is made than the average age at the time of diagnosis. Hereditary nonpolyposis colorectal cancer (HNPCC, also known as Lynch syndrome) increases the risk of ovarian cancer 13-fold (Beckmann et al., 2014). Lifetime risk of developing ovarian cancer has been shown to be decreased by one half with long-term suppression (greater than 5 years) of ovulation through use of oral contraceptives Types of tumors include germ cell tumors, which arise from the cells that produce eggs and are the most common cause of ovarian cancer in women younger than 20 years (Beckmann et al., 2014); stromal cell tumors, which arise in connective tissue cells that produce hormones; and epithelial tumors, which originate from the outer surface of the ovary. Most ovarian cancers are epithelial in origin. Of the many different cell types in ovarian cancer, epithelial tumors constitute 90%. Germ cell and stromal tumors make up the other 10% (Beckmann et al., 2014). Primary peritoneal carcinoma is closely related to ovarian cancer. Extraovarian primary peritoneal carcinoma (EOPPC) resembles ovarian cancer histologically and can occur in women with and without ovaries. Symptoms and treatment are similar. Because of the possibility of EOPPC, oophorectomy lessens the chance, but does not guarantee, that the patient will not develop carcinoma.

Cancer of the Cervix Manifestations

•Discharge +Watery +Dark, foul smelling •Irregular bleeding •Pain •Anemia •Fever Early cervical cancer rarely produces symptoms. If symptoms are present, they may go unnoticed as a thin, watery vaginal discharge often noticed after intercourse or douching. When symptoms such as discharge, irregular bleeding, or pain or bleeding after sexual intercourse occur, the disease may be advanced. Advanced disease should not occur if all women have access to gynecologic care and avail themselves to it. The nurse's role in access to care and its utilization is crucial. In advanced cervical cancer, the vaginal discharge gradually increases and becomes watery and, finally, dark and foul smelling from necrosis and infection. The bleeding, which occurs at irregular intervals between periods (metrorrhagia) or after menopause, may be slight (just enough to spot the undergarments) and occurs usually after mild trauma or pressure (e.g., intercourse, douching, or bearing down during defecation). As the disease continues, the bleeding may persist and increase. Leg pain, dysuria, rectal bleeding, and edema of the extremities signal advanced disease. As the cancer advances, it may invade the tissues outside the cervix, including the lymph glands anterior to the sacrum. In one third of patients with invasive cervical cancer, the disease involves the fundus. The nerves in this region may be affected, producing excruciating pain in the back and the legs that is relieved only by large doses of opioid analgesic agents. If the disease progresses, it often produces extreme emaciation and anemia that usually is accompanied by fever (due to secondary infection and abscesses in the ulcerating mass) and by fistula formation. Because the survival rate for in situ cancer is 100% and the rate for women with more advanced stages of cervical cancer decreases dramatically, early detection is essential.

Hysterectomy Preoperative Care

•Discontinue medications +NSAIDS +ASA +Vitamin E •R/O pregnancy •Prophylactic antibiotics •VTE prophylaxis (TEDs/SCDs, heparin) Patients are advised to discontinue anticoagulant medications, NSAIDs such as aspirin, and vitamin E prior to surgery to reduce the risk of bleeding. Pregnancy is ruled out on the day of surgery. Prophylactic antibiotic agents may be given prior to surgery and discontinued the next day. Prevention of thromboembolic events is critical, and methods depend on the risk profile of the patient.

Cystocele

•Downward displacement of bladder •Injury and strain during childbirth The condition usually appears years later when genital atrophy associated with aging occurs, but younger women who are multiparous and premenopausal may also be affected.

Uterine Prolapse Nursing Assessment: Promoting Home, Community-Based, and Transitional Care

•Educating Patients About Self-Care +Cleanliness +Constipation +Exercise +Avoid heavy lifting and prolonged standing Prior to discharge, education is provided about cleanliness, prevention of constipation, recommended exercises, and avoiding lifting heavy objects or standing for prolonged periods. The patient is instructed to report any pelvic pain, unusual discharge, inability to carry out personal hygiene, and vaginal bleeding. •Continuing and Transitional Care +Perineal exercise +Follow-up visits The patient is advised to continue with perineal exercises, which are recommended to improve muscle strength and tone. She is reminded to return to the gynecologist for a follow-up visit and to consult with the primary provider about when it is safe to resume sexual activity.

Breast Cancer Staging

•Extent of disease •Invasive or noninvasive •Tumor size •Lymph node involvement •Metastasis •Hormone receptors •Genetic mutation Staging involves classifying the cancer by the extent of the disease in the body. It is based on whether the cancer is invasive or noninvasive, the size of the tumor, how many lymph nodes are involved, and if it has spread to other parts of the body. The stage of a cancer is one of the most important factors in determining prognosis and treatment options. The most common system used to describe the stages of breast cancer is the American Joint Committee on Cancer (AJCC) TNM (tumor, nodes, metastasis) system (see Chapter 15, Chart 15-3). Other factors considered in staging include hormone receptors and genetic mutations. Other diagnostic tests may be performed before or after surgery to help in the staging of the disease. The extent of testing often depends on the clinical presentation of the disease and may include chest x-rays, computed tomography (CT) scan, MRI scan, positron emission tomography (PET) scan, bone scans, and blood work (complete blood count, comprehensive metabolic panel, and tumor markers [i.e., carcinoembryonic antigen, cancer antigen 15-3]).

Uterine Prolapse Nursing Assessment: Uterine Prolapse Nursing Assessment: Implementing Preventive Measures

•Extent of surgical procedure •Bowel prep (laxatives and enemas) •Lithotomy position Before surgery, the patient needs to know the extent of the proposed surgery, the expectations for the postoperative period, and the effect of surgery on future sexual function. In addition, the patient having a rectocele repair needs to know that before surgery, a laxative and a cleansing enema may be prescribed. She may be asked to administer these at home the day before surgery. The patient is usually placed in a lithotomy position for surgery, with special attention given to moving both legs in and out of the stirrups simultaneously to prevent muscle strain and excess pressure on the legs and thighs. Other preoperative interventions are similar to those described in Chapter 17.

Fistulas of the Vagina Medical Assessment

•Goal +Eliminate fistula +Treat infection and excoriation •Surgically repaired (If the primary provider determines that a fistula will heal without surgical intervention, care is planned to relieve discomfort, prevent infection, and improve the patient's self-concept and self-care abilities; Usually, the vaginal approach is used to repair vesicovaginal and urethrovaginal fistulas; the abdominal approach is used to repair fistulas that are large or complex. Fistulas that are difficult to repair or very large may require surgical repair with a urinary or fecal diversion. Tissue transfer techniques (skin or tissue grafting) may be used; Despite the best surgical intervention, fistulas may recur. After surgery, medical follow-up continues for at least 2 years to monitor for a possible recurrence.) •Care +Relieve discomfort +Prevent infection (skin breakdown; Cleanliness, frequent sitz baths, and deodorizing douches are required, as are perineal pads and protective undergarments. Meticulous skin care is necessary to prevent excoriation. Applying bland creams or lightly dusting with cornstarch may be soothing.) +Improve self-concept and self-care abilities •Promote healing +Proper nutrition (protein, vitamin C) +Cleansing douches and enemas (NO DOUCHING—unless medically prescribed; Measures to promote healing include proper nutrition, cleansing douches and enemas, rest, and administration of prescribed intestinal antibiotic agents.) +Rest +Prescribed intestinal antibiotic agents •Rectovaginal fistula +Low-residue diet (not a lot of fiber b/c we do not want a lot of loose stool) +Warm perineal irrigations •Permanent +Cleanliness +Sitz baths +Deodorizing douches +Perineal pads (need to change them) +Protective undergarments +Meticulous skin care +Bland creams +Cornstarch •Preoperative +Treat vaginitis if present •Postoperative +Follow-up for 2 years

Hysterectomy Nursing Assessment

•H&P •Pelvic exam •Labs •Psychosocial response (anyone helping, feelings about hysterectomy, etc.) The health history and the physical and pelvic examination are completed, and laboratory tests are performed. Additional assessment data include the patient's psychosocial responses, because the need for a hysterectomy may elicit strong emotional reactions. If the hysterectomy is performed to remove a malignant tumor, anxiety related to fear of cancer and its consequences adds to the stress of the patient and her family. Women who have had a hysterectomy may be at risk for psychological and physical symptoms. Alternatively, women may note improved physical and mental health after hysterectomy as troublesome symptoms may be alleviated.

Benign Disorders: Polycystic Ovary Syndrome (PCOS) Nursing Assessment and Diagnosis

•H&P •US Diagnosis is based on clinical criteria, including hyperandrogenism, chronic anovulation, and polycystic ovaries on ultrasound examination. Two out of three of these criteria must be present to make the diagnosis (Trikudanathan, 2105). Women with PCOS are at increased risk for diabetes, increased blood lipids, cardiovascular disease, nonalcoholic fatty liver disease as well as anxiety and depression

Fistulas of the Vagina Nursing Assessment and Diagnosis

•History of symptoms •Methylene blue dye (to delineate the course of the fistula) •Vesicovaginal fistula +Tampon Test (In a vesicovaginal fistula, the dye is instilled into the bladder along with placement of vaginal packing known as the "tampon test"; stained vaginal packing can be indicative of a fistula) •Cystourethroscopy/IV pyelography (Cystourethroscopy is useful in identifying fistula while cystoscopy or IV pyelography may then be used to determine the exact location.)

Internal Radiation

•Localize implantation •AKA - Brachytherapy •Radiation remains highly localized •Patient is radioactive •Nursing Implications •Private room •Radiation sign on door •Visitors remain at 6ft distance and limited to 30 minutes or less •Follow policy for disposal of bandages, linens, etc. Patient is deemed to be radioactive -private room -hang sign on the door -visitors to remain 6 foot distance and can only remain 30 minutes or less -no children or pregnant women allowed (lead shield apron if they absolutely need to go!) Nursing Care -multiple nurses so no one nurse is getting the radiation exposure day after day -cluster care to prevent too much time in the room

Cancer of the Ovary Nursing Assessment and Diagnosis

•MRI •US +Transvaginal +Abdominal •CXR •CA-125 CT Any enlarged ovary must be investigated. Pelvic examination often does not detect early ovarian cancer, and pelvic imaging techniques are not always definitive. Ovarian tumors are classified as benign if there is no proliferation or invasion, borderline if there is proliferation but no invasion, and malignant if there is invasion. Of all new cases of ovarian tumors, 20% are classified as borderline and have low malignancy potential. However, by the time of diagnosis, most ovarian cancers are advanced (ACS, 2015a; Beckmann et al., 2014). Diagnostic test may include an MRI scan, transvaginal and pelvic ultrasound, chest x-rays, and a blood test for CA-125. An abdominal CT scan with and without contrast may be used to rule out metastasis

Benign Tumors of the Uterus: Fibroids (Leiomyomas, Myomas) Medical Management

•Medical interventions +Observation +Follow-up •Surgical interventions +Myomectomy +Hysterectomy •Pharmacological interventions +Leuprolide +Mifepristone

EBRT (External Beam Radiation Therapy)

•Most used •AKA - Teletherapy •Small doses over several weeks •Client is not radioactive following treatment •Nursing Implications •Nutritional Support •Energy Conservation techniques •Monitor skin and mucus membranes for injury •Monitor CBC (thrombocytopenia and leukocytopenia)

Risk Factors for Breast Cancer

•No single, specific cause •Familial tendency •Long-term smoking •Night shift work •BRCA1 •BRCA2 Female gender 99% of cases occur in women. Increasing age Increasing age is associated with an increased risk. Personal history of breast cancer Once treated for breast cancer, the risk of developing breast cancer in same or opposite breast is significantly increased. Family history of breast cancer Having first-degree relative with breast cancer (mother, sister, daughter) increases the risk twofold; having two first-degree relatives increases the risk fivefold. The risk is higher if the relative was premenopausal at the time of diagnosis. The risk is increased if a father or brother had breast cancer (exact risk is unknown). Genetic mutation BRCA1 and BRCA2 mutations account for majority of inherited cases of breast cancer (see additional information in text). Hormonal Factors Early menarche Before 12 years of age Late menopause After 55 years of age Nulliparity No full-term pregnancies Late age at first full-term pregnancy After 30 years of age Hormone therapy (formerly referred to as hormone replacement therapy) Current or recent use of combined postmenopausal hormone therapy (estrogen and progesterone) Long-term use (several years or more) Exposure to ionizing radiation during adolescence and early adulthood The risk is highest if breast tissue was exposed while still developing (during adolescence), such as women who received mantle radiation (to the chest area) for treatment of Hodgkin lymphoma in their younger years. History of benign proliferative breast disease Having had atypical ductal or lobular hyperplasia or lobular carcinoma in situ increases the risk. Obesity Obesity and weight gain during adulthood increases the risk of postmenopausal breast cancer. During menopause, estrogen is primarily produced in fat tissue. More fat tissue can increase estrogen levels, thereby increasing breast cancer risk. High-fat diet More research is needed. Alcohol intake (beer, wine, or liquor) Two to five drinks daily increases the risk about one and a half times.

Endometriosis Pharmacological Therapy

•Palliative +Analgesics/Prostaglandin inhibitors (PAIN) +Hormonal therapy (effective in suppressing endometriosis and relieving dysmenorrhea (menstrual pain) +Oral contraceptives (provide effective pain relief and may prevent disease progression) -Infrequently, side effects may occur with oral contraceptives, such as fluid retention, weight gain, and nausea. These can usually be managed by changing brands or formulations. +A synthetic androgen, danazol (Danocrine), causes atrophy of the endometrium and subsequent amenorrhea. The medication inhibits the release of gonadotropin with minimal overt sex hormone stimulation - The drawbacks of this medication are that it is expensive and may cause troublesome side effects such as fatigue, depression, weight gain, oily skin, decreased breast size, mild acne, hot flashes, and vaginal atrophy +GnRH agonists decrease estrogen production and cause subsequent amenorrhea. -Side effects are related to low estrogen levels (e.g., hot flashes and vaginal dryness). Loss of bone density is often offset by concurrent use of estrogen. If side effects from GnRH develop, treatment is needed long-term or repeated treatments are necessary, additional therapy should be considered. Norethindrone acetate (Aygestin) (low-dose hormone) given along with GnRH agonist will mitigate the bone density side effects as well as not affect the drug's control of pelvic pain. +Aromatase inhibitor therapy is emerging as an alternative therapy (Beckmann et al., 2014). Most women continue treatment despite side effects, and symptoms diminish for 80% to 90% of women with mild to moderate endometriosis. Hormonal medications are not used in patients with a history of abnormal vaginal bleeding or liver, heart, or kidney disease. Bone density is followed carefully because of the risk of bone loss; hormone therapy is usually short term.

Endometriosis Nursing Management

•Patient goals Relief of: +Pain +Dysmenorrhea +Dyspareunia +Infertility •Explanation of procedures •Alternatives to reproduction ***Surgery does not always repair so you may need to talk to patients about alternatives like: IVF, suregucy, adoption

Erectile Dysfunction Medical Management: Pharmacologic Management

•Phosphodiesterase type 5 (PDE-5) inhibitors as first line treatment •Table 59-3: Pharmacologic Treatment of ED; p.1759 +sildenafil (Viagra) +vardenafil (Levitra) +tadalafil (Cialis) Erection involves the release of nitric oxide in the vasculature of the corpus cavernosum as a result of sexual stimulation. This subsequently leads to smooth muscle relaxation in blood vessels supplying the corpus cavernosum, resulting in increased blood flow and an erection. During sexual stimulation, PDE-5 inhibitors increase blood flow to the penis S/S: Can cause headache flushing, dyspepsia, diarrhea, nasal congestion, and lightheadedness Contraindications: men who take organic nitrates (e.g., isosorbide [Isordil], nitroglycerin), because taken together, these medications can cause side effects such as severe hypotension; must be used with caution in patients with retinopathy, especially in those with diabetic retinopathy. injecting vasoactive agents, such as alprostadil, papaverine, and phentolamine, directly into the penis. Complications include priapism (a persistent abnormal erection) and development of fibrotic plaques at the injection sites. Alprostadil is also formulated in a gel pellet that can be inserted into the tip of the urethra with an applicator to create an erection.

Cancer of the Cervix Medical Management

•Precursor or Preinvasive Lesions +Cryotherapy +Laser therapy +LEEP +Cone biopsy/conization +Hysterectomy •Invasive Cancer +Surgery +Radiation treatment -Intracavitary Brachytherapy -External +Total hysterectomy—removal of the uterus, cervix, and ovaries +Radical hysterectomy—removal of the uterus, ovaries, fallopian tubes, proximal vagina, and bilateral lymph nodes through an abdominal incision (Note: "Radical" indicates that an extensive area of the paravaginal, paracervical, parametrial, and uterosacral tissues is removed with the uterus.) +Radical vaginal hysterectomy—vaginal removal of the uterus, ovaries, fallopian tubes, and proximal vagina +Bilateral pelvic lymphadenectomy—removal of the common iliac, external iliac, hypogastric, and obturator lymphatic vessels and nodes +Pelvic exenteration—removal of the pelvic organs, including the bladder or rectum and pelvic lymph nodes, and construction of diversional conduit, colostomy, and vagina +Radical trachelectomy—removal of the cervix and selected nodes to preserve childbearing capacity in a woman of reproductive age with cervical cancer

Uterine Prolapse Nursing Assessment: Implementing Preventive Measures

•Prenatal care •Kegel exercises Some disorders related to "relaxed" pelvic muscles (cystocele, rectocele, and uterine prolapse) may be prevented. During pregnancy, early visits to the primary provider permit early detection of problems. During the postpartum period, the woman can be educated to perform pelvic muscle exercises, commonly known as Kegel exercises, to increase muscle mass and strengthen the muscles that support the uterus and then to continue them as a preventive action (Beckmann et al., 2014). Delays in obtaining evaluation and treatment may result in complications such as infection, cervical ulceration, cystitis, and hemorrhoids. The nurse encourages the patient to obtain prompt treatment for these structural disorders.

Uterine Prolapse Manifestations

•Pressure •Urinary problems +Incontinence +Retention As the uterus descends, it may pull the vaginal walls and even the bladder and rectum with it. Symptoms include pressure and urinary problems (incontinence or retention) from displacement of the bladder.

Uterine Prolapse Nursing Assessment: Initiating Postoperative Nursing Care

•Prevent infection •Prevent pressure on suture line •Voiding (6-8 hours) •BM Immediate postoperative goals include preventing infection and pressure on any existing suture line. This may require perineal care and may preclude using dressings. The patient is encouraged to void within a few hours after surgery for cystocele and complete tear. If the patient does not void within this period and reports discomfort or pain in the bladder region after 6 hours, she needs to be catheterized. An indwelling catheter may be indicated for 2 to 4 days, so some women may return home with a catheter in place. Various other bladder care methods are described in Chapter 55. After each voiding or bowel movement, the perineum may be cleaned with warm, sterile saline solution and dried with sterile absorbent material if a perineal incision has been made. After an external perineal repair, the perineum is kept as clean as possible. Commercially available sprays containing combined antiseptic and anesthetic solutions are soothing and effective, and an ice pack applied locally may relieve discomfort. However, the weight of the ice bag must rest on the bed, not on the patient. Routine postoperative care is similar to that given after abdominal surgery. The patient is positioned in bed with her head and knees elevated slightly. The patient may go home the day of or the day after surgery; the length of hospital stay depends on the surgical approach used. After surgery for a complete perineal laceration (through the rectal sphincter), special care and attention are required. The bladder is drained through the catheter to prevent strain on the sutures. Throughout recovery, stool-softening agents are given nightly after the patient begins a soft diet.

Male Reproductive System Diagnostic Evaluation

•Prostate-Specific Antigen Test +The cells within the prostate gland produce a protein that can be measured in the blood called the prostate-specific antigen (PSA). It is a sensitive but not specific test for prostate cancer. +less than 4 ng/mL are generally considered normal +greater than 4 ng/mL are considered elevated •Transrectal US +Transrectal ultrasound (TRUS) may be performed in patients with abnormalities detected by DRE and in those with elevated PSA levels. After DRE has been completed, a lubricated, condom-covered, rectal probe transducer is inserted into the rectum (Itano, Brant, Conde, et al., 2016). Water may be introduced into the condom to help transmit sound waves to the prostate. TRUS may be used in detecting nonpalpable prostate cancers and in staging localized prostate cancer. Needle biopsies of the prostate are commonly guided by TRUS. •Prostate Fluid or Tissue Analysis +Specimens of prostate fluid or tissue may be obtained for culture if disease or inflammation of the prostate gland is suspected. A biopsy of the prostate gland may be necessary to obtain tissue for histologic examination. This may be performed at the time of prostatectomy or by means of a perineal or transrectal needle biopsy. Six to 12 biopsies from all four prostate zones may be obtained during a TRUS-guided biopsy. •Tests of Male Sexual Function +Nocturnal penile tumescence tests may be conducted in a sleep laboratory to monitor changes in penile circumference during sleep using various methods to determine number, duration, rigidity, and circumference of penile erections; the results help identify whether the erectile dysfunction is caused by physiologic or psychological factors. Additional tests, including psychological evaluations, are also part of the diagnostic workup and are usually conducted by a specialized team of health care providers.

Nursing Management to Reduce Infections

•Protective Isolation/Reverse Isolation •Hand Hygiene •Aseptic Technique •Avoid communal equipment •Neutropenic Diet •Oral Hygiene •Avoid invasive procedures •ASSESS FREQUENTLY No Live Viral Vaccines

Enterocele

•Protrusion of intestinal wall into vagina •Weakening support structures

Diagnostic Evaluation

•RBC= number of erythrocytes •WBC= number of leukocytes •Differential= breakdown of leukocytes •Hgb= indicates oxygen carrying capacity of the blood •Hct= percentage of blood volume consisting of erythrocytes Indices IN ATI BOOK

Nursing Management: Post Operative

•S/SX of bleeding •DC instructions •Dressing: 48 hrs •Steri-strips: 7-10 days •Support bra Immediate assessment after the procedure includes monitoring the effects of the anesthesia and inspecting the surgical dressing for any signs of bleeding. Once the sedation has worn off, the nurse reviews the care of the biopsy site, pain management, and activity restrictions with the patient. Prior to discharge from the ambulatory surgical center or the office, the patient must be able to tolerate fluids, ambulate, and void. The patient must be accompanied home. The dressing covering the incision is usually removed after 48 hours, but the Steri-Strips, which are applied directly over the incision, should remain in place for approximately 7 to 10 days or until they fall off. The use of a supportive bra following surgery is encouraged to limit movement of the breast and reduce discomfort. A follow-up telephone call from the nurse 24 to 48 hours after the procedure can provide the patient with the opportunity to ask any questions and can be a source of great comfort and reassurance. Most women return to their usual activities the day after the procedure but are encouraged to avoid jarring or high-impact activities for 1 week to promote healing of the biopsy site. Discomfort is usually minimal, and most women find acetaminophen (Tylenol) sufficient for pain relief, although a mild opioid analgesic agent may be prescribed if needed. Follow-up after the biopsy includes a return visit to the surgeon for discussion of the final pathology report and assessment of the healing of the biopsy site. Depending on the results of the biopsy, the nurse's role varies. If the pathology report is benign, the nurse reviews incision care and explains what the patient should expect as the biopsy site heals (i.e., changes in sensation may occur weeks or months after the biopsy due to nerve injury within the breast tissue). If a diagnosis of cancer is made, the nurse's role changes dramatically. This is discussed in depth later in this chapter.

Cancer of Ovary Nursing Management

•Surgery •Chemotherapy •Palliative care •IV fluids •Parenteral nutrition •Postoperative care •Pain control •Drainage tubing maintenance •Comfort measures Nursing measures involve those related to the patient's treatment plan, which may include surgery, chemotherapy, palliative care, or a combination of these. Nursing interventions after pelvic surgery to remove the tumor are similar to those after other abdominal surgeries. If ovarian cancer occurs in a young woman and the tumor is unilateral, it is removed. Childbearing, if desired, is encouraged in the near future. After childbirth, surgical reexploration may be performed, and the remaining ovary may be removed. If both ovaries are involved, bilateral oophorectomy is performed and chemotherapy follows. Patients with advanced ovarian cancer may develop ascites and pleural effusion. Nursing care may include administering IV fluids prescribed to alleviate fluid and electrolyte imbalances, administering parenteral nutrition to provide adequate nutrition, providing postoperative care after intestinal bypass to alleviate any obstruction, controlling pain, and managing drainage tubes. Comfort measures for women with ascites may include providing small frequent meals, decreasing fluid intake, administering diuretic agents, and providing rest. Patients with pleural effusion may experience shortness of breath, hypoxia, pleuritic chest pain, and cough. Thoracentesis is usually performed to relieve these symptoms. The patient with ovarian cancer often has complex needs and benefits from the assistance and support of an oncology clinical nurse specialist. Pleural Infusion: what to watch for Ascities: what to watch for Something about thoracentesis and others

Uterine Prolapse Medical Management

•Surgical options +Suturing +Hysterectomy +Colpopexy +Colpocleisis (vaginal closure-can't have sex anymore) •Nonsurgical options +Lifestyle changes +Pessaries +Pelvic floor muscle training There are surgical and nonsurgical options for treatment. With surgery, the uterus is sutured back into place and repaired to strengthen and tighten the muscle bands. In women who are postmenopausal, the uterus may be removed (hysterectomy) or repaired by colpopexy. Colpocleisis, or vaginal closure, may be an option for women who do not wish to have sexual intercourse or to bear children. Conservative treatments and mechanical options, including lifestyle changes, pessaries, and pelvic floor muscle training, can usually result in symptomatic improvement. These options may be the treatment of choice for women with a mild prolapse, who desire additional children, or who are unable to tolerate surgery

Benign Disorders: Polycystic Ovary Syndrome (PCOS) Medical Management

•Surgical removal •Oral contraceptives •PCOS +Oral contraceptives +Clomiphene citrate +Weight loss +Metformin The treatment of large ovarian cysts is usually surgical removal. However, oral contraceptives may be used in young, healthy patients to suppress ovarian activity and resolve small cysts that appear to be fluid filled or physiologic. Oral contraceptive agents are also usually prescribed to treat PCOS (Trikudanathan, 2015). When pregnancy is desired, medications to stimulate ovulation (clomiphene citrate [Clomid]) are often effective. Lifestyle modification is critical, and weight management is part of the treatment plan. Weight loss as little as 5% to 10% of total body weight can help with hormone imbalance and infertility. Metformin (Glucophage) often regulates periods and can help with weight loss. (Trikudanathan, 2015). Women with this diagnosis are at increased risk for endometrial cancer due to anovulation.

Cancer of the Ovary Surgical Management

•Surgical staging •Exploration •Reduction of tumor mass •Surgical removal Surgical staging, exploration, and reduction of tumor mass are the basics of treatment. Surgical removal is the treatment of choice. Staging the tumor by the FIGO staging system is performed to guide treatment (see Chart 57-10). Likely treatment involves a total abdominal hysterectomy with removal of the fallopian tubes and ovaries and possibly the omentum (bilateral salpingo-oophorectomy and omentectomy), tumor debulking, para-aortic and pelvic lymph node sampling, diaphragmatic biopsies, random peritoneal biopsies, and cytologic washings. Postoperative management may include taxanes or platinum-based chemotherapy. Borderline tumors resemble ovarian cancer but have much more favorable outcomes. Women diagnosed with this type of cancer tend to be younger (early 40s). A conservative surgical approach is used. The affected ovary is removed, but the uterus and the contralateral ovary may remain in place. Adjuvant therapy may not be warranted.

Cancer of the Uterus Medical Management

•Surgical staging •Hysterectomy +Total +Radical •Bilateral salpingo-oophorectomy •Lymph node sampling •CA -125 (blood test) •Radiation +External-beam +Vaginal brachytherapy +Whole pelvis radiotherapy •Hormone therapy •Chemotherapy Treatment for endometrial cancer consists of surgical staging, total or radical hysterectomy (discussed later in this chapter), and bilateral salpingo-oophorectomy and lymph node sampling. Laparoscopy or a robot-assisted laparoscopic surgery is less invasive than abdominal surgery (ACOG, 2015d). Lymph node sampling and visualization of the peritoneum can be accomplished in many women in this manner. Cancer antigen 125 (CA-125) levels must be monitored, because elevated levels are a significant predictor of extrauterine disease or metastasis. Depending on the stage, the therapeutic approach is individualized and is based on stage, type, differentiation, degree of invasion, and node involvement. Radiation may be used in the form of external-beam radiation or vaginal brachytherapy (ACOG, 2015d). Whole pelvis radiotherapy may be used if there is any spread beyond the uterus. Recurrent cancer usually occurs inside the vaginal vault or in the upper vagina, and metastasis usually occurs in lymph nodes or the ovary. Recurrent lesions in the vagina are treated with surgery and radiation. Recurrent lesions beyond the vagina are treated with hormonal therapy or chemotherapy. Progestin therapy is used frequently. Patients should be prepared for such side effects as nausea, depression, rash, or mild fluid retention with progestin therapy.

Tumor Staging

•The tumor‑node‑metastasis (TNM) system is used to stage cancer. •TUMOR (T) Size and Extent of the Tumor ● TX: Unable to evaluate the primary tumor ● TØ: No evidence of primary tumor ● Tis: Tumor in situ ● T1, T2, T3, and T4: •NODE (N)Number of nodes involved or extend of nodal spread ● NX: Unable to evaluate regional lymph nodes ● NØ: No evidence of regional node involvement ● N1, N2, and N3: •METASTASIS (M) Metastasis of the primary tumor ● MX: Unable to evaluate distant metastasis ● MØ: No evidence of distant metastasis ● M1: Presence of distant metastasis Ex: Breast cancer in axillary T 1-I can find it look at it and measure it but it is not obverly larger N1- only able to find it in one node Mx-unable to identify distant metastis *patients refer to staging

Breast Cancer Prognosis

•Type •Tumor size •Lymph node involvement •HER-2 oncogene •Proliferative rate Several different factors must be taken into consideration when determining the prognosis of a patient with breast cancer. Two of the most important factors are tumor size and whether the tumor has spread to the lymph nodes under the arm (axilla). In general, the smaller the tumor appears, the better the prognosis. A tumor starts with a genetic alteration in a single cell and takes time to divide and double in size. A carcinoma may double in size 30 times to become 1 cm or larger, at which point it becomes clinically apparent. Doubling time varies, but breast tumors are often present for several years before they become palpable. Nurses can reassure patients that once breast cancer is diagnosed, they have a safe period of several weeks to make decisions regarding treatment; however, a lengthy delay is not advisable. Prognosis also depends on the extent of spread of the breast cancer. The 5-year survival rate is approximately 88% for a stage I breast cancer and 15% for a stage IV breast cancer (ACS, 2015). The most common route of regional spread is to the axillary lymph nodes. Other sites of lymphatic spread include the internal mammary and supraclavicular nodes (see Fig. 58-5). Distant metastasis can affect any organ, but the most common sites are bone, lung, liver, pleura, adrenals, skin, and brain (ACS, 2015). In addition to the type of breast cancer and the stage, other factors may help determine prognosis (see Chart 58-3). Excessive number of copies of certain genes (amplification) or excessive amounts of their protein product (overexpression) may represent a poorer prognosis. The HER-2/neu (also known as ERBB2) oncogene is the classic example; approximately 25% of invasive breast cancers, which typically involve the more aggressive tumors, have amplification or overexpression of this gene (Press & Ma, 2015). The proliferative rate or rapidity in growth rate (S-phase fraction) and DNA content (ploidy) of a tumor are factors that are also associated with overall survival rate.

Rectocele

•Upward pouching of rectum •Due to muscle tears below the vagina

Uterine Prolapse

•Weakening structures +Prolapse (uterus tunneling down) +Procidentia (uterus outside the body) Usually, the uterus and the cervix lie at right angles to the long axis of the vagina with the body of the uterus inclined slightly forward. The uterus is normally freely movable on examination. Individual variations may result in an anterior, middle, or posterior uterine position. A backward positioning of the uterus, known as retroversion and retroflexion, is not uncommon If the structures that support the uterus weaken (typically from childbirth), the uterus may work its way down the vaginal canal (prolapse) and even appear outside the vaginal orifice (procidentia)

Tumor Grading

•Well‑differentiated means the cells look much like normal cells and tend to grow slowly •Undifferentiated, or poorly differentiated, means the cells do not look like normal cells and tend to grow quickly and spread •Grades ● GX: Grade cannot be determined. ● G1: Tumor cells are well differentiated. ● G2: Tumor cells are moderately differentiated. ● G3: Tumor cells are poorly differentiated, but the tissue of origin can be established. ● Tumor cells are poorly differentiated, and determination of the tissue of origin is difficult

Endometriosis Surgical Management

•therapy •Laparoscopy •Laser surgery •Endocoagulation •Electrocoagulation •Laparotomy •Abdominal hysterectomy •Oophorectomy •Bilateral salpingo-oophorectomy •Appendectomy •Total hysterectomy