NPRO exam 4

Chemotherapy in general, including how it works, side effects and nursing care; Care of the patient receiving chemotherapy

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. Each time a tumor is exposed to chemotherapy, a percentage of the tumor cells (20% to 99%, depending on dosage and agent) are destroyed. Repeated doses of chemotherapy are necessary over a prolonged period to achieve regression of the tumor. Eradication of 100% of the tumor is almost impossible; the goal of treatment is eradication of enough of the tumor so that the remaining malignant cells can be destroyed by the body's immune system (Grossman & Porth, 2014) Actively proliferating cells within a tumor are the most sensitive to chemotherapy (the ratio of dividing cells to resting cells is referred to as the growth fraction). Non-dividing cells capable of future proliferation are the least sensitive to antineoplastic medications and consequently are potentially dangerous. However, the non-dividing cells must be destroyed to eradicate the disease. Repeated cycles of chemotherapy or sequencing of multiple chemotherapeutic agents is used to achieve more tumor cell destruction by destroying the non-dividing tumor cells as they begin active cell division. Reproduction of both healthy and malignant cells follows the cell cycle pattern (see Fig. 15-2). The cell cycle time is the time required for one cell to divide and reproduce two identical daughter cells. The cell cycle of any cell has four distinct phases, each with a vital underlying function (Grossman & Porth, 2014): G1 phase—RNA and protein synthesis occurs S phase—DNA synthesis occurs G2 phase—premitotic phase; DNA synthesis is complete, mitotic spindle forms Mitosis—duplicated chromosomes separate and cell division occurs Classification of Chemotherapeutic Agents Chemotherapeutic agents may be classified by their mechanism of action in relation to the cell cycle. Agents that exert their maximal effect during specific phases of the cell cycle are termed cell cycle-specific agents. These agents destroy cells that are actively reproducing by means of the cell cycle; most affect cells in the S phase by interfering with DNA and RNA synthesis. Other agents, such as plant alkaloids, are specific to the M phase, where they halt mitotic spindle formation. Chemotherapeutic agents that act independently of the cell cycle phases are termed cell cycle-nonspecific agents. These agents usually have a prolonged effect on cells, leading to cellular damage or death. Many treatment plans combine cell cycle-specific and cell cycle-nonspecific agents to increase the number of vulnerable tumor cells killed during a treatment period (Neuss, Polovich, McNiff, et al., 2013). Chemotherapeutic agents are also classified by chemical group, each with a different mechanism of action. These include the alkylating agents, nitrosoureas, antimetabolites, antitumor antibiotics, topoisomerase inhibitors, plant alkaloids (also referred to as mitotic inhibitors), hormonal agents, and miscellaneous agents. The classification, mechanism of action, cell cycle specificity, and common side effects of selected antineoplastic agents are listed in Table 15-7. Chemotherapeutic agents from multiple categories may be used together to maximize cell destruction. Combination chemotherapy relies on agents with varying mechanisms, potential synergistic actions, and differing toxicities. The use of combination therapy also helps prevent the development of drug-resistant cells. Adjunct Chemotherapeutic Agents In certain regimens, additional medications are given with chemotherapy agents to enhance activity or protect normal cells from injury. For example, leucovorin (Wellcovorin) is often given with fluorouracil (5-FU) to treat colorectal cancer. Leucovorin, a compound similar to folic acid, helps fluorouracil bind with an enzyme inside of cancer cells and enhances the ability of fluorouracil to remain in the intracellular environment. Leucovorin also rescues normal cells from the toxic effects of high doses of methotrexate (Trexall). When given at certain doses for the treatment of some forms of leukemia or lymphoma, methotrexate causes a folic acid deficiency in cells, resulting in cell death. Significant toxicity, including severe bone marrow suppression, mucositis, diarrhea and liver, and lung and kidney damage, can occur. Leucovorin helps to prevent or lessen these toxicities. Administration of Chemotherapeutic Agents Chemotherapy may be given in the hospital, outpatient center, or home setting by multiple routes. The route of administration depends on the type of agent; the required dose; and the type, location, and extent of malignant disease being treated. Standards for the safe administration of chemotherapy have been developed by the Oncology Nursing Society (ONS) and the American Society of Clinical Oncology (ASCO) (Neuss et al., 2013). Patient education is essential to maximize safety when chemotherapy is given in the home. Dosage The dosage of chemotherapeutic agents is based primarily on the patient's total body surface area, weight, previous exposure and response to chemotherapy or radiation therapy, and function of major organ systems. Dosages are determined to maximize cell kill while minimizing impact on healthy tissues and subsequent toxicities. The therapeutic effect may be compromised if modified and inadequate dosing is required due to toxicities. Modification of dosage is often required if critical laboratory values or the patient's symptoms indicate unacceptable or dangerous toxicities. Chemotherapy treatment regimens include standard-dose therapy, dose-dense regimens (giving chemotherapy more frequently than standard treatment regimens), and myeloablative therapy for HSCT. For certain chemotherapeutic agents, there is a maximum lifetime dose limit that must be adhered to because of the danger of long-term irreversible organ complications (e.g., because of the risk of cardiomyopathy, doxorubicin [Adriamycin] has a cumulative lifetime dose limit of 550 mg/m2). Extravasation Intravenously given chemotherapy agents are additionally classified by their potential to damage tissue if they inadvertently leak from a vein into surrounding tissue (extravasation). The consequences of extravasation range from mild discomfort to severe tissue destruction, depending on whether the agent is classified as a nonvesicant, irritant, or vesicant. The pH levels of irritant agents (<5 or >9) induce inflammatory reactions but usually cause no permanent tissue damage (Schulmeister, 2014). Vesicants are those agents that, if deposited into the subcutaneous or surrounding tissues (extravasation), cause inflammation; tissue damage; and possibly necrosis of tendons, muscles, nerves, and blood vessels. Although the mechanism of vesicant actions varies with each drug, some agents bind to cell DNA and cause cell death that progresses to involve neighboring cells, whereas other agents are metabolized into cells and cause a localized, painful reaction that usually improves over time (Schulmeister, 2014). Sloughing and ulceration of the tissue may progress to tissue necrosis that is so severe that skin grafting becomes necessary. The full extent of tissue damage may take several weeks to become apparent. Examples of commonly used agents classified as vesicants include dactinomycin (Cosmegen), daunorubicin (DaunoXome), doxorubicin (Adriamycin), nitrogen mustard (Mustargen), mitomycin (Mutamycin), vinblastine (Velban), and vincristine (Oncovin). Chemotherapy administration safety standards require the availability of defined extravasation management procedures, including antidote order sets and accessibility of antidotes in all settings where vesicant chemotherapy is given (Neuss et al., 2013; Schulmeister, 2014). Chemotherapy is given only by those who have the knowledge and established competencies for vesicant and extravasation management (Schulmeister, 2014). Prevention and management of extravasation are essential. Vesicant chemotherapy should never be given in peripheral veins involving the hand or wrist. Peripheral administration is permitted for short-duration infusions only, and placement of the venipuncture site should be on the forearm area using a soft, plastic catheter. For any frequent or prolonged administration of antineoplastic vesicants, right atrial silastic catheters, implanted venous access devices, or peripherally inserted central catheters (PICCs) should be inserted to promote safety during medication administration and reduce problems with access to the circulatory system. Hypersensitivity Reactions Although hypersensitivity reactions (HSRs) can occur with any medication, many chemotherapy agents pose a high risk and have been associated with life-threatening outcomes. HSRs are a subgroup of adverse drug reactions that are unexpected and associated with mild or progressively worsening signs and symptoms, such as rash, urticaria, fever, hypotension, cardiac instability, dyspnea, wheezing, throat tightness, and syncope (Braskett & Cohen, 2014). Immediate HSRs appear within 1 hour of an infusion, while delayed HSRs may occur hours afterward. Although patients may or may not react to the first infusion of a chemotherapy agent, repeated exposure increases the likelihood of a reaction. Most immediate HSRs are immunoglobulin E (IgE)-mediated reaction—an allergic reaction. Examples of agents that may cause an allergic, IgE-mediated response include carboplatin, oxaliplatin (Eloxatin), and L-asparaginase. However, some HSRs, such as anaphylactoid reactions, are non-IgE-mediated (nonallergic) and a result of cytokine release syndrome (Braskett & Cohen, 2014; Castells, 2015). Rituximab and cetuximab are examples of agents associated with non-IgE-mediated (nonallergic) HSRs. When signs and symptoms of HSR occur, the medication should be discontinued immediately and emergency procedures initiated. Many institutions have developed specific protocols for responding to HSRs, including standing orders for administration of emergency medications (Castells, 2015). (Chapter 38 presents further discussion of allergic reactions.) For some chemotherapeutic agents, especially if they are essential in the treatment plan, desensitization procedures may be possible, and the patient is retreated with the agent at reduced dosages or slower infusion rates. Premedication regimens are used for certain chemotherapy agents to prevent or minimize reactions. Toxicity Toxicity associated with chemotherapy can be acute or chronic. Cells with rapid growth rates (e.g., epithelium, bone marrow, hair follicles, sperm) are very susceptible to damage, and the effects may manifest in virtually any body system. Gastrointestinal System The most common side effects of chemotherapy are nausea and vomiting, which may persist for 24 to 48 hours; delayed nausea and vomiting may occur up to 1 week after administration. The experience of chemotherapy-induced nausea and vomiting (CINV) may affect quality of life, psychological status, nutrition, fluid and electrolyte status, functional ability, compliance with treatment, and utilization of health care resources (Gonella & Di Giulio, 2015). Comorbidities, the underlying malignancy, other treatment approaches, and medications, as well as symptoms (i.e., pain), may contribute to CINV. Acute CINV is experienced in the first 24 hours after chemotherapy with a maximal intensity after 5-6 hours; delayed CINV occurs 24 hours posttreatment and may last as many as 7 days with a maximal intensity 48-72 hours after drug administration (Gonella & Di Giulio, 2015). Anticipatory nausea and vomiting, occurring prior to administration of chemotherapy, may be a conditioned response triggered by a stimulus such as the smell of the infusion setting, the sight of the nurse, or the outpatient center waiting room. Several mechanisms are responsible for the occurrence of nausea and vomiting, including activation of multiple receptors found in the vomiting center of the medulla, the chemoreceptor trigger zone, the gastrointestinal tract, the pharynx, and the cerebral cortex. Activation of neurotransmitter receptors in these areas is thought to induce CINV. Stimulation may originate through peripheral, autonomic, vestibular, or cognitive pathways. The primary neuroreceptors known to be implicated in CINV are 5-hydroxytryptamine (5-HT or serotonin) and dopamine receptors (NCCN, 2015e). The approach for managing CINV is based on the knowledge of the probability of emesis of the chemotherapy agents used. Algorithms are used to prevent and treat CINV based on national guidelines that consider this classification of chemotherapy agents (NCCN, 2015e). Corticosteroids, phenothiazines, sedatives, and histamines are helpful, especially when used in combination with serotonin blockers to provide antiemetic protection (NCCN, 2015e). In order to manage delayed nausea and vomiting, antiemetic medications may be combined and are given for the first week at home after chemotherapy. Nonpharmacologic approaches such as relaxation techniques, imagery, acupressure, or acupuncture can help decrease stimuli contributing to symptoms and may be most helpful for patients with anticipatory nausea and vomiting. Small, frequent meals, bland foods, and comfort foods may reduce the frequency or severity of symptoms. Stomatitis is commonly associated with some chemotherapy agents because of the rapid turnover of epithelium that lines the oral cavity. The entire gastrointestinal tract is susceptible to mucositis (inflammation of the mouth, throat, and gastrointestinal tract) with diarrhea. Antimetabolites and antitumor antibiotics are the major culprits in mucositis and other gastrointestinal symptoms, which can be severe in some patients. Hematopoietic System Many chemotherapy agents cause some degree of myelosuppression (depression of bone marrow function), resulting in decreased WBCs (leukopenia), granulocytes (neutropenia), red blood cells (RBCs) (anemia), and platelets (thrombocytopenia) and increased risk of infection and bleeding. Depression of these cells is the usual reason for limiting the dose of the chemotherapy. Myelosuppression is predictable; for most agents, patients usually reach the point at which blood counts are lowest 7 to 14 days after chemotherapy has been given. During these 2 weeks, nurses anticipate associated toxicities, especially a fever associated with neutrophil count less than 1,500 cells/mm3. Frequent monitoring of blood cell counts is essential, and patients are educated about strategies to protect against infection, injury, and blood loss, particularly while counts are low (Manea, 2014). Other agents—colony-stimulating factors (granulocyte colony-stimulating factor [G-CSF] and granulocyte-macrophage colony-stimulating factor [GM-CSF])—can be given after chemotherapy to stimulate the bone marrow to produce WBCs, especially neutrophils, at an accelerated rate, thus decreasing the duration of neutropenia. G-CSF and GM-CSF decrease the episodes of infection and the need for antibiotics and allow for more timely treatment cycles of chemotherapy with less need to reduce the dosage. Erythropoietin (EPO) stimulates RBC production, thus decreasing the symptoms of treatment-induced chronic anemia and reducing the need for blood transfusions. Interleukin 11 (IL-11) (oprelvekin [Neumega]) stimulates the production of megakaryocytes (precursors to platelets) and can be used to prevent and treat severe thrombocytopenia but has had limited use because of toxicities, such as HSR; capillary leak syndrome; pulmonary edema; atrial dysrhythmias; and nausea, vomiting, and diarrhea (Kuter, 2015). Renal System Some chemotherapy agents damage the kidneys because they impair water secretion, leading to syndrome of inappropriate secretion of antidiuretic hormone (SIADH), decrease renal perfusion, precipitate end products after cell lysis, and cause interstitial nephritis (Comerford, 2015). Cisplatin (Platinol), methotrexate, and mitomycin (Mutamycin) are particularly toxic to the kidneys. Rapid tumor cell lysis after chemotherapy results in increased urinary excretion of uric acid, which can cause renal damage. In addition, intracellular contents are released into the circulation, resulting in hyperkalemia, hyperphosphatemia, and hypocalcemia and obstructive nephropathy. (See later discussion of tumor lysis syndrome.) Monitoring laboratory values of blood urea nitrogen (BUN), serum creatinine, creatinine clearance, and serum electrolytes is essential (Comerford, 2015). Adequate hydration, diuresis, alkalinization of the urine to prevent formation of uric acid crystals, and administration of allopurinol (Zyloprim) may be used to prevent renal toxicity. Amifostine has demonstrated an ability to minimize renal toxicities associated with cisplatin, cyclophosphamide (Cytoxan), and ifosfamide (Ifex) therapy. Hemorrhagic cystitis is a bladder toxicity that can result from cyclophosphamide and ifosfamide therapy. Hematuria can range from microscopic to frank bleeding with symptoms ranging from transient irritation during urination, dysuria, and suprapubic pain to life-threatening hemorrhage. Protection of the bladder focuses on aggressive IV hydration, frequent voiding, and diuresis. Mesna (Mesnex) is a cytoprotectant agent that binds with the toxic metabolites of cyclophosphamide or ifosfamide in the kidneys to prevent hemorrhagic cystitis. Cardiopulmonary System Several agents are associated with cardiac toxicity. Anthracyclines (e.g., daunorubicin, doxorubicin) are known to cause irreversible cumulative cardiac toxicities, especially when total dosage reaches 300 mg/m2 and 550 mg/m2, respectively (Comerford, 2015). If these agents are given in the presence of thoracic radiation therapy or other agents with cardiotoxicity potential, the cumulative dose limit is lower. Patients at increased risk for the development of cardiopulmonary toxicities include those older than 70 years, those with a history of preexisting cardiac disease, hypertension, tobacco use, renal or hepatic dysfunction, and longer survival time. Dexrazoxane (Zinecard) has been used on a limited basis as a cardioprotectant when doxorubicin is needed in individuals who have already received a cumulative dose limit and continuation of therapy is deemed beneficial. Patients with known cardiac disease (e.g., heart failure) are treated with lower doses or agents not known to be associated with cardiac toxicity. Cardiac ejection fraction (volume of blood ejected from the heart with each beat) and other signs of heart failure must be monitored closely. Bleomycin (Blenoxane), carmustine (BCNU), busulfan (Busulfex, Myleran), mitomycin, and paclitaxel/docetaxel, among other agents, have toxic effects on lung function, such as alveolar damage, bronchospasm, pneumonitis, and pulmonary fibrosis. Therefore, patients are monitored closely for changes in pulmonary function, including pulmonary function test results. Patients with known lung disease are treated with alternative agents not known to cause pulmonary toxicity. When pulmonary toxicity occurs, the agent is stopped and patients are treated with steroids and other supportive therapies (Schulmeister, 2014). Capillary leak syndrome with resultant pulmonary edema is an effect of cytarabine (DepoCyt, Tarabine, Ara-C), mitomycin C, cyclophosphamide, and carmustine. Subtle onset of dyspnea and cough may progress rapidly to acute respiratory distress and subsequent respiratory failure. Patients who are at significant risk for capillary leak syndrome are monitored closely. Reproductive System Testicular and ovarian function can be affected by chemotherapeutic agents, resulting in possible sterility. Women may develop problems with ovulation or early menopause, whereas men may develop temporary or permanent azoospermia (absence of spermatozoa). Because treatment may damage reproductive cells, banking of sperm is often recommended for men before treatment is initiated (Frankel Kelvin, 2015). Options available for women prior to initiation of chemotherapy include freezing (cryopreservation) of oocytes, embryos, or ovarian tissue (Frankel Kelvin, 2015). Patients and their partners are informed about potential changes in reproductive function resulting from chemotherapy. In addition, many chemotherapy agents are known or thought to be teratogenic. Therefore, patients are advised to use reliable methods of birth control while receiving chemotherapy and not to assume that sterility has resulted. Neurologic System Chemotherapy-induced neurotoxicity, a potentially dose- limiting toxicity, can affect the central nervous system, peripheral nervous system, and/or the cranial nerves. Neurotoxicity characterized by metabolic encephalopathy can occur with ifosfamide, high-dose methotrexate, and cytarabine. With repeated doses, the taxanes and plant alkaloids, especially vincristine, can cause cumulative peripheral nervous system damage with sensory alterations in the feet and hands. These sensations can be described as tingling, pricking, or numbness of the extremities; burning or freezing pain; sharp, stabbing, or electric shock-like pain; and extreme sensitivity to touch. If unreported by patients or undetected, progressive motor axon damage can lead to loss of deep tendon reflexes, with muscle weakness, loss of balance and coordination, and paralytic ileus. Severe peripheral neuropathies may lead to diminished quality of life and functional abilities and result in dose reductions, a change in chemotherapy regimen, or early cessation of treatment (Tofthagen, Visovsky, & Hopgood, 2013). Although often reversible, these side effects may take many months to resolve or persist indefinitely. Along with the usual paresthesias of the hands and feet, oxaliplatin has a unique and frightening neurotoxicity presentation that is often precipitated by exposure to cold and is characterized by pharyngolaryngeal dysesthesia consisting of lip paresthesia, discomfort or tightness in the back of the throat, inability to breathe, and jaw pain. Quality and Safety Nursing Alert Patients receiving oxaliplatin must be instructed to avoid drinking cold fluids or going outside with hands and feet exposed to cold temperatures to avoid exacerbation of these symptoms. Cisplatin may cause peripheral neuropathies and hearing loss due to damage to the acoustic nerve. Cognitive Impairment Many patients with cancer experience difficulty with remembering dates, multitasking, managing numbers and finances, organization, face or object recognition, inability to follow directions, feeling easily distracted, and motor and behavioral changes. Although not completely understood, these are viewed as symptoms of cognitive impairment, defined as a decline in the information-handling processes of attention and concentration, executive function, information processing speed, language, visual-spatial skill, psychomotor ability, learning, and memory (Von Ah, 2015). Commonly referred to by patients as "chemo brain," cognitive impairment has been associated with both cancer and cancer treatments, including surgery, radiation, chemotherapy, and targeted agents (Bender & Thelen, 2013). The symptoms may be subtle or profound with potential negative effects on functional abilities, employment, independence, quality of life, and psychosocial status. Comorbidities, age, medications, pain, impaired nutrition, anemia, fatigue, fluid and electrolyte disturbances, organ dysfunction, infection, and hormonal imbalances are factors that may contribute to the experience of cognitive impairment and make it difficult to fully understand. Underlying mechanisms of cognitive impairment in patients with cancer being explored include neurotoxic effects, oxidative stress, hormonal changes, immune dysregulation, cytokine release, clotting, genetic predisposition, and accelerated aging processes (Merriman, Von Ah, Miaskowski, et al., 2013; Von Ah, 2015) Fatigue Cancer-related fatigue has been defined as an unusual, persistent, and subjective sense of tiredness that is not proportional to recent activity and interferes with usual functioning (NCCN, 2015f). Fatigue is a distressing side effect for most patients that greatly affects quality of life, during treatment and for months after treatment. The health care team works together to identify effective pharmacologic and nonpharmacologic approaches for fatigue management. Nursing Management Nurses play an important role in assessing and managing many of the problems experienced by patients receiving chemotherapy. Chemotherapy agents affect both normal and malignant cells; therefore, their effects are often widespread, affecting many body systems. Laboratory and physical assessments of metabolic indices and the dermatologic, hematologic, hepatic, renal, cardiovascular, neurologic, and pulmonary systems are critical in evaluating the body's response to chemotherapy. These assessments are performed prior to, during, and after a course of chemotherapy to determine optimal treatment options, evaluate the patient's response, and monitor toxicity. Patients are monitored for long-term effects of chemotherapy after active treatment has been completed during the period of survivorship (see Chart 15-4). Assessing Fluid and Electrolyte Status Anorexia, nausea, vomiting, altered taste, mucositis, and diarrhea put patients at risk for nutritional and fluid and electrolyte disturbances. Therefore, it is important for the nurse to assess the patient's nutritional and fluid and electrolyte status on an ongoing basis and to identify creative ways to encourage an adequate fluid and dietary intake. Chart 15-4 Potential Long-Term Complications of Cancer Chemotherapy: Abnormalities in senses of taste, smell, and touch Abnormal balance, tremors, or weakness Avascular necrosis Cardiovascular toxicity (coronary artery disease, myocardial infarction, congestive heart failure, valvular heart disease, peripheral arterial disease) Decreased libido Dental caries Dry mouth Dysphagia Dyspnea on exertion Growth retardation in children Herpes infections (zoster and varicella) Hypothyroidism Immune dysfunction Infertility Osteoporosis Pericarditis (acute or chronic) Pneumococcal sepsis Pneumonitis (acute or chronic) Secondary cancers: Acute myeloid leukemia Myelodysplastic syndromes Non-Hodgkin lymphoma Solid tumors (especially bone and soft tissue, lung, breast) Thyroid cancer Thymic hyperplasia Assessing Cognitive Status Nurses should assess patients routinely for indications of cognitive impairment. Prior to the initiation of treatment, patients and families should be informed about the possibility of cognitive impairment. Nursing assessment plays an important role in determining the need for referral for neurocognitive evaluation and intervention (Jansen, 2013). Modifying Risks for Infection and Bleeding Suppression of the bone marrow and immune system is expected and frequently serves as a guide in determining appropriate chemotherapy dosage but increases the risk of anemia, infection, and bleeding disorders. Nursing assessment and care address factors that would further increase the patient's risk. The nurse's role in decreasing the risk of infection and bleeding is discussed further in the Nursing Care of Patients With Cancer section (see Chart 15-7). Administering Chemotherapy Nurses must be aware of chemotherapy and other agents most associated with HSRs, strategies for prevention, signs and symptoms characteristic of HSRs, and the appropriate early and time-sensitive interventions for preventing progression to anaphylaxis. Nurses provide patient and family education that emphasizes two key points: the importance of adhering to prescribed self-administered premedication before presenting to the infusion center, and recognizing and reporting the signs and symptoms to the nurse once the infusion has started. Patients and families are also educated about signs and symptoms that may occur at home following discharge from the infusion area that may warrant medication administration or immediate transport to the emergency department for further assessment and treatment. The local effects of the chemotherapeutic agent are also of concern. The patient is observed closely during administration of the agent because of the risk and consequences of extravasation. Prevention of extravasation is essential and relies on vigilant nursing care (Neuss et al., 2013). Selection of peripheral veins, skilled venipuncture, and careful administration of medications are essential. Peripheral administration is limited to short duration (less than 1 hour; IV push or bolus) infusions using only a soft, plastic catheter placed in the forearm area. Continuous infusion of vesicants that takes longer than 1 hour or are given frequently are given only via a central line, such as a right atrial silastic catheter, implanted venous access device, or PICC. These long-term venous access devices promote safety during medication administration and reduce problems with repeated access to the circulatory system (see Figs. 15-3 and 15-4). Indwelling or subcutaneous venous access devices require consistent nursing care. Complications include infection and thrombosis (Cotogni, Barbero, Garrino, et al., 20of extravasation during administration of vesicant agents include the following: Absence of blood return from the IV catheter Resistance to flow of IV fluid Burning or pain, swelling, or redness at the site Difficulties or problems with administration of chemotherapeutic agents are brought to the attention of the primary provider promptly so that corrective measures can be taken to minimize local tissue damage. The nurse evaluates the patient receiving neurotoxic chemotherapy, communicates findings with the medical oncologist, provides education to patients and families, and makes appropriate referrals for complete neurologic evaluation and occupational or rehabilitative therapies (Coyle, Griffie, & Czaplewski, 2014). Quality and Safety Nursing Alert If extravasation is suspected, the medication administration is stopped immediately. An extravasation kit should be readily available with emergency equipment and antidote medications, as well as a quick reference for how to properly manage an extravasation of the specific vesicant agent used (although evidence-based data regarding effective antidotes are limited) (Gonzalez, 2013). Nurses should refer to their organization's policy and procedures for reporting, managing, and documenting extravasation. Safety standards require the availability of defined extravasation management procedures, including antidote order sets and accessibility of antidotes in all settings where vesicant chemotherapy is given (Neuss et al., 2013). Recommendations and guidelines for managing vesicant extravasation, which vary with each agent, have been issued by individual medication manufacturers, pharmacies, and the ONS (Neuss et al., 2013; Schulmeister, 2014). Preventing Nausea and Vomiting Nurses are integral to the prevention and management of CINV. They collaborate with other members of the oncology care team to identify factors contributing to the experience of CINV and select effective antiemetic regimens that maximize currently available therapies. Nurses provide education for patients and families regarding antiemetic regimens and care for delayed CINV that may continue at home after the chemotherapy infusion has completed (NCCN, 2015e). Managing Cognitive Changes Although several approaches have been explored, no evidence-based guidelines for the prevention, treatment, or management of cognitive impairment have been established. Examples of nonpharmacologic approaches that nurses recommend to patients include exercise, natural restorative environmental intervention (walking in nature or gardening), and cognitive training programs (Merriman, et al., 2013; Von Ah, 2015). Nurses should assist patients to address factors, such as fluid and electrolyte imbalances, nutrition deficits, fatigue, pain, and infection to minimize their contribution to cognitive impairment. Managing Fatigue Fatigue is a common side effect of chemotherapy. Nurses assist patients to explore the role that the underlying disease processes, combined treatments, other symptoms, and psychosocial distress play in the patient's experience of fatigue. In addition, nurses work with the patient and other team members to identify effective approaches for fatigue management (NCCN, 2015f). Protecting Caregivers Nurses involved in handling chemotherapeutic agents may be exposed to low doses of the agents by direct contact, inhalation, or ingestion. Studies suggest that nurses and others preparing chemotherapy agents or handling linens and other materials that are contaminated with body fluids of patients receiving chemotherapy have been unknowingly exposed (Leduc-Souville, Bertrand, & Schlatter, 2013). Skin and eye irritation, nausea, vomiting, nasal mucosal ulcerations, infertility, low-birth-weight babies, congenital anomalies, spontaneous abortions, and mutagenic substances in urine have been reported in nurses preparing and handling chemotherapy agents (Leduc-Souville et al., 2013). The Occupational and Safety Health Administration (OSHA), the ONS, hospitals, and other health care agencies have developed specific precautions for health care providers involved in the preparation and administration of chemotherapy and for handling materials exposed to body fluids of those who have received these hazardous agents (see Chart 15-5) (Neuss et al., 2013; Schulmeister, 2014). Nurses must be familiar with their institutional policies and procedures regarding personal protective equipment, handling and disposal of chemotherapy agents and supplies, and management of accidental spills or exposures. Emergency spill kits should be readily available in any treatment area where chemotherapy is prepared or given. Precautions must also be taken when handling any bodily fluids or excreta from the patient, as many agents are excreted unaltered in urine and feces. Nurses in all treatment settings have a responsibility to educate patients, families, caregivers, assistive personnel, and housekeepers concerning precautions.

Safe admin & Focus on nursing considerations for the following medications:

Chlorambucil (Alkalyting agent): Actions: Alkylates cellular DNA, interfering with the replication of susceptible cells. Adverse Effects: Tremors, muscle twitching, confusion, nausea, hepatotoxicity, bone marrow suppression, sterility, cancer. Implementation with Rationale • Arrange for blood tests before, periodically during, and for at least 3 weeks after therapy to monitor bone marrow function to aid in determining the need for a change in dose or discontinuation of the drug (see Box 14.5). • Administer medication according to scheduled protocol and in combination with other drugs as indicated to improve effectiveness. • Ensure that the patient is well hydrated to decrease risk of renal toxicity. • Protect the patient from exposure to infection; limit invasive procedures when bone marrow suppression limits the patient's immune/inflammatory responses. • Provide small, frequent meals, frequent mouth care, and dietary consultation as appropriate to maintain nutrition when GI effects are severe. Anticipate the need for antiemetics if necessary (see Box 14.6). • Arrange for proper head covering at extremes of temperature if alopecia occurs; a wig, scarf, or hat is important for maintaining body temperature. • Provide patient teaching about the following: • Follow the appropriate dosage regimen, including dates to return for further doses. • Cover the head at extremes of temperature. • Maintain nutrition if GI effects are severe. • Avoid exposure to infection. • Plan for appropriate rest periods because fatigue and weakness are common effects of the drugs. • Consult with a health care provider, if appropriate, related to the possibility of impaired fertility. • Use barrier contraceptives to reduce the risk of pregnancy during therapy. Methotrexate (Antimetabolite): Actions: Inhibits folic acid reductase, leading to inhibition of DNA synthesis and inhibition of cellular replication; affects the most rapidly dividing cells. Adverse Effects: Fatigue, malaise, rashes, alopecia, ulcerative stomatitis, hepatic toxicity, severe bone marrow suppression, interstitial pneumonitis, chills, fever, anaphylaxis. Implementation with Rationale • Arrange for blood tests to monitor bone marrow function before, periodically during, and for at least 3 weeks after therapy to arrange to discontinue the drug or reduce the dose as needed (see Box 14.5). • Administer medication according to the scheduled protocol and in combination with other drugs as indicated to improve the effectiveness of drug therapy. • Ensure that the patient is well hydrated to decrease the risk of renal toxicity. • Provide small, frequent meals, frequent mouth care, and dietary consultation as appropriate to maintain nutrition when GI effects are severe. Anticipate the use of antiemetics as necessary (see Box 14.4). • Arrange for proper head covering at extremes of temperature if alopecia occurs; a wig, scarf, or hat is important for maintaining body temperature. If alopecia is an anticipated effect of drug therapy, advise the patient to obtain a wig or head covering before the condition occurs. • Protect the patient from exposure to infections because bone marrow suppression will limit immune/inflammatory responses. • Provide support and encouragement to help the patient cope with the diagnosis and the effects of drug therapy. • Provide the following patient teaching: • Follow the appropriate dosage regimen, including dates to return for further doses. Patients need to be reminded to report all other drugs and alternative therapies that they might be using. Box 14.8 discusses alternative therapies often used by cancer patients that could interact with their drug regimen. • Maintain nutrition if GI effects are severe. • Cover the head at extremes of temperature if alopecia is anticipated. • Plan for appropriate rest periods because fatigue and weakness are common effects of the drugs. • Avoid situations that might lead to infection, including crowded places, sick people, and working in the soil. • Use safety measures such as not driving or using dangerous equipment, due to possible dizziness, headache, and drowsiness. • Think about consulting with a health care provider, if appropriate, due to the possibility of impaired fertility. • Use barrier contraceptives to reduce the risk of pregnancy during therapy. Doxorubicin (Antineoplastic Antibiotic): Actions: Binds to DNA and inhibits DNA synthesis in susceptible cells, causing cell death. Adverse Effects: Cardiac toxicity, complete but reversible alopecia, nausea, vomiting, mucositis, red urine, myelosuppression, fever, chills, rash. Implementation with Rationale • Arrange for blood tests to monitor bone marrow function before, periodically during, and for at least 3 weeks after therapy to arrange to discontinue the drug or reduce the dose as needed (see Box 14.5). • Monitor cardiac and respiratory function, as well as clotting times as appropriate for the drug being used, to arrange to discontinue the drug or reduce the dose as needed. • Protect the patient from exposure to infection because bone marrow suppression will decrease immune/inflammatory reactions. • Administer medication according to scheduled protocol and in combination with other drugs as indicated to improve the effectiveness of drug therapy. • Ensure that the patient is well hydrated to decrease the risk of renal toxicity. • Provide small, frequent meals, frequent mouth care, and dietary consultation appropriate to maintain nutrition when GI effects are severe. Anticipate the need for antiemetics as necessary (see Box 14.4). • Arrange for proper head covering at extremes of temperature if alopecia occurs; a wig, scarf, or hat is important for maintaining body temperature. If alopecia is an anticipated effect of drug therapy, advise the patient to obtain a wig or head covering before the condition occurs to promote self-esteem and a positive body image. • Provide the following patient teaching: • Follow the appropriate dosage regimen, including dates to return for further doses. • Maintain nutrition if GI effects are severe. • Cover the head at extremes of temperature if alopecia is anticipated. • Plan for appropriate rest periods because fatigue and weakness are common effects of the drugs. • Avoid exposure to possible infection, including avoiding crowded places, sick people, and working in soil. • Use safety measures such as avoiding driving or using dangerous equipment to prevent injury due to possible dizziness, headache, and drowsiness. • Consult with a health care provider, if appropriate, regarding possibility of impaired fertility. • Use barrier contraceptives to reduce the risk of pregnancy during therapy. Vincristine (Mitotic Inhibitor): Actions: Arrests mitotic division at the stage of metaphase; the exact mechanism of action is not understood. Adverse Effects: Ataxia, cranial nerve manifestations, neuritic pain, muscle wasting, constipation, leukopenia, weight loss, loss of hair, death. Implementation with Rationale • Arrange for blood tests to monitor bone marrow function before, periodically during, and for at least 3 weeks after therapy to arrange to discontinue the drug or reduce the dose as needed (see Box 14.5). Arrange for baseline and periodic ECG if using eribulin to monitor the QT interval which could become prolonged. • Avoid direct skin or eye contact with the drug. Wear protective clothing and goggles while preparing and administering the drug to prevent toxic reaction to the drug. • Administer medication according to scheduled protocol and in combination with other drugs as indicated to improve the effectiveness of drug therapy. • Ensure that the patient is well hydrated to decrease the risk of renal toxicity. • Monitor injection sites to arrange appropriate treatment for extravasation, local inflammation, or cellulitis. • Protect the patient from exposure to infection because bone marrow suppression will decrease immune/inflammatory responses. • Provide small, frequent meals, frequent mouth care, and dietary consultation as appropriate to maintain nutrition if GI effects are severe. Anticipate the need for antiemetics as necessary (see Box 14.4). • Arrange for proper head covering at extremes of temperature if alopecia or epilation occurs; a wig, scarf, or hat is important for maintaining body temperature. If alopecia is an anticipated effect of drug therapy, advise the patient to obtain a wig or head covering before the condition occurs to promote self-esteem and a positive body image. • Provide the following patient teaching: • Follow the appropriate dosage regimen, including dates to return for further doses. • Maintain nutrition if GI effects are severe. • Cover the head at extremes of temperature if alopecia is anticipated. • Plan for appropriate rest periods because fatigue and weakness are common effects of the drugs. • Avoid situations that might lead to infection, including crowded areas, sick people, and working in the soil. • Use safety measures such as avoiding driving or using dangerous equipment, due to possible dizziness, headache, and drowsiness. • Consult with a health care provider, as appropriate, related to the possibility of impaired fertility. • Use barrier contraceptives to reduce the risk of pregnancy during therapy. Tamoxifen (Hormone Modulator): Actions: Competes with estrogen for binding sites in target tissues, such as the breast; a potent antiestrogenic agent. Adverse Effects: Hot flashes, rash, nausea, vomiting, vaginal bleeding, menstrual irregularities, edema, pain, cerebrovascular accident, pulmonary emboli. Implementation with Rationale • Arrange for blood tests to monitor bone marrow function before and periodically during therapy to discontinue the drug or reduce the dose as needed (see Box 14.5) • Provide small, frequent meals, frequent mouth care, and dietary consultation as appropriate to maintain nutrition when GI effects are severe. • Provide comfort measures to help the patient cope with menopausal signs and symptoms such as hygiene measures, temperature control, and stress reduction. Expect to reduce the dose if these effects become severe or intolerable. • Advise the patient of the need to use barrier contraceptive measures while taking these drugs to avert serious fetal harm. • Provide the following patient teaching: • Follow the appropriate dosage regimen, including dates to return for further doses. • Maintain nutrition even if GI effects are severe. • Use barrier contraceptives to prevent pregnancy during therapy • Try using comfort measures such as staying in a cool environment. • Perform hygiene and skin care and use measures to reduce stress to help cope with menopausal effects. • You may need to have periodic blood tests to monitor the effects of this drug on your body. FOCUS ON Safe Medication Administration OSHA (Occupational Safety and Health Administration) and the CDC (Centers for Disease Control and Prevention) warn health care providers about the risk of exposure to antineoplastic agents. The list of hazardous drugs was updated in 2014 and includes drugs that could cause cancer, fetal death, reproductive toxicity, organ toxicity at low doses and genotoxicity. Antineoplastics generally fall into this category. Special care needs to be taken when administering these drugs. Some of these drugs must be prepared in a special setting using a hood that cuts down lung exposure. The nurse should avoid any skin, eye, or mucous membrane contact with these drugs that involves always wearing gloves when exposed to the drug, oral or injected, and may involve using protective goggles, a mask or respirator to protect the lungs, depending on the drug being used. Protecting other people is also an issue. Placing used syringes, etc. in a yellow box for biohazard disposal; double flushing patient wastes; if the patient is taking the drug at home the proper disposal of the drug and administration materials need to be stressed. Nurses working in cancer centers that do a great deal of antineoplastic drug administration receive special training to reduce the risk of exposure and to protect the health care providers and others from the potentially dangerous effects of these drugs. FOCUS ON Safe Medication Administration Preventing and Treating Extravasation When an IV antineoplastic drug extravasates, or infiltrates into the surrounding tissue, serious tissue damage can occur. These drugs are toxic to cells, and the resulting tissue injury can result in severe pain, scarring, nerve and muscle damage, infection, and in very severe cases even amputation of the limb. Prevention is the best way to deal with extravasation. Interventions that can help to prevent extravasation include the following: Use a distal vein, and avoid small veins on the wrist or digits; never use an existing line unless it is clearly open and running well; start the infusion with plain 5% dextrose in water (D5W) and monitor for any sign of extravasation; check the site frequently and ask the patient to report any discomfort in the area; and, if at all possible, do not use an infusion pump to administer one of these drugs because it will continue to deliver the drug under pressure and can cause severe extravasation. If extravasation occurs, there are specific antidotes to use with some antineoplastic drugs. The antidote is usually administered through the IV line to allow it to infiltrate the same tissue, but if the line has been pulled, a tuberculin syringe can be used to inject the antidote subcutaneously into the tissue surrounding the infiltrated area. Drug: etoposide teniposide vinblastine vincristine Antidote and Suggested Dosage: Hyaluronidase (generic), 0.2 mL subcutaneously; then apply heat to disperse the drug and alleviate pain Drug: daunorubicin doxorubicin vinblastine vincristine Antidote and Suggested Dosage: 8.4% Sodium bicarbonate, 5 mL; flush area with normal saline, apply cold compress; local infiltration with corticosteroids may also be ordered at 25-50 mg/mL of extravasate; if ulceration occurs, a plastic surgery consultation should be obtained Drug: mechlorethamine Antidote and Suggested Dosage: Isotonic sodium thiosulfate (1/6 M), 10 mL infused immediately, then apply an ice compress for 6-12 h Drug: dactinomycin Antidote and Suggested Dosage: 50-mg Ascorbic acid injection; flush area with normal saline and apply cold compresses; consider the use of an injectable corticosteroid if reaction is severe

Anemia diagnosis, diet, signs and symptoms.

Clinical Manifestations Aside from the severity of the anemia itself, several factors influence the development of anemia-associated symptoms: the rapidity with which the anemia has developed, the duration of the anemia (i.e., its chronicity), the metabolic requirements of the patient, other concurrent disorders or disabilities (e.g., cardiac or pulmonary disease), and complications or concomitant features of the condition that produced the anemia. In general, the more rapidly an anemia develops, the more severe its symptoms (Bunn, 2017). An otherwise healthy person can often tolerate as much as a 50% gradual reduction in hemoglobin (e.g., over months) without pronounced symptoms or significant incapacity, whereas the rapid loss of as little as 30% (e.g., over minutes) may precipitate profound vascular collapse in the same person. A person who has become gradually anemic, with hemoglobin levels between 9 and 11 g/dL, usually has fewer or no symptoms other than slight tachycardia on exertion and possibly fatigue. People who customarily are very active or who have significant demands on their lives (e.g., a single, working mother of small children) are more likely to have symptoms, and those symptoms are more likely to be pronounced than in more sedentary people. Patients with hypothyroidism with decreased oxygen needs may be completely asymptomatic, without tachycardia or increased cardiac output, at a hemoglobin level of 10 g/dL. Similarly, patients with coexistent cardiac, vascular, or pulmonary disease may develop more pronounced symptoms of anemia (e.g., dyspnea, chest pain, muscle pain or cramping) with a higher hemoglobin level than those without these concurrent health problems. Finally, some anemias are complicated by various other abnormalities that do not result from the anemia but are inherently associated with these particular diseases. These abnormalities may give rise to symptoms that completely overshadow those of the anemia, as in the painful crises of SCD. Assessment and Diagnostic Findings A variety of hematologic studies are performed to determine the type and cause of the anemia. In an initial evaluation, the hemoglobin, hematocrit, reticulocyte count, and RBC indices, particularly the mean corpuscular volume (MCV) and red cell distribution width (RDW), are especially useful. Iron studies (serum iron level, total iron-binding capacity [TIBC], percent saturation, and ferritin), as well as serum vitamin B12 and folate levels, are also frequently obtained (Goroll & Mulley, 2014a). Other tests include haptoglobin and erythropoietin levels. The remaining complete blood count (CBC) values are useful in determining whether the anemia is an isolated problem or part of another hematologic condition, such as leukemia or myelodysplastic syndrome (MDS). Bone marrow aspiration may be performed. In addition, other diagnostic studies may be performed to determine the presence of underlying chronic illness, such as malignancy, or the source of any blood loss, such as polyps or ulcers within the gastrointestinal (GI) tract. Based on the assessment data, major nursing diagnoses may include: Fatigue related to decreased hemoglobin and diminished oxygen-carrying capacity of the blood Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients Activity intolerance related to inadequate hemoglobin and hematocrit Noncompliance with prescribed therapy MAINTAINING ADEQUATE NUTRITION A nutritional assessment is important, because it may indicate deficiencies in essential nutrients such as iron, vitamin B12, and folate. Strict vegetarians are at risk for megaloblastic anemias if they do not supplement their diet with vitamin B12. Older adults also may have a diminished intake of vitamin B12 or folate. Inadequate intake of essential nutrients, such as iron, vitamin B12, folic acid, and protein, can cause some anemias. The symptoms associated with anemia (e.g., fatigue, anorexia) can in turn interfere with maintaining adequate nutrition. A healthy diet should be encouraged. The nurse should inform the patient that alcohol interferes with the utilization of essential nutrients and advise moderation in the intake of alcoholic beverages (Cylwik, Naklick, Gruszewska, et al., 2013) (see Chapter 5). Dietary education sessions should be individualized, involve family members, and include cultural aspects related to food preferences and food preparation. Dietary supplements (e.g., vitamins, iron, folate, protein) may be prescribed. Equally important, the patient and family must understand the role of nutritional supplements in the proper context, because many forms of anemia are not the result of a nutritional deficiency. In such cases, even an excessive intake of nutritional supplements will not improve the anemia. A potential problem in patients with chronic transfusion requirements occurs with the indiscriminate use of iron supplements. Unless an aggressive program of chelation therapy is implemented, these patients are at risk for iron overload from their transfusions (Jordan, Adams-Graves, Kanter-Wasko, et al., 2015). The addition of an iron supplement only exacerbates the situation.

Signs and symptoms of and nursing interventions for increased ICP.

Clinical Manifestations If ICP increases to the point at which the brain's ability to adjust has reached its limits, neural function is impaired; this may be manifested at first by clinical changes in LOC and later by abnormal respiratory and vasomotor responses. Any sudden change in the patient's condition, such as restlessness (without apparent cause), confusion, or increasing drowsiness, has neurologic significance. These signs may result from compression of the brain due to swelling from hemorrhage or edema, an expanding intracranial lesion (hematoma or tumor), or a combination of both. As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required. As neurologic function deteriorates further, the patient becomes comatose and exhibits abnormal motor responses in the form of decortication (abnormal flexion of the upper extremities and extension of the lower extremities), decerebration (extreme extension of the upper and lower extremities), or flaccidity (see Fig. 66-1). If the coma is profound and irreversible with no known confounding factors, brainstem reflexes are absent, and respirations are impaired or absent, the patient may be evaluated for brain death (Wijdicks, 2013). Quality and Safety Nursing Alert The earliest sign of increasing ICP is a change in LOC. Agitation, slowing of speech, and delay in response to verbal suggestions may be early indicators. Detecting Increasing Intracranial Pressure (ICP): Early Signs and Symptoms of Increasing ICP Disorientation, restlessness, increased respiratory effort, purposeless movements, and mental confusion. These are early clinical indications of increasing ICP because the brain cells responsible for cognition are extremely sensitive to decreased oxygenation. Pupillary changes and impaired extraocular movements. These occur as the increasing pressure displaces the brain against the oculomotor and optic nerves (cranial nerves II, III, IV, and VI), which arise from the midbrain and brainstem (see Chapter 65). Weakness in one extremity or on one side of the body. This occurs as increasing ICP compresses the pyramidal tracts. Headache that is constant, increasing in intensity, and aggravated by movement or straining. This occurs as increasing ICP causes pressure and stretching of venous and arterial vessels in the base of the brain. Later Signs and Symptoms of Increasing ICP The level of consciousness continues to deteriorate until the patient is comatose (Glasgow Coma Scale score ≤8). The pulse rate and respiratory rate decrease or become erratic, and the blood pressure and temperature increase. The pulse pressure (the difference between the systolic and diastolic pressures) widens. The pulse fluctuates rapidly, varying from bradycardia to tachycardia. Altered respiratory patterns develop, including Cheyne-Stokes breathing (rhythmic waxing and waning of rate and depth of respirations alternating with brief periods of apnea) and ataxic breathing (irregular breathing with a random sequence of deep and shallow breaths). Projectile vomiting may occur with increased pressure on the reflex center in the medulla. Hemiplegia or decorticate or decerebrate posturing may develop as pressure on the brainstem increases; bilateral flaccidity occurs before death. Loss of brainstem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Nursing Interventions: MAINTAINING A PATENT AIRWAY The patency of the airway is assessed. Secretions that are obstructing the airway must be suctioned with care, because transient elevations of ICP occur with suctioning (Hickey, 2014). Hypoxia caused by poor oxygenation leads to cerebral ischemia and edema. Coughing is discouraged because it increases ICP. The lung fields are auscultated at least every 8 hours to determine the presence of adventitious sounds or any areas of congestion. Elevating the head of the bed may aid in clearing secretions and improve venous drainage of the brain. ACHIEVING AN ADEQUATE BREATHING PATTERN The patient must be monitored constantly for respiratory irregularities. Increased pressure on the frontal lobes or deep midline structures may result in Cheyne-Stokes respirations, whereas pressure in the midbrain can cause hyperventilation. If the lower portion of the brainstem (the pons and medulla) is involved, respirations become irregular and eventually cease. Hyperventilation therapy is a controversial therapy in traumatic brain injury used in some centers to reduce ICP by causing cerebral vasoconstriction and a decrease in cerebral blood volume. The nurse collaborates with the respiratory therapist in monitoring the PaCO2, which is usually maintained at less than 30 mm Hg. Patients undergoing hyperventilation therapy also benefit from multimodality monitoring to determine the overall effect of this therapy on brain perfusion (de Lima Oliveira et al., 2014). A neurologic observation record (see Fig. 66-6) is maintained, and all observations are made in relation to the patient's baseline condition. Repeated assessments of the patient are made (sometimes minute by minute) so that improvement or deterioration may be noted immediately. If the patient's condition deteriorates, the primary provider is notified emergently and preparations are made for surgical intervention. OPTIMIZING CEREBRAL TISSUE PERFUSION In addition to ongoing nursing assessment, strategies are initiated to reduce factors contributing to the elevation of ICP. Proper positioning helps reduce ICP. The patient's head is kept in a neutral (midline) position, maintained with the use of a cervical collar if necessary, to promote venous drainage. Elevation of the head is maintained at 30 to 45 degrees unless contraindicated. Extreme rotation of the neck and flexion of the neck are avoided, because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is also avoided, because this position causes an increase in intra-abdominal and intrathoracic pressures, which can produce an increase in ICP. Relatively minor changes in position can significantly affect ICP. If monitoring reveals that turning the patient raises ICP, rotating beds, turning sheets, and holding the patient's head during turning may minimize the stimuli that increase ICP. Research suggests that patient response to position change is highly variable and requires close hemodynamic monitoring and individualized care (Mitchell, Kirkness, & Blissitt, 2015). The Valsalva maneuver, which can be produced by straining at defecation or even moving in bed, raises ICP and is to be avoided. Stool softeners may be prescribed. If the patient is alert and able to eat, a diet high in fiber may be indicated. Abdominal distention, which increases intra-abdominal and intrathoracic pressure and ICP, should be noted. Enemas and cathartics are avoided if possible. When moving or being turned in bed, the patient can be instructed to exhale (which opens the glottis) to avoid the Valsalva maneuver. Mechanical ventilation presents unique problems for the patient with increased ICP. Before suctioning, the patient should be preoxygenated and briefly hyperventilated using 100% oxygen on the ventilator. Suctioning should not last longer than 15 seconds. High levels of positive end-expiratory pressure (PEEP) must be utilized cautiously, because they may decrease venous return to the heart and decrease venous drainage from the brain through increased intrathoracic pressure (Nemer, Caldeira, Santos, et al., 2015). Activities that increase ICP, as indicated by changes in waveforms, should be avoided if possible. Spacing of nursing interventions may prevent transient increases in ICP. During nursing interventions, the ICP should not increase above 25 mm Hg, and it should return to baseline levels within 5 minutes. Patients with increased ICP should not demonstrate a significant increase in pressure or change in the ICP waveform. Patients with the potential for a significant increase in ICP may need sedation before initiation of nursing activities (Bader, Littlejohns, & Olson, 2016). Emotional stress and frequent arousal from sleep are avoided. A calm atmosphere is maintained. Environmental stimuli (e.g., noise, conversation) should be minimal. MAINTAINING NEGATIVE FLUID BALANCE The administration of osmotic and loop diuretics is part of the treatment protocol to reduce ICP. Corticosteroids may be used to reduce cerebral edema (except when it results from trauma), and fluids may be restricted. All of these treatment modalities promote dehydration. Skin turgor, mucous membranes, urine output, and serum and urine osmolality are monitored to assess fluid status. If IV fluids are prescribed, the nurse ensures that they are given at a slow to moderate rate with an IV infusion pump, to prevent too-rapid administration and avoid overhydration. For the patient receiving mannitol, the nurse observes for the possible development of heart failure and pulmonary edema. The intent of treatment is to promote a shift of fluid from the intracellular to the intravascular compartment and to control cerebral edema. However, this shift of fluid volume to the intravascular compartment may overwhelm the ability of the myocardium to increase workload sufficient to meet these demands, which may cause failure and pulmonary edema. For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus (Hickey, 2014). These patients need careful oral hygiene, because mouth dryness occurs with dehydration. Frequently rinsing the mouth with nondrying solutions, lubricating the lips, and removing encrustations relieve dryness and promote comfort. PREVENTING INFECTION The risk of infection is greatest when ICP is monitored with an intraventricular catheter and increases with the duration of the monitoring. Most health care facilities have written protocols for managing these systems and maintaining their sterility; strict adherence to the protocols is essential. Aseptic technique must be used when managing the system and changing the ventricular drainage bag. The drainage system is also checked for loose connections, because they can cause leakage and contamination of the CSF as well as inaccurate readings of ICP. The nurse observes the character of the CSF drainage and reports increasing cloudiness or blood. The patient is monitored for signs and symptoms of meningitis: fever, chills, nuchal (neck) rigidity, and increasing or persistent headache. See Chapter 69 for a discussion of meningitis. MONITORING AND MANAGING POTENTIAL COMPLICATIONS The primary complication of increased ICP is brain herniation resulting in death (see Fig. 66-2). Nursing management focuses on detecting early signs of increasing ICP, because medical interventions are usually ineffective once later signs develop (Bader et al., 2016). Frequent neurologic assessments and documentation and analysis of trends will reveal the subtle changes that may indicate increasing ICP. Detecting Indications of Increasing Intracranial Pressure. The nurse assesses for and immediately reports any signs or symptoms of increasing ICP (see Chart 66-1). The focus is on detecting early signs of increasing ICP. Monitoring Intracranial Pressure. Because clinical assessment is not always a reliable guide in recognizing increased ICP, especially in patients who are comatose, monitoring of ICP and cerebral oxygenation is an essential part of management. ICP is monitored closely for continuous elevation or significant increase over baseline. The trend of ICP measurements over time is an important indication of the patient's underlying status. Vital signs are assessed when an increase in ICP is noted (Bader et al., 2016). Careful attention to aseptic technique is needed when handling any part of the monitoring system. The insertion site is inspected for signs of infection. Temperature, pulse, and respirations are closely monitored for systemic signs of infection. All connections and stopcocks are checked for leaks, because even small leaks can distort pressure readings and lead to infection (AANN, 2012). When ICP is monitored with a fluid system, the transducer is calibrated at a particular reference point, usually 2.5 cm (1 inch) above the ear with the patient in the supine position; this point corresponds to the level of the foramen of Monro (see Fig. 66-7). CSF pressure readings depend on the patient's position. For subsequent pressure readings, the head should be in the same position relative to the transducer. Fiberoptic catheters are calibrated before insertion and do not require further referencing; they do not require the head of the bed to be at a specific position to obtain an accurate reading. When technology is associated with patient management, the nurse must be certain that the technologic equipment is functioning properly. The most important concern must be the patient to whom equipment is attached. The patient and family must be informed about the technology and the goals of its use. The patient's response is monitored, and appropriate comfort measures are implemented to ensure that the patient's stress is minimized. Location of the foramen of Monro for calibration of the intracranial pressure monitoring system. ICP measurement is only one parameter; repeated neurologic checks and clinical examinations remain important measures. Astute observation, comparison of findings with previous observations, and interventions can assist in preventing life-threatening ICP elevations. MONITORING FOR SECONDARY COMPLICATIONS The nurse also assesses for complications of increased ICP, including diabetes insipidus and SIADH (see Chapters 13 and 52). Urine output should be monitored closely. Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Serum electrolyte levels are monitored for imbalances. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Monro-Kellie Hypothesis: Normally, a reciprocal relationship exists among the three intracranial volumes such that the ICP is maintained within normal limits. Because these volumes are practically incompressible, a change in one component must be balanced by an almost equal and opposite effect in one or both of the remaining components. This is known as the Monro-Kellie hypothesis. Of the three intracranial volumes, the fluid in the CSF compartment is the most easily displaced. The CSF (A) can be displaced from the ventricles and cerebral subarachnoid space to the spinal subarachnoid space, and it can also undergo increased absorption or decreased production. Because most of the blood in the cranial cavity is contained in the low-pressure venous system, venous compression (B) serves as a means of displacing blood volume.

TBI and Increased ICP complications: DI, SIADH, Cerebral perfusion, elevated ICPs (s/s).

Complications Complications of increased ICP include brainstem herniation, diabetes insipidus, and syndrome of inappropriate antidiuretic hormone (SIADH). Brainstem herniation results from an excessive increase in ICP in which the pressure builds in the cranial vault and the brain tissue presses down on the brainstem. This increasing pressure on the brainstem results in cessation of blood flow to the brain, leading to irreversible brain anoxia and brain death. Neurogenic diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The patient has excessive urine output, decreased urine osmolality, and serum hyperosmolarity (Grossman & Porth, 2014). Therapy consists of administration of fluids, electrolyte replacement, and administration of a synthetic vasopressin (desmopressin [DDAVP]). See Chapters 13 and 52 for a discussion of diabetes insipidus. SIADH is the result of increased secretion of ADH. The patient becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Treatment of SIADH includes fluid restriction (less than 800 mL/day with no free water), which is usually sufficient to correct the hyponatremia. In severe cases, careful administration of a 3% hypertonic saline solution may be therapeutic (Aylwin, Burst, Peri, et al., 2015). The change in serum sodium concentration should not exceed a correction rate of approximately 1.3 mEq/L/hr. See Chapters 13 and 52 for further discussion of SIADH. Monitoring Intracranial Pressure and Cerebral Oxygenation The purposes of ICP monitoring are to identify increased pressure early in its course (before cerebral damage occurs), to quantify the degree of elevation, to initiate appropriate treatment, to provide access to CSF for sampling and drainage, and to evaluate the effectiveness of treatment. ICP can be monitored with the use of an intraventricular catheter (ventriculostomy), a subarachnoid bolt, an epidural or subdural catheter, or a fiberoptic transducer-tipped catheter placed in the subdural space or in the ventricle (see Fig. 66-3). When a ventriculostomy or intraventricular catheter monitoring device is used for monitoring ICP, a fine-bore catheter is inserted into a lateral ventricle, preferably in the nondominant hemisphere of the brain (American Association of Neuroscience Nurses [AANN], 2012). The catheter is connected by a fluid-filled system to a transducer, which records the pressure in the form of an electrical impulse. In addition to obtaining continuous ICP recordings, the ventricular catheter allows CSF to drain, particularly during acute increases in pressure. The ventriculostomy can also be used to drain blood from the ventricle. Continuous drainage of CSF under pressure control is an effective method of treating intracranial hypertension. Another advantage of a ventricular catheter is access for the intraventricular administration of medications and the occasional instillation of air or a contrast agent for ventriculography. Complications associated with its use include infection, meningitis, ventricular collapse, occlusion of the catheter by brain tissue or blood, and problems with the monitoring system. The subarachnoid screw or bolt is a hollow device that is inserted through the skull and dura mater into the cranial subarachnoid space (Hickey, 2014). It has the advantage of not requiring a ventricular puncture. The subarachnoid screw is attached to a pressure transducer, and the output is recorded on an oscilloscope. The hollow screw technique also has the advantage of avoiding complications from brain shift and small ventricle size. Complications include infection and blockage of the screw by clot or brain tissue, which leads to a loss of pressure tracing and a decrease in accuracy at high ICP readings. An epidural monitor uses a pneumatic flow sensor to detect ICP. The epidural ICP monitoring system has a low incidence of infection and complications and appears to read pressures accurately. Calibration of the system is maintained automatically, and abnormal pressure waves trigger an alarm system. One disadvantage of the epidural catheter is the inability to withdraw CSF for analysis. A fiberoptic monitor, or transducer-tipped catheter, is an alternative to other intraventricular, subarachnoid, and subdural systems (Sandsmark, Kumar, Park, et al., 2012). The miniature transducer reflects pressure changes, which are converted to electrical signals in an amplifier and displayed on a digital monitor. The catheter can be inserted into the ventricle, subarachnoid space, subdural space, or brain parenchyma or under a bone flap. If inserted into the ventricle, it can also be used in conjunction with a CSF drainage device. Clinical Manifestations If ICP increases to the point at which the brain's ability to adjust has reached its limits, neural function is impaired; this may be manifested at first by clinical changes in LOC and later by abnormal respiratory and vasomotor responses. Quality and Safety Nursing Alert The earliest sign of increasing ICP is a change in LOC. Agitation, slowing of speech, and delay in response to verbal suggestions may be early indicators. Any sudden change in the patient's condition, such as restlessness (without apparent cause), confusion, or increasing drowsiness, has neurologic significance. These signs may result from compression of the brain due to swelling from hemorrhage or edema, an expanding intracranial lesion (hematoma or tumor), or a combination of both. As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required. As neurologic function deteriorates further, the patient becomes comatose and exhibits abnormal motor responses in the form of decortication (abnormal flexion of the upper extremities and extension of the lower extremities), decerebration (extreme extension of the upper and lower extremities), or flaccidity (see Fig. 66-1). If the coma is profound and irreversible with no known confounding factors, brainstem reflexes are absent, and respirations are impaired or absent, the patient may be evaluated for brain death.

Postictal nursing interventions

During a Seizure A major responsibility of the nurse is to observe and record the sequence of signs. The nature of the seizure usually indicates the type of treatment required (AANN, 2016a). Before and during a seizure, the patient is assessed and the following items are documented: Circumstances before the seizure (visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; hyperventilation) Occurrence of an aura (a premonitory or warning sensation, which can be visual, auditory, or olfactory) First thing the patient does in the seizure—where the movements or the stiffness begins, conjugate gaze position, and the position of the head at the beginning of the seizure. This information gives clues to the location of the seizure origin in the brain. (In recording, it is important to state whether the beginning of the seizure was observed.) Type of movements in the part of the body involved Areas of the body involved (turn back bedding to expose patient) Size of both pupils and whether the eyes are open Whether the eyes or head are turned to one side Presence or absence of automatisms (involuntary motor activity, such as lip smacking or repeated swallowing) Incontinence of urine or stool Duration of each phase of the seizure Unconsciousness, if present, and its duration Any obvious paralysis or weakness of arms or legs after the seizure Inability to speak after the seizure Movements at the end of the seizure Whether or not the patient sleeps afterward Cognitive status (confused or not confused) after the seizure In addition to providing data about the seizure, nursing care is directed at preventing injury and supporting the patient, not only physically but also psychologically. Consequences such as anxiety, embarrassment, fatigue, and depression can be devastating to the patient. After a Seizure After a patient has a seizure, the nurse's role is to document the events leading to and occurring during and after the seizure and to prevent complications (e.g., aspiration, injury). The patient is at risk for hypoxia, vomiting, and pulmonary aspiration. To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration (see Chart 66-4). Seizure precautions are maintained, including having available functioning suction equipment with a suction catheter and oral airway. The bed is placed in a low position with two to three side rails up and padded, if necessary, to prevent injury to the patient. The patient may be drowsy and may wish to sleep after the seizure; they may not remember events leading up to the seizure and for a short time thereafter. Care of the Patient During and After a Seizure Nursing Care During a Seizure Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura may have time to seek a safe, private place.) Ease the patient to the floor, if possible. Protect the head with a pad to prevent injury (from striking a hard surface). Loosen constrictive clothing and remove eyeglasses. Push aside any furniture that may injure the patient during the seizure. If the patient is in bed, remove pillows and raise side rails. Do not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything in the mouth during a seizure. Broken teeth and injury to the lips and tongue may result from such an action. Do not attempt to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Nursing Care After the Seizure Keep the patient on one side to prevent aspiration. Make sure the airway is patent. On awakening, reorient the patient to the environment. If the patient is confused or wandering, guide the patient gently to a bed or chair. If the patient becomes agitated after a seizure (postictal), stay a distance away, but close enough to prevent injury until the patient is fully aware.

Neutropenia

Hematopoietic System Many chemotherapy agents cause some degree of myelosuppression (depression of bone marrow function), resulting in decreased WBCs (leukopenia), granulocytes (neutropenia), red blood cells (RBCs) (anemia), and platelets (thrombocytopenia) and increased risk of infection and bleeding. Depression of these cells is the usual reason for limiting the dose of the chemotherapy. Myelosuppression is predictable; for most agents, patients usually reach the point at which blood counts are lowest 7 to 14 days after chemotherapy has been given. During these 2 weeks, nurses anticipate associated toxicities, especially a fever associated with neutrophil count less than 1,500 cells/mm3. Frequent monitoring of blood cell counts is essential, and patients are educated about strategies to protect against infection, injury, and blood loss, particularly while counts are low (Manea, 2014). Other agents—colony-stimulating factors (granulocyte colony-stimulating factor [G-CSF] and granulocyte-macrophage colony-stimulating factor [GM-CSF])—can be given after chemotherapy to stimulate the bone marrow to produce WBCs, especially neutrophils, at an accelerated rate, thus decreasing the duration of neutropenia. G-CSF and GM-CSF decrease the episodes of infection and the need for antibiotics and allow for more timely treatment cycles of chemotherapy with less need to reduce the dosage. Erythropoietin (EPO) stimulates RBC production, thus decreasing the symptoms of treatment-induced chronic anemia and reducing the need for blood transfusions. Interleukin 11 (IL-11) (oprelvekin [Neumega]) stimulates the production of megakaryocytes (precursors to platelets) and can be used to prevent and treat severe thrombocytopenia but has had limited use because of toxicities, such as HSR; capillary leak syndrome; pulmonary edema; atrial dysrhythmias; and nausea, vomiting, and diarrhea. Neutropenia, an abnormally low ANC, is associated with an increased risk of infection. The risk of infection rises as the ANC decreases. As the ANC declines below 1,500 cells/mm3, the risk of infection rises. An ANC less than 500 cells/mm3 reflects a severe risk of infection (NCCN, 2015h; Segal, Walsh, Gea-Banacloche, et al., 2015). The nadir is the lowest ANC following chemotherapy, targeted therapy, or radiation therapy that suppresses bone marrow function. Severe neutropenia may necessitate delays in administration of myelosuppressive therapies or treatment dose adjustments, although the use of the hematopoietic growth factors (i.e., colony-stimulating factors; see previous discussion) has reduced the severity and duration of treatment-associated neutropenia as well as infection-related morbidity and early death (Smith, Bohlke, Lyman, et al., 2015). The administration of these growth factors assists in maintaining treatment schedules, drug dosages, treatment effectiveness, and quality of life. Febrile patients who are neutropenic are assessed for factors that increase the risk of infection and for sources of infection through cultures of blood, sputum, urine, stool, IV and urinary or other catheters, and wounds, if appropriate (see Table 15-10). In addition, a chest x-ray is usually obtained to assess for pulmonary infection. Fever is reported promptly as it is an important sign of infection in patients when associated with neutropenia. Patients with neutropenic fever (see Table 15-10) are assessed for infection and reported promptly (NCCN, 2015h). Antibiotics may be prescribed after cultures of wound drainage, exudates, sputum, urine, stool, or blood are obtained. Careful consideration is given to the underlying malignancy, prior antineoplastic treatment, ANC, comorbidities, and other patient-related factors prior to the identification of the most appropriate antibiotic therapy. Evidence-based guidelines are available for prevention and treatment of cancer-related infections (NCCN, 2015h). Patients with neutropenia are treated with broad-spectrum antibiotics before the infecting organism is identified because of the increased risk of mortality associated with untreated infection.

Lorazepam (Ativan)

Indication: Anxiety, preanesthesia anxiolytic, nausea, antiepileptic for status epilecpticus. The goals of treatment are to stop the seizures as quickly as possible, to ensure adequate cerebral oxygenation, and to maintain the patient in a seizure-free state. An airway and adequate oxygenation are established. If the patient remains unconscious and unresponsive, an endotracheal tube is inserted. IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin is given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Because seizures can occur after head injury and can cause secondary brain damage from hypoxia, anticonvulsant agents may be given. If the patient is very agitated, benzodiazepines are the most commonly used sedative agents and do not affect cerebral blood flow or ICP. Lorazepam (Ativan) and midazolam (Versed) are frequently used but have active metabolites that may cause prolonged sedation, making it difficult to conduct a neurologic assessment. Medications are given to control seizure activity. Intravenously administered diazepam or lorazepam is considered first-line therapy for the condition. Action: Seems to be effective in directly blocking the CTZ to relieve nausea and vomiting caused by cancer chemotherapy; especially effective when combined with a corticosteroid. Dose: 2-6 mg/d PO in divided doses or 0.05 mg/kg IM or 0.044 mg/kg IV Classification: Benzodiazepine Side Effects/ Adverse Reactions: The adverse effects of benzodiazepines are associated with the impact of these drugs on the central and peripheral nervous systems. Nervous system effects include sedation, drowsiness, depression, lethargy, blurred vision, "sleep driving" and other complex behaviors, headaches, apathy, light-headedness, amnesia, and confusion. In addition, mild paradoxical excitatory reactions may occur during the first 2 weeks of therapy. Several other kinds of adverse effects may occur. GI conditions such as dry mouth, constipation, nausea, vomiting, and elevated liver enzymes may result. Cardiovascular problems may include hypotension, hypertension, arrhythmias, palpitations, and respiratory difficulties. Hematological conditions such as blood dyscrasias and anemia are possible. Genitourinary effects include urinary retention and hesitancy, loss of libido, and changes in sexual functioning. Because phlebitis, local reactions, and thrombosis may occur at local injection sites, such sites should be monitored. Abrupt cessation of these drugs may lead to a withdrawal syndrome characterized by nausea, headache, vertigo, malaise, and nightmares. Caution/ Contraindications: Contraindications to benzodiazepines include allergy to any benzodiazepine to prevent hypersensitivity reactions; psychosis, which could be exacerbated by sedation; and acute narrow-angle glaucoma, shock, coma, or acute alcoholic intoxication, all of which could be exacerbated by the depressant effects of these drugs. In addition, these sedative-hypnotics are contraindicated in pregnancy because a predictable syndrome of cleft lip or palate, inguinal hernia, cardiac defects, microcephaly, or pyloric stenosis occurs when they are taken in the first trimester. Neonatal withdrawal syndrome may also result. Breastfeeding is also a contraindication because of potential adverse effects on the neonate (e.g., sedation). Use with caution in elderly or debilitated patients because of the possibility of unpredictable reactions and in cases of renal or hepatic dysfunction, which may alter the metabolism and excretion of these drugs, resulting in direct toxicity. Dose adjustments usually are needed for such patients. Box 20.3 provides information about the effect of benzodiazepines in African American patients. Nursing Implications: Special considerations: Monitor injection sites, reduce dosage of narcotics given with this drug • Do not administer intraarterially because serious arteriospasm and gangrene could occur. Monitor injection sites carefully for local reactions to institute treatment as soon as possible. • Do not mix IV drugs in solution with any other drugs to avoid potential drug-drug interactions. • Give parenteral forms only if oral forms are not feasible or available and switch to oral forms, which are safer and less likely to cause adverse effects, as soon as possible. • Give IV drugs slowly because these agents have been associated with hypotension, bradycardia, and cardiac arrest. • Arrange to reduce the dose of narcotic analgesics in patients receiving a benzodiazepine to decrease potentiated effects and sedation. • Maintain patients who receive parenteral benzodiazepines in bed for a period of at least 3 hours. Do not permit ambulatory patients to operate a motor vehicle after an injection to ensure patient safety. • Monitor hepatic and renal function, as well as CBC, during long-term therapy to detect dysfunction and to arrange to taper and discontinue the drug if dysfunction occurs. • Taper dose gradually after long-term therapy, especially in epileptic patients. Acute withdrawal could precipitate seizures in these patients. It may also cause withdrawal syndrome. • Provide comfort measures to help patients tolerate drug effects, such as having them void before dosing, instituting a bowel program as needed, giving food with the drug if GI upset is severe, providing environmental control (lighting, temperature, stimulation), taking safety precautions (use of side rails, assistance with ambulation), and aiding orientation. • Provide thorough patient teaching, including drug name, prescribed dose, measures for avoidance of adverse effects, and warning signs that may indicate possible problems. Instruct patients about the need for periodic monitoring and evaluation to enhance patient knowledge about drug therapy and to promote compliance. • Offer support and encouragement to help the patient cope with the diagnosis and the drug regimen.

Ondansetron (Zofran)

Indication: Control of severe nausea and vomiting associated with emetogenic cancer chemotherapy, radiation therapy; treatment of postoperative nausea and vomiting. The 5-HT3 receptor blockers have proven especially helpful in treating the nausea and vomiting associated with antineoplastic chemotherapy and radiation therapy and postoperative nausea and vomiting. They are specific for the treatment of nausea and vomiting associated with emetogenic chemotherapy. These are relatively new drugs, and the drug of choice depends on personal preference and experience. Palonosetron is approved for use in children 1 month of age and older. Action: The 5-HT3 receptor blockers block those receptors associated with nausea and vomiting in the CTZ and locally. Dose: Adult: 8 mg PO t.i.d. or 24 mg PO 30 min before chemotherapy; three 0.15-mg/kg doses IV over 15 min beginning before chemotherapy or one 32-mg dose infused over 30 min, given 30 min before chemotherapy; 4 mg IV or IM or 16 mg PO 1 h before surgery to prevent postoperative vomiting Pediatric (4-12 y): 4 mg PO t.i.d., use same IV dose as adults Classification: 5-HT3 Receptor Blockers Side Effects/ Adverse Reactions: Headache, dizziness, drowsiness, myalgia, urinary retention, constipation, pain at injection site. The adverse effects most frequently seen with these drugs are headache, dizziness, and myalgia related to their CNS effects. Pain at the injection site, rash, constipation, hypotension, and urinary retention have also been reported. Caution/ Contraindications: These drugs are contraindicated with known allergy to any component of the drug to prevent hypersensitivity reactions. Caution should be used during pregnancy and lactation because of the potential for adverse effects on the fetus or nursing baby. Nursing Implications: • Assure that the route of administration is appropriate for each patient to ensure therapeutic effects and decrease adverse effects: If used to prevent motion sickness, should be given 30 minutes before activity that involves motion; some oral tablets can be placed in the mouth and allowed to dissolve slowly; rectal suppositories should be inserted high into the rectum; IV infusions should be run slowly, monitoring the patient for CNS depression. • Assess the patient carefully for any potential drug-drug interactions if giving antiemetics in combination with other drugs to avert potentially serious drug-drug interactions. • Provide comfort and safety measures, including mouth care, ready access to bathroom facilities, assistance with ambulation and periodic orientation, ice chips to suck, protection from sun exposure, and remedial measures to treat dehydration if it occurs, to protect the patient from injury and to increase patient comfort. • Provide support and encouragement, as well as other measures (quiet environment, carbonated drinks, deep breathing), to help the patient cope with the discomfort of nausea and vomiting and drug effects. • Provide thorough patient teaching, including the drug name and prescribed dosage; the schedule and method for administration; the need to avoid alcohol and other CNS depressants (if the patient is not hospitalized); signs and symptoms of adverse effects and measures to minimize or prevent them; the use of sunscreen and protective clothing when outside; comfort measures to reduce feelings of nausea, such as adequate ventilation, deep breathing, and a quiet environment; the importance of fluid intake and signs and symptoms of dehydration that should be reported to the health care provider; safety measures, such as assistance with ambulation and gradual position changes; the need to notify the health care provider before using any OTC medications; and the importance of periodic monitoring and evaluation to enhance patient knowledge about drug therapy and to promote compliance.

Phenytoin (Dilantin)

Indication: Control of tonic-clonic and psychomotor seizures, prevention of seizures during neurosurgery, control of status epilepticus. Action: Stabilizes neuronal membranes and prevents hyperexcitability caused by excessive stimulation; limits the spread of seizure activity from an active focus; has cardiac antiarrhythmic effects similar to those of lidocaine. Dose: Adult: 100 mg PO t.i.d., up to 300-400 mg/d; 10-15 mg/kg IV Pediatric: 5-8 mg/kg/d PO; 5-10 mg/kg IV in divided doses Classification: Hydantoin Side Effects/ Adverse Reactions: Nystagmus, ataxia, dysarthria, slurred speech, mental confusion, dizziness, fatigue, tremor, headache, dermatitis, Stevens-Johnson syndrome, nausea, gingival hyperplasia, liver damage, hematopoietic complications, sometimes fatal. The most common adverse effects relate to CNS depression and its effects on body function: Depression, confusion, drowsiness, lethargy, fatigue, constipation, dry mouth, anorexia, cardiac arrhythmias and changes in blood pressure, urinary retention, and loss of libido. Specifically, the hydantoins may cause severe liver toxicity, bone marrow suppression, gingival hyperplasia, potentially serious dermatological reactions (e.g., hirsutism, Stevens-Johnson syndrome), and frank malignant lymphoma, all of which are directly related to cellular toxicity. Caution/ Contraindications: Hydantoins are generally contraindicated in the presence of allergy to any of these drugs to avoid hypersensitivity reactions. Many of these agents are associated with specific birth defects and should not be used in pregnancy or lactation unless the risk of seizures outweighs the potential risk to the fetus. In such cases the mother should be informed of the potential risks. The risk of taking a woman with a seizure disorder off an antiepileptic drug that has stabilized her condition may be greater than the risk of the drug to the fetus. Discontinuing the drug could result in status epilepticus, which has a high risk of hypoxia for the mother and the fetus. Research has not been able to show the effects of even a minor seizure during pregnancy on the fetus, making it important to prevent seizures during pregnancy if at all possible. Women of childbearing age should be urged to use barrier contraceptives while taking these drugs. If a pregnancy does occur, the woman should receive educational materials and counseling. Caution should be used with elderly or debilitated patients, who may respond adversely to the CNS depression, and with patients who have impaired renal or liver function that may interfere with drug metabolism and excretion. Patients with hepatic impairment are at risk for increased toxicity from phenytoin. Caution should be used when giving ethotoin to diabetic patients and patients with severe cardiovascular problems. Patients receiving fosphenytoin intravenously require careful monitoring of their cardiovascular status during the infusion period. Some potentially serious name confusion has occurred with fosphenytoin (see prior Focus on Safe Medication Administration). Other contraindications include coma, depression, or psychoses, which could be exacerbated by the generalized CNS depression. Nursing Implications: • Discontinue the drug at any sign of hypersensitivity reaction, liver dysfunction, or severe skin rash to limit reaction and prevent potentially serious reactions. • Administer the drug with food to alleviate GI irritation if GI upset is a problem. • Monitor for adverse effects and provide appropriate supportive care as needed to help the patient cope with these effects. • Monitor complete blood count (CBC) before and periodically during therapy to detect bone marrow suppression early and provide appropriate interventions. • Discontinue the drug if skin rash, bone marrow suppression, or unusual depression or personality changes occur to prevent the development of more serious adverse effects. • Discontinue the drug slowly, and never withdraw the drug quickly, because rapid withdrawal may precipitate absence seizures. • Monitor for drug-drug interactions to arrange to adjust doses appropriately if any drug is added to or withdrawn from the drug regimen. • Arrange for counseling for women of childbearing age who are taking these drugs. Because these drugs have the potential to cause serious damage to the fetus, women should understand the risk of birth defects and use barrier contraceptives to avoid pregnancy. • Offer support and encouragement to help the patient cope with the drug regimen and diagnosis. • Provide thorough patient teaching, including drug name and prescribed dosage, as well as measures for avoidance of adverse effects and warning signs that may indicate possible problems to enhance patient knowledge about drug therapy and to promote compliance; and the need for periodic blood tests to evaluate blood counts to reduce the risk for infection and for drug levels to evaluate therapeutic effectiveness and minimize the risk for toxicity. • Suggest the wearing or carrying of a MedicAlert bracelet to alert emergency workers and health care providers about the use of an antiepileptic drug.

Mannitol (Osmitrol)

Indication: Prevention and treatment of the oliguric phase of renal failure; reduction of intracranial pressure and treatment of cerebral edema; reduction of elevated IOP; promotion of urinary excretion of toxic substances; diagnostic use for measurement of glomerular filtration rate; also available as an irrigant in transurethral prostatic resection and other transurethral procedures. Action: Elevates the osmolarity of the glomerular filtrate, leading to a loss of water, sodium, and chloride; creates an osmotic gradient in the eye, reducing IOP; creates an osmotic effect that decreases swelling after transurethral surgery. Dose: 50-100 g IV for oliguria; 1.5-2 g/kg IV to reduce intracranial pressure; dose not established for children <12 y Classification: Osmotic diuretic Side Effects/ Adverse Reactions: Dizziness, headache, hypotension, rash, nausea, anorexia, dry mouth, thirst, diuresis, fluid and electrolyte imbalances. The most common and potentially dangerous adverse effect related to an osmotic diuretic is the sudden drop in fluid levels. Nausea, vomiting, hypotension, light-headedness, confusion, and headache can be accompanied by cardiac decompensation and even shock. Patients receiving mannitol should be closely monitored for fluid and electrolyte imbalance. Caution/ Contraindications: Mannitol is contraindicated in patients with renal disease and anuria from severe renal disease, pulmonary congestion, intracranial bleeding, dehydration, and HF, which could be exacerbated by the large shifts in fluid related to use of these drugs. Routine use during pregnancy is not appropriate; it should be reserved for situations in which the mother has pathological reasons for use, not pregnancy manifestations or complications, and only if the benefit to the mother clearly outweighs the risk to the fetus. Nursing Implications: • Administer oral drug with food or milk to buffer the drug effect on the stomach lining if GI upset is a problem. • Administer IV diuretics slowly to prevent severe changes in fluid and electrolytes. • Continuously monitor urinary output, cardiac response, and heart rhythm of patients receiving IV diuretics to monitor for rapid fluid switch and potential electrolyte disturbances leading to cardiac arrhythmia. Switch to the oral form, which is less potent and easier to monitor, as soon as possible, as appropriate. • Administer oral form early in the day so that increased urination will not interfere with sleep. • Monitor the dose carefully and reduce the dose of one or both drugs if given with antihypertensive agents; loss of fluid volume can precipitate hypotension. • Monitor the patient response to the drug (e.g., blood pressure, urinary output, weight, serum electrolytes, hydration, periodic blood glucose monitoring) to evaluate the effectiveness of the drug and monitor for adverse effects. • Assess weight daily to evaluate fluid balance. • Check skin turgor to evaluate for possible fluid volume deficit, and assess edematous areas for changes, including a decrease in amount or degree of pitting. • Provide comfort measures, including skin care and nutrition consultation, to increase compliance with drug therapy and decrease the severity of adverse • effects; provide safety measures if dizziness and weakness are a problem to prevent injury. • Provide a potassium-rich or low-potassium diet as appropriate to maintain electrolyte balance and replace lost potassium or prevent hyperkalemia. • Provide thorough patient teaching, including the name of the drug and dosage prescribed, to enhance patient knowledge about drug therapy and to promote compliance. Additional patient teaching includes the following: • Importance of taking the diuretic early in the day to avoid interference with sleep. • Administration of the drug with food or meals if GI upset occurs. • Need to weigh oneself daily and report any increase in weight of 3 pounds or more in 1 day. • Importance of maintaining an adequate fluid intake to prevent fluid rebound (see Focus on Safe Medication Administration in this chapter's introduction to diuretic agents). • Need to have readily available access to bathroom facilities after taking the prescribed dose. • Signs and symptoms of adverse effects, including hypokalemia, hyperkalemia, and hypercalcemia, and the need to notify the health care provider should any occur. • Danger signs and symptoms to report immediately. • Safety measures, such as moving slowly if dizziness is an issue and avoiding very hot environments and other situations potentially leading to extra loss of fluid. • Dietary sources of foods high in potassium, with an emphasis on the need for intake of these foods or the need to avoid these foods if using a potassium-sparing diuretic. • Need for compliance with therapy to achieve intended results. • Importance of continued follow-up and monitoring, including laboratory testing to determine the effectiveness of therapy. For the patient receiving mannitol, the nurse observes for the possible development of heart failure and pulmonary edema. The intent of treatment is to promote a shift of fluid from the intracellular to the intravascular compartment and to control cerebral edema. However, this shift of fluid volume to the intravascular compartment may overwhelm the ability of the myocardium to increase workload sufficient to meet these demands, which may cause failure and pulmonary edema. For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus (Hickey, 2014). These patients need careful oral hygiene, because mouth dryness occurs with dehydration. Frequently rinsing the mouth with nondrying solutions, lubricating the lips, and removing encrustations relieve dryness and promote comfort.

Methadone (Dolophine)

Indication: Relief of severe pain; detoxification and temporary maintenance treatment of narcotic addiction in adults. Methadone (Dolophine) is a unique opioid analgesic agent that may have advantages over other opioids in carefully selected patients. In addition to being a mu opioid, it is an antagonist at the NMDA receptor site and thus has the potential to produce analgesic effects as a second- or third-line option for some neuropathic pain states (Wu et al., 2014). It may be used as an alternative when it is necessary to switch a patient to a new opioid because of inadequate analgesia or unacceptable adverse effects. The use of conventional equianalgesic dose conversion is not recommended when switching patients to and from methadone. Extensive guidelines on how to safely accomplish this are available elsewhere (Smith, 2013). Methadone is usually given orally but has also been given by virtually every other route of administration. Although it has no active metabolites, methadone has a very long and highly variable half-life (5 to 100-plus hours; average is 20 hours), which makes it a good choice for the treatment of addictive disease; patients must be watched closely for excessive sedation, a sign of drug accumulation during this time period. (The drug is described as "long acting" because of its exceptionally long half-life.) When methadone is used to treat opioid addiction, it is dosed once daily and is not intended to manage pain; acute pain management with other analgesic medications is needed in addition to daily methadone dosing. Other limitations are its propensity to interact with a large number of medications and prolong the QTc interval on the electrocardiogram (ECG). Some drugs (e.g., clarithromycin [Cleocin] and some antifungal medications) that inhibit CYP3A4, the enzyme that metabolizes methadone, should be avoided as they can inadvertently increase methadone levels in the blood (Lehne, 2013). Despite these characteristics, methadone can be an effective and safe drug when prescribed by practitioners who have an appreciation of the drug's characteristics and experience in its use. Action: Acts as an agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, and sedation. Dose: 2.5-10 mg IM, subcutaneous, or PO q3-4 h for pain; 15-20 mg PO for withdrawal, then 20 mg PO q4-8 h for maintenance treatment Classification: Narcotic Agonist Side Effects/ Adverse Reactions: The most frequently seen adverse effects associated with narcotic agonists relate to their effects on various opioid receptors. Respiratory depression with apnea, cardiac arrest, and shock may result from narcotic-induced respiratory center depression. Orthostatic hypotension is commonly seen with some narcotics. GI effects such as nausea, vomiting, constipation, and biliary spasm may occur as a result of CTZ stimulation and negative effects on GI motility. Box 26.4 discusses drugs approved to treat opioid-induced constipation, a significant issue with long-term use in hospice situations and cancer care. Neurological effects such as light-headedness, dizziness, psychoses, anxiety, fear, hallucinations, pupil constriction, and impaired mental processes may occur as a result of the stimulation of CNS opioid receptors in the cerebrum, limbic system, and hypothalamus (Figure 26.3). GU effects, including ureteral spasm, urinary retention, hesitancy, and loss of libido, may be related to direct receptor stimulation or to CNS activation of sympathetic pathways. In addition, sweating and dependence (both physical and psychological) are possible, more so with some agents than with others. Caution/ Contraindications: The narcotic agonists are contraindicated in the following conditions: Presence of any known allergy to any narcotic agonist to avoid hypersensitivity reactions; diarrhea caused by toxic poisons because depression of GI activity could lead to increased absorption and toxicity; and after biliary surgery or surgical anastomoses because of the adverse effects associated with slowed GI activity due to narcotics. Nursing Implications: • Perform baseline and periodic pain assessments with the patient to monitor drug effectiveness and provide appropriate changes in pain management protocol as needed. • Have a narcotic antagonist and equipment for assisted ventilation readily available when administering the drug IV to provide patient support in case of severe reaction. • Monitor injection sites for irritation and extravasation to provide appropriate supportive care if needed. • Monitor timing of analgesic doses. Prompt administration may provide a more acceptable level of analgesia and lead to quicker resolution of the pain. • Use extreme caution when injecting these drugs into any body area that is chilled or has poor perfusion or shock because absorption may be delayed, and after repeated doses an excessive amount is absorbed all at once. • Use additional measures to relieve pain (e.g., back rubs, stress reduction, hot packs, ice packs) to increase the effectiveness of the narcotic being given and reduce pain. • Monitor respiratory status before beginning therapy and periodically during therapy to monitor for potential respiratory depression. • Institute comfort and safety measures, such as side rails and assistance with ambulation, to ensure patient safety; bowel program as needed to treat constipation; environmental controls to decrease stimulation; and small, frequent meals to relieve GI distress if GI upset is severe. • Reassure patients that the risk of addiction is minimal. Most patients who receive these drugs for medical reasons do not develop dependency syndromes. • Offer support and encouragement to help the patient cope with the drug regimen. • Provide thorough patient teaching, including drug name, prescribed dose, and schedule of administration; measures for avoidance of adverse effects; warning signs that may indicate possible problems; safety measures such as avoiding driving, getting assistance with ambulation, avoiding making important decisions or signing important papers; and the need for monitoring and evaluation to enhance patient knowledge about drug therapy and to promote compliance.

Seizure care and interventions

Nursing Interventions: PREVENTING INJURY Injury prevention for the patient with seizures is a priority. Patients for whom seizure precautions are instituted should have pads applied to the side rails while in bed. Steps to prevent or minimize injury are presented in Chart 66-4. REDUCING FEAR OF SEIZURES Fear that a seizure may occur unexpectedly can be reduced by the patient's adherence to the prescribed treatment regimen. Cooperation of the patient and family and their trust in the prescribed regimen are essential for control of seizures. The nurse emphasizes that the prescribed anticonvulsant medication must be taken on a continuing basis and that drug dependence or addiction does not occur. Periodic monitoring is necessary to ensure the adequacy of the treatment regimen, to prevent side effects, and to monitor for drug resistance (Hickey, 2014). In an effort to control seizures, factors that may precipitate them are identified, such as emotional disturbances, new environmental stressors, onset of menstruation in female patients, or fever (AANN, 2016a). The patient is encouraged to follow a regular and moderate routine in lifestyle, diet (avoiding excessive stimulants), exercise, and rest (sleep deprivation may lower the seizure threshold). Moderate activity is therapeutic, but excessive exercise should be avoided. An additional dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two anticonvulsant medications, but it is sometimes used for adults who have had poor seizure control (Nei, Ngo, Sirven, et al., 2014). Photic stimulation (e.g., bright flickering lights, television viewing) may precipitate seizures; wearing dark glasses or covering one eye may be preventive. Tension states (anxiety, frustration) induce seizures in some patients. Classes in stress management may be of value. Because seizures are known to occur with alcohol intake, alcoholic beverages should be avoided. IMPROVING COPING MECHANISMS The social, psychological, and behavioral problems that frequently accompany epilepsy can be more of a disability than the actual seizures. Epilepsy may be accompanied by feelings of stigmatization, alienation, depression, and uncertainty (IOM, 2012). The patient must cope with the constant fear of a seizure and the psychological consequences (AANN, 2016a). Children with epilepsy may be ostracized and excluded from school and peer activities. These problems are compounded during adolescence and add to the challenges of dating, not being able to drive, and feeling different from other people. Adults face these problems in addition to the burden of finding employment, concerns about relationships and childbearing, insurance problems, and legal barriers. Alcohol abuse may complicate matters. Family reactions may vary from outright rejection of the person with epilepsy to overprotection. Counseling assists the patient and family to understand the condition and the limitations it imposes. Social and recreational opportunities are necessary for good mental health. Nurses can improve the quality of life for patients with epilepsy by educating them and their families about symptoms and their management (AANN, 2016a). PROVIDING PATIENT AND FAMILY EDUCATION Perhaps the most valuable facets of care contributed by the nurse to the person with epilepsy are education and efforts to modify the attitudes of the patient and family toward the disorder. The person who experiences seizures may consider every seizure a potential source of humiliation and shame. This may result in anxiety, depression, hostility, and secrecy on the part of the patient and family. Ongoing education and encouragement should be given to patients to enable them to overcome these reactions. The patient with epilepsy should carry an emergency medical identification card or wear a medical information bracelet. The patient and family need to be educated about medications as well as care during a seizure. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Status epilepticus is the major potential complication and is described later in this chapter. Another complication is the toxicity of medications. The patient and family are instructed about side effects and are given specific guidelines to assess and report signs and symptoms that indicate medication overdose. Anticonvulsant medications require careful monitoring for therapeutic levels. The patient should plan to have serum drug levels assessed at regular intervals. Many known drug interactions occur with anticonvulsant medications. A complete pharmacologic profile should be reviewed with the patient to avoid interactions that either potentiate or inhibit the effectiveness of the medications. Quality and Safety Nursing Alert Patients with epilepsy are at risk for status epilepticus from having their medication regimen interrupted. PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Educating Patients About Self-Care. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gingival hyperplasia in patients receiving phenytoin. The patient is also educated to inform all health care providers of the medication being taken, because of the possibility of drug interactions. An individualized comprehensive education plan is needed to assist the patient and family to adjust to this chronic disorder. Written patient education materials must be appropriate for the patient's reading level and must be provided in alternative formats if warranted. Continuing and Transitional Care. Because epilepsy can be lifelong, health promotion is important. See Chart 66-6 for health promotion strategies for the patient with epilepsy. For many patients with epilepsy, overcoming employment problems is a challenge. State vocational rehabilitation agencies can provide information about job training. The Epilepsy Foundation of America (EFA) has a training and placement service. If seizures are not well controlled, information about sheltered workshops or home employment programs may be obtained. Federal and state agencies and federal legislation may be of assistance to people with epilepsy who experience job discrimination. As a result of the Americans with Disabilities Act, the number of employers who knowingly hire people with epilepsy is increasing, but barriers to employment still exist. Patients who have uncontrollable seizures accompanied by psychological and social difficulties should be referred as early as possible to a comprehensive epilepsy center where continuous audio-video and EEG monitoring, specialized treatment, and rehabilitation services are available (AANN, 2016a). Patients and their families need to be reminded of the importance of participating in health promotion activities and recommended health screenings to promote a healthy lifestyle. Genetic and preconception counseling is advised.

Colon cancer risk factors, colostomy, diagnosis.

Adenocarcinoma of the colon is the most common malignancy of the gastrointestinal tract and is the major cause of morbidity and mortality worldwide. It affects approximately 150,000 Americans annually, approximately one third of whom die. It affects approximately 250,000 persons annually in Europe and approximately 1 million persons worldwide. Epidemiology The incidence of colorectal cancer peaks at 60 to 70 years of age, and fewer than 20% of cases occur before age 50. Its incidence is increased among persons with a family history of cancer, persons with Crohn disease or ulcerative colitis, and those with familial adenomatous polyposis of the colon. Persons with a familial risk—those who have two or more first- or second-degree relatives (or both) with colorectal cancer—make up approximately 20% of all persons with colorectal cancer.61 Familial adenomatous polyposis is a rare autosomal dominant trait linked to a mutation in the long arm of chromosome 5. Persons with the disorder develop multiple adenomatous polyps of the colon at an early age. Carcinoma of the colon is inevitable, often by 40 years of age, unless a total colectomy is performed. Diet also is thought to play a role. Attention has focused on dietary fat intake, refined sugar intake, fiber intake, and the adequacy of such protective micronutrients as vitamins A, C, and E in the diet. It has been hypothesized that a high level of fat in the diet increases the synthesis of bile acids in the liver, which may be converted to potential carcinogens by the bacterial flora in the colon. The proliferation of colonic bacteria is enhanced by a high dietary level of refined sugars. Dietary fiber is thought to increase stool bulk and thereby dilute and remove potential carcinogens. Refined diets often contain reduced amounts of vitamins A, C, and E, which may act as oxygen free radical scavengers. In addition to dietary modification, pharmacologic chemoprevention has become an area of great interest. Several studies indicate that aspirin or other NSAIDs may protect against colorectal cancer. An analysis of the incidence of colorectal cancer in the Nurses' Health Study showed a decreased incidence of colorectal cancer among women who took four to six aspirins per week. Although the mechanism of aspirin's action is unknown, it may be related to its effect on the synthesis of prostaglandins, one or more of which may be involved in signal systems that influence cell proliferation or tumor growth. Aspirin inhibits cyclooxygenase, the enzyme that catalyzes the conversion of arachidonic acid in cell membranes to prostaglandins. One form of cyclooxygenase, COX-2, promotes inflammation and cell proliferation, and colorectal cancers often overexpress this enzyme. Clinical Manifestations Cancer of the colon is usually present for a long period of time before it produces symptoms. Bleeding is a highly significant early symptom and usually is the one that causes persons to seek medical care. Other symptoms include a change in bowel habits, diarrhea or constipation, and sometimes a sense of urgency or incomplete emptying of the bowel. Pain usually is a late symptom. Diagnosis and Treatment Cancer of the colon may be detected with a high degree of reliability with barium enema or colonoscopy. Colonoscopy permits biopsy for pathologic confirmation. CT scans, pelvic magnetic resonance imaging (MRI), and ultrasonography may be used to determine the extent of the lesions and whether metastasis has occurred. The only recognized treatment for cancer of the colon and rectum is surgical removal. Preoperative radiation therapy may be used and has in some cases demonstrated increased 5-year survival rates. Postoperative adjuvant chemotherapy may be used. Radiation therapy and chemotherapy are used as palliative treatment methods. The prognosis for persons with colorectal cancer depends largely on the stage of the cancer. Colorectal cancer commonly is classified into four TNM (tumor, node, and metastasis) stages. In this system, a stage I tumor is limited to invasion of the mucosal and submucosal layers of the colon and has a 5-year survival rate of 90% to 100%. Stage IV (metastatic) tumors penetrate the serosa or adjacent organs and have a much poorer prognosis. Colostomy ◦Sigmoid colostomy—most common ◦Double-barrel colostomy ◦Transverse loop colostomy ◦Hartmann procedure

Fibromyalgia s/sx and general care and teaching about symptom relief.

Fibromyalgia is a chronic pain syndrome that involves chronic fatigue, generalized muscle aching, stiffness, sleep disturbances, and functional impairment. It is estimated to affect more than 5 million Americans, representing 2% to 5% of the general population, with women affected more than men. Between 25% and 65% of patients with fibromyalgia have other rheumatologic conditions such as RA, SLE, and AS (CDC, 2015c). Pathophysiology The amplified pain experienced by patients with fibromyalgia is neurogenic in origin (Carter et al., 2015). Specifically, the central nervous system's ascending and descending pathways (that regulate and moderate pain processing) function abnormally, causing amplification of pain signals. Some scientists describe this as if the "volume control setting" for pain were abnormally high (Carter et al., 2015). Therefore, stimulation that may not normally elicit pain, such as touch, may do so. In addition, there are a number of predisposing factors to pain, including anxiety, depression, physical trauma, emotional stress, sleep disorder, and viral infection (Carter et al., 2015). Assessment and Diagnostic Findings The American College of Rheumatology established preliminary diagnostic criteria and symptom severity indices for fibromyalgia (Carter et al., 2015). These criteria emphasize the regions of pain, rather than specific points, and take into account the fatigue, cognitive symptoms, and unrefreshed sleep that patients with fibromyalgia also tend to experience (Carter et al., 2015). Medical Management Treatment consists of attention to the specific symptoms reported by the patient. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants such as amitriptyline (Elavil) and nortriptyline (Pamelor) as well as sleep hygiene measures are used to improve or restore normal sleep patterns (Cash & Glass, 2015). Muscle relaxants such as cyclobenzaprine (Amrix) may also be used to help with relaxation and pain. Cognitive behavioral therapy is also useful in improving sleep and attentional dysfunction. In addition, serotonin norepinephrine reuptake inhibitors, such as duloxetine (Cymbalta), venlafaxine (Effexor), and milnacipran (Savella); selective serotonin reuptake inhibitors, including fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft); as well as anticonvulsants such as gabapentin (Neurontin) and pregabalin (Lyrica) have been reported to be effective (Carter et al., 2015). Individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in affected patients. There has also been some promising research in complementary, alternative, and integrative health therapies, such as acupuncture, massage, homeopathy, hydrotherapy, craniosacral therapy, and myofascial therapy (Carter et al., 2015). Nursing Management Typically, patients with fibromyalgia have endured their symptoms for a long period of time. They may feel as if their symptoms have not been taken seriously. Nurses need to pay special attention to supporting these patients and providing encouragement as they begin their program of therapy. Patient support groups may be helpful. Careful listening to patients' descriptions of their concerns and symptoms is essential to help them make the changes that are necessary to improve their quality of life.

Post radiation nursing care

Nursing Management Nurses anticipate, prevent, and work collaboratively with other providers to manage symptoms associated with radiation therapy in order to promote healing, patient comfort, and quality of life. Symptoms that are not appropriately managed may lead to poor outcomes as a result of interruptions, decreased doses, or early cessation of treatment (Fogh & Yom, 2014). Ideally, nurses consider factors that may be predictive of radiation toxicities or radiosensitivity of tissues. In particular, diminished body mass index (BMI) and elevated radiation doses have been associated with greater toxicity and symptoms (O'Gorman, Sasiadek, Denieffe, et al., 2015). The area of the body being irradiated partially guides the focus of nursing assessments. In patients receiving EBRT, the nurse assesses the patient's skin regularly throughout the course of treatment. In addition, nutritional status and general feelings of well-being are assessed throughout the course of treatment. Evidence-based protocols for nursing management of the toxicities associated with radiation therapy are used. If systemic symptoms, such as weakness and fatigue, occur, the nurse explains that these symptoms are a result of the treatment and do not represent deterioration or progression of the disease. Protecting Caregivers When the patient has a radioactive implant in place, the nurse and other health care providers need to protect themselves, as well as the patient, from the effects of radiation. Patients receiving internal radiation emit radiation while the implant is in place; therefore, contact with the health care team is guided by principles of time, distance, and shielding to minimize exposure of personnel to radiation. Specific instructions are provided by the radiation safety officer from the radiology department and specify the maximum time that can be spent safely in the patient's room, the shielding equipment to be used, and special precautions and actions to be taken if the implant is dislodged (Halperin et al., 2013). Safety precautions used in caring for a patient receiving brachytherapy include assigning the patient to a private room, posting appropriate notices about radiation safety precautions, having staff members wear dosimeter badges, making sure that pregnant staff members are not assigned to the patient's care, prohibiting visits by children or pregnant visitors, limiting visits from others to 30 minutes daily, and seeing that visitors maintain a 6-foot distance from the radiation source. Patients with seed implants typically are able to return home; radiation exposure to others is minimal. Information about any precautions, if needed, is provided to the patient and family members to ensure safety. Depending on the dose and energy emitted by a systemic radionuclide, patients may or may not require special precautions or hospitalization (Halperin et al., 2013). The nurse should explain the rationale for these precautions to keep the patient from feeling unduly isolated. Maintaining Tissue Integrity Some of the most frequently encountered disturbances of tissue integrity include stomatitis, skin and tissue reactions to radiation therapy, cutaneous toxicities associated with targeted therapy, alopecia, and metastatic skin lesions. Stomatitis Mucositis, a common side effect of radiation and some types of chemotherapy, refers to an inflammatory process involving the mucous membranes of the oral cavity and the gastrointestinal tract. Stomatitis, a form of mucositis, is an inflammatory process of the mouth, including the mucosa and tissues surrounding the teeth. Stomatitis is characterized by changes in sensation, mild redness (erythema), and edema or, if severe, by painful ulcerations, bleeding, and secondary infection. Stomatitis commonly develops 5 to 14 days after patients receive certain chemotherapeutic agents, such as doxorubicin and 5-fluorouracil; immunotherapies, such as IL-2 and IFN; and molecular targeted drugs, such as temsirolimus and everolimus. Stomatitis affects up to 100% of patients undergoing high-dose chemotherapy with HSCT, 80% of patients with malignancies of the head and neck receiving radiotherapy, and up to 40% of patients receiving standard-dose chemotherapy (Gibson, Keefe, Lalla, et al., 2013). Stomatitis may be worse in patients with head and neck cancers who receive combined modality therapy of both radiation and chemotherapy. When severe, stomatitis can lead to interruptions, delays, and modifications in the course of treatment, all of which may contribute to less desirable patient outcomes. Severe oral pain can significantly affect swallowing, nutritional intake, speech, quality of life, coping abilities, and willingness to adhere to treatment regimens. In addition, stomatitis may lead to more frequent health care visits, hospitalizations, and increased health care costs (Eilers, Harris, Henry, et al., 2014). Stomatitis and mucositis are attributed to a cascade of molecular processes and submucosal endothelial cell destruction that begin almost immediately after the initiation of radiation and certain types of chemotherapy, prior to the development of signs and symptoms. Mucositis develops as a consequence of a sequence of related and interacting biologic events, culminating in injury and apoptosis of basal epithelial cells, leading to the loss of epithelial renewal, atrophy, and ulceration. Gram-positive and gram-negative organisms can invade the ulcerated tissue and result in infection. Nursing assessment begins with an understanding of the patient's usual practices for oral hygiene and identification of individuals at risk for stomatitis. Oral cavity assessment is performed daily or at each patient visit (Tipian, 2014). Risk factors and comorbidities associated with stomatitis include poor oral hygiene, general debilitation, existing dental disease, prior irradiation to the head and neck region, impaired salivary gland function, the use of other medications that dry mucous membranes, myelosuppression (bone marrow depression), advanced age, tobacco use, previous stomatoxic chemotherapy, diminished renal function, and impaired nutritional status (Eilers et al., 2014). The patient is also assessed for dehydration, infection, pain, and nutritional impairment resulting from mucositis. Optimal evidence-based prevention and treatment approaches for stomatitis remain limited but continue to be studied across disciplines (Eilers et al., 2014). Most clinicians agree that maintenance of good oral hygiene, including brushing, flossing, rinsing, and dental care, is necessary to minimize the risk of oral complications associated with cancer therapies. Palifermin (Kepivance), an IV-administered synthetic form of human keratinocyte growth factor, is beneficial in the prevention of stomatitis in patients with hematologic malignancies who are preparing for HSCT (Vadhan-Raj, Goldberg, Perales, et al., 2013). Palifermin promotes epithelial cell repair and accelerated replacement of cells in the mouth and gastrointestinal tract. Careful timing of administration and monitoring are essential for effectiveness and to detect adverse effects. Other approaches recommended for practice include cryotherapy (topical application of oral ice during infusions), consistent oral hygiene, low-level laser therapy, and sodium bicarbonate mouth rinses (Eilers et al., 2014; Tayyem, 2014). Additional aspects of care are discussed in Chart 15-7: nursing care plan for patients with cancer. Radiation-Associated Impairment of Skin Integrity Although advances in radiation therapy have resulted in decreased incidence and severity of skin impairments, patients may still develop radiation dermatitis associated with pain, irritation, pruritus, burning, skin sloughing without drainage (dry desquamation) or with drainage (wet desquamation), and diminished quality of life. Nursing care for patients with radiation dermatitis includes maintenance of skin integrity, cleansing, promotion of comfort, pain reduction, prevention of additional trauma, prevention and management of infection, and promotion of a moist wound-healing environment (Fogh & Yom, 2014). In order to prevent impaired skin integrity, patients are advised to use moisturizer on the skin, avoid sun exposure to the area of treatment, and avoid tape or bandages and other sources of irritation or trauma. Although a variety of methods and products are used in clinical practice for patients with radiation-induced skin impairment, there is limited evidence to support their value. Patients with skin and tissue reactions to radiation therapy require careful skin care to prevent further skin irritation, drying, and damage, as discussed in the nursing care plan (see Chart 15-7, Risk for impaired skin integrity: erythematous and wet desquamation reactions to radiation therapy). Alopecia The temporary or permanent thinning or complete loss of hair is a potential adverse effect of whole brain radiation therapy, various chemotherapies and targeted agents. Alopecia usually begins 2 to 3 weeks after the initiation of chemotherapy and radiation therapy; regrowth most often begins within 8 weeks after the last treatment. Some patients who undergo radiation to the head may sustain permanent hair loss. The onset of gradually progressing alopecia and body hair loss associated with targeted therapies generally occurs 1 to 3 months after the start of treatment and may be patchy appearing as temporal or frontal hair loss. This type of hair loss is usually reversible after the end of therapy and in some cases beginning sooner. Several targeted agents are associated with changes in hair growth rate, curliness, texture, and pigmentation. Although health care providers may view hair loss as a minor issue, for many patients it is a major assault on body image, challenging to self-esteem, and resulting in psychosocial distress and depression. Despite the significant psychosocial impact of alopecia, few studies have addressed methods to prevent or minimize the impact of alopecia. The use of cryotherapy to the head during the administration of chemotherapy has been explored but is not consistently used because of concern about later development of scalp metastasis. When cryotherapy is offered, its use avoided in patients with hematologic malignancies. Nurses provide information about hair loss and support the patient and family in coping with changes in body image. Patients are assisted to identify proactive choices that may empower them to improve responses to cancer and perceived lack of control as discussed in the nursing care plan (see Chart 15-7, Impaired tissue integrity: alopecia).

Bone marrow transplant, general.

Types of Hematopoietic Stem Cell Transplantation Types of HSCT are based on the source of donor cells and the treatment (conditioning) regimen used to prepare the patient for stem cell infusion and eradicate malignant cells. These include: Allogeneic HSCT (AlloHSCT): From a donor other than the patient (may be a related donor such as a family member or a matched unrelated donor from the National Bone Marrow Registry or Cord Blood Registry) Autologous: From the patient Syngeneic: From an identical twin Myeloablative: Consists of giving patients high-dose chemotherapy and, occasionally, total-body irradiation Nonmyeloablative: Also called mini-transplants; does not completely destroy bone marrow cells AlloHSCTs are used primarily for diseases of the bone marrow and are dependent on the availability of a human leukocyte antigen-matched donor, which greatly limits the number of possible transplants. An advantage of AlloHSCT is that the transplanted cells should not be immunologically tolerant of a patient's malignancy and should cause a lethal graft-versus-tumor effect in which the donor cells recognize the malignant cells and act to eliminate them. AlloHSCT may involve either myeloablative (high-dose) or nonmyeloablative (mini-transplant) chemotherapy. In ablative AlloHSCT, the recipient receives high doses of chemotherapy and possibly total-body irradiation to completely eradicate (ablate) the bone marrow and any malignant cells and help prevent rejection of the donor stem cells. The collected HSCs that are infused IV into the recipients travel to sites in the body where they produce bone marrow and establish themselves through the process of engraftment. Once engraftment is complete (2 to 4 weeks, sometimes longer), the new bone marrow becomes functional and begins producing RBCs, WBCs, and platelets. In nonablative AlloHSCT, the chemotherapy doses are lower and are aimed at destroying malignant cells (without completely eradicating the bone marrow), thus suppressing the recipient's immune system to allow engraftment of donor stem cells. The lower doses of chemotherapy, associated with less organ toxicity and infection, can be used for older patients or those with underlying organ dysfunction for whom high-dose chemotherapy would be prohibitive. After engraftment, it is hoped that the donor cells will create a graft-versus-tumor effect. Before engraftment, patients are at high risk for infection, sepsis, and bleeding. Side effects of the high-dose chemotherapy and total-body irradiation can be acute and chronic. Acute side effects include alopecia, hemorrhagic cystitis, nausea, vomiting, diarrhea, encephalopathy, pulmonary edema, acute kidney injury, fluid and electrolyte imbalances, and severe mucositis (Maziarz & Schubach-Slater, 2015). Chronic side effects include sterility; pulmonary, cardiac, renal, neurologic, and hepatic dysfunction; osteoporosis; avascular bone necrosis; diabetes; and secondary malignancy (Maziarz & Schubach-Slater, 2015). During the first 30 days after the conditioning regimen, AlloHSCT patients are at risk for developing hepatic sinusoidal obstructive syndrome (HSOS) (previously referred to as veno-oclusive disease) related to chemotherapy-induced inflammation of the sinusoidal epithelium. Inflammation causes embolization of RBCs, resulting in destruction, fibrosis, and occlusion of the sinusoids (Maziarz & Schubach-Slater, 2015). Signs and symptoms of HSOS may include weight gain, hepatomegaly, increased bilirubin, and ascites. Although various approaches have been used to treat HSOS, evidence-based strategies have not emerged. The use of peripheral stem cells, specific chemotherapy dosing, and nonmyeloablative regimens have been associated with a decreased incidence (Maziarz & Schubach-Slater, 2015). Graft-versus-host disease (GVHD), a major cause of morbidity and mortality in 30% to 50% of the allogeneic transplant population, occurs when the donor lymphocytes initiate an immune response against the recipient's tissues (skin, gastrointestinal tract, liver) during the beginning of engraftment (Maziarz & Schubach-Slater, 2015). The donor cells view the recipient's tissues as foreign or immunologically different from what they recognize as "self" in the donor. To prevent GVHD, patients receive immunosuppressant drugs, such as cyclosporine (Sandimmune), methotrexate, tacrolimus (Prograf), or mycophenolate mofetil (MMF). GVHD may be acute, occurring within the first 100 days, or chronic, occurring after 100 days (Barbarotta, 2015). Clinical manifestations of acute GVHD include diffuse rash progressing to blistering and desquamation similar to second-degree burns; mucosal inflammation of the eyes and the entire gastrointestinal tract with subsequent diarrhea that may exceed 2 L per day; and biliary stasis with abdominal pain, hepatomegaly, and elevated liver enzymes progressing to obstructive jaundice. The first 100 days or so after AlloHSCT is crucial for patients; the immune system and blood-making capacity (hematopoiesis) must recover sufficiently to prevent infection and hemorrhage. Most acute side effects, such as nausea, vomiting, and mucositis, resolve during this period of time. However, there are some complications that may occur, such as encephalopathy, hemolytic uremia syndrome, hemolytic anemia, and thrombotic thrombocytopenia purpura (Maziarz & Schubach-Slater, 2015). Autologous HSCT (AuHSCT) is considered for patients with disease of the bone marrow who do not have a suitable donor for AlloHSCT or for patients who have healthy bone marrow but require bone marrow-ablative doses of chemotherapy to cure an aggressive malignancy. The most common malignancies treated with AuHSCT include lymphoma and multiple myeloma. However, the use of AuHSCT has gained increasing acceptance in treating neuroblastoma, Ewing sarcoma, and germ cell tumors (Maziarz & Schubach-Slater, 2015). Stem cells are collected from the patient and preserved for reinfusion; if necessary, they are treated to kill any malignant cells within the marrow, called purging. The patient is then treated with ablative chemotherapy and, possibly, total-body irradiation to eradicate any remaining tumor. Stem cells are then reinfused. Until engraftment occurs in the bone marrow sites of the body, there is a high risk of infection, sepsis, and bleeding. Acute and chronic toxicities from chemotherapy and radiation therapy may be severe. The risk of HSOS is also present after autologous transplantation. No immunosuppressant medications are necessary after AuHSCT, because the patient does not receive foreign tissue. A disadvantage of AuHSCT is the risk that tumor cells may remain in the bone marrow despite high-dose chemotherapy (conditioning regimens). Syngeneic transplants result in less incidence of GVHD and graft rejection; however, there is also less graft-versus-tumor effect to fight the malignancy. Syngeneic transplant is associated with transmission of genetic defects (Maziarz & Schubach-Slater, 2015). For this reason, even when an identical twin is available for marrow donation, another matched sibling or even an unrelated donor may be the most suitable donor to combat an aggressive malignancy. Nursing Management Nursing care of patients undergoing HSCT is complex and demands a high level of skill. The success of HSCT is greatly influenced by nursing care throughout the transplantation process. Implementing Care Before Treatment All patients must undergo extensive evaluations before the transplant to assess the current clinical status of the disease. Nutritional assessments, extensive physical examinations, organ function tests, and psychological evaluations are conducted. Blood work includes assessing past infectious antigen exposure (e.g., hepatitis virus, cytomegalovirus, herpes simplex virus, human immunodeficiency virus, and syphilis). The patient's social support systems and financial and insurance resources are also evaluated. Informed consent and patient education about the procedure and care before and after HSCT are vital. Providing Care During Treatment Skilled nursing care is required during the treatment phase of HSCT when high-dose chemotherapy (conditioning regimen) and total-body irradiation are given. The acute toxicities of nausea, diarrhea, mucositis, and hemorrhagic cystitis require close monitoring and symptom management by the nurse. Nursing management during stem cell infusion consists of monitoring the patient's vital signs and blood oxygen saturation; assessing for adverse effects, such as fever, chills, shortness of breath, chest pain, cutaneous reactions, nausea, vomiting, hypotension or hypertension, tachycardia, anxiety, and taste changes; and providing strategies for symptom control, ongoing support, and patient education. During stem cell infusion, patients may experience adverse reactions to the cryoprotectant dimethylsulfoxide (DMSO) used to preserve the harvested stem cells. These reactions may include nausea, vomiting, chills, dyspnea, cardiac dysrhythmias, and hypotension progressing to cardiac or respiratory arrest. Less common toxicities include neurologic and renal impairment (Maziarz & Schubach-Slater, 2015). Quality and Safety Nursing Alert Until engraftment of the new marrow occurs, the patient is at high risk for death from sepsis and bleeding. A cluster of symptoms referred to as engraftment syndrome may occur during the neutrophil recovery phase in both allogeneic and autologous transplants. Clinical features of this syndrome vary widely but may include noninfectious fever associated with skin rash, weight gain, diarrhea, and pulmonary infiltrates, with improvement noted after the initiation of corticosteroid therapy rather than antibiotic therapy (Maziarz & Schubach-Slater, 2015). Until engraftment is well established, the patient requires support with blood products and hematopoietic growth factors. Potential infections may be bacterial, viral, fungal, or protozoan in origin. During the first 30 days following transplant, the patient is most at risk for developing reactivations of viral infections, including herpes simplex, EBV, cytomegalovirus, and varicella zoster. Mucosal denudement poses a risk for Candida (yeast) infection locally and systemically. Pulmonary toxicities offer the opportunity for fungal infections such as Aspergillus. Renal complications arise from the nephrotoxic chemotherapy agents used in the conditioning regimen or those used to treat infection (amphotericin B, aminoglycosides). A neutropenic diet is usually prescribed for patients to decrease the risk of exposure to foodborne infections from bacteria, yeast, molds, viruses, and parasites (Lassiter & Schneider, 2015). Whether a neutropenic diet decreases rates of infection is currently in question; see the nursing research profile in Chart 15-6. Tumor lysis syndrome and acute tubular necrosis are also risks after HSCT. Nursing assessment for signs of these complications is essential for early identification and treatment. GVHD requires skillful nursing assessment to detect early effects on the skin, liver, and gastrointestinal tract. HSOS resulting from the conditioning regimens used can result in fluid retention, jaundice, abdominal pain, ascites, tender and enlarged liver, and encephalopathy. Pulmonary complications, such as pulmonary edema, interstitial pneumonia, and other pneumonias, often complicate recovery. Providing Care After Treatment: Caring for Recipients Ongoing nursing assessment during follow-up visits is essential to detect late effects of therapy after HSCT, which may occur 100 days or more after the procedure. Late effects include infections (e.g., varicella-zoster infection), restrictive pulmonary abnormalities, and recurrent pneumonias. Sterility often results due to total-body irradiation, chemotherapy, or both as components of the ablative regimen. Chronic GVHD can involve the skin, liver, intestine, esophagus, eyes, lungs, joints, and vaginal mucosa. Cataracts may also develop after total-body irradiation. The potential psychological impact of HSCT has been described as unique and unlike other experiences (Miceli, Lilleby, Noonan, et al., 2013). Psychosocial assessments by nursing staff must be ongoing and a priority. In addition to the multiple physical and psychological stressors affecting patients at each phase of the transplantation experience, the nature of the treatment and patient experience can place extreme emotional, social, financial, and physical demands on family, friends, and donors. Nurses assess the family and other caregivers' needs and provide education, support, and information about resources. Caring for Donors Like HSCT recipients, donors also require nursing care. They may experience mood alterations, decreased self-esteem, and guilt from feelings of failure if the transplantation fails. Family members must be educated and supported to reduce anxiety and promote coping during this difficult time. In addition, they must also be assisted to maintain realistic expectations of themselves as well as of the patient.

Lung cancer types, treatment options.

Types of Lung Cancer: Four histologic types account for most primary lung cancers: adenocarcinoma (males 37%, females 47%), squamous cell lung carcinoma (males 32%, females 25%), large cell carcinoma (males 18%, females 10%), and small cell carcinoma (males 14%, females 18%).14 For therapeutic purposes such as staging and treatment, lung cancers are further identified as non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC).13,14 One of the key reasons for this classification is that SCLC has usually metastasized by the time of diagnosis and hence is not typically amenable to surgery. It is usually best treated with chemotherapy, with or without radiation. Non-Small Cell Lung Cancers The NSCLCs include squamous cell carcinomas, adenocarcinomas, and large cell carcinomas. Squamous cell carcinoma is most commonly found in men and is closely correlated with a smoking history. Squamous cell carcinoma tends to originate in the central bronchi as an intraluminal growth and is thus more amenable to early detection through cytologic examination of the sputum than other forms of lung cancer. It tends to spread centrally into major bronchi and adjacent intrapulmonary lymph nodes (Fig 22-9). Central cavitation of the tumor is frequent. Currently, adenocarcinoma is the most common sub- type of lung cancer in North America. Its association with cigarette smoking is weaker than for squamous cell carcinoma. It is the most common type of lung cancer in women and nonsmokers. Adenocarcinoma is a malignant epithelial cell tumor with glandular differentiation or mucin production by the tumor cells. These tumors tend to be located more peripherally than squamous cell sarcomas and are often associated with pleural fibrosis and scarring (Fig. 22-10). In general, adenocarcinomas have a poorer stage-for-stage prognosis than squamous cell carcinomas. Large cell carcinomas have large, polygonal cells. They constitute a group of neoplasms that are highly anaplastic and difficult to categorize as squamous cell carcinoma or adenocarcinoma. They tend to occur in the periphery of the lung, invading subsegmental bronchi and larger airways. They have a poor prognosis because of their tendency to spread to distant sites early in their course. Small Cell Lung Cancer Small cell lung cancer is characterized by a distinctive cell type—small round to oval cells that are approximately the size of a lymphocyte. The cells grow in clusters that exhibit neither glandular nor squamous organization. The tumors are thought to arise from the neuroendocrine cells of the bronchial epithelium, and some of the tumor cells may be able to secrete hormonally active products. This cell type is associated with several types of paraneoplastic syndrome (signs and symptoms caused by secretions of or immune response to tumor cells), including the syndrome of inappropriate antidiuretic hormone secretion (SIADH; see Chapter 8). This type of cancer has the strongest association with cigarette smoking and is rarely observed in someone who has not smoked. Small cell lung cancer is highly malignant, tends to infiltrate widely, disseminate early, and is rarely resectable. About 70% of the cancers have detectable metastases at the time of diagnosis; the rest are assumed to have micrometastases. Brain metastases are particularly common with SCLC and may provide the first evidence of the tumor. Response rates for treatment with chemotherapy (cisplatin and etoposide) are excellent, with 50% to 60% complete response in persons with limited disease and 15% to 20% complete response in those with extensive disease. However, remissions tend to be short-lived with a mean duration of 6 to 8 months. Once the disease has recurred, the mean survival length is 3 to 4 months. Overall the 2-year survival is 20% to 40% in limited-stage disease and less than 5% in extensive disease. Diagnosis and Treatment The diagnosis of lung cancer is based on a careful history and physical examination and on other tests such as chest radiography, bronchoscopy, cytologic studies (Papanicolaou [Pap] test) of the sputum or bronchial washings, percutaneous needle biopsy of lung tissue, and scalene lymph node biopsy. Computed tomographic scans, MRI studies, and ultrasonography are used to locate lesions and evaluate the extent of the disease. Positron emission tomography (PET) is a noninvasive alternative for identifying metastatic lesions in the mediastinum or distant sites. Persons with SCLC should also have a CT scan or MRI of the brain for detection of metastasis. Annual screening of some high-risk groups with low-dose computed tomography (LDCT) has been proposed as a method for reducing the lung cancer mortality rate by detecting the disease at an earlier stage.45 Like other cancers, lung cancer is classified according to extent of disease. Non-small cell lung cancers are usually classified according to cell type (i.e., squamous cell carcinoma, adenocarcinoma, and large cell carcinoma) and staged according to the 2009 revised Tumor, Node, Metastasis (TNM) staging system. Initial clinical staging involves a CT scan of the chest that includes the adrenal gland to determine tumor size, invasion, and local and regional lymph node involvement. Small cell lung cancers are not staged using the TNM system because micrometastases are assumed to be present at the time of diagnosis. Instead, they are usually classified as limited disease, when the tumor is limited to the unilateral hemithorax, or extensive disease, when it extends beyond these boundaries. Treatment methods for NSCLC include surgery, radiation therapy, and systemic chemotherapy. These treatments may be used singly or in combination. Surgery is used for the removal of small, localized NSCLC tumors. It can involve a lobectomy, pneumonectomy, or segmental resection of the lung. Radiation therapy can be used as a definitive or main treatment modality, as part of a combined treatment plan, or for palliation of symptoms. Because of the frequency of metastases, chemotherapy often is used in treating lung cancer. Combination chemotherapy, which uses a regimen of several drugs, is often employed for lung cancer treatment. New targeted treatments are under development with the goal of increasing survival and ultimately providing a cure for this type of cancer. Therapy for SCLC is based on chemotherapy and radiation therapy. Advances in the use of combination chemotherapy, along with thoracic irradiation, have improved the outlook for persons with SCLC. Because SCLC may metastasize to the brain, prophylactic cranial irradiation is often indicated. In most persons who achieve a complete remission from SCLC, the brain is the most frequent site of relapse. About half of such persons develop clinical metastasis within 3 years. Newer combination chemotherapy regimens and targeted therapies are being developed in hopes of providing treatment alternatives that increase survival and produce fewer treatment liabilities.

Grief types

Stage: Denial: "This cannot be true." Feelings of isolation. May search for another health care professional who will give a more favorable opinion. May seek unproven therapies. Nursing implications: Denial can be an adaptive response, providing a buffer after bad news. It allows time to mobilize defenses but can be maladaptive when it prevents the patient or the family from seeking help or when denial behaviors cause more pain or distress than the illness or interfere with everyday functions. Nurses should assess the patient's and family's coping style, information needs, and understanding of the illness and treatment to establish a basis for empathetic listening, education, and emotional support. Rather than confronting the patient with information that he or she is not ready to hear, the nurse can encourage him or her to share fears and concerns. Open-ended questions or statements such as "Tell me more about how you are coping with this new information about your illness" can provide a springboard for expression of concerns. Stage: Anger: "Why me?" Feelings of rage, resentment, or envy directed at God, health care professionals, family, others. Nursing implications: Anger can be very isolating, and loved ones or clinicians may withdraw. Nurses should allow the patient and family to express anger, treating them with understanding, respect, and knowledge that the root of the anger is grief over impending loss. Stage: Bargaining: "I just want to see my grandchild's birth, then I'll be ready...." Patient and/or family plead for more time to reach an important goal. Promises are sometimes made with God. Nursing implications: Terminally ill patients are sometimes able to outlive prognoses and achieve some future goal. Nurses should be patient, allow expression of feelings, and support realistic and positive hope. Stage: Depression: "I just don't know how my kids are going to get along after I'm gone." Sadness, grief, mourning for impending losses. Nursing implications: Normal and adaptive response. Clinical depression should be assessed and treated when present. Nurses should encourage the patient and the family to fully express their sadness. Insincere reassurance or encouragement of unrealistic hopes should be avoided. Stage: Acceptance: "I've lived a good life, and I have no regrets." Patient and/or family are neither angry nor depressed. Nursing implications: The patient may withdraw as their circle of interest diminishes. The family may feel rejected by the patient. Nurses need to support the family's expression of emotions and encourage them to continue to be present for the patient. Grief, Mourning, and Bereavement A wide range of feelings and behaviors are normal, adaptive, and healthy reactions to the loss of a loved one. Grief refers to the personal feelings that accompany an anticipated or actual loss. Mourning refers to individual, family, group, and cultural expressions of grief and associated behaviors. Bereavement refers to the period of time during which mourning for a loss takes place. Both grief reactions and mourning behaviors change over time as people learn to live with the loss. Although the pain of the loss may be tempered by the passage of time, loss is an ongoing developmental process, and time does not heal the bereaved individual completely. That is, the bereaved do not get over a loss entirely, nor do they return to who they were before the loss. Rather, they develop a new sense of who they are and where they fit in a world that has changed dramatically and permanently. Anticipatory Grief and Mourning Denial, sadness, anger, fear, and anxiety are normal grief reactions in people with life-threatening illness and those close to them. Kübler-Ross (1969) described five common emotional reactions to dying that are applicable to the experience of any loss (see Table 16-4). Not every patient or family member experiences every stage; many patients never reach a stage of acceptance, and patients and families sometimes fluctuate on a daily basis in their emotional responses. Furthermore, although impending loss stresses the patient, the people who are close to him or her, and the functioning of the family unit, awareness of dying also provides a unique opportunity for family members to reminisce, resolve relationships, plan for the future, and say goodbye. Individual and family coping with the anticipation of death is complicated by the varied and conflicting trajectories that grief and mourning may assume in families. For example, the patient may be experiencing sadness while contemplating role changes that have been brought about by the illness, and the patient's spouse or partner may be expressing or suppressing feelings of anger about the current changes in role and impending loss of the relationship. Others in the family may be engaged in denial (e.g., "Dad will get better. He just needs to eat more"), fear ("Who will take care of us?" or "Will I get sick, too?"), or profound sadness and withdrawal. Although each of these behaviors is normal, tension may arise when one or more family members perceive that others are less caring, too emotional, or too detached. The nurse should assess the characteristics of the family system and intervene in a manner that supports and enhances the cohesion of the family unit. Parameters for assessing the family facing life-threatening illness are identified in Chart 16-12. The nurse can suggest that family members talk about their feelings and understand them in the broader context of anticipatory grief and mourning. Acknowledging and expressing feelings, continuing to interact with the patient in meaningful ways, and planning for the time of death and bereavement are adaptive family behaviors. Professional support provided by grief counselors, whether in the community, at a local hospital, in the long-term care facility, or associated with a hospice program, can help both the patient and the family sort out and acknowledge feelings and make the end of life as meaningful as possible. Grief and Mourning After Death When a loved one dies, family members enter a new phase of grief and mourning as they begin to accept the loss, feel the pain of permanent separation, and prepare to live a life without the deceased. Even if the loved one died after a long illness, preparatory grief experienced during the terminal illness does not preclude the grief and mourning that follow the death. With a death after a long or difficult illness, family members may experience conflicting feelings of relief that the loved one's suffering has ended, compounded by guilt and grief related to unresolved issues or the circumstances of death. Grief work may be especially difficult if a patient's death was painful, prolonged, accompanied by unwanted interventions, or unattended. Families that had no preparation or support during the period of imminent death may have a more difficult time finding a place for the painful memories. Although some family members may experience prolonged or complicated mourning, most grief reactions fall within a "normal" range. The feelings are often profound; however, bereaved people eventually reconcile the loss and find a way to reengage with their lives. Grief and mourning are affected by several factors, including individual characteristics, coping skills, and experiences with illness and death; the nature of the relationship to the deceased; factors surrounding the illness and the death; family dynamics; social support; and cultural expectations and norms. Uncomplicated grief and mourning are characterized by a range of emotions and behaviors from sadness and yearning to thoughts about or preoccupation with the deceased and for many, a temporary withdrawal from the activities of living in which they engaged before the death (Shear, 2012). After-death rituals, including preparation of the body, funeral practices, and burial rituals, are socially and culturally significant ways in which family members begin to accept the reality and finality of death. Preplanning of funerals is becoming increasingly common, and hospice professionals in particular help the family make plans for death, often involving the patient, who may wish to play an active role. Preplanning of the funeral relieves the family of the burden of making decisions in the intensely emotional period after a death. In general, the period of mourning is an adaptive response to loss during which mourners come to accept the loss as real and permanent, acknowledge and experience the painful emotions that accompany the loss, experience life without the deceased, overcome impediments to adjustment, and find a new way of living in a world without the loved one. Particularly immediately after the death, mourners begin to recognize the reality and permanence of the loss by talking about the deceased and telling and retelling the story of the illness and death. Societal norms in the United States are frequently at odds with the normal grieving processes of people; time excused from work obligations is typically measured in days, and mourners are often expected to get over the loss quickly and get on with life. In reality, the work of grief and mourning takes time, and avoiding grief work after the death often leads to long-term adjustment difficulties. According to Rando (2000), mourning for a loss involves the "undoing" of psychosocial ties that bind mourners to the deceased, personal adaptation to the loss, and learning to live in the world without the deceased. Six key processes of mourning allow people to accommodate to the loss in a healthy way (Rando, 2000): Recognition of the loss Reaction to the separation and experiencing and expressing the pain of the loss Recollection and reexperiencing the deceased, the relationship, and the associated feelings Relinquishing old attachments to the deceased Readjustment to adapt to the new world without forgetting the old Reinvestment Although many people complete the work of mourning with the informal support of families and friends, many find that talking with others who have had a similar experience, such as in formal support groups, normalizes the feelings and experiences and provides a framework for learning new skills to cope with the loss and create a new life. Hospitals, hospices, religious organizations, and other community organizations often sponsor bereavement support groups. Groups for parents who have lost a child, children who have lost a parent, widows, widowers, and gay men and lesbians who have lost a life partner are some examples of specialized support groups available in many communities. Nursing interventions for those experiencing grief and mourning are identified in Chart 16-13. Complicated Grief and Mourning Complicated grief and mourning are characterized by prolonged feelings of sadness and feelings of general worthlessness or hopelessness that persist long after the death, prolonged symptoms that interfere with activities of daily living (anorexia, insomnia, fatigue, panic), or self-destructive behaviors such as alcohol or substance abuse and suicidal ideation or attempts (Howarth, 2011). Complicated grief and mourning require professional assessment and can be treated with psychological interventions and, in some cases, with medications. Chart 16-13 Nursing Interventions for Grief and Mourning Support the Expression of Feelings Encourage the telling of the story using open-ended statements or questions (e.g., "Tell me about your husband"). Assist the mourner to find an outlet for their feelings: talking, attending a support group, keeping a journal, finding a safe outlet for angry feelings (writing letters that will not be mailed, physical activity). Assess emotional affect and reinforce the normalcy of feelings. Assess for guilt and regrets: "Are you especially troubled by a certain memory or thought?" "How do you manage those memories?" Assess for the Presence of Social Support "Do you have someone to whom you can talk about your husband?" "May I help you find someone you can talk to?" Assess Coping Skills "How are you managing day to day?" "Have you experienced other losses? How did you manage those?" "Are there things that you are having trouble doing?" "Do you have/need help with specific tasks?" Assess for Signs of Complicated Grief and Mourning and Offer Professional Referral Are you preoccupied with thoughts of the deceased that interfere with your ability to care for yourself? Do you have frequent and prolonged intense emotional pain?

Cancer surgery goals

Surgery Surgical removal of the entire cancer remains the ideal and most frequently used treatment method. However, the specific surgical approach may vary for several reasons. Diagnostic surgery is the definitive method for obtaining tissue to identify the cellular characteristics that influence all treatment decisions. Surgery may be the primary method of treatment, or it may be prophylactic, palliative, or reconstructive. Diagnostic Surgery Diagnostic surgery, or biopsy, is performed to obtain a tissue sample for histologic analysis of cells suspected to be malignant. In most instances, the biopsy is taken from the actual tumor; however, in some situations, it is necessary to take a sample of lymph nodes near a suspicious tumor. Many cancers can metastasize from the primary site to other areas of the body through the lymphatic circulation. Knowing whether adjacent lymph nodes contain tumor cells helps the health care team plan the best therapeutic approach to combat cancer that has spread beyond the primary tumor site. The use of injectable dyes and nuclear medicine imaging can help identify the sentinel lymph node or the initial lymph node to which the primary tumor and surrounding tissue drain. Sentinel lymph node biopsy (SLNB), also known as sentinel lymph node mapping, is a minimally invasive surgical approach that in many instances has replaced more invasive lymph node dissections (lymphadenectomy) and the associated complications such as lymphedema and delayed healing. SLNB has been widely adopted for regional lymph node staging in selected cases of melanoma and breast cancer (NCCN, 2015c). Biopsy Types Biopsy methods include excisional, incisional, and needle biopsy. The biopsy type is determined by the size and location of the tumor, the type of treatment anticipated if the cancer diagnosis is confirmed, and the need for surgery and general anesthesia. The biopsy method that allows for the least invasive approach while permitting the most representative tissue sample is chosen. Diagnostic imaging techniques can be used to assist in locating the suspicious lesion and to facilitate accurate tissue sampling. The patient and family are provided the opportunity and time to discuss the options before definitive plans are made. Excisional biopsy is used for small, easily accessible tumors of the skin, upper or lower gastrointestinal and upper respiratory tracts. In many cases, the surgeon can remove the entire tumor as well as the surrounding marginal tissues. The removal of normal tissue beyond the tumor area decreases the possibility that residual microscopic malignant cells may lead to a recurrence of the tumor. This approach not only provides the pathologist with the entire tissue specimen for the determination of stage and grade but also decreases the chance of seeding tumor cells (disseminating cancer cells throughout surrounding tissues). Incisional biopsy is performed if the tumor mass is too large to be removed. In this case, a wedge of tissue from the tumor is removed for analysis. The cells of the tissue wedge must be representative of the tumor mass so that the pathologist can provide an accurate diagnosis. If the specimen does not contain representative tissue and cells, negative biopsy results do not guarantee the absence of cancer. Excisional and incisional approaches are often performed through endoscopy. However, a surgical procedure may be required to determine the anatomic extent or stage of the tumor. For example, a diagnostic or staging laparotomy (the surgical opening of the abdomen to assess malignant abdominal disease) may be necessary to assess malignancies such as gastric or colon cancer. Needle biopsy is performed to sample suspicious masses that are easily and safely accessible, such as some masses in the breasts, thyroid, lung, liver, and kidney. Needle biopsies are most often performed on an outpatient basis. They are fast, relatively inexpensive, easy to perform, and may require only local anesthesia. In general, the patient experiences slight and temporary physical discomfort. In addition, the surrounding tissues are minimally disturbed, thus decreasing the likelihood of seeding cancer cells (disseminating cancer cells to adjacent tissue). Fine-needle aspiration (FNA) biopsy involves aspirating cells rather than intact tissue through a needle that is guided into a suspected diseased area. This type of specimen can only be analyzed by cytological examination (viewing only cells, not tissue). Often, x-ray, computed tomography (CT) scanning, ultrasonography, or magnetic resonance imaging (MRI) is used to help locate the suspicious area and guide placement of the needle. FNA does not always yield enough material to permit accurate diagnosis, necessitating additional biopsy procedures. A core needle biopsy uses a specially designed needle to obtain a small core of tissue that permits histologic analysis. Most often, this specimen is sufficient to permit accurate diagnosis. Surgery as Primary Treatment When surgery is the primary approach in treating cancer, the goal is to remove the entire tumor or as much as is feasible (a procedure sometimes called debulking) as well as any involved surrounding tissue, including regional lymph nodes. Two common surgical approaches used for treating primary tumors are local and wide excisions. Local excision, often performed on an outpatient basis, is warranted when the mass is small. It includes removal of the mass and a small margin of normal tissue that is easily accessible. Wide or radical excisions (en bloc dissections) include removal of the primary tumor, lymph nodes, adjacent involved structures, and surrounding tissues that may be at high risk for tumor spread. This surgical method may result in disfigurement and altered functioning, necessitating rehabilitation, reconstructive procedures, or both. However, wide excisions are considered if the tumor can be removed completely and the chances of cure or control are good. Minimally invasive surgical techniques are increasingly replacing traditional surgery associated with large incisions for a variety of cancers. The advantages of minimally invasive approaches include minimization of surgical trauma, decreased blood loss, decreased incidence of wound infection and other complications associated with surgery, decreased surgical time and requirement for anesthesia, decreased postoperative pain and limited mobility, and shorter periods of recovery (Nguyen, Summers, & Finkelstein, 2015). Video-assisted endoscopic surgery, an example of minimally invasive surgery, uses an endoscope with intense lighting and an attached multichip mini-camera that is inserted into the body through a small incision. The surgical instruments are inserted into the surgical field through one or two additional small incisions, each about 3 cm in length. The camera transmits the image of the involved area to a monitor so that the surgeon can manipulate the instruments to perform the necessary procedure. Such surgery is used for many thoracic and abdominal procedures. The use of robotics during laparoscopic procedures permits the removal of tumors with more precision and dexterity than could be accomplished by laparoscopic surgery alone (Niklas, Saar, Berg, et al., 2016). Laparoscopic robotic-assisted surgery has been used for prostate and gynecologic cancers. Transoral robotic-assisted surgery is being used for certain types of oral and laryngeal cancers. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of cancer after the use of a less extensive primary approach. Mastectomy to treat recurrent breast cancer after primary lumpectomy and radiation is an example of salvage surgery. Surgery may completely excise limited areas of metastatic disease (referred to as oligometastatic disease) as well. An example would be colon cancer with one to three small areas of liver metastasis and no evidence of cancer elsewhere. In the past, patients with recurrent or metastatic disease were treated with palliation only as their disease was considered incurable. However, evidence suggests possible cure or prolonged disease-free survival for patients with controlled or completely removed primary cancer and completely removed, limited, metastatic disease (Corbin, Hellman, & Weichselbaum, 2013; Di Lascio, & Pagani, 2014). In addition to surgery that uses surgical blades or scalpels to excise the mass and surrounding tissues, several other types of techniques are available. Table 15-5 provides examples of these techniques. A multidisciplinary approach to patient care is essential for the patient undergoing cancer-related surgery. The effects of surgery on the patient's body image, self-esteem, and functional abilities are addressed. If necessary, a plan for postoperative rehabilitation is made before the surgery is performed. The growth and dissemination of cancer cells may have produced distant micrometastases by the time the patient seeks treatment. Therefore, attempting to remove wide margins of tissue in the hope of "getting all the cancer" may not be feasible. This reality substantiates the need for a coordinated multidisciplinary approach to cancer therapy. Once the surgery has been completed, one or more additional (or adjuvant) modalities may be chosen to increase the likelihood of eradicating the remaining microscopic cancer cells that are undetectable by available diagnostic procedures. However, some cancers that are treated surgically in the very early stages (e.g., skin and testicular cancers) are considered to be curable without additional therapy. Prophylactic Surgery Prophylactic or risk reduction surgery involves removing non-vital tissues or organs that are at increased risk of developing cancer. The following factors are considered when discussing possible prophylactic surgery: Family history and genetic predisposition Presence or absence of signs and symptoms Potential risks and benefits Ability to detect cancer at an early stage Alternative options for managing increased risk The patient's acceptance of the postoperative outcome Colectomy, mastectomy, and oophorectomy are examples of prophylactic surgeries. Identification of genetic markers indicative of inherited cancer syndromes or a predisposition to develop some types of cancer plays a role in decisions concerning prophylactic surgeries. However, what is adequate justification for prophylactic surgery remains controversial. For example, several factors are considered when deciding to proceed with a prophylactic mastectomy, including a strong family history of breast cancer; positive BRCA1 or BRCA2 findings; an abnormal physical finding on breast examination, such as progressive nodularity and cystic disease; a proven history of breast cancer in the opposite breast; abnormal mammography findings; abnormal biopsy results; and individual factors that may influence the patient's decision-making process (Mahon, 2014). Prophylactic surgery is discussed with patients and families along with other approaches for managing increased risk of cancer development. Preoperative education and counseling, as well as long-term follow-up, are provided. Palliative Surgery When surgical cure is not possible, the goals of surgical interventions are to relieve symptoms, make the patient as comfortable as possible, and promote quality of life as defined by the patient and family. Palliative surgery is performed in an attempt to relieve symptoms, such as ulceration, obstruction, hemorrhage, pain, and malignant effusions (see Table 15-6). Honest and informative communication with the patient and family about the goal of surgery is essential to avoid false hope and disappointment. Reconstructive Surgery Reconstructive surgery may follow curative or extensive surgery in an attempt to improve function or obtain a more desirable cosmetic effect. It may be performed in one operation or in stages. The surgeon who will perform the surgery discusses possible reconstructive surgical options with the patient before the primary surgery is performed. Reconstructive surgery may be indicated for breast, head and neck, and skin cancers. The nurse assesses the patient's needs and the impact that altered functioning and body image may have on quality of life. Nurses provide patients and families with opportunities to discuss these issues. The individual needs of the patient undergoing reconstructive surgery and their families must be accurately recognized and addressed. Nursing Management Patients undergoing surgery for cancer require general perioperative nursing care (see Chapter 18). Surgical care is individualized according to age, organ impairment, specific deficits, comorbidities, cultural implications, and altered immunity. Combining other treatment methods, such as radiation and chemotherapy, with surgery also contributes to postoperative complications, such as infection, impaired wound healing, altered pulmonary or renal function, and the development of venous thromboembolism (VTE). The nurse completes a thorough preoperative assessment for factors that may affect the patient undergoing the surgical procedure. Preoperatively, the nurse provides the patient and family with verbal and written information about the surgical procedure as well as other interventions that may take place intraoperatively (i.e., radiation implants). Instructions concerning prophylactic antibiotic requirements, diet, and bowel preparation are also provided. Patients who are undergoing surgery for the diagnosis or treatment of cancer may be anxious about the surgical procedure, possible findings, postoperative limitations, changes in normal body functions, and prognosis. The patient and family require time and assistance to process this information, possible changes, and expected outcomes resulting from the surgery. The nurse serves as the patient advocate and liaison and encourages the patient and family to take an active role in decision making when possible. If the patient or family asks about the results of diagnostic testing and surgical procedures, the nurse's response is guided by the information that was conveyed previously. The nurse may be asked to explain and clarify information for patients and families that was provided initially but was not grasped because of intense anxiety. It is important that the nurse, as well as other members of the health care team, provide information that is consistent. Postoperatively, the nurse assesses patient responses to surgery and monitors the patient for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction. The nurse also provides for the patient's comfort. Postoperative education addresses wound care, pain management, activity, nutrition, and medication information. Plans for discharge, follow-up, home care, and subsequent treatment and rehabilitation are initiated as early as possible to ensure continuity of care from hospital to home or from a cancer referral center to the patient's local hospital and health care provider. Patients and families are encouraged to use community resources such as the ACS for support and information (see the Resources section at the end of this chapter). TABLE 15-5 Selected Techniques Used for Localized Destruction of Tumor Tissue Type of Procedure: Chemosurgery Description: Use of chemicals or chemotherapy applied directly to tissue to cause destruction Examples of Use: Intraperitoneal chemotherapy for ovarian cancer involving the abdomen and peritoneum Type of Procedure: Cryoablation Description: Use of liquid nitrogen or a very cold probe to freeze tissue and cause cell destruction Examples of Use: Cervical, prostate, and rectal cancers Type of Procedure: Electrosurgery Description: Use of an electric current to destroy tumor cells Examples of Use: Basal and squamous cell skin cancers Type of Procedure: Laser surgery Description: Use of light and energy aimed at an exact tissue location and depth to vaporize cancer cells (also referred to as photocoagulation or photoablation) Examples of Use: Dyspnea associated with endobronchial obstructions Type of Procedure: Photodynamic therapy Description: IV administration of a light-sensitizing agent (hematoporphyrin derivative [HPD]) that is taken up by cancer cells, followed by exposure to laser light within 24-48 hours; causes cancer cell death Examples of Use: Palliative treatment of dysphagia associated with esophageal and dyspnea associated with endobronchial obstructions Type of Procedure: Radiofrequency ablation (RFA) Description: Uses localized application of thermal energy that destroys cancer cells through heat: temperatures exceed 50°C (122°F) Examples of Use: Nonresectable liver tumors, pain control with bone metastasis Procedure/Indications Abdominal shunt placement/Ascites Biliary stent placement/Biliary obstruction Bone stabilization/Displaced bone fracture related to metastatic disease Colostomy or ileostomy/Bowel obstruction Cordotomy/Pain Epidural catheter placement (for administering epidural analgesics)/Pain Excision of solitary metastatic lesion/Metastatic lung, liver, or brain lesion Gastrostomy, jejunostomy tube placement/Upper gastrointestinal tract obstruction Hormone manipulation (removal of ovaries, testes, adrenals, pituitary)/Tumors that depend on hormones for growth Nerve block/Pain Percutaneous enteral gastrostomy (PEG) tube placement/Enteral nutrition Pericardial drainage tube placement/Pericardial effusion Peritoneal drainage tube placement/Ascites Pleural drainage tube placement/Pleural effusion Ureteral stent placement/Ureteral obstruction Venous access device placement (for administering parenteral analgesics)/Pain

Cancer levels of prevention, leading cause of cancer death

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. 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. 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. Leading cause Despite significant advances in science and technology, cancer is the second leading cause of death in the United States (Siegel, Miller, & Jemal, 2015). Currently, one in four deaths is caused by cancer. The leading causes of cancer death in the United States in order of frequency and location are lung, prostate, and colorectal cancer in men and lung, breast, and colorectal cancer in women. Most cancer occurs in older adults; according to the American Cancer Society (ACS), 78% of all cancer diagnoses are in people 55 years of age or older (2015a). Overall, the incidence of cancer is higher in men than in women. Cancer incidence and death rates also vary by geography. In states where the prevalence of tobacco use is high, the incidence of lung cancer tends to be greater than in states where smoking is not as common. In locations where there is greater socioeconomic disparity, the incidence of advanced cancer and overall cancer death rates are higher than in regions where there is not such disparity.

Oncological Emergencies

Providing Care in Oncologic Emergencies As a result of advances in all aspects of cancer care, it is more common that individuals are living with cancer that has advanced beyond the original site of development to regional or distant sites. Patients with advanced cancer are likely to experience many of the problems described previously, although more often and to a greater degree. Symptoms of pain, anorexia, weight loss, CACS, fatigue, and impaired functional status and mobility make patients more susceptible to depressive symptoms, skin breakdown, fluid and electrolyte imbalances, and infection. Treatment for the patient with advanced cancer is likely to be palliative rather than curative, with an emphasis on prevention and appropriate management of pain. The use of long-acting analgesic agents at set intervals, rather than on an "as needed" basis, is recommended in addressing pain management. Working with the patient and family, as well as with other health care providers, to manage pain is essential to increase the patient's comfort and offer some sense of control. Other medications (e.g., sedatives, tranquilizers, muscle relaxants, antiemetics) are added to assist in palliating additional symptoms and promoting quality of life. If the patient is a candidate for radiation therapy or surgical interventions to relieve pain or other symptoms, the potential benefits and risks of these procedures (e.g., percutaneous nerve block, cordotomy) are explained to the patient and family. Measures are taken to prevent complications that result from altered sensation, immobility, and changes in bowel and bladder function. Weakness, altered mobility, fatigue, and inactivity typically increase with advanced cancer as a result of the disease, treatment, inadequate nutritional intake, or dyspnea. The nurse works with the patient and family to identify realistic goals and promote comfort. Measures include use of energy conservation methods to accomplish tasks and activities that the patient values most. Efforts are made to provide the patient with as much control and independence as desired but with assurance that support and assistance are available when needed. In addition, health care teams work with the patient and family to ascertain and comply with the patient's wishes about treatment methods and care as the terminal phase of illness and death approach. Emergency: Superior Vena Cava Syndrome (SVCS) Compression or invasion of the superior vena cava by tumor; enlarged lymph nodes; intraluminal thrombus that obstructs venous circulation; or drainage of the head, neck, arms, and thorax. Most often associated with lung cancer, SVCS is also associated with lymphoma, thymoma, and testicular cancers and mediastinal metastases from breast cancer. If untreated, SVCS may lead to cerebral anoxia (because not enough oxygen reaches the brain), laryngeal edema, bronchial obstruction, and death. Diagnosis is confirmed by: Clinical findings Chest x-ray Thoracic computed tomography (CT) scan Thoracic magnetic resonance imaging (MRI) Venogram if intraluminal thrombosis is suspected Clinical Manifestations and Diagnostic Findings: Clinical: Gradually or suddenly impaired venous drainage giving rise to: Progressive shortness of breath (dyspnea), cough, hoarseness, chest pain, and facial swelling Edema of the neck, arms, hands, and thorax and reported sensation of skin tightness, difficulty swallowing, and stridor Possibly engorged and distended jugular, temporal, and arm veins Dilated thoracic vessels causing prominent venous patterns on the chest wall Increased intracranial pressure, associated visual disturbances, headache, and altered mental status Dx: Identify patients at risk for SVCS. Provide patient education regarding signs and symptoms to report Monitor and report clinical manifestations of SVCS. Monitor cardiopulmonary and neurologic status. Avoid upper extremity venipuncture and blood pressure measurement; instruct patient to avoid tight or restrictive clothing and jewelry on fingers, wrist, and neck. Facilitate breathing and drainage from upper portion of body by instructing patient to maintain some elevation of head and upper body with semi-Fowler position; avoid completely supine or prone position (this helps to promote comfort and reduce anxiety associated with dependent and progressive edema). Promote energy conservation to minimize shortness of breath. Monitor the patient's fluid volume status; administer fluids cautiously to minimize edema. Assess for thoracic radiation-related problems such as mucositis with resultant dysphagia (difficulty swallowing) and esophagitis. Monitor for chemotherapy-related problems, such as myelosuppression. Provide postoperative care as appropriate. Management: Radiation therapy to shrink tumor or enlarged lymph nodes and relieve symptoms Chemotherapy for sensitive cancers (e.g., lymphoma, small cell lung cancer) or when the mediastinum has been irradiated to maximum tolerance Anticoagulant or thrombolytic therapy for central venous catheter related intraluminal thrombosis Percutaneously placed intravascular stents may be priority consideration rather than surgery unless symptoms are rapidly progressing. Supportive measures such as oxygen therapy, corticosteroids, and diuretics (in cases of fluid overload) Emergency: Spinal Cord Compression Most commonly caused by compression of the cord and its nerve roots by a metastatic paravertebral tumor that extends into the epidural space; vertebral bone metastasis leading to bone collapse and displacement impinging on the spinal cord or nerve roots; and less commonly, primary malignancy of the cord. May potentially lead to significant and permanent neurologic impairment associated with multiple physical, psychosocial consequences. Most often associated with cancers that metastasize to the bone such as breast, lung, and prostate cancers and lymphoma. Also seen in nasopharyngeal cancer and multiple myeloma. About 70% of compressions occur at the thoracic level, 20% in the lumbosacral level, and 10% in the cervical and sacral regions. The prognosis depends on the severity and rapidity of onset. Clinical Manifestations and Diagnostic Findings: Clinical: Local inflammation, edema, venous stasis, and impaired blood supply to nerve tissues Local or radicular back or neck pain along the dermatomal areas innervated by the affected nerve root (e.g., thoracic radicular pain extends in a band around the chest or abdomen) Pain exacerbated by movement, supine recumbent position, coughing, sneezing, or the Valsalva maneuver Neurologic dysfunction and related motor and sensory deficits (numbness, tingling, feelings of coldness in the affected area, inability to detect vibration, loss of positional sense) Motor loss ranging from subtle weakness to flaccid paralysis Bladder and/or bowel dysfunction depending on level of compression (above S2, overflow incontinence; from S3 to S5, flaccid sphincter tone and bowel incontinence). Diagnostic: Radiofrequency vertebral augmentation: similar to kyphoplasty; instead of the balloon, a small navigational canula is inserted into the vertebra to create small pathways for cement. The cement is heated with radiofrequency to create an ultra high viscosity that is thought to promote bone stability Chemotherapy as adjuvant to other local therapies for patients with chemosensitive cancers such as lymphoma or small cell lung cancer Note: Despite treatment, patients with poor neurologic function before treatment are less likely to regain complete motor and sensory function; patients who develop complete paralysis usually do not regain all neurologic function. Management: Medical: Radiation therapy to reduce tumor size and halt progression; corticosteroid therapy to decrease inflammation and swelling at the compression site Surgery to debulk tumor and stabilize the spine if symptoms progress despite radiation therapy or if vertebral fracture or bone fragments lead to additional nerve damage; surgery is also an option when the tumor is not radiosensitive or is located in an area that was previously irradiated. Minimally invasive surgical procedures, referred to as vertebral augmentation, may be used for patients with vertebral fractures to attain stability of the bone, prevent nerve compression, and decrease pain. Procedures include: Vertebroplasty: involves percutaneous injection of polymethyl methacrylate (PMMA), a bone cement filler, into the vertebral body Kyphoplasty: a balloon is inserted into the damaged vertebral body and then inflated to create a cavity within the bone that can be filled with bone cement. The balloon helps to compress the fracture fragments together as the cavity is created. Nursing: Perform ongoing assessment of neurologic function to identify existing and progressing dysfunction. Control pain with pharmacologic and nonpharmacologic measures. Prevent complications of immobility resulting from pain and decreased function (e.g., skin breakdown, urinary stasis, thrombophlebitis, decreased clearance of pulmonary secretions). Maintain muscle tone by assisting with range-of-motion exercises in collaboration with physical and occupational therapists; patients with unstable vertebral fractures do not initiate physical therapy until spine stabilization procedures have been completed. Institute intermittent urinary catheterization and bowel training programs for patients with bladder or bowel dysfunction. Provide encouragement and support to patient and family coping with pain and altered functioning, lifestyle, roles, and independence. Institute appropriate referrals for home care and physical and occupational therapy. Emergency: Hypercalcemia Hypercalcemia is a potentially life-threatening metabolic abnormality resulting when the calcium released from the bones is more than the kidneys can excrete or the bones can reabsorb. It may result from production of cytokines, hormonal substances, and growth factors by cancer cells, or by the body in response to substances produced by cancer cells, which lead to bone breakdown and calcium release. Most commonly seen in breast, lung, and renal cancers; myeloma; and some types of leukemia Clinical Manifestations and Diagnostic Findings: Clinical: Fatigue, weakness, confusion, decreased level of responsiveness, hyporeflexia, nausea, vomiting, constipation, ileus, polyuria (excessive urination), polydipsia (excessive thirst), dehydration, and dysrhythmias Diagnostic: Total serum calcium level >10.5 mg/dL (2.74 mmol/L) Ionized serum calcium >1.29 mmol/L Management: Identify patients at risk for hypercalcemia and assess for signs and symptoms of hypercalcemia. Educate patient and family; prevention and early detection can prevent fatality. Educate at-risk patients to recognize and report signs and symptoms of hypercalcemia. Provide patient and family education regarding: Need to consume 2-4 L of fluid daily unless contraindicated by existing renal or cardiac disease Use of dietary and pharmacologic interventions such as stool softeners and laxatives for constipation Maintenance of nutritional intake without restricting normal calcium intake Antiemetic therapy for nausea and vomiting Promotion of mobility and emphasis on importance in preventing demineralization and breakdown of bones Safety precautions for patients with impaired mental and mobility status Emergency: Tumor lysis syndrome (TLS) Potentially fatal complication that occurs spontaneously or more commonly following radiation, biotherapy, or chemotherapy-induced cell destruction of large or rapidly growing cancers such as leukemia, lymphoma, and small cell lung cancer. The release of tumor intracellular contents (nuclei acids, electrolytes, and debris) leads to rapidly induced electrolyte imbalances—hyperkalemia, hyperphosphatemia (leading to hypocalemia), and hyperuricemia—that can have life-threatening end-organ effects on the myocardium, kidneys, and central nervous system Clinical Manifestations and Diagnostic Findings: Clinical: Clinical manifestations depend on the extent of metabolic abnormalities. Clinical TLS is diagnosed when ≥1 of 3 conditions arise either 3 days prior to or 7 days after cytotoxic cancer therapy: acute kidney injury (defined as a rise in creatinine to ≥1.5 times the upper limit of normal that is not attributable to medications), dysrhythmias (including sudden cardiac death), and seizures. Neurologic: Fatigue, weakness, memory loss, altered mental status, muscle cramps, tetany, paresthesias (numbness and tingling), seizures Cardiac: Elevated blood pressure, shortened QT complexes, widened QRS waves, altered T waves, dysrhythmias, cardiac arrest GI: Anorexia, nausea, vomiting, abdominal cramps, diarrhea, increased bowel sounds Renal: Flank pain, oliguria, anuria, kidney injury, acidic urine pH Other: Gout, malaise, pruritis Diagnostic: Electrolyte imbalances identified by serum electrolyte measurement and urinalysis (see Chapter 13); electrocardiogram to detect cardiac dysrhythmias Management: To prevent kidney injury and restore electrolyte balance, aggressive fluid hydration is initiated 24-48 hours before and after the initiation of cytotoxic therapy to increase urine volume and eliminate uric acid and electrolytes; urine is alkalinized by adding sodium bicarbonate to IV fluid to maintain a urine pH of 7-7.5; this prevents kidney injury secondary to uric acid precipitation in the kidneys. Diuresis with a loop diuretic or osmotic diuretic if urine output is not sufficient Allopurinol (Zyloprim) therapy to inhibit the conversion of nucleic acids to uric acid; rasburicase (Elitek) may be used to convert already formed uric acid to allantoin, which is highly water soluble and eliminated in urine. Administration of a cation-exchange resin, such as sodium polystyrene sulfonate (Kayexalate), to treat hyperkalemia by binding and eliminating potassium through the bowel Administration of IV sodium bicarbonate, hypertonic dextrose, and regular insulin temporarily shifts potassium into cells and lowers serum potassium levels if a rapid decrease in potassium is necessary. Administration of phosphate-binding gels, such as aluminum hydroxide, to treat hyperphosphatemia by promoting phosphate excretion in the feces Hemodialysis when patients are unresponsive to the standard approaches for managing uric acid and electrolyte abnormalities. Identify at-risk patients. Institute essential preventive measures (e.g., fluid hydration, medications) as prescribed. Assess patient for signs and symptoms of electrolyte imbalances. Assess urine pH to confirm alkalization. Monitor serum electrolyte and uric acid levels for evidence of fluid volume overload secondary to aggressive hydration. Instruct patients to monitor for and report symptoms indicating electrolyte disturbances.

Cerebral perfusion pressure

Regulation of Cerebral Blood Flow The blood flow to the brain is maintained at approximately 750 to 900 mL/minute or 15% of the resting cardiac output.2 The regulation of blood flow to the brain is controlled largely by autoregulatory or local mechanisms that respond to the metabolic needs of the brain. Cerebral autoregulation has been classically defined as the ability of the brain to maintain constant cerebral blood flow despite changes in systemic arterial pressure. This allows the cerebral cortex to adjust cerebral blood flow locally to satisfy its metabolic needs. The autoregulation of cerebral blood flow is efficient within an MABP range of approximately 60 to 140 mm Hg.2 Although total cerebral blood flow remains relatively stable throughout marked changes in cardiac output and arterial blood pressure, regional blood flow may vary markedly in response to local changes in metabolism. If blood pressure falls below 60 mm Hg, cerebral blood flow becomes severely compromised, and if it rises above the upper limit of autoregulation, blood flow increases rapidly and overstretches the cerebral vessels. In persons with hypertension, this autoregulatory range shifts to higher MABP levels. Metabolic factors affecting cerebral blood flow include an increase in carbon dioxide and hydrogen ion concentrations. Increased carbon dioxide provides a potent stimulus for vasodilation—a doubling of the PCO2 in the blood results in a doubling of cerebral blood flow. Carbon dioxide is thought to increase cerebral blood flow by first combining with water to form carbonic acid, with subsequent dissociation into hydrogen ions, which then causes vasodilation of the cerebral vessels. Other substances, such as lactic acid and pyruvic acid, which increase the acidity of brain tissues, will produce a similar increase in cerebral blood flow. Oxygen deficiency also influences cerebral blood flow. Except during periods of intense brain activity, the rate of oxygen utilization by the brain remains within a narrow range. If blood flow to the brain becomes insufficient to supply this needed amount of oxygen, the oxygen deficiency causes the cerebral vessels to dilate, returning cerebral blood flow to near normal. The sympathetic nervous system also contributes to the control of blood flow in the large cerebral arteries and the arteries that penetrate into the brain substance.2 Under normal physiologic conditions, local regulatory and autoregulatory mechanisms override the effects of sympathetic stimulation. However, when local mechanisms fail, sympathetic control of cerebral blood pressure becomes important. For example, when the arterial pressure rises to very high levels during strenuous exercise or in other conditions, the sympathetic nervous system constricts the large and intermediate-sized superficial blood vessels as a means of protecting the smaller, more easily damaged vessels. Sympathetic reflexes are also thought to cause vasospasm in the intermediate and large arteries in some types of brain damage, such as that caused by rupture of a cerebral aneurysm. Cerebral Response to Increased Intracranial Pressure As ICP rises, compensatory mechanisms in the brain work to maintain blood flow and prevent tissue damage. The brain can maintain a steady perfusion pressure if the arterial systolic blood pressure is 50 to 150 mm Hg and the ICP is less than 40 mm Hg. Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg (Hickey, 2014). As ICP rises and the autoregulatory mechanism of the brain is overwhelmed, the CPP can increase to greater than 100 mm Hg or decrease to less than 50 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. Therefore, the CPP must be maintained at 70 to 80 mm Hg to ensure adequate blood flow to the brain. If ICP is equal to MAP, cerebral circulation ceases. Maintaining Cerebral Perfusion Cardiac output may be manipulated to provide adequate perfusion to the brain. Improvements in cardiac output are made using fluid volume and inotropic agents such as dobutamine (Dobutrex) and norepinephrine (Levophed). The effectiveness of the cardiac output is reflected in the CPP, which is maintained at greater than 70 mm Hg (Oddo et al., 2014). A lower CPP indicates that the cardiac output is insufficient to maintain adequate cerebral perfusion. SjvO2 and Licox, described earlier, assist in monitoring cerebral perfusion. Decompressive hemicraniectomy may also be considered as a surgical strategy to assist in the management of refractory intracranial hypertension. The removal of a part of the skull allows the brain to expand without the pressure constraints exerted by the cranial vault. Complications of this procedure include infection and increased potential for injury to the unprotected underlying brain structures. Once the patient is no longer at risk for increased ICP, the bone flap may be surgically replaced

Nursing care breast cancer patients, risk factors for breast cancer, screenings and diagnosis.

Risk factors for breast cancer include increasing age, personal or family history of breast cancer (i.e., at highest risk are those with multiple affected first-order relatives), history of benign breast disease (i.e., primary "atypical" hyperplasia), and hormonal influences that promote breast maturation and may increase the chance of cell mutation (i.e., early menarche, late menopause, and no term pregnancies or first child after 30 years of age). Modifiable risk factors include obesity (particularly after menopause), physical inactivity, caffeine, moderate to heavy consumption of alcohol, cigarette smoking, and long-term use of postmenopausal hormone therapy (especially combined estrogen and progestin).57 Most women with breast cancer have no identifiable risk factors. Approximately 12% of all breast cancers are hereditary. The probability of a hereditary etiology increases with multiple affected first-degree relatives, with women who are affected before 50 years of age, and those who have multiple cancers.57 Mutations in two breast cancer susceptibility genes—BRCA1 on chromosome 17 and BRCA2 on chromosome 13—may account for most inherited forms of breast cancer (see Chapter 7). BRCA1 is known to be involved in tumor suppression. A woman with known mutations in BRCA1 has a lifetime risk of approximately 57% for breast cancer and approximately 40% for ovarian cancer. BRCA2 is another susceptibility gene that elevates lifetime breast cancer risk to 49% and ovarian cancer risk to 18%.59,60 Breast cancer risk reduction options available to known carriers of BRCA1 and BRCA2 mutations include surveillance and surgery. Breast evaluation using MRI, digital mammography, and breast ultrasound give the best sensitivity for detecting breast cancer. Prophylactic surgery, in the form of bilateral mastectomy, bilateral oophorectomy, or both, has been shown to decrease the risk of developing cancer. These controversial surgeries can have physical and psychological side effects that warrant careful consideration before proceeding. Detection Cancer of the breast may manifest clinically as a mass, a puckering, nipple retraction, or unusual discharge. Many cancers are found by women themselves—sometimes when only a thickening or subtle change in breast contour is noticed. The variety of symptoms and potential for self-discovery underscore the need for all women to have an awareness of what their normal breast appearance and texture are like. Mammography is the only effective screening technique for the early detection of clinically inapparent breast lesions. A generally slow-growing form of cancer, breast cancer may have been present for 2 to 9 years before it reaches 1 cm, the smallest mass normally detected by palpation. Mammography can disclose lesions as small as 1 mm and the clustering of calcifications that may warrant biopsy to exclude cancer. In 2003, the American Cancer Society dropped its recommendation that all women perform regular, systematic breast self-examination (BSE). Research has indicated that most women who discover their own cancer do so at times other than scheduled BSE. The American Cancer Society screening guidelines now place primary emphasis for breast cancer diagnosis on clinical breast examination (CBE) by a trained health professional and mammography, while encouraging women in the area of self-awarenenss.21 Between the ages of 20 and 39 years, average risk women should undergo CBE every 3 years, and after age 40 years CBE should take place annually, ideally prior to the woman's annual mammogram. There is no specific upper age at which mammogram should be discontinued. Instead it is suggested that decision to stop mammogram screening should be individualized based on the potential risks and benefits. As long as the woman is in good health and would be a candidate for cancer treatment, it is recommended that she continue to be screened with mammography. Diagnosis and Classification Procedures used in the diagnosis of breast cancer include physical examination, mammography, ultrasonography, percutaneous needle aspiration, stereotactic needle biopsy (i.e., core biopsy), and excisional biopsy. Figure 40-19 illustrates the appearance of breast cancer on mammography. Breast cancer often manifests as a solitary, painless, firm, fixed lesion with poorly defined borders. It can be found anywhere in the breast but is most common in the upper outer quadrant. Because of the variability in presentation, any suspect change in breast tissue warrants further investigation. The diagnostic use of mammography enables additional definition of the clinically suspect area (e.g., appearance, character, calcification). Placement of a wire marker under radiographic guidance can ensure accurate surgical biopsy of nonpalpable suspect areas. Ultrasonography is useful as a diagnostic adjunct to differentiate cystic from solid tissue in women with nonspecific thickening.

Signs and symptoms of skin cancer. Different types of skin cancer. Prevention of skin cancer.

Skin cancer represents the most common malignancy in white-skinned people in the Western world.61 The majority of skin cancers are nonmelanomas, either basal cell or squamous cell carcinoma, which are not associated with a high risk of morbidity or mortality. Although malignant melanoma represents a small subset of skin cancers, it is the most deadly. In 2009 61,646 people in the United States were diagnosed with malignant melanoma—35,436 men and 26,210 women. In the United States, 9199 people also died from melanomas of the skin (5992 men and 3207 women).61 The rising incidence of melanoma and other skin cancers has been attributed to increased sun exposure associated with social and lifestyle changes. The factors linking sun exposure to skin cancer are not completely understood, but both total cumulative exposure and altered patterns of exposure are strongly implicated. Basal cell and squamous cell carcinomas are often associated with total cumulative exposure to UV radiation. Thus, basal cell and squamous cell carcinomas occur more commonly on maximally sun-exposed parts of the body, such as the face and back of the hands and forearms. Melanomas occur most commonly on areas of the body that are exposed to the sun intermittently, such as the back in men and the lower legs in women. They are more common in persons with indoor occupations whose exposure to sun is limited to weekends and vacations. Excessive childhood sun exposure is an important risk factor for melanoma, particularly blistering sunburns. Malignant Melanoma Malignant melanoma is a cancerous tumor of the melanocytes. It is a rapidly progressing, metastatic form of cancer. The dramatic increase in the incidence of malignant melanoma over the past several decades has been credited to increased UV light exposure, including tanning salons. Other risk factors include a family history of malignant melanoma, fair hair and skin, tendency to freckle, and a history of blistering sunburns as a child. Still other significant risk factors for melanoma are atypical moles/dysplastic nevus syndrome, immunosuppression, and prior PUVA therapy. Roughly 90% of malignant melanomas in whites occur on sun-exposed skin. However, in darker-skinned people melanomas often occur on non-sun-exposed areas, such as the mucous membranes and subungual, palmar, and plantar surfaces. Malignant melanomas differ in size and shape. Usually, they are slightly raised and black or brown. Borders are irregular and surfaces are uneven. Most appear to arise from preexisting nevi or new molelike growths (Fig. 46-22). There may be surrounding erythema, inflammation, and tenderness. Periodically, melanomas ulcerate and bleed. Dark melanomas are often mottled with shades of red, blue, and white. These three colors represent three concurrent processes: melanoma growth (blue), inflammation and the body's attempt to localize and destroy the tumor (red), and scar tissue formation (white). Pathogenesis Four types of melanomas have been identified based on their radial and vertical growth progression: lentigo maligna, superficial spreading, acral lentiginous, and nodular. Radial growth describes the horizontal spread of the melanoma within the epidermis and superficial dermis. During this initial stage, the tumor seems to lack the ability to metastasize. Lentigo maligna melanomas, superficial spreading melanomas, and acral lentiginous melanomas are tumors that are in the radial growth phase. Lentigo maligna melanomas are flat, slow-growing nevi that may remain in the radial growth phase for several decades. They are seen primarily on sun-exposed skin of elderly persons. Superficial spreading melanoma, the most common type of melanoma, is seen most commonly in persons who sunburn easily and have intermittent sun exposure. It is characterized by a raised-edged nevus with lateral growth and a disorderly appearance in color and outline. It typically ulcerates and bleeds with growth. Acral lentiginous melanoma has an appearance similar to that of lentigo maligna, and is seen primarily on the palms, soles, nail beds, and mucous membranes. Its occurrence is unrelated to sun exposure. After a variable and unpredictable period of time, melanomas shift from a radial to vertical growth phase, during which the tumor cells invade downward into the deeper dermis layers.11 This growth phase is heralded by the nodular phase and correlates with the emergence of a clone of cells with metastatic potential. Nodular melanomas are raised, dome-shaped lesions that can occur anywhere on the body. They are commonly a uniform blue-black color and tend to look like blood blisters. Nodular melanomas tend to rapidly invade the dermis from the start, with no apparent horizontal growth phase. Diagnosis and Treatment Early detection is critical with malignant melanoma. Regular self-examination of the total skin surface in front of a well-lighted mirror provides a method for early detection. It requires that a person undress completely and examine all areas of the body using a full mirror, handheld mirror, and handheld hair dryer (to examine the scalp). An ABCD rule has been developed to aid in early diagnosis and timely treatment of malignant melanoma.64 The ABCD acronym stands for asymmetry, border irregularity, color variegation, and diameter greater than 6 mm (1/4 inch or pencil eraser size). People should be taught to watch for these changes in existing nevi or the development of new nevi, as well as other alterations such as bleeding or itching. Because of the existence of small-diameter melanomas (i.e., <6 mm in diameter), it has been suggested that people routinely screen their skin for all possible manifestations of skin cancer. Since their description over 20 years ago, evidence has accumulated to add an E for "evolving" to the ABCD rule.68 The E for evolving is intended to encourage the recognition of melanomas at an earlier stage by emphasizing the dynamic nature of their growth. Diagnosis of melanoma is based on biopsy findings from a lesion. Because most melanomas initially metastasize to regional lymph nodes, additional information may be obtained through lymph node biopsy. Consistent with other cancerous tumors, melanoma is commonly staged using the TNM (tumor, lymph node, and metastasis) staging system (see Chapter 7) or the American Joint Committee on Cancer Staging System for Cutaneous Melanoma, in which the tumor is rated 0 to 4 depending on numerous factors, including extent of tumor invasion, ulceration, and metastasis.64 Ulceration and invasion of the tumor into the deeper skin tissue result in a poorer prognosis. The degree and number of lymph nodes involved correlate well with overall survival. Treatment of melanoma is usually surgical excision, the extent of which is determined by the thickness of the lesion, invasion into the deeper skin layers, and spread to the regional lymph nodes. Deep, wide excisions with elective removal of lymph tissue and the use of skin grafts were once the hallmarks of treatment. When diagnosed in a premetastatic phase, melanoma is now treated in ambulatory settings, lessening the cost and inconvenience of care. Current capability allows for mapping lymph flow to a regional lymph node that receives lymphatic drainage from tumor sites on the skin. This lymph node, which is called the sentinel lymph node, is then sampled for biopsy. If tumor cells have spread from the primary tumor to the regional lymph nodes, the sentinel node will be the first node in which tumor cells appear. Therefore, sentinel node biopsy can be used to test for the presence of melanoma cells and determine if radical lymph node dissection is necessary. When nodes are positive, consideration is also given to systemic adjuvant therapy. Although no effective chemotherapy is available for melanoma, interferon alfa-2b is a biologic therapy available for adjuvant treatment of melanoma. At this time, however, the use of interferon is controversial. Clinical trials with other therapies, including combination chemotherapies, vaccines, and hyperthermic isolation limb perfusion, are ongoing. Basal Cell Carcinoma Basal cell carcinoma is a neoplasm of the nonkeratinizing cells of the basal layer of the epidermis.67 It is the most common invasive cancer in humans; approximately 75% of all skin cancers are basal cell carcinomas. Basal cell carcinomas have a tendency to occur in fair-skinned persons with a history of significant long-term sun exposure. They are most frequently seen on the head and neck, most often occurring on skin that has hair. Basal cell carcinomas are slow-growing tumors that extend wide and deep if left untreated, but rarely metastasize. Advanced lesions are often invasive and ulcerative. Risk factors for extensive spread include a tumor diameter greater than 2 cm, location on the central part of the face or ears, long-standing duration, incomplete excision, and perineural or perivascular involvement. Histologically, the tumor cells resemble those in the normal basal layer from the epidermis or follicular epithelium and do not occur on mucosal surfaces. There are two types of basal cell carcinoma, determined by their pattern of growth: superficial basal cell carcinomas originating from the epidermis and extending upward, and nodular basal cell carcinomas in which the tumor grows downward into the dermis. Nodular basal cell carcinoma, the classic type, presents as a small, flesh-colored or pink, smooth, translucent nodule that enlarges over time (Fig. 46-23). Telangiectatic vessels frequently are seen beneath the surface. Over the years, there is a central depression that forms and develops into an ulcer surrounded by the original shiny, waxy border. Superficial basal cell carcinoma presents as a scaly erythematous patch or plaque. Both nodular and superficial forms may contain melanin, imparting a brown, blue, or black color to the lesions. Since basal cell carcinoma is highly curable if detected and treated early, all suspected lesions should undergo biopsy for diagnosis. The treatment depends on the site and extent of the lesion. The most important treatment goal is complete elimination of the lesion. Also important is the maintenance of function and optimal cosmetic effect. Curettage with electrodesiccation, surgical excision, irradiation, laser, cryosurgery, and chemosurgery are effective in removing all cancerous cells. Immune therapy, gene therapy, and photodynamic therapy are emerging treatments. Persons should be checked at regular intervals for recurrences. Squamous Cell Carcinoma Squamous cell carcinomas are the second most common malignant tumors arising on sun-exposed sites in older people, exceeded only by basal cell carcinoma. In addition to sun exposure, occupational exposure to arsenic (i.e., Bowen disease), industrial tars, coal, and paraffin increase the risk for squamous cell carcinoma. Men are twice as likely as women to have squamous cell carcinoma. Black persons are rarely affected. Squamous cell cancers are composed of tumor cells that resemble the epidermal cells of the stratum spinosum to varying degrees and extend into the adjacent dermis. There are two types of squamous cell carcinomas: intraepidermal (termed in situ carcinoma) and invasive carcinoma. Intraepidermal squamous cell carcinoma remains confined to the epidermis for a long time. However, at some unpredictable time, it penetrates the basement membrane to the dermis and metastasizes to the regional lymph nodes. It then converts to invasive squamous cell carcinoma. The invasive type of squamous cell carcinoma can develop from intraepidermal carcinoma or from a premalignant lesion (e.g., actinic keratoses). It may be slow growing or fast growing with metastasis. Squamous cell carcinoma is a red, scaling, keratotic, slightly elevated lesion with an irregular border, usually with a shallow chronic ulcer (Fig. 46-24). The lesions usually lack the pearly rolled border and superficial telangiectases found on basal cell carcinomas. Later, lesions grow outward, show large ulcerations, and have persistent crusts and raised erythematous borders. The lesions occur on sun-exposed areas of the skin, particularly the nose, forehead, helix of the ear, lower lip, and back of the hand. Invasive squamous cell carcinoma has the potential to recur and metastasize. Chief among the risk factors for tumor recurrence and metastasis are the size and location of the tumor. Large lesions (>2 cm in diameter), tumors of the lip and ear, tumors arising in injured or chronically diseased skin, and rapidly growing lesions are at particular risk. Treatment measures are aimed at the removal of all cancerous tissue using methods such as electrosurgery, excision surgery, chemosurgery, or radiation therapy. After treatment, the person is observed for the remainder of his or her life for signs of recurrence.

Status epilepticus

Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks (Trinka, Cock, Hesdorffer, et al., 2015). The term has been broadened to include continuous clinical or electrical seizures (on EEG) lasting at least 30 minutes, even without impairment of consciousness. It is considered a medical emergency. Status epilepticus produces cumulative effects. Vigorous muscular contractions impose a heavy metabolic demand and can interfere with respirations. Some respiratory arrest at the height of each seizure produces venous congestion and hypoxia of the brain. Repeated episodes of cerebral anoxia and edema may lead to irreversible and fatal brain damage. Factors that precipitate status epilepticus include interruption of anticonvulsant medication, fever, concurrent infection, or other illness. Medical Management The goals of treatment are to stop the seizures as quickly as possible, to ensure adequate cerebral oxygenation, and to maintain the patient in a seizure-free state. An airway and adequate oxygenation are established. If the patient remains unconscious and unresponsive, an endotracheal tube is inserted. IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin is given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. An IV line is established, and blood samples are obtained to monitor serum electrolytes, glucose, and phenytoin levels. EEG monitoring may be useful in determining the nature of the seizure activity. Vital signs and neurologic signs are monitored on a continuing basis. An IV infusion of dextrose is given if the seizure is caused by hypoglycemia. If initial treatment is unsuccessful, general anesthesia with a short-acting barbiturate may be used. The serum concentration of the anticonvulsant medication is measured, because a low level suggests that the patient was not taking the medication or that the dosage was too low. Cardiac involvement or respiratory depression may be life threatening. The potential for postictal cerebral edema also exists. Nursing Management The nurse initiates ongoing assessment and monitoring of respiratory and cardiac function because of the risk for delayed depression of respiration and blood pressure secondary to administration of anticonvulsant medications and sedatives to halt the seizures. Nursing assessment also includes monitoring and documenting the seizure activity and the patient's responsiveness. The patient is turned to a side-lying position, if possible, to assist in draining pharyngeal secretions. Suction equipment must be available because of the risk of aspiration. The IV line is closely monitored, because it may become dislodged during seizures. A person who has received long-term anticonvulsant therapy has a significant risk for fractures resulting from bone disease (osteoporosis, osteomalacia, and hyperparathyroidism), which is a side effect of therapy (Karch, 2015). Therefore, during seizures, the patient is protected from injury with the use of seizure precautions and is monitored closely. The patient having seizures can inadvertently injure nearby people, so nurses should protect themselves.

Fosphenytoin (Cerebyx)

Indication: Short-term control of status epilepticus, prevention of seizures after neurosurgery Action: See phenytoin Dose: Adult: Loading dose, 15-20 mg PE/kg IV given as 100-150 mg PE per minute; maintenance, 4-6 mg PE/kg/d; reduce dose with renal or hepatic impairment Classification: Hydantoin Side Effects/ Adverse Reactions: See phenytoin Caution/ Contraindications: See phenytoin Nursing Implications: See phenytoin

Seizure medications (including therapeutic dose range and adverse effects of being out of the therapeutic dose range)

Take anticonvulsant medications daily as prescribed to keep the drug level constant to prevent seizures. Never discontinue medications, even if there is no seizure activity. Phenytoin; Ethotoin Therapeutic dose range: 10 to 20 mcg/mL serum level; 15 to 50 mcg/mL serum level Adverse effects of being out of the therapeutic dose range: Severe skin reaction, peripheral neuropathy, ataxia, drowsiness, blood dyscrasias Valproic Acid Therapeutic dose range: 50-100 mcg/mL serum level Adverse effects of being out of the therapeutic dose range: CNS depression, lethargy and potential encephalopathy, respiratory depression, nausea/vomiting, and myoclonus. Phenobarbital Therapeutic dose range: 15 to 40 mcg/mL serum level Adverse effects of being out of the therapeutic dose range: Skin rash, anemia Diazepam Therapeutic dose range: 200 - 2500 ng/mL serum level Adverse effects of being out of the therapeutic dose range: Respiratory depression, sedation, hypotension Ethosuximide Therapeutic dose range: 40 to 100 mcg/mL serum level Adverse effects of being out of the therapeutic dose range: Skin rash, blood dyscrasias, hepatitis, systemic lupus erythematosus Carbamazepine Therapeutic dose range: 4-12 mg/L serum level Adverse effects of being out of the therapeutic dose range: Severe skin rash, blood dyscrasias, hepatitis

Cushing's triad

A clinical phenomenon known as the Cushing's response (or Cushing's reflex) is seen when cerebral blood flow decreases significantly. When ischemic, the vasomotor center triggers an increase in arterial pressure in an effort to overcome the increased ICP. A sympathetically mediated response causes an increase in the systolic blood pressure with a widening of the pulse pressure and cardiac slowing. This response is seen clinically as an increase in systolic blood pressure, widening of the pulse pressure, and reflex slowing of the heart rate. It is a late sign requiring immediate intervention; however, perfusion may be recoverable if the Cushing's response is treated rapidly. At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, which is a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated. Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure (see Fig. 66-2). The herniated tissue exerts pressure on the brain area into which it has shifted, which interferes with the blood supply in that area. Cessation of cerebral blood flow results in cerebral ischemia, infarction, and brain death.

Epidural hematoma

An epidural hematoma is one that develops between the inner side of the skull and the dura. It usually results from a tear in an artery, most often the middle meningeal, usually in association with a head injury in which the skull is fractured. Because bleeding is arterial in origin, rapid expansion of the hematoma compresses the brain. Epidural hematoma is more common in a young person because the dura is less firmly attached to the skull surface than in an older person; as a consequence, the dura can be easily separated from the inner surface of the skull, allowing the hematoma to grow. Typically, a person with an epidural hematoma presents with a history of head injury and a brief period of unconsciousness followed by a lucid period in which consciousness is regained. There is then a rapid progression to unconsciousness. The lucid interval does not always occur, but when it does, it is of great diagnostic value. With rapidly developing unconsciousness, there are focal symptoms related to the area of the brain involved. These symptoms can include ipsilateral pupil dilation and contralateral (opposite side) hemiparesis from uncal herniation. If the hematoma is not removed, the condition progresses, with increased ICP, tentorial herniation, and death. The prognosis is excellent, however, if the hematoma is removed before loss of consciousness occurs.

Prostate cancer risk factors, nursing care after TURP

Etiology and Pathogenesis The precise cause of prostate cancer is unclear. As with other cancers, it appears that the development of prostate cancer is a multistep process involving genes that control cell differentiation and growth. The incidence of prostate cancer appears to be higher in relatives of men with prostate cancer. It has been estimated that men who have an affected first-degree relative (e.g., father, brother) and an affected second-degree relative (e.g., grandfather, uncle) have an eightfold increase in risk. It has been suggested that dietary patterns, including increased dietary fats, may alter the production of sex hormones and growth factors and increase the risk of prostate cancer. Supporting the role of dietary fats as a risk factor for prostate cancer has been the observation that the diet of Japanese men, who have a low rate of prostate cancer, is much lower in fat content than that of U.S. men, who have a much higher incidence. Several factors appear to be protective against the development of prostate cancer. These include dietary factors such as dietary fat reduction and supplementation with vitamins D and E and selenium. Dietary intake of soy, green tea, and tomato-rich products (lycopene) may also be important. Vitamin D is not technically a vitamin, but a steroid hormone that has a variety of antiproliferative and proapoptotic effects in prostatic as well as other cancer cell lines. Vitamin E, selenium, and lycopene are all antioxidants, thought to play an important role in cellular defenses to oxidative stress. The low incidence of prostate cancer in Asia has led to an interest in the study of soy and green tea, which are highly consumed in these nations. In terms of hormonal influence, androgens are believed to play a role in the pathogenesis of prostate cancer. Evidence favoring a hormonal influence includes the presence of steroid receptors in the prostate, the requirement of sex hormones for normal growth and development of the prostate, and the fact that prostate cancer almost never develops in men who have been castrated. The response of prostate cancer to estrogen administration or androgen deprivation further supports a correlation between the disease and testosterone levels.

Valproic Acid (Depakene)

Indication: Drug of choice for myoclonic seizures; second-choice drug for treatment of absence seizures; also effective in mania, migraine headaches, and complex partial seizures. It has been used for migraine prevention and has a pregnancy category X rating when used for that purpose. Action:. Reduces abnormal electrical activity in the brain and may also increase GABA activity at inhibitory receptors. Dose: Adult: 10-15 mg/kg/d PO up to a maximum 60 mg/kg/d Pediatric: Use extreme caution, determine dose by age and weight Classification: Drugs that Modulate the Inhibitory Neurotransmitter Gamma-Aminobutyric Acid Side Effects/ Adverse Reactions: Valproic acid is associated with liver toxicity. All of these drugs cause CNS effects related to CNS suppression—weakness, fatigue, drowsiness, dizziness, and paresthesias. Caution/ Contraindications: These drugs are contraindicated with known allergy to any component of the drug. Caution should be used in patients with hepatic or renal impairment, which could alter metabolism and excretion of the drug. These drugs should not be used during pregnancy or lactation unless the benefit clearly outweighs the risk to the fetus or neonate because of the potential for serious adverse effects on the baby. Nursing Implications: See phenytoin.