Focused Review Med Surg II Exam 3
Chapter 49: Assessment and Management of Patients with Hepatic
Disorders
- Assessment
- Assess medication history
- Amount and type of alcohol consumed with screening tools
- Assess for presence of an abdominal fluid wave (to dx ascites)
- Palpate abdomen to assess liver size and any tenderness
- A palpable liver presents as a firm, sharp ridge with a smooth
surface in right upper quadrant
- Cirrhosis: The liver of a patient with cirrhosis is small & hard
in the late stages of the disease
- Acute hepatitis: The liver of a patient with acute hepatitis, is
soft & the hand easily moves the edge upon palpation
- If impalpable but tenderness suspected, tap lower right thorax
briskly which may elicit tenderness
- If enlarged, assess the degree to which it descends below the right
costal margin
- Tenderness means acute enlargement with consequent stretching of
the liver
- Absence of tenderness may imply long standing duration of
enlargement
- Diagnostic Eval:
- Liver function tests
- Nature and extent of hepatic dysfunction cannot be determined
with these tests alone
- Serum Aminotransferases: sensitive indicator of injury to liver cells
and useful in detecting acute liver disease
- ALT, AST, GGT
- ALT: increase primarily in liver disorders and used to monitor
course of hepatitis or cirrhosis or effects of treatment (Males 10-55
u/L, Females 7-30 u/L)
- AST; level may be increased if there is damage to or death of tissues
of organs such as the heart, liver, skeletal, and kidney (Males 10-40
u/L, Females 10-25 u/L)
- GGT: increase is associated with cholestasis but can also be due to
alcoholic liver disease (5-40 u/L)
- Liver Biopsy
-
-
-
Removal of a small amount of liver tissue through a needle
aspiration
- Useful when clinical findings or lab tests are not diagnostic
- Coagulation studies are done before liver biopsy is performed
- Ultrasonography, CT, MRI
Jaundice: caused by the increase of bilirubin concentration in blood
- Due to the presence of liver disease, impeded bile, or excessive destruction
of red blood cells
- Becomes clinically evident when serum bilirubin exceeds 2.0 mg/dL
Hepatic Encephalopathy
- Occurs as a complication of liver disease where there is profound liver
failure
- Abnormalities on neuropsychological testing
- Manifestations
- Mental status changes and motor disturbances
- Confused and unkempt and has alterations in mood and sleep
patterns
- Tends to sleep during the day and has restlessness and
insomnia at night
- As it progresses it may be difficult to awaken the patient, and they
may be completely disoriented with respect to time and place
- Further progression causes the patient to go into a frank coma and
possible seizures
TABLE 49-3 Stages of Hepatic Encephalopathy and Applicable Nursing Diagnoses
Stage
Clinical Symptoms
Clinical Signs and EEG
Changes
Selected Potential
Nursing
Diagnoses
1
Normal level of
Impaired writing and ability to
consciousness with
draw line figures. Normal
periods of lethargy and
EEG.
euphoria; reversal of
day-night sleep patterns
Activity
intolerance
Self-care deficit
Disturbed sleep
pattern
2
Increased drowsiness;
Asterixis; fetor hepaticus (the
disorientation;
characteristic breath of
inappropriate behavior;
patients with severe
mood swings; agitation
parenchymal liver disease,
Impaired social
interaction
Ineffective role
performance
which has been said to
Risk for injury
resemble the odor of a
Confusion
mixture of rotten eggs and
garlic. Abnormal EEG with
generalized slowing.
3
Stuporous; difficult to rouse;
Asterixis; increased deep
Imbalanced
sleeps most of the time;
tendon reflexes; rigidity of
marked confusion;
extremities. EEG markedly
Impaired mobility
nutrition
incoherent speech
abnormal.
Impaired verbal
communicatio
n
4
Comatose; may not respond
to painful stimuli
Risk for aspiration
Absence of asterixis; absence of
deep tendon reflexes;
flaccidity of extremities.
EEG markedly abnormal.
-
-
Impaired gas
exchange
Impaired tissue
integrity
Asterixis: the involuntary flapping of the hands, can be seen in stage
II
- Handwriting may be difficult
- Handwriting or drawing sample is taken daily for
progression or reversal of disease
- Constructional apraxia: inability to reproduce a simple figure in two
or three dimensions
- Early stages: deep tendon reflexes are hyperactive
- Worsening: reflexes disappear and extremities become flaccid
- Fetor Hepaticus: sweet, slightly fecal odor to breath
- Freshly mowed grass, acetone or old wine odor or odor of
rotten eggs and garlic
Assessment
- Psychometric tests: Psychometric testing assists clinicians in
evaluating a patient's learning, social, behavioral, and personality
development. Testing results can help with the recognition of
specific disorders and guide planning for educational and mental
health interventions. There are essentially three categories:
aptitude tests, skills tests, and personality tests
-
-
Electroencephalogram shows generalized slowing, increased
amplitude or brain waves, and characteristic triphasic waves
- Medical Management
- Identify and eliminate precipitating cause
- Ammonia-lowering therapy, minimizing potential medical
complications and depressed consciousness, and reversing
underlying liver disease
- Correction of bleeding, electrolyte abnormalities, sedation, or
azotemia (an elevation of blood urea nitrogen (BUN) and serum
creatinine levels
- Lactulose used to reduce serum ammonia levels
- Traps and expels ammonia in the feces
- Two or three soft stools per day are desirable as it indicates
that lactulose is working
- Side effects: intestinal bloating and cramping
- To mask the sweet taste, it can be diluted with fruit juice
- Monitor the patient for hypokalemia and dehydration
- No laxatives are prescribed during lactulose admin
- Can be given through NG tube or enema for those patients
that are comatose
- IV admin of glucose to minimize protein breakdown
- Admin of vitamins to correct deficiencies
- Neomycin, metronidazole, and rifaximin can be used to
reduce levels of ammonia forming bacteria in colon,
(Neomycin belongs to a class of drugs known as aminoglycoside
antibiotics. It works by stopping the growth of bacteria in the
intestines, Metronidazole is in a class of medications called
nitroimidazole antimicrobials. It works by stopping the growth
of bacteria. Rifaximin is in a class of medications known as
Broad-spectrum antibiotics. Rifaximin treats traveler's
diarrhea and irritable bowel syndrome by stopping the growth of
the bacteria that cause diarrhea. Rifaximin treats hepatic
encephalopathy by stopping the growth of bacteria that
produce toxins and that may worsen liver disease)
- Neurologic status assessed frequently, bodyweight daily, vitals
every 4 hours, serum ammonia daily
Hepatic Dysfunction Manifestations
- Edema and bleeding
- Generalized edema caused by hypoalbuminemia from decreased
hepatic production of albumin
-
-
Blood clotting factor production decrease leading to bruising,
epistaxis, and GI bleeding
- Congestion of the spleen from portal hypertension which causes
pooling of platelets in the organ (hypersplenism)
Vitamin Deficiency
- Deficient absorption of vitamin K from the GI tract
- Impairment of absorption of fat-soluble vitamins (A, D, E) as well
as dietary fats
- Vitamins:
- Vitamin A deficiency, resulting in night blindness and eye
and skin changes
-
Thiamine deficiency, leads to beriberi, polyneuritis, and
Wernicke–Korsakoff psychosis, (Beriberi is a deficiency of
thiamine, more commonly known as vitamin B1. Your body
needs thiamine to break down and digest the foods you eat,
to keep your metabolism going, and help your muscles and
nervous system do their jobs effectively. Beriberi can affect
the cardiovascular system or central nervous system.
Polynueuritis is a disorder that affects the peripheral
nerves collectively, Polyneuropathy can have a wide variety
of causes, including exposure to certain toxins such as
alcohol abuse, poor nutrition (particularly vitamin B
deficiency), and complications from diseases such as cancer
or kidney failure Wernicke-Korsakoff's syndrome is a
disorder that primarily affects the memory system in the
brain. It usually results from a deficiency of thiamine
(vitamin B1), which may be caused by alcohol abuse, dietary
deficiencies, prolonged vomiting, eating disorders, or the
effects of chemotherapy.
Wernicke-Korsakoff psychosis
typically can't be reversed. In serious cases, it can cause
brain damage and lead to problems with memory and your
walk/gait that don't go away)
-
Riboflavin deficiency, resulting in characteristic skin and
mucous membrane lesions
-
Pyridoxine deficiency, resulting in skin and mucous
membrane lesions and neurologic changes
-
Vitamin C deficiency, resulting in the hemorrhagic lesions of
scurvy
-
Vitamin K deficiency, resulting in hypoprothrombinemia,
characterized by spontaneous bleeding and ecchymoses
-
-
Folic acid deficiency, resulting in macrocytic anemia
Metabolic Abnormalities
- Blood glucose level may be abnormally high shortly after a
meal
- Hypoglycemia may occur during fasting because of
decreased hepatic glycogen reserves and decreased
gluconeogenesis
- Gynecomastia, amenorrhea, testicular atrophy, loss of pubic
hair in males, menstrual irregularities, and other
disturbances of sexual function can occur because of failure
to inactivate estrogens
- Pruritus (itching)
- Severe pruritus due to retention of bile salts
- Can develop vascular spider angiomas above the waistline
- Spider veins in legs from numerous small vessels
- Reddened palms
Viral Hepatitis
- Necrosis and inflammation of liver cells
- A, B, C, D, E
- A and E are similar with mode of transmission (fecal-oral)
- Hepatitis A
- Fecal-oral
- Found in the stool of infected patients before the onset of symptoms
- Manifestations
- Anicteric (without jaundice) and symptomless
- When symptoms do appear, they resemble mild, flu-like or
upper respiratory tract infection, with low grade fever
- Anorexia is often severe
- In later stages, jaundice and dark urine may become
apparent
- Indigestion may be present with epigastric distress, nausea,
heartburn, and flatulence
- Symptoms tend to clear as soon as jaundice reaches its peak
- Assessment
- Liver and spleen moderately enlarged for a few days after
onset
-
-
-
-
TABLE 49-4
HAV antigen may be found in stool 7-10 days before illness
and 2-3 weeks after symptoms appear
- HAV antibodies are detectable in the serum (blood)
Prevention
- Hand hygiene, safer water, and proper control of sewage
disposal
- Vaccines
- Hepatitis A: Havrix and Vaqta
- Two dose vaccine given to adults 18 years and older
with second dose given 6-12 months after the first
- Children and Adolescents 1-18 years old receive three
doses
- Second dose is given 1 month after first and
third dose given 6-12 months later
- Recommended for those that are traveling to locations
where sanitation and hygiene are unsatisfactory
- Combination A and B vaccine (Twinrix) available for
vaccination of people 18 years and older
- Those who have not be vaccinated, HAV can be prevented by
intramuscular admin of globulin during incubation period if
given within 2 weeks of exposure
- Provides 6-8 weeks of passive immunity
- Globulin recommended for household members and
sexual contacts of people with HAV
- Epinephrine should be available in case of
anaphylactic reactions
Medical Management
- Bed rest during acute stage and nutritious diet
- For anorexia: patient should receive frequent small feedings
- Often have an aversion to food, gentle persistence and
creativity may be required
Nursing Management
- Occurs in the home unless severe
- Avoiding alcohol during and 6 months after recovery
- Sanitation and hygiene measures to prevent spread
Comparison of Major Forms of Viral Hepatitis
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis
D
Hepatitis E
Immunity
Average: 30 days
Homologous
Average: 70–80
Average: 50
Average: 35
days
days
days
Homologous
the Second
Homologous
Average: 31 days
Unknown
attack may
indicate
weak
immunity or
infection
with another
agent.
Nature of Illness
Signs and
May occur with or
symptoms
without symptoms;
flu-like illness
Preicteric phase:
Headache, malaise,
May occur without
symptoms
May develop
Similar to HBV;
less severe
Similar to
Similar to HAV;
HBV
very severe in
and anicteric
pregnant women
arthralgias,
rash
fatigue, anorexia,
fever
Icteric phase: Dark
urine, jaundice of
sclera and skin,
tender liver
Outcome
Usually mild with
May be severe.
Frequent
Similar to
Similar to HAV
recovery. No
Carrier state
occurrence
HBV but
except very
carrier state or
possible.
of chronic
greater
severe in
increased risk of
Increased risk
carrier state
likelihoo
pregnant women
chronic hepatitis,
of chronic
and chronic
d of
cirrhosis, or
hepatitis,
liver disease.
carrier
hepatic cancer.
cirrhosis, and
Increased
state,
hepatic cancer.
risk of
chronic
hepatic
active
cancer.
hepatitis
, and
cirrhosis
-
Hepatitis B
- Transmitted through blood
- Can be found in blood, saliva, semen, and vaginal secretions and
can be transmitted through mucous membranes and breaks in the
skin
- Can be transferred from carrier mothers to their infants
- Most develop antibodies and recover spontaneously in 6 months
-
-
-
Manifestations
- Resembles HAV but the incubation period is longer, 1-6
months
- Some may have arthralgias and rashes
- Loss of appetite, dyspepsia, abdominal pain, generalized
aching, malaise, and weakness
- Jaundice may or may not be evident
- Light colored stools and dark urine
- Liver may be tender and enlarged to 12-14 cm vertically
- Spleen is enlarged and palpable in a few cases
- Posterior cervical lymph nodes may be enlarged
Assessment
- HBsAg appears in circulation 1-10 weeks after exposure and
2-8 weeks before onset of symptoms
- If it persists 6 months or longer after infection, they
are considered HBsAg carriers
- HBeAg appears in serum within 1 weeks of appearance of
HBsAg and disappears within 2 weeks
Preventions
- Screening of blood donors for presence of HBAg decreases
risk of transmission
- Disposables syringes, needles, and lancets
- Gloves worn when handling blood
- Active Immunization
- Those that are high risk and those with HCV and
other chronic liver diseases should receive vaccine
- Yeast-recombinant hepatitis B vaccine (recombivax
HB)
- Boosters recommended for those that are
immunocompromised
- Hepatitis B vaccine from plasma of humans
chronically infected with HBV are given to those that
are allergic or immunodeficient
- Both forms are given intramuscularly in three doses
- Second and third are given 1 and 6 months
after first dose
- Third dose is very important for
prolonged immunity
- Deltoid muscle
- Passive Immunity
-
-
Hepatitis B immune globulin indicated for those
exposed to HBV who have never had hepatitis B and
have never been vaccinated
- Infants born to HBV infected mother should receive
HBIG within 12 hours after delivery
- Should be given within a few hours to a few days after
exposure
- If HBIG and hep B vaccine are given at the same time,
sites should be separated with separate syringes
- Medical Management
- Alpha-interferon for chronic type B viral hepatitis
- 5 million U daily or 10 million U three times weekly
for 16-24 weeks
- Given by injection
- Side effects: fever, chills, anorexia, nausea, myalgias,
and fatigue
- Delayed side effects: bone marrow suppression,
thyroid dysfunction, alopecia, bacterial infection
- Pegylated interferon: once weekly dosing
- Antivirals: entecavir and tenofovir
- Oral for chronic hepatitis B
- Recommended for patients with HBV-related
decompensated cirrhosis
- Bed rest until symptoms subside
- Adequate nutrition
- Antacids and antiemetic can be given if the patient show
dyspeptic symptoms, but should be avoided if vomiting
occurs
- Assessed for other bloodborne diseases
- Nursing Management
- Complete symptomatic recovery may require 3-4 months or
longer
- Gradual resumption of physical activity is encouraged
after jaundice has resolved
- Avoid sexual contact
Hepatitis C
- Blood transfusions and sexual contact account for most cases
- Symptoms are mild or absent
- Increased risk of chronic liver disease after HCV
- Combination of two antiviral agents: peginterferon and
ribavirin, effective in producing improvement and treating relapse
-
-
- Only used for genotype 5 HCV
- Simeprevir plus sofosbuvir, ledipasvir-sofosbuvir, and
ombitasvir-paritaprevir-ritonavir packaged with dasabuvir
- Has fewer side effects, shorter treatment duration, and
higher cure rates than the other antiviral combination
- Hepatitis D
- Occurs in some cases of hepatitis B
- Only people with hepatitis B are at risk
- Anti-delta antibodies in presence of HBAg on testing confirm
diagnosis
- Similar symptoms of hepatitis B except they are more likely to
develop fulminant hepatic failure and progress to chronic active
hepatitis and cirrhosis
- Interferon alfa
- High dose, long-duration therapy for at least a year
- Hepatitis E
- Fecal-oral
- Resembles hepatitis A
- Self limited course and abrupt onset
- Jaundice almost always present
Toxic Hepatitis
- Chemicals that have toxic effects on the liver and produce acute liver cell
necrosis
- Carbon tetrachloride and phosphorus
- Obtain history of exposure to chemicals, medication, or other toxic agents
to assist in treatment and removal of agent
- Anorexia, nausea, and vomiting
- Jaundice and hepatomegaly are noted on physical assessment
- Recovery is rapid if toxin is removed or if exposure has been limited
- Recovery unlikely if prolonged period between exposure and onset
of symptoms
Drug Induced Hepatitis
- Onset is abrupt with chills, fever, rash, pruritus, arthralgia, anorexia,
nausea
- If rash, fever, or pruritus occur, medication should be stopped
immediately
- Later there may be jaundice, dark urine, and enlarged and tender liver
- After offending medication is removed, symptoms gradually subside
- Acetaminophen leading cause
- Short course of high dose corticosteroids with severe hypersensitivity
reactions
-
-
Fulminant Hepatic Failure
- Sudden and severely impaired liver function
- Develops within 8 weeks after the first symptoms of jaundice
- “In hyperacute liver failure, the duration of jaundice before the onset of
encephalopathy is 0 to 7 days; in acute liver failure, it is 8 to 28 days; and
in subacute liver failure, it is 28 to 72 days”
- Hepatic lesion is potentially reversible
- Viral hepatitis is common cause
- Jaundice and profound anorexia
- Coagulation defects, kidney disease and electrolyte disturbances,
cardiovascular abnormalities, infection, hypoglycemia, encephalopathy,
and cerebral edema
- Treatment may include plasma exchange, reduce serum ammonia levels,
and to stabilize the patient awaiting transplant, prostaglandin therapy to
enhance hepatic blood flow
- Fulminant hepatic failure with stage 4 encephalopathy requires
intracranial pressure monitoring and promotion of cerebral perfusion
Hepatic Cirrhosis
- Replacement of normal liver tissue with diffuse fibrosis that disrupts the
structure and function of the liver
- Three types
- Alcoholic: scar tissue surround the portal areas, due to chronic
alcoholism, most common
- Postnecrotic: broad bands of scar tissue, late result of previous bout
of acute viral hepatitis
- Biliary: scarring occurs in the liver around the bile ducts, results
from chronic biliary obstruction and infection
- Areas become sites of inflammation, and bile ducts become occluded with
inspissated bile and pus
- Liver attempts to form new bile channels which causes overgrowth of
tissue
- Child-Pugh classification useful in predicting outcomes of patients with
liver disease and can help choose management approaches
TABLE 49-5
Disease
Modified Child–Pugh Classification of the Severity of Liver
Points Assigned
Parameter
1
2
3
Ascites
Abse
Slight
Moderate
nt
Bilirubin (mg/dL)
≤2
2–3
>3
Albumin (g/dL)
>3.5
2.8–3.5
<2.8
Prothrombin time (seconds over control)
1–3
4–6
>6
Encephalopathy
Non
Grade
Grade
e
1–2
-
3–4
Manifestations
- SS increase in severity as the disease progresses
- Severity is used to categorize the disorder as compensated or
decompensated
- Compensated: less severe, vague symptoms
- Decompensated: result from failure of the liver to synthesize
proteins, clotting factors, and other substances and
manifestations of portal hypertension
Compensated
● Abdominal pain
● Ankle edema
● Firm, enlarged liver
● Flatulent dyspepsia
● Intermittent mild fever
● Palmar erythema (reddened palms)
● Splenomegaly
● Unexplained epistaxis
● Vague morning indigestion
● Vascular spiders
Decompensated
● Ascites
● Clubbing of fingers
● Continuous mild fever
● Epistaxis
● Gonadal atrophy
● Hypotension
● Jaundice
● Muscle wasting
● Purpura (due to decreased platelet
count)
● Sparse body hair
● Spontaneous bruising
● Weakness
● Weight loss
● White nails
-
-
-
-
-
Liver enlargement
- Early in the course of cirrhosis
- Cells are loaded with fat
- Liver is firm and has sharp edge that is noticeable on
palpation
- Abdominal pain can be present due to recent, rapid
enlargement of the liver
- Later in the disease, liver decreases in size as scar tissue
contracts the liver tissue
- Palpable liver edge that is nodular
Portal Obstruction and Ascites
- Late manifestations of cirrhosis
- Blood backs up into the spleen and the GI tract
- These organs become the site of chronic passive
congestion
- It causes indigestion and altered bowel function
- Percussion of shifting dullness or fluid wave for
ascites
Infection and Peritonitis
- Spontaneous bacterial peritonitis
- Bacteremia due to translocation of intestinal flora
- Paracentesis for diagnosis
- Antibiotic therapy is effective in the treatment and
prevention of recurrent episodes
- Precipitating factor to the onset of hepatorenal syndrome
- Form of acute kidney injury that is unresponsive to
admin of fluid and diuretic agents
Gastrointestinal Varices
- Prominent, distended abdominal blood vessels which are
visible on abdominal inspection and distended blood vessels
throughout GI tract
- Distended blood vessels form varices or hemorrhoids,
depending on their location
- It can rupture and bleed
- Observe for occult and frank bleeding from the GI
tract
Edema
- Late symptom
- Reduced plasma albumin concentration predisposes the
patient to the formation of edema
-
-
-
Often affects the lower extremities, upper extremities, and
the presacral area
- Overproduction of aldosterone occurs, sodium and water
retention occurs with potassium excretion
- Vitamin Deficiency and Anemia
- Signs of deficiency are common
- Vitamin K deficiency common causing hemorrhagic
phenomena
- Chronic gastritis and impaired GI function with inadequate
dietary intake and impaired liver function, account for
anemia
- Severe fatigue
- Mental Deterioration
- Deteriorating mental and cognitive function
- There may be impending hepatic encephalopathy and
hepatic coma
- Assess general behavior, cognitive abilities, orientation to
time and place, and speech patterns
Assessment
- Serum albumin level tends to decrease
- Serum globulin level rises
- Enzyme tests indicate liver cell damage
- Serum alkaline phosphatase, AST, ALT, and GGT levels increase
- Serum cholinesterase level may decrease
- Bilirubin tests performed to assess bile excretion or retention
- Increased levels of bilirubin occur
- Prothrombin time is prolonged
- Ultrasound, CT, MRI, radioisotope liver scans, elastography studies
can be performed
- Diagnosis confirmed by liver biopsy
- Arterial blood gas analysis may reveal ventilation-perfusion
imbalance and hypoxia
Medical Management
- Based on the presenting symptoms
- H2 antagonists: cimetidine (Tagamet), famotidine (Pepcid),
nizatidine (Axid) and ranitidine (Zantac) or antacids for gastric
distress
- Vitamins and supplements to promote healing and improve
nutritional status
- Potassium sparing diuretic to decrease ascites (Spironolactone)
- Avoidance of alcohol
-
-
Antifibrotics: colchicine, angiotensin system inhibitors, statins,
diuretics like spironolactone, immunosuppressants, and glitazones
(pioglitazone or rosiglitazone)
- Herb milk thistle (silybum marianum) can treat jaundice, has
anti-inflammatory, and antioxidant properties
- Biliary cirrhosis: ursodeoxycholic acid (actigall, urso)
Nursing Management
- Promoting Rest
- Require rest and supportive measures for the liver to
reestablish functional ability
- Weight, I&O are measured daily
- Oxygen therapy may be necessary to oxygenate damaged
cells
- Rest reduces demands on the liver and increases liver blood
supply
- Improving Nutritional Status
- If no ascites, edema, or signs of impending hepatic coma are
present, patient should receive a high protein nutritious
diet with supplements of vitamins such as, B
complex, as well as A, C, and K
- If ascites present, small frequent meals are more tolerated
- Sodium restriction to prevent worsening ascites
- Patients with steatorrhea or fatty stools should receive
water-soluble forms of fat-soluble vitamins A, D, and E
- Folic acid and iron to prevent anemia
- Providing Skin Care
- Changes in position
- Reducing Risk of Injury
- Side rails in place with pads in case of agitation or
restlessness
- Orient the patient to time and place
- Electric razor, soft-bristled toothbrush is being used to
minimize bleeding
- Monitoring and Managing Complications
- Bleeding and Hemorrhage
- Risk due to decreased production of prothrombin and
decreased ability of diseased liver to synthesize
necessary substances for blood coagulation
- Hepatic Encephalopathy
-
-
-
May manifest as deteriorating mental status or as
physical signs such as abnormal voluntary and
involuntary movements
- Monitor mental status closely so that treatment can be
started promptly
- Serum electrolytes are monitored and corrected if
abnormal
- Monitor fever or abdominal pain as it may signal
onset of bacterial peritonitis
Fluid Volume Excess
- The greater the degree of hepatic decompensation, the
more severe the hyperdynamic state
- Close assessment of cardiovascular and respiratory
status
- Administer diuretic agents, implement fluid
restriction, and enhancing the patient positioning for
pulmonary function optimization (High-Fowler’s)
- Fluid retention can be noted with ascites, swelling,
and dyspnea
- Monitor I&O, daily weight changes, changes in
abdominal girth, and edema formation
- Monitor for nocturia and later oliguria
Cancer of the Liver
- Primary cancers are associated with chronic liver disease, hepatitis B and
C infections, and cirrhosis
- HCC (Hepatocellular Carcinoma) is the most common primary liver
cancer
- Cigarette smoking is a risk factor especially combined with alcohol use
- Liver Metastases
- The liver is a common site for metastases from many cancer types.
Cancers that spread to the liver most often are colorectal cancer
as well as breast, esophageal, stomach, pancreatic, lung,
kidney, and melanoma skin cancers)
- Manifestations
- Pain: continuous dull ache in the right upper quadrant,
epigastrium, or back
- Weight loss, loss of strength, anorexia, and anemia
- Liver may be enlarged and irregular on palpation
- Jaundice present only if the larger bile ducts are occluded
- Ascites develops if nodules obstruct portal veins
- Assessment
-
-
-
Increased levels of bilirubin, alkaline phosphatase, AST<
GGT, and lactic dehydrogenase
- Leukocytosis, erythrocytosis, hypercalcemia, hypoglycemia,
and hypocholesterolemia may be seen
- Serum level of alpha-fetoprotein is elevated
- Tumor marker
- Carcinoembryonic antigen may be elevated
- Marker for advanced cancer of digestive tract
- Carcino and Alpha can distinguish between metastatic and
primary
- Xray, liver scans, CT scans, ultrasound, MRI, arteriography,
and laparoscopy to determine extent of cancer
Medical Management
- Radiation
- Chemotherapy
- Sorafenib for treating patients with HCC
- Percutaneous Biliary Drainage
- Used to bypass biliary ducts obstructed by liver,
pancreatic, or bile duct tumors that are inoperable
- Catheter inserted through abdominal wall and past
obstruction into duodenum
- Bile is observed closely for amount, color, and
presence of blood
- Complications: sepsis, leakage of bile, hemorrhage,
and reconstruction of biliary system
- Observed for fever and chills, bile drainage around
catheter, changes in vitals, and evidence of
obstruction such as pain, pressure, pruritus, and
recurrence of jaundice
- Laser hyperthermia, immunotherapy, transcatherter arterial
embolization can also be performed
Surgical Management
- Surgical resection is the treatment of choice when HCC is
confined to one lobe of the liver and the function of
remaining liver is considered adequate for post recovery
- Lobectomy: removal of a lobe of the liver
- Local Ablation: ethanol or by physical means such as
radiofrequency or microwave coagulation
- Immunotherapy may be used after surgical resection
for HCC to prevent recurrence of lesion
- Liver Transplant
-
-
Milan criteria to limit transplantation to patient who
are most likely to have better outcomes
- Patient must have a single tumor measuring
less than 5 cm or have three or fewer lesions
with one over 3 cm in size
Liver Transplantation
- Treat life-threatening ESLD for which no other form of treatment is
available
- Total removal of diseased liver and replacement with a healthy liver from
cadaver donor or with right lobe from a live donor
- Immunosuppressants: cyclosporine, tacrolimus, corticosteroids,
azathioprine, mycophenolate mofetil, sirolimus, everolimus,
antithymocyte globulin, basiliximab, and daclizumab
- Prevents transplanted organ rejection
- Involve use of more than one agent but minimization to avoid
toxicity
- Triple therapy: corticosteroids, a calcineurin inhibitor
(tacrolimus or cyclosporine), and either an
antiproliferative agent (mycophenolate mofetil) or a TOR
inhibitor (sirolimus and everolimus)
- Induction therapy for the early, high risk months after transplant
- Basiliximab and a lymphocyte immune globulin
- Indications: irreversible advanced chronic liver disease, fulminant hepatic
failure, metabolic liver disease, some hepatic malignancies
- Model for End-Stage Liver Disease (MELD) classification
- Level of illness of those awaiting a liver transplant
- Formula including bilirubin levels, prothrombin time, creatinine,
and the cause of the liver disease
- Surgical Procedure
- Donor liver is freed from other structures, bile is flushed from the
gallbladder to prevent damage, and liver is perfused with a
preservative and cooled
- Before donor liver is placed in recipient, it is flushed with cold
lactated ringer solution to remove potassium and air bubbles
- Portal hypertension increases difficulty of procedure which may
require venovenous bypass that decompresses the venous system
below the diaphragm by temporarily shunting blood to the superior
vena cava via the axillary vein
- Split-liver transplant can be used to provide two individuals donor
organs
- Small left lobe is given to the smaller patient
-
-
-
Living Donor liver transplantations is considered for those who
have high potential for mortality while awaiting cadaveric liver
donor
- Right hepatic lobe from an adult donor to the recipient
- Donors must be completely healthy and have hepatic size
and anatomy compatible with right lobe transplantation
- Perform a formal right hepatic lobectomy
- It is then flushed with preservative solution and
vascular reconstruction is completed to prepare for
implantation
- Recipient operation involved inferior vena-cara sparing
hepatectomy
Complications
- Bleeding
- Admin of platelets, fresh frozen plasma, and other blood
products may be necessary
- Calcium channel blockers such as nifedipine or
amlodipine are used for vasodilatory effects
- Infection
- Pulmonary and fungal infections common
- Increased risk due to immunosuppressive therapy
- Strict asepsis when manipulating venous catheters, arterial
lines, and urine,bile,and other drainage systems
- Monitor for early signs of sepsis
- Rejection
- Immunosuppressive agents used long term to prevent this
response
- These drugs may have major side effects
- Cyclosporine: nephrotoxicity
- Liver biopsy and ultrasound may be required to evaluate
suspected episodes of rejection
- Retransplantation is attempted if liver fails
- Complications of LDLT (living donor liver transplantation) donor
- Pulmonary emboli, portal vein thrombosis, bile duct injury,
and liver insufficiency due to a resection that is too extensive
Nursing Management
- Preoperative
- Placed on a waiting list
- MELD score (model for end-stage liver disease score),
determines organ allocation priorities to the patient that is
most in need
-
-
Patient must be accessible at all times in case an appropriate
liver becomes available
- Malnutrition, massive ascites, and electrolyte disturbances
are treated before surgery
Postoperative
- Environment as free from bacteria, viruses, and fungi as
possible
- All systems are monitored continuously
- Mean arterial and pulmonary artery pressures are monitored
continuously
- Liver function tests, electrolyte levels, coagulation profile,
chest x ray, electrocardiogram, and fluid output are
monitored
- Endotracheal tube in place and requires mechanical
ventilation during initial post-op period
- Sterile humidification is provided
- Close monitoring of liver dysfunction and rejection are
continued throughout hospital stay
- Live donor is admitted to ICU setting as well
- They may experience more pain then the
- recipient requiring analgesia control
Chapter 50: Assessment and Management of Patients with Biliary Disorders
- Cholecystitis
- Inflammation of the gallbladder which can be acute or chronic
- Causes pain, tenderness, and rigidity of the upper right abdomen that can
radiate to the midsternal area or right shoulder
- Associated with nausea, vomiting, and usual signs of acute
inflammation
- Empyema of the gallbladder develops if gallbladder becomes filled with
purulent fluid
- Calculous cholecystitis
- Gallbladder stone obstructs bile outflow
- Bile remaining in the gallbladder initiates a chemical reaction,
autolysis and edema occur, and blood vessels are compressed and
compromised
- Gangrene of the gallbladder with perforation may result
- Acalculous cholecystitis: acute gallbladder inflammation in the absence of
obstruction by gallstones
- Occurs after major surgeries, orthopedic procedures, severe
trauma, or burns
- Bile stasis (lack of gallbladder contraction) and increased viscosity
of bile
- Cholelithiasis
- Calculi or gallstones usually form in the gallbladder from solid
constituents of bile
- More prevalent with increasing age
- Manifestations
- Gallstones can be silent producing no pain and only mild GI
symptoms
-
-
-
-
-
Patient with gallbladder disease resulting from gallstones may
develop two types of symptoms
- Those from the disease of the gallbladder or those due to
obstruction of bile passages
- Epigastric distress like fullness, abdominal distention, and
vague pain in right upper quadrant may occur
- Distress may follow a meal rich in fried or fatty foods
Pain and Biliary Colic
- If gallstone obstructs cystic duct: gallbladder becomes
distended, inflamed, and eventually infected (acute
cholecystitis)
- Develops a fever
- May have palpable abdominal mass
- Biliary colic with excruciating upper right abdominal pain
that radiates to the back or right shoulder
- Bout of colic is caused by contraction of gallbladder
- Colic associated with nausea and vomiting and is noticeable
several hours after a heavy meal
- In some, pain may be constant rather than colicky
- Fundus of distended gallbladder comes in contact with
abdominal wall in 9th and 10 costal cartilages
- Marked tenderness in right upper quadrant during
deep inspiration and prevents full inspiratory
excursion
- If a gallstone dislodges, gallbladder drains and inflammatory
process subsides
- If there is continued obstruction, abscess, necrosis,
and perforation with peritonitis can occur
Jaundice
- Occurs in a few because of obstruction of the common bile
duct
- The bile no longer carried to duodenum is absorbed by the
blood
- Accompanied with marked pruritus
Changes in Urine and Stool Color
- Excretion of bile pigments by the kidneys gives urine a dark
color
- Feces no longer colored with bile pigments are grayish or
clay colored
Vitamin Deficiency
-
-
Interferes with absorption of fat-soluble vitamins A, D, E,
and K
Can show deficiencies in these vitamins if prolonged
Assessment
- Abdominal X Ray
- Ultrasonography
- Diagnostic procedure of choice because it is rapid and
accurate and can be used in patients with liver dysfunction
and jaundice
- Most accurate if the patient fasts overnight so that the
gallbladder is distended
- Radionuclide Imaging or Cholescintigraphy
- Diagnosis of acute cholecystitis or blockage of a bile duct
- Radioactive agent is administered IV which is taken up by
hepatocytes and excreted rapidly through the biliary tract
- Used when ultrasonography is not conclusive
- Oral Cholecystography
- Used if ultrasound equipment is not available or results are
inconclusive
- Used to detect gallstones and to assess the ability of the
gallbladder to fill, concentration in contents, and the ability
for gallbladder to contract, and empty
- Iodide-containing contrast that is excreted by liver and
concentrated in gallbladder is given 10-12 hours before x ray
study
- Should not be allergic to seafood (shellfish) or iodine
- Gallstones if present appear as shadows on xray image
- Can be used as part of evaluation of patients who have been
treated with gallstone dissolution therapy or lithotripsy
- Endoscopic Retrograde Cholangiopancreatography
- Permits direct visualization of structures that previously
could be seen only during laparotomy
- Examines hepatobiliary system through an endoscope that is
inserted through the esophagus to the descending duodenum
- Multiple position changes are required
- Not recommended for the evaluation of suspected common
bile duct stones, but can be used to treat confirmed
choledocholithiasis (Cholelithiasis involves the presence of
gallstones, which are concretions that form in the biliary
tract, usually in the gallbladder. Choledocholithiasis refers to
the presence of one or more gallstones in the common bile
-
duct (CBD). Treatment of gallstones depends on the stage of
disease)
- Nursing Implications
- NPO (Take nothing by mouth) for several hours
before
- Moderate sedation is used
- During the procedure, the nurse monitors IV fluids,
administers meds, and positions the patient
- Assess for signs of perforation or infection
post-procedure
Percutaneous Transhepatic Cholangiography
- Reserved for patients in whom an ERCP may be unsafe due
to previous surgery involving biliary tract
- Has been replaced mainly by ERCP and MRCP (ERCP and
MRCP are used to diagnose problems with the bile
and pancreatic ducts. ERCP is more invasive, but it can
be used as a treatment for certain conditions. MRCP is
non-invasive and is ideal if you're unable to get ERCP. The
main advantage of ERCP is in its ability to perform therapy,
whereas the main advantage of MRCP is its noninvasive
nature and, therefore, minimal risk of complications
- Injected with dye directly into the biliary tract
- Can be carried out even in the presence of liver dysfunction
and jaundice
- Under moderate sedation on a patient who has fasted
- Local anesthesia
- Coagulation should be normal
- Broad spectrum antibiotics given during procedure
- Flexible needle inserted into liver from the right side in the
midclavicular line right beneath the right costal margin
- Bile is aspirated and samples are sent for bacteriology
and cytology
- Water soluble contrast agent is injected to fill biliary system
- Fluoroscopy table is tilted and patient is repositioned to
allow xrays to be taken in multiple projections
- Before needle is removed, as much dye and bile is aspirated
to forestall leakage
- Nursing Implications
- Observe for symptoms of bleeding, peritonitis, and
sepsis
-
-
Antibiotic agents are prescribed to minimize risk of
sepsis and septic shock
Medical Management
- Nutritional and supportive therapy
- Rest, IV fluids, NG suction, analgesia, and antibiotic agents
- Surgical intervention is delayed until acute symptoms
subside
- Diet immediately after an episode is low-fat liquids
- Powered supplements high in protein and
carbs stirred in skim milk
- Avoid eggs, cream, pork, fried foods, cheese,
rich dressings, gas forming veggies, and
alcohol
- Pharmacologic Therapy
- Ursodeoxycholic acid and chenodeoxycholic acid are
used to dissolve small, radiolucent gallstones composed
primarily of cholesterol
- UDCA has fewer side effects than CDCA and can be
given in small doses
- Can reduce size of existing stones, dissolves small
stones, and prevents new stones from forming
- 6-12 months of therapy is required
- Dose depends on body weight
- Indicated for those patients that refuse surgery or where
surgery is contraindicated
- Recurrence is high
- Those with significant frequent symptoms, cystic duct
occlusion, or pigment stones are not candidates for
pharmacologic therapy
- Cholecystectomy is more appropriate
- Nonsurgical Removal of Gallstones
- Dissolving Gallstones
- Infusion of a solvent into gallbladder
- Infused through a tube or catheter inserted
percutaneously directly into the gallbladder, through a
tube that is inserted through a T tube tract to dissolve
stones, endoscopically with ERCP, or via a transnasal
biliary catheter
- Indicated for those that may not be candidates for
cholecystectomy procedure due to safety concerns
regarding anesthesia
-
-
Stone removal by instrumentation
- Catheter and instrument with a basket are threaded
through a t tube tract or fistula formed
- Basket is used to retrieve and remove stones
lodged in common bile duct
- Second procedure uses ERCP endoscope where a
cutting instrument is passed through into the ampulla
of vater of the common bile duct
- It cuts, enlarging the opening which allows
lodged stones to pass
- Another tool with a basket can be inserted to
retrieve stones
- Observed for bleeding, perforation, and
development of pancreatitis
- Intracorporeal lithotripsy
- Laser pulse is directed under fluoroscopic
guidance with use of devices that distinguish
stones and tissues
- Mechanical shock wave
- Pressure waves that causes stones to fragment
- Repeated procedures may be necessary due to
stone size, local anatomy, bleeding, or technical
difficulty
- Extracorporeal Shock Wave Lithotripsy
- Nonsurgical fragmentation of gallstones
- Repeated shock waves directed at gallstones
- Transmitted to the body through a fluid-filled
bag or by immersing the patient in a water bath
- Several sessions are usually necessary
Surgical Management
- Preoperative measures
- Chest x ray, electrocardiogram, and liver function
tests
- Vitamin K may be given if prothrombin level is low
- Laparoscopic Cholecystectomy
- Standard therapy for symptomatic gallstones
- If common bile duct is thought to be obstructed by a
gallstone, ERCP with sphincterotomy may be
performed to explore the duct before laparoscopy
-
-
Before procedure, educated the patient on the
possibilty of an open abdominal procedure, which
may be necessary and that general anesthesia is given
- Small incision or puncture made through the
abominal wall at the umbilicus
- Cavity is insufflated with carbon dioxide to assist in
inserting the laparoscope and to aid in visualizing the
abdominal structures
- Other punctures are made in the abdominal wall to
introduce other instruments
- Gallbladder is separated from hepatic bed and
removed from abdominal cavity after bile and small
stones are aspirated
- Does not experience paralytic ileus that usually occurs
with open abdominal surgery
- Conversion to an open procedure occurs if there is
inflammation in and around the gallbladder
- Most serious complication is a bile duct injury which
can be identified and corrected at the time of the
procedure
- Postoperatively a bile leak that may occur and
the patient might not develop symptoms until
several days after the procedure
- Can result in fluid collections
- Bile peritonitis, rare, may result
- Must have assistance at home during the first 24-48
hours because of drowsiness
- Must be educated on symptoms to look for:
- Loss of appetite, vomiting, pain, distention of
abdomen, and temp elevation
- Pain in the right shoulder or scapular area can occur
and heating pad for 15-20 mins hourly may be
recommended
Cholecystectomy
- Gallbladder is removed through an abdominal
incision (right subcostal) after cystic duct and artery
are ligated
- Some may have a drain placed close to the gallbladder
bed and brought out through a puncture wound if
there is a bile leak
-
-
Only a small amount of serosanguineous fluid drains
in the initial 24 hours after surgery, afterward drain is
removed
- Small Incision Cholecystectomy
- Gallbladder is remove through a small abdominal
incision
- If needed, it is extended to remove larger gallbladder
stones
- Choledochostomy
- Reserved for the patient with acute cholecystitis who
may be too ill to undergo a surgical procedure
- Making an incision in the common duct for the
removal of stones
- After removal, tube is inserted into the duct for
drainage of bile until edema subsides
- Laparoscopic cholecystectomy is planned for a future
date after acute inflammation has resolved
- Surgical Cholecystostomy
- Performed when patients condition precludes more
extensive surgery or when an acute inflammation
reaction is severe
- Gallbladder surgically opened, stones, bile and
purulent drainage are removed, and a drainage tube is
secured
- Connected to a drainage system to prevent bile
from leaking around the tube or escaping into
the cavity
- Percutaneous Cholecystostomy
- Treatment and diagnosis of acute cholecystitis in
patients who are poor risk for any surgical procedure
or for general anesthesia
- Fine needle is inserted through the abdominal wall
and liver edge into the gallbladder under the guidance
of ultrasound or CT
- Bile aspirated to ensure placement of needle
- Almost immediate relief of pain and resolution of SS
of sepsis and cholecystitis
- Antibiotics given before, during, and after
Gerontologic Considerations
- Atypical SS
-
-
Accompanied or preceded by symptoms of septic shock like
oliguria, hypotension, changes in mental status, tachycardia,
and tachypnea
- Nursing Management
- After recovery, placed in low Fowlers position
- NG suction may be instituted to relieve abdominal distention
- Nurse fastens tubing from drainage to dressings or patients gown,
with leaving enough leeway for the patient to move
- Observe for jaundice if obstruction is suspected
- After several days, T-tube may be clamped for 1 hour, before and
after meals, to deliver bile to the duodenum which will aid in
digestion
- Diet low in fats and high is carbs and proteins
immediately after surgery
- Avoid excessive fats
- Fat restrictions lifted in 4-6 weeks
Acute Pancreatitis
- Inflammation of the pancreas
- Medical emergency & associated with high risk of life-threatening
complications
- Does not usually lead to chronic pancreatitis unless complications develop
- Resulst from cholelthiasis or sustained alcohol abuse
- Mild is self limited, severe is rapidly fatal not responding to any treatment
- Interstitial edematous pancreatitis: lack of pancreatic or
peripancreatic parenchymal necrosis with diffuse enlargement of
the gland due to inflammatory edema
- necrotizing pancreatitis: presence of tissue necrosis in either
pancreatic parenchyma or in the tissue that surrounds the gland
- Manifestations
- Severe abdominal pain and tenderness and back pain result from
irritation and edema of inflamed pancreas
- Pain usually occurs in midepigastrium
- Occurs 24-48 hours after a very heavy meal or alcohol
ingestion
- Generally more severe after meals and unrelieved by
antacids
- Abdominal distention, poorly defined palpable abdominal mass,
decreased peristalsis, vomiting that fails to relieve pain or nausea
- Appear ill, abdominal guarding
- Rigid or boardlike abdomen can develop indicating
peritonitis
-
-
-
Ecchymosis in the flank or around umbilicus can indicate
severe pancreatitis (Cullen’s Sign, hemorrhagic
discoloration of the umbilical area, due to intraperitoneal
hemorrhage, Turner’s Sign, hemorrhagic discoloration of
the flank associated with acute hemarrhagic pancreatitis)
- Nausea and vomiting common
- Fever, jaundice, mental confusion, and agitation can occur
- Hypotension reflects hypovolemia and shock due to loss of large
amounts of protein rich fluid
- Tachycardia, cyanosis, and cold clammy skin
- Acute kidney injury is common
- Respiratory distress and hypoxia are common
- Hypocalcemia, hyperglycemia
Assessment
- Based on abdominal pain, presence of known risk factors, exam
findings, and diagnostic findings
- There will be a Serum amylase and lipase level elevation
within 24 hours of the onset of symptoms
- Amylase usually returns to normal within 48-72
hours
- Lipase may remain elevated for a longer period,
days after amylase
- White blood cell is usually elevated
- Transient hyperglycemia and glycosuria and elevated
bilirubin occur in some patients
- Xray of abdomen and chest
- MRI, CT
- Hematocrit and Hemoglobin are monitored for bleeding
Medical Management
- Relieving symptoms and preventing complications
- NPO: All oral intake is withheld to inhibit stimulation
- Enteral route used and started early in the course
- NG suction may be used to relieve nausea and vomiting to decrease
painful abdominal distention and paralytic ileus
- Histamine 2 antagonists(cimetadine, Tagamet,
famotadine, Pepcid, nizatadine, Axid, ranitidine, Zantac)
to decrease pancreatic activity, PPI (omeprazole, Prilosec,
Esomeprazole, Nexium, lansoprazole, Prevacid,
rabeprazole, AciPhex, pantoprazole, Protonix) if they
cannot tolerate h2 antagonist
- Adequate admin of analgesics
-
-
Parenteral opioids such as morphine, fentanyl, or
hydromorphone
- Closely monitor ABGs, use humidified oxygen with intubation and
mechanical ventilation
- Placement of biliary drains and stents through endoscopy to
reestablish drainage of pancreas
- Surgical
- Multiple drains, surgical incision can be left open for
irrigation and repacking every 2-3 days
- Post Acute management
- Oral feedings that are low in fat and protein
- Caffeine and alcohol eliminated in diet
- Medications are discontinued if they caused pancreatitis
Nursing Management
- Pain and Discomfort
- Parenteral opioids via patient controlled analgesia or bolus
- Oral feeding withheld to decrease secretion of secretin
- Parenteral fluids and electrolytes prescribed to restore and
maintain fluid balance
- Frequent oral hygiene and care
- Bed rest to decrease metabolic rate and reduce secretion of
pancreatic and gastric enzymes
- Increasing severity of pain needs to be reported as they may
be experiencing hemorrhage of pancreas or dose of analgesic
may be inadequate
- Frequent and repeated simple explanations about their
needs due to confusion and delirium from pain
- Breathing Pattern
- Semi-fowler position
- Nutrition
- Lab results and daily weights for nutritional status
- Enteral or parenteral nutrition as prescribed
- Monitor serum glucose levels every 4-6 hours
- Between attacks diet is high in protein and low in fat
- Avoid heavy meals and alcoholic beverages
- Monitoring Potential Complications
- Assess abdominal girth daily if ascites is suspected
- Report decreased blood pressure and reduced urine output
which can indicate hypovolemia and shock or acute kidney
injury
- Low serum calcium and magnesium can occur
-
Chronic Pancreatitis
- Often goes undetected because classic clinical findings are not always
present in early stages
- Can be characterized by acute episodes
- Progressive destruction of the pancreas, cells are replaced with fibrous
tissue
- Alcohol consumption and malnutrition are major causes
- Manifestations
- Recurring attacks of severe upper abdominal and back pain
accompanied by vomiting
- So painful that large doses of opioids may not provide relief
- Risk of opioid dependence is increased
- As it progresses, recurring attacks of pain are more severe,
frequent, and of longer duration
- Some can be severe continuous pain, while others may have dull,
nagging constant pain
- Weight loss from anorexia or fear that eating will precipitate an
attack
- Malabsorption occurs when pancreatic function is less than 10%
- Digestion of fat is impaired
- Stools become frequent, frothy, and foul smelling with high
content of fat (steatorrhea)
- Calcification of the gland can occur and possible calcium stones in
the ducts
- Assessment
- ERCP most useful in the diagnosis of chronic pancreatitis
- It obtains tissue for analysis and differentiates between
conditions
- MRI, CT, ultrasound can be used for evaluation
- Glucose tolerance test evaluates pancreatic islet cell function
- If abnormal can indicate diabetes associated with
pancreatitis
- Exacerbations can result in increased serum amylase levels
- Steatorrhea is analyzed of fecal fat content
- Medical Management
- Depends on the probable cause in each patient
- Directed toward preventing and managing attacks, relieving pain,
and managing exocrine and endocrine insufficiencies
- Nonsurgical
-
-
Endoscopy to remove pancreatic duct stone, correct
strictures, and drain cysts may be effective in selected
patients
- Focus on the use of nonopioid methods to manage pain
- Three step ladder for chronic pain
- Monotherapy
- Combination therapy with peripherally acting
and centrally acting meds
- May start with nonopioid but as pain becomes more
debilitating, introduction of opioids is necessary
- Antioxidants have shown to have an effect in pain relief
- Endoscopic ultrasound guided placement of a celiac nerve
block can be performed
- Avoiding alcohol and foods that produce pain and discomfort
- No other treatment is likely to relieve pain if they
continue to use alcohol
- Diabetes is treated with diet, insulin, and oral antidiabetics
- Education on hazard of severe hypoglycemia with
alcohol use
- Pancreatic enzyme replacement is indicated for those
patients with malabsorption and steatorrhea
Surgical
- Surgery selection considerations occur if the patient
continues alcohol use, and the likelihood to manage
endocrine changes are low
- Pancreaticojejunostomy: side to side anastomosis or joining
of the pancreatic duct to the jejunum
- Allows drainage of pancreatic secretions into the
jejunum
- Pain relief occurs within 6 months but returns as the
disease progresses
- Whipple Resection: can relieve pain of chronic pancreatitis
- Beger or Frey Operations: remove most of the head of the
pancreas except for a shell of tissue posteriorly
- When due to gallbladder disease, surgery performed to
explore common duct and remove stones
- Gallbladder is usually removed
- May experience weight gain an improved nutritional status
as a result from the pain reduction but will continue to have
pain later in the disease
Chapter 57: Management of Patients with Female Reproductive Disorders
- Human Papillomavirus
- Most are self-limiting and without symptoms while others can cause
cervical and anogenital cancers
- Can be latent, subclinical, or clinical
- Warty growths (condylomata) that can appear on the vulva, cervix, and
anus
- Often visible or may be palpable
- Medical Management
- External genital warts: topical application of trichloroacetic acid,
podophyllin, cryotherapy, or surgical removal
- Topical agents for external lesions: podofilox and imiquimod
- Should not be used during pregnancy
- Electrocautery and laser therapy indicated with a
large number or area of genital warts
- They can resolve spontaneously without treatment or may recur
even with treatment
- More resistant to treatment in patients with diabetes, pregnant,
smokers, or immunocompromised
- Must follow application of topical agents as prescribed
- Must be able to identify warts and apply medication to them
- Patient is i
- nstructed to anticipate mild pain or local irritation with use
of agents
- Those with HPV should have annual pap smears as it has the
potential to cause dysplasia
- Prevention
- Routine vaccination of boys and girls aged 11-12 years old before
they become sexually active
- 3 intramuscular doses with the initial dose followed by a second
dose in 2 months and a third dose 6 months after the first dose
- Must have three doses for immunity to develop
- Vaccine contraindicated in women who are pregnant
- Pelvic Inflammatory Disease
- Inflammatory condition of the pelvic cavity that may begin with cervicitis
and involve the uterus, fallopian tube, ovaries, pelvic peritoneum, or pelvic
vascular system
- Most causes are polymicrobial
-
-
Fallopian tubes can become narrowed and scarred which increases
chances of ectopic pregnancy, infertility, recurrent pelvic pain,
tubo-ovarian abscess
- Manifestations
- Begin with vaginal discharge, dyspareunia, dysuria, pelvic or lower
abdominal pain, tenderness that occurs with menses and postcoital
bleeding
- Fever, general malaise, anorexia, nausea, headache, possible
vomiting
- Pelvic exam: intense tenderness may be noted on palpations of the
uterus or movement of cervix
- Complications
- Pelvic or generalized peritonitis, abscess, strictures, and fallopian
tube obstruction can develop
- Obstruction can cause ectopic pregnancy
- Scar tissue can occlude tubes resulting in sterility
- Adhesions common due to chronic pelvic pain that may require
removal of uterus, fallopian tubes, and ovaries
- Medical Management
- Broad-spectrum antibiotics therapy
- Combinations of ceftriaxone, doxycycline, and metronidazole
- Treatment of sexual partenrs is necessary to prevent reinfection
- Nursing management
- Assess the characteristics and amount of vaginal discharge
- Admin of analgesics
- Rest and healthy diet encouraged
Uterine Prolapse
- If the structures that support the uterus weaken the uterus may work its
way down the vaginal canal and even appear outside the vaginal orifice
- As it goes down, it may pull the vaginal walls and even bladder and rectum
with it
- Pressure and urinary problems (incontinence, retention) from
displacement of bladder
- Aggravated when a woman coughs, lifts heavy objects, or stands for a long
time
- Medical Management
- Surgery
- Sutured back into place and repaired to strengthen and
tighten the muscle bands
-
-
If postmenopausal, hysterectomy may be an option or can be
repaired by colpopexy (surgical procedure to correct pelvic
organ prolapse in women)
- Colpocleisis (vaginal closure) may be an option for women
who do not wish to have sexual interourse or to bear children
- Conservtive treatments
- Lifestyle changes, pessaries, and pelvic floor muscle training
for symptomatic improvement
- Can be treatment of choice for women with mild prolapse,
who desire children, or unable to tolerate surgery
Nursing Management
- During pregnancy, early visits to the primary provider permit early
detection of problems
- Postpartum period, they can educated to perform pelvic muscle
exercises (kegel), to increase muscle mass and strengthen the
muscles that support the uterus
- Delays in treatment may result in complications, encourage prompt
care
- Preoperative
- Those with rectocele repair need to know that before surgery
they may be prescribed a laxative and cleansing enema
- Placed in lithotomy position for surgery with special
attention to moving both legs in and out of stirrups
simultaneously to prevent muscle strain and excess pressure
on legs and thigh
- Postoperative
- Encouraged to void within a few hours after surgery for
cystocele and complete tear
- If they cannot void or reports pain in bladder region
after 6 hours, they need to be catheterized
- Indwelling catheter may be indicated for 2-4 days
- After voiding or bowel movement, perineum may be cleaned
with warm, sterile solution and dried with sterile absorbent
material if perineal incision has been made
- External perineal repair
- Sprays containing combined antiseptic and anesthetic
solutions
- Ice pack to relieve discomfort,the ice pack must rest
on the bed and not on the patient
- Position the patient in bed with head and knees elevated
slightly
-
Ovarian Cysts
- Can be simple enlargements of normal ovarian constituents, the graafian
follicle, or the corpus luteum, or they can arise from abnormal growth of
the ovarian epithelium
- Can be often detected on routine pelvic examination
- Often benign but should be evaluated to exclude ovarian cancer
particularly in women who are postmenopausal
- Manifestations
- May or may not report acute or chronic abdominal pain
- Ruptured cyst mimic various acute abdominal emergencies such as
appendicitis or ectopic pregnancy
- Larger cysts may produce abdominal swelling and exert pressure on
adjacent organs
- Removal of ovarian cyst is similar to abdominal surgery
- Marked decrease in intra-abdominal pressure from removal of large cyst
usually leads to considerable abdominal distention
- May be prevented to some extent with a snug-fitting abdominal
binder
- If undergoing bilateral ovary removal, surgeon may give the patient an
option of a hysterectomy
- Polycystic ovary syndrome (PCOS) is a type of hormonal imbalance or
cystic disorder that affects ovaries
- PCOS is a disorder in the hypothalamic-pituitary and ovarian
network or axis resulting in chronic anovulation and
hyperandrogenism
- Features can include obesity, insulin resistance, glucose
intolerance, dyslipidemia, sleep apnea, and infertility
- Related to androgen excess
- The patient will present with irregular menstrual periods from lack
of regular ovulation, infertility, obesity, and hirsutism
- Cysts form because the hormonal milieu cannot cause ovulation on
a regular basis
- Diagnosis based on clinical criteria: hyperandrogenism, chronic
anovulation, and polycystic ovaries
- Two of three must be present to make diagnosis
- Medical Management
- Large ovarian cysts are usually treated with surgical removal
- Oral contraceptives may be used in patients to suppress ovarian
activity and resolve small cysts that appear fluid filled and
physiologic
- Commonly prescribed to treat PCOS
-
-
When pregnancy is desired, medications to stimulate
ovulation like clomiphene citrate (Clomid) are often effective
- Lifestyle modification is critical, Weight loss is part of the treatment
plan because it can help with hormone imbalances and infertility
- Metformin ( Glucophage) often regulates periods and help with
weight loss
- Women that are DX with PCOS are at an increased risk for
endometrial cancer due to anovulation
Endometriosis
- Chronic disease, benign lesion or lesions that contain endometrial tissue
found in the pelvic cavity outside of the uterus (it is a disorder in which
tissue that normally lines the uterus grows outside of the uterus. Tissue
can be found on the ovaries, fallopian tubes, or intestines)
- It is a major cause of chronic pelvic pain and infertility
- Manifestations
- Vary with dysmenorrhea, dyspareunia, and pelvic discomfort or
pain
- Dyschezia (pain with bowel movements) and radiation of pain to
the back or leg may occur
- Infertility may occur because of fibrosis and adhesions
- Assessment
- Health history of menstrual pattern
- Bimanual pelvic examination: fixed tender nodules that can
sometimes be palpated, uterine mobility may be limited which is
indicative of adhesions
- Laparoscopic exam confirms diagnosis and helps to stage disease
- Stage 1: superficial or minal lesions
- Stage 2: mild involvement
- Stage 3: moderate involvement
- State 4: extensive involvement and dense adhesions with
obliteration of cul-de-sac (The cul-de-sac is also known as:
The Pouch of Douglas or rectovaginal septum) This is the
space between the rectum and the uterus. This is the lowest
part of the abdominal cavity.)
- Ultrasonography, MRI, CT can be help to visualize
- Medical Management
- Pharmacology
- Analgesic agents and prostaglandin inhibitors for pain
- Hormonal therapy is effective in suppressing endometriosis
and relieving dysmenorrhea (menstrual pain)
-
-
Oral Contraceptives may provide pain relief and prevent
progression of disease
- Side effects: fluid retention, weight gain, nausea
- Danazol (synthetic androgen): causes atrophy of the
endometrium and subsequent amenorrhea
- GnRH agonists: decrease estrogen production and cause
subsequent amenorrhea
- Norethindrone Acetate can be given along with GnRH
agonist to mitigate the bone density side effects
- Hormonal Medications not used in patients with a history of
abnormal vaginal bleeding or liver, heart, or kidney disease
- Surgical Management
- If conservative measures are not helpful, surgery may be
necessary to relieve pain and improve possibility of
pregnancy
- Laparoscopy may be used to fulgurate endometrial implants
and to release adhesions
- Laser surgery vaporizes or coagulates the endometrial
implants which can destroy tissue
- Anticoagulation and electrocoagulation, laparotomy,
abdominal hysterectomy, oophorectomy, bilateral salpingo
oophorectomy, and appendectomy
- Total hysterectomy is the definitive procedure
- Nursing Management
- Assess the woman's reproductive plans
- Encourage Patient to seek care if dysmenorrhea or dyspareunia
occur
Cancer of the Cervix
- Preventative measures
- Annual pelvic exam with a pap smear
- Delaying first intercourse, avoiding HPV infection, engaging in
safer sex practices, smoking cessation, receiving HPV immunization
- Most cervical cancers if not detected or treated spread to regional pelvic
lymph nodes and local recurrence is not uncommon
- Manifestations
- Early cervical cancer rarely produces symptoms
- If present, they may go unnoticed like thin, watery vaginal
discharge after intercourse or douching
- If discharge, irregular bleeding, pain, or bleeding after sex occur,
the disease may be advanced
- Advanced:
-
-
-
vaginal discharge gradually increases and becomes watery
and finally, dark and foul smelling from necrosis and
infection
- Bleeding is irregular between periods (metrorrhiagia) or
after menopause (post-menopausalbleeding), may be light or
spotty, and occur after mild trauma or pressure (sex, bearing
down)
- As it progresses, bleeding may persist and increase
- Leg pain, dysuria, rectal bleeding, and edema signal
advanced disease
- Can invade the tissues outside the cervix (lymph glands anterior to
the sacrum)
- Invasive can involve the fundus which can produce excruciating
pain in the back and legs that is relieved only by large doses of
opioid analgesic agents
- Progression can cause extreme emaciation and anemia that is
usually accompanied by fever and by fistula formation
- Progression can also be seen with unilateral leg edema, sciatica, and
ureteral obstruction
Assessment
- Diagnosis may be made on the basis of abnormal pap smear results
followed by biopsy which identifies severe dysplasia
- Early stages, cancer is found microscopically by pap smear
- Later stages, pelvic exam may reveal large, reddish growth or a deep
ulcerated lesion
- The patient may report spotting or bloody discharge
Medical Management
- Precursor or Preinvasive Lesions
- Careful monitoring by frequent pap smears and conservative
treatment if possible
- Cryotherapy or laser therapy
- Loop electrocautery excision procedure (LEEP) can be used
to remove abnormal cells
- Thin wire loop with laser is used to cut away a thin
layer of cervical tissue
- Analgesic given before and local anesthetic agent
injected into the area
- Allows for pathologist to examine if sample border is
disease free
-
-
Preinvasive cervical cancer occurring in women that have
completed childbearing, simple hysterectomy is
recommended
- Precursor or premalignant lesions need reassurance that
they do not have invasive cancer
- It is important to emphasize close follow up as it may
progress to cancer
- Invasive Cancer
- Depends on stage, age and general health, and judgment of
provider
- Surgery and radiation are most often used
- Frequent follow up after surgery is important because of
recurrence which can happen within the first 2 years
- Radiation can be delivered by external beam or by
brachytherapy
- Vaginal stenosis is a frequent side effect, preventative
therapy can be used to avoid severe permanent
stenosis
- Pelvic exenteration
- Several pelvic organs are removed
- Reserved for women with a high likelihood of cure
- Patients with advanced disease are not candidates for
this procedure
Cancer of the Uterus (Endometrium)
- Cumulative exposure to estrogen is considered the major risk factor
- Other risk factors are obesity, infertility, diabetes, and use of tamoxifen
- Tamoxifen is used to treat and prevent breast cancer, those that
take this drug should be monitored
- Assessment
- Annual checkups including gynecologic exam
- Any irregular bleeding should be checked promptly
- If menopausal women experiences bleeding, endometrial aspiration
or biospy is performed to rule out hyperplasia
- Transvaginal ultrasound can also be used to measure thickness of
endometrium
- Biopsy or aspiration is diagnostic
- Medical Management
- Total or radical hysterectomy or bilateral salpingo-oophorectomy
and lymph node sampling
- Laparoscopy
-
-
Cancer antigen 125 levels monitored as elevation can predict
metastasis
- Radiation in form of external beam or brachytherapy
- Whole pelvis radiotherapy may be used if spreads beyond the
uterus
- Recurrent treated with surgery and radiation
- Recurrent beyond the vagina are treated with hormonal and
chemotherapy
- Progestin therapy
- Side effects: nausea, depression, rash, mild fluid retention
Cancer of the Vulva
- Manifestations
- Long-standing pruritus and soreness are most common
- Itching occurs in half of patients
- Bleeding, dysuria, foul-smelling discharge, and pain can be signs of
advanced disease
- Lesions of the vulva are visible and accessible and grow slowly
- Early lesions appear as chronic dermatitis, later it may be a node
that continues to grow and become hard, ulcerated, cauliflower like
growth
- Any vulvar lesion that persists, ulcerates, or fails to heal should be
biopsied
- Medical Management
- Preinvasive can be treated with local excision, laser ablation,
application of chemotherapeutic creams, or cryosurgery
- If invasive, wide excision of the vulva and vulvectomy may be
considered
- Wide excision done only if lymph nodes are normal
- External beam radiation may be used which results in sunburn like
irritation that resolves in 6-12 months
- Laser and chemo are possible treatments
- If widespread and advanced, radical vulvectomy with bilateral groin
dissection may be performed
- Antibiotic and heparin prophylaxis may be prescribed to
prevent infection, DVT, and PE
- Nursing Management
- Preoperative
- Cleanse lower abdomen, inguinal areas, upper thighs, and
vulva with chlorhexidine for several days before procedure
- Postoperative
-
-
Wide excision may cause severe pain, analgesic given
preventively and other measures
- Patient controlled analgesia
- Careful positioning with pillow, low fowler or pillow
placed under the knees reduces pain and relieves
tension, on the side with pillows between legs and
against lumbar region
- Soothing back rubs
- Overhead trapeze bar to help move
- Wound is cleansed daily with warm, normal saline
irrigations as prescribed or a transparent dressing may be
placed
- After dressing is removed, bed cradle may be used to keep
bed linens away from surgical site
- Sex counselor referral
- Monitored closely for SS of infection: purulent drainage,
redness, increased pain, fever, and increased white blood cell
count
- Low residue diet prevents straining on defecation and wound
contamination
- Wide excision increases chances of bleeding, pressure
dressings may be applied after surgery
Cancer of the Vagina
- Most are secondary and invasive at time of diagnosis
- Risk factors: previous cervical cancer, exposure to DES (Diethylstilbestrol
is a synthetic form of the female hormone estrogen which can cause clear
cell adenocarcinoma (CCA) - A rare type of vaginal and cervical cancer),
previous vaginal or vulvar cancer, previous radiation therapy, history of
HPV, or pessary use
- Any previous cervical cancer should be examined regularly for vaginal
lesions
- Vaginal pessaries have been associated with vaginal cancer as they cause
chronic irritation if not cared for correctly
- Most do not have symptoms but report slight bleeding after intercourse,
spontaneous bleeding, vaginal discharge, pain, and urinary or rectal
symptoms
- Diagnosis is made by pap smear
- Medical Management
- Early lesions
- Local excision, topical chemo, or laser
- Advanced
-
-
Surgery depends on size and stage
Radical vaginectomy, a vagina can be reconstructed with
tissue from intestine, muscle and skin grafts
After vaginal reconstructive surgery and radiation, regular
intercourse may be helpful with preventing vaginal stenosis
- Water-soluble lubricants are helpful in reducing pain
Following surgery, radiation therapy may be given through
external beam or brachytherapy
Cancer of the Ovary
- Often difficult to detect because they are usually deep in the pelvis, no
early screening mechanism exist at present
- Ovarian cancer is the leading cause of gynecological cancers in the United
States
- Tumor associated antigens are helpful in determining follow-up care after
diagnosis and treatment, and to evaluate for recurrent disease, but are not
useful in early general screening
- Manifestations
- Nonspecific and can include increased abdominal girth, pelvic
pressure, bloating, back pain, constipation, abdominal pain, urinary
urgency, indigestion, flatulence, increased waist size, leg pain, and
pelvic pain
- Symptoms are vague so they are often ignored
- Enlargement of the abdomen from an accumulation of fluid is a
common sign
- All women with GI symptoms without a known cause must be
evaluated for potential ovarian cancer
- Vague, undiagnosed, persistent GI problems should alert a
nurse
- A palpable ovary in a woman who has gone through menopause is
investigated immediately because ovaries normally become smaller
and less palpable after menopause
- Assessment
- Pelvic exam often does not detect early ovarian cancer
- By time of diagnosis most are advanced
- MRI scan, transvaginal and pelvic ultrasound, chest x ray, blood
tests for CA-125
- Medical Management
- Surgery
- Staging the tumor by FIGO staging system to guide
treatment
-
-
Total abdominal hysterectomy with removal of fallopian
tubes and ovaries and possible omentum, tumor debulking,
para-aortic and pelvic lymph node sampling, diaphragmatic
biopsies, random peritoneal biopsies, and cytologic washing
- Post-op management: taxanes or platinum based chemo
- Borderline tumors: affected ovary is removed but uterus and
contralateral ovary may remain
- Pharmacological
- Chemo admin IV with combination of platinum and taxane
agents
- Paclitaxel plus carboplatin most often used
- It can cause leukopenia, contraindicated in
those that have hypersensitivity to
polyoxyethylated castor oil and baseline
neutropenia
- Hypotension, dyspnea, angioedema, and
urticaria indicate severe reaction
- Carboplatin may be used in the initial
treatment and in patients with recurrence
- Caution in patients with renal
impairment
- Usually 6 cycles are given
- Liposomal therapy allows for the highest possible dose of
chemo to the tumor target with reduction of adverse effects
- Intraperitoneal chemo is reserved for women with good
kidney function
Nursing Management
- Patients with advanced ovarian cancer may develop ascites and
pleural effusion
- IV fluids to alleviate fluid and electrolyte imbalances, admin
of parenteral nutrition, control of pain, managing drainage
tube
- Small frequent meals, admin of diuretics, and rest
- Pleural effusion may cause SOB, hypoxia, chest pain, and
cough
- Thoracentesis may be performed to alleviate symptoms
Chapter 58: Assessment and Management of Patients with Breast Disorders
- Breast Assessment
- Erythema may indicate benign local inflammation or superficial lymphatic
invasion by a neoplasm
- Prominent venous pattern can signal increased blood supply required by a
tumor
- Edema or pitting can give an orange peel appearance (peau d’ orange)
- Nipple inversion of one or both breats is not uncommon, and is significant
only when of recent origin
- ulceration , rashes, or spontaneous nipple discharge requires evaluation
- Skin dimpling or retraction
- Askthe patient to raise both arms overhead, both breasts should be
elevated equally
- Place hands on waist and push in, should not alter breast contour or
nipple direction
- The brests are palpated sitting and lying down
- Supine: positioned with shoulder elevated with small pillow
- Lymph node enlargement is noted
- Diagnostic
- Breast Self examination
- Best performed after menses
- Routine, monthly BSE will help the patient become familiar with
“normal abnormalities” if a change is detected they should seek
medical attention
- Mammography
- Breast imaging technique used to detect small abnormalities
- Takes about 15 min to perform
- Two views are taken and the breasts are mechanically compressed
from top to bottom and side to side
- May experience some discomfort
- Can detect tumor before it is clinically palpable
- Should have them done every year beginning at age 45
- Women 55 and older may continue yearly or transition to
every 2 years
- Contrast Mammography
- Injection of less than 1 ml of radiopaque material through a cannula
inserted into a ductal opening on the areola followed by a mammogram
- It is performed to evaluate an abnormality within the duct when the
patient has bloody nipple discharge on expression, spontaneous nipple
discharge, or a solitary dilated duct noted on mammography
- Ultrasonography
-
-
MRI
-
Adjunct to mammography helps to distinguish fluid-filled cysts from other
lesions
IV injection of gadolinium can improve visibility
Lies face down and breast is placed through a depression in the table
Coil placed around the breast
Annual MRI scan in addition to mammography in women at high risk for
breast cancer
- Candidates include women who have a BRCA1 or 2 mutation, a first
degree relative with either of these mutations, or radiation to the
chest between 10-30 years of age
Procedures for tissue analysis
- Percutaneous biopsy
- Used to sample palpable and nonpalpable lesions
- Fine-needle Aspiration
- Small gauge needle inserted into a mass
- Core Needle Biopsy
- Larger gauge needle is used, local anesthesia is applied
- Has a more definitive DX than FNA because actual tissue is
removed
- Stereotactic Core Biopsy
- Performed on non palpable lesion detected by
mammography
- The patient lies prone on a stereotactic table
- Breast is suspended through an opening in the table and
compressed between two x ray plates
- Images are obtained
- Local anesthetic is injected, core needle is inserted and
sample tissues are taken
- Several passes are taken
- Post biopsy images are then taken to check that the sample
was adequate
- Small titanium clip is placed at site so it can be located for
further treatment
- Ultrasound Guided Core Biopsy
- Magnetic Resonance Imaging Guided Core Biopsy
- Used when an abnormal area in the breast is too small to be
felt but visible on MRI
- Surgical Biopsy
- Uses local anesthesia and IV sedation
- Lesion is excised and sent to lab
-
-
Preceded by core biopsy
Excisional Biopsy
- Standard for a palpable breast mass
- Entire mass plus margin of tissue is removed
- Lumpectomy
- Incisional Biopsy
- Surgically removes a portion of a mass
- Performed to confirm a diagnosis and to conduct special
studies
- Complete excision may not be possible or immediately
beneficial
- Often done on women with locally advanced breast cancer or
suspected cancer recurrence
- Wire needle localization
- Locates non palpable masses or suspicious calcium deposits
detected on mammogram, ultrasound, or MRI that require
an excisional BX
- The radiologist inserts a long, thin wire through a needle that
is then inserted into the area of abnormality, using x-ray or
U/S guidance, the wire remains in place after the needle is
withdrawn to ensure the precise location
- The patient is then taken to the operating room, where the
surgeon will follow the wire to the tip and excises the area
- Dressing covering the lesion is usually removed after 48 hours but
steri-strips that are applied directly over the incision should remain
in place for 7-10 days or until they fall off
- A supportive bra after is encouraged to limit movement and reduce
discomfort
Malignant Breast Cancer
- Ductal Carcinoma in Situ
- Proliferation of malignant cells inside the milk ducts without
invasion into surrounding tissue
- Can develop into invasive breast cancer if left untreated
- Manifested on a mammogram with appearance of calcifications
- Invasive Cancer
- Infiltrating ductal carcinoma: solid irregular mass in the breast
- Infiltrating lobular carcinoma: multicentric and can be bilateral
- Medullary carcinoma: can be large and mistaken for fibroadenoma
- Mucinous Carcinoma: slow growing
-
-
-
-
-
-
Tubular Ductal Carcinoma: accounts for 2% of breast cancers.
Because axillary metastases are uncommon with this histology,
prognosis is usually excellent
- Inflammatory Carcinoma: diffuse edema and erythema of the skin
- Paget Disease: scaly, erythematous, pruritic lesion of the nipple.
Often represents DCIS of the nipple but may have an invasive
component
Risk Factors
- Many are sporadic, no family history
- Family history, increasing age, genetic mutation, hormonal factors,
obesity
- Mutations in BRCA1 and 2
- Recommended to start having mammos 5-10
years earlier than their youngest affected
family member or mammography by 25 years
of age
Protective Factors
- Breastfeeding for at least 1 year, regular or moderate physical
activity, healthy body weight
- Extra virgin olive oil regularly in ones diet
Breast Cancer prevention strategies in those who are High Risk
- Clinical breast exams may be performed twice a year starting as
early as 25 years of age
- Chemoprevention
- Prophylactic Mastectomy
- Total mastectomy accompanied by immediate breast
reconstruction
Manifestations
- Usually found in the upper outer quadrant where most breast tissue
is located
- Lesions are nontender, fixed, and hard with irregular borders
- Diffuse breast pain and tenderness with menstruation are
associated with benign breast disease
- Advanced: skin dimpling, nipple retraction, skin ulceration
Prognosis
- Factors: tumor size and whether it has spread to lymph nodes
- The smaller the tumor, the better the prognosis
- Breast tumors are often present for several years before they
become palpable
- Distant metastasis common sites: bone, lung, liver, pleura,
adrenals, skin, and brain
-
- Stage and type help to determine prognosis
Surgical Management
- Modified Radical Mastectomy
- Treats invasive breast cancer
- Removal of breast tissue including nipple-areola complex
- Portion of axillary lymph nodes are removed
- Immediate breast reconstruction can be done but needs
referral to a plastic surgeon prior to surgery
- Pectoralis major and minor chest wall muscles are left intact
- Total Mastectomy
- Removal of breast and nipple-areola complex but not the
lymph nodes
- Can be done in those with noninvasive breast cancer
- Can be done prophylactically in those at high risk
- May be performed in conjunction with sentinel lymph node
biopsy for patients with invasive cancer
- Breast Conservation treatment
- Lumpectomy, wide excision, partial or segmental
mastectomy, quadrantectomy
- The goal is to excise the tumor in the breast completely and
obtain clear margins while achieving acceptable cosmetic
result
- If invasive, lymph node removal is indicated
- Sentinel Lymph Node Biopsy
- Sentinel lymph node is the first node that receives drainage
from the primary tumor in the breast
- It is identified by injecting radioisotope into the breast
- The node is excised and sent to pathology
- If positive the surgeon can proceed with immediate removal
- Inform them that blue green discoloration of urine or stool is
normal and can occur in the first 24 hours
- Lymphedema (painful swelling of the arm), decreased arm
mobility, and seroma formation can occur
- Shorter recovery time than ALND (axillary lymph node
dissection)
Hand and Arm Care After Axillary Lymph Node Dissection
The nurse instructs the patient to:
● Avoid blood pressures, injections, and blood draws in affected extremity.
● Use sunscreen (higher than 15 SPF) for extended exposure to sun.
● Apply insect repellent to avoid insect bites.
● Wear gloves for gardening.
● Use cooking mitt for removing objects from oven.
● Avoid cutting cuticles; push them back during manicures.
● Use electric razor for shaving armpit.
● Avoid lifting objects heavier than 5–10 pounds. (avoided for about 4-6 weeks)
● If a trauma or break in the skin occurs, wash the area with soap and water, and
apply an over-the-counter antibacterial ointment (Bacitracin or Neosporin). Observe
the area and extremity for 24 hours; if redness, swelling, or a fever occurs, call the
surgeon or nurse.
-
Radiation Therapy
- Used to decrease chances of local recurrence in the breast
- It is adjunct with breast conservation treatment
- If radiation is contraindicated, mastectomy would be
indicated
- External Beam typically begins about 6 weeks after breast
conservation to allow for healing
- If chemo is indicated, radiation is started after its completion
- Radiation is given to the entire breast region, lasts only a few
minutes, generally 5 days a week for 5-6 weeks
- After completion, they may receive a boost to the site
- Brachytherapy: placed close to the tumor within the breast
- Given 4-5 days a week
- After mastectomy, postop radiation may be indicated for those at
high risk
- Side effects
- Mild to moderate erythema, breast edema, and fatigue
- Skin breakdown may occur in the fold or near the axilla at
the end of treatment
- Usually resolves within a few weeks to a few months after
treatment is completed
- Nursing Management
- Education: use mild soap and minimal rubbing, avoid
perfumed soaps, use hydrophilic lotions, use non drying soap
if pruritus occurs, avoid tight fitted clothing or underwire
bras
-
-
Minimize sun exposure to treated areas and reassure the
patient that minor pain is normal after treatment
Systemic Treatment
- Chemotherapy
- Anticancer agents in addition to other treatments to delay or
prevent a recurrence of breast cancer
- Recommended in those that have positive lymph nodes or
invasive tumors greater than 1cm in size
- Most commonly initiated after surgery and before radiation
- Polychemotherapy, given over a period of 3-6 months
- Regimen: cyclophosphamide, methotrexate, and fluorouracil
(CMF)
- Anthracycline-based regimens
- Taxanes are incorporated for patients with larger,
node-negative cancers and for those with positive axillary
lymph nodes
- Side Effects:
- Nausea and vomiting, neutropenia and anemia
- Taste changes, alopecia, mucositis, neuropathy, skin
changes, and fatigue
- Weight gain of more than 10 lbs
- Premenopausal, temporary or permanent amenorrhea
- Taxanes: peripheral neuropathy, arthralgias, myalgias
in high doses
- Nursing Management
- Antiemetic agents with optimal dosing schedule can
help to relieve nausea and vomiting
- Rinsing mouth with normal saline or sodium
bicarbonate solution, avoiding hot and spicy food, and
using a soft toothbrush for mucositis
- Hematopoietic growth factors to minimize
neutropenia and anemia
- Granulocyte colony-stimulating factors boost white
blood cell count
- Filgrastim: subq or IV for 7-10 days after
chemo admin
- Pegfilgrastim: injected once no earlier than 24
hours after chemo
- Erythropoietin growth factor: increasse the
production of RBC
- Epogen is given weekly
-
-
Provide a wig before hair loss begins
- Give a list of suppliers
- Hormonal Therapy
- Considered in women who have hormone-receptor-positive
tumors
- Its use can be determined by the results of an estrogen and
progesterone receptor assay
- Hormonal therapy involves the use of synthetic hormones or
other meds that compete with estrogen by binding to the
receptor sites or the use of aromatase inhibitors which block
estrogen production by the adrenal glands
- SERM (selective estrogen receptor modulators) tamoxifen:
has estrogen antagonistic and agonistic effects on certain
tissues
- Increases incidence of endometrial cancer
- Aromatase inhibitors: anastrozole, letrozole, exemestane
- Decreases level of circulating estrogen in peripheral
tissues
- Side effects: hot flashes, vaginal dryness, nausea and
vomiting, musculoskeletal symptoms, risk of endometrial
cancer and thromboembolic events, risk for osteoporosis
- Target Therapy
- Trastuzumab: regulates cell growth and slows tumor growth
- Side effects: fever, chills, nausea, vomiting, diarrhea,
headache
- This medication has been shoen to improve survival rates in
women with HER-2/neu positive metastatic breast cancer
and is noe regarded as standard therapy
- Can be given as a singule agent or in combination with
chemo
Treatment of Recurrent and Metastatic Breast Cancer
- In metastatic disease the bone, usually the hips, spine, ribs, skull, or
pelvis are common sites of spread
- Other sites of metastasis include: Liver, lungs, pleura, brain
- Local recurrence with no systemic disease is treated aggressively
with surgery, radiation, and hormonal therapy
- Chemo if tumors are not hormonally sensitive
- Local recurrence may be an indicator that systemic disease
will develop in the future, particularly if it occurs within 2
years of the original DX
-
-
Treatment of recurrent metastatic Breast Cancer: hormonal
therapy, chemotherapy, and targeted therapy
- Metastatic breast cancer involves the control of the disease
rather than cure
- If hormone dependent tumor, removal of ovaries or suppression of
estrogen production
Reconstructive Procedures after Mastectomy
- Delayed reconstruction is preferable in women who have a difficult
time deciding on the type of reconstruction or those with advanced
disease since breast cancer treatments should begin without delay
- Any delays in healing after reconstruction may interfere with
treatment
- Tissue Expander Followed by permanent implant
- The skin and the underlying muscle must gradually be
stretched by a process called tissue expansion
- Small amount of saline is injected through a metal port
intraoperatively to partially inflate the expander
- 6-8 weeks, weekly intervals, patient receives additional
saline injections through the port until fully expanded
- Remains fully expanded for about 6 weeks to allow
skin to loosen
- It is then exchanged for a permanent implant
- The patient is cautioned not to have an MRI while tissue
expander is in place as it contains metal
- The patient is informed not to engage in any exercises that
will develop pectoralis muscle as this can result in distortion
- Tissue Transfer Procedures
- Use of patients own skin/tissue to create a breast mound
- Transverse rectus abdominal myocutaneous flap, gluteal
flap, or latissimus dorsi flap
- Resembles more closely to a real breast
- TRAM flap most common
- Those with medical conditions such as atherosclerosis or
heart failure are not good candidates as it affects circulation
- Also those with diabetes or who are obese are not
good canidates
- TRAM has a lengthy recovery (6-8 weeks) with incisions
both at the mastectomy site and donor site
- To reduce tension on the abdominal incision, elevation of the
bed to 45 degrees and flexing the knees helps
- Nipple-Areola Reconstruction
-
-
After breast mound is created and healed, some may have
the nipple reconstructed
Use of local flaps which are wrapped around each other to
create a projected nipple
- Skin graft, upper inner thigh is a common donor site
Micropigmentation after healing can be done for a more
natural look
Prosthetics
- External form that simulates the breast
- Most often made of silicone
- Can be place inside a pocket in a bra or adhere to chest wall
- Provide a temporary, light weight, cotton filled form that can be
worn until surgical incision is well heal (4-6 weeks)
- After that, they can be fitted for a prosthesis
- Pregnancy and Breast Cancer
- Diagnosed during gestation or within 1 year of childbirth
- It can be difficult to diagnose as breast tissue becomes tender and
swollen
- Ultrasound is the diagnostic method of choice as it involves no
radiation
- Modified radical mastectomy is the most common surgical
treatment
- Radiation can be delayed until after delivery if breast conservation
treatment is considered (after third trimester)
- Termination of the pregnancy may be considered if it is aggressive
and early in pregnancy
- If mass is found while breastfeeding, she is urged to stop to allow
the breast to involute
Chapter 59: Assessment and Management of Patients with Male
Reproductive Disorders
- Assessment
- Evaluate urinary function and symptoms
- Enlarged prostate can cause urinary frequency, decreases force of
urine stream, or double/triple voiding
- Also assess for dysuria, hematuria, nocturia, or hematospermia
- Also assess for sexual function
- Ask about medications that can affect sexual function
- Digital Rectal Exam
- To screen for prostate cancer
- Recommended annualy for every man older than 50 or 45 if he is
high risk
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Lubricated, gloved finger placed in the rectum to assess size,
symmetry, shape, and consistency of posterior surface of prostate
gland
- Assess for any tenderness or presence of nodules
- Have the patient lean over a table or positioned in a side lying
position with legs flexed toward the abdomen or supine with legs
resting in stirrups
- Patient is instructed to take a deep breathe and exhale slowly when
the finger is inserted
- Feet should be turned inward so toes are touching
- Testicular Exam
- Examined for abnormalities and palpated for masses
- Scrotum is palpated for nodules, masses, or inflammation
- Penis is inspected and palpated for ulcerations, nodules,
inflammation, discharge, and curvature
- If uncircumcised, foreskin is retracted for visualization of the glans
- Opportunity to educate on TSE and the importance for early
detection (TSE- testicular self-examination)
- Should begin during adolescence
Diagnostic
- Prostate-Specific Antigen Test
- PSA is sensitive but not specific for prostate cancer
- Increased levels may indicate prostate cancer however other
conditions may cause the levels to rise such as BPH, acute urinary
retention, or acute prostatitis
- It can also rise after ejaculation
- Less than 4 is considered normal, greater than 4 is abnormal
- Age specific reference range is encouraged to minimize
unnecessary biopsies
- Serum PSA and DRE (digital rectal exam) are recommended to
screen for prostate cancer in those with at least a 10 year life
expectancy and for men at high risk, including those with a strong
family HX of prostate cancer and those of African American
ethnicity
- When used together their accuracy increases
- Also used to monitor for recurrence after treatment
- Ultrasonography
- Transrectal ultrasound may be used in patients with abnormalities
detected in DRE and elevated PSA levels
- Lubricated, condom covered, rectal probe transducer is inserted
into the rectum
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Water may be introduced into the condom to transmit sound waves
Can be used to detect nonpalpable prostate cancers and in staging
of localized prostate cancer
- Needle biopsies are guided with this tool
- Prostate Fluid or Tissue analysis
- May be obtained if disease or inflammation of prostate gland is
suspected
- Can be performed at time of prostatectomy or by needle biopsy
- 6 to 12 biopsies may be obtained in all four prostate zones
during a TRUS-guided biopsy (transrectal-guided U/S for
biopsy)
- Tests of Male Sexual Function
- If they cannot engage in sexual intercourse to their satisfaction, a
detailed history is taken
- Nocturnal penile tumescence tests may be done in a sleep
laboratory to monitor changes in penile circumference during sleep
with various methods to determine number, duration, rigidity, and
circumference of erection
- It can identify whether it is caused by physiologic or psychological
factors
Prostatitis
- Inflammation of the prostate gland associated with lower urinary tract
symptoms and symptoms of sexual discomfort and dysfucntion
- Can be caused by infectious agents or conditions like BPH
- Four types
- Acute bacterial prostatitis
- Chronic bacterial prostatitis
- Chronic prostatitis or chronic pelvic pain syndrome
- Asymptomatic inflammatory prostatitis
- Manifestations
- Acute is characterized by sudden onset of fever, dysuria, perineal
prostatic pain, and severe lower urinary tract symptoms
- Dysuria, frequency, urgency, hesitancy, and nocturia
- Acute can progress to chronic bacterial
- Those with type three often do not have bacteria in the urine
- Type four is usually diagnosed incidentally during a workup for
infertility, an elevated PSA, or other conditions
- Medical Management
- Eradicate causal organism
- Based on the type and the results of the culture and sensitivity
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If bacteria found, antibiotics agents such as
trimethoprim-sulfamethoxazole or fluoroquinolone may be
prescribed
- If afebrile and normal urinalysis, anti-inflammatory agents may be
prescribed
- Alpha adrenergic blockers, tamsulosin to promote bladder
and prostate relaxation
- Nursing Management
- Acute prostatitis may be hospitalized for IV antibiotic therapy
- May be prescribed analgesics and sitz bath
Benign Prostatic Hyperplasia
- Noncancerous enlargement or hypertrophy of the prostate
- Lower urinary tract symptoms that can interfere with daily activities and
sleep patterns
- Manifestations
- May or may not affect lower urinary tract symptoms
- Range from mild to severe, that increases with age
- Urinary frequency, urgency, nocturia, hesitancy in starting
urination, decreased or intermittent force of stream,
sensation of incomplete bladder emptying, abdominal
straining, decrease in volume and force of urinary stream,
dribbling, complications of acute urinary retention or
recurrent UTIs
- Chronic urinary retention and large residual volumes can
lead to azotemia (accumulation of nitrogenous waste
products) and kidney failure
- Fatigue, anorexia, nausea, vomiting, and pelvic discomfort
- Assessment
- Voiding diary is used to record voiding frequency and urine volume
- DRE reveals large, rubbery, and nontender prostate gland
- Urinalysis to screen for hematuria and UTI is recommended
- PSA level is obtained
- International prostate symptom score can be used to assess severity
- Urinary flow rate and measurement of postvoid residual urine
- Complete blood studies are performed
- Medical Management
- The goals in the medical management of BPH are to improve quality of
life, improve urine flow, relieve obstruction, prevent disease progression,
and minimize complications.
- Tx depends on the severity of SX’s, the cause of the disease, the severity of
the obstruction, and the patients condition
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If patient is admitted on an emergency basis because of the
inability to void, he is immediately catheterized
- The ordinary catheter may be too soft and pliable to advance
through the urethrainto the bladder in this case, a thin wire
is introduced by a urologist into the catheter to prevent the
catheter from collapsing when it encounters resistance
- A metal catheter with a pronounce prostatic curve
may be used if obstruction is severe
- Cystostomy may be needed to provide urinary drainage
Patients with mild symptoms or those not bothered by them with
no complications can be managed by watchful waiting
- Monitored and reexamined annually
Pharm
- Alpha-adrenergic blockers
- Alfuzosin, terazosin, doxazosin, tamsulosin (flowmax)
which relax smooth muscles of bladder neck and
prostate
- Hormonal manipulation with antiandrogen agents, and
5-alpha-reductase inhibitors
- Finasteride, dutasteride to prevent the conversion of
testosterone to DHT (dihydrotestosterone)and
decrease prostate size
- Combination of the two has decreased symptoms and
progression
- Side effects include: dizziness, headache,
asthenia/fatigue, postural hypotension, rhinitis or
sexual dysfunction
- Serenoa repens (saw palmetto berry) and pygeum africanum
(African Pl,um) should not be used as they can interact with
finasteride, dutasteride, and estrogen-containing medication
Minimally Invasive Therapy
- Transurethral microwave thermotherapy, application of heat
to prostate tissue
- Probe is interested into the urethra and microwave is
directed to the prostate tissue
- tissue becomes necrotic and sloughs
- Some systems have a water cooling apparatus to
minimize damage
- Transurethral needle ablation (TUNA) by radiofrequency
energy and the UroLume stent is a minimally invasive TX
option
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Delivered by thin needles placed in prostate gland to
produce localized heat that destroys prostate tissue
while sparing other tissue
- Stents are only used in patients with urinary
retentions and those who are poor surgical risks
- Surgical Resection
- Used in patients with moderate to severe lower urinary tract
symptoms of BPH and those with acute urinary retention
and other complications
- It can be open or endoscopic and be performed by
electrocautery or laser depending on the surgeon, size of
gland, presence of medical disorders, and preference of
patient
- All clotting defects must be correct and meds withheld
because of bleeding potential
- Transurethral resection of prostate (TURP) is benchmark for
surgical treatment
- Surgical removal of the inner portion of the prostate
through an endoscope inserted through the urethra,
no incision is made
- Treated tissue either vaporizes or becomes necrotic
- Removed in small chips
- Eliminates risk of transurethral resection syndrome
(hyponatremia, hypovolemia)
- SS: collapse, headache, hypotension, lethargy,
muscle spasms, nausea, seizures
- Discontinue irrigation, admin diuretics, replace
bladder irrigation with normal saline
- Transurethral incision of the prostate, transurethral
electrovaporization, laser therapy, and open prostatectomy
- TUIP is for smaller prostates with one or two cuts
made in the prostate and prostate capsule to reduce
constriction of urethra and decrease resistance to flow
of urine, no tissue removed
- Prostatectomy: removal of inner portion of the
prostate
Cancer of the Prostate
- Greater in men whose diet contains excessive amounts of red meat or
dairy products that are high in fat
- Manifestations
- Early stages, rarely produces symptoms
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Urinary obstruction occurs in advanced disease
If cancer is large enough to encroach on the bladder neck, SS of
urinary obstruction occurs
- Blood in the urine or semen and painful ejactulation
- Hematuria may occur if cancer invade the urethra or bladder
- Sexual dysfunction is common before the diagnosis is made
- It can spread to lymph nodes or bones
- Backache, hip pain, perineal and rectal discomfort, anemia,
weight loss, weakness, nausea, oliguria, and spontaneous
pathologic fractures
- These can be the first indication of prostate cancer
Assessment
- If detected early, likelihood of cure is high
- It can be diagnosed with an abnormal finding in the DRE, serum
PSA, and ultrasound-guided TRUS with biopsy
- More likely to be detected with combined diagnostic
procedures
- Routine DRE is important as it can detect nodule within the gland
or as an extensive hardening in the posterior lobe
- More advanced if lesion is stony hard and fixed
- It is confirmed by histologic exam of tissue removed by TURP, open
prostatectomy, or ultrasound-guided transrectal needle biopsy
- Fine needle biopsy is painless and quick method
- TRUS can help detect nonpalpable prostate cancers and
assists with staging of localized cancers
- Gleason score for tumor grading
- With each increase in the score, tumor is more aggressive
- 8-10 indicates a high-grade cancer
- Pelvic CT scan can determine if it has spread to lymph nodes
Medical Management
- Watchful waiting involved, actively monitoring the course of disease
and intervening only if cancer progresses or if symptoms warrant
other interventions
- Option for those with a life expectancy of less than 5 years
and low-risk cancers
- Therapeutic vaccines that kill existing cancer cells and provide long
lasting immunity against further cancer development
- sipuleucel-T for men with metastatic prostate cancer that no
longer respond to hormone therapy
- Abiraterone acetate and cabazitaxel is an option for those
requiring management of metastatic castration-resistant
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prostate cancer that does not respond to vaccine or usual
treatment
Surgical
- Radical prostatectomy is first line treatment for those with
the tumor confined to the prostate
- Complete removal of prostate, seminal vesicles, tips of vas
deferens, and often surrounding fat, nerves, and blood
vessels
- Sexual acitivity may be resumed in 6-8 weeks
- A vasectomy may be performed to prevent infection from
spreading from prostatic urethra through the vas and into
the epididymis
- Total prostatectomy has a risk for impotence
Radiation
- Teletherapy and brachytherapy
- External bean is prescribed for a total dose over a certain
time frame
- For those with low-risk prostate cancer
- Intermediate or high risk cancers receive high doses
- Pelvic lymph node irradiation and androgen deprivation
therapy: surgical or medical castration
- Intensity-modulated radiation therapy is one method of
delivery for external beam
- Sets a dose for the target volume and restricts the
dose to surrounding tissue
- Implantations of seeds under anesthesia
- Early, clinically organ-confined prostate cancer
- Places 80-100 seeds
- Avoid close contact with pregnant women and infants
for up to 2 months
- Strain urine for seeds that pass and use condom
during sexual intercours for 2 weeks after
implantation to catch any seeds
- They may experiences inflammation of the rectum, bowel,
and bladder due to proximity of these organs
Hormonal
- ADT is used to suppress androgenic stimuli to the prostate
decreasing level of circulating plasma testosterone or
interrupting the conversion to or binding of DHT
- Prostatic epithelium atrophies
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Accomplished by either surgical castration (removal of both
testes) or by medical castration with admin of meds such as
luteinizing hormone-releasing hormone agonists
- May be given the option for testicular prostheses to be
placed
- LHRH: leuprolide and goserelin
- Additional hormone medications such as
antiandrogens may need to be prescribed when
testosterone suppression is inadequate (should be less
than 50)
- Flutamide, bicalutamide, nilutamide
- This causes adrenal androgen suppression
- Both castrations can cause hot flushing
- Second line hormonal intervention: adrenal ablating drugs
- Ketoconazole
- Admin of this drug requires steroid supplementation
to prevent adrenal insufficiency
- Hypogonadism occurs: vasomotor flushing, loss of libido,
decreases bone density, anemia, fatigue, increased fat mass,
lipid alterations, decreased muscle mass, gynecomastia, and
mastodynia
- Chemotherapy
- Docetaxel-based regimen for non-androgen dependent
prostate cancer
- Others
- Cryosurgery: ablate prostate cancer with transperineal
probes inserted into the prostate to freeze tissue directly
- Repeated TURPs may be required to keep urethral passage
patent
- If impractical, catheter drainage is instituted
- Opioid and nonopioid meds are given to control bone pain
for metastases
- EBRT (external beam radiation therpy) can be
delivered to relieve pain
- Radiopharmaceuticals like strontium or samarium can be
injected IV to treat multiple sites of bone metastasis
Nursing Management
- At risk for imbalanced fluid volume because of irrigation of the
surgical site
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Urine output and amount of fluid used is closely monitored
to determine if fluid is being retained and to ensure adequate
urine output
- Monitored for hyponatremia, increasing BP, confusion, and
respiratory distress
Assisted to sit and dangle his legs over the side of the bed on the day
of surgery post-op
- Next morning assisted to ambulate
Those with bladder spasms may report urgency to void, feeling of
pressure or fullness in bladder, and bleeding from the urethra
around the catheter
- Flavoxate and oxybutynin can relax muscles to ease the
spasm
- Warm compresses to pubis or sitz bath can also provide
relief
Monitors drainage tubing and irrigates system as prescribed
- Catheter is irrigated with 50 ml of fluid at a time
- Make sure the same about of fluid is recovered
- Securing drainage to leg or abdomen can help decrease
tension and prevent bladder irritation
Prune juice and stool softeners are provided to ease bowel
movements
Drainage normally begins as a reddish pink and then
clears to a light pink within 24 hours
After TURP catheter must drain well
- Furosemid may be prescribed
- Observe lower abdomen so that catheter has not become
blocked
- A distinct, rounded swelling above the pubis is a
manifestation of an overdistended bladder
- Three way drainage system is useful in irrigation
- Any complaints of pain, the tubing is examined and then
irrigated with 50 ml of irrigating fluid if prescribed to clear
obstructions
Orchitis
- Acute, inflammatory response of one or both testes as a complication of
systemic infection or as an extension of an associated epididymitis caused
by bacterial, viral, spirochetal, or parasitic organisms
- SS: fever, pain, which may range from mild to severe, tenderness in one or
both testicles, bilateral or unilateral testicular swelling, penile discharge,
blood in the semen, leukocytosis
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Bacterial is treated with antibiotic agents and supportive therapy
If STI, partner needs to be treated
Viral is treated with supportive: rest, elevation of the scrotum, ice packs,
analgesics, and anti-inflammatory meds
- Bilateral may cause sterility in some
- Mumps vaccination is recommended for postpubertal men
- Orchitis may develop in postpubertal men with mumps 4-6 days
after parotitis starts
Testicular Torsion
- Surgical emergency requiring immediate diagnosis to avoid loss of the
testicle
- Rotation of the testis which twists the blood vessels in the spermatic cord
and impedes arterial and venous supply to the testicle and surrounding
structures
- Sudden pain in the testicle developing over 1-2 hours
- Nausea, lightheadedness, and swelling of the scrotum may develop
- Testicular tenderness, elevated testis, a thickened spermatic cord, and a
swollen, painful scrotum can be present
- If it cannot be reduced manually, surgery to untwist the spermatic cord
and anchor both testes in their correct position to prevent recurrence
should occur within 6 months of the onset of symptoms
- After 6 months, the risk of loss of the testicles increases
Testicular Cancer
- Classification
- Germinal: grow from germ cells that produce sperm
- Seminomas are slow growing forms of testicular cancer
- Usually localized in the testes
- Nonseminomas: made up of different cell types
- Nongerminal: can develop in supportive and hormone producing
tissues, or stroma of the testicles
- Secondary
- Lymphoma is most common cause of secondary
- Can spread from the prostate, lung, skin, kidney, and other
organs
- Risk factors
- Cryptorchidism (undescended testicle), family history, and personal
history of testicular cancer
- Caucasian american men are more likely
- Higher risk in HIV positive men
- Manifestations
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Appear gradually with a mass or lump on the testicle and are
usually a
- painless enlargement of the testis
- Enlargement without pain is a significant diagnostic finding
- May report heaviness in the scrotum, inguinal area, or lower
abdomen
- Backache, abdominal pain, weight loss, and general weakness may
result from metastasis
Assessment
- Educate on the need for urgent evaluation of any mass or
enlargement or unexplained testicular pain for early detection
- TSE education starting in adolescence
- Monthly
- Annual testicular examination by a clinician
- Tumor markers: alpha-fetoprotein (AFP) and beta-human
chorionic gonadotropin (beta-hCG) may be elevated in patients
with testicular cancer
- Microscopic analysis of tissue is only definitive way to determine if
cancer is present
- But is usually done at the time of surgery rather than
diagnostic
Medical Management
- Highly responsive to treatment
- Early stage disease is curable
- Primary treatment includes removal of the affected testis by
orchiectomy through an inguinal incision with a high ligation of the
spermatic cord
- They are offered implantation of a testicular prosthesis
during the orchiectomy
- No impairment of endocrine function occurs after unilateral
orchiectomy
- Decreased hormonal levels may suggest that the
unaffected testis is not functioning normally
- Retroperitoneal lymph node dissection may be performed
after orchiectomy to diagnosis and prevent lymphatic spread
of the cancer
- Sperm banking before treatment may be considered
- Radiation
- More effective with seminomas than with nonseminomas
- Only delivered to the affected side and the other testis is
shielded from radiation to preserve fertility
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Also used in those that do not respond to chemo or where
lymph node surgery is not recommended
- Chemo
- Can be used for seminomas, nonseminomas, and advanced
metastatic disease
- Cisplatin can be used in combination with other agents such
as etoposide, bleomycin, paclitaxel, ifosfamide, and
vinblastine
- Nonseminomas: aggressive surgical resection of masses
following chemo is standard
- Good results may also be obtained by combining different
treatments
- If no response to high-dose salvage chemo, cancer is nearly
incurable
- Nursing Management
- Educate on importance of adhering to follow-up appointments for
early detection of recurrence
- Performing TSE in the treated or remaining testis
- Recommend birth control for 18-24 months after the last cycle of
chemo as this is the period of time where sperm return to normal
Cancer of the Penis
- Risk factors: lack of circumcision, poor genital hygeine, phimosis, HPV,
smoking, ultraviolet light treatment, increasing age, lichen sclerosus
- Manifestations
- Penile lesion alerts the presence of penile cancer
- Painless lump, ulcer, or wart like growth on the skin
- Change in skin color like red rash, bluish growths, or whitish
patches
- Malodorous and persistent drainage in the late stages
- Assessment
- Thorough physical examination is necessary with assessment and
palpation of the penis and inguinal lymph nodes
- Incisional or excisional biopsy to determine cell types
- Prevention
- Avoid risk factors whenever possible
- Gardasil, a vaccine that protects against HPV vaccine
- Good genital hygiene
- Medical Management
- Complete excision with adequate margins
- Surgery is most common treatment
- Organ sparing surgical approaches are preferable
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Partial penectomy is preferred to total because they can still
participate in sexual intercourse, stand for urination, and maintain
cosmesis
Topical chemotherapy with 5-fluorouracil cream or biologic therapy
Radiation is used to treat small squamous cell carcinomas
Those that present with enlarged lymph nodes should undergo
treatment of primary lesion followed by 4-6 week course of oral
broad spectrum antibiotic
- Persistent enlarged lymph nodes after antibiotics should be
considered metastatic disease and treated with sentinel
lymph node biopsy