This area focuses on the nursing care of patients with problems such as fibroids; pyloric stenosis; cancer of the liver, prostate, breast, lung, and uterus; Wilms' tumor; leukemias; sarcomas; and lymphomas.

A. Theoretical framework - basis for care

1. Types of abnormal cellular growth

a. Problems resulting from benign abnormal cellular growth (for example: fibroids, gestational trophoblastic disease [hydatidiform mole], fibrocystic disease of the breast)

Uterine fiboids

Uterine fibroids, also called leiomyomas, are benign tumors of the uterine muscles. Frequently asymptomatic, symptoms appear in about half of women with leiomyomas, with onset usually around the 50 year old mark. With menopause, symptoms often end.

Hypermenorrhea, abnormal menstrual bleeding either excessive amount or longer duration, is the most common presentation. Associated resulting anemia symptoms of tiredness, lethargy and weakness occur.

With fibroids pressing on the bladder, increased urinary frequency may occur, as may urinary retention. Additionally, constipation, abdominal pain and back pain may occur.

Hydatidiform mole

A complete hydatidiform mole can develop into malignant choricarcinoma, a chorinepithelioma. Characterized by early metastasizing tendency, it can rapidly and widely metastasize to mot commonly the lung but also vagina, brain and CNS, liver, kidney, and spleen.

b. Problems resulting from hypertrophy (for example: pyloric stenosis, prostatic hypertrophy)

Pyloric Stenosis

In the previously healthy infant at four to six weeks age, pyloric stenosis is marked by the onset of unresolved projectile vomiting which may be accompanied by visible reverse peristaltic waves. This condition of vomiting after feeding leads to dehydration and weight loss.

Pyloric stenosis is benign hypertrophy of the pyloric sphincter reducing and preventing movement of food products from the stomach into the duodenum. It is much more common in boys than girls, and more common in white than black or oriental infants.

Benign Prostatic Hypertrophy (BPH)

One of the most common disorders affecting men, benign prostatic hypertrophy (BPH) occurs with aging. Incidence is to the degree that 50 % of men at age 50 have BPH to some degree. The prostrate enlargement results in occlusion of urinary outflow resulting in the symptoms of a lack of force in the urinary stream and decreased caliber of the stream.

Conservative interventions and techniques aimed at decreasing urinary retention, can significantly decrease symptoms. Bladder muscle tone can be lost if over distended quickly, leading to acute retention.

One needs to avoid taking to in a large fluid quantity, void whenever the urge exists ensuring not wait, and avoiding alcohol because of its diuretic effect in addition to the fluid. Alcohol intake is the main common factor leading to acute urinary retention.

Sits bath, a regular pattern of intercourse, and prostatic massage my relieve symptoms through releasing small amounts of prostatic fluid, resulting in decreased edema. Surgery is the definitive treatment for relieving urinary obstruction resulting from BPH, with transuretheral resection of the prostate (TURP) the most widely used of all prostrate surgeries.

c. Problems resulting from malignant abnormal cellular growth (for example: cancer of the skin, stomach, intestines, liver, prostate, breast, uterus, lungs, bladder: Wilms' tumor; neuroblastoma; leukemia; sarcomas; lymphomas)

Skin

Carcinoma - cancer growth of epithelia tissue

Melanoma - tumor arising from the deep skin layer pigment producing cells

The most common cause of nonmelanoma skin cancers (NMSC), especially squamous cell carcinoma, is the cumulative excessive exposure to the sun, in the form of ultraviolet radiation (UVR). Those working outdoors or enjoying excessive outdoor recreational activities are at increased risk. Exposure during the time that the sun rays are the most direct, between 11:00 A.M. and 3:00 P.M. there is additional increased risk. Other factors for risk include fair skin, blue or green eyes, blonde or red hair, sun induced freckles, inability to tan, actinic keratoses, and the genetic disorder xeroderma pigmentosa. Those who have had NMSC are again at increased risk. The other exposure risk factors include ionizing radiation and chronic exposure to carcinogens such as soot, tar, petroleum and creosote.

Sun exposure has a role in melanoma; however other risk factors are greater. Melanoma occurs most often in new or existing moles that are undergoing changes in appearance (changes in color, size, texture, or surface; drainage, oozing, bleeding, itchiness, tenderness, or pain; development of an irregular border). Abnormal moles can be identified in self examination through he pneumonic ABCD; asymmetry, border irregularity, color variegation, diameter greater than 6 mm.

Stomach Cancer

Several dietary factors increase the risk for stomach cancers; smoked or salted foods, aflatoxin contaminated foods (some grains or peanuts), and a low intake of fruits and vegetables. The helicobacter pylori that causes gastric ulcers is associated with stomach cancer, but the actual role is unclear. Rates for stomach cancer has declined. Males have a higher rate than females. African Americans have a higher rate, and it is still a major cause of death in Japan.

Pancreatic Cancers

The Whipple procedure (pancreaticoduodenectomy) involves the removal of the head of the pancreas, duodenum, gastric antrum, bile duct, and gall bladder. Most of the pancreatic cancers are located at the head of the pancreas and are ductal adenocarcinomas.

Rectal (Colorectal) Cancer

The two primary risk factors for colon and rectal (colorectal) cancer are being male and increasing age over 40. Inflammatory bowel disease, familial polyposis syndrome history, cigarette smoking, diet, and alcohol consumption are but a few other risk factors.

Colorectal cancer is usually asymptomatic when localized. Symptoms develop as the cancer progresses and compromises the colon and rectal structures. Symptoms include abdominal pain and cramping; change in bowel habits such as diarrhea, constipation, or narrowing of stool diameter; urgency to defecate with pain; unexplained weight loss; and symptoms of anemia such as paleness and fatigue form blood loss, usually occult. Early detection through a yearly digital rectal examination (DRE) beginning at age 40, and a yearly fecal occult blood testing (FOBT) at age 50 accompanied with a flexible sigmoidoscopy and thereafter every 3 to 5 years is recommended.

Prostrate Cancer

Primary malignant bone cancer is uncommon. Cancer metastases to bone from primary sites in other locations.

Testicular Cancer

The rate for testicular cancer is higher in the white male than for the black male. A major risk factor is history of a cryptorchid (undescended) testis, with risk increased the longer until performance of an orchiopexy, surgical decent of the cryptorchid testis. For the 15 to 40 year old group, the risk of testicular cancer is great resulting in the most common malignancy for this age group.

Monthly testicular self examination (TSE) is recommended from puberty through age 40. Performed after a warm bath or shower, each testicle is examined by both hands, using a gentle rolling motion, noting for lumps. The normal testis has a homogenous consistency and is freely movable, separate from the epididymis. Classically, the testicular tumor is non tender, with acute pain only presenting in about 10% of patients. Rarely, infertility is the presenting complaint; however, over 75% are oligospermic (sperm deficient) on presentation, questing the value of sperm banking prior to follow up therapy, especially given the rapid metastasis of this type of cancer. Spermatogenesis recover has a high rate after two to three years. Overall cure rate is 80% and approached 100% on early detection, with a 5% 30 year cumulative risk for developing cancer in the remaining testicle.

Breast Cancer

Women who perform regular breast self examination (BSE) find changes earlier than those who do not perform BSE regularly. Most lesions are self detectable, although only a minority perform regular and proficient BSE. Controversy continues to exist on the effectiveness of BSE.

Mammography

Cervical Cancer

For cervical cancer, the primary screening test is the Papanicolaou smear. The screening of asymptomatic women is an annual Pap smear and pelvic examination for all sexually active or over 18 years of age. The most common symptom causing women with cervical cancer to seek medical attention is abnormal vaginal bleeding, either increased length or amount of flow.

Papanicolaou smear is about 95% effective in diagnosing early cervical cancer, with an abnormal pap smear requiring further investigation through biopsy for histological study. The tissue biopsy is needed to diagnose the cervical cancer as being pre-invasive or invasive.

Endometrial (Uterine) Cancer

Endometrial or uterine cancer is the most common form of gynecological malignancy for those in the over 50 age group. This cancer is linked to decreased estrogen hormone production, with multiple risk factors, including most of the various gynecological abnormalities and life style risks. Prolonged, excessive, or irregular postmenopausal, and also premenopausal, bleeding is often the first presenting sign, and as a result should be assessed.

Although the Pap smear is up to 95% accurate in early detection of cervical cancer, it is only about 40% accurate for endometrial cancer; however, it should be continued after menopause. Endometrial tissue sampling is recommended fro asymptomatic high risk women.

To aid in cervical or uterine tissue biopsy, when abnormal lesions can not be identified, Schiller's iodine solution may be applied. Here the normal tissue takes up the stain and appears a darker brown colour. The glycogen depleted abnormal tissue does not absorb the stain, appearing lighter yellow. A hysteroscopy may be used to view and take the biopsy of the intrauterine cavity tissue with this type of endoscope.

Lung Cancer

Smoking is the leading cause of lung cancer, responsible for about 85% of the total, thus making this cancer mainly preventable. Other environmental causes are those like second hand smoke, air pollution, industrial exposures especially asbestos. The overall survival rate for lung cancer is low, with no long term survival difference with early screening methods.

Symptoms of lung cancer often mimic other respiratory problems and conditions, producing changes in respiratory patterns, persistent cough, sputum streaked with blood, and recurrent episodes of pleural effusion, pneumonia or bronchitis. To be detectable on chest x-ray films, the cancer tumor must have a diameter of at least 1 cm; however, metastasis has usually occurred by this point.

With non-small cell lung cancers, NSCLC, surgery is the primary treatment option; however, less than 25% of NSCLC at time of diagnosis do not have distant metastases and are only localized in the thoracic cavity. Small cell lung cancers, SCLC, respond well to chemotherapy and radiation because of the rapid growth rate for this type of cancer; however, this same rapid growth rate characteristic for this cancer produces metastatic spread.

Bladder Carcinoma

Found mainly on the lateral and posterior walls as well as the trigone, the triangular base of the bladder established by the openings of the two posterior ureteral openings and the one anterior urethral opening, bladder carcinoma is the most common of the urinary tract malignant tumors. Environmental carcinogenic agents that are identified include aniline dye, ß-naphthamine, 4-aminodiphenyl, and tobacco tar. Cigarette smoking produces a six fold higher incidence of bladder carcinoma.

Renal Cancer

For kidney, or renal, cancer the radical nephrectomy has proved to be the efficient, effective, conventional and principal surgical intervention.

Wilms' Tumor

Usually presenting as an asymptomatic one sided flank abdominal mass in an otherwise healthy child, Wilms' Tumor is a nephroblastoma diagnosed usually in life with the peak arround the three years of age range. Other presentations of vague abdominal pain, hematuria and fever occur, as does the problem of hypertension related to adrenal effects. Usual treatment is surgery, a heminephrectomy or total nephrectomy, of the effected kidney, and additional chemotherapy or radiation therapy depending on the stage of the tumor and distant metastasis, present 25% at time of diagnosis with lungs being the site of the metastasis. Survival rate is up to 90% depending upon the stage of the cancer. Antihypertensive agents may need to be continued after treatment.

Neuroblastomas

Arising from cells of the sympathetic nervous system, neuroblastomas occur most frequently as retropertoneum abdominal masses near the adrenal gland or spinal ganglia, although they may occur in other locations. Usually discovered as a palpable mass, other presentations may include general weight loss and anorexia, and if the tumor put pressure on the adrenal glands then excessive sweating, flushed face, and hypertension. Myosis or miosis (contraction of the pupil), slight ptosis (drooping eyelid) with enophthalmos, and anhidrosis (deficient sweating) associated with Horner's syndrome may be present if the tumor is located in the cervical or thoracic ganglia. Treatment varies depending upon the stage, with intensive and aggressive surgical, chemotherapy and radiation has improved the survival rate for Stage III to above 70%.

Leukemia

Both children with acute lymphocytic leukemia (ALL) and acute myelogenous leukemia present with the same symptoms resulting from bone marrow depression which includes a low grade fever, pain, bleeding, petechiae, purpura, fatigue, anemia, pallor, recurrent upper respiratory infections, and lymphadenopathy. ALL accounts for one third of the leukemia in children with AML about 20%, with the remaining being other types. Leukemia is the uncontrolled over proliferation of white blood cells with the symptoms resulting from these cells crowding the bone marrow limiting the production of red blood cells (RBCs) and platelets. In ALL the malignant cell is the lymphoblast, an immature lymphocyte; and in AML, the granulocyte.

As a result of the decreased levels of functioning white blood cells and the immunosuppressive drugs used, children undergoing chemotherapy for leukemia are at high risk for infection. Reverse isolation, or reverse barrier precautions or technique, protects the patient form pathogens. The object is to prevent exposure of the patient to pathogens. Those with obvious respiratory infections are prevented from patient contact, and all others will gown, and mask and glove as required. Isolation of the patient is required to prevent casual contact, but also a separate clean air supply to the room may be needed. Leukocyte transfusion, and prophylactic antibiotics may be used.

Sarcoma

Sarcoma, the suffix oma to the root sarc (flesh), designate a tumor of collective tissue origin, such as bone, and cartilage. The prefix osteo for bone is added for osteosarcoma, and the prefix chondro for cartilage is added for chondrosarcoma.

Radical surgery, combined with radiation or chemotherapy, is the common treatment for primary osteosarcoma. For chondrosarcoma surgical excision is preferred, but because of recurrence, amputation is considered.

Multiple Myeloma

A rare malignancy, multiple myeloma is a neoplastic condition of plasma cells that occurs over 40 years of age, with an average of 60, with a 14 times greater incidence in blacks than whites. The overproduction of plasma cells results in decreased production of RBCs, leukocytes and platelets. This produces the main symptoms of anemia, infections and bleeding tendencies. There is a long presymptomatic period of five to twenty years during which diagnosis can be made; however, most are diagnosed during the asymptomatic period through randomness of the increased serum protein level. Bence-Jones urine protein levels, the first known tumor marker, is one laboratory test used in diagnosis.

Lymphadenopathy (Hodgkin's & Non-Hodgkin's Disease)

Hodgkin's disease, named after the physician who first described this progressive lymphadenopathy, presents with painless enlarged lymph nodes (often cervical), fever, night sweats, weight loss, pruritus (itching), and post alcohol ingestion induced pain over involved nodes. Affecting young adults, incidence increases during adolescence occurrence and peaks mainly between the ages of twenty to forty, with more men than women affected, with boys five times greater than girls. Additionally, a second peak occurs between the years 60 to 70. Differentiation between Hodgkin's and Non-Hodgkin's disease is through the identification of Reed-Sternberg cells (giant, multinucleated, transformed lymphocytes that are probably nonfunctioning monocyte-macrophages).

Aplastic Anemia

2. Clinical manifestations of abnormal cellular growth

a. Alteration in size

b. Alteration in rate of growth

c. Altered function of involved cells

d. Local and systemic effects resulting form altered size, altered rate of growth, and altered function of involved cells (for example: metastasis, pressure on vital organs, pain)

e. Behavioral changes (for example: confusion, slurred speech, altered mentation)

3. Factors influencing the patient's response to abnormal cellular growth

a. Age and physiological factors

Cancer incidence increases with age, with currently greater than half the cancer diagnosis made after age 65. More males develop cancer than females, although rates for lung cancer are increasing in females due to prevalence of cigarette smoking. Overall black males have the highest incidence of cancer; however, white females have a higher incidence rate than black females. Race variations within the different forms of cancer also exists.

b. Psychological factors

c. Socioeconomic and cultural factors (for example: lifestyle, family history, occupation, health practices)

Although cancer incident rates and types varies between countries, many of these variations are due to specific factors like diet producing the high incidence of stomach cancer in Japan. Sunlight exposure, both a physical and cultural element, in Australia produces high skin cancer rates. Air pollution produces a higher urban cancer rate than for the rural population.

Sexual Activity

There is associated cancer risks with various sexual activity. Females that have coitus early, either in marriage or otherwise, have an increased risk for cervical cancer. Other factors that increase risk are multiple sexual partners, and sexually transmitted disease (STD) history. STDs in general but also specific viruses increase risk especially herpes simplex virus (HSV) and human papillomavirus (HPV).

A male partner with penile HPV (genital wart or condyloma accumulation) increases the risk for cervical cancer in the female. Increase cervical cancer is also associated with the male partner being uncircumcised.

Penile cancer, although rare, almost never occurs in the circumcised male. This rare skin cancer is found in older uncircumcised male with cronic irritation or poor hygiene practices, including STD history. First presenting as a dry, wart like, painless penile growth many males fail to address the problem and as a result the cancer has developed to include both the foreskin and penile shaft with metastasis before medical attention is obtained thus requiring penile shaft resection, or amputation. At early diagnosis, only excision and circumcision may be needed.

First pregnancy at a later age over thirty, or no history of pregnancy, is associated with increased breast cancer rates. Early, before age 20< first pregnancy is associated with lower rates. Breastfeeding, associated with the decreased ovulation until cessation of breastfeeding, reduces the risk for breast cancer.

d. Nutritional status

e. Presence of other illness

f. Site of abnormal cell growth (for example: local vs. distant)

g. Degree of involvement (for example: benign vs. malignant, acute vs. chronic)

4. Theoretical basis for interventions related to abnormal cellular growth

a. Medications (for example: antineoplastic agents, steroids, analgesics, hormonal therapy)

b. Other treatment modalities (for example: chemotherapy, radiation therapy, surgical intervention, immunotherapy, bone marrow transplant)

c. Preoperative and postoperative care (for example: laryngectomy, mastectomy, prostatectomy, colostomy, ileal conduit)

d. Health instruction (for example: risk factors, warning signs, prevention, breast self-examination, testicular self-examination)

B. Nursing care related to theoretical framework

1. Assessment - gather and synthesize data about the patient's health status in relation to the patient's functional health patterns

a. Gather assessment data

1) Obtain the patient's health history (for example: subjective symptoms, diet, medications, health habits, family history, allergies, occupation)

2) Assess factors influencing the patient's response to abnormal cell growth (for example: weight loss, occupation, [seeIIA3])

3)Obtain objective data related to the patient's abnormal cellular growth (for example: determine clinical manifestations, weight changes, presence of mass, abdominal distention)

4) Review laboratory and other diagnostic data (for example: biopsy, scan, blood studies, vital signs, complete blood count [CBC], uric acid, calcium, acid phosphatase, prostate-specific antigen [PSA], magnetic resonance imaging [MRI])

b. Synthesize assessment data (see IIB1a[1-4])

2. Analysis - identify the nursing diagnosis (patient problem) and determine the expected outcomes (goals) of patient care

a. Identify the psychological and physiological ramifications of treatment modalities on the patient and family (for example: consider the effects of alopecia, stomatitis, osteoporosis, erythema, bone marrow depression, pancytopenia, nausea and vomiting, bone marrow transplant, depressed mood, body image)

b. Identify actual or potential nursing diagnoses (for example: impaired oral mucous membranes related to immunosuppression secondary to chemotherapy; altered nutrition: less than body requirements related to difficulty swallowing; ineffective individual coping related to denial secondary to diagnosis of cancer)

c. Set priorities (for example: based on Maslow's hierarchy of needs, based on the patient's developmental level)

d. Establish expected outcomes (patient-centered goals) of nursing care (for example: patient will state coping mechanisms to be utilized, patient's mouth will be free of ulcers)

3. Planning - formulate specific strategies to achieve the expected outcomes

a. Consider factors influencing the patient's response to abnormal cell growth and involve the patient's family in planning individualized patient care (for example: consider role changes, sexuality, changes in body image, changes in lifestyle)

b. Plan nursing measures on the basis of established priorities to help the patient achieve the expected outcomes (for example: provide a low-residue diet for a patient receiving radiation therapy, provide a mechanically soft diet for the patient with stomatitis, provide play therapy for a child with leukemia)

4. Implementation - carry out nursing plans designed to move the patient toward the expected outcomes

a. Provide instruction in the prevention and detection of abnormal cellular growth (for example: instruct patients concerning breast and testicular self-examination, the seven danger signals of cancer, carcinogenic factors, screening and diagnostic testing, preventive dietary measures)

b. Use nursing measures to provide patient comfort (for example: imaging, meditation, medications, patient-controlled analgesia [PCA], intraspinal analgesics, positioning, mouth care, skin care)

c. Use nursing measures to promote optimal nutrition (for example: offer small frequent feedings, continuous enteral feedings, total parenteral nutrition [TPN])

d. Use nursing measures to promote elimination (for example: manage altered elimination routes such as ileo-conduit or colostomy, instruct the patient regarding self-care, monitor urinary drainage in a patient following a transurethral prostatectomy)

e. Use nursing measures to promote safety (for example: prevention of infection and hemorrhage; minimize side effects of treatment modalities by providing skin care, mouth care, and protective isolation)

f. Use nursing measures to provide spiritual and emotional support

g. Use nursing measures specific to prescribed medications (for example: monitor platelet count with antineoplastic agents, monitor fluid balance for a patient receiving steroids, monitor for side effects of medications)

h. Use nursing measures to provide information and instruction (for example: provide referrals to self-help groups, reinforce patient's knowledge about prosthetic devices, emphasize conception control for a patient following removal of a gestational trophoblastic neoplasm [hydatidiform mole])

5. Evaluation - appraise the effectiveness of the nursing interventions relative to the nursing diagnosis and the expected outcomes

a. Assess and report the patient's response to nursing actions (for example: record daily weight for a patient on total parenteral nutrition, report skin breakdown for a patient undergoing radiation therapy, chart intake and output for an infant with pyloric stenosis)

b. Revise the plan of care (for example: increase fluid intake when hematuria is noted in a patient on chemotherapy)