NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: NEUROMUSCULAR SYSTEM

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

HERNIATED/RUPTURED DISK (ruptured nucleus pulposus): strain or injury to a weakened cartilage between vertebrae can result in herniation of the nucleus, causing pressure on nerve roots in spinal canal, pain, and disability.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: pulpy substance of disk interior (nucleus pulposus) bulges or ruptures through the outer annulus fibrosus → irritation and pressure on nerve endings in the spinal ligaments → muscle spasm and distortion of the joints of vertebral arches.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Strain as result of poor body mechanics.
  • Trauma.
  • History of back injuries.
  • Degenerative disk (spondylosis).

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Lumbar injuries (90% of herniations):

a. Subjective data:

  • Pain: low back, radiating to buttocks, posterior thigh, and calf; relieved by recumbency; aggravated by sneezing, coughing, and flexion; sciatic pain continues even when back pain subsides.
  • Numbness, tingling.

b. Objective data:

  • Muscle weakness—leg and foot.
  • Inability to flex leg.
  • Sensory loss, leg and foot.
  • Alterations in posture: leans to side, unable to stand up straight.
  • Edema: leg and foot.
  • Positive Lasègue’s sign: straight leg raising with hip flexed and knee extended will produce sciatic pain.

2. Cervical injuries (10% of herniations):

a. Subjective data:

  • Pain—upper extremities, radiating to hands and fingers; aggravated by coughing, sneezing, and straining.
  • Tingling, burning sensation in upper extremities and back of neck.

b. Objective data:

  • Upper extremities: weakness and atrophy.
  • Neck: restricted movement.
  • Diagnostic tests for both lumbar and cervical injuries.

(a) Spine x-rays.
(b) CT scan.
(c) MRI.
(d) Myelography (less preferred than CT scan or MRI).
(e) Electromyography.
(f) Neurological examination: special attention to sensory status, including pain, touch, and temperature identification; and to motor status, including strength, gait, and reflexes.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Pain related to pressure on nerve roots.
  • Fear related to disease progression and/or potential surgery.
  • Knowledge deficit (learning need) related to correct body mechanics.
  • Impaired physical mobility related to continued pain.
  • Sleep pattern disturbance related to difficulty finding comfortable position.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Goal: relieve pain and promote comfort.

a. Bedrest with bedboard.

b. Position—avoid twisting.

  • Lumbar disk: William’s (head elevated 30 degrees, knee gatch elevated to flatten the lumbosacral curve). Can be duplicated at home with pillow placement.
  • Cervical: low Fowler’s.

c. Medications as ordered:

  • Analgesics.
  • Muscle relaxants.
  • Anti-inflammatory.
  • Stool softeners.

d. Moist heat.

e. Fracture bedpan.

f. Gradual increase in activity.

g. Brace application for support.

h. Traction application prn for comfort.

i. Prepare for surgery if medical regimen unsuccessful.

2. Goal: health teaching.

  • Correct body mechanics, keep back straight.
  • Exercise program as symptoms decrease.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Reports pain decreased.
  • Mobility increased, normal body posture attained.

Physiological Integrity: Nursing Care of the Adult Client

LAMINECTOMY: excision of dorsal arch of vertebrae with or without spinal fusion of two or more vertebrae with a bone graft from iliac crest, to stabilize spine.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Pain related to edema of surgical procedure.
  • Impaired physical mobility related to pain and discomfort resulting from surgery.

B. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Goal: relieve anxiety.

a. Answer questions, explain routines.

2. Goal: prevent injury postoperatively.

a. Monitor vital signs:

  • Neurological signs (e.g., check sensation and motor strength of limbs).
  • Respiratory status (risk for respiratory depression with cervical laminectomy).

b. Monitor I&O (urinary retention common, especially with cervical laminectomy); may need catheterization. Encourage fluids.

c. Monitor bowel sounds (paralytic ileus common with lumbar laminectomy).

d. Monitor dressing for possible bleeding.

e. Bed position as ordered:

  • For lumbar laminectomy: head of bed flat; supine with slight flexion of legs; with pillow between knees for turning and side-lying position.
  • For cervical laminectomy: head of bed elevated, neck immobilized with collar or sandbags.

f. Encourage deep breathing to prevent respiratory complications. Use of inspirometer q1h when awake.

g. Prevent strain or flexion at surgical site: logrolling with spinal fusion.

h. Some surgical interventions that require small incisions (microsurgery) have no specific postoperative positions.

3. Goal: promote comfort.

a. Administer analgesics if sciatic-type pain continues after lumbar surgery (arm pain after cervical surgery), due to edema from trauma of surgery.

4. Goal: prepare for early discharge.

a. Clients having microsurgery for repair of herniated disk will usually be discharged from the hospital 1 day postoperative; teaching regarding allowed and restricted activities must be done early.

5. Goal: health teaching.

a. How to turn and move from side to side in one motion, sit up, and get out of bed without twisting spine; to get out of bed: raise head of bed while in side-lying position, then put feet over edge of bed, and stand.

b. Proper positioning and ambulation techniques.

c. Correct posture, body mechanics, activities to prevent further injury; increase activities according to tolerance.

d. Referral: physiotherapy; encourage compliance for full rehabilitation.

C. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. No respiratory, bowel, or bladder complications noted.

a. Lung sounds clear.

b. Bowel sounds present; able to pass gas and feces.

c. Urinary output adequate.

2. Regains mobility.

3. Comfort level increases: reports leg and back pain decreased.

4. Demonstrates protective positioning and mbulation techniques.

Physiological Integrity: Nursing Care of the Adult Client: ONCOLOGICAL DISORDERS

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

THE CLIENT WITH CANCER: Cancer is a multisystem stressor. Regardless of the specific type of cancer, certain aspects of the disease and of nursing care are the same. The following principles apply universally and should be referred to when studying individual kinds of cancer.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: result of altered cellular mechanisms. Several theories about causation, but current thinking is multiple causation. Alterations result in a progressive, uncontrolled multiplication of cells, with selective ability to invade and metastasize.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Heredity (e.g., retinoblastoma).
  • Familial susceptibility (e.g., breast).
  • Acquired diseases (e.g., ulcerative colitis).
  • Virus (e.g., Burkitt’s lymphoma).
  • Environmental factors:

a. Tobacco.

b. Alcohol.

c. Radiation.

d. Occupational hazards.

e. Drugs (e.g., immunosuppressive, cytotoxic).

f. Asbestos.

  • Age.
  • Air pollution.
  • Diet (e.g., high animal protein).
  • Chronic irritation.
  • Precancerous lesions (e.g., gastric ulcers).
  • Stress.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Specific symptoms depend on the anatomical and functional characteristics of the organ or structure involved.

2. Mechanical effects:

  • Pressure—tumors growing in confined areas such as bone produce pain early, whereas tumors growing in expandable areas such as the abdomen may be undetected for some time.
  • Obstruction—tumors that compress tubular structures such as the esophagus, bronchi, or lymph channels may cause symptoms such as swallowing difficulties, shortness of breath, edema. Symptoms depend on location of tumor and on the particular organ or structure receiving pressure.
  • Interruptions of blood supply—compression of blood vessels or diversion of blood supply may cause necrosis or ulceration or may precipitate hemorrhage.

3. Systemic effects:

a. Anorexia, weakness, weight loss.

b.Metabolic disturbances—malabsorption syndrome.

c. Fluid and electrolyte imbalances.

d. Hormonal imbalances—increased antidiuretic hormone (ADH), adrenocorticotropic hormone (ACTH), thyrotropin (TSH), or parathyroid hormone (PTH).

e. Diagnostic tests:

  • Biopsy—excision of part of tumor mass.
  • Needle biopsy—aspiration of cells from subcutaneous masses or organs such as liver.
  • Exfoliative cytology—scraping of any endothelium (cervix, mucous membranes, skin) and applying to slide.
  • X-rays—detect tumor growth in GI, respiratory, and renal systems.
  • Endoscopy—visualization of body cavity through endoscope.
  • Computed tomography (CT)—visualization of a body part whereby layers of tissue can be seen utilizing the very narrow beams of this type of x-ray equipment.
  • Magnetic resonance imaging (MRI)—a scanning device using a magnetic field for visualization.
  • Positron emission tomography (PET)—a scanning device in which radioactive glucose is injected prior to scanning. Areas of high glucose uptake, such as rapidly dividing cancer cells, are dramatically displayed in the scan imagery; useful in detecting early cancers.

f. Laboratory data:

  • Blood and urine tests—refer to Appendix A for normal values.
  • Alkaline phosphatase—greatly increased in osteogenic carcinoma (>92 units/L).
  • Calcium—elevated in multiple myeloma bone metastases (>10.5 mg/dL).
  • Sodium—decreased in bronchogenic carcinoma (<135 mEq/L).
  • Potassium—decreased in extensive liver carcinoma (<3.5 mEq/L).
  • Serum gastrin—measures gastric secretions. Decreased in gastric carcinoma. Normal value 0 to 180 ng/L.
  • Neutrophilic leukocytosis—tumors.
  • Eosinophilic leukocytosis—brain tumors, Hodgkin’s disease.
  • Lymphocytosis—chronic lymphocytic anemia.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Pain related to diagnostic procedures, pressure, obstruction, interruption of blood supply, or potential side effects of drugs.

2. Anxiety related to fear of diagnosis or disease progression, treatment, and its known or expected side effects.

3. Altered nutrition, less than body requirements, related to anorexia.

4. Risk for injury related to radioactive contamination of excreta.

5. Body image disturbance related to loss of body parts, change in appearance as a result of therapy.

6. Powerlessness related to diagnosis and own perception of its meaning.

7. Self-esteem disturbance related to impact of cancer diagnosis.

8. Risk for infection related to immunosuppression from radiation and chemotherapy.

9. Altered urinary elimination related to dehydration.

10. Risk for injury related to normal tissue damage from radiation source.

11. Fluid volume deficit related to nausea and vomiting.

12. Diarrhea related to radiation of bowel.

13. Constipation related to dehydration.

E. Nursing care plan/implementationgeneral care of the client with cancer:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Goal: promote psychosocial comfort.

  • Assist with diagnostic work-up by providing psychological support and information about specific disease, diagnostic tests, diagnosis, and treatment options.
  • Reduce anxiety by listening, making referrals for special problems (peer support groups, self-help groups such as Reach to Recovery), supplying information, or correcting misinformation, as appropriate.
  • Stress-management techniques.
  • Nursing management related to client who is depressed.

2. Goal: minimize effects of complications.

a. Anorexia/anemia:

  • Decrease anemia by:

(a) Providing well-balanced, iron-rich, small, frequent meals.
(b) Administering supplemental vitamins and iron as ordered.
(c) Administering packed red blood cells as ordered.
(d) Maintaining hyperalimentation as ordered.
(e) Monitoring red blood cell count.

  • Enhance nutrition by providing nutritional supplements and a diet high in protein; necessary because of increased metabolism related to metastatic process. Consult with dietitian for suggestions of best food for individual client.

b. Hemorrhage: monitor platelet count and maintain platelet infusions as ordered. Teach client to monitor for any signs of bleeding.

c. Infection: observe for signs of sepsis (changes in vital signs, temperature of skin, mentation, urinary output or pain); monitor laboratory values (WBCs); administer antibiotics as ordered.

d. Pain and discomfort: alleviate by frequent position changes, diversions, conversations, guided imagery, relaxation, back rubs, and narcotics as ordered.

e. Assist in adjusting to altered body image by encouraging expression of fears and concerns. Do not ignore client’s questions, and give honest answers; be available.

f. Fatigue. Encourage periods of rest and a decrease in daily exertion.

3. Goal: general health teaching.

a. Self-care skills to maintain independence (e.g., client who has a colostomy should know how to manage the colostomy before going home).

b. Importance of follow-up care and routine physical examinations to monitor for general health and possible signs of further disease.

c. Dietary instructions, adjustments necessary to maintain nutrition during and after treatment.

d. Health maintenance programs: teach hazards of the use of tobacco and alcohol. Avoid high-fat, low-roughage diet.

e. Risk factors: family history, stress, age, diet, occupation, environment.

f. Access to information: clients should have telephone numbers for facility where questions can be answered and symptoms reported 24 hours a day.

F. General surgical intervention: surgery may be diagnostic, curative (when the lesion is localized or with minimal metastases to the lymph nodes), palliative (to decrease symptomatology), or reconstructive.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Nursing care plan/implementationpreoperative:

a. Goal: prevent respiratory complications.

  • Coughing and deep-breathing techniques.
  • No smoking for 1 week before surgery.

b. Goal: counteract nutritional deficiencies.

  • Diet:

(a) High protein, high carbohydrate for tissue repair.
(b) Vitamin and mineral supplements.
(c) Hyperalimentation as ordered.

  • Blood transfusions may be needed if counts are low.

c. Goal: reduce apprehension.

  • Clarify postoperative expectations.
  • Explain care of ostomies or tubes.
  • Answer client’s questions honestly.

2. Postoperative:

a. Goal: prevent complications.

  • Monitor respiratory status and hemodynamic status.
  • Wound care; active and passive exercises as allowed; respiratory hygiene; coughing, deep breathing, and turning; fluids.

b. Goal: alleviate pain and discomfort.

  • Encourage early ambulation, depending on surgical procedure.
  • Administer prescribed medications as needed.
  • Administer stool softeners and enemas as ordered.

c. Goal: health teaching.

  • Involve client, significant others, and family members in rehabilitation program.
  • Prepare for further therapies, such as radiation or chemotherapy.
  • Referral: support groups, as appropriate: Reach to Recovery, Ostomy Associates, Laryngectomy Association.
  • Develop skills to deal with disease progression if cure not realistic or metastasis evident.

G. Chemotherapy: used as single treatment or in combination with surgery and radiation, for early or advanced diseases. Used to cure, increase survival time, or decrease specific life-threatening complications. Antineoplastic agents’ primary mode of action involves interfering with the supply and utilization of building blocks of nucleic acids, as well as interfering with intact molecules of DNA or RNA, which are needed for replication and cell growth. Bone marrow, hair follicles, and the gastrointestinal tract are three areas of the body in which cells are actively dividing; this is why most side effects are related to these areas of the body. Most often antineoplastic agents are used in combination.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Types: alkylating agents, antimetabolites, antitumor antibiotics, antimiotic agents, plant alkaloids, enzymes, hormones, and biotherapy (e.g., bacille Calmette-Guérin [BCG], interferon).

2. Major problem: lacks specificity, thus affecting normal as well as malignant cells.

3. Major side effects: bone marrow depression, stomatitis, nausea and vomiting, gastrointestinal ulcerations, diarrhea, and alopecia.

4. Routes of administration: oral, intramuscular, intravenous (Hickman or Groshong catheter), subclavian lines, portacaths, peripheral, intraarterial (may have infusion pump for continuous or intermittent flow rate), intracavitary (e.g., bladder through cystoscopy).

5. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

a. Goal: assist with treatment of specific side effects.

  • Nausea and vomiting—antiemetic drugs (e.g., prochloroperazine, ondansetron [Zofran]) as ordered and scheduled; small, frequent, high-calorie, high-potassium, high-protein meals; chopped or blended foods for ease in swallowing; include milk and milk products when tolerated for increased calcium; carbonated drinks; frequent mouth care; antacid therapy as ordered; rest after meals; avoid food odors during preparation of meals; pleasant environment during meals; appropriate distractions; IV therapy; nasogastric tube for control of severe nausea or as route for tube feeding if unable to take food by mouth; hyperalimentation.
  • Diarrhea—low-residue diet; increased potassium; increased fluids; atropine SO4–diphenoxylate HCl (Lomotil) or kaolin-pectin (Kaopectate) as ordered; avoid hot or cold foods/liquids.
  • Stomatitis (painful mouth)—soft toothbrushes or sponges (toothettes); mouth care q2–q4; viscous lidocaine HCl (Xylocaine) as ordered before meals. Oral salt-and-soda mouth rinses; avoid commercial mouthwashes that contain high level of alcohol, which could be very irritating to mucous membranes. Avoid hot foods/liquids; include bland foods at cool temperatures; remove dentures if sores are under dentures; moisten lips with lubricant.
  • Skin care—monitor: wounds that do not heal, infections (client receives frequent sticks for blood tests and therapy); avoid sunlight; use sunblock, especially if receiving doxorubicin (Adriamycin).
  • Alopecia—be gentle when combing or lightly brushing hair; use wigs, nightcaps, scarves; provide frequent linen changes. Advise client to have hair cut short before treatment with drugs known to cause alopecia (bleomycin, cyclosphosphamide, dactinomycin, daunorubicin hydrochloride, doxorubicin hydrochloride, 5-fluorouracil, ICRF-159, hydroxyurea, methotrexate, mitomycin, VP 16–213, vincristine). Other techniques may be used, depending on client’s age and protocol in clinical agency.
  • Extravasation—infiltration of chemotherapeutic agents into surrounding tissues. Document and treat according to agency protocols for administered drug.

b. Goal: health teaching.

  • Orient client and family to purpose of proposed drug regimen and anticipated side effects.
  • Advise that frequent checks on hematological status will be necessary (client will receive frequent IV sticks, laboratory tests).
  • Advise client/family on increased risk for infection (avoid uncontrolled crowds and individuals with upper respiratory tract infections or childhood diseases).
  • Monitor injection site for signs of extravasation (infiltration); site must be changed if leakage suspected, and guidelines to neutralize must be followed according to drug protocol.

6. Nursing precautions with chemotherapy:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

a. Nurse should wear gloves and mask when preparing chemotherapy drugs for administration. Mixing of drug into IV bag done under laminar flow hood.

b. Drugs are toxic substances, and nurses must take every precaution to handle them with care.

c. When expelling air bubbles from syringes, care must be taken that the drugs are not sprayed into the atmosphere.

d. Contaminated needles and syringes should be disposed of intact (to prevent aerosol generation) in plastic-lined box according to environmental standards. Disposable equipment should be used whenever possible.

e. If skin becomes contaminated with a drug, wash under running water.

f. Nurses should know the half-life and excretion route of the drugs being administered and take the special precautions necessary. For example, while the drug is actively being excreted, use gloves when touching client, stool, urine, dressings, vomitus, etc.

g. If the nurse is in the early phase of pregnancy, she should seek specific information about risks to her unborn child before caring for the client receiving chemotherapeutic agents.

H. Radiation therapy: used in high doses to kill cancer cells, or palliatively for pain relief. Side effects of radiation therapy depend on site of therapy (side effects are also variable in each individual): nausea, vomiting, stomatitis, esophagitis (Candida), dry mouth, diarrhea, depression of bone marrow, suppression of immune response, decreased life span, and sterility.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. External radiation: cobalt or linear accelerator machine.

a. Procedure: daily treatments, Monday through Friday, for prescribed number of times according to size and location of tumor (length of treatment schedule is usually 4 to 6 weeks). Client remains alone in room during treatment. (Nurse, therapist, family members cannot stay in room with client due to radiation exposure during treatment.) Client instructed to lie still so exactly same area is irradiated each treatment. Marks (tattoos or via permanent-ink markers) are made on skin to delineate area of treatment; marks must not be removed during entire treatment course.

b. Nursing care plan/implementation:

  • Goal: prevent tissue breakdown.

(a) Do not wash off site identification marks (tattoos cannot be removed); dosage area is carefully calculated and must be exact for each treatment.
(b) Assess skin daily and teach client to do same (most radiation therapy is done on outpatient basis, so client needs skills to manage independently).
(c) Keep skin dry; cornstarch usually the only topical application allowed; 100% aloe (no alcohol) for redness.
(d) Contraindications:

(i) Talcum powders, due to potential radiation dosage alteration.
(ii) Lotions, due to increased moistening of skin.
(iii) Products containing alcohol, due to increased dryness.

(e) Reduce skin friction by avoiding constricting bedclothes or clothing, and by using electric shaver.
(f) Dress areas of skin breakdown with non-adherent dressing and paper tape.

  • Goal: decrease side effects of therapy.

(a) Provide meticulous oral hygiene.
(b) If diarrhea occurs, may need IV infusions, antidiarrheal medications; monitor bowel movements (possible adhesions from surgery and radiation treatments).
(c) Monitor vital signs, particularly respiratory function, and BP (sloughing of tissue puts client at risk for hemorrhage).
(d) Monitor hematological status—bone marrow depression can cause fatal toxicosis and sepsis.
(e) Institute reverse isolation as necessary to prevent infections (reverse isolation usually instituted if less than 50% neutrophils).

  • Goal: health teaching.

(a) Instruct client to avoid:

(i) Strong sunlight; must wear sunblock lotion, protective clothing over radiation site.
(ii) Extremes in temperature to the area (hot-water bottles, ice caps, spas).
(iii) Synthetic, nonporous clothes or tight constrictive clothing over area.
(iv) Eating 2 to 3 hours before treatment and 2 hours after, to decrease nausea; give small, frequent meals high in protein and carbohydrates and low in residue.
(v) Strong alcohol-based mouthwash; use daily salt-and-soda mouthwash.
(vi) Fatigue, an overwhelming problem. Need to pace themselves, nap; may need someone to drive them to therapy; can continue with usual activities as tolerated.
(vii) Crowds and persons with upper respiratory infections or any other infections.

(b) Provide appropriate birth control information for clients of childbearing age.

2. Internal radiation: sealed (radium, iridium, cesium):

a. Used for localized masses (e.g., mouth, cervix, breast, testes). Due to exposure from radiation source, precautions must be taken while it is in place. Health-care personnel and family must adhere to principles of time, distance, and shielding to decrease exposure (shortest amount of time possible, stay as far away as possible from the source of radiation, and wear protective lead apron, gloves). If source of radiation accidentally falls out, it should be picked up only with forceps. Radiation officer should be notified immediately. Client should be in private room, and bed should be in the center of the room, if possible, to protect others. Unless the walls are lead lined, radiation will penetrate them; placing the bed in center of room will decrease exposure. Once the source of radiation has been removed, there is no exposure from client, excretions, or linens.

b. Nursing care plan/implementation:

  • Goal: assist with cervical radium implantation (cervical radium is used here as the most common example of internal radiation source).

(a) Before insertion—give douche, enema, perineal prep; insert Foley catheter, as ordered.
(b) After implantation—check position of applicator q24h.

(i) Keep client on bedrest in flat position to avoid displacing applicator (may turn to side for eating).
(ii) Notify physician if temperature elevates, nausea and/or vomiting occur (indicates radiation reaction or infection).
(iii) After removal of implant (48 to 144 hours)—bathe, douche, and remove catheter as ordered.

  • Goal: health teaching.

(a) Explain that nursing care will be limited to essential activities in postinsertion period.
(b) Signs and symptoms of complications so client can notify staff if something unusual happens (bleeding, radiation source falls out, fever, etc.).

c. Nursing precautions for sealed internal radiation:

  • Never handle radium directly—if applicators should accidentally be removed, pick up applicator by strings with long-handled forceps and notify radiation officer.
  • Linen must remain in client’s room and not be sent to laundry until source of radiation has been accounted for and returned to its container.
  • Time, distance, and shielding are factors that increase or decrease potential effects on personnel. Need to minimize exposure of nursing staff, client’s family, and other health professionals. Nurses who may be pregnant should not care for clients with internal radiation because of possible damage to the fetus from radiation exposure. Children under 16 should not be allowed to visit while internal radiation is in use.

3. Internal radiation: unsealed (radioisotope/ radionuclide):

a. Source of radiation is given orally or intravenously or instilled into a cavity as a liquid.

b. Nursing care plan/implementation: Goal: reduce radiation exposure of others.

  • Isolate client and tag room with radioactivity symbol.
  • Rotate personnel to avoid overexposure (principles of time, distance, and shielding). Staff should use good hand-washing technique. Client should be in a room with running water. (Nurse who may be pregnant should not care for client while radiation source still active.)
  • Encourage family to maintain telephone contact or use intercom, to decrease exposure to others.
  • Plan independent diversional activities.

c. Specific nursing precautions (post in chart, on client’s door):

  • Radioactive iodine (131I): half-life 8.1 days; excreted in urine, saliva, perspiration, vomitus, feces.

(a) Wear gloves and isolation gowns when handling client, excreta, or dressings directly.                                                                                                             (b) Collect paper plates, eating utensils, dressings, and linen in impermeable bags; label and dispose according to agency protocol.
(c) Collect excreta in shielded container and send to laboratory daily to monitor excretion rate and disposal.

  • Radioactive phosphorus (32P): half-life 14 days; injected into cavity or given IV or orally.

(a) If injected into cavity, turn client q10–15 min for 2 hours to ensure distribution.
(b) No radiation hazard unless leakage from instillation site or from client’s excreta, which are collected in lead-lined containers and brought to the radioisotope laboratory for disposal. Linen is collected in container, marked radioactive, and brought to the radioisotope laboratory for special handling.
(c) Seepage will stain linens blue; wear gloves when handling contaminated linens, dressings. Excreta disposed of as in (b).

  • Radioactive gold (198Au): half-life 2.7 days; usually injected into pleural or abdominal cavity.

(a) May seep from instillation site or drainage tubes in cavity; stains purple.
(b)Turn client q15 min for 2 hours, as in (2)(a).
(c) Same precautions regarding handling excreta as in (1)(a) and (2)(b).

4. Precautions for nurses:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

a. Use principles of time, distance, and shielding when caring for clients who are having active radiation therapy treatments.

b. Nurses who may be pregnant should not accept an assignment caring for clients who have active radiation in place.

c. Always use gloves, gowns to protect skin and clothing.

d. Wear detection badge to determine exposure to energy source.

I. Immunotherapy: it has been hypothesized that clinical malignancy may occur as a result of failure of the immunological surveillance system of the body to fight off cancer cells as they develop. The goal of immunotherapy is to immunize clients against their own tumors.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Nonspecific immunotherapy—encourages a host immune response by use of an unrelated agent. Bacille Calmette-Guérin (BCG) vaccine and Corynebacterium parvum are the two agents used for this type of immunotherapy.

2. Specific immunotherapy—uses substances that are antigenically related to the tumor that stimulate a specific host immune response.

3. Side effects—malaise, chills, nausea, vomiting, diarrhea; local reaction at site of injection, such as pruritus, scabbing.

4. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

a. Goal: decrease discomfort associated with side effects of therapy.

  • Identify measures to lessen symptoms of side effects.
  • Know type of immunotherapy being used, adverse and desirable effects of therapy.
  • Administer fluids, encourage rest.
  • Administer acetaminophen as ordered to decrease flu-like symptoms.
  • Administer antiemetics as ordered for nausea.
  • Monitor for respiratory distress.
  • Administer analgesics as ordered for pain.

b. Goal: health teaching.

  • Comfort measures to decrease side effects of therapy.
  • Expected and side effects of therapy.
  • Investigational nature of therapy.
  • Care of site of administration.
  • Answer questions honestly.

J. Palliative care: when treatment has been ineffective in control of the disease, the nurse must plan palliative, terminal care. Cure is not possible for such clients in an advanced phase of malignancy. Symptoms increase in severity; clients and family have many special problems.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. General problems of clients with terminal cancer:

a. Cachexia: progressive weakness, wasting, and weight loss.

b. Anemia: leukopenia, thrombocytopenia, hemorrhage.

c. Gastrointestinal disturbances: anorexia, constipation.

d. Tissue breakdown leading to decubiti, seeping wounds.

e. Urine: retention, incontinence, renal calculi, tumor obstruction of ureters.

f. Hypercalcemia occurs in 10% to 30% of clients.

g. Pain due to: tumor growth, obstruction, vertebral compression, or secondary to complications (e.g., decubiti, stiffened joints, stomatitis). Also neuropathy, due to prolonged use of neurotoxic chemotherapeutic agents such as vincristine.

h. Fatigue: major and debilitating problem.

2. Nursing care plan/implementation:

a. Goal: make client as comfortable as possible; involve nursing staff, family, support personnel, clergy, volunteers, support groups. Hospice is very valuable program.

  • Nutrition: obtain nutritional consultation; high-calorie, high-protein diet; small, frequent meals; blenderized or strained; commercial nutritional supplements
    (Ensure, Vivonex, Sustacal).
  • Prevent tissue breakdown and vascular complications: frequent turning, massage, air mattress, active and passive ROM exercises.
  • GI tract disturbances: observe for toxic reactions to therapy, particularly vomiting and diarrhea; administer medications: antiemetics, antidiarrheal agents as ordered.
  • Relieve pain.

(a) Use supportive measures such as massage, relaxation techniques, guided imagery; and drugs for pain relief: administer codeine, fentanyl, aspirin–oxycodone HCl (Percodan), pentazocine (Talwin), morphine, methadone, as ordered.
(b) Methods of administration: oral, injected, rectal, analgesic patches, or pumps (IV or SQ).
(c) Monitor for side effects of narcotics: depressed respiratory status, constipation, anorexia.

b. Goal: assist client to maintain self-esteem and identity.

  • Encourage self-care.
  • Spend time with client; isolation is a great fear for the client who is dying.

c. Goal: assist client with psychological adjustment—see nursing care for clients who are grieving, clients who are dying.

K. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Tolerates treatment modality—complications of surgery are avoided or minimized; tolerates chemotherapy; completes radiation therapy.

2. Side effects of treatment are managed by effective nursing care and health teaching.

3. Maintains good nutritional status.

4. Uses effective coping mechanisms or seeks appropriate assistance to deal with psychosocial concerns.

5. Makes choices for follow-up care based on accurate information.

6. Finds methods to control pain and minimize discomfort.

7. Participates in decisions regarding continuation of therapy (living will, health-care proxy, do-not-resuscitate [DNR] decisions).

8. Dignity maintained until death and during dying.


Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: squamous cell carcinoma: undifferentiated, pleomorphic in appearance; accounts for 45% to 60% of all lung cancer; small cell (oat cell) carcinoma: small, dark cells located between cells of mucosal surfaces; characterized by early metastasis and poor prognosis; large cell (giant cell) carcinoma: located in the peripheral areas of the lung, has poor prognosis; adenocarcinoma: found in men and women; not necessarily related to smoking.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Heavy cigarette smoking, 20-year smoking history.

2. Exposure to certain industrial substances, such as asbestos.

3. Increased incidence in women during the last decade of life.

C. Assessment:

1. Subjective data:

a. Dyspnea.
b. Pain: on swallowing; dull and poorly localized chest pain, referred to shoulders.
c. Anorexia.
d. History of cigarette smoking over a period of years; recurrent respiratory infections with chills and fever, especially pneumonia or bronchitis.

2. Objective data:

a. Wheezing; dry to productive persistent cough; hemoptysis, hoarseness.
b. Weight loss.
c. Positive diagnosis: cytology report of cells from bronchoscopy.
d. Chest pain.
e. Signs of metastasis.

D. Analysis/nursing diagnosis:

1. Ineffective breathing pattern related to pain.

2. Impaired gas exchange related to tumor growth.

3. Pain related to disease progression.

4. Fear related to uncertain future.

5. Powerlessness related to inability to control symptoms.

6. Knowledge deficit (learning need) related to disease and treatment.

E. Nursing care plan/implementation:

1. Goal: make client aware of diagnosis and treatment options.

a. Allow time to talk and to discuss diagnosis.
b. Client makes informed decision regarding treatment.

2. Goal: prevent complications related to surgery for client who is diagnosed early and for whom surgery is an option: wedge or segmental resection, laser therapy, lobectomy, or pneumonectomy are usual procedures.

a. Nursing care plan/implementation for the client having thoracic surgery.
b. Monitor vital signs, including accurate respiratory assessment for respiratory congestion, blood loss, infection.
c. Assist client to deep breathe, cough, change position.

3. Goal: assist client to cope with alternative therapies when surgery is deemed not possible.

a. Radiation: megavoltage x-ray, cobalt—usual form of radiation.
b. Chemotherapy:

  • Cisplatin and VP-16 with irradiation has become standard form of induction chemotherapy. Cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), CCNU, methotrexate, vincristine sulfate (Oncovin) are the other drugs given for lung cancer.

4. Goal: health teaching.

a. Encourage client to stop smoking to offer best possible air exchange.
b. Encourage high-protein, high-calorie diet to counteract weight loss.
c. Force fluids, to liquefy secretions so they can be expectorated.
d. Encourage adequate rest and activity to prevent problems of immobility.
e. Desired effects and side effects of medications prescribed for therapy and pain relief.
f. Coping mechanisms for maximal comfort and advanced disease.

F. Evaluation/outcome criteria:

1. Copes with disease and treatment.

2. Side effects of treatment are minimized by proper nursing management.

3. Acid-base balance is maintained by careful management of respiratory problems.

4. Client is aware of the seriousness of the disease.





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