NCLEX: Physiological Integrity: Nursing Care of the Adult Client

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


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

A. Risk factors:

1. Men, middle age, personal or family history of colon and rectal cancer, personal or family history of polyps in the rectum or colon, ulcerative colitis.

2. Diet high in beef and low in fiber.

3. Gardner’s syndrome (multiple colonic adenomatous polyps, osteomas of the mandible or skull, multiple epidermoid cysts, or soft tissue tumors of the skin).

B. Assessment:

1. Subjective data:

a. Change in bowel habits.
b. Anorexia.
c. Weakness.
d. Abdominal cramping or vague discomfort with or without pain.
e. Chills.

2. Objective data:

a. Diarrhea (pencil-like or ribbon-shaped feces) or constipation.
b. Weight loss.
c. Rectal bleeding; anemia.
d. Fever.
e. Digital examination reveals palpable mass if lesion is in ascending or descending colon.
f. Signs of intestinal obstruction: constipation, distention, pain, vomiting, fecal oozing.
g. Diagnostic tests:

  • Digital examination.
  • Slides of stool specimen, for occult blood.
  • Proctoscopy.
  • Sigmoidoscopy, colonoscopy.
  • Barium enema.

h. Laboratory data: occult blood, blood serotonin increased, carcinoembryonic antigen (CEA); positive radioimmunoassay of serum or plasma indicates presence of carcinoma or adenocarcinoma of colon; positive result after resection indicates return of tumor.

C. Analysis/nursing diagnosis:

1. Constipation or diarrhea related to presence of mass.

2. Altered health maintenance related to care of stoma.

3. Sexual dysfunction related to possible nerve damage during radical surgery.

4. Body image disturbance related to colostomy.

D. Nursing care plan/implementation.

1. Radiation: to reduce tumor or for palliation.

2. Chemotherapy: to reduce tumor mass and metastatic lesions.

a. Antitumor antibiotics—mitomycin C, doxorubicin HCl (Adriamycin).
b. Alkylating agents—methyl-CCNU.
c. Antimetabolites—5-fluorouracil (5-FU).
d. Steroids and analgesics for symptomatic relief.

3. Prepare client for surgery (colostomy) if necessary.

E. Evaluation/outcome criteria:

1. Return of peristalsis and formed stool following resection and anastomosis.

2. Adjusts to alteration in bowel elimination route following abdominoperineal resection (e.g., no depression, resumes lifestyle).

3. Demonstrates self-care skills with colostomy.

4. Makes dietary adjustments that affect elimination as indicated.

5. Identifies alternative methods of expressing sexuality, if needed.


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

A. Risk factors:

1. Women older than age 50.

2. Family history of breast cancer.

3. Never bore children, or bore first child after age 30.

4. Had breast cancer in other breast.

5. Menarche before age 11.

6. Menopause after age 50.

7. Exposure to endogenous estrogens.

8. Exposure to ionizing radiation.

9. High alcohol and fat intake may increase risk.

B. Assessment:

1. Subjective data:

a. Burning, itching of nipple.
b. Reported painless lump.

2. Objective data:

a. Firm, nontender lump or mass.
b. Asymmetry of breast.
c. Nipple—retraction, discharge.
d. Alteration in breast skin—redness, dimpling, ulceration.
e. Palpation reveals lump.
f. Diagnostic tests: mammography, needle biopsy, core biopsy, excisional biopsy—level of estrogen-receptor protein predicts response to hormonal manipulation of metastatic disease and may represent a prognostic indicator for primary cancer; carcinoembryonic antigen (CEA) useful with metastatic disease of the breast.

C. Analysis/nursing diagnosis:

1. Risk for injury related to surgical intervention.

2. Body image disturbance related to effects of surgery, radiation, or chemotherapy.

3. Altered sexuality patterns related to loss of breast.

D. Nursing care plan/implementation.

1. Goal: assist through treatment protocol.

a. Radiation—primary treatment modality; adjunctive, external, or implantation to primary lesion site or nodes.                                                                                    b. Chemotherapy usually given in combinations.

  • Cytotoxic agents to destroy tumor and control metastasis.
  • Alkylating agents: cyclophosphamide (Cytoxan).
  • Antitumor antibiotics: doxorubicin (Adriamycin).
  • Antimetabolites: fluorouracil (5-FU); methotrexate (Amethopterine, MTX).
  • Plant alkaloids: vincristine sulfate (Oncovin).
  • Hormones to control metastasis, provide palliation: androgens, fluoxymesterone (Halotestin), testosterone (Teslac), diethylstilbesterol (estrogen).
  • Antiestrogens: tamoxifen (Nolvadex) may be used after initial treatment.
  • Cortisols: cortisone, prednisolone (Delta-Cortef), prednisolone acetate (Meticortelone), prednisone (Deltasone, Deltra).

c. Surgery.

  • Preoperative:

(a) Goal: prepare for surgery—types:

(i) Lumpectomy (with or without radiation)—used when lesion is small; section of breast is removed with clear margin around lesion (often accompanied by radiation therapy and then radium interstitial implant).
(ii) Simple mastectomy—breast removed, no alteration in nodes.
(iii) Modified radical mastectomy— breast, some axillary nodes, subcutaneous tissue removed; pectoralis minor muscle removed.
(iv) Radical mastectomy—breast, axillary nodes, and pectoralis major and minor muscles removed.
(v) Reconstructive surgery—done at time of initial mastectomy or (most often) later, when other adjuvant therapy has been completed.

(b) Goal: promote comfort.

(i) Allow client and family to express fears, feelings.
(ii) Provide correct information about diagnostic tests, operative procedure, postoperative expectations.
(iii) Client may be hospitalized for 24 hours or less. Have telephone number available for questions. Make appropriate community referrals.

  • Postoperative:

(a) Goal: facilitate healing.

(i) Observe pressure dressings for bleeding; will appear under axilla and toward the back.
(ii) Report if dressing becomes saturated; reinforce dressing as need; monitor drainage from Hemovac or suction pump.
(iii) Position: semi-Fowler’s to facilitate venous and lymphatic drainage; use pillows to elevate affected arm above right atrium, to prevent edema if nodes removed.

(b) Goal: prevent complications.

(i) Monitor vital signs for shock.
(ii) Use gloves when emptying drainage.
(iii) Maintain joint mobility—flexion and extension of fingers, elbow, shoulder.
(iv) ROM as ordered to prevent ankylosis.
(v) If skin graft done, check donor site and limit exercises.

(c) Goal: facilitate rehabilitation.

(i) Encourage client, significant others, and family to look at incision.
(ii) Involve client in incisional care, as tolerated.
(iii) Refer to Reach to Recovery program of the American Cancer Society
(iv) Exercise program, hydrotherapy for clients who are postmastectomy, to reduce lymphedema.

(d) Goal: health teaching.

(i) How to avoid injury to affected area; how to prevent lymphedema.
(ii) Exercises to gain full ROM.
(iii) Availability of prosthesis, reconstructive surgery.
(iv) Correct breast self-examination (BSE) technique (client is at risk for breast cancer in remaining breast) (Breast self-examination). Best time for
examination: women who are premenopausal, seventh day of cycle; women who are postmenopausal, same day each month.

E. Evaluation/outcome criteria:

1. Identifies feelings regarding loss.

2. Demonstrates postmastectomy exercises.

3. Gives rationale for avoiding fatigue and avoiding constricting garments on affected arm; necessity for avoiding injury (cuts, bruises, burns) while carrying out activities of daily living.

Physiological Integrity: Nursing Care of the Adult Client

4. Describes signs and symptoms of infection.

5. Demonstrates correct BSE technique.

UTERINE CANCER (endometrial): originates from epithelial tissues of the endometrium; second only to cervical cancer as cause of pelvic cancer. Slow growing;
metastasizes late; responsive to therapy with early diagnosis; Papanicolaou (Pap) test not as effective— more effective to have endometrial tissue sample (Papanicolaou (Pap) Smear Classes and Uterine Cancer: Recommended Treatment, by Stage of Invasion). International System of Staging for Cervical Carcinoma discusses cervical cancer.

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

A. Risk factors:

1. History of infertility (nulliparity).

2. Failure of ovulation.

3. Prolonged estrogen therapy.

4. Obesity.

5. Menopause after age 52.

6. Diabetes.

B. Assessment:

1. Subjective data:

a. History of risk factor(s).
b. Pain (late symptom).

2. Objective data:

a. Obese.
b. Abnormal cells obtained from aspiration of endocervix or endometrial washings.
c. Postmenopausal uterine bleeding.
d. Abnormal menses; intermenstrual or unusual discharge.

C. Analysis/nursing diagnosis:

1. Pain related to surgery.

2. Risk for injury related to surgery.

3. Body image disturbance related to loss of uterus.

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

D. Nursing care plan/implementation.

1. Goal: assist client through treatment protocol.

a. Radiation—external, internal, or both with client who is a poor surgical risk.
b. Chemotherapy—to reduce tumors and produce remission of metastasis. Antineoplastic drugs: dacarbazine (DTIC), doxorubicin (Adriamycin), medroxyprogesterone acetate (Provera), megestrol acetate (Megace).

2. Goal: prepare client for surgery—types:

a. Subtotal hysterectomy: removal of the uterus; cervical stump remains.
b. Total hysterectomy: removal of entire uterus, including cervix (abdominally [approximately 70%] or vaginally).
c. Total hysterectomy with bilateral salpingooophorectomy: removal of entire uterus, fallopian tubes, and ovaries.

3. Goal: reduce anxiety and depression: allow for expression of feelings, concerns about femininity, role, relationships.

4. Goal: prevent postoperative complications.

a. Catheter care—temporary bladder atony may be present as a result of edema or nerve trauma, especially when vaginal approach is used.
b. Observe for abdominal distention and hemorrhage:

  • Auscultate for bowel sounds.
  • Measure abdominal girth.
  • Use rectal tube to decrease flatus.

c. Decrease pelvic congestion and prevent venous stasis.

  • Avoid high Fowler’s position.
  • Antiembolic stockings as ordered.
  • Institute passive leg exercises.
  • Apply abdominal support as ordered.
  • Encourage early ambulation.

5. Goal: support coping mechanisms to prevent psychosocial response of depression: allow for verbalization of feelings.

6. Goal: health teaching to prevent complications of hemorrhage, infection, thromboemboli.

a. Avoid:

  • Douching or coitus until advised by physician.
  • Strenuous activity and work for 2 months.
  • Sitting for long time and wearing constrictive clothing, which tend to increase pelvic congestion.

b. Explain hormonal replacement if applicable; correct dosage, desired and side effects of prescribed medications.
c. Explain:

  • Menstruation will no longer occur.
  • Importance of reporting symptoms (e.g., fever, increased or bloody vaginal discharge, and hot flashes).

E. Evaluation/outcome criteria:

1. Adjusts to altered body image.

2. No complications—hemorrhage, shock, infection, thrombophlebitis.

PROSTATE CANCER: malignant neoplasm, usually adenocarcinoma; most common cause of cancer in men.

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

A. Risk factors:

1. Men older than age 50.

2. Familial history.

3. Geographic distribution, environmental (e.g., industrial exposure to cadmium).

4. Hormonal factors (testosterone).

5. Diet (high fat).

B. Assessment:

1. Subjective data:

a. Difficulty in starting urinary stream (hesitancy); urgency.
b. Pain due to metastasis in lower back, hip, legs; perianal or rectal discomfort.
c. Symptoms of cystitis; frequency, urgency.

2. Objective data:

a. Urinary: smaller, less forceful stream; terminal dribbling; frequency, nocturia; retention (inability to void after ingestion of alcohol or exposure to cold).
b. Diagnostic tests: digital rectal examination (DRE); transrectal ultrasonography (TRUS). Needle biopsy or tissue specimen reveals positive cancer cells.
c. Laboratory data: increased:

  • Prostate-specific antigen (PSA)—over 4 ng/mL.
  • Urine RBCs (hematuria).
  • Gleason score for prostate cancer grading system (range: 2 to 10).

C. Analysis/nursing diagnosis:

1. Altered urinary elimination related to incontinence.

2. Altered sexuality pattern related to nerve damage and erectile dysfunction.

3. Anxiety related to diagnosis.

4. Pain related to metastasis to bone.

D. Nursing care plan/implementation.

1. Goal: assist client through decisions about treatment protocol (varies by stage: 0 to IV).

a. Radiation—alone or in conjunction with surgery. Types: external beam radiation, 3-D conformal (focal), radioactive seed implants (brachytherapy).
b. Surgery—cryosurgery; radical retropubic prostatectomy.
c. Other options: hormones (luteinizing hormone–releasing hormone agonists [Lupron, Zoladex, Casodex, Nilandron]), antiandrogen (flutamide [Eulexin]); drugs in conjunction with orchiectomy, to limit production of androgens (androgen deprivation therapy).
d. Watchful waiting—recommended with small contained tumor; older men; where surgery is contraindicated for other serious health problems.


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

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

BLADDER CANCER: bladder is most common site of urinary tract cancer.

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

A. Risk factors:

  • Contact with certain dyes.
  • Cigarette smoking.
  • Excessive coffee intake.
  • Prolonged use of analgesics with phenacetin.
  • Three times more common in men.

B. Assessment:

1. Subjective data:

  • Frequency, urgency.
  • Pain: flank, pelvic; dysuria.

2. Objective data:

  • Painless hematuria (initially).
  • Diagnostic tests:
    (1)Cystoscopy, intravenous pyelogram (IVP)—mass or obstruction.
    (2)Bladder biopsy, urine cytology—malignant cells.
  • Laboratory data: urinalysis—increased RBCs (>4.8 × 1012/L—men, >4.3 × 1012/L— women).

C. Analysis/nursing diagnosis:

  • Risk for injury related to surgical intervention.
  • Altered urinary elimination related to surgery.

D. Nursing care plan/implementation (see also Nursing care plan/implementation—general care of the client with cancer,:

1. Goal: assist client through treatment protocol.

  • Radiation: cobalt, radioisotopes, radon seeds; often before surgery to slow tumor growth.
  • Chemotherapy:
    (1)Antitumor antibiotics: doxorubicin HCl (Adriamycin), mitomycin.
    (2)Antimetabolites: 5-fluorouracil (5-FU).
    (3) Alkylating agents: thiotepa.
    (4) Sedatives, antispasmodics.

2. Goal: prepare client for surgery—types:

  • Transurethral fulguration or excision: used for small tumors with minimal tissue involvement.
  • Segmental resection: up to half the bladder may be resected.
  • Cystectomy with urinary diversion: complete removal of the bladder; performed when disease appears curable.

3. Goal: assist with acceptance of diagnosis and treatment.

4. Goal: prevent complication during postoperative period.

  • Transurethral fulguration or excision:
    (1)Monitor for clots, bleeding, spasms.
    (2)Maintain patency of Foley catheter.
  • Urinary diversion with stoma:
    (1)Protect skin, ensure proper fit of appliance—because constantly wet with urine (see also Ileal conduit.
    (2)Prevent infection by increasing acidity of urine and increasing fluid intake.
    (3)Health teaching.
    (a) Self-care of stoma and appliance.
    (b)Expected and side effects of medications.
    (c) Importance of follow-up visits for early detection of metastasis.

E. Evaluation/outcome criteria:

  • Accepts treatment plan.
  • Uses prescribed measures to decrease side effects of surgery, radiation, chemotherapy.
  • Plans follow-up visits for further evaluation.
  • Maintains dignity.


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

A. Risk factors:

  • Eight times more common in men.
  • Occurs most often after age 60.
  • Cigarette smoking.
  • Alcohol.
  • Chronic laryngitis, vocal abuse.
  • Family predisposition to cancer.

B. Assessment:

1. Subjective data:

  • Dysphagia—pain in areas of Adam’s apple; radiates to ear.
  • Dyspnea.

2. Objective data:

  • Persistent hoarseness.
  • Cough and hemoptysis.
  • Enlarged cervical nodes.
  • General debility and weight loss.
  • Foul breath.
  • Diagnosis made by history, laryngoscopy with biopsy and microscopic study of cells.

C. Analysis/nursing diagnosis:

  • Impaired verbal communication related to removal of larynx.
  • Body image disturbance related to radical surgery.
  • Ineffective airway clearance related to increased

Physiological Integrity: Nursing Care of the Adult Client: EMERGENCY NURSING PROCEDURES

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

PURPOSE—to initiate assessment and intervention procedures that will speed total care of the client toward a successful outcome.




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