II. Leukemia

A. Description

1. Leukemia is a malignant exacerbation in the number of leukocytes, usually at an immature stage, in the bone marrow.

Common feature of the leukemias is an unregulated proliferation or accumulation of white blood cells (WBCs) in the bone marrow

2. Leukemia affects the bone marrow, causing anemia, leukopenia, the production of immature cells, thrombocytopenia, and a decline in the immunity.

Also proliferation in the liver and spleen and invasion of other organs, such as the meninges, lymph nodes, gums, and skin

Commonly classified according to the stem cell line involved, either lymphoid or myeloid

Classification of Leukemia

Class DescriptionAcute Lymphocytic Leukemia Mostly lymphoblasts present in

bone marrow.Age of onset is less than 15 years

Acute Myelogenous Leukemia Mostly myeloblasts present in bone marrow.

Age of onset is between 15 and 39 years.

Chronic Myelogenous Leukemia Mostly granulocytes present in bone marrow.

Age of onset is after 50.Chronic Lymphocytic Leukemia Mostly lymphocytes present in

bone marrow.Age of onset is after 50 years.

WBC

(bone marrow)

granulocytes agranulocytes

myeloblasts monoblasts

myelocytes monocytes

(basophils, eosinophils, neutrophlils)

(Lymphoid tissues)

agranulocytes

lymhoblasts

lymphocytes

Pathophysiology (ELEMENTARY): Leukemia

Proliferation/accumulation of WBC in bone marrow

↑ cell activity ↑ immature cells crowd at joints prevents mature cells infiltration

↑ cell metabolism blast cells joint pain infection, bleeding, at the anemia spleen,

brain, kidney, liver

fever infection

hepatosplenomegaly

Onset:

Acute : sudden, less than 6 months, immature (blast) cellsChronic : gradual, longer, mature WBC

Risk Factors: Cause is unknown Gene damage cells, leading to the transformation of cells from a

normal state to a malignant state. Viral pathogenesis may be involved Bone marrow damage from radiation exposure or chemicals such as

benzene and alkylating agentsB. Assessment

1. Anorexia, fatigue, weakness, weight loss

2. Anemia3. Bleeding (nosebleeds, gum bleeding, rectal bleeding, hematuria, increased menstrual flow)4. Petechiae5. Fever6. Pallor and dyspnea on exertion7. headache, bone pain and joint pain8. Normal, elevated, or reduced WBC9. (+) bone marrow biopsy of leukemic blast cells

Cardinal signs and symptoms1. Weakness and fatigue,2. Bleeding tendencies, 3. Petechiae and ecchymoses, 4. Pain, 5. Headache,6. Vomiting,7. Fever, 8. Infection

Nursing Diagnoses• Risk for infection and bleeding• Risk for impaired skin integrity related to toxic effects of chemotherapy, alteration in nutrition, and impaired mobility• Impaired gas exchange• Impaired mucous membranes from changes in epithelial lining of the gastrointestinal (GI) tract from chemotherapy or antimicrobial medications• Imbalanced nutrition: less than body requirements related to hypermetabolic state, anorexia, mucositis, pain, and nausea• Acute pain and discomfort related to mucositis, leukocytic infiltration of systemic tissues, fever, and infection• Hyperthermia related to tumor lysis and infection• Fatigue and activity intolerance related to anemia, infection, and deconditioning• Impaired physical mobility due to anemia, malaise, discomfort, and protective isolation• Risk for excess fluid volume related to renal dysfunction, hypoproteinemia, need for multiple intravenous (IV) medications and blood products• Diarrhea due to altered GI flora, mucosal denudation, prolonged use of broad-spectrum antibiotics• Risk for deficient fluid volume related to potential for diarrhea, bleeding, infection, and increased metabolic rate• Self-care deficits related to fatigue, malaise, and protective isolation• Anxiety due to knowledge deficit and uncertain future• Disturbed body image related to change in appearance, function, and roles• Grieving related to anticipatory loss and altered role functioning• Risk for spiritual distress

• Deficient knowledge of disease process, treatment, complication management, and self-care measures

C. Infection

1. Infection is the major cause of death in the immunosuppresed client2. Common sites of infection are the skin, respiratory and GI tracts.3. Initiate protective isolation procedures.4. Use strict aseptic technique5. Reverse isolation for the client• Assess temperature elevation, flushed appearance, chills, tachycardia, and appearance of white patches in the mouth.• Observe for redness, swelling, heat, or pain in eyes, ears, throat, skin, joints, abdomen, and rectal and perineal areas.• Assess for cough and changes in character or color of sputum.• Give frequent oral hygiene.• Wear sterile gloves to start infusions

D. Bleeding

1. Blood transfusion2. Examine all body fluids and excrement for the presence of blood.3. Handle client gently; use caution when taking blood pressures to prevent skin injury4. Measure abdominal girth.5. Keep sharp things away from the client.6. Instruct client to avoid blowing of the nose.7. No constricting or tight clothings.8. No rectal suppositories, enemas, thermometers.9. No NSAID’s and aspirin.10. Use electric razor when shaving.• Assess for thrombocytopenia, granulocytopenia, and anemia.• Report any increase in petechiae, melena, hematuria, or nosebleeds.• Avoid trauma and injections; use small-gauge needles when analgesics are administered parenterally, and apply pressure after injections to avoid bleeding.• Use acetaminophen instead of aspirin for analgesia.• Give prescribed hormone therapy to prevent menses.• Manage hemorrhage with bed rest and transfuse red blood cells and

platelets as ordered.E. Fatigue and Nutrition

1. Well-balanced diet2. SFF, require little chewing3. High calorie, high protein, high carbohydrate4. Assist client in activities.5. Avoid unnecessary activities.

6. Administer blood products (pRBC) for anemia.7. Help patient balance activity and rest; suggest a stationary bicycle

and sitting up in chair.Maintaining Fluid and Electrolyte Balance• Measure intake and output accurately; weigh the patient daily.• Assess for signs of fluid overload or dehydration.• Monitor laboratory tests (electrolytes, blood urea nitrogen [BUN], creatinine, and hematocrit), and replace blood, fluids, and electrolyte components as ordered and indicated.

F. Additional Interventions

1. Chemotherapy2. Antibiotic, antiviral, antifungal as prescribed.3. Prepare client for transplantation as prescribed.4. Maintain infection and bleeding precautions.5. Provide adequate diet and rest periods.6. Provide an activity that will conserve energy.7. Provide psychosocial support and support services for home care.

XIV. Prostate Cancer

A. Description

1. This slow-growing cancer of the prostate gland is usually an androgen-dependent type of adenocarcinoma.Most common cancer in men (other than nonmelanoma skin cancer)

2. The risk increases in men with each decade after 50; increasing age, a family history, and possibly a high-fat diet; Endogenous hormones, such as androgens and estrogens,3. Prostate cancer can spread via direct invasion of surrounding tissues or by metastasis, through the bloodstream and lymphatics, to the bony pelvis and supine.

B. Assessment

1. Asymptomatic in early stages2. Hard, pea-seized nodule palpated on rectal examination.3. Hematuria4. Late symptoms such as weight loss, urinary obstruction, and pain radiating from the lumbosacral area down the leg. 5. PSA is not necessarily an indicator of malignancy and use is routine to monitor the client’s response to therapy.

6. Spread and metastasis are indicated by elevated serum acid phosphatase.

SIGNS/SYMPTOMS IN ADVANCED STAGE• Lesion is stony hard and fixed.• Obstructive symptoms occur late in the disease: difficulty and frequency of urination, urinary retention, decreased size and force of urinary stream.• Blood in urine or semen; painful ejaculation.• Cancer can spread to lymph nodes and bone.• Symptoms of metastases include backache, hip pain, perineal and rectal discomfort, anemia, weight loss, weakness, nausea, oliguria, and spontaneous pathologic fractures; hematuria may result from urethral or bladder invasion.• Sexual dysfunction

Assessment and Diagnostic Methods• Digital rectal examination (DRE; preferably by the same examiner).• Histologic examination of tissue removed surgically by transurethral resection of the prostate (TURP), open prostatectomy, ultrasound-guided transrectal needle biopsy, or fine-needle aspiration.• Prostate-specific antigen (PSA) level; transrectal ultrasound; bone scans, skeletal x-rays, and MRI; pelvic CT scans; or monoclonal antibody-based imaging

C. Nonsurgical Interventions

Radiation Therapy• Teletherapy (external beam radiation therapy [EBRT]): treatment option for patients with low risk prostate cancer• Brachytherapy (internal implants): commonly used monotherapy treatment option for early, clinically organ-confined prostate cancer• Side effects: inflammation of the rectum, bowel, and bladder (proctitis, enteritis, and cystitis); acute urinary dysfunction; pain with urination and ejaculation; rectal urgency, diarrhea, and tenesmus; rectal proctitis, bleeding, and rectal fistula; painless hematuria; chronic interstitial cystitis; urethral stricture erectile dysfunction; and rarely, secondary cancers of the rectum and bladder

Hormone Therapy• Androgen deprivation therapy (ADT): accomplished either by surgical castration (bilateral orchiectomy, removal of the testes) or by medical castration with the administration of medications, such as luteinizing hormone–releasing hormone(LHRH) agonists Lupron, Eulexin, or DES, as prescribed, to slow the rate of growth of the tumor

• Hypogonadism is responsible for the adverse effects of ADT, which include vasomotor flushing, loss of libido, decreased bone density (resulting in osteoporosis and fractures), anemia, fatigue, increased fat mass, lipid alterations, decreased muscle mass, gynecomastia (increased breast tissue), and mastodynia (breast/nipple tenderness

Other Therapies

• Chemotherapy•Cryosurgery for those who cannot physically tolerate surgery or for recurrence• Repeated TURPs to keep urethra patent; suprapubic or transurethral catheter drainage when repeated TUR is impractical• Opioid or nonopioid medications to control pain with metastasis to bone• Blood transfusions to maintain adequate hemoglobin levels

D. Surgical Interventions

1. Prepare the client for orchiectomy, if prescribed, which will limit the production of testosterone.2. Prepare the client for TURP or prostatectomy, if prescribed.3. Cyrosurgical ablation is a minimally invasive procedure that may be an alternative to radical prostatectomy; liquid nitrogen freezes the gland, and the body absorbs the dead cells.

E. TRANSURETHRAL RESECTION OF THE PROSTATE

1. The procedure involves inserting of a scope into the urethra to excise prostatic tissue.2. Bleeding is common following TURP, and monitoring for hemorrhage is very important.3. Continuous bladder irrigation is prescribed postoperatively to maintain the urine at a pink color.4. Bladder spasms are common following surgery, and atispasmodics may be prescribed.5. Dribbling or incontinence may occur postoperatively, and it is important for the nurse to instruct the client to monitor for these occurrences.6. Sterility may or may not occur following the surgical procedure.

F. Radical Prostatectomy

• Removal of the prostate, seminal vesicles, tips of the vas deferens, and often the surrounding fat, nerves, and blood vessels through:

a. suprapubic approach (greater blood loss)b. perineal approach (easily contaminated, incontinence, impotence, and

rectal injury common), or retropubic approach (infection can readily start).

• This procedure is used with patients whose tumor is confined to the prostate.• Sexual impotency and various degrees of urinary incontinence commonly follow radical prostatectomy

Suprapubic Prostatectomy

1. It is the removal of prostate gland by an abdominal incision with bladder incision.2. The client will have an abdominal dressing that may drain copious amount of urine, and the abdominal dressing will need to be changed frequently.3. Severe hemorrhage is possible, and monitoring for blood loss is an important nursing intervention.4. Bladder spasm are common, and antispasmodics may be prescribed.5. Continuous bladder irrigation is prescribed and administered to keep the urine pink.6. A longer healing process is involved as compared with the TURP.7. Sterility occur with this procedure.

Retropubic Prostatectomy

1. It is the removal of the prostate gland by a low abdominal incision without opening the bladder.2. Less bleeding occurs with this procedure compared with the suprapubic procedure, and the client experiences fewer bladder spasms.3. Abdominal drainage is minimal.4. Continuous bladder irrigation may be used.5. Sterility occurs with this procedure.

H. Perineal Prostatectomy

1. It is removal of prostate gland via an incision made between the scrotum and anus.2. Minimal bleeding occurs.3. Increased risk of infection; watch out.4. Urinary incontinence is common.5. This procedure causes sterility.6. Teach the client perineal exercise.7. Avoid inserting rectal tubes, taking temperature rectally, or administering enemas.

Nursing Diagnosis

Preoperative Nursing Diagnoses• Anxiety related to inability to void• Acute pain related to bladder distention• Deficient knowledge of the problem and treatment protocolPostoperative Nursing Diagnoses• Acute pain related to surgical incision, catheter placement, and bladder spasms• Deficient knowledge about postoperative care

Planning

Preoperative goals: 1. reduced anxiety 2. learning about his prostate disorder and the perioperative experience.

Postoperative goals:1. maintenance of fluid volume balance, 2. relief of pain and discomfort, 3. ability to perform self-care activities, 4. absence of complications

Preoperative Nursing Interventions

Reducing Anxiety• Clarify the nature of the surgery and expected postoperative outcomes.• Provide privacy, and establish a trusting and professional relationship.• Encourage patient to discuss feelings and concerns.

Relieving Discomfort• While patient is on bed rest, administer analgesic agents; initiate measures to relieve anxiety.• Monitor voiding patterns; watch for bladder distention.• Insert indwelling catheter if urinary retention is present or if laboratory test results indicate azotemia.• Prepare patient for a cystostomy if urinary catheter is not toleratedProviding Instruction• Review with the patient the anatomy of the affected structures and their function in relation to the urinary and reproductive systems, using diagrams and other teaching aids if indicated.• Explain what will take place while the patient is prepared for diagnostic tests and then for surgery (depending on the type of prostatectomy planned).• Reinforce information given by the surgeon.

• Explain procedures expected to occur during the immediate perioperative period, answer questions the patient or family may have, and provide emotional support.• Provide information about postoperative pain management.Preparing Patient for Treatment• Apply graduated compression stockings.• Administer enema, if ordered

I. Postoperative Interventions

Maintaining Fluid Balance• Closely monitor urine output and the amount of fluid used for irrigation; maintain intake/output record.• Monitor for electrolyte imbalances (eg, hyponatremia), increasing blood pressure, confusion, and respiratory distress.

Increase OFI to 2400 to 3000 ml a day unless contraindicated Monitor three-way Foley catheter, which will have a 30-40 ml retention

balloonRelieving Pain• Distinguish cause and location of pain, including bladder spasms.• Give analgesic agents for incisional pain and smooth muscle relaxants for bladder spasm.• Monitor drainage tubing and irrigate drainage system to correct any obstruction.• Secure catheter to leg or abdomen.• Monitor dressings, and adjust to ensure they are not too snug or not too saturated or are improperly placed.

• Provide stool softener, prune juice, or an enema, if prescribed.Monitoring and Managing Complications• Hemorrhage:

1. Observe catheter drainage; 2. Note bright red bleeding with increased viscosity and clots; 3. closely monitor vital signs; 4. administer medications, IV fluids, and blood component therapy as

prescribed; 5. Maintain accurate record of intake and output; 6. Carefully monitor drainage to ensure adequate urine flow and patency

of the drainage system. 7. Monitor for arterial bleeding as evidenced by bright red urine with

numerous clots, and if it occurs, increase Continuous Bladder Irrigation and notify the physician immediately

8. Expect red to light pink urine for 24 hours, turning to amber in 3 days9. Provide explanations and reassurance to patient and family.

• Infection: 1. Use aseptic technique with dressing changes;

2. avoid rectal thermometers, tubes, and enemas; 3. provide sitz bath and heat lamps to promote healing after sutures are

removed; 4. assess for urinary tract infection (UTI) and epididymitis; 5. administer antibiotics as prescribed.

• Thrombosis: 1. Assess for deep vein thrombosis and pulmonary embolism; 2. Apply compression stockings. 3. Assist patient to progress from dangling the day of surgery to

ambulating the next morning; 4. Ambulate the client as early as possible and as soon as urine begins to

clear in color. 5. Encourage patient to walk but not sit for long periods of time. 6. Monitor the patient receiving heparin for excessive bleeding.

• Obstructed catheter: 1. Observe lower abdomen for bladder distention; 2. Examine drainage bag, dressings, and surgical incision for bleeding; 3. Monitor vital signs to detect hypotension; 4. Observe patient for restlessness, diaphoresis, pallor, any drop in blood

pressure, and an increasing pulse rate. 5. Provide for patent drainage system; perform gentle irrigation as

prescribed to remove blood clots. 6. Maintain Continuous Bladder Irrigation with sterile bladder irrigation

solution as prescribed to keep the catheter free of obstruction and maintain the urine pink in color.

7. Instruct the client that a continuous feeling of an urge to void is normal.