Meanings

of

Reproductive Organs

Breast:

feminitity

nurturing

sexual attractiveness

identity

motion of arm & strength

fit of clothing

part of self concept

use in sex

infant feeding

Meanings

of

Cervix

Uterus

Ovaries

reproductive power, strength, vitality

childbearing ability

menses as cleansing, part of rhythm of life

may feel weakened by hysterectomy

CA as punishment for sex or abortion

shortened vagina, less lubricated; may make intercourse painful

Reactions

of

surgery

&

other TX

strong relationships= stronger, make adjustments

poor relationships= maybe, maybe not

single= need to disclose about CA

depends on how woman & partner view loss (don't assume orientation)

ROLE OF RN: help through period of alignment

CA as a long-term illness

&

CA as a chronic illness

loss of body parts, loss of health

FOCUS on living w/it

number of hurdles still to be jumped

LIVING w/possibility of reoccurence

concerns over maintaining job, keeping health insurance while feeling sick & exhausted

Developmental Issues

w/CA

Young woman= may have young children

plans for family, ability to raise children

Single= worry about finding partner

Older woman= may be in established relationship

may fear abandonment

may be less concerned w/reproductive issues, esp. if postmenopausal

Breast CA

risk factors

age >50

Family HX, mutations of BRCA 1 & 2

Personal CA HX

early menarche, late menopause

benign breast CA

obesity, dietary fat, ETOH, HRT

exposure to ionizing radiation

BRCA 1 & 2 mutations

Gene that helps prevent abnl. cell growth

If there is a mutation, increased risk of breast, ovarian, colorectal, prostate CA

legal issues & insurance implications: may not want to show this mutation b/c it effects insurance

Anxiety & depression surrounding testing process

complex family dynamics

Dectection

of

Breast CA

Clinical breast exam

Breast self exam; saying do not do, but still fav by american college of OB & GYNs

Mammography

ultrasound

MRI

DX

of

Breast CA

physical findings & mammography suggestive

Need biopsy to examine tissue

-fine needle aspiration, excisional, or incisional biopsy

Sterotactic breast biopsy for nonpalpable lesions

Workup to determine spread; TX CA.

Breast CA staging

1) Tumor size

2) Regional Lymph nodes involvement

3) Distant metastasis

staging , esp II & III is complex

importantance of histiologic type-tissue

estrogen & progesterone receptor proteins

tumor's proliferative rate & DNA content

lymphatic mapping= axilla/armpit node biopsy

sentinel node biopsy= inject dye

stage I= good stage IV= bad

Surgical Opitions

for

Breast CA

CA systemic at time of DX w/bloodborne micrometastese

emphasis has shifted from radical surgical procedures to more local approaches in combo w/radiation & chemo.

Mastectomy:

removal of breast

Various procedures

alternative: breast conservation w/radiation

Drains: jackson pratt or Hemovac

-nsg teaches how to take care of drains

Pre-op Care

for

Breast surgery

nsg dx

risk for body image disturbance

decisional conflict regarding Tx options

ineffective individual coping

anticipatory grieving

altered role performance

Pre-op Care

of

Breast surgery

Consent

TCDB, ambulation

PT, prothesis

Exercise

Rings on opp. hand

IV in opp. arm

Post-op

Care

of

client

w/breast surgery

PC of surgery:

Hemorrhage

infection

seroma

hematoma

brachial plexus injury(nerve damage)

lymphedema

Short length of stay, often d/c w/drain still in place-must learn to empty & care for incision

Elevate arm, issues of balance w/large breast

Breast Reconstruction

Saline implants=done when breast removed

TRAM & latissimus dorsi flaps

Timing issues, ongoing surveillance

NO SMOKING!- vasoconstriction willl compromise the reconstruction

Types of Breast reconstruction

Breast reconstruction w/Tissue expander

Breast reconstruction w/TRAM p.1498

-muscle taken away from rectis abd. tunnel under & reconstruct

Breast reconstruction w/Latissimus Dorsi Flap

-not always big enough

Nsg DX for

reconstruction

Risk for impaired physical mobility

risk for self concept disturbance

grieving

ineffective management of therapeuticregimen;

wound care, exercise, s/sx of PC reoccurence, hand/arm precautions, community resources, follow up care.

Learning needs

for

reconstruction/removal

of breast client

BSE on remaining breast

long gloves, gardening, mitts in kitchen to avoid burns

No BP, injections, venipuncture in affected arm

thimble, sewing, electric razor, suncreen: all needed

careful w/cuts, insect bites, avoid tight elastic cuffs in clothing

Adjuvant Hormonal Therapy

Chemo or hormonal after surgery

Tamoxifen (Nolvadex)=

estrogen blocker, antieoplastic agent

Raloxifine (evista)= use for 5 years.

SE:

hot flashes, HA, lightheadedness, hair loss, photosensitivity, visual changes, thromboembolic disease, osteoporosis, hypercalcemia, endometrial CA

Other Chemo

CMF: cytoxan, methotrexate, 5FU

CAF: cytoxan, adriamycin, 5FU

SE:

n/v, alopecia, fatigue, anorexia, constipation

new: dense dosing schedule

Targerted Therapy

Herceptin (trastuzumab) binds to HER2/neu protein, which regulates cell growth.

monoclonal antibodies:

rapidly changing cells

Hormonal Therapy:

Aromatase Inhibitors

Block enzymes responsible for the small amount of estrogen produced in postmenopausal women

Not effective if ovaries are still working

Anastrazole (arimidex)

letrozole (femara)

exemestane (arosin)

Stress approach to care

as

TEAM EFFORT

tumor board= oncologist, radiologist, surgeon; all need to work together to plan progression of therapy

Don't do a procedure & then refer

Confusing area w/new data coming out & geographic variation in approaches.

Stages of Adjustment

1) Dx phase: processing info

2) Post surgical Phase: coping w/loss

3) Adjuvant therapy stage: making decisions

4) Ongoing recovery: ongoing surveillance

-5yrs until remission

communication w/pt & partner is key & social support

CA of Uterus:

Cervix

&

Endometrium

Cervix CA:

rates decreasing w/Pap smears

low pap smear rate in poverty or rural state

Gardasil: immunization for HPV

virus r/t CA of cervix

give to girls b/t 10-12

Cervical CA

Risk Factors

multiple insults to the cervix

early 1st sex, early childbearing

multiple partners, uncircumcised

EXPOSURE TO HPV

smoking, nutritional issues

DES in utero

associations w/HIV

DX

of

cervical CA

PAP smear (now starts @21, but should get w/1st sex)

earlier the pick up the better

abnl cells are transitional state for a while

S/SX:

leukorrhea (yellow vaginal d/c), bleeding b/t periods, bleeding after menopause

If unTX spreads to nerves, causing pain, abscesses, fever.

Workup to

determine spread

of CA

if preinvasive; cryotherapy(cold) or laser

Conization (cone biopsy)

LEEP: laser electrosurgical excision procedure

may have a simple hysterectomy if childbearing complete

If spread; radiation or radical hysterectomy

Endometrial CA

increasing partly b/c of long lifespan

median age 61

Risk Factors:

obesity, unopposed estrogen replacement, nulliparity, late menopause, infertillity, DM, HTN, gallbladder disease

S/SX:

postmenopausal bleeding

RX:

total abd hysterectomy w/bilateral salpingo-oophorectomy; uterus, ovaries, tubes

Radiation

Therapy

Issues:

skin care, fatigue, transportation

Course of Rx is lengthy; qday 5-6wks

Experimenting w/different RX regimens; more intense, w/shorter periods of time.

may also require radiation, hormonal therapy, chemo

hysterectomy vaginal or abd route

PC:

thrombophlebitis, DVT, urinary probs.(proximity), infection(wound), shock/hemorrhage(nick vessels), paralytic ileus

surgeries

of

Pelvis w/CA

may also require radiation, hormonal therapy, chemo hysterectomy vaginal or abd route

 PC: thrombophlebitis, DVT, urinary probs.(proximity), infection(wound), shock/hemorrhage(nick vessels), paralytic ileus

End stage Symtoms

of

pelvic CA

widespread pelvic disease

fistulas, vaginal drainage, ascites, jaundice, resp. distress, GI obstruction

Nsg DX

of

pelvic CA

risk for infection

risk of self-concept disturbance

altered sexuality pattern

grieving-loss of body part

Management

of

therapeutic regimen

perineal care/incisional care

S/SX: fever, chills, pus @wound

activity restrictions, loss of menses, HRT, followup care

fear, anxiety r/t threat of death, extent of disease

Radiation Implant

highly concentrated dose @tumor site

rapidly diminished dose to adjacent local structures

for invasive cervical & endometrial cancers

Application:

Bowel prep, fleets, folet, TEDS/SCDs, examine under anesthia, applicators inserted & verified w/xrays

client on bed rest w/HOB elevated slightly

flex legs, deep breathing, back care, checl applicator, may have PCA

minimize time @bedside

film badges, lead shielding

low residue diet, codeine to constipate

applicator removed by radiologist

get up slowly(dizzy)

may want shower, peripads

may need dilator (insert once a week) w/out intercourse reg.

Ovarian CA

difficult to Dx & TX

Deep in pelvis, asymptomatic until it advances

Gi complaints, nonspecific

Spreads w/tiny metastastases, seeding in abd cavity

pelvic mass may be dectable in bimanual part of pelvic exam

Risk Factors

&

S/SX

of

Ovarian CA

Risks factors:

irregular menses, nulliparity, infertility, anovulatory or "incessant ovulators", talcum powder on perineum (asbestos)

personal & family CA HX, BRAC 1 & 2

S/SX:

bloating, indigestion, back pain, increased girth

Screening

&

TX

of

Ovarian CA

Screening:

pelvic exams

vaginal ultrasound for high risk pop.

Ca-125 antigen testing nonspecific

prophylactic ooporectomy in some situations

Treatment:

workup to investigate spread

Stages 1 & 2 improved outlook

TAH & BSO, omentectomy;remove

Radiation; liposomal capsule

Chemo; Cisplatinum (platinol)

Taxol (paciltaxel)= peritoneal catheter

Second look surgeries & debulking

PC

of

Ovarian CA

bowel obstruction

malignant ascites

pleural effusion, SOB

swollen LE

block ureters

sepsis

DVT

malnutrition

Nsg care

of

client

with

Ovarian CA

HOB elevated to improve breathing, humidified O2

careful skin care to avoid breakdown w/massive lower body edema

cough suppressant

pain control

emotional support

Tx depression & anxiety