NCM 3115b: Related Learning Experience III

RLE: MS Simulation Can the elements be repeated? Yes, the DAR format may
Week 1: 11/13/2023 be changed based on the situation.

How to Develop the Focus

FDAR Charting (Focus, Data, Action, Response)
Documentation Refers to: Examples:
- Any written or electronically generated
A s/sx Hypotension
information about a client that describes Chest Pain
the service or care provided to that client.
A patient behavior
A written evidence of: nability to ambulate
➔ The interactions between and among
An acute change on the Respiratory distress
healthcare professionals–doctors, patient behavior Code blue
consultants, clients, their families, and Diabetic coma
healthcare organizations (insurances,
contracts w/ the hospital. A significant event in the Surgery
➔ The administration of tests, procedures, patient’s therapy (Appendectomy)
Transfusion of packed
treatments, and client education.
RBC
➔ Response of clients to care given.
A specialized need Discharge Planning
Focus Charting
- Describes the patient’s perspective A nursing diagnosis Altered tissue perfusion
and focuses on documentation of the A medical diagnosis Cardiac arrhythmias
client’s current status. Hyperbilirubinemia
- The nurse identifies a “focus” based
on the client’s concerns or
DATA/ACTION/RESPONSE
behaviors done upon assessment.
➔ Charting in these categories completes the
clinical decision-making cycle, organizes the
Note: In focus charting, DAR (Data, Action,
focus note, promotes clinical monitoring, and
Response), are not necessarily included. However,
assists the writer to communicate to other
DAR should only be the basis for your focus
healthcare professionals in a logical and
charting.
concise manner.

F ● Problem identified from the patient. DATA:

● Identifies the content or purpose of the - As compared to the nursing process, it is
narrative entry and is separated from
similar to the assessment stage.
the body of notes in order to promote
easy data retrieval and communication. - Includes both objective and subjective data.
- Assessment: VS, any observable change in
D ● Is the subjective and objective the condition, and altered behavior are
information supporting the stated focus. written.
A ● Immediate or future nursing actions
based on the nurse’s assessment. ACTION:
- Comparable to the planning and
R ● Describes the patient’s implementation stage of the nursing
outcome/response to interventions, or process; involving the current and possible
describes how the goals have been nursing actions.
attained.
 NCM 3115b: Related Learning Experience III

- Includes the interventions and procedures

error. Write the and phrases such
performed. correct word beside as “good day" or
- Should relate or correspond to the focus. it. “no complaints”.
2. Do use standard
RESPONSE: chart forms.
- Evaluation stage of the nursing process. 3. Do use only
approved
- Gives a detailed and accurate reaction of the
abbreviations.
patient to the nursing action done. 4. Do time and date
all entries.
General Guidelines for Charting in the Nurses’
Notes
Note:
➔ FDAR: everytime you move the patient from
● The words DAR are included in the
one area to another, always assess the
documentation.
patient first.
● Full name and signature by the
nurse-in-charge or healthcare professional
making the entry. CARDIOVASCULAR
● Data and Action are recorded. Response is INTRODUCTION
not added until later, when patient outcome is Week 1: 11/14/2023
evident.
● It may not be necessary to use all four What is an ECG?
categories with each focus entry. These - An electrocardiogram or “ECG” records the
categories are guides. electrical activity of the heart. The heart
● “Received from” is only written during the produces tiny electrical impulses which
transfer from one department to another. It is spread through the heart muscle to make the
not written when receiving from the previous heart contract.
shift.
● Action and Response are repeated without Electrocardiography
additional data to show the sequence of - Is the process of producing an
decision-making based on evaluating patient electrocardiogram (ECG or EKG)
response to the initial intervention. - A recording—a graph of voltage versus time
● Begin the note with “Action” when the —of the electrical activity of the heart using
patient interaction begins with intervention. electrodes placed on the skin.
- These electrodes detect small electrical
Note: changes that are a consequence of cardiac
➔ Responses are always stated in past tense. muscle depolarization followed by
➔ If ASSESSMENT only, no need for repolarization during each cardiac cycle
RESPONSE. (heartbeat).
➔ NEVER write “No complaints made”.
➔ If beginning with interaction, e.g., health The overall goal of performing an ECG is to obtain
teaching, start with ACTION. information about the electrical function of the heart.
➔ For discharge patients, always note
“Instruction fully understood”. Some indications of Performing an ECG include:

DO’s DON’T’s Chest Pain or suspected myocardial

infarction (heart attack), such as ST elevated
1. Do draw a single 1. Don’t use myocardial infarction (STEMI) or non-ST
line through an meaningless words
elevated myocardial infarction (NSTEMI).
 NCM 3115b: Related Learning Experience III

Symptoms such as shortness of breath,

murmurs, fainting, seizures, funny turns or
arrhythmias including new onset palpitations Electrode Name/Placement
or monitoring of known cardiac arrhythmias.
RA On the right arm, avoiding thick muscle.
Medication monitoring (e.g. drug-induced QT
prolongation, Digoxin toxicity) and LA In the same location where RA was placed,
management of overdose (e.g. tricyclic but on the left arm.
overdose)
RL On the right leg, lower end of inner aspect of
Electrolyte abnormalities such as calf muscle (avoid bony prominences).
hyperkalemia.
Perioperative monitoring in which any form of LL In the same location where RL was placed,
anesthesia is involved (e.g. monitored but on the left leg.
anesthesia care, general anesthesia). This V1 In the fourth intercostal space (between ribs
includes preoperative assessment, 4 and 5) just to the right of the sternum
intraoperative and postoperative monitoring. (breastbone).
Cardiac stress testing
V2 In the fourth intercostal space (between ribs
Clinical cardiac electrophysiology in which a 4 and 5) just to the left of the sternum.
catheter is inserted through the femoral vein
(large blood vessel in your thigh) and can V3 Between leads V2 and V4.
have several electrodes along its length to
V4 In the fifth intercostal space (between ribs 5
record the direction of electrical activity within
and 6) in the midclavicular line.
the heart.
V5 Horizontally even with V4, in the left anterior
Electrodes and Leads axillary line.

● Proper placement of the limb electrodes. The V6 Horizontally even with V4 and V5 in the
mid-axillary line.
limb electrodes can be far down on the limbs
or close to the hips/shoulders as long as they
are placed symmetrically.
● Placement of the precordial electrodes. Cardiac Monitor
● Electrodes are the actual conductive pads
attached to the body surface. Any pair of ● Is a device that shows the heart’s electrical
activity as a wave pattern on a monitor.
electrodes can measure the electrical
● A bedside monitor.
potential difference between the two
corresponding locations of attachment. Such Purpose
a pair forms a lead. However, “leads” can
also be formed between a physical electrode ● The cardiac monitor continuously shows the
and a virtual electrode, known as the Wilson’s cardiac rhythm and sends the
Central Terminal, whose potential is defined electrocardiogram (EKG) tracing to a main
as the average potential measured by three monitor in the nursing station.
limb electrodes that are attached to the right ● Most commonly used in the emergency
arm, the left arm, and the left foot, rooms and critical care areas, cardiac
respectively. monitoring allows for continual observation of
● Commonly, 10 electrodes attached to the several patients.
body are used to form 12 ECG leads, with ● Aside from monitoring cardiac patients,
each lead measuring a specific electrical continuous monitoring is useful for
potential difference. observation of postoperative patients,
 NCM 3115b: Related Learning Experience III

patients with severe electrolyte imbalances, ARRHYTHMIA RECOGNITION

and other unstable patients. Sinus Rhythm
● Continuous cardiac monitoring allows prompt NORMAL SINUS RHYTHM
identification and initiation of treatment for ● Look at the p waves:
cardiac arrhythmias and other conditions. Same contour in the same lead?
Upright in I, II, aVF & left precordial
leads
Followed by QRST?

SINUS BRADYCARDIA
ELECTRODE - electrical detection device ● Regularly occurring PQRST
attached to the skin “the sticker”. ● Rate <60/min
MONITOR CABLES - wires that connect
electrodes to the monitor.
LEAD - a tracing of the voltage difference
between two electrodes.

INTERVENTIONAL FUNCTIONS
Transcutaneous (External) Pacing
SINUS TACHYCARDIA
Providing a electrical signal (stimulus) to the ● Regularly occurring PQRST
heart when it’s own built in (natural) ● Rate >100/min
pacemaker or conduction system has failed
GOAL: Control the heart rate and / or rhythm.

Synchronized Cardioversion

Delivering a selected dose of electricity to the

heart at any period in the cardiac cycle.
GOAL: To reset the heart's intrinsic firing ATRIAL FLUTTER
rate. ● Atrial rate = 220-300/min
(P as flutter waves)
Defibrillation ● Variable degree of AV block
(irregular RR interval)
Delivering a selected dose of electricity to the
heart at any period in the cardiac cycle.
GOAL: To terminate disorganized electrical
activity.
 NCM 3115b: Related Learning Experience III

ATRIAL FIBRILLATION
● No discernible P waves
● Irregular RR interval

VENTRICULAR FIBRILLATION

PREMATURE VENTRICULAR CONTRACTION

CARDIAC MARKERS:
● Prematurely occurring complex
● Wide, bizarre looking QRS complex
TROPONIN:
● Usually no preceding P wave
● Presently, cardiac enzymes of choice in most
● T wave opposite in deflection to the QRS
clinical settings.
complex
● Has shown to be more specific and more
● Complete compensatory pause following
sensitive to cardiac injury
every premature beat
● Can be detected within 3-4 hrs
● TROPONIN I & TROPONIN T

TROPONIN I
- Only found in cardiac tissue
- Normal Range: 0-0.04 ng/mL (nanograms
per millilitre)
VENTRICULAR TACHYCARDIA TROPONIN T
- Expressed to a very small degree in
skeletal tissue
- Normal Range: 0-0.01 ng/mL

HIGH SENSITIVITY CARDIAC TROPONIN (hs-cTn)

● Is a newer type of testing
● Normal values are below 14ng/L (<14ng/L)

CREATINE KINASE/CK MB (MM, MB, BB)

● An enzyme found in heart muscle cells.
● Male: 55 to 170 U/L (units per liter)
● Female: 30 to 145 U/L

MYOGLOBIN
SUPRAVENTRICULAR TACHYCARDIA ● Oxygen-binding protein in heart and skeletal
muscles
 NCM 3115b: Related Learning Experience III

● Non-specific Continuous, snoring, gurgling, or rattle-like

● Normal Range: 5 to 70 mcg/L quality
Occur in the bronchi as air moves through
BNP (B-type Natriuretic Peptide) tracheal-bronchial passages coated with
● Hormone mucous or respiratory secretions
● Is released by the heart in response to Often heard in pneumonia, chronic bronchitis,
increased pressure or stress or cystic fibrosis
● Normal Range: less than 100 pg/mL
Usually clear after coughing
(<100pg/mL)(picograms per mL)
● LDH
STRIDOR
● CRP
Throat is louder over the throat
Air is moving roughly over a
partially-obstructed upper airway
Caused by something blocking the larynx
Person choking on an object
Person with an infection
Swelling in the throat
Laryngospasm

FINE CRACKLES – listen to the bases of the lungs

High-pitched, brief, discontinuous, popping
lung sounds
Sound like wood burning in a fireplace or
ABNORMAL BREATH SOUNDS
cellophane being crumpled
● Wheezing
Usually start at the base of the lungs, where
● Rhonchi (Low pitched wheezes)
there is fluid in the lungs
● Stridor
● Crackles - fine and coarse (aka RALES) As fluid fills the lungs more, can be heard
● Pleural Friction Rub closer and closer to the top of the lungs

WHEEZING COARSE CRACKLES – heard over most of anterior

and posterior chest walls
Associated with:
1. Asthma Coarse, rattling, crackling sounds
2. Bronchitis Louder, longer, and lower in pitch than fine
3. Pneumonia crackles
4. COPD Describe as a bubbling sound, as when
5. Smoking pouring water out of a bottle or like ripping
6. Heart Failure open Velcro
7. Inhaling a foreign object into the lungs Often heard just in certain spots on the lungs,
8. Allergic reaction possibly only one side or in different spots on
May occur during inhalation or exhalation both sides
Are continuous with a musical quality Usually caused by mucus in the bronchi

RHONCHI PLEURAL FRICTION RUB

Occur in the bronchi Two inflamed pleural surfaces rub against
Snoring or moaning sounds each other during respiration
 NCM 3115b: Related Learning Experience III

Heard in pleurisy NURSING CARE: monitoring and prevention of

May be continuous or broken and creaking or common complications, preventing dislodgement,
grating and educating the patient on the proper use and
The sound of walking on fresh snow or maintenance of the pacemaker.
rubbing leather together
INTRODUCTION:
Occurs every time the patient inhales and
CELLULAR ABERRATIONS
exhales
BLOOD TESTS
Pleural rubs come and go
Not altered w/ coughing Prostate-specific antigen (PSA)
Can usually be localizing to a specific location - Is a blood test used primarily to screen for
on the chest wall prostate cancer.
Will stop when the px holds their breath - Measures the amount of prostate-specific
antigen (PSA) in the blood.
REMEMBER: - PSA is a protein produced by both
● When there is a loss of breath sounds in an cancerous and noncancerous tissue in the
area, it probably indicates a pneumothorax, prostate, a small gland that sits below the
or a collapsed lung, in which there is no air bladder in men.
movement in that area.
Carcinoembryonic Antigen (CEA)
LUNG SOUNDS: - Test used to check how well treatment is
1. Wheeze - musical noise during respiration or working in certain types of cancer, particularly
expiration. Usually louder during expiration. colon cancer.
(continuous) - CEA are substances (usually proteins) that
2. Stridor - a high-pitched musical sound heard are produced by some types of cancer. In
on inspiration, resembling wheezing, however response to the antigens, the body produces
the sound is louder over the throat, due to a antibodies to help fight them.
partially obstructed airway.
3. Rhonchi - rumbling, coarse sounds, like a Alpha-fetoprotein (AFP)
snore, during inspiration or expiration. May - An AFP tumor marker test is a blood test that
clear with coughing or suctioning. measures the levels of AFP in adults.
(continuous) - Tumor markers are substances made by
4. Crackles - high-pitched, heard during cancer cells or by normal cells izn response
inspiration, not cleared by a cough. to cancer in the body. High levels of AFP can
(discontinuous) be a sign of liver cancer or cancer of the
5. Pleural Friction Rub - occurs during ovaries, as well as noncancerous liver
inhalation and exhalation, may be continuous disease such as cirrhosis and hepatitis.
or broken, and creaking or grating. They stop
when the patient holds their breath. Cancer Antigen 125 (CA-125)
- Measures the amount of the protein CA 125
NURSING RESPONSIBILITIES in the blood.
PACEMAKER
- May be used to monitor certain cancers
during and after treatment. In some cases, a
A pacemaker insertion is the manipulation of a small
CA 125 test may be used to look for early
electronic device that is usually placed in the chest
signs of ovarian cancer in people with a very
(just below the collarbone) to help regulate slow
high risk of the disease.
electrical problems with the heart.
 NCM 3115b: Related Learning Experience III

Urine Cytology
- A test to look for abnormal cells in the MAMMOGRAM
urine. - Is a specialized medical imaging that uses a
- Is used along with other tests and procedures low-dose x-ray system to see inside the
to diagnose urinary tract cancers. breasts.
- Most often used to diagnose bladder cancer, - A mammography exam, called a
though it may also detect cancers of the mammogram, aids in the early detection and
kidney, prostate, ureter, and urethra. diagnosis of breast diseases in women.

SPECIAL PROCEDURES CYSTOSCOPY

- A procedure that allows your doctor to
BIOPSY examine the lining of your bladder and the
- A procedure to remove a piece of tissue or tube that carries urine out of your body
a sample of cells from your body so that it (urethra).
can be analyzed in a laboratory. - A hollow tube (cystoscope) equipped with
- If you’re experiencing certain signs and a lens is inserted into your urethra and
symptoms or if your doctor has identified an slowly advanced into your bladder.
area of concern, you may undergo a biopsy
to determine whether you have cancer or BREAST EXAMINATION MODEL
some other condition.
A BREAST SELF EXAM is the regular examination
FLUOROSCOPY of one’s own breasts to detect lumps or other
- A continuous x-ray beam is passed changes that may need to be further evaluated as
through the body part being examined. part of screening for breast cancer.
- The beam is transmitted to a TV-like monitor
so that the body part and its motion can be TESTICULAR SELF-EXAM
seen in detail.
1. Cup one testicle at a time using both
ENDOSCOPY hands. Best performed during or after a
- The insertion of a long, thin tube directly warm bath/shower.
into the body to observe an internal organ or 2. Examine by rolling the testicle between
tissue in detail. thumb and fingers. Use slight pressure.
- It can also be used to carry out other tasks 3. Familiarize yourself with the spermatic
including imaging and minor surgery. cord and epididymis tube like structures
- Endoscopes are minimally invasive and can that connect on the back side of each testicle.
be inserted into the openings of the body 4. Feel for lumps, change in size or
such as the mouth or anus. irregularities. It is normal for one testis to be
slightly larger than the other.
VIDEO-ASSISTED THORACOSCOPIC
SURGERY (VATS) RADIATION THERAPY
THE ROLE OF THE NURSE
- Minimally invasive surgical technique used to
Week 3: 11/20/2023
diagnose and treat problems in your chest.
- During VATS procedure, a tiny camera
● Patient and family education
(thoracoscope) and surgical instruments
● Assessment and management of symptoms
are inserted into the chest through one or
● Coordination of care
more small incisions in your chest wall.
● Providing emotional support throughout the
treatment
 NCM 3115b: Related Learning Experience III

SELF-CARE GUIDELINES TO MINIMIZE seeing that visitors maintain a 6 feet

RADIATION SKIN REACTIONS: distance from the radiation source.

● Wash treated area gently with lukewarm SAFE HANDLING OF CHEMOTHERAPEUTIC

water and mild soap; pat dry AGENTS
● Avoid applying tape, rubbing or scratching in DRUG PREPARATIONS:
treatment area To ensure safe handling, all
● Wear loose-fitting, soft clothing over the chemotherapeutic drugs should be prepared
treated area according to the package insert in a CLASS II
● Use only an electric razor if shaving in the biologic safety cabinet (BSC).
treated area Personal Protective Equipment includes:
● Avoid swimming in chlorinated water 1. Disposable surgical latex gloves and
● Avoid sun exposure or extremes of heat or gown made of lint-free, low-permeability
cold in treated area fabric with a closed front, long sleeves
● Use only skin care products recommended by and elastic knit cuffs.
the radiation staff 2. Eye-protective splash goggles or a face
● DO NOT apply skin care products 4 hours shield must be worn when these drugs
prior to each treatment are prepared if a BSC is not used.
● For treatment of the breast:
Drug Administration
➔ DO NOT wear bra when possible
● Wear protective equipments (gloves,
➔ AVOID underwire bras
gown, eyewear)
➔ AVOID use of deodorant on the
● Explain to the patient that
treated side
chemotherapeutic drugs are harmful
to normal cells and that protective
NURSING MANAGEMENT: measures used by the personnel
RADIATION THERAPY
minimize their exposure to drugs.
● Administer drugs in a safe, unhurried
● ASSESSMENT. The nurse assesses the
environment
patient’s skin and oropharyngeal mucosa
● Place a plastic-backed absorbent pad
regularly when radiation therapy is directed to
under the tubing during administration
these areas, and also the nutritional status
to catch any leakage.
and general well-being should be assessed.
● SYMPTOMS. If systemic symptoms, such as
PERSONAL PROTECTIVE EQUIPMENT FOR
weakness and fatigue occur, the nurse
COMPOUNDING:
explains that these symptoms are a result of GOWNS AND OTHER
the treatment and do not represent ● Dedicated gowns for hazardous drug
deterioration or progression of the disease. ➔ CHANGE:
● SAFETY PRECAUTIONS. Safety ★ Every time inner pair of gloves changed
precautions used in caring for a patient ★ Contamination
receiving brachytherapy include assigning the ★ Maximum 2-3 hours
patient to a private room, porting appropriate ● Shoe and hair covers
notices about radiation safety ● Eye and face protection required
precautions, having staff members wear ➔ NIOSH-certified N96 respirators required
dosimeter badges, making sure that for compounding
pregnant staff members are not assigned to ● Always wear the proper PPE when working
the patient’s care, prohibiting visits by with anticancer medicines.
children and pregnant visitors, limiting
visits from others to 30 mins daily, and
 NCM 3115b: Related Learning Experience III

DISPOSAL OF SUPPLIES AND UNUSED DRUGS CARING FOR PATIENTS RECEIVING

● Place all unused supplies or drugs in a CHEMOTHERAPEUTIC DRUGS
container in a leak-proof closeable, ● All personnel who handled blood, vomitus, or
puncture-proof, appropriately labelled excreta from patients who have received
container. chemotherapy within the previous 48 hours
● Keep these containers in every area where should wear disposable surgical latex gloves
drugs are prepared or administered so that and gowns, which are discarded
waste materials need not be moved from one appropriately after use.
area to another. ● Linen contaminated with chemotherapeutic
● Dispose of containers filled with drugs, blood, vomitus, or excreta from a
chemotherapeutic supplies and unused drugs patient who has received these drugs within
in accordance with regulations of hazardous the prior 48 hours should be placed in a
waste (in a licensed sanitary landfill) or specifically marked, impervious laundry bag
incinerate at 1832 𝇈F (100 𝇈C). according to procedures for drug spills on
linen.
MANAGEMENT OF CHEMOTHERAPY SPILLS
● Chemotherapy spills should be cleaned up NURSING MANAGEMENT IN CHEMOTHERAPY
immediately by properly protected personnel
trained in the appropriate procedures. ASSESSING FLUID AND ELECTROLYTE
● A spill should be identified with a warning IMBALANCE
sign so that other people will not be - Anorexia, nausea, vomiting, altered taste,
contaminated. mucositis, and diarrhea put patients at risk for
● The following are recommended supplies and nutritional and fluid electrolyte disturbances.
procedures for managing a chemotherapy
spill on hard surfaces, linens, personnel and MODIFYING RISKS FOR INFECTION AND
patients: BLEEDING
➔ A respirator mask for airborne powder - Suppression of the bone marrow and immune
spills system is expected and frequently serves as
➔ Plastic safety glasses or goggles a guide in determining appropriate
➔ Heavy duty rubber gloves chemotherapy dosage but increases the risk
● Dermal exposure from chemotherapy spill: of anemia, infection, and bleeding disorders.
Scaring is likely to occur.
● Absorbent pads to contain liquid spills ADMINISTERING CHEMOTHERAPY
● Absorbent towels for cleanup after spill - The patient is observed closely during its
● Small scoop to collect glass fragments administration because of the risk and
● 2 large waste disposal bags consequences of extravasation, particularly of
● A protective disposable gown vesicant agent.
● Containers for detergent solution and clean
tap water for cleaning up the spill PROTECTING CAREGIVERS
● Puncture-proof, leak-proof closeable - Nurses must be familiar with their institutional
container approved for chemotherapy waste policies regarding personal protective
disposal equipment, handling and disposal of
● An approved, specially labelled, impervious chemotherapeutic agents and supplies, and
laundry bag management of accidental spills or
● Placement of eyewash faucet adapter or exposures.
fountain should be in or near work area
 NCM 3115b: Related Learning Experience III

NURSING RESPONSIBILITIES FOR PATIENTS DECREASING FATIGUE

WITH PROBLEMS IN CELLULAR ABERRATIONS
MAINTAINING TISSUE INTEGRITY: ASSESSMENT. The nurse assesses
physiologic and psychological stressors that
STOMATITIS: Assessment of the patient’s can contribute to fatigue and uses several
subjective experience and an objective assessment tools such as simple visual
assessment of the oropharyngeal tissues and analog scale to assess levels of fatigue.
teeth are important and for the treatment of
oral mucositis, Palifermin (Kepivance), a EXERCISE. The role of exercise as a helpful
synthetic form of human keratinocyte growth intervention has been supported by several
factor, could be administered. controlled trials.

RADIATION-ASSOCIATED SKIN PHARMACOLOGIC INTERVENTIONS.

IMPAIRMENT. Nursing care for patients with Occasionally pharmacologic interventions are
impaired skin reactions includes maintaining utilized, including antidepressants for patients
skin integrity, cleansing the skin, promoting with depression, anxiolytics for those with
comfort, reducing pain, preventing additional anxiety, hypnotics for patients with sleep
trauma, and preventing and managing disturbances, and psychostimulants for some
infection. patients with advanced cancer or fatigue that
does not respond to any medication.
MALABSORPTION. Surgical intervention
may change peristaltic patterns, later IMPROVING BODY IMAGE AND SELF-ESTEEM
gastrointestinal secretions, and reduce the
absorptive surfaces of the gastrointestinal ASSESSMENT. The nurse identifies potential
mucosa, all leading to malabsorption. threats to the patient’s body image
experience, and the nurse assesses the
CACHEXIA. Nurses assess patients who are patient’s ability to cope with the many
at risk of altered nutritional intake so that assaults to the body image experienced
appropriate measures may be instituted prior throughout the course of the disease and
to nutritional declines. treatment.

RELIEVING PAIN SEXUALITY. Nurses who identify physiologic,

psychologic or communication difficulties
ASSESSMENT. The nurse assesses the related to sexuality or sexual function are in a
patient for the source and site of pain as well key position to help patients seek further
as those factors that increase the patient’s specialized evaluation and intervention if
perception of pain. necessary.

CANCER PAIN ALGORITHM. Various opioid ASSISTING IN THE GRIEVING PROCESS

and nonopioid medications may be combined
with other medications to control pain as ASSESSMENT. The nurse assesses the
adapted from the WHO three-step ladder patient’s psychological and mental status, as
approach. well as the mood and emotional reaction to
the results of diagnostic testing and
EDUCATION. The nurse provides education prognosis.
and support to correct fears and
misconceptions about opioid use.
 NCM 3115b: Related Learning Experience III

GRIEVING. Grieving is a normal response to only accounts for only 1% of all solid tumors
these fears and to actual or potential losses. among men.
The incidence of testicular cancer has been
MONITORING AND MANAGING POTENTIAL steadily increasing worldwide since the early
COMPLICATIONS 1900s, and this increase has been largely
restricted to Caucasian males.
INFECTION. The nurse monitors laboratory Testicular cancer is far less common in
studies to detect any early changes in WBC African American men ranging from 4:1 to
counts. 40:1.
SEPTIC SHOCK. Neurologic assessments Worldwide incidence is lowest in Africa and
are carried out, fluid and electrolyte status is Asia, and highest in the Scandinavian
monitored, arterial blood values and pulse countries, Germany, Switzerland, and New
oximetry are monitored, and IV fluids, blood, Zealand.
and vasopressors are administered by the
nurse. KEY STATISTICS FOR TESTICULAR CANCER
BLEEDING AND HEMORRHAGE. The nurse
may administer 1L-11, which has been The American Cancer Society’s estimates for
approved by the FDA to prevent severe testicular cancer in the United States for 2021 are:
thrombocytopenia, and additional About 9,470 new cases of testicular cancer
medications may be prescribed to address diagnosed
bleeding due to disorders of coagulation. About 440 deaths from testicular cancer

PROMOTING HOME AND COMMUNITY-BASED ➔ The incidence rate of testicular cancer has
CARE been increasing in the US and many other
countries for several decades. The increase
Nurses in the outpatient settings often have is mostly in seminomas. Experts have not
the responsibilities for patient teaching and been able to find reasons for this. Lately, the
for coordinating care in the home. rate of increase has slowed.
➔ Testicular cancer is not common: about 1 of
TEACHING PATIENTS SELF-CARE. every 250 males will develop testicular
Follow-up visits and telephone calls from the cancer at some point during their lifetime.
nurse assist in identifying problems and are ➔ The average age at the time of diagnosis of
often reassuring, increasing the patient’s and testicular cancer is about 33. This is largely a
the family’s comfort in dealing with complex disease of young and middle-aged men, but
and new aspects of care. about 6% of cases occur in children and
teens, and about 8% occur in men over the
CONTINUING CARE. The responsibilities of age of 55.
the home care include assessing the home ➔ Because testicular cancer usually can be
environment, suggesting modifications at treated successfully, a man’s lifetime risk of
home or in care to help the patient and the dying from this cancer is very low: about 1 in
family address the patient’s physical needs. 5,000.

TESTICULAR CANCER ETIOLOGY AND RISK FACTORS

Testicular cancer is the most common The etiology of testicular cancer is

malignancy in men aged 15-35, although it UNKNOWN, but certain conditions are
 NCM 3115b: Related Learning Experience III

associated with an increased incidence of this

malignancy. CLASSIFICATION
Specifically, testicular tumors are more likely
to occur in an atrophic testis or a cryptorchid General tumor categories include:
(undescended) testis. 1. Germ Cell Tumors (GCTs)
The relative risk of testicular cancer in ● Seminomas
patients with cryptorchidism is thought to be 5 ● Embryonal Cancers
times the normal expected risk. ● Teratomas
Family history of testicular cancer is ● Choriocarcinomas
associated with 3 to 12 times the average ● Yolk sac tumors
risk, history of a prior germ cell testicular 2. Sex cord-stromal or gonadal stromal tumors
tumor is associated with 23 to 27 times the 3. Mixed germ and stromal cell tumors
risk. 4. Adnexal and Para testicular tumors
5. Other malignancies such as mesothelioma
and lymphoma
PREVENTION, SCREENING, AND DETECTION
6. Additionally, the testes may be the site of
metastatic disease.
Prevention of testicular cancer is not a
7. Approximately 95% of all testicular tumors
reasonable expectation because the etiologic
are GCTs originating in the primordial germ
factors are unknown.
cells essential for spermatogenesis.
The American Cancer Society recommends
8. Testicular Cancer is broadly divided into 2
annual professional testicular examination
groups:
and monthly testicular self-examination (TSE)
● Pure form
Both seminomas and nonseminomatous ● A mixture of cell types
GCTs (germ cell tumors) are preceded by a
premalignant condition termed intratubular
DIAGNOSIS AND CLINICAL FEATURES
germ cell neoplasia of unclassified type
(ITGCNU), testicular intraepithelial neoplasia,
The classic presentation of a testicular
or carcinoma in situ (CIS). This premalignant
tumor is a small, painless mass ranging from
condition (ITGCNU) has been found in
7 millimeters to centimeters, and confined to
testicular tissue adjacent to GCTs in
one testicle.
approximately 90% of adult cases. Left
Patients may first be seen with diffuse pain,
untreated, the risk of progression to invasive
swelling, or firmness of the testis.
testicular cancer in 5 years is 50%.
Acute pain is rare and maybe caused by
TESTICULAR SELF-EXAM: epididymitis. Abdominal pain may be related
1. Cup one testicle at a time using both hands to retroperitoneal node metastasis.
best performed during or after a warm bath A trial antibiotic therapy is sometimes
shower. prescribed on the initial presentation if no
2. Examine by rolling the testicle between your discrete mass is noted.
thumb and fingers. Use light pressure. Definitive diagnosis is only established by
3. Familiarize yourself with the spermatic cord biopsy. Biopsy is obtained via a radical
and epididymis–tube-like structures that orchiectomy through inguinal incision.
connect on the back side or each testicle. Seminomas grow more slowly and have
4. Feel for lumps, change in size or lymphatic involvement, whereas
irregularities. It is normal for one testis to be nonseminomas tend to progress more rapidly
slightly larger than the other. and have marked hematologic spread.
Common sites of distant metastasis include:
 NCM 3115b: Related Learning Experience III

➔ Lungs (most common) cessation and education, and education

➔ Bone (late) regarding prevention of HPV infection.
➔ Liver No screening methods are in place other than
➔ Lymph periodic physical examination by a health
professional.
STAGING
CLINICAL FEATURES
Both clinical examination and radical
orchiectomy are required for clinical staging. Clinical presentation of penile cancer is
variable and can range from a small papule
TREATMENT MODALITIES AND NURSING CARE or a pustule to an extensive fungating wound.
CONSIDERATIONS Patients generally arrive to be seen for
SEMINOMA THERAPY evaluation of nonhealing ulceration, and may
NURSING CONSIDERATIONS: experience burning or itching under foreskin.
If neglected, lesions will progress and
Discussions regarding concerns about body foul-smelling discharge may be seen exuding
image and sexuality should be encouraged. from beneath a phimotic nonretractive
Reassurance is needed that potency is not prepuce.
permanently impaired. Although metastasis is rare in the absence of
RT to the peritoneal area is generally well lymphatic involvement, metastatic sites
tolerated. include the liver, lungs, bone, and the brain.
Aggressive treatment with antiemetic therapy Lesions must be differentiated from those of
is essential. sexually transmitted infectious disease.
Patients should increase fluid intake and
begin a low-residue diet that is high in protein DIAGNOSIS
and carbohydrates.
Foods and beverages that increase Diagnosis is established by incisional
gastrointestinal motility should be eliminated. biopsy.
Measures should be taken to prevent Evaluation includes urethroscopy and
infection and bleeding from cavernosography with contrast media.
chemotherapy-induced myelosuppression. Ultrasound examination and MRI are also
used to view the adjacent structures.
PENILE CANCER Lymph nodes are assessed by direct
EPIDEMIOLOGY palpation, with fine needle aspirations
performed on suspicious nodes.
Penile carcinoma is a rare disease in
industrialized countries. TREATMENT MODALITIES AND NURSING CARE
Indicate rates are higher in less developed CONSIDERATIONS
countries accounting for 10-20% of all
malignancies. SURGERY:
● Penile carcinoma is basically a local and/or
PREVENTION, SCREENING, AND DETECTION regional disease with a low incidence of
distant metastasis. The aim of the treatment
Preventive measures include circumcision is complete removal of the tumor while
and the prevention of phimosis, treatment of maintaining a reasonable QOL.
chronic inflammatory conditions, limiting ● Partial or total penile amputation is the gold
photochemotherapy treatment, smoking standard of therapy.
 NCM 3115b: Related Learning Experience III

● Conservative treatment with Mohs Bladder carcinoma is the most common

Micrographic Surgery (MMS) is also used; it malignant tumor of the urinary tract, with
involves the systematic excision of cancerous approximately 63,210 new cases and 13,180
tissue under complete microscopic control. deaths anticipated in the United States in the
● Laser surgery represents another form of year 2005.
less invasive management and is routinely The American Cancer Society’s estimates for
performed for superficial lesions, bladder cancer in the United States for 2021
precancerous lesions, and CIS. are:
● Nursing management is aimed at the ➔ About 83,730 new cases of bladder
prevention and treatment of surgical cancer (about 64,280 in men and
complications. 19,450 in women)
● Additionally, the psychosocial implications of ➔ About 17,200 deaths from bladder
surgery cannot be overemphasized. cancer (about 12,260 in men and
● Assisting patients and their partners to adjust 4,940 in women)
to major body image alterations may require Bladder cancer is the FOURTH most
referral for counselling. common cancer in men, but it’s less in
women.
RADIOTHERAPY:
● External beam and brachytherapy are used.
ETIOLOGY AND RISK FACTORS
● Circumcision is performed prior to
brachytherapy.
Exposure to dyes - e.g., long exposure to hair
● Brachytherapy - uses iridium-192 silicone
dyes
mold.
Cigarette Smoking - most significant risk
● The device is generally worn for 8 to 10 hours
factor
daily and is removed during micturition and
nursing care. High consumption of fried meats and fats
● High doses are required for squamous cell Exposure to certain drugs such as phenacetin
carcinomas and result in frequent, significant and cyclophosphamide
complications including edema, secondary Pelvic radiation
infection, and urethral mucositis. Parasitic infection with Schistosoma
● Nursing management of these anticipatable haematobium
side effects is crucial and mainly focused on Recurrent UTI
pain management and education regarding
hygiene and the necessity to take antibiotic PREVENTION, SCREENING, AND DETECTION
therapy as directed.
SMOKING CESSATION is the key factor in
CHEMOTHERAPY: risk reduction
● Squamous cell penile tumors do respond to Identification of persons at high risk because
chemotherapy, although randomized control of environmental and work exposure is also a
trials are generally lacking in this area. priority.
● Nursing care aimed at the minimization of
Urine cytology may be of screening value in
distressing side effects, including nausea and
industrial settings and can be used to detect
vomiting is essential.
lesions at an early stage

BLADDER CANCER
CLASSIFICATION
EPIDEMIOLOGY
 NCM 3115b: Related Learning Experience III

TNM system is the most commonly Chest x-ray, abdominal CT scan and MRI.
employed staging tool. Bone scan may be necessary to rule out
Urothelial carcinoma (formerly called metastatic disease.
transitional cell carcinoma) is the most
common carcinoma of the bladder in the NONINVASIVE TUMORS
US (90% of Cases).
The remainder of bladder cancers are These cancers are only in the lining of the
squamous cell carcinoma (5%) and bladder. They may be called non-invasive
adenocarcinomas (less than 1%) (Stage 0), or minimally invasive (stage 1)
Bladder cancer can also be described as bladder cancers. They have not spread into
either low grade or high grade. deeper layers of the bladder wall muscles or
Low grade bladder cancer means that your to other parts of the body. Intravesical
cancer is less likely to grow, spread and chemotherapy is used for these early-stage
come back after treatment. High grade cancers because drugs given this way mainly
means your cancer is more likely to grow, affect the cells lining the inside of the bladder.
spread and come back after treatment. Most patients have been managed with
transurethral resection (TUR) and fulguration
CLINICAL FEATURES using electrical current or laser, with or
without intravesical therapy.
Most common presenting sign is – GROSS Intravesical therapy has been found to be
HEMATURIA. Often described as painless. more effective than TUR alone in preventing
Obstructive symptoms are associated with tumor reccurence.
large tumor burden or metastases. There are two types of intravesical therapy:
Tumor pushing on the urethral orifice may ➔ Immunotherapy
cause urinary hesitancy or decrease in ➔ Chemotherapy
stream force.
CHEMOTHERAPY IVT
Flank pain may be caused by hydronephrosis
➔ Uses a liquid chemotherapy drug such as
if urethral obstruction occurs.
mitomycin C, gemcitabine, or valrubicin.
Back pain, rectal pain, or suprapubic pain
may suggest metastatic disease.
IMMUNOTHERAPY IVT
➔ Uses BACILLUS CALMETTE-GUERIN
DIAGNOSIS
(BCG), an immunotherapy drug that is a
weakened, non-infectious form of the bacteria
Microscopic Urinalysis that causes tuberculosis.
Cystourethroscopy – used to verify the ➔ Placing BCG directly into the bladder triggers
presence of a bladder tumor and to your immune system to attack the cancer
characterize its gross appearance and as a cells and may stop their future growth, too.
means of obtaining a biopsy specimen. ➔ BCG treatment may be repeated once a
Urinary Cytology week for six weeks followed by monthly
Evaluation of the upper tracts (CT scan of the maintenance treatment for up to three years.
pelvis and abdomen with intravenous
pyelography) MAIN TYPES OF URINARY DIVERSION:
Flow Cytometry - a technique that allows
examination of the DNA content of cells 1. BLADDER CATHETERIZATION
within the urines is used for providing ➔ Involves inserting a thin, flexible tube called
information for staging and grading purposes. “catheter” into the bladder to drain urine. The
 NCM 3115b: Related Learning Experience III

urine drains into a collection bag outside the 6. CUTANEOUS URETEROSTOMY

body. Two types of urinary catheters include: ➔ A surgeon attaches one or both ureters
★ FOLEY CATHETER: inserted into the directly to a stoma in your abdomen.
bladder through the urethra.
★ SUPRAPUBIC CATHETER: inserted into 7. CONTINENT URINARY DIVERSION
the bladder through a small hole in the ➔ Continent urinary diversion collects and
skin beneath the belly button stores urine inside the body until you drain
the urine using a catheter or you urinate
2. CYSTOSTOMY through the urethra. The urine flows through
➔ Is a surgical procedure where a doctor inserts the ureters and is stored in an internal pouch
a small tube into your bladder through the created from part of your bowel or in your
skin of the lower abdomen. The tube allows bladder. Continent urinary diversion allows
urine to drain from your bladder into a bag you to control when urine leaves your body.
outside your body.
The main types of continent urinary diversion
3. NEPHROSTOMY include:
➔ Similar to cystostomy, during a nephrostomy,
a surgeon or radiologist makes a tiny incision ★ CONTINENT CUTANEOUS RESERVOIR:
and inserts a small tube called “nephrostomy A surgeon uses a piece of your bowel to
tube” through the skin of your back into your create an internal pouch, or reservoir, to
kidney. hold urine. The internal pouch is placed
➔ The nephrostomy tube allows urine to drain inside your abdomen. The ureters are
from your kidney into a bag outside your attached to the internal pouch, and the
body. internal pouch is attached to a stoma in
your abdomen. Urine flows through the
4. URETERAL STENT ureters and into the internal pouch, where
➔ A ureteral stent is a thin flexible tube that is it is stored until you drain the urine by
inserted into the ureter to help urine flow from inserting a catheter into the stoma. The
the kidney to the bladder. The ureteral stent is stoma is the end of a channel that
guided with a cystoscope into your ureter, connects to the reservoir. The channel has
then one end of the stent is placed in the a valve that prevents urine from exiting the
kidney and the other end is placed in the body until a catheter is inserted. The
bladder. channel can be created from a piece of
➔ You may need a ureteral stent if one of your intestine or by using the appendix.
ureters is blocked as a result of surgery, a
kidney stone, a tumor, or infection. A ureteral ★ BLADDER SUBSTITUTE: A surgeon
stent is usually temporary but, in some cases, uses a piece of your bowel to create an
can be used to permanently manage a internal reservoir, called a bladder
blockage of the ureter. substitute or neobladder, to hold urine. The
bladder substitute is placed in the pelvis.
5. ILEAL CONDUIT The ureters are attached to the bladder
➔ A surgeon removes a piece of your intestine substitute, and the bladder substitute is
to create a passageway for urine. The ureters attached to the urethra. Urine flows
are attached to the piece of intestine, then the through the ureters, into the bladder
intestine is attached to an opening in your substitute, and you urinate through the
abdomen, creating a stoma. The urine flows urethra.
from the ureters, through the piece of
intestine, and out the stoma.
 NCM 3115b: Related Learning Experience III

BLADDER PRESERVATION THERAPIES ● There is a marked male predominance with

1.5 cases in men for every 1 case in women.
Bladder preservation strategies include:
➔ External beam radiotherapy PREVENTION SCREENING AND DETECTION
➔ Multimodality therapy (TUR, RT and
systemic chemotherapy) ● Identification of certain etiologic factors,
lifestyle or environmental modification:
Concurrent radiotherapy and
chemotherapy with cisplatin is the most 1. Encouraging cessation of tobacco use.
studied regimen. 2. Avoidance of developing a tobacco habit in
youth.
RENAL CELL CANCER 3. Stressing dietary modification to decrease or
EPIDEMIOLOGY limit high fat content.
4. Genetic counselling for persons with multiple
Kidney cancer is relatively rare in the United affected relatives
States.
The American Cancer Society's most recent CLASSIFICATION AND STAGING
estimates for kidney cancer in the United
States for 2021 are: The AJCC TNM STAGING SYSTEM is the
➔ About 76,080 new cases of kidney primary system for staging renal carcinoma.
cancer (48,780 in men and 27,300 in Of renal cancers, 90% are renal cell
women) will be diagnosed. carcinomas; and of these, 85% are of the
➔ About 13,780 people (8,790 men and clear cell variety.
4,990 women) will die from this disease
These numbers include all types of kidney
and renal pelvis cancers.
Most people with kidney cancer are older.
The average age of people when they are
diagnosed is 64 with most people being
diagnosed between ages 65 and 74. Kidney
cancer is very uncommon in people younger
than age 45. CLINICAL FEATURES
Kidney cancer is about twice as common in
Renal cell carcinomas generally remain
men than in women and it is more common in
clinically occult until signs of metastasis
African Americans and American Indian
prompt diagnostic evaluation.
/Alaska Natives.
The classic triad of pain, hematuria, and
ETIOLOGY AND RISK FACTORS flank mass is noted in less than 10% of
patients and signals advanced disease.
● The etiology of renal cancer is UNKNOWN. Approximately one third of patients have
● Some factors have been examined including metastases at diagnosis.
obesity, dietary fat intake, tobacco use, The most common sites for non lymphatic
phenacetin use, and occupational exposures metastases are lung, bone, liver, adrenals
to asbestos and petroleum. and brain.
● The highest incidence occurs in the sixth Renal cell carcinoma, are known to secrete
decade of life. hormones, including parathyroid hormone
 NCM 3115b: Related Learning Experience III

and erythropoietin, resulting in PROGNOSIS

hypercalcemia and erythrocytosis.
Hypertension is often encountered and may ➔ Unfortunately, the prognosis for any patient
be mediated by tumor secretion of renin. with treated renal cancer who has relapsing,
recurring, or progressing diseases regardless
DIAGNOSIS of stage or cell type is poor.

● Early-stage renal cell cancer is usually ★ Five-year survival for all stages is 64%.
"silent" and is coincidentally detected when ★ Five-year survival for organs containing
the patient is undergoing work-up for a local diseases is 91%.
non-cancer related procedure such as
cardiac angiography or gallbladder PANCREATIC CANCER
ultrasound. EPIDEMIOLOGY
● Kidney, ureters, and bladder radiography is
performed before and after intravenous ● Pancreatic cancer is the second most
pyelography. Renal ultrasounds and pelvic common Gl cancer and the fourth leading
and abdominal CTs are also employed. cause of cancer death in the United States.
● CT-guided fine-needle biopsy is the current ● Cancers of the pancreas fall into two main
diagnostic standard. categories:
● There is no known tumor or molecular marker 1. Those arising in the Exocrine
to confirm diagnosis, progression, or relapse Parenchyma
at this point. 2. Those arising in the Endocrine cells
of the islets of Langerhans
TREATMENT MODALITIES AND NURSING CARE ● The term pancreatic cancer usually refers to
CONSIDERATIONS cancer of the exocrine pancreas.

● Radical nephrectomy includes the excision of HOW COMMON IS PANCREATIC CANCER?

the kidney, the surrounding lymph nodes, fat, The American Cancer Society's estimates for
and the fascia, as well as the adrenal gland pancreatic cancer in the United States for
on the affected side. 2021 are.
● Nephrectomy remains the standard of care About 60,430 people (31,950 men and
for patients with stage III renal disease. 28,480 women) will be diagnosed with
● The focus of care for patients with stage IV pancreatic cancer.
disease is palliation.
About 48,220 people (25,270 men and
● Renal cell carcinomas are unresponsive to
22,950 women) will die of pancreatic cancer.
radiotherapy; however, RT is indicated for the
Pancreatic cancer accounts for about 3% of
palliative management of skeletal tumors.
all cancers in the US and about 7% of all
● Nursing management focuses on
cancer deaths.
preoperative and postoperative teaching to
minimize complications. It is slightly more common in men than in
● Pain management is a top priority. women.
● Postoperative bleeding is a significant risk
because of the highly vascular nature of the ETIOLOGY AND RISK FACTORS
kidney.
● Post operative teaching focuses on 1. Cigarette smoking - strongest environmental
protecting the function of the remaining factor, accounts for 30% of pancreatic
kidney. cancers
2. Diabetes mellitus
 NCM 3115b: Related Learning Experience III

3. Chronic pancreatitis DIAGNOSIS AND STAGING

4. Dietary factors - high fat and meat, low in
fruits and vegetables ● Since complete surgical resection of the
5. Obesity tumor with negative margins offers the only
6. Familial genetic alterations chance of long-term survival, it is vital to
correctly identify those patients with operable
PREVENTION, SCREENING, AND DETECTION cancers.
● If the tumor cannot be totally resected,
● Avoiding cigarette smoke surgery does not offer any surgical
● Maintaining a healthy weight by consuming a advantage.
diet low in fat and high in fruits and ● Mutietector, multiphase helical CT is the
vegetables optimal study for clinical staging of pancreatic
● Engaging in regular physical activity cancer.
● CA 19-9 a tumor-associated serum antigen ● The objectives of CT are to evaluate for the
elevated in 70% to 90% of pancreatic presence of a primary tumor in the pancreas
adenocarcinomas, has a relatively low or periampullary area, identify the presence
specificity. It is often used in monitoring of peritoneal or liver metastasis, and evaluate
response to therapy. the relationship of the tumor to local
structures such as the superior mesenteric
CLASSIFICATION vein (SMV), the portal vein (PV), the superior
mesenteric artery (SMA), the celiac axis, the
● Of cancers involving the pancreas, 95% arise hepatic artery, and the gastroduodenal artery.
from exocrine cells, and ductal ● Laparoscopy may be added to the staging
adenocarcinoma accounts for 90% of work-up in an effort to further define those
these. patients who will benefit from laparotomy. The
● Less common types of exocrine cancers purpose of laparoscopy is to detect extra
include acinar cell carcinoma, pancreatic tumors not seen on CT scans.
cystadenocarcinomas, mixed If a mass is not seen on contrast-enhanced
adenosquamous tumors, sarcomas, and CT, patients undergo endoscopic
lymphomas. ultrasound and/or endoscopic retrograde
● Two thirds of these adenocarcinomas occur cholangiopancreatography (ERCP).
in the head of the pancreas and the ● The ALCC has recently updated the staging
remainder in the body and tail. system for pancreatic cancer based on tumor
size and extension, regional lymph node
CLINICAL FEATURES involvement, and presence of distant
metastasis using the TNM system.
Sign or Symptom Percentage of Patients
Abdominal Pain 80 HOW IS STAGE DETERMINED?
Anorexia 65 ● The stage of a pancreatic cancer is
Weight Loss 60 determined by three factors: T, N, and M in
Early Satiety 60 a common system used by doctors to stage
Sleep Problems 55
pancreatic tumors. A value is assigned for
Jaundice 50
each of these factors based on the diagnostic
Fatigue 45
Weakness, nausea, or 40 test results. T, Nand M values are then added
constipation up to determine stage.
Depression 40
Ascites 25 ★ T = size and local extent of the tumor
 NCM 3115b: Related Learning Experience III

★ N = evidence of metastases (spread) in staging refers to whether or not the cancer

lymph nodes close to the pancreas has spread to these lymph nodes.
★ M = evidence of distant metastases (spread
of the cancer far from the pancreas N (Regional What It Means
Lymph Nodes)
STAGE IS THE MEASURE OF HOW FAR THE N0 No regional lymph nodes metastasis
CANCER HAS SPREAD: (cancer has not spread to the lymph
➔ Clinicians determine the size and extent of nodes)
the cancer using a combination of biopsy N1 Metastasis (tumor spread) in one to
results and clinical tests such as imaging (CT three lymph nodes
scans). N2 Metastasis (tumor spread) in four or
more regional lymph nodes
● Stages I, Il, III: Cancer is confined to the NX Regional lymph nodes cannot be
pancreas and the immediate surrounding assessed.
=area
● Stage IV: Cancer has spread to other organs M (Metastasis)
➔ The treatment of pancreatic cancer is
T (Tumor) is assigned based on the size of different if the cancer has spread
the tumor (measured in centimeters) and the (metastasized) beyond the pancreas and
extent (whether or not it involves major blood beyond the lymph nodes immediately around
vessels) the pancreas. In general, surgery is not
pursued for patients with metastatic
T (Tumor) What It Means pancreatic cancer. Instead, most patients with
T0 No evidence of primary tumor metastatic pancreatic cancer are treated with
Tis In situ carcinoma combination chemotherapy.
➔ When pancreatic cancer metastasizes, it
TI Tumor < 2cm (2 cm or 0.8 inches or
smaller) often spreads to the liver and/or to the lungs.

T2 Tumor > 2cm and < 4cm in the

★ Liver: Metastases to the liver are a
greatest dimension (tumors between
0.8 and 1.6 inches in size common finding especially with
tumors in the tail and the body of the
T3 Tumor > 4cm in greatest dimension
pancreas. Usually, if there is evidence
(tumors bigger than 1.6 inches)
of liver "mets”, surgery is usually not
T4 Tumor involves the blood vessels of an option. Recently, however, some
the celiac axis or superior mesenteric
surgeons do remove liver metastases
artery (unresectable primary tumor)
("oligometastatic disease') that have
TX Primary tumor cannot be assessed.
been stable or have shrunk after a
year of treatment.
N (Regional Lymph Nodes): ★ Lungs: Spread (metastases) to the
➔ Lymph nodes are small collections of lungs can occur in the setting of
immune cells. Lymph nodes are present widespread disease, or in isolation.
throughout our body. Several studies have found that some
➔ They help us fight off infections and other patients with isolated lung metastases
diseases. When pancreatic cancer spreads live longer than do patients with
beyond the pancreas, cancer cells can isolated liver metastases.
deposit in the lymph nodes normally found
around the pancreas. The "N" designation of
 NCM 3115b: Related Learning Experience III

M (Metastasis) What It Means SURGERY\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\t

M0 Not metastasized
● Two thirds of pancreatic cancers occur in the
M1 Metastasized
head of the pancreas. Patients with operable,
localized disease on staging evaluation will
Overall stage is determined by combining all the
undergo curative resection with
information on T, N, and M
pancreaticoduodenectomy (Whipple
procedure). This involves the removal of the
Stage T N M pancreatic head, the gallbladder, the common
bile duct, the duodenum, the distal stomach,
Stage 0 Tis N0 M0
and regional lymph nodes.
Stage IA TI N0 M0 ● A series of three anastomoses are then
performed to reestablish gastrointestinal
Stage IB T2 N0 M0 integrity; the first between the pancreatic
remnant and the jejunum, a second between
Stage IIA T3 N0 M0
the bile duct and the jejunum, and a third
Stage IIB TI NI M0 between the stomach pouch and the jejunum.
T2 NI M0 ● Gastrostomy and feeding jejunostomy tubes
T3 NI M0 may be placed to relieve gastric distention
and provide nutritional support.
Stage III T1 N2 M0
T2 N2 M0
T3 N2 M0 ➔ There are serious postoperative
T4 any N M0 complications following
pancreaticoduodenectomy; therefore, surgery
Stage IV any T any N MI should only be attempted when there is a
reasonable chance of complete tumor
MEDICAL TREATMENT MODALITIES AND resection.
NURSING CARE CONSIDERATIONS ➔ Operative mortality and morbidity are
inversely associated with surgical volume of
● Pancreatic cancer continues to be the most this procedure.
difficult of all the GI cancers to treat.
● Surgery, as part of a multimodality approach, ● Post operative complications include
is the only potentially curative treatment. pancreatic fistulas, intra abdominal
● Unfortunately, early symptoms are vague and abscesses due to leakage of pancreatic
nonspecific and do not become severe until anastomosis, and Gl or drain tract bleeding.
the cancer invades adjacent organs or ● Long-term complications include delayed
metastasizes. Fewer than 20% of patients gastric emptying, diabetes, and pancreatic
meet the criteria for curative surgery. insufficiency
● Both chemotherapy and radiation therapy ● Nursing care of surgical patients with
are being used as neoadjuvant and pancreatic cancer focuses on monitoring for
adjuvant therapy in operable patients and as and managing postoperative complications.
definitive treatment in locally advanced Bleeding, infection, anastomotic leaking,
disease. Patients with metastatic disease are blood sugar and electrolyte disturbances, and
generally offered systemic treatment with nutritional deficiencies can all be catastrophic
chemotherapy. for patients if not identified and managed
early.
 NCM 3115b: Related Learning Experience III

● Pain control, management of GI symptoms, nurses must be familiar with protocols for
and nutritional support are also priority prevention and management of these
nursing considerations. problems.
CHEMOTHERAPY

● Although pancreatic cancer remains a

relatively chemo resistant disease, with
single-agent objective response rates below
25%, most patients will receive some form of
systemic therapy.
● Neoadjuvant therapy chemotherapy or
chemoradiotherapy may be used in
potentially resectable disease; the hope is to
shrink the tumor and eliminate micro
metastases.
● The standard of care has been 5-FU-based
chemotherapy. This therapy is still used,
especially when combined with radiation
therapy.
● Gemcitabine is currently considered the
standard of care for advanced disease.
Gemcitabine is also offered as adjuvant
treatment for patients who have undergone
surgical resection with negative margins. This
drug was approved based on clinical benefit
response (CBR) rather than tumor shrinkage.
● CBR is a comprehensive assessment of
quality of life and considers such factors
such as pain control, performance status, and
weight gain to evaluate treatment benefit in
patients with advanced pancreatic cancer.
● Many chemotherapy agents have been
combined with gemcitabine, including
cisplatin, oxaliplatin, docetaxel, 5-FU, and
irinotecan, with response rates for the
cisplatin and oxaliplatin combination up to
36%, although no definitive benefit has been
established.
● Nursing management of patients receiving
systemic therapy for pancreatic cancer is
similar to that for HCC (Hepatocellular
carcinoma). In addition, gemcitabine therapy
can cause flu-like symptoms.
● Cisplatin can be renal-toxic and so
necessitates adequate hydration and
monitoring of kidney function and electrolytes.
Also, severe infusion-related reactions are
possible with monoclonal antibodies, so