Textbook of Medical-Surgical Nursing 3e

238

Unit 3   Applying concepts from the nursing process

for prophylactic surgical procedures. For example, a strong family history of breast cancer, positive BRCA-1 or BRCA-2 findings, an abnormal physical finding on breast examination such as progressive nodularity and cystic disease, a proven history of breast cancer in the opposite breast, abnormal mam- mography findings and abnormal biopsy results may be factors con­sidered in making the decision to proceed with a prophy­ lactic mastectomy (Calhourn & Anderson, 2006). Prophylactic surgery is offered selectively to patients and discussed thoroughly with the patient and family because the long-term physiological and psychological effects are unknown. Preoperative teaching and counselling, as well as long-term follow-up, are provided. Palliative surgery When cure is not possible, the goals of treatment are to make the patient as comfortable as possible and to promote a satis- fying and productive life for as long as possible. Whether the period is extremely brief or lengthy, the major goal is a high quality of life—with quality defined by the patient and family. Honest and informative communication with the patient and family about the goal of surgery is essential to avoid false hope and disappointment. Palliative surgery is performed in an attempt to relieve complications of cancer, such as ulcerations, obstructions, haemorrhage, pain and malignant effusions. It may include the insertion of central venous access devices, feeding tubes, stabili­sation of bones, stenting and bypassing procedures, or tumour debulking (Table 11-6). Reconstructive surgery Reconstructive surgery may follow curative or radical surgery and is carried out in an attempt to improve function or obtain a more desirable cosmetic effect. It may be performed in one operation or in stages. Patients are informed about possible reconstructive surgical options before the primary surgery by the surgeon who will perform the reconstruction. Reconstructive surgery may be indicated for breast, head and neck, and skin cancers. The nurse must recognise the patient’s needs and the impact that altered functioning and altered body image may Table 11-6  Indications for Palliative Surgical Procedures Procedure Indications Pleural drainage tube placement Pleural effusion Peritoneal drainage tube placement Ascites (Tenckoff catheter) Abdominal shunt placement Ascites (Levine shunt) Pericardial drainage tube placement Pericardial effusion Colostomy or ileostomy Bowel obstruction Gastrostomy, jejunostomy tube Upper gastrointestinal placement   tract obstruction Biliary stent placement Biliary obstruction Ureteral stent placement Ureteral obstruction Nerve block Pain Cordotomy Pain Venous access device placement (for Pain administering parenteral analgesics) Epidural catheter placement (for Pain

have on quality of life. Providing the patient and family with opportunities to discuss these issues is imperative. The needs of the individual must be accurately assessed and validated in each situation for any type of reconstructive surgery. Nursing management in cancer surgery Patients undergoing surgery for cancer require general peri­ operative nursing care, as described in Unit 4, along with specific care related to the patient’s age, organ impair- ment, nutritional deficits, disorders of coagulation and altered immunity that may increase the risk for postoperative com- plications. Combining other treatment methods, such as radiation and chemotherapy, with surgery also contributes to postoperative complications, such as infection, impaired wound healing, altered pulmonary or renal function, and the development of deep vein thrombosis. In these situations, the nurse completes a thorough preoperative assessment for all factors that may affect patients undergoing surgical procedures. The patient undergoing surgery for the diagnosis or treat- ment of cancer is often anxious about the surgical procedure, possible findings, postoperative limitations, changes in normal body functions and prognosis. The patient and family require time and assistance to deal with the possible changes and outcomes resulting from the surgery. The nurse provides education and emotional support by assessing patient and family needs and exploring with the patient and family their fears and coping mechanisms, encour- aging them to take an active role in decision making when possible. When the patient or family asks about the results of diagnostic testing and surgical procedures, the nurse’s response is guided by the information the doctor previously conveyed to them. The patient and family may also ask the nurse to explain and clarify information that the doctor initially provided but that they did not grasp because they were anxious at the time. It is important for the nurse to communicate frequently with the doctor and other healthcare team members to be certain that the information provided is consistent. After surgery, the nurse assesses the patient’s responses to the surgery and monitors for possible complications such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction. The nurse also provides for patient comfort. Postoperative teaching addresses wound care, activity, nutrition and medi­cation information. Plans for discharge, follow-up and home care, and treat- ment are initiated as early as possible to ensure continuity of care from hospital to home or from a cancer referral centre to the patient’s local hospital and healthcare provider. Patients and families are also encouraged to use community resources such as the Australian Cancer Council and the New Zealand Cancer Society and local support groups. Radiation therapy In radiation therapy , ionising radiation is used to interrupt cellular growth. More than half of patients with cancer receive a form of radiation therapy at some point during treatment. Radiation may be used to cure the cancer, as in Hodgkin’s disease, testicular seminomas, thyroid carcinomas, localised cancers of the head and neck, and cancers of the uterine cervix. Radiation therapy may also be used to control malig- nant disease when a tumour cannot be removed surgically or when local nodal metastasis is present, or it can be used

administering epidural analgesics) Hormone manipulation (removal of ovaries, testes, adrenals, pituitary)

Tumours that depend on   hormones for growth