BUKOVINIAN STATE Medical university
DEPARTMENT OF PATIENTS CARE AND
HIGHER NURSE EDUCATION
on the methodical conference of department
of patients’ care and higher
“ ” ________ 200_ protocol N __
Chief of department, associate professor I.A. Plesh
FOR SELF-PREPARATION OF STUDENTS
TO PRACTICAL CLASS №21
CARE OF THE ONCOLOGICAL PATIENTS.
nursing in surgery
for 3nd year students
of medical faculty №4,
specialty "nurse business''
Methodical instruction was prepared by:
Assistant Riabyi S.I.
Chernivtsi - 2010
1. Topic: CARE OF THE ONCOLOGICAL PATIENTS.
(Introduction in onological process. Classification of tumors. General characteristic of benign and malignant tumors. Clinics and nurse’s diagnostic of tumors. General notion about radical and palliative treatment of malignant tumors. Nurse’s tactics in case of cancer suspicion. Participation of nurse in general prophylactic medical examination of population. Introduction in precancerous stages. Peculiarities of care and dialogue with oncological patients).
3. Study aim:
3.1. The student should know:
concept about tumors.
kind of tumors.
general characteristic of benign tumors.
general characteristic of malignant tumors.
clinics of tumors.
nurse’s diagnostic of tumors.
general notion about radical and palliative treatment of malignant tumors.
participation of nurse in general prophylactic medical examination of population.
introduction in precancerous stages.
peculiarities of care and dialogue with oncological patients).
to make the individual circuit of diagnostic search;
to analyse results of objective research;
to determine a role and a place of laboratory-instrumental diagnostics in formation of the diagnosis;
to plan and prove the plan of individual treatment;
to offer the basic methods of prophylaxis of occurrence of tumors.
to carry out wet cleaning operational and dressing rooms;
to carry out the control of quality of cleaning of a surgery block;
to prepare toolkit for sterilization.
to prepare a little table for instruments and a dressing material;
to assist during dressings;
to perform work of the dressing-room nurse.
examination of patients with tumors;
dressing patients with tumors;
participation in mammography, fluorography, endoscopy, KT;
assistance during puncture, biopsy.
Advice for students:
A tumour is a new growth of cells which fulfills no useful function. The term "tumour" should be reserved for new growths, and should not be applied to inflammatory swellings. Tumours can be benign or malignant.
Causation. Both benign and malignant tumours are due to excessive replication of cells. This may occur either as a result of diminished restraint of cell replication or of increased stimulus to cell reproduction. Normal processes of cell division are controlled by genes protooncogenes: if these are altered to oncogenes, abnormal unrestrained cell growth results and a tumour forms, i.e. progress from normal cell growth to neoplasia represents a change from controlled to uncontrolled growth. The agents which promote this change are called tumour inducers, while those that prevent it are tumour suppressors. Causes of neoplastic change 1. Genetic Retinoblastoma, familial adenomatous polyposis.
2. Environmental Gastric cancer in Japan.
3. Chemical Mesothelioma (asbestos), lung cancer (nicotine).
4. Viral Burkitt's lymphoma (Epstein-Barr virus).
5. Irradiation Malignant melanoma (ultraviolet rays).
6. Chronic irritation. Urothelial carcinoma (calculi), malignisation of stomach ulcer.
A benign tumour grows by expansion, and does not invade body tissues; a malignant tumour grows by invasion of surrounding tissues and in almost all cases is able to spread by metastases. Hypertrophy is an increase in the size of an organ without an increase in cell numbers. Hyperplasia is an increase in the size of an organ due to an increase in cell numbers. Metaplasia. The epithelium from which the tumour grows has already changed its characteristics, e.g. bladder transitional epithelium to squamous epithelium, gallbladder columnar to squamous epithelium, bronchial columnar to squamous epithelium, even gastric columnar epithelial pattern to intestinal epithelial pattern.
Anaplasia. Tumours are usually composed of cells which resemble those of the tissue from which they arise, but with rapid growth the resemblance is less obvious (anaplastic change).
The characteristics of malignancy are:
a) invasion of surrounding tissues;
b) pleomorphism (variable shapes) of cells;
c) rapid growth;
d) the tendency to spread to other parts of the body by the lymphatics
and the blood stream (metastasis);
e) general weight loss (cachexia).
Tumours are divided into groups, according to the tissues of which they consist:
a) epithelial: benign - papillomas (nipple-like), adenomas (glandular)
and cysts (bladder-like); maligant - cancers'(carcinomas);
b) connective tissue: benign - fibromas (consisting of connective tissue, lipomas (consisting of fatty tissue); malignant - sarcomas;
c) vascular: benign - angiomas;
d) muscular: benign - myomas;
e) neural: benign - neurinomas (nerve tumours) and gliomas (brain tumours);
f) mixed: benign and malignant;
g) complex tumours consisting of many tissues (teratomas).
Benign Epithelial Tumours
Papillomas or pediculate tumours are benign tumours of the skin and mucous membranes. Papillomas consist of a connective tissue base (pedicle) covered by multi - layered epithelium; on the skin they have a warty and petaloid appearance, and on the mucosa of the urinary bladder a villous appearance. Papillomas grow only in the direction of the free surface of the skin and mucosa. They produce a severe disease only when occurring in the urinary bladder where they cause haemorrhages. They grow slowly, but may degenerate malignantly. Skin papillomas can be treated surgically, whereas papillomas of urinary bladder are treated by electro-coagulation (through a cystoscope) owing to their tendency to relapse.
^ are glandular tumours whose epithelium lines lobate, tubular or bladder-like cavities (cysts). Many of these tumours are likely to develop into glandular cancer. Adenomas are found in all parts of the body where there are glands, but particularly frequently in glandular organs (mammae, ovaries, uterus) and on the mucous membranes of the nose and intestines. Glandular tumours usually grow slowly, but rapidly-growing forms produce metastases (malignant adenomas) and developing into cancer are also observed. Adenomas of the nasal and intestinal mucosa are pediculate tumours and are called polyps. In the nasal cavity they obstruct the nasal passages which renders respiration difficult, and support inflammatory processes in the nose. In the rectum polyps not infrequently ulcerate and produce haemorrhages.
Treatment: removal with a loop (in the nose) or excision together with the pedicle (in the rectum). Of the cystous forms we shall consider only dermoid cysts – saccate formations which develop because of immersion of small particles during fetal development. They are found on the head, neck and other parts of the body, and consist of a mixture of a dense membrane enclosing a gruel-like mass consisting of a mixture of skin fat and desquamated epithelial scales. These tumours grow slowly. Suppuration may be mentioned as one of the possible complications. Treatment: excision together with the capsule.
Traumatic epithelial cysts and cysts of the sebaceous glands (atheromas) externally resemble the preceding tumours. Atheromas often appear as a result of obstruction of the ducts of sebaceous glands (retention cysts), which leads to accumulation of the content, i. e., the same mass as in dermoids. The sac of an atheroma is the distended capsule of the sebasceous gland. Atheromas form in the thickness of the skin. A white or black point - obstructed duct of the sebaceous gland is not infrequently found on the top. Suppuration of the atheroma is a rather frequent complication.
Treatment - incision with curettage of the cavity in cases of suppuration and complete excision together with the capsule in noncomplicated cases.
^ are not infrequently found in the jaws, ovaries (ovarian cysts, sometimes of enormous sizes) and in a number of other glandular organs.
Maligant Epithelial Tumours
Cancerous tumours are of extraordinarily great importance. All that has been said about tumours, the peculiarities and malignancy of their growth pertains, in the first place, to cancerous tumours.
Primary cancer is found in all the organs of the human body where there is epithelium; it is capable of spreading by metastases to all organs without exception. The organs predominantly affected by cancerous diseases are the stomach, uterus, mammae, intestines, oesophagus, skin and lungs. Histologically planocellular and cylindrocellular cancers are distinguished. Changes in the epithelium, consisting in its acquisition of an atypical structure and its penetration into the underlying connective tissue, are considered signs of a cancerous tumour. The rapid growth of a cancerous tumour and its inadequate blood supply not infrequently condition degeneration of the tissue, in some places to the point of complete mortification and decomposition, which produces an ulceration of the tumour. A primary cancerous tumour develops mainly by multiplication of the original cancerous cells. The development of a cancerous tumour depends upon the general state of the body and the state of its nervous system. Subsequently the tumour spreads to surrounding tissue, affects the adjacent lymphatic vessels and produces metastases in the organs through the blood stream. This causes emaciation of the patients
(cachexia), etc. Outwardly cancer looks like a cicatrising tumour which shrinks and contracts the organ, for example the gland, or like a tumour with excessive tissue growth ,or, lastly, like an ulcer. The external appearance of cancer varies with the place and character of its development. Cancer of glands, for example, of the mammae, looks like a dense node which quickly adheres to the surrounding tissues and not infrequently shrinks the affected organ with cicatrices.
Cancer of the skin and cancer of the mucous membranes very rapidly ulcerate. These forms of cancer have a typical appearance of ulcers with dense, frequently undermined edges and a fatty, dirty floor covered with decomposed tissue . During its growth a cancerous tumour destroys all the adjacent tissues, sometimes extending from one organ to another (for example. from the oesophagus to the bronchi), destroys bones and leads to pathological fractures. A cancerous tumour at first spreads along the lymphatic vessels to the closest lymph nodes, but also penetrates into the blood vessels, producing distant metastases in different organs or general cancerous insemination. In cancer cachexia is usually very strongly pronounced; for example, in cancer of the stomach and much more slowly in cancer of the mammae, uterus, and skin. The course and duration of cancer vary with the place it affects - from several months to several years, a longer course taken only by some cancerous diseases of the skin and the mammae.
Fibromas are tumours resembling in structure dense connective tissue; they are found in almost all the organs of the body, but most frequently on the skin, in subcutaneous tissue, nerve trunks and in the uterus. In most cases they grow slowly and may grow to tremendous size (for example, fibromas of the uterus).
Lipoma are fatty-tissue tumours, usually lobate, sharply demarcated, with a dense capsule growing slowly, but sometimes to considerable size. They appear in any place and not infrequently are multiple. They are almost always benign and are easily removed surgically; no relapses are observed.
Chondromas - tumours made up of cartilaginous tissue and osteomas -tumours formed of bony tissue usually originate from the cartilages and bones of the skeleton. They develop slowly and may take a malignant course (chondrosarcomas and osteosarcomas). Sometimes these tumours are multiple. They produce considerable deformities, especially of the small bones. Their excision not infrequently disturbs the functions of the affected part.
Sarcomas. The structure of sarcomas varies rather widely and depends on the type of cells of which the tumour consists (round, spindleshaped and giant cells) and on the presence in the tumour of cells of the tissue from which the tumour has appeared(chondrofibrosarcoma and osteosarcomas). Sarcomas most frequently develop in young people, grow quickly, not infrequently attain large, distend the cutaneous vessels, grow through and destroy all surrounding tissues, including bones, and produce metastases through the lymphatic and, rather early, through the circulatory system. A permanent cure is possible only by removal of the tumour within the limits of healthy tissues, and on the limbs not infrequenly by amputation of the limb.
Angiomas are vascular tumours. They are very widespread and are of an inborn character. Sometimes they persist without enlarging all through life, for example, so-called birthmarks. In other cases they begin to grow, compress adjacent organs, thin out the skin or mucous membraneand not infrequently cause extensive hemorrhages. Arterial angiomas, venous angiomas (cavernous) and angiomas consisting of lymphatic vessels (lymphangiomas) are distinguished.
Myomas - tumours composed of muscular tissue, most frequently of the smooth muscle fibres of the internal organs; they are usually benign and grow slowly; sometimes their growth is arrested and they even diminish in size. Only myomas of the uterus grow to a large size These tumours are easily cured surgically and roentgenologically.
Neurinomas - tumours composed of nervous tissue, run a benign course, but may cause very intense pains. After their removal the sensitivity and mobility in the region innervated by the affected nerve are frequently disturbed.
Gliomas are tumours composed of cerebral tissue most frequently found in the crania! cavity. They are very dangerous because of their pressure on the brain; they grow rapidly, are removed with great difficulty and not infrequently produce relapses.
The most reliable method of treating tumours is their surgical removal, benign tumours being excised on the borders with the surrounding tissues and malignant tumours with considerable sections of the adjacent healthy tissues so as not to leave any parts of the tumour which have grown into the adjacent tissues. Such removal within the limits of healthy tissues does not completely guarantee that all the remnants of the tumour have been removed; the entire subcutaneous tissue with the lymphatic vessels and adjacent lymph nodes is usually removed together with the tumour.. If a tumour or lymph node have been incised accidentally, the instruments are immediately sterilized and, if the parts being removed have contacted the adjacent tissues, the latter are cauterised. Such an operation must prevent the tumour cells from gaining entrance into the wound and from developing (relapsing). In addition to operations of completely removing tumours (radical operations), a number of other operations are performed for cancer; these somewhat restore the functions disordered by the tumours (palliative operations), for example, making a fistula in the stomach to nourish patients whose oesophagus is obstructed by a cancerous tumour. Another method of treating tumours is that of using X-rays and radium. Treatment with X-rays is effective only in some cancers of the skin, fibromas and cancers of the uterus and cancers of the mammae, while treatment with radium is effective in the same cancers and in some cancers of the mucous membranes, for example, of the mouth and tongue.
During the past decade, it has become increasing apparent that cancer cells have acquired new antigens during neoplastic transformation that are not found in their normal counterparts. These antigens may be of many different types. Fetal antigens are those substances produced as a result of dedifferentiation and reversion of the cell to a primitive embryonic stale. These embryonic antigens are constituents of the normal fetus during embryonic development, but their production is repressed in the normal adult organ. The participation of the fetal antigens in terms of the tumourhost relationship is unclear. However, they probably have their greatest importance as a diagnostic tool to detect malignancy at its earlier stage before other diagnostic findings occur, or to detect recurrence of a neoplasm following surgical treatment and thereby provide the basis for further therapy. Human cancers, like animal neoplasms, appear to contain tumourassociated antigens that are capable of eliciting a specific immune response in the cancer patient. There is considerable clinical evidence that the cancer patient's immune response to these tumour-specific antigens is important in controlling the growth of his neoplasm. Some of these clinical observations that are readily explainable on an immune basis are:
1. There are well-documented instances of spontaneous regression or prolonged remissions of human neoplasms.
2. Immunodeficiency, either congenital or acquired, is associated with an increased incidence of cancer.
3. Cancer patients in whom immunodeficiency develops have more rapidly growing neoplasms and poor prognosis.
Lymphocytes specifically sensitized to tumour-specific antigens appear to be present at all stages of malignant disease. However, it is likely that their effectiveness in mediating inhibition of tumour cell growth is dependent upon circulating serum factors, which are probably antigen - antibody complexes or free antigens that inhibit the activity of sensitized lymphocytes. These blocking factors, found in the sera of patients with growing tumours, can be neutralized by specific antibodies frequently found in the sera of patients who are free of malignant disease. Thus, both cellular and humoral immune responses are probably important in controlling the growth of human cancer. Quantitative factors are very important in the tumour-host relationship, since immunity against cancer is relative rather than absolute. An immune response is quite effective for destroying small numbers 1 to 10 million, of tumour cells, whereas 100 million cells almost uniformly result in progressive tumour growth. Since a neoplasm only 1 cm. in diameter contains appro imately a billion tumour cells, by the time most tumours are clinically detectable they have already outgrown the patient's immune defenses. Surgical therapy, radiation therapy, and chemotherapy may owe their effectiveness to the role they play in reducing tumour mass to a level that can be controlled by host immunity. Evidence for this hypothesis comes from observations that cancer cells are often found in the washings of operative wounds, in the regional lymph nodes or circulating in the blood of patients who are cured of their neoplasms by local removal of the tumour mass in local radiation therapy. Thus, it appears likely that much of the success of cancer therapy is dependent upon the effectiveness of the patient's immune response. It is not surprising, therefore, that patients who are defective in their cell-mediated immune responses are likely to have a poor prognosis after cancer operations. However, immunotherapy is a logical adjunct to definitive surgery for several reasons:
1. Patients who have only a small focus of cancer cells remaining after surgical removal of the bulk of tumour are those most likely to benefit from immunotherapy, because the tumour mass that must be destroyed by host responses is smallest at that time.
2. The specificity of the immune response for cancer cells provides a possible therapeutic tool that will have selectivity for small foci of cancer cells not possible with other currently available treatment modalities, such as chemotherapy or irradiation.
3. Surgical patients are most likely to respond to any immunotherapeutic manoeuves, since the cancer patient's general immunologic competence i.s greatest when the disease is localized.
4. Immunotherapy would be expected to complement rather than interfere with other currently available methods for managing cancer recurrences following operation, such as irradiation and chemotherapy.
5. Since both irradiation and chemotherapy are immunosuppressive agents, immunotherapy should logically precede these treatment modalities.
Concept about tumors.
Kind of tumors.
General characteristic of benign tumors.
General characteristic of malignant tumors.
Clinics of tumors.
Nurse’s diagnostic of tumors.
General notion about radical and palliative treatment of malignant tumors.
Participation of nurse in general prophylactic medical examination of population.
Introduction in precancerous stages.
Peculiarities of care and dialogue with oncological patients).
6.1. Basic :
Textbook of basic nursing / Caroline Bunker Rosdahl. – J. B.Lippincott Company. Philadelphia. - 6th ed. –1995.– 1518 p.
Fundamentals of nursing /Taylor Mary Carol, Mary Carol, Lillis Carol– J. B.Lippincott Company. Philadelphia. - 1989.– 1356 p.
Gostishev V.K. "Guidance to practical employments on general surgery". M., "Medicine" - 1987.
P. of Brown. Operating block. Operating brigade. – Kharkov, 1997. – with. 1-32.
Methodical instruction was prepared by
Assistant Riabyi S.I.
A review is positive, associate professor Chomko O.J.
Materials of control of base level of preparation of students: tests.
Choose the correct answer/statement:
1. Define the clinical displays of of high quality tumour:
a form and fine-grained structure is rounded
immobile and sroshena with surrounding fabrics
megascopic lymphatic knots palpiruyutsya
at palpatsii a tumour is sickly
there is a capsule
flyuktuatsiya above a tumour
2. What from the transferred tumours are of high quality?
3. A cancer develops from:
immature connecting fabric
smooth or striped muscles
4. There is what characteristically for an of high quality tumour?
not srashena with surrounding fabrics
5. There is what characteristically for an of high quality tumour?
propensity to the relapses after the operation
absence of power to give metastases
sharp influence on the exchange of matters
6. There is what not characteristically for a malignant tumour?
presence of capsule
polymorphism of structure
relative autonomy of growth
7. What feature not characteristic for a malignant tumour?
spreads on lymphatic vessels
absence of metastases
germinates surrounding fabrics
can exist right through life sick
develops quickly and without visible reasons
the relapse comes after deleting of tumour
8. All researches help raising of diagnosis of tumour, except for:
anamnesis of sick
9. All behaves to antiblastike, except for:
introduction of protivoopuholevih antibiotics
application of hormonal preparations
application of altitude chamber
application of chemotherapeutic preparations
application of radial therapy
application of fizioprotsedur
10. All can be the complaints of patient with a malignant new formation, except for:
losses of appetite, ishudaniya
nauseas in the morning
pains in area of heart
alternating lameness making to progress
11. All behave to the peredrakovim diseases of geludochno-kishechnogo highway, except for:
chronic anatsidniy gastritis
chronic kaleznoy ulcer
polypuses of stomach
polypuses of thick intestine
12. How are of high quality tumours from smooth and transversal-striped mishechnoy fabric named?
13. How are of high quality tumours from vessels named?
14. Name testimonies to deleting of of high quality tumours:
declining years of patient
permanent injuring of a new formation
suspicion on the regeneration
young age of patient
risk of appearance of metastases
decline of immunity of sick
15. Name testimonies to deleting of of high quality tumours:
mechanical squeezing by the tumour of surrounding structures
declining years of patient
decline of capacity of patient
risk of appearance of metastases
young age of patient