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Introduction
Relevance of the topic. The growth of oncological diseases has recently acquired the character of a planetary epidemic in the world, and the most paradoxical thing is that despite all the efforts made today by the world community to find effective ways to treat and prevent oncological diseases, nevertheless, academic science is still cannot formulate a unified and clear theoretical justification for the causes of the onset and development of malignant neoplasms, and traditional medicine still cannot find effective methods for their treatment and prevention.
According to the Ministry of Health of the Russian Federation, more than 40% of cancer patients registered for the first time in Russia are diagnosed in stages III-IV of the disease. The Healthcare 2020 program has already formulated a reorientation towards primary health care, which involves early diagnosis and prevention of diseases. In this context, nurses can play a particularly important role in shaping the medical activity of the population, in health education, in organizing educational programs, in increasing the motivation of patients to move from theoretical knowledge of prevention to its practical application.
When analyzing the work of mammography rooms for 2008-2009. and 2010-2011 it is noted that the number of women who underwent periodic mammography increased by 40%. According to the stages of the disease, among patients with a first diagnosis in 2010 and 2011, it was found that the number of patients with stage IV breast cancer (BC) decreased from 8% to 4.1%, patients diagnosed with stage III colon cancer decreased from 7% to 4%, IV - from 19% to 11%, and stages I-II, on the contrary, increased from 74% to 85%.
A tumor is a local pathological growth of tissues that is not controlled by the body.
The properties of tumor cells are passed on to their offspring. True tumors increase due to the multiplication of their own cells, in contrast to various swellings ("false" tumors) that occur during trauma, inflammation, or circulatory disorders. Leukemia is also referred to as a true tumor. Oncology is the study of tumors. There are benign and malignant tumors. Benign tumors grow only pushing apart (and sometimes compressing at the same time) the surrounding tissues, while malignant tumors grow into the surrounding tissues and destroy them. In this case, the vessels are damaged, tumor cells can grow into them, which are then carried by the blood or lymph flow throughout the body and other organs and tissues also enter. As a result, metastases are formed secondary nodes of the tumor.
The main successes in the field of fighting cancer have been achieved at the moment mainly only in the diagnosis and treatment of the earliest stages of the disease, the main bimolecular processes occurring in the cells of a diseased organism have been studied quite deeply; rich clinical experience has been accumulated, but, alas, nevertheless, people are still dying and their number is growing every day.
With some types of tumors, almost 100% of people recover. The nursing staff plays a huge role in the recovery process. Good care is a powerful psychological factor that improves the mood and well-being of the patient. At the same time, the volume of work of a nurse in the implementation of general care depends on the severity of the patient's condition and his ability to self-service.
The study of the etiology and pathogenesis of malignant tumors has entered a phase when the facts obtained in animal experiments are of practical importance for the clinic. At present, it is already possible to speak in general terms about the etiology and pathogenesis of certain oncological diseases.
Purpose of the study. The main purpose of the work is the organization of nursing care for cancer patients.
Research objectives.
1. To achieve the goal in the work, it is first necessary to consider the etiology of oncological diseases, types, and their manifestations.
2. Based on the study of oncological diseases, analyze the organization of nursing care for oncological patients.
3. Consider general care for cancer patients.
4. Determine the principles of work of a nurse with cancer patients.
5. Consider the organization of care for cancer patients with pain syndromes.
6. Consider the organization of care for cancer patients with other symptoms of fatigue, digestive disorders.
The research is that for the first time:
* The activities of nurses are considered from the point of view of the implementation of functions in the field of caring for an oncological patient.
* The actually performed functions of nurses are compared with the normatively fixed functions in caring for a cancer patient.
Scientificpractical significance:
The scientific and practical significance of the work done is determined by the fact that, based on the results of the study, proposals have been developed to improve the work of nursing staff in caring for a cancer patient.
Personal contribution to obtaining the results set out in the final qualifying work:
1. Analysis of legal documentation the content of the activities of paramedical personnel of primary health care in the field of caring for a cancer patient.
2. Development of a questionnaire, conducting a questionnaire and analyzing the results to study the correspondence between the activities actually performed by nurses in the field of caring for an oncological patient and the current regulatory functions.
3. Development of a questionnaire, conducting a survey and analyzing the results of a study of the opinions of doctors and nursing staff regarding possible changes in the nature of caring for a cancer patient.
The main provisions submitted for the defense of the final qualifying work:
1. The results of the study of the correspondence between the activities actually performed by nurses in the field of caring for a cancer patient.
2. The results of the analysis of the opinions of doctors and paramedical personnel regarding possible changes in the nature of the work of the district nurse in caring for a cancer patient.
In order to collect information, two questionnaires were developed: the main one - "Compliance with the activities performed by primary care nurses in the field of caring for a cancer patient" and additional: "Questionnaire for analyzing the attitude of primary care nurses to activities in the field of caring for a cancer patient" .
According to the main questionnaire, a survey was conducted in order to identify the compliance of the functions performed by primary health care nurses in their activities with the job functions enshrined in regulatory legal acts. The questionnaire included two blocks of questions: the first block - the frequency of performing a particular function in the daily practice of specialists, the second block - the opinion of nurses on the compliance of their functions in caring for a cancer patient.
The survey involved 10 specialists with a secondary medical education working in outpatient clinics as a nurse.
With the help of additional questionnaires, a more detailed study was conducted, the purpose of which was to analyze the personal attitude of primary health care nurses to work in the field of caring for a cancer patient. 12 specialists took part in this survey.
Research methods:
Scientific and theoretical analysis of medical literature on this topic;
Empirical - observation, additional research methods:
organizational (comparative, complex) method;
subjective method of clinical examination of the patient (history taking);
objective methods of examination of the patient;
Biographical analysis (analysis of anamnestic information, study of medical records);
Psychodiagnostic analysis (conversation).
Theoretical significance of the study is that it substantiates the need and identifies potential opportunities for caring for a cancer patient.
Practical significance of the study. Research provides an opportunity to determine the directions and methods of work to study the skills of nurses in providing nursing care to cancer patients.
The practical significance of the final qualifying work:
- systematization of theoretical knowledge on the topic "Nursing care for cancer patients" and identifying the features of nursing care for cancer patients.
Detailed disclosure of material on this topic will improve the quality of nursing care.
According to its structure, the final qualification work consists of an introduction, two chapters, a conclusion, a list of references and applications.
The introduction defines: the relevance of the work, the methodological basis, the theoretical and practical significance of the study, the purpose, subject, object, methods and objectives of the study, a hypothesis is put forward that requires proof.
In the first chapter "General characteristics of oncological diseases" an analysis of theoretical sources on the problem under study is given.
The second chapter provides material for an experimental study of the activities of a nurse in the implementation of nursing care for cancer patients.
In conclusion, the results of the work are summed up.
1. General charactertick of oncological diseases
1.1 Epidemiology
In economically developed countries, malignant tumors rank second among all causes of death. In most countries, the 1st most common malignant tumor is stomach cancer, followed by lung cancer, uterine and breast cancer in women, and esophageal cancer in men. Malignant tumors affect more often older people. The “aging” of the population, as well as the improvement of methods for diagnosing a tumor, can lead to an apparent increase in the incidence and mortality rates from malignant tumors. Therefore, special corrections (standardized indicators) are used in scientific statistics. The study of tumor statistics on a global scale revealed a significant unevenness in the distribution of individual forms of the tumor in different countries, among different peoples, in various limited populations. It has been established, for example, that skin cancer (usually on exposed parts of the body) is more common among the population of hot countries (excessive exposure to ultraviolet rays). Oral cancer, tongue cancer, and gum cancer are common in India, Pakistan, and some other Asian countries, which is associated with the bad habit of chewing betel. In a number of countries in Asia and South America, penile cancer, uterine cancer, and cervical cancer are common, a likely consequence of non-compliance with the rules of personal hygiene by the population.
Epidemiological studies have shown that the incidence of cancer of a certain localization changes if the living conditions of this population change. So, among the British, who moved to Australia, the USA or South Africa, lung cancer is more common than among the indigenous population of these countries, but less often than among the inhabitants of Great Britain itself. gastric cancer is more common in Japan than in the US; Japanese residents of the United States (for example, in San Francisco) get stomach cancer more often than other residents, but less often and at an older age than their compatriots in Japan
In the structure of mortality in Russia, cancer ranks third after cardiovascular diseases and injuries.
In the Russian Federation, as in most developed countries of the world, there is a steady increase in the incidence of malignant neoplasms and mortality from them. According to published data, the number of patients diagnosed with a malignant neoplasm for the first time in their lives and registered during the year has increased by 20% over the past 10 years. cancer patient nursing
The incidence of malignant tumors in men is 1.6 times higher than in women. Malignant tumors of the lung, trachea, bronchi (16.8%), stomach (13.0%), skin (10.8%), and breast (9.0%) occupy the leading place in the structure of oncological morbidity in the population of the Russian Federation. In 2007, an average of 194 new cases of tumors of these localizations were registered daily in the Russian Federation, 160 of them were observed in men.
1.2 General characteristics of tumors. Benign and malignant tumors
Tumor(tumor, blastoma, neoplasm, neoplasm) is a pathological process, which is based on the unlimited and unregulated reproduction of cells with the loss of their ability to differentiate.
STRUCTURE OF TUMORS.
Tumors are extremely diverse, they develop in all tissues and organs, can be benign and malignant; in addition, there are tumors that occupy, as it were, an intermediate position between benign and malignant - "border tumors". However, all tumors have common features.
Tumors can have a variety of forms - either in the form of nodes of various sizes and consistencies, or diffusely, without visible boundaries, grow into the surrounding tissues. Tumor tissue may undergo necrosis, hyalinosis. calcification. The tumor often destroys blood vessels, resulting in bleeding.
Any tumor is parenchyma(cells) and stroma(extracellular matrix, including stroma, microcirculation vessels and nerve endings). Depending on the predominance of the parenchyma or stroma, the tumor may be soft or dense. The stroma and parenchyma of the neoplasm differ from the normal structures of the tissues from which it arose. This difference between the tumor and the original tissue is called atypical power or anaplasia. There are morphological, biochemical, immunological and functional atypism.
TYPES OF TUMOR GROWTH.
Expansive growth characterized by the fact that the tumor grows as if "from itself". Its cells, multiplying, do not go beyond the tumor, which, increasing in volume, pushes the surrounding tissues away, undergoing atrophy and replacement with connective tissue. As a result, a capsule is formed around the tumor and the tumor node has clear boundaries. Such growth is characteristic of benign neoplasms.
infiltrating, or invasive, growth consists in diffuse infiltration, ingrowth of tumor cells into surrounding tissues and their destruction. It is very difficult to determine the boundaries of the tumor. It grows into the blood and lymphatic vessels, its cells enter the bloodstream or lymph flow and are transferred to other organs and parts of the body. This growth characterizes malignant tumors.
exophytic growth observed only in hollow organs (stomach, intestines, bronchus, etc.) and is characterized by the spread of the tumor mainly into the lumen of the organ.
Endophytic growth also occurs in hollow organs, but the tumor grows mainly in the thickness of the wall.
unicentric growth characterized by the appearance of a tumor in one area of the tissue and, accordingly, one tumor node.
Mulypicentric growth means the occurrence of tumors simultaneously in several parts of an organ or tissue.
TYPES OF TUMORS
There are benign and malignant tumors.
benign tumors consist of mature differentiated cells and are therefore close to the original tissue. They do not have cellular atypism, but there is tissue atypism For example, a tumor of smooth muscle tissue - myoma (Fig. 34) consists of muscle bundles of different thicknesses, going in different directions, forming numerous eddies, with more muscle cells in some areas, stroma in others. The same changes are observed in the stroma itself. Often, foci of hyalinosis or calcification appear in the tumor, which indicates qualitative changes in its proteins. Benign tumors grow slowly, have expansive growth, pushing the surrounding tissue. They do not give metastases, do not have a general negative effect on the body.
However, with a certain localization, morphologically benign tumors can clinically proceed malignantly. So, a benign tumor of the dura mater, increasing in size, compresses the brain, which leads to the death of the patient. In addition, benign tumors can become malignant or become malignant i.e., acquire the character of a malignant tumor.
Malignant tumors characterizes a number of features: cellular and tissue atypism, infiltrating (invasive) growth, metastasis, recurrence, and the overall effect of the tumor on the body.
Cellular and tissue atypism lies in the fact that the tumor consists of immature, poorly differentiated, anaplastic cells and an atypical stroma. The degree of atypism can be different - from relatively low, when the cells resemble the original tissue, to pronounced, when the tumor cells are similar to embryonic ones and it is impossible to recognize even the tissue from which the neoplasm originated by their appearance. So according to the degree of morphological atypism malignant tumors can be:
* highly differentiated (eg, squamous cell carcinoma, adenocarcinoma);
* Poorly differentiated (eg, small cell carcinoma, mucoid carcinoma).
Infiltrating (invasive) growth does not allow to accurately determine the boundaries of the tumor. Due to the invasion of tumor cells and the destruction of surrounding tissues, the tumor can grow into the blood and lymphatic vessels, which is a condition for metastasis.
Metastasis- the process of transferring tumor cells or their complexes with the flow of lymph or blood to other organs and the development of secondary tumor nodes in them. There are several ways to transfer tumor cells:
* lymphogenous metastasis characterized by the transfer of tumor cells along the lymphatic pathways and develops mainly in cancer;
*hematogenous metastasis is carried out along the bloodstream, and in this way mainly sarcomas metastasize;
*perineural metastasis observed mainly in tumors of the nervous system, when tumor cells spread through the perineural spaces;
*contact metastasis occurs when tumor cells spread along mucous or serous membranes that are in contact with each other (pleura, lower and upper lips, etc.), while the tumor moves from one mucous or serous membrane to another;
*mixed metastasis characterized by the presence of several pathways for the transfer of tumor cells. For example, in gastric cancer, lymphogenous metastasis to regional lymph nodes develops first, and as the tumor progresses, hematogenous metastases to the liver and other organs also occur. At the same time, if the tumor sprouts the wall of the stomach and begins to contact the peritoneum, contact metastases appear - peritoneal carcinomatosis.
Recurrence- re-development of the tumor in the place where it was removed surgically or with the help of radiation therapy. The cause of recurrence is the remaining tumor cells. Some benign tumors can sometimes recur after removal.
PRECANCER PROCESSES
Any tumor is preceded by some other diseases, as a rule, associated with continuously recurring processes of tissue damage and constantly ongoing reparative reactions in connection with this. Probably, the continuous tension of regeneration, metabolism, and synthesis of new cellular and extracellular structures leads to the failure of the mechanisms of these processes, which is manifested in a number of their changes, which are, as it were, intermediate between the norm and the tumor. Precancerous diseases include:
*chronic inflammatory processes, such as chronic bronchitis, chronic colitis, chronic cholecystitis, etc.;
* metaplasia-- changes in the structure and function of cells belonging to one tissue germ. Metaplasia, as a rule, develops in the mucous membranes as a result of chronic inflammation. An example is metaplasia of gastric mucosal cells that lose their function and begin to secrete intestinal mucus, which indicates deep damage to repair mechanisms;
* dysplasia- the loss of a physiological character by the reparative process and the acquisition by cells of an ever-increasing number of signs of atypism. There are three degrees of dysplasia, the first two being reversible with intensive treatment; the third degree is very slightly different from tumor atypism, therefore, in practice, severe dysplasia is treated as an initial form of cancer.
CLASSIFICATION OF TUMORS
Tumors are classified according to their belonging to a particular fabric. According to this principle, 7 groups of tumors are distinguished, each of which has benign and malignant forms.
1. Epithelial tumors without specific localization.
2. Tumors of exo- and endocrine glands and specific epithelial integuments.
3. Soft tissue tumors.
4. Tumors of melanin-forming tissue.
5. Tumors of the nervous system and meninges.
6. Hemoblastomas.
7. Teratomas (disembryonic tumors).
The name of the tumor consists of two parts - the names of the tissues and the ending "oma". For example, a bone tumor osteoma, adipose tissue - lipoma, vascular tissue - angioma, glandular tissue - adenoma. Malignant tumors from the epithelium are called cancer (cancer, carcinoma), and malignant tumors from the mesenchyme are called sarcomas, but the name indicates the type of mesenchymal tissue -- osteosarcoma, myosarcoma, angiosarcoma, fibrosarcoma etc.
2. Organization of nursing care for cancer patients
2.1 Tasks of a nurse in helping cancer patients
The main tasks of a nurse in helping cancer patients:
Ø general care;
Ø control over syndromes and symptoms;
Ø psychological support for the patient and family;
Ø training the patient and family in self-help and mutual assistance;
This can be achieved if attention is paid to the solution of the following basic needs and problems of the patient:
Ø relief of pain and alleviation of other painful symptoms;
Ø psychological and spiritual support of the patient;
Ø maintaining the patient's ability to lead an active life;
Ш creation of a support system in the patient's family during illness and after the death of the patient, if any;
Sh in safety, support;
Ø feeling of belonging to the family (the patient should not feel like a burden);
Ш love (manifestations of attention to the patient and communication with him);
Ø understanding (coming from the explanation of the symptoms and course of the disease);
Ø acceptance of the patient in the company of other people (regardless of his mood, sociability and appearance);
Ø self-esteem (due to the participation of the patient in decision-making, especially if his physical dependence on others increases, when it is necessary to find an opportunity for the patient not only to receive, but also to give).
If all those who work with patients do not take seriously and responsibly all these needs of the patient, adequate relief of pain and other symptoms may be completely impossible.
2.2 General care. The principles of the work of a nurse in the provision of care
Good care is a powerful psychological factor that improves the mood and well-being of the patient. The course of the disease at the stage when all radical methods have already been used can be both fast and slow. The volume of work of a nurse in the implementation of general care depends on the severity of the patient's condition and his ability to self-service, the more thorough care should be.
General care means taking care of the body, cleanliness and comfort of the patient and helps him maintain a sense of his importance to others.
Factors affecting the level of patient hygiene:
Ш Social: personal preferences and habits; availability of outside help (from relatives).
Ш Physical: the patient's ability to self-service, which is determined by:
The severity of the symptoms of the oncological disease itself and the severity of the condition (weakness, confusion, pain, depression, the presence of disfiguring tumors, fecal and urinary incontinence matter);
The presence of disabling diseases, such as strokes, deforming arthrosis, poor eyesight, etc.
The principles of the work of a nurse in the implementation of care:
1. Respect for the personality of the patient, regardless of his condition or level of consciousness. Always inform the patient in advance about the upcoming procedure or manipulation and about its progress. Address the patient by name and patronymic, unless he himself prefers another address.
2. Control of the cleanliness of the bed, skin (especially skin folds and bedsores), mucous membranes, eyes, hair, nails of the patient.
3. Monitoring compliance with the rules of personal hygiene. Encourage patients to maintain a neat appearance (for example, remind men to shave and women to comb their hair).
4. Control of the nature of nutrition.
5. Assistance to the patient in the performance of hygiene procedures. Maintain the dignity of the patient and his desire for privacy.
6. Communication with the patient in sufficient quantities: devote more time to the patient.
7. Supporting the patient's sense of independence and independence from others, and, if the condition allows, then stimulating him to partial or complete self-service.
8. Concern for the safety of the patient due to the fact that the condition of cancer patients worsens every day and weakness increases, the likelihood of falls increases (for example, in the morning when getting out of bed or at night when going to the toilet). It is necessary to be nearby during the expected movements of the patient, limit the motor mode, put a duck next to it, provide the patient with a walker. The danger of injury should be explained and the patient should be convinced of the need to call the medical staff for help.
9. Use of care products and devices: drinkers, diapers, lining circles, rollers, lifters, urinals and colostomy bags, skin and mucous membrane care products, etc. Involve social workers or relatives in the purchase of these funds, if necessary.
10. Teaching family members who are close to the methods of caring for the sick, explaining the rules to them. The active participation of family members in the implementation of care is important not only for the patient, but also for the caregivers themselves (such participation helps them cope with feelings of helplessness and guilt, improve mutual understanding in the family and with the staff).
Bed. Attention to the patient's bed should be increased when he stops getting up on his own, and the bed becomes a permanent place for him. An uncomfortable bed can cause or increase pain, insomnia, and general discomfort.
Nurse actions:
1. Pick up a comfortable bed for the patient, a mattress, a blanket, the required number of pillows, if necessary, a wooden shield. On the mattress it should be bumps and dips.
2. Raise the head of the bed (or use a head restraint) for a higher chest position; It is desirable to tie the pillow to the back of the bed.
3. For patients with urinary and fecal incontinence, place an oilcloth between the sheet and the mattress.
4. Every day, preferably every time after meals, in the morning and before going to bed, shake and straighten the sheet.
5. Arrange all the necessary things so that the patient can get and use them himself.
6. Do not exclude the patient from participation in care (for example, give the opportunity to wipe the skin with a napkin to prevent pressure ulcers), even if he does it slowly and not very well.
7. Change of linen should be done at least once every 3-4 days, and immediately if dirty. Especially often it is necessary to change linen in sweating patients.
Eliminate odors. General principles:
1. Frequent ventilation;
2. Timely hygiene procedures;
3. The use of deodorants is undesirable, as this leads to layering and changing the smell, but not to its elimination; many patients do not tolerate the smell of aerosols;
4. In the absence of the effect of the above measures - wiping the surfaces with a solution of baking soda or vinegar.
Skin care. The nurse plans hygiene measures depending on the patient's condition. If the condition allows, then the patient should take a bath or shower daily, even in the presence of a decaying tumor.
The bathroom should be warm, without drafts. The water temperature should not exceed 36?C.
Do not point the jet at the patient's head. If it is impossible for the sick person to take a shower or bath, wipe it daily with a sponge, then dry the skin thoroughly with soft towels. Especially carefully it is necessary to wipe the skin in the most polluted places: in the groin, perineum, buttocks.
After drying the skin, the pelvic area and perineum are covered with a clean diaper. Powders are applied only to dry skin; places of irritation (redness) are smeared with baby cream or boiled vegetable oil.
Oral hygiene. While maintaining the patient's ability to self-care, remind him of independent oral care, especially for older patients. Regular oral care prevents the development of stomatitis.
General rules for oral care:
1. Monitor the condition of the oral cavity, tongue daily, ask about the presence of sensations in the mouth.
2. Keep the denture clean, wash it after eating, put it in water at night.
3. Help the patient brush his teeth twice a day and rinse his mouth after each meal with a solution of baking soda: 1 teaspoon of baking soda in 500 ml of water. If the patient is paralyzed, then do not forget to clean his mouth every time after eating.
4. The absence of bad breath is the best proof of good oral care.
Caring for false dentures:
prepare: a towel, rubber gloves, a container for collecting rinsing water, a cup for dentures, toothpaste, a toothbrush, lip cream, gauze wipes, a glass of water;
* explain to the patient the course of the upcoming procedure;
* ask the patient to turn his head to one side;
* expand the towel, covering the patient's chest with it up to the chin;
* wash your hands, put on gloves;
* put a container for collecting rinsing water under the patient's chin on an unfolded towel;
* ask the patient to hold the container with his hand, take a glass of water with the other hand, fill his mouth with water and rinse;
* ask the patient to remove the dentures and put them in a special cup.
If the patient cannot remove the dentures on his own, then:
*grab the denture with the thumb and forefinger of the right hand using a napkin;
* remove the prosthesis with oscillatory movements;
* put them in a cup for dentures;
* ask the patient to rinse their mouth with water;
*place the cup with dentures in the sink;
* open the tap, adjust the water temperature;
* clean with a brush and toothpaste all surfaces of the denture;
rinse dentures and cup under cold running water;
*put dentures in a cup for storage at night or help the patient put them back on;
*remove gloves, throw them into a plastic bag;
*Wash the hands.
Nasal toilet(if self-care is impossible) it is necessary to produce if there are crusts or mucus in it: a cotton turunda soaked in oil is introduced into the nasal passage with rotational movements, leaving it there for 2-3 minutes to soften the crusts; then rotated to remove.
Nail care. Nails should be trimmed once every 1-2 weeks, preferably with nail clippers. Before and after trimming, the nails and the skin around them are treated with 70% ethyl alcohol (ethanol). With a fungal infection and the absence of special treatments, the nails are treated with a 10% alcohol solution of iodine 2-3 times a week.
Eye Care. Wash the patient twice a day with boiled water. If the eyelashes are stuck together with secretions, gently wipe them with cotton swabs (4-5 swabs, alternately) dipped in a 2% solution of baking soda, in the direction from the outer corner of the eye to the inner and from top to bottom. If the mucous membrane of the eyes is reddened or the patient complains of pain, "sand" in the eyes, instill 2 drops of a 30% solution of albucid or 0.25% aqueous solution of chloramphenicol (eye drops) 4-6 times a day.
Ear care is performed when self-care is impossible and the patient is in a serious condition to remove accumulated sulfur or the presence of secretions. Soak cotton turundas in boiled water. Tilt the patient's head in the opposite direction from you, pull the auricle up and back with your left hand. Remove sulfur with a cotton turunda with rotational movements. If you have a wax plug, put a few drops of a 3% hydrogen peroxide solution into your ear as directed by your doctor. After a few minutes, remove the cork with a dry turunda.
Facial skin care
An unshaven patient looks rather untidy and feels uncomfortable. Not only men suffer, but also women who, in old age, begin active hair growth in the area of the upper lip and chin.
Prepare: a container for water; napkin for compress; towel; safety razor; shaving gel; shaving brush; oilcloth; napkin; lotion. Note: examine the patient's face - if there are any moles on the face, since their damage is very dangerous for the patient's life.
After shaving, it is better to use a lotion containing alcohol, which is an antiseptic that prevents suppuration in case of violation of the integrity of the skin of the face. Shaving includes the following steps:
* help the patient to take a "half-sitting" position (place additional pillows under the back);
* cover the patient's chest with oilcloth and a napkin;
* prepare a container with water (40 - 45 ° C);
* soak a large washcloth in water;
* wring out the napkin and put it on the patient's face (cheeks and chin) for 5 - 10 minutes;
Note: when preparing a woman for shaving, it is not necessary to apply a napkin to her face.
* Whisk the shaving cream with a brush;
* apply it evenly on the skin of the face along the cheeks and chin (for a woman, moisten her face with warm water in the places of hair growth, without using a cream);
* shave the patient, pulling the skin in the opposite direction to the movement of the machine in the following sequence: cheeks, under the lower lip, neck area, under the chin;
*wipe your face after shaving with a damp cloth;
* dry with a clean cloth, soft blotting movements;
*wipe the patient's face with lotion (apply a nourishing cream to the woman's face after the lotion);
* remove the razor, napkin, water container;
*Wash and dry your hands.
Delivery of the vessel and urinal
A seriously ill patient, if necessary, to empty the intestines, uses a vessel in bed, and when urinating - a urinal. The vessel can be used metal with enamel coating, plastic or rubber. A rubber vessel is used for extremely weakened patients, as well as in the presence of bedsores. A foot pump is used to inflate the rubber vessel. Do not inflate the vessel too tight, otherwise it will put considerable pressure on the sacrum.
If a patient has an urge to defecate, it is necessary:
* put on gloves;
*prepare the ship: warm, dry, pour a little water on the bottom;
* ask the patient to bend the knees and raise the pelvis (if the patient is weak, help him raise the buttocks);
* put an oilcloth under the buttocks;
* put the ship on oilcloth;
* help the patient to get down on the vessel so that his perineum is above the opening of the vessel;
* ask the patient to bend the knees, raise the pelvis;
*wipe the anus with toilet paper;
* Thoroughly wash the vessel;
* douse the ship with hot water, put it under the patient;
* dry with a clean cloth;
* remove the vessel, oilcloth;
* help the patient to lie down comfortably.
If the patient is in serious condition, weakened, then it is better to use a rubber vessel:
* put on gloves;
* prepare the vessel (dry, warm), pour some water on the bottom;
* help the patient bend his knees and turn to the side, with his back to you;
*with your right hand, bring the vessel under the patient's buttocks, and with your left hand, holding the patient by the side, help him turn on his back, while pressing the vessel tightly against the patient's buttocks;
* lay the patient so that the perineum is above the opening of the vessel;
* place an additional pillow under the back so that the patient can be in a “half-sitting” position;
* give time for the implementation of the act of defecation;
* turn the patient to one side at the end of the act of defecation, holding him with his left hand, the vessel with his right hand;
*remove the vessel from under the patient;
* Wipe the area of the anus with toilet paper;
* wash the vessel, pour hot water over it;
* place a vessel under the patient;
* wash the patient from top to bottom, from the genitals to the anus;
* dry with a clean cloth;
* remove the vessel, oilcloth;
*remove gloves
* help the patient to lie down comfortably.
After the vessel is washed, it must be rinsed with hot water and placed near the patient's bed.
After using the urinal, the contents are poured out, the container is rinsed with warm water. To remove the strong ammonia smell of urine, you can rinse the urinal with a weak solution of potassium permagnate or Sanitary cleaner.
2.3 Relief of pain in cancer patients
Approximately 10 million new cases of cancer are diagnosed annually worldwide, and about 4 million patients suffer from pain of varying intensity every day. In the most difficult situation of them are patients who are in outpatient and home conditions. This problem has not been given due attention so far, mainly due to the lack of a well-developed system for controlling chronic pain, principles and methods of its treatment. A number of foreign authors indicate that about 40% of patients with intermediate stages of the disease and 60-80% with generalization of the tumor process experience pain from moderate to severe. Therefore, the treatment of pain becomes extremely important, even if it is only a palliative measure, in relation to the underlying disease.
The following correspondences between the categories of pain intensity and the digital values of the scales were established:
1-4 points - mild pain;
5-7 points - moderate pain;
8-10 points - severe and unbearable pain.
Pain control includes 3 consecutive stages, with the participation of nurses along with doctors:
Ø pain assessment;
sh treatment;
III assessment of the effectiveness of treatment.
Pain is a protective mechanism that indicates the presence of an impact on the body of any factor. Pain makes us consciously or reflexively take actions aimed at eliminating or weakening the irritant. Pain occurs when the sensitive nerve endings embedded in the skin, muscles, blood vessels, and internal organs are irritated. Excitation from them is transmitted along the nerve fibers to the spinal cord, and then to the brain.
Thus, the constant readiness of our body to perceive pain is one of the factors that determine self-preservation. The appearance of pain should be perceived as a signal for analyzing the causes of its occurrence and taking active and conscious measures to eliminate it.
Pain during the growth of a malignant tumor arises from stretching or compression of tissues, their destruction. In addition, a growing tumor can cause compression (compression) or occlusion (blockage) of blood vessels.
When the arteries are damaged, tissue malnutrition (ischemia) occurs, which is accompanied by their death - necrosis. These changes are perceived as pain. If the veins are compressed, then the pains are less intense, since trophic disorders; less pronounced in tissues. At the same time, a violation of the venous outflow causes stagnation, swelling of tissues and forms a pain impulse.
When a malignant tumor or its bone metastases are affected, severe pain is caused by irritation of the sensitive endings in the periosteum. The accompanying prolonged muscle spasm is also perceived as a painful sensation.
Visceral pain occurs with spasm of hollow organs (esophagus, stomach, intestines) or when they are overstretched due to the growth of a malignant neoplasm.
Pain in case of damage to parenchymal organs (liver, kidneys, spleen) is due to irritation of pain receptors located in their capsule during its germination or overstretching. In addition, visceral pain may be associated with concomitant diseases, impaired outflow of body fluids during compression or tumor growth of the pancreatic ducts, liver, urinary tract.
Pain sensations of varying intensity in case of damage to the serous membranes lining the pleural and abdominal cavities are aggravated by the accumulation of fluid in these cavities.
The most pronounced pain reactions in malignant neoplasms are associated with compression or germination of various nerve plexuses, roots, nerve trunks of the spinal cord and brain. So, with a malignant tumor of the pancreas, severe pain is associated with compression of the nearby solar plexus.
With brain damage, pain can be associated with sprouting or compression, as well as with increased intracranial pressure. But pain in malignant tumors can be associated with a general weakening of the patient by a forced position in bed, causing a violation of the integrity of the skin that occurs due to malnutrition of tissues.
Without carrying out special measures, one cannot hope for the disappearance of pain in malignant neoplasms, and the earlier they are started, the more effective the result is. The best pain relief is surgery. Removal of organs or tissues affected by the tumor leads to the cure of the disease and the elimination of the accompanying pain reaction. Tumor resorption under the influence of ongoing radiation or drug antitumor therapy leads to a weakening of the effect of the tumor on the sensitive nerve endings in the tissues and reduces or stops pain.
In patients with advanced forms of malignant tumors, pain becomes chronic. A person's constant feeling of pain against the background of the progression of the tumor and the increase in physical ailment leads to depression, sleep disturbance, an increase in feelings of fear, helplessness and despair. If such a patient does not see help and participation from relatives and medical workers, then he may become aggressive or even attempt suicide (suicide).
Preparations for pain relief are selected strictly individually, preferably the use of tablet preparations. The patient's pain sensation is always determined and evaluated according to his subjective assessment of his own pain.
* With mild pain, good results can be achieved when using analgin: 1 - 2 tablets 2-3 times a day in combination with suprastin or diphenhydramine.
*As needed, analgin is replaced by complex analgesics, which include analgin: baralgin, pentalgin, sedalgin, tempalgin.
* The well-known non-specific anti-inflammatory drugs, such as aspirin, indomethacin, diclofenac, ibuprofen and others, also have an analgesic effect; they are prescribed 1-2 tablets 3-4 times a day. As the pain increases, injectable forms of these drugs can also be used.
* With moderate pain, a stronger analgesic is prescribed - tramal, 1 - 2 capsules, from 2 - 3 to 4 - 5 times a day. Tramal can be used in the form of drops, injections. Sedatives (sedatives) are added to the treatment at this stage of the pain syndrome - corvalol, valerian, motherwort or tranquilizers: phenazepam, seduxen, relanium, 1-2 tablets 2 times a day.
* In case of severe pain, the patient is prescribed drugs.
To achieve adequate pain relief using optimal doses of drugs, the fundamental principles of chronic pain management in cancer patients should be followed.
Reception by the hour, not on demand. Compliance with this principle allows you to achieve the greatest analgesic effect with a minimum daily dose of analgesic. Taking the drug "on demand" ultimately entails the use of a much higher dose, since the concentration of the analgesic in the blood plasma falls and additional is required to restore it and achieve a satisfactory level of analgesia. the amount of the drug.
Ascending treatment. Treatment begins with non-narcotic analgesics, moving, if necessary, first to weak, and then to strong opiates. Medicines are best taken by mouth for as long as possible, as this is the most convenient way to take medicines at home.
Getting rid of cancer patients pain is the most important thing in their treatment. This can be achieved only with the joint actions of the patient himself, his family members and medical workers.
2.4 Help with other symptoms of cancer
Weakness in oncological disease. 64% of cancer patients suffer from this unpleasant symptom. With cancer in an advanced stage, weakness is the most common symptom. Drowsiness, fatigue, lethargy, fatigue and weakness are tolerated differently by each patient. In some cases, the situation may be out of control. However, the causes of weakness can be treated. Careful examination of the patient and assessment of the situation is the first step towards solving this problem. Nursing care for a weak patient should be directed towards helping the patient to be as active as possible during the day, which will give him a sense of independence. The nurse must monitor and evaluate the effectiveness of the prescribed treatment, report to the doctor about changes in the patient's condition, teach the patient to lead a correct lifestyle; give him support, inspire a sense of confidence in his abilities.
Help with symptoms of digestive disorders. Constipation is a condition when the evacuation of solid feces occurs less frequently than necessary. The norm for each individual patient may be different, because even in healthy people defecation is not always carried out daily, however, the evacuation of feces less than three times a week can be considered normal only in 1% of cases. For those cancer patients who take opioid drugs and are affected by many other concomitant factors, constant monitoring of the situation is very important. Constipation can cause serious secondary symptoms. For example, urinary retention or intestinal obstruction. With intestinal obstruction, feces fill the rectum, colon, and sometimes even the caecum. While the stools are in contact with the intestinal mucosa, the liquid from them is absorbed, causing them to become solid. Gradually, the mass of feces accumulates so much that it becomes physically impossible to remove it. Liquefaction of the upper faeces by bacteria can cause diarrhea and fecal leakage when the patient complains of loose stools in small amounts after not having a bowel movement for a long time. This may be accompanied by spasmodic rectal pain, tenesmus (prolonged false urge to defecate), bloating, nausea, and vomiting. Elderly patients with an advanced stage of the disease may develop urinary retention.
A patient who is close to death needs care, the purpose of which is to eliminate the symptoms that cause discomfort or suffering. Active treatment may include changing the patient's diet: drinking plenty of fluids, eating fibrous foods (fruits, green vegetables), and taking laxatives.
When caring for a patient suffering from constipation, it is necessary to immediately respond to requests for help with the act of defecation:
* seat the patient on a special vessel-stool (or put the vessel under the patient) so that the posture is the most comfortable and contributes to the tension of the abdominal muscles;
* provide the patient with complete privacy and time for the implementation of the act of defecation.
If these measures do not help the patient, it is necessary to introduce a suppository with bisacodyl into the rectum or put a cleansing or oil enema, preferably at night.
Thus, the content of nursing care for a seriously ill patient includes several points.
I. Ensuring physical and mental rest - to create comfort, reduce the effects of irritants.
2. Monitoring compliance with bed rest - to create physical rest, prevent complications.
3. Changing the position of the patient after 2 hours - for the prevention of bedsores.
4. Ventilation of the ward, rooms - to enrich the air with oxygen.
5. Monitoring the patient's condition (measuring temperature, blood pressure, counting the pulse, respiratory rate) - for early diagnosis of complications and timely provision of emergency care.
6. Control of physiological functions (stool, urination) - for the prevention of constipation, edema, the formation of stones in the kidneys.
7. Personal hygiene measures to create comfort, prevent complications. The nurse performs the following manipulations:
* washing the patient;
* eye care;
* care of the oral cavity;
* nose care;
* cleansing the external auditory canal;
* shaving linden;
* hair care;
* feet care;
* care for the external genitalia and perineum. S. Skin care - for the prevention of bedsores, diaper rash.
9. Change of underwear and bed linen - to create comfort, prevent complications.
10. Feeding the patient, helping with feeding - to ensure the vital functions of the body.
11. Education of relatives in care activities - to ensure the comfort of the patient.
12. Creating an atmosphere of optimism - to ensure the greatest possible comfort.
13. Organization of the patient's leisure - to create the greatest possible comfort and well-being.
14. Training in self-care techniques - to encourage, motivate to act.
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Chapter 22
Nursing process in caring for patients with precancerous, benign
And malignant tumors.
In general, the Russian Federation continues to grow in cancer incidence and mortality. Cancer incidence is 95% represented by cancer of the cervix, endometrium, and ovaries. The main problem remains the late diagnosis of malignant neoplasms in outpatient clinics and the growth of advanced forms, which is due to the insufficient use of modern methods of early diagnosis, the lack of systematic medical examinations, dispensary observation of patients with chronic, background and precancerous diseases, insufficient onco-alertness of the medical staff.
The nurse should be able to identify the patient's disturbed needs associated with cancer, identify real problems in connection with existing complaints, potential problems associated with the progression of the disease and possible complications of cancer, and outline a plan for the nursing process, for the solution of which she must carry out independent and dependent interventions.
A nurse should be a competent, sensitive, attentive and caring specialist who provides assistance to women, who can talk about her condition, methods of examination, treatment, and inspire confidence in a favorable outcome of treatment. The nurse should be a real assistant to the doctor when performing appointments, additional research methods.
Tumors of the external genital organs.
Benign tumors of the vulva.
Fibroma(Fig. 147) - a tumor of a connective tissue nature of a rounded or oval shape, usually single, on a wide base or on a stalk. It is localized more often in the thickness of the labia majora or under the mucous membrane of the vestibule of the vagina. It grows slowly, only desmoid fibroma is honored.
Rice. 147 Fibroma of the vulva in the form of an extensive polypoid growth.
Myoma l localizes in the thickness of the labia majora, has a densely elastic consistency, is mobile, grows slowly.
Lipoma develops from adipose or connective tissue (fibrolipoma), localized in the pubis or labia majora, soft texture, rounded, has a capsule, not soldered to the skin, grows slowly.
Hemangioma arises on the basis of a congenital malformation of the vessels of the skin and mucous membranes of the external genital organs. More often it develops in the region of the labia majora in the form of a knot, a cyanotic or purple spot, rising above the level of the skin or mucous membrane. The tumor grows rapidly and reaches a large size, spreading to the vagina and cervix.
Lymphangioma develops from the lymphatic vessels of the skin, has cavities of various sizes and shapes containing a protein liquid. The tumor consists of small tuberous nodes with a bluish tinge, merging with each other.
Diagnostics. An examination of the external genitalia, colposcopy is carried out, and a biopsy of the tumor is performed to make a final diagnosis.
Surgical treatment of patients with benign tumors of the external genital organs. Sometimes electrocoagulation, cryo-destruction and CO 2 laser are used.
Background and precancerous diseases
Treatment.
1. When combined with inflammatory processes of the vulva and vagina - etiotropic anti-inflammatory treatment (antitrichomonas, antifungal, antiviral, antichlamydial).
2. Do not use products such as sea buckthorn oil, rosehip oil, aloe ointment and other biostimulants. They can contribute to the strengthening of proliferative processes and the occurrence of cervical dysplasia.
3. The most effective treatments for cervical leukoplakia include: cryodestruction and CO 2 - laser vaporization, radio wave surgery in coagulation mode.
4. When leukoplakia is combined with deformity and hypertrophy of the cervix, it is advisable to use surgical methods of treatment in a hospital: knife, laser, radio wave or electroconization; wedge-shaped or cone-shaped amputation of the cervix.
erythroplakia- this is a flattening and thinning of the layer of stratified squamous epithelium due to atrophy of the functional and intermediate layers (reduced cornification).
When viewed in mirrors irregularly shaped areas of hyperemia are determined, they bleed easily.
Colposcopic and red areas of sharply thinned epithelium are visible, through which the underlying tissue shines through.
Histologically thinning of the squamous epithelium is observed, atypical hyperplasia of basal and parabasal cells is observed.
Treatment the same as in leukoplakia.
Polyp of the cervical canal (photo 77.78) - focal proliferation of the endocervix, in which the arborescent outgrowths of the connective tissue protrude into the lumen of the cervical canal or beyond it, are covered with a cylindrical epithelium, can be single or multiple, occur in women after 40 years of age against the background of hyperestrogenism.
When viewed in mirrors in the lumen of the cervical canal, round formations of red or pink color are visible. According to histological
the structure is distinguished by glandular, glandular - fibrous, fibrous polyps. The polyp has a thick or thin stalk, may hang down into the vagina.
Photo 77. Large polyp of the cervix, emanating from the endocervix,
dug by squamous immature epithelium, before and after treatment with Lu-gol's solution.
Photo 78. Multiple polyps on the background of ectopia, covered with CE.
Colposcopically the epithelial cover of the polyp is revealed: cylindrical epithelium or squamous epithelium.
Histologically the structure of polyps is characterized by the presence of a connective tissue stalk covered with epithelium, in the thickness of which glandular or glandular-fibrous structures are formed.
I. Epithelial tumors.
A. Serous tumors.
1. Benign: cystadenoma and papillary cystadenoma; superficial papilloma; adenofibroma and cystadenofibroma.
2. Borderline (potentially low grade): cystadenoma and papillary cystadenoma; superficial papilloma; adenofibroma and cystadenofibroma.
3. Malignant: adenocarcinoma, papillary adenocarcinoma and papillary cystadenocarcinoma; superficial papillary carcinoma; malignant adenofibroma and cystadenofibroma.
B. Mucinous tumors.
1. Benign: cystadenoma; adenofibroma and cystadenofibroma.
2. Borderline (potentially low grade): cystadenoma; adenofibroma and cystadenofibroma.
3. Malignant: adenocarcinoma and cystadenocarcinoma; malignant adenofibroma and cystadenofibroma.
B. Endometrial tumors.
1. Benign: adenoma and cystadenoma; adenofibroma and cyst denofibroma.
2. Borderline (potentially low degree of malignancy): adenoma and cystadenoma; adenofibroma and cystadenofibroma.
3. Malignant:
a) carcinoma, adenocarcinoma, adenoacanthoma, malignant adenofibroma and cystadenofibroma; endometrioid stromal sarcoma; mesodermal (Mullerian) mixed tumors.
D. Clear cell (mesonephroid) tumors: benign: adenofibroma; borderline (potentially low degree of malignancy); malignant: carcinoma and adenocarcinoma.
D. Brenner tumors: benign; borderline (borderline malignancy); malignant.
Table 14. Treatment of glandular hyperplasia of the endometrium.
| Periods | Stage I Hemostasis | Stage II Prevention of relapse | Stage III Clinical examination in the antenatal clinic and monitoring the effectiveness of treatment |
| In the juvenile period | 1. Non-hormonal hemostasis: - (uterotonics, membrane protectors, dicinone, calcium gluconate, vikasol, iron preparations (sorbifer, etc.). 2. Hormonal: - homonal; - single-phase high-dose COCs (bisekurin, non-ovlon, rigevidon) 1 tablet in an hour until bleeding stops with a gradual (per tablet) daily decrease to 1 tablet per day, a course of 21 days; - estrogens (folliculin, sinestrol) 0.01% r.m., 1 ml / m , 1 hour to stop bleeding (6-8 injections) with a gradual dose reduction to 1 ml per day, a course of 14-15 days, followed by the appointment of gestagens - rheopolyglucin, infusion-transfusion therapy - symptomatic therapy 3. Surgical: with Hb< 75г/л, Ht – 20 %, раздельное диагностическое выскабли-вание цервикального канала и полости матки под контролем гистероскопии, с обкалыванием девственной плевы 0,25% раст-вором новокаина с 64 ЕД лида-зы с последующим гистологическим исследо-ванием соскоба. У 87% ЖКГЭ, может быть АГЭ. | - from 16 to 25 days gestagens (duphaston, norkolut) 6-12 months; or 14 and 21 days - 17-OPK 125 ml 6-12 months; - COC (logest, femoden, novinet, regulon) according to the contraceptive scheme; - Ultrasound of the small pelvis after 1,3,6,12 months. | - at least a year after stable normalization of the menstrual cycle. |
| In the reproductive period | Surgical: - separate diagnostic curettage of the cervical canal and uterine cavity with subsequent histological examination; - symptomatic therapy and physiotherapy. | - Regulation of the menstrual cycle; - COC according to the contraceptive scheme for 6 months; - gestagens 6 months; - cyclic vitamin-hormone therapy, physiotherapy for 3 months; - clostilbegit 50-150 mg per day for 5-9 days for 3-6 months, in young women in order to form an ovulatory menstrual cycle and stimulate ovulation. | - Ultrasound of the small pelvis after 3-6-12 months; - aspiration cytology after 6 months; - hysteroscopy with WFD after 6 months; - has been registered at the dispensary for at least 1 year, removed after stable normalization of the cycle. |
| In menopause | Surgical: - separate diagnostic curettage of the cervical canal and uterine cavity under the control of hysteroscopy. | - Gestagens; - gonadotropin inhibitors (danazol, nemestrane); - analogues of gonadotropin releasing hormones (zoladex); - women over 50 years old - androgens; - with contraindications to surgical treatment - electro- or laser ablation of the endometrium. | - Ultrasound of the small pelvis after 3-6-12 months; - aspiration cytology after 3 months; - hysteroscopy with WFD after 6 months; has been registered at the dispensary for at least 1 year, removed after stable normalization of the cycle. |
E. Mixed epithelial tumors: benign; borderline (borderline malignancy); malignant.
B. Gynandroblastoma.
IV. germ cell tumors.
A. Dysgerminoma.
B. Embryonic carcinoma.
G. Polyembryoma.
D. Chorionepithelioma.
E. Teratomas.
1. Immature.
2. Mature: solid; cystic (dermoid, dermoid cyst with malignancy).
3. Monodermal (highly specialized): ovarian struma; carcinoid; ovarian struma and carcinoid; other.
V. Gonadoblastoma.
Cancer of the vulva
Mostly women aged 60-69 get sick. Most often, vulvar cancer affects the labia majora, the periurethral region, and the posterior commissure, and the urethra is the last to be involved (photo 89).
Clinic. If the tumors of the vulva were not preceded by neurodystrophic processes, then in the early stages of the disease, the symptoms are slightly expressed and are manifested by the occurrence of discomfort (itching, burning), and then the development of a small ulcer.
Photo 89. Cancer of the vulva.
As the disease progresses, the severity of these symptoms increases. With infiltration of the underlying tissues, pain appears in the perineum, pain and burning during urination, especially with infiltration of the external opening of the urethra. The formation of a significant mass of the tumor leads to the appearance of profuse, fetid discharge with an admixture of blood, bleeding.
With the development of cancer against the background of dystrophic changes, the leading symptom is itching, paroxysmal, aggravated at night. Changes in the skin and mucous membrane correspond to the clinical manifestations of kraurosis and vulvar leukoplakia. The foci of leukoplakia flatten, coarsen, there is a thickening of the underlying skin layer, an ulcer with dense edges is organized on the surface of leukoplakia.
Frequent and rapid metastasis is noted, which is associated with a developed lymphatic network of the vulva. First, the inguinal lymph nodes are affected, and then the iliac and lumbar lymph nodes. Lymph nodes were affected on the opposite side, due to the abundance of anastomoses between intra- and extra-organ lymphatic vessels.
Diagnostics. When examining the external genital organs, attention should be paid to the size of the primary focus; the background against which the malignant tumor developed; localization of the process, the nature of tumor growth, the state of the underlying tissues. Vaginal-abdominal and rectovaginal examinations are carried out in order to exclude the metastatic nature of the tumor and to establish the extent of the process. Determine the state of the lymph nodes in the inguinal, femoral and iliac regions. In the diagnosis, vulvoscopy, cytological examination of prints from the tumor, histological examination of biopsy materials, ultrasound tomography of the inguinal, femoral and iliac lymph nodes are also used; according to indications - cystoscopy, excretory urography, chest x-ray, cytological examination of punctates from the lymph nodes.
Treatment. In the treatment of preinvasive vulvar cancer, the treatment of choice is vulvectomy or cryosurgery in young women. In patients with microinvasive cancer - a simple vulvectomy.
At stage I (tumor up to 2 cm, limited to the vulva, regional metastases are not detected) - surgical treatment. A radical vulvectomy is performed. In the absence of contraindications, the volume of the operation is supplemented by inguinal-femoral lymphadenectomy.
If the tumor is localized in the clitoris, there are palpable lymph nodes, but not suspicious for metastases, radical vulvectomy and inguinal-femoral lymphadenectomy are performed.
If there are contraindications to surgical treatment, radiation is performed.
At stage II (the tumor is more than 2 cm in diameter, limited to the vulva, regional metastases are not detected) - radical vulvectomy and inguinal-femoral lymphadenectomy. After the operation, the vulvectomy area is treated with radiation therapy. If there are contraindications to combined treatment - combined radiation treatment according to a radical program. Remote gamma therapy is carried out on the region of regional inguinal lymph nodes.
At stage III (limited local spread and regional displaceable metastases) - radical vulvectomy, inguinal-femoral lymphadenectomy, supplemented by indications of iliac lymphadenectomy and subsequent remote irradiation of the vulvectomy zone. With contraindications to combined treatment, combined radiation therapy according to a radical program.
With a significant local or local-regional spread of the tumor, radiation treatment is performed before the operation: remote irradiation of the vulva, intracavitary gamma therapy followed by radical vulvectomy and inguinal-femoral lymphadenectomy, supplemented by indications of the iliac. After the operation, the vulvectomy zone is irradiated.
With contraindications to combined treatment - combined radiation therapy according to a radical program.
Stage IV (the tumor spreads to the upper part of the urethra and / or bladder, and / or rectum, and / or pelvic bones with or without regional metastasis) - radiation therapy according to an individual plan, supplemented by polychemotherapy (fluorouracil, vincristine, bleomycin , methotrexate).
Prevention. Vulvar cancer rarely develops in healthy tissues. It is preceded and accompanied by dysplasia and/or preinvasive cancer. Therefore, the primary prevention of vulvar cancer is the detection during preventive examinations once every six months of background dystrophic processes; clarification of the histological structure of altered tissues, adequate treatment of background processes, detection and surgical treatment of dysplasia, preinvasive cancer of the external genitalia.
Vaginal cancer
Vaginal cancer can be primary and metastatic (with localization of the primary tumor in another organ). Primary vaginal cancer is rare, accounting for 1-2%. Metastatic tumors of the vagina are more common. If squamous cell carcinoma of the cervix and vagina is found at the same time, then this observation is referred to as cervical cancer. When a cancerous tumor of the vulva and vagina is affected, the diagnosis is “vulvar cancer”. Vaginal cancer affects women of any age, but mostly in 50-60 years. The risk group includes women aged 50-60 years who have the following risk factors: chronic irritation due to wearing pessaries; chronic irritations associated with prolapse of the uterus and vagina; involutive and dystrophic processes; infection with HSV-2, PVI; taking diethylstilbestrol by the mother up to 8 weeks of pregnancy; cervical cancer and a history of radiation exposure.
Cervical cancer
Cervical cancer is the most common malignant disease, diagnosed with a frequency of 8-10 cases per 100,000 women.
Rice. 154. Exophytic form of cervical cancer.
Rice. 155 Endophytic form of cervical cancer with a transition to the body of the uterus.
Rice. 156. Endophytic form of cervical cancer with spread to parametrium and vaginal wall.
Rice. 157 Endophytic form of cervical cancer with spread to parametrium and adnexa.
Rice. 158 Endophytic form of cervical cancer with the transition to the body of the uterus and the wall of the vagina.
The highest frequency of cervical cancer is observed in the perimenopausal period - 32.9% less often in 30-39 years. The peak of the disease occurs at the age of 40-60 years, and in case of preinvasive cancer - 25-40 years.
Etiological risk factors in the development of cervical cancer:
- birth trauma, inflammation and trauma after abortion, which leads to deformation, disruption of traffic and tissue innervation, early sexual life, promiscuity, frequent change of sexual partners, smegma factor in the sexual partner (it is believed that smegma accumulates under the foreskin, contains carcinogenic substances); the leading role in the occurrence of cervical cancer is assigned to viral infections (HSV (type 2), HPV) .;
- occupational hazards (tobacco production, mining and coal industries, oil refineries) also play a role in the occurrence of cervical disease;
- heredity (it is believed that the risk of the disease increases by 1.6 times in women with such a predisposition);
background and precancerous diseases of the cervix.
According to the morphological structure, cervical cancer variants are distinguished: squamous - 85-90% of cases; glandular - 10-15% of cases; mixed - 20% of cases. According to the degree of differentiation, there are: a highly differentiated form of cancer; moderately differentiated form of cancer; low-grade form of cancer.
Classification of cervical cancer by stages(Fig. 154, 155, 156, 157, 158).
O stage - preinvasive (intraepithelial) cancer, Ca in situ.
Stage Ia - the tumor is limited to the cervix, invasion into the stroma is not more than 3 mm, the diameter of the tumor is not more than 10 mm - microcarcinoma.
Stage Ib - the tumor is limited to the cervix with an invasion of more than 3 mm. invasive cancer.
Stage IIa - the cancer infiltrates the vagina without moving to its lower third (vaginal variant), or spreads to the body of the uterus (uterine variant).
Stage IIb - cancer infiltrates the parametrium on one or both sides, without moving to the pelvic wall (parametric variant).
Stage IIIa - cancer infiltrates the lower third of the vagina or there are metastases in the uterine appendages; regional metastases are absent.
Stage III6 - cancer infiltrates the parameters on one or both sides to the pelvic wall, or there are regional metastases in the lymph nodes of the pelvis, or hydronephrosis and a non-functioning kidney due to ureteral stenosis are determined.
IVa stage - cancer germinates the bladder or rectum.
IV6 stage - distant metastases outside the pelvis are determined.
clinical picture. The main symptoms are: acyclic (contact) spotting, leucorrhoea (partially streaked with blood), and pain when the tumor expands. Dull aching (usually nocturnal) pain in the lower abdomen, fatigue, irritability are characteristic of pre- and microinvasive cervical cancer. As the process progresses, life-threatening bleeding may occur. When the process spreads to the bladder and rectum, persistent cystitis, constipation, etc. appear; with compression of the ureters by a cancerous infiltrate, disturbances in the passage of urine, hydro- and pyonephrosis are possible.
Metastases of cervical cancer and their diagnosis. Metastasis of cervical cancer is carried out mainly through the lymphatic system, in the final stage of the disease, the lymphatic pathway of the spread of a cancerous tumor can be combined with the hematogenous one. Most often, cervical cancer metastasizes to the lungs, liver, bones, kidneys, and other organs.
Diagnostics. When implementing independent interventions of the nursing process, the nurse should prepare the obstetrician-gynecologist with the necessary tools, sterile material for examining the cervix in mirrors, conducting rectovaginal, recto-abdominal examinations; with independent nursing interventions, the nurse, at the direction of the doctor, prepares everything necessary for performing a colposcopy (simple, extended), and, if necessary, a biopsy of the cervix,
At examination of the cervix in the mirrors with an exophytic form of cervical cancer, tuberous formations of a reddish color are found, with gray areas of necrosis. The tumor resembles a "cauliflower". The endophytic form is characterized by an increase and induration of the cervix, ulceration in the area of the external pharynx.
With cancer of the cervical canal, there are no special changes visible to the eye on the surface of the cervix. When the process spreads to the vagina, smoothing of the folds, whitish walls are noted.
Rectovaginal and rectoabdominal examination clarify the degree of distribution of the process to the parametric fiber, the walls of the vagina, the small pelvis.
Colposcopy reveals corkscrew-shaped vessels are determined located along the periphery of reddish prosovity growths with hemorrhages. Schiller's test establishes the boundaries of pathologically altered areas of the cervix, which remain negative to Lugol's solution. Extended colposcopy allows you to detect suspicious areas for cervical biopsy, histological examination of the resulting tissue . Biopsy should be performed widely, wedge-shaped excising with a scalpel a pathologically altered area of the cervix within healthy tissue.
Treatment of invasive cancer.
Stage I - combined treatment in two versions: remote or intracavitary irradiation followed by extended extirpation of the uterus with appendages or extended extirpation of the uterus followed by remote therapy. If there are contraindications to surgical intervention - combined radiation therapy (remote and intracavitary irradiation).
Stage II - in most cases, a combined beam method is used; surgical treatment is indicated for those patients in whom radiation therapy cannot be carried out in full, and the degree of local spread of the tumor allows for a radical surgical intervention.
Stage III - radiation therapy in combination with restorative and detoxification treatment.
IV stage - symptomatic treatment.
Forecast. Five-year survival of patients with microcarcinoma is 80-90%, stage I cervical cancer - 75-80%, stage II - 60%, stage III - 35-40%.
Treatment of patients with cervical cancer associated with pregnancy. Pregnancy stimulates the growth of malignant growth cells.
Detection of preinvasive cancer in the first trimester of pregnancy is an indication for its termination with obligatory curettage of the cervical canal and subsequent conization of the cervix; in the II and III trimesters, it is possible to maintain pregnancy until the term of delivery with dynamic colposcopic and cytological control. At Ib and II stages of cancer in the I and II trimesters, an extended extirpation of the uterus with appendages is performed, followed by radiation therapy; in the third trimester of pregnancy, treatment for cervical cancer is preceded by a caesarean section. Patients with stage III cancer in the I and II trimesters undergo abortion or amputation of the uterine body, followed by radiation therapy; in the III trimester of pregnancy - caesarean section, amputation of the body of the uterus, combined radiation therapy.
After surgical treatment without the use of adjuvant chemotherapy, it is necessary to monitor the patient at least once every 3 months with clinical, ultrasound and immunological (determination of the level of tumor markers in blood serum) research methods.
Prevention of cervical cancer.
- Carrying out by a nurse and all medical personnel, activities aimed at eliminating risk factors for developing cervical cancer.
- Medical examinations of women, starting from the onset of sexual activity, including cytological screening and colposcopy.
- Prevention of radiation injury.
- Sanitary education work on the dangers of abortion, modern methods of contraception, sexually transmitted infections (HSV, HPV, etc.).
- Vaccination of women before the onset of sexual activity with the recombinant vaccine Gardasil. Vaccination can prevent most cases of cervical cancer caused by HPV types 6,11,16 and 18.
- Compliance with sanitary standards in hazardous industries.
Cancer of the body of the uterus.
The peak incidence of uterine body cancer occurs at 50-60 years of age. In the elderly and senile age, the incidence of cancer of the uterine body remains high. The risk group for the development of uterine cancer includes women with neurometabolic disorders: diencephalic syndrome, obesity, diabetes mellitus, hypertension, and others; hormone-dependent dysfunctions of the female genital organs: anovulation, hyperestrogenism, infertility; hormonally active ovarian tumors that secrete estrogens, which in 25% of cases are accompanied by endometrial cancer; refusal of lactation, short-term lactation; lack of sexual life; no pregnancy, no childbirth; weighed down by heredity; late onset of menarche, late onset of menopause (over 50-52 years old); use for the treatment of estrogenic drugs without additional prescription of gestogens.
T - primary tumor
T is - preinvasive carcinoma (Ca in situ).
TO - the primary tumor is not determined (completely removed during curettage).
T 1 - carcinoma is limited to the body of the uterus.
T 1 a - uterine cavity up to 8 cm.
T 1 b - the uterine cavity is more than 8 cm.
T2 - Carcinoma has spread to the cervix, but not outside the uterus.
T 3 - carcinoma extends beyond the uterus, including the vagina, but remains within the small pelvis.
T 4 - carcinoma extends to the mucous membrane of the bladder or rectum and / or extends beyond the small pelvis.
T x - insufficient data to evaluate the primary tumor.
N- regional lymph nodes of the pelvis
N 0 - metastases in regional lymph nodes are not determined.
N 1 - there are metastases in the regional lymph nodes of the pelvis.
n x - insufficient data to assess the state of regional lymph nodes.
M - distant metastases
M 0 - no signs of distant metastases.
M 1 - there are distant metastases.
M x - not enough data to determine distant metastases.
In each clinical observation, the symbols T, N and M are grouped, which allows us to draw the following analogy with the clinical and anatomical classification by stages:
Stage 0 - T is ; Stage I - T 1 N 0 M 0 ; Stage II - T 2 N 0 M 0 ; Stage III -T 3 N 0 M o ; T 1-3 N 1 M 0 ; Stage IV - T 4 and / or m 1 for any values of T and N.
Ovarian cancer.
Ovarian cancer ranks third in frequency in the structure of oncogynecological morbidity. Ovarian cancer ranks first in the structure of cancer deaths. Cases of a five-year survival rate for ovarian cancer are 15-25%. The incidence begins to increase after the age of 40 and continues to increase until the age of 80. There is a high risk of developing ovarian cancer in the postmenopausal period.
clinical picture.
Ovarian cancer in the early stages asymptomatically or there are symptoms not characteristic of ovarian cancer (dyspepsia, feeling of expansion in the abdomen, nausea, diarrhea alternating with constipation), then there is a violation of menstrual function in the form of metrorrhagia. The disease proceeds aggressive, with early metastasis.
Clinical symptoms appear at advanced common stages of the process, when patients notice fatigue, weakness, sweating, weight loss, deterioration in general condition, difficulty breathing (due to the appearance of effusion in the abdominal cavity and pleura). In large tumors with necrosis, there may be an increase in ESR without leukocytosis, subfebrile temperature (sometimes febrile - up to 38 ° C). Due to the mechanical action of the tumor on the surrounding organs, dull aching pain in the lower abdomen, less often in the epigastric region or in the hypochondrium. The pains are constant, but they can also stop for a certain period, there is a feeling of distension of the abdomen. In cases of torsion of the tumor pedicle, pain occurs suddenly and is acute.
Quite often, one of the first signs of the disease is an increase in the size of the abdomen both due to tumor formation in the small pelvis, and due to ascites. In cancer, accompanied by the early appearance of ascites, as a rule, there is dissemination of implants in the peritoneum and abdominal organs. With percussion of the abdomen, dullness is noted in sloping places.
With advanced forms of ovarian cancer (stage III-IV), the upper half of the small pelvis is partially or completely filled with a conglomerate of tumor nodes, an enlarged and infiltrated greater omentum is palpated, metastases are found in the navel, supraclavicular region, along the peritoneum of the posterior uterine-rectal depression.
With a far advanced process, the menstrual cycle is disrupted by the type of dysfunctional uterine bleeding, the amount of urine excreted decreases, and constipation occurs.
These features - asymptomatic course, rapid progression of the process and early metastasis lead to late diagnosis of ovarian cancer.
uterine fibroids
uterine fibroids(Fig. 159) is a benign, immuno- and hormone-dependent tumor that develops from the myometrium (muscle and connective tissue elements). The occurrence of uterine fibroids is facilitated by disturbances in endocrine homeostasis in the links of the hypothalamus-pituitary-ovary-uterus chain. There are two clinical and pathogenetic variants of the development of uterine fibroids.
1. Due to primary changes: hereditary burden, infantilism, primary endocrine infertility, hormonal imbalances in puberty and post-puberty.
2. The development of fibroids against the background of secondary changes in the myometrium, due to local secondary changes in the receptor apparatus (abortion, postpartum complications, chronic inflammation of the genital organs, etc.).
Rice. 170. Multiple uterine fibroids.
A rare variant of the development of fibroids in the postmenopausal age is associated with neoplasms in the mammary glands or endometrium, due to increased hypothalamic activity.
The following terms are used in the literature: "fibroma", "myo-fibroma", "myoma", "leiomyoma", "fibroma" and others. Depending on the predominance of muscle or connective tissue, subserous nodes are usually called fibromyomas, since the ratio of parenchyma to stroma is 1:3, that is, they are dominated by connective tissue. Intramural and submucosal nodes - fibroids or leiomyomas, where the ratio of parenchyma to stroma is 2:1 or 3:1.
Classification of uterine fibroids.
I. By localization: uterine body fibroids -95%; cervical fibroids (cervical) -5%.
Rice. 161 Scheme of the development of uterine myoma nodes
different localization (according to Albrecht).
Rice. 160 . Intraligamentally located myomatous nodes (Fig. Ya. S. Klenitsky).
II. Growth form: interstitial(intermuscular) - the node is located in the thickness of the myometrium; submucosal(submucosal) - growth towards the uterine cavity; subserous(subperitoneal) - growth towards the abdominal cavity; mixed(a combination of two, three forms of growth); intraligamentary(interligamentous) (Fig. 160) - the growth of the node between the anterior and posterior leaves of the broad ligament of the uterus; retroperitoneal- with exophytic growth from the lower segment of the uterus, isthmus, cervix. On fig. 161 shows a diagram of the development of myomatous nodes according to Albrecht.
Among submucosal fibroids, tumors are born when the growth of the node occurs towards the internal pharynx. The long-term development of such a node leads to the expansion of the cervical canal and is often accompanied by the release of a tumor into the vagina (the birth of a submucosal node).
Clinic of uterine fibroids. Often, uterine fibroids are asymptomatic. The main symptoms of uterine fibroids are menstrual dysfunction, pain, tumor growth and dysfunction of neighboring organs.
hypermenstrual syndrome characteristic of the submucosal or multiple interstitial form. The duration and intensity of uterine bleeding increases with the growth of fibroids. Later, acyclic bleeding may also join. As a result of menorrhagia and metrorrhagia, chronic posthemorrhagic anemia develops, hypovolemia, m
Nursing care for neoplasms: "" DISCIPLINE NURSING IN SURGERY: SPECIALTY 060109 NURSING 51 State educational institution of secondary vocational education of the city of Moscow Medical College No. 5 Department of Health of the City of Moscow
Objectives To introduce students to the role of a nurse in providing care to patients with neoplasms Formation of readiness to carry out nursing interventions in compliance with professional ethics
Objectives To know the basic concepts and terms of the topic. Principles of organizing oncological care in Russia. The need for constant oncological vigilance when working with patients. Principles of treatment of tumors. Nursing process in the pre and postoperative period. Psychological and ethical aspects of the activities of a nurse in the care of cancer patients Be able to apply the knowledge gained in the care of patients with neoplasms. Distinguish between the main features of benign and malignant tumors.
TERMINOLOGICAL GLOSSARY Oncology is a branch of medicine dealing with the study, diagnosis and treatment of tumors. A tumor is a pathological process represented by a newly formed tissue in which changes in the genetic apparatus of cells lead to dysregulation of their growth and differentiation, characterized by structural polymorphism, features of development, metabolism and isolation of growth Palliative surgery is an operation in which the surgeon does not set himself the goal of completely removing the tumor , but seeks to eliminate the complication caused by the tumor and alleviate the suffering of the patient. Radical surgery - complete removal of the tumor with regional lymph nodes.
A tumor is a pathological process represented by a newly formed tissue, in which changes in the genetic apparatus of cells lead to a violation of the regulation of their growth and differentiation, characterized by structural polymorphism, development, metabolism, and isolation of growth.
Historical background Cancer was first described in an Egyptian papyrus from about 1600 BC. e. The papyrus describes several forms of breast cancer and states that there is no cure for this disease.
Historical reference The name "cancer" comes from the term "carcinoma" introduced by Hippocrates (460-370 BC), which meant a malignant tumor. Hippocrates described several types of cancer.
Historical background Roman physician Cornelius Celsus in the 1st century BC. e. proposed to treat cancer at an early stage by removing the tumor, and at later stages - not to treat it in any way. Galen used the word "oncos" to describe all tumors, which gave the modern root to the word oncology.
Theories of the origin of tumors I. Theory of irritation by R. Virchow constant traumatization of tissues accelerates the processes of cell division
Theories of the origin of tumors II. The theory of germinal rudiments by D. Kongeym at the early stage of development of the embryo, more cells can be formed than necessary. Unclaimed cells have the potential for high growth energy
Theories of the origin of tumors III. Mutation theory of Fisher-Wazels as a result of various factors in the body, degenerative-dystrophic processes occur with the transformation of normal cells into tumor cells
Theories of the origin of tumors IV. Viral theory The virus, penetrating into the cell, acts at the gene level, disrupting the regulation of cell division Epstein-Barr virus Herpes virus papillomavirus retrovirus Hepatitis B and
Theories of the origin of tumors V. Immunological theory disorders in the immune system lead to the fact that transformed cells are not destroyed and are the cause of tumor development
Theories of the origin of tumors VI. Modern polyetiological theory Mechanical factors Chemical carcinogens Physical carcinogens Oncogenic viruses
Men Women Common forms Mortality Prostate 33% 31% Breast 32% 27% Lungs 13% 10% Lungs 12% 15% Rectum 10% Rectum 11% 10% Bladder 7% 5% Endometrium Uterus 6%
Features of tumor cells Autonomy - the independence of the rate of cell reproduction and other manifestations of their vital activity from external influences that change and regulate the vital activity of normal cells. Tissue anaplasia is a return to a more primitive type of tissue. Atypia is a difference in the structure, location, and relationship of cells.
Features of tumor cells Progressive growth - non-stop growth. Invasive growth - the ability of tumor cells to grow into surrounding tissues and destroy, replace them. Expansive growth - the ability of tumor cells to displace surrounding tissues without destroying them Metastasis - the formation of secondary tumors in organs distant from the primary tumor
Metastasis Ways of metastasis hematogenous lymphogenous implantation. Stages of metastasis: invasion by cells of the primary tumor of the wall of a blood or lymphatic vessel; exit of single cells or groups of cells into the circulating blood or lymph from the vessel wall; retention of circulating tumor emboli in the lumen of a small diameter vessel; invasion by tumor cells of the vessel wall and their reproduction in a new organ.
Benign (mature) tumors do not grow into surrounding tissues and organs expansive growth clear tumor boundaries slow growth no metastases
II. Morphological classification of benign tissue Malignant Papilloma Polyp Epithelial Cancer Adenocarcinoma Squamous cell carcinoma fibroma chondroma Osteoma Coupling Sarcoma Chondrosarcoma Osteosarcoma Fibrosarcoma rhabdomyomas Muscle Leiomyoma Leiomyosarcoma Rhabdomyosarcoma neuromas neurofibromas Astrocytoma Nervous Neyrofibrosarkoma lymphangioma hemangioma Vascular Hemangiosarcoma lymphangiosarcoma nevus melanoma
III. International classification according to T N M T (tumor) to describe the size and spread of the primary tumor TX - it is not possible to estimate the size and local spread of the primary tumor; T 0 - the primary tumor is not determined; T 1, T 2, T 3, T 4 - categories reflecting the increase in the size and / or local spread of the primary tumor focus
II. International classification according to T N M N (lymph nodes) to describe involvement of regional lymph nodes NX - insufficient data to evaluate regional lymph nodes; N 0 - no metastases to regional lymph nodes; N 1, N 2, N 3 - categories reflecting the varying degree of damage to regional lymph nodes by metastases.
II. International classification by T N M M (metastases) - indicates whether the tumor has distant screenings - MX metastases - there is not enough data to determine distant metastases; M 0 - no signs of distant metastases; M 1 - there are distant metastases.
Stages of malignant tumors I. Stage - the tumor is localized, occupies a limited area, does not germinate the wall of the organ, there are no metastases II. Stage - a tumor of moderate size, does not spread outside the organ, single metastases to regional lymph nodes are possible
Stages of malignant tumors III. Stage - a large tumor, with decay, germinates the entire wall of the organ or a smaller tumor with multiple metastases to regional lymph nodes. IV. Stage - tumor growth into surrounding organs, including non-removable ones (aorta, vena cava, etc.), distant metastases
Dispensary care is a system of active medical and sanitary measures aimed at constantly monitoring the state of people's health, providing medical and preventive care.
, Studies during the patient's dispensary: examinations fluorography mammography examination by a gynecologist rectal examination examination by a urologist (men) esophagogastroduodenoscopy colonoscopy sigmoidoscopy (for chronic diseases of the gastrointestinal tract).
Oncological alertness knowledge of the symptoms of malignant tumors in the early stages; knowledge of precancerous diseases and their treatment; identification of risk groups; timely treatment and dispensary observation; careful examination of each patient; in difficult cases of diagnosis, think about the possibility of an atypical or complicated course of the disease.
Precancerous conditions chronic inflammation malformations long-term non-healing ulcers cervical erosion gastric polyps scars after burns
Cancer syndromes Plus-tissue syndrome Abnormal discharge syndrome Organ dysfunction syndrome Minor signs syndrome
Syndrome of small symptoms Discomfort Fatigue, drowsiness, indifference, decreased performance Taste perversion or lack of appetite Lack of satisfaction from the food taken Nausea, vomiting for no apparent reason
Diagnostics x-ray examination computed tomography (CT) magnetic resonance imaging (MRI) endoscopic examination ultrasound examination (ultrasound) biopsy of tumor material cytological examinations laboratory examinations
Malignant tumors by combined methods - the use of two different types of treatment (surgery + chemotherapy; surgery + RT); combined methods - the use of various therapeutic agents (interstitial and external irradiation); complex method - the use of all three types of treatment (surgical, chemotherapy, radiation therapy).
Surgical methods of treatment Radical surgery - complete removal of the tumor with regional lymph nodes. Contraindications generalization of the tumor process - the occurrence of distant metastases, intractable tumors during surgery. the general serious condition of the patient, due to senile age and decompensated concomitant diseases.
Palliative surgery to restore lost function or alleviate patient suffering. for cancer of the esophagus - gastrostomy, for cancer of the larynx - tracheostomy, for colon cancer - colostomy.
Radiation therapy is the use of various types of ionizing radiation to destroy the tumor focus.
Radiation therapy Types of radiation: Electromagnetic: x-ray, gamma radiation, beta radiation. Corpuscular: artificial radioactive isotopes
Radiation therapy Irradiation methods: remote method (external) - the radiation source is at a distance from the patient contact method (interstitial, intracavitary, application)
Drug therapy is the use of drugs that have a damaging effect on tumor tissue.
Drug therapy Types of drug therapy: Chemotherapy - the use of chemical compounds that destroy tumor tissue or inhibit the reproduction of tumor cells. Cytostatics (antimetabolites), Antitumor antibiotics, Herbal preparations. Hormone therapy: corticosteroids, estrogens, androgens.
Side effects of chemotherapy hemodepression nausea, vomiting decreased appetite diarrhea gastritis cardiotoxic effect nephrotoxicity cystitis stomatitis alopecia (hair loss)
Symptomatic therapy The goal of treatment is to alleviate the suffering of patients. In order to reduce pain, they use: narcotic and non-narcotic analgesics; novocaine blockade; neurolysis is the destruction of pain nerves by surgery or exposure to x-rays.
Oncological ethics and deontology The conversation with the patient is correct, sparing the psyche, giving hope for a favorable outcome of the disease The patient has the right to full information about his disease, but this information must be sparing.
Historical reference The ancient Greek historian Herodotus (500 BC), 100 years before Hippocrates, narrates a legend about the princess Atossa, who suffered from breast cancer. She turned to the famous physician Democedes (525 BC) for help only when the tumor reached a large size and began to bother her. Out of false modesty, the princess did not complain as long as the tumor was small.
Historical background The famous physician Galen (131-200) may have been the first to propose the surgical treatment of breast cancer while preserving the pectoralis major muscle.
in the world more than 1 million new cases of breast cancer are registered annually in the Russian Federation - over 50 thousand.
Risk factors age over 50 abortion menstrual function - onset at age 10-12, late menopause. nulliparous women first births over the age of 35 prolonged period of breastfeeding of children diseases of the female genital organs heredity overweight radiation exposure, smoking, alcohol use use of oral contraceptives
Clinical international (classification T NM) T 1 tumor up to 2 cm T 2 tumor 2-5 cm T3 tumor more than 5 cm T 4 tumor with spread to the chest or skin N 0 axillary lymph nodes are not palpable N 1 dense displaced lymph nodes in the axillary region are palpable on the same side N 2 large axillary lymph nodes are palpated, soldered, limited mobility N 3 palpated on the same side of the sub- or supraclavicular lymph nodes, or swelling of the arm Mo no distant metastases M 1 there are distant metastases
Stages of development Stage I: tumor up to 2 cm without damage to the lymph nodes (T 1, N 0 M o)
Stages of development Stage II a: tumor no more than 5 cm without damage to the lymph nodes (T 1 -2, N o M 0) Stage II b: tumor no more than 5 cm, with damage to single axillary lymph nodes (T 1, N 1 M 0)
Stages of development Stage III: tumor more than 5 cm with the presence of multiple metastases in the axillary lymph nodes (T 1 N 2 -3, Mo; T 2 N 2_3 Mo; T 3 N 0. 3 Mo, T 4 N 0. 3 M 0)
Stages of development Stage IV: the presence of a tumor that has spread to areas of the body located at a significant distance from the chest (any combination of T, N with M +)
Clinical forms nodular form diffuse form edematous - infiltrative form mastitis-like cancer erysipelas-like cancer shell-like cancer Paget's disease (cancer)
Nodular form Early clinical signs: The presence of a clearly defined node in the mammary gland. Dense consistency of the tumor. Limited mobility of the tumor in the mammary gland. Pathological wrinkling or retraction of the skin over the tumor Painlessness of the tumor node. The presence of one or more dense mobile lymph nodes in the axillary region of the same side.
Nodular form Late clinical signs: Visible retraction of the skin at the site of the detected tumor Symptom of "lemon peel" over the tumor. Ulceration or germination of the skin by a tumor. Thickening of the nipple and areola folds is a symptom of Krause. Retraction and fixation of the nipple. Large size of the tumor. Deformity of the breast Large immobile metastatic lymph nodes in the armpit Supraclavicular metastases Pain in the breast Distant metastases identified clinically or radiographically.
Principles of treatment II. Radiation therapy Remote gamma therapy, electron or proton beam is used.
Treatment principles III. Chemotherapy Cytostatics cyclophosphamide 5 - fluorouracil vincristine adriampicin, etc. Hormone therapy androgens corticosteroids estrogens
Nursing care before surgery radical mastectomy The evening before surgery: light dinner, cleansing enema, shower, change of bed and underwear, follow the instructions of the anesthesiologist, In the morning before surgery: do not feed, do not drink, shave the armpits, remind the patient to urinate , bandage the legs with elastic bandages up to the inguinal folds, premedicate for 30 minutes. Before surgery, bring to the operating room in the nude on a gurney, covered with a sheet.
Nursing care after surgery Radical mastectomy Immediately after surgery: Assess the patient’s condition Lay in a warm bed in a horizontal position without a pillow, turning her head to one side Inhale humidified oxygen Put an ice pack on the operation area Check the condition of the drains and the drainage bag Bandage the arm on the side of the operation with an elastic bandage Perform doctor's prescription: administration of narcotic analgesics, infusion of plasma substitutes, etc. conduct dynamic monitoring
Nursing care after surgery radical mastectomy 3 hours after surgery: give a drink; raise the head end, put a pillow under the head; change ice pack make the patient take a deep breath, cough; massage the skin of the back; check the bandages on the legs and arm; follow the doctor's orders; conduct dynamic monitoring.
Nursing care after surgery radical mastectomy 1st day after surgery: help the patient to carry out personal hygiene, sit up in bed; lowering your legs out of bed for 5-10 minutes; feed a light breakfast; perform a back massage with effleurage and cough stimulation; remove the bandages from the arms and legs, massage them and bandage them again; bandage the wound together with the doctor; change the drainage bag - an accordion, fixing the amount of discharge in the observation sheet; conduct dynamic monitoring
Nursing care after surgery Radical mastectomy Day 2-3 after surgery Help the patient get out of bed Help walk around the ward, perform personal hygiene Bandage the arm and legs with a light massage Feed according to the diet of concomitant diseases or diet No. 15 Start training in gymnastics for the arm on the side of the operation to carry out - dynamic monitoring, prevention of late postoperative complications
Nursing care after surgery radical mastectomy From day 4, the ward regime with gradual drainage is removed on days 3-5, and if lymph accumulates under the skin, it is removed by puncture. stitches from the wound are removed on the 10th - 15th day.
Disturbed patient needs:
1. Be healthy
3. Move
4. Lead a normal life (work, study)
5. Be safe
6. Need for comfort
7. The need for self-care
8. Social problem
9. Violation of the psycho-emotional reaction
The real problems of the patient:
1. Headache, dizziness
2. Lack of knowledge
3. Anxiety, fear, negative attitude
4. Sleep disturbance
5. Vomiting, nausea
6. Deterioration of memory, vision, attention
7. Fatigue, weakness
8. Absent-mindedness, irritability
9. Movement disorders (paresis, paralysis)
10. Lack of appetite
Potential patient problem: risk of complications.
Priority problem: lack of knowledge.
The short-term goal is to fill the knowledge gap.
The long-term goal is that the patient is healthy.
Independent Nursing Interventions:
1. Optimization of the microclimate. Regular ventilation of the room. Temperature and humidity control in the room. Conducting general and daily wet cleaning of the ward.
2. Compliance with the sanitary and epidemiological regime.
3. Fulfillment of medical appointments. If necessary, injections and blood sampling should be performed strictly in the patient's room.
4. Therapeutic and protective regime. Provide physical and psychological peace to the patient, teach the patient to be more patient with pain.
5. Help with vomiting.
Reassure the patient, if the condition allows, seat, put on the patient an oilcloth apron, provide a vessel, give water for rinsing the mouth.
Vomit masses must first be shown to the doctor, treated according to the requirements of the sanitary epidemiological regime.
7. Regular hemodynamics, measuring body temperature and entering data into the temperature sheet, monitoring the patient's condition.
In case of changes, inform the doctor.
8. Conduct a conversation about the disease with the patient and his relatives.
Provide moral and psychological support. Give good examples.
The diagnosis of a brain tumor is a big blow for the patient and his family. The nurse should provide maximum support and assistance in caring for the patient.
9. In case of lack of self-care, assist the patient in the morning toilet, taking a hygienic bath, cutting nails in a timely manner, changing bed and underwear, feeding the vessel, feeding the patient, etc.
10. If the patient is in serious condition, prevent bedsores.
Change the position of the patient's body every two hours (if his condition allows), make sure that underwear and bed linen do not gather in folds, put cotton-gauze circles under the limbs, pads under the sacrum and the back of the head, control of skin cleanliness.
11. Tell the patient and his relatives about the diet prescribed by the doctor. Gear control. (see annex 2)
12. Preparing the patient for diagnostic and therapeutic measures, for testing. Preparing the patient for the upcoming operation.
With proper psychological preparation, the level of anxiety, postoperative pain and the frequency of postoperative complications are reduced. A severe traumatic effect is exerted by the painful experiences of the patient about the upcoming operation. A patient with a brain tumor may be afraid of the operation itself and the suffering and pain associated with it. He may fear for the outcome and consequences of the operation. In any case, it is the sister, due to the fact that she is constantly with the patient, who should be able to find out the specifics of the fear of this or that patient, determine what exactly the patient is afraid of and how great and deep his fear is. In addition to the patient's words, one can learn about his fears indirectly, through vegetative signs: sweating, trembling, accelerated cardiac activity, diarrhea, frequent urination, insomnia. The sister informs the attending physician about all her observations, she must become an attentive mediator and, on both sides, prepare a conversation between the patient and the attending physician about the upcoming operation, which should help dispel fears. Both the doctor and the nurse must “infect” the patient with their optimism, make him their companion in the fight against the disease and the difficulties of the postoperative period.
The activities of a nurse working with oncological patients are built according to the stages of the nursing process.
I stage. Initial assessment of the patient's condition. At the first contact with an oncological patient, the nurse gets to know him and his relatives, and introduces herself. Conducts a survey and examination of the patient, determining the degree of his physical activity, the possibility of independent physiological functions, evaluates the functional capabilities of vision, hearing, speech, determines the prevailing mood of the patient and his relatives at the time of admission, guided by facial expressions, gestures, desire to make contact. The nurse also assesses the patient's condition by the nature of breathing, the color of the skin, measuring blood pressure, counting the pulse rate, laboratory and instrumental research data.
All data from the initial examination are analyzed by the nurse and documented.
II stage. Diagnosing or identifying patient problems.
When working with cancer patients, the following nursing diagnoses can be made:
Pain of various localization associated with the tumor process;
Reduced nutrition associated with a decrease in appetite;
fear, anxiety, anxiety associated with the suspicion of an unfavorable outcome of the disease;
Sleep disturbance associated with pain
unwillingness to communicate, take medications, refusal of the procedure associated with a change in the emotional state;
inability of relatives to care for the patient, associated with a lack of knowledge;
weakness, drowsiness due to intoxication;
pallor of the skin due to a decrease in hemoglobin;
Decreased physical activity due to pain and intoxication.
Stage III Stage IV
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PLANNING YOUR PATIENT CARE |
IMPLEMENTATION OF THE NURSING INTERVENTION PLAN |
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Fulfillment of doctor's orders |
1. Control over the timely intake of drugs. 2. Teaching the patient to take various dosage forms enterally. 3. Diagnosed complications arising from the parenteral route of drug administration. 4. Orientation of the patient to timely seeking help in case of side effects of drugs. 5. Monitoring the patient's condition during dressings, medical manipulations. |
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Exclusion of drug overdose |
Information of the patient about the exact name of the drug and its synonyms, about the time of the onset of the effect. |
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Helping the patient with hygiene measures |
1. Train the patient (patient's relatives) in hygiene procedures. 2. Obtain the patient's consent to carry out personal hygiene manipulations. 3. Help the patient clean the mouth after each meal. 4. Wash the vulnerable parts of the patient's body as it gets dirty. |
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Ensuring a comfortable microclimate in the ward that promotes sleep |
1. Create comfortable conditions for the patient in bed and in the ward: optimal bed height, high-quality mattress, optimal number of pillows and blankets, ventilation of the ward. 2. Reduce the patient's anxiety associated with unfamiliar surroundings. |
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Ensuring rational nutrition of the patient |
1. Organize diet food. 2. Create a favorable environment while eating. 3. Help the patient while eating or drinking. 4. Ask the patient in what order he prefers to eat. |
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Reducing patient pain |
1. Determine the localization of pain, time, cause of pain, duration of pain. 2. Analyze together with the patient the effectiveness of previously used pain medications. 3. Distract attention with communication. 4. Teach the patient relaxation techniques. 5. Reception of analgesics by the hour, not on demand. |
V stage. Evaluation of nursing interventions. The time and date of the evaluation of the effectiveness of nursing interventions should be indicated for each problem identified. The results of nursing actions are measured by change in nursing diagnoses. When determining the effectiveness of nursing interventions, the opinion of the patient and his relatives is also taken into account, and their contribution to achieving the goals is noted. The plan for caring for a seriously ill patient has to be constantly adjusted, taking into account the change in his condition.
