Bladder cancer treatment(s) and pre/post nursing care:pg.1702
Therapy for the client with bladder cancer usually begins with surgical removal of the tumors for diagnosis and staging of the disease. For tumors extending beyond the mucosa, surgery is followed by intravesical chemotherapy or immunotherapy. High-grade or recurrent tumors are treated with more radical surgery plus intravesical chemotherapy, radiotherapy, or both. Systemic chemotherapy is reserved for clients with distant metastases. Nonsurgical management: Prophylactic immunotherapy with intravesical instillation of bacille Calmette-Guerin (BCG), a compound used to vaccinate against tuberculosis in some countries, is used to prevent tumor recurrence of superficial cancers. This procedure is more effective than single-agent chemotherapy. Mutliagent chemotherapy and radiation therapy are also useful in prolonging life. Surgical Management: The type of surgery for bladder cancer depends on the type and stage of the cancer and the client's general health. Complete bladder removal (cystectomy) with additional removal of surrounding muscle and tissue offers the best chance of a cure for large, invasive bladder cancers. Four alternatives are used after cystectomy: ileal conduit, continent pouch, bladder reconstruction also known as neobladder, and uretersigmoidostomy. Preoperative Care: Coordinate education before the surgery with surgeon and enterostomal therapist. Discuss the type of planned urinary diversion and the selection of a site for the stoma. The goal is for the client to have a positive attitude about the body image and a positive self-image. Use educational counseling to ensure understanding about self-care practices, methods of pouching, control of urine drainage, and management of odor. Prepare the client for the number and type of drains that will be present after surgery. Postoperative Care: Collaborate with the enterostomal therapist to focus care on the wound, the skin, and the urinary drainage. Assess the stoma every 8 hours early in postoperative period. It should be rose to brick red with minimal swelling and bleeding. A pale or cyanotic stoma indicates altered blood supply; notify the physician. Educate the client and family about drugs, diet, and fluid therapy, the use of external pouching systems, and the technique for catheterizing a continent reservoir.
AV fistula, definition, assessment, nursing care, complications and utilization:Pg.1753
Definition: AV fistula is an internal anastomosis of artery to a vein. The most commonly used vessels are the radial or brachial artery and the cephalic vein of the nondominant arm. Utilization: Used for hemodialysis. Assessment: Some precautions are needed to ensure the functioning of an internal AV fistula or AV graft. First assess for adequate circulation in the fistula or graft as well as in the distal portion of the extremity. Then check for a bruit or a thrill by auscultation or palpation over the assess site. The AV fistula or graft is not used for delivery of IV fluids. Complications: Complications can occur regardless of the type of access. The most common problems are thrombosis or stenosis, infection, aneurysm formation, ischemia, and heart failure. Thrombosis, or clotting of the AV access, is the most frequent complication. Nursing Care: Do not take blood pressure readings using the extremity in which the vascular access is placed. Do not perform venipunctures or start an IV line in the extremity in which the vascular access is placed. Palpate for thrills and auscultate for bruits every 4 hours while the client is awake. Assess the client's distal pulses and circulation. Elevate the affected extremity postoperatively. Encourage routine range-of-motion exercises. Check for bleeding at needle insertion sites or shunt tubing insertion sites. (Keep small clamps handy on the dressing of the AV shunt.) Assess for manifestations of infection at needle sites and shunt tubing insertion sites. Instruct the client not to carry heavy objects or anything that compresses the extremity in which the vascular access if placed. Instruct the client against sleeping with his or her body weight on top of the extremity in which the vascular access is placed.