Cancer Risk Factors

Cancer is the second leading cause of death in the United States. The National Cancer Institute describes these risk factors.

Cancer Treatment

If detected early, cancer can be treated and controlled (Box 28-1). Treatment depends on the tumor type, its site and size, and if it has spread. The treatment goal may be to:

Surgery, radiation therapy, and chemotherapy are the most common treatments.

The Person’s Needs

Persons with cancer have many needs. They include:

Anger, fear, and depression are common. Some surgeries are disfiguring. The person may feel unwhole, unattractive, or unclean. The person and family need support.

Spiritual needs are important. A spiritual leader may provide comfort. To many people, spiritual needs are just as important as physical needs.

Persons dying of cancer often receive hospice care (Chapters 1 and 32). Support is given to the person and family.

See Focus on Communication: The Person’s Needs.

Arthritis

Arthritis means joint (arthr) inflammation (itis). Pain, swelling, and stiffness occur in the affected joints. The joints are hard to move.

Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is a chronic inflammatory disease. It causes joint pain, swelling, stiffness, and loss of function. More common in women, it usually develops between the ages of 20 and 50.

RA occurs on both sides of the body. For example, if the right wrist is involved, so is the left wrist. The wrist and finger joints near the hand are often affected (Fig. 28-3). Other joints affected are the neck, shoulders, elbows, hips, knees, ankles, and feet. Joints are tender, warm, and swollen. Other body parts may be affected. Fatigue and fever are common. The person does not feel well. Symptoms may last for many years.

Treatment goals are to:

• Relieve pain.

• Reduce inflammation.

• Slow down or stop joint damage.

The person’s care plan may include:

• Rest balanced with exercise. Short rest periods during the day are better than long times in bed. An exercise program is prescribed. Range-of-motion (ROM) exercises are included. Exercise helps maintain healthy and strong muscles, joint mobility, and flexibility. It also promotes sleep, reduces pain, and helps weight control.

• Proper positioning. Contractures and deformities are prevented. Bed-boards, a bed cradle, trochanter rolls, and pillows are used.

• Joint care. Good body mechanics and body alignment, wrist and hand splints, and self-help devices reduce stress on joints. Some need walking aids.

• Weight control. Excess weight places stress on the weight-bearing joints. Exercise and a healthy diet help control weight.

• Measures to reduce stress. Relaxation, distraction, exercise, and regular rest help reduce stress.

• Measures to prevent falls. See Chapter 10.

Drugs are given for pain relief and inflammation. Heat and cold applications may be ordered. Some persons need joint replacement surgery.

Emotional support is needed. A good outlook is important. Persons with RA need to stay as active as possible. The more they can do for themselves, the better off they are. Give encouragement and praise. Listen when the person needs to talk.

Joint Replacement Surgery.

Arthroplasty is the surgical replacement (plasty) of a joint (arthro). The damaged joint is removed and replaced with an artificial joint (prosthesis).

Hip and knee replacements are common. See Box 28-2. Ankle, foot, shoulder, elbow, and finger joints also can be replaced.

Box 28-2   Care Measures After Joint Replacement Surgery—Hip and Knee

• Deep-breathing and coughing exercises to prevent respiratory complications (Chapter 26).

• Elastic stockings to prevent thrombi (blood clots) in the legs.

• Exercises to strengthen the hip or knee. These are taught by a physical therapist.

• Measures to protect the hip as shown in Figure 28-4, p. 430.

• Food and fluids for tissue healing and to restore strength.

• Safety measures to prevent falls.

• Measures to prevent infection. Wound, urinary tract, and skin infections must be prevented.

• Measures to prevent pressure ulcers (Chapter 25).

• Assist devices for moving, turning, re-positioning, and transfers.

• Assistance with walking and a walking aid. The person may need a cane, walker, or crutches.

Osteoporosis

With osteoporosis, the bone (osteo) becomes porous and brittle (porosis). Bones are fragile and break easily. Spine, hip, wrist, and rib fractures are common.

Older people are at risk. The risk for women increases after menopause because the ovaries do not produce estrogen. The lack of estrogen and low levels of dietary calcium cause bone changes.

All ethnic groups are at risk. Other risk factors include a family history of the disease, being thin or having a small frame, eating disorders (Chapter 29), tobacco use, alcoholism, lack of exercise, bedrest, and immobility. Exercise and activity are needed for bone strength. Bone must bear weight to form properly. If not, calcium is lost from the bone. The bone becomes porous and brittle.

Back pain, gradual loss of height, and stooped posture occur. Fractures are a major threat. Even slight activity can cause fractures. They can occur from turning in bed, getting up from a chair, or coughing. Fractures are great risks from falls and accidents.

Prevention is important. Doctors often order calcium and vitamin supplements. Estrogen is ordered for some women. Other preventive measures include:

Fractures

A fracture is a broken bone. Fractures are open or closed (Fig. 28-5).

Falls, accidents, bone tumors, and osteoporosis are some causes. Signs and symptoms of a fracture are:

For healing, bone ends are brought into and held in normal position. This is called reduction and fixation.

After reduction, the bone ends must not move. The person has a cast or traction. Splints, walking boots, and external fixators also are used.

• Casts. Casts are made of plaster of Paris, plastic, or fiberglass. Plastic and fiberglass casts dry quickly. A plaster of Paris cast dries in 24 to 48 hours. It is odorless, white, and shiny when dry. When wet, it is gray and cool and has a musty smell. The nurse may ask you to assist with care (Box 28-3).

Box 28-3   Cast Care

• Do not cover the cast with blankets, plastic, or other material. A cast gives off heat as it dries. Covers prevent the escape of heat. Burns can occur if heat cannot escape.

• Turn the person every 2 hours or as directed. All cast surfaces need exposure to air. Turning promotes even drying.

• Do not place a wet cast on a hard surface. It flattens the cast. The cast must keep its shape. Use pillows to support the entire length of the cast (Fig. 28-6, p. 432).

• Support the wet cast with your palms to turn and position the person (Fig. 28-7, p. 432). Fingertips can dent the cast. The dents can cause pressure areas and skin breakdown.

• Report rough cast edges. The nurse needs to cover the cast edges with tape.

• Keep the cast dry. A wet cast loses its shape. Some casts are near the perineal area. The nurse may apply a waterproof material around the perineal area after the cast dries.

• Do not let the person insert anything into the cast. Itching under the cast causes an intense desire to scratch. Items used for scratching (pencils, coat hangers, knitting needles, back scratchers, and so on) can open the skin. Infection is a risk. Scratching items can wrinkle the stockinette or cotton padding. Or they can be lost into the cast. Both can cause pressure and skin breakdown.

• Elevate a casted arm or leg on pillows. This reduces swelling.

• Have enough help to turn and re-position the person. Plaster casts are heavy and awkward. Balance is lost easily.

• Position the person as directed.

• Follow the care plan for elimination needs. Some persons use a fracture pan.

• Report these signs and symptoms at once.

• Pain—pressure ulcer, poor circulation, nerve damage

• Swelling and a tight cast—reduced blood flow to the part

• Pale skin—reduced blood flow to the part

• Cyanosis (bluish skin color)—reduced blood flow to the part

• Odor—infection

• Inability to move the fingers or toes—pressure on a nerve

• Numbness—pressure on a nerve, reduced blood flow to the part

• Temperature changes—cool skin means poor circulation; hot skin means inflammation

• Drainage on or under the cast—infection or bleeding

• Chills, fever, nausea, and vomiting—infection

• Complete a safety check before leaving the room. (See the inside of the front cover.)

• Traction. A steady pull from 2 directions keeps the bone in place. Weights, ropes, and pulleys are used (Fig. 28-8). Traction is applied to the neck, arms, legs, or pelvis. To assist with the person’s care, see Box 28-4, p. 432.

Box 28-4   Caring for Persons in Traction

• Keep the person in good alignment.

• Do not remove the traction.

• Keep the weights off the floor. Weights must hang freely from the traction set-up (see Fig. 28-8).

• Do not add or remove weights.

• Check for frayed ropes. Report fraying at once.

• Perform ROM exercises for the uninvolved joints as directed.

• Position the person as directed. Usually only the supine position is allowed. Slight turning may be allowed.

• Provide the fracture pan for elimination.

• Give skin care as directed.

• Put bottom linens on the bed from the top down. The person uses a trapeze to raise the upper body off the bed (see Fig. 28-8).

• Check pin, nail, wire, or tong sites for redness, drainage, and odors. Report observations at once.

• Observe for the signs and symptoms listed under cast care (see Box 28-3). Report them at once.

• Complete a safety check before leaving the room. (See the inside of the front cover.)

Hip Fractures.

Fractured hips are common in older persons (Fig. 28-9). The fracture requires internal fixation (p. 431) or partial or total hip replacement. Adduction, internal rotation, external rotation, and severe hip flexion are avoided after surgery. Rehabilitation is usually needed.

Post-operative problems present life-threatening risks. They include respiratory complications, urinary tract infections, and thrombi (blood clots) in the leg veins. Pressure ulcers, constipation, and confusion are other risks. Box 28-5 describes the required care.

Box 28-5   Hip Fracture Care

• Give good skin care. Skin breakdown can be rapid.

• Prevent pressure ulcers.

• Prevent wound, skin, and urinary tract infections.

• Encourage deep-breathing and coughing exercises as directed.

• Turn and position the person as directed. Turning and positioning depend on the type of fracture and the surgery. Usually the person is not positioned on the operative side.

• Prevent external rotation of the hip. Use trochanter rolls, pillows, or sandbags.

• Keep the leg abducted at all times. Use pillows (Fig. 28-10) or a hip abduction wedge (abductor splint). Do not exercise the affected leg.

• Provide a straight-back chair with armrests. The person needs a high, firm seat.

• Place the chair on the unaffected side.

• Use assist devices to move, turn, re-position, and transfer the person.

• Do not let the person stand on the operated leg unless allowed by the doctor.

• Elevate the leg following the care plan. With an internal fixation device, the leg is not elevated when the person sits in a chair. Elevating the leg puts strain on the device.

• Apply elastic stockings to prevent thrombi (blood clots) in the legs.

• Remind the person not to cross his or her legs.

• Assist with walking according to the care plan. The person uses a walker or crutches.

• Follow measures to protect the hip. See Box 28-2 and Figure 28-4.

• Practice safety measures to prevent falls.

• Complete a safety check before leaving the room. (See the inside of the front cover.)

Loss of Limb

An amputation is the removal of all or part of an extremity. Severe injuries, tumors, severe infection, gangrene, and vascular disorders are common causes. Diabetes can cause vascular changes leading to amputation.

Gangrene is a condition in which there is death of tissue. Causes include infection, injuries, and vascular disorders. Blood flow is affected. Tissues do not get enough oxygen and nutrients. Tissues become black, cold, and shriveled (Fig. 28-11). Surgery is needed to remove dead tissue. Gangrene can cause death.

The person is fitted with a prosthesis—an artificial replacement for a missing body part (Fig. 28-12). Occupational and physical therapists help the person use the prosthesis.

The person may feel that the limb is still there. Aching, tingling, and itching are common sensations. Or the person complains of pain in the amputated part (phantom pain). This is a normal reaction. It may occur for a short time or for many years.

Stroke

Stroke is a disease that affects the arteries that supply blood to the brain. It also is called a brain attack or cerebrovascular accident (CVA). It occurs when 1 of these happens:

Brain cells in the affected area do not get enough oxygen and nutrients. Brain damage occurs. Functions controlled by that part of the brain are lost (Fig. 28-13).

Stroke is a leading cause of death and disability among adults in the United States. See Box 28-6 for warning signs. The person needs emergency care. Blood flow to the brain must be restored as soon as possible.

Warning signs may last a few minutes. This is called a transient ischemic attack (TIA). (Transient means temporary or short term. Ischemic means to hold back [ischein] blood [hemic].) Blood supply to the brain is interrupted for a short time. A TIA may occur before a stroke. The person also may have nausea, vomiting, and memory loss. Unconsciousness, noisy breathing, high blood pressure, slow pulse, redness of the face, and seizures may occur. So can hemiplegia—paralysis (plegia) on 1 side (hemi) of the body. The person may lose bowel and bladder control and the ability to speak. (See “Aphasia.”) All stroke-like symptoms signal the need for emergency care.

The effects of stroke include:

Rehabilitation starts at once. The person may depend in part or totally on others for care. The health team helps the person regain the highest possible level of function (Box 28-7).

Aphasia

Aphasia is the total or partial loss (a) of the ability to use or understand language (phasia). Aphasia is a language disorder. Parts of the brain responsible for language are damaged. Stroke, head injury, brain infections, and cancer are common causes. Two types of aphasia are:

Some people have both types. This is called expressive-receptive aphasia (global aphasia, mixed aphasia). The person has problems speaking and understanding language.

Parkinson’s Disease

Parkinson’s disease is a slow, progressive disorder with no cure. Movement is affected. Persons over the age of 50 are at risk. Signs and symptoms become worse over time (Fig. 28-14). They include:

Other signs and symptoms develop over time. They include swallowing and chewing problems, constipation, and bladder problems. Sleep problems, depression, and emotional changes (fear, insecurity) can occur. So can memory loss and slow thinking. The person may have slurred, monotone, and soft speech. Some people talk too fast or repeat what they say.

Drugs are ordered to treat and control the disease. Exercise and physical therapy help improve strength, posture, balance, and mobility. Therapy is needed for speech and swallowing problems. The person may need help with eating and self-care. Normal elimination is a goal. Safety measures are needed to prevent falls and injuries.

Multiple Sclerosis

Multiple sclerosis (MS) is a chronic disease. Multiple means many. Sclerosis means hardening or scarring. The myelin (which covers nerve fibers) in the brain and spinal cord is destroyed. Nerve impulses are not sent to and from the brain in a normal way. Functions are impaired or lost. There is no cure.

Symptoms usually start between the ages of 20 and 40. The risk increases if a family member has MS.

Signs and symptoms may include:

MS can present in many ways. For example:

Persons with MS are kept as active as long as possible and as independent as possible. The care plan reflects the person’s changing needs. Skin care, hygiene, and ROM exercises are important. So are turning, positioning, and deep breathing and coughing. Bowel and bladder elimination is promoted. Injuries and complications from bedrest are prevented.

Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS) is a disease that attacks the nerve cells that control voluntary muscles. Commonly called Lou Gehrig’s disease, it is rapidly progressive and fatal. (Lou Gehrig was a New York Yankees baseball player. He died of the disease in 1941.)

More common in men, it usually strikes between 40 and 60 years of age. Most die 3 to 5 years after onset. Some live for 10 years or more.

Motor nerve cells in the brain, brainstem, and spinal cord are affected. These cells stop sending messages to the muscles. The muscles weaken, waste away (atrophy), and twitch. Over time, the brain cannot start voluntary movements or control them. The person cannot move the arms, legs, and body. Muscles for speaking, chewing and swallowing, and breathing also are affected. Eventually respiratory muscles fail.

The disease usually does not affect the mind, intelligence, or memory. Sight, smell, taste, hearing, and touch are not affected. Usually bowel and bladder functions remain intact.

ALS has no cure. Some drugs can slow the disease and improve symptoms. However, damage cannot be reversed. The person is kept active and independent to the extent possible. The care plan reflects the person’s changing needs.