Tuesday, November 30, 2010

Benign or malignant tumors may develop on the bladder. Bladder tumors can develop on the surface of the bladder wall (benign or malignant papillomas) or grow within the bladder wall (usually more virulent) and quickly invade underlying muscles. 
Most bladder tumors are transitional cell carcinomas, arising from the transitional epithelium of mucous membranes. Less common are adenocarcinomas, epidermoid carcinomas, squamous cell carcinomas, sarcomas, tumors in bladder diverticula, and carcinoma in situ. Bladder tumors are most prevalent in men older than age 50 and are more common in densely populated industrial areas, but women are diagnosed at more advanced stages. 
The most common presenting symptom of bladder cancer is hematuria. Gross hematuria obviously warrants a thorough evaluation of the genitourinary system. When gross hematuria is painless and total (present during the entirety of the urinary stream), it especially causes concern for bleeding from the bladder or upper tracts. Irritative urinary symptoms are relatively common at presentation, including frequency, urgency, and dysuria. The combination of these symptoms with hematuria is very suggestive and warrants full urologic evaluation. Depending on the location of their tumors, patients may have symptoms of bladder-outlet obstruction or ureteral obstruction. A small subset, 5% to 10% of patients, have symptoms related to metastatic disease. 

Causes for Bladder cancer 
Environmental carcinogens are known to predispose a person to transitional cell tumors such as 2-naphthylamine, benzidine, tobacco, coffee, and nitrates.Thus, workers in certain industries (rubber workers, weavers, leather finishers, aniline dye workers, hairdressers, petroleum workers, and spray painters) are at high risk for such tumors. The period between exposure to the carcinogen and development of symptoms is about 18 years. Squamous cell carcinoma of the bladder is common in geographic areas where schistosomiasis is endemic, such as Egypt. What is more, it’s also associated with chronic bladder irritation and infection in people with renal calculi, indwelling urinary catheters, chemical cystitis caused by cyclophosphamide, and pelvic irradiation. 

Complications of bladder cancer
If bladder cancer progresses, complications include bone metastases and problems resulting from tumor invasion of contiguous viscera. 

Nursing Assessment 
The patient typically reports gross, painless, intermittent hematuria and often with clots. Patients may complain of suprapubic pain after voiding, and also complain of bladder irritability, urinary frequency, nocturia, and dribbling. If he reports flank pain, he may have an obstructed ureter. 
Patient’s history Gross, painless, intermittent hematuria is the most frequently reported symptom. Occult blood may be discovered during a routine urinalysis. Dysuria and urinary frequency are also reported. Burning and pain with urination are present only if there is infection. The patient may not seek medical attention until urinary hesitance, decrease in caliber of the stream, and flank pain occurs. Other symptoms may include suprapubic pain after voiding, bladder irritability, dribbling, and nocturia. 
Physical assessment The physical examination is usually normal. A bladder tumor becomes palpable only after extensive invasion into surrounding structures. 

Psychosocial assessment Diagnosis of cancer and treatment of cancer with radical cystectomy and creation of a urinary diversion system can threaten sexual functioning of both men and women. The procedure can cause impotence in men and psychological problems similar to those that accompany a hysterectomy and oophorectomy in women. In addition, a portion of the vagina may be removed, thus affecting intercourse. The psychological impact of a stoma and external urinary drainage system can cause changes in body image and libido. 

Diagnostic tests for bladder cancer 
To confirm a bladder cancer diagnosis, the patient typically undergoes Cystoscopy should be performed when hematuria first appears. Biopsy (If the test results show cancer cells, further studies will determine the cancer stage and treatment). Excretory urography can identify a large, early-stage tumor or an infiltrating tumor; delineate functional problems in the upper urinary tract; assess hydronephrosis; and detect rigid deformity of the bladder wall. Urinalysis can detect blood and malignant cells in the urine. Retrograde cystography evaluates bladder structure and integrity. Test results also help confirm a bladder cancer diagnosis. A bone scan can detect metastases. A computed tomography scan can define the thickness of the involved bladder wall and disclose enlarged retroperitoneal lymph nodes. Ultrasonography can find metastases in tissues beyond the bladder and can distinguish a bladder cyst from a bladder tumor. Laboratory tests, such as a complete blood count and chemistry profile, may be ordered to evaluate conditions such as anemia that are associated with bladder cancer. 

Nursing diagnosis 
Common nursing diagnosis found in nursing care plans for bladder cancer 

  • Acute pain 
  • Anxiety 
  • Disturbed body image 
  • Fear 
  • Impaired skin integrity 
  • Impaired urinary elimination 
  • Ineffective coping 
  • Ineffective therapeutic regimen management 
  • Risk for infection 
  • Sexual dysfunction 

Nursing Interventions 
Acute Pain related to activity of disease process (cancer) 
Nursing Outcomes Evaluation Criteria: Client will 

  • verbalize relief or control of pain. 
  • Client will appear relaxed and be able to sleep and rest appropriately. 

Nursing Intervention nursing diagnosis Acute Pain related to activity of disease process (cancer): 

  1. Assess pain level, location, characteristics, and intensity Rationale Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal developing complications. Pains in Surgical causes usually subside gradually as healing begins. Continued or increasing pain may be a sign of infection. 
  2. Listen to the patient’s fears and concerns. Stay with him during periods of severe stress and anxiety, and provide psychological support Rationale Reduction of anxiety and fear can promote relaxation and comfort. 
  3. Encourage and maintain bed rest during acute phase, if indicated Rationale Minimizes stimulation and promotes relaxation 
  4. Administer analgesics, as indicated Rationale Reduce or control pain and decrease stimulation of the sympathetic nervous system 

Anxiety related to underlying Pathophysiology response, change in health status 
Nursing Outcomes

  • verbalize awareness of feelings of anxiety and healthy ways to deal with them. 
  • Patients will Report that anxiety is reduced to a manageable level. 
  • Patients will express concerns about effect of disease on lifestyle and position within family and society. 
  • Patients will demonstrate problem-solving skills and effective coping strategies and Use resources/support systems effectively. 

Nursing Intervention Anxiety 

  • Observe behavior indicative of anxiety which can be a clue to the client’s level of anxiety Rationale 
  • Explain purpose of tests and procedures in bladder cancer treatment Rationale Reduces anxiety attributable to fear of unknown diagnosis and prognosis. 
  • Encourage family and friends to treat client as before. Rationale Reassures client that role in the family and business has not been altered. 
  • Administer sedatives and tranquilizers, as indicated. Rationale May be desired to help client relax until physically able to reestablish adequate coping strategies. 
  • Review coping skills used in past and Identify coping skills the individual is using currently, such as anger, daydreaming, forgetfulness, eating, smoking, lack of problem solving. Rationale These may be useful for the moment, but may eventually interfere with resolution of current situation 

Nursing Diagnosis Impaired urinary elimination 
Nursing Outcomes Evaluation Criteria 

  • Patients will Display continuous flow of urine, with output adequate for individual situation 
  • Patients will verbalize understanding of condition. 
  • Patients will achieve normal elimination pattern. 
  • Patients will demonstrate behaviors/techniques to prevent urinary infection. 
  • Manage care of urinary catheter, or stoma and appliance following urinary diversion. 

Patient Teaching and Home Health Guidance for Bladder Cancer 
Patient teaching, discharge and home healthcare guidelines for patient with Bladder Cancer. In early stages, bladders Cancer have no symptoms. Commonly, the first sign is gross, painless, intermittent hematuria. Patients with invasive lesions often have suprapubic pain after voiding. Other symptoms include bladder irritability, urinary frequency, nocturia, and dribbling. Provide complete information about disease, disease process and treatment. Provide complete preoperative teaching. Include an explanation of the operation the patient is to undergo. Discuss equipment and procedures that the patient can expect postoperatively. Teach the patient the specific procedure to catheterize the continent coetaneous pouch or reservoir. 
Patient Teaching and Home Health Guidance for Bladder Cancer: 

  • Tell the patient what to expect from diagnostic tests. For example, make sure he understands that he may be anesthetized for cystoscopy. 
  • After the test results are known, explain the implications to the patient and his family. 
  • Demonstrate essential coughing and deep breathing exercises. 
  • In patient with orthotopic bladder replacement, teach the patient how to irrigate the Foley catheter. Suggest the use of a leg bag during the day and a Foley drainage bag at night. Once the pouch has healed and the Foley catheter, ureteral stents, and pelvic drain have been removed, teach the patient to “push” or “bear down” with each voiding. 

Following creation of an ileal conduit, teach the patient how to care of the stoma and urinary drainage system: 

  • If needed, arrange for follow-up home nursing care or visits with an enterostomal therapist. 
  • Tell the patient that the ileal conduit stoma should reach its permanent size about 2 to 4 months after surgery. 
  • Teach the patient how to care for his urinary stoma. Instruction usually begins 4 to 6 days after surgery. Encourage appropriate relatives or other caregivers to attend the teaching session. Advise them beforehand that a negative reaction to the stoma can impede the patient’s adjustment. 
  • If the patient is to wear a urine collection pouch, teach him how to prepare and apply it. First, find out whether he will wear a reusable pouch or a disposable pouch. If he chooses a reusable pouch, he needs at least two to wear alternately. 
  • Teach the patient to select the right-sized pouch by measuring the stoma and choosing a pouch with an opening that leaves a (0.3 cm) margin of skin around the stoma. 
  • Instruct the patient to remeasure the stoma after he goes home in case the size changes. 
  • Tell the patient to empty the pouch every 2 to 3 hours or when it’s one-third full. 
  • Advise him to check the pouch frequently to ensure that the skin seal remains intact. 
  • Teach the patient to provide stoma care. 
  • To ensure a better seal and minimize skin breakdown, teach the patient how to use various products to level uneven abdominal surfaces, such as gullies, scars, and wedges. 
  • Postoperatively, tell the patient with a urinary stoma to avoid heavy lifting and contact sports. Encourage him to participate in his usual athletic and physical activities.

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