Biopsy, Various Sites (Bladder, Bone, Intestinal, Kidney, Liver, Lung, Lymph Node, Muscle, Prostate, Skin, Thyroid)
Synonym/Acronym
N/A
Rationale
To assist in diagnosing cancer or other tissue abnormality.
Patient Preparation
There are no activity restrictions unless by medical direction. Explain that diet is restricted to clear liquids from the day prior to the day of an intestinal biopsy. Instruct all patients that to reduce the risk of aspiration related to nausea and vomiting, solid food and milk or milk products are restricted for at least 6 hr, and clear liquids are restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). Patients may be asked to be NPO after midnight. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org.
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period.
Normal Findings
(Method: Macroscopic and microscopic examination of tissue) No abnormal tissue or cells. No infectious organisms.
Study type: Tissue and cell microscopy, from the selected site; related body system: Digestive, Endocrine, Immune, Integumentary, Lymphatic, Musculoskeletal, Reproductive, Respiratory, Urinary systems. Instructions regarding the appropriate transport container for molecular diagnostic studies should be obtained from the laboratory prior to the procedure. Specimens are placed in a labelled container, including site and laterality, with formalin solution, and promptly transport the specimen to the laboratory for processing and analysis.
Biopsy (Bx) is the excision of a sample of tissue that can be analyzed microscopically to determine cell morphology and the presence of tissue abnormalities. This test is used to assist in confirming the diagnosis of cancer or other disease when clinical symptoms or diagnostic findings (e.g., ultrasound or x-ray) are suspicious. A sample of suspicious tissue is then excised and examined macroscopically and microscopically to determine the presence of cell morphology and tissue abnormalities. Samples can be obtained by aspiration of fluid and tumor cells from the tumor site. If the diagnostic imaging examinations indicate the cancer has spread outside the suspicious area, confirmatory samples can be obtained by surgical biopsy.
Needle biopsies are often performed using guidance by CT scan or ultrasound. The choice of method is based on the type of tumor expected, whether the tumor is benign or malignant, and the surgeon’s anticipated plan regarding removal of the tumor.There are two types of needle biopsy:
- Fine-needle biopsy in which fluid and tumor cells are aspirated from the tumor site.
- Core-needle biopsy in which a plug of tissue is removed using a special serrated needle.
Biopsy is sometimes used to collect specimens for infectious disease testing. Molecular technologies are another approach to testing various specimen types, including tissue biopsy, for infections; there are now numerous applications in the areas of pathogen identification, disease identification, and treatment development. Next-generation sequencing (NGS) is a category of molecular testing used to sequence DNA fragments. NGS technology is capable of sequencing DNA fragments from pathogenic organisms across a range in size from small sequences (single-nucleotide polymorphisms) to large sequences (thousands or billions). The indications for NGS have expanded significantly and it is now an important tool in the diagnosis/identification of pathogenic organisms. NGS also provides a means and/or the potential to perform prognostic epidemiologic studies, lineage tracing (cell lines), discovery of genetic variants with drug resistance mutations, development of individualized therapeutic regimens, and development of preventive measures (e.g., vaccines). Multiplex assays are another type of molecular testing designed to simultaneously sequence DNA fragments from multiple pathogens to help identify mixed populations of infectious agents.
Endoscopic Bx
Biopsy specimens may be obtained during endoscopic examinations. Bladder biopsy is performed by a urologist with visualization of the urethra and bladder during cystoscopic examination. A biopsy of the bladder is taken after the bladder is filled with saline for irrigation. The cystoscopy and biopsy are performed either in the urologist’s office with local anesthetics or in the operating room under general anesthesia. See also the study titled “Cystoscopy.” Prostate biopsy using a transurethral approach (TURP) is accomplished when the endoscope is inserted into the urethra and tissue is excised with a cutting loop. An intestinal biopsy specimen is also usually obtained during endoscopic examination.
Many Other Biopsy Specimens Are Obtained Either Percutaneously or After Surgical Incision
Lung Bx
The lung biopsy specimen can be obtained transbronchially or by open lung biopsy. In a transbronchial biopsy, forceps pass through the bronchoscope to obtain the specimen. In a transbronchial needle aspiration biopsy, a needle passes through a bronchoscope to obtain the specimen. In a transcatheter bronchial brushing, a brush is inserted through the bronchoscope. In an open lung biopsy, the chest is opened and a small thoracic incision is made to remove tissue from the chest wall. See also the study titled “Bronchoscopy.” Lung biopsies are used to differentiate between infection and other sources of disease indicated by initial radiology studies, computed tomography scans, or sputum analysis. Specimens are also cultured to detect pathogenic organisms or directly examined for the presence of malignant cells.
Lymph Node Bx
Biopsies most commonly performed on types of lymph nodes include cervical nodes, which drain the face and scalp; axillary nodes, which drain the arms, breasts, and upper chest; and inguinal nodes, which drain the legs, external genitalia, and lower abdominal wall.
Muscle Bx
A muscle biopsy specimen is usually obtained from the deltoid or gastrocnemius muscle after a surgical incision.
Prostate Bx
Biopsy of the prostate gland is performed to identify cancerous cells, especially if serum prostate-specific antigen (PSA) is increased. Serial measurements of PSA in the blood are often performed before and after surgery. Approximately 15% to 40% of patients who have had their prostate removed will encounter an increase in PSA related to the presence of prostate cells somewhere in the body or a recurrence of prostate cancer. For additional information related to assessing for prostate cancer refer to the study titled “Prostate Specific Antigen.”
Skin Bx
A skin biopsy can be obtained by any of four methods:
- Curettage biopsy in which the skin is scraped with a curette to obtain specimen.
- Shaving biopsy in which a scalpel is used to remove a portion of the lesion that protrudes above the epidermis.
- Excision biopsy in which a scalpel is used to remove the entire lesion.
- Punch biopsy in which a small, round punch about 4 to 6 mm in diameter is rotated into the skin to the desired depth. The cylinder of skin is pulled upward with forceps and separated at its base with a scalpel or scissors.
A
Tzanck smear may be prepared from vesicles (blisters) present on the skin. Skin cells in the vesicles can be evaluated microscopically to indicate the presence of certain viruses, especially
herpes, that cause cells to become enlarged and otherwise abnormal in appearance.
Sentinel lymph node biopsy (SLNB) may be considered to assist in the diagnosis of melanoma. A
sentinel lymph node (SLN) is the first lymph node to be infiltrated by cancer cells from the primary tumor. To identify an SLN, the surgeon injects one or more tracers (such as technetium-99m and isosulfan blue dye) near the tumor, then uses a handheld gamma detector to locate the nodes emitting radioactivity or visually inspects the nearby nodes for any that are stained blue from the dye. Once the SNL is located, a small incision is made and the node is removed. The suspicious tissue is checked microscopically for the presence of cancer cells by a pathologist. Lymph node positive samples may warrant immediate removal of additional lymph nodes or removal during a follow-up procedure.
Thyroid Bx
A thyroid biopsy specimen can be obtained by needle aspiration or by surgical excision.
Contraindications
Patients with bleeding disorders (related to the potential for prolonged bleeding from the biopsy site) or an acute infection of the biopsy site of interest.
- Pregnancy may be a contraindication to procedures involving some types of anesthesia.
Factors That May Alter the Results of the Study
Intestinal Bx
- Barium swallow within 48 hr of small intestine biopsy (related to retained barium, which may obscure clear visualization and guidance of the biopsy needle).
Kidney Bx
- Obesity and severe spinal deformity can make percutaneous biopsy impossible.
Liver Bx
Patients with suspected vascular tumor of the liver that may increase the risk of bleeding, ascites that may obscure proper insertion site for needle biopsy, subdiaphragmatic or right hemothoracic infection, or biliary tract infection.
Lung Bx
Conditions such as vascular anomalies of the lung, bleeding abnormalities, or pulmonary hypertension may increase the risk of bleeding.
Conditions such as bullae or cysts and respiratory insufficiency increase the risk of pneumothorax.
Muscle Bx
- If electromyography is performed before muscle biopsy, residual inflammation may lead to false-positive biopsy results.
Prostate Bx
- The various sampling approaches have individual drawbacks that should be considered: Transurethral sampling does not always ensure that malignant cells will be included in the specimen, whereas transrectal sampling carries the risk of perforating the rectum and creating a channel through which malignant cells can seed normal tissue.
Potential Nursing Problems: Assessment & Nursing Diagnosis
| Problems | Signs and Symptoms |
|---|
| Bladder, prostate: Urination (altered—related to disease, obstruction, inflammation, tumor, infection) | Decreased urinary output less than 30 mL/hr, distended bladder, high residual urine, urinary retention, urinary dribbling, complaints of full bladder with inability to void | | Bone: Mobility (related to inflammation, trauma, pain, infection, tumor) | Inability to meet physical demands associated with activities of daily living, ineffective range of motion, pain (worsens at night), weakness, fatigue | | Intestinal: Fecal elimination (inadequate—related to blockage, inflammation, infection, tumor) | Abdominal distention, high-pitched or absent bowel sounds, nausea and vomiting, fecal odor of emesis | | Kidney: Infection (related to obstruction, infection, cyst, abscess, inflammation, tumor, trauma, injury) | Positive culture, fever, chills, elevated temperature, elevated white blood cell count, flank pain, hematuria, urinary frequency | | Liver: Nutrition (insufficient—related to pain, nausea, vomiting, anorexia) | Weight loss, emaciation, malabsorption, poor intake, pain | | Lung: Gas exchange (inadequate—related to obstruction, infection, inflammation, tumor, malignancy) | Difficulty breathing, dyspnea; hypoxia; cyanosis; increased heart and respiratory rates; restlessness; anxiety; sense of impending death and doom; hemoptysis; abnormal arterial blood gas | | Lymph node: Grief (related to diagnosis, fear, poor prognosis, surgery, disease staging) | Verbalization of fear and distress; crying; expressions of anxiety; restlessness | | Muscle: Self-care (deficit—related to loss of mobility and function, malignancy, tumor) | Unable to complete the activities of daily living (eating, bathing, dressing, toileting) without assistance | | Skin: Body image (related to physical changes associated with the disease process) | Expressions of feelings or concerns about visual physical changes, fear of rejection by others due to appearance | | Thyroid: Thought processes (altered—related to decreased cardiac output and impaired cerebral perfusion secondary to a deficit of thyroid hormone) | Altered memory, mental impairment, decreased concentration, depression, inaccurate environmental perception, inappropriate thinking, memory deficits |
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Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in establishing a diagnosis of cancer or other disease (in the tissue of interest).
- Explain that small procedures may be performed in a clinic or HCP’s office; larger procedures will be performed in the operating room.
- Discuss the estimated time of completion as it relates to the specific anatomical site for biopsy and whether the procedure will be performed in an office, clinic, or operating room.
- Review the procedure with the patient.
- Explain that prior to the procedure coagulation testing may be required to determine the possibility of bleeding risk.
- Explain that pregnancy testing may be required.
- Explain that reducing health-care-associated infections is an important patient safety goal and a number of different safety practices will be implemented during their procedure.
- Advise that hair in the area near the incision site may be clipped or shaved and the area cleaned with an antiseptic solution to cleanse bacteria from the skin in order to reduce infection risk.
- Discuss how there may be moments of discomfort or pain when the IV line or catheter is inserted allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- Discuss why prophylactic antibiotics may be administered before the procedure.
- Explain that the biopsy is performed under sterile conditions.
Procedural Information
- Note: The World Health Organization, Centers for Disease Control and Prevention, and Association of periOperative Registered Nurses recommend that hair not be removed at all unless it interferes with the incision site or other aspects of the procedure because hair removal by any means is associated with increased infection rates.
- Hair removal requires facilities to use a protocol that is based on scientific literature or the endorsement of a professional organization.
- Clipping immediately before the procedure and in a location outside the procedure area is preferred to shaving with a razor.
- Shaving creates a break in skin integrity and provides a way for bacteria on the skin to enter the incision site.
- Prophylactic antibiotics may be administered before the procedure.
General Information for All Types of Biopsies
- The most common methods of obtaining tissue specimens are by needle or endoscopic biopsy.
- Positioning for biopsies is based on the safest and most effective site access as directed by the HCP performing the procedure.
- Baseline vital signs are recorded and monitored throughout the procedure.
- A biopsy is performed under sterile conditions.
- After the administration of general or local anesthesia, the site is cleansed with an antiseptic solution and protected with sterile drapes.
- Continuous monitoring is performed to assess for complications related to the procedure (e.g., allergic reaction, etc.).
- Once the study is completed, a pressure dressing is applied over the puncture site.
- Protocols may vary among facilities.
| Procedure | Collection Method/Approximate Time to complete |
|---|
| Bladder biopsy | Endoscopic (Cystoscopy): 5 to 15 min
Surgical procedure: 15 to 30 min | | Bone biopsy | Percutaneous needle biopsy: 30 to 60 min | | Intestinal biopsy | Endoscopic (Esophagogastroduodenoscopy) biopsy: 20 to 30 min | | Kidney biopsy | Percutaneous needle biopsy: 15 to 30 min
Surgical procedure: 1 hr | | Liver biopsy | Percutaneous needle biopsy: 15 min
Surgical procedure: 1 hr | | Lung biopsy | Endoscopic (Bronchoscopy): 30 to 45 min
Percutaneous needle biopsy: 30 to 60 min
Surgical procedure: 1 hr | | Lymph node biopsy | Endoscopic (Mediastinoscopy) biopsy: 60 min, and sutures may be necessary to close the site
Percutaneous needle biopsy: 15 to 30 min
Surgical procedure: 30 to 45 min | | Muscle biopsy | Percutaneous needle biopsy: 10 to 15 min
Surgical procedure: 30 to 45 min | | Prostate biopsy | Percutaneous needle biopsy: 20 min
Endoscopic (transurethral approach/TURP): 60 to 90 min | | Skin biopsy | Curettage, shaving, punch, or excisional biopsy: 10 to 20 min depending on type of biopsy, and sutures may be necessary to close the site | | Thyroid biopsy | Percutaneous needle biopsy: 15 to 30 min
Surgical procedure: 30 min |
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Endoscopic Biopsy
- As appropriate, an anesthetic is administered (e.g., by local injection at the biopsy site, a local spray into the throat, or moderate sedation by IV).
- For studies of the upper portion of the body the endoscope can be introduced through the nose, the mouth, an endotracheal tube, a tracheostomy tube, or a rigid bronchoscope (e.g., to the lungs). As appropriate a protective tooth guard and a bite block may be placed in the mouth.
- Additional local anesthetic is applied through the scope as it approaches the vocal cords and the carina, eliminating reflexes in these sensitive areas.
- Patients with copious secretions or massive hemoptysis, or in whom airway complications are more likely, may be intubated before the bronchoscopy.
- For studies of the lower portion of body the endoscope can be introduced through the anus or meatus (e.g., to the bladder, intestines, or prostate).
- The organs and tissues of interest are visually examined as the endoscope passes through each section.
- Tissue samples are obtained by inserting a cytology brush or biopsy forceps through the endoscope to be used for cytological and microbiological studies.
Open Biopsy
- Adherence to organizational policies and the Centers for Medicare and Medicaid Services (CMS) quality measures is required regarding administration of prophylactic antibiotics.
- Ordered prophylactic antibiotics are given 1 hr before incision, and antibiotics used are consistent with current guidelines specific to the procedure.
- The patient is carefully observed to assess for any signs of respiratory distress during the procedure.
- After administration of general anesthetic and surgical preparation are completed, an incision is made, suspicious area(s) are located, and tissue samples are collected.
- Tissue samples are placed in the appropriate sterile container for culture or appropriate fixative container for histological studies.
- The specimens are labelled indicating site location and laterality, and promptly transported to the laboratory for processing and analysis.
Percutaneous Needle Biopsy
- The patient is directed to take slow, deep breaths when the local anesthetic is injected.
- After the anesthetic is administered, a small incision is made and the biopsy needle is inserted to remove the specimen.
- The site is protected with sterile drapes.
- The patient is directed to take a deep breath, exhale forcefully, and hold the breath while the biopsy needle is inserted and rotated to obtain a core of tissue.
- Specimens from needle aspiration are placed on clean glass microscope slides.
- Once the needle is removed the patient is instructed to resume breathing.
- Pressure is applied to the site for 3 to 20 min and then a sterile pressure dressing is applied. In some biopsies pressure is applied to the site with a petroleum jelly gauze, and a pressure dressing is applied over the petroleum jelly gauze.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
- Actions related to endoscopic biopsy of intestine or lung may include:
- Provide mouth care to reduce oral bacterial flora, as appropriate.
- Remove dentures.
- Notify the HCP regarding the presence of crowns, caps on the teeth, or loose teeth.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure in which bleeding is a potential complication.
- Ensure the patient can remain still and follow directions for the specified biopsy to decrease injury risk.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
Monitor the patient for complications related to the procedure.
- Establishing an IV site and tissue biopsy are invasive procedures that can cause rare complications. For additional information see Appendix A: Patient Preparation and Specimen CollectionPatient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated with Diagnostic Procedures.
Bladder:
- Note that complications related to perforation of the bladder; a bleeding disorder; or the effects of natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or seeding of the biopsy tract with tumor cells are associated with bladder biopsy.
- Instruct the patient to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure.
- Note that the number of days to withhold medication is dependent on the type of anticoagulant.
Liver:
- Assist the patient to the right decubitus position for the first 1 to 2 hr after the procedure, followed by placement in the supine position for an additional 2 to 3 hr in order to avoid post-procedural bleeding or peritonitis.
- Monitor for bleeding evidenced by elevated heart rate and decreased blood pressure.
- Monitor for peritonitis evidenced by elevated temperature.
Lung:
- Note that bleeding related to a bleeding disorder or the effects of natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties, pneumothorax (related to the presence of bullae or cysts and respiratory insufficiency), hemoptysis, air embolism, or seeding of the biopsy tract with tumorcells are possible complications of lung biopsy.
- Note that a chest x-ray may be ordered to assess for pneumothorax.
- Avoid using morphine sulfate in those with asthma or other pulmonary disease. Morphine can further exacerbate bronchospasms and respiratory impairment.
Lymph Node:
- Note that bleeding related to a bleeding disorder, or the effects of natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or seeding of the biopsy tract with tumor cells are possible complications of lymph node biopsy.
- Observe/assess the biopsy site for bleeding, inflammation, or hematoma formation.
- Instruct in the care and assessment of the biopsy site.
- Advise reporting any fever, chills, redness, edema, bleeding, or pain at the biopsy site.
Treatment Considerations
General
- Follow post-procedure vital sign and assessment protocol.
- Assess the ability to swallow until the gag reflex returns and before allowing the patient to drink liquids or eat solid foods to decrease aspiration risk.
- Allow resumption of the usual diet, fluids, and medications, when safe and as directed by the HCP.
- Discontinue prophylactic antibiotics within 24 hr after the conclusion of the procedure, as ordered by the HCP. Protocols may vary among facilities.
- Administer ordered post-procedural antibiotic therapy and emphasize the importance of completing the entire course of antibiotic therapy, even if signs and symptoms disappear before completion of therapy.
- Assess for nausea and pain with administration of antiemetic and analgesic medications as ordered.
Site Specific
Bladder/Prostate: Urination
- Observe urinary pattern and palpate the bladder for retention.
- Measure residual urine directly after voiding or urine retention with a bladder scan.
- Assess bladder distention every 4 hr or as needed.
- Administer ordered medication to facilitate urination, send ordered urine culture, and administer prescribed antibiotics.
- Perform vigilant intake and output.
- Verify competency to record intake and output with the provided appropriate measuring containers.
- Assess for bladder spasms, hemorrhage, or perforation of the urethra or rectum after the biopsy.
- Explain that blood may be seen in the urine after the first or second post-procedural voiding.
- Instruct reporting any further changes in urinary pattern, volume, or appearance.
- Encourage fluid intake of 3,000 mL in 24 hr unless contraindicated.
Bone: Mobility
- Facilitate the use of assistive devices and physical therapy.
- Administer ordered medications (analgesics, steroids, antibiotics).
- Institute fall risk protocols.
Intestinal: Fecal Elimination
- Assess for active bowel sounds in all four quadrants.
- Keep NPO until bowel sounds are active.
- Administer ordered parenteral fluids until taking oral adequately.
- Implement ostomy care as appropriate and provide education related to new dietary restrictions.
Kidney: Infection
- Explain that blood may be seen in the urine after the first or second post-procedural void.
- Perform vigilant intake and output for 24 hr.
- Discuss reporting any changes in urinary pattern, volume, or appearance.
- Consider the need to increase oral liquids if urine volume is less than 200 mL in the first 8 hr, unless contraindicated by another medical condition.
- Monitor and trend laboratory studies for signs of infection (BUN, Cr, WBC count, Hgb, Hct, electrolytes, urine cultures) and evaluate results of complementary diagnostic studies (KUB, CT, MRI, IVP).
- Administer ordered antibiotics and monitor and trend temperature.
Liver: Nutrition
- Monitor daily weight.
- Complete a nutrition history and evaluate intake with a calorie count.
- Consider a culturally appropriate dietary consult.
- Monitor and trend albumin.
Lung: Gas Exchange
- Establish baseline respiratory assessment; rate, rhythm, depth.
- Administer ordered oxygen.
- Use pulse oximetry to monitor oxygen saturation and evaluate the effectiveness of administered oxygen.
- Monitor and trend arterial blood gas results.
- Administer ordered medications; anticoagulants, antibiotics, bronchodilators, steroids, diuretics.
- Elevate the head of the bed to decrease work of breathing and improve ventilation.
- Advise remaining in a semi-Fowler position after bronchoscopy or fine-needle aspiration to maximize ventilation.
- Explain that the patient should stay in bed lying on the affected side for at least 2 hr with a pillow or rolled towel under the site to prevent bleeding.
- Encourage the patient to remain on bedrest for 24 hr, or as ordered.
- Provide ordered lozenges or gargle for throat discomfort.
- Monitor the sputum for blood when a biopsy is taken, since a large amount of blood may indicate the development of a problem; a small amount of streaking is expected.
- Observe for signs of bleeding include tachycardia, hypotension, or restlessness.
Lymph Node: Grief
- Assess coping mechanisms to mitigate anxiety and concerns related to possible death and poor prognosis.
- Facilitate spiritual support and integrate cultural aspects of grieving in planning care.
- Discuss treatment options including hospice care.
Muscle: Self-Care
- Identify and support own self-care ability.
- Evaluate the family’s ability to assist with self-care needs.
- Complete a home health evaluation and provide assistive devices to assist with self-care.
Skin: Body Image
- Provide assurance that feelings of distress over an altered appearance are normal.
- Consider the cultural aspects of body image and incorporate them into the plan of care.
- Ensure privacy to explore personal grief.
- Provide nonjudgmental listening.
- Support positive coping strategies.
- Provide contact information for a support group.
Thyroid: Thought Processes
- Collaborate with the HCP to manage medical problem associated with decreased cerebral perfusion.
- Promote comprehension and understanding of current events
- Create a safe environment.
- Monitor injury risk, violence, fall risk, self-harm risk.
- Administer prescribed thyroid hormone replacement medication.
Safety Considerations
Lung:
- Ensure that emergency resuscitation equipment is readily available if the vocal cords become spastic after intubation.
- Monitor the patient for hemoptysis, dyspnea, tachypnea, air hunger, excessive coughing, pain, hemothorax, or pneumothorax.
- Monitor the chest tube (thoracostomy) patency and drainage after a thoracotomy.
- Consider that a chest x-ray may be ordered to check for the presence of complications.
Nutritional Considerations
Bladder:
- Recommend a culturally competent consult with a registered dietitian, if necessary.
- Note that many adverse effects of treatment for bladder cancer, such as fatigue, bowel disturbances, and weight loss, can result in malnutrition and increased risk for infection.
Lung:
- Note that malnutrition is commonly seen in patients with severe respiratory disease for numerous reasons, including fatigue, lack of appetite, and gastrointestinal distress.
- Discuss the importance of adequate intake of vitamins A and C to prevent pulmonary infection and to decrease the extent of lung tissue damage.
- Stress the importance of following the prescribed diet.
- Offer culturally appropriate foods in several small amounts each day.
Prostate:
- Note that some evidence supports the notion that inflammation and oxidation play key roles in the development of numerous diseases, including prostate cancer.
- Suggest that diets containing dried beans, fresh fruits and vegetables, nuts, spices, whole grains, and smaller amounts of red meats may increase the amount of protective antioxidants.
- Discuss the need for regular exercise, especially in combination with a healthy diet, to bring about changes in the body’s metabolism that decrease inflammation and oxidation.
Clinical Judgement
- Consider the disruptive nature of a cancer diagnosis and what can be done to support positive steps toward health or a good death.
Follow-Up and Desired Outcomes
General
- Acknowledges the time and date for suture removal, if indicated.
- Agrees to attend a smoking cessation program, as appropriate. Cigarette smokers have a higher risk than nonsmokers of developing bladder cancer.
- Acknowledges the importance of taking prescribed medications and adhering to the therapeutic regimen.
- States significant adverse effects associated with the prescribed medication and that upon request a pharmacist is available to review corresponding literature.
- Correctly states the medical versus surgical options for disease management.
- Those with terminal diagnosis understand end-of-life treatment options.
- Surgical patients correctly demonstrate care of surgical site, biopsy site.
- Acknowledges contact information provided for the American Cancer Society (ACS) (www.cancer.org). Educate the patient regarding access to counseling services.
Lung
- Agrees to report symptoms of empyema, such as fever, tachycardia, malaise, or elevated WBC count.
Prostate
- Understands that decisions regarding the need for and frequency of routine PSA testing or other prostate cancer screening procedures should be made after consultation between the patient and HCP.
- Demonstrates awareness that recommendations made by various medical associations and national health organizations regarding prostate cancer screening are moving away from routine PSA screening and toward informed decision making.
- Acknowledges that the most current guidelines for prostate cancer screening of the general population as well as of individuals with increased risk are available from the ACS (www.cancer.org) and the American Urological Association (www.auanet.org).
- For additional information regarding screening guidelines, refer to the study titled “Prostate-Specific Antigen.”
- Discuss that sexual dysfunction related to altered body function, drugs, or radiation may occur.
Skin
- Acknowledges that DNA testing for mutations in the CDKN2A, CDK4, or BRAF V600 genes may be requested to identify those at high risk for developing cutaneous melanoma.
- Understands that the test for TA90 (melanoma-associated antigen) is used to evaluate the status of postoperative patients who have had localized areas of melanoma removed.
- Recognizes that methods for these genetic markers include microarray, reverse transcriptase polymerase chain reaction (RT-PCR), and enzyme-linked immunosorbent assay (ELISA).
- Understands biopsy results in relation to the presenting symptoms and other tests performed.
- Understands that judicious use of UV prevention strategies (sunscreen, hats, clothing) can decrease melanoma risk.
Thyroid
- Understands that genetic testing may be conducted to search for mutations in various genes associated with types of thyroid cancer.
- Demonstrates awareness that other markers associated with a significant incidence of thyroid cancers include BRAF (associated with papillary thyroid cancer), RAS (associated with follicular and papillary thyroid cancers), RET/PTC (associated with an increased risk of developing inherited medullary thyroid cancer, also known as multiple endocrine neoplasia, or MEN), and PAX8/PPAR (associated with congenital hypothyroidism and thyroid dysgenesis).