Advise the patient that if pain persists after taking three sublingual tablets at 5-minute intervals anxiety attack symptoms discount 25mg doxepin mastercard, emergency medical services should be called anxiety symptoms diarrhea doxepin 10mg without prescription. The patient receiving heparin is placed on bleeding precautions anxiety 8 year old discount 75 mg doxepin otc, which include: be decreased gradually over several days before discontinuing it anxiety attack doxepin 75mg with visa. Patients with diabetes who take beta-blockers are instructed to assess their blood glucose levels more often and to observe for signs and symptoms of hypoglycemia. Some decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction (negative inotropic effect). Calcium channel blockers also relax the blood vessels, causing a decrease in blood pressure and an increase in coronary artery perfusion. Calcium channel blockers increase myocardial oxygen supply by dilating the smooth muscle wall of the coronary arterioles; they decrease myocardial oxygen demand by reducing systemic arterial pressure and the workload of the left ventricle. The calcium channel blockers most commonly used are amlodipine (Norvasc), verapamil (Calan, Isoptin, Verelan), and diltiazem (Cardizem, Dilacor, Tiazac). They may be used by patients who cannot take beta-blockers, who develop significant side effects from beta-blockers or nitrates, or who still have pain despite betablocker and nitroglycerin therapy. Calcium channel blockers are used to prevent and treat vasospasm, which commonly occurs after an invasive interventional procedure. First-generation calcium channel blockers should be avoided or used with great caution in people with heart failure, because they decrease myocardial contractility. Amlodipine (Norvasc) and felodipine (Plendil) are the calcium channel blockers of choice for patients with heart failure. Hypotension may occur after the intravenous administration of any of the calcium channel blockers. Other side effects that may occur include atrioventricular blocks, bradycardia, constipation, and gastric distress. Antiplatelet medications are administered to prevent platelet aggregation, which impedes blood flow. Unlike aspirin, these medications take a few days to achieve their antiplatelet effect. They also cause gastrointestinal upset, including nausea, vomiting, and diarrhea, and they decrease the neutrophil level. As with heparin, bleeding is the major side effect, and bleeding precautions should be initiated. Oxygen therapy is usually initiated at the onset of chest pain in an attempt to increase the amount of oxygen delivered to the myocardium and to decrease pain. The therapeutic effectiveness of oxygen is determined by observing the rate and rhythm of respirations. Blood oxygen saturation is monitored by pulse oximetry; the normal oxygen saturation (SpO2) level is greater than 93%. Studies are being conducted to assess the use of oxygen in patients without respiratory distress and its effect on outcome. Coenzyme Q10 was advocated for preventing the occurrence and progression of heart failure (Khatta et al. However, there have not been large, randomized, placebocontrolled studies that identify the direct beneficial effect from these therapies. The answers to these questions form a basis for designing a logical program of treatment and prevention. When a patient experiences angina, the nurse should direct the patient to stop all activities and sit or rest in bed in a semi-Fowler position to reduce the oxygen requirements of the ischemic myocardium. The nurse then continues to assess the patient, measuring vital signs and observing for signs of respiratory distress. If the chest pain is unchanged or is lessened but still present, nitroglycerin administration is repeated up to three doses. Although there is no documentation of its effect on outcome, oxygen is usually administered at 2 L/min by nasal cannula, even without evidence of respiratory distress. If the pain is significant and continues after these interventions, the patient is usually transferred to a higher-acuity nursing unit. Exploring the implications that the diagnosis has for the patient and providing information about the illness, its treatment, and methods of preventing its progression are important nursing interventions. For example, music therapy, in which patients are given the opportunity to listen to selected music through headphones for a predetermined duration, has been shown to reduce anxiety in patients who are in a coronary care unit and may serve as an adjunct to therapeutic communication (Chlan & Tracy, 1999; Evans, 2002). Addressing the spiritual needs of the patient and family may also assist in allaying anxieties and fears. Balance of activity and rest is an important aspect of the educational plan for the patient and family. Exploring with the patient and family what they see as their priority in managing the disease and developing a plan based on their priorities can assist with patient adherence to the therapeutic regimen. It is important to explore with the patient methods to avoid, modify, or adapt the triggers for anginal pain. The goals of the educational program are to reduce the frequency and severity of anginal attacks, to delay the progress of the underlying disease, if possible, and to prevent any complications. The factors outlined in the accompanying checklist Chart 28-5 are important in educating the patient with angina pectoris. The self-care program is prepared in collaboration with the patient and family or friends. The patient needs to understand that any pain unrelieved within 15 minutes by the usual methods (see Chart 28-4) should be treated at the closest emergency center; the patient should call 911 for assistance. Understands ways to avoid complications and demonstrates freedom from complications. Blood pressure may be elevated because of sympathetic stimulation or decreased because of decreased contractility, impending cardiogenic shock, or medications. Skin Cool, clammy, diaphoretic, and pale appearance due to sympathetic stimulation from loss of contractility may indicate cardiogenic shock. Neurologic Anxiety, restlessness, light-headedness may indicate increased sympathetic stimulation or a decrease in contractility and cerebral oxygenation. Headache, visual disturbances, altered speech, altered motor function, and further changes in level of consciousness may indicate cerebral bleeding if patient is receiving thrombolytics. Psychological Fear with feeling of impending doom, or patient may deny that anything is wrong. In each case, a profound imbalance exists between myocardial oxygen supply and demand. As the cells are deprived of oxygen, ischemia develops, cellular injury occurs, and over time, the lack of oxygen results in infarction, or the death of cells. The expression "time is muscle" reflects the urgency of appropriate treatment to improve patient outcomes. Regardless of the location of the infarction of cardiac muscle, the goal of medical therapy is to prevent or minimize myocardial tissue death and to prevent complications. The pathophysiology of heart disease and the risk factors involved are discussed earlier in this chapter. The prognosis depends on the severity of coronary artery obstruction and the extent of myocardial damage. Physical examination is always conducted, but the examination alone is insufficient to confirm the diagnosis. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the emergency department. The Framingham Heart Study revealed that 50% of the men and 63% of the women who died suddenly of cardiovascular disease had no previous symptoms (Kannel, 1986). As the area of injury becomes ischemic, myocardial repolarization is altered and delayed, causing the T wave to invert. The ischemic region may remain depolarized while adjacent areas of the myocardium return to the resting state. With Q-wave infarction, abnormal Q waves develop within 1 to 3 days because there is no depolarization current conducted from necrotic tissue (Wagner, 2001). The T wave becomes large and symmetric for 24 hours, and it then inverts within 1 to 3 days for 1 to 2 weeks. The echocardiogram can detect hypokinetic and akinetic wall motion and can determine the ejection fraction (see Chap. Newer laboratory tests with faster results, resulting in earlier diagnosis, include myoglobin and troponin analysis.
The collection of air anxiety 7 question test order 25 mg doxepin fast delivery, fluid anxiety 5 months postpartum cheap doxepin 25 mg fast delivery, or other substances in the chest can compromise cardiopulmonary function and can also cause the lung to collapse anxiety young living cheap doxepin 25mg overnight delivery. Pathologic substances that collect in the pleural space include fibrin anxiety 4th discount doxepin 10mg amex, or clotted blood; liquids (serous fluids, blood, pus, chyle); and gases (air from the lung, tracheobronchial tree, or esophagus). Chest tubes may be inserted to drain fluid or air from any of the three compartments of the thorax (the right and left pleural spaces and the mediastinum). The pleural space, located between the visceral and parietal pleura, normally contains 20 mL or less of fluid, which helps to lubricate the visceral and parietal pleura. Surgical incision of the chest wall almost always causes some degree of pneumothorax (air accumulating in the pleural space) or hemothorax (build-up of serous fluid or blood in the pleural space). Air and fluid collect in the pleural space, restricting lung expansion and reducing gas exchange. Placement of a chest tube in the pleural space restores the negative intrathoracic pressure needed for lung re-expansion following surgery or trauma. If using a chest drainage system with a water seal, fill the water seal chamber with sterile water to the level specified by the manufacturer. When using suction in chest drainage systems with a water seal, fill the suction control chamber with sterile water to the 20-cm level or as prescribed. In systems without a water seal, set the regulator dial at the appropriate suction level. Attach the drainage catheter exiting the thoracic cavity to the tubing coming from the collection chamber. If suction is used, connect the suction control chamber tubing to the suction unit. If using a wet suction system, turn on the suction unit and increase pressure until slow but steady bubbling appears in the suction control chamber. If using a chest drainage system with a dry suction control chamber, turn the regulator dial to 20 cm H2O. The water acts as a seal and keeps the air from being drawn back into the pleural space. With a wet suction system, the degree of suction is determined by the amount of water in the suction control chamber and is not dependent on the rate of bubbling or the pressure gauge setting on the suction unit. Mark the drainage from the collection chamber with tape on the outside of the drainage unit. This marking shows the amount of fluid loss and how fast fluid is collecting in the drainage chamber. It serves as a basis for determining the need for blood replacement, if the fluid is blood. Visibly bloody drainage will appear in the chamber in the immediate postoperative period but should gradually becomes serous. If the patient is bleeding as heavily as 100 mL every 15 minutes, check the drainage every few minutes. The transfusion of blood collected in the drainage chamber must be reinfused within 4 to 6 hours. Kinking, looping, or pressure on the drainage tubing can produce back-pressure, which may force fluid back into the pleural space or impede its drainage. Frequent position changes promote drainage, and good body alignment helps prevent postural deformities and contractures. Assist the patient with range-of-motion exercises for the affected arm and shoulder several times daily. Make sure there is fluctuation ("tidaling") of the fluid level in the water seal chamber (in wet systems), or check the air leak indicator for leaks (in dry systems with a one-way valve). With a dry system, assess for the presence of the indicator (bellows or float device) when setting the regulator dial to the desired level of suction. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Notify the physician immediately of excessive bubbling in the water seal chamber not due to external leaks. When turning down the dry suction, depress the manual highnegativity vent, and assess for a rise in the water level of the water seal chamber. Observe and immediately report rapid and shallow breathing, cyanosis, pressure in the chest, subcutaneous emphysema, symptoms of hemorrhage, or significant changes in vital signs. If the patient is lying on a stretcher and must be transported to another area, place the drainage system below the chest level. If the tubing disconnects, cut off the contaminated tips of the chest tube and tubing, insert a sterile connector in the cut ends, and reattach to the drainage system. Constant attention to maintaining the patency of the tube facilitates prompt expansion of the lung and minimizes complications. Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. Fluctuation is also a gauge of intrapleural pressure in systems with a water seal (wet and dry, but not with the one-way valve). An air leak indicator shows changes in intrathoracic pressure in dry systems with a one-way valve. The air leak indicator takes the place of fluid fluctuations in the water seal chamber. The indicator shows that the vacuum is adequate to maintain the desired level of suction. Leaking and trapping of air in the pleural space can result in tension pneumothorax. A rise in the water level of the water seal chamber indicates high negative pressure in the system that could lead to increased intrathoracic pressure. Many clinical conditions can cause these signs and symptoms, including tension pneumothorax, mediastinal shift, hemorrhage, severe incisional pain, pulmonary embolus, and cardiac tamponade. Deep breathing and coughing help to raise the intrapleural pressure, which promotes drainage of accumulated fluid in the pleural space. Deep breathing and coughing also promote removal of secretions from the tracheobronchial tree, which in turn promotes lung expansion and prevents atelectasis (alveolar collapse). The chest tube is removed as directed when the lung is reexpanded (usually 24 hours to several days), depending on the cause of the pneumothorax. During tube removal, the chief priorities are preventing air from entering the pleural cavity as the tube is withdrawn and preventing infection. The mediastinal space is an extrapleural space that lies between the right and left thoracic cavities. Mediastinal chest tubes promote the removal of blood or other fluid from around the heart (Finkelmeier, 2000). A mediastinal tube can be inserted either anteriorly or posteriorly to the heart to drain blood after surgery or trauma. Without a tube, compression of the heart could occur, leading to death (Carroll, 2000). Small-bore catheters (7F to 12F) have a one-way valve apparatus to prevent air from moving back into the patient. Large-bore catheters, which range in size up to 40F, are usually connected to a chest drainage system to collect any pleural fluid and monitor for air leaks (Scanlan, Wilkins & Stoller, 1999). After the chest tube is positioned, it is sutured to the skin and connected to a drainage apparatus to remove the residual air and fluid from the pleural or mediastinal space. There will be an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water seal chamber is normal, but continuous bubbling can indicate an air leak. Two-chamber chest drainage systems (water seal chamber and collection chamber) are available for use with patients who need only gravity drainage. The water level in the water seal chamber reflects the negative pressure present in the intrathoracic cavity. A rise in the water level indicates negative pressure in the pleural or mediastinal space. Excessive negative pressure can cause trauma to tissue (Bar-El, Ross, Kablawi & Egenburg, 2001).
Palliative care is an approach to care for the seriously ill that has long been a part of cancer care anxiety symptoms leg pain generic doxepin 10mg mastercard. Both palliative care and hospice have been recognized as important bridges between the compulsion for cure-oriented care and physician-assisted suicide (Saunders & Kastenbaum anxiety breathing techniques buy doxepin 75mg amex, 1997) anxiety symptoms keep changing discount 75 mg doxepin with amex. Advocates for improved care for the dying have stated that acceptance anxiety symptoms all the time 10mg doxepin fast delivery, management, and understanding of death should become fully integrated concepts in mainstream health care (Callahan, 1993a; Morrison, Siu, Leipzig et al. While hospice care is considered by many to be the "gold standard" for palliative care, the term hospice is generally associated with palliative care that is delivered at home or in special facilities to patients who are approaching the end of life. Palliative care is conceptually broader than hospice care, defined as the active, total care of patients whose disease is not responsive to treatment (World Health Organization, 1990). Palliative care emphasizes management of psychological, social, and spiritual problems in addition to control of pain and other physical symptoms. As the definition suggests, palliative care is not care that begins when cure-focused treatment ends. However, definitions of palliative care, the services that are part of it, and the clinicians who provide it are evolving steadily. In an attempt to make this valuable approach to care more widely available, palliative care programs are being developed in other settings for patients who are either not eligible for hospice or are "not ready" to enroll in a formal hospice program. As yet, there is no dedicated reimbursement to providers for palliative care services when they are delivered outside of the hospice setting, making the sustainability of such programs challenging. While there has been regulatory scrutiny on the one hand, long-term care facilities of all types are under increasing public pressure to improve care of the dying and are beginning to develop palliative care units or services, contract with home hospice programs to provide hospice care in the facilities, and educate staff, residents, and their families about pain and symptom management and end-of-life care. Despite the economic and human costs associated with death in the hospital setting, as many as 50% of all deaths occur in acute care settings (Hogan et al. Cicely Saunders, resulted in recognition of gaps in the existing system of care for the terminally ill (Amenta, 1986). It is clear that many patients will continue to opt for hospital care or by default will find themselves in hospital settings at the end of life. Increasingly, hospitals are conducting system-wide assessments of end-of-life care practices and outcomes and are developing innovative models for delivering high-quality, personcentered care to patients approaching the end of life. Hospitals cite considerable financial barriers to providing high-quality palliative care in an acute care setting (Cassel, Ludden & Moon, 2000). Public policy changes have been called for that would provide reimbursement to hospitals for care delivered via designated hospitalwide palliative care beds, clustered palliative care units, or palliative care consultation services in acute care settings. Hospice Care in the United States Although the concept dates to ancient times, hospice as a way of caring for those at the end of life did not emerge in the United States until the 1960s (Hospice Association of America, 2001). The hospice movement in the United States is based on the belief that meaningful living is achievable during terminal illness, and that it is best supported in the home, free from technological interventions to prolong physiologic dying (Amenta, 1986). In the years between 1984 and 1996, which followed the creation of the Medicare Hospice Benefit, there was a 70-fold increase in the number of hospices participating in Medicare (Hospice Association of America, 2001). Despite more than 25 years of existence in the United States, hospice remains an option for end-of-life care that has not been fully integrated into mainstream health care. Although hospice care is available to persons with any life-limiting condition, it has primarily been used by patients with advanced cancer, where the disease staging and trajectory lend themselves to more reliable Palliative Care in Long-Term Care Facilities the place of death for a growing number of Americans after the age of 65 is the long-term care facility (Alliance for Aging Research, 1997) As many as one third of all Medicare beneficiaries who die in any given year spend all or part of their last year of life in a long-term care facility (Hogan et al. The trend favoring care of dying patients in long-term care facilities will continue as the population ages and as managed care payors pressure health care providers to minimize costs (Field & Cassel, 1997). Yet residents of long-term care facilities reportedly have poor access to high-quality palliative care. Regulations that govern how care in these facilities is organized and reimbursed tend to emphasize restorative measures and fail to reward palliative care (Zerzan, Stearns & Hanson, 2000). Although home hospice programs have been permitted since 1986 to enroll long-term care facility residents in hospice programs and provide interdisciplinary services to residents who qualify for hospice care, the Office of the Inspector General, an oversight arm of the federal govern- Chapter 17 prediction about the end of life (Boling & Lynn, 1998; Christakis & Lamont, 2000). Many reasons have been proposed for the reluctance of physicians to refer patients to hospice and the reluctance of patients to accept this form of care. These include the difficulties in making a terminal prognosis, the strong association of hospice with death, advances in "curative" treatment options in late-stage illness, and financial pressures on health care providers that may cause them to retain rather than refer hospice-eligible patients. The result is that patients who could benefit from the comprehensive, interdisciplinary support offered by hospice programs frequently do not enter hospice care until their final days (or hours) of life (Christakis & Lamont, 2000). Hospice is a coordinated program of interdisciplinary services provided by professional caregivers and trained volunteers to patients with serious, progressive illnesses that are not responsive to cure. The goal of hospice care is to enable the patient to remain at home, surrounded by the people and objects that have been important to him or her throughout life. Hospice care does not seek to hasten death, nor does it encourage the prolongation of life through artificial means. Eligibility criteria for hospice vary depending on the hospice program, but generally patients must have a progressive, irreversible illness and limited life expectancy and have opted for palliative care rather than cure-focused treatment. Although hospices have historically served cancer patients, patients with any lifelimiting illness are eligible. Once the patient elects the benefit, the Medicare-certified hospice program assumes responsibility for providing and paying for the care and treatment related to the underlying illness for which hospice care was elected. The Medicarecertified hospice is paid a predetermined dollar amount for each day of hospice care each patient receives. State Medical Assistance (Medicaid) also provides coverage for hospice care, as do most commercial insurers. Federal reimbursement for hospice care ushered in a new era in hospice in which program standards developed and published by the federal government codified what had formerly been a grassroots, loosely organized and defined ideal for care at the end of life. To receive Medicare dollars for hospice services, programs are required to comply with conditions of participation promulgated by the Centers for Medicare and Medicaid Services. Eligibility criteria for hospice coverage under the Medicare Hospice Benefit are specified in Chart 17-1. There is no limit to the length of time that an eligible patient may continue to receive hospice care. Patients who live longer than 6 months under hospice care are not discharged if their physician and the hospice medical director continue to certify that the patient is terminally ill with a life expectancy of 6 months or less, assuming that the disease continues its expected course. The hospice certification and review process and the open-ended benefit structure are intended to address the difficulty physicians face in predicting how long a patient will live, so that patients are not restricted to a lifetime limit on the number of hospice days they may receive. After 72 hours the seizure activity is under control, the family has been instructed how to care for the patient, and the continuous nursing care is stopped. Most hospice care is provided at the "routine home care" level and includes the services depicted in Chart 17-2. According to federal guidelines, hospices may provide no more than 20% of the aggregate annual patient days at the inpatient level. Patients may "revoke" their hospice benefits at any time, resuming traditional coverage under Medicare or Medicaid for the terminal illness. They may also re-elect their hospice benefits at a later time after reassessment for eligibility according to these criteria Nursing Care of the Terminally Ill Patient Many patients suffer unnecessarily when they do not receive adequate attention for the symptoms accompanying serious illness. Advance directives-Written documents that allow the individual of sound mind to document preferences regarding end-of-life care that should be followed when the signer is terminally ill and unable to verbally communicate his/her wishes. The most common types are the living will (also known as a medical directive) and a proxy directive (also known as a durable power of attorney for health care). Proxy directive-The appointment and authorization of another individual to make medical decisions on behalf of the person who created an advance directive when he/she is no longer able to speak for him/herself. This is also known as a health care power of attorney or durable power of attorney for health care. A type of advance directive in which the individual of sound mind documents treatment preferences. Provides instructions for care in the event that the signer is terminally ill and not able to communicate wishes directly. Often accompanied by a proxy directive (also known as a health care power of attorney). Durable power of attorney for health care-A legal document that enables the signer to designate another individual to make health care decisions on his/her behalf when he/she is unable to do so. Despite the continued reluctance of health care providers to engage in open discussion about end-of-life issues, studies have confirmed that patients want information about their illness and end-of-life choices are not harmed by open discussion about death (McSkimming, Super, Driever et al.
Several theories suggest how tumor cells can evade an apparently intact immune system anxiety rating scale 10mg doxepin fast delivery. If the body fails to recognize the malignant cell as different from "self" (non-self or foreign) anxiety after eating order doxepin 25 mg online, the immune response may not be stimulated anxiety symptoms but not anxious order doxepin 75mg with visa. When tumors do not possess tumor-associated antigens that label them as foreign anxiety 9gag gif buy 10 mg doxepin overnight delivery, the immune response is not alerted. The failure of the immune system to respond promptly to the malignant cells allows the tumor to grow too large to be managed by normal immune mechanisms. Tumor antigens may combine with the antibodies produced by the immune system and hide or disguise themselves from normal immune defense mechanisms. Tumors are also capable of changing their appearance or producing substances that impair usual immune responses. Individuals who have inherited specific genetic mutations have an increased susceptibility to cancer. For example, individuals who have familial adenomatosis polyposis have an increased risk for colon cancer. To provide individualized education and recommendations for continued surveillance and care in high-risk populations, nurses need to be familiar with ongoing developments in the field of genetics and cancer (Greco, 2000). Many centers across the country are offering innovative cancer risk evaluation programs that provide in-depth screening and follow-up for individuals who are found to be at high risk for cancer. For example, Phillips, Cohen, and Moses (1999) examined beliefs, attitudes, and practices related to breast cancer and breast cancer screening in African American women (Nursing Research Profile 16-1). They found that cultural, spiritual, and socioeconomic factors seen in the women studied could be identified as barriers to breast health screening behaviors. Nurses can use this type of information in planning education, prevention, and screening programs. Public awareness about health-promoting behaviors can be increased in a variety of ways. Although primary prevention programs may focus on the hazards of tobacco use or the importance of nutrition, secondary prevention programs may promote breast and testicular self-examination and Papanicolaou (Pap) tests. Many organizations conduct cancer screening events that focus on cancers with the highest incidence rates or those that have improved survival rates if diagnosed early, such as breast or prostate cancers. These events offer education and examinations such as mammograms, digital rectal examinations, and prostate-specific antigen blood tests for minimal or no cost. Programs of this nature are often targeted to individuals who lack access to health care or cannot afford to participate on their own. Similarly, nurses in all settings can develop programs that identify risks for patients and families and that incorporate teaching and counseling into all educational efforts, particularly for patients and families with a high incidence of cancer. The American Cancer Society has developed a public education program, "Taking Control," that integrates diet, exercise, and general health habit tips that people can follow to reduce their risk for cancer (Chart 16-2). Nurses and physicians can encourage individuals to comply with detection efforts as suggested by the American Cancer Society (Table 16-3). Oncology: Nursing Management in Cancer Care 323 Chart 16-2 Risk Factors: Taking Steps to Reduce Cancer Risk When teaching individual patients or groups, nurses can recommend the following cancer prevention strategies: 1. Increase consumption of fresh vegetables (especially those of the cabbage family) because studies indicate that roughage and vitamin-rich foods help to prevent certain kinds of cancer. Increase fiber intake because high-fiber diets may reduce the risk for certain cancers (eg, breast, prostate, and colon). Increase intake of vitamin A, which reduces the risk for esophageal, laryngeal, and lung cancers. Increase intake of foods rich in vitamin C, such as citrus fruits and broccoli, which are thought to protect against stomach and esophageal cancers. Practice weight control because obesity is linked to cancers of the uterus, gallbladder, breast, and colon. Reduce intake of dietary fat because a high-fat diet increases the risk for breast, colon, and prostate cancers. Practice moderation in consumption of salt-cured, smoked, and nitrate-cured foods; these have been linked to esophageal and gastric cancers. Reduce alcohol intake because drinking large amounts of alcohol increases the risk of liver cancer. Avoid overexposure to the sun, wear protective clothing, and use a sunscreen to prevent skin damage from ultraviolet rays that increase the risk of skin cancer. Diagnosis of Cancer and Related Nursing Considerations A cancer diagnosis is based on assessment for physiologic and functional changes and results of the diagnostic evaluation. Patients with suspected cancer undergo extensive testing to (1) determine the presence of tumor and its extent, (2) identify possible spread (metastasis) of disease or invasion of other body tissues, (3) evaluate the function of involved and uninvolved body systems and organs, and (4) obtain tissue and cells for analysis, including evaluation of tumor stage and grade. The diagnostic evaluation is guided by information obtained through a complete history and physical examination. Knowledge of suspicious symptoms and of the behavior of particular types of cancer assists in determining which diagnostic tests are most appropriate (Table 16-4). A patient undergoing extensive testing is usually fearful of the procedures and anxious about the possible test results. The nurse encourages the patient and family to voice their fears about the test results, supports the patient and family throughout the test period, and reinforces and clarifies information conveyed by the physician. This is accomplished before treatment begins to provide baseline data for evaluating outcomes of therapy and to maintain a systematic and consistent approach to ongoing diagnosis and treatment. Treatment options and prognosis are determined on the basis of staging and grading. In this system, T refers to the extent of the primary tumor, N refers to lymph node involvement, and M refers to the extent of metastasis (Chart 16-3). Staging systems also provide a convenient shorthand notation that condenses lengthy descriptions into manageable terms for comparisons of treatments and prognoses. Purpose African American women are more likely to develop breast cancer and to be diagnosed later in the disease than Caucasian women. This qualitative study explored beliefs, attitudes, and practices related to breast cancer among African American women. Study Sample and Design Three focus groups were conducted with 26 African American women recruited from three employment groups to represent different socioeconomic groups. The focus group discussions were guided by a semistructured guide developed from the literature on breast cancer screening and the Health Belief Model. Topics included African American women and health, breast health, breast cancer beliefs, breast cancer screening, and health-seeking behavior. Women in the focus groups were also asked their opinions of how best to inform African American women about breast cancer screening. Focus group discussions, lasting 90 minutes, were audiotaped and the tapes of the focus groups were transcribed verbatim. The transcriptions were analyzed for themes and for similarities and differences among the three different socioeconomic groups: employed middle-income women, employed low-income women, and unemployed low-income women. Findings All three groups spoke of panic and fear as the predominant feelings associated with breast cancer, and all groups associated breast cancer with death. Fear, pessimism, and belief that breast cancer is inevitable were common feelings and beliefs that can serve as barriers among African American women to participation in cancer screening. Cost of mammography, problems with transportation, and pain were also identified as barriers to screening. Although unemployed women believed that they were likely to develop breast cancer, the employed low-income women and middle-income women felt that they were somewhat likely and not very likely to develop breast cancer, respectively. The belief that breast cancer is inevitable may contribute to failure to seek screening or early treatment. All three groups indicated that there is limited discussion of breast cancer within the African American community. Nursing Implications the results of this study demonstrate the need to consider the beliefs and concerns of African American women when developing education and implementing screening programs. Further, health care providers need to understand the cultural and socioeconomic factors that influence screening in African American women. The findings of the study demonstrate that differences in beliefs and knowledge occur and that stereotyping by culture or ethnic group should be avoided. These tumors tend to be more aggressive and less responsive to treatment than well-differentiated tumors.
Purchase doxepin 10mg. Treating Anxiety & Depression With Cannabis.
References
Hidalgo M, Amant F, Biankin AV, et al. Patient-derived xenograft models: an emerging platform for translational cancer research. Cancer Discov 2014;4(9):998-1013.
Lipshultz SE, Alvarez JA, Scully RE. Anthracycline associated cardiotoxicity in survivors of childhood cancer. Heart 2008;94:525-533.
Gilron I, Bailey JM, Tu D, et al: Morphine, gabapentin, or their combination for neuropathic pain, N Engl J Med 352(13):1324n1334, 2005.
Plowman DEM: Congenital absence of spleen associated with cardiac abnormalities. BMJ 1957; 1:147-148.
