Care Of Clients With Neoplastic Disorders PDF

Republic of the Philippines Bulacan State University City of Malolos, Bulacan COLLEGE OF NURSING Medical-Surgical Nursing...

Republic of the Philippines Bulacan State University City of Malolos, Bulacan COLLEGE OF NURSING Medical-Surgical Nursing CARE OF THE CLIENTS WITH NEOPLASTIC DISORDERS (Cellular Aberrations/Oncologic Disorders) Terminologies to Remember  Cancer. A disease of the cell in which the normal mechanisms of the control of growth and proliferation have been altered. It is invasive, spreading directly to surrounding tissues as well as to new sites in the body. Also called malignant neoplasm.  Benign neoplasm. A harmless growth that does not spread or invade other tissues.  Neoplasia. Abnormal cellular changes and growth of new tissues.  Hyperplasia. Increase in cell number.  Hypertrophy. Increase in cell size.  Metaplasia. Replacement of one adult cell type by a different adult cell type.  Dysplasia. Changes in cell size, shape and organization.  Anaplasia. Reverse cellular development to a more primitive or embryonic cell type.  Metastasis. Spread of cancer cells to distant parts of the body to set up new tumors.  Oncology. The medical specialty that deals with the diagnosis, treatment and study of cancer.  Adenocarcinoma. Cancer that arises from glandular tissues. E.g. cancer of the breast, lung, thyroid, colon and pancreas.  Carcinoma. A form of cancer that is composed of epithelial cells; develops in tissue coverings or linings of the body such as skin, uterus, or breast.  Sarcoma. A cancer of supporting or connective tissues such as cartilage, bones, muscles or fats.  Carcinoma. Factors associated with cancer causation, e.g. radiation, chemicals, viruses, physical agents. Prepared: JPEM, MAN, RN Page 1 of 15 Pathogenesis of Cancer A. Cellular Transformation and Derangement Theory  Conceptualizes that normal cells may be transformed into cancer cells due to exposure to some etiologic agents. B. Failure of the Immune Response Theory  Advocates that all individuals possess cancer cells. However, the cancer cells are recognized by the immune response system. So, the cancer cells undergo destruction. Failure of the immune response system leads to inability to destroy the cancer cells. C. Defective Cellular Proliferation (Growth) and Defective Cellular Differentiation  Defective Cellular Proliferation - Normal cells respect the boundaries and territory of the cells surrounding them. They will not invade a territory that is not their own. Cancer cells do the opposite, i.e. they have no regard for cellular boundaries and will grow on top of one another and also on top of or between normal cells.  Defective Cellular Differentiation - Cellular differentiation is normally an orderly process that progresses from a state of immaturity (which has the potential to perform all body functions) to a state of maturity (mature cells performing only specific functions). Cancer cells alter these normal functions by “dedifferentiation” or reverting mature cells to their immature or undifferentiated state. Etiologic Factors (Carcinogens) A. Viruses  “Oncogenic viruses”  May be one of the multiple agents acting to initiate carcinogenesis.  Prolonged or frequent viral infections may cause breakdown of the immune system or overwhelm the immune system. “Failure of the Immune Response Theory”. B. Chemical Carcinogens  Act by causing cell mutation or alteration in cell enzymes and proteins → altered cell replication.  Examples: 1. Industrial Compounds o Vinyl chloride (plastic manufacture, asbestos factories, construction works) o Polycyclic aromatic hydrocarbons (refuse burning, auto and truck emissions, oil refineries), air pollution o Fertilizers, weed killers o Dyes o Analine dyes (beauty shops and home use) o Hair bleach o Drugs o Tobacco (tar, nicotine), alcohol o Cytotoxic drugs (Melphalan) Prepared: JPEM, MAN, RN Page 2 of 15  2. Hormones o Estrogen o Diethylstilbestrol (DES) 3. Foods, preservatives o Nitrates (bacon, smoked meat) o Talc (polished rice, salami, chewing gum) o Food sweeteners o Nitrosomines (rubber baby nipples) o Aflatoxins (mold in nuts and grains, milk, cheese, peanut butter) o Polycyclic hydrocarbons (charcoal broiling) C. Physical Agents 1. Radiation  From x-rays or radioactive isotopes  From sunlight/ultraviolet rays 2. Physical irritation/trauma  Pipe smoking  Multiple deliveries  Jagged tooth, irritation of the tongue, “overuse of any organ/body part”. D. Hormones  E.g. estrogen as replacement therapy increases incidence of vaginal and cervical adenocarcinoma. E. Genetics  Oncogene (hidden/repressed genetic code for cancer that exists in all individuals) → when exposed to carcinogens → changes in cell structure → becomes malignant.  Regardless of the cause, several cancers are associated with familial patterns. E.g. retinoblastoma, pheochromocytoma, Wilm’s tumor, lung cancer, breast cancer. Predisposing Factors A. Age  Older individuals are more prone to Cancer; they have been exposed to carcinogens longer; they may have developed immune system alteration. B. Sex  Women – more prone to breast, uterus, cervix cancer.  Men – more prone to prostate, lung cancer. C. Urban vs. Rural residence  Cancer is more common among urban dwellers than rural residents (because of greater exposure to carcinogens) D. Geographic Distribution  E.g. cancer of the stomach in Japan, cancer of the breast in USA.  Due to influence of environmental factors as national diet, ethnic customs, type of pollutions. E. Occupation  E.g. Chemical factory workers, farmers, radiology department personnel F. Heredity  Greater risk with positive family history. G. Stress  Depression, grief, anger, aggression, despair or life stresses decrease immunocompetence (affect hypothalamus and pituitary gland). Prepared: JPEM, MAN, RN Page 3 of 15   Immunodeficiency may spur the growth and proliferation of Ca cells. H. Precancerous lesions  May undergo transformation into Ca lesions and tumors.  E.g. pigmented moles, burns scars, senile keratosis, leukoplakia, benign polyps/adenoma of the colon or stomach, fibrocystic disease of the breast. I. Obesity  Studies have linked obesity to breast and colorectal cancer. Common Causes per Cancer Types 1. Breast Cancer  Early menarche  Late menopause  Nulliparous or older than 30 years at the birth of a first child. 2. Lung Cancer  Tobacco use  Asbestos  Radiation exposure  Air pollution 3. Colorectal Cancer  Greater incidence in men  Familial polyposis  Ulcerative colitis  High – fat, low – fiber diet 4. Prostate Cancer  Common among males who are 50 years old and older  African – Americans have the highest incidence of prostate cancer in the world.  Positive family history  Exposure to cadmium 5. Cervical Cancer  Sexual behaviour - First intercourse at an early age - Multiple sex partners - Sexual partner who has had multiple sex partner  Human papilloma virus and AIDS (acquired immunodeficiency syndrome)  Low socioeconomic status  Cigarette smoking 6. Head and Neck Cancer  More common among males  Alcohol and tobacco use  Poor oral hygiene  Long term sun exposure  Occupational exposures – asbestos, tar, nickel, textile, wood or leather work, machine tool experience. 7. Skin Cancer Prepared: JPEM, MAN, RN Page 4 of 15   Individuals with fair complexion  Positive family history  Moles (nevi)  Exposure to coal tar, creosote, arsenic, radium  Sun exposure between 10 AM to 3 PM Warning Signals of Cancer C – change in bowel or bladder habits A – sore that does not heal U – unsual bleeding or discharge U – unexplained sudden weight loss U – unexplained anemia T – thickening or lump in the breast of elsewhere I – indigestion or difficulty in swallowing O – obvious change in wart or mole N – nagging cough or hoarseness of voice The Cancer Detection Examinations A. Cytologic Examination or Papanicolau test (Pap’s Exam, Pap Smear)  Cytologic specimen can be obtained from tumors that tend to shed cells from their surface, e.g. G.I. tract through endoscopy; respiratory tract through laryngoscopy and bronchoscopy; genitor – urinary tract through colposcopy of the cervix and vagina, cystocscopy of the bladder, laparascopy of the pelvic and abdominal cavity.  Preparation for Pap Exam of the Cervix  No menstruation.  No vaginal sexual intercourse 24 hours before the test.  No vaginal douching 24 hours before the test. Prepared: JPEM, MAN, RN Page 5 of 15   Avoid inserting cervical cap, cervical diaphragm, spermicide or condom into the vagina 24 hours before the test.  Interpretation of Papanicolau Test results are as follows: Class I Normal Class II Inflammation Class III Mild to Moderate Dysplasia Class IV Probably Malignant Class V Malignant B. Biopsy. Involves obtaining tissue samples by needle aspiration or incision of tumor. It is the only definitive means of diagnosing cancer. Excisional Biopsy C. Ultrasound D. Nuclear Magnetic Resonance Imaging (MRI) E. Radiologic Examinations (X-rays) F. Radiologic Techniques (Use of Radioisotopes) G. Computerized Axial Tomography (CT Scan) H. Antigen Skin Test e.g. DNCB I. Laboratory Test UTZ procedure  Alpha-feto-protein (AFP)  Human Chorionic Gonadotropin (HCG)  Prostatic Acid Phosphatase  Prostatic Specific Antigen (PSA) CT & MRI procedures  Carcinoembryonic Antigen (CEA) J. Endoscopic Examination K. Monoclonal Antibodies Endoscopic examination Prepared: JPEM, MAN, RN Page 6 of 15  Comparison of the Characteristics of Benign and Malignant Neoplasm Characteristics Benign Malignant A. Speed of Growth Grows slowly Grows rapidly B. Capsule Encapsulated Not encapsulated C. Cell Characteristics Well differentiated mature cells; cells Poorly differentiated (anaplastic type) function poorly D. Recurrence Extremely unusual when surgically Common following surgery removed E. Metastasis Never occur Very common F. Effect of neoplasm Not harmful to host Always harmful G. Prognosis Very good prognosis Poor prognosis Pathophysiologic Basis of Malignant Neoplasia Predisposing Factors/Etiologic Factors Cellular Aberrations Ca Cell Proliferation Malignant cells produce Anorexia and Cachexia - Disrupt normal cell enzymes, hormones and Syndrome growth and interfere other substances A. Tissue wasting with tissue function (Paraneoplastic Syndrome) B. Sever weight loss A. Pressure A. Anemia C. Severe debilitation B. Obstruction B. Hypercalcemia C. Pain C. Edema D. Effusion D. DIC E. Ulceration F. Vascular Thrombosis, Embolus, Thrombophlebitis A. Proliferation of Cancer Cells 1. Pressure – due to increase in size of neoplastic growth 2. Obstruction – as tumor continues to grow, hollow organs and vessels become compressed and obstructed.  E.g. esophagus, bronchi, ureters, bowel, blood vessels, lymphatic system. 3. Pain  Due to: o Pressure on nerve endings o Distention of organs/ vessels o Lack of O2 to tissues and organs o Release of pain mediators by the tumor  A late sign of Ca 4. Effusion  When lymphatic flow is obstructed, there may be effusion in serous cavities.  E.g. effusion into the pleural cavity (pleural effusion); effusion into the abdominal cavity (ascites) 5. Ulceration and Necrosis Prepared: JPEM, MAN, RN Page 7 of 15   Result as the tumor erodes blood vessels and pressure on tissue causes ischemia → tissue damage and bleeding → infection 6. Vascular Thrombosis, Embolus, Thrombophlebitis  Tumors tend to produce abnormal coagulation factors that cause increased clotting (pulmonary emboli → life-threatening). B. Paraneoplastic Syndrome - malignant cells produce enzymes, hormones and other substances 1. Anemia  Ca cells produce chemicals that interfere with RBC production.  Iron uptake is greater in the tumor that that deposited in the liver.  Blood loss may result from bleeding. 2. Hypercalcemia  Tumors of the bone, squamous cell lung Ca, Ca of the breast produce a parathyroid – like hormone that increases or accelerates bone breakdown and release of calcium.  Also results from metastasis to the bones.  Enhanced by immobilization and dehydration. 3. DIC (Disseminated Intravascular Coagulation)  More likely to occur in Ca of the lungs, pancreas, stomach, prostate.  Precipitated by the release of tissue thromboplastin or endothelial injury. C. Anorexia – Cachexia Sydrome  The final outcome of unrestrained Ca cell growth.  Malignant neoplasms deprive normal cells of nutrition.  Tumors produce alteration in enzyme system necessary for normal metabolism → stored fat is lost, tissues lose nitrogen (negative Nitrogen balance).  Tumors revert to anaerobic metabolism → consume glucose; deplete glycogen stores in the liver and convert glucose to lactate.  Protein depletion, serum albumin levels increase.  Tumors take up Na+. Water retention masks malnutrition and is not immediately reflected as weight loss.  Ca cells produce anorexigenic substances that act in the satiety center of the hypothalamus, causing anorexia.  Taste sensation, diminishes or becomes altered and the individual may have aversion to eating, particularly meat. Staging and Grading of Neoplasia  Staging is determining the size of the tumor and existence of metastases.  Grading is classification of tumor cells.  Staging is necessary at the time of diagnosis to determine the extent of disease (local versus metastatic), to determine prognosis and to guide proper management.  The American Joint Committee of Cancer (AJCC) has developed the TNM Classification System that can be applied to all tumor types.  T – tumor size  N – presence or absence of regional lymph node involvement  M – presence or absence of distant metastasis  T – primary tumor  Tx – primary tumor is unable to be assessed.  To – no evidence of primary tumor.  Tis – carcinoma in situ  T1, T2, T3, T4 – increasing size and/ or local extent of primary tumor  N - presence or absence of regional lymph node involvement  Nx – regional lymph node is unable to be assessed. Prepared: JPEM, MAN, RN Page 8 of 15   No – no regional lymph node involvement.  N1, N2, N3, N4 – increasing involvement regional lymph nodes  M – absence or presence or distant metastasis  Mx – metastasis is unable to be assessed.  Mo – absent or distant metastasis  M1 – presence of distant metastasis Cancer Prevention  Skin. Avoid exposure to sunlight  Oral. Annual oral examination  Breast. Monthly BSE (breast self-examination) from age 20.  Lungs. Avoid cigarette smoking; annual chest X-ray.  Colon. Digital rectal examination for persons over age 40. Rectal biopsy, proctoscopic examination, Guaiac stool examination for person age 50 and above.  Uterus. Annual Pap’s smear from age 40.  Basic. Annual physical examination and blood examination. Dietary Recommendations Against Cancer  Avoid obesity.  Cut down on total fat intake.  Eat more high fiber foods – raw fruits and vegetables, whole grain cereals.  Include foods rich in Vitamin A & C in daily diet.  Include cruciferous vegetables in the diet – broccoli, cabbage, cauliflower, brussel sprouts.  Be moderate in the consumption of alcoholic beverages.  Be moderate in the consumption of salt – cured, smoked – cured and nitrate- cured foods. Different Therapeutic Modalities for Cancer  Surgical Interventions  Chemotherapy  Radiation Therapy  Immunotherapy  Bone Marrow Transplantation A. Surgical Interventions 1. Preventive Surgery. Removal of precancerous lesions or benign tumors. 2. Diagnostic Surgery. Biopsy. 3. Curative Surgery. Removal of an entire tumor (en bloc resection). 4. Reconstructive Surgery. Improvement of structure and function of an organ. 5. Palliative Surgery. Relief of distressing signs and symptoms; retardation of metastasis. E.g. oophorectomy in the client with cancer of the breast to reduce estrogen secretion, thereby retard metastasis. B. Chemotherapy  Objectives  To destroy all malignant tumor cells without excessive destruction of normal cells.  To control tumor growth if cure is no longer possible. Prepared: JPEM, MAN, RN Page 9 of 15   Used as adjuvant therapy.  Contraindications  Infection. The anti – tumor drugs are immunosuppressives.  Recent surgery. The drugs may retard healing process.  Impaired Renal or Hepatic function. The drugs are nephrotoxic and hepatotoxic.  Recent Radiation Therapy. Also immunosuppressive.  Pregnancy. The drugs may cause congenital defects.  Bone Marrow Depression. These drugs may aggravate the condition. The WBC levels must be within normal limits.  Safe Handling of Chemotherapeutic Agents 1. Wear mask, gloves and back – closing gown. 2. Skin contact with drug must be washed immediately with soap and water. Eyes must be flushed immediately with copious amount of water. 3. Sterile/alcohol – wet cotton pledgets should be used – wrapped around the neck of the ampule or vial when breaking and withdrawing the drug. 4. Expel air bubbles on wet cotton. 5. Vent vials to reduce internal pressure after mixing. 6. Wipe external surface of syringes and IV bottles. 7. Avoid self – inoculation by needle stab. 8. Clearly label the hanging IV bottle with ANTINEOPLASTIC CHEMOTHERAPY. 9. Contaminated needles and syringes must be disposed in a clearly marked special container; “leak - proof”, “puncture - proof”. 10. Dispose half – empty ampoules, vials, IV bottles by putting into plastic bag, seal and then into another plastic bag or box, clearly marked before placing for removal. Label as “Hazardous waste”. 11. Handwashing should be done before and after removal of gloves. 12. Trained personnel only should be involved in use of drugs. 13. Ideally, preparation of drugs should be in laminar flow conditions with filtered air.  Nursing Interventions for Chemotherapeutic Side Effects 1. G.I. System – nausea and vomiting, diarrhea, constipation a. Administer antiemetic to relieve nausea and vomiting. b. Replace fluid – electrolyte losses, low – fiber diet to relieve diarrhea. c. Increase fluid intake and fibers in diet prevent/ relieve constipation. 2. Integumentary System a. Pruritus, urticaria and systemic signs.  Provide good skin care. b. Stomatitis  Provide good oral care.  Avoid hot and spicy food. c. Alopecia  Reassure that it is temporary.  Encourage to wear wigs, hats or head scarf. d. Skin pigmentation  Inform that it is temporary. e. Nail changes  Reassure that nails may grow normally after chemotherapy. 3. Hematopoietic System Prepared: JPEM, MAN, RN Page 10 of 15  a. Anemia  Provide frequent rest periods. b. Neutropenia  Protect from infection.  Avoid people infection. c. Thrombocytopenia  Protect from trauma.  Avoid ASA. 4. Genito – Urinary System a. Hemorrhagic cystitis  Provide 2 – 3 L of fluids per day. b. Urine color changes  Reassure that it is harmless. 5. Reproductive System a. Premature menopause or amenorrhea  Reassure that menstruation resumes after chemotherapy.  Antiemetics to Relieve Nausea and Vomiting Related to Chemotherapy 1. Dronabinol (Marinol) 2. Ondansetron (Zofran) 3. Granisetron (Kytril) 4. Alprazolam (Zanax) 5. Lorazepam (Ativan) 6. Haloperidol (Haldol) 7.Prochlorperazine (Compazine)  Summary of Effects of Chemotherapy  Antineoplastic drugs affect both normal and cancer cells by disrupting cell function and division at various point of cell cycle.  Most cancer drugs are most effective against cells that multiply rapidly – neoplasms, bone marrow cells, cells in the GI tract and cells in the skin or hair follicles. Adverse reactions to cancer drugs tend to occur in these organs.  Chemotherapeutic agents should not be used during pregnancy or lactation. Congenital defects may occur in the fetus. Prepared: JPEM, MAN, RN Page 11 of 15  C. Radiation Therapy  Role in Cancer Intervention  Primary curative role  Adjunct to other therapy  Palliation  Sources of Radiation Therapy  External Radiation Therapy (Teletherapy). Administered through an X- ray machine.  Internal Radiation Therapy. Administered within or near the tumor.  Types  Sealed Source (Brachytherapy)  Unsealed Source (oral, IV) Brachytherapy Sample Prepared: JPEM, MAN, RN Page 12 of 15   Side Effects of Radiation Therapy 1. Skin Reactions  Erythema, dry/moist desquamation.  Atrophy, telangiectasia, depigmentation, necrotic/ulcerative lesions.  Nursing Responsibilities:  Observe for early signs of skin reactions and report.  Keep area dry.  Wash area with water, no soap and pat dry (do not rub).  Do not apply ointments, powders or lotions on the area.  Do not apply heat, avoid direct sunshine or cold.  Use soft cotton fabrics for clothing.  Do not erase markings on the skin. These serves as guide for areas of irradiation. 2. Infection  Due to bone marrow suppression.  Nursing Responsibilities:  Monitor blood counts weekly  Good personal hygiene, nutrition, adequate rest  Teach signs of infection to report to physician 3. Hemorrhage  Platelets are vulnerable to radiation.  Nursing Responsibilities:  Monitor platelet count.  Avoid physical trauma or use of aspirin.  Teach signs of hemorrhage.  Monitor stool and skin for signs of hemorrhage.  Use of direct pressure over injection sites until bleeding stops. 4. Fatigue  Result of high metabolic demands for tissue repair and toxic waste removal.  Plenty of rest and good nutrition. 5. Weight loss  Anorexia, pain and effect of cancer. 6. Stomatitis  Ulceration of oral mucous membrane.  Nursing Interventions:  Administer analgesic before meals.  Bland diet, no smoking/alcohol.  Good oral hygiene/saline rinses q 2°.  Sugarless lemon drops or mints to increase salivation. 7. Diarrhea 8. Nausea and vomiting 9. Headache 10. Hair loss/ alopecia 11. Cystitis 12. Social Isolation  Principles of Radiation Protection – “DTS” Prepared: JPEM, MAN, RN Page 13 of 15  1. Distance. Maintain a distance of at least 3 feet when not performing nursing procedures. 2. Time. Limit contact for 5 minutes each time, a total of 30 minutes per shift. 3. Shielding. Use lead shield during contact with client.  Teaching Guidelines Regarding Radiation Therapy 1. It is painless. 2. Lie very still on a special table while the intervention is being given and you may be placed in a special position to maximize tumor irradiation. 3. Each treatment usually lasts for few minutes. You may hear sounds of the machine being operated, and the machine may move during the therapy. 4. As a safety precaution for the therapy personnel, you will remain alone in the treatment room while the machine is in operation. 5. The technologist will be right outside your room observing you through a window or by closed – circuit TV. You may communicate. 6. There is no residual radioactivity after radiation therapy. Safety precautions are necessary only during the time you are actually receiving irradiation. You may resume normal activities of daily living. CARE OF THE CLIENT WITH BREAST CANCER A. Risk Factors Associated with Breast Cancer  Menarche before age 11  Menopause after age 50  Family history of breast cancer – especially mother or sister  Nulliparity or birth of first child after age 30  History of uterine cancer  Link with obesity, diabetes and hypertension  Presence of benign breast disease B. Prevention 1. Breast Self-Examination (BSE)  Start from age 20.  Done after menstruation.  During standing position, note specifically for symmetry of the breasts.  In lying position, elevate shoulders on the side examined with pillow support.  Palpate the breast from periphery to the center in circular motion. Prepared: JPEM, MAN, RN Page 14 of 15  2. Mammogram  This involves X – ray examination of the breast.  The breast is supported on flat, firm surface.  This involves use of 2 X – ray films. C. Pathophysiology - a classic symptoms that define breast cancer include:  Firm, nontender, nonmobile mass  Solidarity, irregularly shaped mass  Adherence to muscle or skin causing dimpling effect  Involvement of upper outer quadrant or central nipple portion of breast  Asymmetry of the breasts  “orange peel” skin  Retraction of nipple  Abnormal discharge from nipple D. Stages of Cancer  Stage I. Tumor size is up to 2 cm.  Stage II. Tumor size is up to 5 cm with axillary lymph node involvement.  Stage III. Tumor size is more than 5cm, with axillary and neck lymph node involvement  Stage IV. Metastasis to distant organs (liver, lungs, bone and brain). E. Collaborative Management 1. Surgery a. Lumpectomy/ Tylectomy. Involves removal of the lump. b. Simple Mastectomy. Involves removal of the entire breast. The pectoralis muscles and the nipples remain intact. c. Modified Radical Mastectomy (MRM). Involves removal of the entire breast, pectoralis major muscle and the axillary lymph nodes. d. Radical Mastectomy (Halstead Surgery). Involves removal of the entire breast, pectoralis major and minor muscles, axillary and neck lymph nodes. It is followed by skin grafting. 2. Chemotherapy Prepared: JPEM, MAN, RN Page 15 of 15  3. Radiation Therapy 4. Surgery: Preoperative Care  Psychosocial Support. Include the husband when necessary.  Teach arm exercises to prevent lymph edema.  Inform about wound suction drainage, e.g. hemovac, Jackson – Pratt.  DBCT exercises to prevent postop respiratory complications. 5. Surgery: Postoperative Care  Place client in semi – Fowler’s position with arm elevated on pillows, abducted. To promote venous return and prevent edema.  Monitor Hemovac output (serosanguinous for the first 24 hours).  Check behind patient for bleeding. Blood flows to the back by gravity.  Post warning signs against taking blood pressure, starting IVs, or drawing blood on the affected side.  Initiate exercise to prevent stiffness and contractures of shoulder girdle.  Reinforce special mastectomy exercises as prescribed.  Provide adequate analgesia to promote ambulation and exercise.  Encourage regular coughing and deep breathing exercise.  Prepare client for size and appearance of the incision and provide support when incision is viewed for the first time.  Provide client with detailed information concerning breast prosthesis.  Fitting is not possible for 4 – 6 weeks.  A temporary prosthesis or lightly padded bras worn until healing is complete.  Teach patient to avoid constrictive clothing and report persistent edema, redness, or infection of incision.  Teach patient the importance of continuing monthly breast examination on the remaining breast. 6. Prevention of Lymphedema a. “AVOIDs”  Cuts  Scratches  Pinpricks  Hangnails  Insect Bites  Burns  Strong detergents b. “DON’Ts” (on the affected arm or side)  Carry purse/anything heavy  Wear wristwatch/jewelry  Pick at/ cut cuticles  Work near thorny plants/ dig in garden  Reach into hot oven  Hold a cigarette  Injections, withdrawal of blood, BP – taking c. “DOs”  Wear loose rubber gloves when washing dishes  Wear a thimble when sewing  Apply lanoline hand cream to prevent dryness  Contact AMD if arm gets red, warm, or hard / swollen.  Return for check – up  Wear “Life Guard Med Aid” tag: CAUTION – LYMPHEDEMA. Prepared: JPEM, MAN, RN Page 16 of 15