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ONCOLOGY NURSING

By: ERIC F. PAZZIUAGAN, RN, MAN



CANCER
malignant neoplasm
is a class of diseases in which a group of cells display
uncontrolled growth (division beyond the normal
limits)
invasion (intrusion on and destruction of adjacent
tissues)
metastasis (spread to other locations in the body via
lymph or blood).

PATHOPHYSIOLOGY OF THE MALIGNANT PROCESS
Cancer begins when an abnormal cell is transformed by the
genetic mutation of the cellular DNA.
Abnormal cell forms a clone and begins to proliferate
abnormally, ignoring growth- regulating signals in the
environment surrounding the cell.
Cells acquire invasive characteristics, and changes occur in the
surrounding tissues.
Cells infiltrate tissues and gain access to the lymph and blood
vessels, which carry the cells to other parts of the body
(metastasis).

Cancer is not a single disease with a single cause; rather it is a
group of distinct diseases with different causes,
manifestations, treatments, and prognoses.

PROLIFERATIVE PATTERNS
Cancerous cells:
malignant neoplasms
demonstrate uncontrolled cell growth that follows no
physiologic demand.


Patterns of cell growth:
Hyperplasia: increase in the number of cells of a tissue; most
often associated with periods of rapid body growth.
Metaplasia: conversion of one type of mature cell into another
type of cell.
Dysplasia: bizarre cell growth resulting in cells that differ in
size, shape or arrangement from other cells of the same tissue.
Anaplasia: cells that lack normal cellular characteristics and
differ in shape and organization with respect to their cells of
origin; usually, anaplastic cells are malignant.
Neoplasia: uncontrolled cell growth that follows no
physiologic demand.
CHARACTERISTICS OF MALIGNANT CELLS
Cell membranes are altered, which affects fluid movement in
and out of the cell.
Contains proteins (tumor- specific antigens), which develop as
they become less differentiated (mature) overtime.
Contain less fibronectin, a cellular cement; therefore, they are
less cohesive and do not adhere to adjacent cells readily.
Nuclei are large and irregularly shaped (pleomorphism).
Nucleoli are larger and more numerous.
Chromosomal abnormalities (translocations, deletions,
additions)
Mitosis occurs more frequently.
As the cells grow and divide, more glucose and oxygen are
needed.
CHARACTERISTICS OF BENIGN AND MALIGNANT
NEOPLASMS




INVASION AND METASTASIS
Invasion: growth of the primary tumor into the surrounding host
tissues.
Mechanical pressure may force finger-like projections of
tumor cells into surrounding tissues and interstitial
spaces.
Malignant cells are less adherent and may break off
from the primary tumor and invade adjacent structures.
Malignant cells produce or possesses destructive
enzymes (proteinases) such as collagenenases,
plasminogen activators, and lysosomal hydrolyses that
destroys surrounding tissue, including the structural
tissues of the vascular basement membrane, facilitating
invasion of malignant cells.
Metastasis: dissemination or spread of malignant cells from the
primary tumor to distant sites by direct spread of tumor cells to
by cavities or through lymphatic and blood circulation.

METASTATIC MECHANISMS
Lymphatic spread
Most common mechanism.
Tumor emboli enter through interstitial fluid that
communicates with lymphatic fluid or by invasion.
After entering the lymphatic circulation, may lodge
in the lymph nodes or pass between lymphatic and
venous circulation.
Hematogenous spread
Malignant cells are disseminated through the blood
stream.
Few malignant cells survive the turbulence of arterial
circulation, insufficient oxygenation, or destruction
by the bodys immune system.
Those that survive are able to attach to
endothelium and attract fibrin, platelets and
clotting factors to seal themselves form
immune system vigilance.
Angiogenesis
Ability of the malignant cells to induce the growth of
new capillaries from the host tissue to meet their
needs for nutrients and oxygen.
THREE STEPS OF CARCINOGENESIS (MALIGNANT
TRANSFORMATION)
I In ni it ti ia at ti io on n
Initiators (carcinogens) escape normal enzymatic
mechanisms and alter the genetic structure of the
cellular DNA where permanent mutation occurs.
P Pr ro om mo ot ti io on n
Repeated exposure to promoting agents (co-
carcinogens) causes the expression of abnormal or
mutant genetic mutation even after long latency
periods.
P Pr ro og gr re es ss si io on n
Cellular changes formed during initiation and promotion
now exhibit increased malignant behaviour.
These cells now show a propensity to invade adjacent
tissues and to metastasize.

ETIOLOGY
Viruses and Bacteria
Viruses as a case are hard to determine because they
are difficult to isolate.
Infectious causes are considered when specific
cancers appear in cluster.
Viruses incorporate themselves in the genetic
structure of the cells, thus altering future generations
of that cell population- perhaps leading to cancer.
Examples:
Epstein- Barr virus: nasopharyngeal cancers,
some type of non- Hodgkins lymphoma and
Hodgkins disease.
Herpes simplex virus type II,
cytomegalovirus, and human papillomavirus
types 16, 18, 31 and 33: dysplasia and cancer
of the cervix.
Hepatitis B virus: cancer of the liver.
HIV: Kaposis Sarcoma
H. Pylori: gastric malignancy secondary to
inflammation and injury of the gastric cells.
Physical agents
Exposure to sunlight or radiation, chronic irritation or
inflammation, and tobacco use.

Chemical agents
75% are thought to be related to the environment
Tobacco smoke: single most lethal carcinogen (30% of cancer
deaths)
Others: aromatic amines and aniline dyes; pesticides and
folmaldehydes; arsenic soot, and tars; asbestos; benzene; betel
nut and lime; cadmium; chromium compounds; nickel and
zinc ores; wood dust; beryllium compounds; and polyvinyl
chloride.
Most chemicals alters DNA structure in body sites distant
from chemical exposure.
Most often affected: liver, lungs and kidneys
Genetic and familial factors
Genetics, shared environments, cultural or lifestyle factors, or
chance alone.
5% to 10% of cancers of adulthood and childhood display a
familial predisposition.
Cancers associated with family inheritance: retinoblastomas,
malignant neurofibromatosis, and breast, ovarian,
endometrial, colorectal, stomach, prostate, and lung cancers.

Dietary factors
35% of all environmental cancers
Dietary substances associated with an increased cancer risk:
Fats, alcohol, salt- cured or smoked- meats, foods containing
nitrates and nitrites, and high- caloric dietary intake.
Foods that lower cancer risks:
High- fiber foods, cruciferous vegetables (cabbage, broccoli,
cauliflower, Brussel sprouts, kohlbari), carotenoids (carrots,
tomatoes, spinach, apricots, peaches, dark- green and deep-
yellow vegetables)
Obesity: associated with endometrial cancer, postmenopausal
breast cancer, cancers of the colon, kidney, and gallbladder.
Hormonal agents
Disturbances in hormonal balance either by the bodys own
(endogenous) hormone production or by administration of
exogenous hormones.
Endogenous: cancers of the breast, prostate and uterus
Oral contraceptives and prolonged estrogen replacement
therapy: hepatocellular, endometrial, and breast cancers.
Hormonal changes with reproduction are also associated with
cancer incidence.
Increased numbers of pregnancies are associated with a
decreased incidence of breast, endometrial and ovarian
cancers.
Cancer Classification
1.Solid Tumors : Associated with the organs from which they
developed, such as breast or lung cancer
2.Hematological Cancers : Originate from blood-cell forming
tissues, such as the leukemias and the lymphomas

Grading and Staging
Are methods used to describe the tumor, these methods
describe the extent of the tumor, the extent to which
malignancy has increased in size, the involvement of regional
nodes, and metastatic development.

Grading
Grading: refers to classification of tumor cells.
Seek to define the type of tissue from which the tumor
originated and the degree to which the tumor cells retain the
functional and histologic characteristics of the tissue of origin.
Can be obtained through cytology (examination of cells from
tissue scrapings, body fluids, secretions or washings), biopsy
or surgical excision.
GRADING
GradeX : Grade cannot be determined
GradeI : Cells differ slightly from normal cells and are well
differentiated (Mild Dysplasia)
GradeII : Cells are abnormal and are moderately differentiated
( Moderate Dysplasia)
GradeIII : Cells are very abnormal and are poorly
differentiated ( Severe Dysplasia)
GradeIV : Cells are immature (anaplasia) and undifferentiated,
cell of origin is difficult to determine.
Staging
Staging: determines the size of the tumor and the existence of
the metastasis.
TNM system:
T: The Extent of the primary tumor
N: The absence or presence of regional lymph node metastasis.
M: The absence or presence of distant metastasis.
Primary Tumor (T)
TX: primary tumor cannot be assessed.
T0: No evidence of primary tumor.
Tis: Carcinoma in situ
T1, T2, T3, T4: Increasing size and/ or local extent of the
primary tumor.

Regional Lymph Nodes (N)
NX: regional lymph nodes cannot be assessed.
N0: no regional lymph node metastasis.
N1, N2, N3: increasing involvement of regional lymph nodes.

Distant Metastasis (M)
MX: distant metastasis cannot be assessed.
M0: no metastasis
M1: distant metastasis

Cancer Prevention, Screening and detection
Prevention is a priority in oncology nursing because at least
one third of all cancers are preventable.
Cancer is also curable if detected and treated early.
The principal role of an oncology nurse as a provider of
information and education in the prevention and early
detection of cancer requires a basic understanding of the
etiology and epidemiology of the disease.

The most successful approach to cancer control is the prevention of
cancer.

Prevention and Detection Measures
1. Promoting cancer awareness:
C hange in bowel or bladder habbits
A ny sore that does not heals
U nusual bleeding or discharge
T hickening or lump in breast or elsewhere
I ndigestion
O bvious change in wart or mole
N agging cough or hoarseness

U nexplained anemia
S udden and unexplained weight loss
Promoting risk factors awareness
Promoting healthy behaviors
Good nutrition and diet
Tomatoes, spinach, red wine, nuts, broccoli, oats,
salmon, garlic, green tea, blueberries
Limiting alcohol consumption
Hepa B virus infant vaccination
Control of STDs
Changing risk behaviors
Teaching skills for early detection programs
Promoting participation in early detection programs

Recommendations of the American Cancer Society for early
cancer detection
1. For detection of breast cancer
Monthly BSEs
Women at age 40 should have a yearly mammogram
and breast examination by a health care provider
2. For detection of colon and rectal cancer
All aged 50 and up should have a yearly fecal occult
blood test
Digital rectal exam and flexible sigmoidoscopy every
5 years
Colonoscopy with Ba enema every 10 years


3. For detection of uterine cancer
Yearly Pap smear for sexually active females and any female
over age 18
At menopause, high-risk women should have an endometrial
tissue sample
4. For detection of prostate cancer
Beginning age 50, yearly digital rectal examination
and prostate-specific antigen (PSA) test


Cancer Screening
Refers to detection of disease through tests, exams, and other
procedures
An oncology nurse should have good hx taking skills. She
should be able to note down all possible clinical as well as
behavioral clues through PE

DIAGNOSTIC TESTS
Biopsy
- is the definitive means of diagnosing cancer and provides
histological proof of malignancy.
- involves the surgical incision of a small piece of tissue of
microscopic examination

Types:
a. Needle : Aspiration of Cells
b. Incisional : Removal of a wedge of suspected tissue from a
larger mass
c. Excisional : Complete removal of the entire lesion
d. Staging : Multiple needle or incisional biopsies in tissues
where metastasis is suspected or likely.

Other means of Detection
Mammography
Papanicolaous (Pap) test
Stools for occult blood
Sigmoidoscopy
Colonoscopy
Skin Inspection

Tumor Markers
protein substances found in the blood or body fluids
derived from the tumor itself

Oncofetal antigens
Normally present in fetal tissue;may indicate an
anaplastic process in tumor cells
Ex:
Carcinoembryonic Antigen (CEA)
Alpha-feto protein
Hormones
ADH
Calcitonin
Catecholamines
HCG
PTH

I Is so oe en nz zy ym me es s
increased when a tissue is experiencing rapid and
excessive growth as a result of a tumor
Neurospecific enolase (NSE)
Prostatic acid phosphatase (PAP)
T Ti is ss su ue e- -s sp pe ec ci if fi ic c a an nt ti ig ge en ns s
identifies the type of tissue affected by malignancy
prostatic-specific antigen (PSA)
M Ma an na ag ge em me en nt t o of f C Ca an nc ce er r
Radiation therapy
Used to kill a tumor, reduce tumor size, relieve obstruction or
decrease pain
Causes lethal injury to DNA

Classification:
Internal radiation therapy (brachytherapy)
External radiation therapy (teletherapy)

Brachytherapy
Sources
Implanted into the affected tissue or body cavity
Ingested as a solution
Injected as a solution into the bloodstream or body
cavity
Introduced through a catheter into the tumor
Side effects:
Fatigue
Anorexia
Immunosuppression


C. Client education
Avoid close contact with others until the treatment is
completed
Maintain daily activities unless contraindicated
Rest
Maintain a balanced diet
Maintain fluid intake
If implant is temporary, the client should be on bed
rest
Excreted body fluids may be radioactive; double
flush toilets after use

d. Nursing management
Minimize time spent in close proximity to the
radiation sources
Limit contact time to 30 mins per 8H shift
Minimum distance should be 6 ft
Use lead shields
Place the client in a private room
Limit visits to 10-30 minutes
Ensure proper handling and disposal of body fluids
Pregnant women and children are not allowed inside
the clients room
Teletherapy
Treatment is usually given 15-30 minutes per day, 5x per
week, for 2-7 weeks
Client does not pose a risk of radiation exposure to other
people
Side effects:
Tissue damage to target area (erythema, sloughing,
and hemorrhage)
Ulcerations of oral mucous membranes
Nausea, vomiting, and diarrhea
Radiation pneumonia
Fatigue
Alopecia
Immunosuppression

Client education
Wash marked area of the skin with plain water only
and pat dry. Do not use soaps, deodorants, lotions,
perfumes, powders, or medications on the site during
the duration of the treatment. Do not wash off the
treatment site marks
Avoid rubbing, scratching, or scrubbing the
treatment site. Do not apply extreme temperatures to
the treatment site. If shaving is necessary, use electric
razor.
Wear soft, loose-fitting clothing over the treatment
area
Protect skin from sun exposure during the treatment
and for at least 1 year after the treatment is
completed. When going outdoors, use sun blocking
agents with SPF of at least 15.
Maintain proper rest, diet, and fluid intake
Hair loss may occur. Choose a wig, hat or scarf to
cover and protect the head.

Chemotherapy
Involves the administration of cytotoxic medications and
chemicals to promote death of tumor cells.
Route of adminstration:

IV
Oral
Intrathecal
Topical
Intra-arterial
Intracavity
Intravesical

C Cl la as ss si if fi ic ca at ti io on n o of f C Ch he em mo ot th he er ra ap pe eu ut ti ic c a ag ge en nt ts s
Alkylating agents
Non-phase-specific and act by interfering with
DNA replication
Cyclophosphamide (Cytoxan)
Busulfan (Myleran)
Mecholorethamine (Mustargen)

b. Antimetabolites
Interfere with metabolites or nucleic acids necessary
for RNA and DNA synthesis
5-fluorouracil (5-FU)
Methotrexate

c. Cytotoxic antibiotics
Disrupt or inhibit DNA or RNA synthesis
Bleomycin (Blenoxane)
Doxorubicin (Adriamycin)
d. Hormones and hormone antagonists
Phase-specific (G1) and act by interfering with RNA
synthesis
Diethylstilbestrol (DES)
Tamoxifen (Nolvadex)
Prednisone

e. Plant alkaloids
V Vi in nc ca a a al lk ka al lo oi id ds s are phase-specific, inhibiting cell
division
E Et to op po os si id de e acts during all cell-cycle phases, interfering
with DNA and cell division at metaphase

N Nu ur rs si in ng g i im mp pl li ic ca at ti io on ns s f fo or r t th he e a ad dm mi in ni is st tr ra at ti io on n o of f c ch he em mo ot th he er ra ap py y
IV routes may be obtained by subclavian catheters, implanted
ports, or peripherally inserted catheters.
Extravasation is the major complication of IV chemotherapy.
Extreme care must be used when administering vesicant
agents
W WA AR RN NI IN NG G: : N NE EV VE ER R T TE ES ST T V VE EI IN N P PA AT TE EN NC CY Y W WI IT TH H
C CH HE EM MO OT TH HE ER RA AP PE EU UT TI IC C A AG GE EN NT TS S. .
Monitor client closely for anaphylactic reactions or serious side
effects. Discontinue infusion according to protocol if reaction
occur
Use caution when preparing, administering, or disposing
chemotherapeutic agents
Nursing management of the common side effects of
Chemotherapy
Bone marrow suppression leads to:
Leukopenia (immunosuppression)
Avoid crowds, people with infections,
and small children when WBC count is
low
Avoid undercooked meat and raw fruits
and vegetables
Thrombocytopenia
Use electric razor when shaving
Avoid contact sports
If trauma occurs, apply ice and seek
medical assistance
Avoid dental work or other invasive
procedures
Avoid aspirin and aspirin-containing
products
b. GI effects (anorexia, nausea, vomiting, and diarrhea)
Client education
Eat small, frequent, low-fat meals
Avoid spicy and fatty foods
Avoid extremely hot foods
Administer antiemetics prior to chemotherapy
Weigh client routinely

c. Stomatitis and mucositosis
Client education
Use a soft toothbrush. Mouth swabs may be
needed during an acute episode
Avoid mouthwashes containing alcohol. Do
not use lemon glycerin swabs or dental floss
Consider using chlorhexidine mouthwash to
decrease risk of haemorrhage and protect
gums from trauma
For xerostomia, apply lubricating and
moisturizing agents to protect the mucous
membranes from trauma and infection
Consider using artificial saliva and hard
candy or mints
Avoid smoking and alcohol
Drink cool liquids, and avoid hot and
irritating foods
d. Alopecia (hair loss)
Encourage the client to choose a wig before hair loss
occurs
Care of hair and scalp includes washing hair two to
three times a week with mild shampoo. Pat hair dry
and avoid the use of blow dryer.

Surgery
Primary treatment
Prophylactic
Palliative
Reconstructive

Responsibilities of the Nurse in CANCER care

Support the idea that cancer is a chronic illness that has acute
exacerbations rather than one that is synonymous with
DEATH and SUFFERING
Assess own level of knowledge relative to the
pathophysiology of the disease process
Make use of current research findings and practices in the care
of the client with cancer and his or her family
Identify patients at high risk for cancer
Participate in PRIMARY and SECONDARY prevention efforts
Assess the nursing care needs of the patient with cancer
Assess the learning needs, desires, and capabilities of the
patient with cancer
Identify nursing problems of the patient and the family
Assess the social support networks available to the patient
Plan appropriate interventions with the patient and the family
Assist the patient to identify strengths and limitations
Assist the patient to design short-term and long-term goals for
care
Implement NCPs that interfaces with the medical regimen and
that is consistent with the established goals
Collaborate with the members of a multidisciplinary team to
foster continuity of care
Evaluate the goals and resultant outcomes of care with the
patient, family, and members of the multidisciplinary team
Reassess and redesign the direction of care as determined by
the evaluation















Multiple Physical Injuries
Multiple Trauma
Caused by a single catastrophic event that causes life-threatening
injuries to at least two distinct organs or organ systems.
Mortality in patients with multiple trauma is related to the
severity of the injuries and the number of systems and organs
involved.
Immediately after injury, the body is hypermetabolic,
hypercoagulable, and severely stressed.
Care of the patient with multiple injuries requires a team
approach, with one person responsible for coordinating the
treatment.
The nursing staff assumes responsibility for:
Assessing and monitoring the patient, ensuring airway and IV
access, administering prescribed medications, collecting laboratory
specimens, and documenting activities and the patients subsequent
responses.

Assessment and Diagnostic Findings
Evidence of trauma may be sparse or absent.
Patients with multiple trauma should be assumed to have a spinal
cord injury until it is proven otherwise.
The injury regarded as the least significant in appearance may be
the most lethal.
Management
Goals of treatment:
o to determine the extent of injuries
o to establish priorities of treatment
Any injury interfering with a vital physiologic function (eg,
airway, breathing, circulation) is an immediate threat to life and
has the highest priority for immediate treatment.
Essential life-saving procedures are performed simultaneously by
the emergency team.
As soon as the patient is resuscitated, clothes are removed or cut
off and a rapid physical assessment is performed.
Transfer from field management to the ED must be orderly and
controlled, with attention given to the verbal report from
emergency medical services.
Treatment in a trauma center is appropriate for patients
experiencing major trauma.

Priority Management in Patients with Multiple Injuries
1.Establish airway and ventilation.
2.Control hemorrhage.
3.Prevent and treat hypovolemic shock.
4.Assess for head and neck injuries.
5.Evaluate for other injuries- reassess head and neck, chest, assess abdomen,
back and extremities.
6.Splint fractures.
7.Perform a more thorough and ongoing examination and assessment.

Intra- abdominal Injuries

Intra-abdominal injuries are categorized as penetrating or blunt
trauma.
Penetrating abdominal injuries (ie, gunshot wounds, stab
wounds) are serious and usually require surgery
o results in a high incidence of injury to hollow organs,
particularly the small bowel.
o liver is the most frequently injured solid organ
o highvelocity missiles (bullets) produce extensive tissue
damage.
Blunt trauma to the abdomen may result from motor vehicle
crashes, falls, blows, or explosions.
commonly associated with extra-abdominal injuries to the chest, head, or
extremities
A challenge because injuries may be difficult to detect
incidence of delayed and trauma-related complications is greater than for
penetrating injuries

Assessment and Diagnostic Test
The abdomen is inspected as a part of the secondary survey for
obvious signs of injury, including penetrating injuries, bruises, and
abrasions.
Auscultation of bowel sounds to provide baseline data from
which changes can be noted.
o Absence of bowel sounds may be an early sign of
intraperitoneal involvement
Further abdominal assessment may reveal progressive abdominal
distention, involuntary guarding, tenderness, pain, muscular
rigidity, or rebound tenderness along with changes in bowel
sounds, all of which are signs of peritoneal irritation.
Hypotension and signs and symptoms of shock may also be
noted.
Chest and other body systems are assessed for injuries that
frequently accompany intra-abdominal injuries.

Laboratory Studies:
Urinalysis to detect hematuria (indicative of a urinary tract
injury)
Serial hemoglobin and hematocrit levels to evaluate trends
reflecting the presence or absence of bleeding
White blood cell (WBC) count to detect elevation (generally
associated with trauma)
Serum amylase analysis to detect increasing levels, which
suggest pancreatic injury or perforation of the gastrointestinal tract

Internal bleeding

Frequently accompanies abdominal injury, especially if the liver
or spleen has been traumatized.
Assessed continuously for signs and symptoms of external and
internal bleeding.
Front of the body, flanks, and back are inspected for bluish
discoloration, asymmetry, abrasion, and contusion.
Abdominal computed tomography (CT) scans permit detailed
evaluation of abdominal contents and retroperitoneal examination.
Abdominal ultrasounds can rapidly assess hemodynamically
unstable patients to detect intraperitoneal bleeding.
Pain in the left shoulder is common in a patient with bleeding
from a ruptured spleen, whereas pain in the right shoulder can
result from laceration of the liver.
During the resuscitation period, pain is managed using
administration of small dosages of opioids.


Intraperitoneal Injury
The abdomen is assessed for tenderness, rebound tenderness,
guarding, rigidity, spasm, increasing distention, and pain.
Referred pain is a significant finding because it suggests
intraperitoneal injury.
The patient is usually prepared for diagnostic procedures, such as
peritoneal lavage, abdominal ultrasonography, or abdominal CT
scanning.
Diagnostic peritoneal lavage (DPL):
o Involves the instillation of 1 L of warmed lactated
Ringers or normal saline solution into the abdominal
cavity.
o After a minimum of 400 mL has been returned, a fluid
specimen is sent to the laboratory for analysis.
o Positive laboratory findings include a red blood cell
count greater than 100,000/mm3; a WBC count greater
than 500/mm3; or the presence of bile, feces, or food.
Genitourinary Injury
Rectal and/or vaginal examination, is performed to determine
any injury to the pelvis, bladder, urethra, or intestinal wall.
To decompress the bladder and monitor urine output, an
indwelling catheter is inserted after a rectal examination has been
completed (not before).
In the male patient, a highriding prostate gland (abnormal
position) discovered during a rectal examination indicates a
potential urethral injury.
Urethral catheter insertion with a possible urethral injury is
contraindicated; a urology consultation and further evaluation of
the urethra are required.
Management
Resuscitation procedures (restoration of airway, breathing, and
circulation) are initiated as previously described.
A backboard may be used for transporting the patient to the x-ray
department, to the operating room, or to the intensive care unit.
Cervical spine immobilization is maintained until cervical x-rays
have been obtained and cervical spine injury has been ruled out.
Logrolling technique
Knowing the mechanism of injury (eg, penetrating force from a
gunshot or knife, blunt force from a blow) is essential to
determining the type of management needed.
If abdominal viscera protrude, the area is covered with sterile,
moist saline dressings to keep the viscera from drying.
Oral fluids are withheld in anticipation of surgery, and the
stomach contents are aspirated with a nasogastric tube to reduce
the risk of aspiration and to decompress the stomach in preparation
for diagnostic procedures.
Trauma predisposes the patient to infection by disruption of
mechanical barriers, exposure to exogenous bacteria from the
environment at the time of injury, aspiration of vomitus, and
diagnostic and therapeutic procedures (hospital acquired infection).
Tetanus prophylaxis and broadspectrum antibiotics are
administered as prescribed.
If there is continuing evidence of shock, blood loss, free air
under the diaphragm, evisceration, hematuria, severe head injury,
or suspected or known abdominal injury, the patient is rapidly
transported to surgery.

Crush Injuries
Crush injuries occur when a person is caught between opposing
forces (eg, run over by a moving vehicle, crushed between two
cars, crushed under a collapsed building).
Assessment and diagnostic findings
Hypovolemic shock resulting from extravasation of blood and
plasma into injured tissues after compression has been released.
Paralysis of a body part
Erythema and blistering of skin
Damaged body part (usually an extremity) appearing swollen,
tense, and hard
Renal dysfunction (prolonged hypotension causes kidney
damage and acute renal insufficiency; myoglobinuria secondary to
muscle damage can cause acute tubular necrosis and acute renal
failure)

Management
In conjunction with maintaining the airway, breathing, and
circulation, the patient is observed for acute renal insufficiency.
Injury to the back can cause kidney damage.
Severe muscular damage may cause rhabdomyolysis, which
signifies a release of myoglobin from ischemic skeletal muscle,
resulting in acute tubular necrosis.
In addition, major soft tissue injuries are splinted promptly to
control bleeding and pain.
The serum lactic acid level is monitored; a decrease to less than
2.5 mmol/L is an indication of successful resuscitation.
If an extremity is injured, it is elevated to relieve swelling and
pressure.
If compartment syndrome develops, the physician may perform a
fasciotomy (ie, surgical incision to the level of the fascia) to restore
neurovascular function
Medications for pain and anxiety are then administered as
prescribed, and the patient is quickly transported to the operating
suite for wound dbridement and fracture repair.
A hyperbaric oxygen chamber (if available) may be used to
hyperoxygenate crushed tissue, if indicated.

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