NURSING CARE

1. NURSING CARE OF PATIENT WITH RENAL AND
BLADDER CANCER
ALBERT BLESSON V

2. RENAL CANCER
About 85% of renal cancers—also called nephrocarcinoma, renal carcinoma, hypernephroma, and
Grawitz tumor—originate in the kidneys. Others are metastasis from various primary-site carcinomas.
Most renal tumors are large, firm, nodular, encapsulated, unilateral, and solitary. They may affect
either kidney; occasionally they are bilateral or multifocal.
Renal cancer can be separated histologically into clear-cell, granular-cell, and spindle-cell types.
Sometimes the prognosis is considered better for the clear-cell type than for the other types; in general,
however, the prognosis depends more on the cancer’s stage than on its type.
Although the cause of renal cancer is unknown, some studies implicate particular factors, including
heavy cigarette smoking. Patients who receive chronic hemodialysis may also be at increased risk

3. SIGNS AND SYMPTOMS
• Hematuria
• Dull, aching flank pain
• Weight loss (uncommon)
• Smooth, firm, nontender abdominal mass

6. TREATMENT
• Open radical nephrectomy, with or without regional lymph node dissection, or laparoscopic radical
nephrectomy
• Radiation (for cancer that has spread into the perinephric region or lymph nodes or when the primary tumor
or metastatic sites cannot be completely excised)
• Chemotherapy
• Biotherapy with lymphokine-activated killer cells plus recombinant interleukin-2 (can be expensive and
causes many adverse reactions)
• Interferon and hormone therapy, such as medroxyprogesterone (Depo-Provera) and testosterone
(Androderm) (for advanced disease)

7. NURSING CONSIDERATIONS
• Before surgery, assure the patient that his body will adequately adapt to the loss of a kidney.
• Administer prescribed analgesics as necessary. Provide comfort measures, such as positioning and
distractions, to help the patient cope with discomfort.
• After surgery, encourage diaphragmatic breathing and coughing. The patient should be instructed to use
an incentive spirometer every hour while awake.
• Assist the patient with leg exercises, and turn him every 2 hours to reduce the risk of venous stasis and
potential thromboembolism formation.
• Check dressings often for excessive bleeding. Original surgical dressings should not be removed, but the
nurse may reinforce the dressing with additional gauze pads as needed. The surgeon should be notified if
the reinforced dressing continues to have excessive bleeding. Watch for signs of internal bleeding, such
as restlessness, sweating, and increased pulse rate

8. • Position the patient on the operative side to allow the pressure of adjacent organs to fill the dead space at
the operative site, improving dependent drainage.
• If possible, assist the patient with walking within 24 hours of surgery.
• Provide adequate fluid intake, and monitor intake and output.
• Monitor laboratory test results for anemia, polycythemia, and abnormal blood chemistry values that may
point to bone or hepatic involvement or may result from radiation therapy or chemotherapy.
• Provide symptomatic treatment for adverse effects of chemotherapeutic drugs.
• Encourage the patient to express his anxieties and fears, and remain with him during periods of severe stress
and anxiety.

9. TEACHING ABOUT RENAL CANCER
• Tell the patient what to expect from surgery and other treatments.
• Before surgery, teach diaphragmatic breathing and effective coughing techniques such as how to splint the
incision.
• Explain the possible adverse effects of radiation and drug therapy. Advise the patient how to prevent and
minimize these problems.
• When preparing the patient for discharge, stress the importance of compliance with the prescribed
outpatient treatment. This includes an annual follow-up chest x-ray to rule out lung metastasis and
excretory urography every 6 to 12 months to check for contralateral tumors.
• If appropriate, refer the patient and his family to palliative care services, cancer support groups, and
hospice care

10. BLADDER CANCER
• Benign or malignant tumors may develop on the bladder wall surface or grow within the wall and quickly
invade underlying muscles. About 90% of bladder cancers are transitional cell carcinomas, arising from the
transitional epithelium of mucous membranes.
• Bladder tumors are most prevalent in people older than age 50, are more common in males than in females,
and occur more often in densely populated industrial areas.
• Certain environmental carcinogens, such as tobacco, 2-naphthylamine, and nitrates are known to
predispose a person to transitional cell tumors. Exposure to these carcinogens places certain industrial
workers at higher risk for developing such tumors, including rubber workers, weavers, aniline dye workers,
hairdressers, petroleum workers, spray painters, and leather finishers

12. SIGNS AND SYMPTOMS
• Gross, painless, intermittent hematuria (typically with clots)
• Bladder irritability
• Urinary frequency
• Nocturia
• Dribbling
• Flank pain (with obstructed ureter)

15. TREATMENT
Superficial Bladder Tumors
• Cystoscopic transurethral resection and fulguration
• Intravesical chemotherapy to prevent recurrence (for tumors in many sites)
• Intravesical administration of live, attenuated Bacillus Calmette–Guérin vaccine (for primary and relapsed
carcinoma in situ)
• Segmental bladder resection to remove a full-thickness section of the bladder (only for tumors which are not
near bladder neck or ureteral orifices)
• Bladder instillations of thiotepa after transurethral resection

16. Infiltrating Bladder Tumors
• Radical cystectomy and urinary diversion (usually an ileal conduit)
Advanced Bladder Cancer
• Cystectomy
• Radiation therapy
• Combination systemic chemotherapy with cisplatin (Platinol) (most effective)
• Doxorubicin (Doxil), cyclophosphamide (Cytoxan), and fluorouracil (may arrest the cancer)
• Urinary diversions

17. NURSING CONSIDERATIONS
• Listen to the patient’s fears and concerns. Stay with him during periods of severe stress and anxiety, and
provide psychological support.
• To relieve discomfort, provide ordered pain medications as necessary.
• Before surgery, offer information and support when the patient and enterostomal therapist or wound ostomy
continence nurse select a stoma site.
• After surgery, encourage the patient to look at the stoma. After ileal conduit surgery, watch for these
complications: wound infection, enteric fistulas, urine leaks, ureteral obstruction, bowel obstruction, and
pelvic abscesses.
• After radical cystectomy and construction of a urine reservoir, watch for these complications: incontinence,
difficult catheterization, urine reflux, obstruction, bacteriuria, and electrolyte imbalances.
• If the patient is receiving chemotherapy, watch for complications resulting from the particular drug regimen.
• If the patient is having radiation therapy, watch for these complications: radiation enteritis, colitis, and skin
reactions.

18. BLADDER CANCER TREATMENTS
Therapies that offer promise for patients with bladder cancer include photodynamic, gene, and
immunotoxin therapies.
Photodynamic Therapy
Photodynamic therapy requires IV injection of a photosensitizing agent called hematoporphyrin derivative
(HPD). Malignant tissue appears to have an affinity for HPD, so superficial bladder cancer cells readily absorb the
drug.
A cystoscope is then used to introduce laser energy into the bladder; exposing the HPD-impregnated tumor
cells to laser energy kills them.However, HPD sensitizes not only tumor tissue but also normal tissue, so the patient
who receives this therapy must avoid sunlight for about 30 days.
Precautions involve wearing protective clothing (including gloves and a face mask), drawing heavy curtains
at home during the day, scheduling outdoor travel for night, and conducting exercises inside or outdoors at night to
promote circulation, joint mobility, and muscle activity. After 30 days, the patient can gradually return to normal
daylight activities

19. Gene Therapy
Researchers have determined that mutations in tumor suppressor cells, such as p53, cause abnormal
bladder cancer cell growth. Although still in the investigation stages, the researchers are studying methods of
infecting bladder cancer cells with viruses that contain a normal p53 gene in the hope that the normal gene,
when placed in a bladder cancer cell, will cause normal cell growth.
Immunotoxin Therapy
Although still in investigational stages, researchers have hope that immunotoxin therapy will someday
effectively treat bladder cancer. Immunotoxins are laboratory-manufactured antibodies with powerful toxins
attached to them that can recognize cancer cells. After an antibody recognizes a cancer cell, it releases the toxin,
which enters the cancer cell and kills it.

20. TEACHING ABOUT BLADDER
• Tell the patient what to expect from diagnostic tests. For example, make sure he understands that he may be
anesthetized for cystoscopy. After the test results are known, explain the implications to the patient and his
family.
• Provide complete preoperative teaching. Discuss equipment and procedures that the patient can expect
postoperatively. Demonstrate essential coughing and deep-breathing exercises. Encourage the patient to ask
questions.

21. For the patient with a urinary stoma:
• Teach the patient how to care for his urinary stoma. Encourage appropriate caregivers to
attend the teaching session. Advise them beforehand that a negative reaction to the stoma
can impede the patient’s adjustment.
• If the patient is to wear a urine collection pouch, teach him how to prepare and apply it.
First, find out whether he will wear a reusable pouch or a disposable pouch. If he
chooses a reusable pouch, he needs at least two to wear alternately.
• Instruct the patient to remeasure the stoma after he goes home in case the size changes.
• Advise him to make sure the pouch has a push-button or twist-type valve at the bottom
to allow for drainage.
• Tell him to empty the pouch when it is one-third full, or every 2 to 3 hours.

22. • Offer the patient tips on effective skin seal. Explain that urine tends to destroy skin barriers
that contain mostly karaya (a natural skin barrier). Suggest that he select a barrier made of
urine-resistant synthetics with little or no karaya. Advise him to check the pouch frequently
to ensure that the skin seal remains intact. Tell the patient that the ileal conduit stoma should
reach its permanent size about 2 to 4 months after surgery.
• Explain that the surgeon constructs the ileal conduit from the intestine, which normally
produces mucus. For this reason, the patient will see mucus in the drained urine. Assure him
that this finding is normal.
• Teach the patient how to keep the skin around the stoma clean and free from irritation.
Instruct him to remove the pouch, wash the skin with water and mild soap, and rinse well
with clear water to remove soapy residue. Tell him to gently pat the skin dry. Never rub.

23. • Demonstrate how to place a gauze sponge soaked in vinegar water (1 part vinegar to 3 parts water) over the
stoma for a few minutes to prevent a buildup of uric acid crystals. When he cares for his skin, suggest that he
place a rolled-up dry sponge over the stoma to collect (or wick) draining urine.
• Next, instruct him to coat his skin with a silicone skin protectant and then cover with the collection pouch.
Advise him to apply hydrocolloid powder to irritated or eroded skin.
• Postoperatively, tell the patient with a urinary stoma to avoid heavy lifting and contact sports. Encourage him
to participate in his usual athletic and physical activities.
• Before discharge, arrange for follow-up home nursing care. Also refer the patient for services provided by the
enterostomal therapist or wound ostomy continence nurse.
• Provide contact information for the Ostomy education and support.

24. THANK YOU
REFERANCE
LippincottVISUAL NURSING
A Guide to Diseases, Skills, and
Treatments
Third Edition