Theresa is a 37 year old; who was diagnosed with bladder cancer. She recently commenced her course of chemotherapy .She rushes to the Emergency Room at 11.45pm complaining of having a fever.

Introduction

The nurse plays an important role in the management of the cancer patient undergoing chemotherapy. This case would look at the case of bladder cancer and how the nurse can plan interventions based on a comprehensive nursing assessment.

Bladder Cancer

Bladder cancer is cancer that occurs in the bladder and is about four different types based on cell type origin. These are transitional cell carcinoma (also called urothelial carcinoma), squamous cell carcinoma, adenocarcinoma and small cell carcinoma (American Cancer Society, 2009).

Transitional cell carcinoma is the most common type occurring in 97% of bladder cancer cases. It can be divided into two subtypes papillary tumors which grow toward the center of the bladder and flat carcinomas which involve the layers of cells lining the bladder wall (American Cancer Society, 2009).

Squamous cell carcinoma makes up about 1 to 2 % of bladder cancer types and these are invasive. Adenocarcinoma makes up about 1% and these are also invasive. Small cell carcinoma makes up less than 1% of the bladder cancer cases (American Cancer Society, 2009).

Risk factors for developing the disease include smoking which is described as the greatest risk factor. Smokers are twice more likely to develop the disease than non smokers. It is believed that the carcinogens from cigarettes are absorbed into the blood stream and filtered by the kidneys which produce urine that is stored in the bladder. This in turn damages the bladder wall which increases the chance of developing bladder cancer (American Cancer Society, 2009).

Other risk factors include chemical exposure such as industrial chemicals in the dye and paint industries; race, twice as likely in whites than African Americans ;age ,over 70% of the cases are over 65 years old; gender, male to female ratio is 4 to 1;chronic bladder inflammation, persons with a history of urinary infections ,kidney and bladder stones have increased incidences of bladder cancer; having cancer in any other part of the urinary tract ;having a family history of cancer ; and previous treatment with chemotherapy or radiation can increase the risk of developing bladder cancer (American Cancer Society, 2009).

Signs and Symptoms

The most common manifestation of bladder cancer is haematuria that is blood in the urine. This can be gross where the blood changes the color of the urine or microscopic where it can only be found in urine test. Other urinary symptoms can occur such as dysuria and urgency (American Cancer Society, 2009).

Diagnostic studies include cystocopy where the bladder is viewed with a cystoscope and a biopsy may be done at the same time and bladder washings to collect samples for microscopic testing (American Cancer Society, 2009).

Bladder cancer is classified according to the TNM system by the American Joint Committee on Cancer (AJCC) .Staging is determined by the depth of the tumor inversion in the bladder wall (Langhorne, Fulton & Otto, 2007).The T describes the tumor spread that is how far it as spread to the bladder wall and tissues and is graded from 1 to 4.The N describes the lymph node involvement and is graded from 0 to 3.The M describes metastatic spread and is graded by 0 or 1.The cancer is then staged from 0 to IV with 0 being the earliest stage and IV being the most advanced stage(American Cancer Society, 2009).

Other clinical test that is done are Intravenous pyelogram ,Retrograde pyelography, chest X Ray, CT Scan, Magnetic resonance imaging, ultrasound, bone scan and positron emission tomography scan .These test can be helpful in determining the cancer spread or presence of metastases (American Cancer Society, 2009).

Treatment

Treatment can be singular or a combination of surgery, chemotherapy, intravesical therapy and radiation and is based on cancer staging and the patient’s wishes.

Surgery can be transurethral resection in which a cystoscope is entered the bladder and the tumor is removed; radical cystectomy which the bladder, lymph nodes and surrounding diseased tissue is removed in men the prostate and seminal vesicles are removed and in women the uterus, ovaries and part of the vagina; segmental cystectomy in which only part or the bladder is removed; and urinary diversions such as a ileal conduits to create a direction for urine flow (National Cancer Insitute, 2009).

Chemotherapy can be administered neoadjuvant, prior to surgery to shrink tumor size or adjuvant, after surgery to kill any remaining cancer cells .It can also be given along with radiation therapy. Commonly used combinations are M-VAC (methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin); GemCIS (gemcitabine and cisplatin) and; Carboplatin and a taxane (either paclitaxel/Taxol or docetaxel/Taxotere) .Other drugs used includes cyclosphosphamide, fluorouracil and mitomycin C (American Cancer Society, 2009).

Intravesical therapy is treatment that is inserted into the bladder. The most commonly used therapy is insertion of Bacillus Chalmette-Guerin (BCG) which is immunotherapy. Interferon and intravesical chemotherapy is also given (American Cancer Society, 2009).

Radiation can be delivered externally or interstitial. It can be given along with chemotherapy but the side effects are increased (American Cancer Society, 2009).

Side Effects of Treatment

The patient recently commenced her course of chemotherapy .Chemotherapy drugs cause myelosuppression which increases the risk of infection. The commonly used drugs in the treatment of bladder cancer cause some form of myelosuppression. Methotrexate and Cisplatin can cause bone marrow suppression along with stomatitis, Vinblastine and Doxorubicin and Gemcitabine has mild to moderate myelosuppressive effects (Yarbro, Frogge and Goodman, 2004).

Myelosuppression results in neutropenia, thrombocytopenia and anaemia. When undergoing chemotherapy there is an expected period where neutropenia is expected this is called the nadir, which usually occurs 7 to 10 days after treatment. At this point the white blood cell count is at its lowest which increases the risk of infection (Langhorne et al, 2007).

Corticosteroid use also suppresses immune function .This may be used in treatment protocols and increases the immune system ability to fight infection. Invasive procedures such as IV therapy, venipunctures, biopsies and catheters can also introduce infection (Yarbro et al, 2004).

Nursing Assessment

In the neutropenic patient the normal signs of infection such as redness swelling and pus formation are not usually seen. Therefore the nurse would need to carry out a comprehensive, focused assessment on the patient. A detailed history will have to be obtained on Theresa chemotherapy regime and any other drugs being used. Past medical history is also obtained to identify any co morbid disorders that would increase her susceptibility to infection (Langhorne et al, 2007).

Physical Assessment

In the neutropenic patient a focused assessment should be carried out to assess for signs of infection. This would include the respiratory, gastrointestinal, genitourinary systems and the skin and mucous membranes (Langhorne et al, 2007).

Firstly the patient’s temperature is assessed. In the neutropenic patient a fever is considered a temperature above 38 degrees in a twenty four hour period or a temperature above 38.5 degrees. The patient is then assessed for any outward sigh of infection such as breakdown of skin integrity, including the perianal areas. If the patient has an indwelling catheter the site is assessed for edema, drainage, erythema and tenderness which can indicate an urinary tract infection (Langhorne et al, 2007).

The mucous membranes are also assessed for redness, tenderness and ulceration which may indicate chemotherapy induced mucositis which can lead to infection. The chest is assessed for rate and depth of breathing, the presence of a cough and mucus production nothing the color, amount and thickness. The chest is ascultated for abnormal breath sounds such as crackles which can indicate a pneumonia infection (Weber &Kelley, 2007).

The gastrointestinal tract is assessed for abdominal tenderness, stiffness, guarding and noting any diarrhea which can indicate peritonitis and infection (Weber &Kelley, 2007).

Upon admission blood cultures should be done along with complete blood count and urinalysis. A chest X ray is also done is done assess for infection and if diarrhea is present a stool sample is tested for bacteria (Langhorne et al, 2007).

The patient is treated with antibiotic therapy and the nurse continues to monitor therapy until the patient is afebrile and neutrophil counts improve. A common complication of infection is septic shock and the nurse monitors for early signs of shock such as fever, rigors, tachypnea, tachycardia and alteration in mental status (Yarbro et al,2004).

Nursing Diagnoses

Possible nursing diagnoses for this patient:

Infection related to effect of chemotherapy (bone marrow suppression) as evidenced by fever.(RnCentral,2007)

Potential for alteration in nutrition: less than body requirements related to the presence of infection.(RnCentral,2007)

Nursing Care Plan

Infection related to effect of chemotherapy (bone marrow suppression) as evidenced by fever.

Goals

The patient will recover completely from infection as evidenced by becoming afebrile.

The patient will remain infection free as evidenced by the absence of fever.

Interventions

1. Asses temperature every four hours.

2. Inspect for erythema, foul smelling drainage, skin breakdown and mucous membranes daily.

3. Asses for cloudiness in urine daily.

4. Carry out neutropenic precautions such as strict hand washing techniques when attending to patient.

5. Avoid invasive procedures such as bladder catheters.

6. Encourage a high protein, high carbohydrate diet.

7. Explore risks for infection and provide patient education on minimizing these risks.

Conclusion

The knowledge of the disease process and the effects of treatment would have enabled the nurse to identify that Theresa had an infection and through a comprehensive focused assessment carry out interventions to prevent complications.