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 growth (division beyond the normal limits)
invasion (intrusion on and destruction of adjacent tissues)
metastasis (spread 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.
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 body’s immune system.
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 m alignant. 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
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)
Initiation
Initiators (carcinogens) escape normal enzymatic mechanisms and alter the genetic structure of the cellular DNA where permanent mutation occurs.
Promotion Repeated exposure to promoting agents (co carcinogens) causes the expression of abnormal or mutant genetic mutation even after long latency periods.
Progression 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- Hodgkin’s lymphoma and Hodgkin’s 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: Kaposi’s 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.
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 i nvolvement 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.
Most chemicals alters DNA structure in body sites distant from chemical exposure.
Most often affected: liver, lungs and kidneys Genetic and familial factors
Staging
Staging: determines the size of the tumor and the existence of the metastasis.
Genetics, shared environments, cultural or lifestyle factors, or chance alone.
5% to 10% of cancers of adulthood and childhood display a familial predisposition.
TNM system:
T: The Extent of the primary tumor
Cancers associated with family inheritance: retinoblastomas, malignant neurofibromatosis, and breast, ovarian, endometrial, colorectal, stomach, prostate, and lung cancers.
N: The absence or presence of regional lymph node metastasis.
Dietary factors
35% of all environmental cancers Dietary substances associated with an increased cancer risk:
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.
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 deepyellow vegetables)
Regional Lymph Nodes (N) NX: regional lymph nodes cannot be assessed. N0: no regional lymph node metastasis. N1, N2, N3: increasing involvement of regi onal lymph nodes.
Obesity: associated with endometrial c ancer, postmenopausal breast cancer, cancers of the colon, kidney, and gallbladder.
Distant Metastasis (M)
Hormonal agents Disturbances in hormonal balance either by the body’s own (endogenous) hormone production or by administration of exogenous hormones.
Endogenous: cancers of the breast, prostate and uterus
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.
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
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
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- 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
Good nutrition and diet
d. Staging : Multiple needle or incisional biopsies in tissues where metastasis is suspected or likely.
Other means of Detection Mammography Papanicolaou’s (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
Tomatoes, spinach, red wine, nuts, broccoli, oats, salmon, garlic, green tea, blueberries
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Limiting alcohol consumption
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Hepa B virus infant vaccination
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Control of STDs
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Changing risk behaviors
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Teaching skills for early detection programs
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Promoting participation in early detection programs
DIAGNOSTIC TESTS
Biopsy
Promoting risk factors awareness
Promoting healthy behaviors
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
Oncofetal antigens Normally present in fetal tissue;may indicate an anaplastic process in tumor cells Ex:
Hormones
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
Carcinoembryonic Antigen (CEA) Alpha-feto protein
ADH Calcitonin Catecholamines HCG PTH
Isoenzymes
increased when a tissue is experiencing rapid and excessive growth as a result of a tumor
Neurospecific enolase (NSE) Prostatic acid phosphatase (PAP)
Tissue-specific a antig ens
identifies the type of tissue affected by malignancy
prostatic-specific antigen (PSA)
Management o of C Cancer
Radiation therapy Used to kill a tumor, reduce tumor size, relieve obstruction or decrease pain Causes lethal injury to DNA
Classification:
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Internal radiation therapy (brachytherapy)
External radiation therapy (teletherapy)
Brachytherapy
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 le ast 15.
Sources
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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
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
Chemotherapy
Involves the administration of cytotoxic medications and chemicals to promote death of tumor cells.
Route of adminstration:
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 client’s 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
Maintain proper rest, diet, and fluid intake Hair loss may occur. Choose a wig, hat or scarf to cover and protect the head.
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IV Oral Intrathecal Topical Intra-arterial Intracavity Intravesical
Cl a a g e n t ts as si f i ic a t ti i o n o f Ch e m ot h he r a a pe p e u t ti ic a
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 inca aalkaloids are phase-specific, inhibiting cell division
N u r rs i n g i m pl a d pl i ic a t ti io n s f or t h he a d m i n i i is t r ra at t i i o n o f ch e m ot h he r a a p y p y
IV routes may be obtained by subclavian catheters, implanted ports, or peripherally inserted catheters.
Extravasation is the major com plication of IV chemotherapy. Extreme care must be used when administering vesicant agents
Eto po poside acts during all cell-cycle phases, interfering with DNA and cell division at metaphase
W ARNING: NEVER T TEST V VEIN P PATENCY W ITH CHEMOTHERAPEUTIC A AGENTS. 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
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
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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
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.
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
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Multiple Trauma
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—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 a nd 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.
results in a high incidence of injury to hollow organs, particularly the small bowel. liver is the most frequently injured solid organ 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 nursing staff assumes responsibility for: ◦Assessing and monitoring the patient, ensuring airway and IV access, administering prescribed medications, c ollecting laboratory specimens, and documenting activities and the patient’s subsequent responses.
—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. Absence of bowel sounds may be an early sign of o 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.
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: to determine the extent of injuries o to establish priorities of treatment o
—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 t o the verbal report from emergency medical services.
—Treatment in a trauma center is appropriate for patients experiencing major trauma.
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.
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
Intraperitoneal Injury
—The abdomen is assessed for tenderness, rebound tenderness, guarding, rigidity, spasm, increasing distention, and pain.
—Crush injuries occur when a person is caught between opposing forces (eg, run over by a moving vehicle, c rushed 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.
—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.
—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)
—Diagnostic peritoneal lavage (DPL): ◦Involves the instillation of 1 L of warmed lactated o Ringer’s or normal saline solution into the abdominal cavity. ◦After a minimum of 400 mL has been returned, a fluid o specimen is sent to the laboratory for analysis. ◦Positive laboratory findings include a red blood cell o 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
Management
—In conjunction with maintaining the airway, breathing, and circulation, the patient is observed for acute renal insufficiency. ◦Injury to the back can c ause 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 débridement and fracture repair.
—A hyperbaric oxygen chamber (if available) may be used to hyperoxygenate crushed tissue, if indicated.
