continuingeducationfornursing - Perspective in Nursing

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					                                                                                                                                                              Vol. 5 No.1

                                                                            Recovery Strategies from the OR to Home

    In This Issue
                                                                        Brachytherapy for                                                             educatio
B                                                                       Patients with Breast                                                       ng
       reast cancer is the most commonly

       diagnosed cancer among women in

       the United States and worldwide (ex-

                                                                                                                                                                        or nursin
cluding skin cancer). In 2003, it is estimated
that 258,600 new cases of breast cancer will
be diagnosed among women in the United
States. Breast conservation, e.g., lumpectomy
and ionizing irradiation, has become a major                            By K. Brandt, RN, MBA                                                                        g

treatment for women with earlier stage breast
cancer. This approach however requires a pro-                               n the past 20 years, breast cancer        has prompted a phase III National Surgi-
longed and time-consuming six-week course                                   has reached epidemic proportions in       cal Adjuvant Breast and Bowel Project
of external beam radiotherapy. To address the                               North America. One in eight women         (NSABP) study that will compare brachy-
challenge of a lengthy course of radiotherapy, a                        will develop breast cancer in their life-     therapy to external beam radiotherapy,
technique called brachytherapy was developed                            time. Clinical research has attempted to      using various outcome measures. This
to accelerate treatment. Ms. Brandt has been                            keep pace with this too common disease.       trial, which is anticipated to involve sever-
involved with this procedure since its inception                               Breast conservation, e.g., lumpecto-   al thousand patients, will begin to accrue
and describes in her article the technique and                          my and ionizing irradiation, has become       in the next two years.
post-procedural care.                                                   a major treatment for women with stage               A 300-patient, prospective, phase II
Sixty-one percent of Americans are overweight                           I and II breast cancer. Seven prospective     trial, which will compare results to an his-
and 25% are considered obese, which is de-                              studies have shown the efficacy of breast     torical control, will open at the University
fined as having a body mass index greater                               conservation, relative to conventional        of Wisconsin Comprehensive Cancer Cen-
than 40. Excess body weight poses numerous                              mastectomy, with regard to long-term,         ter in the next few months.
nursing challenges. Equipment, attitudes, pain                          disease-free survival.                               At this juncture, brachytherapy is
management, and associated comorbidites                                        Clearly, the superior cosmetic out-    appropriate only for selected patients,
such as diabetes, hypertension, soft-tissue in-                         come of breast conservation affords pa-       who are not at risk for multifocal dis-
fection, impaired circulation, etc., are just a few                     tients the potential for reduced emotional    ease. The procedure is labor-intensive,
of these challenges. In her article Dr. Gallagher,                      and psychological trauma. Unfortunately,      skill dependent, and complex, involving a
an expert in obesity and ethics, discusses the                          this approach requires a prolonged, six-      multifaceted team that includes radiation
specialized preoperative, intraoperative, and                           week course of external beam radiothera-      oncology, radiation physics, nursing, sur-
postoperative care for the obese patient.                               py. It often creates geographical and time    gical oncology, and radiology.
                                                                        obstacles, which are stressful and disrup-           In this article, the special consider-
                  Advisory Board                                        tive to daily life.                           ations and issues confronting the nurs-
                                                                               To address the challenge of a          ing staff of a brachytherapy team are re-
             Cheryl Bressler, MSN, RN, CORLN                            lengthy course of radiotherapy, an in-        viewed.
 Oncology Nurse Specialist, Oncology Memorial Hospital, Houston, TX
                                                                        novative approach to sterilization of the
                      Lois Dixon, MSN, RN
        Adjunct Faculty, Trinity College of Nursing, Moline, IL         lumpectomy bed and residual cancer            What is brachytherapy?
    Pulmonary Staff Nurse, Genesis Medical Center, Davenport, IA        cells has evolved. This technique, called           Brachytherapy is a local, targeted
              Jan Foster, RN, PhD, MSN, CCRN                            brachytherapy, accelerates treatment,         method of treating cancer by placing ra-
       Asst. Professor for Adult Acute and Critical Care Nursing        which lasts only four to five days. During    dioactive seed(s) directly at the cancer
                    Houston Baptist University, TX
                                                                        treatment, a radioactive source, known        site and in surrounding tissue. It is stan-
          Mikel Gray, PhD, CUNP, CCCN, FAAN                             as iridium-192, is deposited into multiple    dard treatment for many cancers, e.g.,
     Nurse Practitioner/Specialist, Associate Professor of Nursing,
     Clinical Assistant Professor of Urology, University of Virginia,   catheters or a MammoSite® balloon cath-       cancers of the lung, prostate, oral cavity,
               Department of Urology, Charlottesville, VA               eter, which is surgically placed in the pa-   cervix, uterus, and vagina. The radiation
   Victoria-Base Smith, PhD(c), MSN, CRNA, CCRN                         tient’s resected lumpectomy cavity. This      dose is delivered at a high rate over a
            Clinical Assistant Professor, Nurse Anesthesia,
                      University of Cincinnati, OH
                                                                        method avoids radiation delivery to the       short period, using a machine known as a
                                                                        heart, lung, ribs, and lymph nodes.           high dose afterloader (HDA). In doing so,
             Mary Sieggreen, MSN, RN, CS, NP
  Nurse Practitioner, Vascular Surgery, Harper Hospital, Detroit, MI
                                                                               Brachytherapy, which is now being      less normal tissue is affected by radiation.
                                                                        performed at community and academic           The delivery of radiation is painless.
             Franklin A. Shaffer, EdD, DSc, RN                          centers, is increasingly popular among
      Vice-president, Education and Professional Development,
             Executive Director, Cross Country University               patients and physicians. Its proliferation                                     Continued on page 4

                                                                             Supported by an educational grant from Dale Medical Products Inc.
Postoperative Care of                                                                                 cultural, environmental, and psychosocial
                                                                                                      factors influence weight and its regula-

the Bariatric Patient                                                                                 Demographics
                                                                                                             Over 50% of Americans are over-
By Susan Gallagher, RN, PhD, CNS, CWOCN                                                               weight, and 10% to 15% are considered
                                                                                                      obese.9 Americans spend close to $33
                                                                                                      billion annually in attempts to control or
                                                                                                      lose weight, while $100 billion are spent

       he challenge of surgery in the           crimination.3 They certainly should not ex-           on obesity-related health problems. De-
       overweight patient lies in the spe-      pect such behavior when they are seeking              spite efforts at weight loss, Americans
       cial care and knowledge that are         health care. Clinicians need to ensure a              continue to gain weight. Some argue that
required for successful preoperative, in-       safe haven from obesity-related prejudice             obesity is reaching epidemic propor-
traoperative, and postoperative manage-         and discrimination.4                                  tions. In the early 1960s, only a quarter of
ment. Some authors believe that, from the              Prejudice and discrimination are               Americans were overweight. Today, over
onset, the obese patient is at a surgical       widespread against the obese person. This             half of all adults and 25% of children are
disadvantage, because differential diagno-      prejudice is observed at a very young age.            overweight.
sis is difficult, anesthesia is more trouble-   For example, 6-year-old children have de-                    Obesity has a physical, emotional,
some, and technical procedures are more         scribed silhouettes of obese children as              and economic impact on our patients.
complicated.1                                   lazy, stupid, and ugly. According to this             Obesity is a factor in five of the 10 lead-
       Obesity is associated with numer-        study, prejudice toward the obese child               ing causes of death.10 It is considered the
ous coexisting conditions, such as diabe-       occurs regardless of race or socioeconom-             second most common cause of prevent-
tes, hypertension, soft-tissue infection,       ic status.5 Children are not the only ones            able deaths in the USA.11 In addition to
some cancers, and impaired circulation,         to hold a prejudice against the overweight            the physiologic costs, some authors argue
which could interfere with the patient’s        person; healthcare clinicians often show              that obesity is associated with emotional
general health. Many surgeons are reluc-        this bias.6 It is even observed among obese           conditions, such as depression, altered
tant to perform surgery on obese patients       persons themselves.7                                  self-esteem, and social isolation.12 On the
because of the increase in surgery-related             Healthcare clinicians best serve               other hand, others argue that it is society’s
complications. Many hospitals report con-       their patients when they recognize obesity            response to the obese person that leads to
cerns because of inadequate equipment           as a chronic condition. Historically, obe-            these emotional conditions.13
and personnel to accommodate the needs          sity has been perceived as a problem of                      These factors, among others, influ-
of obese patients. It is true that obesity      self-discipline. However, recent discover-            ence heathcare delivery across practice
could be associated with more complica-         ies suggest that this is far from the truth. It       settings.
tions; however, recent advances in sur-         is true that weight gain occurs when food
gery, particularly in obese patients, have      intake exceeds energy output, i.e., activ-            Preoperative assessment and
helped to reduce some of these risks.1          ity, but the real mystery behind a balanced           preparation
       Clinical care of the morbidly obese      body weight depends on a number of oth-                      The preoperative period for the
patient requires an interdisciplinary ap-       er factors. Genetics, gender, physiology,             morbidly obese patient is a time of physi-
proach. The entire healthcare team must         biochemistry, and neuroscience as well as             cal and emotional preparation. The nurse,
be diligent in caring for the morbidly                                                                as a member of the interdisciplinary
obese, surgical patient. Being aware of                                                               healthcare team, usually spends the most
possible complications and correspond-                                                                time with the patient and is an important
ing interventions is necessary to prevent                                                             player in the patient’s preoperative assess-
potential hazards to both patient and                                                                 ment and preparation. Like all patients,
caregivers.                                                                                           the very overweight patient needs com-
       This article examines the meaning                                                              prehensive preoperative instruction, in-
of obesity, demographics, and factors that                                                            cluding breathing and coughing exercises
place this patient at particular risk during                                                          and appropriate leg exercises.14 Breath-
surgery. Preoperative, intraoperative, and                                                            ing and coughing exercises are especially
postoperative care are discussed. Home-                                                               important to review, as these exercises
care needs are reviewed, as the patient                                                               are useful in preventing atelectasis and
moves from the hospital to home-care                                                                  congestion that can result from shallow
setting.                                                                                              respirations as a result of incisional pain,
                                                                                                      depressive analgesia, inactivity, and obesi-
Understanding obesity                                                                                 ty itself.15 Demonstrations of deep breath-
      The word “obesity” itself holds a                                                               ing and coughing exercises should include
negative connotation. Despite this fact,                                                              splinting the surgical area and use of the
obesity refers to a special condition that                                                            incentive spirometer. The application of
is recognized by the National Institutes                                                              abdominal binders can also increase deep
of Health (NIH). Obesity, according to                                                                breathing. There are velcro-type binder
the NIH, is a diagnostic category that                                                                (Dale Medical) available in extra long
represents a complex and multifactorial                                                               sizes of up to 75” in length and up to 15”
disease.2 Many obese Americans neither                                                                in width.
choose to be overweight nor choose to                                                                        Postoperatively, leg exercises are
experience widespread prejudice and dis-        Fig.1 Dale Abdominal Binder (Dale Medical Products)   important to maintain proper circula-

tion. These exercises prevent the stasis         postoperative assess-
of blood, which could lead to deep-vein          ment. Standard-sized
thrombosis. Teaching includes the demon-         equipment, such as
stration of calf-pumping.15                      blood pressure cuffs,
      Successful preoperative preparation        may be insufficient
includes the patient’s family or other sup-      to accomplish simple
port personnel. An atmosphere of under-          assessment.
standing, cooperation, and trust ensures a             The patient
smoother postoperative course.                   may be discharged
                                                 from the recovery
Intraoperative care                              room to either the
       Although intraoperative care is a         intensive care unit
highly specialized process that is far too       or a general medical-
detailed to cover here, it is important to       surgery unit, depend-
recognize some of the more common obe-           ing on medical as-
sity-specific intraoperative activities and      sessment or hospital
their rationale. It is also important to rec-    policy.                                                 Fig. 2 Foley Catheter Holder (Dale Medical Products)
ognize some safety-oriented activities in
the patient’s intraoperative experience.         Postoperative care
       Most surgical procedures require                 Although the patient is usually        ing properly sized equipment. The patient
two nurses, e.g., a scrub nurse and circu-       awake and alert shortly after surgery,        needs to be repositioned at least every
lating nurse. In caring for obese patients,      extra personnel may be required for the       two hours, as do tubes and catheters.
some hospitals add a third nurse, especial-      transfer to the appropriate postoperative     Commercially available securing devices
ly at the beginning of surgery. The third        unit. Routine monitoring of vital signs and   that can be opened and closed several
nurse may be necessary for positioning. A        physiologic progress that requires docu-      times, and remain in place, will reduce the
task as simple as placing a urinary cath-        mentation includes blood pressure, pulse,     likelihood of skin necrosis. Tubes should
eter can be technically difficult and, as it     quality and number of respirations per        be placed so that the patient does not rest
is an unnecessary embarrassment to the           minute, temperature, coughing, and deep       on them. Tube/catheter holders may be
patient, a nurse usually places the cath-        breathing.                                    helpful in this step.
eter once the patient has been properly                 Patients seem to breathe more eas-            Wound healing can be problematic
sedated or anesthetized.14                       ily when the bed is at 30° (semi-Fowler       in some obese patients. Wounds are prone
       Urinary catheters are used for sever-     position), as this angle reduces the weight   to dehiscence. In addition, blood sup-
al reasons. Assisting a female patient onto      of abdominal adipose tissue that presses      ply to fatty tissues may be insufficient to
a bed pan postoperatively can be difficult       against the diaphragm.16 The patient may      provide an adequate amount of oxygen
for caregivers and uncomfortable for the         need encouragement to perform leg exer-       and nutrients, which can interfere with
patient. In addition, patients receiving an      cises and breathing and coughing exercis-     wound healing. A delay in wound healing
epidural catheter for pain control may re-       es. Providing the patient with an abdomi-     may occur if the patient has a diet that
quire a urinary catheter because of associ-      nal binder (Dale Medical) can encourage       lacks essential vitamins and nutrients.
ated urinary retention. Securing the foley       deep breathing and coughing as well as        Wound healing can also be delayed if the
catheter high on the patient’s thigh with        post-operative mobility (Figure 1).6 Early    wound is within a skin fold, where excess
a foley catheter holder will significantly       activity is encouraged, as it decreases the   moisture and bacteria can accumulate.
reduce the risk of tube dislodgement and         chances of immobility-related complica-       Furthermore, excess body fat increases
thereby reduce the risk of UTI infection         tions. In the acute setting, patients can     tension at wound edges.4 To reduce the
(Figure 2).                                      experience complications related to im-       occurrence of abdominal wound separa-
       Another intervention of concern is        mobility and physical dependence. Some        tion, some clinicians use a surgical binder
the surgical scrub (preparation of the skin      patients will fail to progress postopera-     to support the area. The binder will need
surface prior to surgery). The nurse must        tively either because of surgical complica-   to be large enough to comfortably fit the
ensure that all areas are clean and painted      tions or a critical condition.                patient. For example, the Dale Abdominal
vigorously. This can be especially difficult            Clinicians need to be familiar with    Binder can accommodate waist sizes of
in the presence of deep-skin folds. A third      common obesity-related complications          up to 94 inches.
nurse can help the circulating nurse to          and modify care plans and clinical inter-            Morbidly obese patients tend to
achieve this task.                               ventions to address or prevent them. For      have pulmonary problems, particularly
       Once the surgery is over, warm            example, atypical pressure ulcers and         obesity hypoventilation syndrome (OHS)
sheets and a clean gown are provided             respiratory problems are two immobility-      and sleep apnea. OHA is an acute respira-
for the patient. It is best to plan ahead by     related conditions that could prolong the     tory condition in which the weight of fatty
having larger gowns available in the op-         postoperative course.17                       tissue on the rib cage and chest prevents
erating room, eliminating any last-minute               Obese patients often present with      the chest wall from expanding fully. Be-
embarrassment. Extra personnel may be            atypical pressure ulcers. Pressure within     cause patients are unable to breathe in
required to place the patient onto a gur-        skin folds can be sufficient to cause skin    and out fully, ventilatory insufficiency can
ney or oversized bed for transfer to the         breakdown. Tubes and catheters burrow         occur.17
hospital room, once recovery is complete.        into skin folds, which can further erode             Sleep apnea occurs when the pa-
Recovery staff need to be notified that          the skin surface. Pressure from side rails    tient sleeps in the supine position. The
they will be receiving an obese patient to       and arm rests not designed to accommo-        weight of excess fatty tissue in the neck
allow for any necessary preplanning. This        date an obese person can cause pressure       causes the throat to narrow, severely
step helps to prevent last-minute scram-         ulcers on the patient’s hips. This atypical   restricting or even cutting off breathing
bling to find the tools that are essential for   skin breakdown can be minimized by us-                                                Continued on page 6

Brachytherapy for Patients with Breast
Cancer — continued from page 1

      Breast brachytherapy is traditionally
delivered via interstitial flexible catheters.
They are incorporated into the lumpec-
tomy cavity with a 2-cm margin circum-
ferentially. Two techniques are used: in
prone position with mammographic guid-
ance with the use of a template; or, in
supine position with ultrasound guidance
                                                  Figure 1: The figure represents a patient in prone position on a   Figure 2: The figure illustrates a breast protruding through a
with or without the use of a template. The        stereotactic core biopsy table.                                    stereotactic core biopsy table with a template secured. The inner
most common technique, which will be                                                                                 shaded area overlapping the template relates to the resection cavity.
described here, is prone stereotactic cath-           • breast discomfort                                            The outer shaded area represents a planned 2-cm margin around
                                                      • infection                                                    the resection cavity.
eter placement.
                                                      • fat necrosis: an inflammatory                                local anesthetic or medications prescribed
Patient selection                                       reaction incited by local destruction                        for the procedure.
       Selection criteria for patients to re-           of fat cells
ceive brachytherapy must be well defined.             • fibrosis or scarring                                         Medications
Generally, the treating team avoids pa-               • pock marks: tiny white or red spots                                The patient receives prescriptions,
tients who have residual disease, not en-               where the catheters penetrate the                            with written and verbal instructions, for
compassed by the extent of the treatment                skin under the buttons.                                      the following medications:
field. This concern extends to patients                                                                                 • EMLA cream, which is applied 1 to
who have or are likely to have multicen-                 If the procedure is appropriate and                               2 hours before the procedure to the
tric disease. Typical selection criteria are      the patient agrees to it, the physician ob-                              entire breast. The patient covers the
presented in Table 1. If these criteria were      tains informed consent.                                                  area with Tegaderm or Saran wrap.
widely used, over 70,000 patients per year                                                                              • Cox-2 inhibitor, such as Vioxx®
in the United States would be candidates          The nurse’s role                                                         or Celebrex™ (newer cox-2
for brachytherapy.                                       Patient education is an important                                 inhibitors are more specific to the
                                                  element of nursing care. Its significance                                inflammatory response)
Patient education and preparation                 cannot be doubted in breast brachyther-                               • diazepam (Valium®)
       The physician holds a formal con-          apy. Patients should receive detailed in-                             • narcotic pain medication, such as
sultation with the prospective patient. At        structions, both written and verbal, about                               Vicodin™ or Percocet®
this time, the operative report, pathology        catheter placement, treatment course,
reports (biopsy and lumpectomy), mam-             skin care, and follow-up recommenda-                                    Each medication is taken about
mograms, and other breast images that             tions.                                                             an hour before catheter placement at a
might have been obtained are reviewed to                 Nurses should review the patient’s                          breast-imaging facility.
determine the appropriateness of brachy-          medical history and medications, includ-
therapy. Treatment options are presented,         ing herbals. Patients are recommended to                           Typical catheter placement
giving both physician and patient the op-         discontinue blood-thinning medications,                                    A unilateral mammogram is per-
portunity to review alternatives, potential       such as aspirin, Coumadin, and nonste-                             formed first to assess the lumpectomy
side effects, and complications – common          roidal anti-inflammatory drugs (NSAIDs)                            cavity and to locate any residual microcal-
and rare. This discussion reviews the pos-        such as ibuprofen (Advil®), about one                              cifications if applicable. Secondly, under
sibility of:                                      week before catheter placement. Concom-                            ultrasound guidance, the lumpectomy cav-
   • pneumothorax                                 itant use of some herbal preparations may                          ity is imaged and up to 5 cc of contrast
   • hematoma                                     promote bleeding and interact with the                             is instilled into the lumpectomy cavity.
                                                                                                                     A second mammogram is then obtained.
                                                                                                                     This will highlight and define the cavity.
    Table I: Brachytherapy Selection Criteria for Unifocal Breast Cancer
                                                                                                                             The patient is then escorted to the
                                                                                                                     stereotactic procedure room. The patient
    Diagnosis of:          i)     Invasive ductal, medullary, papillary, colloid (mucinous)                          is assisted in a prone position on a stereo-
                                  and tubular histologies                                                            tactic core biopsy table. The placement of
                                                                                                                     the catheters is done in a sterile environ-
                           ii)    Ductal carcinoma in situ (possibly excluding large high                            ment. A template is secured to the breast
                                  grade lesions)                                                                     (Figure 1). The patient maintains this po-
                                                                                                                     sition for about two hours.
                                                                                                                             Once the template is placed, another
    Tumor stage:                  is, T1, T2 if lesion is less than or equal to 3 cm                                 mammogram is performed on the stereo-
                                                                                                                     tactic table. Dye in the lumpectomy cav-
    Nodal stage:                  N0 (or negative sentinel node with or without further                              ity defines its location, relative to the tem-
                                  dissection is acceptable) or N1 (1-3 nodes positive and                            plate. The coordinates of pre-drilled holes
                                  no extracapsular extension                                                         in the template are chosen for accurate
                                                                                                                     needle insertion. These holes encompass
                                  Clearly a visible target as defined by ultrasound,                                 the surgical cavity plus 2 cm in all dimen-
                                  mammography, or surgical clips                                                     sions (Figure 2).

       A diluted mixture of 2% lidocaine                                 High dose afterloader (HDA)
with epinephrine and sodium bicarbon-
ate is injected at each selected, respective
coordinate. The brachytherapy needle is
placed into the breast through the tem-
plate (Figure 3).
       After all needles are inserted, a
plastic brachytherapy catheter is slid
through each needle. The needles are then
removed and discarded. A hemispherical
catheter button secures the catheters
(Figure 4).
       An antibiotic ointment (bacitracin)
is applied around each catheter button.
Sterile ABD dressings are applied, then                                Figure 5: This figure illustrates patient treatment. Cables or transfer
secured with a support bra.                                            tubes from the high-dose afterloader (HDA) attached to each
       The number of implanted catheters                               catheter. By remote control the source (Iridium-192) travels through
per patient varies. This typically ranges                              each one at a time.
from 19 to 30. The patient returns the fol-                            The 4 - or 8-day treatment regimen deliv-
lowing day for a three-dimensional (3-D),                              ers 4 Gy per treatment for a total dose of
treatment-planning CT scan. Three-di-                                  32 Gy. The 5 day treatment regimen deliv-
mensional, CT-based planning assures                                   ers 3.4 Gy per treatment for a total dose
adequate radiation-dose coverage of the                                of 34 Gy. Usually, two treatments are ad-
target volume. The radiation dose can be                               ministered daily with an interval of least
maximized in the area that needs treat-                                6 hours – the minimum amount of time
ment but restricted from other areas.                                  for normal cell repair. After the treatment                               Post-surgical Bra (Dale Medical Products)
       The nursing staff performs all skin                             neither the patient nor the catheters are
care. Patients are asked not to remove                                 radioactive. Each treatment lasts about an                                dressings and replaces the support bra.
or change the dressings, while the cath-                               hour, including transfer-cable hook-ups,                                  A support bra with a front Velcro closure
eters are in place. It is imperative to keep                           treatment, and skin care.                                                 will provide the clinician with easy access
the dressings dry; patients are asked to                                     Each catheter is connected to the                                   to the dressing and catheters. If a patient
bathe rather than shower. They are asked                               high-dose afterloader (HDA) by a flexible                                 develops a sensitivity to bacitracin, other
to monitor their temperature three times                               cable. A member of the physics staff typi-                                topical antibiotics, such as mupirocin
daily and report if it nears 100° F. The                               cally performs the cable hook-up. During                                  (Bactroban®), may be prescribed. Pruri-
application of a post-surgical bra (Dale                               treatment, the radioactive source enters                                  tus can be managed with topical hydro-
Medical Products), for example, will offer                             each catheter one at a time and stays at                                  cortisone, Benadryl® (topical or oral), or
the patient soft support, hold dressings in                            various points within the catheter, based                                 ice packs. Faint erythema is often notice-
place, and allow the catheters to remain                               on the treatment plan. The patient is                                     able under the buttons, as the treatment
safely “tucked away”.                                                  alone while the treatment is given how-                                   course nears completion. It is most likely
       Antibiotics are not prescribed pro-                             ever the radiotherapy staff are monitoring                                a result of friction.
phylactically. If an infection is detected                             the patient outside the room. The actual                                         Patients usually remain active dur-
or suspected, cephalexin 500 mg three                                  treatment time varies depending on the                                    ing the treatment course; however, arm
times daily for 7 to 10 days is typically                              number of catheters and source strength.                                  movement may be slighted limited. Pa-
prescribed. Sensitivity to pain varies                                 On average the treatment lasts about 12 to                                tients are advised to avoid lifting greater
among patients. Discomfort is often pres-                              15 minutes. The patient feels no discom-                                  than 10 pounds from the start to six
ent within the first 24 hours; however, it is                          fort (Figure 5)                                                           weeks after radiation therapy. Fatigue is
well managed with prescription Vioxx and                                     Skin care and assessment after                                      uncommon. Most patients who live close
narcotic pain medications, as needed.                                  treatments includes visual inspection for                                 by the radiotherapy center continue to
       Radiation treatment is delivered on                             signs of infection. The nurse cleanses                                    work during treatment.
an outpatient basis in the radiotherapy de-                            each catheter button with a diluted per-                                         After the final treatment, the nurse
partment. The patient is scheduled to have                             oxide solution, then applies the antibiotic                               removes the catheters with sterile scis-
between 8 and 10 fractions or treatments.                              ointment. The nurse secures the sterile                                   sors. There is usually minimal to no pain
                                                                                                                                                 and little or no bleeding. Gentle compres-
                                                                                                                                                 sion of the breast, particularly over the
                                                                                                                                                 lumpectomy cavity, will express any se-
                                                                                                                                                 rous fluid that may be present.
                                                                                                                                                        The nurse gives written and verbal
                                                                                                                                                 skin-care instructions to the patient. The
                                                                                                                                                 patient must cleanse the area with diluted
                                                                                                                                                 peroxide solution and apply antibiotic
                                                                                                                                                 ointment and a small dressing twice daily
                                                                                                                                                 until the open holes (pock marks) heal.
                                                                                                                                                 The pock marks usually close in about 2
Figure 3: This figure illustrates the same patient setup as figure 2   Figure 4: This figure shows each needle replaced with a plastic           to 5 days, at which time the patient may
after the insertion of brachytherapy needles. Prior to insertion of    brachytherapy catheter.                                                   shower and use a moisturizing cream.
these needles each pre-drilled coordinate is anesthetized.
                                                                                                                                                 Pock marks look red at first but fade over

time. Twice daily temperature monitoring       value of brachytherapy for breast conser-
continues for 2 weeks.                         vation.                                                    Postoperative Care of the
       Regular follow-up examinations                                                                     Bariatric Patient — continued from page 2
are important after breast brachytherapy.      Selected references for further reading regarding breast
An initial follow-up visit, 4 to 6 weeks af-   conservation                                               for seconds or even minutes at a time.
ter treatment, is recommended to assess                                                                   Breathing can be made easier by keeping
skin healing. Follow-up appointments are       Fisher B, Redmond C, Poisson R, et al. Eight-year          the patient in the semi-Fowlers position,
                                               results of a randomized clinical trial comparing
scheduled every 3 to 4 months for about        total mastectomy and lumpectomy with or without            which takes some of the pressure off the
2 years, then every 6 months for 3 years.      irradiation in the treatment of breast cancer. N Engl J    diaphragm for reasons described earlier.
                                               Med 1989;320:822-828.
Six months after breast brachytherapy,                                                                    Mobilizing the patient as early as possible
                                               Fisher B, Anderson S. Conservative surgery for the
a mammogram is obtained. A skilled ra-         management of invasive and non-invasive carcinoma          also helps. Sleep apnea is often managed
diologist or radiation oncologist must         of the breast: NSABP trials World J Surg 18:63-69,         at night with the use of a continuous posi-
interpret this mammography after brachy-       1994                                                       tive airway pressure (CPAP) machine.18
therapy.                                       Holland R, Connolly JL, Gelman R, et al. The                      If long-term ventilator support be-
                                               presence of an extensive intraductal component
                                               (EIC) following a limited excision predicts for            comes necessary, performing a tracheos-
Conclusion                                     prominent residual disease in the remainder of the         tomy can be especially challenging if the
                                               breast. J Clin Oncol 1990;8:113-118.
      Overall, breast brachytherapy is                                                                    trachea is buried deep within fatty tissue.
                                               Fisher ER, Sass R, Fisher B, et al. Pathologic findings
well tolerated by patients. The acceler-       from the National Surgical adjuvant Breast Project         A large wound may be needed to locate
ated treatment course is an attractive,        (Protocol 6): Relation of local breast recurrence to       the trachea. This larger wound can lead
convenient therapeutic option for select-      multicentricity. Cancer 1986;57:1717-1724.                 to complications, such as bleeding, infec-
ed patients, as it lessens the exposure of     Fowble B, Solin LJ, Schultz DJ, et al. Breast              tion, or damage of the surrounding tissue.
                                               recurrence following conservative surgery and
normal tissues to radiation.                   radiation: patterns of failure, prognosis, and             Postoperative tracheostomy care, there-
      Breast brachytherapy is nurse-inten-     pathologic findings from mastectomy specimens with         fore, includes steps to protect the peris-
                                               impliations for treatment. Int J Rad Oncol Biol Phys
sive. Nurses guide patients through the        1990;19:833-842.                                           tomal skin and manage tracheostomy and
treatment, manage skin care, assess and        Vicini F, White J, Gustafson G, et al. The use of          wound drainage. To compound this dilem-
manage side effects, and provide encour-       iodine-125 seeds as a substitute for iridium-192 seeds     ma, standard-sized tracheostomy tubes
agement and support.                           in temporary interstitial breast implants. Int J Rad       may be inadequate for use with patients
                                               Oncol Biol Phys 1993;27:561-566.
      Brachytherapy offers a new inno-         Kuske RR, Bolton JS, Wilenzick RM, McKinnon
                                                                                                          with larger necks. In addition, narrow
vative approach to breast conservation         WMP, Pullen B, Scroggins TG, Zarkris EL, Fineberg          cloth tracheotomy ties can burrow deep
for women with certain breast cancers.         BB: Brachytherapy As The Sole Method of breast             within the folds of neck, further damaging
                                               Irradiation in TIS, T1, T2, NO-1 Breast Cancer. Int J
Despite the enthusiasm for this new tech-      Radiat Oncol Biol Phys 30 (S1):245,1994.                   the skin. The thicker or wider ties, such
nology, many critical questions still need     Fentiman IS, Poole C, Tong D, Winter PJ, Mayles            as Dale Tracheostomy Tube Holder, have
to be addressed in confirmatory phase II       HMO, Turner P, Chavdary MA, Rubens RD. Iridium             been used by clinicians to prevent this
(compared to an historical control) and        implant treatment without external radiotherapy for        sort of damage. The Dale holder is also
                                               operable breast cancer: a pilot study. Eur J Cancer
prospective, randomized studies.               27(4):447-450, 1991.                                       avaialble with an extension to total 25” in
                                               Ribeiro GG, Dunn G, Swindell R, Harris M, Banerjee         length.
       Outstanding questions include:          SS. Conservation of the breast using two different
                                               radiotherapy techniques; interim report of a clinical
    1. Will this form of brachytherapy         trial. Clin Oncol 2:27-34,1990.                            Home-care needs
       produce non-inferior, local-regional    R Patel, A Forouzannia, R Das, H Odau, R Kuske.                   In the home-care setting, obese pa-
       control of ductal carcinoma in          Definitive Breast Brachytherapy: The University of         tients often pose serious management
       situ (DCIS) and Stage I and II          Wisconsin Experience. Proceedings of the American          problems related to obesity itself as well
                                               Brachytherapy Society Annual meeting 2002; 8:30.
       breast cancer (less than 3 cm           Vicini FA, Baglan FL, Kestin LL, et al. Accelerated
                                                                                                          as associated comorbidities. Planning and
       primary) at 5 years, compared to        treatment of breast cancer. J Oncol 2001;19:1993-          providing care to obese patients can be
       a conventional course of external       2001.                                                      challenging. Not all obese patients will
       beam brachytherapy?                     Vicini FA, Kini VR, Chen P, et al. Irradiation of the      require special accommodation at home;
                                               tumor bed alone after lumpectomy in selected
    2. Is brachytherapy less toxic than        patients with early-stage breast cancer treated with       however, patients who have limited mo-
       external beam radiotherapy?             breast conserving therapy. J Surg Oncol 1999;70:           bility are likely to have special needs and
    3. How does the cosmesis of                33-40.                                                     therefore require special accommodation.
       brachytherapy compare with                                                                                In a recent study, nurses reported
       established criteria?                                           Kimberly A Brandt, RN              five specific challenges in the home-care
    4. What is the level of patient                                    MBA is the Charge Nurse            setting: equipment, reimbursement, ac-
       satisfaction with breast                                        in the Department of Ra-           cess to resources, client motivation, and
       brachytherapy?                                                  diation Oncology at the            family/significant other support.19 The
                                                                       University of Wisconsin
    5. What is the correct way to interpret                            (UW), Comprehensive                challenges cited most often involved spe-
       mammography after interstitial                                  C a n c e r C e n t e r. U W       cialized-equipment issues.
       brachytherapy?                                                  Cancer Center is one of                   Many healthcare providers complain
    6. What are the rates of disease-                                  the few in the nation to           of the inability to turn, transfer, or lift
       free survival, mastectomy-free                                  perform brachytherapy              heavier patients, which can lead to immo-
       survival, and overall survival after                            for breast cancer, and             bility-related concerns.20 Family members
                                                                       Ms. Bra ndt ha s been
       brachytherapy?                                                  involved with this pro-            and caregivers may be at risk for injury
                                                cedure since its inception. Graduating with her           when caring for the obese patient in the
       Only with a defined approach to pa-      Bachelor in Nursing at the Edgewood College,              home, as fewer personnel are available
tient care that incorporates the resources      Ms. Brandt went on to earn her Masters in Busi-           to help. Oversized wheelchairs and walk-
of both community and academic centers          ness Administration at the same institution.              ers with greater weight limitations than
can medical researchers determine the                                                                     standard equipment are readily available
                                                                                                          for purchase or rent in major medical

supply centers. Both items promote in-                          Obese Patient. FD-Communications: North York,
                                                                Canada, 1989.                                        Cross Country University is an
dependence and dignity. Equipment that
                                                          16.   Lasater-Erhard M. The effect of patient position     accredited provider of continuing
nurses find most helpful in the home are                        of arterial oxygen saturation. Crit Care Nurs        education in nursing by the American
the wheelchair, walker, commode, elec-                          1995;15:31-36.                                       Nurses Credentialing Center's Com-
tronically-controlled bed frame, support                  17.   Gallagher SM. Caring for the overweight patient      mission on Accreditation.
surface, and lift.                                              in the acute setting: addressing caregiver injury.
                                                                Nursing98 1998;98(3):32HN1-32HN5.
       When planning for oversized equip-                 18.   Shinohara E, Kihara S, Yamashita S, Yamane M,
                                                                                                                     After reading this article, the learner should be able to:
ment in the home, consider weight lim-                          Nishida M, Arai T. Visceral fat accumulation as      1.     Identify health conditions, which are associated
its, width, and electrical needs. In other                      an important risk factor for obstructive sleep              with obesity, that could interfere with the patient’s
                                                                apnea syndrome in obese subjects. J Intern Med              general level of health.
words, does the patient have a sliding                          1997;241:11-18.
glass door or extra wide doorway through                  19.   Gallagher SM. Needs of the homebound morbidly        2.     Describe factors that influence weight and its
which equipment can be delivered? Or,                           obese patient. Ostomy/Wound Management                      regulation.
will the equipment collapse, so that it can                     1998;44(4):32-42.                                    3.     Develop a plan of care for the larger patient
be delivered through a standard-sized                     20.   Gallagher SM. Reducing caregiver injury                     requiring surgery.
                                                                when caring for the obese patient. Journal of
doorway?                                                                                                             4.     Describe an innovative radiation treatment for
                                                                                                                            early-stage breast cancer.
Conclusion                                                                            Susan Gallagher,               5.     Discuss the role of nursing in the care of a patient
      With obesity on the rise, clinicians                                            RN, MSN, MA, CNS,                     receiving breast brachytherapy.
best serve patient care by employing strat-                                           CWOCN, was an ad-              6.     Recognize the questions that further research
                                                                                      junct faculty member                  must answer regarding the use of breast
egies to reduce or prevent costly compli-                                             of the University of                  brachytherapy.
cations. Although equipment is a helpful                                              Southern California
                                                                                                                     To receive continuing education credit, simply do
adjunct to care, it is never a substitute.                                            ( L A) D e p a r t me nt
                                                                                                                     the following:
Numerous resources are available to cli-                                              of Nursing. She is
nicians across practice settings, and use                                             a consulting editor            1. Read the educational offering (both articles).
of resources in a timely and appropriate                                              of t he Jou r n a l of         2. Complete the post-test for the educational offering.
                                                                                      Wou nd, Ostomy &                  Mark an X next to the correct answer. (You may
manner are thought to improve measur-                                                 Incontinence Nurs-                make copies of the answer form.)
able therapeutic, cost, and satisfaction                                              ing and contributing
outcomes.                                                                                                            3. Complete the learner evaluation.
                                                           editor of Ostomy/Wound Management. She
                                                           worked as a WOCN/CNS at Huntington Memo-                  4. Mail, fax, or send on-line the completed learner
                                                           rial Hospital, Pasadena, California, for seven               evaluation and post-test to the address below.
                                                           years before returning to USC to earn a PhD in            5. 1.0 contact hours for nurses are awarded by Cross
1. Kral JG, Strauss RJ, Wise L. Perioperative risk         Religion and Social Ethics, specifically in public           Country University, the Education and Training
    management in obese patients. In: Deitel M.            policy ethics in obesity. Ms. Gallagher has been             Division of Cross Country Inc., which is accredited
    Surgery for the Morbidly Obese Patient. FD-            an invited speaker to numerous medical meet-                 as a provider of continuing education in nursing
    Communications: North York, Canada, 1989.              ings where she talks on obesity and ethics.                  by the American Nurses Credentialing Center’s
2. Kuczmarski RJ, Fiegel KM, Campbell SM, Johnson                                                                       Commission on Accreditation. Cross Country
    CL. Increasing prevalence of overweight among                                                                       University is an approved provider with the Iowa
    U.S. adults. The National Health and Nutrition                                                                      Board Of Nursing, approved provider #328. This
    Examination surveys, 1960 to1991. JAMA.                                                                             course is offered for 1.0 contact hours. Cross
    1994;272:205-211.                                      Perspectives, a quarterly newsletter focusing
                                                                                                                        Country University is approved by the California
                                                           on postoperative recovery strategies, is dis-
3. Gustafson NJ. Managing Obesity and Eating                                                                            Board of Registered Nursing, Provider #CEP 13345,
    Disorders. Western Schools Press, 1997, p 2.           tributed free-of-charge to health professionals.             for 1.0 contact hours.
4. Gallagher SM. Morbid obesity: a chronic disease         Perspectives is published by Saxe Healthcare
                                                                                                                     6. To earn 1.0 contact hours of continuing education,
    with an impact on wounds and related problems.         Communications and is funded through an ed-                  you must achieve a score of 75% or more. If you do
    Ostomy/Wound Management 1997;43(5):18-27.              ucational grant from Dale Medical Products Inc.              not pass the test, you may take it again one time.
5. Staffieri JR. A study of social stereotype of body      The newsletter’s objective is to provide nurses
    image in children. J Pers Soc Psychol 1967;7:101-                                                                7. Your results will be sent within four weeks after the
    104.                                                   and other health professionals with timely and               form is received.
6. Maiman LA, Wang VL, Becker MH, Finlay J,                relevant information on postoperative recovery            8. The administrative fee has been waived through an
    Simonson M. Attitudes toward obesity and the           strategies, focusing on the continuum of care                educational grant from Dale Medical Products, Inc.
    obese among professionals. J Am Diet Assoc             from operating room to recovery room, ward,
    1992;74:331-336.                                                                                                 9. Answer forms must be postmarked by December
                                                           or home.                                                     12, 2005, 12:00 midnight.
7. Thone RR. Fat: A Fate Worse Than Death. New
    York: Harrington Park Press, 1997.                     The opinions expressed in Perspectives are                Name ___________________________________
8. Gustafson NJ. Managing Obesity and Eating               those of the authors and not necessarily of               Credentials _______________________________
    Disorders. Western Schools Press, 1997, p 13-19.       the editorial staff, Cross Country University,
9. Gallagher S. Meeting the needs of the obese                                                                       Position/title ______________________________
                                                           or Dale Medical Products Inc. The publisher,
    patient. AJN 1996;96(8):1s-12s.                                                                                  Address __________________________________
                                                           Cross Country University and Dale Medical
10. Front-line Fat PBS Home Video. Seattle,
    Washington: Public Broadcasting Service, 1998.         Corp. disclaim any responsibility or liability for        City ___________________ State ___ Zip_______
11. Fox HR. Discrimination: alive and well in the
                                                           such material.
                                                                                                                     Phone ___________________________________
    United States. Obesity Surgery 1995;5:352.             We welcome opinions and subscription requests             Fax _____________________________________
12. Charles S. Psychological evaluation of morbidly        from our readers. When appropriate, letters to
    obese patients. Gastro Clinics of North Am                                                                       License #: ________________________________
    1987;16(3).                                            the editors will be published in future issues.
13. Front-line Fat. Public Broadcasting Service:                                                                     * Soc. Sec. No. _____________________________
    Seattle WA, 1999.                                             Please direct your correspondence to:
                                                                                                                     E-mail ___________________________________
14. French G, Galbraith JL, Dietel M. The nurse’s role            Saxe Healthcare Communications                     * required for processing
    in bariatric surgery. In: Deitel M. Surgery for the          P.O. Box 18, Burlington, VT 00
    Morbidly Obese Patient. FD-Communications:                                                                       Mail to: Cross Country University
    North York, Canada, 1989.                                            Fax: (80) 8-8                                  6551 Park of Commerce Blvd. N.W., Suite 200
15. Crowell DE. Anesthetic management of morbidly                                    Boca Raton, FL 33487-8218
    obese patient undergoing abdominal surgery:
    epidural anesthesia and postoperative epidural                                                                   or:         Fax: (561) 988-6301
    anesthesia. In: Deitel M. Surgery for the Morbidly                                                                 

1. Obesity is associated with numerous coexisting                7.   Planning surgical care for the morbidly obese                        12.. Possible side effects of breast brachytherapy are:
   conditions, which include:                                         patient should include which of the following                                a. local skin infection.
      A. dental caries.                                               professionals:                                                               b. lymphedema.
      B. diabetes, hypertension, soft tissue infection.               A.   physical therapist                                                      c. alopecia.
      C. urinary retention.                                           B.   clinical specialist                                                     d. neutropenia.
      D. mood elevation.                                              C.   bariatric surgeon
                                                                      D.   all of the above, as part of an interdisciplinary               13. Which of the following is a false statement?
2. Factors that influence weight and its regulation                        approach                                                                a. Brachytherapy is more labor intensive than
   include:                                                                                                                                           external beam radiotherapy.
      A.   genetics.                                             8. Which of the following is a false statement.                                   b. Brachytherapy is currently offered as a treatment
      B.   gender.                                                    A. The word “obesity” holds a negative tone.                                    opportunity at a minority of centers.
      C.   biochemistry.                                              B. Prejudice toward the larger person begins at a very                       c. Brachytherapy requires experienced and trained
                                                                         young age.                                                                   staff to perform the procedure and administer the
      D.   all of the above.                                                                                                                          treatment.
                                                                      C. Many Americans choose to be overweight.
3. Two immobility-related conditions that could                       D. Obesity is a chronic, complex, multifactoral disease                      d. Brachytherapy requires the patient to be
   prolong the patient’s postoperative course are:                       that is recognized by the NIH.                                               hospitalized for the treatment.
      A.   respiratory problems.
                                                                 9. Nurses report that home-care challenges include:                       14..Which of the following is a true statement?
      B.   constipation.                                                                                                                           a. Brachytherapy is non-invasive procedure.
                                                                      A.   proper equipment
      C.   atypical pressure ulcers.                                                                                                               b. Lymph nodes are not treated with brachytherapy.
                                                                      B.   adequate reimbursement
      D.   A & C.                                                     C.   access to resources                                                     c. Brachytherapy is applicable for all types of breast
4. Atypical pressure ulcers could be related to:                      D.   all of the above                                                           cancer histologies.
      A.   pressure within skin folds.                                                                                                             d. Nurses are not an integral part of the breast
      B.   tubes and catheters.                                  10. When planning for oversized equipment in the                                     brachytherapy team.
                                                                     home, the following should be considered:
      C.   chairs that are too small .                                A. weight limits of the home and surrounding                         15. Relative contraindication(s) to brachytherapy is
      D.   A, B & C.                                                     structures                                                            (are):
                                                                      B. patient attitude                                                          a. a patient with 6 positive lymph nodes
5. Very overweight surgical patients seem to                                                                                                       b. a patient with multi-focal breast disease
   breathe better when the bed is positioned at the                   C. causes of obesity
   following angle:                                                   D. A & C                                                                     c. a patient with 4-cm tumor mass
      A.   90 degrees                                                                                                                              d. all of the above
      B.   60 degrees
                                                                 11. The major advantage (s) breast brachytherapy are:
                                                                      a. decreased treatment time.                                         16. Which of the following is (are) not a concern
      C.   30 degrees                                                 b. diminished cardiopulmonary morbity.                                   for nurses caring for a patient receiving
      D.   none of the above                                                                                                                   brachytherapy?
                                                                      c. diminished radiation to the contralateral breast.                         a. pain management
6. Extra personnel may be required when                               d. all of the above.                                                         b. infection
   transferring larger patients in order to:
      A.   reduce the risk of caregiver injury.                                                                                                    c. patient and family education
      B.   promote patient safety.                                                                                                                 d. none of the above
      C.   ease patient’s anxiety about falling.
      D.   A, B & C.

      Mark your answers with an X in the box next to the correct answer                                                                                                                   Vol.  No. 1

           A   B     C    D                  A      B   C   D         A      B    C     D                   A    B     C       D               A      B     C     D                   A     B   C       D
 1                                       4                      7                                     10                              13                                         16
           A   B     C    D                  A      B   C   D         A      B    C     D                   A    B     C       D               A      B     C     D
 2                                       5                      8                                     11                              14
           A   B     C    D                  A      B   C   D         A      B    C     D                   A    B     C       D               A      B     C     D
 3                                       6                      9                                     12                              15
     Participant’s Evaluation
1.     What is the highest degree you have earned?                     1. Diploma               2. Associate               3. Bachelor’s                  4. Master’s            5. Doctorate
       Using 1 =Strongly disagree to 6= Strongly agree rating scale, please circle the number that best reflects the extent of your agreement to each statement.
                                                                                                                Strongly Disagree                                             Strongly Agree
2.     Indicate to what degree you met the objectives for this program:
       a. Identify health conditions, which are associated with obesity, that                           1                  2               3                     4                    5             6
           could interfere with the patient’s general level of health.
       b. Describe factors that influence weight and its regulation.                                    1                  2               3                     4                    5             6
       c. Develop a plan of care for the larger patient requiring surgery.                              1                  2               3                     4                    5             6
       d. Describe an innovative radiation treatment for early-stage
           breast cancer.                                                                               1                  2               3                     4                    5             6
       e. Understand the role of nursing in the care of a patient receiving
           breast brachytherapy.                                                                        1                  2               3                     4                    5             6
       f. Recognize the questions that further research must answer regarding
           the use of breast brachytherapy.                                                             1                  2               3                     4                    5             6
3.     Have you participated in a home study in the past? ■ Yes ■ No
4.     How many home-study courses do you typically use per year?
5.     What is your preferred format? ■ video ■ audio-cassette
                                      ■ written ■ combination
6.     What other areas would you like to cover through home study?
        For Iowa nurses, you may submit the evaluation to Iowa Board of Nursing.

           Mail to: Cross Country University, 6551 Park of Commerce Blvd. N.W., Suite 200, Boca Raton, FL 33487-8218
                    or Fax: (561) 988-6301 E-mail:
                                                   Supported by an educational grant from Dale Medical Products Inc.

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