GERIATRIC NURSING

1. CANCER OF
BLADDER AND
KIDNEY

2. BLADDER CANCER
• It is the carcinoma of the bladder

3. INCIDENCE
• About 73,510 new cases of bladder cancer
diagnosed (about 55,600 in men and 17,910 in
women).
• Bladder cancer occurs mainly in older people.
About 9 out of 10 people with this cancer are
over the age of 55. The average age at the
time of diagnosis is 73.

4. ETIOLOGY AND RISK FACTORS
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Smoking
Workplace exposures
Race and ethnicity
Age
Gender
Chronic bladder irritation and infections
Personal history of bladder or other
urothelial cancer

5. Contd…
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Bladder birth defects
Genetics and family history
Chemotherapy and radiation therapy
Arsenic
Low fluid consumption

6. TYPES OF BLADDER
CANCER

7. Transitional cell (urothelial)
carcinoma
• About 95% of bladder cancers are this type.
• The cells from transitional cell carcinomas look
like the urothelial cells that line the inside of
the bladder.
• Urothelial cells also line other parts of the
urinary tract, such as the lining of the kidneys
(called the renal pelvis), the ureters, and the
urethra, so transitional cell cancers can also
occur in these places

8. • Non-invasive bladder cancers are still in the
inner layer of cells (the transitional
epithelium) but have not grown into the
deeper layers
• Invasive cancers grow into the lamina propria
or even deeper into the muscle layer.

9. Papillary carcinomas
• Grow in slender, finger-like projections from
the inner surface of the bladder toward the
hollow center.

10. Flat carcinomas
• Do not grow toward the hollow part of the
bladder at all. If a flat tumor is only in the
inner layer of bladder cells, it is known as a
non-invasive flat carcinoma or a flat
carcinoma in situ (CIS).

13. STAGING OF BLADDER TUMER
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Tis-flat carcinoma insitu
Ta-papillary ,confined to mucosa
T1-invasion of lamina propria
T2-invasion of superficial muscle
T3a-invasion of deep muscle
T3b-invasion of perivesical tissue
T4a-tumour fixed to prostate
T4b-tumour fixed to other pelvic organs

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M0-no evidence of metastatic disease
M1-metastasis present
MX-metastatic state unknown
N0-no regional lymph node metastasis
N1-metastasis in a single lymph node 2cm or
less in greatest dimension
• N2-metastasis in a single lymph node more than
2 cm but not more than 5 cm
in greatest
dimension or multiple lymph nodes more than 5
cm in great
dimension
• N3-metastasis in a lymph node morethan 5 cm in
greatest dimension

15. PATHOPHYSIOLOGY OF BLADDER
CANCER
Due to the etiological factors
Activation of oncogenes and inactivation or loss
of tumor suppressor genes.
• Loss of genetic material on chromosome 9

16. That leads to bladder cancer

17. Exposure of the bladder wall to a carcinogen
Premalignant proliferative changes are found in the
transitional cell layer.
These changes are called dysplasia and refers to
abnormal cell configuration found in several
degrees of sevearity.
The invasion progress through the pelvic lymph
nodes and spreads to liver, bones and lungs
,rectum, vagina, and other pelvic soft tissues

18. CLINICAL FEATURES
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Blood in the urine
Frequency
Dysuria
Urgency
Lower back pain or being unable to urinate

19. DIAGNOSTIC MEASURES
• Medical history and physical exam
• Cystoscopy
• LAB TESTS
1. Urine cytology
2. Urine culture
3. Urine tumor marker tests(tests for NMP22 and
BTA)
•Bladder biopsies

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Intravenous pyelogram
Computed tomography (CT) scan
CT-guided needle biopsy
Magnetic resonance imaging (MRI) scan
Ultrasound

21. MANAGEMENT
• The main types of treatment for cancer of the
bladder are:
Surgery
Intravesical therapy
Chemotherapy
Radiation therapy

22. SURGERIES FOR BLADDER CANCER
1. Transurethral surgery
 TURBT
2. CYSTECTOMY
Partial cystectomy
Radical cystectomy

23. RECONSTRUCTIVE SURGERY
• Urinary Diversions
Urinary diversion procedures are performed to
divert urine from the bladder to a new exit
site, usually through a surgically created
opening (stoma) in the skin.
The main types are:
1. Cutaneous Urinary Diversions
2. Continent Urinary Diversions

24. 1.Cutaneous Urinary Diversions
cutaneous urinary diversion, in which
urine drains through an opening
created in the abdominal wall and
skin,

25. A. Continent Urinary Diversions
. In an ileal conduit, the urine is diverted by
implanting the ureter into a 12-cm loop of
ileum that is led out through the abdominal
wall.

26. B. Cutaneous Ureterostomy
A cutaneous ureterostomy, in which the ureters
are directed through the abdominal wall and
attached to an opening in the skin, is used for
selected patients with ureteral obstruction

27. C. Vesicostomy.
The surgeon sutures the bladder to the
abdominal wall and creates an opening
(stoma) through the abdominal and bladder
walls for urinary drainage.

28. D. Nephrostomy
The surgeon inserts a catheter into the renal
pelvis via an incision into the flank or, by
percutaneous catheter placement, into the
kidney.

29. 2.Continent Urinary Diversions
• continent urinary diversion, in
which a portion of the intestine is
used to create a new reservoir for
urine.

30. A.Continent Ileal Urinary Reservoir
1.Indiana Pouch
The Indiana pouch uses a segment of the
ileum and cecum to form the reservoir for
urine. The ureters are tunneled through the
muscular bands of the intestinal pouch and
anastomosed

31. 2.Kock pouch
U-shaped pouch constructed of ileum, with
a nipplelike one-way valve.With both of
these methods, the pouch must be
drained at regular intervals by a catheter

32. B. Ureterosigmoidostomy
Implantation of the ureters into the
sigmoid colon

33. NURSING MANAGEMENT
1.PREOPERATIVE MANAGEMENT
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Functional assessment
psychosocial resources
Bowel preparation
Adequate hydration
The procedure is explained

34. • For ileal or colon conduit, the stoma site is
planned preoperatively
• Stoma site may also be marked

35. Postoperative Management
• Assessed for immediate postoperative
complications; wound or UTI, urinary or fecal
anastomotic leakage, small bowel obstruction,
paralytic ileus, pelvic thrombophlebitis,
pulmonary embolism, and necrosis of stoma.
• Intake and output are monitored including
amount
• Suction drains are evaluated sudden increase in
drainage suggests an anastomotic leak
• Ureteral stents are used to protect
ureterointestinal anastomoses

36. Nursing Diagnoses
• Impaired Urinary Elimination related to urinary
diversion
• Acute Pain related to surgery
• Disturbed Body Image related to urinary
diversion
• Sexual Dysfunction related to reconstructive
surgery and impotence (in men)
• Risk for impaired skin integrity related to
problems in managing the urine collection
appliance
• Risk for complications related to complexity of
surgery

37. 1.Achieving Urinary Elimination
For ileal or colon conduit patients
• Maintain a transparent urostomy pouch
• Inspect the stoma for color and size
1. Stoma should be red, wet with mucus, soft,
and slightly rubbery to the touch (stoma
lacks nerve ending, so feeling in stoma is
absent).
2. Cyanotic stoma indicates poor circulation.
3. Necrotic stoma is blue-black or tan-brown.

38. • Connect pouches to drainage bag when
patient is in bed, and record urine volume
hourly.
• Initial urostomy pouch remains in place for
several days postoperatively; it is changed
every 3 to 5 days when patient teaching
begins.
• Report bleeding, necrosis, sloughing, suture
separation.
• Check patency of ureteral stents.
• Keep the pouch on at all times, and observe
normal urine

39. •
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For continent urinary diversion
patients
Irrigate with 30 mL saline every 2 to 4 hours
Assess stoma
Record urine output and character of urine
irrigate with 30 mL saline every 2 to 4 hours
Assess stoma
Monitor output of pelvic drain
Record urine output and character of urine
Controlling Pain
Resolving Body Image Issues
Coping with Sexual Dysfunction

40. • Providing stoma and skin care
• Monitoring And Managing Potential
Complications

41. Patient Education and Health
Maintenance
For Ileal or Colon Conduit Patients
• Obtain and familiarize the patient with the
appropriate equipment
• Assist the patient to determine stoma size
• The inside diameter of the skin barrier should
not be more than 1/16 to 1/8 inch larger than
the diameter of the stoma.

42. DISPOSABLE UROSTOMY POUCH

43. • Teach how to change the pouch.
• Pastes or cements, are not usually necessary
with a well-fitting pouch.
• Pouches should be changed every 3 days
• Emptying the pouch when it is a third to half
full to prevent weight of urine from loosening
adhesive seal open drain valve

44. For Continent Ileal Urinary Reservoir
Patients
• Teach irrigation of catheter
• Teach how to change stoma
dressing
• Instruct in use of leg bag or
bedside urinary drainage

45. Teach how to catheterize continent urinary
diversion when healing is verified
• Red rubber or plastic, straight or coud catheters
are used.
• Apply a small amount of water-soluble lubricant
to the tip of the catheter.
• Use clean technique, wash hands before each
catheterization.
• Maintain schedule of catheterizations
• After training period, catheterize four to five
times per day; pouch should not hold more than
400 to 500 mL.
• Irrigate pouch with saline through catheter once
per day to clear it of accumulated mucus.

46. INTRAVESICAL THERAPY
• With intravesical therapy, the doctor puts the
drug directly into the bladder
1. INTRAVESICAL IMMUNOTHERAPY
A.Bacillus Calmette-Guerin therapy
• The body’s immune system cells are attracted
to the bladder and activated by BCG, which
in turn affects the bladder cancer cells
• Started a few weeks after a transurethral
resection of the tumor and is given once a
week for 6 weeks.

47. B. Interferon
• Stimulate the immune system
• Interferon-alpha is the type most often
used to treat cancer.
C. Intravesical chemotherapy
• Mitomycin and thiotepa are the drugs
used most often for intravesical
chemotherapy. Other drugs that are used
include valrubicin, doxorubicin, and
gemcitabine.

48. CHEMOTHERAPY FOR BLADDER
CANCER
• Cisplatin
50 to 70 mg/m2 intravenously once every 3 to 4
weeks
• Cisplatin plus fluorouracil (5-FU)
This consisted of cisplatin 15 mg/m(2) i.v. and 5fluorouracil (5-FU) 400 mg/m(2) i.v. in the
mornings

49. • Mitomycin with 5-FU
12mg/m2 IV Bolus (DAY 1 ONLY)
• Gemcitabine and cisplatin
gemcitabine dose of 1000 mg/m(2) and cisplatin
dose and schedule varied, with total doses
ranging from 70 to 105 mg/m(2)
• Methotrexate, vinblastine, doxorubicin
(Adriamycin), and cisplatin (called M-VAC)
• paclitaxel or docetaxel (for patients with poor
kidney function)
Paclitaxel was given at a dose of 250 mg/m2 by 24hour continuous infusion

50. RADIATION THERAPY FOR BLADDER
CANCER
• External beam radiation therapy

51. PHOTODYNAMIC THERAPY
• A special light-sensitive drug is injected into
the blood and allowed to collect in the tumor
cells for a few days. Then a special type of
laser light is focused on the inner lining of the
bladder through a cystoscope. The light
changes the drug in the cancer cells into a
new chemical that can kill them.

52. TARGETED THERAPIES
Medication that blocks the growth of cancer
cells by interfering with specific
targeted molecules needed
for carcinogenesis and tumor growth rather
than by simply interfering with all rapidly
dividing cells
• Eg-sunitinib,lapatinib ,Erlotinib, trastuzumab

53. GENE THERAPY
• The modified virus is put into the bladder and
infects the bladder cancer cells
• When this infection occurs, the virus injects a
gene into the cells for GM-CSF, an immune
system hormone (cytokine) that may help
activate immune system cells to attack the
cancer

54. PROGNOSIS
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Stage 0 -- 98%.
For stage I -- 88%.
For stage II -- 63%.
For stage III -- 46%, depending on the size of
the cancer deposits present in the tissues next
to the bladder and whether the cancer has
spread to nearby organs.
• For stage IV -- 15%

56. • Renal cell carcinoma (RCC), also known as
renal cell cancer
• Adenocarcinoma, is by far the most common
type of kidney cancer. About 9 out of 10
kidney cancers are renal cell carcinomas

57. INCIDENCE
• As per the Indian cancer registry data in men,
it is the ninth most common cancer
accounting for 3.9% of all cancer cases
• It is three times more common in men than
in women, and 90% of the bladder tumors
are transitional cell carcinoma (TCC)

58. TYPES OF KIDNEY CANCER
1. Papillary renal cell carcinoma
• These cancers form little finger-like
projections (called papillae)
• Sometimes it is called chromophilic because
the cells take in certain dyes and look pink
under the microscope.

59. 2. Chromophobe renal cell carcinoma
• This subtype accounts for about 5%
• The cells of these cancers are also pale, like
the clear cells, but are much larger
3. Collecting duct renal cell carcinoma
This subtype is very rare. The major feature is
that the cancer cells can form irregular tubes.

60. 4.Transitional cell carcinoma
• Transitional cell carcinomas don't start in the
kidney itself, but instead begin in the lining of
the renal pelvis
• 5-10 % OF TOTAL RCC
5. Wilms tumor (nephroblastoma)
• Nephroblastomas, more commonly called
Wilms tumors, almost always occur in
children. This type of cancer is very rare
among adults

61. 6. Renal sarcoma
• That begin in the blood vessels or connective
tissue of the kidney.TOTAL 1%

62. STAGING/TNM CLASSIFICATION
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Primary Tumor (T)
Tx-Primary tumor can not be assessed
T0-No evidence of primary tumor
T1a-Tumor 4 cm, confined to the kidney
T1b-Tumor 4 cm to < 7 cm, confined to the
kidney
• T2a-Tumor ≥ 7 cm to < 10 cm, confined to the
kidney
• T2b-Tumor ≥ 10 cm, confined to the kidney

63. • T3a-Tumor extends into the renal vein or its
segmental branches or invades adrenal gland or
perinephric fat but not beyond Gerota’s fascia
• T3b-Tumor extends into the vena cava below
diaphragm
• T3c-Tumor extends into the vena cava above the
diaphragm or invades the wall of vena cava
• T4-Tumor invades beyond Gerota’s fascia
• Regional Lymph Nodes (N)
• N1-Metastasis in 1 regional lymph node
• N2-Metastasis in > 1 regional lymph node
• Distant Metastases (M)
• M1-Distant metastasis present

64. ETIOLOGY AND RISK FACTORS
• Smoking
• Obesity
• Workplace exposures
• Genetic and hereditary risk factors

65. von Hippel-Lindau disease
• People with this condition often develop
several kinds of tumors and cysts (fluid-filled
sacs) in different parts of the body

66. ETIOL …
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Hereditary papillary renal cell carcinoma
Hereditary leiomyoma-renal cell carcinoma
(FH) gene.
Hereditary renal oncocytoma
Family history of kidney cancer
High blood pressure

67. • Certain medicines
Phenacetin,
Diuretics
• Advanced kidney disease
• Gender
• Race

68. PATHOPHYSIOLOGY
Due to etiology
Loss of VHL protein(von-Hippel-Lindeau)tumour
suppressor gene
Accumulate hypoxia-induced factor (HIF)
Transcriptional activation of multiple
downstream targets

69. RCC

70. CLINICAL FEATURES
• Blood in the urine (hematuria)
• Low back pain on one side (not caused by
injury)
• A mass (lump) on the side or lower back
• Fatigue (tiredness)
• Weight loss not caused by dieting
• Fever that is not caused by an infection and
that doesn't go away after a few weeks
• Anemia (low red blood cell counts)

71. Paraneoplastic Syndromes
1. Erythrocytosis
promoting erythropoietin production from
nonneoplastic renal tissue.
2. Hypercalcemia
Due to production of a parathyroid hormone.
3. Hypertension
Due to excess rennin production

72. 4. Non metastatic hepatic dysfunction
Elevation of alkaline phosphatase and bilirubin,
hypoalbuminemia, prolonged prothrombin
time, and hypergammaglobulinemia. It is
known as Stauffer syndrome

73. DIAGNOSTIC MEASURES
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Urine analysis
Complete blood count
Blood chemistry tests
CT scan
MRI scan
Ultrasound
Positron emission tomography (PET) scan
Intravenous pyelogram
Fine needle aspiration and needle core
biopsy

74. MANAGEMENT
–Surgery
–Radiation therapy
–Chemotherapy

75. SURGERY
• Radical nephrectomy
• Partial nephrectomy (nephron-sparing
surgery)
• Cryotherapy (cryoablation)
• Radiofrequency ablation
• Arterial embolization

76. RADIATION THERAPY FOR KIDNEY
CANCER
• External beam therapy focuses radiation from
outside the body on the cancer

77. CHEMOTHERAPY FOR KIDNEY
CANCER
• Unfortunately, kidney cancer cells are usually
resistant to chemo, and so chemo is not a
standard treatment for kidney cancer.
• Some chemo drugs, such as
vinblastine,floxuridine, 5-fluorouracil (5-FU),
capecitabine, and gemcitabine

78. Targeted therapies
• Targeted drugs are proving to be especially important
in diseases such as kidney cancer, where
chemotherapy has not been shown to be very
effective.
• These include drugs that stop angiogenesis (growth
of the new blood vessels that nourish cancers) and
drugs that target other important cell growth factors.
• EXAMPLES-Sorafenib ,Sunitinib Temsirolimus
,Everolimus ,evacizumab ,Pazopanib

79. Biologic therapy (immunotherapy)
• The goal of biologic therapy is to boost the
body's immune system to fight off or destroy
cancer cells more effectively.
• The main immunotherapy drugs used in
kidney cancer are cytokines. The 2 cytokines
most often used are interleukin-2 (IL-2) and
interferon-alpha.

80. New approaches to local treatment
• High-intensity focused ultrasound is a fairly
new technique that is now being studied for
use in kidney cancer. It involves pointing very
focused ultrasound beams from outside the
body to destroy the tumor

81. NURSING MANAGEMENT
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ASSESSMENT
Nursing Diagnosis
Preoperative nursing diagnosis
Anxiety related to diagnosis of cancer and
possibility of metastatic disease
• Acute Pain and Hyperthermia related to
postinfarction syndrome
• Anticipatory grieving related to loss; altered role
functioning
• Disturbed body image and situational low selfesteem related to changes in appearance,
function,and roles

82. Nursing Interventions
• Reducing Anxiety
 Explain each diagnostic test, its purpose,
and possible adverse reactions
 Answer questions, and encourage more
thorough discussion with health care
 Assess patient's understanding about
diagnosis and treatment options

83. Controlling Symptoms of
Postinfarction Syndrome
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Administer analgesics as prescribed
Encourage rest, and assist with positioning
Administer antiemetics as ordered
Restrict oral intake and provide
Obtain temperature every 4 hours,

84. • Post operative nursing diagnosis
• Ineffective airway clearance related to the
location of the surgical incision
• Ineffective breathing pattern related to surgical
incision and general anesthesia
• Acute pain related to the location of the surgical
incision, the position the patient assumed on the
operating table during surgery, and abdominal
distention
• Urine retention related to pain, immobility, and
anesthesia
• Risk for complications related to major surgical
procedure

85. Nursing interventions
Monitoring And Managing Potential
Complications
Promoting Urinary Elimination
Maintaining Airway Clearance And Breathing
Patterns