Multidimensional 2

68 Part 5 ■ T H E I NT EG U M E NTA RY SY ST E M

Client Profile Mr. Vincent is a 32-year-old man who has scheduled an appointment with a dermatologist to have a black spot on his right ear assessed. Mr. Vincent states,

“My wife noticed a black circular area on my ear about two weeks ago and she sug-

gested I get it looked at since she did not remember the spot being there before.

I know that too much time in the sun is not very good for your skin. I’m a physi-

cal education teacher so I am out in the sun a lot, and I admit that I do not always

remember to apply sunscreen.”

Case Study There is a dark area on Mr. Vincent’s right ear approximately 0.4 cm by 0.4 cm round in size. The color of the surrounding skin is normal. Mr. Vincent says that he

noticed the spot about four months earlier but did not think much of it. “I figured

it was a mole. Since it did not hurt, I really didn’t give it much thought.”

1. You are the nurse working with the dermatolo- gist. Make a list of questions you could ask regarding

the area of concern to help determine if the site on

Mr. Vincent’s ear could be melanoma.

2. Explain the ABCD criteria for assessing a skin lesion.

3. The pathology report from the punch biopsy states, “deep penetrating nevi with atypical features

worrisome for melanoma.” The dermatologist sug-

gests that Mr. Vincent have a sentinel lymph node

mapping and biopsy procedure. How might the

nurse explain what this procedure is, why it is done,

and potential common and serious adverse effects/

complications?

4. Mrs. Vincent says, “How did this happen? My husband has dark hair and olive skin. I thought only

fair-skinned redheads got skin cancer.” Is there any

truth to Mrs. Vincent’s assumption? List five risk

factors the nurse should include in an explanation of

what puts individuals at greater risk for skin cancer.

5. Discuss the incidence of dark-skinned individuals diagnosed with melanoma.

6. The results of the sentinel lymph node mapping and biopsy reveal that the most proximal lymph

node near Mr. Vincent’s parotid gland is positive

with a 0.1 mm micrometastasis. Given that the punch

biopsy was suspicious for melanoma and that there

is a positive sentinel lymph node, the dermatolo-

gist prescribes a CT scan of the head, chest, neck,

abdomen, thorax, and pelvis, a MRI of the brain,

and a PET scan of the body to determine the extent

of Mr. Vincent’s melanoma. Mr. Vincent asks, “What

gland is it near?” and then states, “I know what a

CT scan and MRI are but what is a PET scan?” What

function does the parotid gland serve? Explain a

PET scan to Mr. Vincent.

7. What does it mean to explain cancer according to its “stage” using the TNM system? Melanoma

may be staged according to a “clinical stage” and a

“pathological stage.” Briefly discuss the difference.

8. It has been six weeks since his initial visit to the dermatologist and Mr. and Mrs. Vincent are

meeting with the dermatologist today to get results

of the diagnostic tests. They learn that Mr. Vincent

has been diagnosed with “Stage IIIA T1a, N1a, M0”

malignant melanoma. What does this stage mean?

9. Mr. Vincent asks the dermatologist, “What is my prognosis?” What is Mr. Vincent’s five-year survival

rate?

10. Identify two nursing diagnoses the nurse should consider for Mr. Vincent when he learns of his diag-

nosis of melanoma.

11. Discuss what the nurse can do to reduce the fear and anxiety that Mr. Vincent may feel upon learning

that he has melanoma.

12. Results of Mr. Vincent’s CT scan, MRI, and PET scan are negative. The suggested intervention

is a curative lymph node dissection. There are no

postoperative complications and Mr. Vincent is

being discharged home. He is given a prescription

for oxycodone and acetaminophen 5/325 one to

two tablets every four to six hours as needed for

postsurgical incisional pain. He has staples at his

incision site to which Bacitracin is applied and the

site is covered with a sterile dressing. He will return to

the surgeon’s office two days after discharge to have

the dressing removed and a postoperative incision

check. The nurse is providing discharge teaching.

What are the common adverse effects of oxycodone

and acetaminophen 5/325 and instructions for safe

administration? What warning signs indicate that

Mr. Vincent should call his surgeon?

Questions

C AS E ST U DY 4 ■ M R . V I N C E NT 69

13. Identify two nursing diagnoses the nurse should consider for Mr. Vincent following his lymph node

dissection.

14. Four weeks later, Mr. Vincent sees an oncologist to discuss recommendations regarding adjunct

treatment. The oncologist explains that the only

FDA-approved therapy for stage III melanoma is

high-dose interferon (INF)-alpha 2b, which offers

a modest survival benefit with the risk of adverse

effects. What are the adverse effects of high-dose

interferon (INF)-alpha 2b?

15. The oncologist suggests Mr. Vincent also con- sider treatment offered through participation in a

clinical trial. What is a clinical trial and what are the

three phases of a clinical trial?

16. Mr. Vincent does some research and takes some time to consider the treatment options and discuss

them with his wife. He decides that presented with

only the possibility, and not a guarantee, of an

increase in survival rate with the interferon therapy,

the benefit does not outweigh the risk of the adverse

effects. He declines interferon treatment and is

going to explore clinical trials. As Mr. Vincent’s

nurse, how should you respond to Mr. Vincent’s

decision?

17. What will Mr. Vincent require in terms of follow-up care? Discuss how often Mr. Vincent

will need to see the dermatologist, the symptoms

to report, precautions to take, and the need for

emotional support.

Questions (continued)