NURSING PROCESS:CARE OF THE PATIENT WITH MALIGNANT MELANOMA
Assessment of the patient with malignant melanoma is based on the patient’s history and symptoms. The patient is asked specifi-cally about pruritus, tenderness, and pain, which are not features of a benign nevus. The patient is also questioned about changes in preexisting moles or the development of new, pigmented le-sions. People at risk are assessed carefully.
A magnifying lens and good lighting are needed for inspect-ing the skin for irregularity and changes in the mole. Signs that suggest malignant changes are referred to as the ABCDs of moles (Chart 56-8).
Common sites of melanomas are the skin of the back, the legs (especially in women), between the toes, and on the feet, face, scalp, fingernails, and backs of hands. In dark-skinned people, melanomas are most likely to occur in less pigmented sites: palms, soles, subungual areas, and mucous membranes. Satellite lesions (ie, those situated near the mole) are inspected.
Based on the nursing assessment data, the patient’s major nurs-ing diagnoses may include the following:
· Acute pain related to surgical excision and grafting
· Anxiety and depression related to possible life-threatening consequences of melanoma and disfigurement
· Deficient knowledge about early signs of melanoma
Based on the assessment data, potential complications include the following:
· Infection of the surgical site
The major goals for the patient may include relief of pain and dis-comfort, reduced anxiety and depression, knowledge of early signs of melanoma, and absence of complications.
Surgical removal of melanoma in different locations (eg, head, neck, eye, trunk, abdomen, extremities, central nervous system) presents different challenges, taking into consideration the re-moval of the primary melanoma, the intervening lymphatic vessels, and the lymph nodes to which metastases may spread.
Nursing intervention after surgery for a malignant melanoma centers on promoting comfort, because wide excision surgery may be necessary. A split-thickness or full-thickness skin graft may be necessary when large defects are created by surgical removal ofa melanoma. Anticipating the need for and administering appro-priate analgesic medications are important.
Psychological support is essential when disfiguring surgery is per-formed. Support includes allowing patients to express feelings about the seriousness of this cutaneous neoplasm, understanding their anger and depression, and conveying understanding of these feelings. During the diagnostic workup and staging of the depth, type, and extent of the tumor, the nurse answers questions, clar-ifies information, and helps clarify misconceptions. Learning that they have a melanoma can cause patients considerable fear and anguish. Pointing out patients’ resources, past effective coping mechanisms, and social support systems helps them to cope with the problems associated with diagnosis, treatment, and continuing follow-up. The patient’s family should be included in all discus-sions to clarify the information presented, ask questions that the patient might be reluctant to ask, and provide emotional support.
The prognosis for malignant melanoma is related to metastasis: the deeper and thicker (more than 4 mm) the melanoma, the greater is the likelihood of metastasis. If the melanoma is grow-ing radially (ie, horizontally) and is characterized by peripheral growth with minimal or no dermal invasion, the prognosis is fa-vorable. When the melanoma progresses to the vertical growth phase (ie, dermal invasion), the prognosis is poor. Lesions with ulceration have a poor prognosis. Melanomas of the trunk appear to have a poorer prognosis than those of other sites, perhaps be-cause the network of lymphatics in the trunk permits metastasis to regional lymph nodes.
The role of the nurse in caring for the patient with metastatic disease is holistic. The nurse must be knowledgeable about the most effective current therapies and must deliver supportive care, provide and clarify information about the therapy and the ratio-nale for its use, identify potential side effects of therapy and ways to manage them, and instruct the patient and family about the expected outcomes of treatment. The nurse monitors and docu-ments symptoms that may indicate metastasis: lung (eg, difficulty breathing, shortness of breath, increasing cough), bone (eg, pain, decreased mobility and function, pathologic fractures), and liver (eg, change in liver enzyme levels, pain, jaundice). Nursing care is based on the patient’s symptoms.
Although the chance of a cure for malignant melanoma that has metastasized is poor, the nurse encourages the patient to have hope in the therapy employed while maintaining a realistic per-spective about the disease and ultimate outcome. Moreover, the nurse provides time for the patient to express fears and concerns regarding future activities and relationships, offers information about support groups and contact people, and arranges palliative and hospice care if appropriate.
The best hope of controlling the disease lies in educating patients about the early signs of melanoma. Patients at risk are taught to examine their skin and scalp monthly in a systematic manner (Chart 56-9). The nurse also points out that a key factor in the development of malignant melanoma is exposure to sunlight. Be-cause melanoma is thought to be genetically linked, the family and the patient should be taught sun-avoiding measures.
Expected patient outcomes may include the following:
1) Experiences relief of pain and discomfort
a) States pain is diminishing
b) Exhibits healing of surgical scar without heat, redness, or swelling
2) Is less anxious
a) Expresses fears and fantasies
b) Asks questions about medical condition
c) Requests repetition of facts about melanoma
d) Identifies support and comfort provided by family member or significant other
3) Demonstrates understanding of the means for detecting and preventing melanoma
a) Demonstrates how to conduct self-examination of skin on a monthly basis
b) Verbalizes the following danger signals of melanoma: change in size, color, shape, or outline of mole, mole surface, or skin around mole
c) Identifies measures to protect self from exposure to sun-light
4) Experiences absence of complications
a) Recognizes abnormal signs and symptoms that should be reported to physician
b) Complies with recommended follow-up procedures and prevention strategies
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