leukemia for lect

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Leukemia

Hodgkin¶s Disease Is a malignant lymphoma of the reticuloendothelial system that results in an accumulation of dysfunctional,

immature lymphoid-derived cells.

The disease generally spreads by lymphatic channels, involving lymph nodes, spleen, and ultimately (through the

bloodstream) to extra lymphatic sites, such as gastrointestinaltract, bone marrow, skin, upper air passages, and

other organs.

It is most common in patient ages 20 to 40 and in those older than age 60.

It¶s cause is unknown.

Assessment:

1. Fatigue, fever, chills, night sweats, painless swelling of lymph nodes (generally unilateral), pruritus, weight loss.

2. Wide variety of symptoms may occur if there is pulmonary involvement, superior vena cava obstruction, hepatic

or bone involvement, and involvement of other structures.Diagnostic Evaluation:

1. Lymph node biopsy detects characteristic Reed-sternberg giant cell, helping to confirm diagnosis.

2. Complete blood count and bone marrow aspiration and biopsy determine whether there is bone marrow

involvement.

3. X-rays, CT scan, and MRI detect deep nodal involvement.

4. Lymphangiogram detects size and location of deep nodes involved, including abdominal nodes, which may not be

readily seen by CT scan.

5. Liver function test and liver biopsy determine hepatic involvement.

6. Gallium-67 detects areas of active disease; determines aggressiveness of disease.

7. Surgical staging (laparotomy with splenectomy, liver biopsy, multiple lymph node biopsies) may be done in

selected patients.

Pharmacologic Interventions:

1. Chemotherapy may be used in combination with radiation.

Initial treatment often begins with a specific four-drug regimen known as MOPP (Mustargen, Oncovin,

procarbazine, and prednisone).

Three or four drugs may be given in intermittent or cyclical courses, with periods of treatment to allow recovery

from toxicities.

Surgical Interventions:

1. Autologous or allogeneic bone marrows or stem cell transplantation.



Nursing Interventions:

1. To protect the skin receiving radiation, avoid rubbing, powders, deodorants, lotions, or ointments (unless

prescribed) or application of heat or cold.

2. Encourage patient to keep clean and dry, and to bathe the area affected by radiation gently with tepid water and

mild soap.

3. Encourage wearing loose-fitting clothes and to protect skin from exposure to sun, chlorine, and temperature

extremes.

4. To protect oral and gastro-intestinal tract mucous membranes, encourage frequent, small meals, using bland and

soft diet at mild temperatures.

5. Teach the patients to avoid irritants such as alcohol, tobacco, spices, and extremely hot or cold foods.

6. Administer or teach self-administration of pain medication or antiemetic before eating or drinking, if needed.

7. Encourage mouth care at least twice per day and after meals using a soft toothbrush or toothete and mild mouth

rinse.

8. Assess for ulcers, plaques, or discharge that may be indicative of superimposed infection.

9. For diarrhea, switch to low-residue diet and administer anti-diarrheals as ordered.

10. Teach patient about risk of infection. Advice patient to monitor temperature and report any fever or other sign of

infection promptly.

11. Explain to patient that radiation therapy may cause sterility.

Breast Cancer



Is the leading type of cancer in women.Most breast cancer begins in the lining of the milk ducts, sometimes the

lobule.

The cancer grows through the wall of the duct and into the fatty tissue.

Breast cancer metastasizes most commonly to auxiliary nodes, lung, bone, liver, and the brain.

The most significant risk factors for breast cancer are gender (being a woman) and age (growing older).

Other probable factors include nulliparity, first child after age 30, late menopause, early menarche, long term

estrogen replacement therapy, and benign breast disease.

Controversial risk factors include oral contraceptive use, alcohol use, obesity, and increased dietary fat intake.

About 90% of breast cancers are due not to heredity, but to genetic abnormalities that happen as a result of the

aging process and life in general.

A woman¶s risk of breast cancer approximately doubles if she has a first-degree relative (mother, sister, daughter)

who has been diagnosed with breast cancer. About 20-30% of women diagnosed with breast cancer have a

family history of breast cancer.

STAGES OF BREAST CANCER

STAGE DEFINITION

Stage 0 Cancer cells remain inside the breast duct, withoutinvasion into normal adjacent breast tissue.

Stage I Cancer is 2 centimeters or less and is confined tothe breast (lymph nodes are clear).

Stage IIA No tumor can be found in the breast, but cancer cells are found in the axillary lymph nodes (the

lymph nodes under the arm)OR



the tumor measures 2 centimeters or smaller andhas spread to the axillary lymph nodes

OR the tumor is larger than 2 but no larger than 5

centimeters and has not spread to the axillary

lymph nodes.Stage IIB The tumor is larger than 2 but no larger than 5centimeters and has spread to the axillary lymph

nodesOR

the tumor is larger than 5 centimeters but has notspread to the axillary lymph nodes.

Stage IIIA No tumor is found in the breast. Cancer is found inaxillary lymph nodes that are sticking together or to

other structures, or cancer may be found in lymphnodes near the breastbone

OR the tumor is any size. Cancer has spread to the

axillary lymph nodes, which are sticking together or to other structures, or cancer may be found in

lymph nodes near the breastbone.Stage IIIB The tumor may be any size and has spread to the

chest wall and/or skin of the breastAND

may have spread to axillary lymph nodes that areclumped together or sticking to other structures, or

cancer may have spread to lymph nodes near the breastbone.

Inflammatory breast cancer is considered at leaststage IIIB.

Stage IIIC There may either be no sign of cancer in the breastor a tumor may be any size and may have spread to

the chest wall and/or the skin of the breastAND

the cancer has spread to lymph nodes either aboveor below the collarbone

ANDthe cancer may have spread to axillary lymph nodes

or to lymph nodes near the breastbone.Stage IV The cancer has spread ² or metastasized ² to

other parts of the body.

ASSESSMENT

A firm lump or thickness in breast, usually painless; 50% are located in the upper outer quadrant of the breast.

Spontaneous nipple discharge; may be bloody, clear or serous.

Asymmetry of the breast may be noted as the woman changes positions; compare one breast with the other.

Nipple retraction or scalliness, especially in Paget¶s disease.

Enlargement of auxiliary or supraclavicular lymph nodes may indicate metastasis.



DIAGNOSTIC EVALUATION

Mammography (most accurate method of detecting non-palpable lesions) shows lesions and cancerous changes,

such as microcalcification. Ultrasonography may be used to distinguish cysts from solid masses.

Biopsy or aspiration confirms diagnosis and determines the type of breast cancer.

Estrogen or progesterone receptor assays, proliferation or S phase study (tumor aggressive), and other test of

tumor cells determine appropriate treatment and prognosis. Blood testing detects metastasis; this includes liver function tests to detect liver metastasis and calcium and

alkaline phosphatase levels to detect bony metastasis.

Chest x-rays, bone scans, or possible brain and chest CT scans detect matastasis.

PHARMACOLOGIC INTERVENTIONS

1. Chemotherapy is the primary used as adjuvant treatment postoperatively ; usually begins 4 weeks after surgery

(very stressful for a patient who just finished major surgery).

Treatments are given every 3 to 4 weeks for 6 to 9 months. Because the drugs differ in their mechanisms of

action, various combinations are used to treat cancer.

Principal breast cancer drugs include cyclosphosphamide, methotrexate, fluorouracil, doxorubicin, and

paclitaxel.

Additional agents for advanced breast cancer include docetaxel, vinorelbine, mitoxantrone, and fluorouracil.

Herceptin is a monoclonal antibody directed against Her-2/neu oncogene; may be effective for patients who

express this gene

2. Indications for chemotherapy include large tumors, positive lymph nodes, premenopausal women, and poor

prognostic factors.

3. Chemotheraphy is also used as primary treatment in inflammatory breast cancer and as palliative treatment

in metastatic disease or recurrence.

4. Anti-estrogens, such as tamoxifen, are used as adjuvant systemic therapy after surgery.

5. Hormonal agents may be used in advanced disease to induce remissions that last for months to several years.

SURGICAL INTERVENTIONS

1. Surgeries include lumpectomy (breast-preventing procedure), mastectomy (breast removal), and mammoplasty

(reconstructive surgery).

2. Endocrine related surgeries to reduce endogenous estrogen as a palliative measure.3. Bone marrow transplantation may be combined with chemotherapy.



NURSING INTERVENTIONS

1. Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea, anorexia.

2. Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting, alopecia, weight

gain or loss, fatigue, stomatitis, anxiety, and depression.

3. Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide psychological

support to the patient throughout the diagnostic and treatment process.4. Involve the patient in planning and treatment.

5. Describe surgical procedures to alleviate fear.

6. Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue.

7. Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy.

8. Administer I.V. fluids and hyperalimentation as indicated.

9. Help patient identify and use support persons or family or community.

10. Suggest to the patient the psychological interventions may be necessary for anxiety, depression, or sexual

problems.

11. Teach all women the recommended cancer-screening procedures.

It is also called malignant tumor of thestomach.

It is usually an adenocarcinoma.

It spreads rapidly to the lungs, lymph nodes, and liver.

Risk factors include chronic atrophic gastritis with intestinal metaplasia; pernicious anemia or having had gastric

resections (greater than 15 years prior); and adenomatous polyps.

This cancer is most common in men older than age 40 and in blacks.

Complications are hemorrhage and dumping syndrome from surgery or widespread metastasis and death.

Assessment:

1. Most often, the patient presents with the same symptoms as gastric ulcer. Later, evaluation shows the lesion to

be malignant.

2. Gastric fullness (early satiety), dyspepsia lasting more than 4 weeks, progressive loss of appetite are initial

symptoms.3. Stool samples are positive for occult blood.

4. Vomiting may occur and may have coffee-ground appearance.

5. Later manifestations include pain in black or epigastric area (often induced by eating, relieved by antacids or

vomiting); weight loss; hemorrhage; gastric obstruction.

Diagnostic Evaluation:

1. Upper GI X-ray with contrast media may initially show suspicious ulceration that requires further evaluation.

2. Endoscopy with biopsy and cytology confirms malignant disease.

3. Imaging studies (bone scan, liver scan, CT scan) helps determining metastasis.

4. Complete blood count (CBC) may indicate anemia from blood loss.

Surgical Interventions:

1. The only successful treatment of gastric cancer is gastric resection, surgical removal of partof the stomach with

involved lymph nodes; postoperative staging is done and further treatment may be necessary.

2. Surgical options include proximal or distal subtotal gastric resection; total gastrectomy (includes adjacent organs

such as tail of pancreas, portion of liver, duodenum); or palliative surgery such as subtotal gastrectomy

with gastroenterostomy to maintain continuity of the GI tract.

3. Surgery may be combined with chemotherapy to provide palliation and prolong life.

Nursing Interventions:

1. Monitor nutritional intake and weigh patient regularly.



2. Monitor CBC and serum vitamin B12 levels to detect anemia, and monitor albumin andprealbumin levels to

determine if protein supplementation is needed.

3. Provide comfort measures and administer analgesics as ordered.

4. Frequently turn the patient and encourage deep breathing to prevent pulmonary complications, to protect skin,

and to promote comfort.

5. Maintain nasogastric suction to remove fluids and gas in the stomach and prevent painful distention.

6. Provide oral care to prevent dryness and ulceration.

7. Keep the patient nothing by mouth as directed to promote gastric wound healing. Administer parenteral nutrition,

if ordered.

8. When nasogastric drainage has decreased and bowel sounds have returned, begin oral fluids and progress

slowly.

9. Avoid giving the patient high-carbohydrate foods and fluids with meals, which may trigger dumping syndrome

because of excessively rapid emptying of gastric contents.

10. Administer protein and vitamin supplements to foster wound repair and tissue building.

11. Eat small, frequent meals rather than three large meals.

12. Reduce fluids with meals, but take them between meals.

13. Stress the importance of long term vitamin B12 injections after gastrectomy to prevent surgically induced

pernicious anemia.

14. Encourage follow-up visits with the health care provider and routine blood studies and other testing to detect

complications or recurrence.

Is a malignant tumor.

It accounts for 6% of all childhood cancers.

It generally grows to a large size before it is diagnosed, usually before the child reaches age 5.

The tumor expands the renal parenchyma, and the capsule of the kidney becomes stretched over the surface of the

tumor.

Staging if from I (limited to kidney) to IV (matastasis) and stage V, which indicates bilateral involvement (rare).

The tumor may metastasize to the lymph nodes, lungs, liver, and brain.



Assessment

1. A firm, non-tender mass in the upper quadrant of the abdomen is usually the presenting sign. It may be on either

side.

2. Abdominal pain which is related to rapid growth of the tumor.

3. As the tumor enlarges, pressure may cause constipation, vomiting, abdominal distress, anorexia, weight loss and

dyspnea.

4. Less common manifestation are hypertension, fever, hematuria, and anemia.

5. Associated anomalies includes aniridia (absence of the iris), hemihypertrophy of the vertebrae, and genitourinary

anomalies.

Diagnostic Evaluation

1. Abdominal untrasound detects the tumor and assesses the status of the opposite kidney.

2. Chest X-ray and CT scan may be done to identify matastasis.

3. MRI or CT scan of the abdomen may be done to evaluate local spread to lymph nodes.

4. Urine specimens show hematuria; no increase in vanillylmandelic acid and homovanillic acidlevels as occurs with

neuroblastoma.

5. Complete blood count, blood chemistries, especially serum electrolytes, uric acid, renal function tests, and liver

functions tests, are done for baseline measurement and to detect metastasis.

Pharmacologic Interventions

1. Chemotherapy as initiated postoperatively to achieve maximal killing of tumor cells. Drug combinations include

vincristine and doxorubicin or vincristine and actinomycin D, depending on stage.

Surgical Intervention

1. Surgery is the gold standard of therapy. Accurate staging by the type of the tumor and the extent of invasiveness is

performed.

Nursing Interventions

Observe the surgical incision for erythema, drainage or separation. Report any of theses changes.

Monitor for elevated temperature or sign of infection post-operatively.

Monitor I.V. fluid therapy and intake and output carefully, including nasogastric (NG) drainage.

Encourage the parents to ask questions and to understand fully the risk and benefits of surgery.

Prepare the child for surgery, explain the procedures at the appropriate developmental level. Continue supporting the parents during the postoperative period.

Insert NG tube as ordered. Many children require gastric suction postoperatively to prevent distention or vomiting.

When bowel sounds have returned, begin administering small amounts of clear fluids.

Administer pain control medications as ordered in the immediate postoperative period.

Allow the child to participate in the selection of foods.

As the child recovers, encourage child to eat progressively larger meals.

If unable to eat because of radiation and chemotherapy provide I.V. fluids, hyperalimentation, or tube feedings as

indicated.

Prepare child and family for fatigue during recovery from surgery and with radiation treatments. Plan frequently rest

periods between daily activities.

Prepare the child and parents for loss of hair associated with chemotherapy and encourage use of hat as desired.Reassure the hair will grow back.



Is a common gynecologic malignancy that carries a high mortality because it is not usually diagnosed until well

advanced.

Its exact cause is unknown, about 10% of cases are associated with family history of breast, endometrial, colon,

or ovarian cancer.

High fat diet, smoking, alcohol, environmental toxins; patient history of breast, colon, or endometrial cancer, and

low parity are additional risk factors.

Ninety percent of ovarian tumors arise in epithelial tissue, with germ cell and stromal tissue making up the rest.

Incidence peaks in women age 50 or older.

Ovarian tumors spread intra-abdominally and through the lymph system.

Assessment 1. First manifestation includes vague abdominal discomfort, indigestion, flatulence, anorexia, pelvic pressure, weight

loss or gain, and palpable ovarian enlargement.

2. Late manifestations include abdominal pain, ascites, pleural effusion, and instestinal obstruction.


1. Pelvic sonography (with transvaginal probe) and CT scan may be done. Unfortunately, these are not sensitive to

early detection of ovarian cancer.

2. Color Doppler imaging may be used to detect vascular changes within the ovaries.

3. Paracentesis or thoracentesis are done if ascites or pleural effusion is present.

4. Laparotomy is necessary to stage the disease and determine effectiveness of the treatment.

5. CA 125 is a serum tumor marker that is not reliable for screening because its level may be elevated due to

inflammation; however, an increase signifies progression of disease.

Therapeutic and Pharmacologic Interventions

1. Chemotherapy is more effective if tumor is optimally bulked; usually follows surgery because of frequency of

advanced disease; may be given I.V. or intraperitoneally.

2. Immunotherapy with interferon or hormonal therapy with tamoxifen, an antiestrogen agent may be used.

Surgical Interventions

1. Total abdominal hysterectomy with bilateral salpingooophorectomy and omentectomy is usual treatment because

of delayed diagnosis.



2. Second-look laparotomy may be done after adjunct therapies to take multiple biopsy specimens and determine

effectiveness of therapy.


1. Administer anxiolytic and analgesic medications as prescribed and provide support throughout the diagnostic

process.

2. Administer or teach the patient or caregiver to administer antiemetics as needed for nausea and vomiting due to

chemotherapy.

3. Encourage small, frequent, bland meals or liquid nutritional supplements as able. Assess the need for I.V. fluids if

patient is vomiting.

4. Prepare the patient for body image changes resulting from chemotherapy.

5. Encourage the patient to prepare ahead of time with turbans, wig, hats, and so forth.

6. Stress the positive effects of the patient¶s treatment plan.

7. Prepare the patient for surgery as indicated.

8. Postoperatively, reposition frequently and encourage early ambulation to promote comfort and prevent adverse

effects.

9. Explain to the patient that ovary removal will cause menopausal symptoms.

10. Tell the patient that disease progression will be monitored closely by laboratory tests and that a second-look

laparoscopy may be necessary.

Is the second leading cause of carcinoma in men older than age 65.

The cause of the prostate cancer is unknown; there is an increased risk for people with a family history of the

disease, and the influence of dietary fat, serum testosterone, vasectomy, and industrial toxins is under

investigation.

Most prostate cancers are adenocarcinoma and are palpable on rectal examination because they are arise formthe posterior portion of the gland.

Prostate cancer usually multifocal, slow growing, and can spread by local extension, by lymphatics or through the

bloodstream.

Complications include bone metastasis leading to vertebral collapse, spinal cord compression, and pathologic

fractures, or spread to urinary tract to pelvic lymph nodes.

Assessment



1. First symptoms are caused by obstructed urinary flow, including hesitancy and straining on voiding, frequency,

nocturia, reduced size and force of urinary stream.

2. A firm to hard nodule may be felt on rectal examination of the prostate.

3. Pain in lumbosacral area radiating to hips and down leg (from bone metastases).

4. Perineal and rectal discomforts.

5. Anemia, weight loss, weakness, nausea, oliguria (from uremia).

6. Hematuria

7. Low extremity edema ± occurs when pelvic node metastases compromise when venous return.


1. Needle biopsy (through anterior rectal wall or through perineum) for histologic study of biopsy tissue or aspiration

for cytologic study.

2. Transrectal ultrasonography delineates tumor.

3. Prostate-specific antigen (PSA)

4. Metastatic workup may include skeletal x-ray, bone scan, and CT or MRI to detect local extension, bone, and

lymph node involvement.

Therapeutic Interventions

1. In many patients older than age 70, no treatment may be indicated because the cancer may be slow growing and

will not be the cause of death. Instead, the patients should be followed closely with periodic serum PSA testing

and examined for evidence of metastasis.

2. In advanced prostatic cancer not responsive to treatment, palliative measures include analgesics and opioids to

relieve pain, short course of radiation therapy and transurethral resection of the prostate.

3. Extreme beam radiation using linear accelerator focused on the prostate.

4. Interstitial radiation (brachytherapy).

Pharmacologic Interventions

1. Hormone manipulation deprives tumor cells of androgens or their by products and thereby alleviates symptoms

and retards progress of disease.

2. Analogs of luteinizing hormone-releasing hormone (LNRH), such as leuprolide, reduce testosterone levels.

3. Antiandrogen drugs that blocks androgen action directly at the target tissues and block androgen synthesis within

the prostate gland.4. Combination therapy with LHRH analogs and flutamide blocks the action of all circulating androgen.

5. Complications of hormonal manipulation include hot flashes, nausea, and vomiting, gynecomastia, and sexual

dysfunction.

Surgical Interventions

1. Radical prostatectomy ± removal of entire prostate gland, prostatic capsule, and seminal vesicles, may include

pelvic lymphadenectomy.

2. Cryosurgery freezes prostate tissue, killing tumor cells without prostatectomy.

3. Bilateral orchiectomy (removal of testes) result in reduction of the major circulating androgen, testosterone, as a

palliative measure to reduce symptoms and progression.


1. Assess pain control. Make sure that the patient is not undermedicated.2. Teach relaxation techniques such as imagery, music therapy, and progressive muscle relaxation as adjunct to

pain control.

3. Employ safety measures to prevent pathologic fractures, such as prevention of falls if bone metastasis is present.

4. To reduce anxiety, give repeated explanations of diagnostic tests and treatment options, and help the patient gain

some feeling of control over disease and decisions.

5. To help achieve optimal sexual function, give the patient the opportunity to communicate his concerns and sexual

needs.



6. Inform the patient that decreased libido expected after hormonal manipulation therapy, and that impotence may

result from some surgical procedures and radiation.

7. Suggest options such as sexual counseling, learning other options of sexual expression, and consideration of

penile implant.

8. Emphasize the importance of follow-up for check of PSA levels and evaluation for disease progression.

9. Teach the patient to administer hormonal agents intramuscularly or subcutaneously as indicated.

10. If bone metastasis has occurred, encourage safely measures around the home to prevent pathologic fractures,

such as removal of throw rugs, using handrail on stairs, and usingnightlights.

11. Advise the patient to report symptoms of worsening urethral obstruction, such as increased frequency, urgency,

hesitancy, and urinary retention.

12. Encourage all men to seek medical screening for prostate cancer.

Also called

bronchogenic cancer.

It is a malignant tumor of the lung arising within the bronchial wall or epithelium.



Bronchogenic cancer is classified according to cell type: epidermoid (squamous cell ± most common),

adenocarcinoma, small cell (oat cell) carcinoma, and large cell (undifferentiated)carcinoma.

The lung is also a common site of metastasis from cancer elsewhere in the body through venous circulation or

lymphatic spread.

The primary predisposing factor in lung cancer is cigarette smoking.

Lung cancer risk is also high in people occupationally exposed to asbestos, arsenic, chromium, nickel, iron,

radioactive substances, isopropyl oil, coal tar products, and petroleum oil mists.

Complications include superior vena cava syndrome, hypercalcemia (from bone metastasis), syndrome of

inappropriate antidiuretic hormone (SIADH), pleural effusion, pneumonia, brain metastasis, and spinal cord

compression.

ASSESSMENT

New or changing cough, dyspnea, wheezing, excessive sputum production, hemoptysis, chest pain (aching,

poorly localized), malaise, fever, weight loss, fatigue, or anorexia.

Decreased breath sounds, wheezing, and possible pleural friction rub (with pleural effusion) on examination.

DIAGNOSTIC EVALUATION

Chest X-ray may be suspicious for mass; CT or position emission tomography scan will be better visualize tumor.

Sputum and pleural fluid samples for cytologic examination may show malignant cells.

Fiberoptic bronchoscopy determines the location and extent of the tumor and may be used to obtain a biopsy

specimen.

Lymph node biopsy and mediastinoscopy may be ordered to establish lymphatic spread and help plan treatment.

Pulmonary function test, which may be combined with a split-function perfusion scan, determines if the patient will

have adequate pulmonary reserve to withstand surgical procedure.

PHARMACOLOGIC INTERVENTIONS

Expectorants and antimicrobial agents to relieve

dyspnea and infection.

Analgesics given regularly to maintain pain at

tolerable level. Titrate dosages to achieve pain

control.

Chemotherapy using cisplatin incombination with avariety of other agents and immunotherapy

treatments may be indicated.

SURGICAL INTERVENTIONS

Resection of tumor, lobe, or lung.

THERAPEUTIC INTERVENTIONS

Oxygen through nasal cannula based on level of

dyspnea.

Enteral or total parenteral nutrition for

malnourished patient who is unable or unwilling to eat.

Removal of the pleural fluid (by thoracentesis or tube thoracostomy) and instillation of sclerosing agent to

obliterate pleural space and fluid recurrence. Radiation therapy in combination with other methods.

NURSING INTERVENTIONS

1. Elevate the head of the bed to ease the work of breathing and to prevent fluid collection in upper body (from

superior vena cava syndrome).

2. Teach breathing retraining exercises to increase diaphragmatic excursion and reduce work of breathing.

3. Augment the patient¶s ability to cough effectively by splinting the patient¶s chest manually.

4. Instruct the patient to inspire fully and cough two to three times in one breath.

5. Provide humidifier or vaporizer to provide moisture to loosen secretions.

leukemia for lect

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