Dermatologist

68 Part 5 ■ THE INTEGUMENTARY SYSTEM
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 suggested 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 physical 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 dermatologist. 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 suggests 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 dermatologist 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 diagnosis 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
CASE STUDY 4 ■ MR. VINCENT 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 consider 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)