CASE STUDY

Mr. Gergen 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. Gergen 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 in 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 did not always remember to apply sunscreen.”

Case Study
There is a dark area on Mr. Gergen’s right ear approximately 0.4 cm by 0.4 cm round in size. The color of the surrounding skin is normal. Mr. Gergen 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. Gergen’s ear could be melanoma. * Describe your daily hygiene practices? * What skin products are you currently using? * Do you do anything to protect yourself from the sun? * Are you aware of any situation or stressor that changes your skin condition? * Do you think that stress plays a role in your skin condition? * Has your skin condition changed your relationship with others? * Are there any treatment options that you would be opposed to using?

2. Explain the ABCDE criteria for assessing a skin lesion. * A - Assessing for asymmetry * B - Border irregularity may be fuzzy * C - Color change and variation, can be multiple colors * D - Diameter of 6mm or more * E - Evolving in appearance

3. The dermatologist has scheduled Mr. Gergen for a punch biopsy within 24 hours. Mr. Gergen asks you the nurse to clarify what is a punch biopsy. Provide a brief explanation.
A punch biopsy is used to obtain a tissue sample for histologic study or to remove small lesions, generally reserved for lesions smaller than 0.5 cm. The instrument is rotated to appropriate level to include dermis and some fat. Suturing may or may not be done. Provides full thickness skin for diagnostic purposes.

4. Mrs. Gergen 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. Gergen’s assumption? List eight risk factors the nurse should include in an explanation of what puts individuals at greater risk for skin cancer. * Use of immune suppressive drugs * History of dysplastic nevi * People who have red or blonde hair * People who has blue or light colored eyes * People who are light – colored skin that freckles easily * UV radiation from the sun * Family history of melanomas * UV radiation from sunlamps and tanning booths.

5. Discuss the incidence of dark – skinned individuals diagnosed with melanoma.
Dark skinned persons are less susceptible to skin cancer because of the naturally occurring increased melanin, which is a sunscreen. However, although dark skin lowers the risk of melanoma, people with dark skin can develop melanoma, most often on the palms, soles, and mucous membranes.

6. The pathology report from the punch biopsy states, “deep penetrating nevi with atypical features worrisome for melanoma.” Given that the punch biopsy is suspicious for melanoma, the dermatologist prescribes a CT scan of the head, chest, neck, abdomen, thorax, and pelvis, MRI of the brain, and a PET scan of the body to determine the extent of Mr. Gergen’s melanoma. Explain each diagnosis exam.
CT scan – Performed for diagnosis of lesions difficult to assess by conventional x-ray. Mr. Gergen’s should be well hydrated before and after the procedure. Prior to the exam, he will be assessed for any allergies and renal function. He will also be instructed he will need to lie still on a hard table and the scanner will re____ his body with clicking noises.
MRI – Used to diagnose lesions difficult to assess by CT scan and distinguishing vascular from nonvascular structures. If closed MRI is used and patient has claustrophobia, provide with relaxation or other modes to ___patient must remove all metal before test.
PET scan – Used to distinguish benign and malignant pulmonary nodules. Prior to procedure, the nurse will check the blood glucose levels as high levels interfere with the test. Food and fluids other than water may be restricted for 4. Post procedure the nurse will encourage fluids to excrete radioactive substances.

7. Why is it important for the patient to have a PET scan?
It is important because the PET scan uses an IV radioactive glucose preparation; can demonstrate increased uptake of glucose in malignant lung cells. This is being used to determine if Mr. Gergen’s melanoma has spread to the lungs in his body.

8. What is the best treatment of choice for a patient diagnosed with malignant melanoma?
Initial treatment of malignant melanoma is surgical excision with some lymph node dissection, which may require a skin graft to close.

9. If the melanoma has spread to adjacent tissues and/or organs, what additional (adjuvant) treatments might the patient have to undergo? * Chemotherapy agents (dacarbazine (DTIC)), temozolomide (Temodar), procarbazine (Matulane), carmustine (BCNU), and lomustine (CCNU) * Biologic therapy (alpha – interferon, interleukin – 2) * Radiation therapy

10. Mr. Gergen asks the dermatologist, “What is my prognosis?” What is Mr. Gergen five – year survival rate?
The 5 – year survival rate depends on sentinel node biopsy results, which indicate if metastasis has occurred. If metastasis to other organs is found then treatment becomes palliative.

11. Identify two nursing diagnoses the nurse should consider for Mr. Gergen when he learns of his diagnosis of melanoma.
Anxiety related to diagnosis of cancer
Deficient knowledge related to risk factors for skin cancer.

12. Discuss what the nurse can do to reduce the fear and anxiety that Mr. Gergen may feel upon learning that he has melanoma.