Nursing Management in Cancer Care

Learning to Learning to make a make a differencedifference!!

Those who show strength Those who show strength

and character even in the and character even in the

most difficult times and can most difficult times and can inspire others with their inspire others with their

courage; are the kind of courage; are the kind of

people others look up to as people others look up to as

true heroes!true heroes!

Resource Information Canadian Resource Information Canadian Cancer SocietyCancer Societywww.cancer.ca1-888-939-33331-888-939-3333

Last class focus was on:Last class focus was on: Development of cancer & relationship to Development of cancer & relationship to

the immune systemthe immune system Comparison of normal & abnormal cellsComparison of normal & abnormal cells Importance of understanding cell cycle and Importance of understanding cell cycle and

how physicians try to making best use of how physicians try to making best use of medical treatment specific to phases of medical treatment specific to phases of cyclecycle

Staging & gradingStaging & grading

Today’s Class:Today’s Class: Warning signs of cancerWarning signs of cancer Overview of psychosocial impact, treatment methodsOverview of psychosocial impact, treatment methods FatigueFatigue CachexiaCachexia Nausea & vomitingNausea & vomiting StomatitisStomatitis Constipation & diarrheaConstipation & diarrhea Pain managementPain management

Today’s Class ObjectivesToday’s Class Objectives

Discuss the warning signs of cancerDiscuss the warning signs of cancer Discuss broadly the nurse’s role in planning Discuss broadly the nurse’s role in planning

treatmenttreatment List the different treatment methods for cancerList the different treatment methods for cancer Describe goals for quality end-of-life careDescribe goals for quality end-of-life care Discuss symptom management related to fatigue, Discuss symptom management related to fatigue,

nausea, vomiting, cachexia, stomatitis , nausea, vomiting, cachexia, stomatitis , constipation & diarrhea, painconstipation & diarrhea, pain

Warning Signs CancerWarning Signs Cancer

CC - -Change in bowel or bladderChange in bowel or bladder

AA - A sore that does not heal- A sore that does not heal

UU -Unusual bleeding or discharge -Unusual bleeding or discharge

TT -Thickening or lump -Thickening or lump

II -Indigestion or difficulty swallowing -Indigestion or difficulty swallowing

OO -Obvious change in wart or mole -Obvious change in wart or mole

NN - Nagging cough or hoarseness- Nagging cough or hoarseness

Cancer & the Person:Cancer & the Person:

How will the person How will the person

with cancer deal withwith cancer deal with

initial diagnosis, treatment,initial diagnosis, treatment,

& short/long term consequences & short/long term consequences to self & to significant others?to self & to significant others?

Cancer has taken me twice and flung me to a new space. The first time, I overcame the fear of cancer. This time, I’m working on the anger of recurrence. Always a strong person, I feel both experiences have given me strengths I never have believed I was capable of. I have a deeper sense of life and joy. So in spite of the hair loss, the energy loss, and the protocols, I am becoming tempered, like steel. My metal is tested, and I am not found wanting. I’m living on a higher plane of existence (Ferrell, 1995).

Have you experienced Have you experienced situations where you situations where you

wished you could have wished you could have intervened more positively intervened more positively

to help persons with to help persons with cancer?cancer?

Identify a few?Identify a few?

Cancer Affects:Cancer Affects:

All levels of functioning:All levels of functioning: Intellectual Intellectual PsychologicalPsychological Self-conceptSelf-concept PhysicalPhysical SpiritualSpiritual

Psychosocial Aspects of Psychosocial Aspects of CancerCancer

Cancer is a feared and dreaded disease Cancer is a feared and dreaded disease because:because:

1.1. Maybe present in advanced stages with no Maybe present in advanced stages with no manifestationsmanifestations

2.2. Compliance with vigorous and often Compliance with vigorous and often disfiguring treatments doesn’t guarantee a disfiguring treatments doesn’t guarantee a cure.cure.

3.3. Cancer may recur after many years of Cancer may recur after many years of remission.remission.

4.4. A healthy life-style does not ensure escape A healthy life-style does not ensure escape from the disease.from the disease.

Coping:Coping:

Coping:Coping: is a dynamic process by is a dynamic process by which a client responds to a which a client responds to a problem to bring about relief or problem to bring about relief or equilibrium.equilibrium.

General Coping Strategies:General Coping Strategies:-Rational inquiry -Rational inquiry -Negiotation -Negiotation-Affect reversal-Affect reversal -Tension reduction -Tension reduction-Suppression-Suppression - Disengagement - Disengagement-Mutuality-Mutuality - Projection - Projection-Displacement/redirection -Cooperative -Displacement/redirection -Cooperative

compliancecompliance-Confrontation-Confrontation -Moral masochism -Moral masochism-Redefinition/revision-Redefinition/revision-Fatalism/passive acceptance-Fatalism/passive acceptance-Impulsivity-Impulsivity

Individual’s Responses to Individual’s Responses to CancerCancer

Depend upon:Depend upon: The clients & client’s psychological The clients & client’s psychological

make-upmake-up The client’s family & social communityThe client’s family & social community The disease, disabilities & disfigurement The disease, disabilities & disfigurement

it may causeit may cause Preexisting medical conditions that may Preexisting medical conditions that may

limit treatment options.limit treatment options.

Enabling Factors in Coping with Enabling Factors in Coping with Cancer:Cancer:

Social support systems Problem-solving abilitySocial support systems Problem-solving abilityReligionReligion Perception of control Perception of controlSelf-esteemSelf-esteem Humor Humor Positive appraisalPositive appraisal Hardiness HardinessHopefulnessHopefulness Information-seeking Information-seekingPositive comparisonsPositive comparisons Social skills Social skillsOpen communicationOpen communication

Jalowiec & Dundas (1991)Jalowiec & Dundas (1991)

Hindering factors in Coping with Hindering factors in Coping with Cancer:Cancer:

DenialDenial AvoidanceAvoidanceHelplessnessHelplessness PowerlessnessPowerlessnessHopelessnessHopelessness DepressionDepressionGuiltGuilt IsolationIsolationWishful thinking Erosion of autonomyWishful thinking Erosion of autonomyAnger Blaming othersAnger Blaming othersNoncomplianceNoncompliance

Jalowiec & Dundas (1991)Jalowiec & Dundas (1991)

Purpose of Nursing Purpose of Nursing InterventionsInterventions

The purpose of nursing interventions is to The purpose of nursing interventions is to help help

individuals cope individuals cope withwith the experience of illness & the experience of illness & suffering, and if necessary to find meaning in such suffering, and if necessary to find meaning in such experiencesexperiences. Helping the sick to maintain hope & . Helping the sick to maintain hope & avoid helplessness is a major responsibility for the avoid helplessness is a major responsibility for the nurse nurse (Rustoen & Hanestad, p. 19, 1998).(Rustoen & Hanestad, p. 19, 1998).

Responsibilities of the Nurse in Cancer Care

Support the idea that cancer is a chronic illnessSupport the idea that cancer is a chronic illness Assess own level of knowledge relative to the pathophysiologyAssess own level of knowledge relative to the pathophysiology Make use of current research findings and practices in care of Make use of current research findings and practices in care of

clients with cancerclients with cancer Identify clients at high risk for cancerIdentify clients at high risk for cancer Participate in primary and secondary preventionParticipate in primary and secondary prevention Assess nursing care needs of client with cancerAssess nursing care needs of client with cancer Assess learning needs, desires and capabilitiesAssess learning needs, desires and capabilities Assess social supports of client and familyAssess social supports of client and family Plan and implement appropriate interventions in collaboration Plan and implement appropriate interventions in collaboration

with the multidisciplinary team.with the multidisciplinary team. Evaluate goals and outcome and modify plan of care as Evaluate goals and outcome and modify plan of care as

necessary.necessary.

Nursing Interventions in Supporting Nursing Interventions in Supporting the the Cancer client Cancer client

Be available, especially during difficult timesBe available, especially during difficult times Exhibit a caring attitudeExhibit a caring attitude Listen actively to fears & concernsListen actively to fears & concerns Provide relief from distressing symptomsProvide relief from distressing symptoms Provide essential info regarding cancer & careProvide essential info regarding cancer & care Maintain a relationship build on trust & Maintain a relationship build on trust &

confidence (be honest)confidence (be honest) Appropriate use of touch exhibits caringAppropriate use of touch exhibits caring Assist in setting realistic, reachable goalsAssist in setting realistic, reachable goals Assist in maintaining usual lifestyle patternsAssist in maintaining usual lifestyle patterns Maintain hopeMaintain hope

Maintaining Hope in Persons With Maintaining Hope in Persons With Cancer Nursing InterventionsCancer Nursing Interventions

Encouraging:Encouraging: Belief in oneself & ability (affirm the individual’s

worth) Encourage emotional expression Help recall positive memories, times of joy and

fulfillment Help maintain meaningful relationships with others Active involvement Support spiritual beliefs & values Help conserve or enhance available energy, control

pain Be honest & clear in delivery of “info” Focus on the present – day by day – rather then an

uncertain future. Help find images symbols or rituals that foster hope

Planning Treatment: Nursing Role

Build upon clients strengths Clarify Misconceptions (FEARS) Teach treatment process including simulation

component Teach potential reactions Support client & their support persons Permit the client with uninterrupted time to

talk Mobilizing social support systems

Treatment Modalities Treatment Modalities &&

Cancer Symptom Cancer Symptom ManagementManagement

..

Cancer Treatment may be Cancer Treatment may be aimed at:aimed at:

Cure:Cure: Complete eradication of malignant Complete eradication of malignant

diseasedisease

Control:Control: Containment of cancer cell growth; long Containment of cancer cell growth; long

term survival term survival

Palliation:Palliation: Relief or control of symptoms and Relief or control of symptoms and

maintenance of quality of lifemaintenance of quality of life

Treatment Methods for Treatment Methods for CancerCancer

Surgery Radio-therapy Chemotherapy Hormone-therapy Immuno-therapy Photodynamic therapy Intraoperative Radiation Whole Body Hyperthermia Recombinant Interferon Bone marrow transplant

Whole Body Hyperthermia Photodynamic Therapy

Immunotherapy

Using antibodies to target killer cells directly to cancer cells: Antibodies are bound to the surface of killer cells, and they recognize specific markers on the cancer cell leading to its extermination

Symptoms of Cancer & Symptoms of Cancer & treatments:treatments:

FatigueFatigue

CachexiaCachexia

Nausea & VomitingNausea & Vomiting

StomatitisStomatitis

Constipation/diarrheaConstipation/diarrhea

Skin reactions Skin reactions (Chemo/radiation)(Chemo/radiation)

Pain (separate class)Pain (separate class)

Assessment: Assessment: Symptoms of Cancer & Symptoms of Cancer &

TreatmentsTreatments

InfectionInfection BleedingBleeding Skin reactions, mucositis/stomatitis, hair Skin reactions, mucositis/stomatitis, hair

lossloss Nutritional Concerns (anorexia, cachexia)Nutritional Concerns (anorexia, cachexia) GI disturbances (diarrhea, constipation, GI disturbances (diarrhea, constipation,

nausea & vomiting)nausea & vomiting) PainPain FatigueFatigue Psychosocial statusPsychosocial status Body ImageBody Image

Nursing Diagnoses of Client with Nursing Diagnoses of Client with CancerCancer

Risk for infection related to altered Risk for infection related to altered immunologic responseimmunologic response

Impaired tissue integrity: alopecia r/t the Impaired tissue integrity: alopecia r/t the effects of treatment & diseaseeffects of treatment & disease

Impaired oral mucous membranes: Impaired oral mucous membranes: stomatitisstomatitis

Altered nutrition: less than body Altered nutrition: less than body requirements r/t anorexia & GI changes.requirements r/t anorexia & GI changes.

Pain & discomfort r/to disease & treatment Pain & discomfort r/to disease & treatment effects.effects.

Nursing Diagnoses of Client with Nursing Diagnoses of Client with CancerCancer

Fatigue r/t physical and Fatigue r/t physical and psychological stressors.psychological stressors.

Anticipatory grieving r/t anticipated Anticipatory grieving r/t anticipated loss and altered role function.loss and altered role function.

Body image disturbance r/t changes Body image disturbance r/t changes in appearance and role function.in appearance and role function.

PC: BleedingPC: Bleeding

Infection is the leading cause of deathInfection is the leading cause of death

Predisposing factors includes Predisposing factors includes chemo, chemo, radiation treatment, malnutrition, radiation treatment, malnutrition, catheters, IV’s, age, impaired skin & catheters, IV’s, age, impaired skin & mucous membranes, contaminated mucous membranes, contaminated equipment, meds, chronic illnessesequipment, meds, chronic illnesses

Prolonged hospitalizationsProlonged hospitalizations

Infection

More predisposing Factors to More predisposing Factors to infection:infection:

Nurse Monitors WBC CountsNurse Monitors WBC Counts Leukopenia is a decrease in WBC Leukopenia is a decrease in WBC Neutrophils make up 60-70% of the body’s WBCsNeutrophils make up 60-70% of the body’s WBCs

WBCs play a major role in combating infection by WBCs play a major role in combating infection by engulfing and destroying infective agents in a engulfing and destroying infective agents in a process called phagocytosis. Both the total WBC process called phagocytosis. Both the total WBC and the concentration of WBCs are important in and the concentration of WBCs are important in determining the patient’s ability to fight infection.determining the patient’s ability to fight infection.

Neutropenia puts clients at risk for infectionNeutropenia puts clients at risk for infection Nadir Nadir is the lowest ANC after myelosuppressive

chemo or RT An ANC below 1.0 x 109/L causes severe risk for

infection

ANC: Absolute Neutrophil ANC: Absolute Neutrophil countcount

CalculationCalculation

ANC < 1.0 x 109 = severe risk for infection

Interventions for InfectionInterventions for Infection

Monitor blood cell countsMonitor blood cell counts Protect client from infectionProtect client from infection

Aseptic techniqueAseptic technique Hand washingHand washing Client/family teachingClient/family teaching

Assess for infection: blood cultures, Assess for infection: blood cultures, sputum, stool, urine, catheter or sputum, stool, urine, catheter or woundswounds

CXRCXR

Important to Know Lab Important to Know Lab ValuesValues

has been described as the most prevalent & disturbing symptom of cancer & its treatment –

•80-96% of people on chemo experience fatigue

•Fatigue can be Acute or Chronic

Fatigue like pain, has 4 components:

A) Physical B) Psychological C) Social D) Spiritual aspects

The Impact of Fatigue on Quality of The Impact of Fatigue on Quality of LifeLife

A: PHYSICAL WELL-BEINGA: PHYSICAL WELL-BEING

energyenergy

functional abilityfunctional ability

painpain

sleepsleep

restrest

strengthstrength

The Impact of Fatigue on Quality of LifeThe Impact of Fatigue on Quality of Life

B: SOCIAL WELL-BEINGB: SOCIAL WELL-BEING

caregiver burdencaregiver burden

impact on work- home & workplaceimpact on work- home & workplace

financial burdenfinancial burden

family/ other roles, relationshipsfamily/ other roles, relationships

affection & sexual functionaffection & sexual function

The Impact of Fatigue on Quality of The Impact of Fatigue on Quality of LifeLife

C: PSYCHOLOGICAL WELL-BEINGC: PSYCHOLOGICAL WELL-BEING

anxiety anxiety

frustrationfrustration

fear experiencing fatiguefear experiencing fatigue

feeling uselessfeeling useless

coping & acceptancecoping & acceptance

loss of independenceloss of independence

Loss of cognition/attentionLoss of cognition/attention

depressiondepression

The Impact of Fatigue on Quality of The Impact of Fatigue on Quality of LifeLife

D: SPIRITUAL WELL-BEINGD: SPIRITUAL WELL-BEING Can experience a change in spirituality Can experience a change in spirituality

altered prioritiesaltered priorities

hopelessnesshopelessness

meaning of fatiguemeaning of fatigue

Nursing Interventions : Fatigued Cancer Nursing Interventions : Fatigued Cancer ClientClient

•Careful assessment of ability to carry out ADL

•Mild exercise, pace activities & rest periods

•Rest, naps, sleep (8hrs) & conserve energy, don’t overdo it

•direct /provide counseling

•Manage other manifestations leading to fatigue

•Keep fatigue diary (scale) … “have to” activities 1st

•Get help with least important tasks

•Eat small frequent attractive meals

•Evaluate medications client is taking (over-the-counter)

Name given to symptoms comprising:Name given to symptoms comprising: AnorexiaAnorexia Early satietyEarly satiety Weight lossWeight loss AnemiaAnemia AstheniaAsthenia Tissue wastingTissue wasting Organ dysfunctionOrgan dysfunction

Cachexia-Anorexia Syndrome

Four Causes of Cachexia in Cancer Four Causes of Cachexia in Cancer Clients:Clients:

1.1. Decreased nutritional intake due toDecreased nutritional intake due to:: Anorexia (present 80% terminal ca)Anorexia (present 80% terminal ca) Malfunction of GI tractMalfunction of GI tract Psychological factorsPsychological factors

2. Increased nutritional losses:2. Increased nutritional losses: BleedingBleeding Protein losses through intestineProtein losses through intestine diarrheadiarrhea

tumor-related catabolism has little effecttumor-related catabolism has little effect

Causes of Cachexia in Cancer Clients:Causes of Cachexia in Cancer Clients:Cont’dCont’d

3. 3. Abnormalities of metabolism:Abnormalities of metabolism:increased expenditure of energyincreased expenditure of energychanges in CHO metabolismchanges in CHO metabolismchanges in lipid metabolismchanges in lipid metabolismabnormalities in protein metabolismabnormalities in protein metabolismchanges in body compositionchanges in body composition

4. Effects of anti-tumor treatments4. Effects of anti-tumor treatments:: surgerysurgery chemotherapychemotherapy radiationradiation

Consequences of Cachexia:Consequences of Cachexia:

Protein depletion: enzymes & serum proteinsProtein depletion: enzymes & serum proteins Poor wound healingPoor wound healing Impaired immunityImpaired immunity Fluid retentionFluid retention Vitamin deficiencyVitamin deficiency Fatigue and weaknessFatigue and weakness Death : occurs when 30-50% of body protein Death : occurs when 30-50% of body protein

stores are loststores are lost

Nursing the Client with Cachexia:Nursing the Client with Cachexia:

Nutritional assessment:Nutritional assessment: Determine the rate & extent of wt. lossDetermine the rate & extent of wt. loss Assess for symptoms of malabsorptionAssess for symptoms of malabsorption Assess if client is on any special dietsAssess if client is on any special diets Assess for problems with taste, chewing, Assess for problems with taste, chewing,

N&V, swallowing N&V, swallowing Food allergies/ learned food aversionsFood allergies/ learned food aversions MedicationsMedications

Nursing the Client with Cachexia:Nursing the Client with Cachexia:

Physical AssessmentPhysical Assessment:: integument assessment: dry, scaly, integument assessment: dry, scaly,

atrophic tissuesatrophic tissues Cheilosis, glossitis or other vitamin Cheilosis, glossitis or other vitamin

deficiency signsdeficiency signs Alterations in taste (metallic)Alterations in taste (metallic) Muscle wasting, loss of muscle strengthMuscle wasting, loss of muscle strength Assess pitting edemaAssess pitting edema Monitor lab values (albumin)Monitor lab values (albumin)

Treating Cachexia In Cancer Treating Cachexia In Cancer Clients:Clients:

Factors to consider in choosing Factors to consider in choosing nutrition:nutrition: Client’s ability to chew & swallowClient’s ability to chew & swallow Client’s capacity to digest/absorb Client’s capacity to digest/absorb

enteral nutritionenteral nutrition Client’s complianceClient’s compliance Family supportFamily support costcost

Treating Cachexia In Cancer Treating Cachexia In Cancer Clients:Clients:

Administration Routes:Administration Routes: based on functional status of GI tract.based on functional status of GI tract. enteral feeding preferred (prevents enteral feeding preferred (prevents

mucosal atrophy, preserves gut flora & mucosal atrophy, preserves gut flora & maintains immune status)maintains immune status)

Oral (if able to ingest sufficient Oral (if able to ingest sufficient nutrients)nutrients)

Dietary consultDietary consult

Enteral feeding : Cachexia Enteral feeding : Cachexia ClientClient

Routes:Routes:NG tubesNG tubes most commonly usedmost commonly used short-term use in hospitalshort-term use in hospital left in place usually 4 to 6 weeksleft in place usually 4 to 6 weeks ensure proper placement to prevent aspirationensure proper placement to prevent aspiration

GastrostomyGastrostomy:: tube-placed local anesthesia tube-placed local anesthesia Does not easily clog large (16-20F)Does not easily clog large (16-20F) Unlikely to dislodgeUnlikely to dislodge Allows stomach to dilute solutions (less diarrhea)Allows stomach to dilute solutions (less diarrhea) advantage:advantage: low risklow risk of aspiration of aspiration

NG Tube InsertionNG Tube Insertion

Nursing Management : Feeding Nursing Management : Feeding TubesTubes

Check tube placement before feeding/drugsCheck tube placement before feeding/drugs Assess BSAssess BS Liquid meds if possibleLiquid meds if possible Dilute viscous medsDilute viscous meds Crush tablets & diluteCrush tablets & dilute Elevate HOB, flush tubingElevate HOB, flush tubing Assess for aspiration, diarrhea, abd. Assess for aspiration, diarrhea, abd.

Distension, hyperglycemia, constipation.Distension, hyperglycemia, constipation.

Enteral feeding : Cachexia Enteral feeding : Cachexia ClientClient

cont’dcont’dJejunostomy tubeJejunostomy tube:: Recommended in proximal GI obstruction or fistualRecommended in proximal GI obstruction or fistual Advantages: less stomal leakage, skin erosion, Advantages: less stomal leakage, skin erosion,

N&V, bloatingN&V, bloating Disadvantage: diarrheaDisadvantage: diarrhea

start with small volumes (25-30cc/hr)start with small volumes (25-30cc/hr)

gradually increase volume over 3 to 4 daysgradually increase volume over 3 to 4 days

Do not use antidiarrheals to increase toleranceDo not use antidiarrheals to increase tolerance

Enteral feeding Enteral feeding complications:complications:

Diarrhea & crampingDiarrhea & cramping Vomiting & bloatingVomiting & bloating HyperglycemiaHyperglycemia EdemaEdema CHFCHF hypernatremia/hypercalcemiahypernatremia/hypercalcemia Clogged tubingClogged tubing Rare aspiration pneumonia, esophageal Rare aspiration pneumonia, esophageal

erosionerosion

Occurs in 60% of terminally ill clientsOccurs in 60% of terminally ill clients 40% last week of life40% last week of life Clients stomach cancers prevalentClients stomach cancers prevalent Occurs in up to 60% of clients Occurs in up to 60% of clients

receiving opioidsreceiving opioids

Nausea & Vomiting

Pathyophysiology N&V:Pathyophysiology N&V:

Vomiting reflex begins with nausea Vomiting reflex begins with nausea Vomiting center in brain dorsolateral reticular formation of Vomiting center in brain dorsolateral reticular formation of

medulla coordinates the act of vomiting.medulla coordinates the act of vomiting. FourFour mechanisms trigger vomiting: mechanisms trigger vomiting:

1. 1. vestibular nucleivestibular nuclei:: triggered by dizziness , motion sickness, triggered by dizziness , motion sickness, ear infections, ca cells nervous system, changes in cerebellumear infections, ca cells nervous system, changes in cerebellum

2. 2. cerebral Cortex:cerebral Cortex: triggered by cognitive awareness or triggered by cognitive awareness or anticipatory action to smelling, tasting or thinking about an anticipatory action to smelling, tasting or thinking about an experience that causes N&V.experience that causes N&V.

Pathyophysiology N&V: cont’dPathyophysiology N&V: cont’d3. 3. Chemoreceptor Triggor Zone (CTZChemoreceptor Triggor Zone (CTZ))

Stimulated by buildup of toxic chemicals, chemo & radiation, Stimulated by buildup of toxic chemicals, chemo & radiation, uremia, narcotics, hypercalcemiauremia, narcotics, hypercalcemia

44. . Viscera GIViscera GI triggored by upper GI sends message CNS via Vagal nerves as triggored by upper GI sends message CNS via Vagal nerves as a result of decrease GI mobilitya result of decrease GI mobilitycaused by gastric stasis, tumor obstruction, drugs, radiation, caused by gastric stasis, tumor obstruction, drugs, radiation, metastic disease GI tract.metastic disease GI tract.

Garrett, Walker, Jackson, Sweat (2003)Garrett, Walker, Jackson, Sweat (2003)

Antiemetics are mechanism Antiemetics are mechanism specific:specific:

1. 1. Vestibular nuclei:Vestibular nuclei: Gravol, Benadryl, Gravol, Benadryl, ScopolamineScopolamine

2. 2. Cerebral Cortex:Cerebral Cortex: Ativan, Nabilone Ativan, Nabilone

3. 3. CTZ:CTZ: stemetil, haldol, maxeran, zofran & stemetil, haldol, maxeran, zofran & largactillargactil

4. 4. Viscera GI:Viscera GI: Maxeran, motilium, zofran Maxeran, motilium, zofran

Site of action unknown: decadron & Site of action unknown: decadron & marajuanamarajuana

N/VN/V

Pre-medication for chemotherapy regimes Pre-medication for chemotherapy regimes known to likely combat n/v. Newer serotinin known to likely combat n/v. Newer serotinin receptor antagonists are useful especially in receptor antagonists are useful especially in the 1st 24 hrs of chemo (control afferent the 1st 24 hrs of chemo (control afferent pathway stimulation)pathway stimulation)

Ongoing multidisciplinary assessment Ongoing multidisciplinary assessment essentialessential

Ondansetron or ZofranOndansetron or Zofran

Serotonin 5-HT3 Serotonin 5-HT3 ((hydroxytryptamine)hydroxytryptamine) receptor antagonistreceptor antagonist

AntiemeticAntiemetic Reduces the activity of the vagus nerveReduces the activity of the vagus nerve

Vagus Nerve:Vagus Nerve: Activates the vomiting center in Activates the vomiting center in the medulla oblongatathe medulla oblongata

ZofranZofran: Blocks serotonin receptors in : Blocks serotonin receptors in chemoreceptor trigger zone chemoreceptor trigger zone

Zofran:Zofran: Little effect on vomiting caused by Little effect on vomiting caused by motion sickness motion sickness

Non pharmaceutical Non pharmaceutical interventions interventions for for

N/VN/V Adjustment of fluid & oral intakeAdjustment of fluid & oral intake RelaxationRelaxation ExerciseExercise HypnosisHypnosis biofeedbackbiofeedback Guided imageryGuided imagery Avoid offensive odors to clientAvoid offensive odors to client Small frequent mealsSmall frequent meals Assess client drugs & d/c unnecessary onesAssess client drugs & d/c unnecessary ones

Mucositis/StomatitisMucositis/Stomatitis: a general term referring to : a general term referring to the the inflammation of the oral cavity & shallow inflammation of the oral cavity & shallow ulcerative lesions occurring on the mucosal ulcerative lesions occurring on the mucosal surface of the mouthsurface of the mouth

Increases the risk for infections both local & Increases the risk for infections both local & systemicsystemic

Caused by chemotherapy (causes tissue Caused by chemotherapy (causes tissue damage of the basal layers of oral mucosa & damage of the basal layers of oral mucosa & inhibits replacement of superficial cell layers.inhibits replacement of superficial cell layers.

Normally resolves 1-2 weeks post chemo.Normally resolves 1-2 weeks post chemo.

Mucositis/Stomatitis

Nursing Management Stomatitis:Nursing Management Stomatitis:

Assessment:Assessment: Buccal cavity (red, swollen, painful, ulcers, Buccal cavity (red, swollen, painful, ulcers,

dryness)dryness) Teeth (intact, swollen)Teeth (intact, swollen) Mucous membranes & denturesMucous membranes & dentures Oral pain/bleeding in mouthOral pain/bleeding in mouth Dysphagia, assess changes in tastesDysphagia, assess changes in tastes Know dental history (prior treatment)Know dental history (prior treatment) Mouthcare Q4h vital (no alcohol & no Mouthcare Q4h vital (no alcohol & no

mouthwash) mouthwash) Soft toothbrush Soft toothbrush Chilled or frozen yogurt sooths oral mucosa Chilled or frozen yogurt sooths oral mucosa Foods at room temperature, no acid, spicesFoods at room temperature, no acid, spices

common & potentially debilitating problem common & potentially debilitating problem for advanced cancerfor advanced cancer

Close to 90% clients receiving opioidsClose to 90% clients receiving opioids Due to:Due to:

low-fiber diets, dehydration, low-fiber diets, dehydration, inactivityinactivity

Hypercalcemia & hypokalemiaHypercalcemia & hypokalemia

Tumors, spinal cord compressionTumors, spinal cord compression

ConstipationConstipation

Constipation Symptoms :Constipation Symptoms :

AnoxeriaAnoxeria N & VN & V Abd. Pain may radiate back, chest, upper Abd. Pain may radiate back, chest, upper

legslegs BloatingBloating Diarrhea (leaking feces past the hard fecal Diarrhea (leaking feces past the hard fecal

obstruction)obstruction) UI (urinary incontinence)UI (urinary incontinence) TenesmusTenesmus- painful & ineffective straining - painful & ineffective straining

of stoolof stool

Constipation:Constipation:Abdominal Exam:Abdominal Exam:Auscultate abdomen bowel sounds X4 (1 min)Auscultate abdomen bowel sounds X4 (1 min)DistensionDistensionTenderness right lower quadrant (cecum)Tenderness right lower quadrant (cecum)Rectal exam:Rectal exam: evidence fecal soilingevidence fecal soilingHard impacted fecesHard impacted fecesHemmorroids, painful fissuresHemmorroids, painful fissuresScarring abd. surgeries/ stenosis (tumors)Scarring abd. surgeries/ stenosis (tumors)Abd flat plate:Abd flat plate: rule out obstruction if diagnosis rule out obstruction if diagnosis

unclearunclear

Constipation Interventions:Constipation Interventions:

Prophylactic regimen if on opiods!!Prophylactic regimen if on opiods!! Hydrate clientHydrate client Increase fiber in diet if toleratedIncrease fiber in diet if tolerated Administer stool softeners as ordered after fecal Administer stool softeners as ordered after fecal

impaction is ruled outimpaction is ruled out Start with colonic stimulant (bisacodyl) and stool Start with colonic stimulant (bisacodyl) and stool

softener (colace)softener (colace) Soft infrequent BM’s give senna, more bisacodyl Soft infrequent BM’s give senna, more bisacodyl

to stimulate peristalsisto stimulate peristalsis Hard BM give lactulose Hard BM give lactulose If 3 days no BM , rectal exam & give a supp if not If 3 days no BM , rectal exam & give a supp if not

contraindicatedcontraindicated

Passage of 3-4 loose or fluid stools in Passage of 3-4 loose or fluid stools in 24 hours.24 hours.

Occurs 5-10% cancer clients with Occurs 5-10% cancer clients with advanced diseaseadvanced disease

Far less common than constipation in Far less common than constipation in cancer clientscancer clients

Can lead to dehydration, Can lead to dehydration, malabsorption, fatigue, electrolyte malabsorption, fatigue, electrolyte imbalances.imbalances.

DiarrheaDiarrhea

Causes of Diarrhea in Advanced Causes of Diarrhea in Advanced Cancer:Cancer:

Fecal impaction: opioids without laxativesFecal impaction: opioids without laxatives Intermittent bowel obstructionIntermittent bowel obstruction Effects of treatments chemo, rad, surgeryEffects of treatments chemo, rad, surgery Medications, laxatives, A/B, iron, sorbitol Medications, laxatives, A/B, iron, sorbitol

(cough syrups)(cough syrups) Malnutrition/cachexiaMalnutrition/cachexia Rectal incontinenceRectal incontinence InfectionInfection Carcinoid tumors-secrete serotoninCarcinoid tumors-secrete serotonin

Physical Assessment : DiarrheaPhysical Assessment : Diarrhea

BS: present/absent; hypo/hyperactiveBS: present/absent; hypo/hyperactive Palpable massesPalpable masses Rectal exam: anal sphincter tone, dischargeRectal exam: anal sphincter tone, discharge Stool: number, consistency, colour (keep Stool: number, consistency, colour (keep

record stool chart)record stool chart) Send stools specimens rule out infection O&P, Send stools specimens rule out infection O&P,

C&SC&S

Management Diarrhea:Management Diarrhea:

Stop laxatives if on Stop laxatives if on Rest the bowel- clear fluid diet with additional CHO Rest the bowel- clear fluid diet with additional CHO

(toast) avoid proteins, fats, milk until stops(toast) avoid proteins, fats, milk until stops Replace fluid losses Unable to drink IV RLReplace fluid losses Unable to drink IV RL Assess meds stop meds iron, sorbitol-containing Assess meds stop meds iron, sorbitol-containing

syrupssyrups Give loperamide 4mg then 2mg after each stool Give loperamide 4mg then 2mg after each stool

(16mg/24hrs) if diarrhea resistant to conservative (16mg/24hrs) if diarrhea resistant to conservative measuresmeasures

Peri-care & sitz bathsPeri-care & sitz baths

Maintain integrity of oral mucous membranesMaintain integrity of oral mucous membranes Maintain adequate tissue perfusionMaintain adequate tissue perfusion Maintain adequate nutritional statusMaintain adequate nutritional status Achieves relief of pain & discomfortAchieves relief of pain & discomfort Increased activity tolerance & decreased fatigueIncreased activity tolerance & decreased fatigue Exhibits improved body image & self-esteemExhibits improved body image & self-esteem Progress through grieving processProgress through grieving process Experiences no complications, such as infections, Experiences no complications, such as infections,

bleeding etc.bleeding etc.

EvaluationEvaluation