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Nursing Management in Cancer Care Learning to make a difference! Those who show strength and character even in the most difficult times and can inspire others with their courage; are the kind of people others look up to as true heroes! Resource Information Canadian Cancer Society www.cancer.ca 1-888-939-3333 Last class focus was on: Development of cancer & relationship to the immune system Comparison of normal & abnormal cells Importance of understanding cell cycle and how physicians try to making best use of medical treatment specific to phases of cycle Staging & grading Today’s Class: Warning signs of cancer Overview of psychosocial impact, treatment methods Fatigue Cachexia Nausea & vomiting Stomatitis Constipation & diarrhea Pain management Today’s Class Objectives Discuss the warning signs of cancer Discuss broadly the nurse’s role in planning treatment List the different treatment methods for cancer Describe goals for quality end-of-life care Discuss symptom management related to fatigue, nausea, vomiting, cachexia, stomatitis , constipation & diarrhea, pain Warning Signs Cancer C -Change in bowel or bladder A - A sore that does not heal U -Unusual bleeding or discharge T -Thickening or lump I -Indigestion or difficulty swallowing O -Obvious change in wart or mole N - Nagging cough or hoarseness Cancer & the Person: How will the person with cancer deal with initial diagnosis, treatment, & short/long term consequences 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 situations where you wished you could have intervened more positively to help persons with cancer? Identify a few? Cancer Affects: All levels of functioning: Intellectual Psychological Self-concept Physical Spiritual Psychosocial Aspects of Cancer Cancer is a feared and dreaded disease because: 1. 2. 3. 4. Maybe present in advanced stages with no manifestations Compliance with vigorous and often disfiguring treatments doesn’t guarantee a cure. Cancer may recur after many years of remission. A healthy life-style does not ensure escape from the disease. Coping: Coping: is a dynamic process by which a client responds to a problem to bring about relief or equilibrium. General Coping Strategies: -Rational inquiry -Negiotation -Affect reversal -Tension reduction -Suppression - Disengagement -Mutuality - Projection -Displacement/redirection -Cooperative compliance -Confrontation -Moral masochism -Redefinition/revision -Fatalism/passive acceptance -Impulsivity Individual’s Responses to Cancer Depend upon: The clients & client’s psychological make-up The client’s family & social community The disease, disabilities & disfigurement it may cause Preexisting medical conditions that may limit treatment options. Enabling Factors in Coping with Cancer: Social support systems Religion Self-esteem Positive appraisal Hopefulness Positive comparisons Open communication Problem-solving ability Perception of control Humor Hardiness Information-seeking Social skills Jalowiec & Dundas (1991) Hindering factors in Coping with Cancer: Denial Helplessness Hopelessness Guilt Wishful thinking Anger Noncompliance Avoidance Powerlessness Depression Isolation Erosion of autonomy Blaming others Jalowiec & Dundas (1991) Purpose of Nursing Interventions The purpose of nursing interventions is to help individuals cope with the experience of illness & suffering, and if necessary to find meaning in such experiences. Helping the sick to maintain hope & avoid helplessness is a major responsibility for the nurse (Rustoen & Hanestad, p. 19, 1998). Responsibilities of the Nurse in Cancer Care Support the idea that cancer is a chronic illness Assess own level of knowledge relative to the pathophysiology Make use of current research findings and practices in care of clients with cancer Identify clients at high risk for cancer Participate in primary and secondary prevention Assess nursing care needs of client with cancer Assess learning needs, desires and capabilities Assess social supports of client and family Plan and implement appropriate interventions in collaboration with the multidisciplinary team. Evaluate goals and outcome and modify plan of care as necessary. Nursing Interventions in Supporting the Cancer client Be available, especially during difficult times Exhibit a caring attitude Listen actively to fears & concerns Provide relief from distressing symptoms Provide essential info regarding cancer & care Maintain a relationship build on trust & confidence (be honest) Appropriate use of touch exhibits caring Assist in setting realistic, reachable goals Assist in maintaining usual lifestyle patterns Maintain hope Maintaining Hope in Persons With Cancer Nursing Interventions 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 & Cancer Symptom Management . Cancer Treatment may be aimed at: Cure: Complete eradication of malignant disease Control: Containment of cancer cell growth; long term survival Palliation: Relief or control of symptoms and maintenance of quality of life Treatment Methods for Cancer Surgery Radio-therapy Chemotherapy Hormone-therapy Immuno-therapy Photodynamic therapy Intraoperative Radiation Whole Body Hyperthermia Recombinant Interferon Bone marrow transplant Whole Body Hyperthermia 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 Photodynamic Therapy Symptoms of Cancer & treatments: Fatigue Cachexia Nausea & Vomiting Stomatitis Constipation/diarrhea Skin reactions (Chemo/radiation) Pain (separate class) Assessment: Symptoms of Cancer & Treatments Infection Bleeding Skin reactions, mucositis/stomatitis, hair loss Nutritional Concerns (anorexia, cachexia) GI disturbances (diarrhea, constipation, nausea & vomiting) Pain Fatigue Psychosocial status Body Image Nursing Diagnoses of Client with Cancer Risk for infection related to altered immunologic response Impaired tissue integrity: alopecia r/t the effects of treatment & disease Impaired oral mucous membranes: stomatitis Altered nutrition: less than body requirements r/t anorexia & GI changes. Pain & discomfort r/to disease & treatment effects. Nursing Diagnoses of Client with Cancer Fatigue r/t physical and psychological stressors. Anticipatory grieving r/t anticipated loss and altered role function. Body image disturbance r/t changes in appearance and role function. PC: Bleeding Infection Infection is the leading cause of death Predisposing factors includes chemo, radiation treatment, malnutrition, catheters, IV’s, age, impaired skin & mucous membranes, contaminated equipment, meds, chronic illnesses Prolonged hospitalizations More predisposing Factors to infection: Nurse Monitors WBC Counts Leukopenia is a decrease in WBC Neutrophils make up 60-70% of the body’s WBCs WBCs play a major role in combating infection by engulfing and destroying infective agents in a process called phagocytosis. Both the total WBC and the concentration of WBCs are important in determining the patient’s ability to fight infection. Neutropenia puts clients at risk for infection 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 count Calculation ANC < 1.0 x 109 = severe risk for infection Interventions for Infection Monitor blood cell counts Protect client from infection Aseptic technique Hand washing Client/family teaching Assess for infection: blood cultures, sputum, stool, urine, catheter or wounds CXR Important to Know Lab Values 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 Life A: PHYSICAL WELL-BEING energy functional ability pain sleep rest strength The Impact of Fatigue on Quality of Life B: SOCIAL WELL-BEING caregiver burden impact on work- home & workplace financial burden family/ other roles, relationships affection & sexual function The Impact of Fatigue on Quality of Life C: PSYCHOLOGICAL WELL-BEING frustration fear experiencing fatigue anxiety feeling useless coping & acceptance loss of independence Loss of cognition/attention depression The Impact of Fatigue on Quality of Life D: SPIRITUAL WELL-BEING Can experience a change in spirituality altered priorities hopelessness meaning of fatigue Nursing Interventions : Fatigued Cancer Client •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) Cachexia-Anorexia Syndrome Name given to symptoms comprising: Anorexia Early satiety Weight loss Anemia Asthenia Tissue wasting Organ dysfunction Four Causes of Cachexia in Cancer Clients: 1. Decreased nutritional intake due to: Anorexia (present 80% terminal ca) Malfunction of GI tract Psychological factors 2. Increased nutritional losses: Bleeding Protein losses through intestine diarrhea tumor-related catabolism has little effect Causes of Cachexia in Cancer Clients: Cont’d 3. Abnormalities of metabolism: increased expenditure of energy changes in CHO metabolism changes in lipid metabolism abnormalities in protein metabolism changes in body composition 4. Effects of anti-tumor treatments: surgery chemotherapy radiation Consequences of Cachexia: Protein depletion: enzymes & serum proteins Poor wound healing Impaired immunity Fluid retention Vitamin deficiency Fatigue and weakness Death : occurs when 30-50% of body protein stores are lost Nursing the Client with Cachexia: Nutritional assessment: Determine the rate & extent of wt. loss Assess for symptoms of malabsorption Assess if client is on any special diets Assess for problems with taste, chewing, N&V, swallowing Food allergies/ learned food aversions Medications Nursing the Client with Cachexia: Physical Assessment: integument assessment: dry, scaly, atrophic tissues Cheilosis, glossitis or other vitamin deficiency signs Alterations in taste (metallic) Muscle wasting, loss of muscle strength Assess pitting edema Monitor lab values (albumin) Treating Cachexia In Cancer Clients: Factors to consider in choosing nutrition: Client’s ability to chew & swallow Client’s capacity to digest/absorb enteral nutrition Client’s compliance Family support cost Treating Cachexia In Cancer Clients: Administration Routes: based on functional status of GI tract. enteral feeding preferred (prevents mucosal atrophy, preserves gut flora & maintains immune status) Oral (if able to ingest sufficient nutrients) Dietary consult Enteral feeding : Cachexia Client Routes: NG tubes most commonly used short-term use in hospital left in place usually 4 to 6 weeks ensure proper placement to prevent aspiration Gastrostomy: tube-placed local anesthesia Does not easily clog large (16-20F) Unlikely to dislodge Allows stomach to dilute solutions (less diarrhea) advantage: low risk of aspiration NG Tube Insertion Nursing Management : Feeding Tubes Check tube placement before feeding/drugs Assess BS Liquid meds if possible Dilute viscous meds Crush tablets & dilute Elevate HOB, flush tubing Assess for aspiration, diarrhea, abd. Distension, hyperglycemia, constipation. Enteral feeding : Cachexia Client cont’d Jejunostomy tube: Recommended in proximal GI obstruction or fistual Advantages: less stomal leakage, skin erosion, N&V, bloating Disadvantage: diarrhea start with small volumes (25-30cc/hr) gradually increase volume over 3 to 4 days Do not use antidiarrheals to increase tolerance Enteral feeding complications: Diarrhea & cramping Vomiting & bloating Hyperglycemia Edema CHF hypernatremia/hypercalcemia Clogged tubing Rare aspiration pneumonia, esophageal erosion Nausea & Vomiting Occurs in 60% of terminally ill clients 40% last week of life Clients stomach cancers prevalent Occurs in up to 60% of clients receiving opioids Pathyophysiology N&V: Vomiting reflex begins with nausea Vomiting center in brain dorsolateral reticular formation of medulla coordinates the act of vomiting. Four mechanisms trigger vomiting: 1. vestibular nuclei: triggered by dizziness , motion sickness, ear infections, ca cells nervous system, changes in cerebellum 2. cerebral Cortex: triggered by cognitive awareness or anticipatory action to smelling, tasting or thinking about an experience that causes N&V. Pathyophysiology N&V: cont’d 3. Chemoreceptor Triggor Zone (CTZ) Stimulated by buildup of toxic chemicals, chemo & radiation, uremia, narcotics, hypercalcemia 4. Viscera GI triggored by upper GI sends message CNS via Vagal nerves as a result of decrease GI mobility caused by gastric stasis, tumor obstruction, drugs, radiation, metastic disease GI tract. Garrett, Walker, Jackson, Sweat (2003) Antiemetics are mechanism specific: 1. Vestibular nuclei: Gravol, Benadryl, Scopolamine 2. Cerebral Cortex: Ativan, Nabilone 3. CTZ: stemetil, haldol, maxeran, zofran & largactil 4. Viscera GI: Maxeran, motilium, zofran Site of action unknown: decadron & marajuana N/V Pre-medication for chemotherapy regimes known to likely combat n/v. Newer serotinin receptor antagonists are useful especially in the 1st 24 hrs of chemo (control afferent pathway stimulation) Ongoing multidisciplinary assessment essential Ondansetron or Zofran Serotonin 5-HT3 (hydroxytryptamine) receptor antagonist Antiemetic Reduces the activity of the vagus nerve Vagus Nerve: Activates the vomiting center in the medulla oblongata Zofran: Blocks serotonin receptors in chemoreceptor trigger zone Zofran: Little effect on vomiting caused by motion sickness Non pharmaceutical interventions for N/V Adjustment of fluid & oral intake Relaxation Exercise Hypnosis biofeedback Guided imagery Avoid offensive odors to client Small frequent meals Assess client drugs & d/c unnecessary ones Mucositis/Stomatitis Mucositis/Stomatitis: a general term referring to the inflammation of the oral cavity & shallow ulcerative lesions occurring on the mucosal surface of the mouth Increases the risk for infections both local & systemic Caused by chemotherapy (causes tissue damage of the basal layers of oral mucosa & inhibits replacement of superficial cell layers. Normally resolves 1-2 weeks post chemo. Nursing Management Stomatitis: Assessment: Buccal cavity (red, swollen, painful, ulcers, dryness) Teeth (intact, swollen) Mucous membranes & dentures Oral pain/bleeding in mouth Dysphagia, assess changes in tastes Know dental history (prior treatment) Mouthcare Q4h vital (no alcohol & no mouthwash) Soft toothbrush Chilled or frozen yogurt sooths oral mucosa Foods at room temperature, no acid, spices Constipation common & potentially debilitating problem for advanced cancer Close to 90% clients receiving opioids Due to: low-fiber diets, dehydration, inactivity Hypercalcemia & hypokalemia Tumors, spinal cord compression Constipation Symptoms : Anoxeria N&V Abd. Pain may radiate back, chest, upper legs Bloating Diarrhea (leaking feces past the hard fecal obstruction) UI (urinary incontinence) Tenesmus- painful & ineffective straining of stool Constipation: Abdominal Exam: Auscultate abdomen bowel sounds X4 (1 min) Distension Tenderness right lower quadrant (cecum) Rectal exam: evidence fecal soiling Hard impacted feces Hemmorroids, painful fissures Scarring abd. surgeries/ stenosis (tumors) Abd flat plate: rule out obstruction if diagnosis unclear Constipation Interventions: Prophylactic regimen if on opiods!! Hydrate client Increase fiber in diet if tolerated Administer stool softeners as ordered after fecal impaction is ruled out Start with colonic stimulant (bisacodyl) and stool softener (colace) Soft infrequent BM’s give senna, more bisacodyl to stimulate peristalsis Hard BM give lactulose If 3 days no BM , rectal exam & give a supp if not contraindicated Diarrhea Passage of 3-4 loose or fluid stools in 24 hours. Occurs 5-10% cancer clients with advanced disease Far less common than constipation in cancer clients Can lead to dehydration, malabsorption, fatigue, electrolyte imbalances. Causes of Diarrhea in Advanced Cancer: Fecal impaction: opioids without laxatives Intermittent bowel obstruction Effects of treatments chemo, rad, surgery Medications, laxatives, A/B, iron, sorbitol (cough syrups) Malnutrition/cachexia Rectal incontinence Infection Carcinoid tumors-secrete serotonin Physical Assessment : Diarrhea BS: present/absent; hypo/hyperactive Palpable masses Rectal exam: anal sphincter tone, discharge Stool: number, consistency, colour (keep record stool chart) Send stools specimens rule out infection O&P, C&S Management Diarrhea: Stop laxatives if on Rest the bowel- clear fluid diet with additional CHO (toast) avoid proteins, fats, milk until stops Replace fluid losses Unable to drink IV RL Assess meds stop meds iron, sorbitol-containing syrups Give loperamide 4mg then 2mg after each stool (16mg/24hrs) if diarrhea resistant to conservative measures Peri-care & sitz baths Evaluation Maintain integrity of oral mucous membranes Maintain adequate tissue perfusion Maintain adequate nutritional status Achieves relief of pain & discomfort Increased activity tolerance & decreased fatigue Exhibits improved body image & self-esteem Progress through grieving process Experiences no complications, such as infections, bleeding etc.