Transcript Class_3_AO_N405_Cancer_Nursing_Care_

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:
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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:
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Warning signs of cancer
Overview of psychosocial impact, treatment methods
Fatigue
Cachexia
Nausea & vomiting
Stomatitis
Constipation & diarrhea
Pain management
Today’s Class Objectives
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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:
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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:
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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
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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
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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:
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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
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Cancer Treatment may be aimed
at:
Cure:
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Complete eradication of malignant disease
Control:
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Containment of cancer cell growth; long term
survival
Palliation:
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Relief or control of symptoms and
maintenance of quality of life
Treatment Methods for Cancer
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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
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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
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Risk for infection related to altered immunologic
response
Impaired tissue integrity: alopecia r/t the effects
of treatment & disease
Impaired oral mucous membranes: stomatitis
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Altered nutrition: less than body requirements
r/t anorexia & GI changes.
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Pain & discomfort r/to disease & treatment
effects.
Nursing Diagnoses of Client with Cancer
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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
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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
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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
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Monitor blood cell counts
Protect client from infection
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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
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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
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energy
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functional ability
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pain
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sleep
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rest
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strength
The Impact of Fatigue on Quality of Life
B: SOCIAL WELL-BEING
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caregiver burden
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impact on work- home & workplace
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financial burden
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family/ other roles, relationships
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affection & sexual function
The Impact of Fatigue on Quality of Life
C: PSYCHOLOGICAL WELL-BEING
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frustration
fear experiencing fatigue
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anxiety
feeling useless
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coping & acceptance
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loss of independence
Loss of cognition/attention
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depression
The Impact of Fatigue on Quality of Life
D: SPIRITUAL WELL-BEING
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Can experience a change in spirituality
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altered priorities
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hopelessness
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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:
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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:
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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:
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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
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short-term use in hospital
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left in place usually 4 to 6 weeks
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ensure proper placement to prevent aspiration
Gastrostomy: tube-placed local anesthesia
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Does not easily clog large (16-20F)
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Unlikely to dislodge
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Allows stomach to dilute solutions (less diarrhea)
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advantage: low risk of aspiration
NG Tube Insertion
Nursing Management : Feeding Tubes
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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:
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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:
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Diarrhea & cramping
Vomiting & bloating
Hyperglycemia
Edema
CHF
hypernatremia/hypercalcemia
Clogged tubing
Rare aspiration pneumonia, esophageal erosion
Nausea & Vomiting
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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.
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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
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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
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Serotonin 5-HT3 (hydroxytryptamine) receptor
antagonist
Antiemetic
Reduces the activity of the vagus nerve
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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
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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:
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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
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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 :
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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:
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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
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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:
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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
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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:
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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
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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.