Oncology Nursing

Warning signals of Cancer: CAUTION US C hange in bowel or bladder habits A sore that does not heal U nusual bleeding or discharge T hickening or lump in the breast or elsewhere I ndifestion or difficulty in swallowing O bvious change in wart or small N agging cough or hoarseness U nexplained anemia S udden unexplained weight loss Symptomatic Care in Chemotherapy A. Risk for Infection r/t depressed immune system >Teach patient to guard against infection >Maintaining meticulous total body hygiene because our resident bacteria/ normal flora could be pathologic with depressed immune system. >Avoiding crowds and persons with infection. Kasama ang bantay dito sa instruction >Maintaining good nutrition and fluid intake. >Practicing good oral hygiene after meals. Even before meals >Getting adequate rest and exercise >Reporting ssx of infection to health care personnel immediately. Febrile neutropenia Reverse Isolation Technique 1. Private room, laminar air-flow, sterile linen, sterile hygiene equipment 2. Put on shoe covers, mask and cap, sterile gown, and gloves. B. Bleeding r/t decreased platelet Thrombocytopenia - Reduction in number of circulating platelets 1. Monitor platelet count and coagulation studies. 2. Assess and report and ssx of bleeding. 3. Administer careful oral hygiene to prevent mucosal breaks. 4. Avoid use of the following: - rough towels and wash cloths - razors use electric razors - restraints - tight clothing 5. Provide night-light to prevent bumping into objects or falling. 6. Administer stool softeners as ordered. 7. Emphasize importance of avoiding OTC medications especially those containing ASA, without consulting physician C. Fatigue r/t anemia Anemia - temporary reduction in the number of circulating RBCs and the level of Hgb caused by destruction of cells during chemotherapy PC: Tissue hypoxia 1. Provide adequate rest periods and sleep to improve energy level. 2. Conserve patient’s energy for desired activities. 3. Observe safety precautions: instruct to sit at side of bed before getting up. Postural hypotension, decrease of 20 mm Hg systolic, 10 mm Hg diastolic 4. Provide nutritious diet high in iron 5. Administer O2 therapy as ordered. 6. Administer blood components when ordered. Review how to give blood transfusion D. Altered Nutrition: Less than body requirements r/t n/v, anorexia, and decreased food intake Nausea, vomiting and anorexia

- physioliogc changes resulting from cancer, toxicity of chemo and or/ psychologic expectations PC: severe dehydration, electrolyte imbalance, malnutrition 1. Monitor v/s 2. Weight patient daily (same time, scale, clothing) 3. Avoid motions conducive to nausea 4. Teach patient and/or significant other methods to prevent N/V >small, frequent meals > small dietary intake before treatment > avoidance of greasy spicy foods > rest periods, quiet, peaceful environment > monitor I and O, administer IV replacement fluids as ordered > administer anti-emetics before administration of agents and q4h-q6h for 24h rather than PRN E. Altered oral mucous membranes r/t effects of chemotherapy Stomatitis - temporary inflammatory response of the oral mucosa to the cytotoxic effects of chemotherapy. Mucositis – temporary inflammatory response of mucous membrane 1. Institute prophylactic oral hygiene regimen before >soft-bristled toothbrush >foam stick moistened with mouthwash to remove debris from mucosa 2. Encourage fluid intake to 2000 mL/day; avoid citrus juices 3. If patient has difficulty in eating and maintaining fluid intake, parenteral nutrition may be necessary. 4. Encourage bland diet high in CHON to promote healing 5. Mild analgesic, assess need for use of anti-fungal or antibacterial agents F. Diarrhea r/t chemotherapy effects on GI mucosa Diarrhea – passage of frequent stools 1. Evaluate dehydration and electrolyte status 2. Adjust diet as appropriate. Avoid hot liquids, coffee, fresh fruits, and prune juice 3. Include foods high in K to prevent weakness 4. Encourage increased fluid intake G. Risk for impaired skin integrity, resulting in hair loss r/t effects of chemotherapy Alopecia – temporary loss of body hair as a result chemotherapeutic drugs that interact with cells. Doxorubicin – affects hair loss the most Multidisciplinary management – consult with services related to wigs, caps, scarves, social services and support group 1. Inform patient in advance about impending hair loss (varies among individuals), 2. Mild shampoo, keep head covered when exposed to sun to prevent sunburn. 3. Stress temporary nature of hair loss to alleviate concern. 4. Assist with gentle scalp care during susceptible period. 5. Explain to patient when to expect hair loss >usually begins 10-21 days H. Sexuality - sexual feelings may change because of fatigue, worry, change in self-image, vaginal dryness - potential for male and female sterility, depending on drugs used, length of treatment, age of patient - important to counsel use of birth control while undergoing chemotherapy; suppression of menses Oncologic Emergencies I. Obstructive or Compressive Disorders

A. Superior Vena Cava Syndrome - compression and obstruction of SVC by tumor growth - ssx > edema of the face (especially around the eyes) > tightness of the shirt or blouse collar (Stokes’ sign) > Edema in the arms and hands > Dyspnea > Erythema of the upper body; epistaxis Late signs and symptoms: > hemorrhage > cyanosis > mental status changes > decreased cardiac output > hypotension > DEATH can result if compression is not relieved Collaborative Management - high dose RT to the mediastinal area - assess and notify physician B. Pericardial Effusion/ Cardiac Tamponade - e.g. breast Ca px have chest tube - dyspnea, etc - interventions: emergency pericardiocentesis; sclerosing agent (injection of epinephrine between pericardial coating so that water won’t accumulate in between) C. Leukostasis - hyperviscosity and microcirculatory occlusion with high circulating WBC, common in acute leukemia - ssx of thrombosis and ischemia of involved organs system usually pulmonary and neurologic - mgt leukopheresis or exchange transfusion D. Spinal Cord Compression - occurs when a tumor directly enters the spinal cord or when the vertebral column collapses from tumor entry - collaborative management - assess the client for neurologic changes consistent with spinal cord compression - teach clients and families to recognize ssx of early spinal cord compression and to seek medical assistance as soon as symptoms are apparent II. Metabolic disorders A. Hypercalcemia - late manifestation of extensive malignancy, occurs most often in clients with bone metastasis - collaborative management >oral hydration (conservative management) > parenteral hydration with normal saline (fluid choice) > administer drug as ordered (eg oral glucocorticoids, calcitonin, biphosphate, gallium nitrate, mithramycin) > dialysis if with renal impairment and hypercalcemia is life threatening B. Symptoms Of SIADH - excessive amount of water is removed - mgt treat the condition (fluid restriction) C. Tumor Lysis Syndrome - large quantities of tumor cells are destroyed rapidly - intracellular contents, including k+ and purines, are released into the bloodstream faster than the body’s homeostatic mechanisms can handle them - TLS is a positive sign that cancer treatment is effective Collaborative management

- prevention through hydration - some fluids should be alkaline to help prevent crystallization of uric acid - stress the importance of keeping fluid intake - importance of following the antiemetic regimen III. Disruptions of hematologic/ immunologic function - DIC Sepsis – a condition in which microorganisms enter the bloodstream DIC – can hardly control the bleeding Collaborative Management - strict adherence to aseptic technique - appropriate IV antibiotic therapy when sepsis is present and DIC is likely - administer anticoagulants (heparin) during early - cryoprecipitate late DISCLOSURE - breaking bad news - emotionally charged and conflict creating moments > terminal diagnosis > prognosis and treatment failures > patient’s death - how to break the bad news P SPIKES (Kasper et al) 1. Preparation – mentally prepare > review wht information needs to be communicated > plan, rehearse key steps and phrases 2. Setting the interaction > ensure that the key people are present (family conference) > devote sufficient time-do not squeeze in a discussion > ensure privacy and prevent interruption (cell phone) 3. Patient’s perception and preparation > Establish baseline and assess if family can grasp the information. > Ease tension by allowing patient and family contribute to the discussion DO NOT MONOPOLIZE. 4. Invitation and information needs > Discover what info patient and family needs and know also the limits they want regarding information > “If this condition turns out to be something serious what do you want to know?” 5. Knowledge of the condition > Provide the bad news sensitively. > Do not just damp the information. > Interrupt and check the family’s understanding. 6. Empathy and exploration > Identify the cause of emotions. > Empathize (SYMPATHIZE) with patient and family’s feelings > Explore by asking open ended questions 7. Summary and strategic planning > Delineate for the patient and the family the next steps to take