2018 ~ Nursing Path

Definition

Cancer is a condition that results from abnormal cellular DNA. It is a condition wherein cells mutate and increase number, with changes in their morphology and without any function. The increase in the number of these cells infects other cells and causes them to behave the same way, a condition termed as “malignancy”.Cancer cells infiltrate normal and healthy tissue and they compete with normal cells for sustenance from the blood. Malignant cells compress and kill healthy tissue and deprive them of nutrition. In the long run, cancer cells cause cellular malignancy, nutritional deficiencies, and ultimately, death.

Cancer is the second leading cause of death according to the Centers for Disease Control and Prevention.

Cancer is a poorly understood disease that robs its victims of proper functioning, the ability to perform activities of daily living, and more often than not, brings significant depression.

Causes

Any cell in the body has the potential to mutate and become a cancer cell. However, a healthy immune system is able to kill these cells before they can cause any aberration in the body. The etiology of cancer is unknown and anything that has the potential to cause cellular DNA mutation has the capacity to cause malignancy. The etiology varies across the specific types of cancer on virtually all cells of the body. Anything that can cause cancer is termed a “carcinogen”. Some of these include:

Genetics
- Some genes carry a code for the transcription of cancer and malignancy. It is unclear; however, what causes these genes to cause malignancy. Certain extrinsic triggers may contribute to their activation. One thing is sure though, cancer runs in the family. Genetic Screening may detect presence of these oncogenes.
Tobacco
- Cigarettes contain hundreds of carcinogens and other harmful chemicals. It has been clearly shown through various studies that cigarette smoke, even second-hand smoke increases the risk of cancers of the lungs, oral cavity, lips, esophagus, and larynx. Smokers who inhale the smoke have an increased risk for lung cancer as the smoke reaches the lungs. A new study has coined the term “third hand smoke” wherein smoke particles become active in surfaces for days and inhaling near these surfaces also carries carcinogens into the system.
Diet
- It has been noted in studies that a diet high in nitrates (processed foods), benzopyrenes (grilled foods), alcohol, red meat and fat increases cancer risk. Also, a diet low in vegetables and other greens significantly increase the risk for colon cancer.
Physical Activity
- A sedentary lifestyle contributes to the development of cancer as much as obesity. It is important to control your weight too. It is recommended to have at least 150 minutes of non-vigorous, or 75 minutes of vigorous exercise per week.
Sun and UV Exposure
- Sunlight and the Ultraviolet radiation it carries significantly increases cancer risk and risks for melanomas. Ultraviolet light alters the DNA of cells and this causes malignancies if not controlled by the immune system.
Other Carcinogens
- Carcinogens, certain drugs, viruses, chemicals, pollution, and certain infectious agents all have the potential to cause malignancy. It is important to live in a clean environment to be able to avoid these triggers.

Pathophysiology

Symptoms

Cancer symptoms depend on the severity and specific type of cancer. Most cancers however are asymptomatic and will only produces signs once they are at advances stages. Early detection and treatment is the key to cancer survival. There are many symptoms of cancer but some of the potentially-serious warning signs are:
- C-hanges in bladder or bowel habits
- A-sore that doesn’t heal
- U-nusual bleeding or discharges
- T-hickening or lumps
- I-ndigestion od diffuclty swallowing
- O-bvious changes in warts, moles, or the skin
- N-agging cough or hoarseness of voice
- U-nexplained anemia
- S-udden loss of weight

Management

Management of Cancer depends on the specific stage and site of the cancer. Treatment may be primary(to kill cancer cells), adjuvant(to kill remaining cancer cells), or palliative(to treat signs and symptoms). Some treatment modalities include:

Chemotherapy
Surgery
Radiation therapy
Stem cell transplants
Biological therapy to improve immune function
Hormone therapy

Prevention

There is no sure way to prevent cancer as it is caused by various factors. Each of the 1 trillion cells of the body has the potential to be a cancer cell. However, there are some things we can do to drastically reduce this risk: eating a proper diet rich in fiber and vegetables, having regular exercise, avoidance of triggers, living in a cleanenvironment and having regular screening drastically reduces the risks of cancer and its complications.Cancer is a debilitating and scary disease but it is also preventable. Just make the proper choices. Screening and prevention are keys.

Nursing Care Plan

Nursing Diagnosis

Anticipatory Grieving

May be related to

Anticipated loss of physiological well-being (e.g., loss of body part; change in body function); change in lifestyle
Perceived potential death of patient

Possibly evidenced by

Changes in eating habits, alterations in sleep patterns, activity levels, libido, and communication patterns
Denial of potential loss, choked feelings, anger

Desired Outcomes

Identify and express feelings appropriately.
Continue normal life activities, looking toward/planning for the future, one day at a time.
Verbalize understanding of the dying process and feelings of being supported in grief work.

Nursing Interventions

Expect initial shock and disbelief following diagnosis of cancer and traumatizing procedures (disfiguring surgery, colostomy, amputation).
- Rationale: Few patients are fully prepared for the reality of the changes that can occur.
Assess patient and SO for stage of grief currently being experienced. Explain process as appropriate.
- Rationale: Knowledge about the grieving process reinforces the normality of feelings and reactions being experienced and can help patient deal more effectively with them.
Provide open, nonjudgmental environment. Use therapeutic communication skills of Active-Listening, acknowledgment, and so on.
- Rationale: Promotes and encourages realistic dialogue about feelings and concerns.
Encourage verbalization of thoughts or concerns and accept expressions of sadness, anger, rejection. Acknowledge normality of these feelings.
- Rationale: Patient may feel supported in expression of feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult situation.
Be aware of mood swings, hostility, and other acting-out behavior. Set limits on inappropriate behavior, redirect negative thinking.
- Rationale: Indicators of ineffective coping and need for additional interventions. Preventing destructive actions enables patient to maintain control and sense of self-esteem.
Be aware of debilitating depression. Ask patient direct questions about state of mind.
- Rationale: Studies show that many cancer patients are at high risk for suicide. They are especially vulnerable when recently diagnosed and discharged from hospital.
Visit frequently and provide physical contact as appropriate, or provide frequent phone support as appropriate for setting. Arrange for care provider and support person to stay with patient as needed.
- Rationale: Helps reduce feelings of isolation and abandonment.
Reinforce teaching regarding disease process and treatments and provide information as appropriate about dying. Be honest; do not give false hope while providing emotional support.
- Rationale: Patient and SO benefit from factual information. Individuals may ask direct questions about death, and honest answers promote trust and provide reassurance that correct information will be given.
Review past life experiences, role changes, and coping skills. Talk about things that interest the patient.
- Rationale: Opportunity to identify skills that may help individuals cope with grief of current situation more effectively.
Note evidence of conflict; expressions of anger; and statements of despair, guilt, hopelessness, “nothing to live for.”
- Rationale: Interpersonal conflicts or angry behavior may be patient’s way of expressing and dealing with feelings of despair or spiritual distress and could be indicative of suicidal ideation.
Determine way that patient and SO understand and respond to death such as cultural expectations, learned behaviors, experience with death (close family members, friends), beliefs about life after death, faith in Higher Power (God).
- Rationale: These factors affect how each individual deals with the possibility of death and influences how they may respond and interact.
Identify positive aspects of the situation.
- Rationale: Possibility of remission and slow progression of disease and new therapies can offer hope for the future.
Discuss ways patient and SO can plan together for the future. Encourage setting of realistic goals.
- Rationale: Having a part in problem solving and planning can provide a sense of control over anticipated events.
Refer to visiting nurse, home health agency as needed, or hospice program, if appropriate.
- Rationale: Provides support in meeting physical and emotional needs of patient and SO, and can supplement the care family and friends are able to give.

Nursing Diagnosis

Situational Low Self-Esteem

May be related to

Biophysical: disfiguring surgery, chemotherapy or radiotherapy side effects, e.g., loss of hair, nausea/vomiting, weight loss, anorexia, impotence, sterility, overwhelming fatigue, uncontrolled pain
Psychosocial: threat of death; feelings of lack of control and doubt regarding acceptance by others; fear and anxiety

Possibly evidenced by

Verbalization of change in lifestyle; fear of rejection/reaction of others; negative feelings about body; feelings of helplessness, hopelessness, powerlessness
Preoccupation with change or loss
Not taking responsibility for self-care, lack of follow-through
Change in self-perception/other’s perception of role

Desired Outcomes

Verbalize understanding of body changes, acceptance of self in situation.
Begin to develop coping mechanisms to deal effectively with problems.
Demonstrate adaptation to changes/events that have occurred as evidenced by setting of realistic goals and active participation in work/play/personal relationships as appropriate.

Nursing Interventions

Discuss with patient and SO how the diagnosis and treatment are affecting the patient’s personal life, home and work activities.
- Rationale: Aids in defining concerns to begin problem-solving process.
Review anticipated side effects associated with a particular treatment, including possible effects on sexual activity and sense of attractiveness and desirability (alopecia, disfiguring surgery). Tell patient that not all side effects occur, and others may be minimized or controlled.
- Rationale: Anticipatory guidance can help patient and SO begin the process of adaptation to new state and to prepare for some side effects (buy a wig before radiation, schedule time off from work as indicated).
Encourage discussion of concerns about effects of cancer and treatments on role as homemaker, wage earner, parent, and so forth.
- Rationale: May help reduce problems that interfere with acceptance of treatment or stimulate progression of disease.
Acknowledge difficulties patient may be experiencing. Give information that counseling is often necessary and important in the adaptation process.
- Rationale: Validates reality of patient’s feelings and gives permission to take whatever measures are necessary to cope with what is happening.
Evaluate support structures available to and used by patient and SO.
- Rationale: Helps with planning for care while hospitalized and after discharge.
Provide emotional support for patient and SO during diagnostic tests and treatment phase.
- Rationale: Although some patients adapt or adjust to cancer effects or side effects of therapy, many need additional support during this period.
Use touch during interactions, if acceptable to patient, and maintain eye contact.
- Rationale: Affirmation of individuality and acceptance is important in reducing patient’s feelings of insecurity and self-doubt.
Refer for professional counseling as indicated.
- Rationale: May be necessary to regain and maintain a positive psychosocial structure if patient and SO support systems are deteriorating.

Nursing Diagnosis

Acute Pain

May be related to

Disease process (compression/destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation)
Side effects of various cancer therapy agents

Possibly evidenced by

Reports of pain
Self-focusing/narrowed focus
Alteration in muscle tone; facial mask of pain
Distraction/guarding behaviors
Autonomic responses, restlessness (acute pain)

Desired Outcomes

Report maximal pain relief/control with minimal interference with ADLs.
Follow prescribed pharmacological regimen.
Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Interventions

Determine pain history (location of pain, frequency, duration, and intensity using numeric rating scale (0–10 scale), or verbal rating scale (“no pain” to “excruciating pain”) and relief measures used. Believe patient’s report.
- Rationale: Information provides baseline data to evaluate effectiveness of interventions. Pain of more than 6 mo duration constitutes chronic pain, which may affect therapeutic choices. Recurrent episodes of acute pain can occur within chronic pain, requiring increased level of intervention. Note: The pain experience is an individualized one composed of both physical and emotional responses.
Determine timing or precipitants of “breakthrough” pain when using around-the-clock agents, whether oral, IV, or patch medications.
- Rationale: Pain may occur near the end of the dose interval, indicating need for higher dose or shorter dose interval. Pain may be precipitated by identifiable triggers, or occur spontaneously, requiring use of short half-life agents for rescue or supplemental doses.
Evaluate and be aware of painful effects of particular therapies (surgery, radiation, chemotherapy, biotherapy). Provide information to patient and SO about what to expect.
- Rationale: A wide range of discomforts are common (incisional pain, burning skin, low back pain, headaches), depending on the procedure and agent being used. Pain is also associated with invasive procedures to diagnose or treat cancer.
Provide nonpharmacological comfort measures (massage, repositioning, backrub) and diversional activities (music, television)
- Rationale: Promotes relaxation and helps refocus attention.
Encourage use of stress management skills or complementary therapies (relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and therapeutic touch).
- Rationale: Enables patient to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases patient’s focus on self, which in turn increases the level of pain.
Provide cutaneous stimulation (heat or cold, massage).
- Rationale: May decrease inflammation, muscle spasms, reducing associated pain. Note: Heat may increase bleeding and edema following acute injury, whereas cold may further reduce perfusion to ischemic tissues.
Be aware of barriers to cancer pain management related to patient, as well as the healthcare system.
- Rationale: Patients may be reluctant to report pain for reasons such as fear that disease is worse; worry about unmanageable side effects of pain medications; beliefs that pain has meaning, such as “God wills it,” they should overcome it, or that pain is merited or deserved for some reason. Healthcare system problems include factors such as inadequate assessment of pain, concern about controlled substances or patient addiction, inadequate reimbursement or cost of treatment modalities.
Evaluate pain relief and control at regular intervals. Adjust medication regimen as necessary.
- Rationale: Goal is maximum pain control with minimum interference with ADLs.
Inform patient and SO of the expected therapeutic effects and discuss management of side effects
- Rationale: This information helps establish realistic expectations, confidence in own ability to handle what happens.
Discuss use of additional alternative or complementary therapies (acupuncture and acupressure).
- Rationale: May provide reduction or relief of pain without drug-related side effects.

Administer analgesics as indicated:

Opioids: codeine, morphine (MS Contin), oxycodone (oxycontin) hydrocodone (Vicodin), hydromorphone (Dilaudid), methadone (Dolophine), fentanyl (Duragesic); oxymorphone (Numorphan);
- Rationale: A wide range of analgesics and associated agents may be employed around the clock to manage pain. Note: Addiction to or dependency on drug is not a concern.
Acetaminophen (Tylenol); and nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, ibuprofen (Motrin, Advil);
- Rationale: Effective for localized and generalized moderate to severe pain, with long-acting and controlled-release forms available.
peroxicam (Feldene);
- Rationale: Routes of administration include oral, transmucosal, transdermal, nasal, rectal, and infusions (subcutaneous, IV, intraventricular), which may be delivered via PCA. IM use is not recommended because absorption is not reliable, in addition to being painful and inconvenient. Note: Research is in process for oral transmucosal agent (fentenyl citrate [oralet]) to control breakthrough pain in patients using fentanyl patch.
indomethacin (Indocin);
- Rationale: Adjuvant drugs are useful for mild to moderate pain and can be combined with opioids and other modalities.
Corticosteroids: dexamethasone (Decadron);
- Rationale: May be effective in controlling pain associated with inflammatory process (metastatic bone pain, acute spinal cord compression and neuropathic pain).

Nursing Diagnosis

Altered Nutrition: Less Than Body Requirements

May be related to

Hypermetabolic state associated with cancer
Consequences of chemotherapy, radiation, surgery, e.g., anorexia, gastric irritation, taste distortions, nausea
Emotional distress, fatigue, poorly controlled pain

Possibly evidenced by

Reported inadequate food intake, altered taste sensation, loss of interest in food, perceived/actual inability to ingest food
Body weight 20% or more under ideal for height and frame, decreased subcutaneous fat/muscle mass
Sore, inflamed buccal cavity
Diarrhea and/or constipation, abdominal cramping

Desired Outcomes

Demonstrate stable weight/progressive weight gain toward goal with normalization of laboratory values and be free of signs of malnutrition.
Verbalize understanding of individual interferences to adequate intake.
Participate in specific interventions to stimulate appetite/increase dietary intake.

Nursing Interventions

Monitor daily food intake; have patient keep food diary as indicated.
- Rationale: Identifies nutritional strengths and deficiencies.
Measure height, weight, and tricep skinfold thickness (or other anthropometric measurements as appropriate). Ascertain amount of recent weight loss. Weigh daily or as indicated.
- Rationale: If these measurements fall below minimum standards, patient’s chief source of stored energy (fat tissue) is depleted.
Assess skin and mucous membranes for pallor, delayed wound healing, enlarged parotid glands.
- Rationale: Helps in identification of protein-calorie malnutrition, especially when weight and anthropometric measurements are less than normal.
Encourage patient to eat high-calorie, nutrient-rich diet, with adequate fluid intake. Encourage use of supplements and frequent or smaller meals spaced throughout the day.
- Rationale: Metabolic tissue needs are increased as well as fluids (to eliminate waste products). Supplements can play an important role in maintaining adequate caloric and protein intake.
Create pleasant dining atmosphere; encourage patient to share meals with family and friends.
- Rationale: Makes mealtime more enjoyable, which may enhance intake.
Encourage open communication regarding anorexia.
- Rationale: Often a source of emotional distress, especially for SO who wants to feed patient frequently. When patient refuses, SO may feel rejected or frustrated.
Adjust diet before and immediately after treatment (clear, cool liquids, light or bland foods, candied ginger, dry crackers, toast, carbonated drinks). Give liquids 1 hr before or 1 hr after meals.
- Rationale: The effectiveness of diet adjustment is very individualized in relief of posttherapy nausea. Patients must experiment to find best solution or combination. Avoiding fluids during meals minimizes becoming “full” too quickly.
Control environmental factors (strong or noxious odors or noise). Avoid overly sweet, fatty, or spicy foods.
- Rationale: Can trigger nausea and vomiting response.
Encourage use of relaxation techniques, visualization, guided imagery, moderate exercise before meals.
- Rationale: May prevent onset or reduce severity of nausea, decrease anorexia, and enable patient to increase oral intake.
Identify the patient who experiences anticipatory nausea and vomiting and take appropriate measures.
- Rationale: Psychogenic nausea and vomiting occurring before chemotherapy generally does not respond to antiemetic drugs. Change of treatment environment or patient routine on treatment day may be effective.
Administer antiemetic on a regular schedule before or during and after administration of antineoplastic agent as appropriate.
- Rationale: Nausea and vomiting are frequently the most disabling and psychologically stressful side effects of chemotherapy.
Evaluate effectiveness of antiemetic.
- Rationale: Individuals respond differently to all medications. First-line antiemetics may not work, requiring alteration in or use of combination drug therapy.
Hematest stools, gastric secretions.
- Rationale: Certain therapies (antimetabolites) inhibit renewal of epithelial cells lining the GI tract, which may cause changes ranging from mild erythema to severe ulceration with bleeding.
Review laboratory studies as indicated (total lymphocyte count, serum transferrin, and albumin or prealbumin).
- Rationale: Helps identify the degree of biochemical imbalance, malnutrition and influences choice of dietary interventions. Note: Anticancer treatments can also alter nutrition studies, so all results must be correlated with the patient’s clinical status.
Refer to dietitian or nutritional support team.
- Rationale: Provides for specific dietary plan to meet individual needs and reduce problems associated with protein, calorie malnutrition and micronutrient deficiencies.
Insert and maintain NG or feeding tube for enteric feedings, or central line for total parenteral nutrition (TPN) if indicated.
- Rationale: In the presence of severe malnutrition (loss of 25%–30% body weight in 2 mo) or if patient has been NPO for 5 days and is unlikely to be able to eat for another week, tube feeding or TPN may be necessary to meet nutritional needs.

Nursing Diagnosis

Risk for Fluid Volume Deficit

Risk factors may include

Excessive losses through normal routes (e.g., vomiting, diarrhea) and/or abnormal routes (e.g., indwelling tubes, wounds)
Hypermetabolic state
Impaired intake of fluids

Desired Outcomes

Display adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor, prompt capillary refill, and individually adequate urinary output.

Nursing Interventions

Monitor I&O and specific gravity; include all output sources, (emesis, diarrhea, draining wounds. Calculate 24-hr balance).
- Rationale: Continued negative fluid balance, decreasing renal output and concentration of urine suggest developing dehydration and need for increased fluid replacement.
Weigh as indicated.
- Rationale: Sensitive measurement of fluctuations in fluid balance.
Monitor vital signs. Evaluate peripheral pulses, capillary refill.
- Rationale: Reflects adequacy of circulating volume.
Assess skin turgor and moisture of mucous membranes. Note reports of thirst.
- Rationale: Indirect indicators of hydration status and degree of deficit.
Encourage increased fluid intake to 3000 mL per day as individually appropriate or tolerated.
- Rationale: Assists in maintenance of fluid requirements and reduces risk of harmful side effects such as hemorrhagic cystitis in patient receiving cyclophosphamide (Cytoxan).
Observe for bleeding tendencies (oozing from mucous membranes, puncture sites); presence of ecchymosis or petechiae.
- Rationale: Early identification of problems (which may occur as a result of cancer or therapies) allows for prompt intervention.
Minimize venipunctures (combine IV starts with blood draws). Encourage patient to consider central venous catheter placement.
- Rationale: Reduces potential for hemorrhage and infection associated with repeated venous puncture.
Avoid trauma and apply pressure to puncture sites.
- Rationale: Reduces potential for bleeding and hematoma formation.
Provide IV fluids as indicated.
- Rationale: Given for general hydration and to dilute antineoplastic drugs and reduce adverse side effects (nausea and vomiting, or nephrotoxicity).
Monitor laboratory studies (CBC, electrolytes, serum albumin).
- Rationale: Provides information about level of hydration and corresponding deficits.

Nursing Diagnosis

Fatigue

May be related to

Decreased metabolic energy production, increased energy requirements (hypermetabolic state and effects of treatment)
Overwhelming psychological/emotional demands
Altered body chemistry: side effects of pain and other medications, chemotherapy

Possibly evidenced by

Unremitting/overwhelming lack of energy, inability to maintain usual routines, decreased performance, impaired ability to concentrate, lethargy/listlessness
Disinterest in surroundings

Desired Outcomes

Report improved sense of energy.
Perform ADLs and participate in desired activities at level of ability.

Nursing Interventions

Have patient rate fatigue, using a numeric scale, if possible, and the time of day when it is most severe.
- Rationale: Helps in developing a plan for managing fatigue.
Plan care to allow for rest periods. Schedule activities for periods when patient has most energy. Involve patient and SO in schedule planning.
- Rationale: Frequent rest periods and naps are needed to restore and conserve energy. Planning will allow patient to be active during times when energy level is higher, which may restore a feeling of well-being and a sense of control.
Establish realistic activity goals with patient.
- Rationale: Provides for a sense of control and feelings of accomplishment.
Assist with self-care needs when indicated; keep bed in low position, pathways clear of furniture; assist with ambulation.
- Rationale: Weakness may make ADLs difficult to complete or place the patient at risk for injury during activities.
Encourage patient to do whatever possible (self-bathing, sitting up in chair, walking). Increase activity level as individual is able.
- Rationale: Enhances strength and stamina and enables patient to become more active without undue fatigue.
Monitor physiological response to activity (changes in BP, heart and respiratory rate).
- Rationale: Tolerance varies greatly depending on the stage of the disease process, nutrition state, fluid balance, and reaction to therapeutic regimen.
Perform pain assessment and provide pain management.
- Rationale: Poorly managed cancer pain can contribute to fatigue.
Provide supplemental oxygen as indicated.
- Rationale: Presence of anemia and hypoxemia reduces O2available for cellular uptake and contributes to fatigue.
Refer to physical or occupational therapy.
- Rationale: Programmed daily exercises and activities help patient maintain and increase strength and muscle tone, enhance sense of well-being. Use of adaptive devices may help conserve energy.

Nursing Diagnosis

Risk for Infection

Risk factors may include

Inadequate secondary defenses and immunosuppression, e.g., bone marrow suppression (dose-limiting side effect of both chemotherapy and radiation).
Malnutrition, chronic disease process
Invasive procedures

Desired Outcomes

Remain afebrile and achieve timely healing as appropriate.
Identify and participate in interventions to prevent/reduce risk of infection.

Nursing Interventions

Promote good handwashing procedures by staff and visitors. Screen and limit visitors who may have infections. Place in reverse isolation as indicated.
- Rationale: Protects patient from sources of infection, such as visitors and staff who may have an upper respiratory infection (URI).
Emphasize personal hygiene.
- Rationale: Limits potential sources of infection and secondary overgrowth.
Monitor temperature.
- Rationale: Temperature elevation may occur (if not masked by corticosteroids or anti-inflammatory drugs) because of various factors (chemotherapy side effects, disease process, or infection). Early identification of infectious process enables appropriate therapy to be started promptly.
Assess all systems (skin, respiratory, genitourinary) for signs and symptoms of infection on a continual basis.
- Rationale: Early recognition and intervention may prevent progression to more serious situation or sepsis.
Reposition frequently; keep linens dry and wrinkle-free.
- Rationale: Reduces pressure and irritation to tissues and may prevent skin breakdown (potential site for bacterial growth).
Promote adequate rest and exercise periods.
- Rationale: Limits fatigue, yet encourages sufficient movement to prevent stasis complications (pneumonia, decubitus, and thrombus formation).
Stress importance of good oral hygiene.
- Rationale: Development of stomatitis increases risk of infection and secondary overgrowth.
Avoid or limit invasive procedures. Adhere to aseptic techniques.
- Rationale: Reduces risk of contamination, limits portal of entry for infectious agents.
Monitor CBC with differential WBC and granulocyte count, and platelets as indicated.
- Rationale: Bone marrow activity may be inhibited by effects of chemotherapy, the disease state, or radiation therapy. Monitoring status of myelosuppression is important for preventing further complications (infection, anemia, or hemorrhage) and scheduling drug delivery.
Obtain cultures as indicated.
- Rationale: Identifies causative organism(s) and appropriate therapy.
Administer antibiotics as indicated.
- Rationale: May be used to treat identified infection or given prophylactically in immuno- compromised patient.

Nursing Diagnosis

Risk for Altered Oral Mucous Membranes

Risk factors may include

Side effect of some chemotherapeutic agents (e.g., antimetabolites) and radiation
Dehydration, malnutrition, NPO restrictions for more than 24 hr

Desired Outcomes

Display intact mucous membranes, which are pink, moist, and free of inflammation/ulcerations.
Verbalize understanding of causative factors.
Demonstrate techniques to maintain/restore integrity of oral mucosa.

Nursing Interventions

Assess dental health and oral hygiene periodically.
- Rationale: Identifies prophylactic treatment needs before initiation of chemotherapy or radiation and provides baseline data of current oral hygiene for future comparison.
Encourage patient to assess oral cavity daily, noting changes in mucous membrane integrity (dry, reddened). Note reports of burning in the mouth, changes in voice quality, ability to swallow, sense of taste, development of thick or viscous saliva, blood-tinged emesis.
- Rationale: Good care is critical during treatment to control stomatitis complications.
Discuss with patient areas needing improvement and demonstrate methods for good oral care.
- Rationale: Products containing alcohol or phenol may exacerbate mucous membrane dryness and irritation.
Initiate and recommend oral hygiene program to include:
- Rationale: May be soothing to the membranes.
Avoidance of commercial mouthwashes, lemon or glycerine swabs;
- Rationale: Rinsing before meals may improve the patient’s sense of taste.
Use of mouthwash made from warm saline, dilute solution of hydrogen peroxide or baking soda and water;
- Rationale: Rinsing after meals and at bedtime dilutes oral acids and relieves xerostomia.
Brush with soft toothbrush or foam swab;
- Rationale: Prevents trauma to delicate and fragile tissues. Note: Toothbrush should be changed at least every 3 mo.
Floss gently or use WaterPik cautiously;
- Rationale: Removes food particles that can promote bacterial growth. Note: Water under pressure has the potential to injure gums or force bacteria under gum line.
Keep lips moist with lip gloss or balm, K-Y Jelly, Chapstick;
- Rationale: Promotes comfort and prevents drying and cracking of tissues.
Encourage use of mints or hard candy or artificial saliva (Ora-Lube, Salivart) as indicated.
- Rationale: Stimulates secretions and provides moisture to maintain integrity of mucous membranes, especially in presence of dehydration and reduced saliva production.
Instruct regarding dietary changes: avoid hot or spicy foods, acidic juices; suggest use of straw; ingest soft or blenderized foods, Popsicles, and ice cream as tolerated.
- Rationale: Severe stomatitis may interfere with nutritional and fluid intake leading to negative nitrogen balance or dehydration. Dietary modifications may make foods easier to swallow and may feel soothing.
Encourage fluid intake as individually tolerated.
- Rationale: Adequate hydration helps keep mucous membranes moist, preventing drying and cracking.
Discuss limitation of smoking and alcohol intake.
- Rationale: May cause further irritation and dryness of mucous membranes. Note: May need to compromise if these activities are important to patient’s emotional status.
Monitor for and explain to patient signs of oral superinfection (thrush).
- Rationale: Early recognition provides opportunity for prompt treatment.
Refer to dentist before initiating chemotherapy or head or neck radiation.
- Rationale: Prophylactic examination and repair work before therapy reduce risk of infection.
Culture suspicious oral lesions.
- Rationale: Identifies organism(s) responsible for oral infections and suggests appropriate drug therapy.

Administer medications as indicated:

Analgesic rinses (mixture of Koatin, pectin, diphenhydramine [Benadryl], and topical lidocaine [Xylocaine]);
- Rationale: Aggressive analgesia program may be required to relieve intense pain. Note: Rinse should be used as a swish-and-spit rather than a gargle, which could anesthetize patient’s gag reflex.
Antifungal mouthwash preparation such as nystatin (Mycostatin), and antibacterial Biotane;
- Rationale: May be needed to treat or prevent secondary oral infections, such as Candida, Pseudomonas, herpes simplex.
Antinausea agents;
- Rationale: When given before beginning mouth care regimen, may prevent nausea associated with oral stimulation.
Opioid analgesics: hydromorphone (Dilaudid), morphine.
- Rationale: May be required for acute episodes of moderate to severe oral pain.

Nursing Diagnosis

Risk for Impaired Skin Integrity

Risk factors may include

Effects of radiation and chemotherapy
Immunologic deficit
Altered nutritional state, anemia

Desired Outcomes

Identify interventions appropriate for specific condition.
Participate in techniques to prevent complications/promote healing as appropriate.

Nursing Interventions

Assess skin frequently for side effects of cancer therapy; note breakdown and delayed wound healing. Emphasize importance of reporting open areas to caregiver.
- Rationale: A reddening or tanning effect (radiation reaction) may develop within the field of radiation. Dry desquamation (dryness and pruritus), moist desquamation (blistering), ulceration, hair loss, loss of dermis and sweat glands may also be noted. In addition, skin reactions (allergic rashes, hyperpigmentation, pruritus, and alopecia) may occur with some chemotherapy agents.
Bathe with lukewarm water and mild soap.
- Rationale: Maintains cleanliness without irritating the skin.
Encourage patient to avoid vigorous rubbing and scratching and to pat skin dry instead of rubbing.
- Rationale: Helps prevent skin friction and trauma to sensitive tissues.
Turn or reposition frequently.
- Rationale: Promotes circulation and prevents undue pressure on skin and tissues.
Review skin care protocol for patient receiving radiation therapy: Avoid rubbing or use of soap, lotions, creams, ointments, powders or deodorants on area;
- Rationale: Designed to minimize trauma to area of radiation therapy. Can potentiate or otherwise interfere with radiation delivery. May actually increase irritation and reaction. Skin is very sensitive during and after treatment, and all irritation should be avoided to prevent dermal injury.
Avoid applying heat or attempting to wash off marks or tattoos placed on skin to identify area of irradiation;
- Rationale: Helps control dampness or pruritus. Maintenance care is required until skin and tissues have regenerated and are back to normal.
Recommend wearing soft, loose cotton clothing; have female patient avoid wearing bra if it creates pressure;
- Rationale: Protects skin from ultraviolet rays and reduces risk of recall reactions.
Apply cornstarch, Aquaphor, Lubriderm, Eucerin (or other recommended water-soluble moisturizing gel) to area twice daily as needed;
- Rationale: Reduces risk of tissue irritation and extravasation of agent into tissues.
Encourage liberal use of sunscreen or block and breathable, protective clothing.
- Rationale: Development of irritation indicates need for alteration of rate or dilution of chemotherapy and change of IV site to prevent more serious reaction.
Assess skin and IV site and vein for erythema, edema, tenderness; weltlike patches, itching and burning; or swelling, burning, soreness; blisters progressing to ulceration or tissue necrosis.
- Rationale: Presence of phlebitis, vein flare (localized reaction) or extravasation requires immediate discontinuation of antineoplastic agent and medical intervention.
Wash skin immediately with soap and water if antineoplastic agents are spilled on unprotected skin (patient or caregiver).
- Rationale: Dilutes drug to reduce risk of skin irritation and chemical burn.
Advise patients receiving 5-fluorouracil (5-FU) and methotrexate to avoid sun exposure. Withhold methotrexate if sunburn present.
- Rationale: Sun can cause exacerbation of burn spotting (a side effect of 5-fluorouracil) or can cause a red “flash” area with methotrexate, which can exacerbate drug’s effect.
Review expected dermatologic side effects seen with chemotherapy (rash, hyperpigmentation, and peeling of skin on palms).
- Rationale: Anticipatory guidance helps decrease concern if side effects do occur.
Inform patient that if alopecia occurs, hair could grow back after completion of chemotherapy, but may or may not grow back after radiation therapy.
- Rationale: Anticipatory guidance may help in preparation for baldness. Men are often as sensitive to hair loss as women. Radiation’s effect on hair follicles may be permanent, depending on rad dosage.
Apply ice pack or warm compresses per protocol
- Rationale: Controversial intervention depends on type of agent used. Ice restricts blood flow, keeping drug localized, while heat enhances dispersion of neoplastic drug or antidote, minimizing tissue damage.

Nursing Diagnosis

Risk for Constipation/Diarrhea

Risk factors may include

Irritation of the GI mucosa from either chemotherapy or radiation therapy; malabsorption of fat
Hormone-secreting tumor, carcinoma of colon
Poor fluid intake, low-bulk diet, lack of exercise, use of opiates/narcotics

Desired Outcomes

Maintain usual bowel consistency/pattern.
Verbalize understanding of factors and appropriate interventions/solutions related to individual situation.

Nursing Interventions

Ascertain usual elimination habits.
- Rationale: Data required as baseline for future evaluation of therapeutic needs and effectiveness.
Assess bowel sounds and record bowel movements (BMs) including frequency, consistency (particularly during first 3–5 days of Vinca alkaloid therapy).
- Rationale: Defines problem (diarrhea, constipation). Note: Constipation is one of the earliest manifestations of neurotoxicity.
Monitor I&O and weight.
- Rationale: Dehydration, weight loss, and electrolyte imbalance are complications of diarrhea. Inadequate fluid intake may potentiate constipation.
Encourage adequate fluid intake (2000 mL per 24 hr), increased fiber in diet; regular exercise.
- Rationale: May reduce potential for constipation by improving stool consistency and stimulating peristalsis; can prevent dehydration associated with diarrhea.
Provide small, frequent meals of foods low in residue (if not contraindicated), maintaining needed protein and carbohydrates (eggs., cooked cereal, bland cooked vegetables).
- Rationale: Reduces gastric irritation. Use of low-fiber foods can decrease irritability and provide bowel rest when diarrhea present.
Adjust diet as appropriate: avoid foods high in fat (butter, fried foods, nuts); foods with high-fiber content; those known to cause diarrhea or gas (cabbage, baked beans, chili); food and fluids high in caffeine; or extremely hot or cold food and fluids.
- Rationale: GI stimulants that may increase gastric motility frequency of stools.
Check for impaction if patient has not had BM in 3 days or if abdominal distension, cramping, headache are present.
- Rationale: Further interventions and alternative bowel care may be needed.

Monitor laboratory studies as indicated:

Electrolytes
- Rationale: Electrolyte imbalances may contribute to altered GI function.
Administer IV fluids;
- Rationale: Prevents dehydration, dilutes chemotherapy agents to diminish side effects.
Antidiarrheal agents;
- Rationale: May be indicated to control severe diarrhea.
Stool softeners, laxatives, enemas as indicated.
- Rationale: Prophylactic use may prevent further complications in some patients (those who will receive Vinca alkaloid, have poor bowel pattern before treatment, or have decreased motility).

ANSWER KEY
1. B	2. D	3. C	4.B	5.A
6. C	7. B	8.D	9. B	10. A
11. A	12.C	13.E	14.B	15.B

VIEWERS

Followers

Definition

Causes

Pathophysiology

Symptoms

Management

Prevention

Nursing Diagnosis

Anticipatory Grieving

May be related to

Possibly evidenced by

Desired Outcomes

Nursing Interventions

Nursing Diagnosis

Situational Low Self-Esteem

May be related to

Possibly evidenced by

Desired Outcomes

Nursing Interventions

Nursing Diagnosis

Acute Pain

May be related to

Possibly evidenced by

Desired Outcomes

Nursing Interventions

Nursing Diagnosis

Altered Nutrition: Less Than Body Requirements

May be related to

Possibly evidenced by

Desired Outcomes

Nursing Interventions

Nursing Diagnosis

Risk for Fluid Volume Deficit

Risk factors may include

Desired Outcomes

Nursing Interventions

Nursing Diagnosis

Fatigue

May be related to

Possibly evidenced by

Desired Outcomes

Nursing Interventions

Nursing Diagnosis

Risk for Infection

Risk factors may include

Desired Outcomes

Nursing Interventions

Nursing Diagnosis

Risk for Altered Oral Mucous Membranes

Risk factors may include

Desired Outcomes

Nursing Interventions

Nursing Diagnosis

Risk for Impaired Skin Integrity

Risk factors may include

Desired Outcomes

Nursing Interventions

Nursing Diagnosis

Risk for Constipation/Diarrhea

Risk factors may include

Desired Outcomes

Nursing Interventions

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