drainage (dry desquamation) or with drainage (wet

Nursing Care of Patients with Cancer desquamation), and diminished quality of life
 Maintenance of skin integrity, cleansing, promotion of
MAINTAINING TISSUE INTEGRITY comfort, pain reduction, prevention of additional trauma,
prevention and management of infection, and promotion of
MUCOSITIS a moist wound-healing environment
- Common side effect of radiation and some types of  Prevent impaired skin integrity, patients are advised to use
chemotherapy, refers to an inflammatory process involving the moisturizer on the skin, avoid sun exposure to the area of
mucous membranes of the oral cavity and the gastrointestinal treatment, and avoid tape or bandages and other sources
tract of irritation or trauma.

STOMATITIS ALOPECIA
 Form of mucositis, is an inflammatory process of the  Temporary or permanent thinning or complete loss of
mouth, including the mucosa and tissues surrounding the hair is a potential adverse effect of whole brain
teeth changes in sensation, mild redness (erythema), and radiation therapy, various chemotherapies and
edema or, if severe, by painful ulcerations, bleeding, and targeted agents
secondary infection  Begins 2 to 3 weeks after the initiation of
 Develops 5 to 14 days after patients receive certain chemotherapy and radiation therapy; regrowth most
chemotherapeutic agents, such as doxorubicin and 5- often begins within 8 weeks after the last treatment
fluorouracil; immunotherapies, such as IL-2 and IFN; and  Onset of gradually progressing alopecia and body hair
molecular targeted drugs, such as temsirolimus and loss associated with targeted therapies generally
everolimus. occurs 1 to 3 months after the start of treatment and
 100% of patients undergoing high-dose chemotherapy may be patchy appearing as temporal or frontal hair
with HSCT, 80% of patients with malignancies of the loss
head and neck receiving radiotherapy, and up to 40% of  Usually reversible after the end of therapy and in
patients receiving standard-dose chemotherapy some cases beginning sooner
 Worse in patients with head and neck cancers who
receive combined modality therapy of both radiation and NURSING MANAGEMENT
chemotherapy  Providers may view hair loss as a minor issue, for
many patients it is a major assault on body image,
NURSING MANAGEMENT challenging to self-esteem, and resulting in
 Nursing assessment begins with an understanding of the psychosocial distress and depression.
patient’s usual practices for oral hygiene and identification  Use of cryotherapy to the head during the
of individuals at risk for stomatitis. Oral cavity assessment administration of chemotherapy has been explored
is performed daily or at each patient visit but is not consistently used because of concern about
 Poor oral hygiene, general debilitation, existing dental later development of scalp metastasis.
disease, prior irradiation to the head and neck region,  Provide information about hair loss and support the
impaired salivary gland function, the use of other patient and family in coping with changes in body
medications that dry mucous membranes, image assisted to identify proactive choices that may
myelosuppression (bone marrow depression), advanced empower them to improve responses to cancer and
age, tobacco use, previous stomatoxic chemotherapy, perceived lack of control
diminished renal function, and impaired nutritional status
 Patient is also assessed for dehydration, infection, pain, MALIGNANT SKIN LESIONS
and nutritional impairment resulting from mucositis  Most commonly associated with breast cancer
 Maintenance of good oral hygiene, including brushing,  Occur with local extension or metastasis of the tumor
flossing, rinsing, and dental care, is necessary to minimize into the epithelium and its surrounding lymph and
the risk of oral complications associated with cancer blood vessels
therapies.  Either locally invasive or metastatic cancer to the skin
may result in redness (erythema), discolored nodules,
Palifermin (Kepivance) or progression to wounds involving edema, exudates,
 IV-administered synthetic form of human keratinocyte and tissue necrosis
growth factor, is beneficial in the prevention of  Most extensive lesions involve ulceration (referred to
stomatitis in patients with hematologic malignancies as fungating lesions) with an overgrowth of
who are preparing for HSCT promotes epithelial cell malodorous microorganisms.
repair and accelerated replacement of cells in the
mouth and gastrointestinal tract. NURSING MANAGEMENT
 Careful timing of administration and monitoring are  Nurses carefully assess malignant skin lesions for the
essential for effectiveness and to detect adverse size, appearance, condition of surrounding tissue,
effects odor, bleeding, drainage, and associated pain or other
symptoms, including evidence of infection.
CRYOTHERAPY  Palliative measures to maintain patient comfort for
 (Topical application of oral ice during infusions), potential for serious complications such as
consistent oral hygiene, low-level laser therapy, and hemorrhage, vessel compression/obstruction, or
sodium bicarbonate mouth rinses airway obstruction, especially in head and neck
cancer
RADIATION ASSOCIATED IMPAIRMENT SKIN INTEGRITY  Wound cleansing, reduction of superficial bacteria,
 Patients may still develop radiation dermatitis associated control of bleeding, odor reduction, protection from
with pain, irritation, pruritus, burning, skin sloughing without further skin trauma, and pain management.

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  Altered metabolic processes and tumor responses
PROMOTING NUTRITION lead to cytokine release, causing generalized
systemic inflammation
NUTRITIONAL IMPAIRMENT  Complain of loss of appetite, early satiety, and fatigue.
 Experience some weight loss during their illness  Protein losses are associated with the development of
 Anorexia, malabsorption, and cancer-related anorexia- anemia, peripheral edema, and progressive
cachexia syndrome (CACS) are some common nutritional debilitation results in decreased quality of life,
problems psychological distress, and anxiety for both patient
 Nutritional concerns include decreased protein and caloric and family as they respond to actual and perceived
intake, metabolic or mechanical effects of the cancer, impending losses, fear, lack of control, and
systemic disease, side effects of the treatment, or the helplessness
patient’s emotional status
GENERAL NUTRITION CONSIDERATIONS
ANOREXIA  Assessment of the patient’s nutritional status is
 Alterations in taste, manifested by increased salty, conducted at diagnosis and monitored throughout the
sour, and metallic taste sensations and altered course of treatment and follow-up.
responses to sweet and bitter flavors  Early identification of patients at risk for problems with
 Contribute to decreased appetite and nutritional intake intake, absorption, and cachexia, particularly during
and subsequently protein– calorie malnutrition the early stages of disease, can facilitate timely
 Result from mineral (e.g., zinc) deficiencies, increases implementation of specifically targeted interventions
in circulating amino acids and cellular metabolites, or that attempt to improve quality of life, treatment
the administration of chemotherapeutic agents outcomes, and survival
 Patients undergoing radiation therapy to the head and  Patients have a percutaneous endoscopic
neck may experience “mouth blindness,” which is a gastrostomy (PEG) tube placed for enteral nutrition
severe impairment of taste prior to initiation of treatment and the onset of
 Patients develop early satiety after eating only a small mucositis, weight loss, and other consequences of
amount of food impaired oral intake
 Sense of fullness occurs secondary to a decrease in  Speech therapy consult may be helpful for patients
digestive enzymes, abnormalities in the metabolism of with oropharyngeal or laryngeal tumors or surgical
glucose and triglycerides, and prolonged stimulation interventions that are anticipated to effect swallowing,
of gastric volume receptors, which convey the feeling secretion management, speech, or respiratory
of being full function.
 Psychological distress (e.g., fear, pain, depression,  Prokinetic agents such as metoclopramide (Reglan)
and isolation) throughout illness may also have a are used to increase gastric emptying in patients with
negative impact on appetite. early satiety and delayed gastric emptying
 Patients may develop an aversion to food because of  Megestrol acetate (Megace) or corticosteroids (on a
nausea and vomiting associated with treatment. short-term basis) may be used to improve appetite
 Supplements containing n-3 polyunsaturated fatty
MALABSORPTION acids (omega-3), arginine, and nucleotides are
 Unable to absorb nutrients from the gastrointestinal suggested to decrease the inflammatory response
system as a result of tumor activity, cancer and improve oxygen metabolism and intestinal
treatments, or both function
 Affect gastrointestinal activity in several ways (i.e.,  Approaches incorporate nutritional counseling,
impaired enzyme production, interference with both exercise, pharmacological interventions to combat
protein and fat digestion) that can lead to increased anorexia, and symptom management when feasible
gastrointestinal irritation, peptic ulcer disease, and  Patients receiving parenteral nutrition are at increased
 Chemotherapy and radiation associated with risk for complications, including catheter-related and
mucositis cause damage to mucosal cells of the systemic infection
bowel, resulting in impaired nutrient absorption
RELIEVING PAIN
 Abdominal irradiation has been associated with
sclerosis of intestinal blood vessels and fibrotic  Chronic pain syndromes, such as postsurgical
changes in the gastrointestinal tissue, both impacting neuropathies (pain related to nerve tissue injury),
nutrient absorption occur. Some chemotherapeutic agents cause tissue
necrosis, peripheral neuropathies, and stomatitis—all
 Surgical intervention may change peristaltic patterns,
potential sources of pain—whereas radiation therapy
alter gastrointestinal secretions, and reduce the
can cause pain secondary to skin, nervous tissue, or
absorptive surfaces of gastrointestinal mucosa, all of
organ inflammation.
which contribute to malabsorption.
 Assess the patient for the source and site of pain as
CANCER RELATED ANOREXIA-CACHEXIA SYNDROME well as those factors that influence the patient’s
perception and experience of pain, such as fear and
 Complex biologic process that results from a
apprehension, fatigue, anger, and social isolation
combination of increased energy expenditure and
using Pain Assessment Scales
decreased intake
 Provides information regarding factors contributing to
 Occur in both the curative and palliative stages of
the pain experience, pain perception, and tolerance
treatment and care. Combined immunologic,
as well as pharmacologic and nonpharmacologic
neuroendocrine, and metabolic processes give rise to
nursing interventions addressing pain
anorexia, unintentional weight loss, and increased
metabolic demand with impaired metabolism of  Provides strategies for nursing assessment and
glucose and lipids. management of chronic pain.

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 Analgesics are given based on the patient’s reported  Assesses the patient’s ability to cope with the many
level of pain. bodily changes that may be experienced throughout
the course of disease and treatment.
 Nurse serves as a listener and counselor to both the
patient and the family. Possible influences of the
patient’s culture and age are considered when
discussing concerns and potential interventions

ADDRESSING SEXUALITY
 Patients at the greatest risk of sexual dysfunction are
those with tumors that involve the sexual or pelvic
organs and those whose treatment affects the
hormonal systems mediating sexual function
 Infertility, a common consequence of cancer and
cancer treatments, can be of concern to patients and
their partners

ASSISTING IN GRIEVANCE PROCESS

 Grieving is a normal response to these fears and to
actual or potential losses: loss of health, normal
sensations, body image, social interaction, intimacy,
independence, and usual social roles
 Nurses continue to assess the patient and family for
positive or maladaptive coping behaviors,
interpersonal communication, and evidence of the
need for additional psychosocial support or
interventions such as referral for professional
counseling.
 Patient enters the terminal phase of disease, the
nurse may assess that the patient and family
members are at different stages of grief.
 Nurse also empowers the patient and family to
explore preferences for issues related to end-of-life
care, such as withdrawal of active disease treatment,
desire for the use of life-support measures, and
symptom management approaches
 Oncology nurses respectfully support the patient’s
spiritual or religious views and facilitate contact with
their preferred clergy member, if desired
 After the death of a patient with cancer, home care
and/or hospice nurses follow up with surviving family
members for bereavement counseling to facilitate
expression and coping with feelings of loss and grief.

MANAGEMENT OF PSYCHOSOCIAL DISTRESS

 Screen patients for psychosocial distress during the
DECREASING FATIGUE course of the cancer experience.
 Patients report that fatigue persists and interferes with  Support in managing various sources and levels of
activities of daily living for months to years after the distress
completion of treatment  Referral to mental health providers may be helpful to
 Exists in isolation; patients typically experience other address specific concerns
symptoms concurrently, such as pain, dyspnea,
anemia, sleep disturbances, or depression. MONITORING AND MANAGING POTENTIAL
 Nurse distinguishes between acute fatigue, which COMPLICATIONS
occurs after an energy-demanding experience, and
 Monitors laboratory studies to detect early changes in
cancer-related fatigue, which is defined as “a
WBC counts.
distressing persistent, subjective sense of physical,
emotional and/or cognitive tiredness or exhaustion  Common sites of infection, such as the pharynx, skin,
related to cancer or cancer treatment that is not perianal area, urinary, and respiratory tracts, are
proportional to recent activity and interferes with usual assessed on a regular basis
functioning”  Typical signs of infection (swelling, redness, drainage,
 Acute fatigue serves a protective function, whereas and pain) may not occur in myelosuppressed patients
cancer-related fatigue does not. because of decreased circulating WBCs and a
diminished local inflammatory response
 Fever may be the only sign of infection as WBC
IMPROVING BODY IMAGE AND SELF-ESTEEM function is often impaired in patients with cancer. The
 Identifies potential threats to the patient’s body image nurse monitors the patient for sepsis, particularly if
and

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 invasive catheters or long-term IV catheters are in in other abdominal or thoracic venous tributaries such
place as the mesenteric veins or the superior vena cava.
 Among the five types of WBCs, (neutrophils
[granulocytes], lymphocytes, monocytes, basophils,
and eosinophils), neutrophils serve as the body’s Promoting Home, Community-Based, and
primary initial defense against invading organism Transitional Care
 Comprising 60% to 70% of the body’s WBCs,  Easily understood, concrete, objective information that
neutrophils act by engulfing and destroying infective assists patients to understand what to expect and
organisms through phagocytosis includes sensory and temporal components is
 Total WBC count and the concentration of neutrophils important
are important in determining the patient’s ability to  Technologic advances allow home administration of
fight infection IV chemotherapy, blood products, and antibiotics;
 Decrease in circulating WBCs (leukopenia). enteral or parenteral nutrition; and parenteral
Granulocytopenia (decrease in neutrophils), analgesics.
(neutropenia) abnormally low ANC, is associated with  Patients and families are taught to care for vascular
an increased risk of infection. access devices, infusion pumps, various types of
 Nadir is the lowest ANC following chemotherapy, drainage catheters, and on occasion complex
targeted therapy, or radiation therapy that suppresses wounds. The importance of patient safety and
bone marrow function infection control is included in patient and family
 Gram-positive bacteria (Streptococcus, enterococci, education
and Staphylococcus species) and gram-negative  Nurses are often available to provide some assistance
organisms (Escherichia coli, Klebsiella pneumoniae, with cancer care in the home, patients and families
Enterobacter, and Pseudomonas aeruginosa) are the need information that will enable them to have a
most frequently isolated causes of infection. sense of comfort, decrease distress, improve coping,
 Fungal organisms, such as Candida albicans, also foster self-management, promote adherence, and
contribute to the incidence of serious infection. enhance quality of life
 Viral infections in immunocompromised patients are  Ongoing nursing visits and/or phone contact from the
caused most often by herpes simplex, respiratory home or transitional care nurse assist in prevention,
syncytial, parainfluenza, and influenza A and B early identification, prompt reporting, and
viruses. management of patient problems
 Make referrals and coordinate available community
SEPTIC SHOCK resources (e.g., local office of the ACS, home aides,
 Frequently for signs and symptoms of infection and church groups, faith community nurses, support
inflammation throughout the trajectory of cancer care groups) to assist patients and caregivers.
 Life-threatening complications that must be prevented
or detected and treated promptly GERONTOLOGIC CONSIDERATIONS
 Working with older adults must understand the normal
BLEEDING AND THROMBOCYTOPENIA physiologic changes that occur with aging and the
implications for the patient with cancer
 Platelets are essential for normal blood clotting and  Existence of comorbidities and multiple medications
coagulation (hemostasis). may contribute to drug interactions and toxicities in
 Thrombocytopenia, a decrease in the circulating older patients
platelet count, is the most common cause of bleeding  Understanding of the effects and tolerance of
in patients with cancer and is usually defined as a chemotherapy, targeted therapies, and radiation in the
platelet count less than 100,000/mm3 (0.1 × 1012/L). older adult is limited, as older adults have been
 Risk of bleeding increases when the platelet count underrepresented in oncology clinical trials
decreases below 50,000/mm3 (0.05 × 1012/L).  Potential chemotherapy-related toxicities, such as
 Platelet counts lower than 10,000/mm3 (0.02 × renal impairment, myelosuppression, fatigue, and
1012/L), the risk for spontaneous bleeding is cardiomyopathy, may increase as a result of declining
increased organ function and diminished physiologic reserves.
 Thrombocytopenia often results from bone marrow  Recovery of normal tissues after radiation therapy
depression after may be delayed, and older adult patients may
 Certain types of chemotherapy and radiation therapy experience more severe adverse effects, such as
and with tumor infiltration of the bone marrow mucositis, nausea and vomiting, and
 Platelet destruction is associated with an enlarged myelosuppression. Because of impaired healing and
spleen (hypersplenism) and abnormal antibody declining pulmonary and cardiovascular functioning,
function, which occur with leukemia and lymphoma older patients are slower to recover from surgery
 Less commonly, posttransfusion complications may  Older patients are also at increased risk for
lead to antibody destruction of platelets causing complications, such as atelectasis, pneumonia, and
profound thrombocytopenia. wound infections.
 Coagulopathies associated with infection or
malignancies, such as gastric and pancreatic cancer, CANCER SURVIVORSHIP
may result in thrombocytopenia  Defined as the period from cancer diagnosis through
 Venous thromboembolism (VTE), a common problem the remaining years of life and focuses on the health
for patients with cancer, includes deep venous and life of a person beyond diagnostic and treatment
thrombosis (DVT), pulmonary embolism (PE), phases.
superficial venous thrombosis (SVT), and thrombosis  Survivorship care plan includes a summary of cancer
diagnosis and treatment and recommendations for

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 follow-up and care, including approaches to treat
symptoms, rehabilitative needs, monitoring for late
effects, and surveillance and screening for new and
recurrent cancer.
 Referrals for specific services such as lymphedema
therapy, chronic pain management, and genetic
counseling are also provided
 Assist in the development of the survivorship care
plan and provide education and care for cancer
survivors

PATIENT CARE FOR ADVANCED CANCER

 Treatment for the patient with advanced cancer is
likely to be palliative rather than curative, with an
emphasis on prevention and appropriate management
of pain.
 Use of long-acting analgesic agents at set intervals,
rather than on an “as needed” basis, is recommended
in addressing pain management
 Other medications (e.g., sedatives, tranquilizers,
muscle relaxants, antiemetics) are added to assist in
palliating additional symptoms and promoting quality
of life
 Candidate for radiation therapy or surgical
interventions to relieve pain or other symptoms, the
potential benefits and risks of these procedures (e.g.,
percutaneous nerve block, cordotomy) are explained
to the patient and family.

HOSPICE CARE
 End-stage illness are best met by a comprehensive
interdisciplinary specialty program that focuses on
quality of life; palliation of symptoms; and provision of
physical, psychosocial, and spiritual support for
patients and families when cure and control of the
disease are no longer possible.
 Delivered through coordination of specialty services
provided by hospitals, home care programs, and the
community.

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