Introduction to care of patients with Cancer

Introduction to care of patients with Cancer

Most people fear a diagnosis of cancer, equating the disease with suffering and death. However, more than 50% of people in North America diagnosed with cancer are cured, and thousands of others live 5 years or longer after the diag­nosis (American Cancer Society, 2001). Regardless of treat­ment type, the experience of cancer always alters a person’s physical and psychologic functioning to some degree.

Providing care to clients and families experiencing cancer is complex and challenging. This chapter describes the gen­eral interventions for and the consequences of cancer and its treatment. For individualized treatment requirements and client problems associated with specific cancer types, consult the interventions chapters in which the cancer is described.

 

GENERAL DISEASE-RELATED CONSEQUENCES OF CANCER

Cancer can develop in any organ or tissue but tends to occur more commonly in some tissues than in others. Cancer de­stroys normal tissue, resulting in decreased function in that tissue or organ. Even when cancers occur ionvital tissues or organs, they can cause death by metastasizing (spreading) into vital organs and disrupting critical physiologic processes. Cancers that are left untreated produce serious health problems, such as the following:

Impaired immune and hematopoietic (blood-producing) function

Altered gastrointestinal (GI) tract structure and function

Motor and sensory deficits

Decreased respiratory function

These impairments cause great physical and emotional dis­tress. Without intervention, persistent cancer invasion of nor­mal tissues leads to death.

Impaired Immune and Hematopoietic Function

Impaired immune and hematopoietic function occurs most of­ten in clients with leukemia and lymphoma, but such impair­ment can occur with any cancer that invades the bone marrow. Tumor cells enter the bone marrow and cause decreased pro­duction of healthy white blood cells (leukopenia), which are needed for normal immune function (see Chapter 20). Thus clients who have cancer, especially leukemia, are at an in­creased risk for infection.

When cancer invades the bone marrow, it also decreases the number of red blood cells (anemia) and platelets (thrombocytopenia). These changes may be caused by the cancer itself, such as in leukemia, or by the cancer treatment. In either case, the client becomes anemic and has an increased tendency to bleed.

–

TABLE 25-1	TEXT LOCATION OF SPECIFIC CANCER CONTENT
Cancer		Patho/	Treatment and
Type	Chaptei	–    Etiol	Nursing Intervention
Breast	74	1736-1738	1738-1749
Lung	30	559-561	562-565
Prostate	76	1789-1790	1791-1793
Colorectal	57	1245-1246	1248-1253
Skin	67	1545-1546	1546-1548
Leukemia	40	846-847	849-858
Lymphoma	40	858-859	859-860
Ovarian	75	1776	1776-1778
Head and
neck	54	1182-1183	1184-1190
Cervical	75	1772-1773	1774-1776
Bladder	70	1637	1638-1639
Stomach	56	1235	1236-1238
Esophageal	55	1205	1206-1212
Kidney	71	1658	1658-1659

 

  Altered Gastrointestinal Structure and Function

Cancer can alter GI function and disturb nutritional status. For example, tumors may cause obstruction or compression any­where along the GI tract and interfere with the client’s ability to obtain adequate nutrients and eliminate waste products. Tumors also can affect basal metabolic rate and increase a client’s requirements for protein, carbohydrates, and fat at the same time he or she has less energy available to prepare and eat meals.

Many tumors spread to the liver, causing profound damage to this organ. The liver has many important metabolic func­tions and helps digest and use proteins and fats. Altered liver function contributes to malnutrition and death among clients with cancer.

The anorexia experienced by clients with cancer often in­terferes with their ability to meet energy requirements.

Cachexia (extreme body wasting and malnutrition) develops from an imbalance between food intake and energy use. This condition may occur in spite of what appears to be adequate nutritional intake. Changes in a client’s taste can result from the cancer or the treatment and cause a decrease in appetite.

Nutritional support for the client with cancer, especially one undergoing cancer therapy, is complex and controversial. A diet high in protein and carbohydrates is often ordered to help the client maintain weight and to provide the necessary nutrients for energy and cellular repair. However, some scien­tists believe that an excessive intake of protein, carbohydrates, and vitamins increases the nutrition of the cancer cells and contributes to cancer progression. Clients often believe their cancer can be cured more easily by eating more food, espe­cially a diet low in fat and high in fiber, grains, fruit, and veg­etables. Currently no one nutritional plan meets the needs of all clients with cancer (Brown, 1999; Wilson, 2000).

Motor and Sensory Deficits

Motor (movement) and sensory deficits can occur when can­cers invade bone or the brain or compress nerves. In adult clients with bone metastases, the primary cancer started in an­other organ (e.g., the prostate, breast, or lung). The bone sites most affected include the vertebrae, ribs, pelvis, and femur. The humerus, scapula, sternum, skull, and clavicle are also common metastatic sites. Bone metastases can cause frac­tures, spinal cord compression, and hypercalcemia, each of which results in decreased mobility for the client.

The client may also experience sensory changes if the spinal cord is damaged by tumor compression or if nerve gan­glia are compressed. Sensory, motor, and cognitive functions are severely disrupted when tumors metastasize to the brain.

The client with cancer may also experience pain. Pain does not always accompany cancer, but it can be a significant prob­lem for clients with terminal cancer. Chapter 7 provides an in-depth discussion of the causes and management of cancer pain.

Decreased Respiratory Function

Cancer can disrupt a client’s respiratory function in several ways and often results in death. For example, tumors involv­ing the airways can cause airway obstruction. If lung tissue is involved, lung capacity is decreased. Tumor growth can also press on vascular and lymphatic structures in the chest, block­ing blood flow through the chest and lungs and resulting in pulmonary edema and dyspnea. In addition, tumors can thicken the alveolar membrane and damage pulmonary blood vessels, reducing gas exchange.

 

CAUSES OF MALNUTRITION IN CLIENTS WITH CANCER

ANOREXIA

Local causes

•  Pelvic or abdominal tumors

•  Hepatic metastases

•  Intestinal compression or obstruction

•  Others

 

Remote causes

•  Food aversions

•  Early satiety

 

Treatment-related causes

•  Postsurgical small stomach or stasis

•  Drugs, including chemotherapy

•  Radiation—local and systemic effects

Systemic illness

•  Infection

•  Hepatitis or pancreatitis

•  Endocrinopathies

 

Taste disorders

•  Drugs (e.g., metronidazole)

•  Remote effects of neoplasm and its treatment

• Local disease and its treatment (e.g., stomatitis, nasopharyngeal tumor, radiation, and surgery)

•  Nausea and vomiting

Psychogenic causes

•  Depression

•  Anxiety

•  Conditioned aversions

 

Intolerance of institutional food

 

DIFFICULTY IN EATING

Head and neck tumors and their treatment

Xerostomia

Stomatitis

Loss of teeth and dental problems

Dysphagia and odynophagia

 

MALDIGESTION OR MALABSORPTION

Pancreatic insufficiency

Bile salt deficiency

Hypersecretory syndrome

•  Zollinger-Ellison syndrome

•  Pancreatic cholera

•  Bowel infiltration

•  Diffuse invasion (e.g., lymphoma)

•  Local blockage

•  Fistula

 

Postsurgical causes

•  Esophageal surgery (with vagotomy, gastric statis, diarrhea, and steatorrhea)

•  Gastrectomy—dumping, achlorhydria, or afferent loop syndrome

•  Small intestine resections

 

Postirradiation causes

•  Enteritis (may occur as late sequelae)

•  Fistula

•  Stenosis

•  Obstruction

PROTEIN-LOSING ENTEROPATHY MALUTILIZATION

Cancer cachexia

 Steroids

•  Nitrogen wasting

•  Hyperglycemia

•  Calcium loss

 

TABLE 25-2   ■   KEY POINTS ABOUT CANCER TREATMENT

•  With a multiapproach to cancer treatment, 50% of clients with cancer can be cured.

•  Surgery is most effective for cancer therapy when tumors are small and well localized.

•  Radiation therapy is effective only on the tissues directly within the radiation path.

•  Side effects of radiation therapy are confined to the tissues within the radiation path.

•  The most common side effects of radiation therapy are skin irritation, fatigue, and altered taste sensation.

•  Chemotherapy is systemic therapy for cancer and affects all body tissues.

•  The most common side effects of chemotherapy are alopecia, nausea and vomiting, mucositis, skin changes, and bone marrow suppression.

•  The most life-threatening side effect of chemotherapy is bone marrow suppression.

 

•  Surgery

RATIONALE FOR CANCER TREATMENT

 

Surgery for cancer involves the removal of diseased tissue. If cancer is confined to the removed tissue, surgery alone can re­sult in a “cure” for that cancer. Although many cancers have spread too far at the time of diagnosis for surgery alone to be curative, it may still be a useful part of diagnosis, treatment, follow-up, and rehabilitation.

  Increase the number of cancer survivors who are living 5 years or longer after diagnosis.

•  Encourage clients to seek early health care advice whenever one of the seven warning signs of cancer are present.

•  Teach clients being treated for cancer the importance of compliance with the scheduled treatment regimen.

•  Teach the client to follow up with health care visits after cancer treatment is completed.

•  Teach the client with cancer to continue with recommended screening practices.

•  Encourage the client who has been treated for cancer to avoid known environmental carcinogens.

•  Assist clients who smoke to reduce or quit smoking.

•  Teach clients about the importance of limiting dietary fat, smoked meats, and red meats.

 

 MECHANISM OF ACTION

Surgery is the oldest form of cancer treatment and is the first method to cure cancer. Cancer surgery may be prescribed for any of the following purposes: prophylaxis, diagnosis, cure, control, palliation, determination of therapy effectiveness, and reconstruction.

 

Prophylaxis

Prophylactic surgery is performed when a client has either an existing “premalignant” condition or a known family history that strongly predisposes the person to the development of cancer. An attempt is made to remove the “at-risk” tissue or organ to prevent the development of cancer. An example of prophylactic surgery for a premalignant condition is remov­ing a benign mole from a location where it would receive con­tinuous irritation or exposure to sunlight.

 

    Diagnosis (Biopsy)

Diagnostic surgery provides histologic proof of malignancy. All or part of a suspected lesion is usually removed for microscopic examination and testing.

• Cure

Without additional therapy, surgery for cure can result in a cure rate of 25% to 30%. All gross and microscopic tumor is either removed or destroyed.

Control (Cytoreductive Surgery)

Cancer control, or cytoreductive surgery, is a “debulking” procedure that consists of removing part of the tumor and leaving a known amount of gross tumor. This type of surgery alone cannot result in a cure, but it does decrease the number of cancer cells and increases the chances that other therapies can be successful.

 Palliation

Palliative surgery aims not to cure (or even increase survival time in many instances) but to improve quality of life during the survival time. The surgeon removes the tumor tissue that is causing pain, intestinal obstruction, or difficulty swallow­ing. The specific procedure used during palliative surgery de­pends on the client’s specific problem.

 

  Determination of Therapy Effectiveness

(“Second Look”)

Second-look surgery is essentially a “rediagnosis” after treat­ment. This procedure is performed to assess the disease status in clients who have been treated and have no symptoms of re­maining or recurrent tumor. The results of this surgery serve as a basis for discontinuing or continuing specific therapy.

 Reconstructive or Rehabilitative Surgery

Reconstructive-rehabilitative surgery is relatively new. People with cancer are surviving long enough to need reconstruction. This type of surgery increases function, enhances cosmetic appearance, or both. Examples include breast reconstruction after mastectomy, replacement of the esophagus after radia­tion damage, bowel reconstruction, revision of scars, release of contractures, and placement of penile implants.

■ SIDE EFFECTS OF SURGICAL THERAPY

Unlike surgery performed for many other reasons, cancer sur­gery often involves the loss of a specific body part or its func­tion. Sometimes whole organs are removed, such as the kid­ney, lung, breast, testes, arm, or tongue. Any organ loss results in reduced function. The amount of function that is lost and how much the loss physically affects clients depends on the location and extent of the surgery. Some surgical procedures  for cancer may result in significant scarring or disfigurement. In addition to actual body part loss and anxiety about the chances of surviving, clients may be grieving about a loss of body image or a change in lifestyle imposed by the cancer or its treatment.

■ NURSING CARE OF CLIENTS UNDERGOING SURGICAL THERAPY

The nursing care associated with cancer surgery is not vastly different from that related to surgery for other reasons (see Chapters 17 to 19). The nurse considers all the physical and psychosocial factors related to the client’s ability (and the ability of family and significant others) to cope with the un­certainty of cancer and it’s treatment and with the changes in body image and role. For example, surgery involving the gen­itals, urinary tract, colon, and rectum may permanently dam­age these organs. Surgical procedures that create a urinary or fecal diversion (e.g., a colostomy) may disturb innervation, causing erectile impotence or ejaculatory dysfunction in men and painful intercourse (dyspareunia) in women.

Radiation

 RATIONALE FOR CANCER TREATMENT

The purpose of all types of radiation therapy for cancer is to destroy cancer cells with minimal exposure of the normal cells to the damaging actions of radiation. The effects of radi­ation are seen only in the tissues in the path of the radiation beam. Some effects are apparent within days or weeks, whereas other effects may not be apparent for months to years after the completion of radiation therapy.

 MECHANISM OF ACTION

Most of the radiation used to treat malignant tumors is ionizing radiation. When cells are exposed to this type of radia­tion, atoms within the cell are “kicked out” of orbit, resulting in a tremendous release of intracellular energy. Ionizing radi­ation is given off naturally by some substances, such as ra­dium and cobalt, and can also be generated by machines called linear accelerators. Naturally occurring radiation is called gamma radiation; radiation that is generated by ma­chine is called roentgen radiation. Their effect on cells is ex­actly the same.

Cells damaged by radiation either die outright or become unable to divide. Radiation damage can occur any time a cell is exposed to radiation; it is not confined to cells actively in the cell cycle. However, cells in the cell cycle do experience more damage when exposed to radiation than do nondividing cells.

Three different types of energy, or rays, are produced by gamma radiation: gamma, beta, and alpha rays.

These rays vary in their ability to penetrate tissues and damage cells. Table 25-6 summarizes the features of these three types of gamma radiation, and Figure 25-1 shows the penetrating abil­ity of each.

The amount of radiation aimed at or delivered to a tissue is called exposure, and the amount of radiation absorbed by the recipient tissue is called the dose. The dose is always some­what less than the exposure. Three major factors determine the absorbed dose: intensity of exposure, duration of expo­sure, and proximity of the radiation source to the cells.

The intensity of the radiation emitted decreases with the distance from the radiation source (Figure 25-2). This phe­nomenon is known as the inverse square law. For example, the radiation dose received at a distance of 2 feet from the ra­diation source is only one fourth of the dose received at a dis­tance of 1 foot from the radiation source; the dose of radiation received at 3 feet is only one ninth of the dose received at 1 foot (Hassey, 1987).

GAMMA RAY

Gamma rays are very light and have a low energy-transfer potential. They travel at the speed of light, allowing them to be concentrated and penetrate deeply into tissues.

This is the most common type of radiation used for the treat­ment of cancer.

This type of radiation can also cause serious, irreversible harm to tissues.

Exposure to this type of radiation must be avoided or se­verely limited.

BETA RAY

Beta rays are heavier and travel at a moderate to high speed. They have a high linear energy-transfer potential and do not penetrate tissues or other substances well.

Some beta rays are used inside the body for specific radia­tion therapy.

Beta rays are used in some diagnostic tests.

Beta rays pose health hazards to humans exposed to them, but exposure must be considerable for damage to occur.

ALPHA RAY

Alpha rays are very heavy and slow. They easily transfer en­ergy to their surroundings and quickly lose their ability to penetrate tissues (0.04 mm into tissue).

Currently, alpha rays are used in laboratory tests rather than as treatment for cancer.

This type of radiation is harmful to humans only if it is in­gested chronically.

 

       Killing Effects of Radiation

If the dose of radiation is high enough, all cells are killed im­mediately. This does not usually happen. Radiation damage to the deoxyribonucleic acid (DNA) of the cell is not usually ap­parent until the cell attempts to divide. In a tumor treated with a single exposure of radiation, all cells within the tumor absorb the radiation slightly differently. Therefore their overall response to the radiation is slightly different. A few cells die immediately, and more die within the next 24 hours as they at­tempt to divide. Some cells become sterile as a result of this single treatment, whereas others repair the radiation-induced damage and continue to reproduce for many cell generations.

Because of the varying responses of all cancer cells within a given tumor, radiation is administered as a series of divided doses. Small doses of radiation are delivered on a daily basis for a set period of time.

Giving radiation treatments sequen­tially rather than as a single dose allows multiple opportunities to catch and destroy cancer cells that survived the initial hit of radiation while minimizing the damage to normal tissues. This  with Cancer dose division is called fractionation.

Standard radiotherapy is usually fractionated between 180 and 250 rad/day, multiplied by as many days as needed to achieve the total prescribed dose. (Rad is an acronym meaning “radiation absorbed dose.”)

 

 

 

 

 

 

Figure 25-2    •    The inverse square law of radiation exposure

 

The total therapeutic dose of radiation to a tumor depends on the size and location of the tumor and on the radiation sen­sitivity of the tumor and surrounding normal tissues. Some normal tissues are more sensitive than others to radiation. For example, a total dose of 1200 rad might be prescribed for a primary liver tumor, but a total dose of 5000 to 6000 rad might be necessary for a breast carcinoma (delivered over 25 to 30 separate days). A 6000-rad dose delivered to the liver would lead to such extensive damage of liver tissue that the client would experience liver failure and die, even if the tumor were destroyed. Healthy breast tissue can tolerate much higher doses of radiation.

Two types of radiation delivery are most commonly used for cancer therapy: teletherapy and brachytherapy. The type used depends on the client’s general condition and state of health and on the site, stage (including size and depth of the lesion), and radiosensitivity of the tumor. Regardless of how it is adminis­tered, the optimum dose of radiation is one that can kill the can­cer cells with an acceptable level of damage to normal tissues (some damage to normal tissues cannot be avoided).

 

 Teletherapy

Teletherapy is derived from the Greek prefix “tele,” meaning distant. In teletherapy, the actual radiation source is external to the client and remote from the tumor site. Because the source is external, the client never emits radiation and poses no hazard to anyone else. This type of therapy is also called beam radiation.

To increase the accuracy of radiation delivery to cancer cells, the exact location of the tumor is determined. Once the pattern of radiation delivery is established, the client must al­ways be in exactly the same position for all treatments. The nurse ensures that the client can get into and maintain this po­sition with relative ease. Position-fixing devices and markings, either on the client’s body or on the devices, ensure the proper position each day of treatment.

   Brachytherapy

Brachytherapy is derived from the Greek word “brack,” meaning short. With brachytherapy, the radiation source must come into direct, continuous contact with the tumor tissues for a specific period of time. The rationale is to provide a high absorbed dose of radiation in tumor tissues and a very limited absorbed low dose in surrounding normal tissues. The radiation delivered by brachytherapy has the same tissue effects as ionizing radiation delivered by external sources.

Brachytherapy involves the use of radioactive isotopes ei­ther in solid form or within body fluids. Isotopes can be de­livered to the tumor tissues in several ways. With all types of brachytherapy, the radiation source is within the client. There­fore the client emits radiation for a period of time and can pose a hazard to others.

 UNSEALED RADIATION SOURCES

Soluble isotopes are unsealed radioactive sources adminis­tered via the oral or intravenous (IV) routes or as an instilla­tion into body cavities, such as the peritoneal cavity and the spinal fluid space. Because the isotopes are unsealed, they are not completely confined to any one body area. However, they may concentrate more in some body tissues than in others. These soluble isotopes enter body fluids and eventually are eliminated from the body in various excreta (waste products), which are radioactive and can be harmful to other people.

An example of brachytherapy with soluble isotopes is the ingestion or injection of the radionuclide iodine¹³¹ (an iodine base with a half-life of 8.05 days) to treat hyperthyroidism and some thyroid malignancies. The radioactive iodine con­centrates in the thyroid gland and destroys the thyroid cancer cells. Most of this isotope is eliminated from the body within 48 hours. Once eliminated, neither the client nor the excreta are radioactive.

         SEALED RADIATION SOURCES

The solid forms of brachytherapy involve sealed radiation sources implanted within the tumor target tissues. These radi­ation sources can be temporary or permanent. Most of the im­plants emit continuous, low-energy radiation to tumor tissues. Some devices (e.g., seeds or needles) can be placed into the tissues and stay in place by themselves. Other solid radiation sources must be held in place within the tissue or cavity by special applicators. Needles and seeds are preloaded with the radioactive isotope and are radioactive at the time of insertion (“hot implantation”). Some of these devices are so small and the half-life of the isotope so short that the device is perma­nently left in place (most often for clients with prostate can­cer). Other devices are removed and reused in other clients.

In afterloading, the implant is placed within the cavity without the radioactive isotope. Special applicators hold the implant in position. When placement has been ascertained and the client is in the proper environment, the implant is loaded with the radioisotope. After the prescribed dose has been delivered, the implant, radioisotopes, and position-holding applicators are removed. With solid implants, the client emits radiation while the implant is in place, but the excreta are not radioactive. Chart 25-1 lists the best practices for the client with sealed implant radiation sources.

 

■       SIDE EFFECTS OF RADIATION THERAPY

The immediate and long-term side effects of all types of radi­ation are limited to the tissues exposed to the radiation. There­fore the side effects vary according to the site. Skin changes and hair loss are local but are likely to be permanent depend­ing on the total absorbed dose.

Depending on the dose, altered taste sensations and fatigue are two systemic side effects ofteoted by clients receiving external beam radiation—regardless of the radiation site. Taste changes are thought to be caused by metabolites re­leased from dead and dying cells. In particular, many clients experience an aversion to the taste of red meats. Fatigue may be related to the increased energy demands needed to repair radiation-damaged cells. Regardless of the physiologic cause, radiation-induced fatigue can be debilitating and may last for weeks to months (see the Evidence-Based Practice for Nurs­ing box on p. 430). Many clients are unprepared for the de­gree of fatigue experienced and require lifestyle adjustments to manage this symptom.

Radiation damage to normal tissues during cancer therapy can initiate the inflammatory responses that cause tissue fi-brosis and scarring. Their effects may not be apparent for many years after radiation treatment. For example, women who receive high-dose radiation therapy for uterine cancer may experience radiation-induced changes in the colon years later, resulting in constipation and obstruction.

 NURSING CARE OF CLIENTS UNDERGOING RADIATION THERAPY

Most clients are anxious about radiation. The nurse must be knowledgeable about its nature and be able to explain its pur­pose and side effects to clients and families. When clients re­ceive concrete, objective information regarding radiation ther­apy, they are better able to cope with the treatment and continue to participate iormal activities.

Chart 25-2 summarizes skin care and other precautions during external radiation therapy.

 

 

The nurse instructs clients not to remove the markings when cleaning the skin until the entire course of radiation therapy is completed. Skin in the path of radiation becomes very dry and may break down. The nurse instructs clients not to use lotions or ointments in these areas unless the radiologist prescribes them. Because skin in the radiation path is more sensitive to sun damage, the nurse advises against direct skin exposure to the sun during treat­ment and for at least 1 year after completing radiation therapy.

The normal tissues most sensitive to external radiation are hematopoietic (blood-producing), epithelial (including skin, mucous membranes, and hair follicles), and gonadal (reproductive) tissues. Some changes caused by radiation are perma­nent. The long-term problems experienced by clients vary with the location and dose of radiation administered.

For example, radiation to the throat and upper chest can cause difficulty in swallowing. Head and neck radiation may damage the salivary glands and cause dry mouth (xerostomia). Bone exposed to radiation therapy may be less dense and break more easily. The nurse teaches about the types of symptoms that might be ex­pected from the location and dose of radiation delivered.

 

Chemotherapy

Chemotherapy, the treatment of disease through chemical agents, has assumed a major role in managing clients with cancer. Chemotherapy as a cancer treatment is used to cure, increase mean survival time, and decrease the risk for specific life-threatening complications.

RATIONALE FOR CANCER TREATMENT

One characteristic of cancer growth is the ability of cancer cells to separate from the orig­inal tumor, spread to new areas, and establish new cancers at distant sites (metastasize). Clients with metastatic disease will die unless treatment focuses on eliminating the metasta­tic cancer cells and the original cancer cells. Chemotherapy is useful in treating cancer because its effects are systemic and thus provide the opportunity to kill metastatic cancer cells that may have escaped local treatment.

• MECHANISM OF ACTION

Chemotherapy can be successful in treating cancer because it has some demonstrated selectivity for killing cancer cells over normal cells. This killing effect on cancer cells appears to be related to the ability of chemotherapy to damage DNA and in­terfere with cell division. Thus the tumors most sensitive to chemotherapy are those that have rapid growth.

Unfortunately, chemotherapeutic agents usually are ad­ministered systemically and exert their cell-damaging (cytotoxic) effects against both healthy cells and cancerous cells. The normal cells most profoundly affected by systemic chemotherapy are those that undergo frequent cell division, including skin, hair, epithelial lining of the gastrointestinal (GI) tract, spermatocytes, and hematopoietic cells.

Chemotherapy includes many drugs or chemical compounds that are effective in killing cancer cells. They are classified by the specific types of biologic action they exert in the cancer cell and by the period in the life of a cell during which the agent is most likely to succeed in disrupting vital processes.

 

Critique.

The study approached a pervasive yet subjective problem using quantitative measures. In addition, the PBFFC is a unidimensional rather than multidimensional measure of fa­tigue. The sample size was relatively large but not randomized.

 

Implications for Nursing.

Clients and families are unpre­pared for the experience of fatigue with radiation therapy for cancer. In fact, because radiation therapy results in relatively few overt changes in clinical manifestations, both clients and families have indicated disbelief at the existence and severity of radiation-induced fatigue. Families have become impatient and clients have felt guilty for not participating in work-related or family activities to the degree expected. The nurse can help the client and family accept and prepare for fatigue as an expected and reversible side effect of radiation therapy for cancer.

 

Antimetabolites

Antimetabolites are chemicals similar to normal metabolites (cofactors, vitamins, and nucleotides [purines and pyrim-idines]) that play critical roles in essential cell processes. Most cellular reactions require metabolites in order to begin or continue the reaction. Antimetabolites closely resemble normal metabolites and can be considered “counterfeit” metabolites that literally fool cancer cells into using the antimetabolites in cellular reactions. Because antimetabolites cannot function as proper metabolites, their presence impairs or prevents cell division.

 Antitumor Antibiotics

Antitumor antibiotics are a class of anticancer drugs initially developed to combat bacterial infections by causing major damage to the cell’s DNA and interrupting DNA or ribonu-cleic acid (RNA) synthesis. Exactly how the interruptions oc­cur varies with each antibiotic.

 Alkylating Agents

All alkylating agents cross-link DNA by various means. Whatever the mechanism, the double strands of DNA become more tightly bound together. This tight binding prevents proper DNA and RNA synthesis, resulting in an inhibition of cell division.

 Antimitotic Agents

Antimitotic agents are substances made from plant sources. Their primary mechanism of action is to interfere with the proper formation of microtubules so cells cannot complete mi­tosis during cell division. As a result, the cell either does not di­vide at all or divides only once, resulting in two daughter cells with unequal amounts of DNA that cannot continue to divide.

 Topoisomerase Inhibitors

Topoisomerase is an enzyme needed for DNA synthesis and cell division. It nicks and straightens the DNA helix, allowing the DNA to be copied, and then reattaches the DNA together. Topoisomerase inhibitors prevent these processes, causing DNA breakage and cell death.

 Miscellaneous Chemotherapeutic Agents

The actions of other chemotherapeutic agents do not fit any of the broad categories of chemotherapeutic agents and include the following:

•  Inhibition of important enzyme systems

•  Competition for important substances in metabolic pathways

 

CHART 25-2

CLIENT EDUCATION GUIDE

Radiation Therapy for Cancer

•  Wash the irradiated area gently each day with either water alone or with a mild soap and water.

•  Use your hand rather than a washcloth to be more gentle.

•  Rinse soap thoroughly from your skin.

•  Take care not to remove the markings that indicate exactly where the beam of radiation is to be focused.

•  Dry the irradiated area with patting motions rather than rubbing motions; use a clean, soft towel or cloth.

•  Use no powders, ointments, lotions, or creams on your skin at the radiation site unless they are prescribed by your radiologist.

•  Wear soft clothing over the skin at the radiation site.

•  Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at the radiation site.

•  Avoid exposure of the irradiated area to the sun.

•  Avoid heat exposure.

CRITICAL THINKING CHALLENGE

The client is a 28-year-old woman diagnosed with breast cancer who is going to receive radiation therapy to the left breast and axillary area after a lumpectomy. She is a pro­fessional golfer and wonders how radiation therapy will affect her game and her appearance.

•  How long will her radiation therapy last?

•  Are there contraindications to playing golf while receiving radiation therapy?

•  What modifications for time of day or dress will you suggest to this client? Why?

•  What will you tell this client about hair loss?

 

TABLE 25-7   ■  CATEGORIES OF CHEMOTHERAPEUTIC AGENTS
Generic Name	Usual Dose	Nadir	Generic Name	Usual Dose	Nadir
ANTIMETABOLITES			ALKYLATING AGENTS—CONT’D
Methotrexate	3.3 mg/m2	10-14 days	Mechlorethamine	0.2-0.3 mg/kg	10-14 days
(Mexate, Folex)			(Mustargen)
6-Mercaptopurine	80-100 mg/m2	5-40 days	Busulfan	1-8 mg	14-21 days
(Purinethol)			(Myleran)
6-thioguanine (Lanvis) 5-Fluorouracil (Adrucil, Efudex, Fluoroplex)	2-3 mg/kg	1-4wk	Chlorambucil	1-4 mg/m2	28 days
	300-750 mg/m2	9-14 days	^LeuKeranj Melphalan	1-6 mg/m2	14-21 days
			^МІКсГсіМ^ Carmustine	200-250 mg/m2	4-6 wk
Fludarabine	25 mg/m2	3-25 days	(BiCNU)
(Fludara)			Lomustine	130 mg/m2	4-6 wk
Floxuridine	0.1-0.6 mg/kg	4-7 days	(CCNU, CeeNU)
(FUDR)			Temozolomide	150-200 mg/m2	20-22 days
Cytarabine	100-300 mg/m2	4-7 days	(Temodar)
(Cytosar, Ara-C)			Thiotepa	0.3-0.8 mg/kg	15-30 days
Pentostatin	4 mg/m2	3-Ю days	(Thioplex)
(Nipent)			Streptozocin	500-1500 mg/m2	14 days
Capecitabine (Xeloda) Trimetrexate	2500 mg/m2	Not reported	(Zanosar)
	45 mg/m2	10-14 days	ANTIMITOTICS
(Neutrexin)			Vincristine	0.5-2.0 mg/m2	7 days
Gemcitabine	1000-1250 mg/m2	7-12 days	(Oncovin, Leuro-
(Gemzar)			cristine, VCR)
			Vinblastine	5-Ю mg/m2	5-11 days
ANTIBIOTICS			(Velban, Velbe*,
Bleomycin	10-20 units/m2	7-14 days	Velsar)
(Blenoxane)			Vindesine	2 mg/m2	2-7 days
Dactinomycin	0.4-0.6 mg/m2	14-21 days	(DAVA, Eldisine*)
(Cosmegen)			Vinorelbine	30 mg/m2	7-Ю days
Doxorubicin	50-80 mg/m2	10-15 days	(Navelbine)
(Adriamycin,			Paclitaxel	100-250 mg/m2	8-11 days
Rubex)			(Taxol)
Daunorubicin	30-60 mg/m2	10-14 days	Docetaxel	60-100 mg/m2	8-Ю days
(Cerubidine)			(Taxotere)
Epirubicin	100-120 mg/m2	10-14 days
(Ellence)			topoisomerase inhib:
Idarubicin	12-25 mg/m2	10-14 days	Irinotecan	125-150 mg/m2	18-25 days
(Idamycin)			(Camptosar)
Plicamycin (Mithracin) Mitomycin С	0.025-0.030 mg/m2	10-12 days	Topotecan (Hycamtin) Etoposide	1.5 mg/m2	7-14 days
	10-20 mg/m2	21-50 days		50-100 mg/m2	8-Ю days
(Mutamycin)			(VP-16, VePesid)
Mitoxantrone	12-14 mg/m2	7-Ю days	Teniposide	100-180 mg/m2	8-Ю days
(Novantrone)			(Vumon, VM-26)
			Estramustine	600 mg/m2	Rare
ALKYLATING AGENTS			(Emcyt)
Cyclophosphamide	50-500 mg/m2	7-14 days
(Cytoxan, РгосуіохФ)			OTHER AGENTS
Altretamine	260 mg/m2	3-4 wk	Procarbazine	100-300 mg	14-28 days
(Hexalen)			(Matulane, Natulan*1)
Cisplatin (Platinol) Carboplatin (Paraplatin) Ifosfamide (IFEX)	25-120 mg/m2	10-20 days	Dacarbazine (DTIC*) Hydroxyurea (Hydrea) Asparaginase (Elspar)	75-250 mg/m2	10-14 days
	360 mg/m2	21-28 days		25 mg/kg	4-7 days
	1.2 g/m2	10 days		200-1000 lU/kg	4-Ю days

■ Combination Chemotherapy

Chemotherapy for cancer usually involves the timed adminis­tration of more than one specific anticancer drug. This tech­nique is called combination chemotherapy. Using more than one drug is much more effective in killing cancer cells than us­ing a single agent. Unfortunately, the damage caused to normal tissues also increases with combination chemotherapy.

The selection of drugs is based on known tumor sensitivity to the drugs and the degree of side effects expected. For ex­ample, most chemotherapeutic drugs suppress bone marrow activity and immune function to some degree, but some agents are more profoundly immunosuppressive than others. Such agents include busulfan, cyclophosphamide, etoposide, dacti-nomycin, doxorubicin, and mechlorethamine. There is also variation in the timing of drag-induced immunosuppression.

The time during which bone marrow activity and periph­eral white blood cell counts are at their lowest levels after chemotherapy is the nadir. The nadir occurs at different times for different chemotherapeutic agents (see Table 25-7). For instance, the expected nadir after cytosine arabinoside admin­istration is 5 to 7 days; after methotrexate, 10 to 14 days; and after mitomycin C, approximately 4 weeks. To minimize immunosuppression, combination chemotherapy is planned to avoid prescribing different drugs with nadirs that occur at or near the same time.

 

TABLE 25-8      R01	JTES OF CHEMOTHERAPY ADMINISTRATION
Route	Typical Cancer
Oral	Hodgkin’s lymphoma
	Leukemia (maintenance phase)
	Small cell lung cancer
Intravenous	Most solid tumors, leukemias
	Lymphomas
Intra-arterial	Hepatic tumors (primary and
	metastatic)
	Head and neck cancers
Isolated limb	Cancers confined to a limb
perfusion	• Osteogenic sarcoma
	• Ewing’s sarcoma
	• Rhabdomyosarcoma
	• Regional melanoma
Intracavitary
• Intraperitoneal	Ovarian cancer
• Intraventricular	Brain tumors
• Intrathecal	Brain tumors
	Prophylaxis for acute lymphocytic
	leukemia
• Intravesical	Bladder tumors

 Drug Dosage

The doses of most chemotherapeutic agents are calculated ac­cording to the type of cancer and the client’s size. A few drag dosages are calculated in terms of milligrams per kilogram of body weight. More commonly, calculations are based on mil­ligrams per square meter of total body surface area (TBSA). This parameter also considers the client’s height and weight and is calculated as follows: the height of the client (in cen­timeters) is multiplied by his or her weight (in kilograms), and the result is divided by 10,000 (moving the decimal point four spaces to the left). For example, a woman who is 68 inches tall (173 cm) and weighs 143 pounds (65 kg) has a TBSA of 11,245 cm², or 1.12 m².

 Drug Schedule

Chemotherapeutic agents are administered on a regular basis and are timed to maximize cancer cell kill and minimize dam­age to normal cells. The schedule may vary somewhat to ac­commodate a client’s response to therapy, but chemotherapy is usually scheduled every 3 to 4 weeks for a specified num­ber of times (on average, 6 to 12 times). The entire planned schedule is the course of chemotherapy; the individual days of administration are the rounds.

 

Drug Administration

Most chemotherapeutic drags are administered intravenously, although other routes may be used for specific cancers. The techniques and nursing care considerations for dif­ferent routes are described with the specific cancer type most commonly associated with the specific administration route.

 

CHEMOTHERAPY TISSUE VESICANTS AND IRRITANTS

VESICANTS        IRRITANTS

Amsacrine             Bleomycin

Dactinomycin       Carmustine

Daunorubicin        Cisplatin

Doxorubicin          Dacarbazine

Epirubicin             Etoposide

Esorubicin             Fluorouracil

Idarubicin             Mitoxantrone

Mechlorethamine  Paclitaxel

Menogaril              Plicamycin

Mitomycin С         Streptozocin

Pyrazofurin           Teniposide Vinblastine Vincristine Vindesine Vinorelbine

The IV route is the most preferred route for chemotherapy because the therapeutic effects of the drugs are rapid and be­cause many of these agents are irritating or damaging to tis­sues. A major complication of IV administration is extravasation, or the movement of the IV needle so the drug leaks into the surrounding skin and subcutaneous tissues. When the administered agents are vesicants (chemicals that cause tissue damage on direct contact), the results of extravasation can in­clude pain, infection, and tissue loss. Surgical intervention is sometimes necessary.

The most important nursing intervention for extravasation is prevention (Wood & Gullo, 1993). Most extravasations re­solve without extensive treatment if less than 0.5 mL of the ir­ritating drug has infiltrated into the tissues. If a larger amount has leaked, extensive tissue damage occurs and surgical inter­vention may be necessary. Immediate treatment depends on the specific agent extravasated. With some agents, cold com­presses to the area are appropriate; for other agents, warm compresses are used. Antidotes may be injected into the site of extravasation. The nurse consults with the oncologist and pharmacist to determine the specific antidote needed for the extravasated agent. Chart 25-3 outlines the best practices for documenting an extravasation event.

Most chemotherapeutic agents are readily absorbed through the skin and mucous membranes. As a result, the health care workers who prepare or administer these chemotherapeutic agents (especially nurses and pharmacists) are at risk for ab­sorbing them (DelGaudio & Menonna-Quinn, 1998). Even at low doses, chronic exposure to chemotherapeutic agents can se­riously affect health. Nurses and other health care professionals must use extreme caution and wear protective clothing when­ever preparing, administering, or disposing of chemotherapeutic agents. The Occupational Safety and Health Administration (OSHA) and the Oncology Nursing Society have established practice guidelines and protective standards.

SIDE EFFECTS OF CHEMOTHERAPY

Serious side effects are associated with aggressive chemotherapy, including alopecia (hair loss), nausea and vomiting, open sores on mucous membranes (mucositis), and various skin changes.

 Documentation of Extravasation

·        Document the date and time when extravasation was suspected or identified.

·        Note the date and time when the infusion was started.

·        Record the time when the infusion was stopped.

·        Note the exact contents of the infusion fluid and the vol­ume of fluid infused.

·        Document the estimated amount of fluid extravasated.

·        Note the needle type and size.

·        Diagram the exact insertion site.

·        Indicate on the diagram the location and number of venipuncture attempts.

·        Record the time between the extravasation and the last full blood return.

·        Identify all agents administered in the previous 24 hours through this site (list agent administered, dosage and vol­ume, and order of administration).

·        Note the client’s vital signs.

·        Take a photograph of the site.

·        Document the administration of neutralizing or antidote agents.

·        Note the application of compresses.

·        Note other nursing interventions.

·        Record the client’s responses to nursing interventions.

·        Document the physiciaotification (including the time).

·        Document the written and oral instructions given to the client about follow-up care.

·        Note any consultation request. Sign the documentation.

The common side effects on the hematopoietic (blood-pro­ducing) system can be life threatening and are the most com­mon reason for altering the dosage or schedule. The chemo-toxic effects on the blood-forming cells of the bone marrow also produce specific side effects, including immunosuppres-sion, anemia, and thrombocytopenia (decreased numbers of platelets).

A newer approach to decrease the impact of chemothera­peutic agents oormal tissues is to administer the agents with drugs that exert a protective influence on specific healthy cells. These drugs, called cytoprotectants, have little if any effect on cancer cells but do offer some protection to normal cells.

 NURSING CARE OF CLIENTS UNDERGOING CHEMOTHERAPY

The major nursing care issue during chemotherapy is manag­ing the distressing symptoms associated with therapy. For some clients, the symptoms are so disagreeable that they discontinue treatment

 

 INTERVENTION ACTIVITIES For The Client with Cancer

Chemotherapy Management:

Assisting the client and fam­ily to understand the action and minimize side effects of antineoplastic agents

•  Monitor for side effects and toxic effects of chemotherapeutic agents.

•  Provide information to client and family on how antineoplastic drugs work on cancer cells.

•  Instruct client and family on ways to prevent infection, such as avoiding crowds and using good hygiene and handwashing techniques.

•  Instruct client to promptly report fever, chills, nosebleeds, excessive bruising, and tarry stools.

•  Instruct client to avoid the use of aspirin products.

•  Administer antiemetic drugs for nausea and vomiting.

•  Teach the client relaxation and imagery techniques to use before, during, and after treatments, as appropriate.

•  Ensure adequate fluid intake to prevent dehydration and electrolyte imbalance.

•  Monitor the effectiveness of measures to control nausea and vomiting.

•  Teach client and family to monitor for signs and symptoms of stomatitis.

•  Instruct client on proper oral hygiene techniques.

•  Inform client that hair loss is expected, as determined by type of  chemotherapeutic agent used.

•  Assist client in obtaining a wig or other head-covering device, as appropriate.

•  Provide nutritious, appetizing foods of client’s choice.

•  Monitor nutritional status and weight.

•  Discuss with client the possibility of sterility and other reproductive system impairments, as appropriate.

•  Instruct long-term survivors and their families of the possibility of second malignancies and the importance of reporting increased susceptibility to infection, fatigue, or bleeding.

NIC intervention activities selected from McCloskey, J.C., & Bulechek, G.M. (Eds.). (2000). Nursing interventions classification (NIC) (3rd ed.). St. Louis: Mosby. No part of this work is to be altered without prior written permission from the Publisher.

 Alopecia

Clients receiving chemotherapy for cancer often experience whole-body hair loss. Some drags (e.g., methotrexate) may cause only thinning of the scalp hair. Others (e.g., doxorubicin, vincristine, and cisplatin) cause a more complete hair loss.

The nurse reassures clients that hair loss is temporary. Hair regrowth usually begins approximately 1 month after comple­tion of chemotherapy. The nurse cautions that the new hair may differ from the original hair in color, texture, and thickness.

No known treatment completely prevents alopecia. How­ever, techniques to reduce the amount of chemotherapeutic agent that reaches the hair follicles during treatment have been somewhat effective in reducing hair loss. These techniques in­clude applying ice packs and caps to the scalp or applying a scalp tourniquet during chemotherapy administration and for a few hours immediately afterward. These techniques are not en­dorsed by oncologists or oncology nurses because it is be­lieved that some circulating cancer cells may escape chemo­therapy, resulting in a less favorable treatment outcome.

Nurses can assist clients in selecting a type of head cover­ing that suits their financial means and lifestyle. High-quality wigs are expensive but can look very much like the client’s own hair. Many local units of the American Cancer Society offer wigs that other clients have used temporarily and have donated to be lent to other clients with cancer. Clients can disguise hair loss relatively inexpensively with caps or by the creative use of scarves and turbans, which are available in many fabrics, styles, and prices.

Nausea and Vomiting

 

Chemotherapy-induced nausea and vomiting arises from a va­riety of local and central nervous system mechanisms. Most chemotherapeutic agents are emetogenic (vomiting inducing) to some degree, depending on the dose. The agents producing the most severe nausea and vomiting include cisplatin, dox­orubicin, mithramycin, nitrogen mustard, vinblastine, and etoposide. Most of these agents induce nausea and vomiting during drag administration and for 1 to 2 days afterward. Some agents, such as cisplatin, induce delayed nausea and vomiting that can continue as long as 5 to 7 days after ad­ministration. Clients who experienced chemotherapy-related nausea and vomiting during one round of chemotherapy may begin experiencing the same symptoms before the next round as a result of sheer anticipation.

 CONSIDERATIONS FOR OLDER ADULTS

At times older clients have received lower doses of chemotherapy agents in anticipation of a reduced capacity to tolerate the side effects of nausea and vomiting. More recent research indicates that older clients do not experience greater nausea and vomiting than do younger clients. Therefore their chemotherapy regimens should not be altered on this basis alone.

 DRUG THERAPY

Many oral and parenteral antiemetics (agents that alleviate nausea and vomiting) are available. These agents vary in their production of side effects and in their effectiveness in con­trolling chemotherapy-induced nausea and vomiting. One or more antiemetics are usually administered before and after chemotherapy. Client response to antiemetic therapy is highly variable, and the drag combinations must be individualized for best effect. In addition, different antiemetic agents vary considerably in cost.

   COMPLIMENTARY AND ALTERNATIVE THERAPIES

The nurse also assists the client with chemotherapy-induced nausea and vomiting to achieve comfort through nonpharma-cologic means, either alone or in conjunction with antiemet­ics. Progressive muscle relaxation, guided imagery, music, acupressure, or distraction may help to reduce anxiety and re­lieve some nausea and vomiting (see the Evidence-Based Practice for Nursing box on p. 436). The nurse also assesses the client for complications associated with excessive vomit­ing, such as dehydration and electrolyte imbalances.

 Mucositis

Clients undergoing chemotherapy for cancer often experience mucositis (sores in mucous membranes) of the entire gastroin­testinal (GI) tract, especially in the mouth (stomatitis). Nor­mally, the mucous membrane of the GI tract undergoes cell division and quickly replaces dead or damaged cells. In chemotherapy, mucous membrane cells are killed more rapidly than they are replaced, resulting in sore formation. Mouth sores are painful and interfere with the desire and ability to eat. Chart 25-6 lists the best practices for clients with mucositis.

Frequent mouth assessment and appropriate hygiene are key in managing stomatitis and mucositis. A major compo­nent in managing oral mucositis is oral hygiene. The nurse stresses the importance of good and frequent oral hygiene, in­cluding tooth cleaning and mouth rinsing. Because most clients with chemotherapy-induced mucositis also have bone marrow suppression, they must take care to avoid traumatiz­ing the oral mucosa. They are instructed to use a soft-bristled toothbrush or disposable mouth sponges and to avoid using dental floss and water pressure gum cleaners (e.g., a Water Рік). The nurse encourages clients to rinse the mouth with plain water or saline every hour while awake. Commercial mouthwashes that contain alcohol or other drying agents that may further irritate the mucosa are avoided.

Oral hygiene equipment must be kept clean. The nurse re­minds clients not to share toothbrushes with anyone. Tooth­brushes can be cleaned daily by running them through a home dishwasher or by rinsing them with a concentrated solution of liquid bleach or hydrogen peroxide.

Many compounds are available for pain relief from stoma­titis or mucositis. Many hospitals offer their own special “swish and spit” mixtures, which usually contain a local anes­thetic combined with anti-inflammatory agents. The nurse stresses that these mixtures are not to be swallowed.

 

DRUG THERAPY FOR CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING

SEROTONIN ANTAGONISTS

Ondansetron (Zofran)

Granisetron (Kytril)

Dolasetron (Anzemet)

CNS DEPRESSANTS

Trimethobenzamide (Tigan, Benzacot, Arrestin, T-Gen)

BENZODIAZEPINES

Lorazepam (Ativan)

PHENOTHIAZINES

Prochlorperazine (Compazine, Stemetil*¹)

Chlorpromazine (Thorazine, Ormazine)

ANTIHISTAMINES

Diphenhydramine (Benadryl)

CORTICOSTEROIDS

Dexamethasone (Decadron)COST OF CARE

ANTIEMETIC THERAPY FOR CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING

Cost of Care

•  Prolonged nausea and vomiting is a common and distressful side effect of cancer chemotherapy.

•  Chemotherapy-induced nausea and vomiting reduces a client’s productivity and has contributed to increased length of stay and costs of care.

•  Antiemetic agents vary in cost from less than $1 per dose to more than $130 per dose.

•  In general, the newer and more expensive antiemetic agents are more clinically effective in reducing the severity of chemotherapy-induced nausea and vomiting than older, less expensive agents.

•  Medicare and managed care organizations have reduced the reimbursement for these agents.

•  Not all clients experience relief from chemotherapy-induced nausea and  vomiting  when  using the  more expensive agents.

Implications for Nursing

Because of the higher costs associated with the administration of serotonin antagonists, nurses need to explore the use of complementary and integrative therapies to assist in the re­duction of chemotherapy-induced nausea and vomiting. Work­ing collaboratively with pharmacists and physicians, nurses can suggest reducing the dosage of the more expensive antiemetic agents and using them in combination with less ex­pensive agents. In addition, nurses can reduce costs to the in­stitution and reduce out-of-pocket expenses for the client by helping clients take advantage of drug company-sponsored “medications for the indigent” programs.

This prospective, single-cycle, randomized study measured the effectiveness of acupressure in combination with standard pharmacologic antiemetic therapy among women receiving chemotherapy for breast cancer. Seventeen women who previ­ously experienced nausea as a side effect of breast cancer chemotherapy were enrolled in the study. These women were randomized to either a treatment group (receiving self-applied acupressure and the usual antiemetic therapy) or a control group (receiving only the usual antiemetic therapy). The women using acupressure were taught the technique using the P6 and ST36 meridians as the acupressure points for nausea. All sub­jects kept a daily log of nausea episodes (from the Rhodes Index of Nausea, Vomiting and Retching [INVR]), medication regimen, and (for the experimental subjects) timing of the inter­vention. In addition, all subjects completed the Chemotherapy Problem Checklist (CPC) at the end of the study. The investiga­tors examined the daily logs from all subjects to compare the incidence and severity of nausea experienced.

During the first 10 days after chemotherapy, subjects who received the acupressure intervention experienced fewer inci­dences of nausea and less severe nausea than did the sub­jects who received only the usual pharmacologic intervention. The difference was statistically significant to the p = 0.01 level for incidence and to the p = 0.04 level for intensity.

Critique. The study represented pilot work in the area of complementary and alternative therapies for chemotherapy-induced nausea and vomiting. The subject populations were largely homogenous and the sample size was small, which limits the generalizability of the results.

Implications for Nursing. Acupressure has been found to reduce nausea and vomiting in morning sickness and motion sickness. It is inexpensive, easy to learn, noninvasive, and re­quires client engagement. These preliminary results are prom­ising. Nurses could teach clients how to use acupressure and perhaps reduce costs related to antiemetic therapy by reduc­ing the amount of drug needed to achieve adequate control over nausea and vomiting.

 

Bone Marrow Suppression

Bone marrow suppression results in decreased numbers of circulating leukocytes, erythrocytes, and platelets. Decreased leukocyte numbers cause immunosuppression. Decreased  erythrocytes and platelets cause hypoxia, fatigue, and an increased tendency to bleed.

Immunosuppression, which places the client at extreme risk for infection, is the major dose-limiting side effect of can­cer chemotherapy. Most chemotherapeutic agents suppress bone marrow function to some degree. The agents associated with severe bone marrow suppression include busulfan, cy-clophosphamide, cytosine arabinoside, dactinomycin, dox-orubicin, daunorubicin, etoposide, mitomycin-C, nitrogen mustard, and triethylenethiophosphoramide. Suppression of immune function is the most life-threatening side effect and presents the nurse with the serious challenge of providing the client with the understanding, environment, and support to withstand this potentially devastating complication.

The clinical problems associated with immunosuppression are related primarily to a temporary reduction of circulating neutrophils and tissue macrophages, which decreases the body’s protective inflammatory responses to microorganism invasion. The severity and duration of the impairment are re­lated directly to the dosage of specific chemo-therapeutic agents. This impairment is usually temporary, with good re­covery of inflammatory responses evident within weeks or months of therapy completion.

However, the seriousness of potential infection complications makes this problem a major treatment concern. The infectious processes most commonly observed include those of fungal origin, yeast, some residual viral breakthrough, and a wide variety of bacteria.

Decreased numbers of circulating erythrocytes (anemia) and platelets (thrombocytopenia) result from the generalized bone marrow suppression caused by some chemotherapeutic agents. Anemia causes clients to feel fatigued, and some tis­sues must operate under hypoxic conditions. The cardiac and respiratory systems may be overtaxed in their effort to main­tain adequate oxygenation. Thrombocytopenia increases the risk for uncontrolled bleeding. When the concentration of platelets is less than 50,000/mm³, any small trauma can lead to episodes of prolonged bleeding. Clients with a concentra­tion less than 20,000/mm³ may experience spontaneous and uncontrollable bleeding, which requires extensive transfusion therapy and other interventions.

■ DRUG THERAPY

In some instances immunosuppression can be managed medically by the administration of biologic response modifiers (BRMs) to stimulate the production of immune system cells in the bone marrow. Although not appropriate for all types of cancer, this supportive treatment can reduce the risk for infec­tion during chemotherapy. However, BRMs are expensive and not consistently covered by insurance. Further discussion of this treatment is presented under Immunotherapy.

    COMPLEMENTARY AND ALTERNATIVE THERAPIES

Many clients experiencing treatment-induced immunosuppression use complementary and alternative therapies to boost immune function and prevent infection. Common therapies include shark cartilage, Echinacea, and megadoses of vitamin С Although the benefit of such therapies has not yet been deter mined in organized clinical trials, there appear to be few harmful effects associated with their use.

■   PROTECTION FROM INFECTION

The nurse works closely with clients and other health care pro­fessionals to provide safe care to clients at risk for infection. Good handwashing by all health care professionals and assistive nursing personnel before contact is the cornerstone for prevention of infection. Health care professionals must practice asepsis (prevention of contact with microorgan­isms) when performing any invasive technique or procedure.

Many clients remain at home during periods of immuno­suppression. The nurse teaches clients and family members precautions to take to reduce the chances of developing an in­fection (Chart 25-8).

The nurse provides a safe hospital environment for clients with thrombocytopenia and teaches them how to avoid exces­sive bleeding when they are discharged before the platelet count has returned to normal. Chart 25-9 lists the best prac­tices for reducing the risk for bleeding during hospitalization. The nurse teaches how to prevent bleeding and what to do if bleeding should occur after discharge.

Care of the Client with Immunosuppression

Place the client in a private room whenever possible. Use good handwashing technique before touching the client or any of the client’s belongings. Ensure that the client’s room and bathroom are cleaned at least once each day.

Do not use supplies from common areas for immunosup-pressed clients. For example, keep a sleeve or box of paper cups in the client’s room, and do not share this box with any other client. Other articles include drinking straws, plastic knives and forks, dressing materials, gloves, and bandages. Limit the number of health care personnel entering the client’s room.

Monitor vital signs every 4 hours; note minor temperature elevation, which may suggest early sepsis. Inspect the client’s mouth at least every 8 hours. Inspect the client’s skin and mucous membranes (espe­cially the anal area) for the presence of fissures and ab­scesses at least every 8 hours. Inspect open areas, such as IV sites, every 4 hours for manifestations of infection. Change wound dressings daily.

Obtain specimens of all suspicious areas for culture, and promptly notify the physician. Assist the client in performing coughing and deep-breathing exercises.

Encourage activity at a level appropriate for the client’s current health status. Change IV tubing daily.

Keep frequently used equipment in the room for use with this client only (e.g., blood pressure cuff, stethoscope, thermometer).

Limit visitors to healthy adults.

Use strict aseptic technique for all invasive procedures. Monitor the white blood cell count, especially the ab­solute neutrophil count (ANC), daily. Avoid the use of indwelling urinary catheters. Keep fresh flowers and potted plants out of the client’s room. Teach the client to eat a low-bacteria diet.

CLIENT EDUCATION GUIDE

 

Prevention of Infection

 

·                    Avoid crowds and other large gatherings of people who might be ill.

·                    Do not share personal toilet articles, such as tooth­brushes, toothpaste, washcloths, or deodorant sticks, with others.

·                    If possible, bathe daily.

·                    Wash the armpits, groin, genitals, and anal area at least twice a day with an antimicrobial soap.

·                    Clean your toothbrush daily by either running it through the dishwasher or rinsing it in liquid laundry bleach.

·                    Wash your hands thoroughly with an antimicrobial soap before you eat or drink, after touching a pet, after shaking hands with anyone, as soon as you come home from any outing, and after using the toilet.

·                    Eat a low-bacteria diet, and avoid salads, raw fruit and vegetables, undercooked meat, pepper, and paprika.

·                    Wash dishes between use with hot, sudsy water, or use a dishwasher.

·                    Do not drink water that has been standing for longer than 15 minutes.

·                    Do not reuse cups and glasses without washing. Do not change pet litter boxes.

·                    Take your temperature at least once a day.

·                    Report any of the following signs or symptoms of infec­tion to your physician immediately:

·        Temperature greater than 100° F (38° C)

·        Persistent cough (with or without sputum)

·        Pus or foul-smelling drainage from any open skin area or normal body opening Presence of a boil or abscess

·        Urine that is cloudy or foul smelling or that causes burning on urination

·                                     Take all prescribed medications as ordered.

·                                     Do not dig in the garden or work with houseplants.

 

Care of the Client with Thrombocytopenia

Handle the client gently.

Use a lift sheet when moving and positioning the client in bed.

Avoid intramuscular injections and venipunctures.

When injections or venipunctures are necessary, use the smallest-gauge needle for the task.

Apply firm pressure to the needle stick site for 10 min­utes or until the site no longer oozes blood.

Apply ice to areas of trauma.

Test all urine and stool for the presence of occult blood.

Observe IV sites every 2 hours for bleeding

Avoid trauma to rectal tissues:

·        Do not take temperatures rectally.

·        Do not administer enemas.

·        Administer well-lubricated suppositories and with caution.

·        Advise the client not to have anal intercourse.

Measure the client’s abdominal girth daily. Use an electric razor. Teach the client to avoid mouth trauma by:

·        Using soft-bristled toothbrush or tooth sponges

·        Not flossing

·        Avoiding dental work, especially extractions

·        Avoiding hard foods

·        Making certain that dentures fit and do not rub

Encourage the client not to blow the nose or insert ob­jects into the nose.

Instruct the client to avoid contact sports.

Advise the client to wear shoes with firm soles whenever he or she is ambulating.

 

CLIENT EDUCATION GUIDE

 

The Client at Risk for Bleeding

 

§        Use an electric razor.

§        Use a soft-bristled toothbrush, and do not floss.

§        Do not have dental work performed without consulting

§        your doctor.

§        Do not take aspirin or any aspirin-containing products.

§        Read the label to be sure that the product does not con­tain aspirin or salicylates.

§        Do not participate in contact sports or any activity likely to result in your being bumped, scratched, or scraped.

§        If you are bumped, apply ice to the site for at least 1 hour.

§        Notify your doctor if you:

Ø     Experience an injury and persistent bleeding results

Ø     Have excessive menstrual bleeding See blood in your urine or bowel movement

§        Avoid anal intercourse.

§        Take a stool softener to prevent straining during a bowel

§        movement.

§        Do not use enemas or rectal suppositories.

§        Avoid bending over at the waist.

§        Do not wear clothing or shoes that are tight or that rub.

§        Avoid blowing your nose or placing objects in your nose.

§        If you must blow your nose, do so gently without block­ing either nasal passage.

 CRITICAL THINKING CHALLENGE

Your client with cancer is receiving IV doxorubicin. She tells you that her arm is burning and hurts around the IV site. You lower the infusion set and get a brisk blood return.

•  Should you continue or discontinue the infusion?

•  What other questions should you ask the client about her discomfort?

•  What should you look for at the site?

•  How will you document this complaint?

Hormonal Manipulation

 RATIONALE FOR CANCER TREATMENT

Hormones are naturally occurring chemicals secreted by en­docrine (ductless) glands and picked up by capillaries. Once in the bloodstream, hormones circulate to all body areas but exert their effects only on their specific target tissues. Some hormones make hormone-sensitive tumors grow more rapidly. Some tumors actually require specific hormones to divide. Therefore altering the availability of these hormones to hormone-sensitive tumors can directly alter the rate of tumor growth.

 MECHANISM OF ACTION

Hormones

Hormonal manipulation can help to control some types of cancer for many years. However, this therapy does not lead to a cure. The endocrine system usually keeps hormones withiarrow ranges and maintains a balance. When a large amount of one hormone is administered, it upsets the bal­ance and disturbs the uptake of other hormones. If a tumor depends on hormone A for growth and a large quantity of hormone В (structurally but not functionally related to A) is given to the client, hormone В will interfere with the tu mor’s uptake of hormone A or will limit the amount of hor­mone A produced (through competition or feedback inhibi­tion). As a result, tumor growth is slowed. Thus hormonal therapy may increase survival time.

Table lists the drugs commonly used in hormonal manipulation for cancer therapy.

 

Hormone Antagonists

Hormone antagonists, competitors for the hormones at the re­ceptor sites, may be antibodies specific to the receptor. When hormone antagonists are administered, they bind to the spe­cific hormone receptor of the tumor cell and prevent the needed hormone from binding to the receptor. If a tumor re­quires a certain hormone to grow and the hormone can enter or activate the cell only through a receptor, hormone antago­nists can slow down tumor growth.

■ SIDE EFFECTS OF HORMONAL MANIPULATION

Androgens and the antiestrogen receptor drugs cause mas­culinizing manifestations in women. Chest and facial hair may develop, menstrual periods stop, and breast tissue shrinks. Women usually experience some fluid retention. For men and women receiving androgens, acne may de­velop, hypercalcemia is common, and liver dysfunction may occur with prolonged therapy. Women receiving estrogens or progestins have irregular but heavy menses, fluid reten­tion, and breast tenderness. Male and female clients who take estrogen or progestins are at an increased risk for thrombus formation.

Certain feminine clinical manifestations usually develop in men who take estrogens, progestins, or antiandrogen receptor drugs. Facial hair thins or disappears, facial skin becomes smoother, body fat is redistributed, and gynecomastia (breast development in men) can occur. In addition, testicular and pe­nile atrophy occurs to some degree. Although sexual function may continue, achieving and maintaining an erection are much more difficult.

Immunotherapy: Biologic Response Modifiers

Biologic response modifiers (BRMs) are agents or approaches that modify the client’s biologic responses to tumor cells to pro­duce a beneficial result (Clark & Longo, 1986). The BRMs in current use or under investigation for use as cancer therapy are cytokines, small protein hormones synthesized by the various leukocytes. Cytokines synthesized by mononuclear phagocytes (macrophages, neutrophils, eosinophils, and monocytes) are monokines; cytokines produced by lymphocytes (especially the T-lymphocytes) are lymphokines. Cytokines essentially make the immune system work better (see Chapter 20, especially Table 20-5).

■ RATIONALE FOR CANCER TREATMENT

Cytokines enhance the effectiveness of the immune system. Immune function plays an important role in cancer prevention (see Chapters 20 and 24). Cytokines and other BRMs are po­tentially therapeutic as a cancer treatment by stimulating the immune system to recognize cancer cells and take actions to eliminate or destroy them. Some BRMs may also be useful in a supporting role. Other BRMs (colony-stimulating factors) stimulate faster recovery of bone marrow function after treat­ment-induced suppression.

 MECHANISM OF ACTION

The activity of cytokines is similar to that of any other type of peptide hormone in that one cell produces and secretes a cy­tokine, which then exerts its effects on other cells of the im­mune system. The cells responding to the cytokine may be right next to the cytokine-secreting cell or quite remote from it. Cells that change their activity in response to the cytokine are responder cells. For a responder cell to be able to respond to a cytokine, the membrane of the responder cell must have a specific receptor for the cytokine. The cytokine binds to this receptor and initiates changes in the activity of the responder cell.

 Biologic Response Modifiers for Cancer Therapy

Three categories of BRMs are being used as cytotoxic therapy for cancer: interleukins, interferons, and monoclonal antibod­ies. Some agents can stimulate specific immune system cells to attack and destroy cancer cells; other agents block access of the cancer cell to some essential function or nutrient.

■ INTERLEUKINS

Sixteen interleukins (ILs) have been identified (see Table 20-5). Many of these are now synthetically produced through recombinant DNA technology. Interleukins help different im­mune system cells recognize and destroy abnormal body cells. In particular, IL-1, -2, and -6 appear to “charge up” the immune system and enhance attacks on cancer cells by macrophages, natural killer (NK) cells, lymphokine-activated killer (LAK) cells, and tumor-infiltrating lymphocytes. Can­cer treatment with interleukins is currently experimental, but good responses have occurred for renal cell carcinoma, colo-rectal cancer, and melanoma.

   INTERFERONS

Interferons are cell-produced substances that can protect noninfected cells from viral infection and replication. There are many types of interferons. Although all of them have similar functions, each type has unique properties and func­tions. The most completely characterized interferon is inter-feron alfa-2b.

Different body cells can produce interferon, with leuko­cytes producing the most. Today interferons are syntheti­cally mass produced by recombinant DNA technology. Cancer-related functions of interferon include the ability to do the following:

•  Slow down tumor cell division

•  Stimulate the proliferation and activation of NK cells

•  Help cancer cells resume a more normal appearance and revert to their previous characteristics

•  Inhibit the expression of oncogenes

Although interferons are approved for limited use as a can­cer treatment, they have been effective to some degree in the treatment of hairy cell leukemia, renal cell carcinoma, ovarian cancer, and cutaneous T-cell lymphoma.

■ MONOCLONAL ANTIBODIES

Antibodies to one or more parts of cancer cells have been used experimentally and in cancer diagnosis for many years. Two monoclonal antibodies for cancer treatment have recently been approved and are currently in use. Trastuzumab (Herceptin) binds to a protein made by some breast cancer cells. Binding this protein prevents the divi­sion of cancer cells and makes them more easily killed by immune system cells. Another monoclonal antibody, ritux-imab (Rituxan) performs a similar function in some types of non-Hodgkin’s lymphoma.

  Biologic Response Modifiers for Cancer Support

BRMs approved for use as supportive therapy during cancer treatment are the colony-stimulating factors. Essentially, these factors induce more rapid recovery of the bone marrow after suppression by chemotherapy.

This effect may have two benefits. First, when bone marrow suppression is less severe or of shorter duration, clients are less at risk for life-threatening infections and anemia. Second, be­cause the colony-stimulating factors allow more rapid bone marrow recovery, clients can receive their chemotherapy on time and may even be able to tolerate higher doses, potentially improving the curative outcome of chemotherapy. These agents must be used cautiously for malignancies in which the cancer cells may also have a BRM receptor, such as leukemias and lymphomas antigen (HLA) genes different from the client’s own HLAs into the tumor cells. This technique makes the client’s im­mune system cells better able to recognize the cancer cells as foreign and take steps to eliminate or destroy them. Both methods of gene therapy for cancer have shown some success in early-phase clinical trials.

TABLE 25-12      COLONY-STIMULATING FACTORS

Cell Type Affected

Sargramostim	All granulocytes	Chemotherapy-induced
(Leukine,	• Neutrophils	leukopenia
Prokine)	• Eosinophils
	Monocytes
	Macrophages
Filgrastim	Neutrophils	Chemotherapy-induced
(Neupogen)		neutropenia
Epoetin alfa	Erythrocytes	Chemotherapy-induced
(Epogen		anemia
Procrit)		Chemotherapy-induced
		fatigue
		Anemia induced by
		renal failure
Oprelvekin	Platelets	Chemotherapy-induced
(Neumega)		thrombocytopenia

 

  SIDE EFFECTS OF BIOLOGIC RESPONSE MODIFIER THERAPY

Clients receiving interleukins at therapeutic doses experience generalized and sometimes severe inflammatory reactions. Fluid shifts and capillary leak are widespread. Tissue swelling affects the function of all major organs and can be life threatening. Clients receiving high-dose BRM therapy should receive care in an intensive care or monitoring unit. The effects of BRM therapy are limited to the period of acute drug ad­ministration and resolve spontaneously when treatment is completed.

Many BRMs induce general symptoms of mild inflammatory reactions during and immediately after administration, including fever, chills, rigors, and flu-like general malaise. Symptoms are worse when higher doses are given, and they seem to become less severe over time. Fever is treated with acetaminophen. Clients with severe rigors are managed with meperidine (Demerol).

Allergic reactions are an issue in clients receiving mono­clonal antibodies. Most of these antibodies were raised in other animal species and may express some of those animal proteins. Clients receiving monoclonal antibodies over time may develop their own antibodies to the drugs, making them less effective and possibly causing severe inflammatory or al­lergic reactions.

Gene Therapy

Gene therapy as a primary or adjunct cancer treatment modal­ity currently has only investigational status. Although re­sponse rates have been limited, experimental successes indi­cate the potential for gene therapy as a form of cancer treatment.

■ INCREASED TUMOR CELL SUSCEPTIBILITY

One method of using gene therapy for cancer is to render the tumor cells more susceptible to damage or death by other treatments. Inserting a viral enzyme gene into brain tumor cells makes them more susceptible to being killed by antiviral agents. Other techniques involve inserting human leukocyte antigen (HLA) genes different from the client’s own HLAs into the tumor cells. This technique makes the client’s immune system cells better able to recognize the cancer cells as foreign and take steps to eliminate or destroy them. Both methods of gene therapy for cancer have shown some success in early-phase clinical trials.

 

■ INCREASED IMMUNE SYSTEM CELL ACTIVITY

Some immune system cells are capable of attacking and killing cancer cells (see Chapter 20). This ability is increased when more of certain cytokines, such as IL-2, are present. Some gene therapy involves inserting additional genes for cy­tokines into the client’s own immune system cells. These “charged-up” cancer-fighting immune system cells remain ac­tive for up to 6 months and can participate in cancer cell-killing episodes.

 

■ POTENTIAL USES OF GENE THERAPY FOR CANCER

Because cancer is caused by one or more changes in the genes of a normal cell, it is not unreasonable to think that gene al­terations could influence a cancer cell to become normal. Ar­eas under current research for gene therapy against cancer in­clude the following:

•  Inserting additional or healthy suppressor genes into cancer cells

•  Inserting chemotherapy resistance genes into normal cells so higher doses of chemotherapy can be given without affecting normal cells

•  Removing damaged, mutated, or activated oncogenes

•  Inserting multiple genes into cancer cells to make them more easily recognized by immune system cells and more susceptible to other treatment modalities

ONCOLOGIC EMERGENCIES

Cancer is considered a chronic disease. However, a number of acute conditions associated with cancer and its treatment can occur. These conditions, or complications, often require im­mediate medical intervention and are thus considered onco-logic emergencies. Early diagnosis of such conditions is es­sential to avoid life-threatening situations.

Sepsis and Disseminated Intravascular Coagulation

 OVERVIEW

Sepsis, or septicemia, is a condition in which microorganisms enter the bloodstream. Septic shock is a life-threatening result of sepsis and a common cause of death in clients with cancer. Clients with cancer are at increased risk for infection and sep­sis because their white blood cell counts are often low and their immune function is usually impaired. Chapter 37 de­scribes the pathophysiology of sepsis and septic shock.

Disseminated intravascular coagulation (DIC) is a condition that indicates a problem with the blood-clotting process. DIC is triggered by many severe illnesses, including cancer. In clients with cancer, DIC is caused by sepsis (usually a gram-negative infection), by the release of thrombin or thromboplastin (clot-ting factors) from cancer cells, or by blood transfusions. DIC is most often associated with leukemia and with adenocarcinomas of the lung, pancreas, stomach, and prostate.

Extensive, abnormal clot formation occurs throughout the small blood vessels of clients with DIC. This widespread clot­ting consumes all circulating clotting factors and platelets. This process is followed by extensive bleeding. Bleeding from many sites is the most common problem and ranges from minimal to fatal hemorrhage. The blockage of blood vessels from clots decreases blood flow to major body organs and results in pain, stroke-like signs and symptoms, dyspnea, tachycardia, oliguria (decreased urine output), and bowel necrosis (tissue death).

 COLLABORATIVE MANAGEMENT

DIC is a life-threatening problem and has a mortality rate greater than 70% even when appropriate therapies are insti­tuted. Therefore the best treatment plan for sepsis and DIC is prevention. The nurse identifies those clients at greatest risk for the development of sepsis and DIC. Strict adherence to aseptic technique is practiced during invasive procedures and during the manipulation of nonintact skin and mucous mem­branes in immunocomprornised clients. The nurse teaches clients and family members the early clinical manifestations of infection and sepsis and when to seek medical assistance. When sepsis is present and DIC is likely, treatment focuses on reducing the infection and halting the DIC process. Ap­propriate IV antibiotic therapy is initiated. During the early phase of DIC, anticoagulants (especially heparin) are admin­istered to limit unnecessary clotting and prevent the rapid consumption of circulating clotting factors. Cryoprecipitated clotting factors are administered when DIC has progressed to the later phase and hemorrhage is the primary problem.

Syndrome of Inappropriate Antidiuretic Hormone

  OVERVIEW

In healthy people, antidiuretic hormone (ADH) is secreted by the posterior pituitary gland only when more fluid (water) is needed in the body, such as when plasma volume is decreased (see Chapter 11). In people with certain health problems, ADH is secreted inappropriately or wheot needed by the body.

Cancer is the most common cause of the syndrome of in­appropriate antidiuretic hormone (SIADH). The type of can­cer most commonly associated with SIADH is carcinoma of the lung (especially small cell lung cancer), but SIADH may occur in other types of cancer, especially when tumors are present in the brain. Some tumors actually make and secrete ADH, whereas others stimulate the brain to synthesize and se­crete ADH. In addition, certain drugs commonly used in clients with cancer can cause the problem (most notably mor­phine sulfate and cyclophosphamide).

In SIADH, excessive amounts of water are reabsorbed by the kidney and put into systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. Mild symptoms occur and include weakness, muscle cramps, loss of appetite, and fatigue. Serum sodium levels range from 115 to 120 mEq/L (normal range is 135 to 145 mEq/L). More serious signs and symptoms are related to water intoxication, including weight gain, nervous system changes (especially personality changes), confusion, and extreme muscle weakness. As the sodium level approaches 110 mEq/L, seizures, coma and, eventually, death may follow unless the condition is rapidly treated.

– COLLABORATIVE MANAGEMENT

SIADH is managed by treating the condition and the cause. Treatment regimens for SIADH usually include fluid restric­tion (sometimes total fluid intake is reduced to 1 L/day), in­creased sodium intake, and drug therapy. A commonly used drug for this condition is demeclocycline, a form of tetracy-cline antibiotic, which is taken orally. The mechanism of ac­tion appears to be antagonistic to ADH. Serum sodium levels must be monitored closely, because hypernatremia can de­velop suddenly as a result of this treatment.

A second method for managing SIADH is to reduce or eliminate the underlying cause. The immediate institution of appropriate cancer therapy, usually either radiation or chemotherapy, can cause such tumor regression that ADH synthesis and release processes return to normal.

Spinal Cord Compression

 OVERVIEW

Spinal cord compression and damage occur when a tumor di­rectly enters the spinal cord or when the vertebral column col­lapses from tumor entry. Tumors may begin in the spinal cord but more commonly spread from other areas of the body, such as the lung, prostate, breast, and colon. Spinal cord compres­sion causes back pain, usually before neurologic deficits oc­cur. Neurologic deficits are related to the spinal level of com­pression and include numbness; tingling; loss of urethral, vaginal, and rectal sensation; and muscle weakness. If paral­ysis occurs, it is usually permanent.

COLLABORATIVE MANAGEMENT

Nurses caring for clients with spinal cord compression must recognize the condition early. The nurse assesses the client for neurologic changes consistent with spinal cord compression. The nurse also teaches clients and families to recognize the symptoms of early spinal cord compression and to seek med­ical assistance as soon as symptoms are apparent.

Treatment is largely palliative. High-dose radiation is usu­ally administered to reduce the size of the tumor in the area and relieve compression. Radiation may be given in conjunc­tion with chemotherapy to treat the total disease. Surgery is occasionally performed to remove the tumor from the area and rearrange the bony tissue so less pressure is placed on the spinal cord. External back or neck braces may be prescribed to reduce the weight borne by the spinal column and to reduce pressure on the spinal cord or spinal nerves.

Hypercalcemia

і OVERVIEW

Hypercalcemia (increased serum calcium level), a late mani­festation of extensive malignancy, occurs most often in clients with bone metastasis. Cancer in bone causes the bone to release calcium into the bloodstream. In clients with cancer in other parts of the body—especially the lung, head and neck, kidney, or lymph nodes—the tumor secretes parathyroid hormone (parathormone), causing bone to release calcium. Decreased physical mobility also contributes to or worsens hypercalcemia. Early signs and symptoms of hypercalcemia include fa­tigue, loss of appetite, nausea, vomiting, constipation, and polyuria (increased urine output). More serious signs and symptoms include severe muscle weakness, diminished deep tendon reflexes, paralytic ileus, dehydration, and electrocar-diographic (ECG) changes. The severity of signs and symptoms depends on how high the serum calcium level is and how quickly it developed.

 

 COLLABORATIVE MANAGEMENT

Hypercalcemia as a consequence of cancer develops very slowly for many clients, which allows the body time to adapt to this electrolyte change. As a result, symptoms of hypercal­cemia may not be evident until the serum calcium level is greatly elevated. Because adaptation does occur, hypercal­cemia associated with cancer is treated only when clinical manifestations are present.

Conservative management, such as oral hydration alone, may be enough to reduce the serum calcium to an acceptable level. Normal saline is the fluid of choice when parenteral hy­dration is needed.

Many drugs lower serum calcium levels. Some agents, such oral glucocorticoids, calcitonin, diphosphonate, gallium ni­trate, and mithramycin, lower levels quite dramatically. These agents do not cure hypercalcemia but instead reduce serum calcium levels temporarily. When cancer-induced hypercal­cemia is life threatening or accompanied by renal impairment, dialysis can temporarily reduce serum calcium levels.

Superior Vena Cava Syndrome

■ OVERVIEW

Superior vena cava (SVC) syndrome occurs when the SVC is compressed or obstructed by tumor growth (Figure 25-3). SVC compression can lead to a painful and life-threatening emergency, most often in clients with lymphomas and bron-chogenic carcinoma. Clients with cancer of the breast, esoph­agus, colon, and testes may also be affected.

The signs and symptoms associated with SVC syndrome result from the blockage of blood flow in the venous system of the head, neck, and upper trunk. In general, early signs and symptoms occur in the early morning and include edema of the face, especially around the eyes (periorbital edema), and tightness of the shirt or blouse collar (Stokes’ sign). As the compression worsens, the client typically experiences edema in the arms and hands, dyspnea, erythema of the upper body, and epistaxis (nosebleeds). Late life-threatening signs and symptoms include hemorrhage, cyanosis, mental status changes from lack of blood to the brain, decreased cardiac output, and hypotension (low blood pressure). Death can re­sult if compression is not relieved.

 COLLABORATIVE MANAGEMENT

SVC syndrome is a late-stage manifestation; the tumor is usu­ally widespread. High-dose radiation therapy to the mediastinal area is the most common treatment of choice and can pro­vide temporary relief in approximately 70% of clients. Surgery is not performed for this condition because the tumor may have increased intrathoracic pressure to such a level that it may be impossible to close the chest after the procedure.

The best therapeutic and palliative results occur when SVC syndrome is in the early stages. The nurse assesses each client for signs and symptoms of SVC syndrome and notifies the physician.

 

Tumor Lysis Syndrome

 overview

In tumor lysis syndrome (TLS), large quantities of tumor cells are destroyed rapidly. Their intracellular contents, including potassium and purines (DNA components), are released into the bloodstream faster than the body’s homeostatic mecha­nisms can handle them. Unlike other oncologic emergencies, TLS is a positive sign that cancer treatment is effective.

Severe or untreated TLS can cause severe tissue damage and death. Serum potassium levels can increase to the point of hyperkalemia, causing severe cardiac dysfunction. In addition, the large quantities of released purines are converted in the liver to uric acid and released into the sys­temic circulation, causing hyperuricemia. These uric acid molecules precipitate in the kidney, forming a sludge in the kidney tubules; this effect blocks them and leads to acute re­nal failure.

TLS is most commonly seen in clients receiving radiation or drug therapy for cancers initially very sensitive to these therapies, including leukemia, lymphoma, small cell lung cancer, and multiple myeloma.

– COLLABORATIVE MANAGEMENT

Prevention through hydration is the best management for TLS. Hydration alone can dilute the serum potassium level and increases the glomerular filtration rate. As a result, urine flows through the kidney at a greatly increased rate. This ac­tion prevents the precipitation of uric acid crystals, increases the renal excretion of potassium, and mechanically flushes any renal tubular sludge.

With tumors known to be very sensitive to cancer therapy, the nurse instructs clients to drink at least 3000 mL (5000 mL is more desirable) of fluid the day before, the day of, and for 3 days after treatment. Some fluids should be alkaline to help prevent the crystallization of uric acid. The nurse stresses the importance of keeping fluid intake relatively consistent throughout the 24-hour day and helps clients draw up a sched­ule of fluid intake.

Because some clients experience nausea and vomiting af­ter cancer therapy and may not feel like ingesting oral fluids, the nurse stresses the importance of following the antiemetic regimen. The nurse also instructs clients to contact their health care provider or cancer clinic immediately if nausea and vomiting prevent adequate fluid intake so they can be started on parenteral fluids.

Treatment becomes more aggressive for clients who be­come hyperkalemic or hyperuricemic. In addition to in­creased fluid intake (oral or parenteral), diuretics (especially osmotic types) are given to increase urine flow through the kidney. These agents are administered with caution because clients must not become dehydrated. Drags that increase the excretion of purines, such as allopurinol (Alloprin, Zylo-prim), are administered. To reduce serum potassium levels, IV infusions containing glucose and insulin may be adminis­tered. Clients who experience more severe and persistent hy-perkalemia and hyperuricemia may require dialysis.

CANCER TREATMENT FAILURE

More than 50% of people diagnosed with cancer in North America this year will be cured of their disease, and many others will live 2 years or longer. However, some will experi­ence cancer treatment failure and die. With cancer, the process of dying is usually long, lasting weeks or months. Clients and families require special support and assistance during this time. Chapter 9 addresses hospice care and other important physical, emotional, social, and spiritual needs of clients and families during and after the dying process.