Chapter 11
Oncology: Nursing management in cancer care
273
Patients with neutropenia are treated with broad-spectrum
antibiotics before the infecting organism is identified because
of the high incidence of mortality associated with untreated
infection. Broad-spectrum antibiotic coverage or empiric
therapy most often includes a combination of medications to
defend the body against the major pathogenic organisms. An
important component of the nurse’s role is to administer these
medications promptly according to the prescribed schedule to
achieve adequate blood levels of the medications.
Strict asepsis is essential when handling intravenous lines,
catheters and other invasive equipment. Exposure of the
patient to others with an active infection and to crowds is
avoided. Patients with profound immunosuppression, such
as BMT recipients, may need to be placed in a protective
environment where the room and its contents are sterilised and
the air is filtered. These patients may also receive low-bacteria
diets, avoiding fresh fruits and vegetables. Hand hygiene and
appropriate general hygiene are necessary to reduce exposure
to potentially harmful bacteria and to eliminate environmental
contaminants. Invasive procedures, such as injections, vaginal
or rectal examinations, rectal temperatures, and surgery, are
avoided. The patient is encouraged to cough and perform
deep-breathing exercises frequently to prevent atelectasis and
other respiratory problems. Prophylactic antimicrobial therapy
may be used for patients who are expected to be profoundly
immunosuppressed and at risk for certain infections. The nurse
teaches the patient and family to recognise signs and symptoms
of infection to report, perform effective hand hygiene, use
antipyretics, maintain skin integrity and administer haemato-
poietic growth factors when indicated.
Septic shock
The nurse assesses the patient frequently for infection and
inflammation throughout the course of the disease. Septicaemia
and septic shock are life-threatening complications that must
be prevented or detected and treated promptly. Patients with
signs and symptoms of impending sepsis and septic shock
require immediate hospitalisation and aggressive treatment in
the ICU setting.
Signs and symptoms of septic shock (see Chapter 8) include
altered mental status, either subnormal or elevated tempera-
ture, cool and clammy skin, decreased urine output, hypo-
tension, arrhythmias, electrolyte imbalances and abnormal
arterial blood gas values. The patient and family members are
instructed about signs of septicaemia, methods for prevent-
ing infection and actions to take if infection or septicaemia
occurs.
Septic shock is most often associated with overwhelming
Gram-negative bacterial infections; however, patients with
prolonged neutropenia or haematological malignancies are
also more susceptible to fungal and viral sources of sepsis as
well. The nurse monitors the blood pressure, pulse rate, respira
tions and temperature of the patient with shock every 15 to
30 minutes. Neurological assessments are carried out to detect
changes in orientation and responsiveness.
Fluid and electrolyte status is monitored by measuring
fluid intake and output and serum electrolytes. Arterial blood
gas values and pulse oximetry are monitored to determine
tissue oxygenation. The nurse administers intravenous fluids,
blood products and vasopressors as prescribed to maintain the
patient’s blood pressure and tissue perfusion. Supplemental
therapy that suppresses bone marrow function. Febrile patients
who are neutropenic are assessed for factors that increase the
risk for infection and for sources of infection through cultures
of blood, sputum, urine, stool, IV or urinary catheters, and
wounds, if appropriate. In addition, a chest x-ray is often
obtained to assess for pulmonary infections.
Defence against infection is compromised in many differ-
ent ways. The integrity of the skin and mucous membranes
is challenged by multiple invasive diagnostic and therapeutic
procedures, by adverse effects of radiation and chemotherapy,
and by the detrimental effects of immobility.
Impaired nutrition as a result of anorexia, nausea, vomiting,
diarrhoea and the underlying disease alters the body’s ability
to combat invading organisms. Medications such as antibiotics
disturb the balance of normal flora, allowing the overgrowth
of normal flora and pathogenic organisms. Other medications
can also alter the immune response (see Chapter 50). Cancer
itself may lead to defects in cellular and humoral immunity.
Advanced cancer can cause obstruction of the hollow viscera
(e.g. intestines), blood vessels and lymphatic vessels, creating a
favourable environment for proliferation of pathogenic organ-
isms. In some patients, tumour cells infiltrate bone marrow and
prevent normal production of WBCs. However, most often, a
decrease in WBCs is a result of bone marrow suppression after
chemotherapy or radiation therapy. Severe neutropenia may
necessitate delays in administration of myelosuppressive ther-
apies or treatment dose adjustments, although the use of the
haematopoietic growth factors, also called colony-stimulating
factors (see previous discussion), has reduced the severity and
duration of neutropenia associated with myelosuppressive
chemotherapy and radiation therapy. The administration of
these factors assists in reducing the risk for infection and,
possibly, in maintaining treatment schedules, drug dosages,
treatment effectiveness and quality of life.
Nurses are in a key position to assist in preventing
and identifying symptoms of infection, as discussed in the
Plan of nursing care (see Chart 11-4). Although multiple
infection control practices are employed, there is a signif-
icant lack of evidence to support many of them (Zitella et
al., 2006). Clinical practice guidelines developed by the
Oncology Nursing Societies are used to guide interventions.
Interventions to prevent infection and education formats to
teach patients and families about infection are high research
priorities.
Gram-positive organisms, such as
Streptococcus
and
Staphylococcus
species, are the most frequently isolated causes
of infection. Gram-negative organisms, such as
Escherichia coli
and
Pseudomonas aeruginosa,
and fungal organisms, such as
Candida albicans,
also contribute to the incidence of serious
infection. Viral infections in immunocompromised patients
are caused most often by herpes viruses and respiratory viruses.
Fever is probably the most important sign of infection
in immunocompromised patients. In neutropenic patients,
any one-time temperature of 38.3°C or higher or 38.0°C or
higher for 1 hour or more is reported and dealt with promptly.
Antibiotics may be prescribed to treat infections after cultures
of wound exudate, sputum, urine, stool or blood are obtained.
Careful consideration is given to the underlying malignancy,
prior antineoplastic treatment, absolute neutrophil count,
comorbidities and other patient-related factors prior to the
identification of the most appropriate initial antibiotic therapy.
