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Unit 3
Applying concepts from the nursing process
Promoting home- and community-based care
Teaching patients self-care
Patients with cancer usually return home from acute care facil-
ities or receive treatment in the home or outpatient area rather
than acute care facilities. The shift from the acute care setting
also shifts the responsibility for care to the patient and family.
As a result, families and friends must assume increased involve-
ment in patient care, which requires teaching that enables
them to provide care. Teaching initially focuses on providing
information needed by the patient and family to address the
most immediate care needs likely to be encountered at home.
Side effects of treatments and changes in the patient’s status
that should be reported are reviewed verbally and reinforced
with written information. Strategies to deal with side effects
of treatment are discussed with the patient and family. Other
learning needs are identified based on the priorities conveyed
by the patient and family as well as on the complexity of care
provided in the home.
It is now possible to administer chemotherapy, TPN, blood
products, parenteral antibiotics and parenteral analgesics
within a home setting. The role of the community nurses is
to continue the planned care and support for patients and
families. Follow-up visits and telephone calls from the nurse
are often reassuring to the patient and family and increase
their comfort in dealing with complex and new aspects of
care. Continued contact facilitates evaluation of the patient’s
progress and ongoing needs of the patient and family.
C
ontinuing
care
.
Referral for home care is often indicated for the
patient with cancer. The responsibilities of the community
nurse include assessing the home environment, suggesting
modifications in the home or in care to assist the patient and
family in addressing the patient’s physical needs, providing
physical care, and assessing the psychological and emotional
impact of the illness on the patient and family.
Assessing changes in the patient’s physical status and
reporting relevant changes to the doctor help to ensure that
appropriate and timely modifications in therapy are made. The
community nurse also assesses the adequacy of pain manage-
ment and the effectiveness of other strategies to prevent or
manage the side effects of treatment modalities.
The patient’s and family’s understanding of the treatment
plan and management strategies are assessed, and previous
teaching is reinforced. The nurse often facilitates the coordi-
nation of patient care by maintaining close communication
with all healthcare providers involved in the patient’s care.
The community nurse may make referrals and coordinate
available community resources (e.g. local office of the
Australian Cancer Council, New Zealand Cancer Society,
local government services, church groups and support groups)
to assist patients and caregivers. This coordinated approach
enables holistic care that addresses all the complex needs of
the cancer patient.
v
Gerontological considerations
More than 60% of all new cancers occur in people older than
65 years of age, and about 70% of all cancer deaths occur in
people 65 years of age and older (Lynch, Marcone & Kagan,
2007). The rising numbers of individuals over the age of 65
with cancer has led to the emergence of geriatric oncology, a
multidimensional and multidisciplinary approach to treating
oxygen and mechanical ventilation is often necessary. Broad-
spectrum antibiotics are administered as prescribed to combat
the underlying infection (see Chapter 8).
Bleeding and haemorrhage
The nurse assesses cancer patients for factors that may contrib-
ute to bleeding. These include bone marrow suppression from
radiation, chemotherapy and other medications that interfere
with coagulation and platelet functioning, such as aspirin,
heparin or warfarin (Coumadin). Common bleeding sites
include: skin and mucous membranes; the intestinal, urinary
and respiratory tracts; and the brain. Gross haemorrhage, as
well as blood in the stools, urine, sputum or vomitus (melaena,
haematuria, haemoptysis, haematemesis), oozing at injection
sites, bruising (ecchymosis), petechiae, and changes in mental
status, are monitored and reported.
Platelets are essential for normal blood clotting and coagu-
lation (haemostasis). Thrombocytopenia, a decrease in the cir-
culating platelet count, is the most common cause of bleeding
in cancer patients and is usually defined as a count of less than
10 × 10
9
/L. When the count falls between 20 and 50 × 10
9
/L,
the risk for bleeding increases. Counts under 20 × 10
9
/L are
associated with an increased risk for spontaneous bleeding, for
which the patient requires platelet transfusion.
Thrombocytopenia often results from bone marrow depres-
sion after certain types of chemotherapy and radiation therapy.
Tumour infiltration of the bone marrow can also impair the
normal production of platelets. In some cases, platelet destruc-
tion is associated with an enlarged spleen (hypersplenism) and
abnormal antibody function that occur with leukaemia and
lymphoma.
In addition to monitoring laboratory values, the nurse
continues to assess the patient for bleeding. The Plan of
nursing care (see Chart 11-4) addresses nursing assessment
and interventions for patients at risk of bleeding. The nurse
may administer IL-11 to prevent severe thrombocytopenia
and to reduce the need for platelet transfusions following
myelosuppressive chemotherapy in patients with non-myeloid
malignancies. In some instances, the nurse teaches the patient
or family member to administer IL-11 in the home with
follow-up support from other community nurses. Additional
medications may be prescribed to address bleeding due to dis-
orders of coagulation.
Ethical considerations in cancer care
Ethical issues are most often underestimated or overlooked in
case of cancer care. However, during the past 35 years, concern
over medical ethical issues has dramatically increased. Many of
the early, important cases of informed consent involved cancer
patients. The issue of truth telling was most starkly raised par-
ticularly when doctors did not disclose to their patients their
diagnosis of cancer. Much of the discussion about euthanasia
and doctor-assisted suicide focuses on cancer patients. Ethical
issues that may arise from cancer care are recognised as being
similar to those in other specialities. Common examples
include issues affecting the professional–patient relationship,
resource allocation, truth telling, confidentiality, respect of
individual and professional autonomy, consent and refusal of
treatment, the withholding and the withdrawal of treatments
at both the macro- and micro-level within palliative and
cancer care (National Health and Medical Research Council,
2011).
