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Unit 3
Applying concepts from the nursing process
However, one cannot assume that all symptoms are related to
the cancer. The new symptoms and problems are evaluated
and treated aggressively if possible to increase the patient’s
comfort and improve quality of life.
Weakness, immobility, fatigue and inactivity typically
occur in the advanced stages of cancer as a result of the
tumour, treatment, inadequate nutritional intake or shortness
of breath. The nurse works with the patient to set realistic
goals and to provide rest balanced with planned activities and
exercise. Other measures include assisting the patient in iden-
tifying energy-conserving methods for accomplishing tasks and
promoting activities that the patient values the most.
Efforts are made throughout the course of the disease to
ensure the patient has as much control and independence
as desired, but with assurance that support and assistance are
available when needed. Additionally, the healthcare team
works with the patient and family to ascertain and comply with
the patient’s wishes about treatment methods and care as the
terminal phase of illness and death approach.
Palliative care
For many years, society was unable to cope appropriately with
patients in the most advanced stages of cancer, and patients
died in acute care settings rather than at home or in facilities
designed to meet their needs. The needs of patients with
terminal illnesses are best met by a comprehensive multidis-
ciplinary program that focuses on quality of life, palliation of
symptoms, and provision of psychosocial and spiritual support
for the patient and family when cure and control of the disease
are no longer possible. The concept of hospice (now referred
to as palliative care), which originated in Great Britain, best
addresses these needs. Most important, the focus of care is on
the family unit, not just the patient. Palliative care can be
provided in free-standing, hospital-based, and community- or
home-based settings.
Palliative care is often delivered by coordinating services
provided by both the hospital and community because of
the high costs associated with maintaining free-standing
units. Although doctors, social workers, pastoral care workers,
dieticians, pharmacists, physiotherapists and volunteers are
involved in patient care, nurses are most often the coor-
dinators of all palliative care activities. It is essential that
community and palliative care nurses possess advanced skills
in assessing and managing pain, nutrition, dyspnoea, bowel
dysfunction and skin impairments (MacDonald, 2005; Pavlish
& Ceronsky, 2007).
In addition, palliative care programs facilitate clear com
munication among family members and healthcare profession-
als. Most patients and families are informed of the prognosis and
are encouraged to participate in decisions regarding pursuing or
terminating cancer treatment. Through collaboration with
other support disciplines, nurses assist patients and families
to cope with changes in role identity, family structure, grief
and loss. Palliative care nurses may be actively involved in
bereavement counselling. In many instances, family support
for survivors may continue for about 1 year. See Chapter 12 for
detailed discussion of end-of-life care.
A survivorship care plan should be provided to all cancer
patients and their primary care doctor at the completion of
treatment.
The survivorship care plan includes a summary of cancer
diagnosis and treatment, recommendations for follow-up and
care, including approaches to treat symptoms, rehabilitative
needs, monitoring for late effects, and surveillance and screen-
ing for new and recurrent cancer.
Referrals for specific services such as lymphoedema therapy,
support groups and genetic counselling are also provided.
Nurses assist in the development of the survivorship care plan
and provide education and care for cancer survivors.
Nurses, other healthcare providers, public health profes-
sionals and patient advocates design and conduct research in
order to identify needs of cancer survivors and evidence-based
approaches to care.
Providing care in oncological
emergencies
For information about these emergencies, see Table 11-12.
Care of the patient with advanced
cancer
The patient with advanced cancer is likely to experience
many of the problems previously described, but to a greater
degree. Symptoms of gastrointestinal disturbances, nutritional
problems, weight loss and cachexia make the patient more
susceptible to skin breakdown, fluid and electrolyte problems,
and infection.
Although not all cancer patients experience pain, those
who do commonly fear that it will not be adequately managed.
Although treatment at this stage of illness is likely to be
palliative rather than curative, prevention and appropriate
management of problems can improve the quality of the
patient’s life considerably. For example, use of analgesia at
set intervals rather than on an ‘as needed’ basis usually breaks
the cycle of tension and anxiety associated with waiting,
until pain becomes so severe that pain relief is inadequate
once the analgesic is given. Working with the patient and
family, as well as with other healthcare professionals, on a
pain-management program based on the patient’s require-
ments frequently increases the patient’s comfort and sense of
control. In addition, the dose of opioid analgesic required is
often reduced as pain becomes more manageable and other
medications (e.g. sedatives, tranquillisers, muscle relaxants)
are added to assist in relieving pain.
If the patient is a candidate for radiation therapy or surgical
intervention to relieve severe pain, the consequences of these
procedures (e.g. percutaneous nerve block, cordotomy) are
explained to the patient and family, and measures are taken to
prevent complications resulting from altered sensation, immo-
bility, and changes in bowel and bladder function.
With the appearance of each new symptom, the patient
may experience dread and fear that the disease is progressing.
