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Unit 3
Applying concepts from the nursing process
Table 11-12 Oncological Emergencies: Manifestations and Management (continued)
Clinical manifestations and
Emergency
diagnostic findings
Management
Hypercalcaemia
In patients with cancer,
hypercalcaemia is a potentially
life-threatening metabolic
abnormality resulting when the
calcium released from the bones is
more than the kidneys can excrete
or the bones can reabsorb. It may
result from:
• Production of cytokines,
hormonal substances and growth
factors by cancer cells, or by the
body in response to substances
produced by cancer cells; which
lead to bone breakdown and
calcium release (Kaplan, 2006a).
• Excessive use of vitamins
and minerals and conditions
unrelated to cancer, such as
dehydration, renal impairment,
primary hyperparathyroidism,
thyrotoxicosis, thiazide diuretics
and hormone therapy.
Pericardial effusion and cardiac
tamponade
Pericardial effusion is an
accumulation of fluid in the
pericardial space. Cardiac
tamponade occurs when the
accumulation compresses the
heart and thereby impedes
expansion of the ventricles and
cardiac filling during diastole. As
ventricular volume and cardiac
output fall, the heart pump fails,
and circulatory collapse develops.
With gradual onset, fluid
accumulates gradually, and the
outer layer of the pericardial space
stretches to compensate for rising
pressure. Large amounts of fluid
accumulate before symptoms of
heart failure occur. With rapid
onset, pressures rise too quickly
for the pericardial space to
compensate.
Diagnostic
• Percussion tenderness at the level of compression
• Abnormal reflexes
• Sensory and motor abnormalities
• MRI, spinal cord x-rays, bone scans and CT scan.
CT-guided myelogram is reserved for patients
who are unable to undergo MRI (Kaplan, 2006b).
Clinical
Fatigue, weakness, confusion, decreased level of
responsiveness, hyporeflexia, nausea, vomiting,
constipation, ileus, polyuria (excessive
urination), polydipsia (excessive thirst),
dehydration and dysrhythmias
Diagnostic
Serum calcium level exceeding 2.74 mmol/L
Clinical
• Neck vein distension during inspiration
(Kussmaul’s sign)
• Pulsus paradoxus (systolic blood pressure decrease
exceeding 10 mmHg during inspiration; pulse gets
stronger on expiration)
• Distant heart sounds, rubs and gallops, cardiac
dullness
• Compensatory tachycardia (heart beats faster to
compensate for decreased cardiac output)
• Increased venous and vascular pressures
Diagnostic
• Electrocardiography (ECG) helps diagnose
pericardial effusion
• In small effusion, chest x-rays show small
amounts of fluid in the pericardium; in large
effusions, x-ray films disclose ‘water-bottle’
heart (obliteration of vessel contour and cardiac
chambers)
• CT scans help diagnose pleural effusions and
evaluate effect of treatment
• Narrow pulse pressure
• Shortness of breath and tachypnoea
Nursing
• Perform ongoing assessment of neurological function
to identify existing and progressing dysfunction
• Control pain with pharmacological and
non-pharmacologial measures
• Prevent complications of immobility resulting from
pain and decreased function (e.g. skin breakdown,
urinary stasis, thrombophlebitis, decreased clearance
of pulmonary secretions)
• Maintain muscle tone by assisting with range-of-
motion exercises in collaboration with physical and
occupational therapists
• Institute intermittent urinary catheterisation and
bowel training programs for patients with bladder or
bowel dysfunction
• Provide encouragement and support to patient and
family coping with pain and altered functioning,
lifestyle, roles and independence
Medical
See Chapter 14.
Nursing
• Identify patients at risk for hypercalcaemia and
assess for signs and symptoms of hypercalcaemia
• Educate patient and family; prevention and early
detection can prevent fatality
• Teach at-risk patients to recognise and report signs
and symptoms of hypercalcaemia
• Encourage patients to consume 2–4 L of fluid daily
unless contraindicated by existing renal or cardiac
disease
• Explain the use of dietary and pharmacological
interventions such as stool softeners and laxatives
for constipation
• Advise patients to maintain nutritional intake
without restricting normal calcium intake
• Discuss antiemetic therapy if nausea and vomiting
occur
• Promote mobility by emphasising its importance
in preventing demineralisation and breakdown of
bones
• Institute safety precautions for patients with
impaired mental and mobility status
Medical
• Patients with small effusions who are not
symptomatic do not require treatment. These
patients are monitored for signs and symptoms of
increasing fluid accumulation (Higdon & Higdon,
2006)
• Pericardiocentesis (the aspiration or withdrawal
of pericardial fluid by a large-bore needle inserted
into the pericardial space); in malignant effusions,
pericardiocentesis provides only temporary relief;
fluid may reaccumulate (Story, 2006); windows
or openings in the pericardium can be created
surgically as a palliative measure to drain fluid into
the pleural space; catheters may also be placed in
the pericardial space and sclerosing agents (such
as bleomycin or thiotepa) injected to prevent fluid
from reaccumulating (Story, 2006)
• Radiation therapy or antineoplastic agents, depending
on how sensitive the primary tumour is to these
treatments and the degree of symptoms that exist; in
mild effusions, prednisone and diuretic medications
may be prescribed and the patient’s status carefully
monitored
