Chapter 11
Oncology: Nursing management in cancer care
279
Continues on following page
Table 11-12 Oncological Emergencies: Manifestations and Management (continued)
Clinical manifestations and
Emergency
diagnostic findings
Management
Cancerous tumours, particularly
from adjacent thoracic tumours
(lung, oesophagus, breast cancers),
and cancer treatment are the
most common causes of cardiac
tamponade. Radiation therapy
of 4000 cGy or more to the
mediastinal area has also been
implicated in pericardial fibrosis,
pericarditis and resultant cardiac
tamponade. Untreated pericardial
effusion and cardiac tamponade
lead to circulatory collapse and
cardiac arrest (Story, 2006).
Disseminated intravascular
coagulation (DIC; also called
consumption coagulopathy)
Complex disorder of coagulation or
fibrinolysis (destruction of clots),
which results in thrombosis or
bleeding. DIC is most commonly
associated with haematological
cancers (leukaemia and
lymphoma); cancer of prostate,
gastrointestinal (GI) tract
and lungs; chemotherapy
(methotrexate, prednisone,
l
-asparaginase, vincristine,
5-fluorouracil, cyclophosphamide;
targeted agents bevacizumab,
thalidomide, interferon; hormonal
agents (tamoxifen, Megace);
and other processes such as
trauma, sepsis, hepatic failure and
anaphylaxis (Ezzone, 2006; Viale,
2005).
Blood clots form when normal
coagulation mechanisms are
triggered. Once activated, the
clotting cascade continues to
consume clotting factors and
platelets faster than the body
can replace them. Clots are
deposited in the microvasculature,
placing the patient at great risk
for impaired circulation, tissue
hypoxia and necrosis. In addition,
fibrinolysis occurs, breaking
down clots and increasing the
circulating levels of anticoagulant
substances, thereby placing the
patient at risk for haemorrhage
(Ezzone, 2006).
• Weakness, chest pain, orthopnoea, anxiety,
diaphoresis, lethargy and altered consciousness from
decreased cerebral perfusion
Clinical
Chronic DIC:
Few or no observable symptoms
or easy bruising, prolonged bleeding from
venipuncture and injection sites, bleeding of
the gums, and slow GI bleeding
Acute DIC:
Life-threatening haemorrhage and
infarction; clinical symptoms of this syndrome
are varied and depend on the organ system
involved in thrombus and infarction or bleeding
episodes
Diagnostic
• Prolonged prothrombin time (PT or protime)
• Prolonged partial thromboplastin time (PTT)
• Prolonged thrombin time (TT)
• Decreased fibrinogen level
• Decreased platelet level
• Decrease in clotting factors
• Decreased haemoglobin
• Decreased haematocrit
• Elevated fibrin split products
• Positive protamine sulfate precipitation test
(thrombin activation test)
• Elevated D-dimer
• Prolonged international normalised ratio (INR)
• Decreased plasminogen levels
Nursing
• Monitor vital signs and oxygen saturation frequently
• Assess for pulsus paradoxus
• Monitor ECG tracings
• Assess heart and lung sounds, neck vein filling, level
of consciousness, respiratory status, and skin colour
and temperature
• Monitor and record intake and output
• Review laboratory findings (e.g. arterial blood gas
and electrolyte levels)
• Elevate the head of the patient’s bed to ease
breathing
• Minimise patient’s physical activity to reduce
oxygen requirements; administer supplemental
oxygen as prescribed
• Provide frequent oral hygiene
• Reposition and encourage the patient to cough and
take deep breaths every 2 hours
• As needed, maintain patent intravenous access,
reorient the patient, and provide supportive
measures and appropriate patient instruction
Medical
• Chemotherapy, biological response modifier
therapy, radiation therapy or surgery is used to treat
the underlying cancer
• Antibiotic therapy is used for sepsis
• Anticoagulants, such as heparin or antithrombin
III, decrease the stimulation of the coagulation
pathways
• Drotrecogin alfa is used with caution in patients
with DIC related to sepsis (Ezzone, 2006)
• Transfusion of fresh-frozen plasma or
cryoprecipitates (which contain clotting factors and
fibrinogen), packed red blood cells, and platelets
may be used as replacement therapy to prevent or
control bleeding
• Although controversial, antifibrinolytic agents such
as aminocaproic acid (Amicar), which is associated
with increased thrombus formation, may be used
Nursing
• Monitor vital signs
• Measure and document intake and output
• Assess skin colour and temperature; lung, heart and
bowel sounds; level of consciousness, headache,
visual disturbances, chest pain, decreased urine
output and abdominal tenderness
• Inspect all body orifices, tube insertion sites,
incisions and bodily excretions for bleeding
• Review laboratory test results
• Minimise physical activity to decrease injury risks
and oxygen requirements
• Prevent bleeding; apply pressure to all venipuncture
sites and avoid non-essential invasive procedures;
provide electric rather than straight-edged razors;
avoid tape on the skin and advise gentle but
adequate oral hygiene
• Assist the patient to turn, cough and take deep
breaths on regular schedule
• Reorient the patient, if needed; maintain a safe
environment; and provide appropriate patient
education and supportive measures
