Chapter 11
Oncology: Nursing management in cancer care
269
not responsive to rest, and it seriously affects quality of life.
Fatigue is a commonly reported side effect in patients who
receive chemotherapy and radiation therapy and may arise
from a number of sources (see Chart 11-10). In recent years,
fatigue has been recognised as one of the most significant and
frequent symptoms experienced by patients receiving cancer
therapy. Nurses help the patient and family to understand that
fatigue is usually an expected and temporary side effect of the
cancer process and of many treatments used. Fatigue also stems
from the stress of coping with cancer. It does not always signify
that the cancer is advancing or that the treatment is failing.
Potential sources of fatigue are summarised in Chart 11-10.
Fatigue is distressing for patients with cancer who are
receiving treatment, for survivors, and for those in the late
stages of disease (Mitchell et al., 2007). Although patients may
describe fatigue in a variety of ways, nurses assess for feelings
of weariness, weakness, lack of energy, inability to carry out
necessary and valued daily functions, lack of motivation, and
inability to concentrate. Several assessment tools, such as
a simple visual analogue scale, may be used to assess levels
of fatigue (Madden & Newton, 2006). The nurse assesses
physiological and psychological stressors that can contribute
to fatigue, including anaemia, electrolyte imbalances, organ
dysfunction, pain, nausea, dyspnoea, constipation, fear and
anxiety (see Chart 11-11).
The role of exercise as a helpful intervention has been
supported by several controlled trials (Mitchell et al., 2007;
Young-McCaughan & Arzola, 2007). The nurse assists patients
with additional non-pharmacological strategies to minimise
fatigue or help the patient cope with existing fatigue as
described in the Plan of nursing care (Chart 11-4) under
‘Fatigue’. Occasionally pharmacological interventions are
utilised, including antidepressants for patients with depression;
anxiolytics for those with anxiety; hypnotics for patients with
sleep disturbances; and psychostimulants for some patients
with advanced cancer or fatigue that does not respond to other
interventions (Abraham, 2005).
The nurse assists patients with non-pharmacological strate-
gies to minimise fatigue or help the patient cope with existing
fatigue. Patients are encouraged to maintain as normal a
lifestyle as possible by continuing with those activities they
value and enjoy. Prioritising necessary and valued activities
can assist patients in planning for each day. Both patients and
families are encouraged to plan to reallocate responsibilities,
such as attending to childcare, cleaning and preparing meals.
Patients who are employed may need to consider reducing the
number of hours worked each week or modifying their roles.
The nurse assists the patient and family in coping with these
changing roles and responsibilities.
Improving body image and self-esteem
The nurse identifies potential threats to the patient’s body
image and assesses the patient’s ability to cope with the many
assaults to body image experienced throughout the course
of disease and treatment. Entry into the healthcare system
is often accompanied by depersonalisation. Threats to self-
concept occur as the patient faces the realisation of illness,
disfigurement, possible disability and death. To accommodate
treatments or because of the disease, many patients with
cancer are forced to alter their lifestyles. Priorities and values
change when body image is threatened. Disfiguring surgery,
hair loss, cachexia, skin changes, altered communication
weak opioid analgesics (e.g. codeine) are used for moderate
pain; and strong opioid analgesics (e.g. morphine) are used for
severe pain. If the patient’s pain escalates, the strength of the
analgesic medication is increased until the pain is controlled.
Adjuvant medications are also administered to enhance the
effectiveness of analgesics and to manage other symptoms
that may contribute to the pain experience. Examples of
adjuvant medications include antiemetics (metoclopramide),
antidepressants (fluoxetine), antianxiety agents (diazepam),
antiseizure agents (carbamazepine), stimulants (benztropine),
local anaesthetics (xylocaine) and corticosteroids (cortisone).
Preventing and reducing pain helps to decrease anxiety
and break the pain cycle. This can be accomplished best by
administering analgesics on a regularly scheduled basis as
prescribed (the preventive approach to pain management),
with additional analgesics administered for breakthrough
pain as needed and as prescribed. A cancer pain algorithm,
developed as a set of analgesic guiding principles, is given in
Figure 11-7.
Various pharmacological and non-pharmacological
approaches offer the best methods of managing cancer pain.
No reasonable approaches, even those that may be invasive,
should be overlooked because of a poor or terminal prog
nosis. Nurses help patients and families to take an active role
in managing pain. Nurses provide education and support to
correct fears and misconceptions about opioid use. Inadequate
pain control leads to suffering, anxiety, fear, immobility, isola-
tion and depression. Improving a patient’s quality of life is as
important as preventing a painful death.
Decreasing fatigue
Acute fatigue, which occurs after an energy-demanding
experience, serves a protective function; chronic fatigue,
however, does not. It is often overwhelming, excessive, and
Non-opioid
+/– Adjuvant
Step 1
Opioid for mild to
moderate pain
+/– Non-opioid
+/– Adjuvant
Pain persisting or increasing
Step 2
Opioid for moderate
to severe pain
+/– Non-opioid
+/– Adjuvant
Pain persisting or increasing
Freedom from cancer pain
Step 3
Figure 11-6
Adapted from the World Health Organization
three-step ladder approach to relieving cancer pain. Various
opioid (narcotic) and non-opioid medications may be combined
with other medications to control pain.
