Textbook of Medical-Surgical Nursing 3e

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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).