Textbook of Medical-Surgical Nursing 3e

276

Unit 3   Applying concepts from the nursing process

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.

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.