Textbook of Medical-Surgical Nursing 3e

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Chapter 11

Oncology: Nursing management in cancer care

Table 11-12  Oncological Emergencies: Manifestations and Management Clinical manifestations and Emergency diagnostic findings Management Superior vena cava syndrome (SVCS) Compression or invasion of the superior vena cava by tumour, enlarged lymph nodes, intraluminal thrombus that Clinical Gradually or suddenly impaired venous drainage giving rise to: • Progressive shortness of breath (dyspnoea), cough, hoarseness, chest pain and facial swelling

Medical • Radiation therapy to shrink tumour size and relieve symptoms • Chemotherapy for chemosensitive cancers (e.g. lymphoma, small cell lung cancer) or when the mediastinum has been irradiated to maximum tolerance (Kuzin, 2006) • Anticoagulant or thrombolytic therapy for intraluminal thrombosis • Percutaneously placed intravascular stents are increasingly being used to reopen the occluded SVC (Kuzin, 2006) • Surgery (less common), such as vena cava bypass graft (synthetic or autologous), to redirect blood flow around the obstruction • Supportive measures such as oxygen therapy, corticosteroids and diuretics Nursing • Identify patients at risk for SVCS • Monitor and report clinical manifestations of SVCS • Monitor cardiopulmonary and neurological status • Avoid upper extremity venipuncture and blood pressure measurement • Facilitate breathing by positioning the patient properly; this helps to promote comfort and reduce anxiety produced by difficulty breathing resulting from progressive oedema • Promote energy conservation to minimise shortness of breath • Monitor the patient’s fluid volume status and administer fluids cautiously to minimise oedema • Assess for thoracic radiation-related problems such as dysphagia (difficulty swallowing) and oesophagitis • Monitor for chemotherapy-related problems such as myelosuppression • Provide postoperative care as appropriate Medical • Radiation therapy to reduce tumour size to halt progression and corticosteroid therapy to decrease inflammation and swelling at the compression site • Surgery to debulk tumour and stabilise the spine if symptoms progress despite radiation therapy or if vertebral fracture or bone fragments lead to additional nerve damage; surgery is also an option when the tumour is not radiosensitive or is located in an area that was previously irradiated (Kaplan, 2006b) • Vertebroplasty is used to stabilise vertebrae when patients have pain without neurological dysfunction; vertebroplasty involves percutaneous injection of polymethyl methacrylate (PMMA), a bone cement filler, into the vertebral body (Kaplan, 2006b) • Chemotherapy as adjuvant to radiation therapy for patients with lymphoma or small cell lung cancer •  Note: Despite treatment, patients with poor neurological function before treatment are less likely to regain complete motor and sensory function; patients who develop complete paralysis usually do not regain all neurological function (Kaplan, 2006b)

• Oedema of the neck, arms, hands and thorax and reported sensation of skin tightness and difficulty swallowing • Possibly engorged and distended jugular, temporal and arm veins • Dilated thoracic vessels causing prominent venous patterns on the chest wall • Increased intracranial pressure, associated visual disturbances, headache and altered mental status Diagnostic Diagnosis is confirmed by: • Clinical findings • Chest x-ray • Thoracic computed tomography (CT) scan • Thoracic magnetic resonance imaging (MRI) Intraluminal thrombosis is identified by venogram.

obstructs venous circulation, or drainage of the head, neck, arms and thorax. Typically associated with lung cancer, SVCS can also occur with breast cancer, Kaposi’s sarcoma, thymoma, lymphoma and mediastinal metastases (Kuzin, 2006). If untreated, SVCS may lead to cerebral anoxia (because not enough oxygen reaches the brain), laryngeal oedema, bronchial obstruction and death.

Clinical • Local inflammation, oedema, venous stasis and impaired blood supply to nervous tissues • Local or radicular back or neck pain along the dermatomal areas innervated by the affected nerve root (Marrs, 2006) (e.g. thoracic radicular pain extends in a band around the chest or abdomen) • Pain exacerbated by movement, supine recumbent position, coughing, sneezing or the Valsalva manoeuvre • Neurological dysfunction, and related motor and sensory deficits (numbness, tingling, feelings of coldness in the affected area, inability to detect vibration, loss of positional sense) • Motor loss ranging from subtle weakness to flaccid paralysis • Bladder and/or bowel dysfunction depending on level of compression (above S2, overflow incontinence; from S3 to S5, flaccid sphincter tone and bowel incontinence)

Spinal cord compression Potentially leading to permanent neurological impairment and associated morbidity and mortality; compression of the cord and its nerve roots may result from tumour, lymphomas, intervertebral collapse or interruption of blood supply to the nerve tissues (Kaplan, 2006b). About 70% of compressions occur at the thoracic level, 20% in the lumbosacral level, and 10% in the cervical region (Marrs, 2006). Metastasis from breast, lung, kidney, prostate cancers, myeloma, lymphoma to the bone or between the bone and the epidural space are associated with spinal cord compression (Kaplan, 2006b). The prognosis depends on the severity and rapidity of onset.

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