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Unit 3   Applying concepts from the nursing process

Table 11-12  Oncological Emergencies: Manifestations and Management (continued) Clinical manifestations and Emergency diagnostic findings Management

Diagnostic • Percussion tenderness at the level of compression • Abnormal reflexes • Sensory and motor abnormalities • MRI, spinal cord x-rays, bone scans and CT scan. CT-guided myelogram is reserved for patients who are unable to undergo MRI (Kaplan, 2006b).

Nursing • Perform ongoing assessment of neurological function to identify existing and progressing dysfunction • Control pain with pharmacological and non-pharmacologial measures • Prevent complications of immobility resulting from pain and decreased function (e.g. skin breakdown, urinary stasis, thrombophlebitis, decreased clearance of pulmonary secretions) • Maintain muscle tone by assisting with range-of- motion exercises in collaboration with physical and occupational therapists • Institute intermittent urinary catheterisation and bowel training programs for patients with bladder or bowel dysfunction • Provide encouragement and support to patient and family coping with pain and altered functioning, lifestyle, roles and independence Medical See Chapter 14. Nursing • Identify patients at risk for hypercalcaemia and assess for signs and symptoms of hypercalcaemia • Educate patient and family; prevention and early detection can prevent fatality • Teach at-risk patients to recognise and report signs and symptoms of hypercalcaemia • Encourage patients to consume 2–4 L of fluid daily unless contraindicated by existing renal or cardiac disease • Explain the use of dietary and pharmacological interventions such as stool softeners and laxatives for constipation • Advise patients to maintain nutritional intake without restricting normal calcium intake • Discuss antiemetic therapy if nausea and vomiting occur • Promote mobility by emphasising its importance in preventing demineralisation and breakdown of bones • Institute safety precautions for patients with impaired mental and mobility status Medical • Patients with small effusions who are not symptomatic do not require treatment. These patients are monitored for signs and symptoms of increasing fluid accumulation (Higdon & Higdon, 2006) • Pericardiocentesis (the aspiration or withdrawal of pericardial fluid by a large-bore needle inserted into the pericardial space); in malignant effusions, pericardiocentesis provides only temporary relief; fluid may reaccumulate (Story, 2006); windows or openings in the pericardium can be created surgically as a palliative measure to drain fluid into the pleural space; catheters may also be placed in the pericardial space and sclerosing agents (such as bleomycin or thiotepa) injected to prevent fluid from reaccumulating (Story, 2006) • Radiation therapy or antineoplastic agents, depending on how sensitive the primary tumour is to these treatments and the degree of symptoms that exist; in mild effusions, prednisone and diuretic medications may be prescribed and the patient’s status carefully monitored

Clinical Fatigue, weakness, confusion, decreased level of responsiveness, hyporeflexia, nausea, vomiting, constipation, ileus, polyuria (excessive urination), polydipsia (excessive thirst), dehydration and dysrhythmias Diagnostic Serum calcium level exceeding 2.74 mmol/L

Hypercalcaemia In patients with cancer, hypercalcaemia is a potentially life-threatening metabolic abnormality resulting when the calcium released from the bones is more than the kidneys can excrete or the bones can reabsorb. It may result from: • Production of cytokines, hormonal substances and growth factors by cancer cells, or by the body in response to substances produced by cancer cells; which lead to bone breakdown and calcium release (Kaplan, 2006a). • Excessive use of vitamins and minerals and conditions unrelated to cancer, such as dehydration, renal impairment, primary hyperparathyroidism, thyrotoxicosis, thiazide diuretics and hormone therapy. Pericardial effusion and cardiac tamponade Pericardial effusion is an accumulation of fluid in the pericardial space. Cardiac tamponade occurs when the accumulation compresses the heart and thereby impedes expansion of the ventricles and cardiac filling during diastole. As ventricular volume and cardiac output fall, the heart pump fails, and circulatory collapse develops. With gradual onset, fluid accumulates gradually, and the outer layer of the pericardial space stretches to compensate for rising pressure. Large amounts of fluid accumulate before symptoms of heart failure occur. With rapid onset, pressures rise too quickly for the pericardial space to compensate.

Clinical • Neck vein distension during inspiration (Kussmaul’s sign)

• Pulsus paradoxus (systolic blood pressure decrease exceeding 10 mmHg during inspiration; pulse gets stronger on expiration) • Distant heart sounds, rubs and gallops, cardiac dullness • Compensatory tachycardia (heart beats faster to compensate for decreased cardiac output) • Increased venous and vascular pressures Diagnostic • Electrocardiography (ECG) helps diagnose pericardial effusion • In small effusion, chest x-rays show small amounts of fluid in the pericardium; in large effusions, x-ray films disclose ‘water-bottle’ heart (obliteration of vessel contour and cardiac chambers) • CT scans help diagnose pleural effusions and evaluate effect of treatment • Narrow pulse pressure • Shortness of breath and tachypnoea