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 (continued) Clinical manifestations and Emergency diagnostic findings Management

Nursing • Monitor vital signs and oxygen saturation frequently • Assess for pulsus paradoxus • Monitor ECG tracings • Assess heart and lung sounds, neck vein filling, level of consciousness, respiratory status, and skin colour and temperature • Monitor and record intake and output • Review laboratory findings (e.g. arterial blood gas and electrolyte levels) • Elevate the head of the patient’s bed to ease breathing • Minimise patient’s physical activity to reduce oxygen requirements; administer supplemental oxygen as prescribed • Provide frequent oral hygiene • Reposition and encourage the patient to cough and take deep breaths every 2 hours • As needed, maintain patent intravenous access, reorient the patient, and provide supportive measures and appropriate patient instruction Medical • Chemotherapy, biological response modifier therapy, radiation therapy or surgery is used to treat the underlying cancer • Antibiotic therapy is used for sepsis • Anticoagulants, such as heparin or antithrombin III, decrease the stimulation of the coagulation pathways • Drotrecogin alfa is used with caution in patients with DIC related to sepsis (Ezzone, 2006) • Transfusion of fresh-frozen plasma or cryoprecipitates (which contain clotting factors and fibrinogen), packed red blood cells, and platelets may be used as replacement therapy to prevent or control bleeding • Although controversial, antifibrinolytic agents such as aminocaproic acid (Amicar), which is associated with increased thrombus formation, may be used Nursing • Monitor vital signs • Measure and document intake and output • Assess skin colour and temperature; lung, heart and bowel sounds; level of consciousness, headache, visual disturbances, chest pain, decreased urine output and abdominal tenderness • Inspect all body orifices, tube insertion sites, incisions and bodily excretions for bleeding • Review laboratory test results • Minimise physical activity to decrease injury risks and oxygen requirements • Prevent bleeding; apply pressure to all venipuncture sites and avoid non-essential invasive procedures; provide electric rather than straight-edged razors; avoid tape on the skin and advise gentle but adequate oral hygiene • Assist the patient to turn, cough and take deep breaths on regular schedule • Reorient the patient, if needed; maintain a safe environment; and provide appropriate patient education and supportive measures

• Weakness, chest pain, orthopnoea, anxiety, diaphoresis, lethargy and altered consciousness from decreased cerebral perfusion

Cancerous tumours, particularly from adjacent thoracic tumours (lung, oesophagus, breast cancers), and cancer treatment are the most common causes of cardiac tamponade. Radiation therapy of 4000 cGy or more to the mediastinal area has also been implicated in pericardial fibrosis, pericarditis and resultant cardiac tamponade. Untreated pericardial effusion and cardiac tamponade lead to circulatory collapse and cardiac arrest (Story, 2006).

Clinical Chronic DIC: Few or no observable symptoms or easy bruising, prolonged bleeding from venipuncture and injection sites, bleeding of the gums, and slow GI bleeding Acute DIC: Life-threatening haemorrhage and infarction; clinical symptoms of this syndrome are varied and depend on the organ system involved in thrombus and infarction or bleeding episodes Diagnostic • Prolonged prothrombin time (PT or protime) • Prolonged partial thromboplastin time (PTT) • Prolonged thrombin time (TT) • Decreased fibrinogen level • Decreased platelet level • Decrease in clotting factors • Decreased haemoglobin • Decreased haematocrit • Elevated fibrin split products • Positive protamine sulfate precipitation test (thrombin activation test) • Elevated D-dimer • Prolonged international normalised ratio (INR) • Decreased plasminogen levels

Disseminated intravascular coagulation (DIC; also called consumption coagulopathy) Complex disorder of coagulation or fibrinolysis (destruction of clots), which results in thrombosis or bleeding. DIC is most commonly associated with haematological cancers (leukaemia and lymphoma); cancer of prostate, gastrointestinal (GI) tract and lungs; chemotherapy (methotrexate, prednisone, l -asparaginase, vincristine, 5-fluorouracil, cyclophosphamide; targeted agents bevacizumab, thalidomide, interferon; hormonal agents (tamoxifen, Megace); and other processes such as trauma, sepsis, hepatic failure and anaphylaxis (Ezzone, 2006; Viale, 2005). Blood clots form when normal coagulation mechanisms are triggered. Once activated, the clotting cascade continues to consume clotting factors and platelets faster than the body can replace them. Clots are deposited in the microvasculature, placing the patient at great risk for impaired circulation, tissue hypoxia and necrosis. In addition, fibrinolysis occurs, breaking down clots and increasing the circulating levels of anticoagulant substances, thereby placing the patient at risk for haemorrhage (Ezzone, 2006).

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