Textbook of Medical-Surgical Nursing 3e

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Chapter 11

Oncology: Nursing management in cancer care

Monitoring serum urea, serum creatinine, creatinine clear- ance and serum electrolyte levels is essential. Adequate hydra- tion, alkalinisation of the urine to prevent formation of uric acid crystals, and the use of allopurinol are frequently indicated to prevent these side effects (Duong & Loh, 2006; Gullatte, 2007). Amifostine has demonstrated an ability to minimise renal toxicities associated with cisplatin, cyclophosphamide and ifosfamide therapy (Hogle, 2007). Haemorrhagic cystitis is a bladder toxicity resulting from cyclophosphamide and ifosfamide therapy. Haematuria can range from microscopic to frank bleeding with symptoms ranging from transient irritative urination, dysuria, suprapu- bic pain, to life-threatening haemorrhage. Protection of the bladder focuses on aggressive IV hydration, frequent voiding and diuresis. Mesna is a cytoprotectant agent that binds with the toxic metabolites of cyclophosphamide or ifosfamide in the kidneys to prevent haemorrhagic cystitis (Hogle, 2007; Wilkes & Barton-Burke, 2007). Cardiopulmonary system.  Antitumour antibiotics (dauno- rubicin and doxorubicin) are known to cause irreversible cumulative cardiac toxicities, especially when total dosage reaches 550 mg/m 2 . Dexrazoxane has been utilised as a car- dioprotectant when doxorubicin is needed in individuals who have already received a cumulative dose of 300 mg/m 2 and continuation of therapy is deemed beneficial (Wilkes & Barton-Burke, 2007; Hogle, 2007). Cardiac ejection fraction (volume of blood ejected from the heart with each beat) and signs of congestive heart failure must be monitored closely. Bleomycin, carmustine (BiCNU), and busulfan are known for their cumulative toxic effects on lung function. Pulmonary fibrosis can be a long-term effect of prolonged dosage with these agents. Therefore, the patient is monitored closely for changes in pulmonary function, including pulmonary function test results. Total cumulative doses of bleomycin are not to exceed 400 units. Capillary leak syndrome with resultant pulmonary oedema is a toxic effect of cytarabine, mitomycin C, cyclophosphamide and BCNU. Subtle onset of dyspnoea and cough may progress rapidly to acute respiratory distress and subsequent respiratory failure (Wilkes & Barton-Burke, 2007). Reproductive system.  Testicular and ovarian function can be affected by chemotherapeutic agents, resulting in possible sterility. Normal ovulation, early menopause or permanent ste- rility may result. In men, temporary or permanent azoo­spermia (absence of spermatozoa) may develop. Reproductive cells may be damaged during treatment, resulting in chromosomal abnormalities in offspring. Banking of sperm is recommended for men before treatments are initiated to protect against ste- rility or any mutagenic damage to sperm. Patients and their partners need to be informed about potential changes in reproductive function resulting from che- motherapy. They are advised to use reliable methods of birth control while receiving chemotherapy and not to assume that sterility has resulted. Neurological system.  Chemotherapy-induced neurotoxicity can affect the CNS, peripheral nervous system (PNS), the cranial nerves or a combination; it is a dose-limiting toxicity. The blood–brain barrier can protect the CNS and PNS from the toxic effects of most water soluble chemother- apy agents, but neurotoxicity characterised by metabolic

encephalopathy can occur with ifosfamide, high-dose metho­ trexate and cytarabine. With repeated doses, the taxanes and plant alkaloids, especially vincristine, can cause peripheral neurological damage with sensory alterations in the feet and hands. These sensations can be described as tingling, pricking or numbness of the extremities, burning or freezing pain, sharp, stabbing, or electric-shock-like pain and extreme sensitivity to touch. If unreported by patients or undetected, progressive motor axon damage can lead to loss of deep tendon reflexes, with muscle weakness, loss of balance and coordination, and paralytic ileus. Although usually reversible, these side effects may take many months to resolve. Along with the usual par- esthesias of the hands and feet, oxaliplatin has a unique and frightening neuro­toxicity presentation that is often precipi- tated by exposure to cold and is characterised by pharyngo­ laryngeal dysaesthesia consisting of lip paraesthesia, discomfort or tightness in the back of the throat, inability to breathe and jaw pain. Patients receiving oxaliplatin must be instructed to avoid drinking cold fluids or going outside with hands and feet exposed to cold temperatures to avoid exacerbation of these symptoms. Cisplatin may cause peripheral neuropathies and hearing loss due to damage to the acoustic nerve (Wilkes & Barton-Burke, 2007). The ability of cytoprotectant agents to prevent these significant neurotoxicities, including amifostine, is being studied (Hogle, 2007; Wilkes & Barton-Burke, 2007). Fatigue.  Fatigue, a distressing side effect for most patients that greatly affects quality of life, can last for months after treatment. Assessment and nursing management of fatigue are discussed in the ‘Nursing care of patients with cancer’ sec- tion of this chapter. Evidence-based interventions for fatigue management are available to provide guidelines for nurses to effectively intervene and assist their patients (Mitchell et al., 2007). Nursing management in chemotherapy The nurse has an important role in assessing and managing many of the problems experienced by the patient undergoing chemotherapy. These problems are often widespread, affecting many body systems because of the systemic effects on normal as well as malignant cells. Assessing fluid and electrolyte status Anorexia, nausea, vomiting, altered taste and diarrhoea put the patient at risk for nutritional and fluid and electrolyte dis- turbances. Changes in the mucosa of the gastrointestinal tract may lead to irritation of the oral cavity and intestinal tract, further threatening the patient’s nutritional status. Therefore, it is important for the nurse to assess the patient’s nutritional and fluid and electrolyte status frequently and to use creative ways to encourage an adequate fluid and dietary intake. Modifying risks for infection and bleeding Suppression of the bone marrow and immune system is an expected consequence of chemotherapy and frequently serves as a guide in determining appropriate chemotherapy dosage. However, this effect also increases the risk for anaemia, infection and bleeding disorders. Therefore, nursing assess- ment and care focus on identifying and modifying factors that further increase the patient’s risk. Aseptic technique and gentle handling are indicated to prevent infection and trauma. Laboratory test results, particularly blood cell counts, are monitored closely. Untoward changes in blood test results