Textbook of Medical-Surgical Nursing 3e

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Chapter 11

Oncology: Nursing management in cancer care

however, risk associated with some of the CAM modalities. As there is the possibility of herb–vitamin–drug interactions, there is concern about the use of biological and dietary sup- plements, which are not regulated by the TGA, MEDSAFE, or the FDA or subjected to rigorous scientific evaluation. Patients often perceive vitamins and dietary supplements as harmless, natural products that have no side effects or potential toxicities. One example of herb–drug interaction is the effect of St John’s wort on the efficacy of irinotecan (Camptosar), cyclophosphamide, tamoxifen, cyclosporine, warfarin (Coumadin) and indinavir (Crixivan). Each nursing assessment should include an open discussion with patients about their use of CAM. This requires that nurses develop the appropriate familiarity and knowledge related to CAM in order to direct patients to safe, reliable and credible sources for information. Unproven and unconventional therapies A diagnosis of cancer evokes many emotions in patients and families, including feelings of fear, frustration and loss of control. Despite increasing 5-year survival rates with the use of traditional methods of treatment, a significant number of patients use or seriously consider using some form of unconven- tional treatment. Although research is scant and accuracy of reporting may be questionable, it is estimated that 30 to 50% of patients with cancer may be using an alternative method of treatment. Many patients elect to pursue complementary therapies because of their own value systems. Sometimes hope- lessness, desperation, unmet needs, lack of factual information and family or social pressures are major factors that motivate patients to seek unconventional methods of treatment and allow them to fall prey to dubious and deceptive practices. Caring for patients who choose unconventional methods may place members of the healthcare team in difficult situa- tions professionally, legally and ethically. Nurses must keep in mind those ethical principles that help guide professional practice, such as autonomy, beneficence, non-maleficence and justice. Unconventional treatments have not demonstrated sci- entific, objective or reproducible evidence for their claim to cure or control cancer. In addition to being ineffective, some unconventional treatments may also be harmful to patients and may cost thousands of dollars. In the age of the Internet, patients have unlimited access to frequently unreliable claims of ‘miracle cures’ that range from plant remedies to metabolic therapy using special diets, supple­ ments or ‘detoxification’ regimes involving unconventional enemas and colonic cleansing procedures. Most unproven cancer treatments can be categorised as machines and devices; drugs and biologicals; metabolic and dietary regimes; or mystical and spiritual approaches. Nursing management in unconventional therapies A trusting relationship, supportive care, and promotion of hope are the most effective means of protecting the patient and family from fraudulent therapy and questionable cancer cures. Truthful responses given in a non-judgemental manner to questions and inquiries about unproven methods of cancer treatments may alleviate the fear and guilt on the part of the patient and family that they are not ‘doing everything we can’ to obtain a cure. The nurse may inform the patient and family of the characteristics common to alternative therapy so that

they will be informed and cautious when evaluating various forms of ‘therapy’. The nurse should encourage any patient who uses unconventional therapies to inform the doctor about such use. Knowing this information can help prevent interac- tions with medications and other therapies that may be pre- scribed and avoid attributing the side effects of unconventional therapies to prescribed medications.

Æ Æ NURSING CARE OF PATIENTS WITH CANCER

The outlook for patients with cancer has greatly improved because of scientific and technological advances. As a result of the underlying disease or various treatment modalities, however, the patient with cancer may experience a variety of secondary problems, such as infection, reduced WBC counts, bleeding, skin problems, nutritional problems, pain, fatigue and psychological stress. Chart 11-4 provides the Plan of nursing care for the care of patients with cancer. Although many considerations relate to the side effects of cancer therapy, care must be holistic in nature. Maintaining skin integrity Some of the most frequently encountered disturbances of tissue integrity, in addition to stomatitis, include skin and tissue reac- tions to radiation therapy, alopecia and metastatic skin lesions. Nursing care for patients with skin reactions includes main- taining skin integrity, cleansing the skin, promoting comfort, reducing pain, preventing additional trauma, and preventing and managing infection (McQuestion, 2006). Stomatitis Mucositis is a common side effect of radiation and some types of chemotherapy that may lead to inflammation and ulcer- ation of any portion of the gastrointestinal tract from the oral cavity throughout the alimentary canal. One form of muco- sitis, stomatitis, an inflammatory response of the oral tissues, commonly develops within 5 to 14 days after the patient receives certain chemotherapeutic agents, such as doxorubi- cin and 5-fluorouracil, and BRMs such as IL-2 and IFN. As many as 40% of patients receiving chemotherapy experience some degree of stomatitis during treatment. Patients receiving dose-intensive chemotherapy (considerably higher doses than conventional dosing), such as those undergoing BMT, are at increased risk for stomatitis. Stomatitis may also occur with radiation to the head and neck (Cady, 2007). Stomatitis is characterised by mild redness (erythema) and oedema or, if severe, by painful ulcerations, bleeding and secondary infection. In severe cases of stomatitis, cancer therapy may be temporarily halted until the inflamma- tion decreases. As a result of normal every day wear and tear, the epithelial cells that line the oral cavity undergo rapid turnover and slough off routinely. Chemotherapy and radiation interfere with the body’s ability to replace those cells. An inflammatory response develops as denuded areas appear in the oral cavity. Poor oral hygiene, existing dental disease, use of other medications that dry mucous membranes, and impaired nutritional status contrib- ute to morbidity associated with stomatitis. Radiation-induced xerostomia (dry mouth) associated with decreased function of the salivary glands may contribute to stomatitis in patients who have received radiation to the head and neck.