Textbook of Medical-Surgical Nursing 3e

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Chapter 11

Oncology: Nursing management in cancer care

not responsive to rest, and it seriously affects quality of life. Fatigue is a commonly reported side effect in patients who receive chemotherapy and radiation therapy and may arise from a number of sources (see Chart 11-10). In recent years, fatigue has been recognised as one of the most significant and frequent symptoms experienced by patients receiving cancer therapy. Nurses help the patient and family to understand that fatigue is usually an expected and temporary side effect of the cancer process and of many treatments used. Fatigue also stems from the stress of coping with cancer. It does not always signify that the cancer is advancing or that the treatment is failing. Potential sources of fatigue are summarised in Chart 11-10. Fatigue is distressing for patients with cancer who are receiving treatment, for survivors, and for those in the late stages of disease (Mitchell et al., 2007). Although patients may describe fatigue in a variety of ways, nurses assess for feelings of weariness, weakness, lack of energy, inability to carry out necessary and valued daily functions, lack of motivation, and inability to concentrate. Several assessment tools, such as a simple visual analogue scale, may be used to assess levels of fatigue (Madden & Newton, 2006). The nurse assesses physiological and psychological stressors that can contribute to fatigue, including anaemia, electrolyte imbalances, organ dysfunction, pain, nausea, dyspnoea, constipation, fear and anxiety (see Chart 11-11). The role of exercise as a helpful intervention has been supported by several controlled trials (Mitchell et al., 2007; Young-McCaughan & Arzola, 2007). The nurse assists patients with additional non-pharmacological strategies to minimise fatigue or help the patient cope with existing fatigue as described in the Plan of nursing care (Chart 11-4) under ‘Fatigue’. Occasionally pharmacological interventions are utilised, including antidepressants for patients with depression; anxiolytics for those with anxiety; hypnotics for patients with sleep disturbances; and psychostimulants for some patients with advanced cancer or fatigue that does not respond to other interventions (Abraham, 2005). The nurse assists patients with non-pharmacological strate- gies to minimise fatigue or help the patient cope with existing fatigue. Patients are encouraged to maintain as normal a lifestyle as possible by continuing with those activities they value and enjoy. Prioritising necessary and valued activities can assist patients in planning for each day. Both patients and families are encouraged to plan to reallocate responsibilities, such as attending to childcare, cleaning and preparing meals. Patients who are employed may need to consider reducing the number of hours worked each week or modifying their roles. The nurse assists the patient and family in coping with these changing roles and responsibilities. Improving body image and self-esteem The nurse identifies potential threats to the patient’s body image and assesses the patient’s ability to cope with the many assaults to body image experienced throughout the course of disease and treatment. Entry into the healthcare system is often accompanied by depersonalisation. Threats to self- concept occur as the patient faces the realisation of illness, disfigurement, possible disability and death. To accommodate treatments or because of the disease, many patients with cancer are forced to alter their lifestyles. Priorities and values change when body image is threatened. Disfiguring surgery, hair loss, cachexia, skin changes, altered communication

Freedom from cancer pain

Opioid for moderate to severe pain +/– Non-opioid +/– Adjuvant

Step 3

Pain persisting or increasing

Opioid for mild to moderate pain +/– Non-opioid +/– Adjuvant

Step 2

Pain persisting or increasing

Non-opioid +/– Adjuvant

Step 1

weak opioid analgesics (e.g. codeine) are used for moderate pain; and strong opioid analgesics (e.g. morphine) are used for severe pain. If the patient’s pain escalates, the strength of the analgesic medication is increased until the pain is controlled. Adjuvant medications are also administered to enhance the effectiveness of analgesics and to manage other symptoms that may contribute to the pain experience. Examples of adjuvant medications include antiemetics (metoclopramide), antidepressants (fluoxetine), antianxiety agents (diazepam), antiseizure agents (carbamazepine), stimulants (benztropine), local anaesthetics (xylocaine) and corticosteroids (cortisone). Preventing and reducing pain helps to decrease anxiety and break the pain cycle. This can be accomplished best by administering analgesics on a regularly scheduled basis as prescribed (the preventive approach to pain management), with additional analgesics administered for breakthrough pain as needed and as prescribed. A cancer pain algorithm, developed as a set of analgesic guiding principles, is given in Figure 11-7. Various pharmacological and non-pharmacological approaches offer the best methods of managing cancer pain. No reasonable approaches, even those that may be invasive, should be overlooked because of a poor or terminal prog­ nosis. Nurses help patients and families to take an active role in managing pain. Nurses provide education and support to correct fears and misconceptions about opioid use. Inadequate pain control leads to suffering, anxiety, fear, immobility, isola- tion and depression. Improving a patient’s quality of life is as important as preventing a painful death. Decreasing fatigue Acute fatigue, which occurs after an energy-demanding experi­ence, serves a protective function; chronic fatigue, however, does not. It is often overwhelming, excessive, and Figure 11-6  Adapted from the World Health Organization three-step ladder approach to relieving cancer pain. Various opioid (narcotic) and non-opioid medications may be combined with other medications to control pain.