- 1 Diagnostic Studies
- 2 Nursing Priorities
- 3 Discharge Goals
- 4 Nursing Care Plans
- 4.1 Anticipatory Grieving
- 4.2 Situational Low Self-Esteem
- 4.3 Acute Pain
- 4.4 Altered Nutrition: Less Than Body Requirements
- 4.5 Risk for Fluid Volume Deficit
- 4.6 Fatigue
- 4.7 Risk for Infection
- 4.8 Risk for Altered Oral Mucous Membranes
- 4.9 Risk for Impaired Skin Integrity
- 4.10 Risk for Constipation/Diarrhea
- 4.11 Risk for Altered Sexuality Patterns
- 4.12 Risk for Altered Family Process
- 4.13 Fear/Anxiety
Test selection depends on history, clinical manifestations, and index of suspicion for a particular cancer.
- Endoscopy: Used for direct visualization of body organs/cavities to detect abnormalities.
- Scans (e.g., magnetic resonance imaging [MRI], CT, gallium) and ultrasound: May be done for diagnostic purposes, identification of metastasis, and evaluation of response to treatment.
- Biopsy (fine-needle aspiration [FNA], needle core, incisional/excisional): Done to differentiate diagnosis and delineate treatment and may be taken from bone marrow, skin, organ, and so forth. Example: Bone marrow is done in myeloproliferative diseases for diagnosis; in solid tumors for staging.
- Tumor markers (substances produced and secreted by tumor cells and found in serum, e.g., carcinogenic embryonic antigen [CEA], prostate-specific antigen [PSA], alpha-fetoprotein, human chorionic gonadotropin [HCG], prostatic acid phosphatase, calcitonin, pancreatic oncofetal antigen, CA 15-3, CA 19-9, CA 125, and so on): Helpful in diagnosing cancer but more useful as prognostic indicator and/or therapeutic monitor. For example, estrogen and progesterone receptors are assays done on breast tissue to provide information about whether or not hormonal manipulation would be therapeutic in metastatic disease control. Note: Any hormone may be elevated because many cancers secrete inappropriate hormones (ectopic hormone secretion).
- Screening chemistry tests, e.g., electrolytes (sodium, potassium, calcium), renal tests (BUN/Cr), liver tests (bilirubin, AST, alkaline phosphatase, LDH), bone tests (calcium):Depend on individual condition, risk factors.
- CBC with differential and platelets: May reveal anemia, changes in RBCs and WBCs; reduced or increased platelets.
- Chest x-ray: Screens for primary or metastatic disease of lungs.
- Support adaptation and independence.
- Promote comfort.
- Maintain optimal physiological functioning.
- Prevent complications.
- Provide information about disease process/condition, prognosis, and treatment needs.
- Patient is dealing with current situation realistically.
- Pain alleviated/controlled.
- Homeostasis achieved.
- Complications prevented/minimized.
- Disease process/condition, prognosis, and therapeutic choices and regimen understood.
- Plan in place to meet needs after discharge.
Nursing Care Plans
May be related to:
- Anticipated loss of physiological well-being (e.g., loss of body part; change in body function); change in lifestyle
- Perceived potential death of patient
Possibly evidenced by:
- Changes in eating habits, alterations in sleep patterns, activity levels, libido, and communication patterns
- Denial of potential loss, choked feelings, anger
- Identify and express feelings appropriately.
- Continue normal life activities, looking toward/planning for the future, one day at a time.
- Verbalize understanding of the dying process and feelings of being supported in grief work.
|Expect initial shock and disbelief following diagnosis of cancer and/or traumatizing procedures (e.g., disfiguring surgery, colostomy, amputation).||Few patients are fully prepared for the reality of the changes that can occur.|
|Assess patient/SO for stage of grief currently being experienced. Explain process as appropriate.||Knowledge about the grieving process reinforces the normality of feelings/reactions being experienced and can help patient deal more effectively with them.|
|Provide open, nonjudgmental environment. Use therapeutic communication skills of Active-Listening, acknowledgment, and so on.||Promotes and encourages realistic dialogue about feelings and concerns.|
|Encourage verbalization of thoughts/concerns and accept expressions of sadness, anger, rejection. Acknowledge normality of these feelings.||Patient may feel supported in expression of feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult situation.|
|Be aware of mood swings, hostility, and other acting-out behavior. Set limits on inappropriate behavior, redirect negative thinking.||Indicators of ineffective coping and need for additional interventions. Preventing destructive actions enables patient to maintain control and sense of self-esteem.|
|Be aware of debilitating depression. Ask patient direct questions about state of mind.||Studies show that many cancer patients are at high risk for suicide. They are especially vulnerable when recently diagnosed and/or discharged from hospital.|
|Visit frequently and provide physical contact as appropriate/desired, or provide frequent phone support as appropriate for setting. Arrange for care provider/support person to stay with patient as needed.||Helps reduce feelings of isolation and abandonment.|
|Reinforce teaching regarding disease process and treatments and provide information as requested/ appropriate about dying. Be honest; do not give false hope while providing emotional support.||Patient/SO benefit from factual information. Individuals may ask direct questions about death, and honest answers promote trust and provide reassurance that correct information will be given.|
|Review past life experiences, role changes, and coping skills. Talk about things that interest the patient.||Opportunity to identify skills that may help individuals cope with grief of current situation more effectively.|
|Note evidence of conflict; expressions of anger; and statements of despair, guilt, hopelessness, “nothing to live for.”||Interpersonal conflicts/angry behavior may be patient’s way of expressing/dealing with feelings of despair/spiritual distress and could be indicative of suicidal ideation.|
|Determine way that patient/SO understand and respond to death, e.g., cultural expectations, learned behaviors, experience with death (close family members/friends), beliefs about life after death, faith in Higher Power (God).||These factors affect how each individual deals with the possibility of death and influences how they may respond and interact.|
|Identify positive aspects of the situation.||Possibility of remission and slow progression of disease and/or new therapies can offer hope for the future.|
|Discuss ways patient/SO can plan together for the future. Encourage setting of realistic goals.||Having a part in problem solving/planning can provide a sense of control over anticipated events.|
|Refer to visiting nurse, home health agency as needed, or hospice program, if appropriate.||Provides support in meeting physical and emotional needs of patient/SO, and can supplement the care family and friends are able to give.|
Situational Low Self-Esteem
May be related to
- Biophysical: disfiguring surgery, chemotherapy or radiotherapy side effects, e.g., loss of hair, nausea/vomiting, weight loss, anorexia, impotence, sterility, overwhelming fatigue, uncontrolled pain
- Psychosocial: threat of death; feelings of lack of control and doubt regarding acceptance by others; fear and anxiety
Possibly evidenced by
- Verbalization of change in lifestyle; fear of rejection/reaction of others; negative feelings about body; feelings of helplessness, hopelessness, powerlessness
- Preoccupation with change or loss
- Not taking responsibility for self-care, lack of follow-through
- Change in self-perception/other’s perception of role
- Verbalize understanding of body changes, acceptance of self in situation.
- Begin to develop coping mechanisms to deal effectively with problems.
- Demonstrate adaptation to changes/events that have occurred as evidenced by setting of realistic goals and active participation in work/play/personal relationships as appropriate.
|Discuss with patient/SO how the diagnosis and treatment are affecting the patient’s personal life/home and work activities.||Aids in defining concerns to begin problem-solving process.|
|Review anticipated side effects associated with a particular treatment, including possible effects on sexual activity and sense of attractiveness/desirability, e.g., alopecia, disfiguring surgery. Tell patient that not all side effects occur, and others may be minimized/controlled.||Anticipatory guidance can help patient/SO begin the process of adaptation to new state and to prepare for some side effects, e.g., buy a wig before radiation, schedule time off from work as indicated.|
|Encourage discussion of/problem-solve concerns about effects of cancer/treatments on role as homemaker, wage earner, parent, and so forth.||May help reduce problems that interfere with acceptance of treatment or stimulate progression of disease.|
|Acknowledge difficulties patient may be experiencing. Give information that counseling is often necessary and important in the adaptation process.||Validates reality of patient’s feelings and gives permission to take whatever measures are necessary to cope with what is happening.|
|Evaluate support structures available to and used by patient/SO.||Helps with planning for care while hospitalized and after discharge.|
|Provide emotional support for patient/SO during diagnostic tests and treatment phase.||Although some patients adapt/adjust to cancer effects or side effects of therapy, many need additional support during this period.|
|Use touch during interactions, if acceptable to patient, and maintain eye contact.||Affirmation of individuality and acceptance is important in reducing patient’s feelings of insecurity and self-doubt.|
|Refer for professional counseling as indicated.||May be necessary to regain and maintain a positive psychosocial structure if patient/SO support systems are deteriorating.|
May be related to
- Disease process (compression/destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation)
- Side effects of various cancer therapy agents
Possibly evidenced by
- Reports of pain
- Self-focusing/narrowed focus
- Alteration in muscle tone; facial mask of pain
- Distraction/guarding behaviors
- Autonomic responses, restlessness (acute pain)
- Report maximal pain relief/control with minimal interference with ADLs.
- Follow prescribed pharmacological regimen.
- Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
|Determine pain history, e.g., location of pain, frequency, duration, and intensity using numeric rating scale (0–10 scale), or verbal rating scale (“no pain” to “excruciating pain”) and relief measures used. Believe patient’s report.||Information provides baseline data to evaluate need for/effectiveness of interventions. Pain of more than 6 mo duration constitutes chronic pain, which may affect therapeutic choices. Recurrent episodes of acute pain can occur within chronic pain, requiring increased level of intervention. Note: The pain experience is an individualized one composed of both physical and emotional responses.|
|Determine timing/precipitants of “breakthrough” pain when using around-the-clock agents, whether oral, IV, or patch medications.||Pain may occur near the end of the dose interval, indicating need for higher dose or shorter dose interval. Pain may be precipitated by identifiable triggers, or occur spontaneously, requiring use of short half-life agents for rescue or supplemental doses.|
|Evaluate/be aware of painful effects of particular therapies, i.e., surgery, radiation, chemotherapy, biotherapy. Provide information to patient/SO about what to expect.||A wide range of discomforts are common (e.g., incisional pain, burning skin, low back pain, headaches), depending on the procedure/agent being used. Pain is also associated with invasive procedures to diagnose/treat cancer.|
|Provide nonpharmacological comfort measures (e.g., massage, repositioning, backrub) and diversional activities (e.g., music, television)||Promotes relaxation and helps refocus attention.|
|Encourage use of stress management skills/ complimentary therapies (e.g., relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and Therapeutic Touch).||Enables patient to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases patient’s focus on self, which in turn increases the level of pain.|
|Provide cutaneous stimulation, e.g., heat/cold, massage.||May decrease inflammation, muscle spasms, reducing associated pain. Note: Heat may increase bleeding/edema following acute injury, whereas cold may further reduce perfusion to ischemic tissues.|
|Be aware of barriers to cancer pain management related to patient, as well as the healthcare system.||Patients may be reluctant to report pain for reasons such as fear that disease is worse; worry about unmanageable side effects of pain medications; beliefs that pain has meaning, such as “God wills it,” they should overcome it, or that pain is merited or deserved for some reason. Healthcare system problems include factors such as inadequate assessment of pain, concern about controlled substances/patient addiction, inadequate reimbursement/ cost of treatment modalities.|
|Evaluate pain relief/control at regular intervals. Adjust medication regimen as necessary.||Goal is maximum pain control with minimum interference with ADLs.|
|Inform patient/SO of the expected therapeutic effects and discuss management of side effects||This information helps establish realistic expectations, confidence in own ability to handle what happens.|
|Discuss use of additional alternative/complementary therapies, e.g., acupuncture/acupressure.||May provide reduction/relief of pain without drug-related side effects.|
|Administer analgesics as indicated, e.g.: Opioids, e.g., codeine, morphine (MS Contin), oxycodone (oxycontin) hydrocodone (Vicodin), hydromorphone (Dilaudid), methadone (Dolophine), fentanyl (Duragesic); oxymorphone (Numorphan);Acetaminophen (Tylenol); and nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, ibuprofen (Motrin, Advil); peroxicam (Feldene); indomethacin (Indocin);Corticosteroids, e.g., dexamethasone (Decadron);||A wide range of analgesics and associated agents may be employed around the clock to manage pain. Note: Addiction to or dependency on drug is not a concern. Effective for localized and generalized moderate to severe pain, with long-acting/controlled-release forms available. Routes of administration include oral, transmucosal, transdermal, nasal, rectal, and infusions (subcutaneous, IV, intraventricular), which may be delivered via PCA. IM use is not recommended because absorption is not reliable, in addition to being painful and inconvenient. Note: Research is in process for oral transmucosal agent (fentenyl citrate [oralet]) to control breakthrough pain in patients using fentanyl patch. Adjuvant drugs are useful for mild to moderate pain and can be combined with opioids and other modalities.May be effective in controlling pain associated with inflammatory process (e.g., metastatic bone pain, acute spinal cord compression and neuropathic pain).|
Altered Nutrition: Less Than Body Requirements
May be related to
- Hypermetabolic state associated with cancer
- Consequences of chemotherapy, radiation, surgery, e.g., anorexia, gastric irritation, taste distortions, nausea
- Emotional distress, fatigue, poorly controlled pain
Possibly evidenced by
- Reported inadequate food intake, altered taste sensation, loss of interest in food, perceived/actual inability to ingest food
- Body weight 20% or more under ideal for height and frame, decreased subcutaneous fat/muscle mass
- Sore, inflamed buccal cavity
- Diarrhea and/or constipation, abdominal cramping
- Demonstrate stable weight/progressive weight gain toward goal with normalization of laboratory values and be free of signs of malnutrition.
- Verbalize understanding of individual interferences to adequate intake.
- Participate in specific interventions to stimulate appetite/increase dietary intake.
|Monitor daily food intake; have patient keep food diary as indicated.||Identifies nutritional strengths/deficiencies.|
|Measure height, weight, and tricep skinfold thickness (or other anthropometric measurements as appropriate). Ascertain amount of recent weight loss. Weigh daily or as indicated.||If these measurements fall below minimum standards, patient’s chief source of stored energy (fat tissue) is depleted.|
|Assess skin/mucous membranes for pallor, delayed wound healing, enlarged parotid glands.||Helps in identification of protein-calorie malnutrition, especially when weight and anthropometric measurements are less than normal.|
|Encourage patient to eat high-calorie, nutrient-rich diet, with adequate fluid intake. Encourage use of supplements and frequent/smaller meals spaced throughout the day.||Metabolic tissue needs are increased as well as fluids (to eliminate waste products). Supplements can play an important role in maintaining adequate caloric and protein intake.|
|Create pleasant dining atmosphere; encourage patient to share meals with family/friends.||Makes mealtime more enjoyable, which may enhance intake.|
|Encourage open communication regarding anorexia.||Often a source of emotional distress, especially for SO who wants to feed patient frequently. When patient refuses, SO may feel rejected/frustrated.|
|Adjust diet before and immediately after treatment, e.g., clear, cool liquids, light/bland foods, candied ginger, dry crackers, toast, carbonated drinks. Give liquids 1 hr before or 1 hr after meals.||The effectiveness of diet adjustment is very individualized in relief of posttherapy nausea. Patients must experiment to find best solution/combination. Avoiding fluids during meals minimizes becoming “full” too quickly.|
|Control environmental factors (e.g., strong/noxious odors or noise). Avoid overly sweet, fatty, or spicy foods.||Can trigger nausea/vomiting response.|
|Encourage use of relaxation techniques, visualization, guided imagery, moderate exercise before meals.||May prevent onset or reduce severity of nausea, decrease anorexia, and enable patient to increase oral intake.|
|Identify the patient who experiences anticipatory nausea/vomiting and take appropriate measures.||Psychogenic nausea/vomiting occurring before chemotherapy generally does not respond to antiemetic drugs. Change of treatment environment or patient routine on treatment day may be effective.|
|Administer antiemetic on a regular schedule before/ during and after administration of antineoplastic agent as appropriate.||Nausea/vomiting are frequently the most disabling and psychologically stressful side effects of chemotherapy.|
|Evaluate effectiveness of antiemetic.||Individuals respond differently to all medications. First-line antiemetics may not work, requiring alteration in or use of combination drug therapy.|
|Hematest stools, gastric secretions.||Certain therapies (e.g., antimetabolites) inhibit renewal of epithelial cells lining the GI tract, which may cause changes ranging from mild erythema to severe ulceration with bleeding.|
|Review laboratory studies as indicated, e.g., total lymphocyte count, serum transferrin, and albumin/ prealbumin.||Helps identify the degree of biochemical imbalance/ malnutrition and influences choice of dietary interventions. Note: Anticancer treatments can also alter nutrition studies, so all results must be correlated with the patient’s clinical status.|
|Refer to dietitian/nutritional support team.||Provides for specific dietary plan to meet individual needs and reduce problems associated with protein/ calorie malnutrition and micronutrient deficiencies.|
|Insert/maintain NG or feeding tube for enteric feedings, or central line for total parenteral nutrition (TPN) if indicated.||In the presence of severe malnutrition (e.g., loss of 25%–30% body weight in 2 mo) or if patient has been NPO for 5 days and is unlikely to be able to eat for another week, tube feeding or TPN may be necessary to meet nutritional needs.|
Risk for Fluid Volume Deficit
Risk factors may include
- Excessive losses through normal routes (e.g., vomiting, diarrhea) and/or abnormal routes (e.g., indwelling tubes, wounds)
- Hypermetabolic state
- Impaired intake of fluids
- Display adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor, prompt capillary refill, and individually adequate urinary output.
|Monitor I&O and specific gravity; include all output sources, e.g., emesis, diarrhea, draining wounds. Calculate 24-hr balance.||Continued negative fluid balance, decreasing renal output and concentration of urine suggest developing dehydration and need for increased fluid replacement.|
|Weigh as indicated.||Sensitive measurement of fluctuations in fluid balance.|
|Monitor vital signs. Evaluate peripheral pulses, capillary refill.||Reflects adequacy of circulating volume.|
|Assess skin turgor and moisture of mucous membranes. Note reports of thirst.||Indirect indicators of hydration status/degree of deficit.|
|Encourage increased fluid intake to 3000 mL/day as individually appropriate/tolerated.||Assists in maintenance of fluid requirements and reduces risk of harmful side effects, e.g., hemorrhagic cystitis in patient receiving cyclophosphamide (Cytoxan).|
|Observe for bleeding tendencies, e.g., oozing from mucous membranes, puncture sites; presence of ecchymosis or petechiae.||Early identification of problems (which may occur as a result of cancer and/or therapies) allows for prompt intervention.|
|Minimize venipunctures (e.g., combine IV starts with blood draws). Encourage patient to consider central venous catheter placement.||Reduces potential for hemorrhage and infection associated with repeated venous puncture.|
|Avoid trauma and apply pressure to puncture sites.||Reduces potential for bleeding/hematoma formation.|
|Provide IV fluids as indicated.||Given for general hydration and to dilute antineoplastic drugs and reduce adverse side effects, e.g., nausea/vomiting, or nephrotoxicity.|
|Monitor laboratory studies, e.g., CBC, electrolytes, serum albumin.||Provides information about level of hydration and corresponding deficits.|
May be related to
- Decreased metabolic energy production, increased energy requirements (hypermetabolic state and effects of treatment)
- Overwhelming psychological/emotional demands
- Altered body chemistry: side effects of pain and other medications, chemotherapy
Possibly evidenced by
- Unremitting/overwhelming lack of energy, inability to maintain usual routines, decreased performance, impaired ability to concentrate, lethargy/listlessness
- Disinterest in surroundings
- Report improved sense of energy.
- Perform ADLs and participate in desired activities at level of ability.
|Have patient rate fatigue, using a numeric scale, if possible, and the time of day when it is most severe.||Helps in developing a plan for managing fatigue.|
|Plan care to allow for rest periods. Schedule activities for periods when patient has most energy. Involve patient/SO in schedule planning.||Frequent rest periods and/or naps are needed to restore/conserve energy. Planning will allow patient to be active during times when energy level is higher, which may restore a feeling of well-being and a sense of control.|
|Establish realistic activity goals with patient.||Provides for a sense of control and feelings of accomplishment.|
|Assist with self-care needs when indicated; keep bed in low position, pathways clear of furniture; assist with ambulation.||Weakness may make ADLs difficult to complete or place the patient at risk for injury during activities.|
|Encourage patient to do whatever possible, e.g., self-bathing, sitting up in chair, walking. Increase activity level as individual is able.||Enhances strength/stamina and enables patient to become more active without undue fatigue.|
|Monitor physiological response to activity, e.g., changes in BP or heart/respiratory rate.||Tolerance varies greatly depending on the stage of the disease process, nutrition state, fluid balance, and reaction to therapeutic regimen.|
|Perform pain assessment and provide pain management.||Poorly managed cancer pain can contribute to fatigue.|
|Provide supplemental oxygen as indicated.||Presence of anemia/hypoxemia reduces O2available for cellular uptake and contributes to fatigue.|
|Refer to physical/occupational therapy.||Programmed daily exercises and activities help patient maintain/increase strength and muscle tone, enhance sense of well-being. Use of adaptive devices may help conserve energy.|
Risk for Infection
Risk factors may include
- Inadequate secondary defenses and immunosuppression, e.g., bone marrow suppression (dose-limiting side effect of both chemotherapy and radiation).
- Malnutrition, chronic disease process
- Invasive procedures
- Remain afebrile and achieve timely healing as appropriate.
- Identify and participate in interventions to prevent/reduce risk of infection.
|Promote good handwashing procedures by staff and visitors. Screen/limit visitors who may have infections. Place in reverse isolation as indicated.||Protects patient from sources of infection, such as visitors and staff who may have an upper respiratory infection (URI).|
|Emphasize personal hygiene.||Limits potential sources of infection and/or secondary overgrowth.|
|Monitor temperature.||Temperature elevation may occur (if not masked by corticosteroids or anti-inflammatory drugs) because of various factors, e.g., chemotherapy side effects, disease process, or infection. Early identification of infectious process enables appropriate therapy to be started promptly.|
|Assess all systems (e.g., skin, respiratory, genitourinary) for signs/symptoms of infection on a continual basis.||Early recognition and intervention may prevent progression to more serious situation/sepsis.|
|Reposition frequently; keep linens dry and wrinkle-free.||Reduces pressure and irritation to tissues and may prevent skin breakdown (potential site for bacterial growth).|
|Promote adequate rest/exercise periods.||Limits fatigue, yet encourages sufficient movement to prevent stasis complications, e.g., pneumonia, decubitus, and thrombus formation.|
|Stress importance of good oral hygiene.||Development of stomatitis increases risk of infection/ secondary overgrowth.|
|Avoid/limit invasive procedures. Adhere to aseptic techniques.||Reduces risk of contamination, limits portal of entry for infectious agents.|
|Monitor CBC with differential WBC and granulocyte count, and platelets as indicated.||Bone marrow activity may be inhibited by effects of chemotherapy, the disease state, or radiation therapy. Monitoring status of myelosuppression is important for preventing further complications (e.g., infection, anemia, or hemorrhage) and scheduling drug delivery.|
|Obtain cultures as indicated.||Identifies causative organism(s) and appropriate therapy.|
|Administer antibiotics as indicated.||May be used to treat identified infection or given prophylactically in immunocompromised patient.|
Risk for Altered Oral Mucous Membranes
Risk factors may include
- Side effect of some chemotherapeutic agents (e.g., antimetabolites) and radiation
- Dehydration, malnutrition, NPO restrictions for more than 24 hr
- Display intact mucous membranes, which are pink, moist, and free of inflammation/ulcerations.
- Verbalize understanding of causative factors.
- Demonstrate techniques to maintain/restore integrity of oral mucosa.
|Assess dental health and oral hygiene periodically.||Identifies prophylactic treatment needs before initiation of chemotherapy or radiation and provides baseline data of current oral hygiene for future comparison.|
|Encourage patient to assess oral cavity daily, noting changes in mucous membrane integrity (e.g., dry, reddened). Note reports of burning in the mouth, changes in voice quality, ability to swallow, sense of taste, development of thick/viscous saliva, blood-tinged emesis.||Good care is critical during treatment to control stomatitis complications.|
|Discuss with patient areas needing improvement and demonstrate methods for good oral care.||Products containing alcohol or phenol may exacerbate mucous membrane dryness/irritation.|
|Initiate/recommend oral hygiene program to include:Avoidance of commercial mouthwashes, lemon/ glycerine swabs; Use of mouthwash made from warm saline, dilute solution of hydrogen peroxide or baking soda and water; Brush with soft toothbrush or foam swab; Floss gently or use WaterPik cautiously; Keep lips moist with lip gloss or balm, K-Y Jelly, Chapstick; Encourage use of mints/hard candy or artificial saliva (Ora-Lube, Salivart) as indicated.||May be soothing to the membranes. Rinsing before meals may improve the patient’s sense of taste. Rinsing after meals and at bedtime dilutes oral acids and relieves xerostomia. Prevents trauma to delicate/fragile tissues. Note: Toothbrush should be changed at least every 3 mo. Removes food particles that can promote bacterial growth. Note: Water under pressure has the potential to injure gums/force bacteria under gum line. Promotes comfort and prevents drying/cracking of tissues. Stimulates secretions/provides moisture to maintain integrity of mucous membranes, especially in presence of dehydration/reduced saliva production.|
|Instruct regarding dietary changes: e.g., avoid hot or spicy foods, acidic juices; suggest use of straw; ingest soft or blenderized foods, Popsicles, and ice cream as tolerated.||Severe stomatitis may interfere with nutritional and fluid intake leading to negative nitrogen balance or dehydration. Dietary modifications may make foods easier to swallow and may feel soothing.|
|Encourage fluid intake as individually tolerated.||Adequate hydration helps keep mucous membranes moist, preventing drying/cracking.|
|Discuss limitation of smoking and alcohol intake.||May cause further irritation and dryness of mucous membranes. Note: May need to compromise if these activities are important to patient’s emotional status.|
|Monitor for and explain to patient signs of oral superinfection (e.g., thrush).||Early recognition provides opportunity for prompt treatment.|
|Refer to dentist before initiating chemotherapy or head/neck radiation.||Prophylactic examination and repair work before therapy reduce risk of infection.|
|Culture suspicious oral lesions.||Identifies organism(s) responsible for oral infections and suggests appropriate drug therapy.|
|Administer medications as indicated, e.g.:Analgesic rinses (e.g., mixture of Koatin, pectin, diphenhydramine [Benadryl], and topical lidocaine [Xylocaine]); Antifungal mouthwash preparation, e.g., nystatin (Mycostatin), and antibacterial Biotane; Antinausea agents; Opioid analgesics: e.g., hydromoph (Dilaudid), morphine.||Aggressive analgesia program may be required to relieve intense pain. Note: Rinse should be used as a swish-and-spit rather than a gargle, which could anesthetize patient’s gag reflex. May be needed to treat/prevent secondary oral infections, such as Candida, Pseudomonas, herpes simplex. When given before beginning mouth care regimen, may prevent nausea associated with oral stimulation. May be required for acute episodes of moderate to severe oral pain.|
Risk for Impaired Skin Integrity
Risk factors may include
- Effects of radiation and chemotherapy
- Immunologic deficit
- Altered nutritional state, anemia
- Identify interventions appropriate for specific condition.
- Participate in techniques to prevent complications/promote healing as appropriate.
|Assess skin frequently for side effects of cancer therapy; note breakdown/delayed wound healing. Emphasize importance of reporting open areas to caregiver.||A reddening and/or tanning effect (radiation reaction) may develop within the field of radiation. Dry desquamation (dryness and pruritus), moist desquamation (blistering), ulceration, hair loss, loss of dermis and sweat glands may also be noted. In addition, skin reactions (e.g., allergic rashes, hyperpigmentation, pruritus, and alopecia) may occur with some chemotherapy agents.|
|Bathe with lukewarm water and mild soap.||Maintains cleanliness without irritating the skin.|
|Encourage patient to avoid vigorous rubbing and scratching and to pat skin dry instead of rubbing.||Helps prevent skin friction/trauma to sensitive tissues.|
|Turn/reposition frequently.||Promotes circulation and prevents undue pressure on skin/tissues.|
|Review skin care protocol for patient receiving radiation therapy:Avoid rubbing or use of soap, lotions, creams, ointments, powders or deodorants on area; avoid applying heat or attempting to wash off marks/tattoos placed on skin to identify area of irradiation;Recommend wearing soft, loose cotton clothing; have female patient avoid wearing bra if it creates pressure;Apply cornstarch, Aquaphor, Lubriderm, Eucerin (or other recommended water-soluble moisturizing gel) to area twice daily as needed;
Encourage liberal use of sunscreen/block and breathable, protective clothing.
|Designed to minimize trauma to area of radiation therapy.Can potentiate or otherwise interfere with radiation delivery. May actually increase irritation/reaction.Skin is very sensitive during and after treatment, and all irritation should be avoided to prevent dermal injury.
Helps control dampness or pruritus. Maintenance care is required until skin/tissues have regenerated and are back to normal.
Protects skin from ultraviolet rays and reduces risk of recall reactions.
Reduces risk of tissue irritation/extravasation of agent into tissues.
Development of irritation indicates need for alteration of rate/dilution of chemotherapy and/or change of IV site to prevent more serious reaction.
|Assess skin/IV site and vein for erythema, edema, tenderness; weltlike patches, itching/burning; or swelling, burning, soreness; blisters progressing to ulceration/tissue necrosis.||Presence of phlebitis, vein flare (localized reaction) or extravasation requires immediate discontinuation of antineoplastic agent and medical intervention.|
|Wash skin immediately with soap and water if antineoplastic agents are spilled on unprotected skin (patient or caregiver).||Dilutes drug to reduce risk of skin irritation/chemical burn.|
|Advise patients receiving 5-fluorouracil (5-FU) and methotrexate to avoid sun exposure. Withhold methotrexate if sunburn present.||Sun can cause exacerbation of burn spotting (a side effect of 5-fluorouracil) or can cause a red “flash” area with methotrexate, which can exacerbate drug’s effect.|
|Review expected dermatologic side effects seen with chemotherapy, e.g., rash, hyperpigmentation, and peeling of skin on palms.||Anticipatory guidance helps decrease concern if side effects do occur.|
|Inform patient that if alopecia occurs, hair could grow back after completion of chemotherapy, but may/may not grow back after radiation therapy.||Anticipatory guidance may help adjustment to/
preparation for baldness. Men are often as sensitive to hair loss as women. Radiation’s effect on hair follicles may be permanent, depending on rad dosage.
|Apply ice pack/warm compresses per protocol||Controversial intervention depends on type of agent used. Ice restricts blood flow, keeping drug localized, while heat enhances dispersion of neoplastic drug/antidote, minimizing tissue damage.|
Risk for Constipation/Diarrhea
Risk factors may include
- Irritation of the GI mucosa from either chemotherapy or radiation therapy; malabsorption of fat
- Hormone-secreting tumor, carcinoma of colon
- Poor fluid intake, low-bulk diet, lack of exercise, use of opiates/narcotics
- Maintain usual bowel consistency/pattern.
- Verbalize understanding of factors and appropriate interventions/solutions related to individual situation.
|Ascertain usual elimination habits.||Data required as baseline for future evaluation of therapeutic needs/effectiveness.|
|Assess bowel sounds and monitor/record bowel movements (BMs) including frequency, consistency (particularly during first 3–5 days of Vinca alkaloid therapy).||Defines problem, i.e., diarrhea, constipation.Note: Constipation is one of the earliest manifestations of neurotoxicity.|
|Monitor I&O and weight.||Dehydration, weight loss, and electrolyte imbalance are complications of diarrhea. Inadequate fluid intake may potentiate constipation.|
|Encourage adequate fluid intake (e.g., 2000 mL/24 hr), increased fiber in diet; regular exercise.||May reduce potential for constipation by improving stool consistency and stimulating peristalsis; can prevent dehydration associated with diarrhea.|
|Provide small, frequent meals of foods low in residue (if not contraindicated), maintaining needed protein and carbohydrates (e.g., eggs., cooked cereal, bland cooked vegetables).||Reduces gastric irritation. Use of low-fiber foods can decrease irritability and provide bowel rest when diarrhea present.|
|Adjust diet as appropriate: avoid foods high in fat (e.g., butter, fried foods, nuts); foods with high-fiber content; those known to cause diarrhea or gas (e.g., cabbage, baked beans, chili); food/fluids high in caffeine; or extremely hot or cold food/fluids.|| GI stimulants that may increase gastric motility/
frequency of stools.
|Check for impaction if patient has not had BM in 3 days or if abdominal distension, cramping, headache are present.||Further interventions/alternative bowel care may be needed.|
|Monitor laboratory studies as indicated, e.g., electrolytes.Administer IV fluids;Antidiarrheal agents;
Stool softeners, laxatives, enemas as indicated.
|Electrolyte imbalances may be the result of/contribute to altered GI function.Prevents dehydration, dilutes chemotherapy agents to diminish side effects.May be indicated to control severe diarrhea.Prophylactic use may prevent further complications in some patients (e.g., those who will receive Vinca alkaloid, have poor bowel pattern before treatment, or have decreased motility).|
Risk for Altered Sexuality Patterns
Risk factors may include
- Knowledge/skill deficit about alternative responses to health-related transitions, altered body function/
- structure, illness, and medical treatment
- Overwhelming fatigue
- Fear and anxiety
- Lack of privacy/SO
- Verbalize understanding of effects of cancer and therapeutic regimen on sexuality and measures to correct/
- deal with problems.
- Maintain sexual activity at a desired level as possible.
|Discuss with patient/SO the nature of sexuality and reactions when it is altered or threatened. Provide information about normality of these problems and that many people find it helpful to seek assistance with adaptation process.||Acknowledges legitimacy of the problem. Sexuality encompasses the way men and women view themselves as individuals and how they relate between and among themselves in every area of life.|
|Advise patient of side effects of prescribed cancer treatment that are known to affect sexuality.||Anticipatory guidance can help patient and SO begin the process of adaptation to new state.|
|Provide private time for hospitalized patient. Knock on door and receive permission from patient/SO before entering.||Sexual needs do not end because the patient is hospitalized. Intimacy needs continue and an open and accepting attitude for the expression of those needs is essential.|
|Refer to sex therapist as indicated.||May require additional assistance in dealing with situation.|
Risk for Altered Family Process
Risk factors may include
- Situational/transitional crises: long-term illness, change in roles/economic status
- Developmental: anticipated loss of a family member
- Express feelings freely.
- Demonstrate individual involvement in problem-solving process directed at appropriate solutions for the situation.
- Encourage and allow member who is ill to handle situation in own way.
|Note components of family, presence of extended family and others, e.g., friends/neighbors.||Helps patient and caregiver know who is available to assist with care/provide respite and support.|
|Identify patterns of communication in family and patterns of interaction between family members.||Provides information about effectiveness of communication and identifies problems that may interfere with family’s ability to assist patient and adjust positively to diagnosis/treatment of cancer.|
|Assess role expectations of family members and encourage discussion about them.||Each person may see the situation in own individual manner, and clear identification and sharing of these expectations promote understanding.|
|Assess energy direction, e.g., are efforts at resolution/problem solving purposeful or scattered?||Provides clues about interventions that may be appropriate to assist patient and family in directing energies in a more effective manner.|
|Note cultural/religious beliefs.||Affects patient/SO reaction and adjustment to diagnosis, treatment, and outcome of cancer.|
|Listen for expressions of helplessness.||Helpless feelings may contribute to difficulty adjusting to diagnosis of cancer and cooperating with treatment regimen.|
|Deal with family members in a warm, caring, respectful way. Provide information (verbal/written), and reinforce as necessary.||Provides feelings of empathy and promotes individual’s sense of worth and competence in ability to handle current situation.|
|Encourage appropriate expressions of anger without reacting negatively to them.||Feelings of anger are to be expected when individuals are dealing with the difficult/potentially fatal illness of cancer. Appropriate expression enables progress toward resolution of the stages of the grieving process.|
|Acknowledge difficulties of the situation, e.g., diagnosis and treatment of cancer, possibility of death.||Communicates acceptance of the reality the patient/family are facing.|
|Identify and encourage use of previous successful coping behaviors.||Most people have developed effective coping skills that can be useful in dealing with current situation.|
|Stress importance of continuous open dialogue between family members.||Promotes understanding and assists family members to maintain clear communication and resolve problems effectively.|
|Refer to support groups, clergy, family therapy as indicated.||May need additional assistance to resolve problems of disorganization that may accompany diagnosis of potentially terminal illness (cancer).|
May be related to:
- Situational crisis (cancer)
- Threat to/change in health/socioeconomic status, role functioning, interaction patterns
- Threat of death
- Separation from family (hospitalization, treatments), interpersonal transmission/contagion of feelings
Possibly evidenced by:
- Increased tension, shakiness, apprehension, restlessness, insomnia
- Expressed concerns regarding changes in life events
- Feelings of helplessness, hopelessness, inadequacy
- Sympathetic stimulation, somatic complaints
- Display appropriate range of feelings and lessened fear.
- Appear relaxed and report anxiety is reduced to a manageable level.
- Demonstrate use of effective coping mechanisms and active participation in treatment regimen.
|Review patient’s/SO’s previous experience with cancer. Determine what the doctor has told patient and what conclusion patient has reached.||Clarifies patient’s perceptions; assists in identification of fear(s) and misconceptions based on diagnosis and experience with cancer.|
|Encourage patient to share thoughts and feelings.||Provides opportunity to examine realistic fears and misconceptions about diagnosis.|
|Provide open environment in which patient feels safe to discuss feelings or to refrain from talking.||Helps patient feel accepted in present condition without feeling judged, and promotes sense of dignity and control.|
|Maintain frequent contact with patient. Talk with and touch patient as appropriate.||Provides assurance that patient is not alone or rejected; conveys respect for and acceptance of the person, fostering trust.|
|Be aware of effects of isolation on patient when required by immunosuppression or radiation implant. Limit use of isolation clothing/masks as possible.||Sensory deprivation may result when sufficient stimulation is not available and may intensify feelings of anxiety/fear and alienation.|
|Assist patient/SO in recognizing and clarifying fears to begin developing coping strategies for dealing with these fears.||Coping skills are often stressed after diagnosis and during different phases of treatment. Support and counseling are often necessary to enable individual to recognize and deal with fear and to realize that control/coping strategies are available.|
|Provide accurate, consistent information regarding
diagnosis and prognosis. Avoid arguing about patient’s
perceptions of situation.
|Can reduce anxiety and enable patient to make decisions/choices based on realities.|
|Permit expressions of anger, fear, despair without confrontation. Give information that feelings are normal and are to be appropriately expressed.||Acceptance of feelings allows patient to begin to deal with situation.|
|Explain the recommended treatment, its purpose, and potential side effects. Help patient prepare for treatments.||The goal of cancer treatment is to destroy malignant cells while minimizing damage to normal ones. Treatment may include surgery (curative, preventive, palliative), as well as chemotherapy, radiation (internal, external), or newer/organ-specific treatments such as whole-body
hyperthermia or biotherapy. Bone marrow or peripheral progenitor cell (stem cell) transplant may be recommended for some types of cancer.
|Explain procedures, providing opportunity for questions and honest answers. Stay with patient during anxiety-producing procedures and consultations.||Accurate information allows patient to deal more effectively with reality of situation, thereby reducing anxiety and fear of the unknown.|
|Provide primary and consistent caregivers whenever possible.||May help reduce anxiety by fostering therapeutic relationship and facilitating continuity of care.|
|Promote calm, quiet environment.||Facilitates rest, conserves energy, and may enhance coping abilities.|
|Identify stage/degree of grief patient and SO are currently experiencing.||Choice of interventions is dictated by stage of grief, coping behaviors, e.g., anger/withdrawal, denial.|
|Note ineffective coping, e.g., poor social interactions, helplessness, giving up everyday functions and usual sources of gratification.||Identifies individual problems and provides support for patient/SO in using effective coping skills.|
|Be alert to signs of denial/depression, e.g., withdrawal, anger, inappropriate remarks. Determine presence of suicidal ideation and assess potential on a scale of 1–10.||Patient may use defense mechanism of denial and express hope that diagnosis is inaccurate. Feelings of guilt, spiritual distress, physical symptoms, or lack of cure may cause patient to become withdrawn and believe that suicide is a viable alternative.|
|Encourage and foster patient interaction with support systems||Reduces feelings of isolation. If family support systems are not available, outside sources may be needed immediately, e.g., local cancer support groups.|
|Provide reliable and consistent information and support for SO.||Allows for better interpersonal interaction and reduction of anxiety and fear.|
|Include SO as indicated/patient desires when major decisions are to be made.||Provides a support system for patient and allows SO to be involved appropriately.|