31.3 Care of the Patient with Cancer

Fatigue and Pain

Fatigue is a nearly universal reported symptom among patients with cancer and patients undergoing treatment for cancer. Both the disease process and the therapies contribute to physical fatigue, and the fatigue is often profound and cumulative over the course of treatment. Reduced sleep in the hospital, anxiety over relationships and finances, along with physiological issues including pain, anemia, and inflammatory processes can significantly contribute to fatigue in patients. Regular physical activity is the only intervention with evidence to reduce fatigue, but safety should be a priority and activity must be balanced with rest periods.

Pain is a common issue and can come from a variety of sources. Medications can be one cause, including colony-stimulating factors that are administered to increase white blood cell growth but can also cause bone pain. Pain can also stem from the site of the tumor. Pain should be managed to the patient’s desired comfort level, often necessitating multiple modalities and the off-label use of some medications to achieve relief. Medications such as narcotics require careful monitoring and management to minimize side effects. Ultimately, the goal of pain management is to enable the patient to participate in day-to-day activities and enjoy their desired quality of life.

Altered Gastrointestinal Function

The gastrointestinal tract is often affected by cancer treatments, from the oral cavity all the way through to the anus. Cell death caused by chemotherapy can cause pain and alterations in the mucosal lining, called mucositis. Patients can often have stomatitis, which is mucositis specifically in the mouth. This condition results in pain with chewing; in the esophagus, there may be difficulty swallowing.

Ulcerations and infections occur more frequently as the mucosal surface is compromised. Having the patient gargle four times each day with a mixture of warm water, salt, and baking soda can help prevent these complications and can reduce the severity or aid in healing. The nurse can also offer a variety of soft food options that require little chewing, are easy to swallow, and are nutrient-rich. Yogurt, peanut butter milkshakes, and protein-rich supplements are useful. At the end of the gastrointestinal tract, rectal bleeding and infection risk are affected by factors such as mucosal alterations, constipation, thrombocytopenia, and neutropenia.

Nausea and vomiting are often caused by the action of chemotherapy in the chemoreceptor trigger zone of the brain but can also be caused by opiates, antibiotics, metabolic alterations, increased intracranial pressure, constipation, and anxiety about treatments (psychogenic response). To help limit patient nausea, remove the lids of food trays before entering the hospital room, as the steam from hot food can increase strong odors. Cold foods generally have milder smells than hot foods and are often a good choice for patients with stomatitis. Additionally, gastric ulcers can be prevented with the prophylactic use of a proton-pump inhibitor. Nausea and vomiting are treated aggressively, typically with multiple antiemetic medications (Table 31.3).

Altered Clotting and Immunity

Hematological complications can occur in patients with hematological cancer, but also in any patient receiving chemotherapy or radiation treatment. Anemia can be severe. The nurse will watch for changes in blood pressure but will also be alert for more subtle cues such as dizziness when changing positions. The goals of therapy should be lower-than-normal hematocrit and hemoglobin values with resolution of symptoms and prevention of complications.

There is a severe risk of bleeding if the platelet count drops below 50,000 platelets per microliter of blood (reference range: 150,000 to 450,000 platelets per microliter of blood). Below 10,000 platelets per microliter of blood, spontaneous bleeding is a serious concern. Monitor for petechiae, pinpoint spots of bleeding that look, at first glance, as a rash (Figure 31.14). Petechiae begin in areas with dependent fluid movement, such as the lower legs, but can occur anywhere. Petechiae are noted before frank bruising or bleeding. Platelet transfusions can be given, but the goal of this transfusion is only to prevent bleeding, not to achieve an acceptable reference range.

Figure 31.14 Petechiae are small and flat. They can be red, purple, or brown in appearance. They are nonblanching evidence of broken capillaries. The lower extremities are a common location for petechiae to first appear. (credit: Peter Rammstein/Wikipedia Commons, Public Domain)

Infection can be life-threatening for the patient with a decreased white blood cell and neutrophil count. Because the immune system is hampered, the nurse does not expect typical signs of infection or sepsis. Typical signs of infection require functional white blood cells and immune responses. A slight temperature elevation or a low temperature could be the only early alteration in vital signs. Cognitive changes are often noticed first, similar to the expected assessment results in the older adult patient.

Altered Nervous System Functions

Certain therapies can affect the brain and nerves, resulting in neuropathy. Nerve damage causes tingling, numbness, or pain in the hands or feet. This affects quality of life and can alter the ability to safely perform certain tasks. Balance and gait can be affected by certain other chemotherapeutic agents.

Cognitive changes, sometimes referred to as “chemo brain,” can result from any chemotherapy. These changes manifest as problems with memory and attention to tasks. Sometimes treatment-related cognitive changes are a safety issue, especially when driving or cooking, when attention to task is critical.

Social isolation can occur when an individual experiences difficulty recalling faces, events, and names. This impairment in memory can lead to a sense of disconnection and frustration, making social interactions challenging. As a result, the person may withdraw from social activities and relationships, further exacerbating feelings of loneliness and isolation. The inability to engage in meaningful conversations and maintain relationships can diminish a patient’s overall quality of life and contribute to emotional distress. Nurses help patients create a plan to address memory issues and provide support to help individuals stay connected with their social networks.

Skin Impairment

Skin and hair changes, such as alopecia, are typical. Nails can become brittle or discolored. Dry skin requires attention and care, because breaks in the skin barrier increase the risk of infection or bleeding. Patients often lose body hair, eyebrows, and eyelashes as well as scalp hair. Losing hair is a distressing psychosocial event for many patients. Sometimes a cold cap is offered to reduce this occurrence. The cooling decreases the metabolic rate in the follicles and decreases medication uptake in the scalp. More long-term studies are needed to assess the risk of cutaneous scalp metastasis (Silva et al., 2020).

Oncological Emergencies

An oncological emergency is an acute issue that may cause mortality or morbidity. Early detection of an oncological emergency is critical. It is the result of either the cancer itself or the treatment regimen for the cancer. These conditions can develop over months or hours, but the results are devastating if they are not caught and treated emergently. These can be classified by how they occur.

Metabolic Emergencies

Metabolic emergencies include tumor lysis syndrome (TLS), hypercalcemia, and syndrome of inappropriate antidiuretic hormone (SIADH). TLS is more common in hematological malignancies such as acute leukemia and non-Hodgkin lymphoma. TLS is a dangerous complication of cancer treatment, characterized by the rapid breakdown of cancer cells leading to metabolic disturbances. It can result in electrolyte imbalances such as hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia, which can lead to serious complications. The nurse monitors labs every four hours during therapy when this complication is likely. Intravenous hydration is very aggressive and urine output is strictly monitored.

Hypercalcemia is often associated with multiple myeloma due to bone destruction and an overproduction of a hormone that mimics the action of parathyroid hormone. Aside from calcium levels, the nurse assesses for manifestations of hypercalcemia, including mental functioning and muscle weakness. SIADH is usually associated with small-cell lung cancer and ectopic production of antidiuretic hormones by the tumor cells. The nurse assesses sodium levels and may note nausea, constipation, and muscle weakness. Sodium levels are corrected slowly and carefully with ongoing assessment.

Hematologic Emergencies

Hematologic emergencies encompass conditions such as febrile neutropenia (neutropenic fever) and hyperviscosity syndrome. Neutropenic fever, commonly seen in patients who have leukemia or are undergoing chemotherapy who have an absolute neutrophil count below 500 cells/ per mm³ and a slightly elevated temperature (100.4°F, or 38°C), requires prompt management, including consultation with the infectious disease department. Failure to recognize and treat neutropenic fever can result in septic shock. Disseminated intravascular coagulation (DIC) can occur, especially in cases of sepsis or other cancer-related complications, leading to a dangerous cycle of simultaneous clotting and bleeding, often with lethal consequences.

Hyperviscosity syndrome is associated with conditions that overproduce proteins, such as multiple myeloma and certain types of leukemia. With multiple myeloma, abnormal plasma cells produce excessive amounts of a specific immunoglobulin, making the blood thicker and more prone to clotting. In certain types of leukemia, particularly chronic lymphocytic leukemia, the increased production of lymphocytes can also contribute to hyperviscosity. Symptoms include headache or dizziness, and the condition can lead to serious complications such as a cerebrovascular accident, myocardial infarction, or organ damage. Using plasmapheresis to filter out the excess proteins reduces symptoms.

Structural Emergencies

Structural emergencies are due to a tumor’s encroachment on an organ or tissue. Examples include superior vena cava syndrome, spinal cord compression, and malignant pericardial or pleural effusion. Lung cancer is a common cause of structural emergencies, although many other types of cancer can impinge on structures and cause emergent issues. Superior vena cava syndrome results from obstruction of blood flow through the superior vena cava. Manifestations of this issue are a direct result of impaired blood flow: facial and neck edema, cough, and shortness of breath at rest. Spinal cord compression can cause back pain early in its course and can progress to disrupted functions related to compression on spinal nerves: difficulty urinating, constipation, and alterations in lower extremity sensation. If not treated, spinal cord compression results in paralysis. Pericardial and pleural effusions represent the accumulation of malignant fluid. Heart sounds or lung sounds may be muffled or absent. Systemic issues follow and are typical of what the nurse expects from decreased perfusion or decreased oxygenation findings.

Radiation Therapy

There are many types of radiation therapy available, and their use depends on individualized factors. Radiation therapy is a cancer treatment that uses radiation to kill cancer cells or shrink tumors. Every effort is made to reduce the effects of radiation on healthy tissue. Radiation oncologists work closely with the patient to ensure the best outcome based on the treatment goals.

The most common is external beam radiation. This treatment uses a machine outside the body to deliver a radiation dose to the cancer site (Figure 31.15). External beam radiation therapy typically occurs on most days of the week for a set number of days. Initially, the patient needs teaching about the treatment, side effects, and issues to report to the provider. Fatigue is also a common side effect of radiation therapy.

Figure 31.15 Radiation therapy is delivered via a machine and doses are targeted to the cancer site. (credit: “Woman Prepared for Radiation Therapy” by NIH/National Cancer Institute, Public Domain)

As treatment days accrue, side effects accumulate and increase in severity. For example, the patient’s skin may develop a reddened area at the irradiated site that worsens with each treatment. Radiation dermatitis requires special care, and the patient should

• avoid constricting garments,
• limit the use of lotions or creams to those approved by the radiation oncologist, and
• employ pain management for comfort.

Internal radiation therapy, or brachytherapy, is a type of radiation treatment in which a radioactive source is placed inside the body near the tumor (Figure 31.16). There are special precautions for nurses and visitors, depending on the type of brachytherapy in use (e.g., sealed, unsealed). The nurse will consider the principles of time, distance, and shielding. Care is grouped to reduce exposure time, and the nurse will work behind a lead shield while keeping as much distance as is reasonable for the required task.

Figure 31.16 Radioactive seeds are one type of internal radiation. They are placed in or near the tumor, minimizing damage to healthy cells. (credit: “Breast Cancer Treatment Using Iridium Seeds” by NIH/National Cancer Institute, Public Domain)

Other types of radiation are more specialized. Stereotactic radiosurgery delivers high radiation doses with a great degree of precision. Proton therapy uses protons to deliver radiation doses to the tumor (Figure 31.17). Intensity-modulated radiation therapy uses computer-controlled beams of radiation from multiple angles.

Figure 31.17 The tumor is noted in red with a proton beam noted by the yellow line. (credit: “Proton Beam Therapy” by NIH/National Cancer Institute, Public Domain)

Chemotherapy

A class of drugs used to destroy cancer cells known as chemotherapy targets cells that are rapidly dividing, a hallmark of cancer cells. Chemotherapy can be used to induce remission of cancer, control its growth, or relieve complications such as a tissue or organ obstruction.

Nurses must be certified to deliver chemotherapy doses to a patient. Chemotherapeutic agents are also known as antineoplastic medications and require special handling when being prepared, administered, and discontinued. Institution protocols dictate requirements for personal protective equipment (PPE) that must be worn and certain cleanup techniques for spills, for example. These medications are marked with a bright yellow sticker to alert the nurse about the hazardous nature of the drug.

Teaching is unique to the drug regimen used in the patient’s therapy. In general, chemotherapy destroys any rapidly dividing cells in the body, including blood cells and cells that make up the mucosal lining of the mouth and entire gastrointestinal tract. However, each class of chemotherapeutic medication has its own adverse effect profile. The unwanted effects of therapy are often severe, and the nurse is often responsible for interdisciplinary coordination to aggressively manage the unwanted effects.

Many therapy regimens begin with a course of pre-administration medications to prevent or reduce common side effects. To prevent or reduce nausea, medications such as lorazepam (a benzodiazepine) and ondansetron (a serotonin receptor antagonist) may be given. Chemotherapy is known for causing chills or fever, so one or more antihistamines may be used prior to each dose of the medication. The nurse also monitors the patient during intravenous chemotherapy infusions for any reactions.

Immunotherapy

A type of treatment that helps the immune system fight cancer is called immunotherapy. Immunotherapy enhances the ability of the immune system to recognize and destroy cancer cells. Common antitumor agents are listed in Table 31.6. The most essential nursing care for the patient receiving immunotherapy is often observing for flu-like reactions during intravenous infusions. Immune-mediated therapy induces the body’s immune system to destroy cancer cells, leading to a high risk of a hypersensitivity reaction. Typical reactions can include urticaria, hypotension, angioedema, bronchospasm, rigors (sudden feeling of cold with severe shivering, and a sharp rise in body temperature), and body aches. Reactions can occur regardless of how often the patient has received this drug in the past. The protocol for administration of immunotherapy should include pre-administration medications, beginning infusion rates to test the patient’s tolerance, and administration of medications such as intravenous steroids if certain reaction parameters are met.