NURSING MANAGEMENT OF PHYSIOLOGICAL CONDITIONS AND

SYMPTOMS OF CANCER PATIENT

EFFECTS OF CANCER ON NUTRITIONAL STATUS AND

ITS CONSEQUENCES: ANEMIA:

DEFINITION—symptom of abnormally low red blood cells (RBCs), quality of hemoglobin (Hgb), and / or volume of packed cells (WHO)

RISK FACTORS

Disease related Slow or persistent blood loss causing

decreased RBC volume Primary malignancies of the marrow, tumor

invasion of the marrow, or genetically transmitted RBC deficiencies (thalassemias) causing decreased quantity / quality of RBC production.

Impaired absorption (post-gastrectomy, celiac disease), inadequate intake (cachexia, alcoholism(, or decreased utilization of iron, folic acid, vitamin K, or vitamin B1; causing decreased maturity and function of RBCs

Autoimmune disorders associated with malignancy

Conditions that lead to decreased erythropoietin (EPO) production, decreased sensitivity to EPO, or a reduction in erythrocyte progenitor cells, such as acute or chronic renal disease, hemolysis

TREATMENT RELATED Chemotherapy—destruction of rapidly dividing

normal hematopoietic cells results in decreased production of RBC precursors and mature RBCs.

Radio Therapy—destruction of RBC precursors in the radiation field.

Pharmacologic agents—inhibit RBC production or cause decreased mineral and vitamin levels (oral contraceptives, estrogen, phenytoin (Dilantin), phenobarbital (Luminal).

MEDICAL MANAGEMENT Once the diagnosis is established; underlying

cause must be identified and, if possible, corrected.

Supplements such as iron, vitamins, folic acid. RBC transfusions are indicated for the

following: Symptomatic anemia (dyspnea, tachycardia)

occurs, regardless of the hematocrit. Client is actively bleeding. Haemoglobin level drops below 8 g / dl

NURSING MANAGEMENT:

History Physical findings Diagnostic tests and findings

Nursing Considerations

Educate the client and the family regarding:- Purpose, dosage, side-effects, toxic effects of the

medication Nutrition- Counsel regarding various iron rich

diets and supplements Activity, frequency and rest periods can be

determined Sign and symptoms regarding complication like

change in mental status, increases shortness in breath, onset of active bleeding

Monitor client for complications related to anaemia

Assess skin for inadequate oxygenation, such as pallor, decreased capillary refill etc

Assess B.P in lying, sitting and standing position for orthostatic hypotension

Monitor occurrence of constipation or diarrhoea related to iron supplements

Assist in activities of daily living in case of severe anaemia

CACHEXIA

Cachexia is a complex mix of symptoms comprising the following:

Anaemia Anorexia Organ dysfunction Reduced appetite and feeling full Wasting of muscles Weakness Weight loss.

CAUSES OF CACHEXIA

Decreased nutritional intake: This is probably the most important issue. It

has several causes, including the following: Anorexia dysphagia bowel obstruction resulting in decreased

nutritional intake malabsorption

Increased nutritional losses: Blood loss. Diarrhoea and protein loss via the intestines.

Metabolic changes: Abnormal metabolism mimicking insulin

resistance with increased energy Expenditure unrelated to the extent of disease. Altered carbohydrate metabolism. Altered lipid metabolism

Poor appetite or poor eating habits: Psychological problems, including

depression, resulting in failure to look after oneself

Treatment side-effects:

-Chemotherapy may be associated with nausea, vomiting or mucositis, thus reducing food intake

-Radiotherapy can cause anorexia, nausea, vomiting, diarrhoea and a dry or sore mouth

CLINICAL MANIFESTATIONS

The main symptoms of wasting syndrome are its defining factors, the loss of weight from muscle and fat deterioration. Secondary symptoms include:

Diarrhoea or vomiting lasting for 30 days or more

Progressive weakness over a 30 day period A fever lasting for several days Loss of appetite or anorexia

Loss of muscle bulk Dry and scaly skin Mouth to see whether there is stomatitis,

cheilosis or glossitis Pitting oedema

DIAGNOSIS OF CACHEXIA

By collection history: Find out how much weight has been lost

in the previous 3 months. A loss of 10% or more of body weight constitutes malnutrition.

Ask about possible reasons for poor food intake and, if necessary, use the assessment tool .

Look at the skin to see whether it is dry and scaly.

Look at the mouth to see whether there is stomatitis, cheilosis or glossitis, indicating iron and vitamin deficiencies.

Assess muscle bulk and muscle strength. Look for pitting oedema.

MANAGEMENT OF CACHEXIA:

Identification of the amount of muscle wasting by use of BIA test or a track a patient's BMI, body mass index, to watch for sudden, pronounced weight loss

Ask the dietitian about food supplements, speak to the occupational therapist about ways to make daily life easier, and arrange appropriate physiotherapy.

Steroids may stimulate the appetite but they do not increase muscle mass.

XEROSTOMIA

DEFINITION:

Xerostomia a subjective sensation of dryness in the mouth characterised by a decrease in composition and physical properties in the quality and quantity of saliva

 ETIOLOGY

A dry and sore mouth is most commonly due to Candida infection, which occurs in about 10–15% of patients with cancer at almost any stage of the illness.

Concurrent disease (e.g. uncontrolled diabetes). Drugs – anticholinergics, antihistamines,

anticonvulsants, beta-blockers, diuretics, opioids or steroids (which predispose to candida infection).

Hypercalcaemia.

Inadequate fluid intake causing dehydration. Malnutrition (e.g. anaemia, protein deficiency or

vitamin deficiency). Mouth breathing, either by day due to debility or

when asleep. Mucositis secondary to chemotherapy. Oral infection (e.g. candida). Oxygen therapy. Radiotherapy to the head and neck causing

diminution of salivary secretion.

MEDICAL MANAGEMENT

Artificial salivary lubricants Surgical interventions- salivary reservoirs

and reconstruction with a mandibular denture

Dental prophylaxis with before, during and post radiation treatment

NURSING MANAGEMENT

Assess the proper history of the client Physical examination The patient and their family can be instructed

in the following measures. Artificial saliva Bicarbonate of soda mouthwashes Chilled fruit Moistening the mouth Sparkling water

DYSPHAGIA

DEFINITION—it is the difficulty in swallowing, pain; usually accompanied by a sensation of material lodging in the esophagus

ETIOLOGY, AND RISK FACTORS

Neurologic impairment Tumour infiltration and impingement of the

esophagus and mouth by tumor and/ or treatment—related effects.

Iatrogenic factors.

1. Psychotropic medications that impair gag reflex and swallowing.

2. Anticholinergic drugs. Lifestyle-related effects

CLINICAL MANIFESTATION OF PROGRESSION OF DYSPHAGIA

Usually insidious and slowly progressive, observe for presence of facial droop, drooling, oral retention, choking, coughing after swallowing, and gurgling voice quality, ability to masticate, hold food in mouth, and propel food to oropharynx using tongue

Usually manifested as difficulty swallowing solids progressing to difficulty in swallowing liquids, including saliva, causing fluids and foods to flow into the lungs, increasing the risk for aspiration and/ or pneumonia.

Usually associated with weight loss, anorexia, nausea, dehydration, protein- calorie malnutrition, cachexia, muscle wasting, and negative nitrogen wasting.

MEDICAL MANAGEMENT

Treatment for underlying disease—nodal radiation, laser surgery antifungal and antibiotic medications.

Endoscopic laser therapy Alternate method for feeding, which may

require short or long-term interventions

Use of thickening agents (e.g., Thick-It, Nutra-Thik, Thick’N Easy) to lessen the risk for flow of liquids into the airway causing choking and aspiration. .

Medications—steroids, expectorants, bronchodilators, pain and anxiety medications to relieve symptoms related to dysphagia.

Swallowing therapy and /or direct swallowing exercise

NURSING MANAGEMENT

Collect the proper history of the client. Previous treatments for cancer. Presence of underlying systemic disease—

infection, cardiac, or stroke. Patterns of dysphagia—incidence; pattern;

alleviating, aggravating, and precipitating factors.

Observe the client for: Observe for presence of facial droop, drooling,

oral retention, choking, coughing after swallowing, and gurgling voice quality.

Determine. ability to masticate, hold food in mouth, and propel food to oropharynx using tongue.

Elicit client's subjective report of pain or discomfort; weakness of lips, tongue, or jaw; "lump in the throat."

Interventions to monitor complications related to dysphagia Maintain daily intake and output chart Weigh daily or at least every other day if daily

weights upset client. Assess for signs and symptoms-—dehydration,

aspiration, increased / decreased secretions Explore the need for alternative methods for

providing nutrition.

Interventions to involve client / family in care Determine willingness of significant

other to assist with care. Teach client/ family all aspects of care,

including emergency measures, pulmonary hygiene, oral hygiene, and appropriate time to report complications to a member of the health care team

Interventions to enhance adaptation Provide ongoing support to client in a situation that

may potentially cause fear, anxiety and inability to cope.

Provide detailed written and / or audiovisual materials.

Initiate early referral to speech therapist and dietitian for nutritional advice and suggestions.

Explore patient’s awareness of and / or use of complementary/ alternative medicine (CAM), such as mind/ body control interventions, homeopathy, acupuncture, and vitamins or herbal products

Nursing Diagnoses

Impaired swallowing Risk for aspiration Disturbed sensory perception: gustatory

NAUSEA AND VOMITING

DEFINITION A highly subjective, unobservable

phenomenon of an unpleasant sensation experienced in the back of the throat and the epigastrium that may or may not culminate in vomiting. One of the most feared side effects of cancer treatment (Finley; 2000).

ETIOLOGY AND RISK FACTORS

Disease related Primary or metastatic tumor of the CNS that

includes the VC, or increased intracranial pressure

Delayed gastric emptying Obstruction of a portion of the GI tract. Food toxins, infection, or motion sickness

Treatment related Stimulation of the receptors of the labyrinth

in the inner ear. Obstruction, irritation, inflammation, and

delayed gastric emptying stimulating the Gl tract through vagal visceral afferent pathways.

Stimulation of the VC through mucosal injury causing release of serotonin associated with chemotherapy

Stimulation of the Vomiting center (VC) through afferent pathways

Side effects of medications, such as digitalis, morphine, antibiotics, iron, vitamins, and antineoplastic agents.

Side effects of concentrated nutritional supplements

Situational Younger age; increased incidence in those less

than 50 years Experienced by females more than males Increased levels of stress, emotions, and/ or

anxiety Noxious odors or visual stimuli. Conditioned (anticipatory) responses to

previous cancer treatment and / or other stressful experiences. Occurs in 25% of chemotherapy patients.

MEDICAL MANAGEMENT

Treatment of underlying disease.

Antiemetic therapy Serotonin antagonists (e.g.,

ondansetron)ne receptor antagonists, such as metoclopramide (Reglan), haloperidol (Haldol), droperidol (lnapsine).

Phenothiazines, such as prochlorperazine Corticosteroids, such as dexamethasone Benzodiazepines, such as lorazepam.

Non-pharmacologic interventions

Relaxation and distraction techniques, including guided imagery and music therapy

Acupressure may decrease symptom experience and / or intensity of nausea

Acupuncture Hypnosis—It is found a complete response to

anticipatory nausea and a major response to chemotherapy—induced nausea.

Foot massage—It is found that foot massage had a significant impact on reducing feelings of nausea.

Deep breathing Exposure to fresh air and elimination of odors Herbal supplements—ginger (dried or fresh)

has been known to have an effect on decreasing nausea associated with chemotherapy (

Aromatherapy—the use of scented candles, essential oils, and sachets is currently being researched

NURSING MANAGEMENT

Assessment the client for: Presence of risk factors for nausea, including a

history of motion sickness or pregnancy-induced nausea

Presence of defining characteristics of nausea. Present symptoms, client’s perception of

possible correlation between occurrence of nausea and distress; and perceived meaning of nausea to the client and family work, role responsibilities, and mood.

Patterns of nausea—onset, frequency associated symptoms, precipitating factors, aggravating factors, and alleviating factors. Assess client’s previous experiences with nausea

II. Physical examination. Signs of sweating, tachycardia, dizziness, pallor,

excessive salivation, and weakness. Laboratory reports to assess for other causes—

serum electrolytes, liver and renal function tests. Weight.

III. Psychosocial assessment. Explore anxiety producing events and

coping abilities. Attempt to identify strengths of client /

family

Nursing Diagnosis

Altered nutrition: less than body requirement

Risk for fluid volume deficit

CONSTIPATION

DEFINITION Constipation is difficulty passing stools or a

decrease in number of stools. It may be accompanied by gas, abdominal cramping or pressure in the lower abdomen. Constipation may lead to stool impaction, a severe form of constipation where the stool will no longer pass through the colon or rectum.

CAUSES

Constipation is caused by a slowing of the intestinal activity. The normal wave-like action of the intestines, called peristalsis, serves to continually move stools out of the body. When peristalsis slows, the stools become hard, dry and difficult to pass.

Constipation can have a number of causes including: Pain medications Chemotherapy drugs

Decreased activity Poor diet Inadequate fluid intake

Chemotherapy drugs can cause either an increase or decrease in peristalsis. An increase in intestinal activity may cause stools to travel faster and be less formed, resulting in cramping and/or diarrhoea. A decrease in intestinal activity may cause stool to travel slower, becoming hard and dry and more difficult to pass, which is constipation.

There are many possible causes of constipation, which fall into

the following categories Bowel obstruction Dehydration Decreased fluid intake or increased losses due to

vomiting or excessive sweating. Disease related to:-

- Decreased appetite and low residue intake due to anorexia.

- Immobility

Drugs

- Anticholinergics.

- Diuretics.

- Granisetron and ondansetron.

- Hyoscine, phenothiazines or tricyclic antidepressants.

- Octreotide.

- Opioids – were they prescribed without a laxative?

Immobility and weakness Various conditions make it difficult to

achieve the necessary increase in intraabdominal pressure for evacuation. These include the following:

-decreased peristalsis associated with immobility and general debility of cancer

Other causes

-Embarrassment about sharing a toilet.

- Inability to get to the toilet unaided.

-Pain on defaecation due to local problem such as haemorrhoids or anal fissure.

CLINICAL MANIFESTATIONS:

A sustained change in frequency of bowel movements from your normal. If the normally bowel movement is once per day, a change may be every 2nd or 3rd day.

Hard, difficult to pass bowel movements or passage of small, marble-like pieces of stool without a satisfactory elimination

Cramping and/or flatulence (gas). Bowel obstruction Confusion and restlessness Faecal incontinence Retention of urine.

MANAGEMENTOF CONSTIPATION

Non-pharmacological management

• Assess bowel function regularly.

• Fibre and fruit intake should be increased if possible.

• Fluid intake should be increased if possible.

• Mobility should be encouraged.

Pharmacological management

• Always prescribe prophylactic laxatives when starting opioids or increasing the dose.

• Use a combination of a stimulant laxative and a faecal softener.

• The amounts of softener and stimulant should be adjusted to suit the individual

Laxatives basically fall into the following categories:

• bulking agents

• faecal softeners

• osmotic agents

• stimulants

• suppositories and enemas

Bulking agents Faecal softener Osmotic agents Stimulants Suppositories and enemas

NURSING MANAGEMENT

Assess the history of the client to find out the needs of the client and the relatives

-Presence of risk factors

-History of defining characteristics of constipation

-Changes in usual pattern of bowel elimination such as decreased frequency, hard stools, abdominal cramping, increased use of laxatives

Date of last bowel movement. Change in factors contributing to bowel

elimination, such as activity level, fluid intake, dietary fibre intake, and/ or laxative use.

History of constipation and/ or chronic laxative use.

Anxiety regarding bowel patterns. Perception of incomplete evacuation following

defecation. Rectal pain associated with inability to defecate.

Pattern of occurrence of constipation- onset; frequency; severity associated symptoms; precipitating, aggravating, and alleviating factors.

Perceived effectiveness of self- are measures to relieve constipation.

Perceived impact of constipation on comfort, activities of daily living, mood.

History of rectal fissures or abscesses.

Physical findings.

A. Inspection of abdomen. 1. Symmetry. 2. Contour. 3. Distension. 4. Bulges. 5. Peristaltic waves.

Auscultation of character, frequency and presence or absence of bowel sounds in the four quadrants of the abdomen.

Palpation of abdomen. 1. Masses or stool in the colon. 2. Areas of increased resistance or

tenderness. Rectal examination to check for fecal

impaction, hemorrhoids, or fissures

Nursing Diagnosis

DIARRHOEA

DEFINITION: Diarrhoea refers to the passage of more than

three unformed stools in 24 hours. It is important to check what the patient means when they refer to ‘diarrhoea.’ Diarrhoea is less common than constipation among cancer patients.

CAUSES OF DIARRHOEA Osmotic Diarrhoea Surgery Secretary Inflammatory damage Infectious diarrhoea Chemotherapy induced Bone marrow transplantation–related Diet Psychological factors

CLINICAL CLASSIFICATION OF DIARRHOEA

MANAGEMENT OF DIARRHOEA

Antibiotics Faecal impaction Ileal resection Intestinal disease (Crohn’s or ulcerative

colitis)

Sulfasalazine or steroids should be used. Laxatives Malabsorption and steatorrhoea

NURSING MANAGEMENT

Assessment: History Review of previous and current treatment of

cancer Review of prescription and nonpescription

medications Usual bowel pattern- frequency, colour, odour,

consistency of stool

Recent changes in factors contributing to usual bowel elimination patterns

1. Increased levels of stress.

2. Dietary changes that increase bowel motility such as addiuon of tiber and roughage, fruit juices, coffee, alcohol, fried foods, or fatty foods

3. Recent course of antibiotic therapy. Known food or medication intolerance or

allergies. Presence of flatus, cramping, abdominal pain,

urgency to defecate, recent weight loss. Fluid intake.

National Cancer Institute Grading Criteria.

Grade 1: increase of fewer than 4 stools / day over pretreatment.

Grade 2: increase of 4 to 6 stools / day or nocturnal stools.

Grade 3: increase of 7 or more stools / day or incontinence or need for parenteral support for dehydration interfering with normal activity.

Grade 4: physiologic consequences requiring intensive care; hemodynamic collapse

HYPERCALCAEMIA

DEFINITION Hypercalcaemia is defined as a

corrected serum calcium concentration above 2.6 mmol/litre (10-12mg/dl). Levels above 4.0 mmol/litre will cause death in a few days.

SYMPTOMS

• Constipation

• Drowsiness, progressing to coma

• Muscle weakness

• Nausea and vomiting

• Polyuria

• Thirst

• Tiredness.

MANAGEMENTASSESSMENT

1. Ask about the following: constipation muscle weakness nausea and vomiting polyuria thirst tiredness.

Assess the following:

• confusion

• dehydration, a major feature of hypercalcaemia due to polyuria and vomiting

• drowsiness.

Check the following:

• corrected serum calcium concentration

• urea and electrolytes

• ECG

• corrected calcium levels

• urea and electrolytes in order to detect hypokalaemia and hyponatraemia

4. The drugs fall into four categories

Bisphosphonates Calcitonin Plicamycin Steroids

Nursing diagnosis

Fluid electrolyte imbalance

TASTE DISTURBANCES

Metallic taste: It may be due to decreased sensitivity of taste buds, decreased number of taste buds, toxic dysfunction of taste buds, nutritional deficiencies or poor dental hygiene. Patient should be advised to reduce urea content of diet; to eat white meats, eggs, dairy products; to drink more liquids; to eat cold food; and to have fresh fruits and vegetables

IMPAIRED MOBILITY

DECUBITUS ULCER

DEFINITION:

‘An area of localised damage to the skin and underlying tissue caused by pressure, shear or friction, or a combination of these’

CAUSES AND RISK FACTORS

Pathogenesis of pressure ulcers There are four main factors that

contribute to the development of pressure ulcers:

• Friction

• Moisture

• Pressure

• shear.

Friction Moisture Pressure

Consider the other factors that might be putting your patient at risk of a pressure ulcer. These include the following:

Anaemia Cachexia Dressings, clothing or bandages causing

abrasion

Hypoproteinaemia causing interstitial oedema Immobility of any part due to any cause Immunosuppressant, which increases the risk

of infection Malnutrition and vitamin C or zinc deficiency,

which impair wound healing Neurological deficit (e.g. diabetes) Restraints or rails that could cause injury or

pressure Vascular insufficiency Wet skin.

NURSING MANAGEMENT

Decubitis ulcers can be prevention, if possible, is the aim. There are four main areas to look at:

• General measures

• Nutrition

• Pressure redistribution

• Skin care.

PATHOLOGIC FRACTURES

DEFINITION:

A pathologic fracture occurs when a bone breaks in an area that is weakened by another disease process.

CAUSES: Tumors

Primary E.G MULTIPLE MYELOMA, PAGETS DISEASE

secondary (metastatic) (most common) Benign Tumors Fractures more common in benign tumors (vs

malignant tumors) most asymptomatic prior to fracture Fibroxanthoma

most common in childrenhumerus femur

bone cyst, NOF, fibrous dysplasia, eosinophilic granuloma

MEDICAL MANAGEMENT

Bone Cyst aspiration and injection methylprednisolone,

bone marrow or bone graft curetting and bone graft (+/-) internal

fixation allow fracture to heal and reassess ORIF for femoral neck fractures

Fibroxanthoma (Femur, distal tibia, humerus Multiple in 8% of patients (associated with neurofibromatosis): curetting and bone graft for impending

fractures immobilization and reassess after healing

for patients with fracture

Fibrous Dysplasia curetting and bone graft (cortical

structural allograft) to prevent deformity and fracture (+/-) internal fixation

expect resorption of graft and recurrence

pharmacologic—bisphosphonates

Primary Malignant Tumors: Immobilization: Traction, ex fix, cast staging biopsy adjuvant treatment (chemotherapy) resection/amputation

NURSING MANAGEMENT

Assess the cause of the problem Provide adequate skin care to avoid skin

redness and ulceration Provide adequate foods rich in calcium and

proteins Provide proper immobilization of the affected

extremity Give psychological support

THROMBOPHLEBITIS

Thrombophlebitis is an inflammation of a vein (phlebitis) accompanied by an increased tendency to form blood clots (hypercoagulability), which leads to the formation of a blood clot (thrombus) in the vein. It can develop spontaneously or can be a complication of an injury, a disease, or a medical or surgical treatment

ETIOLOGY AND RISK FACTORS

Varicose veins Obesity Age older than 60 years (fewer complications

in this age group) Cigarette smoking Caustic materials, such as lighter fluid and

street drugs, injected intravenously

Hypercoagulable states Risk factors for superficial

thrombophlebitis include an increased blood clotting tendency, infection in or near a vein, current or recent pregnancy, varicose veins, and chemical irritation, or other local irritation or trauma.

NURSING CONSIDERATIONS

Assessment History Physical exam Diagnostic Tests

MEDICAL MANAGEMENT

The goals of treatment for with superficial thrombophlebitis are to increase comfort and to prevent progression to DVT. Non-steroidal anti-inflammatory drugs (NSAIDs) usually will reverse the inflammation characteristic of superficial thrombophlebitis and help relieve pain. Anticoagulants (e.g., warfarin) may be used to prevent new clot formation.

Compression stockings Surgical intervention including clot

removal (thrombectomy), vein stripping, or vein bypass is rarely needed in superficial thrombophlebitis but may be considered if anticoagulant therapy is ineffective.

DVT requires anticoagulant therapy as soon as possible after diagnosis is confirmed. Low-molecular-weight heparin (LMW heparin) is used immediately to prevent thrombus extension and often can reduce the risk of thrombus formation and embolus migration. \

Thrombolytic therapy may be given in those with DVT to dissolve the original clot and prevent pulmonary embolism

PULMONARY EMBOLISM

DEFINITION: A pulmonary embolus is a blockage of an

artery in the lungs by fat, air, a blood clot, or tumor cells.

CAUSES

A pulmonary embolus is most often caused by a blood clot in a vein, especially a vein in the leg or in the pelvis (hip area). The most common cause is a blood clot in one of the deep veins of the thighs.

Risk factors for a pulmonary embolus include

Burns Cancer Childbirth Family history of blood clots Fractures of the hips or thigh bone Heart attack Heart surgery

Long-term bed rest or staying in one position for a long time, such as a long plane or car ride

Severe injury Stroke Surgery (especially orthopaedic or

neurological surgery) Use of birth control pills or estrogen

therapy

CLINICAL MANIFESTATIONS

Chest pain Under the breastbone or on one side May feel sharp or stabbing May also be described as a burning, aching, or

dull, heavy sensation May get worse with deep breathing, coughing,

eating, or bending One may bend over or hold your chest in

response to the pain

Sudden cough, possibly coughing up blood or bloody mucus

Rapid breathing Rapid heart rate Shortness of breath that starts suddenly

Other symptoms that may occur: Anxiety Bluish skin discoloration (cyanosis) Clammy skin Dizziness Leg pain, redness, and swelling Lightheadedness or fainting Low blood pressure Sweating Wheezing

MANAGEMENT

Hospitalization and O2 is necessary Thrombolytic therapy. Clot-dissolving

medications include:

-Streptokinase

-T-plasminogen activator (t-PA) Anticoagulation therapy.

-The most common blood thinners are heparin and warfarin

CONTRACTURES

DEFINITION: Contractures are the chronic loss of joint

motion due to structural changes in non-bony tissue. These non-bony tissues include muscles, ligaments, and tendons.

CAUSES

Inherited disorders (such as muscular dystrophy)

Injury (including burns) Nerve damage Reduced use (for example, from

immobilization)

MANAGEMENT

Medication/clinical Check range of motion (ROM)—move limbs gently. Give diazepam if spasms or very spastic. Check ROM in the key 7 joints on both sides: Wrist, knee, elbow, ankle, shoulder

Home care

Encourage mobilization. If patient is immobile, do simple range of motion exercises:

- Exercise limbs and joints at least twice

daily—use booklet to show caregiver how

to do ROM on each of the key 7 joints (on both sides).

Protect the joint by holding the limb above and below it and support as much as you can.

Bend, straighten, and move joints as far as they normally go; be gentle and move slowly without causing pain.

Stretch joints by holding as before but with firm steady pressure.

Let the patient do it as far as they can and help the rest of the way.

Massage.

Exercises to Help Prevent Pain Stiffness and Contractures

FOOT DROP

DEFINITION Foot Drop - also known as drop foot - is a

problem where a person has difficulty in lifting the front part of the foot. With Foot Drop, a patient is unable to lift the toes upwards, or towards the shin.

CAUSES:

Drug Complications Nerve or Muscle Damage Central Nervous System Disorders

CLINICAL MANIFESTATIONS

Often, the only symptom a person may experience with Foot Drop is the inability to lift the front part of the foot.

In typical cases - Foot Drop only affects one foot, though it is possible for both feet to be affected depending on the condition that is causing it to occur

The main signs that a person may be experiencing Foot Drop are a change in gait. Because you are unable to lift the toes, the toes may drag along the ground when walking.

A steppage gait is not only noticeable by the exaggerated motion of the leg in use, but by the sound the foot makes during the gait.

NURSING MANAGEMENT

Physical Therapy Nerve stimulation Use of Accessories and Devices that can help

with Foot Drop like  Blanket Lifters Splints and Braces Foot Positioners, Stabilizers, and Elevators Foot Lifters

DYSPEPSIA

DEFINITION

Dyspepsia is a term which includes a group of symptoms that come from a problem in your upper gut. The gut or 'gastrointestinal tract' is the tube that starts at the mouth, and ends at the anus. The upper gut includes the oesophagus, stomach, and duodenum.

CAUSES Gastro Esophageal reflux disease (GERD),

Chronic gastritis and Chronic peptic ulcer Alcoholic drinks and Spicy foods Chronic infections with Helicobacter pylori

bacteria Obesity Some medicines such as aspirin Cancer e.g. Esophageal tumor. Improper chewing of food Abnormality in pancreas or bile ducts

SIGNS AND SYMPTOMS

Feeling of fullness during a meal. Chronic mild to severe pain. Chronic burning or an unpleasant

sensation of heat (heart burn). Other chronic signs and symptoms of

indigestion are nausea and bloating are noted

Belching

NURSING MANAGEMENT

Advise clients to take the following care Emphasize on antacids taken as required

or pescribed: Antacids are alkali liquids or tablets that can neutralise the stomach acid. A dose may give quick relief. Sucralfate and H2 receptor antagonsist, H+ pump inhibitors anre used to control symptoms.

Advise for test for H. pylori infection and treat if it is present.

For dyspepsia which is likely to be due to acid reflux - when heartburn is a major symptom - the following may also be worth considering

Posture Bedtime

HICCUP

Hiccups are caused by spasms of the diaphragm leading to a sudden intake of breath, which is cut off when the vocal cords close quickly, causing the characteristic sound which gives rise to their onomatopoeic name.

CAUSES Diaphragmatic spasm due to

diaphragmatic irritation results in hiccups. The diaphragmatic irritation is often caused by gastric distension or liver enlargement, the diaphragmatic irritation being stimulated by involvement of two main nerve pathways, namely the vagus nerve and the phrenic nerve.

Drugs

• Barbiturates.

• Benzodiazepines.

• Steroids Stimulation of the phrenic nerve

• Brain tumours, especially brainstem.

• Diaphragmatic tumour invasion.

• Mediastinal tumour.

• Meningeal infiltration by tumour deposits

Stimulation of the vagus nerve

• Abdominal distension (e.g. ascites).

• Distended stomach.

• Gastro-oesophageal reflux.

• Liver tumours. Systemic causes

• Addison’s disease.

• Hyponatraemia.

• Kidney failure.

MANAGEMENT

Assessment of the client: How long has the patient been hiccupping? Did the hiccup start following any recent

change in medication? Do the hiccups stop at night? Psychogenic

hiccups stop during sleep. Has there been any new psychological problem?

Has the patient had a stroke?

Treatment of hiccups: Treatment of hiccup can be unsuccessful,

and no single treatment can be guaranteed.

Stop any drugs that could be responsible (e.g. steroids).

• Pharyngeal stimulation

• Breath-holding or rebreathing into a paper bag. As the PCO2 rises, hiccup should decrease, but it may restart after resuming normal breathing.

• Dry granulated sugar to eat.

• Iced water to sip, or crushed ice to eat.

Pharmacological treatments Gastric distension

• Domperidone 10–20 mg four times daily or

• Metoclopramide 10 mg four times daily. Both of these drugs are pro-kinetics and

may promote gastric emptying

Smooth muscle relaxation

• Baclofen 5 mg three times daily or

• Nifedipine 5 mg as required or three times daily.

Suppression of the hiccup reflex

• Chlorpromazine 25 mg.

Suppression of intracranial tumour CNS irritation

• Dexamethasone, starting with 16 mg daily or

• Phenytoin 200–300 mg at night. Steroids can cause hiccups, so be aware

of this when considering this treatment option.

DYSPNOEA

DEFINITION: Dysponea is one of the most common and

distressing symptoms occurring in the clients admitted to the hospice center with advanced cancer

CAUSES

Primary diagnosis, that is, lung cancer. Secondary diagnosis, that is, pleural

effusion or metastasis to the lungs. Treatment for the primary disease, that is,

as anemia secondary to chemotherapy

Dying clients may experience dyspnea in the absence of hypoxia or lung disease because of progressive muscle weakness from cachexia, malnutrition etc.

The role of oxygen therapy in nonhypoxic, dyspneic cancer clients is uncertain, but it may increase comfort and a trial of oxygen should be used for each client

MANAGEMENT

Assessment

I. Ask client about presence of feelings of breathlessness or shortness of breath with activities

II. Consider the use of a visual analogue scale to measure intensity of dyspnea

III. Assess respiratory status

Nursing Diagnosis

Activity intolerance

Impaired gas exchange

BOWEL OBSTRUCTION DEFINITION: Narrowing of the

intestinal lumen or interference with peristalsis.

CAUSES:

A. Mechanical obstruction—occurs in small intestines and accounts for 90% of all obstructions

Extrinsic lesions

Intrinsic lesions

Non-mechanical obstruction Intra abdominal Extra abdominal

MEDICAL MANAGEMENT

Surgery Abdominal decompression Correction of fluid and electrolyte

imbalances Parenteral nutrition

NURSING CONSIDERATION

Assessment

Planning and Implementation

FUNGATING WOUNDS

The presence of a wound that refuses to heal is something that patients simply cannot ignore. The discharge, bleeding, pain and the need to have regular dressings all act as reminders of the advancing disease.

DEFINITION: Many cancer patients live with the knowledge

that their disease is both progressive and incurable. For a significant minority of these people this reality may be present in the form of a malodorous, exuding, necrotic skin lesion, which can be a constant physical reminder of disease progression. These lesions are commonly known as 'fungating wounds', the term 'fungating' referring to a malignant process of both ulcerating and proliferative growth.

CAUSES

A. Fungating wound may develop in the following ways:

As a result of a primary skin tumour such as squamous cell carcinoma or melanoma

Through direct invasion of the structures of the skin by an underlying tumour, for example breast cancer or haematological malignancy such as cutaneous T-cell lymphoma.

From metastatic spread of a distant tumour. Metastasis may occur along tissue planes, capillaries or lymph vessels

CLINICAL MANIFESTATION

Malodour Exudate Pain Bleeding

MANAGEMENT

Malodour

Debridement removes necrotic tissue and bacteria and is the primary treatment for malodorous fungating wounds.

Antibiotic therapy can also be effective if this destroys the bacteria responsible for malodour, the most common treatment being metronidazole

The use of activated charcoal dressings can have an immediate effect on wound malodour.

Sugar paste and honey have recently come back into use, mainly due to the emergence of many antibiotic resistant strains of bacteria, and both have antibacterial and debriding properties.

Exudate

A variety of dressings have been evaluated for the management of exudate from fungating wounds with varying levels of success.

Where exudate is low, wounds should be managed with dressings that have a low absorbency so as not to dry out the wound, for example hydrocolloids, semi-permeable films and low adherent absorbent dressings.

Pain

Assessment of pain is vital as this will enable the clinician to understand the type of pain the patient is experiencing and determine the most appropriate treatment

It may also be useful to give the patient a pre-medication before dressing changes or a booster dose of their usual opiate is given

If pain cannot be controlled at dressing changes then it may be worth trying a product that requires less frequent changes

Topical opioids are an interesting alternative form of pain control that can be used for painful ulcerating wounds

Morphine and diamorphine are most commonly used, mixed with a hydrogel (about 1 mg of morphine to 1 g of hydrogel for 0.08 to 0.1% mixture).

Bleeding

Preventative measures are important to reduce the risk of bleeding

Oral antifibrinolytics such as tranexamic acid may also help.

For wounds that are actively bleeding, there are a number of strategies available. Sucralfate paste or an alginate may be applied to wounds with a small amount of bleeding.

ANXIETY & DEPRESSION

Three areas of concern in the category of psychologic distress include depression, anxiety and neurocognitive changes .

Clients at the end of life may experience anxiety related to uncertain future, separation from loved ones, burden on family and loss of control.

NURSING CONSIDERATIONS

Assessment I. Recognize evidence of depression, such

as hopelessness, helplessness, worthlessness, guilt, and sustained suicidal ideation

II. Assess for anxiety

Nursing Diagnosis

Anxiety. Risk for suicide.

INSOMNIA

Many patients in palliative care settings complain of tiredness and fatigue, and many attribute this to poor sleep. They may experience difficulty in getting to sleep, difficulty in staying asleep, wakening early, waking normally but still feeling tired, or a combination of these

SYMPTOMS

• Irritability

• Loss of will due to exhaustion, resulting in inability to cope

• Lowered pain threshold, resulting in worsening of pain which interferes with sleep, and the lack of sleep further reduces the pain threshold

• Tiredness and reduced activity, which increases the risk of pressure ulcers.

 

MANAGEMENTAssessment Find out why the patient is not sleeping.

Possible causes include the following:

• Breathing difficulty, especially when lying down

• Delirium, with a disturbed body rhythm, Depression, Fear (e.g. of dying while asleep), Itch, Nausea and vomiting, Nightmares

NURSING CONSIDERATION

Use of General and non-pharmacological measures

Let patients try the following simple measures to see whether they help:

• bathing in order to relax before going to bed

• massage or aromatherapy to aid relaxation

• music to aid relaxation and sleep

• progressive muscle relaxation

• warm milk or a carbohydrate snack at bedtime.