Pain Management

1
Pain Management
2
Safety, Security and Comfort Needs of the Acutely
Ill Client

• PAIN
• The 5th Vital Sign

3
Definitions of Pain

• Pain is whatever the experiencing person says it
  is, existing whenever he/she says it does. -Mc
  Caffery 1968
• An unpleasant sensory and emotional experience
  associated with actual or potential tissue damage
  or described in terms of such damage. - Intl.
  Assoc. for the study of pain

4

• Only 30 of cancer patients get adequate pain
  relief
• 15-20 of Americans have acute pain
• 25-30 of Americans have chronic pain
• Leading cause disability for those lt 45 y/o

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The Mechanisms of Pain

• Transduction
• Transmission
• Perception
• Modulation

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The Mechanisms of Pain

• Transduction-
• Conversion of mechanical, thermal or chemical
  stimulus into a neuronal action.
• Peripheral nerve sites- peripheral afferent
  nociceptor (PAN)
• Action Potential causes movement of pain stimulus
  What causes it?
• Nociceptive- Release of Chemicals
• Neuropathic- Abnormal processing of stimuli by
  the nervous system

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The Mechanisms of Pain

• Transmission- movement of pain impulses from the
  site of transduction to the brain.
• Transmission along the nociceptor fibers to the
  level of the spinal cord.
• Dorsal horn processing.
• Transmission to the thalamus and the cortex.

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The Mechanisms of Pain

• Perception- recognition of pain
• However, there is no precise location where pain
  perception occurs.
• Individualized
• Imagery is a good pain-reduction therapy.
• Subjective
• Sensory Recognition that you have pain.
• Affective Emotional responses to pain.
• Behavioral How someone expresses or controls
  pain.
• Cognitive Persons beliefs attitudes about
  pain.
• Sociocultural Age, Gender, education level,
  culture and support systems.

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The Mechanisms of Pain

• Modulation- activation of descending pathways
  that either inhibit or facilitate effects on pain
  transmission.

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Types of Pain

• Nociceptive Pain
• Normal processing of stimuli that damages or has
  the potential to damage, normal tissues if
  prolonged.
• Different types of origins
• Somatic Pain Arises from bone, joint, muscle,
  skin or connective tissue.
• Visceral Pain Arises from visceral organs, such
  as pancreas or stomach.

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Somatic Pain

• Described as achy, stabbing, sharp
• Examples
• Bone pain, fractures
• Muscle tears, sprains
• Joint pain
• Soft tissue injury

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Visceral Pain

• Diffuse and difficult to localize if d/t
  obstruction of hollow viscus
• Sharp, aching when due to injury to other
  visceral structures such as
• Pancreatitis
• Kidney Stones
• Menstrual Cramps
• Bowel Obstruction

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Neuropathic Pain

• Multiple Pain Syndromes
• Often difficult to treat.
• Believed to be the abnormal firing of the
  peripheral or central nervous system.
• Often described as burning, stinging, shooting,
  traveling, or electric-like.
• Caused by phantom limb pain, complex regional
  limb pain complex regional pain syndromes,
  diabetic neuropathy, post-herpetic neuralgia, or
  trigeminal neuralgia

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Acute VS. Chronic Pain

• ACUTE
• Sudden
• Short Duration lt 3 months
• Mild--gt Severe
• Can identify specific cause.
• Predictable prognosis
• Can be single event or recurrent.
• ? as healing progresses.

• CHRONIC
• Continues for more than one month after healing
  or an acute lesion, or
• Recurs over a chronic period of time.
• Pathophysiology may be unclear.
• Unpredictable prognosis
• Is associated with a lesion that is not expected
  to heal.
• Chronic cancer pain or chronic non-malignant pain.

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Sources of Pain
Visceral Pain Muscloskeletal Neuropathic
Generalized pain related to visceral stretch. Described as sharp ache. Usually localized. Described as dull ache. Irritation of verve. Described as burning, sharp, shooting.
Classic referral pain. PT, massage, heat cold helpful. PT helpful.
Responds best to opioids. Some response w/opioids. Adjuvants helpful. NSAIDs/Steroids, muscle relaxers Opioids usually not helpful- only dull the pain. Adjuvants helpful Tricyclic AD, anti-convulsants.
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Acute VS. Chronic Pain Cont

• May be associated with sympathetic hyperactivity
  and anxiety.
• Usually resolves
• Treated with short-acting drugs.

• May be associated with depressed mood, sleep
  disturbance and disability.
• Treated with long-acting drugs and adjuvant
  therapy.

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Pharmacology of Pain Management

• Individualized- Based on the patients medical
  and pain histories.
• Multi-modal- Targets multiple sites of action.
• Optimize effects
• Minimize adverse effects

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Pharmacology of Pain Management Cont

• Routes of Administration
• Oral
• Sublingual
• Transmucosal
• Transdermal
• Parenteral IV, IM, SQ
• Nebulized
• Rectal
• Epidural/Intrathecal (Morphine, Fentanyl)

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Pharmacology of Pain Management Cont

• How do Opioids work?
• Opioids act on the opioid receptor sites and
  activate endogenous pain suppression systems in
  the CNS (Mu receptor sites).
• Receptor sites are found in
• Dorsal horn of the spinal cord
• Pituitary gland
• GI tract
• Endogenous exogenous opioids control pain by
  locking onto opioid receptor sites and blocking
  the release of neurotransmitters.

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Pharmacology of Pain Management Cont

• How NSAIDs and Acetaminophen work?
• Non-opioids include NSAIDs, Tylenol and Aspirin.
• They act on the peripheral nerve endings at the
  site of injury altering the prostaglandin system.
• NSAIDs have an anti-inflammatory effect.
• Acetaminophen does NOT have an anti-inflammatory
  effect. Like ASA, it has analgesic and
  antipyretic effects.
• Side effects
• NSAIDs GI irritation, possible nephrotoxicity.
• Acetaminophen can cause hepatoxicity.
• Limit 4 grams/24hr

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Pharmacology of Pain Management Cont

• Short Acting Pain Medications
• Provide analgesia within 30 min.
• Diluadid, Morphine
• Actiq-fastest acting oral medication- onset
  within 5 min. (transmucosal)
• oral solution/Roxanol-elixir form of morphine.
• Helpful for pts. with difficulty swallowing.
• Titratable.
• Oxycodone/ tablets- used for short-term therapy
  or supplemental dosing (breakthrough pain).
• Compounds Tylenol 3, Hydrocodone-
  Lortab/Vicodin, Oxycodone- Percocet.
• Propoxyphene- Darvon/Darvocet

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Pharmacology of Pain Management Cont

• Long Acting Opioids
• Usually used for long-term pain.
  
• For patients requiring frequent breakthrough
  dosed of opioids.
• More predictable serum levels
• Easier to use lower dosing intervals, improved
  compliance

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Pharmacology of Pain Management Cont

• Meperidine
• Has a metabolite that is 2x as potent as a
  convulsant and 1/2 as potent as an analgesic.
• Breaks down to nomeperidine which has an active
  metabolite that accumulates w/multiple dosing.
• Hepatic or renal failure and increases toxicity.
• Accumulation of active metabolites can produce
  irritability, tremors, muscle twitching, jerking,
  agitation or seizures.

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Common Nonopiod Analgesics
Drug Adult dose Considerations
Acetaminophen (Tylenol) 650-975 mg q 4 hr Used for headaches, osteoarthritis, lacks peripheral anti-inflammatory activity of NSAIDs.
Aspirin 650-975 mg q 4 hr Used for headaches, osteoarthritis, general pain, antipyretic, inhibits platelet aggregation.
Ibuprofen 400 mg q 4-6 hr Antipyretic, Used for osteoarthritis, available as liquid
Indomethacin (Indocin) 150-200 mg/day Used for gout, antinflammatory, antirheumatic
Naproxen (Naprosyn) 500 mg initial dose, then 250 mg q 6-8 Used for gout, headaches, smooth muscle contraction, available in liquid
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Adjuvant Analgesics

• Nontraditional analgesics, most approved for
  other indications.
• Multipurpose drugs
• For muscloskeletal pain
• Muscle relaxants (Baclofen, Zanaflex)
• For neuropathic pain
• Antidepressants- (Pamelor, Cymbalta)
• Anticonvulsants- Topamax, Gabapentin, Lyrica
• Approved for post-herpatic neuralgia, diabetic
  neuropathy.

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Non-pharmacological Treatments

• Rehabilitative such at PT
• Psychological
• Interventional
• Nerve blocks
• Trigger point injections
• Complementary therapies
• Acupuncture
• Breathing
• Relaxation /Yoga
• Meditation
• Hypnosis
• Massage
• Transcutaneous Electrical Nerve Stimulation (TENS)

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Nursing Pain Assessment

• Subjective Assessment
• I have pain. Pt. complains of pain.
• It is what the client says it is.
• Location- Where?
• Description- How does it feel?
• Objective Assessment
• Intensity- Rating scale
• 0 ? pain
• 10 worst possible pain
• Duration- When did it start, How long does it
  last, Is it continuous or intermittent?

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Nursing Pain Assessment

• Objective Assessment cont.
• Alleviating contributing factors
• What makes the pain better or worse?
• Associative factors
• Nausea
• Vomiting
• Altered LOC
• Impact of pain
• How does it affect their lives?
• Past pain experiences
• Recent surgery, chemical use or abuse

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Nursing Pain Assessment

• Objective Assessment cont.
• Vital Signs
• Face
• Facial grimace
• Clenched jaw
• Muscle tone
• Relaxed
• Rigid
• Vocalization
• Moaning, crying, grunting, whimpering

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Nursing Diagnosis

• Alteration in Comfort
• Impaired Gas Exchange
• Alteration in Cardiac Output
• Potential for Ineffective Airway Clearance
• Anxiety
• Impaired Physical Mobility
• Ineffective Coping
• Potential for Infection
• Altered Bowel Elimination

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Planning, Goal Setting Interventions

• Alleviate Pain!!!!!!!! Improve Comfort.
• By when?
• From what to what? 0-10
• Interventions
• Pain Medication!!
• Adjuvants
• Positioning
• Responsibility
• Involve Family
• Humor
• Preventing Complications!!!!!!

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Important Definitions

• Tolerance- an adaptive process due to exposure to
  a drug over time. Results in a decrease response
  to a drugs effect over time.
• Physical Dependence- a physiologic phenomenon
  that should be expected in persons with
  persistent use of certain drugs. Patients will
  experience a withdrawal syndrome if a drug is
  abruptly stopped, there is a rapid dose
  reduction, or if the person is given a reversal
  agent. Withdrawal can be prevented by gradual
  taper
• Reversal Agents
• Narcan- Opioids
• Romazacon- Benzodiazapam

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Important Definitions Cont.

• Pseudoaddiction- This is not true addiction and
  is created by under treatment of pain. A term
  used to describe behaviors seen in persons who
  fear or who are experiencing uncontrolled pain
  and want to obtain medication for adequate pain
  relief. The clock-watching, requesting extra
  opioids, and demanding behaviors are eliminated
  when the pain is relieved.

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Important Definitions Cont.

• Addiction- A primary, chronic, neurobiological
  disease with genetic, psychosocial and
  environmental factors. Characteristics include
• Impaired control over drug use
• Compulsive use
• Continued use despite harm
• The need to use an opioid for effects other than
  for pain relief and craving.

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Important Definitions Cont.

• Breakthrough Pain-
• Transitory increase in pain to greater than
  moderate intensity which occurs on top of the
  baseline pain.
• Distinguished from
• Continuous or uncontrolled pain
• Acute episodic pain.

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Pain Gerontologic Considerations

• 45-80 of older adults have chronic pain.
• Inadequately assessed and treated.
• Common types osteoarthritis, low back pain and
  previous fracture sites.
• Chronic pain can lead to
• Depression
• Sleep disturbances
• Decreased mobility
• Increased health care utilization
• Physical social role dysfunction

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Pain Gerontologic Considerations Cont.

• Believe that pain is normal.
• Nothing can be done.
• Labeled as burdensome or bad pt.
• Fear of drugs.
• Pain tolerance DECREASES with age.
• Cognitive, sensory-perceptual , and motor
  problems may impair ability to communicate or
  process information.
• Post-stroke aphasia, paraplegia, dementia,
  delirium, vision, hearing impairments

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Fibromyalgia Syndrome

• Widespread, nonarticular muscloskeletal pain and
  fatigue with multiple tender points.
• Non-degenerative, non-progressive
  non-inflammatory.
• Effects over 6 million Americans
• More women than men 20-55 years old.
• Possible causes
• Abnormal levels of serotonin, norepi and other
  neurotransmitters.
• Hyperfunctioning of the hypothalamic-pituitary-adr
  enal axis (HPA).

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Fibromyalgia Syndrome Treatment

• Supportive management
• NSAIDs
• Tricyclic Anti-depressants or SSRIs
• Well balanced diet
• Behavioral Therapy
• Financial concerns and support
• Carefully graduated exercise program.

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Chronic Fatigue Syndrome

• Disorder characterized by debilitating fatigue
  and a variety of associated complaints.
• 3x more likely in women onset 25-45 years old.
• Etiology unknown
• Ideas
• Viral infection usually precipitates the
  syndrome.
• Abnormal immune function.
• Alterations in the CNS.
• Depression usually occurs in patients.

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Nursing Care of the Client with
CancerEnd-of-Life Care
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Nursing Care of the Client with Cancer

• Cancer Background
• A. Definition
• 1. Family of complex diseases
• 2. Affect different organs and organ systems
• 3. Normal cells mutate into abnormal cells that
  take over tissue
• 4. Eventually harm and destroy host
• 5. Historically, cancer is a dreaded disease
• B. Oncology
• 1. Study of cancers
• 2. Oncology nurses specialize in the care,
  treatment of clients with cancer

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Nursing Care of the Client with Cancer

• Incidence and Prevalence
• 1. Cancer accounts for about 25 of death on
  yearly basis
• 2. Males 3 most common types of cancer are
  prostate, lung and bronchial, colorectal
• 3. Females 3 most common types of cancer are
  breast, lung and bronchial, and colorectal

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Nursing Care of the Client with Cancer

• Risk factors for cancer (some are controllable
  some are not)
• 1. Heredity 5 10 of cancers documented with
  some breast and colon cancers
• 2. Age 70 of all cancers occur in persons gt 65
• 3. Lower socio-economic status
• 4. Stress
• 5 Diet certain preservatives in pickled, salted
  foods fried foods high-fat, low fiber foods
  charred foods, high fat foods, diet high in red
  meat
• 6. Occupational risk exposure to know
  carcinogens, radiation, high stress
• 7. Infections, especially specific organisms and
  organ (e.g. papillomavirus causing genital warts
  and leading to cervical cancer)
• 8. Tobacco Use Lung, oral and laryngeal,
  esophageal, gastric, pancreatic, bladder cancers
• 9. Alcohol Use also tied with smoking
• 10. Sun Exposure (radiation) e.g. skin cancer

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Nursing Care of the Client with Cancer

• Nursing role includes health promotion to lower
  the controllable risks
• 1. Routine medical check up and screenings
• 2. Client awareness to act if symptoms of cancer
  occur
• 3. Screening examination recommendations by
  American Cancer Society specifics are made
  according to age and frequencies
• a. Breast Cancer self-breast exam, breast
  examination by health care professionals,
  screening mammogram
• b. Colon and Rectal Cancer fecal occult blood,
  flexible sigmoidoscopy, colonoscopy
• c. Cervical, Uterine Cancer Papanicolaou (Pap)
  test
• d. Prostate Cancer digital rectal exam,
  Prostate-specific antigen (PSA) test

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Nursing Care of the Client with Cancer

• Physiology of Cancer
• A. Background
• 1. Normal Cell Growth includes two events
• a. Replication of cellular DNA
• b. Mitosis (cell division)

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Nursing Care of the Client with Cancer

• 2. Cell cycle is under control of cyclins, and
  suppresor gene products which control process by
  working with enzymes
• cyclins promote cell division
• suppresor gene products limit cell
  division
• 3. Forms the basis of how some chemotherapeutic
  agents work against cancers

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Nursing Care of the Client with Cancer

• Theories of Carcinogenesis (what causes cancer to
  occur)
• 1. Cellular Mutation
• a. Cells begin to mutate (change the DNA to
  unnatural cell reproduction)
• 2. Oncogenes/Tumor Suppressor Genes Abnormalities
• a. Oncogenes are genes that promote cell
  proliferation and can trigger cancer
• b. Tumor suppressor genes normally suppress
  oncogenes but are damaged
• 3. Exposure to Known Carcinogens
• a. Act by directly altering the cellular DNA
  (genotoxic)
• b. Act by affecting the immune system
  (promotional)

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Nursing Care of the Client with Cancer

• 4. Viruses
• viruses break the DNA chain and mutates the
  normal cells DNA
• Epstein-Barr virus
• Human papilloma virus
• Hepatitis virus
• 5. Drugs and Hormones
• a. Sex hormones often affect cancers of the
  reproductive systems (estrogen in some breast
  cancers testosterone in prostate cancer)
• b. Glucocorticoids and steroids alter immune
  system

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• 6. Chemical Agents
• a. Industrial and chemical
• b. Can initiate and promote cancer
• b. Examples hydrocarbons in soot arsenic in
  pesticides chemicals in tobacco
• 7. Physical Agents
• a. Exposure to radiation
• Ionizing radiation found in x-rays, radium,
  uranium
• UV radiation
• Sun, tanning beds
• Immune function
• Protects the body from cancerous cells
• Increased rate of cancer in immunocompromised pts

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Nursing Care of the Client with Cancer

• Neoplasms also called tumors (mass of new tissue
  that grows independently of surrounding organs
• 1. Types of neoplasms
• a. Benign
• 1. Localized growths respond to bodys
  homeostatic controls
• 2. Encapsulated
• 3. Stop growing when they meet a boundary of
  another tissue
• 4. Can be destructive
• b. Malignant
• 1. Have aggressive growth, rapid cell division
  outside the normal cell cycle
• 2. Not under bodys homeostatic controls
• 3. Cut through surrounding tissues causing
  bleeding, inflammation, necrosis (death) of tissue

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Nursing Care of the Client with Cancer

• Malignant tumors can metastasize
• a. Tumor cells travel through blood or lymph
  circulation to other body areas and invade
  tissues and organs there.
• 1. Primary tumor the original site of the
  malignancy
• 2. Secondary tumor (sites) areas where
  malignancy has spread i.e. metastasis (metastatic
  tumor)
• 3. Common sites of metastasis are lymph nodes,
  liver, lungs, bones, brain
• 4. 50 60 of tumors have metastasized by time
  primary tumor identified
• b. Cancerous cells must avoid detection by immune
  system

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Nursing Care of the Client with Cancer

• C. Malignant neoplasms can recur after surgical
  removal of primary and secondary tumors and other
  treatments
• D. Malignant neoplasms vary in differentiation.
• a. Highly differentiated are more like the
  originating tissue
• b. Undifferentiated neoplasms consist of immature
  cells with no resemblance to parent tissue and
  have no useful function
• E. Malignant cells progress in deviation with
  each generation and do no stop growing and die,
  as do normal cells
• F. Malignant cells are irreversible, i.e. do not
  revert to normal
• G. Malignant cells promote their own survival by
  hormone production, cause vascular permeability
  angiogenesis divert nutrition from host cells

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The steps of metastasis
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Nursing Care of the Client with Cancer

• Effects of Cancer
• 1. Disturbed or loss of physiologic functioning,
  from pressure or obstruction
• a. Anoxia and necrosis of organs
• b. Loss of function bowel or bladder obstruction
• c. Increased intracranial pressure
• d. Interrupted vascular/venous blockage
• e. Ascites
• f. Disturbed liver functioning
• G. Motor and sensory deficits
• Cancer invades bone, brain or compresses nerves
• Respiratory difficulties
• Airway obstruction
• Decreased lung capacity

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Nursing Care of the Client with Cancer

• 2. Hematologic Alterations Impaired function of
  blood cells
• Secondary to any cancer that invades the bone
  marrow (leukemia)
• May also be caused by the treatment
• a. Abnormal wbcs impaired immunity
• b. Diminished rbcs and platelets anemia and
  clotting disorders
• 3. Infections fistula development and tumors may
  become necrotic erode skin surface
• 4. Hemorrhage tumor erosion, bleeding, severe
  anemia
• 5. Anorexia-Cachexia Syndrome wasting away of
  client
• a. Unexplained rapid weight loss, anorexia with
  altered smell and taste
• b. Catabolic state use of bodys tissues and
  muscle proteins to support cancer cell growth

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Nursing Care of the Client with Cancer

• 6. Paraneoplastic Syndromes ectopic sites with
  excess hormone production
• a. Parathyroid hormone (hypercalcemia)
• b. Ectopic secretion of insulin (hypoglycemia)
• c. Antidiuretic hormone (ADH fluid retention)
• d. Adrenocorticotropic hormone (ACTH)
• 7. Pain major concern of clients and families
• a. Types of cancer pain
• 1. Acute symptom that led to diagnosis
• 2. Chronic may be related to treatment or to
  progression of disease
• b. Causes of pain
• 1. Direct tumor involvement including metastatic
  pain
• 2. Nerve compression
• 3. Involvement of visceral organs

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Nursing Care of the Client with Cancer

• 8. Physical Stress body tries to respond and
  destroy neoplasm
• a. Fatigue
• b. Weight loss
• c. Anemia
• d. Dehydration
• e. Electrolyte imbalances
• 9. Psychological Stress
• a. Cancer equals death sentence
• b. Guilt from poor health habits
• c. Fear of pain, suffering, death

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Nursing Care of the Client with Cancer

• Collaborative Care
• A. Diagnostic Tests used to diagnose cancer
• 1. Determine location of cancer
• a. Xrays
• b. Computed tomography
• c. Ultrasounds
• d. Magnetic resonance imaging
• e. Nuclear imaging
• f. Angiography
• 2. Diagnosis of cellular type of can be done
  through tissue samples from biopsies, shedded
  cells (e.g. Papanicolaou smear) washings
• a. Cytologic Examination tissue examined under
  microscope
• b. Identification System of Tumors
  Classification Grading -- Staging

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Nursing Care of the Client with Cancer

• 1. Classification according to the tissue or
  cell of origin, e.g. sarcoma, from supportive
• 2. Grading
• a. Evaluates degree of differentiation and rate
  of growth
• b. Grade 1 (least aggressive) to Grade 4 (most
  aggressive)
• 3. Staging
• a. Relative tumor size and extent of disease
• b. TNM (Tumor size Nodes lymph node
  involvement Metastases)

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Nursing Care of the Client with Cancer

• 3. Tumor markers specific proteins which
  indicate malignancy
• a. PSA (Prostatic-specific antigen) prostate
  cancer
• b. CEA (Carcinoembryonic antigen) colon cancer
• c. Alkaline Phosphatase bone metastasis
• 4 Direct Visualization
• a. Sigmoidoscopy
• b. Cystoscopy
• c. Endoscopy
• d. Bronchoscopy
• e. Exploratory surgery lymph node biopsies to
  determine metastases

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Nursing Care of the Client with Cancer

• Treatment Goals depending on type and stage of
  cancer
• A. Cure
• 1. Recover from specific cancer with treatment
• 2. Alert for reoccurrence
• 3. May involve rehabilitation with physical and
  occupational therapy
• B. Control of symptoms and progression of cancer
  
• 1. Continued surveillance
• 2. Treatment when indicated (e.g. some bladder
  cancer, prostate cancer)
• C. Palliation of symptoms may involve terminal
  care if clients cancer is not responding to
  treatment

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Nursing Care of the Client with Cancer

• Treatment Options (depend on type of cancer)
  alone or with combination
• A. Chemotherapy
• 1. Effects are systemic and kills the metastatic
  cells
• 2. Often combinations of drugs in specific
  protocols over varying time periods
• Much more effective then a single agent
• Consider the timing of the nadir of each drug
• The time when the bone marrow activity and WBC
  counts are at their lowest levels after chemo
• Different times for different drugs

64

• 3. Cell-kill hypothesis with each cell cycle a
  percentage of cancerous cells are killed but some
  remain repeating chemo kills more cells until
  those left can be handled by bodys immune system

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Nursing Care of the Client with Cancer

• B. Classes of Chemotherapy Drugs
• 1. Alkylating agents
• 1. Action create defects in tumor DNA
• 2. Examples Nitrogen Mustard, Cisplatin
• 2. Antimetabolites
• 1. Action similar to metabolites needed for
  vital cell processes
• Counterfeit metabolites interfere with cell
  division
• 2. Examples Methotrexate 5 fluorouracil
• 3. Toxic Effects nausea, vomiting, stomatitis,
  diarrhea, alopecia, leukopenia
• 3. Antitumor Antibiotics
• 1. Action interfere with DNA
• 2. Examples Actinomycin D, Bleomycin
• 3. Toxic Effect damage to cardiac muscle

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Nursing Care of the Client with Cancer

• 4. Antimiotic agents
• 1. Action Prevent cell division
• 2. Examples Vincristine, Vinblastine
• 3. Toxic Effects affects neurotransmission,
  alopecia, bone marrow depression
• 5. Hormone agonist
• 1. Action large amounts of hormones upset the
  balance and alter the uptake of other hormones
  necessary for cell division
• 2. Example estrogen, progestin, androgen

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• 6. Hormone Antagonist
• 1. Action block hormones on hormone-binding
  tumors (breast, prostate, endometrium cause
  tumor regression
• Decreasing the amount of hormones can decrease
  the cancer growth rate
• Does not cure, but increases survival rates
• 2. Examples Tamoxifen (breast) Flutamide
  (prostate)
• 3. Toxic Effects altered secondary sex
  characteristics

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• 7. Hormone inhibitors
• Aromatase inhibitors (Arimidex, Aromasin)
• Prevents production of aromatase which is needed
  for estrogen production
• Used in post menopausal women
• Side effects
• Masculinizing effects in women
• Fluid retention

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Nursing Care of the Client with Cancer

• Effects of Chemotherapy
• a. Tissues (fast growing) frequently affected
• b. Examples mucous membranes, hair cells, bone
  marrow, specific organs with specific agents,
  reproductive organs (all fetal toxic, impair
  ability to reproduce).
• Administration of chemotherapeutic agents
• a. Trained and certified personnel, according to
  established guidelines
• b. Preparation
• 1. Protect personnel from toxic effects
• Drugs absorbed through skin and mucous membranes
• Protective clothing and extreme care
• 2. Extreme care for correct dosage double check
  with physician orders, pharmacists preparation
• c. Proper management clients excrement

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Nursing Care of the Client with Cancer

• d. Routes
• 1. Oral
• 2. Body cavity (intraperitoneal or intrapleural)
• 3. Intravenous
• Use of vascular access devices because of threat
  of extravasation (leakage into tissues) and
  long-term therapy
• If the drug is a vessicant it may result in pain,
  infection and tissue loss

71

• e. Types of vascular access devices
• 1. PICC lines (peripherally inserted central
  catheters)
• 2. Tunnelled catheters (Hickman, Groshong)
• 3. Surgically implanted ports accessed with 90
  angle needle

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Hickman Catheter
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PICC Line
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Nursing Care of the Client with Cancer

• Managing side effects of chemotherapy
• A. Nausea and vomiting
• 80 of patients will develop it
• Antiemetics such as Zofran, Tigan, Compazine as
  well as Ativan to control the symptoms
• Monitor for dehydration and need for IV fluids

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• B. Bone marrow suppression
• Decreased number of RBC
• Leads to hypoxia, fatigue
• Hgb 9.5-10 gm/dl require oral iron supplements
• Hgb below 8 gm/dl require transfusion
• May use Epogen to stimulate RBC production

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• Decrease number of WBC (normal 4,500-11,000
  mm3) especially neutrophils (normal 3,000-7,000
  cells/cc)
• Neutropenia-count below 2000
• Pt at extreme risk for infection
• May order granulocyte colony stimulating factor
  (leukine) to stimulate bone marrow to increase
  WBC count
• Neutropenic precautions
• Private room
• Good handwashing
• Monitor temp q 4 hours, monitor for chills,
  pneumonia
• Limit visitors to healthy adults
• No flowers or plants
• Monitor neutrophil count

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• Thrombocytopenia
• Drop in platlet count (normal 150,000-400,000/mm3)
  below 100,000
• Test pt for bleeding in stool and urine
• Avoid punctures for IV or IM
• Handle pt gently
• Use electric razor
• Avoid placing foley or rectal thermometers
• Avoid oral trauma with soft bristle brushes,
  avoid flossing, avoid hard candy
• Watch for ALOC, pupil changes that might indicate
  intracranial bleeds
• Stool softeners to avoid straining

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• C. Mucocitis
• Inflammation and ulceration of mucous membranes
  and entire GI tract
• Rinse mouth with ½ normal saline and ½ peroxide
  every 12 hours
• Topical analgesic medication
• Avoid mouthwashes with alcohol
• Avoid spicy or hard food
• Watch nutritional status

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• D. Alopecia
• Hair loss
• 2-3 weeks after treatment is started
• Affects all the hair, including eyebrows,
  eyelashes
• Within 4-8 weeks after treatment hair begins to
  grow back
• Before hair loss, have the pt pick out a wig that
  is similar to hair color

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• E. Peripheral neuropathy
• Numbness and tingling to fingers and toes in a
  glove and sock pattern
• May cause gait and possible fall problems
• F. Provide emotional and spiritual support to
  patient and families

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Nursing Care of the Client with Cancer

• Surgery
• 1. Diagnosis, staging, and sometimes treatment of
  cancer
• 2. May be prophylaxis or removal of at risk
  tissue or organ prior to development of cancer
  (breast cancer)
• 3. Involves removal of body part, organ,
  sometimes with altered functioning (e.g.
  colostomy)
• 4. Debulking (decrease size of) tumors in
  advanced cases
• 5. Reconstruction and rehabilitation (e.g. breast
  implant post mastectomy)
• 6. Palliative surgery to improve the quality
  of life
• Removal of tumor tissue that is causing pain or
  obstruction
• 5. Psychological support to deal with surgery as
  well as cancer diagnosis

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Nursing Care of the Client with Cancer

• Radiation Therapy
• 1. Treatment of choice for some tumors to kill
  or reduce tumor, relieve pain or obstruction
• Destroy cancer cells with minimal exposure to
  normal cells
• Cells die or are unable to divide
• 2. Delivery
• a. Teletherapy (external) radiation delivered in
  uniform dose to tumor
• Beam radiation
• b. Brachytherapy delivers high dose to tumor and
  less to other tissues radiation source is placed
  in tumor or next to it in the form of seeds
• Radiation source within the patient so pt emits
  radiation for a period of time and is a hazard to
  others
• c. Combination

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• 3. Goals
• a. Maximum tumor control with minimal damage to
  normal tissues
• b. Caregivers must protect selves by using
  shields, distancing and limiting time with
  client, following safety protocols
• Private room
• Caution sign on the door for radioactive material
• Dosimeter film badge by staff
• No pregnant staff
• Limit visitors to ½ hour per day and keep them at
  least 6 ft from the source

84
Nursing Care of the Client with Cancer

• 4. Treatment Schedules
• a. Planned according to radiosensitivity of
  tumor, tolerance of client
• b. Monitor blood cell counts
• 5. Side Effects
• a. Skin (external radiation) blanching,
  erythema, sloughing, breakdown
• Use mild soak
• Dry skin with a patting motion, not rubbing
• Dont use powders or lotions unless prescribed by
  radiologist
• Wear soft clothing over the site
• Avoid the sun and heat

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• b. Ulcerated mucous membranes pain, lack of
  saliva (xerostoma)
• c. Gastrointestinal nausea and vomiting,
  diarrhea, bleeding, sometimes fistula formation
• d. Radiation pneumonitis
• 1-3 months after treatment
• Cough, fever
• Treated with steroids to decrease inflammation

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• Gene therapy
• experimental
• May insert gene into the tumor cells to make them
  more susceptible to being killed by antiviral
  agents
• May insert genes for cytokines that increase
  their effectiveness in killing cancer cells

87
Nursing Care of the Client with Cancer

• F. Bone Marrow Transplantation and Peripheral
  Blood Stem Cell Transplantation
• 1. Stimulation of nonfunctioning marrow or
  replace bone marrow
• 2. Common treatment for leukemias
• G. Pain Control
• 1. Includes pain directly from cancer, treatment,
  or unrelated
• 2. Necessary for continuing function or comfort
  in terminally ill clients
• 3. Goal is maximum relief with minimal side
  effects
• 4. Multiple combinations of analgesics (narcotic
  and non-narcotic) and adjuvants such as steroids
  or antidepressants includes around the clock
  (ATC) schedule with additional medications for
  break-through pain
• 5. Multiple routes of medications
• 6. May involve injections of anesthetics into
  nerve, surgical severing of nerves radiation
• 7. May need to progress to stronger pain
  medications as pain increases and client develops
  tolerance to pain medication

88
Nursing Care of the Client with Cancer

• Nursing Diagnoses for Clients with Cancer
• A. Anxiety
• 1. Therapeutic interactions with client and
  family community resources such as American
  Cancer Society, I Can Cope
• 2. Availability of community resources for
  terminally ill (Hospice care in-patient, home
  care)
• B. Disturbed Body Image
• 1. Includes loss of body parts (e.g.
  amputations) appearance changes (skin, hair)
  altered functions (e.g. colostomy) cachexic
  appearance, loss of energy, ability to be
  productive
• 2. Fear of rejection, stigma
• C. Anticipatory Grieving
• 1. Facing death and making preparations for
  death will be consideration
• 2. Offer realistic hope that cancer treatment may
  be successful

89
Nursing Care of the Client with Cancer

• D. Risk for Infection
• E. Risk for Injury
• 1. Organ obstruction
• 2. Pathological fractures
• F. Altered Nutrition less than body requirements
• 1. Consultation with dietician, lab evaluation of
  nutritional status
• 2. Managing problems with eating anorexia,
  nausea and vomiting
• 3. May involve use of parenteral nutrition
• G. Impaired Tissue Integrity
• 1. Oral, pharyngeal, esophageal tissues (due to
  chemotherapy, bleeding due to low platelet
  counts, fungal infections such as thrush)
• 2. Teach inspection, frequent oral hygiene,
  specific non-irritating products, thrush control

90
Nursing Care of the Client with Cancer

• Oncologic Emergencies
• A. Pericaridal Effusion and Neoplastic Cardiac
  Tamponade
• 1. Concern compression of heart by fluid in
  pericardial sac, compromised cardiac output
• 2. Treatment pericardiocentesis

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• B. Superior Vena Cava Syndrome
• 1. obstruction of venous system with increased
  venous pressure and stasis facial and neck edema
  with slow progression to respiration distress
• Late signs are cyanosis, decreased cardiac output
  and hypotension
• 2. Treatment respiratory support decrease tumor
  size with radiation or chemotherapy

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Compression of the superior vena cava in SVC
syndrome
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• C. Sepsis and Septic Shock
• 1. Early recognition of infection
• Patients at risk secondary to low WBC and
  impaired immune system
• 2. Treatment prompt intervention with
  antibiotics and vasopressors

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• D. DIC disseminated intravascular coagulation
• Triggered by severe illness, usually sepsis in
  cancer patients
• Abnormal clotting uses up existing clotting
  factors and platelets quickly then the pt
  hemorrhages
• Mortality rate is 70
• Prevention of sepsis is key

95
Nursing Care of the Client with Cancer

• E. Spinal Cord Compression
• 1. Pressure from expanding tumor or vertebral
  collapse can cause irreversible paraplegia
• 2. Back pain initial symptom with progressive
  paresthesia and paralysis
• Paralysis is usually permanent
• 3. Treatment early detection
• High dose corticosteroid to decrease the swelling
• radiation or surgical decompression

96

• F. Obstructive Uropathy
• 1. Concern blockage of urine flow undiagnosed
  can result in renal failure
• 2. Treatment restore urine flow

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• G. Hypercalcemia
• 1. High calcium (normal 9-10.5) usually from
  bone metastases
• 2. May also come from cancer of the lung, head,
  neck, kidney and lymph nodes that secrete
  parathyroid hormone that causes the bone to
  release calcium
• 2. Symptoms include fatigue, muscle weakness,
  polyuria, constipation, progressing to coma,
  seizures
• 3. Treatment
• restore fluids with intravenous saline which
  also increases the excretion of calcium
• loop diuretics increase calcium excretion
• Calcium chelators such as mithracin
• Inhibit calcium resorption from the bone with
  calcitonin, diphosphonate

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• H. Tumor Lysis Syndrome
• 1. Occurs with rapid necrosis of tumor cells with
  chemotherapy
• When tumor cells die they release potassium and
  purines
• Potassium (norm 3.5-5.5) elevation causes cardiac
  arrhthymias, muscle weakness, twitching, cramps
• Purines convert to uric acid which causes renal
  failure, flank pain, gout when elevated above 10
  mg/dl
• Hyperphosphatemia with secondary to hypocalcemia
  causes heart block, HTN, renal failure

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• Treatment
• Hydration
• Instruct pt to increase fluid intake before and
  after chemo
• May need IV hydration
• Diuretics to increase urine flow
• Allopurinol to increase uric acid excretion
• May need dialysis

100
Nursing Care of the Client with Cancer

• I. SIADH (Syndrome of Inappropriate Antidiuretic
  Hormone Secretion)
• 1. Ectopic ADH production from tumor leads to
  excessive hyponatremia
• 2. holds onto too much fluid which decreases
  sodium level (normal 135-145)
• 3. Symptoms
• Weakness, muscle cramps, fatigue, ALOC, headache,
  seizures
• 2. Treatment restore sodium level
• Fluid restriction
• Increase sodium
• Antibiotic demeclocycline works in opposition to
  ADH
• Limits ADH effect on distal renal tubules so they
  can excrete water