NCLEX-RN: Oncology Nursing

Oncology Nursing: Chemotherapy

Focus topic: Oncology Nursing

Characteristics
A. The medical management of cancer includes the use of chemotherapy. First used in the early 1950s, there are now more than 80 effective drugs available.

  • Chemotherapy is method of choice when there is suspected or confirmed spread of malignant cells.
  • Method used when the risk of recurrence is high.
  • May be used as palliative measure to relieve pain or increase comfort.

B. Mechanism of action.

  • Functions at cellular level by interrupting cell life—modifies or interferes with DNA synthesis.
  • Chemotherapeutic agents eradicate cells, both normal and malignant, that are in the process of cell reproduction.

Drug Classification

Focus topic: Oncology Nursing
A. Drugs classified by group into those that act on a certain phase of cell reproduction (cell cycle specific) or those that do not reproduce (cell cycle nonspecific).
B. Cell cycle–specific agents: antimetabolites and mitotic inhibitors.

  • Act on the cell during a particular phase of reproduction.
  • Most effective in tumors where a large number of cells are dividing.
  • Divided doses produce greater cytotoxic effects (not all cells will be in the same phase at the same time).
  • Antimetabolites.
    a. Specific for the S phase—replaces building blocks of DNA so cell can’t divide.
    b. Examples of antimetabolites: Trexall (methotrexate), Purinethol (6-mercaptopurine), Adrucil (5-fluorouracil), Vidaza (azacitidine), Cytosar-U (cytarabine), Hydrea (hydroxyurea).
  • Plant alkaloids.
    a. Specific for the M phase—prevent cell division by destroying the mitotic spindle.
    b. Examples of mitotic inhibitors: plant alkaloids—Oncovin (vincristine), Eldisine (vindesine), Velban (vinblastine), Vumon (teniposide).

C. Cell cycle–nonspecific drugs: alkylating agents, antitumor antibiotics, and nitrosoureas.

  • Act on cells during any phase of reproduction— some drugs will attack cells in the resting phase (not actively dividing).
  • Agents are dose dependent—the more drug given, the more cells destroyed.
  • These drugs are more toxic to normal tissue because they are less selective.
  • Alkylating agents.
    a. These drugs prevent cell division by damaging the DNA “ladder” structure and are effective in all phases of the cell cycle.
    b. Included in almost all chemotherapy regimens.
    c. Examples of alkylating agents: Cytoxan (cyclophosphamide), Myleran (busulfan), Alkeran (melphalan [L-PAM]), Thioplex (thiotepa), Platinol (cisplatin).
  • Antitumor antibiotics.
    a. These drugs attack DNA (they act like alkylating drugs) by slipping between the DNA strands and preventing replication.
    b. Examples of antitumor antibiotics: Adriamycin (doxorubicin), Cosmegen (dactinomycin).
  • Nitrosoureas.
    a. Alkylating agents that are stronger and have a greater ability to attack cells in the resting phase of cell growth.
    b. These drugs can cross the blood–brain barrier.
    c. Examples of nitrosoureas: Zanosar (streptozocin), semustine (methyl-CCNU), Gliadel (carmustine or BCNU), azacitidine (chlorozotocin or DCNU).

D. Other miscellaneous agents (such as Matulane [procarbazine]) are used in the chemotherapy group, but their exact mechanism of action is unknown.
E. Hormonal agents (estrogens, androgen, progestins) work in all cycles and are used in therapy to affect the hormonal environment (Decadron [dexamethasone], DES, Halotestin [fluoxymesterone], Nolvadex [tamoxifen], Deltasone [prednisone]).

  • Affect the growth of hormone-dependent tumors.
  • Steroids interfere with the synthesis of protein and alter cell metabolism (lymphomas and leukemias).
  • Antihormones (Nolvadex and Evista [Raloxifene]) block tumor growth by depriving the tumor of the necessary hormones.

F. Combination chemotherapy.

  • Most often administered in combination, which enhances the response rate: for example, Adriamycin, Blenoxane (bleomycin), Velban, and dacarbazine (ABVD) used for Hodgkin’s lymphoma.
  • Studies at Stanford University now suggest ABVD and a fifth or sixth chemotherapy drug be combined with Deltasone (for its antiinflammatory effect) for 3 months for Hodgkin’s disease.
  • Cancer cells divide erratically on different schedules; thus drugs that are effective alone and have different mechanisms of action can combine to destroy even more cells.
  • Drugs used in combination for synergistic activity.
  • Guidelines for drug administration are carefully planned and referred to as protocols or regimens.
    a. Package inserts are based on single-agent therapy, so it is important to adhere to the ordered protocol.
    b. Dosages of drugs are based on height and weight calculated as body surface area.

G. Other chemotherapeutic agents that do not fall into specific categories.

  • Elspar (asparaginase)—an enzyme used to treat lymphocytic leukemia; Eulexin (flutamide)—antiandrogen used to treat prostate cancer; and Taxol (paclitaxel)—used to treat ovarian, breast, and cell lung cancers.
  • Chemotherapeutic drugs cause myelosuppression; nursing interventions include blood counts and instituting precautions if blood count falls below normal, and assess for infection.

Goals of Treatment

Focus topic: Oncology Nursing
A. The major goal is to cure the malignancy.

  • Chemotherapy, as primary mode of treatment, may include curing certain malignancies such as acute lymphocytic leukemia, Hodgkin’s disease, lymphosarcomas, Wilms’ tumor.
  • Cure may also occur in combination with other modes of treatment, radiation, or surgery.

B. Control may be the goal when cure is not realistic; the aim is to extend survival and improve the quality of life.
C. Palliation may be the goal when neither cure nor control may be achieved; this goal is directed toward client comfort.

Chemotherapeutic Administration

Focus topic: Oncology Nursing
A. Chemotherapeutic agents are administered through a variety of routes.

  • Oral route—used frequently. Safety precautions must be observed.
  • Intramuscular and subcutaneous used infrequently, as drugs are not vesicants.
  • Intravenous is the most common route—provides for better absorption.
    a. Potential complications: infection, phlebitis.
    b. Prevention of complications: Use smallest gauge needle possible; maintain aseptic technique; monitor intravenous (IV) site frequently; change IV fluid every 4 hours.
  • Central venous catheter infusion—used for continuous or intermittent infusions.
    a. Potential complications: infection, catheter clotting, sepsis, malposition of needle.
    b. Prevention of complications: Maintain aseptic technique and monitor site daily; flush catheter daily and between each use with heparin solution; assess client for signs of sepsis.
  • Venous access devices (VADs)—used for prolonged infusions.
    a. Potential complications: infection and infiltration from malposition.
    b. Assess site frequently and assess for systemic infection.
  • Intra-arterial route—delivers agents directly to tumor in high concentrations while decreasing drug’s systemic toxic effect.
    a. Potential complications: infection or bleeding at catheter site, catheter clotting,or pump malfunction.
    b. Change dressing site daily and assess for signs of infection; irrigate catheter with heparin solution and avoid kinks in tubing.
  • Intraperitoneal—used for ovarian and colon cancer. High concentration of agents delivered to peritoneal cavity via catheter, then drained.
  • Other less frequently used routes are intrapleural, intrathecal, and ventricular reservoir.

B. Factors for deciding dosage and timing of drugs.

  • Dosage calculated on body surface area and kilograms of body weight.
  • Time lapse between doses to allow recovery of normal cells.
  • Side effects of each drug and when they are
    likely to occur.
  • Liver and kidney function, as most antineoplastics are metabolized in one of these organs.

Chemotherapy Safety Guidelines

Focus topic: Oncology Nursing
A. Antineoplastic drugs are potentially hazardous to personnel and may have teratogenic and/or carcinogenic effects.
B. Safety guidelines have been issued by the Occupational Safety and Health Administration (OSHA).

  • Obtain special training for drug administration.
  • Use two pairs of powder-free, dispensable chemotherapy gloves, and a disposable, closed, long-sleeved gown with outer pair of gloves covering gown cuff whenever there is risk of exposure to hazardous drugs.
  • Provide syringes and IV sets with Luer lock fittings for preparing and administering hazardous drugs. Also provide containers for their disposal.
  • Use a closed-system drug-transfer device and needleless system to protect nursing personnel during drug administration.
  • Label all prepared drugs appropriately.
  • Double-bag chemotherapy drugs once prepared, before transport.
  • Have equipment ready to clean up any accidental spill (spill kit).
  • Dispose of all materials in marked containers labeled hazardous waste.
  • Dispose of all needles and syringes intact.
  • Follow facility’s policies and procedures when preparing to administer chemotherapy.
  • Double-check chemotherapy orders with another oncology nurse.
  • Read material safety data sheets (MSDS) prior to administration.
  • Use personal protective equipment (PPE).
  • Wash your hands both before you put on and after you take off gloves.
  • After infusion is complete, promptly dispose of any equipment that contained the drug in a puncture-proof container that is clearly marked.
  • Chemotherapy agents may be excreted in body fluids; these may be contaminated for 48 hours after the last drug dose. Wear PPE when handling such excreta, and wash your hands after removing gloves.
  • Check facility’s policies about handling linen that’s been contaminated with chemotherapy.
  • If a chemotherapy drug comes into contact with your skin or a client’s skin, thoroughly wash the affected area with soap and water, but don’t abrade the skin with a scrub brush.
  • If the drug gets in your eyes, flush with copious amounts of water for at least 15 minutes while holding back your eyelids. Then get evaluated by employee health or the emergency department (ED).

C. When infusing vesicant drugs, monitor IV carefully—at first sign of extravasation, remove IV and implement Rx protocol.

Side Effects and Nursing Management

Focus topic: Oncology Nursing
A. Side effects occur primarily due to the mechanism of action of potent drugs on normal cells.

  • Normal cells most affected are bone marrow cells, epithelial cells of the gastrointestinal (GI) tract and hair follicles, and cells of the gonads.
  • Since other normal cells are not actively reproducing (except with tissue injury and repair), they are not severely affected.
  • Time of most severe depression of cells (termed nadir) is different for each type of cell.

B. Skin and mucosa, protective linings of the body, are damaged.

  • Mucositis (cells of the mucosa are affected)—may extend from oral cavity and stomach through GI tract.
    a. Symptoms may be nausea, vomiting, anorexia, fluid and electrolyte imbalance, dietary insufficiency, and stomatitis.
    b. Assess for erythema, tenderness, and ulceration.
  • Clients at high risk are those with dental caries, those with gum disease, smokers, and those who drink alcohol.
  • Nursing interventions include good oral hygiene with soft toothbrush, mouthwashes (viscous Xylocaine [lidocaine]), avoiding foods that are hot, sharp, spicy, or acidic—diet should be soft, bland, tepid.

C. Alopecia, or hair loss, caused by damage to rapidly dividing cells of the hair follicles.

  • Hair loss begins 2–3 weeks after chemotherapy and continues through the cycles of chemotherapy; regrowth occurs following the course of therapy.
  • Nursing interventions include scalp hypothermia (ice cap) and scalp tourniquet; both reduce the amount of drug reaching the hair follicle and may prevent hair loss.

D. Nausea, vomiting, and anorexia are common in clients receiving chemotherapy.

  • Antiemetic regimens (Reglan [metoclopramide], Zofran [ondansetron]) may counteract these symptoms.
  • Nursing interventions include supporting changes in food preferences, additional or less seasoning, small and more frequent high-calorie, high-protein meals.
  • Offer high-calorie and protein supplements.

E. Elimination disturbance occurs when the client does not eat well, is not exercising, or has mucositis.

  • Diarrhea is related to toxicity of the drugs on the mucosal lining and can quickly cause fluid volume deficit; diet bland and low residue.
  • Constipation may be related to the drugs (especially Velban and Oncovin) that affect nerve endings in the GI tract.
    a. Add more fiber and liquid to diet (3000 mL/day).
    b. Avoid milk and dairy products.
    c. Include low-residue foods and foods high in potassium.
    d. Stool softeners are ordered to minimize constipation; may add vegetable laxative.

F. Elevated uric acid and crystal urate stone formation may occur.
G. Hematological disruptions: Damage to normal cells in the bone marrow can be life-threatening and is, therefore, the most dangerous side effect.

  • White blood cells (WBCs) and platelets have a shorter life span than red blood cells so they are more susceptible to damage.
  • White blood cell suppression—leukopenia (less than 5000/mm3 when normal white blood cell count is 5000–10,000/mm3).
    a. Granulocytes are the most suppressed, which places client at risk for bacterial infection.
    b. Common sites of infection are the lung, urinary tract, skin, and blood.
    c. Implementation includes meticulous aseptic technique for IV therapy as well as hand hygiene; avoid exposure to infected persons.
    d. Assess for fever, chills, and sore throat.
    e. Teach signs and symptoms of infection to the cancer client with instructions to report symptoms to the doctor or nurse.
    f. Medications may be given to stimulate the production of WBCs, e.g., Neupogen (filgrastim).
  • Platelet suppression to below normal (less than 150,000 mm3) is called thrombocytopenia.
    a. A number less than 50,000/mm3 makes the client susceptible to bleeding gums and/or nose, easy bruising, heavier menstrual flow, etc.
    b. Teach client precautions: soft toothbrush, avoidance of douches and enemas, care with trimming nails, avoiding venipunctures when possible, and avoidance of any activity that might increase intracranial pressure (ICP).
  • Red blood cell suppression—anemia is not usually a severe toxicity.

H. All hormonal agents cause fluid retention: Monitor weight gain, intake and output (I&O), edema, and administer diuretics as ordered.

Nutrition in Oncology

Focus topic: Oncology Nursing
A. Maintaining a healthy diet with supplements can affect cancer diagnosis.

  • Nutrition is a factor in the cause of some cancers.
  • Poor diet increases cancer risk.
  • High-fat meat and low fiber is linked to breast, prostate, and colon cancer. Alcohol and tobacco connected to head and neck cancers.
  • Low calcium is linked to colon cancer, and low vitamin D is linked to prostate cancer.

B. Recommended diets.

  • Low fat and high fiber—high intake of fruits and vegetables with limited alcohol intake.
  • Avoid high weight gain and add physical activity.

C. Cancer cachexia—weight loss associated with certain types of cancer.

  • With this type of weight loss, weight is lost equally from muscle and fat.
  • Most often seen with lung and pancreatic cancer, but is present with other cancers.

D. Certain nutrients may be deficient in cancer clients—nutrient supplement (vitamins and minerals) recommended.

Psychosocial Impact of Chemotherapy

Focus topic: Oncology Nursing
A. Assessment.

  • Client’s reaction to illness and chemotherapy.
  • Prior experience with those receiving chemotherapy.
  • Coping style under stress.
  • Support network.
  • Psychosocial changes resulting from cancer.
    a. Threats to the roles client has in life: career, marriage, parent, etc.
    b. Threat to life goals.
    c. Altered independence.

B. Implementation.

  • Support client’s coping style without attempting to change style.
  • Provide accurate information, encourage questions, and expression of concerns.
  • Allow time for client to communicate, express fears, concerns, and adjustment to both disease and treatment.
  • Refer client to appropriate healthcare providers and to support groups.

Targeted Medicine: Pharmacogenomics
A. Medicine targeted to illness and genetic makeup

  • Advances in genetics are transforming medicine.
  • Genetic markers can predict how drugs are absorbed and metabolized and how clients will respond.
  • Increase in serious adverse drug reactions, costs, morbidity, and mortality provide impetus for advancing targeted drugs.

B. Oncology is one area where targeted drugs now are being used.

  • Breast cancer: Herceptin (trastuzumab) targets a protein found in certain type of cancer; blocks growth of tumor cells.
  • Has far fewer side effects than traditional chemotherapy.

C. Targeted therapy, used to treat many kinds of diseases, consists of drugs that block the growth and spread of cancer by interfering with specific molecules involved in carcinogenesis (the process by which normal cells are transformed into cancer cells) and tumor growth.

  • Targeted therapy drugs.
    a. Are technically considered “chemotherapy.”
    b. Do not work in the same ways as standard chemotherapy drugs.
    c. Are often able to attack cancer cells while doing less damage to normal cells by going after the cancer cells’ inner workings—the programming that sets them apart from normal, healthy cells.
    d. Tend to have different (and often less severe) side effects than standard chemotherapy drugs.
  • Types of targeted therapies.
    a. Enzyme inhibitors
    (1) Block (inhibit) enzymes that are signals for cancer cells to grow.
    (2) Blocking these cell signals can keep the cancer from getting bigger and spreading.
    (3) Even if the tumor is not getting smaller, its out-of-control growth has been interrupted.
    (4) May give regular chemo a better chance to work.
    (5) May also help people live longer, even without adding other drugs.

b. Apoptosis-inducing drugs.
(1) Change proteins within the cancer cells and cause the cells to die.
(2) Many cancer treatments, including radiation and chemo, cause cell changes that lead to apoptosis. Targeted drugs in this group are different, because they are aimed right at the parts of the cell that control whether cells live or die.
c. Angiogenesis inhibitors.
(1) Block the vascular endothelial growth factor (VEGF) made by some tumors.
(2) VEGF proteins can attach to the VEGF receptors of blood vessel cells causing new blood vessels to form around the tumors. Blocking this process prevents formation of new blood vessels to feed tumors so they could grow.

Oncology Nursing: Pain in Cancer

Focus topic: Oncology Nursing

Characteristics

Focus topic: Oncology Nursing
A. Incidence.

  • Various studies suggest that 50% of persons with cancer will not experience significant pain.
  • Severe pain is experienced by about 60–80% of hospitalized clients.
  • In early stages of cancer there is little pain—pain that is felt is associated with treatment (surgery).

B. Causes of pain in cancer.

  • Physiological causes.
    a. Bone destruction with infraction results from metastatic lesions secondary to primary carcinomas.
    b. Obstruction of an organ by tumor growth (intestinal obstruction).
    c. Compression of peripheral nerves produces sharp, continuous pain—pain follows nerve distribution.
    d. Infiltration or distention of tissue produces a localized, dull pain that increases in intensity as tumor grows.
    e. Inflammation, infection, and necrosis cause pain from pressure or dilatation and distention of tissue distal to an obstruction.
  • Psychological causes.
    a. This form of pain depends on client’s perceived threat from the condition or stress reaction to it.
    (1) Fear or anxiety generated from the effects the disease may have on the person’s lifestyle or relationships.
    (2) Loss or threat of loss may produce a reactive depression with feelings of despair.
    (3) Frustration of drives or lack of need satisfaction may also contribute to psychological pain.
    b. Perception of threat or stress is influenced by client’s personality characteristics: self-concept, independence–dependence, emotional stability, education, age, etc.

C. The nature of cancer pain falls into two general categories: chronic and intractable pain.

Assessment of Pain

Focus topic: Oncology Nursing
A. Physical dimension of cancer pain is variable.

  • The severity of pain is assessed using a 0- to 10-point scale—0 being pain free and 10 being the worst pain.
  • Teach “pain tasks” to client.
    a. Encourage client to identify and state what, where, and when pain occurs.
    b. This method will help determine which symptoms are most troublesome.
  • Evaluate the meaning of the pain experienced by the client—understand pain as the client views it.

B. Scope of pain assessment must encompass several factors.

  • Severity and duration of pain.
  • Nature of the disease process.
  • Probable life expectancy.
  • Temperament and psychological state.
  • Occupational, domestic, and economic background of the client.

C. Assess vital signs as indicators of pain.

  • Low to moderate pain and superficial in origin—the sympathetic nervous system is stimulated.
    a. Increased blood pressure and pulse.
    b. Increased respiratory rate and muscle tension.
  • Severe pain or visceral in origin—the parasympathetic nervous system is affected.
    a. Decreased blood pressure and pulse.
    b. Nausea, vomiting, and weakness.
  • Pain present for a month or longer (late-stage pain); there will probably be no change in vital signs.

D. Assess client’s behavior as an indicator of pain.

  • Alterations in body posture/gestures.
  • Alterations in activities of daily living.

E. Assess verbalizations, both verbal and nonverbal, as indicators of pain.

  • Ask systematic questions to determine degree of pain: location, radiation, onset, frequency, duration, quality.
  • Determine situational factors that influence pain level: level of consciousness, meaning of pain, attitudes and feelings of others, presence of secondary gains, fatigue level, and stressful life events.
  • Assess and document client’s pain often and regularly.

Oncology Nursing: Treatment Methods

Focus topic: Oncology Nursing

Medication Management

Focus topic: Oncology Nursing
A. Drug therapy is considered the cornerstone of cancer pain management—begins with least invasive and progresses to opioids as pain intensifies.

  • Acetaminophen, aspirin, nonsteroidal antiinflammatory drugs (NSAIDs) relieve mild pain.
  • Opioids (codeine or Vicodin [hydrocodone]) added to regimen as pain progresses.
    a. Given in fixed-dose combinations with aspirin.
    b. Progresses to higher dose or more potent opioid (morphine, Dilaudid [hydromorphone]).
    c. Drugs can be given 24/7 with additional “rescue” doses as needed.
  • Intraspinal morphine administration.
    a. An implantable infusion pump delivers a continual supply of opiate to the epidural or subarachnoid space.
    b. Useful for eliminating intractable pain below the mid- to low-thoracic level where spinal cord opiate receptors respond to morphine.

B. Evaluate client continually for opioid side effects (constipation, nausea, vomiting, sedation, respiratory depression, and urinary retention) that interfere with the goal of the therapy.

Surgical Management

Focus topic: Oncology Nursing
A. Various neurological and neurosurgical interventions effectively manage pain experienced by cancer clients.

  • Nerve blocks, either peripheral or intrathecal, can relieve pain.
  • Procedures involve interruption of pain pathways someplace along the path of transmission from the periphery to the brain.

B. Electrical stimulation of the periventricular gray matter in the brain is used for pain relief.

  • An electrode is implanted through a burr hole on the side opposite the most intense pain.
  • Electrical pulses are then sent periodically into the brain.

Noninvasive Modalities
A. Electrical stimulation may be used for pain relief.

  • Transcutaneous methods: transcutaneous electrical nerve stimulation (TENS) applies stimulation to the skin surface over the painful area.
  • A peripheral nerve implant applies stimulation to peripheral nerves.
  • Electrodes implanted in the dorsal column stimulate spinal column fibers.

B. Hypnosis is currently viewed as one component of pain management.

  • A hypnotic state can achieve significant analgesia.
  • Self-control over pain and its associated anxieties can be assisted with hypnosis.

Oncology Nursing: WORLD HEALTH ORGANIZATION THREE-STEP ANALGESIC LADDER

Focus topic: Oncology Nursing

Oncology Nursing

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Psychosocial Implications

Focus topic: Oncology Nursing
A. Key stress periods for client with cancer are time of diagnosis, period of hospitalization, and release from the hospital.

  • Shock and fear are the major reactions.
  • Severe depression is experienced by some clients.
  • The emotional pain of the diagnosis initially outweighs the physical component of the cancer.

B. Adjustment to cancer depends on past life experiences.

  • A client’s previous attitude toward medical practices, hospitalization, and treatment methods influence adjustment.
  • The manner in which a client has coped with previous stress or crises will determine, in part, how this stress is handled.

C. Phases of psychological adaptation to terminal illness include denial, anger, bargaining, depression, and acceptance.

  • These phases may be experienced differently, clients may experience them in a different order, or they may not experience all of the phases.
  • It is important for the nurse to understand the characteristics of these phases and to recognize which phase the client is in.

D. The client will experience a range of feelings and defense mechanisms.

  • Denial may occur initially with the diagnosis; this is a protective mechanism necessary until the diagnosis can be confronted.
    a. Allow the client to be in denial until he or she is ready to face reality.
    b. Provide opportunities for the client to confront her illness—be open to questions and clarification.
  • Fear and anxiety may manifest in physical symptoms: insomnia, nausea, vomiting, diarrhea, headaches, etc.
  • Anger and resentment, especially in the initial phases of the disease, may be a healthy way of expressing feelings.
    a. Encourage expression of anger—let the client know that you are able to listen to anger, resentment, and frustration.
    b. Encourage client to focus anger on external problem solving and more adaptive coping patterns.
  • Depression may be considered normal for a period of time following surgery.
    a. Observe for the signs of depression.
    b. Because suicide is always a risk with depression, interventions should be aimed at safety for the client.

Psychosocial Care for the Cancer Client

Focus topic: Oncology Nursing
A. Develop a collaborative relationship with the client.

  • Identify and attempt to solve problems together.
  • Engage with clients so that they do not feel they have to cope alone.
  • Provide emotional support to help allay fears and anxieties.

B. Always be honest with the client.

  • Truth is easier to cope with than uncertainty and the unknown.
  • Honesty provides the foundation for a nurse– client relationship.
  • Accurate information can be followed by an open discussion of the disease, the prognosis, the client’s feelings, etc.
  • Knowing the truth enables the client to begin to accept and work out the future without being immobilized by fears.

C. Assist the client to cope with pain.

  • Stay with the client, especially when the pain is severe.
  • Explore the nature of pain with the client.
  • Respect the client’s response to pain and believe what the client tells you.

D. Provide general comfort measures.

  • Position for proper alignment.
  • Use touch and massage for painful areas.
  • Exercise extremities gently to maintain range of motion.
  • Maintain patency of tubes and keep free of infection using meticulous hand hygiene and aseptic techniques.
  • Preserve the client’s energy by prioritizing activities.
  • Assist the client to obtain adequate rest at night and during the day to reduce fatigue.

E. DO NOT under medicate for cancer pain.

  • Under treatment with analgesics has been identified as a major problem (70% to 80%) for cancer clients—and nursing has a crucial responsibility to correct this problem.
  • Two forms of under treatment: physicians under prescribe and nurses routinely administer less than half the amount clients could receive.
  • The danger of overuse of narcotics is a potential problem.
    a. This concern should not result in under treatment.
    b. Only a very small percentage of clients are over medicated.

F. Support family of the client as they move through the grieving process.

  • Be honest with family members to establish a firm relationship.
  • Encourage expression of feelings.

G. Introduce the hospice concept—provides care for the terminally ill client and family.

  • Primary goal is to provide emotional support for the client and family.
  • An accompanying goal is to provide for physical care.
  • Relief of pain is just as important to a dying person as emotional support.

Hospice Care

Focus topic: Oncology Nursing
A. Hospice care provides treatment, comfort, and support for the terminally ill client, as well as relief and solace for the family. Approximately one in three elderly Americans uses hospice service.
B. Hospice neither speeds up nor slows down the dying process—it provides a specialized environment where a dying client may receive medical care in addition to emotional and spiritual support during the dying process.

  • One of the real advantages of hospice is that the personnel are trained to treat pain aggressively.
  • The client should be as pain free as possible, while at the same time remaining as alert as possible.

C. Hospice care includes an interdisciplinary team that includes a registered nurse, a social worker, a home health aide, a chaplain, and trained volunteers.
D. Hospice is reimbursed by Medicare in all states and by Medicaid in some states; for most other insurers, the percentage of care paid for varies by insurance carrier.

E. There are several barriers to hospice care.

  • The client’s physician must certify that the life expectancy of the client is 6 months or less.
  • Some insurance carriers require clients to waive their rights to medical benefits if they are receiving hospice care.
  • The largest obstacle is that there is a problem with communication—between physician and client, client and family, and family and client.
  • When the finality of dying cannot be discussed, hospice care may not present itself as an option.
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