Oncology Nursing Care Plans PDF

Oncology Nursing
Care Plans
Daniele Gde, R.N,, M.S.

Jane Chareffe, R.N., B.S.N., 0.C.N
DELMAR
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THOMSON LEARNING
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Library of Congress Cataloging-in-Publication Data

ISBN 1-56930-004-5
ln frroductory Remarks
An exciting component of this book is the require special certification. Others are very
use of the Nursing Interventions Classifica- basic and may be delegated to another health
tion, a new research based taxonomy of care team member but still need to be
nursing interventions or actions. It was planned, supervised and evafuated by the
developed by a p u p of nurse researchers at professional nurse. For this reason specific in-
the University of Iowa. Nursing Interven- terventions are selected from the set of defin-
tions Classification (NIC) was created to as- ing activities for each NIC label that are
sist nurses in documenting their care, most appropriate for the selected nursing
facilitate the development of nursing diagnosisand type of cancer. The current
knowledge through the evaluation of patient classification represents the completion of
outcomes, help provide a standard language phase 1 of the research project. In phase 2 an
nurses can use to describe their behaviors organizing structure that is easy to use and
when delivering nursing treatments, expand clinically meaningful will be devised. This
nursing knowledge about similarities and process is ongoing. Our thanks to Mosby for
differencesamong diagnoses and treatments, granting us permission to use Nursing Inter-
assist in the development of information sys- ventions Classification (MC)in this book.
tems, provide methods to teach decision We would also like to extend our thanks to
making to students, assist in costing nursing our families especially our husbands for
care and allocating nursing resources, help their unfailing support and patience while
provide communicationbetween nursing we were writing this book.
and non-nursing and help link nursing con-
tent.
Each Nursing InterventionsClassification

(NIC) has three parts: the label or name
describing the concept, the definition of the
concept and a set of defining activities or ac-
tions that a nurse may perform to implement
the intervention concept. The interventions
are very broad based and encompass a wide
range of nursing activities. As such no one
nurse could be expected to perfom all inter-
ventions listed for each label. Many interven-
tions require special training and many
This Page Intentionally Left Blank
Using Oncology Hematology
Care P i a ~ s
These plans have been developed to reflect Nursing InterventjonsClassifica-
tion (NIC) fabel(s)and its defi~tion
nursing care of persons with cancer includ- and selected specific interventions
ing the treatment of cancer and the most with rationales
common types of cancer. In the treatment Information, Instruction,
Demonstration including interven-
chapters a general discussion of the treat- tions and rationales that pertain to
ment is followed by the essential nursing the teaching function of the nurse
diagnoses and care plans using Nursing In- Discharge or Maintenance Evalua-
tion including specific behaviors ex-
terventions Classification (NIC) labels for the pected of a person as a result of the
most common problems. More specific nurs- interventions planned to achieve
the desired outcomes
ing diagnoses and care plans using NIC are
included in the various chapters on specific Since it is not uncommon for persons with
types of cancer for the less comrnon or more cancer to have more than one problem
drug specific type of problems. In the disease and f o r require multiple treatments simul-
specific chapters, an overview of the specific taneously, it may be necessary for the reader
type of cancer is provided followed by essen- to combine plans or use only those portions
tial nursing diagnoses and care plans using of the plan applicable to their individual
NIC. These essential nursing diagnoses and client.
care plans may be cross-referenced with the Oncology/hematology care plans are
nursing diagnoses on managing common designed as a reference for care planning for
side effects from the treatment chapters or nursing students and experienced nurses
other types of cancer where similar nursing caring for persons with cancer in all settings.
care is required. Each essential nursing diag- The overviews of the treatments and types of
nosis and care plan includes: cancer are brief summaries intended to
Nursing Diagnosis as stated in famiIiarize the reader with the most impor-
NANDA taxonomy
tant information, not as a primary informa-
Related factors or risk fac-
torsfetiologies)and the defining tion source.
c h a r ~ t e r i s t i c s ~ sand
i~s
~ p t ospecific ~ ) to each related
factor that have a lat ti on ship to
the specific treatment or type of can-
cer
Outcome Criteria defining the ex-
pected general goal to be achieved
Table of Contents
CHAPTER O N E Diagnosis of Cancer .. l l l l I I . I I . I 3
CHAPTER TWO Surgical Treatment I . I I I I . 4 1 1 . . 4 1 . llll.l.l.l...lll 19
CHAPTER THREE Radiation Therapy.... .....,. .... . ,. ,. ,.. . ,. ,. 49
C U A P E R FOUR Chemotherapy........................ ..... ....63

CHAPTER FIVE Biologic Therapy ,... .... .. ......,..... .. ,.... ...... , .....93
CHAPTER SIX Structural Oncology Emergencies I ,. I I ,. I 1 15
CHAPTER SEVEN Metabolic and Physiologic
Oncologic Emergencies .. ,. ,. ,. . 13 1 I I I I ,. I
CHAPTER EIGHT Lung Cancer......I.. .... . .. .. .. . . . ... . . ... . .. ... ., .. . 155

a I I I
CHAPTER NINE Breast Cancer.., .I.. .. . ,.. ... . .,..,. ... .. .. ..,.... , 179
, I
CHAPTER TEN Genitourinary Cancers . .......... ........ .. ... 203

CHAPTER ELEVEN Gynecologic Cancers .. ,. . ,. .. .. .. .,....... ... 229 I
CHAPTER TWELVE Gastrointestinal Cancers ,. ,. ..... I 243 I I I I . I I I I
CHAPTER THIRTEEN
CHAPTER FOURTEEN
CHAPTER FIFTEEN
CHAPTER SIXTEEN Head and Neck Cancers ..lllllll.l.llllllll..lll. 317
CHAPTER SEVENTEEN Brain Cancer ............................................... 341
CHAPTER EIG H TEEN Sarcomas, Bone, and Soft Tissue .. I . . .. ... ,, .. 365
CHAPTER NINETEEN AIDS Related Malignancies,.. .. I.. , , .. 383 I.I
CHAPTER TWENTY Rehabilitation Needs of the

Oncology Patient. ,. .. ,......,,. I I ,. I ., ., ,. 395
CHAPTER TWENTY - O N € Care of the Terminally Ill
Cancer Patient. I I I I I I I I I ,.. I 363
Chap f er One
Diagnosis of Cancer
Diagnosis of Cuncer
The American Cancer Society estimates that tings. More importantly, never starting to
about one in three Americans now living will s m k e must be stressed in the education of
develop cancer in their lifetime. An es- our youth.
timated 1,700,000 new cases of cancer are
Sunlight is an important factor in the
diagnosed each year in the United States.
deve~opmentof skin cancers. It has been pos-
This estimate does not include carcinoma in
tulated that 90% of all skin cancers could be
situ and basal and squamous cell skin can- prevented by avoiding sun exposure or by
cers. The fiveyear survival rate for all can- using sunscreens and protective measures
cers is around 52%. In this year alone about while in the sun. This is another area in
526,000 deaths will be attributable to cancer.
which early education can lower the in-
In men the most common types of cancers cidence of cancer, because it has been found
are prostate, lung, colon, and rectum; in 80%s f sun-exposure which a person ex-
women they are breast, colon, rectum, and periences in his or her lifetime, occurs before
lung. the age of eighteen.
though anyone can get cancer, it is more Diet, too, appears to play a role in both in-
c o ~ o innthe very old and the very young. cidence and prevention of cancem. Research
Incidence of cancer is associated with a has shown that a high-fat diet may increase
variety of factors including chemicals, radia- the risk of breast, colon, prostate, and
tion, viruses, hormones, certain immune con- ovarian cancers. On the other hand, a high
ditions, and inherited mutations. fiber diet may decrease the risk of colon and
Many types of cancer are thought to be ovarian cancer.
preventable. For example, cigarette smoking The term cancer actually is used to describes
is linked to 90%of lung cancer cases among a group of over 100 different diseases. While
men and 79% of lung cancer cases among there are many different types of cancer, all
women, Smoking is also related to many have a common characteristic- cells gone
other types of cancer, including head and astray. W e n a cell becomes cancerous it
neck cancers, gastrointestinal cancers, and loses its ability to control its rate of division,
some urinary tract cancers. Smoking cessa- and grows without regard to the body’s
tion shouId be a goal in all health care set- needs. Normally, cell birth equals cell death.
However, when a cell becomes malignant or
cancerous, it continues to divide regardless
of need.
4 Oncologv Nursing Care Plans
As these cells accumulate, a tumor or "new ness, rate of growth, and degree of abnor-
growth" develops. Not all new growths are mality of a tumor. They are used in estab-
cancerous. When a biopsy is taken of a new lishing a prognosis and a treatment plan.
growth, the pathologist who reviews the tis- Prognostic markers include the S phase
sue determines whether or not the growth is Index, ploidy, estrogen receptor assay
cancerous based on the growth's ability to (ERA), progesterone receptor assay (PRA)
metastasize or spreading, into other tissues and cathepsin D. Use of these markers is dis-
or organs. The pathologist also tries to iden- cussed in later chapters.
tify the cell from which the tumor arose. This Once the pathologic diagnosis of cancer is
is called the primary, or the site of the made, the patient's tumor must be staged.
cancer's origin. The importance of identify- Staging refers to a classification system,
ing the primary tumor cell is that cancer which is based on the extent of the disease.
treatment is based on it's type. The Tumor, Node, Metastases (TNM) system
Another characteristic of cancer cell growth is the most commonly used staging system.
is its lack of specificity.Normally, cell growth In it the T refers to the primary tumor, the N
is well-ordered and the daughter cell is an refers to regional lymph node involvement,
exact replica of the mother cell. Cancer cells and M refers to metastasis, or spread to dis-
divide in a less controlled manner, dividing tant sites. Based on the TNM system all
into three or four cells instead of the usual tumors are then divided into four stages. The
two cells. As a result, of this anomaly, the stages differ somewhat across various types
daughter cells often lack the materials they of cancers. However, in general, Stage 1
need to continue the normal work of the cell tumors have a good prognosis and Stage 4
and never "mature". cancers, ones that are usually metastatic,
Another term for maturity is differentiation. have a poorer prognosis.
When a cell is less, or poorly, differentiated For some types of cancer a blood test is avail-
the cell is less similar to the tissue of origin. able to assist in diagnosing the cancer and in
The pathologist grades tumors as grade 1 monitoring disease status during treatment.
(well differentiated), grade 2 (moderately These blood tests look for certain substances
well differentiated),grade 3 (poorly differen- called "tumor markers" that are produced by
tiated) and grade 4 (undifferentiated).Grad- tumors. Some tumor markers are very
ing plays a role in prognosis. The less specific and are found in only one type of
differentiated a tumor is the less responsive cancer. Others are less specific and may be
it is to treatment. So, patients with poorly un- present in a variety of cancers. The most com-
differentiated tumors often have poor prog- mon tumor markers include CEA (car-
noses. cinoembryonic antigen), CA 15-3,CA19-1,
Prognostic markers are tests performed on CA 19-9, CA 125, PSA (prostate specific an-
tissue samples which indicate aggressive- tigen) b-HCG (beta Human Chorionic
Diagnosis of Cancer 5
gonadotropin)and alpha fetoprotein(AFT). Essential Nursing

Tumor markers are discussed in later chap-
Dugnoses in Patients
ters under the specific type of cancer in
which their identification is most useful.
with Cancer
Despite advances in the treatment of cancer,
people many still believe that a diagnosis of
cancer think means an immediate; painful
Knowledge Deficit
and disfiguring death. Some people fear 0 Relatedto:
being ostracized, treated differently or Lack of knowledge about the cancer
misunderstood. As a result, the diagnosis of disease process and it's treatment.
cancer is seen as a major life crisis. Common 0 Defining Characteristics:
reactions include'shock, fear, anxiety, grief,
Verbalization of the problem,inac-
agitation, sadness, preoccupation, and curate follow-through of instruc-
withdrawal. However, people cope by draw- tion, request for information.
ing on the same defenses and emotional 0 Outcome Criteria:
resources they have used at other stressful Appropriate knowledge of disease
times in their lives. And, since cancer process and prescribed medical
regime.
patients vary in personality, and experience,
no single coping strategy will be effective for 0 NIC: Teaching- Disease Process
all patients. Definition: Assists the patient to
understand his or her specific can-
The diagnosis of cancer often affects the en- cer and possible treatment options.
tire family and may lead to increased stress
and tension not only for the person with can-
cer, but for their family members, even those
not living with the patient. Reactions of fami- Teaching- Disease Process
ly members to a cancer diagnosis can have a
significant impact on the patient's adapta- I
I
Activities Rationales
tion to the disease. Therefore nursing inter-
Appraise patient's Data will provide
vention must address the problems and current level of baseline for teaching,
needs of both patient and family. knowledge related to avoiding duplication.
cancer.
Describe the cancer Assists patient in
disease process as understanding the
appropriate. disease process.
Provide information Assists patient in
about therapy and/or making treatment
treatment options and decisions.
potential risks and/or
benefits.
4 Oncology Nursing Care Plans
Teaching- Disease Process

I Values Clarification
Activities Rationales Activities Rationales

Use booklets, pictures, Visual aides reinforce Help patient identify Encourages patient to
video tapes charts in instructions. the advantages and look rationally at
teaching disadvantagesof each treatment option.
patient/family. treatment option.
Encourage patient to Promotes patient Obtain informed Promotes informed
explore options or get advocacy in medical consent when consent.
a second opinion as care. amromiate.
appropriate.
Discharge or Maintenance
Instruct patient on Enhances safety upon €valuation
signs and symptoms to discharge.
report to health care Verbalizes knowledge of dis-
provider; give ease process.
necessary phone Identifies potential treatment
numbers. plans along with risks and
Reinforce information Corrects benefits associated with each.
provided by other misinformation.
health care providers.
0 NIC: Values Clarification Ineffective I ndividuaI Coping

Definition: Assists cancer patient
to clarify her/his own values in 0 Related to:
order to facilitate effective decision- Diagnosis of cancer and uncertain
making. prognosis.
Defining characteristics:
Inability to meet basic needs, de-
pendency, chronic fatigue, worry,
Values Clarification
I anxiety poor self esteem, verbaliza-
tion of inability to cope.
Activities Rationales I 0 Outcome Criteria:

I
Determine if there are Allows for correction Anxiety, worry, fatiguereduced to a

differencesbetween misconceptionsor manageable level: demonstrates in-
the patient's view of misunderstanding. creased independence in activities
his or her condition and decision-making process.
and the view of health 0 NIC: Coping enhancement
care providers.
Definition: Assists the patient to
Inform patient of Assist patient in adapt to perceived stressors, chan-
alternative options as understanding options.
ges or threats which interferc?with
appropriate.
meeting life demands and roles.
Coping Enhancement Instructions, Information,

Demonstration
Use a calm reassuring Assists the patient in
approach and provide establishing trust in Answer patient’s Meeting patient
an atmosphere of health care provider. questions or assist education needs may
acceptance. them in obtaining assists in coping.
needed information.
Evaluate the patient‘s Aids in assessment of
decision-making independence in Encourage patient‘s To meet patient’s need
abilities. decision making. assertiveness in for information.
information seeking.
Encourage an attitude Promotes self worth.
of realistic hope. Inform patient of Assists patient in
community resources obtaining appropriate
Support use of Increases ability to
for patient’s and their support as needed.
appropriate defense cope.
families facing cancer.
mechanisms.
Appraise needddesire Provides for patient’s 13 Discharge or Maintenance
for social support. needs. Evaluation
Introduce patient to Provides information Uses appropriate coping and
persons or groups who and support from problem-solving skills in
have undergone the others with similar adapting to functional losses.
same disease experiences. Maintains appropriate level of
experience. functioning and meets basic
Provide spiritual To meet patient’s needs.
resources if desired. spiritual needs. . Requests assistance when
needed.
Encourage family Assists patient to meet
involvement as needs.
atmromiate.
Altered Family Processes
0 Relatedto:
Instructions, Information, Impact of cancer diagnosis and un-
Demonstration certain prognosis.
0 Defining characteristics:
Activities Rat ionales I
Family systems unable to meet
physical, emotional needs. of
Clarify patient’s Assists in patient, or verbalization by family
perceptions about understanding members of inability to cope.
disease process, necessary information
treatments and/or and dispels myths. 0 Outcome Criteria:
possible side effects.
Family demonstrates ability to meet
physical and emotional needs of the
patient and family members.
0 NIC: Family Support

Promotes support of family inter-
I Family Support
ests and goals during the diagnosis

period. Activities Rationales
I
Encourage family To meet family’s need

assertiveness in for information.
information seeking.
Family Support Inform family of Assists family in
community resources obtaining appropriate
for patients and their support as needed.
Activities Rationales families facing cancer.
Appraise family’s To assess for family’s 0 NIC: Family Involvement

emotional reaction to need for emotional
patient’s condition. support. Facilitates family participation in
the emotional and physical care of
Facilitate Promotes the cancer patient.
communication of communication.
concerns/ feelings
between patient and
family and/or between
family members. Family Involvement
Support adaptive To assist family in
coping mechanisms coping with patient’s
used by family if illness. Activities Rut ionales
appropriate.
Identify self-care To identify areas in
Assure family that best To reassure family that deficits in patient. which patient may
care possible is being patient‘s needs are need family’s
given to patient. being met. assistance.
Identify family To obtain needed
Provide spiritual To meet patient’s members’ preferences information in
resources as spiritual needs. and capabilities for planning for patient’s
appropriate. involvement in care after transition.
Introduce family to To provide information patient’s care.
other families and emotional support Identify other Assess areas in which
undergoing similar from others with situational stressors for family may need
experiences. similar experiences. the family. support.
Provide family with Assists the family in Encourage an To provide realistic
information regarding obtaining needed emphasis on positive hope regarding
patients illness and information. aspects of patient’s patient‘s situation.
progress, in accordance situation.
with patient’s wishes.
Encourage family To promote family
Answer family‘s To meet educational members to maintain integrity.
questions or assist needs. family relationships as
them in obtaining appropriate.
needed information.
Instructions, Information, 0 Outcome Criteria:

Demonstration Verbalizes the impact that the diag-
nosis of cancer may have on his or
her role(s) and demonstrates ability
Activities Rationales to deal with role conflict or chang-
ing role(s).
Facilitate family’s To provide family with
acquisition of needed necessary information 0 NIC: Role Enhancement
information, and to make decisions
promote family regarding patient’s Assists patient, significant other,
management of care, if needed. and/or family in clarifying impact
medical aspects of of cancer diagnosis on roles, and
illness, if appropriate. thereby improve relationships.
Assist family to Assists the family to

acquire necessary provide adequate care
knowledge, skills, and for patient at home.
equipment to provide Role Enhancement
care for patient at
home as atmromiate.
0 Discharge or Maintenance Activities Rat ionales

Evaluation Assist patient to To asses baseline roles.
Family demonstrates cohesion identity usual roles in
and unity her/his family, work,
and co munity.
Family participates in the
emotional and physical care Assist patient to To establish role
of the cancer patient identify specific role changes that may be
Uses appropriate support changes required due necessary.
resources provided by com- to illness.
munity / private professionals. Assist patient to Promotes resolution of
identify positive potential role conflicts.
strategies for
managing role changes.
Altered Role Performance Facilitate discussion of Open communication
role adaptations of assists in preventing
0 Related to:
family to compensate conflict over role
Impact of cancer diagnosis on the for ill member’s role changes.
patient‘s roles within her or his changes.
family and community. Assist jfamily to Promotes successful
0 Defining Characteristics: acquire necessary implementation of
knowledge, and skills needed role changes.
Change in patient’s self-perception to support role
of role; change in others’ perception chan~esas needed.
of role; change in physical
capacities to resume role(s)and/or
responsibilities.
Role Enhancement
I I Anxiety Reduction

I I
Instruct on possible Provides financial and Assess for signs and Assists in identifymg
support services psychological symptoms of anxiety. severity of anxiety.
available to assist counseling.
Use a calm reassuring Promotes trusting
patient and/or family
approach. environment.
while coping with role
changes. Employ active Encourages venting of
listening techniques. feelings.
0 Discharge or Maintenance
Evaluation Support use of Defense mechanisms
appropriate defense assist in coping during
s Discusses impact of diagnosis mechanisms. stressful periods.
on role(s). Administer Promotes ability to
Identifies personal strengths medications to reduce cope.
and resources to deal with anxiety as appropriate.
role changes.
Anxiety Instructions, Information,

Demonstration
0 Relatedto:
Perceived threats to self due to can-
cer. Act iuities Rationdes
0 Defining Characteristics: Explain all procedures. Alleviates anxiety.
Communication of feelings of uncer- Instruct in relaxation Alleviates anxiety.
tainty, apprehension, fear and/or techniques such as
presence of restlessness, sleepless- relaxation exercises,
ness, or other signs of anxiety. guided imagery, music
therapy.
0 Outcome Criteria:
Refer to support Provides support
Anxiety level reduced and main- groups and/or during periods of
tained at acceptable level. counseling as stress due to cancer
NIC: Anxiety Reduction appropriate. diagnosis.
Facilitate collaborative Promotes self-control
Definition: Minimizes apprehen-
decision-making. over treatments.
sion or uneasiness over cancer as an
anticipated danger. Help patient explain Provides support for
her or his decision to patient's decision.
others.
0 Discharge or Maintenance 0 NIC:Hope Instillation

Evaluation
Definition: Facilitates the develop-
Statements that anxiety is ment of a positive outlook on the
reduced. cancer diagnosis and treatment o p
Participation in anxiety, reductions when appropriate.
ing techniques.
Anticipatory Grieving Hope Instillation
0 Related to:
Actual and/or perceived losses due
to cancer, such as loss of health, loss Assist pa tient /family Promotes feelingsof
of life, work, income, privacy, in- to identify areas of self-worth.
timacy and relationships. hope in life.
0 Defining characteristics: Assist the patient to Promotes self-control
devise, and revise, over situation.
Patient exhibits and /or expresses goals related to hope
feeling of sadness or loss. object.
0 Outcome Criteria: Avoid masking the Promotes trusting
truth. relationship.
Patient identifies perceived and/or
actual losses; demonstrates move- Encourage therapeutic Provides needed
ment through stages of the grieving relationships. emotional support.
process; identifies resources to deal Support spiritual Providing spiritual
with losses.
beliefs. support can help
0 NIC: Grief Work Facilitation reduce anxietv.
Assists cancer patient with resolu-

tion of loss associated with cancer.
Grief Work Facilitation
Assist patient in Allows for venting of
identifymg the loss feelings.
and encourage
expression of feelings
about it.
Assist in identifymg Promotes patient’s
personal coping ability to cope with
strategies. potential life-
threatening illness.
Instructions, Information, 0 NIC: Sexual Counseling

Demonstration Definition: Use of an interactive
helping process focusing on the
need to make adjustments in sexual
Activities Rationales I
practice or to enhance coping with
a sexual event/disorder.
Instruct in phases of Promotes
the grieving process as understanding of
appropriate. behaviors in grieving.
Inform of community Positive support
resources available that systems assist patient Sexual Counseling
help with loss. in coping with illness.
Teach patient and Assists patient/family
family of positive in understanding need Activities Rationales
aspects of hope. for hope.
~~ ~~~ ~~ ~
Establish a therapeutic Promotes open

relationship based on communication.
Evaluation trust and respect and
provide privacy and
Patient discusses feelings confidentiality.
regarding anticipated loss.
Assess the effects of Provides information
Patient maintains significant the illness or treatment to assist patient in
relationships and support sys- on sexuality as coping with effects.
tems. appropriate.
Patient maintains self-care
and basic needs. Encourage patient to Provides patient with
verbalize fears and ask needed knowledge.
Patient identifies resources to questions.
deal with losses.
Help patient to express Promotes working
grief and anger about through the grieving
alterations in body process a normal part
Altered Sexual Patterns functioning/appearance of dealing with loss.
as appropriate.
0 Related to: Discuss alterative Promotes sexual
forms of sexual expression.
Cancer disease process, ineffective expression that are
control of symptoms, and the ef- acceptable to the
fects of cancer treatments. patient as appropriate.
0 Defining Characteristics: Include spouse/sexual Promotes open
Verbalization of inability to perfom partner in discussion communication
sexually, achieve sexual satisfaction, as much as possible. between patient and
altered body structure from surgery sexual partner.
or cancer treatment impaired sexual Refer to sexual Promotes healthy
or reproductive functioning. therapist as sexual relationship.
0 Outcome Criteria: appropriate.
Patient/significant other will return

to a satisfying sexual relationship.
Diagnosis of Cancer 1.3
Instructions, Information, 0 Defining Characteristics:

Demonstration Patient/family express difficulty in
maintaining their home adequately,
describe outstanding debts or finan-
cial crisis, or request assistance with
home maintenance.
Instruct patient/family Prevents possible birth
of rationale for defects due to C>utcomeCriteria:
avoiding pregnancy mutagenicity of
during chemotherapy. chemotherapy agents. Patient/familydescribe resources
to maintain home management.
Inform patient/sexual Promotes informed
partner of possible consent to herapy as 0 NIC: Home Maintenance
long term effect on appropriate, Assistance
reproduction due to Definition: Helping the
chemotherapy, surgery patient/family to maintain the
Dr radiation therapy as home as a clean, safe, and pleasant
appropriate. place to live.
Inform patientfpartner Provides method for
of spermlegg banking preserving
as an option for reproductive
expected long term functioning.
reproductive effects as Home Maintenance Assistance
appropriate.
Discharge or Maintenance Activities Rationales

Evaluation
Determine patient's Provides knowledge to
Patient will describe personal home maintenance develop plan of care
risk factors for sexual dysfunc- requirements. based on needs.
tion and alternate exceptable
methods of sexual expression Assist family members Promotes realistic
and intimacy. to develop realistic planning.
Patient will discuss options to expectationsof
preserve reproductive themselves in
functio~ng if possible. ~ r f o r ~ nofc their
e
rolse.
Offer mlutions to Promotes resolving of
financial problems as financial concerns.
Impaired Home appropriate.
Maintenance ~ a n a ~ e m e n ~ Refer to social services Promotes use of
as ap~ropriate. appr~priateresources.
Relatedto:
0 IVIC: Discharge Planning
Diagnosis of cancer and its treat-
ment depleting family resources Definition: Preparation for moving
financial or patient unable to main- a patient from one level of care to
tain home due to inadequate sup- another within or outside the cur-
port systems. rent health care agency.
Discharge Planning Instructions, Information,

Demonstration
I Activities Rat ionales
Monitor readiness for Provides information
discharge. for planning discharge. Instruct/demonstrate Provides
on any identified Patient/family with
Identify patient Promotes development
unmet educational needed information.
teaching needed post- of realistic dishcarge
needs prior to dischare.
discharge. plan.
Inform of respite care Provides relief for
Encourage self care as Promotes
available as caregivers as
appropriate. independence.
appropriate.
~~~
appropriate. ~~
Collaborate with Provides continuity of

physician, care acress all levels of 0 Discharge or Maintenance
patient/ family,,and care. Evaluation
other health care team
members in planning Patient/family describes dis-
for continuity of care. charge plan and date.
Patient/family demonstrate
Arrange for caregiver Provides needed care necessary skills to provide
support (home health in the home setting. care in the home setting or
nurse, aid, sitter, provide care need by use of
PT/OT, hospice) as home health care providers.
appropriate.
Develop a plan that Promotes development
considers the health of a realistic plan of
care, social and care. Fear
financial needs of the
patient. 0 Related to:
Fear of death due to diagnosis of
cancer.
0 Defining Characteristics:
Instructions,Information,
Demonstration Expresses fear of death, feeling of
dread, pessismism over diagnosis.
0 Outcome Criteria:
Patient verbailzes methods to cope
Inform community Promotes use of with fears over cancer diagnosis
resources available for appropriate resources.
persons with cancer 0 NIC: Active Listening
including the Definition: Attending closely to or
American Cancer attaching significance to a patient's
Society, National verbal and nonverbal messages.
Cancer Institute,
~ Hospie etc.
Active Listening
Display interest in the Promotes sharing by
patient and what is patient.
being communicated.
Display an awareness Converys interest and
of and sinsitivity to empathy towards
emotions. patient.
Listen for the Promotes full
unexpressed message. understanding of
patient's message.
Time a response that Promotes
reflects an communicationin an
understanding of the appropriate manner.
received message.
Be aware of the tone, Promotes
tempo, volume, pitch, communicationof
and inflection of the intended message.
voice.
0 NIC: Crisis Intervention

Definition: Use of short term coun-
seling to help the patient cope with
a crisis and resume a state of
functioningcomparable to or better
than the pre-crisis state.
Crisis Intervention
Encourage expression Promotes ventilation of
of feelings in a feelings.
nondestructive manner.
Assist in identification Promotes use of
of personal strengths patient's strengths in
and abilities that can coping with cancer
be utilized in resolving diagnosis.
the crisis.,Promotes use
of patient's strengths
in coping with cancer
diagnosis.
Chapter Two
Surgery
Surgical Treatment
Surgery was the earliest intervention for the Needle Aspiration
treatment of tumors, and it remains one of
the integral parts in the management of can- Needle aspiration refers to a suctioning of
cer patients today. Almost every patient diag- tumor cells into a syringe. The patient is
nosed with cancer will undergo a surgical given a local anesthetic and a needle is in-
procedure during the course of their treat- serted and passed through the tumor as suc-
ment. The surgical approach is used to tion is applied. This is a simple, inexpensive
prevent cancers from occurring, treat exist- procedure; however, the cells obtained may
ing disease, facilitate the various treatments, be fragmented,affording only a cytologic
prevent recurrence, and to relieve symptoms. diagnosis rather than histologic.
Diagnosis Needle Biopsy

The successful treatment of cancer requires a The needle biopsy is performed with a spe-
treatment plan based upon a pathological cially designed needle and biopsy apparatus
diagnosis of the disease. The tissue upon in which a core of tissue is removed as the
which this diagnosis is made is obtained by a needle moves into or out ofthe
surgical intervention, a biopsy. The type of tumor.(e.g.,True Cut, Franklin etc.)
biopsy performed is a decision made based The patient generally is given a local anes-
on the type of cancer, it's location, the extent thetic, then the location of the tumor may be
of disease, and the patient's general state of confirmed with an imaging technique. This
health. All patients with a particular type of method of biopsy is relatively simple but
cancer will not undergo the same tests; often is not used if the disease is located near
evaluation of tests is individualized and major blood vessels or fragile, normal tissues.
based on many factors.
Four methods are used to obtain tissue for
diagnosis - needle aspiration, needle biopsy, lncisional Biopsy
incisional biopsy, and excisional biopsy. Each
has its advantages and disadvantages. The incisional biopsy is performed through
an opening in the skin created with a scalpel.
The procedure is often performed in an out-
patient setting. Following the local ancs-
thetic, an incision is made and a piece of
20 ONCOLOGY NURSING CARE PLANS
tumor is carefully removed to avoid any chemotherapy or radiation therapy. This pro-
spread of tumor cells. This method of biopsy cedure is not as routine as it once was be-
is used to confirm tumors (e.g.,sarcomas) cause of the improvements in imaging and
when more extensive surgery is anticipated. biopsy techniques. Staging laparotomy is the
procedure of choice for many intra-ab-
dominal malignancies.
Excisioncrl Biopsy
Excisional biopsy also requires a surgical in- Treatment
cision, but during this operation the entire
tumor is removed. Depending on the size Surgery alone can be used in the treatment of
and type of tumor, this procedure may also cancer or used in combination with treat-
be done in the outpatient setting. ments of chemotherapy, radiation therapy,
and/or biotherapy. These treatments may
precede a surgical procedure to shrink the
Staging tumor, making it operable. They also are
used to treat micrometastatic disease. In-
Some cancers require surgery as part of the traoperative radiation therapy and
sk-gingprocess. Staging of cancer refers to chemotherapy are used to treat both residual
the process of establishing the extent of a tumors and the area from which the tumor
person's disease, and is often completed was removed. Sometimes, such treatments
with radiologic imaging and surgery. Staging are used following surgery to treat residual
of disease allows for a systematic approach disease or to prevent recurrence.
to planning treatment. Many different types of surgical interven-
An example of a surgical staging procedure tions are performed in the removal of
is the diagnostic laparotomy, a major surgical tumors. One, local excision, refers to the
procedure during which the surgeon can ob- removal of cancer with a small margin of nor-
serve and biopsy internal organs and lymph mal tissue. The wide excision refers to the
nodes, remove organs (if possible), or removal of the disease along with surround-
remove suspicious lymph nodes. During the ing lymph nodes and often adjacent tissue.
procedure markers may be placed to Cryosurgery is the use of liquid nitrogen to
evaluate the course of treatment. The staging freeze tissues, and has been successful in the
laparotomy was used routinely for many treatment of prostate and hepatic cancers.
years in the treatment of Hodgkin's disease. Electrosurgery employs an electrical current
It was used to determine if disease was to kill cancer cells. Chemosurgery, a techni-
present below the diaphragm, which indi- que using topical chemotherapy and layer-
cated whether that patient should receive by-layer removal of cancerous tissue, is a
SURGICAL TREATMENT 21
common treatment for squamous cell cancer radiation therapy is generally placed in the
of the skin. Laser surgery ionizes water in a operating room then loaded with the radioac-
pin point fashion to destroy tumor cells. The tive material after the patient has returned to
type, or types, of surgical intervention that a their room. Chemotherapy, immunotherapy,
patient receives depends on the type of can- blood products, TPN, and the administration
cer, the extent of disease, the goal of treat- of antimicrobialsare reasons for implanting
ment, and the general health of the patient. multi-lumen, vascular access devices. These
devices allow for delivery of therapy at
Surgery is sometimes used in the prevention
of cancer. For example testicular cancer has home without the risk of peripheral IV in-
filtration. For example, the ommaya reser-
been associated with undescended testicles;
voir is a device that allows administration of
Orchiopexy, a procedure to bring the testicle
chemotherapy to the central nervous system,
down into the scrotum, is performed with
thereby eliminating the need for frequent,
the hope of preventing the occurrence of this
painful lumbar punctures. Implanted pumps
cancer. Other examples of preventive
have been used for direct arterial administra-
surgery include: colectomy for ulcerative
colitis, mastectomy for high risk breast can- tion of chemotherapy to the tumor over a
long period of time (e.g.,hepatic artery in-
cer, thymidectomy to prevent medullary can-
fusion).Many different types of pumps, ac-
cer of the thyroid, and oophorectomy for
cess devices, and catheters are in use, and it
familial ovarian cancer.
is important to refer to agency protocol when
The surgical removal of existing disease
using this equipment.
often includes reconstruction at the time of
Surgery is also used as a palliative. When a
the procedure. Many women who choose
cure is no longer possible, and comfort
mastectomy for the treatment of breast can-
and/or improved quality of life is the goal,
cer have a reconstructive procedure at the
surgery may be ordered. Examples include,
time of breast removal; others may choose to
but are not limited to, stabilization of a bone
have reconstruction done at a later time.
to prevent fracture; removal of a solitary
Bone cancers are often excised after which
metastasis (e.g.,brain); reIief of an obstruc-
rods, grafts, or stabilizing devices are put in
tion in an airway, the bowel, or ureters; and
place during the procedure. A cystectomy,
treatment of an oncologic emergency. The
removal of the bladder, can be followed by
remLova1 of fluid from the pericardial sac
the creation of an internal or external device
which is causing cardiac tamponade would
to collect urine. These are only a few ex-
be such an oncologic emergency. Surgery is
amples of reconstructive procedures.
also a frequent intervention for symptom
Facilitationof treatment by implanting ac-
control in advanced cancer. Pain may be
cess devices, ports, pumps, or other
treatted by a nerve blocking procedure or the
hardware is another common reason for
surgery. The hardware used for internal
placement of a spinal catheter to deliver 0 Outcome Criteria:

medication. Appropriate understanding of the
surgical intervention,perioperative
Surgical oncology has become a specialty and post-operative recovery.
within cancer care, challenging providers to 0 NIC: Teaching- Preoperative
provide devise unique care for their patients.
Definition: Assisting a patient to un-
derstand and mentally prepare for
surgery and the postoperative
recovery period.
Essential Nursing
Diugnoses for the
Surgical Oncology
Teaching-Preoperative
Anxiety Determine the Provides data for

patient’s previous individualization of
(a.
1) surgical experiences teaching.
and level of knowledge
0 Relatedto:
related to surgery.
Perceived threat to self due to n- Appraise the patient’s Provides opportunity
cer and uncertain surgical outcome. anxiety about surgery. to express feelings, and
0 Defining Characteristics: to obtain information
to help alleviate
Communication of feelings of uncer- anxiety.
tainty, apprehension, fear, and/or
presence of restlessness or other Inform the patient and Provides infomation
signs of anxiety. significant other(s)of to patient and family.
the scheduled date,
0 Outcome Criteria: time, and location of
surgery.
Anxiety level reduced to an accept-
able level. Inform the patient and Information may
significantother(s) alleviate anxiety.
regarding how long
surgery is expected to
last.
Knowledge Deficit
Describe the Assists patient in
0 Relatedto: preoperative routines understanding the
of anesthesia, diet, need for these
Lack of knowledge about an im- bowel preparation procedures.
pending surgical intervention. testdlabs, voiding,
0 Defining Characteristics: skin preparation, IV
therapy, clothing,
Verbalization of the problem, inac- transportation to
curate follow-through of instruc- operating room as
tion, request of information. appropriate.
Teaching-Preopera tive Teaching-Preoperative

Describe any Assists patient in Evaluate the patient’s Prevents
preoperative understanding the ability to return misunderstanding of
medications, their need for these demonstrate splinting instructions and allows
effects on the patient, medications and their incision, coughing, and for clarification if
and the rationale for potential side effects. deep breathing. necessary.
their use.
Instruct the patient on Provides opportunity
Provide time for the Allows for clarification how to use incentive to learn and practice
patient to ask of information. spirometer. with equipment.
questions and discuss
Evaluate the patient’s Prevents
concerns.
ability to return misunderstanding of
Reinforce the patient’s Reduces anxiety. demonstrate proper instructions and allows
confidence in the staff use of the incentive for clarification if
involved. spirometer. necessary.
Provide information Promotes increased Instruct the patient on Provides opportunity
about what will be knowledge and leg exercises. to learn and practice
heard, smelled, tasted, decreased anxiety. exercises.
or felt during the
Evaluat’ethe patient‘s Prevents
experience.
ability to return misunderstanding of
Discuss possible pain Provides information demonstrate leg instructions and allows
control measures. regarding options exercises. for clarification if
available. necessary.
Explain the purpose of Allows patient to Stress the importance Promotes cooperation
frequent postoperative understand routine, of early ambulation of patient in
assessments. which reduces anxiety. and pulmonary care. postoperative routine.
Describe the Increase’s patient’s Inform ithe patient Allows patient to
postoperative understanding of about how he or she participate in care.
routines/equipment surgical plan of care. can aid in recuperation.
(medications,
Determine the Provides opportunity
respiratory treatments,
patient’s expectations to reinforce potential
tubes, machines,
of the surgery. surgical outcomes.
support hose, surgical
dressings, ambulation, Correct unrealistic Promotes
diet, family visitation) expectations of surgery. understanding of
and explain their surgery.
Pu’po=* Instruct the patient to Provides information
Instruct the patient on Provides opportunity use coping techniques the patient may use as
the technique of to learn and practice in contmlling specific necessary.
splinting incision, behavior. aspects of the
coughing, and deep experience (e.g. ,
breathing. relaxation. imaeerv).
Teaching-Preoperative
I 0 Discharge or Maintenance
Evaluation
Expresses reduction in anxiety
Activities Rationales about surgical procedure.
I
Verbalizes understanding of
Inform the significant Provides information
surgical procedure and ex-
other(s) on where to about location.
pected routines.
wait for results of
surgical procedure. + Participates in self-care follow-
ing surgery.
Conduct a tour of the Promotes increased
post-surgical unit. knowledge and
reduces anxiety.
Introduce the patient Promotes familiarity Ineffective Airway Clearance
to surgical and post- with personnel.
operative staff. Related to:
Tracheobronchial secretions,
obstruction, or infection associated
with anesthesia administered
during surgery.
Instructions, Information,
Demonstration 0 Defining characteristics:
Abnormal breath sounds (rales,
crackles, rhonchi, wheezes), cough,
Activities Rat ionales change in rate or depth of respira-
tion, dyspnea, tachypnea, cyanosis.
Explain reason for Provides information
surgical procedure and about surgery and 0 Outcome Criteria:
what to expect in the desired effects.
preoperative, Breath sounds remain as close to
perioperative, and baseline as possible
postoperative periods. Ability to cough and remove secre-
tions.
Inform patient and Reduces fear of
significant other(s) of unknown; may Absence of respiratory infectious
types of tubes, decrease anxiety. process.
dressings, and 0 NIC: Respiratory Monitoring
equipment to be used
during hospitalization. Definition: Collection and analysis
of patient data to ensure airway
Correct any Prevents unnecessary patency and adequate gas exchange.
misinformation and fear due to inaccurate
answer all questions information or beliefs.
honestly and in lay
language.
Respiratory Monitoring Instructions, Information,

Demonstration
Activities Rat ionales

.Activities Rationales
Assess patient's cough, Reveals characteristics
it's onset duration, and that may indicate Instruct patient to Provides subjective
patterns.espiratory infection or report changes in infomation on
status. inflammation. respiratory pattern, respiratory status.
effort, and secretions.
Assess patient's Reveals infection or
Rspiratory secretions inflammation. 0 NIC: Cough Enhancement
(amount, color,
consistency, odor). Definition: Promotion of deep in-
Monitor rate, rhythm, Provides baseline data halation with subsequent genera-
depth and effort of regarding patient's r tion of high intrathoracic pressures
respirations. and compression of underlying
lung parenchyma for the forceful ex-
Auscultate breath Assesses the character pulsion of air.
sounds, noting areas of of each patient's
decreased or absent breathing pattern and
ventilation and provides data which
presence of may indicate a
adventitious sounds. developing problem. Cough Enhancement
Note location of Provides baseline data.
trachea.
Provides information
.4cfivities Rationales
Monitor for noisy
respirations. regarding possible Assess coughing Provides background
airway obstruction. ability i3nd limitations. data.
Monitor chest x-ray Provides data that may Assist patient to a Facilitates coughing.
reports. require physician's sitting position with
intervention. head slightly flexed,
Monitor patient's Reinforcement of shouldias relaxed, and
ability to cough preoperative knees flexed.
effectively. instructionsmay be Encourage patient to Provides adequate
necessary. take several deep reserve prior to
Document monitoring Provides pertinent breaths'. coughing.
data in the patient's information regarding Encourage patient to Promotes airway
medical record. the patient's take a deep breath, expansion and
respiratory status. hold it for 2 seconds, movement of
cough 2 or 3 times in secretions.
succession.
Instruct patient to Facilitates airway re-
follow #coughingwith expansion.
several maximal
inhalation breaths.
Cough Enhancement Ventilation Assistance
Act iuit ies Rationales I Activities Rationales

Teach patient how to Promotes deep Administer pain Prevents
splint abdominal breathing. medication. hypoventilation.
incisions and to use Ambulate as ordered. Promotes lung
pain medications expansion.
before coughing.
Administer Promotes airway
Encourage use of Promotes deep medications that are patency and gas
incentive spirometer. breathing;. ordered (e.g. exchange.
bronchodilators,
inhalers).
Demonstration
Demonstration
Reinforce preoperative Promotes raising and
instructions regarding expectoration of I
deep breathing and secretions.
Inform patient about Promotes compliance
ccughing. importance of changes with prescribed
in position and medical regimen.
NIC: Ventilation Assistance
ambulation.
Definition: Promotion of an op- Instructs patient in Ensures understanding
timal spontaneous breathing pat- administration of of correct drug dosage,
tern that maximizes oxygen and medications via proper route, and potential
carbon dioxide exchange in the route, time of day, side-effects.
lungs. relationship to foods or
drinks, management,
and the reporting of
side-effects.
Ventilation Assistance 0 Discharge or Maintenance
Evaluation
Activities Rat ionales . Patient verbalizes under-

standing of need for changes
Maintain a patent Promotes air exchange. in position and ambulation
airway. postoperatively.
Position to alleviate Facilitates chest
. Participates in self-care includ-
ing, deep breathing, cough-
dyspnea. expansion and
ing, and use of the incentive
respiratory efficiency.
spirometer.
Assist with frequent Prevents accumulation
position changes. of secretions.
0 Changes in patient’s Airway Management

respiratory status are docu-
mented.
I
I
Act ivit ies RationaZes
Provide mouth care Prevents drying of oral
Ineffective Breathing after suctioning. mucus membranes.
Administer humidified Promotes liquefaction
0 Relatedto: air. of secretions for easier
Postoperative inability to maintain elimination.
gas exchange sufficient for cellular Regulate fluid intake Maintains hydration
requirements. to optimize fluid which aids in
0 Defining characteristics: balance. liquefaction of
secretions.
Shortness of breath, dyspnea,
tachypnea, cough, respiratory
depth changes, cyanosis, abnormal
arterial blood gases.
0 Outcome Criteria: Instructions, Information,
Demonstration
Return of respiratory status to
baseline parameters.
Optimal breathing pattern Activit ies Rationales
and ventilation.
Effective breathing effort. Discuss reasons for Promotes cooperation
Absence of respiratory infec- chest physical therapy through increased
tious process. and siictioning. understanding.
Inform patient of need Liquefies secretions for
0 NIC: Airway Management
to maintain or increase easier elimination.
Definition: Facilitation of patency fluid intake.
of air passages.
I7 Discharge or Maintenance
Evaluation
Patient maintains thin, clear
secretions that can be
I Airway Management coughed up or removed from
airways by suctioning.
Maintains hydration status
Activities Rationales with increases in intake when
I
needed.
Perform chest physical Promotes ventilation
therapy. by dislodging and 0 NIC: Oxygen Therapy
raising secretions.
Definition: Administration of
Remove secretions by Removes secretions oxygen and monitoring of its effec-
suctioning. when patient is unable tiveness.
to expectorate on their
own.
Oxygen Therapy Instructions, Information,

Demonstration
I
Activities RationaZes
Clear oral, nasal, and Promotes the delivery
tracheal secretions. of oxygen. Discuss with family Promotes cooperatioi
reasons for through increased
Instruct patient about Promotes correct
administration of understanding.
importance of leaving administration of
oxygen therapy.
oxygen device in place. oxygen.
Instruct patient to Provides data
Monitor position of Prevents incorrect
report changes in regarding patient‘s
oxygen delivery device. placement of
ability to breathe comfort with oxygen
equipment.
comfortably with therapy.
Periodically check Promotes delivery of oxygen therapy.
oxygen delivery device oxygen as ordered.
to ensure that the 0 Discharge or Maintenance
prescribed Evaluation
concentration is being
administered. Patient complies with ordered
oxygen therapy.
Change oxygen Promotes adequate Maintains position of oxygen
delivery device from nutrition. therapy equipment.
mask to nasal prongs
Reports changes in breathing
during meals as
pattern.
tolerated.
Monitor patient’s Provides data
anxiety related to the regarding patient’s
need for oxygen emotional state. Impaired Gas Exchange
therapy.
Assess for skin Re-position oxygen 0 Related to:
breakdown from therapy delivery
Postoperative ventilation perfusion
friction of oxygen equipment as
imbalance.
therapy device. necessary.
Provide for oxygen Provides continuity of 0 Defining characteristics:
therapy when patient care. Confusion, restlessness, irritability
is transported. hypoxia, hypercapnia, inability to
move secretions.
Outcome Criteria:
Arterial blood gases within normal
range; return of respiratory rate and
depth to baseline parameters; ab-
sence of hypoxemia .
0 NIC: Acid/Base Management-
Respiratory Acidosis
Definition: Promotion of acid-base
balance and prevention of complica-
tions resulting from serum pCoZ 0 NIC: Acid-Base Management-

levels higher than desired. Respiratory Alkalosis
tions resulting from serum pCoZ
levels lower than desired.
Acid/Base ManaQement-
Respiratory Acidosis
Activities Rationales Acid/Base Management-

Respiratory Alkalosis
Monitor patient Provides for ongoing
symptoms. assessment.
Obtain ordered Provides data related Activities Rationales
specimens for base to laboratory analysis
balance (e.g., ABG's, of acid-base balance. Monitor arterial blood Provides lab value that
urine, serum). gases for increasing pH. may indicate
development of
Monitor arterial blood Provides lab value that
may indicate respiratory alkalosis.
gases for decreasing
PH. development of Maintain patient Provides access to
respiratory acidosis. intravenous. circulation lines.
Facilitate adequate Promotes chest Monitor for neurologic Ensures early
ventilation to expansion and ease of and/or neuromuscular recognition of signs
prevent/treat breathing, pulmonary manifestations of that may indicate
respiratory acidosis circulation, and gas respiratory alkalosis respiratory alkalosis.
(e.g., position patient exchange. (e.g.,paresthesia,
upright, maintain tetany, seizures).
airway).
Monitor for Provides data that may
Promote adequate rest Provides short periods cardiopulmonary indicate development
periods. of sleep. alkalosis of respiratory alkalosis.
(e.g.,arrhythmias,
hyperventilation).
Promote orientation. Decreases anxiety.
Instruction,lnformation,
Demonstration
Activities Rationales Demonstration
I
Monitor neurologic Ensures early

status (e.g.,level of recognition of changes
consciousness, in mental status. I
I
confusion).
Instruct patient and Provides information
family on actions taken about procedures.
to treat respiratory
acidosis/alkalosis.
Instructions, Information, Mechanical Ventilation

Demonstration

Provide patient with a Promotes
Explains reasons for Promotes cooperation. means of communication of
patient positioning. communication (e.g., thoughts and feelings.
paper and pencil,
0 Discharge or Maintenance alphabet board) during
Evaluation mechanical
ventilation.
Patient Maintains acid -base
balance. Check all ventilator Prevents leaks.
Maintains position of optimal connections regularly.
chest expansion and ventila- Empty condensed Removes a potential
tion. water from water traps. source of infection.
0 NIC: Mechanical Ventilation Use aseptic technique. Prevents transfer of
organisms.
Definition:Use of an artificial
device to assist a patient to breathe. Monitor ventilator Ensures proper
pressure readings. ventilator settings.
Mechanical Ventilation
Demonstration
Monitor patient’s Provides patient data.
physiological and Activities Rationales
psychological status in Explain to patient all Reduces patient
response to mechanical procedures and use of anxiety about
ventilation. equipment. equipment.
Routinely monitor Promotes adherence to Inform patient of Promotes cooperation,
ventilator settings. ordered ventilation reasons for reduces anxiety.
assistance. medications (e.g.,
Monitor for decrease in Provides information muscle paralyzing
exhale volume and that may indicate agents).
increase in inspiratory change in patient’s
pressure. breathing pattern. 0 Discharge or Maintenance
Evaluation
Ensure that ventilator Ensures immediate
alarms are on. awareness of problems. Maintains adequate gas ex-
change.
Administer muscle Promotes patient
paralyzing agents, comfort during
sedatives, and narcotic mechanical ventilation.
analgesics.
Decreased Cardiac Output lnstru~tjons,Information ,

Demonstration
0 Related to:
Surgical intervention and ad-
ministration of anesthesia.
D Defining characteristics: Communicates Allows for prompt
changes in TPR and BP treatment to prevent
Variations in blood pressure read- to medical personnel. complications.
ings, jugular vein distension, Documents Provides information
decreased peripheral pulses, arryth- instrumentation to staff.
mia, color changes in skin and evaluation.
mucous membranes, cold, clammy
skin, oliguria, dyspnea, rales, rest- 0 NIC: Intravenous Therapy
lessness.
Definition:Administration and
D Outcome criteria: monitoring of intravenous fluids
Maintenance of stable blood pres- and medications.
sure, pulse rate and rhythm,
respiratory parameters within
baseline readings, absence of ar-
rhythrmas.
IntravenousTherapy
0 NIC: Vial Signs Monitoring
Definition: Collection and analysis
of cardiovascular,respiratory, and Activities Rationales
body temperature data to deter-
mine, and prevent, complications. Verity order for IV Prevents error.
therapy.
Maintain strict aseptic Prevents infection.
technique.
Vital Signs Monitoring

I Exanune the solution
for type, amount,
expiration date,
Promotes IV therapy.
character of the
Activities ~#i~n~les solution, and lack of
damage to container.
he nit or blood Provides baseline and
pressure, pulse, continuing data for Select and prepare Tv Ensures accurate rate
temperature, and comparative infusion. of infusion.
respiratory rate. judgements.
Monitor IV flow rate Promotes early
Monitor skin color, Provides information and IN. recognition of site
temperature, and regarding patient's during infusion
moistness. hernodynamic status. phlebitis and
extravasation.
Check periodically the Promotes collection of
accuracy of correct info~ation. Monitor for fv pateney Prevents extravasation
i n s ~ used ~ ton ~ of medication.
prior to a d ~ n i s ~ a t i o n
acquire patient data. of IV medication.
Intravenous Therapy Instructions, tnformation,

D~monstrat~on
Performs IV site care Prevents infection.
according to agency Demonstrate to patient Promotes
protocol. and family technique independence.
for moving with IV
Replace IV cannula, Promotes asepsis.
therapy equipment.
apparatus, and
infusate according to
agency protocol.
Administer lV Promotes patient well- Definition: Collection and analysis
medications as being. of patient data to regulate fluid
prescribed and balance.
monitor for results.
Record intake and Provides data.
output.
Rush IV lines between Prevents precipitation Fluid ~ o n ~ t ~ r i n g
a d ~ s t r a t i o of
n of medi~tions.
incompatible solutions
and clotting of IV line. Activities Rationales
Limit intravenous Prevents hyperkalemia. Monitor weight. Provides baseline and
potassium to agency comparative data.
protocol.
Monitor serum and Promotes awareness of
Maintain universal Prevents infection. urine electrolytevalues. condition.
precautions.
M o ~ ~mucus
or Provides i ~ o ~ t i o n
membranes, skin that may indicate
turgor, and thirst. dehydration.
Monitor color, Provides additional
Instructions, Information, quantity, and specific data.
Demonstration gravity of urine.
Monitor orthostatic Provides specific
blood pressure and info~ation regarding
A&tiviti~ Rat i u ~ a ~ e s cardiac rhythm. fluid balance.
Instruct patient on Promotes patient Restrict and allocate Promotes fluid balance.
procedure. cooperation. fluid intake.
Inform patient and Prevents infusion rate
family of importance errors.
of infusion pumps and
request that changes be
made by staff only.
Instruct patient to Promotes early
report pain, redness, or intervention to prevent
swelling at IV site. complications.
Instructions, Information, Fluid/Electrolyte Management

Demonstration
Minimize oral intake of Promotes accurate
Instruct patient on Promotes cooperation. ice chips, etc., or oral nasogastric contents
fluid intake consumed by measurements.
allocation/restriction. patient with gastric
suction tubes.
Inform patient of Provides information,
reasons for testing. reduces anxiety. Monitor for side effects Provides information
of premibed regarding the patient’s
0 NIC: Fluid/Electrolyte Management supplemental ability to tolerate
electrolytes (e.g., GI medications.
Definition: Regulation and preven- irritation).
tion of complications from altered
fluid and/or electrolyte levels. Administer prescribed Provides information
electrolyte on the electrolyte
binding/excreting binding/excreting
medications. medication.
Monii:or for fluid loss Provides additional
Fluid/Electrolyte Management (e.g., bleeding, data.
vomiting, diarrhea,
perspiration).
Activities Rat ionales Administer prescribed Promotes electrolyte
Provides additional electrolyte balance.
Assess patient’s buccal
membranes, sclera, data. binding/excreting
and skin for med i t ntions.
indications of altered
fluid and electrolyte
balance (e.g., dryness,
cyanosis, jaundice).
Obtain laboratory Provides information Instructions, Information.
specimens for fluid regarding altered fluid Demonstration
and electrolyte levels or electrolytebalance.
(e.g., Hct, BUN,
protein, sodium, Activities Rationales
potassium).
Infonn patient of need Promotes cooperation.
Administer prescribed Promotes to restrict oral intake
nasogastric fluid /electrolyte while nasogastric tube
replacement as output balance. is in place.
may require.
Infonm patient of Promotes cooperation.
Irrigate nasogastric Prevents obstruction. rationale for electrolyte
tubes with normal binding/ excreting
saline. medication.
Instructions, Information, 0 Defining characteristics:

Demonstration Variations in blood pressure read-
ings, jugular vein distension,
decreased peripheral pulses, arryth-
Activities Rat ionales mia, color changes in skin and
mucous membranes, cold, clammy
Instruct patient to Provides information skin, oliguria, dyspnea, rales, rest-
report side effects, regarding patient's lessness.
ability to tolerate experience with
electrolyte medication. 0 NIC: Acid-Base Management-
binding / excreting Metabolic Acidosis
medication.
Definition:Promotion of acid-base
0 Discharge or Maintenance balance and prevention of complica-
Evaluation tions resulting from serum bicar-
bonate levels lower than desired.
Vital signs remain within
baseline parameters for age
and sex.
Equipment used for monitor-
ing vital signs provides ac- Acid/Base Management-
curate data. Metabolic Acidosis
Intravenous fluids and
medications are administered
as prescribed. Activities Rationales
IV site is maintained without
development of phlebitis or Monitor for CNS Promotes early
extravasation. manifestations of intervention.
. Absence of fluid and
electrolyte imbalance, ade-
metabolic acidosis
(e.g., headache,
drowsiness, decreased
quate circulating fluid volume.
mentation, seizures,
Correct calculation and ad- coma).
ministration of fluids in
proportion to losses. Monitor ABG's for Provides data.
. Progressive return to baseline
fluid intake orally.
decreasing pH.
Monitor for electrolyte Promotes early
Verbalizes side effects and imbalances associated recognition of
tolerance of electrolyte bind- with metabolic impending metabolic
ing/excreting medication. acidosis (e.g., acidosis.
hyponatremia, hyper
or hypokalemia,
hypocalcemia,
Decreased Cardiac Output hypophosphatemia,
hypomagnesemia).
0 Related to: Monitor loss of Provides data for
bicarbonate through accurate replacement
Surgical intervention and ad-
the GI tract (e.g., of GI losses.
ministration of anesthesia.
diarrhea, pancreatic
fistula, small bowel
fistula, ileal conduit).
Acid/Base Management- AcidjBase Management-

Metabolic Acidosis Metabolic Alkalosis

I
Administer prescribed Promotes return to Administer H2 Prevents further loss of

alkaline medications acid-base balance. receptor antagonist acid.
(e.g., sodium (e.g., ranitidine,
bicarbonate). cimeti'dine)to block
hydrochloride
Avoid administration Prevents errors. secretion from stomach.
of medications
resulting in lowered Administer carbonic Promotes return to
HCO3 (e.g., chloride- anhyd rase-inhibiting acid-base balance.
containing solutions). diuretics (e.g.,
acetazolamide or
0 NIC: Acid-Base Management: metazolamide) to
Metabolic Alkalosis increase excretion of
bicarbonate.
balance and prevention of complica- Administer antiemetics Prevents further loss of
tions resulting from serum bicar- to reduce loss of HCL acid.
bonate levels higher than desired. in emesis.
Avoid administration Promotes return to
of alkaline acid/base balance.
subsGinces(e.g.IV
sodiujrn bicarbonate,
Acid/Base Management- PO or NG antacids).
Metabolic Alkalosis
Monitor for electrolyte Promotes early Instructions, Information.
imbalances associated recognition of Demonstration
with metabolic impending metabolic
alkalosis (e.g., alkalosis.
hypokalemia, Activities Rationales
I
hypercalcemia,
hypochloremia). Instnict patient and Provides information
family on actions about procedures.
Monitor ABG's for Provides data. instituted to treat
increasing pH. metabolic
Monitor for renal loss Provides additional acidosis/alkalosis.
of acid (e.g.,diuretic information. Inform patient of Promotes
therapy). changes in prescribed understanding.
Monitor for GI loss of Provides data for medications.
acid (e.g.,.vomiting, accurate replacement
NG suctioning, of GI losses.
diarrhea with high
chloride content.)
0 NIC: Dysrhythmia Management Instructions, Information,

Definition: Preventing, recogniz- Demonstration
ing, and facilitating treatment of ab-
normal cardiac rhythms.
Inform physician of Provides current
conditions that information that may
Dysrhthmia Management precipitate lead to change in care.
dysrhythmias.
Inform patient of Promotes patient
Activities Rationales reasons for EKG knowledge of medical
monitoring. intervention.
Ascertain patient and Provides data.
Instruct patient to Allows for prompt
family history of heart
report changes in chest intervention.
disease and
sensations and
dysrhythmias.
breathing pattern.
Monitor and correct Promotes normal
oxygen deficits, acid- cardiac rhythms. NIC: Resuscitation
base imbalances, and
electrolyte imbalances Definition: Administering emergen-
which may precipitate cy measures to sustain life.
dysrhythmias.
Apply EKG electrodes Provides EKG data.
and connect to a
cardiac monitor. Resuscitation
Set alarm parameters Provides auditory
on the EKG monitor. notification of
abnormalities. Activities Rat ionales
Note activities Provides information. Use either the head tilt Promotes ventilation.
associated with the or jaw thrust
onset of dysrhythmias. maneuver to maintain
Note frequency and Provides data. an airway.
duration of Clear oral, nasal, and Provides for a clear
dysrhythmia. tracheal secretions. airway.
Ensure ready access of Facilitates quick Administer manual Promotes respiratory
emergency treatment. ventilation. function.
dysrhythmia
medications. Performs Promotes circulatory
cardiopulmonary function.
Administer Advanced Promotes respirations resuscitation.
Cardiac Life Support, and cardiac rhythm.
Connect the person to Provides ECG data.
an ECG monitor.
Initiate an IV line and Provides access to
administer IV fluids as circulation, promotes
indicated. adequate hydration.
0 NIC: Code Management Instructions, Information,

Definition: Coordination of emer- Demonstration
gency measures to sustain life.
Explain procedures to Provides information
patient, as appropriate, and support.
Code Management
during code.
Inforrn family of Promotes
Activities Rationales reasons for emergency understanding.
interventions.
Call a code according Ensures notification of
to agency standard. necessary personnel. 0 Discharge or Maintenance
Evaluation
Bring a code cart to the Provides equipment.
bedside. Maintains acid-basebalance.
Attach the cardiac Provides data. Verbalizes understandingof
monitor and determine changes in medications.
the rhythm. Absence of dysrhythmias
noted on EKG.
Deliver cardioversion Promotes improved
function of the heart. Participates effectively in a
or defibrillation as
ordered. code.
Performs cardiopulmonary
Ensure that someone is Provides ventilation resuscitation according to
oxygenating the assistance. agency protocol.
patient and assisting
with intubation.
Ensure that someone is Provides emotional
attending to needs of support. Altered Skin Integrity
the family if present.
Ensure that someone is Provides coverage for 0 Related to:
coordinating care of other patients. Surgical intervention.
other patients on the
floor/ unit . 0 Defining characteristics:
Review actions post Promotes competent Surgical Incision.
code to identify areas delivery of emergency
of strength and those care. 0 NIC: Incision Site Care
that need Definition: Cleansing,monitoring,
imtmvement. and promotion of healing in a
wound that is closed with sutures,
clips, or staples.
lncisional Site Care Instructions, Information,
Demonstration
Explain the procedure Promotes
to the patient. understanding. Inform patient to Provides for early
report any redness, recognition of potential
Inspect the incision site Promotes early swelling, pain, problem.
for redness, swelling, intervention if purulent drainage
or signs of dehiscence abnormality develops.
from incision.
or evisceration.
Instruct patient on Provides information
Note characteristics of Provides data. how to care for the that will protect the
any drainage.
incision during incision.
Cleanse the area Prevents infection. bathing or showering.
around the incision
Instruct the patient in Prevents unnecessary
with an appropriate
how to minimize stress strain.
cleansing solution.
on the incision site.
Swab from clean area Promotes asepsis.
toward the less clean 0 Discharge or Maintenance
area. Evaluation
Cleanse the area Prevents Absence of redness, drainage,
around any drain site contamination of clean or swelling at incision site.
or drainage tube last. drain site or area. . Incision healing in progress
Apply antiseptic Promotes healing and
ointment as ordered. prevents infection.
Change the dressing as Provides observation
ordered. of the incision at Altered Nutrition: Less than
regular intervals. Body Requirements
Apply the appropriate Protects incision site.
dressing.
Relatedto:
Inability to ingest or digest food or
absorb nutrients because of biologi-
cal or psychological factors ex-
perienced postoperatively.
Instructions, Information, 0 Defining characteristics:
Demonstration
Weight loss, anorexia, report altered
taste sensation, dysphagia, regur-
I
gitation, early satiety, vomiting,
diarrhea, abdominal cramping,
Instruct patient in Promotes wound malabsorption syndromes, vitamin
dressing change, allow cleanlinessand healing. deficiency, increased metabolic
for return demand, chronic illness, abdominal
demonstration. pain with or without pathology
0 Outcome Criteria: Nutrition Management

Adequate intake of appropriate
nutrients and sufficient calories.
0 NIC: Nutrition Therapy
Determine food Provides data for
Definition: Administration of food preferences with nutritional plan.
and fluids to support metabolic consideration of
processes of a patient who is mal- cultural and religious
nourished or at high risk for becom- preferences.
ing malnourished
Select malts, shakes, Provides additional
0 NIC: Nutrition Management and ice cream to calories.
Definition: Assisting with or supplement nutrition,
providing a balanced dietary intake if not lactose intolerant.
of foods and fluids. Ensure ithat diet Promotes regular
includes foods high in gastrointestinal
fiber to prevent function.
constipation.
Encourage bringing Promotes return to
Nutrition Management home-cooked food to regular diet.
the institution as
appropiiate.
Provide oral care Promotes appetite.
Inquire if patient has Provides data. before meals as needed.
any food allergies.
Determine, in Provides nutritional
collaboration with plan of care.
dietician, number of
calories and type of Instructions, Information,
nutrients needed to Demonstration
meet nutrition
requirements.
Encourage increased Promotes healing. I
intake of protein, Instruct patient and Promotes knowledge
vitamin C, and iron. family i n caloric needs that will reinforce
Monitor recorded Provides information for surgical recovery. adequate nutrition.
intake for nutritional for evaluation and Inform patient and Promotes adequate
content and calories. recommendations. family of need for food caloric intake.
Encourage patient to Promotes chewing and supplements.
wear properly fitted swallowing. Instruct patient and Promotes adherence to
dentures. family regarding restricted diet.
Monitor Promotes balanced diet. dietary restrictions.
appropriateness of diet
orders to meet daily 0 NIC: EnteralTube Feeding
nutritional needs.
Definition: Delivering nutrients
and water through an intestinal
tube.
Enteral Tube Feeding Enteral Tube Feeding
Activities Rationales Activities Rat ionales

Insert nasogastric, Provides access to Check gravity drip rate Promotes accurate
nasodoudenal or gastrointestinal system. or pump every hour. delivery rate of feeding.
nasojejund tube, as per Keep cuff of Prevents aspiration.
type of fluid and endotracheal or
nutrients to be
tracheostomy tube
delivered. inflated during
Monitor for proper Prevents mis- feedings.
placement of the tube placement of tube.
by checking pH of
aspirate.
Request tube Provides data.
placement x-ray when Instructions, Information,,
placement is Demonstration
questionable.
Monitor for presence Provides data.
of bowel sounds. Activities ~
Rationales
Elevate the head of the Promotes delivery of Inform patient and Provides information
bed during feedings. feedings. family of need for tube regarding alternative
feeding. method of obtaining
Discontinue feedings Prevents aspiration.
calories.
30-60 minutes before
placing the head of the Explain equipment. Promotes knowledge,
bed in a flat position. reduces anxiety.
Slow tube feeding rate Promotes absorption of Instructs patient and Promotes cooperation
to control diarrhea. nutrients. family of sensations to with nutritional plan
report. of care.
Monitor for sensation Provides data.
of fullness, nausea, and 0 NIC: Total Parenteral Nutrition (TPN)
vomiting. Administration
Check residuals every Provides information
4-6 hours during regarding patient’s Definition: Preparation and
continuous feedings, ability to digest the delivery of nutrients intravenously
and before each ordered volume of and monitoring of patient respon-
intermittent feeding. feeding. siveness.
Use clean technique in Prevents infection.

administering tube
feedings.
Discard enteral feeding Promotes asepsis.
containers and
administration sets
according to agency
policy.
Total Parenteral Nutrition OPN) Instructions, Information,

Administration Demonstration
Activities Rationales Activities Rut ionales

Assist with insertion of Provides support to Informlpatient and Promotes
central line. patient and physician. family of reasons for understanding.
TI" administration.
Ascertain correct Provides data to
placement of provide safe care. Instruct patient and Promotes accurate
intravenous central family not to alter administration of TI"
catheter by x-ray. settings of infusion solution.
Maintain central line Prevents air embolus Pump.
patency and dressing and infection. Instruct patient to Promotes early
per agency protocol. report discomfort, intervention.
pressure, pain, or other
Monitor for infiltration Promotes early changes at central line
and infection. treatment of potential
insertion site.
complications.
Check the TI" Prevents errors. 0 Discharge or Maintenance
solution to ensure E:valuation
correct nutrients are
Complies with and tolerates
included as ordered.
daily intake of nutrient re-
Maintain sterile Prevents infection. quirements.
technique when Verbalizes caloric and special
preparing and nutritional guidelines.
handling TPN Verbalizes sensations of full-
solutions. ness, nausea, and bloating.
Use an infusion pump Promotes accurate Maintains acceptable weight.
for delivery of TPN infusion of TPN Verbalizes changes at central
solutions. solutions. line insertion site.
Avoid rapidly Prevents bolus Refrains from altering in-
replacing lagging TPN dextrose fusion pump settings.
solution. administration.
Monitor serum Provides data.
albumin, total protein,
electrolytes, glucose, Pain
and chemistry profile.
0 [?elatedto:
Monitor urine glucose Provides additional
for glycosuria, acetone information. Surgical intervention.
and protein.
Administer insulin as Prevents
ordered to maintain hyperglycemia. Diaphoresis, blood pressure and
serum glucose in the pulse rate changes, crying, moan-
designated range. ing, guarding and protective be-
havior, refusal to move or change
position, restlessness, irritability,
complaint of pain.
0 Outcome Criteria: Analgesic Administration

Absence or control of pain
NIC: Analgesic Administration Activities Rationales
Definition: Use of pharmacologic Administer analgesics Prevents peaks and
agents to reduce or eliminate pain. around-the-clock, troughs of blood levels
especially for severe of medication.
pain.
Administer adjuvant Promotes best
Analgesic Administration analgesics and/or response to analgesic.
medications when
needed to potentiate
analgesia.
Consider use of Provides consistent
Determine pain Provides data. continuous infusion blood level of
location, analgesia with bolus medication.
characteristics, quality, opioids to control pain.
and severity, prior to
medicating patient. Correct Promotes cooperation
misconceptions/ myths with pain management
Check medical order Prevents errors. held by patient or care plan.
for drug, dose, and family members
frequency of analgesic regarding analgesics,
prescribed. particularly opioids
Check history for drug Provides information. (e.g.,addiction, risks of
allergies. overdose).
Choose appropriate Provides patient with Evaluate the Provides information.
analgesic when more optimal pain effectiveness of
than one is prescribed. medication. analgesic at regular
frequent intervals.
Choose the IV,via PCA Promotes optimal
pump route, rather absorption. Observe for any signs Promotes early
than IM, for frequent or symptoms of intervention to
pain medication untoward effects of alleviate problems.
injections, when analgesics (e.g.,
possible. respiratory depression,
nausea and vomiting,
Monitor vital signs Provides data dry mouth,
before and after regarding patient’s constipation).
administering narcotic response to medication.
analgesics for first time
dose, or if unusual
signs are noted.
Assist in relaxation to Promotes best
facilitateresponse to response to medication.
analgesia.
Instructions, Information, 0 MC: Urinary Elimination

Demonstration h4anagement
Definition: Maintenance of an o p
timum urinary elimination pattern.
Inform patient and Promotes
family of need for understanding.
medication and Urinary Elimination Management
potential side effects.
Instruct to request Promotes effectiveness
PRN pain medication of PRN medication. Activities Rationales
before the pain
becomes severe. Monitor urinary Provides baseline
elimination including information.
Inform patient and Provides increased
frequency, consistency,
family of additional awareness of
odor, volume and color.
methods to help relaxation techniques,
control pain. breathing rhythms, Monitor for signs and Prevents bladder
and meditation. symptoms of urinary distention.
retention, including
Instruct patient that Prevents potential
absence of voiding and
pain medication is for problems.
lower (abdominal
patient's use
distention.
exclusively.
Note time of last Provides data.
Discharge or Maintenance urinary elimination.
Evaluation
Obtain midstream Provides data from
Verbalizes that pain is voided specimen for urinalysis, and
reduced or absent. urinalysis and culture information from
if UTI suspected. culture for appropriate
antimicrobial therapy.
Teach patient to drink Promotes adequate
Urinary Elimination, Altered recommended amount urine flow.
of fluids.
0 Related to:
Record time of first Provides information
Disease process or surgical interven- voiding, and for early detection of
tion contributing to incontinence or appearance of urine, potential problems.
retention. following procedures.
0 Defining Characteristics: Assist with Promotes regular
development of a urinary elimination.
Inadequate output, dysuria, fre- toileting routine.
quency, urgency, inability to control
urinary flow, decreased awareness
or sensation of urination.
0 Outcome Criteria:
Demonstrates appropriate under-
standing and management of
regular urinary output.
Instructions, Information, 0 NIC: Bowel Management

Demonstration Definition: Establishment and
maintenance of a regular pattern of
bowel elimination.
Instruct patient/family Promotes an
on recording U I - ~ M I ~ awareness of urinary
output as appropriate. pattern. Bowel Management
Inform patient /family Provides information.
of signs & symptoms
of UTI, including fever, Activities Rationales
flank pain, dysuria,
and hematuria. Monitor bowel Provides baseline
movements including information.
Instruct patient to Prevents distention
frequency, shape,
respond as quickly as and reduces risk of
volume, and color.
possible to the urge to infection.
void. Note date of last bowel Provides data.
movement.
Evaluation Record preexistent Prevents
bowel problems, bowel misinterpretation of
Verbalizes strategies for routine, and laxative data.
management of regular urina- USe.
tion.
Monitor bowel sounds. Provides information
regarding bowel
activity.
Altered Elimination: Bowel Report an increase in Promotes early

frequency, presence of recognition of potential
0 Related to: high pitched or absent problems.
bowel sounds.
Disease process or surgical interven- Monitor for signs and Promotes regular
tion that contributes to constipation symptoms of diarrhea, bowel pattern.
or diarrhea. constipation, and
0 Defining Characteristics: impaction.
Abdominal pain, cramping, in- Insert rectal Provides for bowel

creased or decreased bowel sounds, suppository as needed. evacuation.
loose, liquid, watery stools, urgen- Initiate bowel training Promotes self care in
cy, frequency, hard formed stools, program as regular bowel habits.
decreased frequency of bowel move- appropriate.
ments, and flatus.
Evaluate medication Prevents bowel
0 Outcome Criteria: profile for complications related
gastrointestinal side to medications.
Demonstrates appropriate under- effects.
standing and management of
regular bowel movements. Obtain guaiac of stool. Provides information
regarding
gastrointestinalblood
loss.
Bowel Management
Refrain from Prevents perforation of
performing rectal exam mucosa which can
on granulocytopenic result in infection.
patients.
Demonstration
Inform patient/family Promotes dietary
about foods that intake that supports
promote bowel bowel regularity.
regularity.
Reinforce adequate Prevents constipation.
fluid intake.
Instruct patient in Provides information
strategies to counter to encourage self care.
bowel-related side
effects.
Evaluation
Patient verbalizes strategies to
ensure regular bowel habits.
Chapter Three
Radiation Therapy
Radiation Therapy
Radiotherapy is the use of high-energy par- skin, cervical, and laryngeal cancers.
ticles to destroy cells in the treatment of dis- Another goal is disease control, either long-
ease. Cell death is the result of chemical or short-term, as with brain tumors, bladder,
reactions within the cell that cause DNA and ovarian, and lung cancers. Palliative treat-
RPJA changes, diminishing the cells’ ability ment to improve quality of life by relieving
to function. The amount of DNA and RNA symptoms or preventing complications is
damage a cell receives depends on the another important goal of therapy. Patients
radiosensitivity of a cell. There are four fac- with metastatic breast or prostate cancer may
tors that influence the radiosensitivity of receive radiation to multiple lesions over a
cells: period of many years. Abony metastatic site
Rate of cell division also may be irradiated to prevent fracture, or
Phase of the cell cycle in a vertebra to prevent spinal cord compres-
Degree of cellular
differentiation sion. Obstructions or impending obstruc-
Cell’s level of oxygenation tions (e.g., in trachea, bowel, esophagus,
Rapidly dividing cells, whether they are nor- ureters, superior vena cava) also may be
treated with radiotherapy. Other potential
mal or cancerous, are more susceptible to
radiation therapy. Cells undergoing gap 2 uses with a palliative intent are control of
phase (the period following DNA synthesis bleeding and brain metastases.
before mitosis) of the cell cycle are the most Radiation therapy can be further classified
sensitive to radiotherapy. Poorly differen- by its type and by the method of administra-
tiated cells and well-oxygenated cells are tion. The form of energy used in
also very radiosensitive. Cancers most sensi- radiotherapy is ionizing radiation, the
tive to radiotherapy include lymphoma, highest energy in the electro-magnetic
seminoma, squamous cell of the oropharyn- spectrum. All electromagneticradiation is in
geal area, skin, and cervical epithelia. Nor- the form of waves, and particulate radiation
mal cells most sensitive to radiotherapy is in the form of particles. It can be delivered
include blood cells produced in the bone from a source outside the body by external
marrow, hair follicles, and cells of the beam c r teletherapy, or delivered from a
gastrointestinal tract. source placed within the body by a method
To treat cancer, radiation therapy is used known as internal- or brachytherapy,
alone or in combination with surgery, whereby sealed sources of radioactive
chemotherapy and/or immunotherapy. The material are placed within or near a tumor.
An external source is the Linear Accelerator,
goal of treatment may be curative, as in
Hodgkin’s Disease, seminoma of the testes, a machine that delivers electron energy in
precise beams with little scatter. Other tures are to be blocked and protected from
machines use gamma rays from cesium or radiation therapy.
cobalt sources. Teletherapy and The physicist works with the radiation
brachytherapy can be used either alone or in therapist to ensure accuracy of technical
combination with each other, depending on aspects. A body contour of the patient may
the patient’s needs. be obtained during simulation, and is used
It is important that each individual’s tumor to produce a computer generated treatment
be defined specifically in terms of location plan based on tumor volume and body con-
and volume. When the decision has been tour.
made that a patient will receive radiation Calculation of the total dose of treatment,
therapy, a consultation is planned with the fractionated dose, number of fields, and time
radiation oncologist and radiation therapy schedule are also determined during the
nurse. Also present are the radiation tech- treatment planning period. These calcula-
nician, physicist, social worker, and tions are based on the relationship between
nutritionist. This consultation generally is radiosensitivity of tumor cells and that of
known as the ’“simulationvisit”, which can normal cells and tissues; on the tumor size
be lengthy. During the meeting a simulator and location; on the total dose of radiation to
machine is set up with several component be delivered versus the time of treatment;
parts, including x-ray, tomography, and the goal of therapy.
ultrasound and fluoroscopy. Once the tumor
Radioactive isotopes for brachy-therapy are
has been carefully defined by the team, the
available in many different forms including
physician can determine the field of treat-
wires, ribbons, needles and seeds. The source
ment. This field, also called the ”treatment
is selected by the radiation oncologist accord-
port” is duplicated on the patient’s skin with
ing to the location of the tumor, size of
marks or tatoos. It is important that these
tumor, and whether the implant is to be tem-
marks stay in place during the 4-6 weeks of
porary or permanent. The aim of treatment is
therapy because they are used daily to posi-
to deliver a concentrated dose to a specific
tion and focus equipment. At some treat-
area and minimize the exposure to surround-
ment facilities these markings are placed on
ing, normal tissues. The radiation source
a plastic form or mask rather than the skin.
may be placed into a cavity, or placed in-
Restraining or positioning devices may be
tracavitary, (cesium implant in vagina), into
constructed at the time of simulation to aid
tissue, interstitially (iridium implants into
in the patient’s ability to be in the exact same
the breast), or on the surface of the skin.
position each day. Another important part of
simulation and treatment planning is shap- When hardware is to be placed surgically the
ing the field and determining which struc- patient is taken to the operating room. There,
needles may be placed into breast tissue or
gynecologic applicators in the vagina. These
are examples of "afterloading" devices be- Radiation therapy is not considered to be a
cause they are loaded with the source of systemic therapy but a therapy aimed to af-
radiation after the patient is returned to a fect a specific site, or sites, of disease.
private room. T h ~ r e ~side l ~ experienced by a
c ~effects
Implanted sourcesof radiation may be either patient should be limited to the treated area.
temporary (cesium implant €orcancer of the However, the person receiving radiation
cervix) or permanent (e.g. iodine seeds into a therapy may experience systemic effects,in-
bronchial tumor). Nonsealed sources of cluding nausea, anorexia and fatigue. These
radiation may be given orally, intravenously s ~ ~may~be related t o to the~ breakdown
or intracavitary. Iodine 131, an example of an of cancer cells and the filtering of these by-
unsealed radiation source, is given orally for products through the body. The complaint of
the treatment of h ~ ~ h ~ ~ ~ fatigue
d ~may be
~ partially
* related to the effort
expended getting to and from the treatment
The side effects of radiation therapy occur
center every day of the week for many
when normal cells within the field of treat-
weeks. Generally most patients tolerate
ment are temporarily or permanently af-
radiation therapy well,
fected. Side effects occurring within 6
months are referred to as acute side effects
and those occurring after 6 months are called
fate or chronic side effects. The acute side ef-
fects- those that occur in rapidly dividing
cells of the skinrmucous membranes, hair fol-
licles, and bone marrow- are general$ re-
versible. The late side effects, in cells that
divide slowly such as muscle or vessel cells,
Anxiety
are usually permanent.
(CH. 1)
Since all teletherapy is delivered through the 0 17elated tu:
skin, some type of skin reaction is to be ex-
Fear of radiation therapy and pos-
pected, anything from mild erythema to sible side-effects.
moist desquamation. Every organ system of
I3 Defining Characteristics:
the body has a specific "maximal tolerance
Voices fears of radiation therapy
dose," defined as the dose to which a given and its side effects, appears ap-
population of clients is exposed under a prehensive, nervous.
standard set of treatment conditions, and
will result in a 50% complication rate within
5 years.
I neff ective I ndividual Coping Outcome Criteria
(CH. 1) Patient will be able to discuss poten-

tial side effects from radiation
0 Related to: therapy and possible strategies for
their management.
Anxiety and fears about radiation
therapy and its potential side effects. 17 NIC: RadiationTherapy
Management for Treatment
0 Defining Characteristics: Delivered from an Internal Source
Inability to meet basic needs, worry,
Definition: Assisting the patient to
anxiety, verbalization of fears, in- understand and minimize the side
ability to cope.
effects of radiation treatments from
an internal source.

(CH. 1)
RadiationTherapy Management-
0 Relatedto: Internal Source
Anxiety and fears about radiation
therapy and its impact on the family.
Initiate and maintain Promotes safety for
Family system unable to meet radiation protection as patient, family and
physical or emotional needs of per agency protocol for Staff.
patient due to radiation therapy patient receiving
treatments. internal radiation (e.g.,
cervical implant
radiophannaceutical
agents).
Essential Nursing Explain radiation Promotes increased
Diagnoses Related fo protection protocols to
patient, family,and
understanding of
guidelines and
Treatment visitors. promotes compliance.
Offer diversional Prevents boredom.
activities while patient
is in radiation
Knowledge Deficit protection.
Limit visitor time in Prevents over-
0 Related to: the room as exposure to radiation
Radiation therapy as a treatment for appropriate. therapy source.
cancer. Limit staff time in Promotes safety of staff
Defining Characteristics: room if patient is using the principles of
isolated for radiation time, distance, and
Patient expresses lack of knowledge precautions. shielding..
and/or asks questions regarding
radiation therapy treatments.
RADIATION THERAPY 53
RadiationTherapy Management- Radiation Therapy Manugement-

Internal Source External Source
- Activities Rationales
Distance oneself from Prevents exposure. Avoid use of adhesive Prevents further injury
the radiation source tapes and other skin to fragile areas.
while giving care te.g. irritating substances.
stand at the head of the Avoid application of Prevents further
bed of patients with
deodorants and after- irritation.
cervical or uterine
shave lotion to treated
implants; stand at the
area.
foot of bed for patients
with interstitial breast Expliiiin the importance Promotes accurate
implants). of protecting skin delivery of radiation
"porit" markings. therapy.
Shield oneself using a Prevents exposure to
lead apron/shield reproductive organs. Discuss the avoidance Prevents potential ski^
while assisting with of soap and other reactions.
procedures involving ointments.
radiation.
Discuss the need for Prevents increasing th
NIC: Radiation Therapy protection during radiation effect on the
Management for Treatment sunbathing or heat skin.
Delivered from an External Source application.
Explain to patient that Provides reinforcemer
Definition: Assisting the patient to hair may not grow
understand and minimize the side back after radiation
effects of radiation treatments from therapy is terminated.
an external source.
Assilst patient in Promotes
planning for hair loss independence.
by teaching about
available alternatives
RadiationTherapy Management- (e.g..,wigsscarfs hats
External Source turb.ans,etc).
Monitor for indications Promotes early
of infection of oral intervention.
~~~
I
mucous membranes.
Provide special skin Prevents maceration Encourage good oral Prevents infection.
care to tissue folds and infection. hygjene with use of
which are prone to soft toothbrush
moistness te.g., mouthwash without
buttocks, perineum, alcohol, Water Pik, and
groin). floss, if atxmmriate.
Monitor for alterations Promotes early
in skin integrity and intervention.
treat appropriately.
Radiation Therapy Management- Instructions, Information,

External Source Demonstration
I
Monitor patient for Provides data for Inform patient and Promotes
anorexia, nausea, recognition of potential family of reasons for understanding and
vomiting, changes in problems. radiation protection cooperation.
taste, stomatitis, protocols.
esophagitis and
Inform patient of Promotes compliance
diarrhea.
potential for and participation in
Encourage adequate Promotes nutritional complicationsof care.
fluid and caloric intake. balance and hydration. implanted
radiotherapv sources.
Administer anti- Prevents recurrence of
emetics as needed to nausea and vomiting if
control nausea and given on a regular Evaluation
vomiting. schedule rather than
PRN (e.g.,give anti- Patient/family report side ef-
emetic one hour prior fects promptly to radiation
to scheduled radiation care team.
therapy). Patient/family are able to
Assist patient in Promotes adequate rest. manage side effectswith assis-
managing fatigue by tance of health care providers.
planning frequent rest
periods, spacing
activities, and limiting
daily demands. Risk for Impaired Skin Integrity
Assist patient in Promotes comfort.
receiving pain 0 Related to:
management Response of normal skin to radia-
techniques that are tion therapy.
effective and
acceptable to patient. 0 Defining Characteristics:
Monitor for signs and Provides for early Acute side effects include erythema,
symptoms of systemic recognition and pruritus, and dry or wet desquama-
infection, anemia, and prompt intervention. tion; late effects include shiny,
bleeding. smooth, taut skin, and telangiec-
Facilitate patient’s Provides an awareness tasia.
discussing feelings of feelings. 0 Outcome Criteria:
about radiation
therapy equipment as Patient identifies skin reactions as
appropriate. expected local radiation reactions
and demonstrates appropriate skin
Facilitate expression of Provides opportunity care.
fears concerning to vent fears.
prognosis or success of Skin will remain intact or moist
radiation therapy desquamation will be identified
treatments. early.
NIC: Radiation Therapy Radiation Therapy Management-

Management Skin Care
Definition: Assisting the patient to
understand and minimize the side
effects of radiation treatments. Activities Rationales
Discuss need for skin Protects irradiated skin
care maintenance from injury or
including 1.Not enhancement of skin
Radiation Therapy Management- washing off any lines reaction.
Skin Care or markings; 2.
Avoiding powders,
lotions, creams,
alcohol, deodorants,
Activities Rat ionales perfum12s,or after
shave lotion; 3.
Assess skin for color Provides information
Protecting skin from
integrity and drainage. for planning care.
exposure to direct
Monitor for alterations Promotes early sunlight, chlorinated
in skin integrity. identification of altered swimming pools, and
skin integrity. temperature extremes
(hot water bottle,
Cleansing treatment Prevents enhancement heating pad) and/or
area during of skin reaction, avoiding shaving.
radiotherapy should decreases potential
include 1.Washing from thermal injury Avoid use of adhesive Prevents trauma to
skin in treatment area and/or friction. tapes and other skin- irradiated skin.
with tepid water, Not irritating substances.
using soap unless Avoid tight fitting Reduces friction over
approved by radiation clothing,'over treatment area.
oncology team; 2. treatment area.
Showers but with
avoidance of hot water Avoid scratching skin Prevents mechanical
directly on treated in treatment area. injury.
skin; 3. Not soaking
Patients receiving Enhances air exchange
treatment area in tub pelvic irradiation and absorbs moisture.
for more than 15-20 should wear cotton
minutes per day; 4.
underwear, women
Patting treatment area should not wear
dw. pantyhose.
Provide special skin Prevents infection and
care to itissue folds (e.g. enhanced skin reaction
buttocks, perineum, in areas with poor
groin,) including tolerance to radiation.
keeping dry, dusting
lightly with baby
powder.
Radiation Therapy Management- Instructions, Information,

Skin Care Demonstration

Water-soluble aloe Vera Provides moisture and Inform of possible Promotes
based gels may be prevents pruritus. permanent skin understanding of
used for dryness if changes from radiation possible permanent
recommended by the therapy including skin changes.
radiation oncology permanent tanning,
team. smooth, shiny, taut
skin, telangiectasia,
Avoid use of any Many skin care
slow healing.
ointments or solutions products draw more
not ordered by the radiation to the skin Inform of possible Promotes knowledge
radiation therapy surface, worsening the radiation recall that of late, possible side
health care team. skin effect. can occur to previously effects from radiation
radiated skin when therapy.
certain chemotherapy
agents are given
including DTIC, and
adriamycin.
Demonstration Instruct on possible Promotes knowledge
enhanced skin of possible enhanced
reactions that can skin reactions from
Activities Rat ionales occur to irradiated skin radiotherapy.
when chemotherapy
Instruct patient/family Promotes skin care to agents are given
in skin care (see above). prevent injury to including Bleomycin,
irradiated skin. Hydroxyurea, 5-
Fluorouracil,
Instruct to expect Normal response to Methotrexate, and
redness. radiation.
Actinomvcin-D.
Instruct to wear loose Prevents trauma to
fitting clothing. irradiated skin. !Discharge
I! or Maintenance
Evaluation
Instruct to cover Prevents thermal injury.
treatment area to Skin will remain intact and
protect from direct skin reactions will be iden-
sunlight especially tified early and treated.
during treatments. Patient/family will
Instruct to always Prevents trauma to demonstrate preventative skin
protect irradiated skin irradiated skin. care precautions.
from sunlight by using Patient describes methods to
sunscreens (SPF 15 or protect skin from injury.
greater) even after Describes possible acute side
treatment is completed. effects and long term skin
changes from radiation
therapy.
Impaired Skin Integrity Skin Care-Topical Treatments
0 Relatedto:
,4ctivities Rationales
Moist desquamation due to radia-
tion therapy. Use Domboro solution Minimizes loss of
0 Defining Characteristics: for soaks as fluid, keeps area clean,
appropriate. improves comfort.
Red, raw skin with areas of moist Avoid use of ointments Many skin care
desquamation causing disruption or solutions not products may
of skin surface. ordered by the aggravate irradiated
0 Outcome Criteria: radiation therapy skin reactions.
health care team.
Skin will heal without development
of infection. Initiate consultation Promotes optimal skin
services of a radiation care though use of
Skin demonstrates signs of healing.
oncology nurse as experts.
0 NIC: Skin Care--Topical Treatments appropriate.
Definition: Application of topical Administer analgesics Promotes comfort.

substances or manipulation of as appropriate.
devices to promote skin integrity Administer antibiotics Promotes wound
and minimize skin breakdown. as appropriate. healing and treats
confirmed infection.
Skin Carc+Topical Treatments

Demonstration
Inspect irradiated skin Promotes early
port and exit sites daily identification of skin .4ctivities Rationales
for color, scaling, breakdown.
Demon.strateskin care Promotes compliance
bleeding, drainage
areas o C moist with skin care
(color, amount,
desquamation. prescribed.
consistency), increased
temperature. Instruct patient /family Prevents further
to use only skin care trauma to skin from
Evaluate patient’s Provides information
products unless contraindicated
routine skin care for care planning.
prescrilbed by radiation products.
practices.
health (careteam.
Cleanse open areas Prevents further
Teach signs and Promotes early
with saline and water, trauma to irradiated
symptoms that should identification of
pat or air dry. skin.
be reported to health complications.
Apply occlusive Promotes healing, and care team immediately,
dressing or comfort. such as pain, bleeding,
nonadherent dressing green or foul smelling
over open moist areas drainage, temperature
as appropriate. elevation.
Instructions, Information, Activity Intolerance

Demonstration
(CH. 4)
0 Related to:
Activities Rationales I Fatigue associated with five-day-a-
Instruct patient to Prevents further week treatments for 4-6 weeks, and
avoid shaving irritated irritation of damaged anemia associated with radiation
skin, wearing tight skin. therapy.
clothing, use of
deodorants, perfumes,
exposure to sunlight, Verbal report of fatigue or malaise,
shaving lotions, exertional dyspnea, appears tired.
strenuous activities.
I7 Discharge or Maintenance
Evaluation
Risk for Altered Mucous
Skin will heal without com- Membranes
plications.
Patient/family will
(CH.
4)
demonstrate skin care for Related to:
moist. desquamation.
Patient/family will describe Damage to the rapidly dividing
measures to avoid to prevent cells of the mucosa from radiation
further trauma to damaged therapy.
skin. 0 Defining Characteristics:
Patient/family will state signs
and symptoms that must be Pain/discomfort, coated tongue,
reported to the health care xerostomia, reddened gums,
team immediately. stomatitis, lesions, ulcers, vaginitis,
vaginal discharge.
Potential for Infection

Body Image Disturbance
(CH. 4)
(CH. 4)
Related to:
0 Related to:
Radiation therapy to bone marrow
resulting in immunosuppression. Alopecia, weight loss and/or skin
changes associated with radiation
Defining characteristics: therapy.
Granulocytopenia, an absolute Defining Characteristics:
granulocyte count (AGO below
1,000 cells/mm3, neutropenia, an Patient verbalizes fear of rejection
absolute neutrophil count (ANC) or reaction of others to altered ap-
below l,000/m3. pearance, negative feelings about
body, concern over hair loss and
skin changes.
Altered Nutrition: Less than 0 Outcome Criteria:
Body Requirements Patient verbalizes an understanding

of strategies for coping with this
(CH.2) side effect.
0 Related to:
0 NIC: Diarrhea Management
Inability to ingest adequate food in-
Definition: Prevention and allevia-
take because of mucous membrane tion of diarrhea
changes associated with radiation
therapy; taste changes; xerostomia;
nausea and vomiting.
Diarrhea Management
Reported decrease in food intake,
early satiety, presence of mouth
soreness and/or ulcerations,
anorexia, weight loss. Activities Rationales
Obtain stool for culture Provides information
and sensitivity. regarding infection.
Evaluate medication Prevents use of
Altered Sexuality Patterns profile for medications that can
(CH. 10) gastrointestinal side cause diarrhea.
effects.
CI Relatedto:
Monitor skin in Promotes skin care and
Radiation Therapy perianal area for may prevent infection.
Iz1 Defining Characteristics: imtation and
ulceration.
Voices difficulties, limitations, or
Weigh. regularly. Provides information
changes in sexual behaviors related
regarding adequacy of
to changes due to radiation therapy
diet.
such as dry mucous membranes,
vaginal stenosis, diarrhea, fatigue,
or changes in sexual-self image re-
lated to hair loss.
Demonstration
Diarrhea
Related to: Activities Rat ionales
Change in mucous membranes of Teach patient Promotes slowing of
colon and large intestine. appralpriate use of anti- bowel movements.
diarrheal medications.
Teach patient to Prevents further bowel
Loose watery stools, frequency, ur- eliminate gas forming irritations.
gency. and spicy foods from
diet.
Demonstration

Instruct in low-fiber, Promotes caloric intake.
high-protein, high-
calorie diet.
Instruct to eliminate Prevents
use of laxatives. misunderstandings of
use of medication.
Evaluation
Patient verbalizes an under-
standing of cause of diarrhea.
Maintains stable weight
during therapy.
Impaired Gas Exchange

(CH. 2)
0 Related to:
Radiation pneumonitis.
Shortness of breath, dyspnea.
Chapter Four
Chem o th er upy
The drugs used to treat cancer are called All cells, both normal and cancerous, go
chemotherapy or antineoplastic agents. through a cell cycle. Chemotherapyagents
These medications are used primarily to kill work at different phases of the cell cycle {See
cancer cells or inhibit their reproduction..Of Table 2.1). Agents that work during specific
the estimated one million people diagnosed phases of the cell cycle are called cell cycle-
with cancer this year, over half of them will specific.Agents that work in all phases of the
have metastatic disease or be at risk for cell cycle are called cell cycle-nonspecific.
metastatic disease at the time of diagnosis. Most chemotherapeutic agents are most effec-
These people require a systemic approach to tive when cells are actively dividing. Unfor-
the treatment of their disease, for which tunately, because these agents cannot
chemotherapy is the primary option avail- discriminate, they affect healthy cells that are
able today. actively dividing as well, such as hair fol-
The goal of chemotherapy treatment licles, cells lining the gastrointestinal tract,
depends on the type of cancer and its stage and bone marrow stem cells. This effect on
at the time of diagnosis. Some cancers have actively dividing, healthy cells results in the
an anticipated cure and are curable with most common side effects seen with
chemotherapy- hair loss, gastrointestinal
chemotherapy treatments. In other cases
mucasal damage, and myelosuppression.
treatment may be given to prevent the cancer
from recurring; this is called adjuvant treat- Normal cells can recover from the injuries
ment. In some cases, chemotherapy is given caused by chemotherapy,so these side ef-
fects are usually short in duration. However,
to control the disease for a prolonged period
cancer cells, once damaged, usually cannot
of time although a cure is not possible. If the
recover.
cancer is widespread and in late stages,
chemotherapymay be used as a palliation to
provide a better quality of life.
Chemotherapy is a relatively new treatment
lyL3es of
for cancer. It was only in the late 1940s that Chemotherapeutic
drugs were found to affect tumor growth. Agents
Through clinical trials we have learned, and
are still learning, how to effectivelyuse the Che~~otherapy
is a term used to describe the
drugs to treat cancer. use of over thirty different drugs. However,

each antineoplasticagent, or
chemotherapeutic drug, has specific actions
Cell Cycle Specific C h e m o t ~ ~ r Drugs

a~y
S Phase
Cytarabine
5-Fluoroucil
Hydroxyurea
Methotrexate
n i 0 g u a n i n f l - h B Phase
G,leomycin
Etoposide
M Phase
Paclitaxel
Vinblastine
Vincristine
\ -GI//
G, Phase
Vindesine
L-isparag inase
Prednisone
Cell Cycle Non-Specific chemotherapy Drugs

Alkylating Agents Nitrosamines Antibiotics Miscellaneous
Busulfan Carmustine Bleomycin L-asparginase
Carboplatin Lomustine Dactinomycin Mitoxantrone
Chlorambucil Semustine Daunomycin Procarbazine
Cisplatin Streptozocin Doxorubicin Navelbine
Cy c l o p h ~ s p h ~ i d e Id~bucin
Dacarbazine
Ifoshmide
Meclorethamine Hormonal Agents
Melphalan Aminoglutethimide
Riotepa G oserelin Acetate
Leuprolide
Novaldex
Megace
Table 2.1 -Cell Cycle Specific ChemotherapyDrugs. Walotestin
CHEMOTHERAPY 65
and side effects. These drugs are classified in function that may occur include oligosper-
several ways which can assist us in learning mia, azoospermia, and amenorrhea. A late
their actions and major side effects. The six side effect of alkylating agents is the develop-
major classifications of chemotherapy drugs ment of secondary malignancies such as
are: bladder cancers or leukemia. Nitrosoureas
Alkylating agents are agents from the family of akylating
Antimetabolites agents that are thought to cross the blood-
Antitumor antibiotics
brain barrier. Their mechanisms of action are
Plant alkaloids
Miscellaneousagents simil.ar to those of other akylating agents as
Hormonal agents are their side effects. Common alkylating
For each classification, the primary method agents are carmustine (BCNU), lomustine
of action and specific tumors on which the (CClW), streptozocin, and semustine
agents are active will be discussed below. (methyl-CCNU).
Common agents and major side effects will Antimetabolites kill cancer cells by blocking
also be explored. the synthesis of DNA and RNA. They do this
Alkylating Agents are cell cycle-nonspecific by numicking the chemical structure of essen-
agents that work by interacting chemically tial metabolites, the nutrients essential for
with the cellular DNA to prevent cell replica- normal cell metabolism. These agents are
tion. Common agents include: most effective in the S-phase of the cell cycle,
Busulfan (Myeleran) making them cell cycle specific drugs. Com-
Chlorambucil (Leukeran) mon agents include cytarabine (ARA-C),
Cisplatin (CDDP) floxuridine (FLTDR), 5-fluorouracil(5-Fu),
Cyclophosphamide (Cytoxan) hydroxyurea (Hydrea),6-mercaptopurine (6-
Dacarbazine (DTIC)
. Ifosfamide (IFXX)
MP), methotrexate (Mexate), and 6-
thioguanine. Fast-growing tumors such as
Mechlorethamine
(Nitrogen Mustard) lymphomas, and leukemia are most affected
-Melphalan (Alkeran) by antimetabolites. Other tumors treated
Thiotepa (TSPA)
with antimetabolites include head and neck
The alkylating agents have proved effective tumors, breast cancer, and colon cancers. The
in the treatment of lymphomas, Hodgkin’s most common side effects include stomatitis,
disease, breast cancer, and multiple bone marrow suppression, and diarrhea.
myeloma. The main side effectsof akylating
Antitumor antibiotics are cell cycle non-
agents include bone marrow suppression,
specific drugs that work by several different
nausea, vomiting and gonadal dysfunctions.
mechanisms to produce their cytotoxic ef-
Bone marrow suppression including throm-
fects. Bleomycin’s (Blenoxane) primary ac-
bocytopenia, neutropenia, and anemia may
tion is to produce single- and double-strand
become more severe and last longer with
breaks in DNA. The anthracyclines like
repeated treatments. The changes in gonadal
daunorubicin (Daunomycin)and major classes mentioned and whose actions

doxorubicin (adriamycin) intercalate DNA, and side effects vary. Miscellaneous agents
cause oxidation reactions, and react directly include L-asparaginase (Elspar),
with cell membranes at low concentrations mitoxantrone (Novantrone),procarbazine
to change membrane functions. Mitomycinc (Matulane),Navelvine, and mitotane
(Mutamycin) causes cross-linked alkylation (Lysodren).
in DNA. Actinomycin-D (dactinomycin) Hormonal agents work on tumors that
binds directly to the DNA, leading to the in- depend on a specific hormonal environment
hibition of DNA-dependent RNA synthesis. to grow, By changing that environment
Cancers treated with antitumor antibiotics in- either by depriving the environment of the
clude breast cancer, bladder cancer, gastric hormone or by adding a hormone that
cancer, lung cancer, lymphomas, and tes-
counteracts the effect of the hormone, tumor
ticular cancer. Side effects include bone mar- growth is impaired or stopped. Examples in-
row suppression, nausea, and vomiting. In clude Tamoxifen (nolvadex) for breast can-
addition, bleomycin can cause pulmonary cer, Lupron (leuprolide) and goserelin
fibrosis. Cardiac toxicity and skin ulceration acetate (Zoladex)for prostate cancer, and
from extravasation are seen with aminoglutethimide (Cytadren) for uterine
doxorubicin. cancers. Effects on the sex hormones include
Plant Alkaloids are cell cycle-specific agents secondary sexual characteristics, changes in
that work by crystallizing the microtubular libido, and fluid retention. Cortocosteroids
mitotic spindle proteins during metaphase, work differently from other hormones by
which arrests mitosis, causing cell death. recruiting cells out of the Go phase of the cell
Common agents include etoposide (VP-16), cycle, making them vulnerable to
vinblastine (Velban),vincristine (Oncovin), chemotherapeutic agents. Corticosteroidsin-
taxol (Paclitaxel),and teniposide (VM-26). clude prednisone and prednisolone for the
These agents are used in combination with treatment of leukemia, lymphomas, and
other agents to treat lymphomas, lung can- myelomas. Their side effects include hyper-
cer, testicular cancer, bladder cancer, and tension, fluid retention, hyperglycemia, ul-
multiple myelomas. Myelosuppresionand cers, osteoporosis, emotional instability
neurotoxicity, including peripheral increased susceptibility to infections, mask-
neuropathies and paralytic ileus, are the ing of fevers, increased appetite, and Cushin-
most common side effects from plant goid features.
alkaloids. In addition, both vincristine and
vinblastine can cause severe skin ulceration
if extravasation occurs.
Miscellaneous agents are those whose

mechanism of action differ from those in the
CHEMOTHERAPY 67
Principles of different side effects, have been tried. In
Chemotherupy most tumors, it has been well established

that combining chemotherapeuticagents is
Several general principles are used in more effective than single agent therapy.
prescribing chemotherapy. First, since Com~~nation
therapy increases responsive-
chemotherapy works best against cells in the ness of tumors to treatment while minimiz-
process of dividing, tumors with a high ing toxicities. In addition, combination
growth fraction tie., a large percentage of Chemotherapyseems to decrease the
dividing cells) are treated more effectively development of drug resistant clones. The
with chemotherapy than those with a low larger the tumor, the greater the number of
growth fraction. As tumors grow larger, tumordoubling prior to the initiation of
usually fewer cells are undergoing active chemotherapy treatments, and therefore the
division; therefore, larger tumors have low more likely for drug-resistant cells or clones
growth fractions and so are less responsive to be present in the tumor. Single agent
to chemotherapy. Conversely, smaller tumors therapy seems to increase the number of
usually have higher growth fractions and are drug resistant celfs by exposing tumor cells
more sensitive to chemotherap~In other to a drug without effective; however com-
words, chemotherapy is usually more effec- bination therapy seems to prevent the
tive when there is a small tumor burden and development of drug resistant cells.
less effective in later disease when there is a As previously discussed, chemotherapy af-
high tumor burden. fects healthy cells as well as cancer cells,
Another principle is that most resulting in the side effects commonly seen
chemotherapeuticagents follow first-order with the treatment. These include hair loss,
kinetics, which means a fixed percentage of bone marrow suppression, and gastrointes-
cells are killed with each chemotherapy treat- tinal disturbances. Nursing assessmentand
ment- not a fixed number of cells. There- mariagement of these side effects is critical to
fore, even tumors with smaIl tumor burdens ensure safe a d ~ ~ ~ ~ of
a tthese
i o agents.
n In
may require many sequential administra- addition, the side effects are not seen for
tions of chemotherapybefore the full benefit many days after therapy, and often occur
of treatment can be realized. after discharge from the hospital or out-
patient setting. As a result, patient education
For most drugs the higher the dose, the
in nnanaging side effects at home is neces-
greater the cell kill. However, as the dose is
sary. The most common side effects and their
increased, toxicities begin limiting the useful-
associated nursing diagnoses and manage-
ness of single agent therapy Due in part to
ment are discussed in this chapter. The less
the limits of single agent therapy, the com-
c o n ~ o side
n effects are discussed
ina at ion of various agents that affect dif-
~ ~ ) u g h othe
u t book. Table 2.2 summarizes
ferent stages of the cefl cycle, and have
these side effects and refers the reader to the

appropriate nursing diagnoses in later chap-
ters.
Table 2.2 Less Common Side Effeds of Table 2.2 Less Common Side Effects of
Chernotheram D n 5
I "
Chemotherapy Dr
Cardiac Doxorubcin Altered Impotence, Leuprolide sexual
Toxicity Daunarubcin Cardiopulmoni decreased Goserelin Dysfunction
ry Tissue libido acetate (CH. 10)
Perfusion Aminogluthe-
(CH. 13) thimide
CNS Toxicity Ifosfamide Sensory/
Cytosine Perceptual Liver Toxicity Methotrexate Risk For Injury
Arabinoside Alteration: Nitrosoureas (CH. 9)
Procarbazine Kinesthetic Mithramycin
Fludarabine (CH. 18) S treptozocin
Constipation Vincristine Potential for Menstrual Nolvadex Potential For
Vinblastine Constipation Irregularities Megace sexual
(CH. 8) & Hot Flashes Halotestin Dysfunction
(CH. 9)
Diarrhea 5-Fluorouracil Diarrhea
(CH. 16) Peripheral Vincristine Risk For
Neuropathy Vinblastine Neurovascular
Flare Reaction Novaldex Potential for Cisplatin Dysfunction
Leuprolide Pain (CH. 9) Procarbazine (CH. 8 )
Goserelin Potential for
acetate Pain (CH. 8 )
Aminogluthe-
thimide Pulmonary Bleomycin Impaired Gas
Toxicity Carmustine Exchange
Hearing Loss Cisplatin Potential for (CH. 10)
Sensory/
Perceptual Renal Toxicity Cisplatin Potential
Alteration Methotrexate Alteration in
(Auditory) Nitrosoureas Urinary
(CH. 11) Streptozocin Elimination
(CH. 11)
Hemorrhagic Ifosfamide Potential
Cystitis Altered Weight Gain Nolvadex Potential
Cyclophosphar Urinary Steroids Alteration in
ide Elimination Megace Nutrition:
(high dose) (CH. 18) More Than
Body
Hypotension Etoposide Potential For Requirements
Paclitaxel Injury (CH. 8) (CH. 9)
CHEMOTHERAPY 69
Essential Nursing Altered Family Processes

Diagnoses Related fo (CH..1)
Coping with the Side 0 17elated to:
Effects of Anxiety and fears about

chemotherapy and its impact on the
Chemotherapy family.
0 IDefining Characteristics:
Family system unable to meet
physical or emotional needs. of
Risk for Sexual Dysfunction patient due to chemotherapy treat-
(CH.1) ments.
0 Related to:
Chemotherapy treatments, and can-
cer disease process. Anxiety
Defining Characteristics:
0 Related to:
Patient voices difficulties, limita-
Fear of chemotherapy and possible
tions, or changes in sexual be-
side effects.
haviors secondary to changes due
to chemotherapy, such as vaginal Defining Characteristics:
dryness, or fatigue, or changes in
sexual self image due to weight Patient voices fears of
loss, hair loss, or impaired reproduc- chemotherapy and its side effects;
tion functioning. appears apprehensive, nervous; in-
creased pulse rate, rapid breathing.
0 Outcome Criteria:
Ineffective Individual Coping Patient will verbalize that anxiety is

reduced to a manageable level.
(CH.1)
0 NIC: Anxiety Reduction
0 Related to:
Definition: Minimizing apprehen-
fear of chemotherapy and it's pos- sion, dread, foreboding, or uneasi-
sible side effects. ness related to an unidentified
0 Defining Characteristics: source of anticipated danger.
Inability to meet basic needs, worry,

anxiety, verbalization of fears, in-
ability to cope.
Anxiety Reduction Discharge or ~ a ~ n ~ ~ n a n ~ ~

Evaiuati~n
* Anxiety is decreased to a
Activifies Rafionales manageable level.
Use a calm, reassuring Prevents anxiety.
approach.
Utilize comfort Promotes relaxation. Knowledge Deficit
measures such as back
rub, positioning. 0 Relatedto:
Listen attentively to Creates atmosphere of Chemotherapy and it’s side effects.
expressions of feelings trust.
and concerns. t3 Defining Characteristics:
Provide diversional Diversions can reduce Patient verbalizes lack of informa-
activities. tension. tion about chemot~erapyand its
Administer M~icationsreduce side effects and how to manage
medications to reduce anxiety. those side effects.
anxiety as appropriate. Outcome Criteria::
Patient describes treatment plan,
possible side effects, and what to do
about them.
Instructions, Information,, 0 NIC: Chemotherapy Management
Demonstration
Definition: Assisting the patient
and family to understand the action
and minimize side effects of an-
tineoplastic agents.
Provide factual Knowledge of what to
~ n f o ~ a t about
~on expect can decrease
disease, treatment, and anxiety.
prognosis.
lnshvct patient on Self care measures
1 Chemotherapy Management 1
measures they can use promote control and
to lessen the severity of lessen anxiety.
side effects from Activities Rationales
chemotherapy, such as Assess knowledge of Provides needed
relaxation, imagery, chemotherapy information to
music therapy. treatment plan, formulate teaching
Instruct patient on anti- Promotes compliance possible side effects, plan.
anxiety medications with health care and self-care measures.
including when to regime.
take, possible side
effects,and what to do
about the side effects.
CHEMOTHERAPY 71
Chemotherapy Management
Activities
Provide patient with
written materials such
as ”Chemotherapy and
You” from the
National Cancer
Rationales
Written materials
reinforce verbal
instructionsand
provide a resource for
patients when health
r Chemotherapy Management
Activit ies
Inform patient of
changes that must be
reported to the health
care team immediately:
Signs of infections,
Rationales
Prevention of serious
complications by
promoting early
reporting to the health
care team.
Institute, and care worker is not persistent nausea and
institutional fact sheets present. vomitin,g,unusual
on drugs. bleeding or bruising,
diarrheai, or acute
Inform patient of the Promotes patient
changes in mental or
names of knowledge. L
emotional status.
chemotherapy
medications, purpose, Discharge or Maintenance
route, method, Evaluation
schedule of
administration. Patient states names, route,
Promotes self-care method, and schedule of ad-
Instruct on possible
ministration of chemotherapy
side effects and self- management and
decreases incidence medications and any medica-
care measures for each
tions prescribed to treat the
medication. and severity of
side effects of chemotherapy.
complications.
Lists possible side effects of
Provide written Written materials chemotherapy drugs and self-
information about each reinforce verbal care measures to manage the
drug including action, instructions. side effectsif they occur.
purpose, side effects. . Identifies changes that require
Instruct patient not to Prevents harmful drug immediate notification of the
take any other interactions. health care team.
medications unless
prescribed by the
physician, including
over the counter drugs.
Advise patient not to Aspirin and
take aspirin or nonsteroidal anti-
nonsteroidal anti- inflammatory drugs
inflammatory drugs can inhibit platelet
(NSAIDs),check labels activity; Aspirin and
of OTC drugs carefully NSAIDs are present in
for these drugs. many OTC drugs.
Instruct patient on Prevents or lessens
medications prescribed severity of side effects.
to assist patient with
side effects of the
antiemetics.
0 NIC: Infection Protection

Essential Nursing
Definition: Prevention and early
Diagnoses Related to detection of infection in a patient at
Bone Marrow risk.
Suppression from
Chernotherupy
Infection Protection
Altered tissue Perfusion, Activities Rationales

Cardiopulmonary Monitor WBC, An AGC below 500
(CH. 13) differential, calculating cells/mm 3 places the
the AGC (AGC= Total patient at severe risk of
0 Related to: WBC x [%segs+l developing an
Anemia from myelosuppresion %bands). infection.
caused by chemotherapy. Monitor for systemic Lack of neutrophils
0 Defining Characteristics: or localized infection, during
keeping in mind that granulocytopenia
Cold extremities, pale skin, pale the normal signs of inhibit ability to fight
mucous membranes, shortness of infection (redness, pus, infection and can mask
breath, tachycardia, tachypnea, inflammation, the signs of infection.
anxiety, angina. warmth) are due to the
actions of WBCs, so
"normal" signs of
infection may be
Risk for Infection absent.
Monitor vital signs, Fever or hypothermia
0 Related to: including temperature, may indicate presence
every 4 hours and of infection in the
Chemotherapy treatments due to
more often if granulocytopenic
the destruction of rapidly dividing
appropriate. patient.
normal hematopoietic cells, result-
ing in immunosuppression. Assess all sites of Helps identify
invasive procedures complications.
0 Defining Characteristics: for evidence of
Granulocytopenia, an absolute infection.
granulocyte count (AGC)below Assess skin and Skin and mucosa
1000 cells/mm 3. Neutropenia, an mucosal surfaces for provide the first line of
absolute neutrophil count (ANC) breaks. defense against
below 1000 cells/mm 3. microorganisms.
0 Outcome Criteria:: Report fevers of Temperature elevation
100.5T to physician due to low numbers of
Reduced potential for infection.
immediately. WBCs may be the only
sign of infection in the
granulocytopenic
pa tient.
CHEMOTHERAPY 73
Infection Protection Infection Protection
Activities Rationales Activities Rationaks

At first fever spike, Cultures help identify Administer antibiotics, Prevent and/or treat
quickly obtain cultures the source of infection, antifungal, and for infectious agents in
as appropriate, (urine, although many times a antimicrobial agents as the immune
blood, open wounds, source cannot be appropriate. compromised patient.
and/or sputum). identified.
Administer colony Colony stimulating
Start antibiotics Granulocytopenic stimulating factors factors reduce duration
immediately after patients can develop such as G-CSF or GM- of neutropenia.
obtaining necessary overwhelming sepsis CSF as iippropriate.
cultures. Do not wait within 12 hours of
Change all dressings Prevents line sepsis
for culture results fever spikes if
daily including those and infections in other
before initiating untreated with
over central lines. areas.
antibiotic therapy. antibiotics.
Institute Granulocytopenic
Granulocytopenic precautions are
precautions per initiated in some
institutional policy institutions when ANC Instructions, Information,,
including 1)A private and in others when
Demonstration
room with door closed; ANC Measures
2) Rigorous decrease risk of
handwashing by exposure to
patient, family/friends endogenous and Act ivities
~
Rat ionales
and hospital staff;3) exogenous organism.
Teach patient, Reduces infection
Barring ill persons
family/ friends potential.
from entering unless
measures to decrease
absolutely necessary
risk of infections (see
and donning a mask;
above).
4) Patient should wear
a mask when leaving Teach patient, Enhances compliance
the room; 5 ) Institute a familyifriends signs with nursing regime.
low bacterial diet, no and symptoms of
fresh fruits, vegetables, infection, stressing
pepper, or spices; what tal report to
6 ) No fresh cut flowers health care team.
or plants; 7) Patient
Instruct patient to take Antibiotics treat
should avoid large
any medications infectious organisms.
crowds; 8) Patient
prescribed, such as CSFs reduce duration
should wear gardening
antibiotics or colony of neutropenia; if not
gloves and use electric
stimulating factors taken as directed,
shaver.
(CSFs)such as G-CSF. serious sepsis may
Assist patient with Reduces presence of occur.
personal hygiene in endogenous organisms.
bathing, oral, and
perineal care.
Encourage rest as Fatigue can depress
appropriate. immune function.
Instructions, Information,, 0 Defining characteristics:

Demonstration Fevers greater than 100.5 F,
O
tachycardia, and/or tachypnea;

complaints of chills, rigors, flushed
skin.
Explain to patient Many of the newer R Outcome criieria
expected cost of drugs agents are very
such as CSFs and expensive. If insurance Patient’s temperature elevation will
assess insurance does not cover cost, be identified immediately and cor-
coverage. If not patient may be unable rect treatment initiated promptly.
covered by insurance, to follow prescribed 5 NIC: Fever Treatment
assess ability to pay regime without
and discuss indigent assistance. D e ~ t i ~Ma~gement
n: of a
policies of patient with hyperemia caused by
manufacturers,as nonenvironmental factors.
appropriate.
Instruct patient to Contact with infectious
avoid people with persons could lead to
respiratory infections serious infections.
{flu, cold), children Fever Treatment
exposed to infectious
diseases (chicken pox),
and avoid direct Activities Rationales
contact with cold sores
and other herpetic Monitor temperature Temperature elevation
lesions. every 4 hours. may be the only sign of
infection in the
0 Discharge or ~ajn~enance ~ ~ u l ~ y t o p e ~ a
Evaluation patient due to the low
numbers of WBCs.
Patient can verbalize
measures to prevent infection. Monitor pulse, blood Fevers can cause
pressure, and tachycardia,
Absence of signs and respiration every 4 hypotension, or
symptoms of infection. hours. tachypnea.
Ability to pay for prescrip-
tions for CSFs either through oni it or intake and Fevers cause increased
insurance or other methods. output. insensibfelosses which
Follow-up visits to physician lead to dehydration.
and laboratory scheduled and Notify physician of Fever may be only sign
completed as directed. first fever spike in the of infection in the
neutropenic patient. neutropenic patient
and requires
immediate
intervention.
Administer antipyretic, Acetaminophen
0 Related to: acetaminophen every 4 reduces fevers without
hrs PRN fever 100.5 the increasing the risk
Infection secondary to
granuIocytopenia from (avoid aspirin), if of bleeding.
chemotherapy amrowiate.
CHEMOTHERAPY 75
Fever Treatment
1 High Risk for Injury
0 Relatedto:
I Thrombocytopenia chemotherapy.
Use thermic mattress Provides warmth
as needed. during chills and
cooling during high Platelet count below 50,000
fevers. cells/mm3, fatigue, bruising
Administer IV fluids as and/or bleeding.
ordered. 0 Outcome Criteria::
Patient will remain free of bleeding
and tissue hypoxia.
0 NIC: Bleeding Precautions
Insrutctions, Information,
Demonstration Definition: Reduction of the risk of
blood loss for a patient with a
reduced coagulability.
If granulocytopenic Temperature elevation
patient is at home, may be the only sign of
instruct patient to infection in the Bleeding Precautions
check temperature in granulocytopenia
AM, PM, and if chilled patient due to the low
or warm. If fever is numbers of WBCs. Activities Rat ionales
above 100.5T' notify
MD immediately. Monitor platelet count Decreases risk of
closely; if <50,000 complications from
Instruct patient to Extra fluids are needed institUtebleeding thrombocytopenia.
drink at least 2-3 liters during high fevers to precautions including;
fluids (8to 12 glasses). replace insensible 1)Avoiding injury,
losses. injections, invasive
Instruct patient to take Granulocytopenic procedures, flossing of
antibiotics as ordered patients may need teeth ,and use of a hard
(entire 7-10 days). antibiotics to prevent toothbrush; 2) Avoid
infections. Inadequate rectal temperatures,
coverage by antibiotics enemas, suppositories,
may occur if patient and omstipation;
fails to complete entire 3) Avoid use of aspirin,
prescription and could or anticoagulants.
result in serious 4) Apply 5-10 minutes
"suver" infection. of pressure to
necessary injection
sites;
5) Using an electric
razor 6 ) NOT walking
in baire feet.
Bleeding Precautions Instructions, Information,,

Demonstration
Monitor hemoglobin Reductions in the
and hematocrit closely. hemoglobin and Teach patient/family Decreases risk of
hematocrit counts about bleeding complications from
could indicate bleeding precautions (see above). thrombocytopenia by
increasing compliance.
Monitor for signs and Clinically significant
symptomsof bleeding anemia may require Instruct patient/family Side effects from
such as dizziness, blood transfusions. about the signs and chemotherapy may
petechiae, and symptoms of bleeding occur at home.
presence of blood in and point at which
excreta; monitor signs nurse and/or
and symptoms of physician should be
anemia such as pale notified.
mucous membranes,
Teach patient/family Severe anemia r e q d
fatigue, dyspnea on
symptoms of anemia transfusion.
exertion, and angina.
(fatigue, dyspnea on
Monitor vital signs as Presence of exertion, angina) and
appropriate. hypotension and to notify health care
tachycardia may team if they occur.
indicate bleeding.
Use soft tooth brush Prevents injury to Evaluation
for oral care. gums which could
result in bleeding Patient can verbalize precau-
gums. tions necessary to prevent
'kansfuse with blood Plateletsare usually bleeding and actions to take
products as given when platelet should bleeding or anemia
appropriate. count falls below 10- occur.
20,000 cells/mm3 or if Bleeding episodes are
platelet count falls prevented or brought under
below 50,000 control.
cells/mm3 and Follow-up visits and
bleeding is present. laboratory testing done as
Packed red blood cells scheduled.
are usually given if
hemoglobin is below 8,
sooner if bleeding
present. Activity Intolerance
0 Reldedto:
Fatigue secondary to anemia from
chemotherapy.
Verbal report of fatigueor weak-
ness, abnormal heart rate or blood
CHEMOTHERAPY 77
pressure in response to activity, ex- Energy M a n a g e m e n t

ertional dyspnea.
0 Outcome Criteria::
.ktivities Rationales
Patient maintains optimal activity
level. Assist patient in Conserves energy.
Patient will maximize energy by prioritizing tasks in life
resting as needed to minimize effect and seeking assistance
of fatigue on activities of daily from family/friends in
living. those tasks patient is
unable to perform.
I3 NIC: Energy Management
Assist patient in Maintains protein
Definition: Regulating use of ener- adequade diet intake. stores needed for
gy to treat or prevent fatigue and energy production.
optimize function.
Offer soft, easy-to- Fatigue may impair
chew foods. ability to chew.
Energy Management
Instructions, Information,,
Activities Rat ionales Demonstration
Assess patient’s Determines baseline
fatigue/rest patterns. for assisting patient Activities Rationales
with fatigue.
Teach Understanding causes
Encourage patient to Promotes self control. patient/family/friends of side effects will help
maintain normal that fatigue is an patient feel more in
sleep/ rest /activity expected side effect control.
patterns as much as from chemotherapy
possible. and/or anemia.
Encourage patient’s Assist patient in Instruct patients to Measures promote
verbalization of coping with fatigue. 1) Priolritized activities; energy conservation.
feelings regarding 2) Recognize signs of
limitations. fatigue;
Assist patient to plan Promotes activity 3) Plan activities and
activities based on while preventing rest around rest
fatigue/rest patterns. fatigue. periods; 4)Ask
family/friends for
Encourage patient to Promotes adequate rest. help; 5) Sleep at night
plan rest periods as and maintain
needed throughout the normal routine as
day. possible during the day.
Encourage light Light exercise will Instruct patient on Promotes compliance.
exercise. promote normal benefits of light
sleep/rest pattern. exercise and assist as if
needed.
Instructions, Information,, Patient will be without nausea and

Demonstration vomiting or, if present, will be con-
trolled and minimal.
I
0 NIC: Nutrition Management
Activities Rut ionales
Definition: Assisting with or
Stress importance of Proteins are needed for providing a balanced dietary intake
diet in maintaining basic energy of foods and fluids.
energy. requirements.
Instruct family Promotes energy
members to restrict conservation.
length of visits if
fatigue is severe. Nutrition Management
Evaluation Activities Rationales
Rests when fatigued. Assess intake of foods Provides dietary
Schedules activities around and fluids and food information for
fatigue patterns. preferences. planning.
Inquire if patient has Prevents allergic
any food allergies. reactions by ingestion
of foods.
Essential Nursing Collaborate with Determines number of
Diagnosis Related to dietician as
appropriate.
calories and types of
nutrition needed to
Gastrointestinal Side meet nutritional
requirements based on
Effects patient’s food
preferences.
Weigh patient on Provides gain loss
admission and weekly information.
Altered Nutrition: Less than using the same scale.
Body Requirements Encourage small, Prevents nausea.
frequent meals if
0 Related to: patient has no appetite
Anorexia, nausea, vomiting, and or early satiety.
diarrhea from chemotherapy. Offermeals and snacks Protein provides
that are high-protein, energy and prevents
high calorie, and easy muscle wasting.
Patient reports inadequate food in- to consume.
take due to anorexia, and nausea, Discourage fatty, Taste alterations
loss of weight, early satiety, diar- greasy, spicy, and during chemotherapy
rhea. sweet foods during may include
0 Outcome Criteria: treatments. intolerance to these
foods.
Patient will maintain weight within
5% of pretreatment weight.
-
CHEMOTHERAPY 79
~~ ~~~
Nutrition Management Instructions, Information,,

Demonstration
Ac~i~~~es Rationales
Encourage bland diet Bland foods are easier
during chemotherapy to tolerate during Provide patient with Written materials
treatments. treatments. free, written materials reinforce verbal
on nutrition in cancer, instructionsand
Offer high caloric Provides calories and
such as "Eating Hints" provide knowledge
liquid or custard protein in smafl easy-
from '&eNational source when health
supplements. to-consume volume.
Cancer Institute or care team members are
Encourage patient to Chemotherapy can ''Nutrition Tips" from not present.
try different foods if cause taste changes. the American Cancer
taste changes are noted. Socieby.
Encourage patient to ~ iunplea~nt
~ Instruct
~ patient/fa~ly
~ s Knowledge will
suck on hard candy tastes from that anorexia is an decrease anxiety.
during treatments. chemotherapy. expected side effect,
that weight loss may
Administer antiemetic Prevention of nausea
occur, and that both
prior to chemotherapy, and vomiting will
will subside once
then regularly through assist in continuation
~ e a t ~ eisnover.
t
expected duration of of chemotherapy
nauSea and vomiting. treatments. fnstnict to eat small Measures prevent over-
frequent meals of high- distention, and
Administer Night administration proteins will prevent
caloric, high-protein
chemotherapy at night of chemotherapy foods. muscle wasting.
or late afternoon, if significantly decreases
possible. emetic episodes, and Instnict to take Prevents nausea and
many antiemetics antiemetic prior to vomiting.
promote sleep. eating:if nausea or
vomiting is present.
Control noxious odors, Noxious stimuli can
excessive noise, if increase anxiety and Instnxt to avoid non- Non-caloric foods and
possible. aggravate such side caloric food and beverages promote
effects as nausea. beverages such as satiety without
coffee, tea, diet soda, or nutrients or calories.
diet foods.
Instruct family on Promotes family
ways to assist patient structure and assists
with increasing caioric patient in ~~~~g
intake. caloric intake.
Encourage patient to Chemotherapy can
try different foods if cause taste changes.
1 taste changes are noted.
0 Discharge or ~ a i n t e n u ~ c ~
Evaluation
Weight maintained within 5%
of baseline.
Daily intake of adequate Fluid/Electrolyte Management

calories and proteins.
Nausea and vomiting
episodes absent or decreased. Activities Rationales
Assess blood pressure Changes in blood
lying down, sitting, pressure may indicate
Risk for Fluid Volume Deficit and standing. orthostatic
hypotension.
Related to: Assess amount and Provides information
Side effects from chemotherapy. frequency of stools for planning needed
and/or emesis. fluid replacements.
0 Defining Characteristics: Assess for weakness, Signs and symptoms of
Tachycardia, low urine output, dry paresthesia, leg hypokalemia due to
mucous membranes, decreased cramps, muscle Potassium loss from
fluid intake, anorexia, nausea, fatigue, pulse vomiting and/or
vomiting, fluid losses due to diar- irregularities. diarrhea.
rhea, electrolyte imbalances, or Monitor electrolyte Nausea, vomiting,
weight loss. levels as appropriate. diarrhea can lead to
Outcome Criteria: electrolyte depletions.
Weigh daily and Weight assists in
Fluid and electrolyte balance will be
monitor trends. measurement of fluid
maintained throughout
balance.
chemotherapy.
Monitor BUN, and Some chemotherapy
NIC: Fluid/Electrolyte Management creatinine. agents such as cisplatin
Definition:Regulation and preven- and methotrexate can
tion of complications from altered cause renal damage.
fluid and/or electrolyte levels. Monitor for signs and Too rapid infusion of
symptoms of over- replacement IV fluids
hydratiodfluid excess can lead to over-
while treating for hydration.
under-hydration.
Fluid/Electrolyte Management
Encourage patient to Vomiting and diarrhea
drink fluids with salts can lead to loss of
and to avoid fluids Potassium, but can be
Activities Rat ionales without salts such as replaced by oral fluids
Monitor vital signs, Inadequate oral intake water, if fluid intake is with salts.
intake and output as can cause hypovolemia minimal.
appropriate. whose symptoms Supplement Potassium Replaces fluid loss and
include tachycardia, intake with IV fluids ensures fluid intake.
hypotension, and and/or nasogastric
elevations in body feedings as
temperature due to appropriate.
dehydration.
Ef Relatedto:
Consult the physician Promotes maintenance
if signs and symptoms of fluid/electrolyte Large amounts of IV fluids used for
of fluid or electrolyte balances. hydration during chemotherapy.
imbalance persist or
worsen. t~e~ning
C h ~ a c t ~ ~ ~ s :
Administer prescribed Corrects electrolytes. Edema, weight gain, shortness of

electrolyte breath, intake greater than output,
supplementsas abnormal breath sounds, rdes
ordered. (crackles),change in respiratory or
mental status, blood pressure chan-
ges, altered electrolytes,anxiety,
restlessness.
Demonstration
Pain
17elatedto:
Nausea and vomiting from
Instruct patient to M ~ n ~fluidi n and chemotherap~and anxiety related
drink 8-10 glassesof electrolyte levels. to treatments.
fluids with salts daily.
0 Defining characterjstics:
Teach patient to notify Signs of hypovolemia
the nurse and or that require immediate Patient expresses feeling of pain or
doctor if any of the intervention. discomfort, moans, cries, is
following occur: diaphoresis, has blood pressure
dizziness or and/or pulse changes.
l~ghthead~n~,
inability to take I3 Outcome Criteria::
adequate fluids, Patient will express comfort or
vomiting persists for relief of pain through pain relief
more than 12 hours. measures and/or medications.
Instruct patient to call Prevents falls and Patient will verbalize decrease in
for assistance before injury. anxiety and increased physical com-
getting up if dizzy or fort.
~ i ~ ~ t - h ~ a d ~ .
NIC: Pain Management
Discharge or Maintenance Definition: Alleviation of pain or a
Evaluation reduction in pain to a level of com-
Patient will drink adequate fort that is acceptable to the patient.
fluids.
Patient’s serum electrolytes
will be maintained within nor-
mal limits.
Pain Management 0 Discharge or Maintenance

Evaluation:
Patient will be comfortable
Activities Rationales during chemotherapy treat-
ments.
Assess for pain or Provides information
discomfort, location needed for planning
and duration of pain care.
and any measures that
make pain worse or Risk for Altered Oral Mucous
better. Membranes
Provide emotional Reduces anxiety,
support . Related to:
Consider use of anti- Reduced anxiety will Damage to rapidly dividing cells of
anxiety drugs in promote comfort. the mucosa due to chemotherapy.
antiemetic regime such Defining Characteristics:
as lorezepam.
Minimize waiting time Oral pain/discomfort, coated
Decreases anxiety.
for treatments or tongue, xerostomia, and/or hyper-
procedures. emia.
Provide distractions Promotes comfort by 0 Outcome Criteria:

during treatments such diverting attention Oral mucous membranes intact and
as TV/VCR,radio, from pain. free of irritation and pain.
reading materials.
0 NIC:Oral Health Maintenance
Keep emesis basin Promotes comfort
within reach, provide during emesis. Definition: Maintenance and
mouth care post promotion of oral hygiene and den-
emesis. tal heaIth for the patient at risk for
developing oral or dental lesions.
Instructions, Information,,
Demonstration
Teach patient Promotes self-control
progressive relaxation over side effectsby
techniques or guided reducing stress and
imagery. anxiety.
Teach patient when to Promotes desired
take medications for actions and results;
pain and/or anxiety, prevents drug adverse
possible side effects reactions.
and how to manage
them.
CHEMOTHERAPY 83
Oral Health ~ a i n t e n u n c ~
Activities Rat ionales Activities Raf ionales

Establish baseline Provides necessary Discourage smoking Smoking and alcohol
assessment of oral information to and tolbacco use. can dry and damage
mucosa including establish plan of care. mucous membranes.
1) History of alcohol
use or smoking;
2) History of dental
problems, oral hygiene
practices; 3) Prior or Instructions, Information,,
current radiation to Demonstration
head and neck;
4)Oral exam examine
lips, gums, upper inner
lip, gums, tongue, hard Activities Rationales
and soft palate, floor of
Demonstrate and Promotes clean oral
mouth, teeth, and oral
instruct patient on cavity and prevents
pharynx; 5) Assess
teeth brushing, dental problems.
amount and
flossing, and denture
consistency or saliva;
care.
6 ) Assess fit and
condition of dentures. Inforni of importance Provides adequate
of foo8 and fluid nutrition and fluid
Perform oral Identifies problems
intake of at least 2 intake.
assessment every shift. early.
liters (8-10 glasses)per
Assess nutritional Problems with oral day.
status. health can effect intake
Inform of reasons to Acidic juices, alcohol,
of foods and fluids.
abstain from smoking hot liquids, and
Initiate dental referral Promotes clean or drinking irritating smoking can cause
if appropriate. bever,agessuch as damage to oral mucosa.
alcohol, acidic juices,
Establish a mouth care Promotes clean teeth or very hot liquid.
regime, including and gums.
brushing and flossing Discharge or Maintenance
teeth after each ma1 Evaluation
and before bedtime
and rinsing mouth = Oral mucosa pink, moist and
with gentle alcohol free intact.
mouthwash. Well-fitting dentures and lor
Assist with oral care or Provides care if patient teeth in good repair.
denture care as needed. is unable. Able to ingest foods and
fluids without pain.
Apply lubricant to Keeps mouth moist.
mouth, lips, and gums.
Offer fluids frequently. Promotes moist
mucous membranes.
Altered Oral Mucous Oral Health Restoration

Membranes
Relatedto: Actidies Rationales
Damage to mucous membranes Perform oral Assesses progress of
from chemotherapy. assessment every shift. healing process and for
signs of infection.
Monitor vital signs and Assesses for signs of
Oral pain/discomfort, stomatitis, temperature every shift. infection.
desquamation, oral vesicles, hemor-
Assess nutritional Problems with oral
rhagic gingivitis, xerostomia,
status. health can affect intake
dehydration, malnutrition.
of foods and fluids.
0 Outcome Criteria: Initiate dental referral Promotes clean and
Oral mucosa will heal and become if appropriate. healthy teeth and
pink and moist. gums.
NIC: Oral Health Restoration Assist with oral care or Provides care if patient
denture care as needed. is unable.
Definition: Promotion of healing in
Use a soft toothbrush Prevents injury to
a patient with oral mucosal or den-
or toothette for gums.
tal lesion.
removal of dental
debris.
Encourage flossing Removes bacteria
between teeth twice which may cause
Oral Health Restoration daily with unwaxed dental caries or
dental floss if platelet septicemia.
levels are above
Activities Rationales 50,000/mm3.
Encourage frequent Soothes injured oral
Establish baseline Provides necessary rinsing of the mouth mucosa and keeps
assessment of oral information to with sodium mouth clean and moist.
mucosa ,including establish plan of care. bicarbonate solution,
1) History of alcohol normal saline, or
use or smoking; 2) medicated mouth
History of dental wash.
problems, oral hygiene
practices, prior or Apply lubricant to Keeps mouth moist.
current radiation to mouth, lips, and gums.
head and neck; 3) Oral Remove dentures in Prevents further injury
exam: examine lips, case of severe to mucosa.
upper inner lip, gums, stomatitis.
tongue, hard and soft
palate, floor of mouth, Provide artificial saliva Provide relief from dry,
teeth, and oral as appropriate. oral mucous
pharynx; 4)Assess membranes.
amount and Offer fluids frequently. Promotes moist
consistency or saliva;
mucous membranes.
5) Assess fit and
condition of dentures.
CHEMOTHERAPY 85
Oral Health Restoration Instructions, Information,,

Demonstration
Activities Rut ionales

Discourage smoking Smoking and alcohol
and tobacco use. can dry and damage Demonstrate and Promotes healing of
mucous membranes. instnrct patient on oral cavity and
teeth Imshing, prevents further oral
Administer topical Numbs mucosa so
flossing, denture, care and dental problems.
anesthetics and/or patient can eat; rdieves
and soothing mouth
systemic pain pain.
rinses every 1-2 hours.
medications.
Inforrn of importance Provides adequate
Administer topical Treats infection in oral
of food and fluid nutritional and fluid
and/or oral antibiotics. cavity and /or any
intake of at least 2 intake.
systemic infection.
liters ‘(8-10
glasses) per
Assist patient to select Prevents further day.
soft, bland diet, and discomfort and
Inforrn of reasons not Knowledge of irritants
non-acidic foods. irritation to mucous
to smoke or drink. will promote
membranes.
compliance.
Plan small, frequent Promotes nutritional
Discuss need for hyper Promotes maintenance
meals high in calories status.
alimentation. of adequate nutrition.
and protein.
Offer liquid nutritional Provides complete Discharge or Maintenance
supplementsif patient nutrition. Evaluation
is having trouble
swallowing solids. Oral mucosa will heal and be
pink and moist.
Offer popsicles, ice Cold foods soothe and Oral nutritional intake will be
cream, as desired. provide liquid and adequate to maintain body
calories. weight.
Administer hyper Provides needed
alimentationif oral nutrients when patient
intake is not adequate. is unable to take them
orally. Pain
Explain reasons for Measures will relieve
topical anesthetics pain. Related to:
and/or systemic pain Stomatitisfrom chemotherapy.
medications.
Patient reports of pain upon swal-
lowing and/or eating, unable to eat
or drink due to pain in oral cavity.
0 Outcome Criteria::
States relief from oral pain.
NIC: Pain Management Instructions, Information,,

Demonstration
Definition:Alleviation of pain or a
reduction in pain to a level of com-
fort that is acceptable to the patient.
Explain reasons for Promotes
topical anesthetics understanding.
and/or systemic pain
Pain Management
medications.
Demonstrate and Dry irritated mucosa is
Activities Rationales instruct patient on very painful; measures
teeth brushing, promote healing,
Perform Provides information flossing, denture care, decrease pain.
comprehensive needed to formulate and soothing mouth
assessment of pain. plan of care. rinses every 1-2 hrs.
Observe for nonverbal Patient may not be able Teach patient Measures promote
cues of discomfort or willing to nonpharmacologic pain relief.
especially if communicate their measure to control
communication is pain. pain: relaxation,
impaired. guided imagery music
therapy, distraction.
Administer topical Numbs mucosa so
anesthetics and/or patient can eat and 0 Discharge or Maintenance
systemic pain reliefs pain. Evaluation
r;ledications.
Patient verbalizes relief
Administer parenteral Stomatitiscan be
and/or control of oral pain.
analgesics including severe. Narcotics may
morphine infusions as be needed to control
appropriate. pain.
Evaluate the To observe for any
effectivenessof signs and symptoms of Common Nursing
analgesic administered
at frequent intervals
untoward reactions
and ensure against
Diagnoses Related to
relief. pain. Integumentary
Attend to comfort To facilitate response Changes
needs and other to analgesics.
activities that assist
relaxation.
Collaborate with the To make specific Body Image Disturbance
physician if drug, dose, recommendations to
route of ensure patient’s pain is Related to:
administration, or relieved.
interval changes are Alopecia, weight loss and/or skin
indicated. changes secondary to
chemotherapy.
CHEMOTHERAPY 87
Patient verbalizes fear of rejection
or reaction of others to altered ap-
pearance, negative feelings about
body concern over hair loss, and
skin changes.
r
I
Elody Image Enhancement
Activities
Encourage patient to
Rationales
Assists beautician in
get hair prosthesis fitting patient for a wig
0 Outcome Criteria: while hair is still similar to normal hair
present. color and style.
Patient will verbalize an under-
standing of why chemotherapy Encourage patient to Skin and eyes are more
causes alopecia, and/or skin chan- use protective methods at risk for injury due to
ges. for skin and eyes: sun changes induced by
Discusses measures to minimize im- screens (SPF 151, chemotherapy.
pact of hair loss and skin changes eyeglasws, hats with
on lifestyle. wide brim.
0 NIC: Body Image Enhancement

Definition: Improving a patient's
conscious and unconscious percep-
tions and attitudes toward his/her Instructions, Information,,
body. Demonstration
Body Image Enhancement Instruct patient on the Adriamycin causes
amount of hair loss to total hair loss; other
expect and when it will agents like cisplatin
regrow. only thin hair.
Act ivities Rationales
Inform that hair loss is Chemotherapy hair
Assess patient's Alkylating agents, usually temporary, and loss is almost always
chemotherapy antimetabolites, that regrowth is temporary; knowledge
treatment plan for especially adriamycin sometimes a different will assist patient in
drugs that may cause and tumor antibiotics, color or texture. coping with loss.
alopecia. can cause alopecia.
Instruct on proper Promotes scalp, skin
Assess impact of Provides information scalp and skin care. integrity.
alopecia on lifestyle. to formulate plan.
Provide information Chemotherapy can
Assist patient to Provides outlet for and/or referral to cause skin changes
discuss feelings about emotions. cosmetologist, skilled and /or loss of
body image changes. in skin care and make- eyebrows and
Encourage patient to Minimizes shock over up techniques to cover eyelashes. The
cut long hair. total hair loss. loss of eyebrows and American Cancer
eyelashes. society provides
Identify measures to Promotes self-control training to
reduce the impact of over loss. cosmetologists to treat
hair loss such as wigs, these problems.
scarfs, turbans, hats.
Evaluation:
I Skin Care- Topical Treatments
Patient implements measures

to minimize impact of loss of Activities Rat ionales
hair on lifestyle.
Avoid use of rough Prevents trauma to
bed linens. skin.
Keep bed linens clean Prevents maturation of
Impaired Skin Integrity and dry. skin from moistness.
Use assistive devices Promotes skin integrity
0 Related to: on bed (eg, sheepskin, and comfort.
Perianal skin imtation from diar- foam/air mattresses,
rhea, secondary to chemotherapy or heal protectors).
infection. I Assist patient to bathe Keeps skin clean and
I frequently. dry-
Presence of risk factors such as

physical immobilization, and
decreased nutritional intake from
chemotherapy. lnstruct~ons,Informution,,
0 Outcome Criteria: Demonstration
Skin will remain free of further in-

jury and open areas will heal. Activities ~ ~ ~ n u ~ e
0 NIC: Skin Care- Topical Treatments
Consult with skin care Experts may be able to
Definition: Application of topical specialistsas needed. provide i n f o ~ t i o to
n
substancesor manipulation of assist with hard-to-
devices to promote skin integrity heal areas.
and minimize skin breakdown. Encourage patient to l ~ o b i l i t promotes
y
ambulate, and to be as skin breakdown.
active as possible while
hospitalized.
Instruct patient in skin Knowledge promotes
care techniques such as compliance with
keeping skin clean and nursing regime.
dry, etc.
Activities
Instruct patient to These chemotherapy
Assess skin integrity. Provides information avoid sun exposure or agents cause
for planning care. take appropriate p h o t o ~ n s ~which
ti~~
precautions such as can cause a severe
Encourage and/or Feces left on skin can wearing protective sunburn to exposed
assist patient to cleanse irritate skin, causing unprotected skin.
clothing, hats, and/or
and gently dry breakdown. Keeping sunscreens if sun
perianal area after each skin clean and dry will cannot be avoided, or
loose stool. help prevent this. if receiving 5-W,
Apply protective Protects skin from Methotrexate, or
aP;entsto perianal area. irritating stool. steroids.
CHEMOTHERAPY 89
0 Discharge or Maintenance Intravenous Therapy

Evaluation
Patient skin will remain in-
take and free of breakdown. Activities Rat #na les
Areas of skin breakdown will
Administer vesicant Minimizes injury
show granulation and
through a new IV and should extravasation
evidence of healing.
a free flowing IV, occur.
monitoring site
constantly.
Risk for Impaired Skin Integrity For continuous Prevents extravasation

infusion of a vesicant of vesicants when no
0 Related to: drug, a central line is health care member is
usually required. present to initiate care
Extravasation of vesicant immediately.
chemotherapy. If extravasation is Measures will
cl Defining Characteristics: suspected 1)Stop the minimize damage to
drug and follow any tissues from
Patient complains of pain, burning; i n s t i t ~ t i policy
o ~ ~ and extravasated
skin appears red, necrotic, progress- procedure; 21 Aspirate chemotherapy should
ing to tissue sloughing. any residual I drug it occur.
and/or blood from IV
0 Outcome Criteria:
tubing or catheter if
Extravasation if it occurs is detected possible; 3) Instill
early with immediate intervention. antidote if applicable;
4)Remove needle;5)If
17 NIC: IntravenousTherapy applicable inject
Definition: Administration and antidote into area of
monitoring of intravenous fluids infiltration; 6) Apply
and medications. topical cream if
recommended; 7)
Cover lightly with
sterile cmlusive
dressing; 8)Apply
warm or cold
Intravenous Therapy comprises as
applicalble;
9) Elevate arm; 10)
~ ~ t ~ ~~ i u ~~ ~ l ~tAssess
s site ~ regularly ~
for paiin, progression of
Insert IV using asepsis Prevents injury to erythema, induration
and careful technique, tendons and nerves if andlor evidence of
including selecting site extravasation, and necrosjs.
away from underlying identifies site problems
tendons and nerves; early.
secure IV so insertion
site is visible.
Demonstration
Inform patient if their Patients have a right to
chemotherapy drug is know of serious
a vesicant, and instruct potential
on potential complications.
complications should
extravasation occur.
Instruct patient to Signs and symptoms of
notify nurse if IV site extravasation.
becomes painful, red,
or swollen during
infusions of vesicants,
especially if burning is
noted.
Discuss possible need Patients with poor
for venous access venous access may
devices to safely give benefit from a venous
vesicant agents. access device.
Evaluation
Intravenous site will remain
free of signs and symptoms of
extravasation during ad-
ministration of vesicant
chemotherapy agents.
Should extravasation occur, it
will be identified and treated
early to minimize tissue
damage.
Chapter F.ive
Biotherap y Treatment
Biologic Therapy
Biologic therapy, or biotherapy, is rapidly developed post operative infectionsfollow-
emerging as a fourth treatment modality for ing surgical resections of their tumors
cancer. Biotherapy is based on the theory remained tumor free. He theorized that the
that if the immune system will recognize the infection somehow stimulated the patient’s
tumor cells as foreign invaders it will destroy immune system to fight the cancer. Coley’s
them. Agents or approaches that stimulate toxins were used as late as 1975.
the immune system are called biologic In the late 1960s and 70s scientists used im-
response modifiers or BRMs. The National munotherapy to induce a general immune
Cancer Institute in 1981 formally defined response by injecting tumors with Bacillus
biologic response modifiers as agents or treat- calmetle guerin and corynebacterium
ments that alter the relationship between the parium. These efforts did not have the
tumor and the host’s natural response to response rates hoped for, and encountered
tumor cells, with resultant therapeutic effect. difficulties. Immunotherapy fell out of favor.
There are several characteristics common to Follciwing some technologic advances in the
BRMs: They are naturally produced in the 19809, interest in immunotherapy, or
body in small amounts; They function as im- biotherapy, was renewed. These advances in-
portant regulators and messengers of im- clude recombinant DNA and hybridoma
mune functions; They boost the body’s technology. Recombinant refers to a recom-
response to foreign substances; and they act bined DNA molecule. A gene involved in the
directly or indirectly to stimulate or enhance production of a desired protein is combined
the activity of the immune system. with a DNA strand from another organism
(like a bacterium) which is easily
reproducible. This results in a DNA factory
Historical Perspective that produces DNA exactly like the original
molrrule. Through this process a specific
For over a century scientists have looked for genetic code can be copied, sequenced, and
a way to stimulate the body to destroy can- produced in bulk. This mass production has
cer cells. In 1891 Dr. William Coley, a sur- produced a whole new classification of
geon at Memorial Hospital in New York, drugs called “biotechnologics”.
developed what came to be known as
The FDA defines biotechnology as a techni-
Coley’s Toxins. He first induced infections in
que that uses living organisms or a part of a
cancer patients using live bacteria and, later,
living organism to produce or modify a
filtered toxins. Dr. Coley did this because he
product; to improve a plant or animal; or to
noticed that some of his patients who
develop a microorganism for a specific pur- side effects are flu-like symptoms such as
pose. The FDA has approved twenty biotech- fever, chills, rigors, fatigue, nausea, vomit-
nologic products including "humulin" ing, and diarrhea.
insulin, a growth hormone; vaccines;
cytokines, which include interferons; inter-
leukins; colony stimulating factors (CSF);
Types Of Biologic
thrombolytic agents; and a monoclonal an-
tibody called OKT3. More than 100 other
Response Modifiers
products are in clinical trials. These drugs dif- Types of biologic response modifiers includ-
fer from previous new drugs in that their ing vaccines, monoclonal antibodies, colony
mass production is more difficult and there- stimulating factors(CSFs),interleukins(IL),
fore more expensive to develop and produce and interferons(1FN).Each type will be dis-
for clinical use. It is ironic that these cussed.
products are emerging at a time when resour-
ces and monies for these therapies are becom-
ing very limited.
Monoclonal
An tibodies
Properties of BRMs Monoclonal antibodies are artificially
manufactured antibodies specifically
Several aspects of BRMs are unique. First, a
designed to find targets on the cancer cells
simple dose/response relationship, as seen
for diagnostic or treatment purposes. Some
with chemotherapy, does not exist. The con-
scientists call them biologic hunters or "tar-
cept of maximum tolerated dose, so impor-
get- specific magic bullets". It is hoped that
tant for chemotherapy doses, may not apply
in the future a radioactive isotope or
to BRMs. Rather, the concept of optimum
chemotherapy drug can be attached to a
biologic dose (OBD) is used. The OBD is the
monoclonal antibody and then injected into
minimum dose at which the maximum
the human body. The antibody would then
biologic effect is achieved. Key to determin-
seek out the cancer cells. This should allow
ing OBD is to identify those effects which
only cancer cells to be damaged by the
contribute to the desired antitumor response.
chemotherapy.
A second unique aspect of BRMs is that their
effects can take months to document. Lastly,
side effectsof BRMs mimic the body's nor-
mal immune response. The most coinmon Vaccines
Many scientists are trying to develop vac-
cines to fight cancer. These vaccines are
BIOLOGIC THERAPY 95
made from irradiated, inactivated cancer subcutaneously. Side effects include diar-
cells. The vaccines may sensitize the immune rhea, rashes, and malaise.
system to recognize cancer cells as foreign Erytlwopoietin is a CSF that acts on erythroid
and increase the body's ability to destroy
progenitor cells to stimulate maturation of
them.
red blood cells. It was FDA-approved in 1989
as Epogen and Procrit, and it is used for
chronic renal failure and HIV-infected
Colony Stimulating patients receiving myeloid suppressive
Factors therapy Recently added to the list of indica-
tions was anemia due to cancer treatment.
Colony Stimulating Factors (CSFs)are Epogen and Procrit are well tolerated if hy-
naturally- produced, hormone-like proteins pertension is well controlled before therapy.
that stimulate the growth, maturation, and Iron replacement may be required during
regulation of various types of blood cells. treatment.
They are also called growth factors. Five
growth factors are approved by the FDA and
are in use today. These are Neupogen,
Ink r feron
Leucine, Prokine, Procrit, and Epogen.
G-CSF, or Granulocyte CSF, stimulates Interferon (IF") was discovered in 1957 by

proliferation and differentiation of Isaccs and Lindenman. Its name comes from
neutrophils, the body's first line of defense its albility to interfere with virus replication.
against infections. It is FDA-approved under It has both antiviral and antitumor respon-
the name of Neupogen with a broad indica- ses. There are three types of interferon:
tion for patients with myeloid malignancy Alpha, Beta, and Gamma. In cancer care, In-
who are recovering from myelosuppressive terferons work in several ways by slowing
chemotherapy. It is given subcutaneously down cell replication, protein synthesis, and
daily for 10-14 days following chemotherapy. DN.4 production. They thereby prolong the
Generally the drug is well tolerated, with cell cycle; and by stimulating a host immune
bone pain as the most common side effect. response, in turn,they enhance natural killer
cell activity.
GM-CSF is another CSF that stimulates
proliferation and differentiation of multi- Only Alpha interferon is FDA-approved for
lineage colonies, specifically neutrophils, the treatment of cancer. Sold under the
eosinophils, and macrophages. It is FDA-ap- names Intron-A and Roferon-A, Alpha-IFN is
proved with two products available, approved for treatment of hairy cell
"Leucine" and Prokine, which accelerate leukemia, Kaposi's sarcoma, and hepatitis C.
myeloid recovery in bone marrow transplant It is also used against lymphoma, melanoma,
patients. It is administered intravenously or and renal cell cancer. Gamma-IFN was
recently approved for treatment of chronic Interleukin-2 Side

granulomatous disease. Clinical trials also
Effects
are underway with a Beta-IFN for the treat-
ment of multiple sclerosis. The side effects of IL-2 are dose related. The
Interferon can be given subcutaneously,by higher the dose, the greater the side effects.
intravenous infusion, or injection. The major The most frequent side effects are sum-
side effects of Interferon are flu-like marized in the table below:
symptoms including fever, chills, headaches,
muscle aches, joint aches, and fatigue. These
are usually treated with antipyretics and
Frequent IL-2 Side Effects
analgesics. Other side effects include bone
marrow suppression, nausea, vomiting, diar-
rhea, and mental status changes including Flu-like Symptoms Fevers, chills, rigors,
fatigue, muscle aches,
depression, anxiety, and insomnia. headache.
Cardiovascular Hypotension, capillary
leak syndrome,
vascular dehydration,
Interleukin angina, myocardial
infarction,
Interleukins are important messengers and arrhythmias,
pulmonary edema,
regulators of immune functions. Twelve in- peripheral edema.
terleukins have been identified to date. Inter-
Renal Oliguria, anuria,
leukin-2 (IL-2)is the only one azotemia, creatinine
FDA-approved, under the name of elevations.
Proleukin. The actions of IL-2, a lymphokine, Gastrointestinal Anorexia, nausea,
vomiting, diarrhea.
include:
Stimulating proliferation of T Mental Status Changes Depression, anxiety,
& B lymphocytes and Natural insomnia, psychosis,
Killer (NKkells coma.
Enhancing cytotoxicity of Skin Changes Erythema, burning and
monos, T-lymphs and NK cells itching.
Inducing secretion of an-
Bone Marrow Lymphopenia,
tibodies, Tumor Necrosis Fac- Depression thrombocytopenia,
tor (TNF),and gamma-IFN anemia.
0 Initiating Lymph-Activated
Killer (LAW cell production.
BIOLOGIC THERAPY .~
97
Common Side Effects cular space and enter the interstitial spaces.
of Biologic Therapy Expansion of fluid volume becomes difficult
as even replacement fluids leak out. How-
Excellent nursing care is crucial to patients ever if hydration is too vigorous, edema will
undergoing biotherapy. Because the side ef- result, as will ascites and pulmonary edema.
fects of biotherapy can be life-threatening Most clinicians will not treat hypotension to
and because many of these agents are given lower incidence of pulmonary edema, unless
at home or are self-administered, education its symptomatic. In severe cases of hypoten-
of patient and family is paramount. sion, vasopressors are given.
The most common side effects seen with Other, less common, cardiovascular side ef-
BRMs are the flu-like symptoms such as fects of IL-2 include arrhythmias, ischemia,
fever, chills, muscle aches, fatigue and rigors. angina, myocardial infarction, myocarditis
Fever can be prevented with nonsteroidal and hypocontractility. Decreased renal per-
anti-inflammatorydrugs. Acetaminophen fusion can result from vascular dehydration,
and a cooling blanket may provide the best leading to oliguria, anuria, and azotemia.
combination of prophylaxis and treatment. TheFe latter conditions are characterized by
Rigors are usually treated with Merperedine sodium depletion and elevations in serum
intravenously, or morphine if the use of crealtinine and blood urea nitrogen levels.
Meperidine is contraindicated.As treatment Vigclrous hydration-the usual treatment for
continues, fatigue progresses and is some- these conditions- however, is contraindi-
times a dose limiting toxicity. Extreme cated during IL-2 treatment. Close monitor-
fatigue can lead to decreased food and fluid ing of serum creatinine is required; IL-2 is
intake, and soon, dehydration; therefore ener- usually stopped if serum creatinine is
gy conservation must be stressed along with elevated three times the patient’s normal
planned rest periods. value. Use of nonsteroidal anti-inflammatory
drugs are usually contraindicated because of
In patients undergoing therapy with Inter-
theiir nephrotoxic effects. Renal recovery
leukin-2, the most common side effect is car-
begins 24 hours after discontinuing IL-2.
diopulmonary toxicity. Dose limiting are
IL-2’s cardiovascular effects, one of which is Gastrointestinal problems such as nausea,
hypotension due to a decrease in vascular vomiting, and diarrhea are not uncommon
resistance. The hypotension occurs within an with BRMs. These symptoms usually are
hour after the first dose of IL-2 and worsens more chronic and can be treated with an-
as treatment proceeds. Later, as cardiac con- tiemetics, and antianxiety medications. An-
tractility decreases, vascular or capillary leak tidiarrheal medications have been less
syndrome (See below) occurs. successful.
Vascular or capillary leak syndrome is a con- Additional side effects of BRMs include men-
dition during which fluids escape the vas- tal status changes, skin changes, and bone
marrow suppression. Common with BRMs Analgesic Administration

are changes in mental status, depression,
anxiety, insomnia, psychosis, and in rare, Activities Raf ionales
severe cases, coma. Skin problems range
Assess pain, including Provides needed
from mild erythema, causing a location, information to
maculopapular rash, to diffuse erythema characteristics,quality, formulate plan of care.
with burning and pruritus. Lymphopenia oc- severity. For example, muscle
aches may be caused
curs within hours of starting BRMs, especial- by build up of lactic
ly IL-2. Thrombocytopenia, anemia, and acid in muscles during
rigors, while
eosinophilia also may occur. The side effects headaches may be
from BRMs usually are self-reversing within caused by low blood
24 hours of discontinuing therapy, but con- sugars due to poor
intake or dehydration.
scientious management of patient receiving
Check for history of Necessary to ensure
biologic therapy remains vital. drug allergies. Check safe administration of
medical order for drug, analgesics.
dose, and frequency of
analgesic prescribed.
Essential Nursing Select appropriate Chills/rigors, usually
Diagnoses Related to analgesics and
administer Meperidine
acute, precede fever by
about 1hour and range
Flu-Like Symptoms IV for chills/rigors; from just feeling cold
acetaminophen for to severe rigors.
myalgia and/or Meperidine relaxes
headaches. smooth muscles.
Myalgia /headaches
Pain precede or coincide
with fever;
0 Relatedto: acetaminophen
Biotherapy side effects produces antipyresis
through its action on
Defining Characteristics: the hypothalamic heat-
regulating center.
Communication of discomfort such
as myalgia, muscle aches, Evaluate at frequent Identifies signs and
headaches, and other pain descrip- intervals the symptoms of
tors. Observation of chills, rigors, effectiveness of untoward reactions
restlessness, and other pain'be- analgesics and ensures pain relief.
haviors. administered.
0 NIC: Analgesic Administration Attend to comfort Facilitates response to
needs and activities analgesics.
Definition: Use of pharmacologic that relaxation.
agents to reduce or eliminate pain.
BIOLOGIC THERAPY 99
Analgesic Administration
1 0 NIC: EnvironmentalManagement-
Comfort
Definition: Ma~pulationof
Acti~~ies Xat i o ~ a ~ e s patient's surroundings to promote
optimal comfort.
Collaborate with the Specifies
MD if drug, dose, recommendations to
route of ensure patient's pain is
a d ~ ~ s t r a t i oor
n, relieved.
interval are indicated.
Environmental Management -
Comfort
Activities ~ t ~ ~ ~ a ~
lnstruct~ons, ~nformati~n, I__
Demonstration Select appropriate Promotes comfort.

roommate, for or
provide private room.
Activities Rat ionales Provide clean, Promotes rest.
c o ~ o r ~ abed.
~le
Inform patient of Flu-like symptoms
potential discomfort of usuaHy occur 2-4 hours Avoid unnecessary Provides rest periods.
side effects from post-injection, last interruptions of rest.
BRMs, such as about 8 hours, and are
Facilitate hygienic
chills/rigors, muscle manageable. Promotes comfort.
measures (wiping
aches, headaches, and
brow, applying skin
joint aches.
creams, clean body
Instruct patient to take Acetaminophen may hair, and oral cavity).
acetaminophen before be used to prevent or
Position for comfort Facilitates comfort by
B R M and every 4-6 partially alleviate body
using proper body supporting joints, and
hours as needed for aches.
mechanics, use of normal body
discomfort.
pillows, splints over aIignment.
Instruct patient to Bedtime incisions or painful
administer any self administration will bodv parts.
injections of BRMs at allow the patient to
bedtime. sleep through flu-like
symptoms.
Instruct patient to Patient may develop
'
continue BRMs as tolerance to flu-like Instructions , Information,
ordered. symptoms; but if Demonstration
therapy is halted, these
symptoms may
reappear or increase in Ac~ivi~~~ ~tion~l~s
severity when therapy
is resumed.
-l Teach family members Promotes rest at home.
to provide restful
home surroundings.
Instructions , Information, 0 NIC: Fever Treatment

Demonstration
Defined Management of a patient
with hyperemia caused by non-en-
vironmental factors.
Act iuit ies Rationales
Demonstrate hygienic applying skin creams,
measures such as assisting patient with
wiping brow with cool bathing and oral care,
Fever Treatment
washcloths and changing linens as
needed.
Instruct family Use of good body Activities Rationales
members on proper mechanics in
positioning for comfort. positioning promotes Monitor temperature BRMs can cause
comfort. every 4 hours when stimulation of the
patient is awake. body’s temperature
0 Discharge or Maintenance control center resulting
Evaluation in fever.
Statements indicating patient is Monitor pulse, blood Fevers can cause
comfortable. pressure, and tachycardia,
Relaxed expressions, able to rest respiration every 4 hypotension or
without complaints of discomfort. hours. tachypnea.
Monitor intake and Fevers cause increased
output. insensible losses which
lead to dehydration.
High Risk for Altered Body Administer antipyretic, Acetaminophen
Temperat ure acetaminophen PRN reduces fever without
prior to BRMs (avoid increasing the risk of
0 Related to: aspirin and bleeding as aspirin
nonsteroidal anti- can, or damaging the
Stimulation of the preoptic anterior inflammatory drugs), kidneys as NSAIDs
hypothalamus, the body’s tempera- NSAIDs. can.
ture control center, by BRMs.
Use thermic mattress Provides warmth
0 Defining Characteristics: as needed. during chills, and
Presence of temperatures above nor- cooling during high
mal. fevers.
0 Outcome Criteria: Administer IV fluids as IV fluids are used

ordered, PRN. sparingly with IL-2 to
Patient’s temperature will return to avoid capillary leak
normal (baseline)by 12 hours post svndrome.
BRM. Patient will not develop com-
plications from high fevers.
BIOLOGIC THERAPY 101
Instructions , Information, CI Defining Characteristics:

Demonstration Reported inadequate food intake
due to anorexia, and nausea, loss of
weight, early satiety, diarrhea.
CI Outcome Criteria:
Instruct patient to Fever from BRMs
check temperature at occurs 4-8 hours post. Patients will be able to ingest ade-
least 3 times a day Causes of persistent quate food and fluids and weight
when at home (prior to fever, including will remain stable.
BRh4, and 8 and 12 infections, should be 0 NIC: Nutrition Management
hours post). Notify assessed.
MD if fevers above Definition: Assisting with or
101 OF persist beyond 8 providing a balanced dietary intake
hours post BRM. of foods and fluids.
Instruct patient to Extra fluids are needed
drink at least 2-3 liters during high fevers to
fluids (8-12 glasses). replace insensible
losses.
Nutrition Management
Instruct patient to To provide warmth
apply blankets when during chills and
to home when cold or cooling during high
chilled, and to use fevers. - Activities Rat ionales
tepid baths or ice bags Assess intake of foods Provides information
when fever is elevated. and fluids, inquiring for dietary planning
Instruct patient to take Acetaminophen is an a b u t food allergies and avoidanceof
antipyreticand will and food preferences. certain foods.
acetaminophen prior
to each BRM and every help to lessen the Weigh patient on Provides gain or loss
4 hours as needed for severity of fevers, admission, and daily information.
fevers, chills and chills and muscle aches. using the same scale.
muscle aches.
Encourage small Prevents nausea,
CI Discharge or Maintenance frequent meals if overdistention,
Evaluation patient has little or no dyspepsia, and
appetite. upward pressure on
Patient will be able to treat diaphragm.
elevated temperature and re-
Offer meals and snacks Protein provides
lated side effects adequately
that are high-protein, needed energy to
at home.
high calorie, and easy maintain nutrition
to cclnsume. while preventing
further muscle wasting.
Altered Nutrition: Less Than Offer high caloric Provides addition^

liquid or custard protein and caloric
Body Requirements suppIements (Ensure, intake.
Carnation).
Related to:
Adnunister antiemetic Antiemetics will
Anorexia, nausea, vomiting, and 30 to 40 minutes prior prevent nausea and
diarrhea from biotherapy. to eating if nausea is a vomiting.
problem.
-
102 ONCOLOGY N U E I N G CARE PLANS
Activities
Collaborate with
Rationales
Provides complete
1 Activities Rationales
dietician as nutritional Instruct to avoid Noncaloric foods and
appropriate to requirements with noncaloric foods and beverages promote
determine caloric and consideration to beverages such as satiety without
nutrition needs, given preferences. coffee, tea, diet soda or providing adequate
patient's food diet foods, clear soups, nutrients or calories.
preferences. or plain salads.
Encouragepatient to Cancer treatments can Instruct family on To provide family wii
try different foods if cause taste changes ways to assist patient alternatives in patien
taste changes are which m a y alter with increasing caloric intake.
reported (addingmore patient's food 1
intake.
sugar to recipes, preferences.
serving red meats cold, Discharge or Maintenance
or adding lemon juice Evaluation
to them). Weight will remain within 5%
at baseline.
Instructions , Information, Fatigue

Demonstration
U Relatedto:
Activities Rationales Altered body chemistry from
biotherapy.
Instruct patient/family Helps prevent anxiety
that anorexia is an over expected side R Defining Characteristics:
expected side effect, effects. Verbalizes lack of energy, sense of
that weight loss may exhaustion, inability to maintain
occur, and that both usual routines, lethargy, listlessness,
will subside once inability to concentrate, and/or
treatment is over. decreased performance,
Instruct to eat small Small meals prevttnt
0 Outcome Criteria:
frequent meals of high- overdistention; high
calorie high-protein protein, high-calorie Patient will maximize energy by
foods. foods prevent muscle resting, as needed, to minimize ef-
wasting. fect of fatigue on activities of daily
Instruct to take Pwvents nausea and living.
antiemetic prior to vomiting. NIC:Energy Management
eating if nausea or
vomitinn occurs. Definition: Regulating energy to
treat or prevent fatigue and op-
timize function.
Energy ~ u n a g ~ m e n t
Assess patient's D e t e ~ n ebaseline
s
fatigue/rest patterns. for activity limitations Teach Understandingside
to prevent fatigue, patient / f ~ i l y / f ~ e n d effects
s will help patient
that fatigue is an and family feel more in
Encourage patient to P r o ~ o t eusual
s
expected side effect of control.
maintain norinal lifestyles.
BRMs.
sleep/rest/aetivity
patterns as possibe. Instruct patients to: 1. Basic needs while
Prioritize activities 2. preventing fatigue.
Encourage patient to Assists patient in
Plan activities around
express feelings coping with fatigue.
time of BRMs dose
regarding limitations. 3.RecOgniZe signs of
Assist patient to plan ~ a i n t a i nactivity
s fatigue 4. Plan
activitiesbased on while preventing activitiesand rest
fatigue/rest pa tterns. fatigue. around fatigue/rcst
pattern 5.Ask
Encourage patient to Promotes normal f ~ lfriendsy ~for help
plan rest periods as sleeplrest patterns. 6. Sleep at night and
needed throughout the maintam normal
day. routine as much as
Encourage light Promotes normal possible during the day.
exercise during the day. sleep/rest patterns. Instruck patient on Encourages
Assist patient in Conserves energy. benefits of light comp~anc~.
prioritizing daily tasks exercise provide
and seekinghelp from assistarice as needed.
f ~ y / f ~ e nind those
s Teach importance of Proteins are needed for
tasks patient maybe diet in ~ ~ n t a i ~ n basic
g energy
unable to fulfill, energy. requirements to
Assist patient in Fatigue impairs ability prevent fatigue.
adequate diet intake by to chew and swallow Provide written Written materials
providing easy-to- foods. materiads about fatigue reinforce verbal
chew foods and management. instructions.
assisting during meals.
n Discharge or ~ a i ~ ~ e ~ a n c e
Evaluutlon
Patient will rest as needed.
Patient will perform activities
around fatigue pattern.
Altered Thought Processes Emotional Support
Relatedto:
CNS or frontal lobe toxicity from
biotherapy. Support the use of Promotes coping.
appropriate defense
U Defining Characteristics:
mechanisms.
Verbalization of memory deficit Encourage patient to Talking can be a means
problems, impaired concentration, express feelings related to decrease and release
depression, confusion, andlor to biotherap~ emotional response to
anxiety. illness.
0 Outcome Criteria: Refer to appropriate To provide holistic care
Patient will remain orientated to resources as needed to meet patient’s needs.
person, place and time. feg, social service,
counselors, p s y c h i a ~ ~ .
N1C: Emotional Support
NIC: Anxiety Reduction
Definition: Providing reassurance
and encouragement during times of Definition:Minimizing apprehen-
stress. sion, dread, foreboding, or uneasi-
ness related to an u ~ d e n t i ~ ~
source of anticipated danger.
Emotional Support
~
Anxiety Reduction
Assess patient for Patients with a history Activities Rationales
history of pyschiatric of severe psychiatric
condition disorder should not be Use a calm, reassuring Prevents anxiety.
treated with BRMs approach.
such as interferon
Utilize comfort Promotes relaxation.
Assess use of CNS depressants may measures such as back
concomitant CNS exacerbate CNS side rub, positioning.
depressants(eg, effects; reducing
Listen attentively to Creates an atmosphere
tranquilizers, dosage or
expressions of feelings of trust.
sedatives, narcotics, discontinuing therapy
and concerns.
alcohol). may be needed.
Assess level of Provide quiet, calm Prevents anxiety
BRMs may cause
consciousness and environment. caused by stimulation.
di~rientation.
reorient to Provide diversional Reduces tension.
surroundings as activities.
needed.
Administer anxiety Reduces anxiety
Assess patient’s use of Provides information medications like without causing CNS
coping mechanisms in of patient’s past Buspar or Axvan as depression.
dealing with stress. responses to illness. appropriate.
Instructions, Information, 13 NIC:Skin Care Topical Treatments

Demonstration Definition: Application of topical
substances or manipulation of
devices to promote skin integrity
Adivities
Provide factual
Rationales
I and minimize skin breakdown.
information about
disease, treatment,
prognosis and all Skin Care Topical Treatments
expected side effects of
BRMS.
Instruct patient on Self care measures .Activities Rationales

measures to lessen the promote patient self-
severity of side effects control. Assess skin integrity. Provides information
of BWs such as necessary for planning
relaxation techniques. care.
Explain all procedures, Reduces anxiety. Assess skin for rashes, Therapy regimen may
including any expected itching, dryness, cause changes in sweat
sensations. changes in color. glands and destruction
of epithelial cells.
Instruct patient on anti- Promotes compliance
anxiety medications with medical regime. Use only smooth bed Prevents trauma to
including when to linesn. skin.
take, possible side
Keep bed linens clean Prevents maturation of
effects, and instruct to
and dry. skin due to moistnes.
side effects. I
Use comforting Promotes skin integrity
13 Discharge or Maintenance devices on bed (e.g., and comfort.
Evaluation sheepskin, foamlair
mattre:jses, h e 1
Patient will remain orientated protectors).
to person, place and time and
without depression and/or Apply skin emollients Decreases irritation
anxiety. such as Eucerin cream and dryness.
or Aloe Vera lotion.
Assist ]patientto bathe Maintains skin
frequently, keeping integrity.
Risk for Impaired Skin Integrity skin clean and dry.
0 Relatedto: Offer soothing baths Provides comfort.

with such emollientsas
Side effects from biotherapy. baby oil or bath oils.
Defining Characteristics: Use topical medicated Prevents damage to
lotions or oral skin from scratching.
Presence of risk factors such as hy- antipniritic agents for
perthermia, physical immobi- severe pruritus as
lization, and decreased nutritional appropriate.
intake from biotherapy.
13 Outcome Criteria:
Skin will remain intact.
Skin Care Topical Treatments € s s e ~~~ ~ ur ~s i n ~

Activities Rationales Capillary Leuk
Consult with skin care
specialists as needed.
Experts will provide
information on caring
S y ~ ~ r ~ r n ~
for unusual conditions.
Encourage patient to Immobility can lead to
ambulate, walk, and be skin breakdown.
as active as possible
Risk for fluid Volume Deficit
while hospitalized.
0 Relatedto:
Capillary Leak Syndrome as a side
effect of Interleukin-2, increased
body temperature resulting in in-
lnstr~ctions,
Information, creased insensible fluid loss,
Demonstration decreased fluid intake from
anorexia, and fluid losses due to
diarrhea.
Acfivif ies R a f i ~ ~ ~ ~ e1 s Defining C~ara~eris~ics:
Instruct patient in such Promotes compliance Hypotension, orthostasis, tachycar-
skin care techniques as with nursing regime. dia, tachypnea, low urine output, in-
keeping skin clean and creased body temperature, dry
dry, and in the mucous membranes, electrolyte im-
importance of balances, diarrhea, decreased fluid
ambulation while intake, andlor weight loss.
recovering from BRMs.
Cl Outcome Criteria:
Instruct patient in skin Self care measures
care (use of creams, promote sense of Patient will maintain adequate oral
bathing, etc.). control. hydration as evidenced by ability to
mentate when dangling on edge of
Discharge or Maintenance bed.
Evaluation
0 NIC: Fluid/Electrolyte Management
Patient’s skin will remain in-
Definition: Regulation and preven-
tact and free of breakdown. tion of comp~icationsfrom altered
fluid andfor eIectrolyte levels.
~~ ~~ -
Fluid/E~ectrolyteManagement F~uid/ElectrolyteM a n a ~ e ~ e n t
-I
Monitor vital signs, Capillary leak Consult the physician Promotes electrolyte
intakeloutput, as syndrome can cause if signs and symptoms balance.
appropriate. hypovolemia whose of fluid and/or
symptoms include electrcdyte imbalance
tachycardia, persist or worsen.
I
hypotension, and
further elevations in Admi~sterprescribed Corrects electrolyte
body temperature from electrolyte imbalances.
supplc.rments as
dehydration.
ordered.
Monitor for signs of Signs indicate presence
fluid retention such as of capillary leak
edema, increased syndrome.
specific gravity,
and/or BUN.
Weigh daily and During increased Demonstration
monitor trends. insensible fluid loss
and capillary leak
syndrome, the most Activities Rationales
accurate measurement
of fluid balance. Instruct patient to Replaces lost fluids
Monitor electrolyte As fluids leave the drink 8-10 glasses of and electrolytes.
levels as appropriate. vascular compar~ent, fluids per day that
have salts in them.
electrolyte levels are
altered. Teach patient to notify Indicates hypovolemia
the nurse and/or and/or in adequate
Hold Interluekin-2 if Indicates acute renal
doctor if any of the oral intake.
oliguria persists, or failure.
follou~ingoccurs:
serum creatine is 3
dizziness or
times the normal limit.
lightheadedness;
Encourage patient to To promote inability to take
drink fluids with salts maintenance of adequate fluids;
and to avoid fluids electrolyte balance. vomiting persisting for
without salts such as more than 12 hours.
water if fluid intake is
Instruct patient to call Prevents injury from
minimal.
for assistance before falls.
Supplement PO intake During capillary leak getting up if feels
with IV fluids syndrome, intravenous dizzv or k h t headed.
sparingly if orthostatic fluids administered
hypotension is present. will leak from the 0 NIC: H~ovolemiu~ u n a g e ~ e n t
vascular compartment
into the lungs and Definition: Expansion of intravas-
other interstitial spaces. cular fluid volume in a patient who
is volume depleted.
1U8 ONCOLOGY NURSfNG CARE PLANS
Hypovoiemia Management Instructions, information,

Demonstration
Activities Rntiolzales
Act ivities Rationales
Maintain patient IV For emergency
access. o nIV
a d ~ n i s t r a ~ i of Instruct patient to Prevents syncopal
fluids and medications. avoid rapid changes of episodes.
position, especially
Assess blood pressure Assesses for orthostatic from lying to standing,
lying down, sitting, hypotension.
and to call for
and standing.
assistance before
Monitor intake and Assesses fluid status. getting out of bed,
output especially especially if dizziness
insensible losses. occurs.
Monitor weight daily. Weight good Instruct the Promotes compliance
indication of fluid patient/f&ly in with medical regime.
status. measures used to treat
hypovolemia.
Monitor for signsand Intravenous fluids may
symptoms of over- leak into lungs and
hydrat~on/~uid excess other interstitial spaces
while treating for if capillary leak
under-hydration. syndrome is present. 0 Patient’s weight will remain
Monitor for increased Indicates impending stable.
HJNpcreatinine, acute renal failure. Patient will demonstrate ade-
decreased urine output. quate hydration by mentating
while dangling on edge of bed,
Monitor hemoglobin Assess for blood loss.
and hmiatocrit as
appropriate.
Do not transfuse Transfusion of PRWs Risk for Wid Volume Excess
packed red blood cells during IL-2 has been
PRBCs within 24 hours shown to induce 0 Relatedta:
before, after, initiating hemolytic anemia in
or post IL-2. animal models, so Treatment of fluid volume deficit
should be avoided. from IL-2 secondary to capillary
leak syndrome.
Do not use IL-2 causes decreased
antihypertensive capillary resistance [7 Defining Characteristics:
medications. resulting in
hypotension. Edema, weight gain, shortness of
breath, intake greater than output,
Administer isotonic Isotonic fluids promote abnormal breath sounds, rdes
solutions (NS,LW extra cellular (crackles),change in respiratory or
sparingly as rehydration however mental status, blood pressure chan-
appropriate, too much fluid can ges, altered electrolytes, anxiety!
cause capillary leak and restlessness.
syndrome and
pulmonary edema.
Provide frequent oral Promotes comfort.
hviziene.
Outcome criteria Instructions, Information,

Patient’s lungs will remain clear Demonstration
without abnormal breath mounds.
No weight gain will occur.
0 NIC:Fluid Management
Instruct patient on Side effects may occur
Definition: Promotion of fluid signs and symptoms of rapidly and require7
balance and preventi~nof complica- fluid overload and i~ediat~
tions resulting from abnon6al or un- when to notify nurse inte~~tion.
desired fluid levels. or physician of
problems.
Teach expected side Decreases anxiety.
effects of medications
Fluid Management administered.
Efvaluations
Activities ~ ~ i ~ ~ ~ l e s
+ Patient’s assessment will
Assess lung and heart Signs of fluid overload. remain stable and heart and
sounds for presence of lung sounds will be normal.
crackles, S3 or S4;
assess for presence of
edema, neck vein
distention and ascites.
I m paired Gas Exchange
Monitor mucous Indicates hydration
membranes, adequacy status. 0 17elatedto:
of pulses and blood
pressure as Pulmonary edema from fluid re-
appropriate. placement during capillary leak
syndrome from IL-2.
Weigh daily and Weight is good
monitor trends. indication of fluid Defining Characteristics:
balance.
Confusion, restlessness, hypoxia, in-
Maintain accurate Provides fluid balance ability to move lung secretions.
intake and output. information.
0 Outcome Criteria:
Promote oral intake. Maintains fluid
balance. Pulmonary edema will be identified
and treated promptly.
Administer IV fluids if Restores fluid balance.
appropriate. 0 NIC: Airway ~ a ~ a g e m e n ~
Administer prescribed Treats over~ydration. Definition: Facilitationof patency
diuretics as of air passages.
appropriate.
Administer electrolyte Maintain electrolyte
replacement therapy as balance.
appropriate and
monitor patient‘s
response.
~ ~~ ~
Airway Management 0 Defining Characteristics:

Immunosuppressionsecondary to
treatments, malnutrition secondary
Activities Rationales to treatment and/ or disease
process, presence of pathogens
Monitor lung, heart Assesses secondary to hospitalization.
sounds and vital signs cardiopulmonary
as appropriate. status. 0 Outcome Criteria:
Identlfy patient Maintains airway. Patient will remain free from infec-
requiring insertion of tion.
artificial airway and
assist with insertion as 0 NIC: Infection Protection
appropriate. Definition: Prevention and early
Position patient in high Maximizes ventilation detection of infection in a patient at
Fowlers. potential. risk.
Encourage deep Promotes secretion
breathing and removal.
coughing.
Administer oxygen as Maintains oxygenation. Infection Protection
appropriate.
Administer prescribed Promotes open
medications (eg airways. Activities Rat wnales
diuretics,
bronchodilator, Monitor WBC daily, BRMs cause abnormal
inhalers nebulizer calculating Absolute blood profiles are due
treatments) as neutrophile count, to bone marrow
appropriate. ANC. suppressions.
Perform endotracheal Maintains open airway. Monitor vital signs BRMs cause bone
of nasotracheal especially temperature marrow suppression,
suctioning if 44 hours and PRN. resulting in
appropriate. immunosuppression,
predisposing patient to
0 Discharge or Maintenance infection.
Evaluations Monitor for systemic Bone marrow
and localized signs and suppressions inhibit
Patient will maintain airway
symptoms of infection, ability to fight
and adequate oxygenation to
including complete infections.
tissues.
physical assessment as
appropriate.
Risk for Infection

0 Related to:
Granulocytopenia and throm-
bocytopenia from biotherapy.
infection Protection Instructions, Information,

Demonstration

Institute Prevents exposure and
Granulocytopenic transmission of Teach,patient/family Side effectsfrom BRMs
precautions if ANC is organisms that may about signs and may occur at home.
less than loo0 cause infection during s ~ p t ofoinfection
~
including private ~~unosuppress~ and when to notify
room; keeping state. nurse and/or
patient's door dosed; physician.
stringent
Instnict patient on Enhances compliance
handwashing; with medical regime
need for
preventing ill persons designed to prevent
granulocytopenic
from entering; if ill infection.
precautions when
person must enter, ANC including
should wear a mask wearing a mask,
If patient develops Temperature elevation avoiding ill persons;
temperature above may be the only signs avoiding crowds;
100.5 F notify of infection in the practicing good
physician stat. Be immune suppressed personal hygiene;
ready to obtain patient. avoiding breaks in skin
cultures and start (e.g., using gardening
antibiotics immediately. gloves and not using a
straiF:ht razor).
Change any central Prevents line sepsis.
line dressings daily Discharge or Maintenance
when ANC<lOOO. Evaluations
Administer antibiotics Prevents or treats
bacterial or fungal Patient will demon st ratio^
or antifungal agents as
no signs of infection except
appropriate. infectio~.
fever.
Assist with personal Promotes cleanliness, Fever patterns will be consis-
hygiene including prevents breaks in skin tent with expected fever pat-
bathing, brushing teeth and bacterial terns from BRMs
after each meal, pen contamination of administration.
care after stools etc. meatal orifice.
Encourage normal rest Fatigue depresses
and activity pattern. immune functioning..
Risk for Injury
Relatedto:
Thrornbocytopenia from biotherapy
El Defining Characteristics:
Thrombocytopenia,poor oral in-
take, increased risk of falls due to
presence of orthostatic hypotension
secondary to BRMs.
112 ONCOLOGY NURSING CAJ3.E PLANS
NIC: Bleeding Precautions Bleeding Precautions

Definition: Reduction of the risk of
blood loss for a patient with a
reduced coagulability. Activities Rationales
Teach patient/family Promotes compliance
about bleeding with nursing regime.
precautions including
avoiding injury fe.g.,
Bleeding Precautions
using an electric razor),
injections, invasive
procedures; avoid
Activities Rat ionales rectal temperatures,
enemas, suppositories
Monitor platelet count Measures reduce and constipation;
closely if 2,000, potential for bleeding. avoid use of aspirin, or
institute bleeding anticoa~lants;apply 5-
p ~ c a u t i including
o~ 10 minutes of pressure
avoiding skin injury to necessary injection
(e.g., use electric sites; use softtooth
razor), injections, brush for oral care.
invasive procedures;
avoid taking rectal
temperatures, enemas,
suppositories and
constipation; avoid use
of aspirin, or Instructions, Information,
anticoagulants. Demonstration
Apply 5-10 minutes of Prevents excessive
pressure k, necessary bleeding.
injection sites. Activities Rationales
Monitor hemoglobin l~unosuppr~sion ~ y effects from BWs
Instruct p a t i ~ t / f a ~ Side
and h e ~ t o cclosely
~t causing about the signs and may occur when
for signs an symptoms thrombocytopenia as a symptoms of bleeding patient is at home.
of bleeding. result of BRM; reduced and when to notify
Hct and Hdg leads to nurse and/or
anemia if bleeding is physician.
persistent.
Discharge or ~ ~ i n t e n ~ n ~ e
Monitor vital signs as Presence of Evaiuutions
appropriate. hypotension and
tachycardia may Patient will remain free from
indicate bleeding. injury.
Use soft tooth brush Prevents trauma to
for oral care. mucous membranes.
Transfuse with blood Giving PRBCs during
products as IL-2 in animal models
appropriate taking care resulted in hemolytic
not to give PRBCs anemia.
within 24 hours of IL-2
if tmssible.
Chapter Six
Structural Oncology
Em ergen cies
Structural Oncology
t rnergen cies
Structural oncology emergencies are life- with myeloma, sarcoma, prostate cancer,
threatening conditions that require immedi- breast cancer, lymphoma, or lung cancer.
ate attention. Spinal cord compression, The most common symptoms associated
cardiac ~ ~ n a dand
e superior
, vena cava are pain, weak-
with spinal cord c o m p ~ s i o n
syndrome are the most common structural ness, autonomic dysfunction, and sensory
oncologic emergencies. Each of these is dis- loss. Pain may occur weeks before the onset
cussed in this chapter. Nursing care and the of more progressive symptoms. The pain can
most critical nursing diagnoses also are high- be localized over the tumor. Nerve root corn-
lighted. pression can cause referred radicular pain.
Weakness in muscles and hypotonicity are
motor deficits that may progress to ataxia
and h ~ ~ f l e x iSenmry
a. deficits include
Compression numbness, paresthesia, loss of sensation,
paraplegia, impotence, and urine or fecal in-
Spinal cord compression (SCC) is usually continence or retention. Autonomic dysfunc-
caused by a tumor that is encroaching, com- tion is due to spinal shock and involves the
pressing, or invading the structures on the loss of motor, sensory, autonomic, and reflex
anterior spinal column, or by the collapse of function below the level of involvement. Ven-
a spinal vertebrae into the bone fragments tilation may be affected in patients with high
that invade the epidural space. Damage to cervical lesions. Diagnostic testing includes
the spinal cord can occur from direct tumor spinal x-rays, bone scans, myelography, CT
invasion into the cord or indirectly from is- scan and magnetic resonance imaging to
chemia. Very rarely (less than 3%)spinal detect tumor presence, bone erosion or com-
cord compressions are due to primary spinal pression.
cord disease. Most spinal cord compressions
Radiation therapy is the treatment of choice
are due to metastatic disease in the epidural
for spinal cord compression. Surgery may be
space. Cancers of the breast and lung most
used if the tumor is either not responsive to,
frequentlyinvolve the cervical and thoracic
or was previously treated with, r a d i ~ t h e r a p ~
vertebrae, while prostate cancer and
Surgical decompression of the area by
melanoma are more likely to metastasize in
laminectomy may be indicated. Steroids are
the lumbosacral spine. Patients most at risk
used to reduce spinal cord edema and for
for the development of SCC include those
pain relief. An added oncolyticeffect may be
116 ONCOLOGY CARE PLANS
seen with some tumors when the patient is Essential Nursing

treated with steroids. Chemotherapy may be Diagnoses Related to
indicated adjuvantly to radiation therapy
and/or surgery, or as treatment for recur-
Spinal Cord
rence at sites of previous surgery or radia-
Compression
tion. Analgesics are usually required because
about 95% of patients with spinal cord com-
pression have pain. Pain
Nursing plays a key role in the early detec- (CH. 2)
tion of spinal cord compression through fie- 17 Related to:
quent assessment of patients at risk. Once Spinal cord compression.
SCC is suspected immediate notification of 0 Defining Characteristics:
the physician can lead to prompt interven-
Patient verbalizes pain in back,
tion before neurologic sequelae develop. muscle weakness, numbness,
Patient education regarding the early signs and/or tingling in extremities.
and symptoms is important since most
patients receive their treatments as out-
patients. An important goal of treatment of Fear
SCC is to stabilize, and return to optimum, (CH. 1)
the patient’s neurologic functioning. There- 17 Relatedto:
fore rehabilitation may be needed early in
Sensory and motor losses from
the treatment plan. The following section spinal cord compression.
highlights the most important nursing care
for the patient with spinal cord compression.
Fear of never being able to walk
again, or control bowel and bladder.
Bowel Incontinence
(CH. 2)
0 Related to:
Sensory and motor function losses
due to spinal cord compression.
Abdominal pain, watery stools,
decreased frequency of bowel move-
ments, incontinence.
S ~ ~ E~R
~ ONCOLOGY
C LG E ~ C I E S 117
Altered Urinary Elimination Risk for Sensory/Perceptual

(CH.2) Alterations: Tactile
0 Relatedto: Relatedto:
Sensory and motor function losses Sensory deficits from spinal cord
from spinal cord compression. compression.
Defining C~aracteristic~: fining Characteristics:
Urinary incontinence, retention, fre- Numbness, tingling, pain in af-
quency, or decreased awareness or fected extremities.
sensation of urination.
IJ Outcome Criteria:
Early identification of spinal cord
compression.
Sexual Dysfunction Minimize sequelae of spinal cord
(CH.10) compression
Relatedto: NIC: Peripheral Sensation
Sensory and motor deficits from
~anagement
spinal cord compression. Definition: Prevent or minimize in-
jury or discomfort in the patient
Defining Characteristics: with altered sensation
Impotence.
Risk For Impaired Skin

integrity
(CH. 21)
U Relatedto:
Impaired mobility, incontinenceof
bladder and bowel from spinal cord
compression.
Bedrest, incontinence, immobility,
previous or c 5 n ~ ~radiation
n t
therapy to dependent areas.
Peripheral Sensation Management

I Positioning - Neurologic
Act iuif ies

Assess neurologic
Rationales
I Activifies
Immobilize head of
Rafionales
Prevents rotation of
status including: to formulate plan of patient with cervical neck and head which
1. Pain (sharp/dull) care, and promotes injury by use of could lead to trauma to
and temperature early identification of cervical collar, spinal cord.
fhot/cold) sensation; spinal cord sandbags, no pillow-
2. Paraethesias: compression.
Maintain bedrest as Promotes stabilization
numbness, tingling,
appropriate. of spine and prevents
hyperesthesia,
further trauma to
hypesthesia;
spinal.
3. Impaired motor
status: gait, Use Iog roll technique Maintains spinal
coordination, range of when turning or alignment when
motion; transferring patient. positioning patient.
4.Ability to void and
Maintain proper body Promotes spine
defecate;
alignment. stabilizationand
5. Level of
prevents contracture.
consciousness;
6. Muscle strength; Encourage use of brace Maintains and
7.Respiratory rate and when out of bed as supports spinal
depth; appropriate. alignment when out of
8. Level of neurologic bed.
involvement /deficits.
Apply and maintain Promotes alignment of
Protect patient from Prevents injury to traction as appropriate. vertebrae.
thermal and other tissues in patient with
types of injury by altered sensation. Perform care of Prevents infection at
avoiding use of traction pin site as pin insertion site.
hea ting pads or ice appropriate.
packs; encourage use Brace traction weights Prevents injury during
of gloves or protective when movine Datient. moving of patient.
clothing over affected
body parts during cold
weather.
Establish a means of Promotes bladder and
voiding and/or bowel bowel functioning.
evacuation as
0 NIC: Positioning--Neurologic
* Definition: Achievement of
optimal, appropriate body
alignment for the patient with
a cervical injury.
STRUCTURAL ONCOLOGY EMERGENCIES 119
~nstruction~,
informati~n,
Demonstration
0 Related to:
Neuromuscular impairment from
spinal cord compression.
Instruct high-risk Promotes early
patients about the identification of SCC
signs and symptoms of and prompt Inability to move, limited range of
SCC and the need to intervention should it motion, decreased muscle strength
promptly notify health occur. or control.
care team of symptoms
including back pain, Outcome Criteria:
pain radiating from Patient identifies measures to
back to chest,
promote mobility.
abdomen, or groin,
change in motor Patient verbalizes potential com-
functioning; decrease plications of i ~ o b ~ ~ ~
in muscle strength or 0 NIC: Activity Therapy
control, constipation,
urinary retention or Definition: Prescription of and as-
incontinence. sistance with specific physical, cog-
nitive, social, and spiritual activities
Demonstrate to Preventsinjury andlor to increase the range, frequency, or
patient/family how to identifies skin duration of an individual's (or
visually monitor breakdown early. group's) activity.
position of body parts
and examine skin if
sensation and/or
proprioceptionis
impaired.
Inform patient/family Promotes maintenance I Activity Therapy
of measures to protect of injury-freestate.

affected body parts
from injury due to loss
of sensation. Assess patient's ability Provides information
to walk or bear weight for care planning.
Discharge or Maintenance on legs, and ability to
Evaluation transfer and/or move
around bed.
Patient/fa~lylists signs and
symptoms that should be Monitor for signs of Promotes early
reported to the health care thrombophlebitis, calf identification of
team immediately. pain, tenderness, thrombophlebitis, a
Spinal cord compression is redness, Homan's sip, complication of
identified early and edema. i~obili~.
neurologic sequelae will be
minimized.
Activity Therapy Instructions, information,

Demonstration
Actiuit ies Rationales

Consult with Promotes early
I Activities Rationales
occupational, physical, rehabilitation to Instruct patient/family Promotes compliance
and/or recreational prevent further how to perform with activities.
therapists in planning deteriorationin desired exercise.
and monitoring an physical mobility.
Demonstrate to Promotes proper use of
activity program as
patient/family how to assistive devices.
appropriate.
apply brace as
Encourage patient to Prevents skin appropriate.
change position at least breakdown.
every 2 hours. 0 Discharge or Maintenance
Evaluation
Assist with regular Promotes activity.
activities as Patient will not develop com-
appropriate. plications from immobility.
Assist patient to Promotes participation Patient will achieve optimal
perform prescribed in prescribed exercise mobility.
exercises as program.
appropriate.
Perform range-of- Prevents loss of muscle
motion exercises on tone. Superior Vena Cava
affected extremities.
Syndrome
Consider the patient's Prevents injury from
spine to be unstable unstable spine. Superior vena cava syndrome (SVCS) is a
until diagnostic studies
are completed and medical emergency that occurs most com-
patient is allowed out monly in persons with cancer. Very rarely
of bed.
benign conditions can cause SVCS. Cancers
Have patient use brace Provides stabilization in which SVCS commonly occur are lung,
when out of bed. of spine.
breast and lymphoma. Lung cancer is most
Provide positive Promotes participation
reinforcement for in rehabilitation. often responsible for SVCS, especially small
participation in rehab cell. Less commonly SVCS is seen in
activities.
esophageal cancer, leukemia, melanoma, and
sarcoma. Superior vena cava syndrome is
seen four times as often in men than women.
It is the presenting sign of malignancy in
some cases. Occlusion of the superior vena
cava in oncology patients can also occur
from thrombus formation around a central
venous catheter. Fibrolytic therapy and/or
S T R U W L ONCOLOGY EMER~ENC~ES 121
removal of the catheter may be required to present with acute respiratory distress, neces-
treat SVCS from this benign problem. sitating immediate intervention to prevent
Occlusion of the superior vena cava causes respiratory arrest. This may mean treating
impaired venous return from the head and first and establishing a pathologic diagnosis
upper thorax. This occlusion from the tumor later when the patient is more stable. In slow-
can cause a partial or total occlusion of the ly progressing SVCS, a treatment plan is
superior vena cava, resulting in SVCS. The developed after diagnosis is established. This
severity of the signs and symptoms are de- plan is based on proper treatment for the un-
pendent on the severity of the blockage. The derlying disease. Chemotherapy may be the
most common signs and symptomsof SVCS treatment of choice for patients with small
are facial, neck, and periorbital edema, cell lung cancer and for patients having a
dyspnea and swellingof the trunk and past history of mediastinal radiation.
upper extremities so that rings and/or Steroids are used to decrease inflammation,
watches are tight. Headache, chest pain, especially if respiratory distress is present.
cough, hoarseness, dysphagia, and chest Diuretics such as Lasix may be used. Throm-
pain also may be present. Physical examina- bolytic therapy is used if thrombus forma-
tion may include, thoracic and neck vein dis- tion is present or to prevent its formation.
tention, a ruddy (purple hue) is noted, Nursing care focuses on measures to provide
orthopnea, tachypnea, tachycardia, cyanosis, symptomatic relief during the diagnosis
severe upper respiratory obstruction with period, such as administering steroids,
stridor, and upper extremity edema. Other diuretics, oxygen, positioning for comfort
symptoms and signs include Horner’s and ease of breathing, and providing infor-
syndrome, characterized by eyelid droop, mation about the disease process and its
pupil constriction, and conjunctivitisin one treatment.
eye with absence of sweat on only one side Treatment will vary depending on the under-
of face. The latter indicates cervical sym- lying type of cancer and any previous
pathetic nerve supply interference.Late therapies. Once therapy is initiated to treat
signs and symptoms include visual distur- SVCS, the focus of nursing care should be on
bances and altered level of consciousness. assessment and treatment of possible side ef-
Tests used in the diagnosis of SVCS include fects of therapy. The reader should refer to
chest x-ray, and CT scans. If SVCS is the the appropriate chapters for i n f o ~ t i o on
n
presenting sign of malignancy, pathologic the specific disease and specific treatment.
diagnosis needs to be established by an ap- The essential nursing care specific to the
propriate biopsy method prior to initiation patient experiencing SVCS follows.
of treatment. Radiation therapy is the
primary treatment of SVCS. Patients with
rapidly progressing severe SVCS may
Outcome Criteria:
Essential Nursing
Open airway will be maintained.
NIC: Airway Management
Superior Vena C a w
Definition: Facilitation of patency
Syndrome of air passages.
Knowledge Deficit ~~ ~~ ~
Airway Management
(CH. 8)
0 RelatedTo:
Radiation therapy to the chest.
Assess for changes in Neurologic symptoms
neurologic status, are rare and usually
Patient voices lack of knowledge including decrease in indicate hypoxia.
and/or questions about radiation orientation to person,
therapy treatments and possible place or time,
side effects. confusion, lethargy,
blurred vision,
headaches, anxiety.
Auscultate breath Promotes early
Decreased Cardiac Output sounds, monitor identification of
(CH. 2) respiratory rate and for respiratory distress.
distress, stridor,
Relatedto: cyanosis, orthopnea,
tachypnea, cough,
svcs dyspnea.
0 Defining Characteristics: Identify patient Maintains open
requiring airways.
Variations in blood pressure read-
actual/ potential
ings, tachycardia, neck vein disten-
airway insertion.
tion, impaired return of blood to
heart. Position patient in high Maximizes ventilation
or semi-fowler. potential.
Administer oxygen Promotes adequate
therapy as appropriate. oxygenation.
Ineffective Airway Clearance
Instruct in rationale for Measures treat
0 Relatedto: elevating head of bed, respiratory distress.
oxygen, frequent
Obstructivemass in the thorax lead- monitoring."
ing to SVCS and respiratory distress.
Dyspnea, orthopnea, tachypnea,
cyanosis, cough, stridor.
~ ~ E~ERGE
U ONCOLOGY LN C ~ S 123
Airway Management
~-
I Circulatory Care

Inform patient/family Promotes early Perform appraisal of Provides baseline
of symptoms that need identification and peripheral circulation assessment for later
to be reported to health treatment of worsening including peripheral comparison.
care team i ~ ~ i a t e SVCS.
of l ~ pulse check, capillary
such as increased refill, color, and
respiratory distress, temperature of
confusion, increased extremities, edema.
edema.
Monitor for signs of Promotes early
progressive edema identification of
Evaluation such as increased worsening of SVCS.
swelling in face or
Patient/family identify signs arms, or increasd
and symptoms that need to be thoracic or neck
i ~ ~ a t ereported
l y to the distention.
health care team. Monitor for decreased Promotes early
Patient’s airway is maintained. or absent pulses, identification and
decrease in blood treatment of changes in
pressure, pale or tissue perfusion.
cyanotic skin or nail
Altered Tissue Perfusion, beds.
Cardiopulmonary Avoid venipuncture, Prevents worsening of
IV fluid administration svcs.
Relatedto: and blood pressure
readings in upper
Obstruction of the superior vena extremities.
cava.
Remove rings and Prevents injury from
Defining Characteristics: watches as appropriate. constriction of blood
flow.
Facial edema, edema of upper ex-
tremities, cyanosis, thorax and neck Maintain lower Prevents further
vein distention, chest pain, purple extremitiesin a pressure on upper
hue to face. dependent position. extremities.
0 Outcome Criteria: Administer diuretics as Promotes decrease in
appropriate. edema.
Cardiopuhonary tissue perfusion
will be improved as evidenced by Administer Decreases or prevents
decrease in facial and upper ex- thrombol~c or thrombus f o r ~ t i o n
tremity edema, resolution of other a n t i c o a ~ ~ atherapy,
nt due to SVCS.
signs of SVCS. if appropriate.
0 NIC: Circulatory Care

Definition: Promotion of arterial
and venous circulation.
Circulatory Care
I Cardicrc Tamponade
Activifies Rationales I
I
Cardiac tamponade is a life-threatening
medical emergency that occurs when in in-
Perform appraisal of Provides baseline
peripheral circulation assessment for later trapericardiac pressure increases, inhibiting
including peripheral comparison. ventricular expansion and heart filling. Car-
pulse check, capillary diac output then decreasesand eventually
refill, color, and
temperature of causes total circulatory collapse and death.
extremities, edema. The increase in intrapericardiac pressure
Monitor for signs of Promotes early may result from fluid accumulation in the
complications from identification of pericardial sac, direct or metastatic tumor in-
thrombolytic/ anticoagu complications of
lant therapy such as thrombolytic vasion into the pericardial sac, and/or
bleeding, petechiae, anticoagulant. fibrosis of the pericardial sac from radiation
ecchymosis, prolonged
FIT,or PT. therapy. The cancers most likely to cause car-
diac tamponade include breast cancer,
leukemia, lymphoma, melanoma, lung can-
cer, gastrointestinal cancers, and sarcoma.
Instructions, Information, Very rarely primary tumors of the heart such
Demonstration as mesothelioma and sarcoma can involve
the pericardium.
Acfivif ies Rzt ionales Patients with impending cardiac tamponade

Inform of rationale for Promotes compliance may complain of retrostemal chest pain,
diuretics and with medical regime. severe dyspnea, and cough, and may exhibit
anticoagufant / thrombol extreme anxiety and apprehension. Qinicail
ytic therapy.
findingsinclude venous distention, faint
0 Discharge or Maintenance heart sounds, pericardial friction rub,
Evaluation
hypotension, tachycardia, and cyanosis. A
Venous circulation will be im- paradoxical pulse may be present; that is, the
proved as evidenced by
decreased facial and upper ex- pulse may be significantlyweaker during in-
tremity edema, adequate spiration than during expiration. Also, sys-
peripheral pulses, normal
tolic blood pressure, which normally is only
skin color, and vital signs
within normal limits. 8 to 10 mm Hg lower during inspiration,
may be greater than 10 mm Hg lower with
cardiac tamponade. This lower blood pres-
sure is due to the decreased venous return
and stroke volume. Late symptoms include
elevated central venous pressures, arrhyth-
SeUC?URAL ONCOLOGY EMERGENCIES 125
mias, pale ashen diaphoretic skin, tachypnea,

peripheral edema, oliguria, hepatomegaly
and altered level of consciousness.
Diagnostic testing may include chest x-rays,
echocardiogram, ECG, pericardial fluid cytol-
ogy, and CT scans. Treatment of cardiac tam-
ponade centers on hemodynamic
Ineffective Breathing Pattern
03.2)
stabilizationand removal of fluid from the
pericardial sac. Pericardiocentesis- a proce- ti Related to:
dure in which fluid from the pericardial sac Inability to maintain sufficient supp-
is removed - involves inserting a needle into ly of cellular components due to
decreased cardiac output from fluid
the pericardial space to drain the fluid. This in the pericardial sac.
is a temporary measure. The patient will 0 Defining Characteristics:
need a more permanent resolution through
Shortness of breath, dyspnea,
systemic therapy, such as chemotherapyor tachypnea, cyanosis orthopnea.
local therapy, to treat the underlying cause.
Patients with recurrent pericardial effusions
or requiring prolonged palliation may need a Pain
pericardial window. Some oncologists prefer
(CH. 2)
drainage followed by sclerosingwith agents
D Relatedfo:
like tetracycline, quinacrine, thiotepa,
nitrogen mustard, and fluorouraciI.Steroids Fluid in pericardial sac or constric-
tion of pericardial sac.
are sometimes used to treat inflammation of
constrictive pericarditis. Radiation therapy
has also been used but carries with it the Retrosternal chest pain, tachycar-
dia, tachypnea, blood pressure chan-
potential risk of damage to the pericardium ges.
and myocardium. Very rarely a total pericar-
diectomy, removal of the pericardial sac, is
performed for patients with constrictive or
Decreased Cardiac Output
recurrent pericarditis. Nursing management
of the patient with cardiac tamponade begins 0 Related to:
with early recognition of the signs and Increased intrapericardiacpressure
symptoms and prompt diagnosis and treat- decreasing left ventricular filling
and ability of heart to pump.
ment. The following section highlights the es-
sential nursing diagnoses for the patient
with cardiac tamponade. Retrostemal chest pain, dyspnea,
cough, faint heart sounds, pericar-
dial friction rub, cyanosis, tachycar-
dia, tachypnea, paradoxical pulse, Cardiac Care - Acute

increased CVF, altered level of con-
sciousness, oliguria, peripheral
edema.
0 Outcome Criteria:
Assess Promotes early
Patient maintains adequate cardiac cardiopulmonary identification of
output as evidenced by relief of status including vital worsening in
chest pain, blood pressure and signs, heart sounds, cardiopulmonary
pulse returns to prebaseline. lung sounds, ECG status and prompt
readings, treatment.
NIC: Dysrhythmia Management presence/severity of
(CH. 2) chest pain and
respiratory distress.
0 NIC: Cardiac Care: Acute
Assess catheter site for Promotes early
Definition: Limitation of complica- signs and symptoms of identification of
tions for a patient recently ex- infection, if present. complication from
periencing an episode of an pericardial catheter.
imbalance between myocardial
oxygen supply and demand result- Evaluate extremities Peripheral edema is a
ing in impaired cardiac function. for edema. late sign and indicates
worsening of cardiac
condition.
Monitor intake/output. Provides information
regarding cardiac
Cardiac Care - Acute output, intake greater
than output may
indicate heart failure.
Acfivifies Rationales Monitor for trends in Provides the most
hemodynamic accurate reflection of
parameters like CVP cardiac output.
cardiopulmonary identification of
status including vital readings, and
worsening in
pulmonary
signs, heart sounds, cardiopulmonary
capillary/ wedge
lung sounds, ECG status and prompt
pressures, if available.
presence/severity of Administer oxygen Promotes adequate
chest pain and therapy and monitor oxygenation of tissues.
respiratory distress. its effectiveness.
Monitor neurologic Promotes early Position with head of Promotes ventilation
status including level recognition neurologic bed elevated. and comfort.
of consciousness, changes.
changes in behavior, Administer steroids as Reduces inflammation
orientation and appropriate. in pericardial sac.
awareness. Administer Promotes relief of chest
Assess character and Provides information medications to pain.
amount of drainage regarding fluid relieve/treat pain as
from pericardial draining from atmronriate.
catheter if present. pericardial sac.
S T R ~ C ONCOLOGY
~ L E~ERGE~CIES 127
I Cardiac Care - Acute without arrhythmias, CVP

readings, and puImonary
capillary wedge pressures
Activities Rationales within normal limits, and
stabilization of vital signs.
cardiopulmonary identification of
status including vital worsening in
signs, heart sounds, cardiopulmo~a~
lung sounds, ECG status and prompt
presencelseverityof
chest pain and
respiratory distress.
Maintain an Promotes energy
environment conservation and
conducive to rest and healing.
Demonstration
Activities Rafionales
Explain all procedures Decreases anxiety
to patient/fam~ly t ~ o u g knowledge.
h
before initiating.
Inform of rationale for Promotes compliance
treatments such as with health care team’s
pericardial window, regime.
sclerosing therapy,
chemotherapy,
radiation as
appropriate.
U Discharge or ~ a j ~ ~ e n a n c ~
Eva1uation
Patient explains rationale for
treatments used to treat car-
diac tamponade.
Cardiac output is maintained
at an adequate level as indi-
cated by cardiac rhythm
Chapter Seven
Metabolic and
Physiologic
tmergencies
Metabolic and Physiologic
Persons with cancer may experiencea include agitation, anxiety, dizziness, nausea,
variety of medical emergencies both as a urticaria, rhinitis, abdominal cramps,
result of their disease and of its treatment. At respiratory distress,and edema of the face or
times the presenting symptoms of the malig- eyes. Late signs of anaphylaxisinclude
nancy may be an oncologic emergency. Such hypotension, chest tightness, tachycardia, ar-
emergenciesmay include anaphylaxis, acute rhythmias, laryngeal edema, bronchospasm,
tumor lysis syndrome, hypercalcemia, dis- and stridor.
seminated intravascular coagulation (DIC),
Hypersensitivity reactions have been
and syndrome of inapprop~ateantidiuretic
reported with intravenous ~ t i n ~ o p l a s t i c
hormone secretion (SIADH).This chapter agents including L-asparaginase/cisplatin,
discusses briefly each of these conditions bleomycin, cyclophosphamide (Cytoxan),
and outlines essential nursing diagnoses. mechlorethamine(nitrogen mustard),
methotrexate, etoposide (VP-16), and
mephalan. Also posing a risk for
Anaphylaxis anaphylaxis are newer, less refined, prepara-
tions such as those used in phase 1 studies,
Anaphylaxis is an immediate hypersen-
or agents given IV at high doses in succes-
sitivity reaction caused by an overstimulat~ sion. At high risk for anaphylaxisare
immune system. The immune system be-
patients with a past history of allergic reac-
comes overstimulated when a foreign sub- tions to agents such as foods, radiographic
stance or antigen results in the heightened contrast media, blood products, insulin, and
formation of antibodies. These reactions are
opiates.
mediated by immunoglobulin E (IgE),a
product of the B lymphocytes. Systems af-
fected by anaphylaxisinclude the in-
t e ~ m e n tc~a ~, i o v a ~ u l arespiratory,
r,
neurologic, and gastrointestinal tract. The In most heaIth care settings, it is the nurse
signs and symptoms of anaphylaxis arise who has primary responsibility for ad-
from the effects of the IgE mediators on tar-
minisbation of medications and
get systems. Immediate signs and symptoms
chemotherapy Therefore, nursing assess-
ment and interventions are extremely impor- Essentlal Nursing

tant in the management of allergic reactions.
Before any medications are administered, a An aphyluxis
nursing history should be taken. The history
should include previous allergic responses to
chemotherapy, and any other drugs or
agents. A baseline assessment of pulse, blood
Anxiety
(CH. 1)
pressure, respiration, and mental status
should be recorded. When risk for l Relatedto:
E
anaphylaxis is anticipated because of a Anaphylaxis
drug’s potential for hypersensitivityreac- 0 Defining characteristics:
tions or because of the patient‘s past history,
Patient communicates feelings of
the nurse should make sure that emergency uncertainty, apprehension, fear, or
drugs and equipment are available. Patients agitation.
should be informed of the symptoms of a
possible allergic reaction and instructed to
notify the health care team if they occur. Risk for Injury
Some antineoplasticdrugs such as 0 Related to:
bleomycin require a test dose of a small Hypersensitivity and anaphylactic
amount to determine if sensitivityis present reactions to chemotherapy and
prior to giving a full dose. If a reaction is other agents.
suspected, the infusion should be stopped 0 Defining Characteristics:
immediately, the intravenous line main- Patient complains of itching, hives,
tained, and the physician notified. Ex- anxiety’ feeling of doom, chest pain,
respiratory distress, nausea, vomit-
peditious nursing care is required for the ing, abdominal discomfort, and/or
patient experiencing an anaphylactic reac- past history of allergic responses.
tion. If an anaphylactic reaction is suspected, 0 Outcome Criteria:
medical and emergency services should be
Allergic reaction will not occur or
requested, and cardiopulmonary resuscita- will be detected and treated imme-
tion instituted as necessary. diately.
Patient will describe signs and
symptoms of anaphylaxis to health
care team.
NIC: Allergy Management
Definition:Identification, preven-
.. .. . . .. .
METABOLIC AND PHYSIOLOGIC EMERGENCIES 133
Allergy Management I ~
Allergy Management
~~ ~ ~~
Activities Rationafes ~
Activities ~~ ~~
Rationales
~ ~
Identify known Provides information Administer medication Promotes early

medication/ food for formulating plan of while observing identification of
allergies and usual care by identifying patient closely for hypersensitivity
reaction; document as patients at risk for signs and symptoms of reactions.
appropriate. allergic reaction. hypersensitivity
reactions including
If allergic reaction is Promotes safe
agitation, anxiety,
anticipated, ensure administration of
dizziness, nausea,
that emergency medications if allergic
urticaria, rhinitis,
equipment and reaction occurs.
abdominal cramps,
medications are readily
respiratory distress,
available.
and edema of the face
An anaphylaxis kit
or eyes. Late signs
includes
include hypotension,
1.Epinephrin 1:lOO 1.Constricts peripheral
chest tightness,
blood vessels, dilates
tachycardia,
bronchi, elevates blood
arrhyhuas, laryngeal
pressure, and
edema, bronchospasm,
decreases itching.
and stridor.
2. Hydrocortisone 2. Inhibits synthesis of
sodium succinate mediators of delayed Should symptoms Reduces or minimizes
(SoluCortef) immune response. occur, stop infusion, allergic response.
3. Diphenhydramine 3. Blocks histamine consult physician, and
HCL (Benadryl) actions and decreases provide medications
itching. from the anaphylaxis
4. Aminophylline 4. Dilates bronchi. kit as prescribed.
5. Cimetidine 5. Decreases laryngeal
Provide lifesaving Promotes basic life
edema.
measures during support during
Prior to drug Provides baseline for anaphylactic shock or anaphylactic reactions.
administration, obtain comparison should a severe reactions.
baseline vital signs and reaction occur.
Discuss with physician Prevents future allergic
mental status.
desensitization versus reactions.
drug discontinuance.
Administer Prevents future allergic
premedications responses.
prescribed with future
medications as
appropriate.
Instructions, Information, causes rapid cell lysis and necrosis of the

Demonstration
tumor mass. These actions result in the
1 Activifies Rationales
release of large amounts of intracellular
electrolytes and chemicals into the extracel-
Inform patient/family Promotes early Mar fluid. Less common is TLS associated
of the potential for identification of with a biologic treatment such as Interleukin-
allergic reaction and to allergic reaction by
2, given for the treatment of large bulky
report any unusual prompt patient
symptoms such as reporting. tumors.
uneasiness, agitation,
itching, abdominal Acute TLS is characterized by hyperkalemia,
cramping, chest hyperuricemia, hyperphosphatemia, and
tightness, hypocalcemia. It is seen most often in dis-
lightheadedness or
dizziness, difficulty eases with large tumor burdens and high
breathing. growth fractions that are very sensitive to
Instruct patient to Prevents future allergic cytotoxic treatments. Such diseases include
avoid allergic and wear responses.
hematologic malignancies such as high-
substance; use medical
grade lymphomas, and leukemia with high
leukocyte counts. Acute TLS is less common
Evaluations in solid tumors such as small cell lung can-
cers, metastatic breast cancer, and metastatic
Allergic reactions, if they
occur, will be detected early medulloblastoma. Patients usually have
and treated without injury to signs of TLS within the first 24-48 hours after
patient.
the initiation of chemotherapy, and persist
Future allergic reactions will
be prevented. for 5-7 days after therapy has been com-
pleted. Recognition of patients at risk for
TLS, and its prevention are essential to the
management of this disorder.
Acute Tumor Lysis
Syndrome
Acute tumor lysis syndrome (TLS)occurs as Treatment
a result of the rapid release of intracellular
contents such as potassium, phosphorus, The primary goal of the treatment of TLS is
and nucleic acid into the blood stream. Some- the prevention of renal failure. Prior to the in-
times the level of these components can rise itiation of chemotherapy, patients at risk for
to life-threatening concentrations. Potential TLS should receive aggressive intravenous
effects of TLS are renal failure and cardiac ar- hydration for at least 48 hours. Also, any
rhythmias. Chemotherapy is the most fre- acid-base problems or severe electrolyte im-
quent initiator of this syndrome because it balances should be corrected.
~ETA~~L I CPHYSIOLOGIC E ~ E R G E ~ C I E S
AND 135
Following the administration of sessed for signs and symptoms of electrolyte

chemotherapy, aggressive hydration should imbalance.
be continued to maintain urine output at 3 or Clinical indicators of hyperkalemia include
more liters per day. Diuretics such as nausea, vomiting, diarrhea, weakness,
furosemideor mannitol may be given to muscle cramps, paresthesia, bradycardia,
promote diuresis, especially in patients with
and EKG changes. Patients experiencing hy-
a coexisting disease such as impaired cardiac
p e ~ h o s p h a t e may
~ a develop oliguria,
function or decreased renal function; such anuria, and azotemia due to renal insufficien-
conditions could increase the risk of fluid cy. Hypocalcemia is manifested by muscle
overload. cramping and twitching, carpopedal spasm,
Huid balance is closely monitored by daily tetany, laryngospasm, paresthesia, convul-
weights, intake and output, and assessing for sions, hypotension, and EKG changes. Early
edema in lower extremities. Due to the use of signs of hyperuricemia include nausea,
potassium depleting diuretics and rapid re- vomiting, diarrhea, and anorexia. Because
placement of electrolytes,including potas h ~ e ~ ~affects c e the~ kidneys,
a the
sium and magnesium, may be needed. patient can exhibit letharw, flank pain,
Measures to decrease hyperuricemia should anuria, oliguria, and cloudy urine with sedi-
be initiated prophylactically.These measures ment. If hyperkalemia develops, 50% glucose
include Allopurinol and alkalinization to should be given intravenously to raise plas-
maintain a urine pH at 7 or greater. This may ma insulin levels. This will create an intracel-
be accomplished by adding 50-100 mEq of lular shift in potassium. Supplemental
sodium bicarbonate to each IV liter of fluid. insulin may be needed. Kayexalate may be
Many physicians r ~ o ~ e aggressive
n d given orally or rectally as an enema. If car-
diuresis as the primary means to control uric diac or neuromusculartoxicity is seen, cal-
acid because alkalinizationis considered con- cium gluconate may be given.
troversial. Hyperphosphatemiaand hypocalcemia are
Another important goal in the treatment of treated by oral supplements such as Am-
TLS is managing potentially life-threatening phogel or Basaljel. Acute tumor lysis usually
electrolyte imbalances. Serum electrolytes, resolves in about seven days, the time it
uric acid, phosphorus, calcium and takes for cytolysis to subside after
creatinine levels should be checked every 6- chemotherapy.If adequate renal function has
12 hours until stable for 3-5days post been maintained and metabolic parameters
chemotherapy.Nursing assessment includes treated, no long term effects from the TLS are
cardiac monitoring and close monitoring of expected. However, with relapse of
metabolic parameters including electrolytes, hematologic malignancies, TLS may recur.
calcium, blood urea nitrogen, and creatinine
levels. The patient should also be closely as-
Essential Nursing Electrolyte Management
Diugnoses Rekrted to
Tumor Lysis Syndrome Actiwities Rationales
Monitor serum TLS manifestations
eIectrolytes every 6 include hyperkalemia,
hours and as needed. hyperphosphatemia,
Risk For Injury hyperu~cemia,
hypocalcemia.
(CH. 17)
Monitor for signs and Promotes early
0 Relatedto: symptoms of recognition and
electrolyteimbalance. treatment of electrolyte
Seizures, disorientation imbalances.
0 Defining Characteristics: Maintain patient IV Provides route for
Seizure activity with change in con- access. rapid administration of
sciousness, muscle flaccidity or medications and fluids.
rigidity, muscle weakness. Administer Promotes electrolyte
supplemental balance.
electrolytesas
prescribed, if
High Risk for Altered Tissue appropriate.
Perfusion, Renal 0 NIC: Electrolyte Management-
Hyperkalemia
0 Relatedto:
Definition: Promotion of potas-
Tumor lysis resulting in increased sium balance and prevention of
release of intracellularcontents and compIicationsresulting from serum
the inability of kidneys to ~ i n t a i n potassium levels higher than
normal serum com~sition. desired.
Cl Defining Characteristics:
Elevationsin serum potassium,
phosphorus, and uric acid;
decreased calcium; increased serum Electrolyte Management-
creatinine levels; nausea; vomiting Hyperkalemia
diarrhea; paresthesia; tetany;
oliguria; anuria; flank pain; convul-
sions from electrolyte imbalances. i I
Outcome Criteria:
A
Monitor serum
~ ~ ~ ~ ~~
Promotes early
nt ~
I ~
Electrolyte imbalances will be iden- potassium levels as recognition of

tified early and treated promptly. appropriate. hyperldemia or
hypokalemia.
0 NIC: Electrolyte Management
Monitor causes of Provides information
Definition:Promotion of electrolyte increasing serum for formulating plan of
balance and prevention of complica- potassium levels (TLS, care.
tions resulting from abnormal or un- renal failure).
desired serum electrolyte levels.
~ETABOLICAND PHYSIOLOGIC E ~ E R G ~ C I E S 137'
Electrolyte Management- Electrolyte Management-

Hyperkalemia Hyperkalemia

Assess for potential Promotes early Administer calcium Alleviates the action of
signs and symptoms of ~dentification of gluconate as hyperkalemia on the
h ~ e r ~ e ~ a , cardiac a ~ h y ~ a s prescribed if heart.
including due to rising serum appropriate.
cardiovasculareffects potassium, causing
Administer sodium Alkalinizes the plasma,
such as EKG changes, depolarization of the
bicarbonate as causing a temporary
peaked and narrow T- myocardial cells, with
prescribed, if shift of potassium into
waves, shortening of decreased
appropriate. the cells, Also sodium
the QT interval, wide responsivenessto
QRS complex, loss of p- stimulation, alleviates the cardiac
effects of potassium.
wave, ventricular progressing to cardiac
tachycardia, arrest if untreated. Administer hypertonic Shifts potassium into
ventricular fibrillation, dextrose and regular the cells, lowering
asystole, cardiac arrest, insulin as prescribed, if serum levels.
blood pressure and appropriate.
pulse changes.
Avoid potassium- Prevents retention of
Assess for potential Promotes identification sparing diuretics. potassium.
clinical signs and of neuro-muscular
symptoms of dysfunctions by rise in Administer potassium- Promotes excretion of
depleting diuretics as potassium.
hyperkalemia, serum potassium
including depolarizingcells. prescribed, if
neuromusculareffects appropriate.
such as muscle Monitor potassium Prevents development
weakness or cramping, levels following of hypokalemia from
paresthesia, and GI diuresis. o v e r - ~ ~ ~ mofe n t
effectssuch as nausea, h~erk~emia.
vomiting, diarrhea,
intestinal colic. Encourage compliance Promotes decrease in
with low potassium potassium intake.
Monitor phosphate Hyperkalemia can lead diet.
levels as appropriate. to
Treat cardiac Promotes normal
hyperphosphatemia.
arrhythmias according cardiac functioning
Monitor for Prevents unintentional to policy. through prompt
unintentional elevation of serum intervention.
potassium intake potassium.
present in such Respond to cardiac ~ ~ e r k a lcan
e ~lead
a
amst. to asystole.
medications as
penicillin and
NIC: Electrolyte Management-
potassium
Hyperphosphatemia
supplements.
Administer cation- Binds and eliminates Definition: Promotion of phos-
exchange resins such potassium via the phate balance and prevention of
as kayexalate as bowel. complicationsresulting from serum
appropriate. phosphate levels higher than
desired.
Electrolyte Management- Electrolyte Management-

Hy perphosphatemia Hy perphosphatemia

Monitor serum Provides information Institute seizure Hyperphosphatemia
phosphate levels. for developing plan of precautions: Remain can lead to seizures.
care. with the patient,
loosen tight clothing,
Monitor renal function Promotes identification
turn head to side,
and signs of of clinical
monitor for respiratory
insufficiency like manifestations of
distress, alter
anuria, oliguria, and hyperphosphatemia.
environment to
azotemia.
promote safety.
Monitor serum High levels of serum
Prepare patient/family Renal dialysis may be
calcium levels. inorganic phosphate
for dialysis, if needed to correct renal
may lead to
atmotxiate. failure.
precipitation of
calcium phosphate
salts in nonosseous
sites, which decreases
serum calcium.
Avoid phosphate-rich Prevents increase in Demonstration
foods such as dairy phosphate in take from
products, whole grain dietary sources.
cereal, nuts, dried
fruits and vegetables, Act ivities Rationales
organ meats.
Teach patient/family Promotes compliance
Administer prescribed Promotes excretion of about the types, causes with health care
phosphate-binding phosphate via the of, and treatments for regime.
and diuretic bowel as the electrolyte imbalance
medications such as aluminum in these as appropriate.
Amphogel, Phos-Lo medications bind with
Teach patient/family Frequent urination
sookie, basaljel with phosphate.
food. the rationale for may be uncomfortable;
diuretic therapy. knowledge promotes
Encourage high-fiber Prevents constipation acceptance.
foods such as bran, caused by phosphate
leafy vegetables; binding which Instruct in,and give Prevents increase in
increase fluid intake; aluminum products rationale for, dietary potassium and
administer stool may cause. changes such as low phosphate from
softener as appropriate. potassium, high fiber dietary sources;
foods. prevents constipation.
Administer prescribed Promotes reduction in
calcium and vitamin D phosphate levels.
supplementsas
appropriate.
Instructions, Information, 0 NIC: Fluid Management

Demonstration
Definition: Promotion of fluid

I balance and prevention of complica-
tions resulting from abnormal or un-
desired levels.
Teach patient/family Promotes early
signs and symptomsof identification of
electrolyte imbalance eledrolyte imbalance
and to report to health and increases
Fluid Management
care team occurrence likelihood of prompt
of nausea, diarrhea, intervention.
muscle twitching or
weaknesq'decreased Activities Rationales
urine output, irregular
heart rhythm, chest Monitor serum Promotes early
pain. creatinine and BUN identification of renal
levels as appropriate. dysfunction and
0 Discharge or Maintenance prompt treatment.
Evaluation Administer Prevents uric acid
Allopurinol nephropathy by
Patient /family will report prophylactically. inhibiting the enzyme
signs and symptomsof
xanthine oxidase,
electrolyteimbalance to the
which in turn blocks
health care team.
the conversion of uric
Patient will eat low potas- acid precursors into
sium, low phosphate, high uric acid.
fiber diet.
Begin IV 48 hours Reduces urate deposits
before and continue 48 in the kidneys and
hours after enhances clearance of
chemotherapy, with phosphates and urate.
Risk for Altered Urinary 5% Dextrose in 0.45%
Elimination normal saline at a rate
of 3L/m2/24 hours.
Relatedto:
Encourage patient to These measures
Uric acid nephropathy and acute drink 12-15 glasses of promote adequate
renal failure from tumor lysis water per day while at diuresis to prevent
syndrome. home. urate deposits in
kidneys.
Mintain urinary These measures
Decreased urine output, elevations output at 100cc/hour promote adequate
in serum creatinine and blood urea by oral and lV. diuresis to prevent
nitrogen (BUN) levels. urate deposits in the
kidneys.
0 Outcome Criteria:
Administer diuretics as These measures
Patient will demonstrate adequate ordered. promote adequate
urinary eliminations as evidenced diuresis to prevent
by urine output greater than 30 cc urate deposits in the
per hour; normal serum creatinine kidneys.
and BUN levels.
Fluid Management Discharge or Maintenance

Evaluation
Patient prevents uric acid
Activities Rationales nephropathy by demonstrat-
ing such self-care measures as
Monitor serum Promotes early taking dlopurinol and drink-
creatinine and BUN identification of renal ing 12-15 glasses of water per
levels as appropriate. dysfunction and day.
prompt treatment. Patient reports decreased
Administer Promotesbicarbonate urine output to health care
acetazolarnide as excretion and team immediately.
prescribed. alkalinization of urine
by inhibiting the
resorption of
bicarbonate. Risk for Fluid Volume Excess
Maintain urine pH of 7 Promotes
or greater by adding alkalinization which [7 Related to:
50-100 mEq of sodium increases the solubility Preventing renal failure from TLS
bicarbonate to each of uric acid in the urine through vigorous hydration before
liter of IV fluid. aiding excretion.
and after chemotherapy.
Intake greater than output, short-
ness of breath, abnormal breath
Instructions, Information, sounds (rales), s3 heart sound,
Demonstration blood pressure or pulse changes,
jugular vein distention.
Activities 0 Outcome Criteria:

Patient's fluid volume will be main-
Instruct patient /family Promotes compliance
tained at an adequate level.
on rationale for, urine with health care
collection and regime. CJ NIC: Fluid Management
measurement, and
medications. Definition: Promotion of fluid
Instruct patient to Promotes adequate tions resulting from abnormal or un-
drink 12-15 glasses of hydration at home; desired levels.
fluid per day. prevents urate deposits
in the kidney.
Inform p a t i e n t / f ~ l y Prevents urate deposits
to report decreased due to low urine
urine output to health output and promotes
care team. early detection of renal
dvsfunction.
~ETABOLICAND PHYSIOLOGIC E ~ R ~ ~ C I E S 141
Fluid Management Hy p ercakemicr

Activities Rationales Hypercalcemia is an elevation in the serum
calcium level, and it is the most common me-
Monitor the following Promotes early
tabolic emergency in cancer patients. The
every 4 hours and prn: identification of
1.Blood pressure and symptoms of fluid overall incidence of this symptom is about
pulse volume excess. for all types of cancer. However, in
1~%-20%
2. Heart and lung
sounds patients with multiple myeloma and breast
3. Intake and output cancer, about 40%-50%develop an elevation
4.Jugular vein in serum calcium levels at some point in
distention
5. Presence of edema their disease. Elevations in serum calcium
Obtain daily weights. Weight gain may are common when bone metastases are
indicate fluid overload. present. The symptom often indicates a lack
Consult physician if Promotes prompt of control of the disease process. Death can
signs and ~ p t o mofs treatment fluid volume occur from a h ~ r c a l c e crisis
~ a within 12
fluid volume excess excess.
persist or worsen. hours, yet only about 5%of patients with hy-
Maintain prescribed IV Prevents fluid percalcemia require lifesaving treatment.
hydration. imbalance.
Patient’s with cancer of the breast, lung,
head, or neck, and those with kidney or
hematologic malignancies such as multiple
myeloma, leukemia, and lymphomas are
~~~onstra~ion most at risk for developing hypercalcemia,
especially when bone m~astasesare present.
Other risk factors include immobility,
Activities Rationales dehydration, renal dysfunction, skeletal frac-
Inform patient /family Promotes compliance tures, primary hyperparathyroidism,history
of rationale for with health care of thiazide diuretic, lithium and estrogen
measures to increase regime.
output and decrease therapy, and advanced age. The main sys-
intake, if appropriate. t e m affected by hypercalcemia are
I3 Discharge or ~ a i n t e n a n ~ e gastrointestinal,neuromusc~ar,cardiac, and
valuation renal. Clinical presen~tionsinclude dehydra-
0 Patient’s fluid balance will be tion, pruritus, polydipsia, anorexia, nausea,
maintained as evidenced by vomiting, constipation, weight loss, fatigue,
blood pressure and pulse
within patient’s normal range; lethargy, muscle weakness, hyporeflexia, con-
lungs clear to auscultation; ab- fusion, psychosis, seizure, obtundation,
sence of neck vein distention; coma, bradycardia, prolonged P-R interval,
absence of edema.
shortened Q-T interval, wide T-wave, atrial
or ventricular arrhythmias, polyuria and calcium phosphate. Gallium nitrate and

renal insufficiency. diphosphate may also be administered to
The severity of presentation is not related ex- decrease the serum calcium salts in the bone.
clusively to the degree of elevation in the For chronic or mild hypercalcemia, oral phos-
serum calcium level, but is also related to the phate may be given. Indomethacin and
steroids may also be p r e ~ i ba~l ~, o u g h
rapidity with which the elevation occurs.
Patients with a slight-to- oder rate increase their effectiveness is considered controver-
sial.
which occurs rapidly may present in an ob-
tunded state, while patients with long-stand- Patients can help decrease the incidence of
ing elevations may tolerate higher elevations hypercalcemia by frequent ambulation and
with few symptoms. drinking 2-3 liters of fluid per day. In per-
sons at risk for hypercalcemia, thiazide
diuretics are contraindicated because they in-
hibit calcium excretion. ~ ~ ~ t doses
a I i smay
need to be lowered as the action of digitalis
The best treatment for cancer-related hyper- is enhanced in a hypercalcemic state. While
calcemia is treatment of the underlying emergent hypercalcemia can be reversed
malignancy. However, hypercalcemia is most about 80%of the time, the duration of this
common in patients with advance disease reversal may be short-lived unless the under-
who have failed prior therapy, which makes lying malignancy is controlled. For a p
this approach difficult. Usual therapies for propriate nursing diagnoses for the
h ~ r c a l c start
e ~ with vigorous hydra tion treatment of the underlying malignancy,
to restore normal volume of extracellular refer to the specific chapter for that cancer
compartment fluid; increasing glomerular and /or the appropriate treatment chapter.
filtration; and promoting urinary calcium ex- The folIowing are nursing diagnoses specific
cretion. Infusion of 4-6 liters of normal saline to the patient with hypercalcemia.
(0.9%)per day for at least 48 hours is com-
mon. lntravenous furosemide is given to
promote sodium and calcium diuresis and to
prevent h ~ ~ a ~ e and m heart
i a failure
from fluid overload. Fluid and e ~ ~ ~ o l y t e
balance and renal function should be closely
monitored. Etidronate Disodium,
Mithramycin and/or Calcitoninmay be
given to inhibit bone resorption of calcium.
Phosphate may be given if other measures
fail to promote the precipitation of inorganic
~ L PHYSIOLOGIC
~ E T A ~ AND I ~ E~ERG~CIES 243
blood pressure or pulse changes,

Essential Nursing jugular vein distention.
Hyp ercdcemia
Constipation
(CH. 21)
Altered T ~ ~ uProcesses
g ~ t Relatedto:
(CH. 17) Hypercalcemia and it’s treatment.
5 Relatedto: Defining characteristics:
Physiological changes secondary to Decreased frequency of stools, hard
hypercalcemia. formed stools, abdominal pain or
cramping.
Disorientation to time, place, cir-
cumstances and events, change in
~~uousness. Risk For injury
c3 Relatedto:
HypercaIcemia from advancing
Fluid Volume Deficit malignant disease process.
(CH. 4)
(3 Defining Characteristics:
U Relatedto:
Elevation in serum calcium levels,
Dehydration from hypercalcemia. complaints of lethargy weakness,
nausea, vomiting, constipation, in-
Defjnin~
Characteristics: creased thirst and u ~ ~ t iandlor
~ n ,
Tachycardia, low urine output, dry itching.
mucous membranes, decreased (3 Outcome Criteria:
fluid intake from anorexia, nausea,
vomiting, and/or weight loss. Patient identifies symptoms of hy-
percalcemia to report to the health
care team, and learns measures to
take to prevent hypercalcemia.
Risk for Fiuid Volume Excess Hypercalcemia will be prevented or
identified early.
(Tumor Lysis Syndrome, this Chapter)
Ki NIC: Electrolyte ~ a n a g e m ~ n t -
Cl ~ e ~ ~ i e d t o ; ~yperca~cemia
Vigorous hydration to treat hyper- Definition: Promotion of calcium
calcemia balance and prevention of complica-
0 Defining Characteristics: tions resulting from serum calcium
levels higher than desired.
Intake greater than output, short-
sounds (rales), s / 3 heart sound,
144 ONCOLOGY CARE rums
Electrolyte Management- ElectrolyteManagement-

Hypercalcemia Hypercalcemia

rdentify clients at risk Promotes early 4dminister prescribed Promotes reduction in
:or hypercalcemia. identification and/or nedications as serum calcium levels
prevention in ippropriate, such as accordingly:
population at risk. 1. Furosemide 1. block calcium
resorption & inhibit
Assess for signs and Promotes early sodium absorption
symptoms of identification of ?.Prednisone 2. inhibits bone
hypercalcemia, hypercalcemia effects resorption
including dehydration, due to a decrease in 3. Calcitonin 3. inhibits bone
pruritus, polydipsia, neuromuscular activity. resorption
anorexia, nausea, t. Etidronate Disodium 4.inhibits bone
vomiting, constipation, resorption
weight loss, fatigue, 5. Mithramycin 5. inhibitsbone
lethargy, muscle resorption
weakness, 5. Indornethacin 6. inhibits
hyporeflexia, prostaglandin synthesis
confusion, psychosis, 7. Phosphates 7. Inhibits bone
seizure, obtundation, resorption, limits
coma, and polyuria. calcium absorption
Monitor for EKG Promotes early from the gut, and
changes including identification of effects promotes soft-tissue
bradycardia, of hypercalcemia on and skeletal
prolonged P-R the heart due to calcification.
interval, shortened Q-T increased contractility. Avoi lithium Prevents renal calcium
interval, wide T-wave, carbonate and thiazide excretion.
and atrial or diuretics.
ventricular
arrhythmias. Discourage dietary Prevents additional
intake of calcium by increase in serum
Monitor for digitalis Action of digitalis is calcium from dietary
limiting dairy
toxicity, if appropriate. potentiated in a sources.
products, seafood,
hypercalcemic state.
nuts, broccoli, spinach,
Monitor the following: Provides information as appropriate.
1. Intake and output regarding effectiveness Prevents bone
Encourage
2. Renal Function of treatments and renal resorption.
mobilization and
OWN, CR) function. ambulation.
3. Serum calcium
4.Serum electrolytes Prepare for dialysis. Provides rapid,
temporary relief of
Administer vigorous Promotes urinary
hypercalcemia.
hydration as excretion of calcium
prescribed, usually 4-6 and restores hydration.
liters of normal saline
in 24 hours.
~ E T ~ E ~ AND
L I CPHYSIOLOGIC E ~ E ~ ~ ~ C I E S 145
Instructions, information, Syndrome of

Demonstration
inappropriate
Antidiuretic Hormone
Instruct patientlfamily Promotes compliance
Secretion (SIADH)
in rationale for with health care
measures to treat regime. Syndrome of i~ppropriateantidju~tichor-
hypercalcemia. mone secretion (SIADH)was first postulated
Instruct patient to Promotes urinary in 1938 when an association of hyponatremia
drink 8-12 glasses of excretion of calcium. and lung cancer was noted. It is a
fluid daily.
paraneoplastic disease usually associated
Inform patientlfamily Promotes early
of need to report identification and with an excess of ADH. This excess results
symptoms of prompt intervention of from ectopic production or abnormal
hypercalcemia to the hypercalcesnia. stimulationof the h ~ t h ~ m u s - p i t ~ i t a r y
health care team.
network. Small cell lung cancer is the most
Instruct on calcium- Prevents increase in
rich foods to avoid serum calcium from c o ~ o malign
n an^ associated with this dis-
such as dairy products, dietary sources. order. It is occasionally associated with other
seafoods, nuts, malignancies such as gastrointestinalcan-
broccoli, spinach.
cers, thymoma, lymphoma, Hodgkin’s dis-
Stress importance of Prevents bone
activity. resorption. ease, bladder cancer, and sarcoma. Other
Instruct on use and Promotes safe use of proposed causes of SIADH include infec-
side effects of these medications in tions; CNS lesions or trauma; and treatment
medicationsused to the home. with ~ c l o p h o s p ~ ~vincristine,
de,
treat chronic
hypercalcemia, such as cisplatin, thiazide diuretics, morphine,
oral phosphate, and I or antidepressants.
indomethacin, and oral
steroids. The manifestations of (SIADH)appear as a
result of water intoxication. Excessive
CI Discharge or Maintenance
Evaluation amounts of water are retained, plasma os-
molarity drops, and dilutional hyponatremia
Hypercalcemia will be
prevented or identified early occurs. Clinical symptoms include altered
and treated promptly. mental status, confusion, lethargy, psychotic
Patient will demons~rate
behavior, seizures, coma, and o c c a s i o ~ ~ ~ y
measures to prevent hypercal-
cemia andlor reduce its death. Other symptoms include thirst,
severity. headache, anorexia, muscle cramps, nausea,
vomiting, hyporeflexia, decreased urine out-
put and weight gain without evidence of
edema. Indications of SIADHare
hyponatremia with sodium levels below 130
mEq/L with low serum osmolarity, high their tumors to treatment. Occasionally,
urine sodium level, and high urine 0s- SIADH persists despite tumor control. How-
molarity. ever, its presence, especially recurrence, sug-
gests tumor progression. The nursing care of
the patient experiencing SIADH is presented
Treatment below. For information about patients receiv-

ing chemotherapy for treatment of their dis-
Successful treatment of SIADH centers ease, refer to the appropriate disease chapter
around management of the underlying and Chapter 4, Chemotherapy.
malignancy. Since most cases of SIADH in-
volve lung cancer, the reader is referred to
Chapter 8 for treatment and nursing care of Essential Nursing
the patient with lung cancer.
Diagnoses Related To
For symptomatic hyponatremia and serum
SlADH
sodium levels less than 130mEq/L, fluid
restriction to less than 500 d / 2 4 hours will
allow patients to increase their plasma 0s-
molarity slowly over 7-10 days. Since treat- Altered Thought Processes
ment of the underlying malignancy with (CH. 17)
chemotherapy often requires hydration, and 0 Relatedto:
close monitoring of both body weight and in- Physiological changes due to
take and output, serum sodium and other electrolyte imbalances.
electrolytes will be needed. Symptomatic Defining Characteristics:
moderate hyponatremia, in which serum Disorientation to time, place, cir-
sodium levels are less than 125 mEq/L, re- cumstances and events; change in
consciousness.
quires infusion of normal saline and
electrolytes with diuresis and furosemide
before systemic chemotherapy. Patients with
severe hyponatremia, with which less than for Fluid Volume Excess
120 mEq/l and profound neurologic changes 0 Related to:
are associated, may require 3%hypertonic
Vigorous hydration before and after
saline infusions and furosemide diuresis. chemotherapy and/or water in-
Chronic SIADH which appears despite toxication due to SIADH.
chemotherapy may require therapy with 0 Defining Characteristics:
demeclocycline and/or lithium. Intake greater than output; weight
The overall prognosis for the patient with gain; weakness and fatigue; con-
fusion; headache; lethargy; thirst;
SIADH depends on the responsiveness of decreased serum sodium with
M E T A B ~ L AND
I ~ P ~ S I ~ L E~ ~ I~ CR G ~ C I E S 147
decreased serum osrnolarity; and in- Electrolyte Management-

creased urine sodium and urine os- Hyponatremia
molarity.
Outcome Criteria:
Activities Rat wnales
SIADH will be identified early and
treatment will be initiated promptly. Assess for symptoms Promotes early
of SIADW, including i d e n t i f ~ ~ t i of
on
NIC: Fluid ~ a ~ a ~ e ~ e n ~ altered mental status, SIADH.
Definition: Promotion of fluid confusion, lethargy
balance and prevention of complica- psychotic behavior,
tions resulting from abnormal or un- seizures, coma, thirst,
desired levels. headache, anorexia,
muscle cramps,
nausea, vomiting,
hyporeflexia,
decreased urine output
Fluid M a n a g ~ m ~ n ~ and weight gain
without evidence of
edema.
Identify cause of Promotes normal
SIADH and treat if sodium and water
Monitor the following Promotes early possibIe. levels.
every 4 hours and pm: identification of
1.Blood pressure and
Administer Promotes treatment of
symptoms of fluid
pulse 2. Heart and chemotherapy as underlying malignancy.
volume excess
lung sounds prescribed.
3. Intake and output For symptomatic Allows patient to
4. Jugular vein hyponatremia and increase plasma
distention 5. Presence serum sodium levels osmolarity slowly
of edema. less than 230 mEq/L,
Obtain daily weights. restrict fluids to less
Weight gain would
than 500 mV24 hours.
indicate fluid overload.
Consult physician if To decrease thirst, Moistens mucous
Promotes prompt
provide such comfort membranes without
signs and symptoms of treatment fluid volume
measures such as increasing fluid intake.
fluid volume excess excess.
dividing fluid amounts
persist or worsen.
between day, evening,
Administer diuretics as Promotes diuresis of and night; offer
appropriate. excess fluids. sugarfree gum or
candy; rinse mouth
~ a i n t a i nprescribed lV Prevents fluid
with water every 2
hvdration. imbalance.
hours.
0 NIC: Electrolyte Management-
Hyponatremia
Definition: Promotion of sodium
tions resulting from serum sodium
levels lower than desired.
Electrolyte Management- Instructions, Information,

Hyponatremia Demonstration
~ ~~

For symptomatic Promotes normal Instruct patient /family Promotes compliance
moderate sodium levels. on rationale for with health care
hyponatremia and measures to treat regime through
serum sodium levels hyponatrernia. knowledge.
less than 125 mEq/L
Instruct on reason for Promotes oral comfort
infuse normal saline
fluid restriction and and compliance with
and electrolytes and
measures to promote fluid restriction.
administer furosemide
comfort when thirst
before systemic
occurs.
chemotherapy.
Instruct patient /family Promotes early
For severe Promotes normal
hyponatremia, serum
on signs and identification of
sodium levels and
symptoms to report to SIADH and prompt
sodium level less than excretion of excess
health care team, treatment.
120 mEq/L and fluids.
including weight gain
profound neurologic
(5 lbs in 1 day),
changes, administer
decrease in urine
3%hypertonic saline
output, mental status
infusions and
changes, nausea, and
furosemide.
seizure activitv.
For chronic SIADH Promotes normal
administer sodium level by Discharge or Maintenance
demecocycline and/or interfering with the Evaluation
lithium. ADH action on the
tubules. Patient's fluid balance will be
restored as evidenced by
Institute seizure Hyponatremia can blood pressure and pulse
precautions including lead to seizures. within patient's normal range,
remaining with the lungs clear to auscultation, ab-
patient, loosening tight sence of neck vein distention,
clothing, turning head absence of edema, normal
to side, monitoring for sodium and serum osmolarity
respiratory distress, levels.
altering environment
to promote safety.
- Patient will state signs and
symptoms of SIADH that
Encourage intake of Promotes increase in need to be reported to health
foods high in sodium. sodium from dietary care team.
sources. SIADH will be identified
early and treated promptly.
Disseminated Usually DIC is diagnosed if two or more
Infravascular coagulation abnormalities are present.
Coagulation
Disseminated intravascular coagulation Treatment
(DIC) may present as either an acute or
chronic disorder. In acute coagulation disor- Treatment of DIC involves identification and
der, widespread clotting occurs within the treatment of all precipitating factors such as
arterioles and capillaries. This clotting results the primary cancer and sepsis, infection, or
in consumption of clotting factors and leads transfusion reaction. A response of the malig-
to hemorrhage. When more chronic in na- nancy to treatment is often associated with
ture, coagulation abnormalitiesare seen response of the DIC.The use of heparin
without clinical manifestations. DIC in can- remains controversial. Heparin, if used, is
cer patients can be related to the disease given to inhibit factors9 and 10, thereby halt-
process or treatment. ing the clotting cascade.
Epsilonaminocapmic acid (EACA) has been
About 15%of persons with cancer will ex-
given in conjunction with heparin to main-
perience DIC. The most common neoplasms
tain platelet and fibrinogen levels, but its use
associated with DIC are acute promyelocytic
is controversial. Aggressive support through
leukemia (about 85%of patients will have
blood product replacement is usually re-
DIC), and adenocarcinomas such as gastric,
quired, including transfusions of packed red
lung, pancreas, and prostate tumors. Known
blood cells (PRBCs), platelets, and fresh
to trigger DIC are such complications of can-
frozen plasma (FFP)for replacement of clot-
cer treatments as sepsis, bacterial infections,
ting factors. Measures to protect the patient
and intravascular hemolysis resulting from
from injury are instituted if the platelet count
hemolytic transfusion reactions. Clinical
falls below 50,000 m3.
Chronic DIC can be
presentations include bleeding, bruising,
effectively treated with subcutaneousinjec-
petechiae, tachycardia, restlessness, blood in
tions of heparin or antiplatelet agents such as
urine, emesis, or stools. Bleeding into the
aspirin or dipyridamole.
brain manifests in the signs and symptoms
of increased intercranial pressure which in- For treatment of the specific cancers, refer to
clude confusion, headaches, changes in men- the appropriate chapters. The following nurs-
tal status, vision changes, and even coma. ing diagnoses are for the treatment of DIC
only.
Laboratory abnormalitiesassociated with
DIC include prolonged prothrombin time,
prolonged activated partial thromboplastin
time, prolonged thrombin time, low plasma,
fibrinogen, and decreased platelet count.
Essential Nursing Risk For Injury

Diagnoses Related to 0 Relatedto:
Disseminated DIC
Intravascular 0 Defining Characteristics:
Coagulation Prolonged PT, PTT, lT,FSP, platelet
count, and/or fibrinogen level,
bleeding, petechiae, blood in urine,
emesis, or stools.
Risk For Injury 0 Outcome Criteria:
(CH. 4) DIC will identified and treatment
0 Related to: initiated promptly.
Thrombocytopenia from 0 NIC: Bleeding Reduction

chemotherapy, the cancer disease Definition: Limitation of the loss of
process and/or DIC. blood volume during an episode of
0 Defining Characteristics: bleeding.
Platelet count below 50,000 mm3,

bleeding or easy bruising noted.
Bleeding Reduction
Altered Tissue Perfusion,
Cardiopulmonary Activities Rationales
(CH. 13) Identify persons at risk Promotes early
for DIC. identification of
0 Related to:
persons at risk for DIC.
Anemia caused by blood loss due to Assess for signs and Promotes identification
DIC. symptoms of DIC of persons with DIC.
0 Defining Characteristics: including bleeding,
bruising and petechiae,
Cold extremities, pale skin, pale tachycardia,
mucous membranes, shortness of restlessness, confusion,
breath, tachycardia, tachypnea, blood in urine, emesis,
anxiety, and or angina. or stools.
Assess for laboratory DIC is usually
abnormalities diagnosed if two or
including prolonged more coagulation
PT, PlT, and/or TT abnormalities are
levels, and decreased present.
plasma fibrinogen
levels and platelet
count.
Bleeding Reduction Blood Products Aministration
Activities Rat ionales Activities Rationales

Monitor laboratory Provides information Monitor hemoglobin, Provides information
values including PT, for evaluating hematocrit, and for evaluating
PlT, 'IT, platelet count effectivenessof platelet count. response to
and fibrinogen levels. treatments. transfusions.
Monitor amounts of Provides record of Verify physician order Prevents errors in
bleeding by weighing accurate blood loss to for blood product. blood administration.
dressings,,counting ensure accurate
Verify that blood Prevents hemolytic
peripads, measuring replacement.
product matches transfusion reaction
bloody drainage, hema
patient's blood type from improperly
testing urine, stool, or
emesis. and physician order. matched blood.
Perform venipuncture Provide intravenous
Administer heparin Inhibit clotting factors
prescribed, if 9 and 10, thereby
using appropriate line for blood
appropriate. halting the clotting technique. administration.
cascade. Administer Promotes replacement
appropriate blood of blood lost and
Administer Maintain platelet and
epsilonaminocaproic fibrinogen levels products, including clotting factors.
PRBCs, FFP, and
acid (EACA)in during heparin therapy
platelets.
conjunction with
heparin as appropriate. Monitor vitals before, Promotes identification
during, and after of transfusion reactions
Elevate and apply Prevents further blood
transfusion.
direct pressure, loss until clotting can
pressure dressings, or take place. Monitor for fluid Identifies
sandbags to sites of overload and blood complications of
active bleeding. transfusion reactions transfusions.
during transfusion.
For chronic DIC, Prevents clotting
administer abnormalities in Stop transfusion if Prevents further
subcutaneous patients with chronic blood reaction occurs, infusion of
injections of heparin or DIC. and maintain open IV mismatched blood and
antiplatelet agents, line with saline. provides N access for
such as aspirin or emergency
dimridamole. medications.
NIC: Blood Products Administration Obtain first voided Provides evidence of

urine specimen after a renal damage.
Definition: Administration of transfusion reaction.
blood or blood products and Notify physician and Promotes identification
monitoring of patient's response. laboratory if of transfusion reaction
transfusion reactions
occur.
we-
Maintain universal Prevents spread of
precautions. disease.
Demonstration
Instruct patient/family Promotes early
about critical signs and identification of DIC
symptoms to report to and prompt treatment.
health care team,
including bleeding,
blood in stools or
urine, changes in
mental status.
Instruct patient/family Promotes compliance
in rationale for with health care
measures to treat DIC regime.
and prevent injury.
Evaluation
Patient exhibits resolution of
signs and symptoms of DIC
such as cessation of bleeding,
return of hematologic values,
coagulation and fibrinogen
levels returning to n o m l .
Patient’s fluid balance will be
restored as evidenced by
blood pressure and pulse
within patient’s normal range;
lungs clear to auscultation; ab-
sence of neck vein distention;
absence of edema; normal
sodium and serum osmolarity
levels.
Chapter Eight
Lung Cancer
Lung Cancer
Lung cancer is a major health problem in the cell, lymphocytic, and spindle cell cancers.
United States. Annually 170,000new cases These cancers are more likely to occur near
are diagnosed. It is the second most common the mediastinurn or hilus, and are usually
cancer in men, with a 17%incidence and the widespread (metastatic)when they occur,
third most common cancer in women with a and can cause rapid deterioration. Non-
12% incidence rate. Peak incidence in men is small cell lung cancers (NSCLC)include
between the ages of 50 and 60. Lung cancer epidermoid (squamous), adenocarcinoma,
is the leading cause of cancer death for both and large cell. Squamouscell carcinomas
men and women. The five year survival rate usually arise in the segmented bronchi and
is only 13%. spread locally, causing bronchial obstruction.
Adenocarcinoma of the lung is usually lo-
cated in the lung periphery and spreads to
Risk Factors the brain, bones, liver, and the other lung.
Large cell lung cancers start out as bulky
Risk factors for lung cancer include smoking peripheral tumors, spreading locally before
(linked to 85% of all lung cancers), exposure metastasizing. Lung cancer commonly metas-
to certain industrial substances such as ar- tasizes to the liver, spleen, brain, and bones.
senic, asbestos(especial1y smokers),coal dis-
tillates, iron oxide, tar, and chronic exposure
to air pollution, radon, or radiation such as Presenting Signs und
uranium. Additionally, some researchers
have suggested a genetic predisposition, and
Symptoms
the presence of chronic obstructive pul- There are no early signs and symptoms of
monary disease, progressive, systemic lung cancer. Late presenting signs and
sclerosis, and scars from tuberculosis or in- symptoms include persistent cough,
flammation increase the individual’s risk of shoulder, arm, or chest pain, hemoptysis,
developing lung cancer. dyspnea, wheezing, hoarseness, dysphagia,
anorexia, weight loss, fatigue, and superior
vena cava syndrome.
There are two major types of lung cancer,

small cell and non-small cell. Small cell lung
cancers (SCLC) include oat cell, hexagonal
Diagnostic Tests accessible tumors by bronchoscopy. For

larger tumors lobectomy (removal of a lobe
There is no accurate early screening test for of the lung), wedge resection (removal of a
lung cancer. Diagnostic tests to determine wedge of the lung), segmentectomy
the presence of a mass include chest x-ray, (removal of a segment of the lung), or
chest computed tomographic (CT) scan, lung pneumonectomy (removal of the whole
tomography, and magnetic resonance scan- lung), may be done if disease appears local-
ner (MRI). Tests to determine if the mass is ized. Radiation therapy (external beam) can
cancer include sputum cytology, bronchos- be done alone with a curative intent for early
copy with brushing or washings, needle stage NSCLC, if lung function is impaired, or
biopsy, mediastinoscopy, and scalene node if surgery is contraindicated for other
biopsy. At times a thoracotomy must be done reasons. It may also be done adjuvantly
if tissue cannot be obtained in any other way preoperatively or postoperatively. Palliative
to determine the type of lung cancer. As part radiation therapy for control of symptoms
of the staging process, tests are done to deter- may be indicated for those patients with
mine if the cancer has spread. CAT scans or more widespread disease. Chemotherapy
M W s may be done of the adrenals, liver, may be used to improve response rates in
spleen, bones, or brain. Carcinoembryonic later stage disease, but does not appear to in-
antigen enzyme titer (CEA) is sometimes crease survival. Combination chemotherapy
used as a tumor marker in lung cancer. High regimes are usually platinum-based. Addi-
CEA levels indicate extensive tumor in- tional chemotherapy agents used in NSCLU
vasion. Fluctuations in CEA levels may indi- include cyclophosphamide (Cytoxan), car-
cate either a response to treatment (lowering boplatin-doxorubicin (Adriamycin),
of CEA) or failure of treatment (increasing Etoposide (VP- 161, mitomycin, vincristine or
CEA levels). vinblastine,
Treatment of Treatment of Small

Non-Small Cell Lung Cell Lung Cancer
Cancer (NSCLC) (SCLC)
Treatment varies depending on the type of Surgery is rarely an option for SCLC because
cancer and stage at presentation. Surgery it is usually metastatic at the time of diag-
remains the treatment of choice and best nosis. However, if at the time of diagnosis
hope of cure in non-small cell lung cancer. the tumor is resectable and there is no
Various surgical options are available, includ- evidence of disease in any other area,
ing laser phototherapy for small superficially surgery may be done. This is usually fol-
LUNG CANCER 157
lowed by an adjuvant course of Complicutions of the

chemotherapy.
Disease
Chemotherapy is the more common treat-
ment of choice with SCLC as it appears to im- Pneumonia is a frequent complication of
prove the survival rate. Those most common lung cancer before, as well as after, the diag-
combinations include platinum and nosis is made. Often, when recurrent
etoposide (VP-16). Other common combina- respiratory infections are not cleared up with
tions include CAY cyclophosphamide antibiotic therapy, a chest x-ray is done to as-
(Cytoxan),doxorubin (Adriamycin), vincris- sist in the diagnosis of lung cancer. As the
tine, and ICE, ifosfamide, cisplatin, and tumor grows it often occludes airways, lead-
etoposide. Cranial radiation prophylacticly ing to the patient’s inability to clear secre-
to prevent or retard incidence of brain metas- tions from behind the occlusion. These
tases in SCLC is controversial. In late stage secretionsbuild up and can lead to
disease, radiation and/or chemotherapy pneumonia and even consolidation of these
may be used to palliate symptoms. blocked areas.
Infections and blocked airways can lead to
abnonnal blood gas values as the body com-
Investigational pensates for the decrease in lung tissue for
the exchange of gases. This problem is fur-
Treatments
ther complicated in many patients who, due
Biologic agents like interleukin-2 and inter- to their smoking history, already have
feron are currently be investigated alone and chronic pulmonary disease which impairs
in combination with chemotherapy as treat- their respirations.
ment for lung cancers. The data are not yet Another complication seen frequently is
conclusive to indicate the role, if any, of these shoulder and arm pain related to the com-
agents in the treatment of lung cancer. Nal- pression on adjacent structures as the tumor
velbine is a new chemotherapeuticagent grows. Severe compression of the superior
being investigated for lung cancer. Some re- vena cava disables blood flow on the side of
searchers have found a vaccine made of blockage to return to the heart. This condi-
proteins thought to be unique to lung cancer tion is called Superior Vena Cava Syndrome
cells, and it seems to increase survival rates and is characterized by distention of the arm
in some lung cancer patients. This vaccine and neck veins, and facial, neck, and arm
will not be available for many years as clini- edema on the affected side. This is a medical
cal trials are still underway. Studies are un- emergency and is usually treated by radia-
derway that combine radiation therapy and tion therapy or chemotherapy. If the laryn-
chemotherapy in new ways to see if they will geal nerve is involved, hoarseness may
work better in the treatment of lung cancer.
occur. This is an important symptom as its Anti cipatory Grieving

presence usually contraindicatessurgery. (CH. 1)
Metabolic complications are seen more often 0 Relatedto:
in small cell lung cancers which may have a Losses due to lung cancer such as
rapid response to treatment. See Chapter 6, loss of health, income, work, in-
timacy, relationships, and possible
Structural Oncologic Emergencies, for more life.
information. These may include acute tumor
lysis syndrome (TLS) and/or syndrome of in-
Patient exhibits or voices expres-
appropriate antidiuretic hormone (STADS). sions and/or feelings of sadness or
See Chapter 7,Metabolic Oncologic and loss or concerns over possible loss
Physiologic Emergencies, for more informa- of work, income, life.
tion.
Ineffective Individual Coping

(CH. 1)
Common Nursing
Relatedto:
Diagnosis of lung cancer and its
Curing for All Clients poor prognosis.
With Lung Cancer 0 Defining Characteristics:
Inability to meet basic care needs,
fatigue,verbalization of inability to
cope.
Anxiety
(CH. 1)
CI Related to:
Altered Nutrition: Less than
Perceived threat to self due to diag- Body Requirements
nosis of lung cancer and its poor
prognosis or its treatment. Relatedto:
Inability to ingest adequate food in-
Patient verbalizes feelings of uncer- take because of tumor location, and
tainty, apprehension, fear, sleepless- treatments of tumor such as
ness, restlessness, or other signs of chemotherapy and/or radiation
anxiety. therapy.
Anorexia, nausea, vomiting, loss of
weight, reported decrease in food
intake, early satiety, inability to eat
due to dyspnea or fatigue, presence
of mouth soreness and/or ulcera-
tions.
LUNG CANCER 159
0 Outcome Criteria: Weight Gain Assistance

Patient ingests enough food to
maintain body weight within 5%of
baseline weight. Activities Rat ionales
Reports increase intake of food and
Provide oral care Stomatitis from
fluids resulting in weight gain.
before meals and/or chemo/radiation can
0 NIC: Weight Gain Assistance topical anesthetics if cause dry, irritated,
oral pain is a problem. painful mucosa
Definition: Facilitating gain of making it difficult to
body weight. eat.
Offer artificial saliva Promotes moistness in
(Salivant)if dry mouth oral cavity which is a
is a problem. side effect from
Weight Gain Assistance radiation.
Offer frequent small Prevents
meals. overdistention of the
Activities Rut ionales stomach which can
cause increased
Assess for anorexia, Signs and symptoms pressure on the
nausea, vomiting associated with diaphragm making
(number of episodes chemotherapy/ radiatioi breathing more
and amount) affecting oral and difficult.
stomatitis, mucositis, gastrointestinal
Offer high calorie, high Provides high protein
dyspepsia, or mucosa which make
protein snacks and/or and calorie intake
dysphagia. food ingestion difficult.
liquid supplements needed to maintain
Assess food intake Provides information that are easy to protein stores and
likes and dislikes. for diet planning. consume. prevent fatigue.
Assess for early satiety; Promotes adequate Offer wine, brandy or Measures stimulate
if present, encourage food intake. administer megace appetite.
patient to eat even prior to meals.
when not hungry.
Offer soft bland foods Foods are easy to
Assess weight loss, Results from catabolic like ice cream, custards. ingest, nonirritating to
weakness, effectof tumor on gastrointestinal tract.
tissue / muscle wasting, body metabolism and
Offer meals in clean, Promotes improved
cachexia. trapping of nutrients
pleasant odor-free intake as odors and
by rapidly dividing
environment. noxious stimuli can
tumor cells.
increase anxiety and
Administer antiemetic Prevents nausea and nausea.
prior to meals. vomiting and
promotes adequate
food intake.
Administer Decreases stimulus to
chemotherapy at night. the vomiting center
and less nausea is seen
due to promo tion of
sleep.
Instructions,information, Impaired Gas Exchange

Demonstration
0 Related to:
Activities Rationales Ventilation perfusion imbalance

from lung of affected lung surface
Instruct patient/family Promotes intake of from cancer or pneumonia.
on ways to increase foods that provide
calorie intake by eating proteins for cell
high calorie, high building calories for Dyspnea, hypoxia, hypercapnia,
protein foods. energy. restlessness, abnormal blood gases.
Teach to avoid hot, These foods can irritate Outcome Criteria
spicy, or acidic foods gastric mucosa already
and fluids. inflamed by Maintenance of adequate oxygena-
radiation/chemo. tion to tissues.
Instruct on bland foods Provides high calorie, 0 NIC: Airway Management
and fluids such as milk high protein snacks
shakes, popsicles, ice that are easy to Definition: Facilitation of patency
cream, custards. consume without over- of air passages.
distending the
stomach, making it
difficult for patient to
breathe.
Airway Management
Instruct to avoid Beverages may fill up
beverages that have no stomach making
calories or nutrients patient unable to
such as coffee, tea, diet ingest foods and/or Activities Rat ionales
pop, water if early fluids with calories Assess respiratory rate, Changes in respiratory
satiety or anorexia are and proteins. depth, and ease, rate or pattern,
present. presence of dyspnea, cyanosis, dyspnea, or
use of accessory use of accessory
0 Discharge or Maintenances muscles and /or muscles may indicate
Evaluation cyanosis. respiratory distress
Daily intake of food and/or and need for
fluids that meet caloric and immediate
nutritional needs. intervention.
Weight maintained within 5% Auscultate breath Decreased or absent
of baseline. sounds, assessing for breath sounds may
Weight gain, if appropriate, as decreased or absent indicate lung collapse,
indicated by nutritional as- ventilation and presence of adventious
sessment . presence of sounds could indicate
Nausea and vomiting are con- adventitious sounds need for additional
trolled. such as rales (crackles), interventions.
Patient verbalizes improved wheezing, rhonchi.
appetite and intake of food Assess for changes in Presence may indicate
and fluids. consciousness, decreased oxygenation
mentation, to brain tissue.
restlessness, irritabilitv.
LUNG CANCER 161
Airway Management Instructions, Information,

Demonstration
Assess results of blood 0 2 and COZ diffusion
gases if performed. and exchange are Teach patient safe use Improper use of
affected when less of prescribed medications could
tissue surface is medications such as have serious
available and may bronchodilators, consequences, such as
result in life- inhalers; explain side increased respiratory
threatening acid base effects and their distress.
imbalances that may management,
require immediate respiratory distress of
intervention. side effects.
Encourage coughing Assists in secretion Instruct to avoid Increase in oxygen
and deep breathing. removal. activities that cause demand may not be
increased dyspnea. able to be met due to
Encourage fluid intake Adequate fluid intake
decrease in lung
of 2 literdday. is needed to loosen
surface area secondary
secretions and make
to tumor.
them easier to cough
out. Teach safe use of May need home
oxygen at home as oxygen to promote
Position in semi or Promotes maximum
appropriate such as adequate oxygenation
high fowler or allow to ventilation potential.
rate, cannula care, no which poses
sit in chair
smoking during use. educational needs for
Administer oxygen as Helps to maintain safe use.
appropriate, usually by adequate oxygenation
cannula at 2-3 liters/m. to tissues without Discharge or Maintenance
depressing respiratoq Evaluation
drive.
Adequate oxygenation of tis-
Administer aerosol or Measures promote sues with correct administra-
nebulizer treatments as expansion of airways. tion of oxygen.
appropriate. Respiratory rate and depth
Administer postural Measures promote within patient’s baseline.
drainage, percussion, mucous clearance. Absence of dyspnea that inter-
and vibration as feres with normal activities.
appropriate.
Administer Promotes open
bronchodilators as airways.
appropriate.
Administer antibiotics Infections are
if ordered. frequently present and
decrease lung surface
for exchange of oxygen,
sciousness from anesthesia, and/or

Essential Nursing pain relief medications which may
Diagnoses Related to impair ability to clear secretions.
Surgery c7 Defining Characteristics:

Abnormal breath sounds (races,
crackles, rhonchi), decrease in rate
and depth of respirations, tachycar-
dia, ineffective cough, cyanosis,
Pain dyspnea, pain inhibiting ability to
(CH. 2) cough.
c7 Relatedto: Outcome Criteria
Tissue manipulation and/or injury Return to baseline respiratory rate
from surgery. with patent airways.
0 Defining Characteristics: 0 NIC: Airway Suctioning
Voices complaints of pain at the sur- Definition: Removing airway secre-
gical site and/or from site of chest tions by inserting a suction chateter
tube placement, increased pulse, into the patient’s oral airway
respiratory rate and/or blood pres- and/or trachea.
sure.
-
Decreased Cardiac Output Airway Suctioning
(CH. 2)
0 Related to: Activities Rationales
Blood loss during surgical proce- Determine need for May be necessary to
dure. oral and/or tracheal maintain open airway.
Defining Characteristics: suctioning.
Auscultate breath Determines if
Decrease in urine volume, low
sounds before and suctioning is effective.
blood pressure, tachycardia drop-
ping hemoglobin and/or after suctioning.
hematocrit, bloody sputum,
tachycardia or blood on dressing.
Risk for Ineffective

Airway Clearance
Cl Related to: Select catheter one-half Monitor 0 2 before,
Increase in secretions from surgical diameter of airway. during, and after.
manipulations, presence of artificial
airway inhibiting ability to clear
secretions, decrease in level of con-
LUNG CANCER 163
Airway Suctioning 0 Defining Characteristics:

Dropping hemoglobin and/or
hematocrit, bloody sputum,
Activities Rationales tachycardia or blood on dressing,
restlessness, dyspnea, tachypnea,
Use lowest amount of Measures prevent cyanosis, atrial dysrhythmia,
wall suction necessary desaturation and and/or tracheal deviation from the
to remove secretions. excessive trauma midline, change in arterial blood
during gas results indicating lower oxygen
nasopharyngeal levels.
suctioning.
Use sterile equipment Prevents introduction
El Outcome Criteria
for each nasotracheal of bacteria into lungs Maintenance of adequate oxygena-
suctioning procedure. which could lead to tion to tissues as evidenced by
infection. maintenance of normal respiratory
Stop suctioning and Signs that indicate rate.
provide supplemental respiratory and/or Prevention and/or early detection
oxygen if patient cardiac distress due to of hemorrhage, pneumothorax,
becomes bradycardic, lack of oxygen. mediastinal shift.
shows increase in
Cl NIC: Bleeding Reduction
ventricular ectopy,
and/or desaturation. Definition: Limitation of the loss of
Instruct the patient Promotes compliance. blood volume during an episode of
and/or family of need bleeding.
for suctioning.
Instruct patient/and or Assists pa tien t/ family
family in oral and/or in maintaining patent
nasotracheal airway when health Bleeding Reduction
suctioning techniques care providers are not
as appropriate. present.
Evaluation Assess for signs and Presence may indicate
Patient maintains adequate symptoms of bleeding: bleeding and/or
oxygenation to tissues. Bloody sputum., hemorrhage and
tachycardia, blood on require immediate
dressings, frank blood nursing intervention.
in large amounts in
chest tube drainage.
High Risk for Injury
Monitor hemoglobin Drop in hemoglobin
0 Relatedto: and hematocrit. and /or hematocrit
may indicate blood
Complications of surgery such as loss.
hemorrhage, pneumothorax and /or
mediastinal shift and presence of Monitor trends in vital Hypotension in
chest tubes. signs. presence of
tachycardia may
indicate blood loss.
Bleeding Reduction 17 NIC: Tube Care--Chest

Definition: Management of a
patient with an external water-seal
Activities Rationales drainage device exiting the chest
cavity.
Monitor fluid status, Blood loss during
intake and output. surgery could result in
hypovolemia
postoperatively.
Maintain patent IV IV access may be Tube Care - Chest
access. needed to replace
fluids and blood.
Administer IV fluids as Fluids may be needed Activities Rationales
appropriate. to replace lost blood
and fluids. Monitor for signs and Signs of early
symptoms of respiratory distress
Arrange for If hemorrhage occurs, respiratory distress: indicate need for
transfusion of blood administration of Increased respiratory immediate
products as blood may be needed. rate, increase in intervention.
appropriate. dyspnea, nasal flaring,
and use of accessory
Avoid deep suctioning. May cause trauma to
muscles.
suture line and
bleeding. Monitor for signs and Pneumothorax can
symptoms of occur if chest tube
pneumothorax: Absent becomes occluded or
breath sounds system develops a
unilaterally, tracheal break.
Instructions, Information, deviation, and
Demonstration increased shortness of
breath.
Assess the chest tube 1)Intact water seal
I
drainage system: 1)
Water seal intact. 2)
prevents
pneumothorax. 2)
Instruct patient/family Bleeding requires Water level of seal at Maintains correct
on signs of bleeding immediate nursing proper amount, and pressure. Lack of
and appropriate intervention. fluctuations in water fluctuationsmay
actions. seal chamber should indicate occlusion of
Instruct patient to
be present. 3) Drainage tube. 3) Bloody
Prevents further
in tubings, drainage may indicate
restrict activities that bleeding.
color /amount. hemorrhage; greenish
may increase bleeding.
foul-smelling drainage
Instruct patient/family Knowledge promotes may indicate infection.
on need for compliancewith
appropriate action
1) Assure that all 1) Leaks in system
health care regime.
(blood products etc.). tubing connections are could occur if tubing is
securely attached and not taped securely. 2)
taped. 2) Provide Allows freedom of
sufficiently long movement. 3) Prevents
tubing. 3) Anchor accidental dislodement
I tubing securelw of chest tube.
LUNG CANCER 165
Tube Care - Chest Instructions, Information,

Demonstration
Activifies Rationales
Assess the drainage May indicate leak in
system for breaks: system. Instruct patient/family Promotes compliance
Continuous large in need for chest tube. with health care
amount of bubbling, regime.
air leak noises in the
Instruct pa tient on Promotes lung
system.
splinting during expansion by assisting
1)Assess for cause of Poor-fitting connectors coughing and deep patient to control pain.
air leak noises: could be cause of air breathing.
1)Check dressing at leak.
Instruct patient to take Pain can prevent lung
insertion site.
pain medications as expansion and inhibit
2) Determine chest
needed. patient from
tube placement.
performing measures
3) Check fit of any con-
that promote optimal
nectors. 4) Check for
pulmonary functioning
defective equipment.
Monitor presence and Increasing crepitus 0 NIC: Airway Management
amount of crepitus. may indicate air leak
around the tube. Definition: Facilitation of patency of
air passages.
Keep drainage Promotes drainage and
container below chest prevents backflow of
level. drainage into lung.
Change dressing Prevents infection and
around chest tube air leak at site. Airway Management
every 2-3 days and pm
using petroleum jelly.
Obtain chest x-ray and Ensures placement of
blood gas values as tube and provides Monitor for signs and Signs of early
appropriate. information on symptoms of respiratory distress
oxygenation. respiratory distress: that indicate need for
Position client after Promotes expansion of Increased respiratory immediate
lobectomy or lung to fill lung space rate, increase in intervention.
segmentectomy and protect remaining dyspnea, nasal flaring,
avoiding prolonged lung space. and use of accessory
lying on operative side. muscles.
Administer pain Adequate pain control After pneumonectomy, Mediastinal shift
medications as will promote lung assess for signs of requires immediate
appropriate. expansion, and chest mediastinal shift: intervention and can
tubes can be very restlessness, dyspnea, occur after
uncomfortable. tachypnea cyanosis pneumonectomy if
atrial, dysrhythmia, nonoperative lung
tracheal deviation from moves into space
the midline. created by removal of
other lung.
I Airway Management Chest tubes will remain

patent, and air leaks will not
occur.
Position patient after Protects remaining
pneumonectomy
avoiding lying on
lung tissue by
avoiding positions that
Essentia/ Nursing
surgery-free side and could interfere with Diagnoses Related To
trendelenburg. expansion of
remaining lung. Radiatjon Therapy
Assist with coughing Measures promote
and deep breathing optimal pulmonary
position changes, functioning.
ambulation. Fatigue
If chest tube is present Post pneumonectomy, tCH. 5)
in post most surgeons want 0 Related to:
pneumonectomy remaining surgical
patients, ensure that it space to fill with fluids Lung cancer disease process,
is clamped. and consolidate; once anemia related to radiation therapy
this occurs, risk of and radiation itself.
mediastinal shift is no
longer a danger. Defining Characteristics:
Voices feeling of weariness, tired-
ness and/or loss of energy, exter-
tional dyspnea present and unable
to carry on functions of daily living.
Demonstration
Altered Nutrition: Less than
Activities Rat ionales Body Requirements
Instruct patient/family Measures promote (CH. 2)
on importance of optimal pulmonary
coughing and deep functioning and 0 Related to:
breathing, position knowledge will Esophagitis and dysphagia usually
changes, and promote compliance. occurring 3 weeks after initiation of
ambulation. radiation therapy to chest.
Discharge or Maintenance 0 Defining Characteristics:
Evaluation
Inability to swallow solids and li-
Hemorrhage will be quids due to pain in throat and
prevented or detected and esophagus, presence of oral lacera-
treated early. tions in pharynx and esophagus, in-
Pneumothorax and/or adequate food ingestion and/or
mediastinal shift will not weight loss.
occur or, if it does, it will be
detected and treated early.
LUNG CANCER 167
Risk for Skin Impairment Teaching - Procedure/Treatment

(CH. 3)
0 Relatedto: Activities Rat ionales
Side effects from radiation therapy. Assess knowledge of Provides information
Defining Characteristics: radiation therapy to develop treatment
treatment plan and plan based on patient's
Skin reactions such as dryness, possible side effects. needs.
erythema usually occur 7-10 days Inform patient/family Information the
after treatment is begun, emaciation when the treatment patient /family needs
due to weight loss from disease will begin, time, length to plan daily activities
and/or its treatment. and duration of around treatments.
treatments, purpose of
treatments.
Knowledge Deficit Explain possible side Due to physiological

effects from radiation effect of radiotherapy
therapy to the chest: to pulmonary fields
0 Relatedto:
Hair loss, skin and surrounding tissue
Radiation therapy to the chest for reactions in field ( 7-10
lung cancer. days after treatment is
begun), dysphagia and
0 Defining Characteristics: esophagitis (3 weeks
Patient voices lack of knowledge after treatment is
and/or questions about upcoming begun), tenacious
radiation therapy treatments. bronchial secretions,
pneumonitis (1-3
0 Outcome Criteria months later),
pulmonary fibrosis,
Patient will be able to discuss the pericarditis, myelitis
possible side effects of radiation (lone term).
treatments to the chest and how to
manage them if they occur.
NIC: Teaching-- Procedure/
Treatment
Definition: Preparing a patient to
understand and mentally prepare
for prescribed procedure or treat-
ment.
Instruct patient/family Promotes self care

on measures they can management.
use to manage the
possible side effects
from radiation therapy
' to the chest.
Instructions, Information, Identifies changes that should

Demonstration be reported to the health care
team immediately.
Teach client/family of Knowledge will Knowledge Deficit
half-life radioisotopes promote compliance
(if receiving implant) with safety measures Related to:
and safety precautions for needed length of
needed during time time. Cranial radiation therapy
implant is present and 0 Defining Characteristics:
after if required.
Voices lack of knowledge and/or
Instruct patient on Smoking cessation will
questions about upcomingradia-
advantages of smoking decrease severity of
tion therapy treatments
cessation. symptoms of disease
and its treatment. 0 Outcome Criteria:
Provide written Written materials Patient will be able to discuss the
information on reinforce verbal possible side effects of cranial radia-
radiation therapy instructions. tion treatments and how to manage
treatments and self them if they occur.
care measures.
0 NIC: Teaching-- Procedure/
Advise patient not to Prevents possible drug Treatment
take any medications interactions.
including OTC drugs Definition: Preparing a patient to
unless ordered, or understand and mentally prepare
okayed by physician - for prescribed procedure or treat-
even aspirin. ment.
Inform patient verbally Promotes prevention
and in writing of of serious
changes that must be complications by
reported to the health promoting early
care team immediately: reporting. Teaching - Procedureflreatment
Signs of infection,
persistent nausea and
vomiting, unusual Activities Rationales
bleeding or bruising,
acute changes in Assess knowledge of Provides information
mental or emotional radiation therapy to develop treatment
status. treatment plan and plan based on patient’s
possible side effects. needs.
0 Discharge or Maintenance Inform patient/family Provides information
Evaluation when the treatment the patient / family
States possible side effects and will begin, time, length needs to plan daily
self care management techni- and duration of activitiesaround
ques to cope with side effects. treatments, purpose of treatments.
Patient receives radiation treatments.
treatments as prescribed by
physician.
LUNG CANCER 169
Teaching - Procedureflreatment
I Instructions, Information,
Demonstration
Explain the possible Provides information
side effects from about physiological Inform patient verbally Promotes prevention
cranial radiation effect of radiotherapy and in writing of of serious
therapy, and that they to brain and changes that must be complications by
are usually temporary, surrounding tissue. reported to the health promoting early
including hair loss, care team immediately: reporting.
desquamation of signs of infection,
portion of ear, and persistent nausea and
CNS syndrome vomiting, unusual
(memory loss, tremor, bleeding or bruising,
somnolence, slurred acute changes in
speech, learning mental or emotional
disability). status severe
headaches, and vision
changes.
Instructions, Information, Evaluation
Demonstration Patient states possible side ef-
fects and self care manage-
ment techniques to cope with
Activities Rationales side effects.
Receives radiation treatments
Instruct patient/family Promotes self care as prescribed by physician
on measures they can management. Identifies changes that should
use to manage the
be reported to the health care
possible side effects
team immediately.
from cranial radiation
therapy.
Provide written Written materials
information on reinforce verbal Altered Thought Processes
radiation therapy instructions.
treatments and self Relatedto:
care measures.
CNS syndrome and/or increased in-
tracranial pressure secondary to in-
jury from cranial radiation therapy.
Memory loss, tremors, somnolence,
slurred speech, learning disability,
headaches, vision changes, nausea,
and vomiting.

Demonstration
Patient and/or significant other
identifies mental status changes
that need to be reported to health
care team. Activities Rationales
0 NIC: Neurologic Monitoring Explain that CNS Knowledge will assist
syndrome is a possible in coping with side
Definition: Collection and analysis side effect of radiation effect.
of patient data to prevent or mini- therapy.
mize neurologic complications.
Instruct patient\family Promotes immediate
on signs of ICP and intervention of a
need to inform health serious complication.
care immediately if
Neurologic Monitoring they occur.
Inform of reasons for Sudden
taking steroids and not discontinuance of
Activities Rat ionales to stop unless steroids can cause
instructed by physician. rebounding of ICP.
Assess for signs of Cranial radiation can
increased intracranial cause swelling to 0 Discharge or Maintenance
pressure (ICP):vision injured tissues Evaluation
changes, nausea,
vomiting, headaches. Remains orientated and/or
reorients to surroundings as
Avoid activities that Prevents further brain appropriate.
increase intracranial trauma. * Signs of increased intracranial
pressure. pressure (ICP)are recognized
Monitor neurologic Cranial radiation can and treated early.
status on an ongoing cause C N S syndrome
basis. which results in
change in neurologic
status.
Essential Nursing
Provide optimistic but Promotes adaptation to
realistic reassurance to altered mental status. Diagnoses Related to
patient /family. Chemotherapy
Assess orientation and Promotes orientation.
reorient as appropriate.
Administer anti- Reduces brain swelling.
inflammatory Knowledge Deficit
medications such as (CH. 4)
steroids.
Related to:
Chemotherapy, its side effects, and
their management.
Verbalizes lack of information
and/or questions about
LUNG CANCER 171
chemotherapy, its side effects, Body Image Disturbance

and/or how to manage them.
(CH. 4)
0 Related to:
Potential for Infection Alopecia, weight loss and/or skin

changes secondary to etoposide,
(CH. 4) adriamycin, and vinca alkaloid
0 Related to: (vinblastine, vincristine)
chemotherapy drugs.
Chemotherapy’s rapid destruction
of dividing hematopoietic cells, 0 Defining Characteristics:
resulting in immunosuppression. Patient verbalizes fear of rejection
0 Defining Characteristics: or reaction of others to altered ap-
pearance, especially hair loss.
Presence of granulocytopenia, an
absolute granulocyte count (AGC)
below 1000 cells/mm3
Risk for Altered Skin Integrity
(CH. 4)
High Risk for Injury El Relatedto:
(CH.4) Extravasation of vesicant
17 Relatedto: chemotherapy agents such as
adriamycin, vincristine, vinblastine.
Bone marrow suppression from
chemotherapy 0 Defining Characteristics:
0 Defining Characteristics: Complaints of pain, burning, red-

ness in IV site; swelling, redness,
Presence of thrombocytopenia with necrosis progressing to tissue
a platelet count below 50,000 sloughing at IV site.
cells/mm3, presence of easy bruis-
ing, bleeding.

Pain Cardiopulmonary
(CH. 13)
(CH.4)
0 Related to:
0 Related to:
Damage to cardiomyopathy from
Nausea and vomiting from adriamycin and/or high-dose
chemotherapy and/or anxiety re- cyclophosphamide.
lated to treatments.
Decrease in ejection fraction, weak-
Expresses feelings of pain or dis- ness, fatigue, and resulting decrease
comfort, moans, cries, is in ability to perform activitiesof
diaphoretic; elevation in blood pres daily living.
sure, pulse rate observed.
Altered Sexuality Patterns Altered Urinary Elimination

(CH. 1) (CH. 18)
0 Related to: 0 Related to:
Chemotherapy treatments and its Hemorrhagic cystitis from cytoxan
side effects. and/or ifosfamide chemotherapy
drugs.
Patient verbalizes difficulties, limita-
tions, or changes in sexual be- Hematuria, gross or microscopic;
haviors, secondary to changes due complaints of blood in urine while
to chemotherapyand/or concerns receiving cytoxan and/or ifos-
over fertility due to testicular famide;
atrophy or amenorrhea.
High Risk for Peripheral

Risk for Altered Urinary Ne urovascula r Dysfunction.
Elimination
(CH. 11) 0 Relatedto:
0 Related to: Damage to nerves from

chemotherapy, especially the vinca
Necrosis of proximal and distal alkaloid agents such as vincristine
renal tubules from cisplatin prevent- and vinblastine, and other agents
ing reabsorption of Mg, Ca, and K. such as cisplatin, procarbazine,
taxol.
Increasing serum creatinine levels,
decreasing creatinine clearance Patient verbalizes loss of fine motor
values, decreasing serum Mg, Ca, movements, burning pain in ex-
and K levels, and hyperuricemia. tremities, numbness in extremities,
gait disturbances, and loss of
proprioception.
Cl Outcome Criteria
Risk for Sensory/
Perceptual Alterations Sensory/perceptual changes will be
identified early and discomfort
(CH. 10) and/or disfunction from them will
El Related to:
be minimized.
Neurologic toxicity from cisplatin.

0 NIC: Neurologic Monitoring
0 Defining Characteristics: Definition: Collection and analysis

of patient data to prevent or mini-
Presence of high-frequency hearing mize neurologic complications.
loss, voices complaints of hearing
loss.
LUNG CANCER 173
Neurologic Monitoring instructions, Information.

Demonstration
Activities Rat ionaks
Monitor for Parasthesias from
parasthesias: vinca alkaloids may be Instruct patient/family Knowledge is part of
Numbness, tingling due to demyelination on potential informed consent.
prior to each drug dose. and axonal neurotoxicity of vinca
degeneration of nerves. alkaloids.
Monitor response to Nerve damage from Instruct patient/family All are signs of nerve
tactile stimuli. vinca alkaloids may of need to inform damage from vinca
impair ability to health care team if they alkaloid agents,
perceive tactile note numbness or usually requiring dose
stimulus. tingling in extremities, reduction and/or
loss of fine motor discontinuing agent.
Assess proprioceptive Nerve damage from movements such as
functions such as gait, vinca alkaloids may
difficulty writing,
deep tendon reflexes, cause changes in
trouble buttoning
muscle weakness or proprioceptive buttons, or difficulty
atrophy, balance, functions.
walking up stairs.
placement of body
parts. Inform patient of need Once damage occurs it
to stop or decrease may not be reversible.
Notify physician of Promotes early
dose of vinca alkaloid
any changes in identification of side
drug if neuropathies
neurologic status. effects from agents
occur.
which may result in
stopping or reducing Discharge or Maintenance
dose of agents. Evaluation
Discuss impact of Promotes
Patient will be free from injury.
neurologic changes on independenceby
activities of daily maximizing Patient will report changes in
living and possible functioning. tactile and proprioceptive
need for occupational function.
and/or physicai I Patient will develop safe
therapy. measures to compensatefor
losses if they occur.
Refer as appropriate Sensory impairments
for occupationalor may affect ability to
physical therapy. perform activities of
daily living, requiring
professional assistance Pain
to maximize
functioning. 0 Relatedto:
Painful paresthesias from
chemotherapy agents.
Patient verbalizescomplaints of
burning, tingling, or prickling pain
in extremities.
0 Outcome Criteria Instructions, Information,

Demonstration
Patient will have decreased pain.
___
0 NIC: Pain Management

Definition: Alleviation of pain or
reduction in pain to level of comfort Instruct patient /family Neuropathic pain is
that is acceptable to the patient. of measures to relieve more difficult to relieve
pain including and may require use of
medications and other nontraditional pain
techniques that are relief measures.
helpful with
Pain Management neuropathic pain.
Inform patient of dose, Promotes correct use of
time, frequency of pain medications for
Activities Rationales medications prescribed maximum benefit.
Assess comfort level Provides necessary and that effect from
and presence of severe information to develop medication may not be
tinghng or prickling plan of care. immediate.
sensation, cramping, or
burning, noting 0 Discharge or Maintenance
intensity,quality and Evaluation
frequency of Patient’s pain will be relieved
sensations. or adequately controlled by
Identify precipitating Cold and/or heat can medications and/or measures
factors such as increase pain. prescribed.
exposure to heat or
cold and ways to avoic
Administer adjunctive These agents are
analgesics with indicated in the Risk for Constipation
neurologic actions treatment of
such as amitriptyline dysesthetic pain. 0 Related to:
HCL (Elavil), Neurotoxicity from vinca alkaloid
phenytoin sodium chemotherapy agents such as
(Dilantin). vinblastine or vincristine.
Offer patient Measures may be Defining Characteristics:
nonpharmacologic helpful in relieving
measures to relieve neurologic pain that is More common with vincristine
pain, such as guided resistant to more and/or high dose (20 mg) vinblas-
imagery, progressive traditional pain tine, complaints of constipation,can
muscle relaxation, management methods lead to adynamic ileus with severe
massage, etc. such as non-narcotic abdominal pain.
and narcotic pain
medications. 0 Outcome Criteria
Patient wil1 have regular bowel
movements.
LUNG CANCER 175
NIC: Constipation/lmpaction
Management Demonstration
Definition: Prevention and allevia-
tion of constipation/impaction.
Activities Rat iona2es
Instruct patient/family Prevents constipation
to notify health care if which can lead to ileus.
Constipation/lmpaction unable to move bowels
Management at least once a day.
Instruct on proper use Improper use of
of laxatives as needed. laxatives can result in
Activities Rationales dependence and/or
other problems.
Assess bowel Provides baseline
elimination pattern. Instruct to report any Abdominal pain could
information.
abdominal pain indicate presence of
Monitor bowel sounds Provide information to immediately. ileus.
and/or bowel formulate plan.
movement. 0 Discharge or Maintenance
Eva1uatio ns
Encourage intake of 2- Promotes greater fluid
3 liters of fluid daily. content of stool for Patient will have regular
easier passage. bowel movements.
Encourage foods high Fiber and bulk Patient will notify health care
in fiber and bulk. degradation in colon team of signs/symptoms of
assist in formation and ileus early, such as lack of
passage of stool. daily bowel movement and
abdominal pain.
Encourage regular Promotes propulsive
exercise. bowel action.
Administer laxatives if Prevents ileus through
unable to move bowels regular bowel Risk for Injury
at least once a dav. movements.
0 Related to:
Hypotension due to rapid infusion
of etoposide (VP-16).
Instructions, Information, Defining Characteristics:
Demonstration
Low blood pressure noted during
administration of etoposide.
I
NIC: Vital Signs Monitoring
Definition: Collection and analysis
promote regular regular bowel of cardiovascular, respiratory, and
elimination such as 8- elimination. body temperature data to deter-
10 glasses of fluids per mine and prevent complications.
Vital Signs Monitoring
Monitor blood Promotes early
pressure prior to, q5-10 identification of
min x 3, then q30 min hypotension.
until infusion of VP-16
complete.
Should hypotension Hypotension is usually
occur stop drug, notify rapidly resolved once
MD, restart infusion at drug is stopped, and
a slower rate, once indicates need for
hypotension resolves, slower infusion.
if ordered by MD.
Infuse VP-16 over at Prevents hypotension
least 30-60 minutes. commonly seen during
rapid infusion.
Dilute drug at Promotes stable drug
concentration of 0.2 at correct
m g / d stable for 96 concentration.
hrs in glass and 48 hrs
in plastic.
Demonstration
Instruct on possible Knowledge prepares
side effects of VP-16, patient for possible
including hypotension. side effects.
Inform of need for Knowledge will
frequent blood decrease anxiety over
pressure readings. frequencyof procedure.
Evaluation
0 Patient’s blood pressure will
remain within normal range.
Hypotension, if it occurs, will
be identified early and treated
without serious complications.
Chapter Nine
Breast Cancer
BREAST CANCER 179
Breast C a n c e r
Annually 183,000 new cases of breast cancer However, only 25% of women who develop
are diagnosed in the United States; only breast cancer have any of these risk factors.
about 1,000 of these cases are men. Not only Therefore,the single most important risk fac-
does breast cancer afflict far more women tor is simply being a woman. Some research
than men, it is also, among women, the num- has suggested a dietary link between high fat
ber one cancer. By the age of 85 one of every intake, obesity, and breast cancer develop
nine women will develop breast cancer. ment, but this link has not been firmly estab-
Breast cancer is the second major cause of lished.
cancer death in women, with an estimated
46,000 deaths in 1994. However the 5-year
survival rate for localized breast cancer is Types of Breast Cancer
93%. If the cancer has spread regionally at
the time of diagnosis, the 5-year survival is There are many types of breast cancer. The
72%and for persons with distant metastases most common type is infiltrating ductal car-
at the time of diagnosis, the 5-year survival cinoma, accounting for about 7040% of all
is only 18%. breast cancers. Other types of carcinoma in-
clude medullary, mucinous, colloid, invasive
lobular. Also included are Paget’s disease, in-
Risk Factors flammatory breast cancer, and lobular car-

cinoma in situ. The most common sites of
Risk Factors for breast cancer include: breast cancer are the upper outer quadrant of
6 Being over the age of forty the breast and under the nipple.
A personal or family history
of breast cancer
Early age of menarche
Late age of menopause Signs und Symptoms
Childless or having one’s first
child at a late age Early breast cancer is asymptomatic. A pain-
Higher education and/or
socioeconomic status less lump or thickening in the breast is the
Long term use of exogenous most common sign. Most- about ninety per-
estrogen and pmgestin Ex- cent- are discovered by women themselves.
posure to excessive ionizing
radiation However, most are discovered accidentally,
History of fibrocystic disease not by breast self-exam (BSE), despite the
Endometrial, ovarian, or nationwide emphasis on early detection
colon cancer through BSE. The majority of lumps dis-
covered are not breast cancer. Only 25%of all Suspiciousbreast lumps are evaluated in
breast lumps are found to be malignant. other ways including percutaneous needle
Late signs and symptoms of breast cancer in- biopsy, needle aspiration and excisional or in-
clude dimpling of the skin, nipple retraction cisional biopsies. Once the pathologic diag-
or deviation, scalinessof skin or nipple, and nosis of breast cancer has been made, it is
pain, tenderness, or discharge, especially recommended that the tumor be evaluated
bloody, from the nipple. Peau d'orange skin, for the presence of a variety of hormone
thickened skin with prominent pores similar receptors. These assist in predicting the ag-
to the peel of an orange, and/or ulceration of gressivenessof the tumor and its response to
the breast, are both late signs of disease. If treatment. They include estrogen-recep-
nodal involvement is present there may be tors(ER) and progesterone-receptors(PR1.
firm, enlarged axillary lymph nodes and/or Women with ER- and PR-positive tumors
have a lower risk of recurrence than women
palpable supraclavicular nodes in the neck
area. Signs and symptoms of distant metas- with ER- and PR-negative tumors. Addition-
tasis include pain in the shoulder, hip, lower ally, ER-positive often means a woman will
back, or pelvis; persistent cough; anorexia or be more likely to respond to hormonal and
weight loss; digestive disturbances; dizzi- chemotherapy treatments than are women
ness; blurred vision; and headache. with ER- and PR-negative tumors. Breast can-
cer tumors also are assayed for cellular
deoxyribonucleic acid (DNA)content and S-
phase fraction. An abnormal DNA amount in
Diagnosis tumor cells, is called aneuploidy and indi-
Mammography is usually the first step in cates an aggressive tumor, as do a large per-
evaluating suspiciousbreast lumps. It is also centage of cells in the S-phase.
effective in screening asymptomatic women An important predictor of recurrence is
for very early stage breast cancer. Mammog- whether or not there is lymph node involve-
raphy has found cancers in situ so small that ment at the time of diagnosis. If an axillary
they are not detectable by physical examina- lymph node dissection is done and no lymph
tion. Notably, in situ breast cancers are nodes are positive, the woman has a 35%
believed to be almost 100%curable. The chance of recurrence at 10 years. When one
American Cancer Society recommends that to three lymph nodes are positive she has a
women undergo a screening mammography 55% recurrence rate at 10 years. Four to ten
by the age of forty; women 40 to 49 are ad- positive nodes predict 70% recurrence rate
vised to get a mammogram every 1-2 years; at 10 years. More than 11positive nodes
and after the age of 50, asymptomatic predict 82%recurrence rate at ten years.
women should have a mammogram yearly. Various additional testing is done at the time
of diagnosis but usually includes a complete
BREAST CANCER 181
blood count, liver chemistry results, a chest x- and her family time to consider options and
ray, and tumor markers such as CEA, U S A - adjust to the diagnosis and the possible loss
P and/or CA 15-3. Staging for breast cancer of a breast prior to undergoing major
may include a bone scan and a liver scan if surgery. Additionally, this approach allows
clinically indicated. the woman to explore second opinions if
Treatment of Primary Breast Cancer desired. The two-step is the more common
Treatment of breast cancer is based on the approach at this time.
stage of disease and several other factors.
Early stage breast cancer is often curable
Women have more options today in the treat-
with surgery alone. The current trend is to
ment of breast cancer than ever before. The
perform breast-conserving surgery in
treatment of breast cancer usually involves a
women with early stage disease when pos-
combination of surgery, chemotherapy and sible. The increase in this approach is due in
radiation therapy. The role of each treatment part to recent studies demonstrating equal
modality in breast cancer will be discussed. survival and recurrence rates for women
with early stage disease who have breast-
sparing procedures, versus modified radical
Surgery mastectomies. One breast-sparing procedure
is the segmental mastectomy (lumpectomy)
Biopsy is usually the first type of surgery a
followed by irradiation of the breast. Women
woman with breast cancer will undergo. The
with stage 0 (cancer in situ), and stage 1dis-
purpose of performing a biopsy is to deter-
ease when the tumor is small are usually
mine if a mass is malignant and the type of treated with a segmental mastectomy with
breast cancer it is. Often, the woman will be axillary node dissection, followed by breast
given the option of having a biopsy per- irradiation. Segmental mastectomy involves
formed as a one-step or two-step procedure. removal of the tumor and a portion of tissue
A one-step procedure is done under general around it to ensure tumor free margins. Since
anesthesia with immediate frozen section.
the primary purpose of the segmental mas-
Should the frozen section reveal malignancy, tectomy is cosmetic, some women with small
the surgeon proceeds with a mastectomy if breasts- or depending on the location of the
appropriate. The one step procedure allows tumor- may achieve a more cosmetically ac-
the biopsy and surgery to be done under one ceptable result with a modified radical mas-
general anesthesia saving time in recovering. tectomy with reconstruction than with
In the two-step procedure, the biopsy is segmental mastectomy.
usually done under local anesthesia, and the
Women with stage 1 (larger tumors), stage 2,
women is sent home. Once the biopsy results
and stage 3 disease will usually be treated
are available the physician advises the
with a modified radical mastectomy. This
patient and family on the recommended
procedure involves en bloc removal of the
treatment. This approach allows the woman
breast, pectoralis minor muscles, intervening ease. The immediate side effect seen with ir-
lymphatics and a sampling of the axillary radiation of the breast is skin reactions. Rib
lymph nodes. In some cases reconstructive fractures and pneumonitis are later effects.
surgery is done at the same time. The Lymphedema may be seen if the axilla is in-
Halston radical mastectomy, once the cluded in the field.
mainstay of breast cancer treatment has been
abandoned in favor of more conservative
measures. Patients with advanced local dis- Chemotherapy
ease may be treated with simple mastectomy
as a comfort measure even if control of the Chemotherapy utilizing antineoplastic
disease may not be possible. agents and hormonal drugs play a vital role
in the treatment of breast cancer. The role of
these agents is changing rapidly as more is
Radiation Therapy understood about breast cancer and tumor
f primary importance in the role of
biology. O
Radiation therapy may be used as primary antineoplastic agents in primary breast can-
treatment for stage 1 and 2 breast cancer. Sur- cer is an understanding that many patients
vival rates are comparable to surgical treat- at the time of diagnosis already have estab-
ment. This is not surprising as both are lished micrometastatic disease not clinically
considered local forms of treatment. As local detectable by current methods. The
therapy they will not affect any distant likelihood that micrometastatic disease will
micro-metastases present but not clinically become clinically evident can be predicted
detectable at the time of diagnosis. An ad- by characteristics of the primary tumor
vantage of primary radiation is the pos- which include size, hormonereceptor status,
sibility of both local tumor control and breast pathologic characteristics,histologic type,
preservation. Adjuvant irradiation of the and axillary lymph node status.
breast, following segmental mastectomy
In 1985 and again in 1990 the National In-
(lumpectomy) for early stage disease, is the stitutes of Health sponsored a Consensus
recommended standard of care. A combina- Development Conference on Adjuvant
tion of low dose external radiation and an im- Chemotherapy and Endocrine Therapy for
plant of 192Ir helps minimize the occurrence Breast Cancer. The following table sum-
of radiation-induced rib fractures and radia- marizes chemotherapy/endocrine treatment
tion pneumonitis. Radiation therapy may
recommendations from those two conferen-
also be used to treat inflammatory breast can-
ces as well as more recent studies.
cer before chemotherapy is given. Addition-
ally, radiation therapy may be used to treat
local recurrences, to ablate ovarian function,
and to palliate symptoms of metastatic dis-
BREAST CANCER 183
Table 1: General Adjuvant substitutes doxorubcin (Adriamycin)for

Treatment Recommendations For
Breast Cancer methotrexate and is commonly called CAF.
Which of these combinations is most effec-
tive for adjuvant therapy remains controver-
Sfage Nodal Premenopausal Post sial. These regimens are usually
Status Women Menopausal
Women administered for 3 to 6 months. Combina-
tions of chemotherapy and hormones like
0 (not usually Not Not
evaluated) recommended recommended tamoxifen may increase response rates but
1- Adjuvant Tamoxifen, have not necessarily shown an increased sur-

chemotherapy, possibly vival rate. Concurrent administration of
possibly with Adjuvant chemotherapy with irradiation to the breast
tamoxifen chemotherapy
may result in more pronounced side effects
2A +/- Adjuvant Tamoxifen for
chemotherapy HR*receptor and toxicities. In larger tumors
plus Adjuvant chemotherapy may be given preoperatively
chemotherapy to shrink tumors, making them easier to sur-
if HR*negative
gically resect.
2B +/- Adjuvant Tamoxifen for
chemotherapy H R * receptor
plus Adjuvant
chemotherapy
if HR* negative Treatment of
3A + Adjuvant Adjuvant Metastatic Disease
chemotherapy chemotherapy
3B - Adjuvant Adjuvant Approximately 50%of women with breast
chemotherapy chemotherapy cancer will have metastatic disease, some at
*Hormone-Recep for diagnosis. The most common sites of metas-
All General recommendations may be tasis include bone, liver, soft tissue, lung
modified by other risk factors (eg. size of and/or CNS. Although chemotherapy and
primary tumor, histologic grade, aneuploidy, hormonal therapy are effective in relieving
proliferative index and hormone-receptor the symptoms of metastatic breast cancer, the
[E/PRl status). treatments have not been shown to affect sur-
Adjuvant chemotherapy for breast cancer in- vival. Combination chemotherapy is the
volves multidrug combinations which are standard for premenopausal patients and
more effective than single agent therapy. The postmenopausal women with hormone
most frequently recommended combination receptor-negative tumors. Postmenopausal
is called CMF and includes cyclophos- women with metastatic breast cancer, who
phamide (Cytoxan),methotrexate, have hormone receptor-positive tumors, may
fluorouracil(5-FU), with or with out respond to hormonal therapy alone.
tamoxifen. A variation of this combination
Combination chemotherapy, such as CMF or Specific agents include estrogens(diethylsti1-

CAF with and/or without prednisone, often bestrol), progestins (megestrol acetate),
results in response rates of 50 to 70%, lasting androgens (fluoxymesterone),corticosteroids
9 to 12 months. However, only 10 to 20 per- (prednisone),and antiestrogens (Tamoxifen).
cent of these responses are complete Women starting on tamoxifen should be cau-
responders. tioned on the possibility of a flare reaction.
Agents used as second therapy include During a flare reaction there may be an in-
mitoxantrone; low dose adriamycin, weekly crease in pain in the bone and tumors and an
or continuously; nalvelbine; Mitomycin-C; increase in the size of the tumors. These ef-
fects usually last only about two weeks; but
and Taxol. In general, premenopausal
women respond to chemotherapy more it is important that women continue with the
often than do postmenopausal women. This tamoxifen because these are side effects and
may be because premenopausal women typi- do not indicate a lack of response to therapy.
cally have more aggressive disease with Prescribing, and /or increasing, pain medica-
faster tumor growth rate than tions and allowing the patient to continue
postmenopausal women who have more in- treatment is vital.
dolent disease. Radiation therapy may also be used to pal-
The role of bone marrow transplant in liate symptoms of metastatic disease. It is
women with breast cancer is still not clearly especially useful in alleviating pain from
defined. Clinical trials are still underway to bone metastasis. Radiation therapy also
determine its effectiveness and at what stage plays a role in the palliative treatment of
brain metastasis.
women should undergo transplant. Addition-
ally, the use of peripheral stem cell harvest-
ing has increased and may play an important
role in treating breast cancer. Invesfigafional
A major form of treatment for metastatic dis- Therapies
ease is endocrine therapy accomplished by
Investigational agents being studied for the
surgery, radiation therapy, and/or
treatment of breast cancer include alkeran,
chemotherapy. Endocrine therapy in the past
vindesine, platinum derivatives, amonafide,
has included ablative therapy through such
Trimexate, and the use of biologic agents
surgical procedures as adrenalectomy and
such as interleukin-2 and interferon. Various
hypophysectomy. Surgical oophorectomy or
new combinations are also being inves-
ovarian radiation are equally effective treat-
tigated. These include chemoim-
ments with response rates of about 32%.In
munotherapy, chemohormonal therapy, and
metastatic disease, hormones are indicated if
hypothalamic hormone analogs such as
the tumor is ER-positive and not easily
buserelin and leuprolide.
treated by surgery or radiation therapy.
BREAST CANCER 185
Complications of Anticipatory Grieving

Diseuse (CH. 1)
Related to:
Complications of metastatic breast cancer in- Losses due to breast cancer such as
clude bone metastasis. If in the spine, spinal loss of breast, health, income, work,
cord compression may occur. This is a medi- intimacy, relationships, and possib-
ly life.
cal emergency and must be treated immedi-
ately ( see Chapter 6, Structural Oncologic
emergencies).Brain metastasis occurs in Patient exhibits or voices expres-
sions and/or feelings of sadness or
about 30%of women with metastatic dis- loss, or concerns over possible loss
ease. This can be devastating both physically of work, income, or life.
and emotionally for patient and family.
Chronic lymphedema may become a prob-
lem if a tumor reoccurs in the axilla, or as a Altered Sexuality Patterns
complication of axillary lymph dissection, (CH. 1)
and radiation therapy to the axilla. 0 Relatedto:
Impact of breast loss/disfigurement
and/or disease process on sexual
Common Nursing relationships
Diagnoses Related to Defining Characteristics:
Caring for All Clients Patient voices changes in sexual pat-

tern or sexual relationship(s) due to
With Breast Cancer impact of loss of breast or disfigure-
ment of breast.
Anxiety Fear
(CH. 1)
(CH. 1)
0 Related to: 0 Relatedto:
Perceived threat to self due to diag-
Diagnosis of breast cancer, breast
nosis of breast cancer and its uncer-
disfigurement or loss due to treat-
tain prognosis or treatment.
ments and uncertain prognosis.
Patient verbalizes feelings of uncer-
Inability to meet basic care needs,
tainty, apprehension, fear, sleepless-
fatigue, verbalization of inability to
ness, restlessness, or other signs of
cope, and/or fear.
anxiety.
KnowIedg e Deficit I Teaching - Disease Process
Related to:
Breast cancer and treatment options. I
Discuss Promotes open
therapy/ treatment discussion, informed
Patient voices questions about options such as decision-making.
breast cancer and/or its treatment. segmental mastectomy
vs. modified radical
Outcome Criteria: mastectomy; one step
Patient is able to participate in ongo- vs two step biopsy.
ing decision-makingabout breast Promote discussion of Promotes informed
cancer treatment. questions with decision-making.
Discusses rationale for treatments informed physician as
and verbalizes actions to cope with auurouriate.
0 NIC: Teaching- Disease Process
Definition:Assisting the patient to
understand information related to a Instructions, Information,
specific disease process. Demonstration
Teaching - Disease Process Inform patient/family Informs of community
of community resources.
resources such as Y-
Activities Rat ionales ME, Reach to Recovery
(ACS),Look Good Feel
Assess the Provides information Better (ACSand
patient /family to formulate National Cosmetology
knowledge of breast individualized Association), and
cancer and treatment teaching plan. Encore (YWCA),for
recommendations. women with breast
cancer.
Explain Promotes
pathophysiology of understanding of Provide written Written materials
breast cancer as disease process. materials about reinforce verbal
appropriate. community instruction.
Avoid empty organizations, breast
Empty assurances
assurances. cancer, and treatments.
minimize importance
of patients concerns. Teach importance of Women diagnosed
performing BSE in with breast cancer
Provide information Promotes informed
about treatment remaining breasth). have an increased risk
decision-making.
options as appropriate of developing breast
cancer in remaining
breast(s).
BEAST CANCER 187
Instructions, Information, 0 NIC: Body Image Enhancement

Demonstration Definition: Improving a patient’s
tions and attitudes toward hidher
Activities Rationales body.
Teach importance of Frequent follow-up is
following prescribed necessary to identify
schedule and recurrence early.
procedures for routine
Body Image Enhancement
follow-up.
Evaluation Actiuit ies Rationales
Identifies type of breast can- Encourage patient to Promotes acceptance
cer and rationales for treat- express feelings over of changes.
ment. breast cancer
Describes possible side effects diagnosis, its
of treatment and self care treatment, and
measures. expected impact on
Appropriately identifies time lifestyle.
at which health care team Evaluate patient’s Promotes insight of
should be notified and when feelings regarding patient.
follow-up should be breast
scheduled. loss/disfigurement to
Demonstrates BSE correctly. her sexual identity,
relationships, and
body image.
Assist patient to Promotes positive self
Body Image Disturbance separate physical image.
appearance from
Related to: feelings of personal
worth.
Loss of breast and/or disfigure-
ment from segmental mastectomy Give permission to Allows patient needed
(lumpectomy)and/or irradiation of grieve over breast time to cope with
the breast. loss/disfigurement losses.
and to resolve losses.
Allow to vent negative Promotes coping, as
Patient voices concerns over loss of emotions such as anger these are normal
breast or breast disfigurement from and guilt. reactions to loss.
surgery and/or radiation therapy;
expresses fear of rejection or reac- Monitor patient’s Inability to look at
tion by others to changes/loss of ability to look at affected breast may
breast. affected breast. indicate coping
difficulties.
0 Outcome Criteria:
Patient copes with loss of breast.
Body Image Enhancement Instructions, information,

Demonstration
Activities Rationales I Activities Rat wnales

Encourage open Promotes
communication family/patient coping. Teach patient about Phantom breast
between patient and possibility of phantom sensation, should it
family over loss of breast sensation after occur in a woman who
breast and impact of mastectomy (pain or is unaware, could be
illness. sensation in a breast very upsetting.
that no longer exists).
Discuss breast Provides means of
prothesis, if reducing impact of
appropriate. breast loss. Eva1uation
Discuss possible Reduces impact of
options for breast breast loss. 0 Identify potential community
reconstruction, if resources to meet demands of
appropriate. breast cancer treatment and
survivorship.
Encourage visit from Visits from women Discuss options for temporary
Reach to Recovery who have had similar and permanent cosmetic res-
volunteer. changes in body toration of breast.
image, and who are
able to cope, promote
coping.
Common Nursing
Diugnoses Related to
Instructions, Information, Surgery
Demonstration
Activities Rationales Pain

Inform of community Provides community (CH. 2)
resources such as Y- resources to assist in 0 Related to:
ME, Reach to Recovery seeking support.
(ACS), Look Good Feel Tissue manipulation and/or injury
Better (ACS and from surgery
National Cosmetology
Association), and 0 Defining Characteristics:
Encore (YWCA) for Patient voices complaints of pain at
women with breast the surgical site and/or site of chest
cancer. tube placement, increased pulse,
Provide written Written materials respiratory rate and/or blood pres-
materials about reinforce verbal sure.
community instructions.
organizations, breast
cancer, and treatments.
BREAST CANCER 189
Fluid Volume Deficit Circulatory Care

(CH. 2)
0 Relatedto: Activities Rat ionales
Blood loss during surgical proce- Elevate affected arm Facilitates venous
dure with hand higher than drainage.
elbow and elbow
higher than shoulder.
Decrease in urine volume, low Avoid using affected Prevents lymphedema.
blood pressure, tachycardia drop- arm for blood pressure
ping hemoglobin and/or readings, injections, or
hematocrit, bloody sputum, blood testing.
tachycardia or blood on dressing.
Apply pressure sleeve Promotes venous
to affected arm. return.
Encourage exercise of Exercise promotes
Altered Tissue Perfusion, affected arm as venous return of blood.
Peripheral appropriate.
Place sign over bed Promotes compliance
Cl Related to: advising to avoid among health care
affected arm for IVs, providers with
Removal of axillary lymph nodes
BP readings, injections, measures to prevent
0 Defining Characteristics: and blood withdrawal. lymphedema.
Patient voices complaints of arm
swelling on the surgical side,
presence of edema in arm and hand.
0 Outcome Criteria:
Demonstration
Adequate lymphatic drainage will
be maintained as evidenced by lack
of swelling in affected arm or hand.
1
I
Activities Rat ionaZes
NIC:Circulatory Care
Instruct on importance Prevents lymphedema.
Definition: Promotion of arterial of arm elevation.
and venous circulation.
Teach measures to Promotes compliance
avoid lymphedema; with healthcare regime
avoid BP reading in to prevent
affected arm; avoid lymphedema.
Circulatory Care
I allowing affected arm
to be in a dependent
position for long time.
Activities Rationales Teach how to use Helps prevent
I
eressure sleeve. lvmphedema.
Monitor affected Early detection of
extremity for edema. edema can facilitate
quick intervention,
lessen severity.
Instructions, Information, ExerciseTherapy -Joint Mobility

Demonstration
Assist patient in Promotes maintenance
Teach patient to Promotes early performance of limited of some joint
measure circumference recognition and exercise in the first 24 movement without
of both arms and to treatment of hours, such as trauma to surgical site.
notify health care team lymphedema. squeezing a ball, and
if affected arm is 5 cm wrist and elbow
larger than unaffected. flexion, extension.
Adduct arm for first 24 Minimizes tension on
Evaluation hours. suture line.
Initiate pain control Promotes compliance
Affected arm will remain free measures before with planned exercise.
of lymphedema. exercise.
Begin active range of Promotes joint
motion exercises as mobility.
Impaired Physical Mobility appropriate, usually on
the second or third
post-op day.
0 Related to:
Assist patient with Prevents injury during
Removal of axillary lymph nodes maintenance of exercise.
and pectoralis muscles. optimal body position
!Defining Characteristics:
I during exercise.
Complains of pain in affected arm Explain purpose and Promotes compliance

and or shoulder, limiting mobility plan of exercises to with health care
of arm and shoulder motion. patient /family. regime.
0 Outcome Criteria:
Full range of motion restored in af-
fected arm and shoulder.
0 NIC: Exercise Therapy- Joint Demonstration
Mobility
Definition: Use of active or passive
body movement to maintain or re- Activities Rationales
store joint flexibility.
Instruct on active Exercises promote joint
range of motion mobility.
exercises such as arm
swings, pulley motion,
hand wall climbing,
rope turning.
instructions for reinforce verbal
exercise. instructions.
BREAST CANCER 191
Instructions, Information, Circulatory Precautions

Demonstration
I
Assess affected arm for Promotes early
Actiuities Rationales signs of infection. identification of
Instruct to avoid lack Lack of activity of infection in affected
of activity and/or over- affected arm can lead arm.
Use. to lymphedema and Assess integrity of skin Promotes early
over-use can cause a flaps over chest wall identification of
seroma in chest wall. for signs of redness, infection in surgical
swelling and yellow or site.
Discharge or Maintenance green foul-smelling
Evaluation drainage.
Patient demonstrates range of Avoid using affected Measures prevent
motion exercises of affected extremity for Ws, BP breaks in skin.
arm and shoulder. readings, injections, or
Restoration of full range of blood withdrawal.
motion to affected arm and
Place sign over bed Promotes compliance
shoulder.
advising to avoid among health care
Patient lists possible complica- affected arm for IVs, providers with
tions of under and/or over BP readings, injections, measures to prevent
use of affected arm. and blood withdrawal. infection.
Assess drainb) left in Drain(s) are left in 7-10
chest wall for patency, days (or until output is
strip tubing; empty 30 d/24 hours) to
Risk for Infection and record output. prevent accumulation
of fluid under chest
0 Related to: wall.
Impaired lymphatic drainage from Assess insertion site of Drains are a potential
axillary lymph node dissection and drains for redness, source of infection.
presence of surgical drains. pain, swelling, or
0 Defining Characteristics: purulent drainage.
Assist in skin and nail Prevents infection in
Impaired lymphatic drainage places
care in affected arm. affected arm.
patient at risk for infection in af-
fected extremity, presence of signs
of infection in affected arm or surgi-
cal wound.
0 Outcome Criteria:
Absence of infection in affected ex-
tremity and/or surgical wound.
NIC: Circulatory Precautions
Definition: Protection of a localized
area with limited perfusion.
instructions, Information,
Demonstration
Essentiul Nursing
Rudiation Therapy
Teach to avoid using Measures prevent
affected extremity for breaks in skin.
IVs, BP readings, Fatigue
injections, blood
withdrawal. (a.5)
Avoid injury to Measures promote skin 0 Related to:

affected arm by using integrity and prevent
Breast cancer disease process,
electric shaver to shave injury to affected arm. anemia related to radiation therapy
underarm hair; wear and radiation therapy itself.
gardening gloves; use
thimble when sewing. 0 Defining Characteristics:
Instruct that if break in Helps prevent Patient voices feeling of weariness,
skin occurs to wash infection if breaks in tiredness and/or loss of energy; ex-
with antimicrobial skin occur. ertional dyspnea; inability to per-
soap and apply form functions of daily living.
antimicrobial ointment
with occlusive
dressing, changing
daily and when soiled.
Risk for Impaired Skin Integrity
Teach patient to empty Patients are usually
(CH. 3)
drain, and strip tubing; discharged with drains
measure and record in place, left in 7-10 R Relatedto:
output as appropriate. days.
Side effects from radiation therapy
Teach to report to Maximizes patient
health care team any safety. 0 Defining Characteristics:
signs and symptoms of
Skin reactions such as dryness,
infection of surgical
erythema usually occur 7 to 10 days
site and affected arm.
after treatment has begun; emacia-
tion due to weight loss from disease
Evaluation and/or its treatment.
Affected arm and surgical site

will remain free from injury
and infection. Knowledge Deficit
Should injury occur to af-
fected arm,infection will be 0 Relatedto:
prevented.
Demonstrates appropriate Radiation therapy to the breast for
care of incision(s), and surgi- cancer
cal drain(s) at the time of dis-
charge.
BREAST CANCER 193
~~~
Defining Characteristics: Teaching-- Procedure/Treatment

Patient voices lack of knowledge
and/or asks questions about up-
coming radiation therapy treat- Activities Rat ionales
ments.
Explain possible side Due to physiological
Outcome Criteria: effects from radiation effect of radiotherapy
therapy: to breast and
Patient will be able to discuss the 1)Hair loss in field surrounding tissue,
possible side effects of radiation 2) Skin reactions in skin changes are
treatments to the chest and how to field (7-10 days after transient and clear 1 to
manage them if they occur. treatment has begun) 3 weeks after therapy
0 NIC: Teaching- Procedure/ vary from dry completed.
Treatment desquamation;
hyperpigmentation to
Definition:Preparing a patient to moist desquamation;
understand and mentally prepare 3) Lymphedema with
for prescribed procedure or treat- high doses and/or
ment. damage to brachial
plexus
Late reactions include:
1)Spontaneous rib
fractures 2) Chest wall
Teaching-- ProcedurePTreatment
I discomfort
3) Unproductive cough;
4) Mild shortness of
Activities Rationales Instruct patient family Promotes self care
on measures they can management.
Assess knowledge of Provides information use to manage the
radiation therapy to develop treatment possible side effects
treatment plan and plan based on patient's from radiation therapy
possible side effects. needs. to the breast.
Inform patient and Allows patient and Provide written Written materials
family of when the family to plan daily information on reinforce verbal
treatment will begin, activities around radiation therapy instructions.
time, length and treatments. treatments and self-
duration of treatments; care measures.
purpose of treatments.
Advise patient not t Prevents possible drug
take any medications, interactions.
including OTC drugs,
unless ordered by or
okayed by physician-
even aspirin.
Teaching--Procedure/Treatment 13 Defining Characteristics:

Patient verbalizes lack of informa-
tion, or asks questions about
Activities Rationales chemotherapy, its side effects, how
to manage these side effects.
Inform patient Promotes prevention
verbally, and in of serious
writing, of changes complicationsby
that must be reported promoting early
to the health care team reporting. Risk for Infection
immediately. These (CH. 4)
include signs of
infection, persistent 0 Related to:
nausea and vomiting, Chemotherapy’s rapid destruction
unusual bleeding or of dividing hematopoietic cells
bruising, acute changes resulting in immunosuppression.
in mental or emotional
status. El Defining Characteristics:
0 Discharge or Maintenance Presence of granulocytopenia, an

Evaluation absolute granulocyte count (AGC)
below 1000 cells/mm3.
Patient states possible side ef-
fects and self-caremanage-
ment techniques to cope with
side effects. Risk for Injury
Receives radiation treatments
as prescribed by physician. (CH. 4)
Identifies changes that should 0 Related to:
be reported to the health care
team immediately. Thrombocytopenia from
chemotherapy
Presence of thrombocytopenia with
Essential Nursing a platelet count below 50,000
Diagnosis Related to cells/mm 3,presence of easy bruis-
ing, and/or bleeding.
Chemotherapy
Risk for Pain

Knowledge Deficit (CH.4)
(CH. 4) Relatedto:
Relatedto:
Nausea and vomiting from
Chemotherapy, its side effects and chemotherapy and/or anxiety re-
management of side effects. lated to treatments.
BREAST CANCER 195
0 Defining Characteristics: Altered Tissue Perfusion,

Patient expresses feelings of pain or Cardiopulmonary
discomfort, moans, cries, is
diaphoretic; exhibits elevation in (CH. 13)
blood pressure and/or pulse rate. 0 Related to:
Damage to cardiomyopathy from
adriamycin and/or high-dose
Body Image Disturbance cyclophosphamide.
(CH. 4) Defining Characteristics:
0 Relatedto: Decrease in ejection fraction, weak-

ness, fatigue, and resulting decrease'
Alopecia, weight loss, and/or skin in ability to perform activities of
changes secondary to adriamycin, daily living.
and vinca alkaloid( vinblastine,
vincristine) chemotherapy drugs.
Altered Urinary Elimination
or reaction of others to altered ap- (CH. 18)
pearance, especially hair loss. 0 Related to:
Hemorrhagic cystitis from
cyclophosphamide(Cytoxan)
and /or ifosfamide chemotherapy
Risk for Impaired Skin Integrity drugs.
(CH. 4)
0 Related to:
Hematuria, gross or microscopic,
Extravasation of vesicant complaints of blood in urine while
chemotherapy agents such as receiving cyclophosphamide
adriamycin, vincristine, and/or (Cytoxan)and/or ifosfamide.
vinblastine.
Complaints of pain, burning, red- Altered Nutrition: Less Than
ness in IV site and/or swelling, red-
ness, necrosis progressing to tissue
Body Requirements
sloughing at IV site. (CH. 4)
0 Relatedto:
Nausea, vomiting, stomatitis, and
diarrhea from 5-fluorouracil, cyclos-
phosfamide, adriamycin, tamoxifen.
Weight loss, anorexia,nausea, vomit-
ing, diarrhea.
196 ONCOLOGY CARE rLms
Risk for Altered Oral Mucous Medication Management

Membranes
(CH. 4) Activities Rationales
0 Related to: Establishes baseline
Obtain baseline LFTs
Damage to rapidly dividing cells of prior to drug dose. liver function.
the mucosa from 5-fluorouracil, Notify physician if Promotes prevention
cyclophosphamide, adriamycin. baseline LFTs are of hepatotoxicity.
0 Defining Characteristics: elevated.
Administer Prevents overdosage of
Oral pain/discomfort, coated
methotrexate dose methotrexate.
tongue, stomatitis, oral lesions, or
mouth ulcers. correctly,double
checking dose.
Monitor for signs of Promotes early
hepatotoxicity during identification of
Risk for Injury therapy with toxicity.
methotrexate.
Related to: Monitor LFTs during Promotes early
therapy. identification of
Damage to liver from methotrexate
hepatoxicity.
especially high dose therapy.
Administer Leucovorin is used as a
0 Defining Characteristics: Leucovorin as rescue to replenish the
Transient elevations of liver func- appropriate. folate pool, which is
tion tests (LFTs) may occur 1 to 10 reduced by high doses
days post RX, with high dose of methotrexate.
therapy (500mg/m2) and above re-
quiring Leucovorin rescue);
presence of jaundice; increased risk
for hepatotoxicity when given other
hepatotoxic agents such as alcohol; instructions, Information,
persistent elevations of LFT.s post Demonstration
treatment.
0 Outcome Criteria:
Hepatotoxicity will be identified
early. Teach importance of Prevents excessive
taking Leucovorin toxicity from
NIC: Medication Management rescue on time with methotrexate.
Definition: Facilitation of safe and high dose therapy.
effectiveuse of prescription and Instruct on need for Promotes compliance
over the counter drugs. LFTS. with health care
regime.
BREAST CANCER 197
0 Discharge or Maintenance Risk for Sexual Dysfunction

Evaluation
Hepatotoxicity will be 0 Related to:
prevented though Leucovorin Side effects of tamoxifen.
rescue or identified early and
treatment initiated. 0 Defining Characteristics:
Presence of menstrual irregularity,
hot flashes, vaginal discharge and
bleeding, or voiced concerns over
Essential Nursing reproductive dysfunction or chan-
Diugnoses Reluted to ges in sexual pattern.
Hormonal Therapy 0 Outcome Criteria:

Identifies strategies for coping with
sexual dysfunction.
0 NIC: Sexual Counseling
Risk for Injury
Definition: Use of an interactive
0 Relatedto: helping process focusing on the
need to make adjustments in sexual
Transient thrombocytopenia from practice or to enhance coping with
tamoxifen. a sexual event/disorder.
Platelet counts below normal, un-
usual bruising or bleeding.
Sexual Counseling
Risk for Infection Activifies Rationales

Establish a therapeutic Promotes an
0 Relatedto:
relationship ensuring atmosphere that allows
Transient granulocytopenia from privacy and expression of feelings.
tamoxifen confidentiality.
0 Defining Characteristics: Explore with Provides necessary
patient /partner issues information to assist
Absolute granulocyte count less of reproductive and patient in planning
than 1000. sexuality patterns, and methods to cope with
impact that tamoxifen possible alterations.
may have on them.
Discuss strategies to Promotes sexual and
preserve sexual and reproductive health.
reproductive health.
Allow/help patient to Promotes venting of
express feelings of feelings.
grief and/or anger
about alterations.
Sexual Counseling 0 Defining Characteristics:

Patient voices increase in bone
and/or tumor pain or concern over
Activities Rat ionales increase in tumor size.
Use humor as Promotes coping with 0 Outcome Criteria:
appropriate to relieve a sometimes
anxiety and/or uncomfortable topic. Patient discusses signs and
embarrassment. symptoms of flare reaction and
strategies to cope with it.
0 NIC: Teaching Self-Administration
of Prescribed Medication
Definition: Preparing patient to
Instructions, Information, safely take prescribed medication
Demonstration and monitor it5 effects.

Instruct patient Provides patient with Teaching Self-Administration of
/partner of possible information to safely
Prescribed Medication
side effects of take necessary
medication on medication.
sexuality, such as
menstrual irregularity, Activif ies Rationales
hot flashes, vaginal
Instruct on possibility Flare reaction may
discharge, and
of flare reaction, occur with initial
bleeding.
increase in pain and tamoxifen therapy.
Teach alternate forms Provides outlet for tumor.
of sexual expression sexual expression.
Inform that flare Promotes compliance
acceptable to
reaction is transient with medication
patient /partner.
and usually will last regime.
only 2 weeks.
Evaluation Teach patient strategies Provides methods to
to cope with flare cope with Flare
Demonstrates ability to cope reaction without
reaction, such as taking
with sexual and reproductive or increasing pain stopping therapy.
dysfunction.
medications.
Evaluation
Risk for Pain
. Should flare reaction occur,
0 Relatedto: patient will institute measures
to cope with reaction and con-
Initial "flare" reaction to tamoxifen. tinue taking tamoxifen.
BREAST CANCER 199
Altered Nutrition: Risk for Instructions, Information,

Demonstration
More Than Body
Requirements
D Related to:
Teach patient well- Promotes weight
Hormonal therapy for breast cancer. balanced diet planning. maintenance.
0 Defining Characteristics: ' Instruct patient to Identifies trends in
Weight gain while taking hormonal maintain log of weekly weight.
agents for breast cancer. ~ weights.
0 Outcome Criteria: Discharge or Maintenance

Evaluation
Weight gain will not occur.
NIC:Weight Management
. Weight will be maintained
within 5%of baseline.
Definition:Facilitating main- If weight gain occurs, patient
tenance of optimal body weight will institute measures to
and percent body fat. reduce weight to baseline.
Weight Management
Activit ies Rationales

Assess past weight Provides information
history as well as for planning.
typical food intake.
Determine ideal Provides information
weight and body fat for planning.
percent.
Monitor weight Identifies trends in
regularly. weight.
Discuss possible side Promotes
effect of weight gain understanding of
from hormonal therapy. possible side effects.
Discuss relationship Increased food intake
between food intake, without increase in
exercise, weight gain exercise will result in
or loss. weight gain.
If weight gain occurs Promotes maintenance
institute measures to of ideal body weight.
assist in weight loss if
so desired.
Chapter Ten
Genit o urinar y
Cancers
Genitourna r y Cancers
Introduction: This chapter deals with the
genitourinary cancers; including kidney
bladder, testicular and prostate. Although There are two types of kidney cancer- renal
penile cancer does occur in the United States, cell carcinoma and cancer of the renal pelvis.
it is more of a health concern inunder- Renal cell carcinoma is the most common, oc-
developed nations, so it will be reviewed in curring in 75-85%of kidney cancer patients.
this text. It can be of clear cell or granular cell origin,
and arises from the epithelial cells of the kid-
ney tubules. Renal cell cancer occurs in the
parenchyma of the kidney and tends to grow
Kidney cancer
towards the medullary or inner portion of
Kidney cancer is an uncommon disease, ac- the organ. It can spread by direct extension
counting for only 3%of all cancer cases, with to the renal vein and the vena cava. This ex-
an estimated occurrence of 27,200 cases an- tension of tumor can sometimes be visual-
nually. Peak incidence is between the ages of ized by radiological imaging. Cancer of the
forty and fifty. At diagnosis 30-50%of kidney renal pelvis is rare and occurs in 59% of kid-
cancer patients have metastatic disease. The ney cancers. It arises from the epithelial tis-
over all five year survival rate is 55%;this in- sue in the renal pelvis where urine is
creases to 85% for those patients with local- emptied from the kidney into the ureter.
ized kidney cancer, but for.patients whose
cancer.
Signs and Symptoms
Hematuria is present in approximately 50%
Risk Factors of patients with kidney cancer, and this may
Risk factors are thought to be exposure to be associated with anemia. Flank pain and
cadmium, lead pigment in printing ink, as- abdominal mass are other signs of clinical
bestos and coal tars. Cigarette smoking come presentation indicating advanced disease.
lates strongly with the development of this The classic triad of symptoms includes pain,
disease. Frequent use of phenacetin contain- abdominal mass and hematuria. Fever,
ing analgesics is associated with an increased weight loss, hypercalcemia and
incidence of cancer of the renal pelvis. erythrocytosis also may be present.
Diagnostic Tests from a metastatic bone lesion may be al-

leviated with radiotherapy, however and
There is no early accurate diagnostic screen- cranial radiation therapy may be suggested
ing test for kidney cancer. Diagnostic tests to following the removal of a brain lesion.
determine the presence of a mass include kid-
Chemotherapy has not had a significant im-
ney, ureter, and bladder (KUB)x-ray;
pact on metastatic kidney cancer. Vinblastine
nephrotomography; excretory urography
(velban), given as a single agent has shown a
(e.g., intravenous pyelogram, or IVP); renal
small response rate of about 15%.Hormonal
ultrasound; renal angiography; renal com-
therapy with progesterone, depo-provera
puterized tomographic (CT) scan; and mag-
and megestrol acetate, has also shown only a
netic resonance imaging(MRI).
15%response rate. Physicians prefer to use
the hormonal therapies because they are as-
sociated with few toxicities.
Treatment Immunotherapy has demonstrated the best
Treatment strategies depend on the extent of response rates, to date, in the treatment of ad-
disease at the time of diagnosis. Localized vanced renal cell carcinoma. Proleukin, inter-
disease, confined within the kidney, can leukin-2(IL-2), was FDA approved for this
often be cured surgically with a radical purpose and has shown a 30% response rate.
nephrectomy. In renal cell cancer, the af- The treatment with this biologic agent is as-
fected kidney and the surrounding lymph sociated with the toxicities often seen with
nodes are removed. When the diagnosis is immunotherapy including fever, chills, flu-
cancer of the renal pelvis, a more extensive like syndrome, myalgias, headaches,
operation is recommended, including the anorexia, fatigue, and capillary leak
removal of the kidney, lymph nodes, ureter syndrome. The side effects are dose related
and sometimes the upper portion of the blad- with larger doses associated with an increase
der. in the incidence and severity of symptoms.
Surgical intervention for patients with metas-

tatic kidney cancer is controversial. Some
physicians believe that palliative surgical in vestigationai
nephrectomy may improve quality of life by Treatments
relieving pain and correcting anemia in
patients with hematuria. Neurosurgery for Clinical trials are ongoing for the treatment
an isolated brain metastasis is often sug- of kidney cancer. These studies are evaluat-
ing the combination of chemotherapeutic
gested to improve neurologic status.
agents with immunotherapy. Another area of
Radiation therapy is not often used because
research for this disease is gene therapy.
renal cell carcinoma is radioresistant. Pain
GENITOURINARY CANCERS 205
Complicutions Anxiety
(CH.1)
Complications of the disease are associated 0 Relatedto:
with the treatment or the development of
Perceived threat to self due to diag-
metastases. Surgical complicationsas- nosis of kidney, bladder, or prostate
sociated with nephrectomy include the cancers.
development of atelectasis, pneumonia, 0 Defining Characteristics:
hemorrhage, infection and paralytic ileus. Patient verbalizes feelings of uncer-
The most common sites of metastases of kid- tainty, apprehension, fear, sleepless-
ney cancer include the lungs, brain, and ness, or restlessness.
bones.
Knowledge Deficit
(CH. 2,4)
Common Nursing
0 Related to:
Surgery, chemotherapy and/or im-
Curing for All Clients munotherapy.
with Genitourinury 0 Defining Characteristics:
Cancers Patient verbalizes lack of informa-
tion and/or questions about
These more general nursing diagnoses are to surgery, chemotherapy,or im-
be used with all of the genitourinary cancers. munotherapy, the side effects of
these modes of treatment, and/or
Specific nursing diagnoses will be listed in- the management of these side ef-
dividually following the bladder and pros- fects.
tate introductions.
Impaired Skin Integrity

Altered Family Processes (CH.2)
(CH.1) 0 Relatedto:
0 Relatedto: Nephrectomy, cystectomy, prostatec-
tomy.
Anxiety and fears about the diag-
nosis of a genitourinary cancer 0 Defining Characteristics:
Defining Characteristics: Surgical incision.
Family system unable to meet
physical or emotional needs of
patient, related to diagnosis.
Alteration in Comfort: Pain Decreased Cardiac Output

(CH. 2) (CH. 2)
0 Related to: Cl Related to:
Nephrectomy, cystectomy, prostatec- Surgical intervention and ad-
tomy. ministration of anesthesia.
0 Defining Characteristics: Defining Characteristics:
Diaphoresis, blood pressure and Variations in blood pressure read-
pulse rate changes, crying, moan- ings, jugular vein distension,
ing, guarding and protective be- decreased peripheral pulses, ar-
havior, refusal to move or change rhythmias, color changes in skin
position, restlessness, irritability. and mucous membranes, cold clam-
my skin, oliguria, dyspnea, rales,
restlessness.

(CH. 4)
Skin Integrity: High Risk for
0 Related to: Impairment
Systemic chemotherapy or systemic (CH. 2)
immunotherapy.
0 Related to:
Surgery and postoperative recovery.
Granulocytopenia or neutropenia.
Reddened skin area (especiallyover
bony prominences), verbalized dis-
Alteration in Nutrition comfort in a local area, physical im-
mobilization, excretions/secretions
Less Than Body on skin, altered sensation, altered
Requirements consciousness, altered metabolic
and nutritional state, altered circula-
(CH. 2) tion, alterations in skin turgor, and
immunologic factors.
El Relatedto:
Surgery, systemic chemotherapy, or
systemic immunotherapy that may
cause anorexia, nausea, vomiting or
diarrhea.
Reported or observed inadequate in-
take of calories.
Common Nursing Patient Controlled Analgesia

(PCA) Assistance
Diugnoses for the
Client with Kidney Activities Rationales
Cuncer Validate that patient Promotes comfort by
can use a PCA device expediting
(ability to administration of
communicate, required analgesic.
Pain comprehend
explanations, and
0 Related to: follow directions).
Length of incision for nephrectomy. Document the patient’s Provides data for other
pain, amount and health care
0 Defining Characteristics: frequency of drug professionals to
dosing, and response monitor effectiveness
Diaphoresis, blood pressure and
to pain treatment. of pain management.
pulse rate changes, crying, moan-
ing, guarding and protective be- Recommend a bowel Prevents constipation
havior, refusal to move or change regimen, if appropriate. related to narcotics.
position, restlessness, irritability
Consult with clinical Provides the most
0 Outcome Criteria: experts about patients expert care for the
who have difficulty patient.
Absence or control of pain. achieving pain control.
0 NIC: Patient Controlled Analgesia
(PCA) Assistance
Definition:Facilitating patient con-
trol of analgesic administration and Instructions, Information,
regulation. Demonstration
Act iuities Rationales

Patient Controlled Analgesia Inform patient of the Promotes
(PCA) Assistance action and side effects understanding.
of pain-relieving
agents.
Teach patient how to Provides the patient
Assess pain levels and Prevents allergic use PCA device. the ability to treat pain
pain relief. Ensure reactions. as needed.
patient is not allergic Instruct patient and Promotes consistent
to proposed analgesic. family not to alter delivery of medication.
settings of PCA device.
Evaluation
. Patient verbalizes that pain is
reduced or absent.
Alteration in Fluid Balance: Defining Characteristics:

Deficit Confusion, restlessness, irritability,
inability to move secretions,
0 Relatedto: hypoxia, hypercapnia.
Capillary leak syndrome from Inter-

leukin-2, increased body tempera-
ture resulting in increased
insensible fluid loss, decreased fluid
Fatigue
intake from anorexia, and fluid los- (CH. 3)
ses due to diarrhea.
0 Related to:
Anemia due to preoperative
Hypotension, orthostasis, tachycar- hematuria, immunotherapy with In-
dia, tachypnea, low urine output, interleukin-2.
creased body temperature, dry
mucous membranes, electrolyte im- 0 Defining Characteristics:
balances, diarrhea, decreased fluid Lethargy, malaise, exhaustion,
intake, and/or weight loss. decreased capacity for physical and
mental activities.
Potential for lneffective Air-

way Clearance High Risk for Peripheral
(CH.2) Neurovascular Dysfunction
Relatedto: (CH. 8)
Surgical procedure requiring anes- Relatedto:

thesia. Chemotherapy with vinblastine
Defining Characteristics: (velban).
Abnormal breath sounds (rales, 0 Defining Characteristics:

crackles, bronchi, wheezes), cough, Patient verbalizes loss of fine motor
change in rate and depth of respira- movements, numbness in fingers
tions, dyspnea, tachypnea, and toes, gait disturbances and loss
cyanosis. of proprioception.
Impaired Gas Exchange Blcrdder Cancer

(CH. 2)
Related to: Bladder cancer is the most common malig-
Proximity of surgical incision to the nancy of the urinary tract. The incidence has
diaphragm. been increasing over the past two decades
with an estimated 52,300 cases in 1993. The
five-year survival rate for early stage disease
is 90%; with regional disease this rate drops
to 46%; and is only 9% for patients with Presenting Signs und

metastatic lesions.
Symptoms
Hematuria is the most common first indica-
Risk Fuctors tion of bladder cancer, although it may not
be an early sign. Bleeding is often intermit-
Age, sex, and race are risk factors for tent, which may delay follow up of this
developing bladder cancer. The incidence of symptom because the person and physician
this disease increases with age, generally oc- may think that the problem has resolved. Al-
cumng in people over fifty, with the peak in- most all patients do have microscopic
cidence in the seventh decade. Men are four hematuria. Urinary frequency and dysuria
times more likely to develop bladder cancer may also indicate the presence of this disease.
than women, and it is most common in
Caucasians. Smoking is the greatest risk fac-
tor, with smokers having twice the risk of
Diagnostic Tests
nonsmokers. Increasing the risk of develop-
ing the disease include such occupational fac- There is no accurate early screening test for
tors as exposure to arylamines, used in paint, bladder cancer. Urine cytology from a late
dye, rubber, leather and tar. Living in an morning or early afternoon specimen may
urban area also increases the risk. reveal cancer cells. Bladder lavage with nor-
mal saline (bladder washings) can be more
reliable than urine cytology in detecting the
presence of cancer cells. Flow cytometry of
urine to examine DNA ploidy may be useful
The most common type of bladder cancer in diagnostically and in follow-up of treated
the United States is transitional cell car- patients. The intravenous pyelogram(IVP)is
cinoma, representing over 90%of cases. an excretory urogram used to evaluate the
These tumors arise from the epithelial layer upper urinary tracts and bladder filling. Cys-
of the bladder. Squamous cell cancer repre- toscopy, the visualization of the interior of
sents 643% of bladder cancers. Adenocar- the organ is performed by inserting a slender
cinomas of the bladder occur but are rare. tube, fitted with a lens and a light, into the
bladder through the urethra.
Biopsies of suspicious areas are usually per-
formed during cystoscopy. The transurethral
ultrasound may help identify the extent of
disease. Pelvic computerized tomograph (CT
Scan) assists in identifying regional lymph
nodes to assess for metastasis. Magnetic also a therapeutic possibility for patients
resonance imaging (MRI) may assist in detcr- with small lesions.
mining the extent of tumor within the blad-
Segmental bladder resection is used for
der wall and in determining pelvic lymph
large, single tumors at the bladder dome or
node involvement. The chest x-ray or chest lateral wall or for adenocarcinomas. It is also
CT scan also may be used to evaluate the
the procedure used when a patient is at too
lungs for pulmonary metastases. high a risk for cystectomy.
When the tumor is invasive or cannot be con-

trolled with more conservative approaches, a
Treatment cystectomy is the treatment of choice.
Simple cystectomy in a man includes the
The type of tumor, depth of invasion within
removal of the bladder, prostate, and seminal
the bladder, extent of disease, and general
vesicles; in a woman it involves the excision
medical condition of the patient are factors
of the bladder and the urethra. Radical cys-
that influence treatment plans. These factors
tectomy in a male patient involves the
can be significant in the care of bladder can-
removal of the bladder, surrounding fat, at-
cer patients since many of these clients are
tached peritoneum, prostate gland, and semi-
older, with pre-existing medical problems.
nal vesicles. Radical cystectomy in a female
Surgery, radiotherapy, chemotherapy, and
patient would include the removal of the
immunotherapy are used alone, or more fre-
bladder, urethra, ovaries, uterus, fallopian
quently in combination in the treatment of
tubes, and anterior wall of the vagina. In
bladder cancer.
men, radical cystectomy can be associated
Transurethral resection (TUR) and fulgura-
with impotence related to nerve damage. A
tion are used for carcinoma in situ or for
pelvic lymph node dissection may also be
small superficial lesions. Since the rate of
performed at the time of cystectomy to locate
recurrence is high, intravesical
possible metastatic disease.
chemotherapy or immunotherapy may be
Urinary diversion following cystectomy may
recommended. Thiotepa, mitomycin
be achieved by using a segment of ileum to
(mutamycin),and doxorubicin (adriamycin)
form a conduit between the ureters and the
have been agents used for intravesical treat-
ment. Interferon or BCG are the im- external abdomen. This procedure requires
munologic agents used for this form of the patient to wear a urinary collection
treatment. Systemic side effects from device. Another option for patients may be
chemotherapy or immunotherapy are less the creation of a continent ileal reservoir
likely to occur with intravesical administra- which does not require an external collection
tion of these medications. Laser therapy is apparatus.

Radiation therapy for bladder cancer as a Investigational

single mode of treatment, for invasive dis-
Treatments
ease has only a 16-30%cure rate. This is a
much lower cure rate than is achieved by cys- There is an ongoing national study to
tectomy, but radiation may be used in evaluate MVAC and/or cystectomy. Some
patients who are not surgical candidates. centers are using high dose cyclophos-
Radiotherapy may be used pre-operatively phamide (cytoxan)as a single agent. Many
to reduce the size of the tumor and to new chemical and biologic agents are being
decrease the risk of pelvic node recurrence. tested as intravesical treatments. There are
No definitive chemotherapeuticregimen has also studies using radiation implants in the
been devised for the treatment of advanced bladder. Modificationsof surgical cystec-
bladder cancer. Single agents that have been tomy to preserve potency are being inves-
used include: doxorubicin (adriamycin), tigated.
etoposide (VP-16, Vepesid, epipodophyl-
lotoxin), methotrexate (Mexate),vinblastine
(velban), and cisplatin (CDDP, Platinol). Complications
Combination chemotherapy has included
numerous agents; one of the combinations Surgical complications may include bleeding
seen most frequently is W A C or, or infection. Side effects of chemotherapy are
methotrexate, vinblastine, adriamycin, and mentioned earlier. Radiation therapy can
cisplatin. This rigorous program is repeated produce strictures of the ureters, urethra or
every twenty eight days for six cycles. The colon. Other complications are related to
use of growth factors to promote bone mar- sites of metastatic disease.
row recovery has allowed patients to receive
the suggested doses of chemotherapy.
Patients with a history of cardiac disease
may not receive doxorubicin (adriamycin),
related to the potential of cardiac toxicity.
Some centers are replacing cisplatin with car-
boplatin or etoposide to decrease toxicity.
The major side effects of W A C are alopecia,
bone marrow suppression, nausea, vomiting,
neurotoxicity, nephrotoxicity, ototoxicity, and
the risk of cardiac hypertrophy.
Common Nursing Urinary Catheterization-

Intermittent
Caring for the Client
with any Genitourinary
1 Activities Rationales
Teach patient and Promotes
Cancer family the purpose, understanding,
method, and goals of decreases anxiety.
(Refer to section following Kidney Cancer) therapy.
Use sterile technique Prevents infection.
catheterization.
Common Nursing
Diagnoses for the
Client with Bladder Instructions, Information,
Cancer Demonstration
Knowledge Deficit Instruct patient to void Promotes retention of
prior to instilling chemotherapeutic or
Related to: medication. immunologic agent.
Chemotherapy or immunotherapy Inform patient and Provides information.
given directly into the bladder. family of importance
of regular visits.
Instruct patient to roll Promotes coating of
Patient verbalizes lack of informa- from side to side. the bladder interior
tion about treatment and potential with medication.
side effects of intravesicular
Instruct patient to wait Provides increased
chemotherapy or immunotherapy.
to void for several contact of the
0 Outcome Criteria: hours. medication with
interior surface of
Patient is able to verbalize treat- bladder.
ment schedule and goals of treat-
ment. Instruct patient in Prevents exposure to
careful toileting voided chemotherapy
0 NIC: Urinary Catheterization- following treatment. or immunotherapy.
Intermittent
Definition: Periodic use of a Evaluation
catheter to instill immunotherapy
or chemotherapy into the bladder. Patient verbalizes an under-
standing of treatment.
Patient comes regularly for
treatment
Body Image Disturbance Body Image Enhancement
Relatedto:
Creation of urinary diversion.
Assist patient to Promotes positive self
separate physical image.
Patient voices fears regarding appearance and
change in physical appearance, feelings of personal
nonverbal responses to change in worth.
body appearance (ostomy),fears of Give permission to Allows patient time
anticipated change in activities of grieve over loss of needed to cope with
daily living and social relationships. normal bladder losses.
Outcome Criteria: function.
Body image improved, preserved, Allow to vent negative Promotes coping

and maintained; accommodations emotions such as anger because these are
made for, and adaptation to, 0s- a,nd guilt. normal reactions to
tomy begun. loss.
Monitor whether Inability to view
0 NIC: Body Image Enhancement ostomy may indicate
patient can look at
Definition: Improving a patient’s ostomy. coping difficulties.
conscious and unconscious percep- Encourage open Promotes
tions and attitudes toward his or communication family/ patient coping.
her body. between patient an
family over creation of
ostomy and impact of
illness.
Body Image Enhancement
Activities Rationales Instructions, Information,

Encourage patient to Promotes integration Demonstration
express feelings of changes into
regarding ostomy and lifestyle.
diagnosis of bladder Activities Rationales
cancer, and expected
impact on lifestyle. Inform patient of Provides potential
community resources resources for
Evaluate patienYs Provides background such as ostomy groups. continued support.
feelings regarding data on which to
urinary diversion and formulate care plan. Give patient written Provides reinforcement
its effect on sexual materials regarding of verbal information.
identity, relationships, ostomy groups.
and body image.
Evaluation
Patient is able to care for 0s-
tomy.
Patient verbalizes an aware- Ostomy Care

ness of possible modes of s u p
port other than family post
hospital discharge.
Encourage Provides opportunity
patient /significant to vent feelings.
Altered Urinary Elimination & other to express
Impairment of Skin Integrity feelings and concerns
about changes in body
image.
0 Related to:
Encourage visitation to Reduces anxiety and
Creation of an abdominal exit for client by person from fears of adaptive
urine, permanent diversion of urine. ileostomy support ability through visit
0 Defining Characteristics: €PUP- with a person in
similar circumstances.
Presence of a stoma or opening on
the abdominal wall. Assist patient in Provides information
obtaining ostomy and promotes
0 Outcome Criteria: supplies. compliance.
Participates in activities related to Change or empty Provides opportunity
care of ileostomy ostomy bag as to reinforce technique
appropriate. of changing equipment
0 NIC: Ostomy Care and to evaluate stoma.
Definition: Maintenance of elimina- Encourage Provides opportunity
tion through a stoma and care of participation in ostomy for patient to talk with
surrounding tissue. support group post a variety of other
hospital discharge, if people having
appropriate. ostomies.
Ostomy Care
Apply properly fitting Prevents irritation to
ostomy appliance. skin in surrounding
area. I
Assist patient in Promotes correct Instruct Promotes
providing ileostomy technique. patient/ significant understanding of
self-care. other in the use of correct techniques of
ileostomy equipment. using appliance.
Monitor Promotes early I
incision/stoma for intervention of Have patient Provides opportunity

healing. complication. demonstrate use of to assess patient's
equipment. understanding.
Instruct patient on Provides opportunity
mechanisms to reduce to assess patient's
odor. understanding.
Discharge or Maintenance Instructions, Information,

Evaluation Demonstration
Participates in care of ileos-
tomy.
Patient verbalizes signs and Activities Rationales
symptoms to report to
Instruct patient on Provides information.
physician.
hand washing
techniques.
Teach patient about Provides information
Potential for Infection signs and symptoms of and promotes
infection and when to compliance.
(Pyelonephritis) report them to health
care provider.
Related to:
Teach patient and Prevents infections.
Surgical opening in the abdominal familymembers how
wall for the elimination of urine. to avoid infections.
Defining Characteristics: Teach patient and Prevents infections.
family to drain bag
Fever, flank pain, malodorous frequently to prevent
urine, hematuria, positive urine cul- reflux into stoma.
ture.
Instruct patient to take Promotes compliance.
0 Outcome Criteria antibiotics as
prescribed.
Absence of urinary tract infection
0 NIC: Infection Control 0 Discharge or Maintenance
Evaluation
Definition: Minimizing the acquisi-
tion and transmission of infectious Absence of urinary tract infec-
agents. tion.
Prostute Cancer
I Infection Control
I Prostate cancer is the second most common
Activities Rat ionales cancer in men, following skin cancer, with an
estimated 165,000 new cases in the United
Use antimicrobial soap Prevents transmission
for hand washing. of organisms. States evejr year. There has been a sig-
Ensure adequate fluid Promotes urinary flow. nificant rise in the incidence of prostate can-
intake. cer in the United States, probably related to
improved detection. The incidence increases
with each decade after fifty, and is the
second leading cause of cancer deaths in
men. The five year survival rate for localized
prostate cancer is 91%. Of all patients diag-
nosed, 58%have localized disease. The five frequent urination especially at night, pain
year survival rate for all stages of disease is or burning on urination, blood in the urine,
76%. and inability to urinate. These symptoms are
nonspecific and may be related to benign
conditions such as infection or enlargement
Risk Factors of the prostate. Advanced disease may
present with bladder outlet obstructive
Incidence increases with age, so that ap- symptoms with urinary retention. Bone pain
proximately one in ten men will develop is the most frequent complaint of patients
prostate cancer by age 85. Of all men diag- who present with metastatic disease.
nosed, more than 80%are over 65. The in-
cidence rates are 40% higher for African
American men than white men, and African Diagnostic Tests
American men have the highest rate of in-
cidence in the world. The disease is more Digital rectal examination to feel for the
common in North America and presence of a nodule or irregularity in the
Northwestern Europe. Workers exposed to prostate remains the most reliable means of
cadmium, men in tire and rubber manufac- early detection. Fifty percent of palpable
turing, mechanics, farmers, and sheet metal prostate nodules are found to be cancerous.
workers have an increased risk of develop The American Cancer Society (ACS) recom-
ing prostate cancer. There has also been some mends that digital examination be done as
familial clustering of the disease. part of a routine physical examination in
men over forty.
Core needle biopsy is used in the United

States, often using a biopsy gun. This
method of biopsy provides tissue for pathol-
The major prostate cancer is adenocar-
ogy, and may not require an anesthetic.
cinoma.
The use of transrectal ultrasonography
(TRUS)is being re-evaluated. There has been
concern expressed regarding over-treatment
Presenting Signs and of clinically insignificant disease, expense of
Symptoms equipment and the amount of training r e
quired of personnel who administer the ex-
Changes in the urinary pattern may be in-
amination. Patients also complain about the
dicative of prostate cancer. These changes
discomfort of the procedure.
may include weak or interrupted urine flow,
difficulty starting or stopping the urine flow, The use of blood studies, the prostatic acid
phosphatase (PAP),and the prostatic specific
GENITOURINARYCANCERS 217
antigen (PSA)remain controversial. The The surgical approach of prostatectomy is

PSA, which is more sensitive than the PAP, often preceded by a pelvic lymph node ex-
will be elevated in 36%of men with non- ploration. The reason for this is that if the dis-
malignant disease. The ACS recommends the ease has already spread away from the
test annually for men fifty and older. The prostate, and confirmed by the presence of
PSA can often be used to evaluate the positive lymph nodes, then a radical surgical
response to treatment in men who have high procedure may no longer be recommended.
antigen levels, and is used to detect recurrent Prostatectomy can be accomplished with
disease in men who previously had an in- surgical approaches to the organ from dif-
creased level that fell with treatment. ferent angles- perineal, suprapubic, and
Imaging techniques used to evaluate the retropubic. The retropubic approach has
patient with prostate cancer include bone been associated with a lower incidence of
scan to detect bone metastases, chest x-ray to urethral stricture formation, and a reduced
examine for lesions, and MRI and CT scans possibility of damage to pelvic nerves
to detect metastases anywhere in the body. needed for erection. The potential complica-
tions related to these surgical interventions
are impotence, incontinence and urethral
strictures.
Treatment
Another potential surgical approach is the
Controversy surrounds the treatment of men use of cryosurgery to freeze the tumor. This
seventy years or older who are diagnosed method is now being evaluated in clinical tri-
with low grade cancer which is nonaggres- als. Depending on the location of the tumor
sive pathologically. The controversy that within the prostate, urethral damage may
without treatment men may live ten years potentially occur. The prostatectomy and
after diagnosis, and that all present modes of cryosurgery in localized tumors are surgical
therapy compromise quality of life; incon- approaches used for cure, especially when
tinence, impotence, and diarrhea adversely there has been a negative lymph node dissec-
effect activities of daily living. A "watch and tion. Surgical procedures are also used for
wait" approach with frequent follow-up is the treatment of metastatic disease. Bilateral
often recommended. This conflicts with the orchiectomy, the removal of the testicles, is
widespread belief that cancer is to be treated used instead of hormonal therapy to
immediately and aggressively for cure. The decrease the production of androgens. This is
best approach remains for the patient to have an option for men with metastatic disease
the options for treatment explained, includ- who dislike taking regular medications.
ing potential side effects and to allow him to Radiation therapy is another option for the
make his own decision.
treatment of prostate cancer. Two types of
radiation therapy may be used- external
beam and interstitial implants. A temporary (Lupron)or by subcutaneous tracking

or permanent radioactive source (e.g., iodine (Zoladex).These medications decrease the
125 seeds) can be implanted within the pros- production of testosterone and are associated
tate for eradication of disease. This treatment with fewer side effects than the previous
is associated with a lower incidence of im- estrogen therapy. However, they do cause im-
potence. External beam radiotherapy is ad- potence as a side effect of the decrease of tes-
ministered in divided doses for five tosterone. Flutamide (Eulexin)may be used
treatments each week over a six to seven in conjunction with an LHRH analogue. This
week period. A total dose of 60-70Gy is ad- testosterone inhibitor is given orally daily in
ministered. External beam radiotherapy to divided doses. Megace (megestrol acetate) is
the prostate may be localized or may include an antiandrogen that can be used as a single
the surrounding lymph nodes. Some centers agent for the treatment of metastatic prostate
combine radiation therapy with a surgical cancer. It is often also used in the treatment
procedure. Bone pain from metastatic pros- of breast cancer or as an appetite stimulant in
tate lesions is very successfully treated with AIDS or cancer patients. It is given orally,
external beam radiation therapy. Another use twice daily. Aminoglutethimide (Cytadren)
of radiation therapy is in the treatment of a is a medication which blocks adrenal func-
potential spinal cord compression caused by tion. It is given orally four times a day and
a metastatic lesion in a vertebrae. should be accompanied by the administra-
Hormonal manipulation is the common ap- tion of divided daily doses of hydrocortisone
proach for the treatment of metastatic dis- for glucocorticoid replacement.
ease. This can be achieved, as mentioned These hormonal manipulations may be effec-
above, with surgery or the administration of tive against metastatic prostate cancer for a
medication. Diethylstilbestrol, DES was period of months to years. Although they are
used previously, but the side effects includ- associated with impotence they can relieve
ing increased incidence of venous throm- symptoms, related to metastatic disease (e.g.,
bosis, pulmonary embolism, stroke, bone pain), benefiting overall quality of life.
myocardial infarction, hypertension, im- Generally the hormonal medications are well
potence, and gynecomastia were worrisome. tolerated.
The use of DES has often been replaced with
the gonadotropin-releasinghormonal
therapy. This class of medications is often
Chern0therapy
referred to as the LHRH or Gn-RH
analogues. There are two drugs in this class, Although not widely accepted, both
Lupron (Leuprolide)and Zoladex (Goserlin adriamycin and cyclophosphamide have
acetate). They are administered once every been used in the treatment of metastatic pros-
28 days, either by intramuscular injection tate cancer. Cyclophosphamide (Cytoxan)
has been administered in high doses in- Common Nursing

travenously (grams per metered squared) Diagnoses Related to
and has demonstrated some responses; but it
is associated with severe bone marrow sup-
Prostate Cancer
pression, especially in men with many bone
metastases. The use of growth factors (Im-
munotherapy Chapter) in conjunction with Altered Urinary Elimination
this therapy is being explored. Adriamycin (CH. 2)
(doxorubicin)is often given in weekly in- Related to:
travenous boluses (20mg/m2) as it is in Increased size of the prostate gland
metastatic breast cancer. causing urethral stricture.
Dysuria, frequency, urgency, uri-
Investigational nary retention, inadequate output.
Treatments
Suramin, a chemotherapeutic agent derived Altered Bowel Elimination
from an organic dye, is being investigated in (CH. 2)
clinical trials. This agent has demonstrated Related to:
promise in the treatment of metastatic pros-
Prostatectomy and external beam
tate cancer. radiation therapy.
Increased frequency of bowel move-
Common Nursing ments, urgency, loose liquid watery
stools.
Diagnoses related to
Genitourinar y Cancer
(Please refer to section following Kidney Sexual Dysfunction
Cancer.)
13 Related to:
Prostatectomy, hormonal blockade
for the treatment of metastatic pros-
tate cancer.
Impotence, decreased libido
Outcome Criteria:
Patient verbalizes understanding of SexuaI Counseling

changes in sexuality, and alternative
methods of sexual expression.
0. NIC: Sexual Counseling Activities Rationales
Definition: Use of an interactive Use humor as Promotes coping with
helping process focusing on the appropriate to relieve an uncomfortable topic.
need to make adjustments in sexual anxiety and/or
practice or to enhance coping with embarrassment,
a sexual disorder.
~ ____
Sexual Counseling Demonstration

Establish a therapeutic Promotes an Inform patient that Prevents patient from
relationship based on atmosphere that allows sexuality is an feeling that concerns
trust and respect. expression of feelings. important part of life. related to sexuality are
Ensure privacy and Provides a therapeutic unimportant.
confidentiality. milieu. Instruct pa tient on Provides information.
Assure Promotes inquiry. penile prosthesis.
patient /significant
other that you are CI Discharge or Maintenance
prepared to answer Evaluation
any questions about Demonstrates ability to adapt
sexual functioning. to sexual dysfunction.
Discuss patient's Provides information
general knowledge of on which a plan may
sexuality- be based.
Discuss the effects of Promotes Testicular Cancer
surgery and hormonal understanding of
therapy on sexual reasons for Cancer of the testes is one of the most fre-
function. dysfunction.
quently occurring malignancies in young
Encourage Promotes venting of
verbalization of fears. feelings. adult males in the 15-35 age group. It repre-
Discuss necessary sents about 1%of cancers in men and has an

Provides alternatives
modifications in sexual to present sexual annual occurrence of 6,600 cases. The sur-
activity. behavior. vival rates are related to the type and stage
Encourage expression Promotes venting of of disease. Early stage cancer of the testes of
of grief/ anger about feelings.
alterations. all cell types is associated with a 96-100%
five-year survival. In advanced (metastatic)
Discuss alternative Prevents perception
forms of sexual that sexual expression testicular cancer the five-year survival rate is
expression. has terminated. 7045%. These significant improvements in
the past twenty years are related to the remainder being teratomas or choriocar-
development of effective combination cinomas. The non-germ cell tumors are rare
chemotherapy regimens. The disease is and represent only 3%of cases. Since half of
responsible for 350 deaths each year in the these tumors are seminomas, the general clas-
United States. sification is either seminoma or non-semi-
noma, although, as discussed above, the
non-seminomas may not all be of germ cell
Risk factors origin.
Geographic location is an influential factor in

the development of this cancer. The Scan- Sjgns and Sympfoms
dinavian countries have the highest in-
cidence of testicular cancer worldwide, Asia There are no early indications of testicular
and Africa have the lowest occurrence. Sex is cancer, most patients have a painless swell-
obviously a factor; it occurs only in males. In ing of the affectedtesticle. Many athletic
the United States, cancer of the testes is young men associate the development of the
found more often in Caucasians than in any disease with trauma. However, the sports re-
other racial group. The peak incidence is be- lated injury is coincidental, drawing atten-
tween the ages of 1540 years. Males with a tion to the testicle, and not a cause of the
history of cryptorchidism (undescended tes- malignancy. Many patients are referred to
ticle) have a much greater risk of being diag- the oncologist when the swelling, thought to
nosed with testicular cancer. The mother's be epididymitis, has not responded to treat-
exposure to estrogen may also influence the ment with antibiotics. When pain is present
development of testicular cancer. it may be related to bleeding into the tumor.
Pediatricians should routinely encourage Flank pain or low back pain may indicate
parents of boys with undescended testicles retroperitoneal node metastases.
to have them surgically brought down from
the inguinal tract into the scrotum.
Diagnostic Testing
The American Cancer Society recommends
regular testicular self exam to promote early
A majority (97%)of testicular cancers arise detection of testicular carcinoma. Palpation
from a germ cell which originates in the yolk of the testicles, complete physical examina-
sac of the embryo. Seminoma is the most tion and medical history are essential in the
common germ cell tumor, comprising almost early phase of diagnosis. Once the presence
half of all cases. Embryonal carcinoma ac- of a mass has been confirmed, scrota1
counts for another 25%of diagnoses with the ultrasound assists in specificlocation and
delineation of the mass. Intravenous pyelog- field to be irradiated depends on the extent
raphy (IVP) is completed to evaluate for of tumor. The area treated will be larger, in-
ureteral deviation from nodal involvement. cluding the entire pelvis, if positive lymph
Computerized tomographic scanning (CT) nodes exist. Nonseminoma testicular cancer
assists in the assessment of retroperitoneal is not as responsive to radiotherapy and has
and paraaortic lymph nodes. X-ray, been replaced by surgery and chemotherapy.
tomogram or CT Scan of the chest evaluates However, radiotherapy may be helpful in
for the presence of pulmonary metastases. cases where a metastatic lesion has not
Two blood tests are used to evaluate tumor responded to chemotherapy and cannot be
markers in testicular cancer patients. These surgically removed. Surgical intervention in-
are alpha-fetoprotein (Am)and beta-human volves retroperitoneal lymph node dissec-
chorionic gonadotropin (beta-HCG, beta sub- tion or the removal of metastatic areas which
unit). They are very reliable and one factor or have not responded to chemotherapy.
the other will be elevated in 85%of patients Combination chemotherapy is used in ad-
with active disease. Often, there is confusion vanced seminomas and in nonseminoma tes-
in the lab when a beta-HCG is sent with a tes cancer. The initial chemotherapeutic
male name, but this can be avoided by mark- regimen that demonstrated improved out-
ing the lab slip ”rule-out testicular cancer”. comes in advanced testicular malignancies
These markers, if elevated at diagnosis can was PVB, or cisplatin (Platinol), vinblastine
be helpful in evaluating the effectivenessof (Velban)and bleomycin (Blenoxane),given
treatment or be an early indication of recur- over a period of 3-6 months. Although cura-
rent cancer. tive in a large percentage of cases this
therapy was associated with severe toxicities
Biopsy for a testicular mass involves high
including bone marrow suppression,
radical inguinal orchiectomy, a procedure in
ototoxicity, and neurotoxicity. In an effort to
which the testis, the epididymis, a portion of
reduce toxicities, investigators replaced the
the vas deferens, and the gonadal lymphatics
vinblastine with etoposide (VP-16, VePesid)
are removed. Surgeons may offer the patient
resulting in the BEP regimen (bleomycin,
the option of having a testicular prosthesis
etoposide, cisplatin). When patients do not
implanted at the time of surgery.
respond to the standard chemotherapeutic
protocol, they often receive what is called
“Salvage” treatment. This treatment for testes
Tieatmenf cancer is VIP including either vinblastine or
etoposide, or ifosfamide and cisplatin. Ifos-
Radiotherapy is used for localized seminoma
famide is always administered with mesna, a
and in the setting of a few positive lymph
uroprotector. This treatment is associated
nodes. This is because seminoma is very sen-
with a good response rate in patients who
sitive to radiation therapy. The size of the
have previously received other treatments.
Investigational Essential Nursing

Therapies Diagnoses Related to
There is an ongoing national study to
Genitourinary Cancer
evaluate the benefits and toxicities of BEP (Refer to section following Kidney Cancer.)
versus VIP chemotherapy. In cases where
patients have not responded to other treat-
ment modalities bone marrow transplant is Essentiul Nursing
being investigated. Trials of existing com-
binations (above)are being conducted to
evaluate their required length of treatment
Testicular Cancer
and their associated toxicities.
I nef f ective IndividuaI Coping

Complications (CH. 1)
0 Related to:
Complications associated with testicular can- Diagnosis of testicular cancer, loss
cer are related to the type of treatment neces- of testicle, potential loss of fertility,
sary.The psychological impact of the loss of losses due to treatments.
a testicle cannot be overlooked. Many men Defining Characteristics:
may associate this with castration even Inability to meet basic care needs,
though the remaining testicle provides tes- fatigue, verbalization of inability to
cope.
tosterone. The issue of fertility should be
raised prior to treatment and sperm banking
may be considered. Some men who are diag-
nosed with testes cancer already have a low
Altered Sexuality
production of sperm. Chemotherapy may Related to:
result in long term infertility.Some degree of Treatments of testicular cancer in-
sexual dysfunction may be associated with cluding surgery, chemotherapy and
retroperitoneal lymph node exploration, radiation therapy.
depending on the extent of the procedure 0 Defining Characteristics:
and the involvement of the nerves located in Patient voices fears of potential
this area. Dry ejaculate may result from surgi- sexual inadequacy related to loss of
testicle; dry ejaculate related to
cal intervention, and its possibility should be surgery; verbalizes changes in
fully discussed with the patient prior to the sexual feelings related to loss offer-
operation. Radiation side effects are related tility.
to field size, alterations in bowel or ureteral NIC: Sexual Counseling, Prostate

function may occur.
Body Image Disturbance Potential for Injury

(CH. 9,13) (Anaphylaxis)
Relatedto: Related to:
Loss of testicle. Chemotherapy with bleomycin.
Defining Characteristics: Defining Characteristics:
Verbalizes fears of loss of manhood Patient verbalizes complaints of
related to surgery. itching, hives, anxiety, restlessness,
feelings of impending doom,
respiratory distress, wheezing,
hypotension, facial edema.
High Risk for Altered Urinary
(CH. 7,181
Relatedto: High Risk For Peripheral
Chemotherapy with cisplatin or Neurovascular Dysfunction
ifosfamide. (CH. 8)
Defining Characteristics: 0 Related to:
Decreased serum levels of potas- Chemotherapy with vinblastine or
sium, magnesium, and calcium, cisplatin.
decreased urine production, in-
creased serum BUN and creatinine, Defining Characteristics:
hematuria. Patient verbalizes loss of fine motor
movements, burning pain in ex-
tremities, gait disturbances, and
loss of proprioception.
High Risk for Fluid Volume
Excess
(CH. 7)
Risk for Sensory/
Relatedto: Perceptual Alteration,
Vigorous hydration before and after Auditory
chemotherapy to promote excretion
of cisplatin. 0 Related to:
0 Defining Characteristics: Chemotherapy with cisplatin.
Intake greater than output, short- 0 Defining Characteristics:
sounds (rales), blood pressure or Reduced auditory acuity, partial or
pulse changes, jugular vein di'sten- complete inability to hear.
sion.
Outcome Criteria:
Facilitation and maximization of
auditory function.
0 NIC: Communication Communication Enhancement-

Enhancement- Hearing Deficit Hearing Deficit
Definition: Assistance in accepting
and learning alternate methods for
living with diminished hearing. Activities Rat ionales
Discuss community Provides information.
resources.
Communication Enhancement-
Hearing Deficit
Assess hearing ability Provides baseline data.

prior to start of
______
chemotherapy.
Teach patient that Promotes
Facilitate appointment Promotes identification sounds will be understanding.
for hearing of loss. experienced differently
examination. with the use of a
Encourage use of Promotes hearing aid.
hearing aid. maximization of Instruct patient/family Promotes optimal
remaining function. function of hearing aid.
to keep hearing aid
Speak slowly and Prevents clean and to have extra
clearly. misunderstanding. batteries.
Face patient when Provide written Reinforces verbal
speaking. information on suggestions
community resources
Give one simple for hearing impaired.
direction at a time.
Increase voice volume 0 Discharge or Maintenance
as needed. Eva1uation
Refrain from shouting. Prevents Optimizes hearing ability.
embarrassment of
patient and family.
Obtain patient's Promotes
attention through communication.
touch.
Use alternate method
of communication
when necessary.
Assess ability to afford
hearing aid or
telephone for hearing-
impaired.
Chapter Eleven
Gyn e cologic
Cancers
Gynecologic Cancers
The gynecologic cancers represent one of the ing cervical cancer. The peak incidence of in-
most common forms of cancer in women. vasive cervical cancer is between the ages of
This chapter discusses cervical, endometrial, 45-55 years old, while the peak for CIS oc-
and ovarian cancers, then covers nursing curs ten years earlier. African American
diagnoses and nursing interventions of these women and Hispanic American women
three disease processes. have a higher incidence of cervical cancer
than do Caucasians in the United States.
Women who become sexually active at an
Cervical Cancer early age, have multiple sexual partners, and
are multiparous have increased risk. Pros-
The concept of screening for early stage can- titutes have four times the risk of developing
cer has certainly proved beneficial in cervical cervical cancer, while religious nuns are al-
cancer. The incidence of invasive disease has most completely free of the disease. Papil-
dropped almost 50% since 1945 in the United lomavirvirus and herpes simplex virus type
States. During the same period of time, the 2 have been identified as potential etiologic
incidence of early stage disease, carcinoma in sources. Exposure to diethylstilbestrol (DES)
situ (CIS), has risen dramatically with ap- in utero has been linked to a higher in-
proximately 45,000 new cases annually. The cidence of clear cell adenocarcinoma of the
incidence of invasive disease is 13,500 cases a vagina and cervix.
year, with 4,400 estimated deaths. The five- Male risk factors are also beginning to be
year survival rates are dependent on the ex- identified as a potential cause for cervical
tent of disease and the presence of cancer’s occurrence in women. These factors
metastases. Localized disease is associated include sperm contents, hygienic conditions,
with an 89%five-year survival rate, drop- numbers of sexual partners, smoking, penile
ping to 14%in advanced disease. Cervical cancer and incidence of cervical cancer in a
cancer continues to be a serious health prob- previous wife.
lem of women in underdeveloped nations.
Risk Fucfors
Cervical intraepithelial neoplasia (CIN)
Age, race, socioeconomic status, sexuality refers to the presence of preinvasive disease
patterns, smoking, and exposure to viruses at the squamocolumnar junction of the cer-
especially HIV are all risk factors for develop-
vix. This is the area where the columnar should have on Pap smear every three years
epithelium of the endocervix joins the until age 65.
squamous epithelium of the exocervix. The When dysplasia or carcinoma in situ are
degree of dysplasia present in these cells present a colposcopy is performed. This in-
defines the category CIN I (mild) through strument allows a magnified view of the cer-
CIN I11 (severe).Carcinoma in situ describes vix, and abnormal areas may be biopsied.
a lesion that has changed from dysplasia to endocervical curettage is performed when
neoplasia but remains localized.
the areas of abnormal tissue can not be
There are two main histological types of cer- visualized. A cone biopsy obtains a larger
vical cancer, squamous carcinoma and wedge of cervical tissue to investigate
adenocarcinoma. Squamous carcinoma com- whether or not invasive cancer is present.
prises 80-95%of cancers and occurs more Tests recommended to evaluate for bladder
often in older women. The remainder of the or rectum involvement include cystoscopy,
cases are adenocarcinoma which occurs intravenous pyelogram (IVP), barium enema
more frequently in younger women and and sigmoidoscopy. Either magnetic
tends to be an aggressive cancer. resonance imaging (MRI) or abdominal/pel-
vic computerized tomographic scanning
(CT) are used to evaluate local extension of
Signs and Symptoms the tumor and/or t he involvement of
regional lymph nodes.
There is no specific symptom for cervical can-
cer. Bleeding is caused by an ulceration on
the epithelial surface of the cervix but is not Treatmenf
always present as tumors may spread
without ulceration. Any abnormal bleeding Preinvasive disease is treated with a local
should prompt a women to seek medical at- therapy which sometimes needs to be
tention. Lower abdominal or back pain repeated. Local therapies include biopsy,
might be a symptom of extensive disease. cryosurgery, cautery, laser therapy and con-
ization. Hysterectomy may also be used
depending on the woman’s age, childbearing
Diagnostk Tests status, and/or desire for sterilization.
Invasive cervical cancer is generally treated
Screening with the Papanicoloau smear (Pap
with surgery or radiation therapy and in
smear) should begin in women at age 18 or
some cases a combination of both. Radical
when sexual activity begins. Following three
hysterectomy involves the removal of the
consecutive negative annual exams, women
uterus, pelvic and paraaortic lymph nodes.
bilateral salpingo-oopherectomy may also be
GYNECOLOGIC CANCERS 231
performed in postmenopausal women. exter- depending on organs removed in addition to

nal beam radiotherapy would be added if the uterus and surrounding lymph nodes.
lymph nodes are positive or if surgical mar- Removal of the bladder rectosigmoid colon
gins include tumor. requires the creation of a colostomy and or
In early or more advanced disease primary ileal conduit.
radiation therapy offers an alternative cura- Combination chemotherapy has been used
tive approach. This may include both exter- for metastatic disease because therapy with
nal beam and intracavitary implants single agents has not proved to be beneficial.
depending on the extent and location of the The highest response rates have been as-
tumor. The type of treatment recommended sociated with a regimen containing cisplatin
is tailored to that particular women’s needs. (Platinol).Other agents in use include;
If a large tumor is present external beam bleomycin (Bleoxane),methotrexate
therapy may precede intracavitary place- (Mexate), doxorubicin (Adriamycin),Vincris-
ment of a radiation source, the intent would tine (Oncovin) and mitomycin (Mutamycin).
be to shrink the tumor to allow for place- In some regimens response rates have been
ment of the apparatus. The apparatus is high but the duration of response has not
generally placed into the uterus in the operat- been associated with long-term, disease-free
ing room under general anesthesia. It is then survival.
loaded with a radiation source in the
patient’s room once correct placement has
been confirmed. In some cases, depending Investigational
on tumor location and size a tampon like ap-
plicator is used which does not require place-
Therapies
ment in the operating room. Women having The Gynecologic Oncology Group (GOG) is
this therapy have a urinary catheter in place, pursuing clinical trials to improve outcomes
remain in bed, eat a restricted diet, and take in women with advanced disease. The future
medications to prevent bowel movements. role of adjuvant chemotherapy and combina-
The length of treatment is 2 4 days dependl- tions of surgery, radiation, and
ing on the dose to be delivered. The rationide chemotherapy are being explored.
for intracavitary treatment is that a larger
dose of radiation can be delivered directly to
the tumor, sparing surrounding organs.
Complicutions
Locally recurrent cancer is treated with pel-
vic exenteration. This aggressive surgical ap- The complications related to surgical inter-
proach should only be undertaken when vention are becoming less frequent due to im-
there is no metastatic disease present. Ex- proved surgical techniques. They included
enteration can be anterior, posterior, or total, ureteral fistulas, bladder dysfunction, pul-
monary embolus, lymphocyte, lymphocyts, Risk Factors

pelvic infection, bowel obstruction, and rec-
tovaginal fistulas. Many risk factors have been associated with
the development of endometrial malignancy.
Complications experienced immediately fol-
The highest incidence is between the ages of
lowing radiation therapy are skin reactions,
50-59. This tends to be a postmenopausal dis-
radiation cystitis, proctosigmoiditis and
ease, as 80%of patients are postmenopausal
enteritis. Long-term or delayed effects are re-
when diagnosed. Obesity and large body
lated to the dose of radiation administered.
frame are risk factors, as is a high fat diet.
These include rectovaginal fistulas,
The existence of other conditions including
rectrouterine fistulas, ureteral stricture, blad-
hypertension, diabetes, failure of ovulation,
der and ureteral vaginal fistulas, sigmoid
irregular menses, Stein-Leventhal syndrome
stricture, procititis, bladder and ureteral
and infertility increase a womans risk of en-
vaginal fistulas, and proctitis.
dometrial cancer. Having a past history of
The complications related to chemotherapy breast, colorectal, or ovarian cancer also
depend on the combination of drugs used. raises risk. Exposure to endogenous or ex-
Bone marrow suppression, nausea, and ogenous estrogens increases incidence be-
vomiting are common side effects of cause it is thought to influence endometrial
cisplatin-based chemotherapy. hyperplasia, a potential precursor of the
malignancy. A genetic influence may exist, al-
though no marker has yet been discovered.
Cancer In 12-28% of cases, the tumor occurs in
families.
Cancer of the corpus or body of the uterus is
often referred to as endometrial cancer, since
most cases arise from the endometrial lining
of the uterus. The term uterine cancer would
become confusing because the cervix is part Adenocarcinoma of the endometrium repre-
of the organ. Endometrial cancer is the sents 90%of all endometrial malignancies.
fourth most common cancer in women and The remaining 10%include sarcomas,
the most common malignancy of the female mesodermal tumors, clear cell carcinomas,
reproductive organs. It comprises 13%of all
lymphomas and epidermoid tumors.
cancers diagnosed in women. Its estimated
annual incidence is 31,OO cases, with 5,700
predicted yearly deaths. The five-year sur-
vival rate for endometrial cancer is 94%,and
for metastatic disease it is 26%.
Signs and Symptoms Treatment

Bleeding in a postmenopausal woman is The treatment of endometrial cancer
found in about 33%of endometrial cancers, depends on the stage, grade, depth of
so this symptom should alert women to seek myornetrial invasion, cell type,and the char-
gynecologic attention. Other early symptoms acteristicsof the woman. Hysterectomy with
include irregular or heavy menstrual flow in or without radiation therapy is the treatment
a premenopausal woman and vaginal dis- of choice for early stage disease. Vaginal
charge in a woman of any age. Lumbosacral hysterectomy is not recommended because
pain and hemorrhage are associated with ad- of the limited view gained during surgery of
vanced disease. the retroperitoneal lymph nodes. Bilateral sal-
pingo-oophorectomy, lymph node sampling,
and peritoneal cytology are generally per-
Diagnostic Tests formed in addition to abdominal hysterec-
tomy. Further treatment is based on
Physical exam with palpation of the uterus is pathology results. When disease has invaded
not reliable because the uterus often does not the muscles of the uterus or spread outside
change shape until advanced disease is of the uterus, postoperative external beam
present. Endometrial biopsy is the preferred radiation is used. The entire pelvis is ir-
method of obtaining tissue for histology, this radiated.
is generally an outpatient procedure. If bleed- Hormonal therapy with megestrol acetate
ing persists with a negative biopsy, dilation (megace)or medroxyprogestrone (Depo-
and curettage (D & C)is performed, during Provera) is administered orally each day for
this procedure a separate endocervicalcuret- recurrent disease. It is generally well
tage is completed. The reason for this is to tolerated with weight gain as a potential side
distinguish the area from which the tumor effect. Adjuvant therapy, that is following ini-
arises. If bladder or rectal involvement is tial treatment before signs of recurrence, has
suspected, a cystoscopy, intravenous not proved to be beneficial in preventing
pyelogram (IVP), barium enema, and proc- relapse of endometrial cancer. Tamoxifen
toscopy are done. Other examinations used (Nolvadex)is given orally each day if the
to evaluate extent of disease include above cited therapies are not effective.
hysterography, hysteroscopy, ultrasound,
Single agent chemotherapy,both with
lymphangiogram, computerized
doxorubicin (Adriamycin),and cisplatin
tomographic scan (CT)and magnetic
(Platinol),has demonstrated responses. Com-
resonance imaging (MRI).There is no diag-
bination chemotherapy with cisplatin,
nostic tumor marker for endometrial cancer.
doxorubicin and cyclophosphamide
(Cytoxan),which is associated with in-
creased adverse effects, has demonstrated no is 39%- higher if the tumor is found early.
further benefit. However, 60-70% of these cancers have
progressed by the time of diagnosis.
Complications
Risk Factors
Complications from treatment of en-
dometrial cancer depend on the type of treat- The peak incidence of ovarian carcinoma is
ment a patient receives. Patients with 55-59 years of age. Only 74% of these
endometrial cancer are often older than tumors occur in women under 35 years old.
those with other gynecologic malignancies, If a woman has had breast cancer her risk for
therefore the incidence of other co-morbid developing ovarian cancer doubles. A his-
diseases tends to be greater (i.e., pulmonary, tory of a colon malignancy also increases
cardiac). Preexisting diabetes and hyperten- risk. The greatest risk is prolonged uninter-
sion may increase the incidence of post- rupted ovulation. The use of birth control
operative problems. Curative doses of pills, multiple pregnancies and breastfeeding
radiation therapy may be associated with which decrease the frequency oof ovulation
ureteral strictures, proctitis, and skin reac- seem to be protective. Many other factors in-
tions. Chemotherapy’s adverse effects including nulliparity, infertility, (especially the
clude bone marrow suppression, nausea, use of infertility drugs to stimulate ovula-
vomiting, and hair loss. tion) and estrogen therapy have been
hypothesized as risk factors but none have
been proven. A genetic link may exist, as
Ovarian Cancer there are many cases of familial clustering of
ovarian tumors. The use of prophylactic
Ovarian carcinoma is the second most com- oophorectomy in women with family history
mon malignancy of female reproductive or- of ovarian cancer remains controversial.
gans, with an estimated incidence of 22,OO Types
new cases yearly. It is the fourth most com- Tumors arising from epithelial tissue com-
mon cause of cancer-dated death in prise 90% of all malignant ovarian cancers.
women, responsible for 13,300 deaths annual- These are further identified as serous, en-
ly. Deaths related to ovarian cancer are dometroid, clear cell, mucinous, Brenner,
greater than those from endometrial and cer- and undifferentiated carcinomas. Germ cell
vical cancer combined. In the United States tumors account for 4% of ovarian cancers
this disease makes up 4% of all malignancies and they are the most common type of this
in females. Also, it is predicted that one of malignancy seen in younger women. The
every 65 women will develop ovarian cancer remaining 6% of these tumors are stromal or
by age 85. The overall fiveyear survival rate sex cord in origin.
Signs and Symptoms invasion can be evaluated by cystoscopy and

intravenous pyelogram (IVP).Pelvic com-
Unfortunately, there are no specific early puterized tomographic scan (CT) and mag-
signs or symptoms of ovarian cancer. This is netic resonance imaging (MRI) may indicate
the prime reason that so many of these the presence of involved lymph nodes. If as-
tumors are discovered only when they have cites is present, paracentesis is performed to
become advanced. Vague complaints includ- evaluate fluid for cytology. Chest x-ray is
ing abdominal discomfort, dyspepsia, used to detect pulmonary metastases. A
flatulence, and gastrointestinaldistress may laparotomy is necessary for complete staging.
be present. These symptoms can easily be at-
tributed to multiple other causes. Ascites,
weight loss, intestinal obstruction and pain
Treatment
often indicate the presence of advanced can-
cer. Surgical treatment involves total abdominal
hysterectomy, bilateral salpingo-oophorec-
tomy, omentectomy, lymph node biopsies,
Diugnostic Tests peritoneal cytology, and multiple biopsies of
any suspicious areas on surrounding organ
No widespread screening test for ovarian surfaces. In addition to staging, the surgical
cancer is available. Suspicious enlarged, or ir- goal is to debulk as much tumor as possible,
regular, ovaries may be detected during leaving no masses larger than 2 cm or no
routine gynecologic examination. This find- visible masses at all. Surgery may also be
ing should be further investigated with used following chemotherapy and /or radia-
ultrasound, especially in postmenopausal tion for a "second-look" to visually assess
women. The serum tumor marker for the abdomen for residual disease that cannot
ovarian cancer, CA-125, will be elevated in be detected by any other method.
80%of women with epithelial tumors. The
Postoperative treatment may include radia-
alpha-fetoprotein ( A F P ) and human
tion in early staged disease. External beam
chorionic gonadotropin (HCG) levels are
radiotherapy may be delivered to the pelvic
elevated in the small percentage of ovarian
area or the entire abdomen depending on the
tumors of germ cell origin.
extent of the tumor. Radioactive isotopes can
Routine diagnostic tests are most often used be administered intraperitoneally.
to rule out the presence of another tumor or
Chemotherapy may be used adjuvantly for
to evaluate for metastatic disease. Barium
advanced disease or recurrent ovarian can-
enema, upper gastrointestinal series, and sig-
cers. A combination regimen containing
moidoscopy are used to detect bowel invol-
cisplatin (Platinol) has been the standard
vement, or rule out colon cancer. Bladder
treatment. CAP (Cyclophosphamide,
doxorubicin, cisplatin) has been replaced ovarian tumors. The response rate is not has
with CP (cisplatin and cyclophosphamide) high as it is in testicular tumors.
because of the similar response rates and Treatment has also been given by the in-
decreased side effects with the latter com- traperitoneal (IP) method of administration
bination. Complete clinical remissions are for ovarian malignancies. A catheter is
seen in 40-50% of patients. placed into the abdomen and the agent is in-
One of the controversies in the initial fused, then drained. Both biologic agents
chemotherapeutic management of patients is and chemotherapeutic agents have been
the use of a multi-drug combination versus delivered by this route. Benefits cited for in-
single agent. Some researchers think that traperitoneal administration include a higher
using higher doses of cisplatin or carboplatin concentration of the agent coming in direct
(Paraplatin) alone will prove to be as effec- contact with the tumor; decreased systemic
tive as combination therapy. Tax01 side effects of the drug; and higher doses of
(Paclitaxel), ifosofamide (Ifex), etoposide (VP- treatment can be given. Cisplatin,
161, and teniposide (VM-26) have been suc- adriamycin, taxol, methotrexate, cytosine
cessfully used for patients who haven’t arabinoside, etoposide, and 5-fluorouracil
responded to another chemotherapeutic have been used intraperitoneally with vary-
regimen. Oral chemotherapeuticagents have ing degrees of response. Biologic agents that
been used for treatment of ovarian cancer have been tried by this method are tumor
especially in older women. Melphlan necrosis factor (TNF), interleukin-2 (IL-2),
(Alkeran), chorambucil (Leukeran),and and gamma and alpha interferon. The role of
hexamethyl-melamine (Altretamine)have IP therapy remains to be defined.
been associated with responses. Melphalan
Biologic agents have been used systematical-
may also be used in the adjuvant setting fol- ly alone or in combination with
lowing radiotherapy. Hexamethylmelamine
chemotherapy for the treatment of ovarian
has been used alone or in combination with malignancies. IP administration of the
intravenous chemotherapy protocols.
biologic agents has been associated with
Tamoxifen (Nolvades), megestrol acetate
greater response rates than systemic ad-
(Megace), leuprolide (Lupron),and
ministration. The role of biologic therapy in
gosereilin acetate (Zoladex) are hormonal
ovarian malignancies has yet to be defined.
agents that have been used with some suc-
cess in the palliation of patients with ovarian
cancer.
Investigational Studies
Ovarian cancers of germ cell origin are
treated with a chemotherapy treatment The gynecologic oncology group and many
similar to that of testicular cancers. However regional oncology study groups are actively
these cases represent a small number of pursuing treatment protocols for ovarian can-
cer patients. The goal is to combine agents to anxiety, poor self-esteem, verbaliza-
develop a successful treatment for advanced
disease.
Anticipatory Grieving
(CH. 1)
Complications 0 Related to:
In ovarian carcinoma patients it is often dif- Actual and/or perceived losses due
to cancer such as loss of health, life,
ficult to distinguish complications which are work, income, privacy, intimacy,
disease related from those that are caused by relationships.
treatment. Infertility is the result of surgery 0 Defining Characteristics:
in premenopausal women. Cisplatn based
Patient exhibits and/or expresses
chemotherapy is associated with nausea, feelings of sadness or loss.
vomiting, and bone marrow suppression.
The potential for ototoxicity,nephrotoxicity
and neurotoxicity exist also. Uncontrolled Altered Role Performance
recurrent disease is associated with bowel (CH. 1)
obstruction, ascites, fistulas, and lower ex-
0 Related to:
tremity edema.
Impact of the diagnosis of cancer on
the patient's roles within her family
and community.
Essentiai Nursing Defining Characteristics:
Diagnoses for the Change in self-perceptionof role,
change in others perception of role,
Client with a change in physical capacities to
Gynecologic resume role(s) and/or respon-
sibilities.
Malignancy

Ineffective Individual Coping (CH. 1)
(CH. 1) 0 Related to:
0 Related to: Impact of cancer diagnosis and un-
Diagnosis of a gynecologicmalig- certain prognosis.
nancy and uncertain prognosis. 0 Defining Characteristics:
0 Defining Characteristics: Family systems unable to meet
Inability to meet basic needs, de- physical, emotional needs of
pendency chronic fatigue, worry, patient; or verbalization by family
members of inability to cope.
Knowledge Deficit Altered Tissue Perfusion,

(CH. 1) Cardiopulmonary
0 Related to: (CH. 13)
Lack of knowledge about the cancer 0 Related to:

disease process and its treatment. Anemia and thrombocytopenia
I3 Defining Characteristics: caused by chemotherapy, especially
in patients with previous pelvic ir-
Verbalization of the problem, inac- radiation.
curate follow-through of instruc-
tion, request for information. 0 Defining Characteristics:
Cold extremities, pale skin, pale
mucous membranes, shortness of
breath tachycardia, tachypnea,
Risk for Infection anxiety, angina, bleeding, bruising.
(CH. 13)
Related to:
Chemotherapy/ radio therapy Risk for Pain
which impairs rapidly dividing nor-
mal hematopoietic cells resulting in 0 Related to:
immunosuppression. Nausea and vomiting as a result of
0 Defining Characteristics: chemotherapy, anxiety about treat-
ment.
Granulocytopenia, an absolute
granulocyte count (AGC) below Defining Characteristics:
1000 cells/mm3, neutropenia, an ab- Patient expresses feelings of pain or
solute neutrophil count (ANC) discomfort, moans, cries,
below 1000 cells/mm3. diaphoresis, ha6 blood pressure or
pulse changes.

(CH. 4) Activity Intolerance
Bone marrow suppression resulting El Related to:

in thrombocytopenia from Fatigue secondary to anemia
chemotherapy.
caused by chemotherapy and/or
I7 Defining Characteristics: radiation therapy.
Thrombocytopenia with platelet 0 Defining Characteristics:

count below 50,000 cells/mm3.
Verbal report of fatigue or weak-
pressure in response to activity.
Altered Nutrition: Less Than Knowledge Deficit

Body Requirements
Related to:
(CH. 2,8)
Chemotherapy, radioisotopes, or
Related to: biologic therapy given directly into
Anorexia, nausea, vomiting as a the abdomen.
result of chemotherapy, gastrointes- 0 Defining Characteristics:
tinal involvement of gynecologic
malignancy. Patient verbalizes lack of informa-
tion about treatment and potential
0 Defining Characteristics: side effects of intraperitoneal
Reported inadequate food intake, therapy.
loss of weight, early satiety. 0 Outcome Criteria:
Patient is able to verbalize treat-
ment plan and goals of therapy.
Body Image Disturbance NIC: Medication Administration-
(CH. 4) lntraperitoneal**
0 Related to: Definition: Administration of

medication through an in-
Alopecia, weight loss, ascites. traperitoneal catheter for the treat-
ment of a malignancy.
**not yet an accepted NIC
Verbalizes fear of rejection or reac-
tion of others to altered physical ap-
pearance.
Medication Administration-
lntraperitoneal
Excess Activities Rat ionales
0 Related to: Position patient in bed. Promotes comfort.
Large amounts of IV fluids used for Assess patency of Promotes delivery of
hydration during chemotherapy. abdominal catheter. therapy.
Defining Characteristics: Administer Prevents reactions.
premedications if
Edema, weight gain, shortness of
ordered.
abnormal breath sounds, rales, Monitor patient for Promotes early
crackles, change in respiratory or reactions during recognition of potential
mental status, blood pressure chan- infusion. problems.
ges, altered electrolytes, anxiety and
Note any leakage that Promotes accurate
restlessness. readings of output.
may occur from
catheter site.
~~ ~~~ ~~ ~~
Medication Administration- Altered Urinary Elimination

lntraperitoneal
(CH. 2)
Relatedto:
Surgical procedure for gynecologi-
Assist patient in Promotes distribution cal malignancy.
moving from side to of medication.
side.
Record amount Provides information. Dysuria, frequency, urgency, uri-

infused and drained nary retention, inadequate output.
from abdomen.
Constipation
(CH. 2)
Demonstrations I7 Related to:
Surgical procedure for gynecologi-
cal malignancy, pelvic and/or ab-
Activities Rationales dominal radiation therapy,
postoperative pain medication.
Teach patient/family Increased knowledge
purpose, benefits, and promotes 0 Defining Characteristics:
rationale for understanding. Constipation, absence of regular
intraperitoneal therapy. bowel movements, hard stool, loose
Inform patient of both Provides self-care watery stools, frequency of bowel
immediate, potential, information. movements, urgency.
and delayed effects.
Evaluation
Patient is able to verbalize un-
derstanding of procedure.
Sexual Dysfunction
(CH. 10)
Relatedto:
Hysterectomy, bilateral salpingo-
oophorectomy,pelvic exenteration.
Decreased libido, hormonal chan-
ges, physical changes due to
surgery.
Chapter Twelve
Gastrointestinal
Colorec tat
Cancers
Gastrointestina/ Cancers
This section includes discussions of cancers foods that are smoked or salt cured. Sex,
of the esophagus, stomach, liver, pancreas, race, and age also are risk factors, the disease
and large intestines. Following the specific occurs more commonly in males, African
disease discussions is a listing of the related Americans, and in people between 50 and 70
nursing diagnoses and the nursing interven- years old. People who have the inherited con-
tions for gastrointestinal malignancies. dition tylosis, which is recognized by an ex-
cessive growth of skin on the palms and
soles, are at greater risk for developing
Esophageal Cancer esophageal cancer. Medical conditions that
contribute to repeated imtation of the
Cancer of the esophagus, in the United esophageal mucosa including hiatal hernia
States, is a relatively uncommon disease. The (which causes reflux), achalasia, and
estimated incidence is 11,300 cases yearly. In esophageal stasis, are associated with an in-
Lin Xian county of the Chinese Henan creased incidence of this disease. Barrett’s
Province the disease is reported to be en- mucosa, in which metaplasia is present and
demic occurring in approximately 130 of the past history of an exposure to a caustic
every 100,000 persons. In the U.S., the prog- substance are also risk factors.
nosis of patients with esophageal cancer is
poor, with five-year survival rate of 9%.This
unfavorable outlook is related to the nature
of the disease: It grows rapidly, metastasizes
quickly and is advanced when diagnosed. The majority of esophageal lesions are
squamous cell in origin, comprising the
largest type of this cancer. These tumors arise
Risk Factors from the epithelial lining of the esophagus.
Aden0 carcinoma is the second most com-
Many factors have been associated with the mon type and sometimes is combined with
development of this disease, especially smok- squamous cell resulting in the classification
ing and alcohol consumption Dietary habits, of adenosquamous carcinoma. This classifica-
particularly frequent ingestion of tion of tumor is thought to arise from the
nitrosamines, is felt to contribute to the esophagogastric junction or to extend up-
development of esophageal cancer. These ward from the stomach. Rare types of this
substances are contained in high amounts in
244 ONCOLOGY NURSING PLANS
disease include sarcomas, melanomas, and esophagus for cytologic examination. The
verrucous quamous cell lesions. use of a similar type of screening in this
country has not been tried possibly because
that it would not be cost effective. Endo-
Signs and Symptoms scopic examination of the esophagus with
brushing to obtain cells or biopsy is often
Esophageal cancer in the United States is diagnostic. Barium swallow is used but can
often not diagnosed until advanced or metas- miss smaller lesions. Bronchoscopy is used
tatic disease is present. This is related to the when tumors are located in the upper section
fact that the initial complaints of a patient in- of the esophagus to determine whether or
cluding dysphagia, indigestion and a feeling not there has been extension into trachea or
of gastrointestinal fullness are vague and can lungs. The role of radiologic imaging (CT
be attributed to many other conditions. Scan or MRI) is not in diagnosis, but in the
These symptoms may be experienced for a evaluation of the extent of disease.
long period of time before the patient seeks
medical attention. There are many over-the-
counter medications available and adver- Treatment
tised for such ailments, which leads patients
to self-medicate. These symptoms can be Surgical treatment with radiation therapy is
easily attributed to the consumption of a par- the standard treatment for esophageal can-
ticular type of food(e.g., spicy fried,ethnic). cer. The type of surgical procedure depends
Also,the normal process of aging can be on the tumor’s location along the esophagus
used as an rationale for their existence. Dys- and the extent of disease. Esophagogastrec-
phagia and weight loss are the two most tomy involves the removal of the esophageal
common symptoms of esophageal cancer. segment containing tumor, then an anas-
Other symptoms may include anorexia, tomosis between the remaining esophagus
anemia, cervical adenopathy, choking after and the stomach is made. A section of colon
eating, and pain on swallowing. or jejunum may need to be used if there is
not enough of the esophagus remaining fol-
lowing tumor resection. Lesions in the upper
Diagnostic Tests portion of the esophagus may require exten-
sive procedures if the disease has spread to
Early diagnosis in the United States is rare surrounding areas. The thyroid, trachea,
related to the lack of screening tests. In the larynx, pharynx, and surroundinglymph
areas of China where the disease is endemic, nodes may be involved.
early diagnosis is possible through routine
Radiation therapy has been used both pre-
testing with a nasogastric tube that has an at-
and post-operatively. Squamous celi cancer
tached device to scrape cells of the
GASTROINTESTINAL/COLORECTALCANCERS 245
is radiosensitive, however this therapy alone vomiting, and difficulty swallowing may be
has not resulted in long term survival. Exter- severe. A complete disinterest in any kind of
nal beam radiotherapy may be given over 4 food may be present. Nutritional support
6 weeks in divided doses, then the patient with total parenteral nutrition and/or feed-
recovers for 1-2 months prior to surgery. It ings via a gastrostomy tube, is usually re-
may also be used palliatively to relieve quired. Aspiration of vomitus into the lungs
obstruction. The location of the tumor along remains a concern for these patients.
the esophagus influences the effectiveness of The risk of surgical mortality has decreased,
radiotherapy. Lesions above the aortic arch leaks at the sites of anastomoses now occur
are easier to radiate because there is less less frequently. Cardiovascular complica-
obstruction from surrounding organs. tions, including myocardial infarction and
Chemotherapy has been used both before pulmonary embolus, occur rarely but can be
and after surgery in combined modality treat- fatal. Gastric function will be altered when
ment, with or without radiation therapy. the stomach has been moved up to join the
These more aggressive approaches have not esophagus.
yet demonstrated increased survival and are Perforation of the esophagus and/or hemor-
associated with greater toxicity. Clinical trials rhage may occur once the tumor has been
are underway to evaluate the benefits of com- treated with radiotherapy or chemotherapy.
bined modality therapy. Cisplatin, alone or This is the result of response to treatment of
in combination with other drugs, has shown a tumor which extends through the
the most promise against squamous cell esophagus. The tumor cells are destroyed
lesions. Other forms of palliative treatment faster than normal cell replacement occurs,
include laser therapy to shrink tumors and leaving a disruption in the integrity of the
the placement of stents to open the esophagus. Strictures of the esophagus may
esophagus. occur following radiation, requiring dilata-
tion of the area to allow for swallowing.
Chemotherapy sideeffects are related to the
Complications agent or combination of medications used.
The most common side-effects related to
Nutritional concerns are often of prime im-
therapy with cisplatin include ototoxicity,
portance with the esophageal cancer patient.
neurotoxicity, bone marrow suppression,
At the time of diagnosis the person has usual-
nephrotoxicity, and nausea with vomiting.
ly experienced significant weight loss in a
The use of growth factors (See Chapter 5) has
short period of time. Experts report that
decreased episodes of neutropenic infection.
severe weight loss of 20-30 pounds is seen in
The development of new antiemetics, espe-
esophageal and pancreatic cancer patients.
cially the serotonin blockers granisitron
Anorexia related to the symptoms of nausea,
(Kytril) and ondansetron (Zofran)has
decreased the severity of nausea and vomit- gastric tumors. Smoking and alcohol con-
ing. sumption correlate with the development of
the disease. Workers in certain industries
also have a higher incidence of gastric can-
Gastric Cancer cer. These occupations include coal mining,

nickel refining, timber processing, and the
Cancer of the stomach is one of the few can- handling of rubber or asbestos. Lower
cers that has declined in incidence in the socioeconomic status is a definite contribut-
United States over the past fifty years. The es- ing factor, which may explain the nutritional
timated occurrence annually is 24,000 cases. and occupational influences. Race and age
This pattern of decreasing incidence in the also are risk factors. The diagnosis is made
United States is not evident in other twice as often in African Americans, and in-
countries. Statisticians report other changes creases in people over forty. The presence of
regarding the occurrence of this tumor, in- such health problems as pernicious anemia,
cluding increasing age at diagnosis, change gastric ulcers or polyps, chronic gastritis, in-
in location within the stomach, and a shifting testinal metaplasia, and another primary
pattern of pathological diagnosis. The five tumor, increases incidence.
year overall survival rate has improved to ap-
proximately 16%.
Risk Factors The most common type of gastric carcinoma

is adenocarcinoma, an epithelial tumor.
The most significant risk factor for develop- Malignant lymphoma is the second most
ing gastric cancer is the country where a per- common form of the disease, accounting for
son lives. This disease is a major health 8%of cases. When lymphoma occurs in the
problem in Japan, Chile, Finland, Poland, stomach it may be part of a systemic process;
Austria, Iceland and Yugoslavia. Japan has however, it is frequently a solitary presenta-
the highest incidence worldwide. Im- tion of the disease. Many of the soft tissue
migrants to the United States retain the risks sarcomas arise in the stomach, leiomyosar-
of their country of origin but their children coma being the most common, representing
do not. Nutritional and environmental issues 1-3%of overall pathologic diagnoses. Car-
may influence the development of stomach cinoid and plasmacytoma occur but the in-
cancer. The ingestion of foods high in cidence is quite low.
nitrates and nitrites, that have been salt-
cured, an absence of dairy products and
decreased amounts of Vitamins C, A, and E,
in the diet, seems to increase the incidence of
GASTROINTESTINALICOLORECTAL CANCERS 247
Signs and Symptoms indicator of a gastric tumor if the lesion

causes bleeding. The carcinoembryonic an-
Unfortunately, there are no specific early tigen (CEA) and cancer antigen 19-9 (CA 19-
signs and symptoms of gastric cancer. The 9) may be elevated in the serum.
most frequent complaints are epigastric dis- Unfortunately, false positive tests can occur
comfort, indigestion, and a feeling of fullness in patients with other gastrointestinalcondi-
after eating. These are vague symptoms easi- tions such as inflammatory bowel disease.
ly associated with an upset stomach, stress, Radiologic procedures, including an upper
or the consumption of fried or spicy food. GI series or barium swallow, may indicate
There are many remedies for these the presence of a lesion within the stomach.
symptoms available over the counter which Computerized tomography (CT) and mag-
most people try prior to seeking medical at- netic resonance imaging (MRI) may be help-
tention. Often symptoms have been present ful in delineating a mass and determining
many months, and physicians will prescribe the extent of the disease. Endoscopy with
a trial of antacids or ulcer prevention medica- biopsy or brush cytology remains the defini-
tions because the patient fails to accurately tive method of diagnosing this tumor.
report the length of time symptoms have per-
sisted. In many cases the symptoms of
gastric cancer are similar to peptic ulcers.
Treatment
Late symptoms of the disease may include
weight loss, anemia, vomiting, and weak- Surgical resection is the prime mode of
ness. A small percentage of patients present therapy for gastric carcinoma and will result
with acute symptoms such as gastrointes- in cure for early staged localized lesions. The
tinal bleeding or perforation. In these cases type of surgery depends on the size of the
emergency surgery may be required. lesion, location of the tumor within the
stomach, and the extent of disease. The goal
of surgery is to excise the tumor with a mar-
Diagnosis gin of adjacent tissue free of disease. When
the cancer is located in the fundus of the
There is no routine screening test for gastric stomach, a proximal subtotal gastrectomy is
cancer used in the United States. The performed; a lower portion of the esophagus
Japanese have undertaken routine endo- may need to be removed as well. Tumors lo-
scopic screening, because the disease is so cated in the body or central part of the
prevalent there. This testing has increased stomach usually require a total gastrectomy.
the numbers of patients diagnosed with A distal subtotal gastrectomy is the proce-
early stage disease and in those patients, test- dure of choice when disease is in the antrum,
ing has increased five-year survival to 90%. or lower part of the stomach. In addition to
A positive stool occult blood test may be an the options mentioned above, the surgeon
may elect to undertake a more extensive Complications

operation removing regional lymph nodes, a
portion of the duodenum, pancreas or liver, Following surgery, complications may in-
and spleen. The use of more extensive surgi- clude steatorrhea, dumping syndrome,
cal procedures remains controversial because nausea, vomiting, weight loss, vitamin
the overall fiveyear survival rate has not deficiency,diarrhea, and leaks at the sites of
been improved in cases of advanced disease. anastomoses. Medications may be required
Surgery may also be performed with a pallia- to slow gastric motility and control diarrhea.
tive intent, to reduce bleeding, or to alleviate The development of bezoars is a unique com-
an obstruction to improve the patient’s plication related to gastric surgery. A bezoar
quality of life. Laser surgery has been used to is an entangled mass of food residue, which
treat bleeding and obstruction when an may cause intestinal obstruction. It can
operative approach is not indicated. develop when food is not digested in the
usual fashion. Of course, this is related to the
Radiation therapy delivered by external
surgical procedure, which decreases the size
beam may be administered following
of the stomach. Sometimes they can be dis-
surgery to attempt to prevent recurrence.
solved using papain, an enzyme, or fresh
Since there are many organs in close
pineapple. However, if these treatments fail,
proximity to the stomach, toxicities ex-
surgical or endoscopic removal is necessary
perienced by the patient may be dose-limit-
to relieve obstruction. Metatases may occur
ing. Intraoperative radiotherapy, that is
quickly in gastric cancer because the
treatment administered in the operating
stomach is an organ with many lymphatic
room to the area prior to surgical closure, has
and blood vessels.
demonstrated some benefit in fiveyear sur-
vival rates. Research using this treatment
modality continues.
Single agent chemotherapy using 5-W,

Pancreatic Cancer
FUDR, Mitomycin, Thiotepa, or Doxorubicin Pancreatic cancer is the ninth most common-
has is some cases transiently improved ly occurring malignancy in the United States.
symptoms, but has not resulted in improved The estimated occurrence annually is 27,000
survival. Combinations of drugs including cases. It represents the fourth most common
FAM (5-FU, Adriamycin [doxorubicinl,
cause of cancer-related death in men and the
Mitomycin) and 5-FU with methyl CCNU fifthin women. The Korean population of
have demonstrated responses. Clinical trials Los Angeles has the highest incidence of the
with a variety of chemotherapeuticagents to
disease worldwide, occurring in 16.4 per
further improve response rates are continu-
100,000 people. The five year survival rate is
ing.
only 3%.
Risk Factors signs und Symptoms

Smoking is a risk factor for developing Unfortunatelythere are no early clinical
pancreatic cancer. The incidence is more than signs of pancreatic cancer. It is often referred
twice as high for smokers. Pancreatic cancer to as a silent tumor for this reason. Weight
is more common in black men than in white loss, jaundice and pain in the back or
men. Risk increases over age fifty with peak epigastric region are the most common friad
incidence in the seventh and eighth decades of symptoms. Unexpected weight loss may
of life. Pancreatic cancer incidence is not be significant, between twenty and thirty
higher in patients with chronic pancreatitis pounds, lost over a short period of time. Pain
or diabetes. There are no proven occupation- is a presenting symptom in 70-80%of
al risks. Reports in the past implicated coffee patients. The characteristicsof the pain may
consumption and alcohol use; however, depend on location of the tumor within the
these findings could not be replicated. Al- pancreas. Approximately 80%of pancreatic
though unusual, a genetic predisposition to cancers are located in the head of the
the development of the disease exists. Ac- pancreas. Pain related to these lesions tends
quired chromosomal abnormalities and gene to be midepigastric, dull, boring, steady and
mutations have been recognized in usually worse at night. Left upper quadrant
pancreatic cancer patients. The oncogeny pain is more common in lesions occurring in
KRAS and abnormalitiesin the tumor sup- the body or tail of the pancreas. Pain may
pression gene p53 have occurred singularly also radiate to the back. Lying flat may ex-
in over fifty percent of patients. acerbate the feeling whereas sitting up and
bending forward relieves it. Jaundice is
another common symptom, and is thought
to be related to bile duct obstruction. It is
often accompanied by annoying pruritus,
Adenocarcinoma of ductal origin accounts which can be resistant to medications. The
for 90% of pancreatic tumors. Islet cell itching may be caused by retained bile salts.
tumors make up another 5% of diagnoses A patient who has a palpable gallbladder
and the remaining cases are rare types in- without symptomsof cholangitis may have a
cluding, cystadenocarcinomas, malignant obstruction of the common bile
adenosquamous carcinomas, and duct. Other nonspecific gastrointestinal
microadenocarcinomas. symptoms include, anorexia, diarrhea, bloat-
ing, flatulence and melena. Thromboph-
lebitis, without other known cause, is often
related to pancreatic cancer.
Diagnosis Treatment
Abdominal x-rays and upper gastrointes- Surgery is the only curative option for
tinal contrast studies have not proved help- pancreatic cancer. At this time, many
ful in the diagnosis of cancer of the pancreas. patients are not candidates for a surgical pro-
Although ultrasound can detect blockages as cedure related to the presence of metastatic
well as some small tumor, experts recom- disease. The standard surgical approach has
mend computerized tomographic scanning been the pancreatoduodenectomyor Whip-
(CT)as the radiologic procedure of choice for ple procedure. This operation involves the
these tumors. Magnetic resonance imaging removal of the lower portion of the stomach,
has not been found to be superior to CT scan- the head of the pancreas, duodenum, upper
ning. The newest method of ultrasound, via jejunum and gallbladder with the common
endoscope, may be able to detect smaller bile duct. The gastrointestinalsystem is then
lesions than CT scans. Cells for cytologic ex- reconstructed anastomosing the remaining
amination may be obtained by endoscopic stomach, pancreas and liver to the jejunum.
retrograde cholangiopancreaticography Another surgical option is the pyloms-
(ERCP). The practice of angiography preserving pancreaticoduodenectomy
preoperatively to assess vessel invasion by (PPPD). This procedure differs from the
the tumor remains controversial. Fine-needle Whipple in that the stomach and a small por-
aspiration biopsy (IFNAB), is another area of tion of the duodenum remain intact. The ra-
controversy, because the procedure can be as- tionale for this operation is to maintain
sociated with complications, including the normal function of the stomach, reducing the
potential spread of cancer cells and bleeding. occurrence of postoperative gastric
Diagnostic blood screening has recently problems. Total pancreatectomy involves the
emerged as an indicator for the presence of removal of the entire pancreas, spleen,
pancreatic cancer. New tests such as CA 19-9, duodenum, lower portion of the stomach,
CA 242, CA 494, CA 50, Span 1, and DU- gallbladder and distal common bile duct.
PAN-2 are available to test the amount of The theory behind this procedure is that the
mucin-like antigens in the blood. At this risk of recurrence from residual tumor
time, no one test alone has emerged as an ab- within the pancreas has been eliminated.
solute indicator of the disease. However, in However, postoperative glycemic control
combination, the CA 19-9 and CA 242 can presents a formidable challenge. Patients
predict this tumor with some reliability. The must take pancreatic enzyme replacements.
present prognosis for advanced pancreatic In the small number of cases where the
cancer is poor, Earlier detection with blood tumor occurs in the body or tail of the
tests and endoscopic ultrasound may im- pancreas, and remains resectable, a radical
prove outcomes. distal pancreatectomy with splenectomy is
performed. Surgery may also be used with a
GASTROINTESTINAL/COLORECTAL CANCERS 251
palliative intent, to facilitate gastrointestinal Complications

function, when metastatic disease is present.
There are numerous procedures that may be Potential complications following surgery
undertaken depending on the location and for pancreatic cancer include anastomotic
extent of tumor. leaks, gastric dumping, and alteration in
pancreatic function. Pancreatic enzymes may
Chemotherapy has been used adjuvantly
need to be replaced orally. The control of
(following surgical resection), neoadjuvantly
pain and nutritional support to improve
(prior to surgery to shrink unresectable
quality of life remain prime concerns in the
tumors), and for the treatment of metastatic
care of these patients.
disease. The most active single agent is 5-
fluorouracil(5-FU).The combinations with
the greatest response rates have been FAM,
[5-FU, Doxorubicin (Adriamycin), Liver Cancer
Mitomycin C]and SMF [Streptozotocin,
Primary hepatic carcinoma, or liver cancer,
Mitomycin C, 5-FUI. Although responses
is uncommon in the United States with an es-
have been seen with chemotherapy, the over-
timated 14,000 cases annually. The incidence
all five-year survival rate has not improved.
of the disease is highest in China, Southeast
The Gastrointestinal Tumor Study Group
Asia, Taiwan, Hong Kong and parts of
(GITSG) conducts clinical trials with
Africa. The five-year survival rate is low, ap-
chemotherapy and radiotherapy to evaluate
proximately 2%.
treatments for pancreatic and other
gastrointestinal malignancies.
External beam radiotherapy and implanted
radiation sources have been used in the treat-
Risk Factors
ment of pancreatic cancer. The delivery of Age and sex can contribute to the develop-
doses of radiotherapy necessary to control ment of this malignancy, it occurs more com-
tumor growth may be influenced by the ex- monly in men and average age at diagnosis
tent and location of disease. There have been is 60 to 70 years. In the United States hepatic
cases of long term survival when tumoricidal cancer occurs more frequently in urban in-
doses of radiation therapy were ad- dustrialized areas. Cirrhosis of the liver
ministered. The role of intraoperative which has been alcohol-induced is associated
radiotherapy alone, or in combination with with the occurrence of hepatocellular car-
external beam therapy or chemotherapy is cinoma. Experts suggest that hepatitis B
being explored. Radiation therapy is often virus may cause hepatic cancer. Aflatoxins
used for symptom control, relieving pain from the fungus Aspergillus flavus are car-
and obstruction. cinogenic in animal models. It is thought
that the repeated consumption of aflatoxin-
contaminated food may cause malignant Symptoms

liver tumors in humans. This has been a
problem with food storage in tropical The most commonly occumng symptom of
countries. Parasitic infections are also primary liver cancer is abdominal pain
thought to influence the development of this which is aching, dull, and located in the right
disease. These infections occur frequently in upper quadrant. This pain is often con-
poverty-stricken areas where malnourish- tinuous, interferes with sleep, is worse lying
ment is a problem. Occupational exposure to on the right side, and may radiate to the
vinyl chloride or arsenic may increase risk. right scapula. Gastrointestinal symptoms in-
clude, weight loss, epigastric fullness, and
anorexia. Elevated liver function tests, jaun-
dice, ascites and the presence of a palpable
mass upon examination of the liver are often
Adenocarcinoma is the predominant cell signs of advanced disease. It has been
type of primary malignant hepatic cancers. reported that approximately 30%of patients
Hepatocellular carcinoma which arises from are asymptomatic at the time of diagnosis.
liver cells occurs most frequently and ac-
counts for 90% of tumors. Cholangiocar-
cinomas which arise from the bile duct cells Diugnostic Tests
make up 10%of diagnoses. The remainder of
these cancers are of a mixed cellular origin. Radiologic tests, including abdominal or
chest x-rays and liver ultrasound, may in-
Metastatic spread of other cancers to the
cidentally reveal the presence of a mass.
liver is a common occurrence. This occurs
Computerized tomographic imaging (CT
either through growth of an adjacent cancer
Scan) with contrast may assist the physician
into the liver or spread through blood ves-
in determining whether or not the
sels. The treatment of metastatic disease in
lesion/lesions are benign or malignant. Mag-
the liver may be similar to the treatment of
netic resonance imaging(MRI) has not
primary liver cancer. However, a metastatic
proved to be superior to CT Scan with con-
lesion usually retains the characteristics of
trast in detecting liver tumors. Angiography
the primary site. The method of treatment
defines blood vessel involvement prior to
for metastatic cancer may be very different
surgery. Needle biopsy is not recommended
from therapies recommended for hepatic can-
if surgical resection is a possibility, because it
cer. Metastatic breast and prostate cancer in
is thought that the tumor may tract into the
the liver may respond to hormonal treat-
abdominal cavity. In cases where needle
ments.
biopsy is performed, hemorrhage is a poten-
tial complication related to the increased risk
of bleeding with compromised liver func- resection but is not performed when curative
tion. resection is a possibility. This procedure is
Diagnostic blood tests include alpha- particularly useful when lesions are in dif-
fetoprotein (AFP)and carcinoembyronican- ferent lobes of the liver; standard resection
tigen (CEA).The AFF is elevated in would not leave sufficient functioning liver
approximately 80%of patients with tissue. A probe is inserted into the tumor
hepatocellular carcinoma, and is not usually with ultrasound guidance, then the lesion is
frozen. This treatment may be repeated at
increased in those people with cholangiocar-
cinoma or metastatic liver cancer. The CEA several sites. Cryosurgery is also useful in
may be elevated in patients with gastrointes- the treatment of metastatic liver cancers
tinal or other adenocarcinomas that are depending on the size, location and number
of tumors. Liver transplantation is not usual-
metastatic to the liver, especially colorectal
cancer. It is also elevated in 40-70% of people ly a surgical option for patients with hepatic
with hepatocellular carcinoma. Liver func- cancer related to the immunosuppressive
tion tests including transaminases are not medications necessary to prevent organ rejec-
diagnostic of cancer but elevations may alert tion following the procedure. This surgical
option is used in children with rare, isolated,
the physician to a potential hepatic problem.
hepatic tumors especially when a living, r e
lated donor is available. An ongoing clinical
trial is evaluating liver transplantation fol-
Treatment lowed by chemotherapy for several months.
Surgery is the only curative approach to Chemotherapy may be a treatment option
hepatocellular carcinoma but many long when surgical resection is not initially pos-
term survivals have been reported with sible or in the adjuvant setting following sur-
hepatic artery infusion of chemotherapy. gical resection. This approach may be used
Criteria for surgical resection includes the either systemically or via hepatic artery in-
size of the tumor, location of the cancer and fusion. If the tumor is located in an area that
the function of the noninvolved liver. receives blood supply from the hepatic
Hepatocellular carcinoma may occur in a artery, this vessel may be catheterized, and
local or diffuse pattern, one or two lesions in chemotherapy can be directly administered
the same lobe are easier to remove than to that specific area. Angiography must indi-
many tumors throughout the liver. Normal cate that the blood flows to the location of
hepatic tissue has the ability to regenerate. the cancer. Implanting an infusion pump
The patient with cirrhosis may not have facilitates outpatient treatment of
enough normal liver tissue in reserve to suc- chemotherapy by continuous slow infusion.
cessfully undergo resection. Cryosurgery, Direct administration of 5-FU, F'UDR or
freezing of liver tumors, is an alternative to other agents into the hepatic artery allows a
higher dose of medication to be ad- Complications

ministered than would be possible systemi-
cally. The reason for this is that the liver Complications are related to the form of
detoxifies many chemotherapeuticagents. treatment provided and to the disease’s
The drug is less potent by the time it reaches ability to compromise normal hepatic func-
the circulation, so there are usually less sys- tion. Postoperative concerns include hemor-
temic adverse effects. Response rates have rhage due to alterations in the clotting
been reported to be high; however, in the factors, biliary fistula, infection, and pul-
small number of patients treated with a monary problems. Adverse effects from
variety of medications, it is difficult to chemotherapy are specific to agents used: 5-
generalize. The technical improvements in FU and FeJDR may exacerbate anorexia, and
catheter placement and ambulatory infusion diarrhea. Jaundice and ascites are generally
pumps have decreased the reported number associated with advanced disease. The inser-
of complications. tion of a biliary drainage tube may decrease
jaundice. Lotions and medications (antihis-
Radiation therapy delivered by external
tamines, cholestyramine) can relieve annoy-
beam, alone or in combination with
ing pruritus. Paracentesis temporarily helps
chemotherapy has a role in palliative care of
ascites; however, reaccumulation of fluid
patients with hepatocellular carcinoma. The
usually occurs.
dose of radiotherapy is the limiting factor, re-
lated to the organ tolerance of the treatment.
High doses of radiation to the liver may
cause hepatitis and liver failure. Lower doses Colorecfa/ Cancer
delivered over a few weeks may decrease
Colorectal cancer is a common disease in the
pain and alleviate other symptoms contribut-
United States, with a predicted incidence of
ing to an improved quality of life.
152,000 new cases yearly. This estimate in-
Ligation or embolization of blood vessels cludes 109,000 tumors arising in the colon
that supply the tumor is another option for and 43,000 lesions originating in the rectum.
treatment of inoperable hepatic cancer. The The incidence of the disease in this country is
rationale for this approach is to starve cancer higher than in many other nations. Exclud-
cells by eliminating oxygen and nutrition ing skin cancer, it is the second most fre-
supplied by the circulation. A quently occumng malignancy in women and
chemotherapeutic agent may be given simul- third in men. Colorectal cancer is the third
taneously with either of these procedures. most common cause of cancer-related death
in the United States. The five-year survival
rates are related to stage of the disease at
diagnosis. Early noninvasive tumors are as-
sociated with a 85-91%survival, but this fig-
ure drops to 51-60% survival with local

spread, and to 7% survival when distant
metastases are present. The five-year overall Adenocarcinoma is the most common type
survival rate for anal cancer is 48-66%. of colorectal cancer, with 95% of tumors in
the large intestine of this cell type. Other, less
frequently-occurring types, are squamous
Risk Fuciors cell carcinoma, malignant melanoma, basal

cell carcinoma, lymphoma, sarcoma, and car-
Colorectal cancer occurs equally in both cinoid tumors.
sexes, the incidence increases over the age of
50 years. Predisposing diseases have been
identified with increased risk of developing Signs and Symptoms
these tumors. Familial polyposis, chronic ul-
cerative colitis and Crohn’s disease are as- Change in bowel habits, blood in the stool,
sociated with tumor occurrence at an earlier constipation, change in appearance of the
age than the general population. Genetic stool, tenesmus, anemia and rectal bleeding
predisposition for the disease has been recog- are common complaints that may indicate
nized and published in recent reports. In- the presence of a colorectal cancer. Unfor-
creased risk is associated with family cancer tunately, many people with rectal bleeding
syndrome, in which members have greater will attribute this to hemorrhoids and delay
incidence of colon, breast, and uterine seeking medical attention for many months.
tumors. Dietary influences such as a low Symptoms of more advanced disease include
fiber and high fat content in foods are palpable mass, obstruction, nausea, weight
thought to increase risk. Countries with diets loss, pain, and pressure in rectum.
high in fiber and low in fat content have less
incidence of colorectal cancer. The reason for
this may be that diets higher in fiber are as- Diagnostk Tests
sociated with increased bowel movements
preventing prolonged contact of a potential The American Cancer Society recommends
carcinogen with the mucosa of the large in- annual digital rectal exam over age 40, stool
testine. Irritation of the anal canal may con- sample for occult blood annually after 50,
tribute to the development of cancers in this and proctosigmoidoscopy every 3-5years
segment of the bowel. Hemorrhoids, fistulas, after 50, following two negative annual
fissures and abscesses in the anus may be as- exams. These recommendations are for
sociated with lifestyle and/or sexual prac- asymptomatic people, more frequent evalua-
tices. tion is necessary in individuals with known
risk factors.
The stool sample for occult blood, although gin of normal tissue, and regional lymph
not specifically diagnostic for colorectal can- nodes. Palliative operations are often less ex-
cer, is an inexpensive, relatively easy test that tensive. When a cancer develops in the rec-
indicates the presence of blood in the diges- tum, an anterior resection or abdominal
tive tract. It is important that the dietary and perineal resection is performed. The low
medication restrictions are clearly under- anterior resection is used when the tumor is
stood by patients having this test to ensure located 10 cm or more away from the anal
accurate results. False positive tests may verge. Relatively normal bowel function can
occur, but repeated positive results should be be expected following this procedure. Reser-
followed by a radiologic exam of the vation of anal continence requires that anal
gastrointestinal tract. sphincter control be maintained, this can be
Barium enema can identify interior lesions achieved if sufficient tissue remains follow-
of the colon. Direct visualization of the ing removal of the cancer. The ab-
mucosa and biopsy, or removal of polyps, is dominoperineal resection is a more

complicated procedure involving incisions in
possible with the colonoscopy or proctosig-
moidoscopy. Computerized tomographic the lower abdomen and perineal areas. This
scanning (CT)is valuable in the staging of procedure is associated with sexual dysfunc-
the disease. The examination of the entire pel- tion in men. The creation of a permanent
vis may identify lymph node involvement or colostomy is necessary when the rectum is
liver metastases. removed.
There is no definitive diagnostic blood test If the tumor is located in the colon, a
for colorectal cancer. The carcinoembryonic primary renastamosis, or a colostomy, or
antigen (CEA), a tumor marker, may be double barreled colostomy is performed. The
elevated in any adenocarcinoma. However, size of the tumor and its location influence
this test may be used to evaluate the the need for a permanent colostomy with
response to treatment in specific patients. surgery. A temporary colostomy may be
created during emergent procedures to
relieve obstruction; however, in many cases a
permanent colostomy is necessary.
Treatment
Surgical intervention for anal cancer invol-
Surgery is the recommended treatment ap- ves the removal of the entire anal canal, and
proach in approximately 75% of patients if local metastases has occurred adjacent
with colorectal cancer. The type of operation structures may also be removed. Colostomy
performed depends on the size, location, and and urinary diversion may be necessary
extent of the tumor. When the goal of depending on the extent of disease.
surgery is curative the procedure involves
Chemotherapy with fiveday 5-FU has been
the removal of the tumor, a surrounding mar-
useful in the adjuvant setting for colorectal
carcinomas. Recent treatments use 5-FU with cause diarrhea, nausea, and bone marrow
levamisole or leucovorin. Other agents used suppression. Radiotherapy can contribute to
have been methotrexate, 5-fluorouracil the development of strictures and irregular
doexyribonucleoside (FUDR), and cisplatin. bowel function.
Palliative treatment has been used to control
symptoms of metastatic disease.
Radiotherapy can be used preoperatively to Essential Nursing
shrink inoperable tumors, postoperatively Diagnoses Related to
when margins have not been as wide as the
Coping with the
surgeon would have preferred, or in more in-
vasive tumors and intraoperatively. This
Diugnosis of
mode of therapy may also be used adjuvant- Gastrointestinal
ly with or without chemotherapy. Malignancy
Radiation therapy is the treatment of choice
for small, well-differentiated rectal and anal
cancers. A recent approach for anal cancer is Fear
the combination of radiotherapy and (CH. 1)
chemotherapy with 5-FU and Mitomycin. R Related to:
This approach is an alternative to colostomy, Diagnosis of a gastrointestinal
with radiation, when treatment is successful. malignancy, possibility of poor
Radiation therapy has also had a role in pal- prognosis, colostomy, loss of nor-
mal gastrointestinal function.
liative symptom control in metastatic dis-
ease.

(CH. 1)
Complications 0 Relatedto:
Surgical complications are specific to the Diagnosis of esophageal, gastric,
procedure performed. Hemorrhage, anas- pancreatic, hepatic or colorectal can-
cer, and uncertain prognosis.
tomotic leaks, stricture, abscess, wound infec-
tion and bowel irregularity are potential
problems. Sexual dysfunction may be an ex- Inability to meet basic needs, de-
pected outcome, depending on the opera- anxiety, poor self esteem, verbaliza-
tion, and colostomy should be discussed tion of inability to cope.
with the client prior to surgery. Adverse ef-
fects associated with chemotherapy are re-
lated to the medication given. 5-FU may
Altered Family Processes Anxiety

(CH. 1) (CH. 1)
0 Related to: 0 Relatedto:
Impact of cancer diagnosis and un- Perceived self threat due to diag-
certain prognosis. nosis of a gastrointestinal malignan-
cy (poor prognosis in esophageal,
0 Defining Characteristics: pancreatic, gastric and hepatic can-
Family systems unable to meet cers) or treatment.
physical, emotional needs of Defining Characteristics:
patient, or verbalization by family
members of inability to cope. Verbalizesfeelings of uncertainty,
apprehension, fear, sleeplessness, or
other signs of anxiety.
Knowledge Deficit
(CH. 2,4,3)
Essential Nursing
Related to:
Lack of knowledge about
gastrointestinal cancer disease Disease or Treatment
process and it’s treatment.
Verbalization of the problem, inac- Altered Nutrition: Less than
tion, request of information. Body Requirements
(CH. 2)
0 Related to:
Anticipatory Griev in g Gastrointestinal dysfunction
and/or obstruction, surgical inter-
(CH. 1)
ventions, and/or side effectsfrom
0 Related to: chemotherapy or radiotherapy in-
terfering with patient’s ability to in-
Actual and/or perceived losses due gest /digest food.
to cancer such as loss of health, loss
of life, work, privacy, intimacy and 0 Defining Characteristics:
relationships.
Weight loss, dysphagia, inability to
0 Defining Characteristics: swallow, anorexia, vomiting, diar-
rhea, dumping syndrome.
feelings of sadness or loss.
Pain High Risk for Aspiration

(CH. 2," (CH. 16)
0 Related to: 0 Related to:
Organ manipulation during surgi- Swallowing dysfunction related to
cal procedure and incision sites pos- esophageal cancer, surgical inter-
toperatively vention for lesions in the cervical
area, gastrointestinal malignancies
0 Defining Characteristics: causing vomiting.
Patient voices complaints of pain at III Defining Characteristics:
the incision site/sites and/or from
gastrointestinal tube. Impaired swallowing, choking, fre-
quent vomiting.
IneffectiveAirway Clearance
(CH. 8) Decreased Cardiac Output
(CH.2)
0 Related to:
I7 Related to:
Increase in secretions from surgical
manipulations, presence of an artifi- Surgical procedure and administra-
cial airway inhibiting ability to clear tion of anesthesia.
secretions; decrease in level of con-
sciousness from anesthesia and/or 0 Defining Characteristics:
pain relief medications which may Variations in blood pressure read-
impair ability to clear secretions. ings, jugular vein distension,
0 Defining Characteristics: decreased peripheral pulses, arryth-
mia, color changes in skin and
Abnormal breath sounds (rales, mucous membranes, cold, clammy
crackles, rhonchi), decrease in rate skin, oliguria, dyspnea, rales, rest-
and depth of respirations, tachycar- lessness.
dia, ineffective cough, pain inhibit-
ing ability to cough.
Risk for Injury

Impaired Gas Exchange 0 Related to:
(CH. 2) Complications of surgery such as
0 Related to: anastomotic leaks, fistula formation.
Postoperative ventilation perfusion 0 Defining Characteristics:

imbalance. Excessive drainage from chest
0 Defining Characteristics: tubes, pneumothorax, hydrop
neumothorax, change in type of
Confusion, cyanosis, dyspnea, chest tube drainage, change in type
hypoxia, restlessness, hypercapnia, of gastrointestinaltube drainage.
inability to move secretions.

Prompt recognition of anastomotic Demonstration
leaks
0 NIC: Tube Care- Gastrointestinal Activities Rut ionales
Definition: Management of a Instruct patient and Promotes consistent
patient with a gastrointestinal tube. family not alter suction.
settings of equipment.
Instruct patient to Provides data that may
report feelings of indicate partial or
Tube Care- Gastrointestinal fullness and nausea. complete blockage of
tube.
Activities Rut ionales Evaluation
Maintain suction as Prevents increased Patency of gastrointestinaltube is
ordered. pressure on suture maintained.
lines.
Irrigate tube regularly Promotes patency of
as ordered. tube.
Secure tube with Prevents accidental Impaired Skin Integrity
consideration for pulling of operative (CH.2)
patient comfort and area.
skin integrity. 0 Related to:
Monitor fluid and Provides data on Surgical incisions.
electrolyte status. which changes may be 0 Defining Characteristics:
made.
Replace the amount of Redness around incision site,
Prevents fluid and
gastrointestinal output purulent drainage from incision
electrolyte.
with the ordered IV site; patient verbalizes increased dis-
solution imbalance. comfort at incision site.
Provide nose and Promotes integrity of

mouth care as mucous membranes.
scheduled. Body Image Disturbance
Allow physician to Prevents trauma to
reposition tube. anastomotic areas. Related to:
Creation of an ostomy due to loca-
tion of colorectal cancer.
L7 Defining Characteristics:
Patient voices fears regarding
change in physical appearance, non-
verbal responses to change in body
appearance (ostomy), fears of an-
ticipated change in activities of
daily living, and of changes in so-

cial or sexual relationships.
1 Body Image Enhancement
0 Outcome Criteria:
Body image improved, preserved
and maintained. Encourage open Promotes
Accommodationsmade for and communication family/patient coping.
adaptation to ostomy begun. between patient and
family over creation of
0 NIC: Body Image Enhancement ostomy and impact of
illness.
Definition: Improving a patient's
conscious and unconscious percep- Encourage visitor from Promotes feelings of
tions and attitudes toward hidher an ostomy group to see acceptance.
body. patient before
discharge.
Body Image Enhancement ~ ~~ -~
Demonstration
Encourage patient to Promotes integration
express feelings of changes into Activities Rationales
regarding ostomy and lifestyle. Inform patient of Provides potential
diagnosis of colorectal community resources resources for
cancer, and expected such as ostomy groups. continued support.
impact on lifestyle.
Give patient written Provides reinforcement
Evaluate patient's Provides background materials regarding of verbal information.
feelings regarding data on which to ostomy groups.
ostomy and its effect formulate care plan. -
on sexual identity, 0 Discharge or Maintenance
relationships, and Evaluation
body image.
Patient is able to care for os-
Assist patient to Promotes positive self-
tomy.
appearanceand Patient verbalizes an aware-
feelings of personal ness of possible modes of s u p
worth. port other than family
following hospital discharge.
Give permission to Allows patient needed
grieve over loss of time to cope with
normal bowel function. losses.
Allow to vent negative Promotes coping as Sexual Dysfunction
emotions such as anger these are n o d (CH.10)
and guilt. reactions to loss.
Inability to view
0 Relatedto:
Monitor whether
patient can look at ostomy may indicate Some surgical interventions for
ostomv. coping difficulties. colorectal cancer.
Inability to perform sexually as was
possible preoperatively; decreased
libido.
Chapter Thirteen
Leukemia
LEUKEMIA 245
Leukemia
Leukemia is a malignancy originating in the the philadelphia chromosome abnormality
stem cells of the hematopoietic system which in chronic myelogenous leukemia (CML).
results in uncontrolled proliferation of white There have been reported cases of clustering
and, rarely, red blood cells. It is a disease of of CML and chronic lymphocytic leukemia
the blood and the organs in which blood (CLL) within families. The presence of cer-
cells are formed, and characterized by the tain congenital disorders influence the occur-
proliferation of abnormal immature cells. rence of leukemia. Down’s syndrome,
The presence of these cells affects the produc- Fanconi’s anemia, Kleinfelter’s syndrome,
tion of other normal blood cells. Bloom’s syndrome, Turner’s syndrome and
The estimated annual incidence of leukemia Wiskott-Aldrich syndrome are all associated
is 29,300 new cases in the United States. The with an increased incidence of the disease.
occurrence is evenly split between chronic Many acquired disorders also seem to in-
crease the risk of leukemia. These include:
and acute leukemia. Occurring more often in
adults than children, the total yearly myeloproliferative conditions such as,
polycythemia Vera, primary thrombocytosis,
childhood incidence is 2,600 cases yearly.
However, it remains the most common agnogenic myeloid metaplasia,
malignancy of childhood, representing 30% myelodysplastic syndromes, and paroxysmal
nocturnal hemoglobinuria (PNH).
of pediatric cancers. The five year survival
rate has steadily improved over the past thir- Exposure to ionizing radiation has been as-
ty years and is presently 37% overall, with sociated with the development of leukemia.
an annual death rate of 18,600. The Epidemiologic studies have revealed the in-
Leukemia Society of America has poignantly creased incidence in radiologists and in
illustrated the improved survival rates with Japanese people following the atomic bomb
the television commercial of a sports exposure which ended World War 11.
stadium with filling seats for those long term Chemical exposure to benzene and deriva-
survivors. tives of this chemical is known to increase
risk. Other drugs, especially the alkylating
agents used to treat certain cancers, may
Risk Factors cause leukemia. Patient‘s who have been
treated for Hodgkin’s disease, especially
The cause of leukemia remains unknown, those who have received both radiation
but genetic influences have been implicated. therapy and chemotherapy with nitrogen
A specific example of this is the presence of mustard, have a higher incidence of
leukemia. In this instance many questions

have been raised, whether the treatment of
Hodgkin’s disease is responsible, or is the Leukemias are classified as either acute or
presence of this type of lymphoma the chronic, then further subdivided by the
reason for a greater number of leukemic malignant cell line involved. The two major
cases. Another quandary is the correlation types of acute leukemia are acute lym-
observed between long-term treatment of phoblastic leukemia (ALL) and acute non-
multiple myeloma and melphalan (Alkeran). lymphoblastic leukemia (ANLL).
This medication is another alkylating agent The most frequently occurring childhood
associated with the development of secon- leukemia is ALL, representing 80%of
dary malignancies. Chloramphenicol, an an- pediatric cases. The disease is further
tibiotic has also been implicated in the divided by the immunologic cell involved
development of leukemia. such as T-cell, B-cell, or undifferentiated. The
Although it remains unproven in childhood disease develops rapidly, usually without
cases, viruses are thought to be a potential warning. The immature white blood cells
trigger of oncogenies that may lead to retain some of the properties of normal lym-
leukemia. Adult T-cell lymphotrophic virus phoblasts which allows them to migrate to
(HTLV)-I is associated with adult T-cell any organ or area of the body.
leukemia, and hairy cell leukemia, a variant Acute myelogenous leukemia (AML), often
of chronic lymphoblastic leukemia (CLL) has used as a subdivision instead of ANLL, is the
been linked to the HTLV-11 virus. most common subdivision of the acute non-
Age is a risk factor for certain types of lymphoblastic leukemias. AML occurs in the
leukemia. Acute lymphoblastic leukemia, late adolescent years and in young adults,
comprising 80%of all cases, occurs most fre- and there is another peak of the disease after
quently in childhood. Chronic lymphocytic age fifty. The leukemic transformation can
leukemia (CLL) occurs most frequently in occur at any stage along the myeloid matura-
persons over 50 years old. The peak in- tion pathway. The specific name for a par-
cidence of chronic myelogenous leukemia ticular type of ANLL indicates the malignant
(CML) is between 50 and 60 years old; how- cell involved. An example of this is acute
ever, this disease does occur in children. promyelocytic leukemia (APL) which invol-
ves the promyelocyte, a precursor of the
Race may also be a risk factor. In the United
myelocyte. Like ALL, ANLL develops rapid-
States Caucasians develop acute lymphoblas-,
ly without warning.
tic leukemia (ALL)more commonly than
African Americans. CLL is slightly higher in The chronic forms of this disease are chronic
men than women. myelogenous leukemia (CML)and chronic
lymphocytic leukemia (CLL). Chronic
myelogenous leukemia is a disease of
LEUKEMIA 267
myeloid white cells, and it is associated with hepatosplenomegaly are often present. The
the presence of the Philadelphia complete blood count is abnormal with a
chromosome abnormality in 90% of cases. low hemoglobin and hematocrit, a decreased
Chronic lymphocytic leukemia is a malignan- platelet count and an elevated white count;
cy of lymphocytes. The chronic leukemias however, infection-fightinggranulocytes are
tend to occur slowly over a period of time usually very low on the differential. Usually
with the exception of a blast crisis, or ac- noted are blasts which are lymphoblasts or
celerated phase, of CML. An unusual type of immature lymphocytes.
chronic leukemia is hairy cell leukemia. ANLL's presentation may be similar to that
Under a microscope the malignant cell has of ALL. Fever, fatigue, easy bruisability, infec-
projections from its surface. It is these fine tion, shortness of breath, weight loss, and
cytoplasmic strands that give the bleeding may be among reasons that the
mononuclear cell the appearance of being patient seeks medical attention. Particular
hairy. presenting symptoms are peculiar to certain
subtypes of ANLL. Patients with Ah4L m y
show the presence of gingival hyperplasia
Signs and Symptoms from leukemic infiltrates on oral exam. Skin
showing appearance of a rash may reveal
Symptoms of leukemia can be very mild or cutaneous invasion of these leukemic cells.
nonexistent as commonly Seen in the chronic Bleeding or hemorrhage related to Dissemi-
leukemias, or they can be severe, as some nated IntravascularCoagulation (DIC) is a
times observed in the acute leukemias. serious condition associated with APL.
The presentation of ALL includes symptoms When the white blood count is very high
of anemia, bleeding, fever, malaise, infection, (100,000 immature cells) leukostasis, or
and bone pain. The bone pain is sometimes clumping of these cells, may occur and has
attributed to the growing pains of childhood; the potential of causing serious neurological,
however, it is caused by the proliferation of cardiac, or pulmonary complications. The
leukemic cells, especially in the long bones. total white blood count is usually elevated,
Neurological symptoms including headache, with blasts on the differential.
nausea, vomiting, and visual disturbances The patient with CLL may present with only
present may be related to leukemic infiltra- a mildly elevated white blood cell count.
tion of the central nervous system. Fatigue This is generally an indolent disease which
from anemia and petechiae related to throm- may be present for a long period of time
bocytopenia also are common symptoms. without the person's knowledge. Symptoms
Bruises appearing on parts of the body not such as fatigue, weight loss, night sweats,
normally associated with trauma are some- shortness of breath, and bleeding may be
times detected. Lymphadenopathy and noted in more advanced cases. Anemia and
thrombocytopenia are present at diagnosis in Therapy for ALL is divided into stages, and
25-35% of patients. the initial treatment is called remission induc-
The presenting signs and symptoms of CML tion. Usually three or more drugs are given
depend on which stage of the disease at the in a prescribed sequence, depending on the
regimen or protocol. Many induction plans
time of diagnosis. The three stages of CML
are stable or chronic, accelerated and blast include prednisone, vincristine (Oncovin),
crisis, or acute. Abnormal blood counts, daunorubicin (Daunomycin),and L-
fever, night sweats, weight loss, fatigue, asparaginase (Elspar).Other medications

malaise, bruising, bleeding, and decreased that may be included in initial treatment are
exercise tolerance may be initial symptoms. 6-mercaptopurine (Purinethol)and
Splenomegaly is present in about 50% of methotrexate (Mexate). Allopurinol is ad-
patients often causing abdominal discom- ministered orally in conjunction with
fort. The accelerated period is marked by chemotherapy to prevent hyperuricemia and
worsening symptoms related to increased potential kidney damage. Following four

weeks of therapy, 85-90%of children and
production of malignant cells. Often present
are bone pain or tenderness, and over 50% of adults with ALL are in complete
hepatomegaly. When persons are in the blas- remission. Teniposide (VM-26) and cytosine
tic phase of CML, the above symptoms are arabinoside (Ara-C) may be used to induce
severe. remission if the initial regimen fails. A short

Diagnosis consolidation phase of treatment may follow
The complete blood count with differential is remission induction; this phase is controver-
the first indication that leukemia may be sial and the patient may begin maintenance
present. All of the leukemias are diagnosed chemotherapy. Methotrexate and 6-mercap-
by bone marrow aspiration and biopsy. topurine are the two drugs given most often
These samples are usually obtained from the in the maintenance phase, which lasts 2-3
iliac crests following a local anesthetic and years and is outpatient therapy. Many ALL
can also be taken from the sternum. Physical patients will relapse within months if main-
examination and a detailed recent medical tenance chemotherapy is not given.
history are important elements of diagnosis. Central nervous system (CNS) prophylaxis is
given to patients with ALL, because many
relapses occur in the CNS. Intrathecal
Treatmenf chemotherapy and/or craniospinal radiation
therapy have been used for this treatment.
The goal of treatment of acute leukemias is An ommay reservoir may be placed for in-
complete remission, which is defined by less trathecal chemotherapy to avoid repeat lum-
than 5%blasts in the bone marrow, Treat- bar punctures. If relapse occurs, a second
ment of choice is combination chemotherapy. complete remission may be achieved with
LEUKEMIA 269
chemotherapy; however the time between sion induction. CNS prophylaxis is not
each subsequent relapse will be shorter. Bone routine in ANLL as it is in ALL. If C N S dis-
marrow transplant has been used to treat ease is present in ANLL, cranial irradiation
relapsed patients. Testicular relapse is com- and intrathecal cytosine arabinosideand/or
mon in males with ALL. Treatment of adults methotrexate are used. Unfortunately many
with ALL is basically the same as that of patients relapse and re-induction therapy for
children; however long term remission is less ANLL is not as successful as it is for ALL.
common.
Bone marrow transplant, either autologous
Remission induction is the initial treatment (from a person’s own marrow) or allogenic
in ANLL. Other phases of treatment are con- (from a donor), may be performed. Generally
solidation, maintenance, and reintensifica- the best results are seen in patients in rernis-
tion. Combination chemotherapy used sion. Allogenic bone marrow transplant may
initially usually includes cytosine be associated with graft versus host disease
arabinoside (Ara-C)and daunarubicin (GVHD),a condition where the donor T lym-
(Daunomycin).Other medications that have phocytes react against the immunosup-
been used for this phase of treatment are 6- pressed recipient tissues. GVHD may be
Thioguanine (Thioguanine),Idarubicin exhibited by mild or severe symptoms in-
(Idamycin),Mitoxantrone (Novantrone)and volving the skin, liver, and gastrointestinal
Etoposide (VP-16, VePesid). About 60%of tract. Successful bone marrow transplant can
patients with ANLL experiencecomplete result in long-term survival.
remission. The decision to begin treatment for the
Severe neutropenia associated with induc- patient with CLL usually is dependent on
tion therapy may cause extended hospitaliza- the patient‘s symptoms and the degree to
tions. Consolidation therapy may include which those symptoms interfere with the
cycles of the previous drug regimen or other patient’s quality of life. Patients who are
medications such as 5-azacytidine or am- asymptomatic generally do not benefit from
sacrine (M-AMSA).Maintenance therapy early treatment. When anemia and throm-
generally continues for at least a year; how- bocytopenia develop, chlorambucil
ever, the need for, and duration of, main- (Leukeran)and prednisone may be started.
tenance and reintensificationphases of These oral drugs are given in low doses. If
treatment remain controversial. The follow- the blood counts return to normal, medica-
ing agents have been tried in combination of tion may be discontinued for a period of
two or more: Vincristine, cytosine time. Cyclophosphamide (Cytoxan),vincris-
arabinoside, 6-mercaptopurine and pred- tine (oncovin)and prednisone, or CVP,is
nisone. another mode of therapy if the former treat-
The reintensification phase may involve a ment is ineffective. CVP may be given with
return to the medications used during remis- doxorubicin (Adriamycin).Fludarabine

(Fludara) and 2-CdA (Cladribine)are other marrow suppression, bleeding due to throm-
chemotherapeutic agents that have proved bocytopenia, and neurological incidents, re-
helpful in treating patients with advanced lated either to hemorrhage, leukemic
disease or when other agents are no longer infiltrates in the CNS, or to leukostasis.
successful in controlling symptoms. Radia- Tumor lysis syndrome, which may occur
tion therapy has also been used in the treat- during treatment, and disseminated intravas-
ment of CLL, primarily for enlarged lymph cular coagulation, related to acute
nodes or splenomegaly. promyelocytic, are discussed in the metabo-
Hairy cell leukemia, a CLL variant, was lic emergency chapter. The care of the bone
treated in the past primarily with splenec- marrow transplant patient has become an on-
tomy and supportive care. The use of alpha cologic nursing specialty, and a specific nurs-
ing reference should be consulted for this
interferon and/or deoxycoformycin (Pentos-
tatin) have shown such promising results in information.
clearing these abnormal cells from the cir- Infection related to the patient’s inherent
culation that this treatment may replace microorganisms may occur whenever aggres-
splenectomy. Another agent that has sive chemotherapy is given or bone marrow
demonstrated success in the treatment of transplantation is performed. Non-inherent
hairy cell leukemia is 2-CdA. organisms including viruses, protozoa,
The treatment of CML is dependent on the parasites, fungi and environmental bacteria
phase of disease a person is in when they are also pose a great risk for the im-
diagnosed. Patients in the chronic phase of munocompromised patient. Septic shock
treatment generally receive a oral may occur, and is most commonly seen, with
chemotherapeutic agent either melphalan gram-negative bacteria. The febrile

neutropenic patient requires close monitor-
(Alkeran),busulfan (Myleran)or
hydroxyurea (Hydrea). Alpha interferon, ing because as an unexplained drop in blood
given subcutaneously, has also proved effec- pressure, or increase in heart rate and respira-
tive. Once the disease has progressed to blast tions, may herald the late phase of shock. It
crisis, aggressive chemotherapy has been is essential that the causative organism be
used but with only small remission rates. Al- treated with antimicrobial medications. This
logenic bone marrow transplantation offers presents a formidable challenge because it is
the only potentially curative option, if a often difficult to identify the organism. This
suitable donor is available. The results of is why prophylactic antimicrobial medica-
bone marrow transplantation are improved tions are given to leukemic patients.
if it is performed prior to blast crisis.
Complications
Complications related to leukemia and its
treatment include infection related to bone
LEUKEMIA 271
Essentiul Nursing
Diagnoses Related to feelings of sadness or loss.
the Diagnosis of
1eukemia
KnowIedge Deficit
(CH.1)
Ineffective Individual Coping 0 Relatedto:
(CH.1) Lack of knowledge about leukemia
and its treatment.
Relatedto:
Diagnosis of leukemia and uncer-
tain prognosis. Verbalization of the problem, inac-
curate follow-throughof instruc-
Defining Characteristics: tion, request for information.
Inability to meet basic needs,
chronic fatigue, dependency, worry,
anxiety, poor self esteem, verbaliza-
tion of inability to cope. Essential Nursing
Bone Marrow
(CH. 1 1
Suppression
0 Related to:
Impact of leukemia diagnosis and
uncertain prognosis. Risk for Infection
Defining Characteristics: 0 Related to:
Family systems unable to meet Leukemic infiltration of bone mar-
physical, emotional needs of row and chemotherapeuticmedica-
patient, or verbalization by family tion used for treatment.
Granulocytopenia, an absolute
granulocyte count (AGO below
Anticipatory Grieving 1000 cells/mm3. Neutropenia, an
(CH. 1 ) absolute neutrophil count (ANC)
below 1000/M3.
0 Related to:
0 Outcome Criteria:
to leukemia such as loss of health, Reduced potential for infection.
life, work, income, privacy, in-
timacy and relationships.
NIC: Infection Protection Infection Protection

Definition: Prevention and early
detection in a patient at risk.
Act iuities Rationales
Institute In some institutions
Granulocytopenic granulocytopenic
precautions per precautions are
Infection Protection
institutional policy initiated when ANC>
including 1000 and in others not
1)Private room with until the A N 0 500.
Activities Rat ionales door closed;
2) Rigorous hand
Monitor WBC, An AGC 500 washing by patient,
differential, AGC = cells/mm 3 places the staff, and
Total WBC x patient at severe risk of family/visitors;
(%segs+%bands). developing an 3) Persons with
infection. respiratory or other
Monitor vital signs, Fever or hypothermia infections should not
including temperature may indicate presence enter the room;
every 4 hours or more of infection in the 4)Patient should wear
often, if appropriate. granulocytopenic a mask when leaving
patient. the room;
5 ) Institute a low
Report fevers of Temperature elevation bacteria diet, excluding
1OO.5 F to physician. may be the only sign of fresh fruits, pepper,
infection in the vegetables and spices;
granulocytopenic CI"hispractice remains
patient due to the low controversial, and
numbers of WBC's. often not practiced
At first fever spike, Cultures will help until ANC> 50)
obtain cultures as identify the source of 6 ) No fresh cut flowers
appropriate, usually of infection. Often a or plants;
the urine, blood throat, source is not identified. 7) Patient should avoid
sputum and open crowds;
wounds. 8) Wear gardening
gloves when
Start antibiotics Granulocytopenic gardening;
IMMEDIATELY after patients can develop 9) Use an electric
obtaining cultures.Do overwhelming sepsis shaver when shaving.
not wait for culture within 12 hours of "
results before initiating fever spikes if
antibiotic therapy. untreated with
antimicrobials.
LEUKEMIA 273
Infection Protection Instructions, Information,

Demonstration
Monitor for systemic Lack of neutrophils
and/or localized during Teach patient, Reduces potential for
infection, keeping in granulocytopenia family/visitors infection.
mind that the normal inhibits patient's measures to decrease
signs of patient's ability to fight risk of infection (see
ability to fight infection. above).
infection (redness, pus,
Teach patient, Knowledge enhances
warmth, infection,
family/ visitors signs compliance with plan
Inflammation) are
related to presence of
and symptoms of of care.
infection, stressing
WBC's thus topical
facts to report to health
signs of infection may
care team.
be absent.
Instruct patient to take Antimicrobials treat
Administer antibiotics, Prevents and/or treats
any prescribed infectiousorganisms; if
antifungal, and other infectious agents in the
medication until no not taken as directed,
antimicrobialsas immune compromised
longer necessary such serious sepsis may
appropriate. patients.
as antimicrobials or occur. CSPs reduce
Administer colony Colony stimulating colony stimulating duration of
stimulating factors factors reduce duration factors. neutropenia.
such as G-CSFor GM- of neutropenia.
CSG as ordered.
Explain to patient the Many of the newer
expected cost of drugs, agents are very
Assist patient with Reduces presence of and assess insurance expensive, and
personal hygiene such endogenousorganisms. coverage, or ability to without coverage,
as bathing, oral and pay. Discuss patient may be unable
perineal care. manufacturers' to adhere to prescribed
indigent programs. regimen.
Encourage rest as Fatigue can depress
appropriate. immune function. Instruct patient to Contact with infectious
avoid people with persons couId lead to
Assess all sites of Promotes early
respiratory infections serious infections in
invasive procedures detection of
(flu,cold), and the
for evidence of complications.
immunocompromised
children exposed to
infection.
infectious diseases patient.
Assess skin and Skin and mucosa (chickenpox); and to
mucosal surfaces for provide the first line of avoid contact with
breaks. defense against cold sores or other
microbes. herpetic lesions.
Change all dressings Prevents
(7 NIC: Fever Treatment
daily, including those microorganisms from
over central lines daily multiplying under Definition: Management of the
according to dressings. patient with hyperpyrexia caused
institutional standard. by nonenvironmental factors.
Fever Treatment Instructions, Information,

Demonstration

Monitor temperature Temperature elevation
every 4 hours. may be the only sign of Instruct Temperature elevation
infection in the granulocytopenic out- may be the only sign of
granulocytopenic patient to check infection in the
patient due to low temperature in AM granulocytopenic
white blood count. and PM or if feeling patient; related to low
chilled or warm. WBCs.
Monitor pulse, blood Infection may cause
pressure and tachycardia, Notify M.D. Temperature elevation
respirations every 4 hypotension or immediately if temp may be the only sign of
hours. tachypnea. >100.5 T. infection in the
granulocytopenic
Monitor intake and Dehydration may be patient; related to low
output. caused by insensible
WBCs.
losses.
Instruct patient to During febrile
Notify physician of This may be the only drink at least 2-3 liters episodes, extra fluids
first fever spike in the sign of infection and
of fluid/day (8-12 are needed to replace
neutropenic patient. requires immediate
glasses). insensible losses.
intervention. I
Instruct patient to take Prevents development
Administer antipyretic Acetaminophen
antimicrobials as of resistant organisms.
as ordered reduces fevers without
ordered (7-14days).
Acetaminophen every the increased risk of
4 hours PRN fever bleeding.
>100.5 "F (avoid Evaluation
aspirin).
Use thennic mattress Provides warmth Patient verbalizes measures to
as needed. during chills and prevent infection.
cooling during high Patient/family promptly
fevers. reports signs and symptoms
of infection.
Administer IV fluids as Replaces fluid loss.
Demonstrates ability to obtain
ordered.
and take prescribed medica-
tions.
Keeps scheduled laboratory
and physician appointments.

Cardiopulmonary
0 Related to:
Anemia and thrombocytopenia
caused by leukemia and/or
chemotherapy.
LEUKEMIA 275
Defining Characteristics: Blood Products Administration

Cold extremities, pale skin, pale
mucous membranes, shortness of
breath, tachycardia, tachypnea, Activities Rationales
anxiety, angina, bleeding.
Administer WBC-poor Prevents transfusion
0 Outcome Criteria: or irradiated products reactions in
as ordered. immunocompromised
Recognition and management of leukemic patients.
anemia.
Prevention of complications of Monitor vital signs Helps to identify
bleeding episodes. before, during, and transfusion reactions.
after transfusion.
0 NIC: Blood Products Administration
Refrain from Blood products are not
Definition: Administration of administering any compatible with
blood or blood products and medications into blood medications.
monitoring of patient’s response. or infusion lines.
Observe for and These symptoms may
question about indicate a transfusion
patient’s itching, hives reaction or fluid
and shortness of breath. overload.
Blood Products Administration
Monitor and regulate Promotes delivery of
flow rate during product according to
transfusion. institutional policy.
Monitor IV site Prevents infiltration of
Monitor hemoglobin, Provides information (peripheral or central) blood products.
hematocrit, and for evaluating for pain, redness, or
platelet count. response to swelling.
transfusions.
Refrain from rapid Prevents fluid
Verify physician order Prevents errors in administration of overload.
for blood product and blood product lagging red blood cells.
its rate of infusion. administration.
Administer Promotes diuresis.
Insert appropriate Provides access to medications to treat
gauge needle for blood implanted VAD for fluid overload.
product administration blood product
into implanted venous administration. Stop transfusion if Prevents further
access device WAD). reaction occurs and infusion of causative
maintain IV access product and provides
Access appropriate Multi-lumen catheters with normal saline. IV access for
lumen of multi-lumen generally have a port emergency
central catheter. designated for blood medications.
product administration
Notify physician and Promotes identification
Assemble appropriate Provides filter if blood bank if of type of transfusion
administration system. necessary for the transfusion reaction reaction and
particular product occurs. immediate treatment.
being given.
Prime the Isotonic saline is
administration system compatible with blood
with isotonic saline. products.
Blood Products Administration Essential Nursing

Activities Rat ionales Chemotherapy
Obtain blood Provides samples for
specimens and 1st testing.
voided urine specimen
according to Knowledge Deficit
institutional policy.
Complete transfusion Provides information 0 Related to:
reaction and return to to prevent further
blood bank with blood reactions. Chemotherapy and its side effects.
container & tubing. 0 Defining Characteristics:
Document reaction, Promotes awareness of Patient verbalizes lack of informa-
amount infused, vital patient’s experience. tion about chemotherapy, and its
signs, and patient’s side effects, and their management.
response, in medical
record.
Maintain universal Prevents
precautions. contamination and High Risk for Injury
I
spread of infections.
Related to:
Bone marrow suppression from
chemotherapy.
Instructions, Information, 0 Defining Characteristics:
Demonstration
Thrombocytopenia with platelet
count below 50,000 cells/mm3,
I Activifies Rationales
anemia, fatigue, bruising, petechiae.

about signs and recognition of
symptoms to report transfusion reaction. Pain
during transfusion
(i,e., hives, chills, Relatedto:
itching, shortness of
breath). Nausea and vomiting from
chemotherapy and anxiety about
Inform patient and Promotes treatment.
family of need for understanding.
repeat transfusions. Defining Characteristics:
0 Discharge or Maintenance Patient expresses feelings of pain or

Evaluation discomfort; moans, cries;
diaphoresis; has blood pressure
Control of symptoms related and/or pulse changes.
to anemia and throm-
bocytopenia.
LEUKEMIA 277
Risk for Altered Mucous Altered Nutrition: Less Than

Membranes Body Requirements
(CH.2,8)
Relatedto:
0 Related to:
Damage to rapidly dividing cells of
the mucosa from chemotherapy. Anorexia, nausea, vomiting, and
diarrhea from chemotherapy.
I7 Defining Characteristics:
Oral, vaginal, rectal pain/discom-
fort, coated tongue or vagina, xeros- Reported inadequate food intake
tomia, stomatitis,vaginitis, due to anorexia, nausea and vomit-
presence of lesions or ulcers. ing, loss of weight, early satiety,
diarrhea.

Excess Body Image Disturbance
(CH.4)
0 Related to:
0 Related to:
Large amounts of IV fluids used for
hydration during chemotherapy. Alopecia, weight loss, skin or gum
infiltrates with leukemic cells
0 Defining Characteristics: (AML).
Edema, weight gain, shortness of 0 Defining Characteristics:
abnormal breath sounds, rales, Patient verbalizes fear of rejection
crackles, change in respiratory or or reaction of others to altered ap-
mental status, blood pressure chan- pearance especially hair loss.
ges, altered electrolytes, anxiety
and/or restlessness.
Risk for AlteredSkin Integrity

(CH.2)
Activity Intolerance 0 Related to:
0 Relatedto: Extravasationof vesicant
chemotherapy agents such as
Fatigue secondary to anemia.
daunarubicin, adriamycin, or
0 Related to: vincristine.
Leukemia and chemotherapy 0 Defining Characteristics:
0 Defining Characteristics: Complaints of pain, burning, red-
ness at IV site and/or swelling, red-
Verbal report of fatigue or weakness, necrosis progressing to tissue
ness, abnormal heart rate or blood sloughing at IV site.
pressure in response to activity, ex-
ertional dyspnea.
High Risk For Altered Tissue High Risk For Injury:

Perfusion, Renal Disseminated lntravascular
(CH. 7) Coagulation
Cl Related to: (CH. 7)
Leukemic cell lysis resulting in in- Related to:

creased release of intracellular con- Acute Promyelocytic Leukemia.
tents and the inability of the
kidneys to maintain normal serum 0 Defining Characteristics:
composition.
Prolonged M', PTT, T I', FSP;
0 Defining Characteristics: decreased platelet count; bleeding;
petechiae; blood in urine, emesis, or
Elevationsin serum potassium, stools.
phosphorus and uric acid,
decreased calcium, increase in
serum creatinine levels, presence of
nausea, vomiting, and diarrhea,
paresthesia, tetany, oliguria, anuria, Risk For Decreased
flank pain, and/or convulsions Cardiac Output
from electrolyte imbalances.
(CH. 2)
0 Related to:
Septic shock due to overwhelming
High Risk For Injury: sepsis in the immunocompromised
Anaphylaxis patient.
(CH. 7) Cl Defining Characteristics:
Cl Relatedto: Variations in blood pressure,
Hypersensitivity or anaphylactic jugular vein distension, decreased
reactions due to chemotherapy with peripheral pulses, arrythnua, color
L-asparaginase (Elspar). changes in skin and mucous
membranes, cold, clammy skin,
0 Defining Characteristics: oliguria, dyspnea, rales, restlessness.
Patient verbalizes complaints of
itching, hives, wheezing, anxiety,
feeling of doom, chest pain,
respiratory distress, nausea, vomit- Risk for Decreased
ing, flank pain. Cardiac Output
Cl Related to:
Cardiomyopathy due to adriamycin
(Doxorubicin),daunorubicin
(Daunomycin),or high dose
cyclophosphamide (Cytoxan).
LEUKEMIA 279
Defining Characteristics: Instructions, Information,

Decreased left ventricular ejection Demonstration
fraction (LVEF), nonspecific EKG
changes (flatT waves).
CI Outcome Criteria:
Instruct patients to Provides information
Early signs and symptoms of car- report dyspnea. regarding patient‘s
diomyopathy will be identified. perceptions.
0 NIC: Cardiac Precautions for Informpatient/family Knowledge promotes
Chemotherapy of cardiac risks, prior understanding.
Definition: Recognition of im- to treatment.
paired cardiac function.
Evaluation
Cardiac Precautions for Cardiac toxicity will be recog-
Chemotherapy nized early.
Identify patients at Provides information
risk: to formulate plan of
a)Adriamycin>550 care.
mg/m2 or < 450
mg/m 2 with
cyclophosphamide;
Assess patient’s Provides baseline data.
baseline prior to
beginning
chemotherapy.
Assess quality and
regularity of heartbeat.
Periodic EKG’s of Promotes early
patients at risk. recognition of
problems.
Facilitate regular gated
pool scans (MUGA) for
cardiac evaluation.
Chapter Four teen
Lymphoma
Lymphoma
Lymphoma is a malignancy that arises from phoma vary greatly In Africa a type of NHL
the lymphatic system. It is the sixth most called Burkitt’s lymphoma is very common
common type of cancer, with an estimated in young children. The Middle Eastern na-
annual incidence of 50,900 cases. It is sub- tions have a high incidence of N H L involv-
divided into Hodgkin‘s disease (HJ3) and ing the intestinal tract of children. Neither of
non-Hodgkin’s lymphoma (NHL).The year- these examples occur frequently in the
ly incidence of HD is 7,900 cases; the remain- United States.
ing 43,000 occurrences are NHL. For reasons Chronic immunosuppression contributes to
that remain unclear, the incidence of NHL the development of NHL. Patients on long-
has been increasing in the United States. term steroids, related either to organ
Total annual deaths related to lymphoma are transplantation or collagen vascular diseases,
22,000. The five-year survival rate varies have a higher incidence of NHL. Also, per-
depending on stage and cell type of the dis- sons with inherited immune disorders and
ease. Hodgkin’s disease has a 77%five-year people with AIDS have a greater risk of
survival rate; 51% for Non-Hogkin’s lym- developing NHL. Other diseases associated
phoma. with an increased risk of NKL are Wiskott-
Aldrich syndrome and ataxia telangiectasia.
Viruses, too, have been associated with the

Risk Factors development of certain lymphomas. A her-
pes virus, now referred to as the Epstein-Barr
The incidence of both Hodgkin’s Disease and
virus or EBV, is thought to be an etiologic
non-Hodgkin’s lymphoma is slightly greater
agent in Burkitt’s lymphoma, and some re-
in males than in females. HD is associated
searchers suspect a link to Hodgkin’s dis-
with a double peak incidence of occurrence.
ease. The human T-cell lymphotropic virus 1
The early peak is between the ages of 15-35
(HTLV-1) has been linked to T-cell lym-
years old and the second peak is after age 55.
phomas (NHL)in Japan, the Caribbean, and
The median age at diagnosis of NHL is 42
the United States.
years old. The incidence seems to increase
steadily with age. Although Hodgkin’s dis- Epidemiologic studies in the United States in-
ease is most often associated with adoles- dicate a relationship between increased af-
cents, non-Hodgkin’s lymphoma is the third fluence and education and the incidence of
most common cancer in children in the HD. Also, siblings of HD patients have a
United States. Throughout the world the higher risk of developing the disease. No
types and peak ages of incidence of lym- such relationships have been seen in NHL.
Signs and Symptoms cidence of CNS disease is increasing in NHL

especially in association with AIDS- related
Lymphomas classically present with one or lymphoma and Post Transplant
several enlarged, painless lymph nodes, Lymproliferative Disorder (MLD).
most often in the neck. Lymphadenopathy
generally causes the patient or parent to seek
medical attention. The axillary or inguinal
Diagnostic Tests
lymph nodes may also be areas of presenta-
tion. Many patients may be asymptomatic, Tissue obtained during lymph node biopsy
with their only complaints being malaise or or needle biopsy confirms the diagnosis of
lack of energy. lymphoma. Staging of the disease to deter-
Fevers, night sweats, and weight loss are mine its extent follows a positive biopsy.
referred to as " B symptoms. These are Radiologic examinationsmay include com-
present in about one-third of patients and puterized tomographic scan (CT), magnetic
usually indicate a more widespread rather resonance imaging (MRI), chest x-ray, lym-
than localized disease. Patients with HD also phangiogram, intravenous pyelogram (IVP)
have generalized puritis and may experience and bone scan if bone pain is present. Bone
lymph node pain following alcohol con- marrow aspirate and biopsy is generally per-
sumption. There has been no physiologic ex- formed to determine if the bone marrow is
planation for the itching or pain. involved. A laparotomy may be done for HD
patients when disease is suspected below the
Symptoms may reflect areas of involvement
diaphragm. This procedure includes splenec-
of the disease. Lowered blood counts may be
tomy, lymph node biopsies, and liver biopsy.
related to bone marrow involvement or auto-
If advanced disease is confirmed early in the
immune hemolytic anemia, which are more
diagnostic processes, either by positive bone
common in NHL. Gastrointestinal disturban-
marrow or liver biopsy results, further
ces may indicate NHL in the GI tract. Medias-
evaluation is not necessary, and treatment is
tinal involvement is more common in HD,
started. There is no specific tumor marker
although it is specifically associated with T-
blood test for the lymphomas.
cell lymphoblastic lymphoma. Both pul-
monary and cardiac symptoms may be
experienced with mediastinal disease.
Neurological changes may signify central
nervous system (CNS) involvement. The in-
Hodgkin's Disease-
The presence of Reed-Stemberg cells in a
biopsy confirms the diagnosis of Hodgkin's
disease. These are large cells with two or
LYMPHOMA 285
~~ ~~
more mirror-image nuclei. Reed-Sternberg Rappaport Working

Formulation
cells may also be present in nonmalignant
conditions such as mononucleosis, some (Low-Grade)
viral infections, inflammatory lymph nodes,
Diffuse, well- a. Small, lymphocytic
and phenytoin therapy. Thus it is important differentiated,
that diagnosis be based upon both his- lymphocytic
topathological findings and presence of these Nodular, poorly- b. Predominantly
differentiated, small-cleaved
cells. lymphocytic
The Rye classification system is based on the Nodular, mixed- c. Mixed, small-
histologic subtype of the tumor, There are lymphocytic-histiocytic cleaved, and large cell
four categories in this system. Nodular
sclerosisis the most common and accounts (Intermediate-Grade)
~~~~ ~~
for between 3060% of cases and seen fre-

Nodular, histiocytic d. Predominantly large
quently in young female patients. Lym- cell
phocyte-predominant occurs in 5-15% of Diffuse, poorly- e. Small cleaved cell
patients and is associated with the best prog- differentiated,
1ymphocytic
nosis, as disease is often localized. Mixed cel-
lularity, second in overall frequency, makes Diffuse, mixed- f. Mixed, small and
lymphocytic-histiocytic large cell
up about 30%of diagnoses. The least com-
Diffuse, histiocytic g. Large cell
mon subtype of HD is Lymphocyte-depleted,
seen frequently in older patients.
Widespread disease and B symptoms are fre- (High-Grude)
quently seen with this classification. Diffuse, histiocytic h. Large cell,
immunoblastic
Non-Hodgkin’s Lymphoma-
Diffuse, lymphoblastic i. Lymphoblastic
One of the most confusing aspects of NHL,
Diffuse, j. Small noncleaved cell
for the nurse and the general public, is the undifferentiated
many classification systems that exist. His-
topathological classification divides N H L
into low, intermediate, high, and miscel-
laneous grades. The following chart lists the
Treufmenf
cell types and grades from the Rappaport Hodgkin’s Disease-
system and Working Formulation.
The role of surgery as mentioned above is
diagnostic. The treatment plan is based on ex-
tent or stage of disease. Radiation therapy is
curative in patients with localized HD. Exter-
nal beam radiotherapy is delivered in
divided doses over several weeks to the in- the patient may undergo surgery also to
volved and adjacent nodal areas. The resect areas at risk of bleeding or perforation
”Mantle Field” refers to the irradiation of all following treatment with radiotherapy or
lymph nodes above the diaphragm. When chemotherapy.N H L in the stomach or the
the disease is also detected in lymph nodes gastrointestinal tract is often resected prior to
below the diaphragm, subtotal or total nodal other therapy. Patients with enlarged spleens
irradiation is recommended depending on may undergo a splenectomy before begin-
the node location. Organ or bone marrow in- ning treatment.
volvement indicates more advanced disease Radiation therapy is a curative approach
which requires chemotherapy. only when N H L is localized to a particular
Combination chemotherapy is associated area. This occurs less frequently in NHL than
with complete remission in 80%of patients in HD, since less than 10%of patients have
treated for HD. The combination regimen, localized lymphoma at diagnosis. Whole
MOPP (nitrogen mustard brain radiotherapy is used in the manage-
[Mechlorethaminel, vincristine [Oncovinl, ment of CNS disease, but has not enjoyed the
prednisone, procarbazine [Matulanel), was same success rates as with other localized
the first successful combination sites. Electron beam radiotherapy may be
chemotherapy regimen. This led to the used to treat skin involvement with NHL.
development of many other multidrug An example of this is in the palliative treat-
therapy protocols now associated with many ment of mycosis fungoides (a N H L that in-
cases of long-term, disease-free survival. volves the skin).
Either MOPP or ABVD (doxorubicin When to begin chemotherapy in the patient
[Adriamycinl, bleomycin [Bleoxane], vinblas-
with low grade lymphomas remains con-
tine [Velbanl, darcarbazine [DTICI) are ad- troversial. The natural history of these N H L s
ministered for multiple cycles as initial
has shown that with minimal treatment, sur-
therapy. ABVD produces complete r e d s -
vivals of 7-10 years may be expected. Mini-
sions in approximately half of the patients
mal treatment may be defined as low-dose,
who have not responded to MOPP. Relapses
oral chemotherapy (i.e., chlorambucil
usually occur within the first two years after
[Leukeranl)with or without prednisone.
initial therapy, and are now being treated
Once the disease becomes progressive then a
with salvage chemotherapy regimens or
more aggressive approach is recommended,
bone marrow transplantation.
using combination chemotherapy. Many
Non-Hodgkin’s Lymphoma- agents including cyclophosphamide, vincris-
The treatment of N H L is not as definitive as tine, vinblastine, bleomycin, and
the treatment of HD because there are so doxorubicin have been used. COP
many different types of NHL. Surgery is es- (cyclophosphamide,oncovin [vincristine],
sential in establishing a diagnosis. In N H L prednisone) is often give once a month or
LYMPHOMA 287
every six weeks. Patients generally tolerate Investigational Studies

these therapies well, especially older people
with other co-morbid diseases. At a few can- In HD, use of biologic agents and im-
cer centers, younger patients with low-grade munoconjugates are being explored. Re-
lymphomas are undergoing bone marrow searchers are also attempting to define the
transplantation. The optimal regimen for this appropriateagents and role of bone marrow
group of NHLs remains to be identified. transplantation in recurrent disease.
The intermediate and high-grade NHLs are a There are many ongoing studies, as there are
more aggressive disease entity than the low- many questions to be answered in the
grade NHLs. It is in this group of patients management of patients with NHL. The
that significant progress has been made in biologic agents including lymphokines,
long-term, disease-free survivals with aggres- monoclonal antibodies, and interferon may
sive combination chemotherapy. Numerous prove to be useful in the future.Research
chemotherapeuticregimens are being used, continues to identify the best treatment ap-
the most common are: CHOP,CHOPE,m- proach for the low-grade lymphomas. In the
BACOD, ProMACE-CytaBOM, COMLA and treatment of the intermediate- and high-
MACOP-B. The response rates vary with grade NHLs, the optimal chemotherapeutic
these protocols and it remains to be deter- regimen remains to be identified and success-
mined which is superior. All of these f u l salvage therapies need to be developed.
therapies are associated with neutropenia in- The best use of bone marrow transplantation
creasing the patient’s risk of infection. Bone also needs to be determined.
marrow transplantation has been used in
patients who have not responded to initial
therapy and those with recurrent NHL. Complications
Pediatric and adolescent patients with NHL
are treated differently than adults. Aggres- Complicationsexperienced by patients with
sive multi-drug combinations are used over lymphoma are related to treatment or recur-
at least a two-year period. Children also rent disease. Common adverse effects related
receive CNS prophylaxis with either intrathe- to chemotherapy include alopecia, nausea,
cal chemotherapy (methotrexate and/or vomiting, bone marrow suppression,
cytosine arabinoside)and /or radiation stomatitis, and gastrointestinal disturbances.
therapy. Infection is a very serious potential complica-
tion that may cause septic shock.The risk of
sepsis is higher with aggressive
chemotherapy regimens and bone marrow
transplantation. Delayed effects from
chemotherapy include sterility, car-
diotoxicity, and pulmonary fibrosis. The 0 Defining Characteristics:

development of leukemia following therapy Patient verbalizes feelings of uncer-
tainty, apprehension, sleeplessness,
with alkylating agents may be a fatal com- restlessness, or other signs of
plication. anxiety.
Side effects of radiation therapy are related
to the area treated. When treatment is to the
cervical lymph nodes or throat, dry mouth, Fear
dysphagia, nausea, vomiting, loss of hair at (CH. 1)
the nape of the neck, and decreased produc- Related to:
tion of saliva occur. There also may be an in- Fear of the unknown due to the
crease in dental caries. When lymph nodes in diagnosis of lymphoma.
the abdomen are treated, the effects are Defining Characteristics:
nausea, vomiting, diarrhea, fatigue, anorexia,
Patient verbalizes fears of shor-
and bone marrow suppression. Radiation tened life span, feeling of dread,
pneumonitis may be a delayed effect of treat- pessimism over diagnosis.
ment to the mediastinal area.
Superior vena cava syndrome and spinal
cord compression are structural oncologic
(CH. 1)
emergenciesthat often occur with lym-
phomas. Tumor lysis syndrome may develop Related to:
with the treatment of advanced lymphomas. Diagnosis of lymphoma and uncer-
Hypercalcemia may be seen during therapy tain prognosis.
when bone involvement is present. Defining Characteristics:
Inability to meet basic needs,
chronic fatigue, dependency,worry,
anxiety, poor self-esteem, verbaliza-
Essential Nursing tion of inability to cope.
Diagnoses Related To
Diagnosis and Coping
(CH.1)
Related to:
Anxiety
(CH. 1) Actual and/or perceived losses due
to diagnosis of lymphoma such as
0 Related to: loss of health, life, work, income,
privacy, intimacy, and relationships.
Perceived threat of self due to diag-
nosis of lymphoma.
LYMPHOMA 289
0 Defining Characteristics: Altered Tissue Perfusion,

Patient exhibits and/or expresses Cardiopulmonary
(CH. 13)
0 Relatedto:
Anemia and thrombocytopenia
Knowledge Deficit caused by lymphoma and/or
(CH. 1) chemotherapy.
Relatedto: 0 Defining Characteristics:
Lack of knowledge about lym- Cold extremities, pale skin, pale
phoma and its treatment. mucous membranes, shortness of
breath, tachycardia, tachypnea,
0 Defining Characteristics: anxiety, angina, bleeding.
Verbalization of the problem, inac-
tion, request for information.
(CH. 4)
Esentid Nursing Relatedto:
Diagnoses Reluted to Bone marrow suppression from

chemotherapy.
Bone Marrow Defining Characteristics:
Suppression Thrombocytopenia with platelet
count below 50,000 cells/m3,
bruising, bleeding, petechiae.

(CH.4,13)
Related Chemotherapy for treat- Risk for Decreased
ment of lymphoma, bone marrow Cardiac Output
involvement of lymphoma. (CH. 1)
0 Defining Characteristics: Relatedto:
Granulocytopenia, an absolute Septic shock due to overwhelming
granulocyte count (AGC)below sepsis in the immunocompromised
1000 cells/mm3, Neutropenia, an patient.
absolute neutrophil count (AN0
below lo00 cells/mm3. 0 Defining Characteristics:
Variations in blood pressure,
jugular vein distension, decreased
peripheral pulses, arrythmia, color
changes in skin and mucous
membranes, cold clammy skin,
oliguria, dyspnea, rales, restlessness.
Essential Nursing
Diagnoses Related to ness, abnormal heart rate or blood
Treatment pressure in response to activity, ex-
ertional dyspnea.
Knowledge Deficit Altered Nutrition:

(CH.4, 13) Less than Body Requirements
Chemotherapy and radiation 0 Related to:
therapy for the treatment of lym-
phoma. Anorexia, nausea, vomiting, and
diarrhea from chemotherapy or
Defining Characteristics: gastrointestinal lymphoma.
Verbalizes lack of information 0 Defining Characteristics:
about chemotherapy and/or radia-
tion therapy, potential side effects Reported inadequate food intake
and their management. due to anorexia, nausea, loss of
weight, early satiety, diarrhea.
Know1edge Deficit
Fluid Balance Deficit
(CH. 8)
(CH. 4)
0 Relatedto:
Related to:
Cranial radiation therapy.
Side effects from chemotherapy.
and/or questions about radiation Tachycardia, low urine output, dry
therapy treatments. mucous membranes, decreased
fluid intake, anorexia, nausea,
vomiting, fluid losses due to diar-
rhea or fever, electrolyte imbalan-
ces, weight loss.
Activity Intolerance
(CH. 4)
0 Relatedto:
Fatigue secondary to anemia from
bone marrow involvement of lym-
Excess
phoma or chemotherapy.
0 Related to:
Large amounts of IV fluids used for
hydration during chemotherapy.
LYMPHOMA 29 1
0 Defining Characteristics: 0 Related to:

Edema, weight gain, shortnessof Alopecia, weight loss, and/or skin
breath, intake greater than output, changes secondary to
abnormal breath sounds,rales, chemotherapy.
change in respiratory or mental
status, blood pressure changes, al- 0 Defining Characteristics:
tered electrolytes, anxiety, restless- Patient verbalizes fear of rejection
ness. or reaction of others to altered ap-
bod3 concern over hair loss and
skin changes.
Pain
(CH.4)
0 Relatedto: Risk for Altered Skin Integrity
Nausea and vomiting from (CH. 4)
chemotherapy, and anxiety related
to treatments. 0 Relatedto:
0 Defining Characteristics: Extravasationof vesicant

chemotherapy.
Patient feels pain or discomfort,
moans, cries, is diaphoretic, has Defining Characteristics:
blood pressure/pulse changes. Patient complains of pain, burning
during administrationof agent,
skin looks red, necrosis with tissue
sloughing.
Risk for Alterred Mucous
Membranes
(CH. 4)
High Risk for Altered Urinary
Relatedto: Elimination,
Damage to rapidly dividing cells of (CH. 7)
the mucosa from chemotherapy.
0 Relatedto:
Uric acid nephropathy and acute
Oral/vaginal pain/discomfort, m ~failml from tumor lysis
coated tongue, stomatitis, vaginitis, syndrome.
oral/vaginal lesions ulcers.
Decreased urine output, elevations
in serum creatinine and blood urea
Body Image Disturbance nitrogen (BUN) levels.
Altered Urinary Elimination High Risk for Peripheral

Neurovascular Dysfunction
0 Related to:
(CH. 8)
Side effects from high-dose
cyclophosphamide (Cytoxan) 0 Related to:
chemotherapy resulting in Damage to nerves from
hematuria. chemotherapy, especially the vinca
0 Defining Characteristics: alkaloids such as vincristine and
vinblastine.
Hematuria, dysuria, urinary fre-
quency. 0 Defining Characteristics:
Patient verbalizes loss of fine motor
movements, burning pain in ex-
tremities, numbness in fingers and
Potentialfor Injury toes, gait disturbances, and loss of
(CH. 7) proprioception.
0 Related to:
Hypersensitivity and anaphylactic
reactions to a chemotherapeutic High Risk for Altered Renal
agent (Bleomycin). Tissue Perfusion
0 Defining Characteristics: (CH. 7)
Patient verbalizes complaints of 0 Related to:
itching, hives, anxiety, feeling of
Lymphoma cell lysis resulting in in-
doom, chest pain, respiratory dis-
creased release of intracellular con-
tress, nausea, vomiting, history of
tents and the inability of the
allergic reactions.
kidneys to maintain normal serum
composition; high dose
methotrexate chemotherapy.
Risk for Constipation 0 Defining Characteristics:

(CH. 8) Elevations in serum potassium,
phosphorus and uric acid,
0 Related to: decreased calcium, increase in
Neurotoxicity from vinca alkaloid serum creatinine levels, presence of
chemotherapy agents such as nausea, vomiting and diarrhea,
vinblastine (Velban)or vincristine oliguria, anuria, flank pain, convul-
(Oncovin). sions from electrolyte imbalances.
Absence of regular bowel move-
ments, abdominal pain or cramp-
ing, and dynamic ileus.
LMMPHOMA 293
Sexual Dysfunction Family Planning- Infertility
0 Related to:
Possible infertility related to
Adivities Rationales
chemotherapy with nitrogen mus- Assist with problem- Provides information.
tard, retroperitoneal lymph node solving to help couple
radiation therapy for Hodgkin’s dis- evaluate alternativesto
ease. biologic parenthood.
0 Defining Characteristics: Determine effect of Promotes early
infertility on couple’s recognition of potential
Patient voices feelings of sadness relationship. long-term problems.
about inability to be a biologic
parent, expresses feelings of loss. Inform patient about Provides information.
sperm banking or ova
0 Outcome Criteria: removal prior to
Patient and sigruficantother will be treatment.
aware of alternate means of parent- Refer patient to cancer Provides support.
ing. couples group and/or
social worker.
0 NIC: Family Planning- Infertility
Definition: Management, educa- Discharge or Maintenance
tion, and support of the patient and Evaluation
significant other in dealing with in- Patient is able to express feel-
fertility
ings regarding loss of fertility.
Knowledge Deficit
r -
Family Planning- Infertility

0 Relatedto:
Activities Rationales Chemotherapy given diredly into
the cerebral spinal fluid via lumbar
Assist with expressions Provides opportunity puncture or ommaya reservoir.
of grief, to vent feelings.
disappointment, and 0 Defining Characteristics:
feelings of failure.
Patient verbalizes lack of informa-
Encourage expressions Provides opportunity tion about intrathecal
of feelings about to vent feelings. chemotherapy treatment and its
sexuality, self-image, side effects.
self-esteem.
0 Outcome Criieria:
Refer Provides support.
patient/significant Patient is able to verbalize treat-
other to support group ment plan and goals of therapy
for infertile couples as
appropriate.
NIC: Medication Administration-

Intrathecal""
medication into the central nervous
system
**Not yet an accepted NIC
Medication Administration-
lntrathecal
Follow the five rights Prevents errors.
of medication
administration.
Position patient in bed Promotes comfort.
(for LP)or recliner
(ommaya tap).
Assist physician with Provides information.
samples of spinal fluid
for cytology.
Monitor patient for Promotes early
reactions during recognition of potential
medication problems.
administration.
Teach patient/family Increased knowledge
purpose, benefits, and promotes
rationale for therapy. understanding.
Inform patient of both Provides selfcare
immediate and information.
potential delayed
effects.
Evaluation
Patient is able to verbalize un-
derstanding of procedure.
Chapter Fifteen
Skin Cancers
Skin Cancers
Skin cancer is the most common form of can- The less melanin in the skin the higher the
cer. Annually between 900,000 and 1.2 mil- risk of developing skin cancer; hence, the
lion new cases of non-melanoma skin cancer highest rate of skin cancer is seen among
will be diagnosed in the United States. This Caucasians. Melanoma occurs less often
has increased a half a million more per year among Hispanics, Asians and African
than previously estimated. Based on these Americans, the later having the lowest rate
new statistics 1in 5 Americans will get non- due to the high concentration of melanin in
melanoma skin cancer in his or her lifetime. their skin. Persons working outside are more
Malignant melanoma, the most deadly form at risk due to their increased exposure to
of skin cancer, is increasing at a faster rate ultraviolet rays. Also,people with actinic or
than any other cancer. An estimated 32,000 solar keratosis, a precancerous skin condi-
cases will be diagnosed per year, or 1in 105 tion due primarily to sun exposure, are at in-
Americans will develop melanoma in their creased risk. Less important risk factors
lives. In 1935, only one in 1,500 Americans include repeated medical and industrial X-
developed melanoma. Experts universally ray exposure; scarringfrom disease or burns;
agree the main reason for this rapid increase occupational exposure to such compounds
in skin cancer is American’s love for the sun. as coal and arsenic; and a family history of
Despite this alarming increase, skin cancer rare hereditary disorders, such as xeroderma
remains one of the most curable forms of can- pigmentosum, albinism, and nevoid basal
cer, with only 2,500 deaths annually from cell carcinoma syndrome.
non-melanoma skin cancers and 6,900 deaths
annually from melanoma.
Risk Fuctors There are three basic types of skin cancer:

basal cell carcinoma, squamouscell car-
Ultraviolet radiation from the sun is the cinoma, and malignant melanoma. Together,
major risk factor for non-melanoma skin can- basal cell and squamous cell carcinomas are
cers. The most common types of skin cancer, often referred to as non-melanoma skin can-
basal cell and squamous cell carcinoma, are cers to distinguish them from melanoma of
believed to be caused by cumulative sun ex- the skin. The most common type of skin can-
posure. Recent studies also show that the cer is basal cell carcinoma. Basal cell car-
sun is the central factor behind most cases of cinoma arises from the basal cells in the
melanoma. Another risk factor is skin type. epidermis and is a slow-growing cancer that
rarely spreads to other parts of the body. age of melanomas, only 4-10%. Acral len-
Squamous cell carcinoma is the second most tiginous melanoma usually occurs in the
common type and begins in the squamous soles of the feet or the palms of the hand and
cells of the epidermis. This type of cancer is occurs in only 2 to 8 percent of Caucasian
faster growing than basal cell and metas- persons with melanoma. However, it ac-
tasizes about 2% of the time. However, counts for 35 to 60 percent of melanomas in
squamous cell carcinoma that arises on the darker-skinned individuals.
lips, or in burns or x-ray Scars metastasizes Melanoma has two growth phases - radial
about 20%of the time. and horizontal. During the radial growth
Malignant melanoma is the third type of skin phase the lesion spreads across the skin sur-
cancer and is considered more serious than face. Removal of the melanoma during this
the non-melanoma skin cancers. It develops phase is almost always curable through
in the melanocytes of the epidermis. surgery alone. The horizontal or vertical
Melanoma is usually black-brown in color, al- growth phase begins as the melanoma ex-
though lesions may be nonpigmented tends downward through the layers of the
(amelanotic).It usually affects the skin but dermis, epidermis, and into the sub-
can occur in other sites as well, such as the cutaneous tissue. As it grows downward it
eye, anus, esophagus, and/or the vulva. Al- invades the lymphatic and vascular systems
though melanoma is less common than other resulting in local, regional, and distant
skin cancers, it is more serious because of its lymph node and/or visceral organ involve-
propensity to metastasize to other body or- ment. Prognosis is dependent on the depth
gans such as the lungs! liver, or brain. Once of invasion of the primary lesion at the time
this occurs it is more difficult to treat. People of diagnosis. When the melanoma is thin
at risk for melanoma include fair-skinned (less than 1mm), and has not spread beyond
people tending to burn easily, persons with the initial area of growth, it is curable
red or blond hair, persons with a history of through surgery more than 90%of the time.
several blistering sunburns as child, and per- Lesions less than 3 mm thick are curable in
sons having 20 or more moles or unusual 70-80% of cases. Lesions greater than 3 mm -
moles. There are four types of melanoma: su- deep melanomas - have a relapse probability
perficial spreading melanoma, nodular of 40-50%.Once metastatic disease is diag-
melanoma, lentigo maligna melanoma and nosed the median survival is only 6-9
acral lentiginous melanoma. Superficial months.
spreading melanoma accounts for 70% of all
melanomas. Nodular melanoma is the
second most common type. It accounts for
15-30%of all cases of melanoma. Lentigo
maligna melanomas occur in a small percent-
SKIN CANCERS 299
Signs and Symptoms lesion is "shaved o f f , incisional, and ex-

cisional biopsies. If melanoma is suspected
The most common warning sign of non- an excisional biopsy is the preferred method
melanoma skin cancers is a change on the so that the depth of the lesion can be
skin. Basal cell and squamous cell car- measured. This direct measurement of the
cinomas have many different appearances. depth is called the Breslow's Level and has
Either can start as a small, smooth, shiny, important prognostic indications. For thin
pale, waxy, or fleshy bump or nodule on the melanomas and most basal cell and
head, neck, or hands. These sometimes bleed squamous cell carcinomas, surgical removal
or develop a crust. Other times they appear is all that is indicated and no further diagnos-
as a flat red spot either scaly and crusty or tic testing is required. For deeper
smooth and shiny. Occasionally, they appear melanomas, tests may be indicated to rule
as a firm red lump. out metastatic disease. These include blood
Malignant melanoma may appear suddenly tests, chest x-ray, and/or CT scanning.
without warning, but it usually appears in or
near a mole or other dark spot on the skin.
Any change in an existing mole should be Treatment
evaluated by a physician. A mole is more
Non-Melanoma Skin Cancers--
likely to be abnormal if it is Asymmetric (one
Surgery is the primary treatment for non-
half of the mole does not match the other),
melanoma skin cancers in which a wide
the Border of the mole is jagged or irregular,
variety of procedures are used successfully.
it is more than one Color or its Diameter is
These include excision of the lesion, Moh's
larger than 5 mm. These characteristics asym-
micrographic surgery or chemosurgery, curet-
metry, border, color, and diameter are known
tage and electrodesiccation, and cryotherapy.
as the ABCDs of melanoma. Late signs in
Radiotherapy and chemotherapy are some-
melanoma include a horizonal increase in
times used to treat basal cell and squamous
the mole or lesion, and bleeding and crusting
cell carcinomas.
of the lesion. Early detection of skin cancer is
vital because most types are curable in their Factors considered in the treatment of non-
early stages. melanoma skin cancers are tumor type, Ioca-
tion, size, growth pattern, and whether the
tumor is primary or secondary.
Diagnosis Surgical excision may be simple or complex.

In simple excisions the surgeon removes the
The diagnosis of skin cancer is made by biop- lesion and a margin of unaffected tissue to
sy of the suspicious lesion. Types of biopsies prevent recurrence. More complex excisions
include shave, where a thin top layer of the involve the use of a skin graft or flap if, say,
the lesion is large or if it is located in an area metic results and minimal discomfort are all
where there is insufficient tissue for closure. advantages. Disadvantages include
Advantages of this method include rapid prolonged healing time, possible bleeding
healing, the availability of the entire and nerve damage, and the need for wound
specimen for pathologic evaluation, and care.
good cosmetic results. Radiotherapy is recommended only for in-
Chemosurgery, or Moh’s micrographic operable non-melanoma lesions, lesions lo-
surgery, is a procedure that involves horizon- cated in sites such as the nose, eyelid, lip,
tal shaving and staining of tissue in thin and canthus, or for patients who are poor
layers, with careful histologic mapping of all surgical risks. Major advantages of
specimen margins. The advantages of this radiotherapy are the ability to preserve
procedure are that it allows the preservation anatomic structures, extend treatment to sur-
of tissue for reconstruction, the ability to rounding areas if needed, and the lack of
map tumor margins, and for the procedure pain. However, the lack of tumor for his-
to be performed in an outpatient setting. tologic evaluation, long treatment periods,
However, not all surgeons are trained in this and need for clinical facilities with specially
special, time-consuming procedure. trained personnel are disadvantages of
Curettage and electrodesiccationis used only radiotherapy. Also, the treatment may cause
for small superficial basal cell carcinomas. skin cancer to develop years later.
Using curettage, the surgeon scrapes out the Chemotherapy for non-melanoma skin can-
tumor, then treats the tumor base with cers may be either topical or systemic. Topi-
electrodesiccation or a low voltage electrode. cal chemotherapy applied directly to the
Advantages of this procedure are good cos- lesionb) is effective in premalignant
metic results, preservation of normal tissue, keratosis and Bowen’s disease. The agent
rapidity of the procedure, and the ability to most frequently used is 5-fluorouracil.To
obtain specimens for histologic evaluation. treat recurrent skin cancers, especially
Disadvantages include no margin control, squamous cell, systemic chemotherapy is
prolonged healing, and the need for a skilled used. It is used also for non-melanoma skin
physician. cancers that are advanced and no longer
Cryotherapy involves using liquid nitrogen manageable by surgery or radiation.
to freeze and thaw tumor tissue. It is used for
small-to-large primary tumors, recurrent Malignant Melanoma-
lesions in previously radiated tissue, multi- Treatment of melanoma is based on many
ple superficial basal cell carcinomas, and factors including the patient‘s age, general
lesions needing palliation. The speed of the health, type of melanoma and the stage of
procedure, that it can be done as an out- the disease. There are four basic forms of
patient procedure, that it provides good cos- treatment for melanoma: surgery, radiation
SKIN CANCERS 301
therapy, chemotherapy, and biotherapy. A nodes from involved basins. A single site of
brief summary of each type of treatment is metastatic disease may be ressected. How-
listed below. One, or possibly several, of ever, the majority of patients suffer from dis-
these therapies may be used in combination ease recurrence within 6-9 months foHowing
to best manage the disease. surgery. For this reason combinations includ-
ing surgery, chemotherapy,biotherapy, or
radiation therapy are used, usually, to help
Surgery relieve symptomsand to treat metastatic dis-
ease.
Surgery is used to treat approximately 95%
Radiation therapy is another form of local
of patients with melanoma. When the lesion
treatment. It is the use of high energy x-rays,
is thin (less than 1mm) and has not spread
cobalt, electrons, or other radiation sources
beyond the initial area of growth, it is
to damage or kill the melanoma cells. In
curable more than 90% of the time with
general, melanoma is not considered to be
surgery alone. The surgeon will usually
very sensitive to radiation therapy. However,
remove the lesion, plus a border area of nor- radiotherapy may be used palliatively to
mal tissue around it, to prevent the tumor
treat local recurrences or to treat melanomas
from recurring. A margin of 1-2 cm around
that have spread to distant organs, such as
the melanoma is considered adequate for the lung, liver, or brain, to provide relief
melanomas with a thickness less than 3 mm. from symptoms.
Lesions greater than 1mm deep but less than
3 mm deep are cured with surgery ap-
proximately 7040% of the time. Deep lesions
(greater than 3 mrn) have a relapse prob-
Chemotherapy
ability of 40-50%. The margin of resection Chemotherapy can be administered in a
around these deeper melanomas is usually variety of ways to treat melanoma. One is
recommended to be at least 2-3 cm. A skin topically, in which the agent is applied direct-
graft may be needed for these wider ex- ly to the lesion. Agents used for this purpose
cisions or if the location of the lesion include 5-fluorouracil or psoralen. Other
prevents adequate closure of the skin. For methods use isolated limb perfusion and
deeper melanomas, prophylactic lymph arterial perfusion of chemotherapy into the
node dissections may be recommended to affected arm or leg. These two methods
help reduce recurrence of melanoma. How- enable high doses to be delivered directly
ever, this procedure remains controversial. into the affected arm or leg. Since the
Patients developing regional or local disease chemotherapy does not go into the main
recurrence usually are treated with surgical blood stream, the patient does not ex-
removal by radical dissection of lymph perience the side effects common to systemic
SKIN CANCERS 313
Fluid Volume Deficit

(CH.5 )
U Related to:
Capillary leak syndrome from inter-
leukin-2.
Hypotension, orthostasis, tachycar-
dia, tachypnea, low urine output,
diarrhea, decreased fluid intake,
weight loss.

Excess
(CH.5 )
Related to:
Treatment of fluid volume deficit
from IL-2due to capillary leak
syndrome.
Edema, weight gain, shortness of
abnormal breath sounds, rales
(crackles), changes in blood pres-
sure, respiration, mental status.
Head and Neck
Cancers
Head and Neck Cancers
Head and neck cancers account for about 6% head and neck cancer; together these two fac-
of newly diagnosed cancers in the United tors create a higher risk than either factor
States annually. They comprise 4% of all alone. Also, if a person continues to smoke
male cancers, and 2% of all female cancers. and drink, the chance of cure is significantly
Although easily detected, the tumors are decreased and their risk for developing of a
usually diagnosed late in the disease. At the second primary of the aerodigestive tract is
time of diagnosis 60% of the 54,200 persons increased. Poor oral hygiene and poor denti-
diagnosed each year in the United States tion, including constant irritation from a
with head and neck cancers have advanced jagged carious tooth or ill fitting dentures are
disease. Thirty to fifty percent will die of also risk factors. The inhalation of wood
their disease from recurrent tumors within 5 dusts, nickel compounds, nitrosamines,
years and up to 60% will have distant metas- hydrocarbons, and asbestos have been
tases. The incidence of head and neck can- linked to the development of tumors of the
cers is high among lower socioeconomic oral cavity, nasal cavity, and paranasal
groups, with the greatest incidence during sinuses.
the fifth and seventh decades of life. There is The Epstein-Barr virus shows a close relation-
a high incidence of a second primary (about ship, especially in younger persons, to the
five percent) at the time of diagnosis. There- development of nasopharyngeal cancers. A
fore, close evaluation for a second primary possible link between herpes simplex and
during the initial staging work-up is vital. human papilloma virus and the develop-
Also, approximately 25-30% of patients with ment of head and neck cancer has been iden-
head and neck cancer will develop a second tified. A genetic predisposition has also been
primary after treatment of the initial suggested for nasopharyngeal cancer due to
primary. The most common sites of distant the high incidence among Cantonese popula-
metastases include lung liver, and bone. tions and the presence of a specific HLA an-
tigen profile in those persons.
Cancers of the oral cavity and pharynx are

Risk Factors commonly seen in persons with Plummer-
Vinson syndrome. Also,a diet deficient in
Personal and social habits seem to contribute
vitamin A and retinoids may increase the
to the high incidence of head and neck can-
risk of developing head and neck cancers.
cers in the lower socioeconomic groups. The
The opportunity for preventive teaching of
use of tobacco, both smoking and chewing,
populations at risk for developing head and
combined with heavy alcohol consumption
neck cancer is apparent from the risk factors.
is highly correlated with the development of
Communication Enhancement I7 Discharge or Maintenance

Evaluation
. Establishment of a successful
method of alternate com-
munication.
Establish a method of Provides an alternative
communication form of
appropriate to communication.
patient's abilities and
needs. Sensory/ Perceptual
Allow patient to hear / Promotes speech
Alteration: Visual
spoken language as recognition.
appropriate. cl Related to:
State verbal prompts Provides cues. Neurological deficits caused by
and reminders. brain tumor or treatment.
Use simple words and Promotes Defining Characteristics:

short sentences. understanding.
Inability to see (partial or complete
Enunciate clearly, Prevents multiple loss of sight), myopia, visual field
speak slowly. stimuli. cuts, reduced visual acuity.
Use a calm reassuring Promotes trust, builds 0 Outcome Criteria:
approach. relationship.
Evaluation and maximization of
Speak in normal tone Prevents distraction visual function.
of voice, refrain from from loud noises.
shouting. 0 NIC: Communication
Enhancement-Visual Deficit
Stand in front of Promotes
patient while speaking. understanding. Definition: Assistance in accepting
Encourage patient to and learning alteinate methods for
Provides opportunity
living with diminished vision.
repeat words. to hear own voice.
Use picture board if Promotes
appropriate. communication.
Inform family of Promotes
reasons for understanding and Communication Enhancement-
communication deficit. cooperation. Visual Deficit
Teach family to use Provides opportunity
alternate methods of for them to Activities Rat ionales
communication, communicate
independently with Identify yourself when Promotes awareness.
patient. you enter the patient's
Encourage family to Prevents pa tien t from space.
use positive becoming discouraged. Note patient's reaction Provides data.
reinforcement. to diminished vision.
Accept patient's Provides
reaction to diminished understanding.
vision.
BRAIN CANCER
Communicution Enhancement- Sensory/Perceptual

Visual Deficit
Alteration, Auditory
Related to:
Brain tumor, result of presence o
Maximize patient's Prevents tumor or treatment.
remaining capabilities. discouragement.
Do not move items in Prevents injury.
patient's room without Inability to hear (partial or com-
informing patient. plete deafness), change in usual
response to auditory stimuli, al-
Read mail, newspaper, Prevents isolation.
tered communication pattern.
and other pertinent
information to patient.
Identify items on a tray Promotes
in relation to numbers independence. Risk for tnfection
on a clock.
Initiate occupational Provides expert advice. 0 Relatedio:
therapy referral.
Chemotherapy with nitrosourea
Inform patient and Provides a realistic BCNU and CCNU.
family of potential appraisal of visual
abilities and ability. Defining Characteristics:
impairment. Granulocytopenia occurring 3-5
Instruct in eye care and Promotes health of weeks following treatment.
administration of eyes.
medications.
Inform of national and Provides information
community agencies and support for family Risk for Constipation
that provide materiak and patient.
or services for visually 0 Related to:
immired. Neurotoxicity from vinca alkalo
chemotherapy agents as vincrisl
0 Discharge or Maintenance (oncovin).
Evaluation
+ Patient optimizes visuai
acuity. Decrease in regular bowel move
Uses aids to maximize vision ments, hard stools, complaints c
and independence. dominal discomfort.
Adapts to visual loss and
maintains activities.
Body I mage Disturbance

0 Retatedto:
Loss of hair from craniotomy,
alopecia from radiation therapy
which lasts longer than
chemotherapy, (may be permanent),

alopecia from chemotherapy.
pearance, negative feelingsabout
body, concern over hair loss.
Chapter Eighteen
Sarcomas of
Bone and
s’oT t i is s ues
Sarcomas, Bone, and
Soff Tissue
Sarcomas are tumors that originate in connec- tendency in bone cancers. Also, some
tive tissue. They are generally divided into preexisting bone conditions such as Paget's
two groups, bone and soft tissue. Bone sar- disease seem to predispose individuals to
comas are very uncommon, compromising bone cancer.
only 0.2% of all malignant tumors in the
United States. About 2,100 cases are diag-
nosed annually. The incidence is higher
among Caucasians and among men. Soft tis-
sue sarcomas refers to a group of more than There are four major types of bone sarcomas:
50 types of cancers which account for only chondrosarcoma, Ewing's sarcoma, fibrosar-
1%of all malignancies in men and 0.6% in coma, and osteosarcoma. Chondrosarcoma
women. Annually in the United States about arises from the cartilage and accounts for
5,000 new cases are diagnosed and ap- 13%of malignant bone tumors. It is more
proximately 3,000 persons die from sarcomas common in males and persons between 30-
each year. These tumors are more common 70 years of age. The two major forms of
in children than in adults, accounting for 6% chondrosarcoma are peripheral, arising in
of all malignancies before the age of 25. Since the extremities, and central, arising in the
these two groups are so different, each will trunk. The survival of individuals treated
be discussed separately. with wide resection is 67% for 5 years and
50%for 10 years.
Ewing's Sarcoma is seen in about 5%of
Bone Sarcomas those diagnosed with malignant bone
tumors. It arises from the marrow spaces in
the shafts of the long bone. Ewing's is more
common in males, with 90% of all cases oc-
Risk Factors curring between the ages of 5 and 25. The 5-
High-dose irradiation has been linked to the year survival rate is about 50%' which has
development of bone cancer, although there improved in recent years from only 5%, due
has not been an increased incidence seen to chemotherapy.
among survivors of the atomic bomb in Fibrosarcoma accounts for only 4% of malig-
Japan. There is some evidence of a familial nant bone tumors. It occurs most often in the
long bones and is characterized by interlac- Diagnosis

ing bundles of collagen. There is no age or
sex predominance, although fibrosarcoma is A variety of radiographic methods may be
a very rare tumor in children. Survival rates used to evaluate malignant bone tumors in-
are 28% for 5 years and about 21% for 10 cluding radiographs, bone scans, arteriog-
years. raphy, computerized tomography(CT),
fluoroscopy, and magnetic resonance imag-
Osteosarcoma is the most common type of
ing (MRI). Biopsy is of course vital in deter-
malignant bone tumor, accounting for about
mining the type of malignant bone tumor so
20% of all cases. It is a high-grade, malignant
that treatment can be planned. This may in-
spindle-cell tumor arising within a bone. Os-
clude an incisional, excisional, and/or
teosarcoma is more common in males and
needle biopsy of the suspicious lesion. In
persons between the ages of 11 and 20. The
general, laboratory studies are not useful in
overall 5-year survival rate is about 60%.
diagnosing bone tumors.
However, the 2-year survival rate for those
with localized disease is 40-90% whereas
those with metastatic disease have a 2-year
survival rate of 3040%. Treatment
Treatment is dependent on the type and
stage of the tumor at diagnosis. The overall
Signs and Symptoms goals of treatment include eradication of the
tumor, avoidance of amputation if possible,
Pain from bone tumors usually has a gradual
and preservation of maximum functioning in
onset. It may be present for months, and is
the affected limb. Treatment may include
described as dull, deep, and feeling as if it
surgery, chemotherapy, radiotherapy,
were boring into the bone. However, an
biotherapy or a combination of therapies. A
abrupt onset of sharp pain may be seen if
brief summary of the treatment for each type
pathologic bone fracture is the presenting
will be discussed.
sign and symptom. Other symptoms may in-
clude a lump or swelling on or over a bone Chondrosarcoma is refractory to
or joint. chemotherapy, and surgery remains the
mainstay of treatment. Palliative
Symptoms of metastatic disease include
radiotherapy may be used for those with ad-
hemoptysis, chest pain, cough, fever, weight
vanced or inoperable tumors.
loss, and malaise.
Radical surgery is the mainstay for the treat-
ment of fibrosarcoma.This tumor is
radioresistant so,consequently radiotherapy
is used only for inoperable tumors. The role
SARCOMAS OF BONE & SOFT TISSUES 357
of adjuvant chemotherapy after resection is immediate ambulation and resumption of

being studied at this time. normal activities, which helps minimize the
Ewing's sarcoma is treated with radiation negative psychosocial impact of the amputa-
and/or surgery combined with tion. In the second approach a conventional
chemotherapy. Radiotherapy can cure locally delayed prothesis fitting is done about 12
with 5,000cGy by means of shrinking fields. weeks post-op. Immediately after surgery
The chemotherapy agents used include Dac- the stump is covered with a dressing and an
tinomycin (actinomycinD), Adriamycin elastic bandage. The individual is fitted with
(doxorubicin),Oncovin (vincristine), a temporary prothesis at about three weeks
Cytoxan (cyclophosphamide)and Ifosfamide when the acute swelling has subsided.
(IFEX).
Osteosarcoma is usually treated with surgery

and/or irradiation and adjuvant So# Tissue Surcomus
chemotherapy. The chemotherapy protocols
Soft tissue sarcomas are rare tumors that
used include Adriamycin (doxorubcin),high-
arise in the tissues derived from the
dose Cytoxan (cyclophosphamide),or high-
embryonic mesoderm. They may occur
dose Methotrexate ( M E 0 with leucovorin
anywheE but the most common site is the
rescue. These agents may be used alone or in
legs. In 1994, an estimated 6,000 new cases
combination.
were diagnosed in the United States and
When chemotherapy is used preoperatively about 3,300 deaths will occur from this dis-
or neoadjuvantly it as even more effective ease. Prognosis and survival are based on
with 2-year disease-free survival rates of 85% many factors including the grade of the sar-
to 90% being reported by some investigators. coma, size, location, lymph node status, and
When preoperative chemotherapy is used it DNA ploidy. However, the most important
allows the effectiveness of the chemotherapy indicator is histologic grade. The 5-year sur-
to be assessed at the time of surgery. The vival rate for Grade 1is 72-83%,Grade 2 is
higher the percentage of tumor necrosis the 53-59%,and Grade 3 is 2642%. Patients with
greater the survival rate. Also, for those tumors less than 5 cm in diameter have a bet-
tumors with low necrosis rates, the ter prognosis as do those diagnosed with ex-
chemotherapy agents can be changed pos- tremity sarcomas. Patients with no lymph
toperatively. node involvement and diploid tumors also
When amputation is required there are two have a better prognosis.
major approaches. One approach includes
immediate fitting of a temporary prothesis
using a cast with a pylon prosthesis unit at-
tached. Advantages to this approach include
chest is done to rule out pulmonary metas-

tasis, the most common site of
There are several histologic subtypes of soft hematogenous spread.
tissue sarcomas. The most common types are
liposarcoma and malignant fibrous his-
tiocytoma. Other types include leiomyosar-
Treatment
coma, fibrosarcoma, rhabdomyosarcoma,
synovial sarcoma, angiosarcoma, heman- Resection remains the primary treatment
giopericytoma, alveolar soft-part sarcoma, modality for soft tissue sarcomas.Limb-spar-
and epithelioid sarcoma. ing procedures are most often used, and the
current rate of amputation is about 6 percent.
Radiation therapy has been used preopera-
Signs and Symptoms tively, postoperatively, or in a split course
before and after surgery. The role of adjuvant
The most common signs and symptoms of and neoadjuvant chemotherapy remains un-
soft tissue sarcomas are swelling and pain. clear, with some studies reporting beneficial
Patients sometimes attribute these symptoms results and others not.
to a n injury, which often delays their seeking
Treatment of recurrence includes aggressive
medical attention. Another delay may be in
surgical intervention for local recurrence and
the physician's presumption of a benign
pulmonary metastatic disease.
growth without biopsy confirmation. These
Chemotherapy has had limited success.
factors combined contribute to an average
There is no standard chemotherapy regime,
delay of about 6 months between onset of
but commonly used agents include Ifos-
symptoms and the time of diagnosis.
famide (IFSX), Adriamycin (doxorubicin),
Methotrexate (MTX),Dactinomycin (Ac-
tinomycin-D)and Dacarbazine (DTIC).
Diagnosis
The most common methods of evaluating a
soft tissue sarcoma include computed tomog- Investigafional
raphy (CT)and magnetic resonance imaging Therapies
(MRI). An open biopsy is required for a
Current trials for sarcomas include the com-
definitive diagnosis, which may include ex-
bination of a chemotherapy regime called
cisional, incisional, or needle biopsies.
MAID with biologic therapy such as inter-
Preoperatively, arteriograms or venograms
feron and/or interleukin-6. MAID stands for
may be needed to delineate the boundaries
Mesna, Adriamycin (doxombcin),Ifosfamide
of major adjacent vessels near the tumor
(IFEX), and Dacarbazine (DTIC).It is has
mass. Also, a chest x-ray and/or CT of the
been shown to have a higher response rate in Essential Nursing

some studies than any single agent. This
Diaanoses Related to
regime frequently causes thrombocytopenia;
interleukin-6 is thought to stimulate throm-
thekiagnosis of
bocyte production. Administeringinter- Sarcoma
leukin-6 after MAID is hoped to decrease the
severity and length of thrombocytopenia.
(CH. 1)
Complications 0 Related to:
Diagnosis of cancer and uncertain
The complicationsof sarcoma from the dis- prognosis.
ease process include metastasis to the lung
and lymph nodes and need for amputation.
Inability to meet basic needs, de-
Surgical complications include allograft non- pendency, chronic fatigue, worry,
union, arthritic-type conditions, iatrogenic anxiety, poor self esteem, verbaliza-
fractures, joint dislocation, and infection. tion of inability to cope.
When radiation is employed there may be
delayed wound healing and skin necrosis
afterwards. Complications from Altered Role Performance
chemotherapy include nausea, vomiting, (CH. 1)
stomatitis, cardiac myopathy, hemorrhagic 0 Related to:
cystitis, peripheral neuropathies, and liver Impact of cancer diagnosis on the
damage. patient’s roles within her /his fami-
ly and community.
Change in self-perception of role;
change in others’ perception of role;
change in physical capacities to
resume role(s) and/or respon-
sibilities.
(CH. 1)
0 Related to:
to cancer such as loss of health, life,
work, income, privacy, intimacy,

and relationships. Essential Nursing
0 Defining characteristics: Diagnoses Related to
Patient exhibits and/or expresses Chemotherapy
Risk for Infection

Knowledge Deficit (CH. 4)
(CH.1)
0 Related to:
13 Related to:
Chemotherapy treatments due to
Lack of knowledge about the cancer the destruction of rapidIy dividing
disease process and its treatment. normal hematopoietic cells, result-
ing in immunosuppression.
Defining Charucteristics:
Verbalization of the problem, inac-
curate follow-through of instruc- Granulocytopenia, an absolute
tion, request of information. granulocyte count (AGC) below
1000 cells/m3. Neutropenia, an
absolute neutrophil count (ANC)
below 1000 cells/m3.
(CH. 1)
Related to: Risk for Injury
Impact of cancer diagnosis and un- (CH. 4)
certain prognosis.
0 Related to:
Bone marrow suppression resulting
Family systems unable to meet in thrombocytopenia from
physical, emotional needs of chemotherapy.
Thrornbocytopenia with platelet
count below 50,000 cells/m3,
anemia, fatigue, and decreased oral
intake due to chemotherapy.
SARCOMAS OF BONE & SOFT "ISSUES 361
Altered Nutrition: Less Than Altered Urinary Elimination

Body Requirements 0 Related to:
(CH.4)
Side effects from ifosfamide (IFEX),
Related to: or high dose cytoxan chemotherapy
Anorexia, nausea, vomiting, and resulting in hematuria and/or renal
diarrhea from chemotherapy. toxicity.
IJ Defining Characteristics:
Reported inadequate food intake Hematuria, dysuria, urinary fre-
due to anorexia and nausea, loss of quency, increased BUN and serum
creatinine, or decreased urine
weight, early satiety diarrhea.
creatinine clearance.
c3 Outcome Criteria:
Optimum urinary elimination will
Body Image Disturbance be maintained.
{CH.4)
0 NIC: Urinary Elimination
0 Related to: Management
Alopecia, weight loss and/or skin Definition: Maintenance
changes secondary to
chemotherapy.
Patient verbalizes fear of rejection Urinary Elimination Management
body, concern over hair loss and Activities Rationales
skin changes.
Monitor urinary Promotes early
elimination including identification of
color, volume, urinary problems.
Rlsk for Impaired Skin Integrity presence of RBC's,
BUN, and creatinine.
(CH.4)
Administer chemo in Minimizes acrolein
Relatedto: early AM. accumulation in
bladder during sleep.
Extravasation of vesicant
chemotherapy such as adriamycin, Administer Mesna binds with
and/or vincristine. uroprotector agent, acrolein, the metabolite
mesna, usually 60% of of chemo that can
0 Defining Characteristics: chemo dose, 20%pre, cause hemorrhagic
Patient complains of pain, burning; 20% 4 hrs & 8 hrs post cystitis.
skin looks red; necrotic progressing chemo.
to tissue sloughing.
Urinary Elimination Management Sensory/Perceptual

Alter ations, Kinesthetic
Act iuities Rationales 0 Related to:
Encourage adequate Promotes adequate CNS toxicity from Ifosfamide
hydration, flow through the (IFEX).
prehydration 2-3 kidneys to prevent
liters/day, post-chemo renal toxicity. 0 Defining Characteristics:
2-3 liters/day for 2
Confusion, somnolence, hallucina-
days post-chemo.
tions, weakness, incontinence,
seizures and/or coma.
0 Outcome Criteria:
Neurologic alterations will be iden-
Instructions, Information, tified early.
Demonstration
0 NIC: Neurologic Monitoring
Definitions: Collection and
Activities Rationales analysis of patient data to prevent
or minimize neurologic complica-
Instruct patient to Promotes adequate
tions.
drink at least 8-12 blood flow through the
glasses of fluids before kidneys to prevent
and for two days after renal toxicity.
chemo.
Instruct patient to void Prevents accumulation Neurologic Monitoring
every 2-3 hrs before of acrolein in the
bedtime, and when bladder which imtates
awake at night. bladder lining causing Activities Rationales
hemorrhagic cystitis.
Inforin about the Knowledge promotes Monitor neurologic CNS side effects are
rationale for adequate compliance with and mental status seen in about 12%of
fluid intake and health care regime. including level of patients.
freauent voidinp. consciousness,
orientation, response
Cl Discharge or Maintenance to stimuli, muscle
Evaluation strength, prior to,
during, and post IFEX.
Patient will not develop
hemorrhagic cystitis, or it will Assess possible role Medications with CNS
be detected early. other medications may side effects such as
have in C N S toxicity. antiemetics,
Renal toxicity will be
tranquilizers, narc0tics,
prevented or detected early.
and antihistamines
could increase severity
of CNS toxicity.
Neurologic Monitoring 0 Discharge or Maintenance

Evaluation
Neurologic changes, if they
Activities Rationales occur, will be identified early
and treatment begun, mainly
Identify patients at risk Incidence of CNS possible cessation of IFEX.
for neurotoxicity and toxicity is higher in
observe closely. patients with
compromised renal
function and those
receiving high dose Essen tid Nursing
therapy.
Monitor for seizure Seizures, although less
activity. common, may be seen Surgery
with rapid IFEX
administration.
Provide protective Prevents injury during
environment if seizure. Knowledge Deficit
seizures occur (padded (CH. 2)
side rails, etc.).
Relatedto:
Lack of knowledge about the surgi-
cal procedure.
Instructions, Information, Defining Characteristics:

Demonstration Verbalization of concerns/ques-
tions regarding impending surgical
procedure.
Inform reasons for CNS side effects due to
C N S side effects. overload of toxic
metabolite Pain
(chloracetaldehyde). (CH. 2)
Instruct patient/family Promotes early Related to:
to report any detection of CNS side
alterations in behavior, effects and early Surgical intervention.
sensation, perception. treatment. 0 Defining Characteristics:
Inform patient /family Knowledge will
that CNS side effects promote coping with Diaphoresis, changes in blood pres-
are usually completely side effects. sure and pulse rate, crying, moan-
reversible. ing, protective behavior, refusal to
move or change position due to
Instruct patient not to Medications with CNS pain; voices complaints of pain, dis-
take any other side effects may comfort.
medications, without increase the severity of
physician’s knowledge CNS toxicity from
while taking IFEX. IFEX.
~~
Impaired Physical Mobility Amputation Care
0 Related to:
Decreased strength, pain from
surgery, and/or amputation of af- Position patient with Promotes hip flexion
fected limb, surgical interruption or leg amputation on and prevents hip
removal of muscles, cartilage, and stomach three times a contracture.
ligaments. day.
[7 Defining Characteristics: Position below-the- Prevents stump
knee stump in an contracture.
Inability to move, transfer, or ambu- extended position.
late; decreased muscle strength
and/or control. Wrap stump several Promotes a smooth
times a day. conical-shaped stump
0 Outcome Criteria: for proper prothesis fit.
Patient moves and transfers inde- Provide an over the Assists with
pendently. bed trapeze. movement in bed.
0 NIC: Amputation Care Assist with exercises as Promotes mobility.
appropriate.
Definition: Promotion of physical
and psychological healing after am- Dangle and transfer to Prevents complications
putation of a body part. a chair starting first of bed rest.
day post-op.
Start crutch walking as Promotes
soon as strenath allows. independence.
Amputation Care 0 NIC: Cast Care- Wet
Definition:Care of a new cast
Activities RationaZes during the drying period.
Assess stump for Promotes early

swelling, signs of detection of
infection. complications and
Assess dressing for

healing.
Hemorrhage may be
I Cast Care-Wet
I
bleeding. indicated by excessive
bleeding through I
dressing.
Assess skin near edges Promotes early
Elevate head of bed for Prevents swelling in of cast for friction rubs, identification of
the first 24 hours post stump and promotes swelling, or complications.
amputation. venous return. discoloration.
Position affected limb Promotes healing of Inspect cast for signs of With immediate fitting,
in proper body stump. drainage from wound prothesis hemorrhage
aliment. under cast. is less likely due to
compression, but can
occur.
Cast Care-Wet instructions, Information,

Demonstration

Monitor for signs of Due to cast covering
infection such as fever, stump, wound cannot Instruct patient in Prevents contracture of
increased white blood be visualized. stump extension stump.
count, and /or exercises.
significant stump pain.
Instruct patient on Promotes maintenance
Expose cast to air and Promotes drying of range of motion of muscle strength.
place on pillows. cast. exercise.
Maintain neutral Prevents hip and joint Instruct in transfer Promotes
alignment and contracture. procedures. independence.
encourage frequent
Instruct that phantom Knowledge promotes
position changes of
affected extremity. limb pain may start coping.
several weeks post
Refer to physical Promotes maximizing surgery and may be
therapy as appropriate. of patient’s abilities. triggered by pressure
on other areas.
NIC: Pain Management
Instruct patient to ask Promotes comfort.
Definition: Alleviation of pain or a for analgesics.
reduction in pain to a level of com- Instruct to avoid Promotes cast integrity.
fort that is acceptable to the patient. getting cast wet.
Evaluation
Pain Management Stump heals without com-
plications.
9 Patient demonstrates range of
Activities Rationales motion and stump extension
exercises.
Perform Provides information Pain is maintained at level ac-
comprehensive pain to formulate plan. ceptable to the patient.
assessment.
Assess for phantom Promotes identification
limb pain, the presence of phantom limb pain
of burning, cramping, and provides Body Image Disturbance
or timgling where the information to
limb was. formulate plan. 0 Relatedto:
Administer analgesics Promotes comfort and Amputation, extensive resection of
as needed for pain. increased mobility. soft-tissue, or limb shortening for
sarcoma.
Amputation of a limb, voices con-
cerns over others’ reactions to am-
putation, affect of amputation of Instructions, Information,

lifestyle and/or relationships. Demonstration
Outcome Criteria:
Identifies ways to cope with loss of Activities Rationales
body part.
Instruct on information Promotes coping and
NIC: Amputation Care about technical aides independence.
Definition: Promotion of physical or prothesis.
and psychological healing after am- Instruct on care of Promotes
putation of a body part. prothesis as independence.
appropriate.
Inform of amputation Provides opportunities
support groups. for interactions with
Amputation Care persons with similar
experiences.
Inform that permanen Promotes realistic
Activities Rationales prothesis is usually goals for resumption of
fitted 12 weeks post-op. normal activities.
Appraise patient's Provides information
adjustment to loss of to formulate nursing 0 Discharge or Maintenance
limb. care plan. Evaluation
Accept need for initial Supports patient's Patient demonstrates resump-
concealment of change coping mechanism. tion of normal activities as ap-
as appropriate. propriate.
Use gentle persuasion Promotes acceptance Sensory/Perceptual Altera-
to assist patient in of loss. tions: Tactile, Potential For
viewing affected body
part.
Use proper name for Shows respect for loss.
affected body part. Risk for Sensory/Perceptual
Assist patient through Grieving for loss is a
Alte rati ons: Ta cti I e
grieving process. normal reaction to
amputation. 0 Related to:
Facilitate identification Promotes coping with Possible nerve damage from limb-
of needed changes in loss. sparing surgery.
lifestyle due to Defining Characteristics:
amputation.
Assist patient in Presence of paresthesia, or com-
Promotes self-care.
setting of mutual goals plaints of numbness, tingling in af-
for progressive self- fected extremity.
care. Outcome Criteria:
Affected limb will not develop
numbness or tingling.
If paresthesias develop, they will be
identified early.
NIC: Surveillance 0 Discharge or Maintenance

Evaluation
Definition: Purposeful and ongo-
ing acquisition, interpretation, and Nerve damage will be
synthesis of patient data for clinical avoided or identified early.
decision making. Affected extremity will not be
injured due to lack of sensa-
tion.
Surveillance
I Risk for Ineffective Individual
Activities Rationales Coping
Conduct baseline Nerve injury could Related to:
assessment of occur during surgery. Use of cadaver donor for bone graft.
neuromuscular
function distal to Defining Characteristics:
surgical site.
Patient voices concerns and/or
Monitor Promotes early rejection of cadaver source of bone
neuromuscular identification of nerve graft.
function as appropriate. injury.
Ci Outcome Criteria:
Collaborate with Prevents further nerve
physician if changes in injury. Patient verbalizes acceptance of
neuromuscular cadaver donor for bone graft.
function occur.
El NIC: Coping Enhancement
Instructions, Information, Coping Enhancement

Demonstration
Activities Rat iondes

Activit ies Rat ionales
Assess patient’s Provides information
Instruct patient to Promotes early acceptance of cadaver for care planning.
inform health care identification of donor by encouraging
team if numbness or complications. verbalizations of fears,
tingling occurs. questions, concerns
If numbness is present, Prevents injury to regarding cadaver
instruct in safety affected limb. donor.
measures such as Provide factual written Dispels any myths or
avoiding temperature and verbal misconceptions that
extremes, testing water explanations of the patient may hold.
with unaffected cadaver donor process.
extremity; examine
skin daily for injury.
Coping Enhancement Knowledge Deficit

I I 0 Related to:
Radiation therapy to affected ex-
Support patient in Promotes patient tremity.
decisions regarding control. Defining Characteristics:
donor source.
Discharge or Maintenance and/or questions about upcoming
Evaluation radiation therapy.
Patient will verbalize accep- 111 Outcome Criteria:
tance of cadaver bone graft
donor. Patient verbalizes possible side ef-
fects and self-care management
strategies should side effects occur.
0 NIC: Radiation Therapy
Essenfia1 Nursing Management
Diagnoses Related to Definition: Assisting the patient to
understand and minimize the side
Radiation Therapy for effects of radiation treatments.
Sarcoma
Radiation Therapy Management

Risk for Impaired Skin
(CH. 3)
Relatedto:
Assess knowledge of Provides information
Tissue injury from radiation therapy. radiation therapy for individualized plan
0 Defining characteristics: treatment plan and of care.
Presence of red, raw skin, or com-
plaints of pain in radiated areas. Monitor and treat skin As radiation passes
alterations. through the skin,
changes may occur
including redness,
irritation, dryness,
Fatigue itching, moistness,
(CH. 5) weeping (moist
desquamation), and
Relatedto: darkening of skin.
Side effects from radiation therapy. Inform patient/family Assists patient/family
when treatment will in planning daily
111 Defining Characteristics: begin, purpose, length, activities around
Patient voices complaints of weak- and duration of treatment.
ness, tiredness, lack of energy in- treatment.
ability to maintain normal activities.
Radiat ion Therapy Manage me nt team and treated appropriate-

~ ~ ~ ~ ~~~~
ly.
Patient completes prescribed
Activities Rationales radiation treatment.
Explain possible side Knowledge promotes

2ffects from radiation informed consent.
therapy to extremities
including fibrosis,
Zontractures
sometimes leading to
imputation, edema of
2xtremity distal to site
sf irradiation,
Zessation of growth in
irradiated limb, and
nonhealing fractures.
Instruct on skin care Measures promote skin
measures during integrity during
radiation therapy: radiation therapy.
1) Keep skin clean and
dry;
2) Wash affected skin
with mild soap (Ivory,
or Dove), rinsing well
and patting skin dry;
3) Wear loose-fitting
clothes to protect skin
from sun;
4) NEVER apply lotion
to skin (unless
prescribed by the
health care team) nor
wash off marking
during treatments.
materials on radiation reinforce verbal
therapy. instructions.
Encourage rest periods Fatigue is a common
as appropriate. side effect of radiation
theram.
CI Discharge or Maintenance
Eva1uations
. Skin will remain intact during
radiation therapy.
Side effects from radiation
will be identified early,
reported to the health care
Chapter Nineteen
HI V-Relaf e d
Malignancies
AIDS Related Malignancies
Acquired Immunodeficiency Syndrome through a public education effort. This be-
(AIDS)was recognized as a major health havior change has not significantly in-
problem in the United States in the early fluenced needle sharing behaviors of
1980's. The disease is caused by a retrovirus intravenous drug abusers; however, it is
of the lentivirus group called human im- predicted that this group will comprise the
munodeficiency virus type I, now referred to majority of AIDS patients in future years.
as HIV.This syndrome is the result of T4 lym- Many cities in the United States have con-
phocyte dysfunction resulting in deteriora- sidered instituting clean needIe exchange
tion of humoral and cell-mediated immunity. programs for this reason. Male and female
The host becomes susceptible to opportunis- prostitution, with or without intravenous
tic infections and may also develop unusual drug abuse, remains a high risk lifestyle.
malignancies, specifically aggressive lym- Sexual intimacy without condom protection,
phomas and Kaposi's sarcoma. A normally especially with a partner who has had multi-
functioning immune system is thought to ple sexual experiences, places an individual
help the body resist malignancy. This is not at risk for exposure to HIV.
the case in HIV-positive persons who have
developed AIDS. As the incidence of AIDS in-
creases the number of related cancers will Types of AIDS Related
also rise.
Malignancies
Kaposi's sarcoma and lymphomas are the
Risk Factors two most commonly sited AIDS related
malignancies. Increased incidence of
Prior to widespread testing of the blood Hodgkin's disease, and cervical cancer has
supply for this virus, many groups of people also been reported on HIV positive patients.
were unknowingly infected with HIV: these Many other case reports exist of certain can-
were patients requiring transfusion, cers in AIDS patients.
hemophiliacs, and children of infected
Prior to the AIDS epidemic, Kaposi's sar-
mothers. The transmission of HIV is now
coma (Ks)was seen in the United States in
generally associated with specific lifestyles
the classic pattern initially reported by Dr.
and behaviors. The homosexual and bisexual
Kaposi during the 1870's in Hungary. This
male population in the United States has
dermatologist reported the occurrence of
modified risky sexual practices (sexually in-
cutaneous purplish lesions in older men of
timate acts without condom protection)
Italian or Eastern European Jewish descent, lung, gastrointestinal, and bone marrow in-
beginning on the arches of the feet or lower volvement occurs more frequently in AIDS
extremities. These lesions would slowly patients than the general population. Epstein
spread over the skin and ultimately involve Barr Virus (EBV) is thought to be a causative
the visceral organs. The disease was slow- agent in this type of Lymphoma.
growing over a period of many years. Since
that time, other forms of the disease have
been documented, including the African Signs and Symptoms
form of the disease which is Seen in children
and young adults. Organ transplant AIDS related KS usually presents with
recipients who have received long-term im- purplish or brownish lesions, which may ap-
munosuppression to prevent organ allograft pear anywhere on the skin. They often ap-
rejection also have been known to develop pear suddenly in a widespread pattern over
Kaposi's sarcoma. the body rather than isolated to the feet or
lower extremities, as in classic KS. Without
In the United States ADS related KS has
been associated with homosexual men in treatment, these lesions tend to multiply
about 95%of cases. The median age at quickly and may be painful. The lesions may
presentation is 34 years old. Since the begin- be associated with a greater degree of dermal
ning of the AIDS epidemic, more than 25,000 invasion. They also may be detected in the
cases of AIDS related KS have been reported oral mucosa, gastrointestinal tract, anal
to the Centers for Disease Control (CDC). mucosa, lymph nodes, heart, spleen, testes,
However, the number of cases continues to and lungs. Pulmonary involvement is an
drop. This disease is very different from the ominous sign, associated with only a few
classic presentation of KS, especially in cases months' survival.
where organ systems are involved. The presenting signs and symptoms of AIDS
The occurrence of AIDS related lymphoma related lymphoma may be similar to those ex-
in the United States has not been associated perienced by non-infected persons. Fever,
with any particular risk group, in contrast to night sweats and/or weight loss are known
AIDS related KS. Females with AIDS seem to as classic B symptoms of lymphoma, and
have less risk for developing a related lym- these are present in 0-70% of AIDS infected
phoma. The median age at diagnosis is 38 patients. Lymphadenopathy is another com-
years old; in the non-AIDS population, mon symptom of lymphoma. In the AIDS
median age at diagnosis is 56 years old. population it may be difficultto determine,
AIDS related lymphoma differs from the without biopsy, whether this is related to
usual presentation in that it is generally an AIDS or lymphoma. When lymphoma is
aggressive Rcell disease that presents in un- present in a site outside of the lymphatic sys-
usual sites. Central nervous system, liver, tem, it is referred to as an extranodal site of
HN-RELATED MALIGNANCIES 375
disease. In AIDS related lymphoma, ex- with CNS symptoms. However, brain biopsy
tranodal sites of disease include bone mar- remains the only method of determining
row, gastrointestinal tract, anus, liver, and whether the C N S lesions are due to toxoplas-
central nervous system (CNS). Unlike typical mosis or lymphoma.
lymphoma, 30%of patients with AIDS re-
lated lymphoma have C N S involvement.
Neurological symptoms of mental status Treatment
changes, headache, cranial nerve palsies,
seizures or somnolence may indicate either a Treatment of HIV related malignancies has
CNS infection or CNS lymphoma. Surgical been based on the principles used in treating
biopsy of the involved area, if possible, is the cancer in the non-immunocompromised
only method available to confirm the diag- patient. Radiation and chemotherapy
nosis. present an even greater risk for infection in
persons who are already im-
munocompromised by AIDS.
Diagnostic Tests
The initial blood test to determine the Kaposi ‘S Sarcornu
presence of HIV infection is the enzyme-
linked immunosorbent assay (ELISA)which Surgery has been used to remove KS lesions
tests for the presence of antibody. This is the that have not responded to other therapies,
screening test most commonly performed. If especially when a specific lesion interferes
this test is positive it is generally repeated, with function or appearance. Lesions in the
then confirmed by Western blot. The length oral cavity that cause edema and those of the
of time between infection with the AIDS head and neck have been surgically excised.
virus and the development of antibodies However this is not the principle mode of
remains unknown. For this reason persons therapy
who have been exposed to the virus should KS lesions are generally radiosensitive. Der-
have periodic testing to confirm their status. mal involvement may be treated with
Surgical biopsy confirms KS or lymphoma. electron beam radiotherapy, which is superfi-
Bronchoscopy, endoscopy or colonoscopy cial therapy and does not penetrate to under-
may be necessary to obtain biopsies of pul- lying tissues. This is particularly good
monary and/or gastrointestinallesions. therapy for isolated facial lesions, having an
Computerized tomographic scanning (CT) acceptable cosmetic result. Standard radia-
may be helpful in determining the extent of tion therapy in low doses may be used to
KS or lymphoma. Radiographic neurologic treat internal involvement. This mode of
imaging is generally completed for patients therapy is very helpful in relieving lym-
phedema caused by a KS lesion. The goal of COMET-A (cyclophosphamide, vincristine,

treatment with radiotherapy is palliative be- methotrexate, etoposide, and cytosine
cause there is no cure for the underlying dis- arabinoside)has been associated with a good
ease process. response rate but no survival benefit.
Systemic chemotherapy has demonstrated MACOP-B (methotrexate, doxorubicin,
promise in the treatment of AIDS related Ks. cyclophosphamide, vincristine, prednisone,

and bleomycin) and m-BACOD
Agents may be given alone or in combina-
tion. The vinca alkaloids, vincristine (On- (methotrexate, bleomycin, adriamycin,
covin), and vinblastine (Velban) cyclophosphamide, vincristine, and
administered once a week, alternating the dexamethasone)have both been tested and
drugs, have shown lengthy durations of have demonstrated response. UnfortunatelF
response. The side effects of the vinca long term survival rates are disappointing
alkaloids are minimal. Etoposide (VP-14)has and do not approach those seen in the non-
been a very effective single agent without sig- AIDS population.

nificant adverse effects. It may be used initial- CNS AIDS related lymphoma is generally
ly or when other regimens have failed. treated with whole brain radiotherapy and
Regimens containing Adriamycin corticosteroids. Unfortunately, only 50% of
(doxorubicin)are associated with a high rate patients respond to this mode of therapy. In
of response but with greater toxicities. Other addition to radiation therapy C N S lym-
chemotherapeutic medications have in- phomas may be treated with intrathecal
cluded: bleomycin (Blenoxane), methotrexate chemotherapy. Agents used are methotrexate
(Mexate),and dacarbazine (DTIC).In- and cytosine arabinoside.
tralesional chemotherapy, that is giving the The biologic colony stimulatingfactor, GM-
agent directly into the affected area (Ks
CSF (Leukine, Prokine) has been studied in
lesion), with vinblastine has been used. combination with CHOP (cyclophos-
Alpha-interferon (Intron A) is a biologic phamide, doxorubicin, vincristine, pred-
agent used in the treatment of AIDS related nisone) chemotherapy, versus CHOP alone,
KS, and is sometimes used concomitantly for AIDS related lymphoma. The combina-
with zidivudine (AZT).
tion including GM-CSF was associated with
a similar response rate but fewer occurrences
of infection and neutropenia.
Lymphoma HIV related lymphoma is not treated with a
surgical approach except for biopsy.
The present mode of treatment of AIDS re-
lated lymphoma is chemotherapy. The recent
approach is a multi-drug combination, yet
no specific regimen has yet been defined.
HIV-RELATED MALIGNANCIES 377
Investigationa1 Studies Essential Nursing

The AIDS Clinical Trials Group (ACTG)is
conducting multicenter studies in the United
Diagnosis and Coping
States involving treatment of AIDS patients.
Some of these trials are intended to evaluate
different methods of treating AIDS related Anxiety
KS and lymphoma, and to develop new treat-
Related to:
ment regimens. The experimental work with
immunotoxinsand immunoconjugatesmay Perceived threat to self due to diag-
nosis of AIDS and a malignancy.
contribute to successful therapies for the fu-
ture.
Patient verbalizes feelings of uncer-
tainty, apprehension, fear, sleepless-
ness, restlessness, or other signs of
Complications anxiety.
The complicationsencountered in treating

AIDS related malignancies are formidable. Fear
Since AIDS causes immunosuppression, the (CH. 1)
patient is already at risk or already has ex- Relatedto:
perienced life-threatening infections. Further
Fear of death due to diagnosis of a
immunocompromising these patients with malignancy in addition to the diag-
radiotherapy and chemotherapy may result nosis of AIDS.
in fatal septic episodes. Anemia in AIDS 0 Defining Characteristics:
patients is often a disease related or treat- Patient verbalizes fears of shor-
ment-associated problems. Epoetin alpha tened life span, feeling of dread,
(Procrit)is given three times a week by sub- pessimism over diagnosis.
cutaneous injection until the hematocrit has
returned to an acceptable level.
(CH. 1)
0 Relatedto:
Losses related to AIDS diagnosis
and an AIDS related cancer such as
loss of health, income, work, in-
timacy, relationships, and possibly
life.
0 Defining Characteristics: I7 Outcome Criteria

Patient exhibits or voices expres- Identifies strategies to cope with dis-
sions, feelings of sadness or loss, or mal diagnosis.
concerns over possible loss of work,
income, life. 0 NIC: Hope Instillation
Definition: Facilitation of the
development of a positive outlook
in a given situation.
(CH. 1)
0 Related to:
Hope Instillation
Diagnosis of AIDS related cancer,
uncertain prognosis.
ci Defining Characteristics: Activities Rationales
Inability to meet basic care needs, Assist patient / family Provides concrete
fatigue, verbalization of inability to to identify areas of references.
cope. hope in life.
Expand the patient’s Promotes self-esteem
repertoire of coping through sense of
mechanisms. control.
Knowledge Deficit
Assist the patient to
(CH. 3,4,) devise and revise goals.
0 Related to: Help the patient to
AIDS related cancer and its treat- expand spiritual self.
ment. Facilitate the Promotes a sense of
0 Defining Characteristics: patient/family reliving self worth.
and savoring past
Voices questions about treatment achievements and
for AIDS related KS or lymphoma. experiences.
Employ guided life
review and/or
reminiscence.
Hope1essness
Involve the patient Promotes sense of
0 Relatedto: actively in his or her control.
own care.
Diagnosis of AIDS and an AIDS re-
lated malignancy.
Expresses feelings of despair, voices
concerns of having a disease for
which no cure is available.
Instructions, Information, Spirit uaI Distress

Demonstration
(CH. 15)
Relatedto:
Act iuit ies Rationales
Having a disease without a known
Teach reality Prevents the cure, shortened life expectancy.
recognition by development of
surveying the situation unrealistic
and making expectations. Patient expresses concern with
contingency plans. meaning of life/death and/or belief
Demonstrate hope by Promotes sense of self systems, anger towards God, mood
recognizing the worth. swings, and difficulty handling
patient’s intrinsic emotions.
worth and viewing the
patient’s illness as only
one facet of the
individual. €ssentia/Nursing
Inform patient/family
of support groups and
Provides opportunity
to be involved with
community resources. support groups. Treatment
Evaluation
Identifies areas of hope in life. Body Image Disturbance
0 Related to:
Loss of weight, KS lesions especial-
Altered Family Processes ly on face, alopecia due to
(CH. 1) chemotherapy or whole brain radia-
tion therapy.
0 Related to:
Impact of AIDS and AIDS as-
sociated malignancy diagnosis. Patient voices concerns about chan-
ges in physical appearance, expres-
0 Defining Characteristics: ses fear of rejection or reaction by
Family systems unable to meet others to physical changes.
physical, emotional needs of 0 Outcome Criteria
members of inability to cope. Body image improved, preserved
and maintained.
0 NIC: Body Image Enhancement
Definition: Improving a patient’s
tions and attitudes toward his or
her body.
Body Image Enhancement 0 Discharge or Maintenance

Evaluation
Identifies community resour-
Activities Rationales ces to support AIDS patient
with a malignancy.
Encourage patient to Promotes integration
express feelings of changes into
regarding differences lifestyle.
in appearance and
expected impact on Altered Nutrition: Less Than
lifestyle. Body Requirements
Evaluate patient's Provides background KH. 8 )
feelings regarding date on which to
changes in appearance formulate care plan. 0 Relatedto:
and its effect on sexual AIDS, diarrhea from infection,
identity, relationships, malignancy, or treatment, anorexia,
and body image. early satiety.
Assist patient to Promotes positive self 0 Defining Characteristics:
appearance and Anorexia, vomiting, loss of weight,
feelings of personal reported decrease in food intake,
worth. early satiety, presence of mouth
Give permission to Allows patient needed soreness and/or ulcerations, oral in-
grieve over loss of time to cope with fection.
previous appearance. losses.
Allow patient to Promotes coping as
ventilate negative these are normal High Risk for Infection
emotions such as anger reactions to loss.
and guilt. (CH. 4,131
Refer to social worker Promotes coping by Related to:
for support in providing support
Immunosuppression from the AIDS
emotional, financial, services to assist with
vocational and changes. virus, further im-
adjustment issues. munocompromised due to
chemotherapy or radiation therapy.
Inform patient that Provides information.
hair will grow back Defining Characteristics:
following Granulocytopenia,an absolute
chemotherapy. granulocyte count (AGO below
Inform patient of Promotes community 1,000 cei1s/m3, neutropenia, an
community AIDS support. absolute neutrophil count (ANC)
resources. below 1,000 c e ~ s / m m ~
Activity intolerance 0 NIC:Medication Administration -

Intralesional**
(CH. 4)
Related to: chemotherapy directly into the
lesion.
Fatigue secondary to treatments for
an AIDS associated cancer. **Not yet an accepted NIC"
Medication Administration -
pressure in response to activity, ex-
lntralesional
ertional dyspnea.
Pain
I Activities
Rat ionales
Position patient so that Promotes comfort.
area to be injected is
0 Related to: well supported.
Fevers associated with AIDS virus Cleanse area to be Prevents infection.
or infection. injected.
0 Defining Characteristics: Monitor patient for Promotes early
reactions during recognition of potential
Patient voices discomfort such as injection. problems.
myalgias, muscle aches, fever,
chills, or rigors. Document patient Provides information.
response to treatment.
KnowIedg e Deficit
Relatedto: Instructions, Information.
Demonstration
Chemotherapy administration into
a KS lesion.
Defining Characteristics: 1 Activities Rat ionales
Verbalizes lack of information Teach patient purpose, Increased knowledge
about treatment and potential side benefits, and rationale promotes
effects of intralesional for this therapy. understanding.
chemotherapy. Inform patient of both Provides selfcare
0 Outcome Criteria: immediate and information.
potential delayed
Patient is able to verbalize treat- effects.
ment plan and goals of therapy.
~~~ ~
0 Discharge and Maintenance

Eva1uation
Patient is able to verbalize
understanding of procedure.
Impaired Skin Integrity Risk for Decreased Cardiac

(CH. 2) Output
0 Related to: Related to:
Presence of KS lesions, herpes infec- Septic shock due to overwhelming
tion. sepsis in the immunocompromised
0 Defining Characteristics: patient.
Disruption of skin surface by Defining Characteristics:

presence of KS lesion or herpetic in- Variations in blood pressure,
fection, perirectal lesions due to in- jugular vein distension, decreased
fection or diarrhea. peripheral pulses, anythmia, color
changes in skin and mucous
membranes, cold clammy skin,
oliguria, dyspnea, rales, restlessness.
(CH. 17)
0 Related to:
Seizures, disorientation due to
AIDS associated CNS lymphoma or
toxoplasmosis infection.
Seizure activity with a change in
consciousness,change in sensation
of a body part, muscle weakness,
falls.
Altered Thought Processes

(CH. 17)
Related to:
AIDS associated CNS lymphoma,
toxoplasmosis infection, physiologi-
cal changes.
Disorientation to time, place, cir-
cumstances and events, changes in
consciousness,inappropriate affect,
altered attention span, memory
deficit.
Chapter Twenty
Rehabill’fation
Rehabilitation Needs of the
Oncology Patienf
The goal of care of the oncology patient has identify rehabilitative needs. These needs are
been to cure the disease to preserve life. not limited to the obvious physical ones and
However, in the process of saving a life, the include psychological, vocational, spiritual,
quality of that life has sometimes been forgot- social, and sexual needs. Each individual‘s
ten. Now patients are becoming partners in identity is unique and multifaceted and is
their care, insisting on knowing the potential based on cultural, emotional and spiritual
side effects of treatment that may affect their back- grounds. Often a relationship needs to
quality of life. Armed with this information, be established before an individual will
they can make choices for themselves based share this information with health care
on their values and beliefs. Rarely will a providers. When a patient’s priorities have
patient allow the physician to do what the been identified, a realistic plan may be
physician thinks is best without question. developed. The plan should reflect attainable
This participation in one’s own care often goals based on the patient’s condition. For ex-
transfers well into the realm of rehabilitation. ample, the goal for a testicular cancer patient
The national Cancer Act in 1971and the successfullytreated with chemotherapy may
Rehabilitation Act of 1973 began the trend be his returning to work, whereas a brain
that has made rehabilitation an integral part tumor patient’s goal may be to walk inde-
of the cancer patient’s care. Prior to the early pendently.
1970’s (and unfortunately in some cases
Rehabilitation has been defined as the
today) the oncology patients were not development of the disabled individual to
thought of as people who were going to live the fullest physical, psychological, social,
long enough to benefit from rehabilitativeef-
vocational, and educational potential.
forts. Now, in the United States, more than Rehabilitative care can include almost every
half of patients treated for malignancies have health care specialty. Some persons will re-
long-term disease-free survivals. Their
quire more services than others. No oncol-
ability to return to an enjoyable lifestyle
ogy patient should be treated without
often is dependent on early rehabilitative in- consideration of his or her short- or long-
tervention.
term rehabilitative needs.
Greater numbers of oncology patients are
The following nursing diagnoses relate to the
being treated as outpatients, spending less
most basic of a person’s needs.
time on inpatient units. Therefore the nurse
must develop a quick assessment strategy to
Essential Nursing
Caregiver verbalizes concern over
Diagnoses Related to lack of sleep, fear of inability to
Role Changes meet patient’s needs, and/or need
for respite care.
Ineffective IndividuaI Coping Impaired Home

(CH. 1) Maintenance
0 Related to:
0 Related to:
Diagnosis and treatment of cancer.
Altered role of adult member of
0 Defining Characteristics: household, caring for person with
cancer in the home, financial chan-
Inability to meet basic needs, de- ges.
anxiety, poor self-esteem, verbaliza- 0 Defining Characteristics:
Verbalization of inability to care for
patient at home, lack of knowledge
regarding home services.
Altered Family Processes 0 Outcome Criteria:
(CH. 1) Caregiver verbalizes an under-
Cl Relatedto: standing of discharge plan.
Caregiver knows who to contact for
Impact of cancer diagnosis and un- problems.
certain prognosis.
0 NIC: Discharge Planning
Definition: Preparation for moving
Family systems unable to meet a patient from one level of care to
physical, emotional needs of another within or outside the cw-
patient, or verbalization by family rent health care agency.
High Risk For Caregiver Role Discharge Planning

Strain
(CH. 21)
Acfiuities Rat ionales
17 Related to:
Assist Promotes awareness of
Patient’s illness, constant care needs patient/ family/significa change.
of patient, lack of respite care. nt others to prepare for
discharge.
REHABILITATION 387
Discharge Planning Instructions, Information,

Demonstrations
Collaborate with Prevents
patient/family and misunderstanding of Demonstrate Provides information.
health team members discharge plan. procedures to be done
in planning for
continuity of care.
0 NIC: Home Maintenance
Identify patient/family Promotes self care. Assistance
teaching needed for
postdischarge care. Definition: Helping the
Communicate patient‘s Provides for continuity patient/family to maintain the
discharge plan to of care. home as a clean, safe, and pleasant
appropriate agencies. place to live.
Document patient’s Promotes an

discharge plans in awareness by staff.
medical record.
Develop a plan that Prevents unrealistic Home Maintenance Assistance
considers the social expectations.
and financial needs of
the patient and family. Activities Rationales
Arrange for post- Promotes continuity of Involve patient/family Promotes realistic plan.
discharge evaluation care. in deciding home
as aumouriate. maintenance
requirements.
Suggest necessary Promotes safety.
structural changes in
home, if appropriate.
Demonstrations Assist family members Prevents caregiver role
to develop realistic strain.
expectations of
themselves in
performance of their
Teach patient/family Promotes roles.
aspects of care understanding of care Order homemaker Provides assistance in
necessary, plan. services as appropriate. the home.
postdischarge.
Help family to utilize Provides support.
Give written Provides reinforcement. social support network.
instructions.
Identify patient/ family Promotes self care.
Instruct patient/family Promotes teaching needed for
about medication administration of postdischarge care.
administration. ordered medications.
Communicate patient’s Provides for continuity
discharge plan to of care.
appropriate agencies.
Home Maintenance Assistance 1 Support System Enhancement

- ~

Document patient's Promotes an Assess psychological Provides information.
discharge plans in awareness by staff. response to situation.
medical record. Assess availability of
Develop a plan that Prevents unrealistic support system.
considers the social expectations.
Determine adequacy of Prevents unrealistic
and financial needs of existing social expectations.
the patient and family.
networks.
Arrange for post Promotes continuity of
Identify degree of
discharge evaluation care. family support.
as appropriate.
Identify degree of
family financial
support.
Determine support Promotes
Instructions, Information, systems currently used. understanding of
Demonstration needs.
Determine barriers to
using support systems.
Refer to a community- Provides services close
Teach patient/family Promotes based to home.
aspects of care understanding of care treatment /rehabilita tion
necessary, post plan. promam.
discharge.
Give written Provides reinforcement.
instructions.
Instruct patient / f amily Promotes Instructions, Information,
about medication administration of Demonstration
administration. ordered medications.
Provide information Prevents caregiver role
on respiet care as strain. Activities Rat ionales
needed.
Inform Provides information.
NIC: Support System Enhancement patient/caregiver of
community resource
Definition: Facilitation of support agencies.
to patient by family, friends and
community, Explain to concerned
others how they can
help.
Cl Discharge or Maintenance El Outcome Criteria:
Evaluation
Patient’s body will be washed.
Caregiver is able to care for
patient at home. El NIC: Bathing
Caregiver utilizes support ser- Definition: Cleaning of the body
vices as needed. for purposes of relaxation, cleanli-
ness, and healing.
Essentjal Nursing
Diagnoses Related to Bathing
Altered Ability to Cure
for Self Activities Rationales
Assist with chair Promotes cleanliness.
shower, tub bath,
bedside bath, standing
Altered Thought shower, or sitz bath as
Processes needed.
(CH.17) Wash hair as needed.
0 Relatedto: Administer foot soaks

as needed.
Neurological complicationsof can- Prevents infection.
Assist with perineal
cer or its treatment.
care.
0 Defining Characteristics: Monitor skin condition Promotes early
Disorientation to time, place, cir- while bathing. recognition of potential
cumstances and events, changes in problems.
consciousness, inappropriate affect, Apply lubricating Prevents breaks in skin.
altered attention span, memory ointment and cream to
deficit. dry skin areas.
Offer hand washing Promotes cleanliness.
after toileting and
before meals.
Self Cure Deficit,
Bathing/Hygiene
Relatedto:
Psychological or physical impair-
ment of function due to cancer diag-
nosis or its treatment.
Inability to bathe or perform
routine hygienic activities.
Instructions, Information, Dressing

Demonstration
Actizities Rationales
Dress patient after Provides covering for
Demonstrate bedside Provides information. personal hygiene body.
bath, use of shower completed.
chair, or sitz bath to
Encourage Promotes
patient /caregiver.
participation in independence.
0 Discharge or Maintenance selection of clothing.
Evaluation Dress affected Promotes ease of
extremity first. dressing.
Patient will have regular
baths. Dress in personal Promotes self-esteem.
clothing as appropriate.
Change patient's Provides normal
clothing at bedtime. routine.
Self Care Deficit, Select shoes/slippers Provides support to
Dressing/Grooming conducive to walking feet.
and safe ambulation.
0 Related to:
ment of function due to cancer diag-
nosis or its treatment.
0 Defining Characteristics: Demonstration
Inability to dress or groom self.
0 Outcome Criteria: Activities Rationales
Patient will be dressed and
Demonstrate dressing Provides information.
pomed.
of patient to
0 NIC: Dressing family/ careniver.
Definition: Choosing, putting on, 0 Discharge or Maintenance
and removing clothes for a person Evaluation
who cannot do this for self.
Patient will be dressed
I Dressing I Self Care Deficit, Feeding

I I 0 Relatedto:
Activities Rationales Psychological or physical impair-
Assess patient's ability Provides information. ment of function due to cancer
to dress self. and/or its treatment.
REHABILITATION 391
Defining Characteristics: Feeding

Inability to feed self.
0 Outcome Criteria: Activities Rut ionales
Patient will have adequate nutri- Feed unhurriedly. Promotes food intake.
tional intake.
Encourage family to
0 NIC: Feeding feed patient.
Definition: Providing nutritional in-
take for patient who is unable to
0 NIC: Self Care Assistance -
feed self.
Feeding
Definition: Assisting a person to
eat.
Feeding
Self Care Assistance-

Activities Rat ionales Feeding
Identify prescribed diet. Prevents feeding of
inappropriate food. Activities Rut ionales
Create a pleasant Promotes appetite.
environment during Set food tray and table Promotes appetite.
mealtime (e.g., put attractively.
bedpan, urinal out of Fix food tray as Assists in eating.
sight). necessary, such as
Provide for adequate cutting meat or peeling
pain relief prior to an egg.
meals as appropriate. Avoid placing food on Lets patient see food.
Provide for oral person’s blind side.
hygiene prior to meals. Describe location of Promotes
Ask patient preference Promotes nutritional food on tray for person independence in eating,
for order of eating. intake. with vision
impairment.
Maintain in an upright Promotes chewing and
position with head and swallowing. Provide foods at most Promotes nutritional
neck flexed slightly appetizing intake.
forward during temperature.
feeding. Provide adaptive Promotes
Place food in the devices to facilitate independence.
unaffected side of patient’s feeding self
mouth as appropriate. (e.g., long handles,
handle with large
Use bib as appropriate. Protects clothing. circumference, or small
Provide a drinking Promotes fluid intake. strap on utensils).
straw as needed or Use unbreakable and Prevents spillage.
desired. weighted dishes as
necessarv.
Self Care Assistance- 0 Outcome Criteria:

Feeding Patient will regularly eliminate
urine and stool.
I
0 NIC: Self Care Assistance-
Toileting
Provide frequent Promotes eating.
cueing and close Definition: Assisting another with
supervision as elimination.
appropriate.
Self Care Assistance- Toileting

Demonstration
I Remove essential
clothing to allow for
Prevents elimination
on clothing.
elimination.
Instruct patient/family Provides information
in any dietary on recommended diet. Assist patient to use Promotes elimination.
restrictions. toilet/bedpan/fracture
pan/urinal at specified
Teach patient/family Promotes caloric intake. intervals.
about high protein,
high calorie Provide privacy during
supplements. elimination as
appropriate.
0 Discharge or Maintenance Facilitate toilet hygiene Promotes cleanliness.
Evaluation after completion of
Patient will have adequate elimination.
nutritional intake. Replace clothing on Provides assistance
Patient will maintain weight. patient after with dressing.
elimination.
Flush toilet, cleanse Promotes cleanliness.
elimination utensil.
Self Care Deficit, Toileting
0 Relatedto:
ment of function due to cancer
and/or its treatment.
Patient is unable to independently
participate in toileting.
REHABILITATION 393
Instructions, information, Environmental Management-

Demonstration Safety
Activities Rat ionaies Activities Rationales

Institute a toileting Promotes regular Identify the safety Provides information.
schedule. elimination. needs of patient, based
on level of physical
Instruct patient/family Promotes regular
and cognitive function,
in toileting routine. elimination.
past history, and
Demonstrate use of Provides information. behavior.
urinal, bed pan,
Identify safety hazards Promotes appropriate
fracture pan, or
in the environment. interventions.
external catheter.
Remove hazards from Prevents injury.
0 Discharge or Maintenance environment when
Eva1uat ion possible.
. Patient has a regular elimina- Modify the
environment to
tion schedule.
minimize hazards and
risks.
Provide adaptive Increases the safety of
Risk for Injury devices (e.g., shower the environment.
rails, handrails).
0 Relatedto:
Use protective devices
Psychological or physical limita- (e.g., siderails, locked
tions due to cancer and/or its treat- doors) to physically
ment. limit mobility or access
to harmful situations.
Gait disturbances, seizures, syn-
cope, loss of balance, dizziness,
visual deficit.
0 Outcome Criteria: Demonstration
Patient will not sustain injury.
17 NIC: Environmental Management
I Activities Rationales
Safety
Demonstrate use of Promotes safety.
Definition: Monitoring and
manipulation of the physical en- side rails to
vironment to promote safety. family/ caregiver.
Inform
family/caregiver of
potential hazards in
the environment.
0 NIC: Fall Prevention Fall Prevention

Definition: Instituting special
precautions with patient at risk for
injury from falling. Activities
~~___________~
Rationales
Provide bed mattress
with firm edges for
easy transfer.
Fall Prevention Use siderails of Prevents falls from bed.
appropriate height and
length.
Activities Rationales Provide the dependent Prevents feeling of
patient with a means isolation.
Identify cognitive or Promotes awareness of of summoning help
physical deficits of the potential problems. when caregiver is not
patient that may
present (eg., call bell,
increase the potential
intercom).
of falling in a
particular environment. Avoid clutter on floor Prevents tripping.
surface.
Identify characteristics
of environment that Provide adequate
may increase the lighting for increased
potential for falls (e.g., visibilitv.
slippery floors, scatter
rugs).
Monitor gait, balance, Provides information.
and fatigue level with
ambulation. Instructions, Information,
Demonstration
Assist unsteady Provides physical
individual with support if necessary.
ambulation.
Provide assistive I
devices to steady gait Instruct patient to call Prevents falls.

(e.g., cane, walker). for assistance with
movement as
Lock wheels of Prevents falls.
appropriate.
wheelchair or bed
during transfer of Teach patient how to Prevents serious injury.
patient. fall so as to minimize
injury.
Place articles within
easy reach of patient.
Provide elevated toilet Promotes safe transfers Eva1uation
seat for easy transfer.
Provide chairs of
. Patient will not fall.
proper height, with
backrests and armrests.
Chapter Twenty-one
Care of the
ierminally Ill
Care of the Terminally 111
Cancer Patient
Cancer as previously discussed is incurable Some ethical dilemmas are inherent in these
about 50%of the time. For many patients types of trials. One dilemma is how to weigh
with cancer there comes a time when all con- the benefits versus the risks of treatment
ventional treatments have been tried and when the risk of potentially life-threatening
have failed. The focus of the patient‘s care complications and side effects are unknown.
shifts from active treatment to supportive Also, is it ethical to experiment on terminally
care. Some patients are unable or unwilling ill patients who are so vulnerable and often
to accept that there is nothing more that can willing to try anything? Another question in-
be done to actively treat the tumor with the volves the concept of informed consent: do
goal of control or cure. They choose to con- patients truly understand the purpose of
tinue with every possible aggressive/cura- phase-1 trials? ”No,” said a recent survey of
tive treatment measure until the last few patients undergoing phase-1 clinical trials at
days of life. If no conventional treatment is the University of Chicago Hospitals, one of
available, they may seek out experimental or America’s six Comprehensive Cancer Care
unconventional treatments. Centers that offer phase-1 trials. When asked
the purpose of the clinical trial they were par-
These patients may take a chance on ex-
perimental treatments such as phase-1 drug- ticipating in, most patients stated they were
testing programs. The goal of phase-1 trials there to get a drug to help themselves. The
is to find the maximum tolerated dose of a reality is that these trials are more likely to
new drug or the amount of medication a benefit future patients than the patients un-
dergoing the trial. Some patients do take the
patient can receive without lifethreatening
medication for altruistic reasons. As one
side effects. These trials focus on the newest
patient stated in the survey, “I look at (drug
drugs that often have never before been
trials) on the basis that I’m fortunate enough
given to humans, although these agents have
that I can assist other people, regardless of
demonstrated activities against tumors in
the outcome for me.” Many ethicists feel that
animal models. Therefore, it is not known
despite such questions, it is ethical to treat
what type of cancer, if any, the drug will act
terminally ill patients in these trials because
upon and the amount of medication needed.
patients are capable, regardless of their vul-
For many patients such trials are their only
nerability of participating in these decisions
hope and they are willing to try it.
and making informed choice.
Nurses play a major role in ensuring that cancer, hospice may be an excellent option
patients truly are making informed choices. for living their last days to the fullest. The
Nurses, as patient advocates, can make sure hospice philosophy, as summed up by Dr.
the patient receives a written consent and Cicely Saunders, a major founder of the
can voice an understanding of what is in the hospice movement, is that the patient mat-
consent. We can ensure that all the patient’s ters to the last moment of his or her life.
questions are answered and, whenever pos- Hospice will do all it can, not only to help
sible, that treatments are adjusted to meet the patient die peacefully, but to live until
the patient‘s individual needs. A hard reality they die. Hospice is not a building or a place
we all must accept is that without phase1 tri- but rather a concept of care. A key concept in
als, no new medications would ever be hospice care is the multidisciplinary ap-
developed and medical science would not proach to treatment, including doctors, nur-
progress beyond the status quo. As one wise ses, home health aides, social workers,
and wonderful patient once stated as he was clergy, nutritionists, physical therapists, oc-
about to become the first patient ever to cupational therapists, speech therapists,
receive a new drug, “For every drug on the volunteers, and pharmacists. As the focus of
market today, someone had to be willing to care shifts from active treatment to suppor-
be the first person to try it. Why not me? tive care, the hospice team works with
Who knows, maybe it just might help. I patients and families to make each patient’s
know what will happen if I do nothing. At final months and days as happy, comfort-
least I’m going down fighting.” We, as nur- able, and meaningful as possible. After
ses, must support our patients’ choices even death, hospice continues to provide support
if they are not the same choices we think we to the grieving family as well.
would make. Symptom control, especially pain manage-
Unconventional treatments are additional op- ment, are essential to ensuring the last days
tions patients may seek out in the last days of living are meaningful. By helping to al-
of living. This can prove very costly with lit- leviate pain and discomfort and offering
tle benefit to the patient. Some of these treat- psycho-social support, hospice reduces the
ments may not harm the patient and may patient’s fear of abandonment and makes
provide therapeutic value. Nurses need to be them feel more secure. The National Hospice
patient advocates. We need to assist the Organization reports that each year more
patient in evaluating alternative options in a Americans are turning to hospice. Of 246,000
logical manner by providing factual informa- patients and their families served by hospice,
tion about the treatments and encouraging 78%had cancer.
patients to discuss options with their doctor.
Most hospices specify that a person is
For patients able to accept that there is no eligible for hospice if his or her life expectan-
more that can be done to actively treat the cy is less than six months and has a person
CARE OF THE TERMINALLY ILL 399
willing to assume the role of primary The best way to address these problems is
caregiver. Some hospices require approval of with a multidisciplinary approach. However,
the patient’s primary physician. Others have it is the nurse who usually is on the scene
medical directors managing the patient’s leading the team. The nurse identifies the
care. The home model of hospice care is the time at which other team members are
primary model in the U.S.Most hospices needed and coordinates the care to best meet
have an inpatient care unit available if the the patient’s needs. The most common
patient needs short-term pain management, problems of the person in the last days of
symptom control and/or respite care. Most living will be addressed and nursing care
experts agree that hospice provides the best highlighted.
form of care available for the dying.
Pain management and symptom control are

the foundation of high quality hospice care. Gastrointestinal
It is impossible to address a patient’s psycho- Problems
social needs if the patient is in constant, un-
controlled discomfort. Discomfort may be Gastrointestinal problem are common in the
due to pain, nausea, vomiting, diarrhea, last days of living. These include anorexia,
mouth sores, or various other problems. The nausea, vomiting, oral infections such as can-
most common problems experienced by the dida and herpes zoster, constipation, bowel
hospice patient in order of frequency include obstruction, compression of the stomach,
weight loss, pain, anorexia, dyspnea, cough, and weight loss. Anorexia is a problem for
constipation, weakness, nausea, vomiting, most patients for a variety of reasons. The
edema, ascites, pleural effusion, insomnia, inpatient’s appetite may be depressed by break-
continence, dysphagia, skin breakdown, down of the tumor’s by-products as the can-
hemorrhage, drowsiness, paralysis, jaundice, cer grows. These tumor peptides seem to
and diarrhea. The approach to treating these depress the appetite, cause early satiety, and
problems is very different from conventional taste changes.
cancer treatment whose aim is to find the Tumors in the abdominal cavity or in the
cause and treat it. Many of these problems liver, as they grow larger, can actually com-
can be directly attributed to the cancer. If the press the stomach and intestines, or cause
cancer is resistant to treatment, the approach bowel obstructions leading to nausea and
must be to find a way to manage the vomiting. Liver and kidney failure both con-
symptom since the cause can‘t be treated. It tribute to anorexia and cause nausea. In their
is difficult at times to do this and may take immunosuppressed state, due to the disease
several attempts before adequate control is or its treatment, cancer patients frequently
obtained. contract mouth infections like candida or her-
pes, making it difficult to eat. Medications
around identifying the cause for sleepless- nary expertise. The multidisciplinary hospice
ness and working closely with the patient team is for managing pain. Effective pain
and family to find a plan that addresses the management requires careful assessment,
patient’s particular concerns. meticulous planning, and provision of emo-
tional, social, and spiritual support.
A key to understanding pain is accepting

Skin Froblerns that pain is personal and unique to the per-
son experiencing it. McCaffrey expresses this
Due to immobility, poor nutritional status, best in her definition of pain as ”whatever a
edema and diminished circulation decubiti person says it is, existing whenever he or she
are sometimes a problem. Prevention by in- says it does.” The patient is the authority
struction of the patient and caregivers is the about his or her pain - not the nurse or the
key to this problem. The nurse needs to doctor. There are two types of pain, acute
show the carcgivers how to position patients and chronic. The person with cancer can ex-
who are unable to turn themselves. The im- perience acute or chronic pain or both at the
portance of keeping incontinent patients same time. Acute pain is intense, sharp, local-
clean and dry must be stressed with the ized, and may last from one second to
caregivers as well. Fungating wounds occur several weeks. Chronic pain can be a con-
with some patients with cancer but are most tinuum from ache to agony. It is frequently
common in those with breast cancer. These described as dull or aching and is not usual-
lesions cause distress to the patient and their ly localized. Chronic pain can be as severe as
families due to their noxious odor and acute pain and lasts months to years. The
drainage. Special care of these lesions can pain may become the focal point of living
reduce the odors and make them more and can cause great frustration for the
tolerable to the patient and their family. patient. Health care workers often find
chronic pain more difficult to treat and may
become frustrated as well.
Cuncer Pain The effects of the disease can cause pain in
the cancer patient. There are several reasons
It is estimated that between 50-70%of the ter-
for this including compression of nerve
minally ill patients with cancer will have
roots, invasion of the tumor causing com-
pain, with about 20% experiencing ”agony”.
pression and obstruction of blood vessels or
Pain can be so debilitating that simple acts
gastrointestinal or genitourinary viscus,
like eating, walking, and living become in-
necrotic tissue caused by the tumor or infec-
tolerable. Depression and anxiety may make
tion, and inflammation of pain sensitive
it difficult to sleep and some patients have
structures. Side effects from cancer treat-
even become suicidal. The successful treat-
ments may cause pain as well. Surgical proce-
ment of severe pain requires interdiscipli-
dures, radiation treatment, and even of the two or all three of the groups, as the
chemotherapy can cause pain in some cause of pain may have many factors.
patients. Whenever possible, the source of Most pain experts recommend a 3-Step Anal-
the patient's pain should be identified and gesic ladder for managing cancer pain. The
treated if possible. first step for patients with mild to moderate
Careful assessment of pain is essential. Pain pain is to treat the patient with a nonopioid
assessment includes questions regarding analgesic combined with an adjuvant anal-
when the pain occurs, its severity, duration, gesic as appropriate. Patients who fail the
and location. What makes it worse, what first step regimen, or who present with
helps, accompanying symptoms, its effect on moderate to severe pain, should use the
activities of daily living should be assessed. second step and be treated with an oral
If the patient has been taking any medica- opioid combined with a nonopioid analgesic,
tions, their effectiveness should be discussed. as well as an adjuvant analgesic as ap-
A variety of excellent tools are available in propriate. Step 3 is for patients who fail step
the literature and should be employed. Once 2 or present with very severe pain and
a complete assessment has been performed, should be treated with an opioid, with or
a plan can be developed to meet the patient's without a non-opioid analgesic, or with an
needs. adjuvant analgesic as appropriate. The
An important concept in chronic pain preferred route of administration is oral.
management is round-the-clock dosing for However, rectal, sublingual, dermal, and
round-the-clock pain. Administering pain parental routes may be employed as needed.
medications on a regular schedule may be While medications are the mainstay of pain
necessary and often decreases the total management, many behavioral approaches
medication requirement. The three main may prove beneficial. Behavioral approaches
groups of analgesics are nonnarcotics or non- include biofeedback, hypnosis, guided im-
steroidal anti-inflammatorydrugs, narcotics agery, relaxation techniques, and music, play,
or opioids, and adjuvant analgesics. Nonnar- or art therapy. At times, radiation therapy or
cotics or nonsteroidal anti-inflammatory surgery may be beneficial. Successful pain
drugs work primarily at the peripheral nerv- management in the cancer patient requires
ous system level. Narcotics or opioids work an interdisciplinary approach that uses a
at the central nervous system level. Adjuvant variety of pain relief techniques. The patient
analgesics represent a diverse group of drug in pain must be involved with all aspects of
classes that have other indications but are the treatment plan. The treatment plan needs
analgesic under certain circumstances. These to be constantly reevaluated and revised to
include tricyclic antidepressants, anticonvul- best meet the patient's needs as the disease
sants, oral local anesthetics, and neurolep- progresses and pain increases.
tics. Patients may benefit from a combination
Emotional support propriate spiritual assistance, such as contact-

ing clergy, or simply praying with the patient
An important component of the hospice pro- or family. Explaining the probable signs and
gram is the provision of emotional support symptoms of impending death to the family
for the patient and his or her family and will help them cope. The nurse can help the
friends as they deal with many losses. Death family maintain a sense of control and
is the ultimate loss and while it is difficult for decrease anxiety by sharing pertinent
the family to lose a loved one, we must knowledge. Most families will realize that no
remember the patient is losing everything - one can know exactly when someone will
loved ones, family friends, life, work, and die and appreciate any information that as-
their future. sists them in planning. Physical care remains
A large part of the hospice worker’s time important and assistance from the hospice
may be spent listening to the patient and nurse at this time may be appreciated. When
family. Helping the patient and family iden- death finally occurs it is usually a time of
tify support systems is a vital part of the role. relief and grieving. Often the hospice nurse
Hospice workers also need to reaffirm to the is called upon to provide emotional support
caregivers that they are doing a good job. to the family. The hospice nurse can also as-
Counseling should include instruction about sist the family with the legalities of death
the grieving process and facilitation of an- and in some states even sign the death certifi-
ticipatory mourning, a normal process as- cate. Nursing support of the family con-
sociated with the dying process. The dying tinues after death. This may include
person may feel more comfortable talking to attending the funeral or memorial service,
the nurse than to a family member. However, written notes or visits several weeks after
the nurse needs to foster open communica- death, and contact on special dates in the
tion with the patient and family as much as year after death such as birthdays and an-
possible without losing the patient’s trust. niversaries. Some hospices have formal
The nurse can help the dying person and his bereavement programs that include monthly
or her family formulate realistic goals to gatherings and support groups.
make the most of the time remaining. Dylng The care of the patient in the last days of
persons have a need for love and affection. living can be very challenging. If the patient
The hospice nurse needs to encourage the chooses to pursue active curative treatment
patient and partner to find a way of express- right up to the last days, their care will be as
ing their love and affection. outlined in previous chapters specific to the
Once it becomes apparent that death is near, type of cancer with which the patient has
the hospice nurse can assist in many ways. been diagnosed. For those patients choosing
These include assisting the family in discuss- hospice as an alternative, the care focus
ing funeral arrangements, offering ap- shifts from curative to supportive. The fol-
lowing are the essential nursing diagnoses Sleep Pattern Disturbances

for patients and their caregivers during this
0 Relatedto:
time.
Fear of dying, uncertainty about fu-
ture, uncontrolled symptoms such
as pain, shortness of breath, restless-
ness, night sweats.
Essential Nursing
Verbal complaints of difficulty fall-
Emotional Suppori ing asleep, awakening earlier than
desired, interrupted sleep, ir-
ritability, frequent yawning, dark
circles under eyes.
Anticipatory Grieving 0 Outcome Criteria:
(CH. 1) Patient will reestablish regular
Related to: sleep/ rest pat terns.
Losses due to terminal cancer such 0 NIC: Sleep Enhancement

as loss of health, life, work, income, Definition: Facilitation of regular
privacy, intimacy, and relationships. sleep/wake cycles.
Patient voices or expresses feelings
of sadness or loss.
Sleep Enhancement

I Activities Rat iondes
I
(CH. 1)
Assess patient’s Provides information
Related to: sleep/activity pattern. for formulating plan of
care.
Impact of cancer diagnosis and
poor prognosis. Monitor / record Provides factual
sleep/rest pattern and information about
Defining Characteristics: number of hours sleep/rest pattern.
Family unable to meet physical patient sleeps.
and/or emotional needs of patient, Assess factors that Promotes identification
verbalizes inability to cope. could contribute to of cause of sleepjrest
sleep/rest problems problems.
such as pain, shortness
of breath, fear, anxiety.
Sleep Enhancement Risk For Caregiver Role Strain

0 Related to:
Act ivit ies Rat ionales
Patient‘s sleep disturbance, con-
Provide emotional Anxiety and stant care needs of patient, lack of
support and/or depression can respite care.
counseling for contribute to sleep
patient/family to help disturbances.
eliminate anxiety Caregiver verbalizes concern over
and/or depression. lack of sleep, fear of inability to
Adjust environment to Promotes sleep by meet patient’s needs and/or need
promote sleep such as adjusting environment. for respite care.
decreasing light, noise, 0 Outcome Criteria:
temperature.
Caregiver will voice ability to pro-
Offer back rubs, warm Promotes relaxation to vide for patient without strain or
milk, proper aide in restful sleep. burnout.
positioning at bedtime.
0 NIC: Caregiver Support
Administer Treats depression
antidepressants as which may be Definition: Provision of the neces-
appropriate. contributing to sleep sary information, advocacy, and
disturbance. support to facilitate primary patient
Administer antianxiety Relief of anxiety will care by someone other than a health
agents as appropriate. promote rest. care professional.
Provide activities that Assists patient in

promote daytime limiting daytime sleep.
wakefulness.
Encourage use of sleep Lack of REM sleep can Caregiver Support
medications that don’t lead to hallucinations.
suppress REM sleep.
Instruct patient/family Promotes identification
about factors that of factors contributing Assess caregiver’s Provides information
contribute to to sleep disturbance. level of knowledge. to assist in planning
sleep/rest disturbance. care.
Inform of measures to Encourage caregiver to Promotes care for
Dromote s l e e ~ . assume role as patient without
appropriate and overstressingcaregiver.
0 Discharge or Maintenance request assistance from
Evaluation other family members
Patient will sleep at night and as appropriate.
awake feeling rested. Provide information Provides caregiver
Patient/famiIy will state about patient’s with information
measures to use to promote condition as needed to care for
sleep. appropriate. patient.
Caregiver Support 0 Discharge or Maintenance

Evaluation
Caregiver will demonstrate
Activities Rat ionales ability to care for patient
without strain or burnout.
Ensure caregiver has Provides follow-up
phone numbers of assistance by the
health care team health care team for
members such as the caregiver.
hospice nurse, Knowledge Deficit
physician.
0 Related to:
Identify sources of Prevents caregiver
respite care. respite. The dying process.
Encourage caregiver Promotes emotional 0 Defining Characteristics:
participation in support for the
support groups. caregiver. Patient /family voices questions
and/or concerns over the dying
Encourage caregiver to Prevents burnout and process.
care for self as well as role strain on caregiver.
patient. 0 Outcome Criteria:
Support caregiver Provides assistance in Patient/family discuss impending
through the grieving coping with loss of death and verbal needs as ap-
process. loved one. propriate.
Educate caregiver Promotes acceptance 0 NIC: Dying Care
about the grieving of impending loss.
process. Definition: Promotion of physical
comfort and psychological peace in
the final phase of life.
Demonstration Dying Care

I
Inform caregiver of Provides caregiver Monitor for anxiety, Provides information

health care and with resources to cope pain, mood changes, for planning care.
community resources. with role. deterioration of
Teach caregiver Promotes use of physical and mental
strategies to access resources by caregiver. abilities.
health care and Encourage Provides outlet for
community resources. patient/family to feelings and concerns.
Teach caregiver stress Promotes stress discuss feelingsabout
management management by death, or concerns.
techniques. caregiver. Support family Grieving is a normal
through stages of grief. response to loss.
Dying Care Postmortem Care

~

Minimize discomfort Promotes comfort. Remove all tubes and Promotes comfort for
when possible. cleanse body, close family viewing.
Assist with basic care eyes, place dentures in
Promotes comfort and
as needed. mouth as appropriate.
energy conservation.
Raise head of bed Prevents pooling of
Stay physically close to Reassures them that
frightened patient. slightly. fluids in head and face.
they are not alone.
Respect need for Notify clergy as Promotes spiritual
Provides for patient's
privacy as appropriate. needs. requested by family. support for family.
Facilitate and support Provide emotional
Modify environment Promotes comfort.
family viewing the support for family.
as appropriate.
body.
Support family's Promotes fulfillment of
If in hospital transport Promotes disposition
efforts to remain at family and patient's
bedside. to the morgue and of body.
needs.
notify mortician.
Include the family in Promotes family
If at home notify Promotes disposition
care decisions and cohesion.
appropriate persons of body.
activities as desired.
and mortician.
Facilitate legal aspects Eases the burden on
of death for family the family at the time
such as signing the of death.
Instructions, Information, death certificateas
Demonstration amrotxiate.
'1 I
Evaluation
Family is involved in the
Inform family of Offers opportunity to death of patient as is ap-
possible signs of call other family propriate for them.
impending death as members to bedside as Family provides needed care
appropriate. appropriate. for the patient during the
Facilitate discussion of Provides opportunity dying process.
funeral arrangements to involve patient in
with patient/family as decision making.
appropriate.
0 NIC: Postmortem Care

Definition: Providing physical care
of the body of an expired patient
and support for the family viewing
the body.
Essentiul Nursing Nutritional Counseling
Diagnoses Reluted to
Gustrointestinal Activities Rat ionales
Problems Assess patient’s ability,
or lack of, to ingest
as to cause of
food, food preferences, decreased food intake
presence of nausea, to assist in the
vomiting, constipation, development of a plan
Altered Nutrition: Less than oral infections altered of care.
Body Requirements taste, abdominal pain,
early satiety.
0 Related to: Discuss meaning of Provides information
food to patient and to assist in planning
Progressive cancer causing anxiety, family. care.
gastric irritation, bowel obstruction,
constipation, and/or compression Establish realistic goals Prevents frustration of
of the stomach. for nutrition. patient/family when
unable to meet
0 Defining Characteristics: unrealistic goals.
Weight loss, anorexia, nausea, Treat cause of food Promotes increase in
vomiting, fatigue, altered taste sen- ingestion problem if food intake.
sation, early satiety, inadequate able.
food intake, abdominal pain,
stomatitis, oral candida, or herpes Refer to dietician as Promotes use of
zoster. appropriate. experts in care to best
meet patient‘s needs.
0 Outcome Criteria:
Provide support to Promotes family’s
Patient will ingest foods they enjoy family if patient unable acceptance and
in amounts and at times as they are to ingest food in prevents anger and
able. adeauate amounts. frustration.
Family will accept patient’s in-
ability to maintain adequate intake. 0 NIC: Nutrition Management
0 NIC: Nutritional Counseling Definition: Assisting with provid-

ing a balanced dietary intake of
Definition: Use of an interactive foods and fluids.
helping process focusing on the
need for diet modifications.
I Nutrition Management
Discourage patient Prevents frustration
from weighing self. over weight loss.
~~
Nutrition Management Nutrition Management
Activities Rationales Act izrities Rat ionales

Offer small frequent Promotes intake in Administer appetite Promotes food intake
meals if early satiety or amounts patient is able stimulants such as a by stimulating appetite.
anorexia are a problem. to ingest. small amount of
alcohol, megace, or a
Offer meals and snacks Provides energy and
short course of steroids.
high in protein and proteins to prevent
calories that are easy to further muscle wasting. Administer Promotes comfort in
consume, medications to treat mouth to encourage
mouth infections. food intake.
Offer high Provides calories and
caloric/protein liquid proteins in a small Administer viscous Treats pain in mouth to
or custard volume that is easy to Xylocaine as assist in food intake.
supplements. consume. appropriate.
Suggest use of lemon Lemon juice seems to Control constipation. Constipation can cause
juice on red meats if make red meats more nausea and vomiting.
patient complains of palatable.
metallic taste. Control noxious Noxious stimuli can
stimuli like odors, increase anxiety and
Replace distasteful Promotes adequate excessive noise. cause nausea.
foods such as red amounts of protein in
Encourage family not Prevents anger,
meats with other the diet.
to force patient to eat if frustration and nausea,
protein sources such as
patient doesn’t want to vomiting.
eggs, cheese, fish or
eat.
chicken.
Offer food when it is Promotes intake of
cool. food that some
patients may prefer.
Encourage patient to Due to taste changes Instructions, Information,
try different foods. patient may prefer Demonstration
different foods.
Encourage intake of Promotes intake of
fluids with calories fluids with calories to Activities Rationales
such as juices, soda provide energy.
Instruct patient/family Promotes self
pop, milk shakes and
in measures to control management of
discourage intake of
problems such as problems.
noncaloric beverages
nausea, vomiting, and
such as water, tea, and
constipation.
coffee.
Encourage patient to Instruct patient/family Knowledge may help
Provides socialization
join family at dinner during meal times. that weight loss is decrease anxiety.
expected and may not
table if possible.
be preventable.
Administer antiemetics Prevents nausea and
30 minutes prior to vomiting. Instruct to avoid Noncaloric food and
eating if nausea is a noncaloric foodsand fluids promote satiety
problem. fluids. without providing
calories for energy.
Instructions, Information, 0 NIC: Oral Health Restoration

Demonstration Definition: Promotion of healing
for a patient who has an oral
mucosa or dental lesion.
Instruct family on Provides family with

ways to assist patient methods to assist
in increasing calorie patient with food Oral Health Restoration
and protein intake. intake.
Inform family of Promotes family
reasons patient may acceptance of patient's Activities Rat ionaZes
not be able to ingest limitations.
adequate amounts of Perform oral Provides information
foods. assessment and to formulate plan of
examine lips, gums, care.
Discharge or Maintenance teeth, and mucosa for
Evaluations dryness, ulcerations,
and signs of infection.
Patient will ingest adequate
amounts of food to provide Assist with oral care Promotes clean, moist,
energy for activities. after each meal and oral mucosa.
. Family will accept patient's in- Pm.
ability to ingest adequate Increase oral care if Prevents further injury
amounts of food as ap- stomatitis is present. to mucosa.
propriate.
Offer ice chips, hard Promotes moistness of
candy, and frequent the oral mucosa.
sips of liquids if
dryness is a problem.
Altered Oral Mucous
Offer popsicles, ice Provides calories in a
Membranes cream, milkshakes. soothing easy-tosat
form.
0 Related to:
Encourage mouth Promotes comfort in
Dehydration, mouth breathing, oral rinsing frequently with oral mucosa.
infections like candida or herpes, saline/baking soda
stomatitis. mixture.
Defining Characteristics: Discourage smoking Prevents dryness and
and drinking alcohol. irritation to mucous
Oral pain/discomfort, xerostomia,
oral lesions or ulcers. membranes.
Avoid commercial Prevents drying of
Outcome criteria: mucous membranes as
mouthwashes, lemon,
Oral mucous membrane ulcers or and glycerin swabs. commercial
lesions will heal. mouthwashes may
Oral infections will be treated suc- contain up to 25%
cessfully. alcohol and glycerin is
acidic and can irritate
mucous membranes.
Oral Health Restoration El Discharge or Maintenance

Evaluation
Oral mucosa will heal and be-
Activities Rat ionales come pink and moist.
Apply lubricants such Promotes comfort.
. Patient/family will describe
as petroleum jelly to measures to promote oral
lips. health.
Administer Promotes comfort in

medications to treat mouth by promoting
mouth infections. healing of oral
infections. Essentiai Nursing
Administer viscous Treats pain in mouth Diagnoses Related to
Xylocaine as
appropriate.
by numbing tissues. Respkatory Problems
Activity Intolerance
Instructions, Information, (CH. 4)
Demonstration
~~~
0 Related to:
Fatigue secondary to the cancer dis-
Activities Xationales ease process and its treatment.
Demonstrate correct Promotes performance 17 Defining Characteristics:
ways to perform oral of measures that
care. promote oral health. Verbal reports of fatigue or weak-
ness, exertional dyspnea, breathless-
Inform of reasons not Promotes compliance ness, abnormal heart rate.
to smoke and drink with abstinence from
alcohol. smoking and alcohol.
Instruct on measures to Prevents further
promote comfort for drying of mucous Risk for Ineffective
dry mouth such as ice membranes. Airway Clearance
chips, sucking on hard
candy, frequent sips of (CH. 8)
fluids. 17 Related to:
Inform patient about Promotes compliance Increase secretions, decrease in level
prescribed medications with prescribed of consciousness from disease
for oral infections medications. progression and/or pain relief
and/or stomatitis, any medications which may impair
side effects to expect ability to clear secretions.
and what to do if they
occur. 17 Defining Characteristics:
Presence of abnormal breath
sounds frales, crackles, rhonchi),
decrease in rate and depth of
respirations, tachycardia, ineffective
cough, cyanosis, dyspnea, inability Respiratory Monitoring

to cough and clear secretions.
Impaired Gas Exchange Identify etiology of Respiratory failure is
respiratory distress very distressing for
0 Relatedto: and treat if able and patient and family
appropriate. even if comfortis the
Decreased lung tissue for oxygen ex- goal. Measures should
change due to cancer disease be employed to treat
process. respiratory distress if
possible.
Administer oxygen Oxygen promotes
Dyspnea, shortness of breath, therapy as appropriate. oxygenation.
cyanosis of mucous membranes
and nail beds. Administer Bronchodilator opens
bronchodilator as air passages if
0 Outcome Criteria: appropriate. constricted.
Patient’s respirations will become Administer antibiotics Antibiotics treat
easy and regular. as appropriate. pneumonia.
0 NIC: Respiratory Monitoring Administer steroids as Steroids reduce
appropriate. inflammation and
Definition: Collection and analysis swelling of the
of patient data to ensure airway bronchial tree.
patency and adequate gas exchange.
Administer antianxiety Anti-anxiety
medications as medications decreases
appropriate. anxiety and
restlessness often
Respiratory Monitoring resulting in decrease in
oxygen demand.
I
Administer narcotic
analgesics as
appropriate.
Narcotics reduce
respiratory drive,
reduce inappropriate
Assess respiratory rate, Provides information tachycardia, and lessen
rhythm, depth, and to formulate plan of overventilation, thus
effort. care. decreasing oxygen
Monitor for increased Signs of hypoxia need.
restlessness, anxiety, indicating failing Administer Codeine will suppress
air hunger, cyanosis of respiratory effort. expectorant with a chronic dry, hacking
nail beds and mucous codeine on a regular cough.
membranes. schedule.
Administer atropine Atropine will dry
sulfate IM or SC for mucous membranes
”death rattles”. and decrease moist,
noisy respirations.
Respiratory Monitoring
I Instructions, Information,
Demonstration
Administer respiratory Respiratory treatments
treatments as promote Instruct in safety Promotes safe use of
appropriate. bronchodilation of measures for home oxygen therapy.
airways. oxygen use such as no
smoking while oxygen
Provide comfort Promotes comfort by
is on and never
measures as easing respiratory
turning oxygen above
appropriate such as a effort.
prescribed levels
fan or humidifier,
without consulting
relaxation tapes, music
with health care team.
therapy, elevate head
of bed. Instruct family if Knowledge will
patient is experiencing decrease anxiety over
noisy, moist distressing symptom.
respirations sometimes
~
called ”death rattles”
that death may be
imminent.
Demonstration
Evaluation
Patient/family will state
Instruct patient/family Promotes safety and safety measures for oxygen
in use of medications independence in therapy in the home.
to treat respiratory
problems such as
medication
administration.
. Patient/family will describes
measures to ease respiratory
bronchodilator, effort.
antibiotics, steroids,
Valium, morphine,
respiratory treatments.
Instruct patient/family
in etiology of
Promotes acceptance
of limitations in
Essential Nursing
respiratory distress medical care. Diagnoses Related to
and what is possible to
correct, and in comfort Skin Care
measures to treat other
problems.
Instruct patient/family Relaxation can
in relaxation decrease oxygen Risk for Impaired Skin Integrity
techniques. demand and ease
respiratory effort. 0 Relatedto:
Immobility and/or disease progres-
sion such as poor nutritional status,
urinary incontinence.
17 Defining Characteristics: Pressure Management

Reddened skin, altered skin turgor,
cachexia.
17 Outcome Criteria:
Monitor for sources of Prevents irritation
Skin remains intact and free from pressure and friction. from an unexpected
trauma. source.
0 NIC: Pressure Management
0 NIC: Pressure Ulcer Prevention
From Surgery and NIC: Pressure
Ulcer Prevention Definition: Prevention of decubitus
ulcers for a patient at high risk for
13NIC: Pressure Management developing them.
Definition: Minimizing pressure to ~
body parts.
Pressure Ulcer Prevention
Pressure Management Remove excess Prevents irritation and
moisture on the skin maceration.
due to perspiration,
Activities Rat ionafes wound drainage, and
fecal or urinary
Place on an Promotes skin integrity. incontinence.
appropriate mattress
according to agency Apply protective Promotes intact
policy.. barriers such as creams epidermis.
or moisture-absorbing
Refrain from applying Prevents vulnerable pads to remove excess
pressure to the affected part from pressure. moisture.
body part.
Post turning schedule Provides a reminder
Administer back/ neck Promotes circulation at bedside. for staff, patient and
rub. and relaxation. family.
Turn the immobilized Prevents pressure areas Position with pillows Prevents irritation.
patient at least every 2 from developing to elevate pressure
hours according to a points off the bed.
specific schedule.
Keep bed linens clean, Prevents excoriation
Monitor skin for areas Provides data about dry, and wrinkle-free. and irritation.
of redness and areas that require
breakdown. treatment. Provide trapeze to Promotes
assist patient in independence in
Use appropriate Prevents soreness and shifting weight. frequent position
devices to keep heels breakdown. changes.
and bony prominences
off the bed.
Massage around the Promotes circulation.
affected area.
Instructions, Information, Skin Care-Topical Treatments

Demonstration
Assess open lesions for Provides information
Inform patient to Provides early foul smelling drainage, to formulate plan of
report soreness, assessment and and/or infection. care.
redness, discomfort, intervention.
Cleanse wound with Promotes clean wound.
pain from any area.
antibacterial soap as
Instruct patient to Prevents pressure appropriate.
change position points.
Spread plain yogurt Promotes change in
frequently. bacterial flora to
over fungating, foul-
Demonstrate turning Promotes frequent smelling lesions. decrease odors.
techniques to family if position changes.
Administer systemic Treats infection and
amromiate. antibiotics as decreases odors.
appropriate.
Evaluation Consider Palliative treatment of
chemotherapy, lesions may shrink
Absence of skin impainnent radiotherapy, and /or lesions and decrease
with intactness maintained. hormones to treat odors.
Skin free of inflammation and fungating lesions.
imtation.
Obtain room air Reduces odor.
freshener, or odor
eliminator as
appropriate.
Impaired Skin Integrity
Place charcoal in Charcoal is a natural
0 Related to: appropriate container odor absorber.
in room with patient.
Fungating cancer lesions.
Open windows and air Reduces odors in room.
CI Defining Characteristics: out room as
appropriate.
Open cancer lesions on skin, foul
smelling drainage. Refer to skin Promotes optimal care
care/ enterostomal by use of specialists.
0 Outcome Criteria: nurse specialist as
Odor and drainage from fungating appropriate.
lesion will be controlled.
0 NIC: Skin Care Topical Treatments
Definition:Application of topical
substances or manipulation of
devices to promote skin integrity
and minimize breakdown.
Instructions, Information, NIC: Tube Care- Urinary

Demonstration Definition: Management of a
patient with urinary drainage equip-
ment.
Act i d ies RationaZes
Instruct patient/family Promotes comfort by
in measures to decreasing odors.
decrease odors from Tube Care- Urinary
fungating lesions.
Demonstrate skin care Promotes correct
procedures to wound care by Activities Rationales
patient/family for patient/ family.
fungating lesions and Assess patient/family Provides information
observe return ability to care for for planning care.
demonstration. urinary drainage
svstem.
Evaluation
. Fungating lesion will become
clean and odor free.
. Patient/family will Instructions, Information,
Demonstration
demonstrate recommended
wound care.
Demonstrate correct Promotes correct care
Essential Nursing foley care to of urinary drainage
Diagnoses Related to patient/family
including
systems which
prevents urinary tract
Urinary Problems 1)Handwashing prior infections.
to all care;
2) Emptying of urinary
drainage bag at
appropriate intervals;
Knowledge Deficit 3) Noting urine
characteristics; 4)
0 Related to: Regular cleansing of
urinary catheter and
Foley catheter care.
meatus; 5) Irrigation of
CI Defining Characteristics: foley if appropriate; 6 )
Maintenance of closed
Family verbalizes questions and drainage system.
concerns over care of foley catheter,
or fears over ability to care for Provide written Written materials
patient with foley catheter. instructions on foley reinforce verbal
care. instruction.
0 Outcome Criteria:
Family will demonstrate safe care of
urinary drainage system.
Instructions, Information, NIC: Fever Treatment

Demonstration Definition: Management of a
patient with hyperemia caused by
nonenvironmental factors.
Instruct patient/famiIy Maintains adequate
on importance of urine output.
drinking 8-10 glasses
Fever Treatment
of fluid per day.
to notify the health identification and Activities Raf ionales
care team if signs and treatment of urinary
symptoms of a urinary tract infections. Assess temperature as Temperature within
tract infection include appropriate. normal limits is
cloudy, foul smelling expected within 72
urine, and an elevated hours after starting
temperature occur. antibiotics.
Discharge or Maintenance Monitor WBC Elevated white cell

Evaluation urinalysis and urine blood count and
culture as appropriate. presence of WBCs and
Patient/family will care for mucous in the urine
urinary drainage system. indicate urinary tract
Urinary tract infections will infection.
be prevented or identified Administer pyridium Treats burning during
early. as appropriate. urination.
Administer antibiotics Treats urinary tract
as appropriate. infection.
Infection Administer Antipyretics reduce
antipyretics as fevers.
0 Related to: appropriate.
Urinary tract infection. Institute measures to Promotes temperature
decrease temperature reduction.
0 Defining Characteristics: such as tepid sponge
baths, ice packs to
Patient verbalizes pain on urina- groin and axilla for
tion, presence of cloudy, foul- smell- comfort as appropriate.
ing urine, elevated temperature,
and white blood cells and/or
mucous in urinalysis.
0 Outcome Criteria:
Urinary tract infection will resolve
as evidenced by clear yellow urine
and temperature within normal
limits.
instructions, Information, Pain

Demonstration
(CH. 10)
0 Related to:
Length of surgical incision and
Inform patient/family Promotes safe need for PCA pump.
on correct use of administration of
medications, possible medications.
side effects and what Diaphoresis, blood pressure and
to do if they occur. pulse changes, crying, moaning,
Instruct patient/family Promotes temperature guarding and protective behavior,
in measures to regulation and comfort. restlessness, irritability, voices com-
decrease fevers. plaints of sharp, severe, sporadic
pain.
Evaluation
Urinary tract infection will Pain, Chronic
resolve.
0 Related to:
Cancer disease progression.
Essential Nursing 0 Defining Characteristics:
Diagnoses Related to Patient verbalizes aching, dull or
sharp, poorly localized pain, pain
Pain interfering with activities of daily
living such as eating, moving, sleep-
ing.
Cl Outcome Criteria:
Pain
Pain will be controlled to a level
0 Related to: tolerable to the patient.
Surgical intervention. 17 NIC: Pain Management
0 Defining Characteristics: Definition: Alleviation of pain or
reduction in pain to a level of com-
Diaphoresis, blood pressure and fort that is acceptable to the patient.
pulse changes, crying, moaning,
guarding and protective behavior,
restlessness, irritability, voices com-
plaints of sharp, severe, sporadic
pain.
Pain Management Pain Management
Activities Rationales Activities RationaZes

Perform a Provides information Administer analgesics Prevents the
comprehensive pain to formulate a plan of early and around the development of severe
assessment to include care. clock. pain.
location,
Evaluate pain relief Promotes relief of pain.
characteristics,
measures and revise
onset/duration,
plan as appropriate.
frequency, quality,
intensity or severity of Administer analgesics Effective route of pain
and precipitating by mouth. control for most
factors. patients.
Evaluate current and Provides information Consider rectal, Promotes pain
past pain control as to what works and subcutaneous, dermal, management in patient
measures. what doesn’t. intramuscular, or unable to take
intravenous routes as medications by mouth.
Evaluate source of pain Promotes comfort by
appropriate.
and treat if able. eliminating source of
pain. Schedule any pain- Provides pain relief
inducing activities or during painful
Communicate belief in Promotes
procedures during activities or procedures
pain and commitment psychological comfort.
peak analgesics effect.
to work with patient
until pain is relieved. Suggest the Promotes pain relief by
administration of working at both the
Implement measures Promotes physical central and peripheral
nonnarcotic and
for physical comfort comfort.
narcotic pain nervous system.
such as maintaining
medications as
proper body
indicated.
alignment, use of
special beds, applying Monitor for and treat Promotes safe use of
cold or heat, side effects of narcotic narcotic pain relievers.
minimizing noxious pain relievers such as
environmental stimuli changes in respiratory
such as noise, heat, status, changes in
light. central nervous
system,
Implement relaxation Promotes relaxation by
gastrointestinal,
measures such as decreasing painful
genitourinary and
massage, guided stimuli.
dermatologic status.
imagery, hypnosis,
deep breathing Refer to professionals Promotes pain relief by
exercises. practicing utilizing all
nonpharmologic appropriate measures.
Encourage use of Provides distraction
methods of pain
distraction as from painful stimuli.
control as atmrotxiate.
appropriate such as
humor, reading,
watching TV,
occupational therapy,
music therapy.
Instructions, Information, I7 Outcome Criteria:

Demonstration Patient will have a soft formed
stool, without straining, at least
every three days.
NIC: Constipation/lmpaction
Inform patient/family Promotes safe Management
about correct use of administration of
medications, possible medications. Definition: Prevention and allevia-
side effects and what tion of constipation/impaction.
to do if they occur.
Teach the use of Provide patient with
nonpharmacologic methods to control,
techniques such as prevent pain. Constipation/lmpaction
massage, guided Management
imagery, hypnosis,
deep breathing
exercises, distraction,
music therapy,
hot/cold application, Identify factors that Provides information
and/or massage. may cause or for formulating
contribute to individualized plan of
0 Discharge or Maintenance constipation such as care.
Evaluation medications, bed rest,
Patient/family will identify low fiber diet, poor
measures to control pain. fluid intake.
Patient/family will employ Assess for signs of Provides information
measures to control pain. constipation. for formulating plan of
Patient’s pain will be relieved care.
or controlled to an acceptable Monitor bowel Promotes early
level as determined by the movements and bowel recognition of
patient. sounds. constipation.
Encourage patient to Adequate fluid intake
drink at least 8-10 will help to promote
Constipation glasses of fluid per day soft stools.
if able.
Related to: Encourage foods high High fiber diet
in fiber if able to eat. promotes adequate
Cancer disease process, side effect bulk to prevent
of narcotics for pain management. constipation.
Defining Characteristics: Encourage daily Exercise stimulates
Decreased frequency of stools, hard exercise if able. peristalsis and
formed stools, abdominal pain, mevents constir>ation.
1 1
straining at stools, nausea, vomiting

due to obstructions.
Constipation/lmpaction
Management
Administer laxatives, Promotes restoration of
stool softeners and/or bowel function in
enemas as appropriate. patients who are
unable to drink fluids,
eat high fiber diet, or
exercise.
Remove fecal Removes stool from
impaction manually if impacted bowel.
necessary.
Demonstration
Instruct pa tient/family Promotes natural
on measures to prevent methods to prevent
constipation like constipation.
fluids, high fiber diet,
exercise.
Inform patient/family Prevents constipation
on appropriate use of in patients unable to
laxatives, stool eat and drink adequate
softeners, enemas. amounts.
Explain etiology of Knowledge will reduce
problem and rationale anxiety and promote
for actions such as acceptance of
enemas, manual procedures.
extraction of impaction.
Evaluation
Patient/family will describe
measures to prevent constipa-
tion or treat it should it occur.
Patient will have a soft
formed stool at least every
three days.
n
i3eterences
0
Jaffe, M. Geriatric Nursing Care Plans. Skid-
REFERENCES more Roth Publishing, Inc., El Paso, TX,
1991.
Johnson, B.L. and Gross, J. (eds).Handbook
of Oncology Nursing. Fleaschner Publishing
Books Company, Bethany, Connecticut, 1985.
Amenta, M.O., and Bohnet, N.L. Nursing McCloskey, J.C. and Bulechek, G.M. (eds).
Care of the Terminally Ill. Little, Brown & Nursing Interventions Classification: By the
Company, Boston, MA, 1986. Iowa Intervention Project. Mosby Year Book,
St. Louis, MO, 1992.
Brunner, D.W., Iwamoto, R., Keane, K. and
Strohl, R. (eds).Manual For Radiation Oncol- McNally, J.C., Somerville, E.T., Mias-
ogy Nursing Practice and Education. Oncol- kowski, C. and Rostad, M. (eds).Guidelines
ogy Nursing Society, Pittsburgh, PA, 1992. for Oncology Nursing Practice, Second Edi-
tion. W.B. Saundeers Company, Philadel-
Burke, M.B., Wilkes, G.M., Berg, D., Bean, phia, PA, 1991.
C.K. and Ingwersen, K. Cancer
Chemotherapy: A Nursing Process Approach. Osteen, R.T. (ed). Cancer Manual, 8th Edi-
Jones and Bartlet Publishers, Boston, MA, tion. American Cancer Society, Mas-
1989. sachusetts Division, Incorporated, Boston,
MA, 1990.
Campanacci, M. Bone and Soft Tissue
Tumors. Springer-Verlag Wien-New York,
New York, N.Y.,1990.
Clark, J.C., and McGee, R.F. (eds). Oncol-
ogy Nursing Society: Core Curriculum For Periodicals
Oncology Nursing, Second Edition. W.B. American Cancer Society, Cancer Facts &
Saundeers Company, Philadelphia, PA, Figures-1994. American Cancer Society,
1992. Inc., Atlanta, GA, 1994.
Carpenito L.J. Nursing Diagnosis: Applica- Arbour, R. ’What You Can Do To Reduce
tion to Clinical Practice, Third Edition. J.B. Increased I.C.P.,” Nursing 93,23(11): 41-46,
Lippincott Company, Philadelphia, PA, 1993.
1989. Boring, C.C., Squires, T.S., and Tong, T.
DeVita, V.T., Hellman, S., and Rosenberg, ”Cancer Statistics, 1993,” C A A Cancer
S.A. Cancer: Principles and Practice of Oncol- Journal for Clinicians, 43W: 7-26,1993.
ogy, Fourth Edition. Lippincott, Philadel- Boyle, N. et al. “A Patient’s Guide to
phia, PA, 1993. Taxol,” Oncology Nursing Forum, 21(9):
Dow, K.H. and Hilderley, L.J. Nursing Cure 1569-1572,1994.
in Radiation Oncology. W.B. Saundeers Brendler, C.B. and Walsh, P.C. “The Role
Company, Philadelphia, PA, 1992. of Radical Prostatectomy in the Treatment
Eriksson, J.A.H. Springhouse Notes: Oncol- of Prostate Cancer,” CA, 42(4): 212-222,
ogy Nursing, Second Edition. Springhouse 1992.
Corporation, Springhouse, PA, 1994. Brower, V. “The Right Way to Die,”
Groenwald, S.L., and Frogge, M.H., Good- Health, June: 3943,1991.
man, M. and Yarbro, C. H. (eds).Cancer Daly, J.M. NIC Interventions Linked to
Nursing: Principles and Practice: Second Edi- NANDA Diagnosis. Iowa Intervention
tion. Jones and Bartlett Publishers, Boston, Project, 1993.
MA, 1992. Devine, S.M. and Larson, R.A. ”Acute
Holleb, A.I., Fink, D.J. and Murphy, G.P. Leukemia in Adults: Recent Develop-
American Cancer Society Textbook of Clinical ments in Diagnosis and Treatment,” CA,
Oncology. American Cancer Society, Inc., 44(6): 326-352,1994.
Atlanta, GA, 1991.
Epstein, B.E. and Hanks, G.E. ”Prostate Lilley, L.L. and Schaffer, S. “Human Papil-
Cancer: Evaluation and Radiotherapeutic lomavirus: A Sexually Transmitted Disease
Management,” CA, 42(4), 223-240. With Carcinogenic Potential,” Cancer
Gotaskie, G.E. and Andreassi, B.F. Nursing, 13(6):366-372,1990.
”Paclitaxel,” Cancer Practice, 2(1):27-33, Lovejoy N.C. ”Precancerousand Can-
1994. cerous Cervical Lesions: The Multicultural
Held, J.L. et al. “Cancer of the Prostate: ”Male”Risk Factor,” Oncology Nursing
Treatment and Nursing Implications,” On- Forum, 21(3):497-504,1994.
cology Nursing Forum, 21 (9): 1517-1529, Lynch, M.P., and Ruland, T. ’‘Ifosfamide:
1994. Patient Care Management,” Cancer Nurs-
Held, J.L. and Peahota, A. ”Nursing Care ing, 16(5):362-365,1993.
of Patients With Esophageal Cancer,” On- Magurie-Eisen, M. ”Diagnosis and Treat-
cology Nursing Forum, 19(4):627434, ment of Acute Adult Leukemia,” Seminars
1992. in Oncology Nursing, 6 0 ) :17-24/1990,
Held, J.L. and Volpe, H. ”Bladder Preserv- Mainous, A.G. and Hagen, M.D. ”Public
ing Combined Modality Therapy for In- Awareness of Prostate Cancer and the
vasive Bladder Cancer,” Oncology Prostate-SpecificAntigen Test,” Cancer
Nursing Forum, 18(1):49-57,1991. Practice 2(3):217-221,1994.
Held, J.L. and Peahota, A. ”Nursing Care Melamed, M.R. “Natural History and
of the Patient with Spinal Cord Compres- Clinical Behavior of In Situ Carcinoma of
sion,” Oncology Nursing Forum, 20(10): the Human Urinary Bladder,” CA, 43(6):
1507-1514,1993. 351-370,1993.
Hoebler, L. and Irwin, M.M. “Gastrointes- Mellette, S.J. and Parker, G.G. “Future
tinal Tract Cancer: Current Knowledge, Directions in Cancer Rehabilitation,” Semi-
Medical Treatment, and Nursing Manage- nars in Oncology Nursing, 8(3):219-223,
ment,’’ Oncology Nursing Forum, 19(9): 1992.
1403-1415,1992. Moynihan, T.J. and Grossman, S.A. ‘The
Karakousis, C.P., and Perez, R.P. ”Soft Tis- Role of Chemotherapy in the Treatment of
sue Sarcomas in Adults,” CA: A Cancer Primary Tumors of the Central Nervous
Journal For Clinicians, 44(4),: 200-210,1994. System,” Cancer Investigation, 12(1):88-
Keehn, D.M. and Frank-Stromborg, M. “A 97,1994.
Worldwide Perspective on the Epidemiol- Murphy, G.P. ”Report on the American
ogy and Primary Prevention of Liver Can- Urologic Association/American Cancer
cer,” Cancer Nursing, 14(4):163-174,1991. Society Scientific Seminar on the Detection
Lamb, M.A. and Sheldon, T.A. “The and Treatment of Early-Stage Prostate Can-
Sexual Adaptation of Women Treated for cer,” CA, 44(2):91-95,1994.
Endometrial Cancer,” Cancer Practice, Murr, M.M. et al. ”Pancreatic Cancer,” CA,
2(2): 103-113. 44(5):304-318,1994.
Lapemere, N.J. and Bernstein, M. Nail, L.M. ”Coping with Intracavitary
”Radiotherapy for Brain Tumors,” CA, Radiation Treatment for Gynecologic Can-
44(2): 96-105,1994. cer,” Cancer Practice, l(3): 218-224,1993.
Lauerman, C. “Strong Medicine,” Chicago Nash, K. “Hospice,” CCONS Update,
Tribune, September 25,1995, Section 5, pp 16(3):1-2/1994.
1,7. ”New Skin Cancer Statistics Shatter All-
Laws, E.D. and Thapar, K.T. ”Brain Time Records,” Sun & Skin News: A Publi-
Tumors,” CA43(5): 263-271,1993. cation Of The Skin Cancer Foundation,
Lestingi, T.M., and Richards, J.M. ”Im- 11(2), 1-2/1994.
munotherapy and Combination Chemoim-
munotherapy in Metastatic Melanoma,”
Interferons and Cytokines 2:6-17,1993.
Richards, J.M., Mehta, N., Ramming, K. Wells, R.J. “Rehabilitation:Making the
and Skosey, P. ”Sequential Chemoim- Most of Time,” Oncology Nursing Forum,
munotherapy in the Treatment of Metas- 17(4):503-507,1990.
tatic Melanoma,” Journalof Clinical Zacharias, D.R. et al. “Quality of Life and
Oncology, 10: 1338-1343,1992. Coping in Patients With Gynecologic Can-
Richards, J.M. and Lotze, M.T. ”IL-2: Cur- cer and Their Spouses,” Oncology Nurs-
rent Status and Future Directions,” Con- ing Forum, 21(10):1699-1706,1994.
temporary Oncology, September: 34-41,
1992.
Rogers, B.B. ”Taxol: A Promising New
Drug of the ’90s: Oncology Nursing
Forum, 20(10): 1483-1489,1993.
Runowicz, C.D. ”Advancesin the Screen-
ing and Treatment of Ovarian Cancer,”
CA, 42(6): 327-349,1992.
Russell, S . ”Septic Shock Can You Recog-
nize the Clues?,” Nursing 94,24(4): 40-46,
1994.
Saba, M.T. and Magolan, J.M. ”Under-
standing Cerebral Edema: Implications for
Oncology Nurses,” Oncology Nursing
Forum, 18(3):499-505,1991.
Safai, B. et al. “Malignant Neoplasms As-
sociated with Human Immunodeficiency
Virus Infection,” CA, 42(2): 74-95,1992.
Sawyers, J.E. and Eaton, L. “Gastric Can-
cer in the Korean-American: Cultural Im-
plications,” Oncology Nursing Forum,
19(4):619623,1992.
Shantz, D.S. and Spitz, M.C. “What You
Need to Know About Seizures,” Nursing
93,23(11): 34-40,1993.
Stanley, H. et al. ”HIV-Related Non-
Hodgkin’s Lymphoma,” Oncology Nurs-
ing Forum, 18(5): 875-880,1991.
Truett, L. ”The Septic Syndrome,” Cancer
Nursing, 14(4): 175-180,1991.
Tucker, R. and Rahr, V. ”Nursing Care of
the Patient With Non-Hodgkin‘s Lym-
phoma: A Case Study,” Cancer Nursing,
13(4):229-234,1990.
Waxman, E.S. “Sexual Dysfunction Follow-
ing Treatment for Prostate Cancer: Nurs-
ing Assessment and Interventions,”
Oncology Nursing Forum, 20(10): 1567-
1571,1993.
Weinshel, E.L. and Peterson, B.A.
”Hodgkin’s Disease,” CA, 43(6): 327-350,
1993.
Index
Anticipatory grieving, 11
lndex Anxiety, lO,22
Anxiety reduction, 10,104
Artificial airway management, 328
Aspiration
A riskfor, 324
Acid/base management Astrocytomas, 342
respiratory acidosis, 28
Acid/base management metabolic
alkalosis, 35
Acid/base management respiratory B
alkalosis, 29 Basal cell carcinoma, 297
Acquired immunodeficiency syndrome Bathing, 389
(AIDS), 373 Biologic response modifiers
Active listening, 14 BRMs, 93
Activity therapy, 119 Biologic therapy, 93
Acute lymphoblastic leukemia (ALL), 266 Biotechnology, 93
Acute non-lymphoblastic leukemia Biotherapy, 93
(ANLL), 266 Bladder cancer
Acute tumor lysis syndrome, 131,134 types, 209
Adenocarcinoma, 155 Bladder cancers
endometrium, of the, 232 adenocarcinomas, 209
Airway management, 27,109,122,165 Bleeding precautions, 112
Airway suctioning, 162,327 Bleeding reduction, 150,163
Allergy management, 132 Blood products administration, 151
Alpha-fetaprotein (AFP), 235 Body image disturbance, 187,260,306,
Altered body temperature, high risk for 323,365,379
100 Body image enhancement, 187,213
Altered elimination Bone sarcomas, 355
bowel, 44 Bowel management, 44
Altered family processes, 7 Brachytherapy, 49 -50
Altered nutrition: less than body Brain cancer, 341
requirements, 38,101,158,408 Brenner carcinomas, 234
Altered nutrition: more than body require- BRMs, 93
ments
riskfor, 199
Altered oral mucous membranes, 410
Altered role performance, 9 C
Altered sexual patterns, 12
Cancer of the renal pelvis, 203
Altered sexuality, 223
Carcinoembryonicantigen (CEA), 256
Altered skin integrity, 37
Carcinoembryonicantigen enzyme titer
Altered thought process, 104
Altered thought processes, 348 (CEA), 156
Altered tissue perfusion Cardiac tamponade, 115,124
cardiopulmonary, 123,274 Caregiver role strain
peripheral, 189 riskfor, 405
renal, highriskfor 136 Caregiver support, 405
Altered urinary elimination, 43,361,139 Cervical cancer, 229
Alterted thought processes, 169 Cervical intraepithelial neoplasia (CIN),
Amputation care, 366 229
Analgesic administration, 42,98 Chondrosarcoma, 355
Anaphylaxis, 131 Chronic lymphocytic leukemia (CLL), 266
aneuploidy, 180 Chronic myelogenous leukemia (CML),
266 Energy management, 102
Circulatory care, 123 Enteral tube feeding, 39
Circulatory precautions, 191 Environmental management, 393
Clear cell carcinoma, 232 comfort, 99
Clear cell carcinomas, 234 Epidermoid
Code management, 37 squamous, 155
Colony stimulating factors Epidermoid tumors, 232
CSFs, 95 Epithelial tissue, 234
Epogen, 95 Epogen, 95
G-CSF, 95 ER positive tumors, 180
GM-CSF, 95 Erythropoietin, 95
Granulocyte CSF (G-CSF), 95 Esophageal cancer, 243
Leucine, 95 Estrogen receptors (ER), 180
Neupogen, 95 Ewing‘s sarcoma, 355
procrit, 95 Excisional biopsy, 20
Prokine, 95 Exercise therapy 334
Colorectal cancer, 254 joint mobility, 190
Communication enhancement, 330,349 External beam, 49
Confusion management, 348
Constipation, 420
riskfor, 174
Coping enhancement, 6,367 F
Crisis intervention, 15 Fall prevention, 394
CSF Family involvement, 8
see Colony stimulating factors, 95 Family support, 8
Fatigue, 102
Fear, 14
Fever treatment, 100,273
D Fibrosarcoma, 355
Decreased cardiac output, 31,34,125 Fluid management, 109,139 -140,147,
riskfor, 278 Fluid monitoring, 32
Diarrhea, 59,338 Fluid/electrolyte management, 33,106
Diarrhea management, 59,338 Fluid volume deficit, risk for 106
Discharge planning, 13,386 Fluid volume excess, risk for 108,140,146
Disseminated intravascular coagulation
(DIC), 131,149
Dressing, 390
Dying care, 406 G
Dysrhythmia management, 36 Gastric cancer, 246
Germcell, 221
Germ cell tumors, 234
Glioma, 342
E Grief work facilitation, 11
Edema management, 348
Electrolyte management, 136
hypercalcemia, 143
hyperkalemia, 136 H
hyperphosphatemia, 137 Head and neck cancers, 317
Embryonal carcinoma, 221 Hexagonal cell, 155
Emotional suppport, 104 Hodgkin’s disease, 284
Endometrial cancer, 232 Hodgkin’s disease (HD), 283
Endometroid carcinomas, 234 Home maintenance assistance, 13,387
Hope instillation, 11,309,378 L
Hopelessness, 378 Large cell, 155
Hospice, 398 Larynx, 320
Human chorionic gonadotropin (HCG), Leucine, 95
235 Leukemia, 265
Hypercalcemia, 131,141 Linear accelerator, 49
Hypersensitivity reactions, 131 Lip and oral cavity, 319
Hypopharynx, 320 Liposarcoma, 358
Hypovolemia management, 107 Liver cancer, 251
Lung cancer, 155
Lymphocytic, 155
Lymphoma, 283
I Lymphomas, 232,373,376
Immunotherapy, 93 AIDS related, 376
Impaired gas exchange, 28,109,160,412
Impaired home maintenance, 386
Impaired home maintenance
management, 13 M
Impaired physical mobility, 119,190,334, Malignant fibrous histiocycloma, 358
364 Malignant melanoma, 297
Impaired skin integrity, 57,310,331,415 Mechanical ventilation, 30
risk for, 54,105,413 Medication management, 196
Impaired tissue integrity, 336 Mesodermal tumors, 232
Impaired verbal communication, 349 Mucinous carcinomas, 234
Incision site care, 37,307,331
Incisional biopsy, 19
Ineffective airway clearance, 24,122
risk for, 162,327 N
Ineffective breathing, 27 Nasal cavity and paranasal sinuses, 318
Ineffective individual coping, 6 Nasopharyngeal, 319
riskfor, 367 Needle aspiration, 19
Infection, 417 Needle biopsy, 19
risk for, 110,191,271 Neupogen, 95
Infection control, 215 Neurologic monitoring, 172
Infiltrating ductal carcinoma, 179 NIC:
Injury total parenteral nutrition administration,
high risk for, 163,346 40
risk for, 111,132,143,150,175,196,259, acid /base management respiratory
333,393 acidosis, 28
Interferon, 95 active listening, 14
Interleukin, 96 activity therapy, 119
Interleukin 2 cardiac care, 126
side effects, 96 airway management, 27,109,122,160,165
Internal therapy, 49 airway suctioning, 162,327
Intravenous therapy, 31 allergy management, 132
amputation care, 366
analgesic administration, 42,98
anxiety reduction, 10,104
K artificial airway management, 328
Kaposi's sarcoma, 373,375 aspiration precautions, 325
Knowledge deficit, 5,22,52,168,186,192, bathing, 389
212,239,293,304,306,326,381,416 bleeding precautions, 112
bleeding reduction, 150,163 teaching, 305,326
Blood products administration, infection control, 215
151,275 infection protection, 110,272
body image disturbance, 306 family planning, 293
body image enhancement, 187,213, urinary catheterization, 212
261,323,379 radiation therapy management
bowel management, 44 for treatment, 52
cardiac precautions chemotherapy, 279 medication administration, 381,239,294
caregiver support, 405 intravenous therapy, 31
tube care, 164 exercise therapy, 190
circulatory care, 123,189 mechanical ventilation, 30
circulatory precautions, 191 medication management, 196
code management, 37 acid/base management, 34,35
environmental management, 99 positioning, 118
communication enhancement, 330,349 neurologic monitoring, 170,172,346,362
confusion management, 348 nutrition management, 39,101,408
constipation/im$action management, nutrition therapy, 39
175,420 nutritional counseling, 408
coping enhancement, 6,367 oral health restoration, 336,410
cough enhancement, 25 ostomy care, 214
crisis intervention, 15 oxygen therapy, 27
diarrhea management, 59,338 pain management, 365,418
discharge planning, 13,386 patient controlled analgesia (PCA)
teaching, 5,186 assistance, 207
dressing, 390 peripheral sensation management, 117
dying care, 406 postmortem care, 407
dysrhythmia management, 36 teaching, 22
edema management, 348 pressure management, 414
electrolyte management, 136 pressure ulcer prevention, 414
emotional support, 104 teaching, 167 -168,193,307
energy management, 102 sexual counseling, 223
enteral tube feeding, 39 radiation therapy management, 55,368
environmental management safety., 393 acid/base management, 29
exercise therapy, 334 respiratory monitoring, 24,412
radiation therapy managment for resuscitation, 36
treatment, 53 role enhancement, 9
fall prevention, 394 seizure management, 347
family involvement, 8 teaching, 198
family support, 8 sexual counseling, 12,197,220
feeding, 391 -392 skin care topical treatments, 105
fever treatment, 100,417 sleep enhancement, 404
fluid management, 109,139 -140,147 spiritual support, 308
fluid monitoring, 32 support system enhancement, 388
fluid/electrolyte management, 33,106 surveillance, 333,367
tube care, 260 skin care, 57,415
grief work faciIitation, 11 tubecare, 416
communication enhancement, 225 urinary elimination management, 43,361
home maintenance assistance, 13,387 values clarification, 6
hope instillation, 11,309,378 ventilation assistance, 26
electrolyte management, 143,136,137,147 communication enhancement, 350
hypovolemia management, 107 vital signs monitoring, 31,175
incision site care, 37,307,331 weight gain assistance, 159
weight management, 199
cast care, 364 R
wound care, 310,331 Radiation therapy
Non-germ cell tumors, 221 brachytherapy, 49 -50
Non-Hodgkin’s lymphoma, 285 external beam, 49
Non-Hodkin’s lymphoma, 283 internal therapy 49
Non-small cell lung cancer (NSCLC) teletherapy, 49
adenocarcinoma, 155 Radiation therapy management, 368
Non-small cell lung cancers Radiation therapy managment
(NSCLC), 155 for treatment
large cell, 155 external source, 53
epidermoid, 155 internal source, 52
Nutrition management, 39,101,408 Radioactive isotopes, 50
Nutrition therapy, 39 Radiotherapy, 49
Nutritional counseling, 408 Rehabilitation, 385
Renal cell carcinoma, 203
Respiratory monitoring, 24,412
Resuscitation, 36
0 Risk for sensory/perceptual alterations
Oat cell, 155 tactile, 117
Oral health restoration, 336,410 Role enhancement, 9
Oropharyngeal, 320
Osteosarcoma, 355
Ostomy care, 214
Ovarian cancer, 234 S
Oxygen therapy, 27 S-phase fraction, 180
Sarcomas, 232,355
Self care assistance
feeding, 391
P toileting, 392
Pain, 41,98,173,207 Self care deficit
acute, 418 bathing/hygiene, 389
chronic, 418 dressing/grooming, 390
riskfor, 198 feeding, 390
Pain management, 418 toileting, 392
Pancreatic cancer, 248 Seminoma, 221
Peripheral neurovascular dysfunction Sensory/perceptual alteration
high risk for, 172 auditory, risk for, 224
Peripheral sensation management, 117 kinesthetic, 362
Phase-1 testing programs, 397 tactile, risk for, 117,366
Postmortem care, 407 visual, 350
Potential for infection Serous carcinomas, 234
pyelonephritis, 215 Serum tumor markers
PR negative tumors, 180 CA-125, 235
Pressure management, 414 Sexual counseling, 12,197
Pressure ulcer prevention, 414 Sexual dysfunction, 219,293
Procrit, 95 riskfor, 197
Progesterone receptors (PR), 180 Skin cancer, 297
Prokine, 95 Skin care
Prostate cancer, 215 topical treatments, 105,415
Sleep enhancement, 404
Small cell lung cancers (SCLC), 155
Soft tissue sarcomas, 357
Spinal cord compression, 115 V
Spindle cell cancers, 155 Vaccines, 94
Spiritual distress, 308 Values clarification, 6
Spiritual support, 308 Ventilation assistance, 26
Squamouscell cancer, 209 Verbal communication
Squamouscell carcinoma, 297 impaired, 330
Staging, 4,20 Vital signs monitoring, 31,175
(TNM), 4
Superior vena cava, 115
Superior vena cava syndrome, 120
Support system enhancement, 388
Surgery, 19
w
Weight gain assistance, 159
Surveillance, 333,367 Weight management, 199
Syndrome of inappropriate antidiuretic Wound care, 310,331
hormone secretion, 131,145
T
Teaching
disease process, 5
individual, 305,326
procedure/treatment, 167,307
preoperative, 22
Self-administrationof prescribed
medication, 198
Teletherapy, 49
Terminally ill, 397
Testicular cancer, 220
TNMsystem, 4
Transitionalcell carcinoma, 209
Treatment, 20
Tube care
chest, 164
urinary, 416
Tumor markers, 4
CEA, 181
Tumor, Node, Metastases (TNM)
System, 4
U
Undifferentiated carcinomas, 234
Urinary elimination management, 43,361
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Oncology Nursing

Daniele Gde, R.N,, M.S.

Africa Australia Canada Denmark Japan Mexico New Zeaiand Philippines

Printed in the United States of America

Library of Congress Cataloging-in-Publication Data

Each Nursing InterventionsClassification

C U A P E R FOUR Chemotherapy........................ ..... ....63

CHAPTER EIGHT Lung Cancer......I.. .... . .. .. .. . . . ... . . ... . .. ... ., .. . 155

CHAPTER TEN Genitourinary Cancers . .......... ........ .. ... 203

CHAPTER TWELVE Gastrointestinal Cancers ,. ,. ..... I 243 I I I I . I I I I

CHAPTER TWENTY Rehabilitation Needs of the

Another term for maturity is differentiation. have a poorer prognosis.

gonadotropin)and alpha fetoprotein(AFT). Essential Nursing

Teaching- Disease Process

Activities Rationales Activities Rationales

0 NIC: Values Clarification Ineffective I ndividuaI Coping

Activities Rationales I 0 Outcome Criteria:

Determine if there are Allows for correction Anxiety, worry, fatiguereduced to a

Coping Enhancement Instructions, Information,

0 NIC: Family Support

ests and goals during the diagnosis

Encourage family To meet family’s need

Appraise family’s To assess for family’s 0 NIC: Family Involvement

Instructions, Information, 0 Outcome Criteria:

Assist family to Assists the family to

0 Discharge or Maintenance Activities Rat ionales

Activities Rationales Activities Rationales

Anxiety Instructions, Information,

0 Discharge or Maintenance 0 NIC:Hope Instillation

Anticipatory Grieving Hope Instillation

Assists cancer patient with resolu-

Grief Work Facilitation

Instructions, Information, 0 NIC: Sexual Counseling

Establish a therapeutic Promotes open

Patient/significant other will return

Instructions, Information, 0 Defining Characteristics:

Discharge or Maintenance Activities Rationales

Discharge Planning Instructions, Information,

Collaborate with Provides continuity of

0 NIC: Crisis Intervention

Diagnosis Needle Biopsy

placement of a spinal catheter to deliver 0 Outcome Criteria:

Anxiety Determine the Provides data for

Teaching-Preopera tive Teaching-Preoperative

Activities Rationales Activities Rationales

Respiratory Monitoring Instructions, Information,

Activities Rat ionales

Cough Enhancement Ventilation Assistance

Act iuit ies Rationales I Activities Rationales

Activities Rat ionales . Patient verbalizes under-

0 Changes in patient’s Airway Management

Oxygen Therapy Instructions, Information,

tions resulting from serum pCoZ 0 NIC: Acid-Base Management-

Activities Rationales Acid/Base Management-

Monitor neurologic Ensures early

Instructions, Information, Mechanical Ventilation

Activities Rat ionales

Decreased Cardiac Output lnstru~tjons,Information ,

Vital Signs Monitoring

Intravenous Therapy Instructions, tnformation,

Instructions, Information, Fluid/Electrolyte Management

Instructions, Information, 0 Defining characteristics:

Acid/Base Management- AcidjBase Management-