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Unit 3   Applying concepts from the nursing process

3 months, are usually not considered to be candidates for par- enteral nutrition (Mirhosseini, Fainsinger & Baracos, 2005). TPN can be administered in several ways: by a long-term venous access device, such as a tunnelled central catheter, an implanted venous port, or a peripherally inserted central catheter (PICC) (Figure 11-5). The nurse teaches the patient and family to care for venous access devices and to administer TPN. Community nurses may assist with or supervise TPN in the home. Interventions to reduce cachexia usually do not prolong survival but may improve the patient’s quality of life. Before invasive nutritional strategies are instituted, the nurse should assess the patient carefully and discuss the options with the patient and family. Creative dietary therapies, enteral (tube) feedings or TPN may be necessary to ensure adequate nutri- tion. Nursing care is also directed towards preventing trauma, infection and other complications that increase metabolic demands. Relieving pain Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that when cancer patients are asked about possible outcomes, pain is reported to be the most feared outcome (Munoz Sastre et al., 2006). Pain in patients with cancer can be directly associated with the cancer (e.g. bony infiltration with tumour cells or nerve compression), a result of cancer treatment (e.g. surgery or radiation), or not associated with the cancer (e.g. trauma). However, most pain associated with cancer is a direct result of tumour involvement. As in any other situation involving pain, cancer pain is affected by both physical and psychosocial influences. Of all patients with progressive cancer, more than 90 to 95% experience pain (Stoneberg & von Gunten, 2006). Pain, among the most common symptoms of cancer, impacts on multiple domains of well-being. Significant numbers of patients continue to experience pain despite pharmaco­logical interven- tions. Although there is evidence to suggest that acceptance of pain is related to better well-being among patients with chronic non-malignant pain, little is known about acceptance of cancer pain. Although patients with cancer may have acute

pain, their pain is more frequently characterised as chronic. (For more information on cancer-related pain, see Chapter 9.) Cancer can cause pain in various ways (Table 11-8). Pain is also associated with various cancer treatments. Acute pain is linked with trauma from surgery. Occasionally, chronic pain syndromes, such as postsurgical neuropathies (pain related to nerve tissue injury) occur. Some chemotherapeutic agents cause tissue necrosis, peripheral neuropathies and stomatitis— all potential sources of pain—whereas radiation therapy can cause pain secondary to skin or organ inflammation. Cancer patients may have other sources of pain, such as arthritis or migraine headaches, that are unrelated to the underlying cancer or its treatment. In today’s society, most people expect pain to disappear or resolve quickly, and in fact it usually does. Although control- lable, cancer pain is commonly irreversible and not quickly resolved. For many patients, pain is a signal that the tumour is growing and that death is approaching. As the patient anticipates the pain and anxiety increases, pain perception heightens, producing fear and further pain. Chronic cancer pain then can be best described as a cycle progressing from pain to anxiety to fear and back to pain again, especially when the pain is not adequately managed. Pain tolerance, the point past which pain can no longer be tolerated, varies among people. Pain tolerance is decreased by fatigue, anxiety, fear of death, anger, powerlessness, social isolation, changes in role identity, loss of independence and past experiences. Adequate rest and sleep, diversion, mood elevation, empathy and medications such as antide- pressants, antianxiety agents and analgesics enhance toler- ance to pain. Inadequate pain management is most often the result of misconceptions and insufficient knowledge about pain assessment and pharmacological interventions on the part of patients, families and healthcare providers (Xue et al., 2007). Successful management of cancer pain is based on thorough and objective pain assessment that examines physical, psy- chosocial, environmental and spiritual factors. A multi­ disciplinary team approach is essential to determine optimal management of the patient’s pain. Unlike instances of chronic non-malignant pain, systemic analgesics play a central role in managing cancer pain. The World Health Organization advocates a three-step approach to treating cancer pain (see Figure 11-6). Analgesics are administered based on the patient’s level of pain. Non- opioid analgesics (e.g. paracetamol) are used for mild pain;

Internal jugular v.

Median basilic v.

Cephalic v.

Table 11-8  Sources of Cancer Pain Source Descriptions

Underlying cancer

Bone metastasis

Throbbing, aching Breast, prostate,   myeloma

Median cephalic v. Basilic v.

Nerve compression,

Burning, sharp,   tingling Dull, aching,   tightness Sharp, throbbing Dull, crampy,

Breast, prostate,   lymphoma Lymphoma, breast,   Kaposi’s sarcoma Kaposi’s sarcoma

infiltration

Lymphatic or venous

Axillary v.

obstruction

Subclavian v. Brachiocephalic v. Superior vena cava

Ischaemia

Organ obstruction

Colon, gastric

  gnawing

Organ infiltration Skin inflammation,

Distension, crampy Liver, pancreatic

Burning, sharp

Breast, head and   neck, Kaposi’s

Figure 11-5  A peripherally inserted central catheter (PICC) is advanced through the cephalic or basilic vein to the axillary, subclavian, or brachiocephalic vein or the superior vena cava.

ulceration, infection,

necrosis

  sarcoma