Oncology Study Guide 2021

REQUIRED READINGS: Ignatavicius, D. D., & Workman, M. L., (2016). Medical-surgical nursing: patient-centered collaborative care. (8th ed.). St Louis, MO; Elsevier Inc. Chapters 7, 21, 22, 40 (pp. 806-819) NORMAL LABS: WBC: 5-10K HCT: M:42-52%; F:37-47% RBC: M: 4.7-6.1; F: 4.2-5.4 HGB: M:14-18; F:12-16 PLT: 150-400 CA+: 9-10.5 TOPICAL OUTLINE: I. End-of-Life Care a. Overview of Death and Dying -Concept of “good” (with dignity) death and “bad” (without dignity) death -Nurses can greatly impact dying process -Virginia Henderson’s definition of nsg: “assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery or a peaceful death” (1966) • Nurse must: o Have compassion o Be a patient/family advocate o Have good communication skills i. Death in the United States Statistics on Death in U.S. • Over 2.6 million deaths in 2014 • Most deaths occur after a long period of illness (10% = sudden deaths) • 75% deaths occur age 65 or greater • 25% deaths occur in home • 75% deaths occur in hospital/nsg home ii. Pathophysiology of Dying -Death— cessation of heartbeat, absence of spontaneous respirations, or irreversible brain dysfunction -Most common cause of death U.S. = heart disease, followed by cancer -Direct causes of death = heart failure, resp failure, shock iii. Planning for End-of-Life and Advance Directives Advance Directives (always ask patients about these) • Written documents specifying the medical care provided or not provided if one becomes incapacitated. 11.30.17 gm ONCOLOGY STUDY GUIDE 2021 2 • Person must have decision-making ability when advance directives written • 2 common advance directives: o Durable power of attorney (DPOAHC) • legal document assigning decision-making power to another person in the event person becomes incapable of making decisions (ex p. 93) o Living will • legal document that instructs physicians and family about what life-sustaining treatment a person does or does not want at some future time (CPR, respirator, tube feeding, DNR status) iv. Hospice and Palliative care -Hospice - interdisciplinary approach to assess & address holistic needs of pts & families to facilitate quality of life & a peaceful death -assess home, patient, family -goals: pain meds (morphine-sublingual, PO), supplies, do they know how to do things when they get home -Does not hasten or prolong death -Free standing hospice, home, hospital, nsg home, assisted living facilities • Benefits paid if prognosis of 6 months or less to live (Medicare guidelines) • Hospice treated as last resort option • Studies show hospice improves quality of life and lowers costs • Symptom relief kit, chart 7-3 (p. 97) o Pain • Morphine (20mg/1ML solution) 0.25-0.5ML orally or SL q2hp o Dyspnea (raise HOB) • Morphine (20mg/1ML solution) 0.25-0.5ML orally or SL q2hp • **Offer oxygen to any patient with dyspnea near death regardless of his/her oxygen saturation, because comfort is desired outcome o Agitation and restlessness • Determine if pt in pain, treat accordingly • If pt experiencing urinary retention, insert cath • Haloperidol 0.5-1mg orally or SL q6h • Lorazepam 0.5-1mg elixir or tab q4h o Oral secretions • Atropine drops 1% (2 drops orally or SL) q4hp 11.30.17 gm 3 • Palliative Care o a philosophy of care and a system for delivering care for pts with a life-threatening illness (not going to die within 6 mos) o Goals: • to identify pts/family’s goals of care • assist with informed decisions making • facilitate quality symptom management o Comparison of hospice & palliative care – table 7-2 (p. 95) HOSPICE CARE PALLIATIVE CARE -patients have prognosis of 6 mos or less to live -care is provided when curative treatment such as chemo, has been stopped -care is provided in 60 and 90 day periods with an opportunity to continue if eligibility criteria is met -ongoing care is provided by RNs, social workers, chaplains and volunteers -patients can be in any stage of serious illness -a consult is provided that is concurrent with curative therapies or therapies that prolong life -care is not limited by specific time periods -care is in the form of consult visit by a physician or advanced practice nurse who makes recommendations, follow-up visits may be provided. Symptoms at End of Life • Pts often have s/s of decline in physical function: • Weakness • Anorexia • Changes in cardiovascular function (BP, P then ceases) • Changes in breathing patterns (Cheyne-Stokes, apnea, death rattle) • Changes in GI function (no H2O/food) • Changes in GU function (decreased UOP) Physical Assessment • Common physical s/s of approaching death - Chart 7-1 (p. 96) • Coolness of Extremities • cover the pt with blanket (not electric blanket) • Increased sleeping (23 hrs) • Do not force to stay awake • Talk to the person normally • Fluid/food decrease intake • Do not force them to eat/drink • Offer small sips or ice chips 11.30.17 gm 4 • Use swabs to keep mouth/lips moist • Incontinence • Keep perineal area clean and dry • Maybe use a foley • Congestion and gurgling • Position them on their side • Breathing pattern change • Elevate person’s head, put them on their side • Disorientation • Identify yourself when you communicate with them • Reorient as needed • Restlessness • Play soft music, room dimly lit, noise to a minimum • Do not restrain them • Reduce number of people in room • Talk quietly Psychosocial Assessment • Assessment o Fear and anxiety o Difficulty coping o Feelings of patient and significant others  Help pt/family talk about feelings (asking for forgiveness, etc.)  Find out their spiritual needs o Common emotional s/s of approaching death – Chart 7-2  Withdrawal • Preparing to let go from surroundings/relationships  Vision-like experiences • Do not deny/argue with them, affirm the experience  Letting go • Tell them it’s okay to let go  Saying goodbye • Touch, hug, cry, say I love you, I’m sorry • Nursing Care: Pain Management 11.30.17 gm 5 o Pain = symptom that dying pts fear most  Make sure pt is comfortable o Pain meds should be scheduled to prevent any recurrence of pain o Consider alternative route of pain medication and adm as needed  Dysphagia near death is an issue for drug therapy. Some tabs may be crushed, some like sustained released capsules cannot. Reassess need for each medication. Identify alternate routes or drugs to maintain control of symptoms. Choose least invasive route such as oral, buccal mucosa, transdermal or rectal. SubQ or IV may be used if access available. IM route is almost never used at end of life as it is considered painful to patients. o Complementary and alternative therapies (massage, music, aromatherapy) • Nursing Care: Weakness Management o Aspiration precautions (HOB raised) o Mouth care and moisture for lips o Altered routes of medication adm—choose the least invasive route of medication adm with the most effective treatment (sublingual) • Nursing Care: Breathlessness/Dyspnea Management (goal: keep comfortable) o Treat primary cause, and relieve the psychological distress of dyspnea o Pharmacologic interventions: • Opioids (morphine) - MS • Bronchodilators • Corticosteroids • Sedatives • Diuretics • Antibiotics • Anticholinergics • Benzodiazepines • Oxygen therapy (offer O2 to any patient with dyspnea near death regardless of their O2 sat because comfort is the ultimate goal) Non-Pharmacologic Interventions: (Teach family) o Cool air o Wet cloths to pt’s face o Positioning of the pt to facilitate chest expansion o Frequent rest periods o Encouraging imagery and deep breathing o Nursing Care: N/V Management o Assess for and treat constipation o Antiemetic agents o Remove any source of odors o Comfortable room temperature o Dietary changes o Nursing Care: Restlessness & Agitation Management