Principles of Symptom Management
Alopecia
DEFINITION
• Can result from genetic factors, aging, local or systemic disease or can be therapy induced
• Minimal hair loss is considered less than 25%, moderate hair loss is 25%-50%, and severe hair loss is more than 50%.
• At least 50% of hair must be lost for it to be noticeable.
• In oncology settings, toxic alopecia generally occurs because of chemotherapeutic agents or radiation therapy.
• Toxic alopecia is usually temporary and can include body hair as well as hair of the head.
• The average daily hair loss is approximately 100 hairs.
• Because hair follicles are mitotically active structures, they are at risk for damage from radiation and chemotherapy.
• Scalp hair is the most sensitive to damage, followed by the male beard, eyebrows, axilla, pubis, and fine hair.
• The degree of alopecia depends on the treatment given, the dose, the schedule, and the route of administration.
• Bolus-dosing schedules of chemotherapy will cause more alopecia than cumulative doses given over extended periods.
• Radiation doses at 2500-3000 cGy fractionated over 2 or 3 weeks will cause hair loss. A single dose as small as 500 cGy may cause hair loss.
• Radiation doses of more than 4500 cGy may cause permanent alopecia.
• More than 6000 cGy may cause sebaceous and sweat glands to stop functioning.
PATHOPHYSIOLOGY AND CONTRIBUTING FACTORS
• When cells in the hair bulb absorb the chemotherapeutic agent or damage to the cells from radiation occurs, cellular division and protein synthesis can be suppressed or halted.
• Cells can enter the telogen phase early, enabling the hair to be shed.
• Hair loss will usually occur within 2-3 weeks after the first exposure to the toxin.
• Continued loss can occur over the next 3-4 weeks, although this varies according to chemotherapeutic agent.
• Generally, hair loss will begin on the crown and the sides of the head above the ear.
• Regrowth will occur within 3-5 months. New hair growth may be of different texture, color, or consistency.
• Regrowth may occur before the end of therapy because of the tricyclic nature of hair growth phases.
ASSESSMENT TOOLS
DIFFERENTIAL DIAGNOSES
• Noncytoxic drugs such as allopurinol, amphetamines, anticoagulants, antithyroid drugs, heavy metals, hypocholesterolemic drugs, levodopa, oral contraceptives, propranolol, and retinoids
• Alopecia of different etiologies such as congenital, alopecia areata, androgenetic alopecia, trauma, tinea capitis, folliculitis decalvans, and alopecia neoplastica
INTERVENTIONS
• Prevention has been a subject of debate since the 1960s.
• Various preventive methods have been used, including scalp tourniquets and scalp hypothermia. Discomfort and the risk of creating a “drug-free area” that could be a site for recurrence have discouraged these practices.
Nonpharmacologic Interventions
• Alopecia can cause the skin to be sensitive or tender. Warmth, lotions, massage, or other symptomatic treatments may be used, although there are no guidelines in the medical literature to advise these.
• Patients should be reassured that hair regrowth will occur.
• Psychosocial adjustment should be continually assessed throughout the treatment period until regrowth.
PATIENT TEACHING
• Instruct as to when hair loss will occur.
• Advise the patient to obtain a wig or head covering if desired before hair loss, while a good color and style match can be made.
• Sunscreen and the use of hats should be encouraged.
• Care should be taken to avoid cuts or nicks to the scalp if the head is shaved.
Camp-Sorrell D. Chemotherapy toxicities and management. In: Yarbro C., Frogge M., Goodman M. Cancer nursing principles and practice. 6th ed. Sudbury, MA: Jones & Bartlett; 2005:412–457.
Common terminology criteria for adverse events. Retrieved January 5, 2006, from http://ctep.cancer.gov/forms/CTCAEv3.pdf, 2003. version 3.0.
Ferri F. Ferri’s clinical advisor. St. Louis: Mosby, 2005.
Groenwald S., Frogge M., Goodman M., et al. Cancer nursing principles and practice. Sudbury, MA: Jones & Bartlett, 1997.
Reeves D. Alopecia. In: Yarbro C., Frogge M., Goodman M. Cancer symptom management. 2nd ed. Sudbury, MA: Jones & Bartlett; 1999:275–284.
Viale P. Chemotherapy and cutaneous toxicities: Implications for oncology nurses. Seminars in Oncology Nursing. 2006;22:144–151.
Wiedemeyer K., Schill W., Loser C. Disease of hair follicles leading to hair loss. Part I: nonscarring alopecias. SKINmed. 2004;3:209–214.
Alterations in Sexuality
DEFINITION
• Human sexuality is more than just sexual function. It is defined as a combination of feelings and behaviors that are unique for each person and includes sexual response, intimacy, emotions, fertility, and hormonal function.
• Sexual function is a specific aspect of sexuality that includes gender and involves the mind and body.
• Sexuality is an important part of normal life for most people and important to their quality of life.
• Sexual dysfunction can occur in 20%-100% of cancer patients, depending on the cancer site.
• Long-term sexual dysfunction has been documented in at least 50% of breast, prostate, colorectal, or gynecological cancer patients.
• Although sexual dysfunction is common, fewer than 20% of men or women seek medical help.
Pathophysiology and Contributing Factors
• Cancer or cancer treatments may damage one of the physiological systems, such as hormonal, vascular, neurological, or psychological systems, needed for healthy sexual responses.
• The most common sexual problem diagnosed after cancer treatment is loss of desire for sex in both men and women, erectile dysfunction in men, and dyspareunia in women.
• Less likely to resolve over time, unlike other cancer treatment side effects
• Pelvic surgery, radiation, chemotherapy, or hormonal agents may affect sexuality:
In men, prostate, bladder or rectal surgery, radiation to the pelvis (including brachytherapy), or hormonal therapy may contribute to impotence.
Testicular damage is dose dependent and the specific drug and age of the patient has less importance.• Drugs associated with impotence:
• Rule of thumb: If fertility is to be recovered in men, the sperm counts will return to normal within 3 years after therapy completion.
ASSESSMENT TOOLS
• Should be part of the initial new patient history and routine follow-up
• A quiet, private, nonthreatening environment should be provided and confidentiality ensured.
• The PLISSIT model addresses both assessment and rehabilitation:
• The ALARM model for the assessment of sexual functioning:
• Physical assessment should include:
LABORATORY AND DIAGNOSTIC TESTS
DIFFERENTIAL DIAGNOSES
INTERVENTIONS
• Giving permission to patients to discuss sexual concerns legitimizes concerns.
• Specific suggestions may be given when patients require more information than addressed in the general, limited information process.
• Intensive therapy may be required for some patients:
• A proactive approach is needed rather than waiting until the patient asks for information.
• Discussions should occur before treatment decision making. Patients should be well informed about the potential and expected side effects of each treatment option.
• Fertility preservation should be considered in those who are of childbearing years.
• Sexual rehabilitation should include both behavior changes and partner involvement, addressing such problems as
• Written information for the patient and partner to review in private is also helpful.
• If the health care provider is unable to provide the required information or treatment, then an appropriate referral should be made.
• Control physical symptoms before sexual relations:
PATIENT TEACHING
RESOURCES
• American Cancer Society: www.cancer.org
• Chemocare.org: www.chemocare.org
• Female sexual dysfunction: www.femalesexualdysfunctiononline.com
• Fertile Hope: www.fertilehope.org
• National Cancer Institute: www.cancer.gov
• The North American Menopausal Society (NAMS): www.menopause.org
• Oncology Nursing Society’s CancerSymptoms.org: www.cancersymptoms.org
Bokhour B., Clark J., Inui T., et al. Sexuality after treatment for early prostate cancer: exploring the meanings of “erectile dysfunction.”. Journal of General Internal Medicine. 2001;16:649–655.
Bostwick D.G., Crawford E.D., Higano C.S., et al. American Cancer Society’s complete guide to prostate cancer. Atlanta: American Cancer Society, 2005.
Bruner D., Iwamoto R. Altered sexual health. In: Yarbro C., Frogge M., Goodman M. Cancer symptom management. 2nd ed. Sudbury, MA: Jones & Bartlett; 1999:549–566.
Fenstermacher K., Hudson B. Practice guidelines for family nurse practitioners, 2nd ed. Philadelphia: W. B. Saunders, 2000.
Ferri F. Ferri’s clinical advisor, 2005. Philadelphia: Elsevier Mosby, 2005.
Fincannon J.L., Bruss K.V. Couples confronting cancer. Atlanta: American Cancer Society, 2003.
Katz A. The sounds of silence: Sexuality information for cancer patients. Journal of Clinical Oncology. 2005;23:238–241.
Krebs L. Sexual and reproductive dysfunction. In: Yarbro C., Frogge M., Goodman M. Cancer symptom management. 6th ed. Sudbury, MA: Jones & Bartlett; 2005:841–869.
Mick J., Hughes M., Cohen M. Using the BETTER model to assess sexuality. Clinical Journal of Oncology Nursing. 2004;8:84–86.
Penson R., Gallagher J., Gioiella M., et al. Sexuality and cancer. The Oncologist. 2000;5:336–344.
Polovich M., White J., Kelleher L. Chemotherapy and biotherapy guidelines and recommendations for practice, 2nd ed. Pittsburgh, PA: Oncology Nursing Society, 2005.
Schover L. Sexuality and fertility after cancer. American Society of Hematology, Educational Program. 2005:523–527.
Schwartz S., Plawcki H. Consequences of chemotherapy on the sexuality of patients with lung cancer. Clinical Journal of Oncology Nursing. 2002;6:212–216.
Anorexia
DEFINITION
• Weight loss greater than 10% within a 6-month period
• Occurs in as many as 40% of cancer patients at diagnosis and up to 70% in patients in advanced stages
• Highest incidences occur in patients with gastrointestinal cancers.
• Often associated with cachexia (lean tissue wasting)
• Weight loss is a major cause of morbidity and mortality in patients with advanced cancer.
• Associated with a lower quality of life, poor response to chemotherapy, reduced performance status, and shorter survival times
PATHOPHYSIOLOGY AND CONTRIBUTING FACTORS
• End result of altered central and peripheral neurohormonal signals that govern appetite
• Involuntary systemic effect of underlying disease
• Predisposed by disease progression
• Direct result of supportive treatment modalities, including surgery, radiation, and chemotherapy
• Humoral and inflammatory responses:
• Psychological factors, including depression
INTERVENTIONS
Brown J.K. A systematic review of the evidence on symptom management of cancer-related anorexia and cachexia. Oncology Nursing Forum. 2002;29:517–532.
Cope D. Management of anorexia, cachexia, and weight loss in patients with advanced cancer. Clinical Journal of Oncology Nursing. 2002;6:241–242.
Davis M.P., Dreicer R., Walsh D., et al. Appetite and cancer-associated anorexia: A review. Journal of Clinical Oncology. 2004;22:1510–1517.
Esper P., Heidrich D. Symptom clusters in advanced illness. Seminars in Oncology Nursing. 2005;21:20–28.
Laviano A., Meguid M., Rossi-Fanelli F. Cancer anorexia: Clinical implications, pathogenesis, and therapeutic strategies. The Lancet Oncology. 2003;4:686–694.
Molassiotis A. Anorexia and weight loss in long-term survivors. Journal of Clinical Nursing. 2003;12:925–927.
Von Meyenfeldt M. Cancer-associated malnutrition: An introduction. European Journal of Oncology Nursing. 2005;9:S35–S38.
Yavuzen T., Davis M.P., Walsh D., et al. Systematic review of the treatment of cancer-associated anorexia and weight loss. Journal of Clinical Oncology. 2005;23:8500–8511.
Anxiety
PATHOPHYSIOLOGY AND CONTRIBUTING FACTORS
• Thought to result from an inappropriate activation of the sympathetic nervous system
• Increased levels of norepinephrine with decreased levels of serotonin and gamma-aminobutyric acid
• Hormonal input such as hypothalamus, pituitary, and adrenal glands interfere with normal processes, leading to feelings of panic or a sense of dread.
• Cardiovascular abnormalities contribute to anxiety as a result of altered regulation of the autonomic nervous system.
• Medication induced: see list under “Assessment Tools”
• Withdrawal from alcohol or nicotine
• Disease stage—anxiety increases as disease advances or physical status declines
• Difficulty with treatment regimens or lifestyle changes and financial concerns
• Dealing with family issues or conflicts and facing death
• Family and staff anxiety can contribute to the patient’s level of anxiety and vice versa.
SIGNS AND SYMPTOMS
• Restlessness, panic, tachycardia, difficulty concentrating, palpitations, sweating, dizziness, urinary frequency, abdominal discomfort, sleep disturbances
• Chest pain, irritability, headache, apprehension, and anorexia
• Any repetitive behaviors to prevent discomfort (pacing, rubbing hands)
• Vital signs: elevated heart rate, blood pressure, or respiratory rate and temperature
• Skin examination may reveal endocrine-associated changes that contribute to anxiety—dry skin in thyroid disorder, Addison’s disease symptoms—facial puffiness, and increased skin pigmentation. Skin turgor may predict poor appetite, dehydration, or hypernatremia.
ASSESSMENT TOOLS
• Depression and anxiety screening. Tools to help evaluate subjective feelings of anxiety and level patient is experiencing. Can rate anxiety on a visual analog scale or verbal rating scale like pain ratings, 0-10
• Ask questions such as: “Do you feel nervous?” “Do you worry about your diagnosis or treatment?” Goal is to understand what may be contributing to the anxiety.
• History should include any history of psychosocial disorders, adjustment disorders, or panic attacks.
• Any history of generalized anxiety disorders or phobias or history of agitated depression
• What are the presenting symptoms, including precipitating factors, onset, and duration?
• What makes the symptoms better or worse?
• How does the patient cope with anxiety? What methods does the patient use to manage anxiety?
• Medication history, including over-the-counter medications. Medications associated with anxiety include stimulants, thyroid replacement medications, corticosteroids, bronchodilators and decongestants, epinephrine, antihypertensives, antihistamines, anticholinergics, anesthetics, and analgesics.
• Uncontrolled pain, hypoxia, sepsis, adverse drug effects, and withdrawal can lead to anxiety.
• Cardiac examination to identify irregular heart rate or abnormal heart sounds
• Pulmonary examination to rule out hypoxia related to pneumonia, pleural effusions, or embolus
• Neurological examination to identify cranial nerve palsies and neuropathies
INTERVENTIONS
• Treating anxiety is related to the patient’s subjective level of distress.
• Moderate to severe anxiety can interfere significantly with the patient’s ability to comply with treatments.
Pharmacologic Interventions
Nonpharmacologic Interventions
• Initiate a discussion of concerns that may be contributing to the feeling of anxiety, such as pain, fear, dependence issues. Use open-ended questions and clarification remarks.
• Help patient identify what has helped him or her get through times like this before. Talk about how we can help you use those strategies now.
• Encourage the patient to identify people who can support him or her through this anxiety.
• Recognize that as patients move through anxiety from mild to severe the cause may be lost as the anxiety takes over. Preventive strategies can be useful to minimize anxiety or stabilize the escalation.
• Increase opportunities for control
• Evaluate dietary intake to reduce caffeine products and alcohol to promote sleep.
PATIENT TEACHING
• Provide patient and family education to support reduction of fear and anticipatory reactions. Give instructions on medications and side effect management. Goal of education is to reduce stress and anxiety.
• Increase patient and family participation in activities.
• Use a family member or friend as the support person to stay present to help the patient.
• Provide accurate information to help restructure unrealistic fearful beliefs.
• Teach anxiety-reducing interventions such as relaxation, visualization, deep breathing, massage, touch, and physical exercise.
• Stress management may also include music and art therapy, yoga.
Breitbart W., Chochinov H.M., Passik S. Psychiatric symptoms in palliative medicine. In: Doyle D., Hanks G., Cherny N., et al. Oxford textbook of palliative medicine. 3rd ed. New York: Oxford University Press; 2004:746–771.
Dahlin C. Anxiety. In: Camp-Sorrell D., Hawkins R.A. Clinical manual for the oncology advanced practice nurse. Pittsburgh: Oncology Nursing Society; 2006:1105–1111.
End-of-Life Nursing Education Consortium. Oncology-module 3: Symptom management. Duarte, CA: American Association of Colleges of Nursing, 2006.
Pasacreta J., Minarik P.A., Nield-Anderson L. Anxiety and depression. In: Ferrell B., Coyle N. Textbook of palliative nursing. 2nd ed. New York: Oxford University Press; 2006:375–399.
Arthralgias and Myalgias
PATHOPHYSIOLOGY AND CONTRIBUTING FACTORS
• Generally the pathophysiology is unclear.
• Proposed theories include the following:
• Risk factors include the following:
ASSESSMENT TOOLS
• Assessment of the patient with arthralgias or myalgias should include the following:
LABORATORY AND DIAGNOSTIC TESTS
• Complete blood cell count (CBC) with differential to evaluate neutropenia and rule out infection
• Chemistries to rule out hypo- or hyperkalemia, hypomagnesemia, hypocalcemia, hypo- or hypernatremia, hypophosphatemia
• Creatinine kinase levels to rule out muscle inflammation or damage
• Urinalysis focusing on red blood cells
• Thyroid-stimulating hormone (TSH)
• Blood cultures if neutropenia is suspected
• Electromyelogram (EMG) to differentiate myelopathy from neuropathy
DIFFERENTIAL DIAGNOSES
• Cancer or metastatic disease
• Infections such as toxoplasmosis, trichinosis, influenza, herpes
• Electrolyte imbalance such as hypo- or hyperkalemia, hypomagnesemia, hypocalcemia, hypo- or hypernatremia, hypophosphatemia
• Drugs: steroid withdrawal, paclitaxel (especially in combination with cisplatin), docetaxel, vincristine, vinblastine, vinorelbine, rituximab, etoposide, bacille Calmette-Guérin, filgrastim, sargramostim, interferon, interleukin-2, dacarbazine, altretamine, topotecan, gemcitabine, procarbazine, fludarabine, letrozole (aromatase inhibitors as a class), azacytidine, cladribine, L-asparaginase
INTERVENTIONS
Pharmacologic Interventions
Arthralgias and myalgias. Retrieved September 29, 2007, from http://www.lungcanceronline.org/effects/arthralgias.html, 2007.
Chemotherapy and pain, myalgias, arthralgias. Retrieved February 7, 2007, from www.Chemocare.com/managing, 2005.
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Myalgias and arthralgias: long term consequences of the aromitase inhibitors. Retrieved December 30, 2006, from http://www.medscape.com/viewarticle/516882_4, 2005.
Rumsey K.A. Myalgia. In: Camp-Sorrell D., Hawkins R.A. Clinical manual for the oncology advanced practice nurse. Pittsburgh: Oncology Nursing Press; 2000:775–781.
Confusion
DEFINITION
• Confusion, or cognitive failure, is a symptom or a description of a person’s mental state.
• It is a number of different subjective symptoms and objective behaviors.
• May be operationally defined as behaviors that fall into the following four categories:
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