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Exam 4 Cell Regulation & Grief

CELLURAL REGULATION (30)
Cellular Regulation is the process by which cells replicate, proliferate, and grow.
 Refers to all functions carried out within the cells to maintain homeostasis, including their
responses to extracellular signals (e.g., hormones, neurotransmitters) and the way
each cell produces an intracellular response. Included within these functions
is cellular replication and growth
Proliferation: production of new cells through cell division
Differentiation: acquisition of specific cell function
Neoplasm /tumor: new and abnormal tissue growth that is uncontrolled and progressive
 Benign → does not invade surrounding tissue or spread to other parts of the body; not cancer.
 Malignant→ cancerous tumor cells

Exemplars
Solid Tumors (5): → NO LIQUID
Abnormal (localized) mass of tissue that does not contain cysts or liquids
 May be benign (non-cancerous) or malignant ( cancerous)
Types of tumors:
 Sarcoma → Begin in the connective tissue; the tissue that the body uses
to connect or support other tissues
 Carcinoma → originate from the epithelial tissues; this tissue that lines
your organs ( lungs, liver, breast , colon or prostate)

Lymphoproliferative Disorder (2): → FLUID

Refer to several conditions in which lymphocytes are produced in excessive quantities

Leukemia→ cancer of blood cells NO TUMOR
Leukemia happens when the DNA of immature blood cells, mainly white cells, becomes damaged in
some way. This causes the blood cells to grow /divide rapidly, so that there are too many. Healthy
blood cells die after a while and are replaced by leukemia cells, which are produced in the bone
marrow.
Lymphoma → lump is a type of neoplasm that affects lymphoid tissue.
TWO TYPES:
Hodgkin lymphoma (HL): Non-Hodgkin lymphoma
 Reed Sternberg cells  Often involves malignant B Cells,
(malignant , proliferation usually originates outside lymph node
giant multinucleated cells)
 Most common
 > men
 Affects 50-70 yr old
 Two peaks: 15-30; above 55- 75 years of age
 Common: men/white race
 Originates in lymph nodes (cervical nodes)
 No known cause → linked to viruses,
 ↑ in pts w/HIV
immune disorders, genetic
 Onset: Insidious
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B SYMPTOMS: abnormalities, exposure to chemicals,

 fever (100.4 F), weight loss (> 10% in 6 months) infection Helicobacter pylori
 drenching night sweats Assessment:
Assessment:  PAINLESS lymph node enlargement
 PAINLESS enlarged lymph node on ONE side  Fever w/out chills, night sweats, ↓
of neck (cervical or sub clavicular region) weight 10 %
 Fatigue/weakness  Abdominal pain/N/V
 Anorexia/dysphagia  Hematuria
 Pruritus & jaundice  Peripheral neuropathy, cranial nerve
 Severe brief pain after drinking alcohol palsies, HA, visual disturbance, change
 Abdominal pain & BONE PAIN LOC, seizures
Diagnostic:  Lymphocytopenia
Presence of reed Sternberg in lymph node biopsy  X-ray may reveal pulmonary infiltrate
 Lymph node BIOPSY Identifies cell type
&pattern

Lymphoma Teaching:

Cancer Survivorship (5):

Be aware of late and long term effects of cancer:

Secondary cancer
 Cancer cells from the original tumor may spread
to create secondary cancer at another site. Or an
entirely new cancer may develop in association
with the same risk factors that contributed to
the initial malignancy
 Cognitive changes

Cardiovascular/sexual dysfunction
 Erectile dysfunction (ED)
 Vaginal dryness, sudden menopause and pain in women
 Loss of sexual desire= grief and anger
Why:
 A major cause of these issues is physical damage or changes from cancer treatment.
 Radiation or surgery in the pelvic area can make sex painful or difficult, and may damage blood
vessels or nerves critical for male performance.
 In women, chemotherapy may cause premature menopause, and hormone therapies can be
linked to discomfort or pain.
Talk to provider or nurse and partner

Table 15-22
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P a ti e n t T e a c h i n g

Cancer Survivors

You can help cancer survivors by doing the following:

1. Provide all cancer patients with a treatment summary and care plan outlining treatment
exposures, risk of late effects, preventive care recommendations, and follow-up surveillance plan
after completion of treatment.
• Care plans should clearly identify all members of the interprofessional team and their
responsibilities for follow-up care.
• Include referrals to appropriate supportive care and community resources that would benefit the
patient in recovery or ongoing care.
2. Coordinate care among the oncology team, primary HCP, and other specialists.
3. Teach HCPs about the needs of cancer survivors, including long-term effects of cancer and cancer
treatments.
4. Teach cancer survivors to look for and report any ongoing symptoms resulting from treatment,
including late effects of radiation therapy and chemotherapy.
5. Promote healthy behaviors:
• Prevention: good nutrition, exercise, smoking avoidance, maintenance of proper weight, cardiac
risk reduction, bone health.
• Early detection: routine health screenings (e.g., breast, colon), cholesterol, diabetes,
osteoporosis screening as recommended.
6. Encourage cancer survivors to have regular follow-up examinations with their HCP.
7. Assess for psycho-emotional, financial, health insurance, or vocational problems related to cancer.
Assist patients in getting appropriate help if necessary.

BAZEMORE HANDOUT
Anthracycline induces cardiac toxicity: (heart failure)
DAB: diuretics
Ace inhibitors
Beta blockers;
Diagnosis: Echo
Ejection fraction → 55-70

Anxiety/depression:
 PTDS complication: cognitive behavior therapy, talk about feelings and concerns
 Fear of recurrence
 Anxiety/fear more common than depression
 Females, adolescents, young adults are more vulnerable
 Behavioral tx: cognitive behavior therapy, hypnosis, support groups, self-health management
 Meds:
 SSRI
 BENZODIAZAPINES
 ANXIOLYTICS

Cognitive function:
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Fatigue:
 Worse 1st few days, activity intolerance
 Confused: frequent rest, push fatigue as tolerated, emotional support
 Mineral/vitamins
 Set short term goals
Pain:
 At risk → under treatment for pain/discomfort
 Meds:
 Nonpharmacological
Physical activity:
 Exercise 30 minutes x5 as tolerated
Nutrition:
 Foods not supplements
 No smoking/alcohol
 Whole grain, lean protein (chicken, fish, tofu) low fat dairy (skim, low fat yogurt)
 ↑ FIBER, PROTEIN, low fat

Comfort: Cancer Pain (2):

 Patient report should always be believed and accepted as primary source for pain assessment
data
• Drug therapy should be used to control pain
Under treatment of pain causes
 Needless suffering
 Decreased quality of life
 Increased burden on family caregivers
 Inadequate pain assessment is single greatest barrier to effective cancer
Management of pain:
 Fear of addiction is unwarranted (unnecessary)
 Numerous drug options for pain management
 Nonpharmacological interventions:
o Relaxation therapy and imagery, can be used effectively
Gold standard → opioids
Mild or moderate pain:
 Salicylates
 Acetaminophen
 NSAIDS
Severe pain: → OPIOIDS:
Morphine sulfate
Codeine sulfate
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Comfort: Symptom Management

(Including complications & oncologic emergencies (16)
Chemotherapy: KILLS
 Systemic or local CYTOTOXIC medication → damage cell’s DNA/Destroy rapidly dividing cell;
KILLS
 Adverse effects r/t harm done to NORMAL proliferation cells such as the mucous membranes of
GI, TRACT, hair follicles and BONE marrow.
 Must wear PPE
 Chemo have side effects due to the NORMAL cells being wiped out
Irritant: damage intima of the vein = phlebitis/sclerosis
Vesicants: (agent that causes blistering) if infiltrated in skin = severe local tissue breakdown/necrosis 
Combination therapy: Targets more than one pathway → drug works at different places
NADIR: describes the point when blood cell counts are at their lowest after a chemotherapy treatment.
(7-10 days after therapy) → WBC, RBC, PLT (Longer for RBC; live longer)

Radiation: SHRINKS
Myelosuppression: bone marrow suppression → only bone marrow
treated is affected.
Skin changes:
 Gently clean w/ mild soap & water.
 Apply NON perfumed, non -medicated ointment → Aloe gel,
Biafine cream, Aquaphor
 Avoid sun exposure, tight clothes
 No swimming during treatment
 No ice or heat on radiation sites
Pericarditis/Myocarditis:
Develops 2-3 months after treatment
Monitor: dry hacking cough, fever, exertional dyspnea

Comfort: Symptom management (including complications and oncologic emergencies) (16)

Chemotherapy affects normal cells that grow rapidly, such as blood cells forming in the bone
marrow, cells in the hair follicles or cells in the mouth and intestines.

Nausea & vomiting:

Chemotherapy is emetogenic (induced vomiting or cause anorexia & altered taste in mouth)
Within 1 hour of chemo or few hours after radiation (chest/abdomen)
 Zofran found to be more affective & often administered with corticosteroids phenothiazine and
antihistamine.
 Medication: antiemetic (prior, during, after treatment) → prophylaxis 1 hour before chemo
o Promethazine/ Phenergan
o Dexamethasone
o Ondansetron/Zofran:
-tron: blocks effects of serotonin
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ANOREXIA → Loss of appetite s/e of cancer itself or with chemotherapy

 Consult w/ dietician before cancer treatment
 Implement nonpharmacological methods.
 Preform calorie count to determine intake.
 Provide nutritional liquid supplements as needed.
 Assess for dehydration or fluid and electrolytes imbalance.
 Oral care prior and after meals.
 AVOID drinking liquids during meals.
Med:
 megestrol acetate/ megace: appetite stimulant

Client Education
o Suggest foods that are cold & do not require cooking.
o Small frequent meals a day, Low fat & dry foods (crackers & toast).
o High proteins & high calories (15-11) Lewis pg 246
o Can emit odors that stimulant nausea.
o Use plastic utensils, suck hard candies, avoid red meats, and reduce sensation of
metallic taste.
o Food diary for items that trigger nausea.
DIARRHEA:
Managed with diet modification, antidiarrheal, anti- motility agents, antispasmodics
 Low fiber, low residue diet
Limit high in roughage → fresh fruit, vegetable, seeds, nuts
Avoid fried, fatty, highly seasoned food, , bran, raw fruits and vegetables, and caffeine or food
that produces gas
Avoid milk OR milk products
 Encourage fluid (3L/day) →Hydration, replace electrolytes
 Luke warm Sitz baths- for comfort
 Rectal must be kept clean/dry to maintain skin integrity
 Systemic analgesics for painful skin irritant
 Teach to keep a log to record episodes, aggravating/alleviating factors
 Try a clear liquid diet (one that includes water, weak tea, apple juice, peach or apricot nectar,
clear broth, Popsicles, and gelatin with no solids added) as soon as diarrhea starts or when you
feel that it’s going to start. Avoid acidic drinks, such as tomato juice, citrus juices, and fizzy soft
drinks.
 Eat small meals often. Don’t eat very hot or spicy foods.
 When the diarrhea starts to improve, try eating small amounts of foods that are easy to digest
such as rice, bananas, applesauce, yogurt, mashed potatoes, low-fat cottage cheese, and dry
toast. If the diarrhea keeps getting better after a day or 2, start small regular meals.
 Avoid pastries, candies, rich desserts, jellies, preserves, and nuts.
 Don’t drink alcohol or use tobacco.
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 Be sure your diet includes foods that are high in potassium (such as bananas, potatoes,
apricots, . Potassium is an important mineral that you may lose if you have diarrhea.
Mucositis/Stomatitis
Mucositis →refers to inflammation in mucous lining of the upper GI TRACT from mouth to stomach
Stomatitis → inflammation of tissues in the oral cavity such as gums, tongue, roof and floor of mouth
and inside lips/cheeks
 Irritant inflammation/ulcerations in the mucosa
 Common complications receiving radiation to the head/neck
 Lining of oral cavity is sensitive to the effects of radiation/chemo
 Oral assessment/intervention:

 Inspect mouth orally
 Keep oral cavity moist, clean and free of debris=prevention of infection
 Oral care at least 1 hour before and after each meal, at bedtime or as needed
 Encourage rinse mouth w/ 0.9% sodium chloride solution
 Gentle brush w/ soft bristle toothbrush or sponge
 Rinse mouth before/after meals
 Avoid alcohol or glycerin base mouthwash or swabs = irritation to mucosa
 Avoid alcohol/smoking
 Advise to regular dental follow up every 6 months & use fluoride supplement
 Offer Saliva substitutes for xerostomia (dry mouth) → taking small drinks of water
frequently helps, hard candy
 Offer soft food that cool to warm rather than hard or spicy food
When they have sore (lesion)
 Encourage bland foods & supplements high in calories
 Mash potatoes
 Scrambled eggs
 Cooked cereal
 Milkshakes
 Ice cream
 Frozen yogurts
 Bananas
 Breakfast mixes.
Medication:
 Nystatin/mycostatin
 Acyclovir/Zobirax
Dysgeusia →(altered taste sensation)
 Avoid food that they dislike
 Experiment w/ spices and seasoning to mask taste alteration
o Lemon juice, onion, mint, basal, fruit juice marinade may improve taste of meat and fish
Dysphagia → difficulty swallowing: pt report feeling of ‘LUMP” → soft food
Odynophagia (painful swallow) → give analgesic before meals
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Alopecia: →hair loss

 Impact of self-image;
 Talking about your feelings related to losing hair 
 Inform hair loss occurs 7-10 days after treatment begins (with some selective agents)
 Encourage client to select hair piece before treatment starts.
 Psychosocial (reinforcement) Hair should return 2-3 months after treatment has ended
Client Education
 Protect the scalp from sun exposure & use diaper rash or ointment for itching.
 Consider cutting hair before treatment
 Scarves, wigs, and hair pieces
 Choose a fragrance-free gentle shampoo to clean your hair.
 Consider not washing your hair every day, and do not scrub vigorously.
 Pat your hair dry to prevent damage.
 Choose a soft hairbrush or wide-toothed comb and gently style your hair.
 Use sun protection on your scalp when outdoors, such as sunscreen, a hat, or a scarf.
 Cover your head during the cold months to retain body heat.
 Avoid blow-drying your hair with high heat or pulling it.
 Avoid curling or straightening your hair with chemical products.
 Avoid permanent or semi-permanent hair coloring.
 Choose a soft, comfortable covering for your bed pillow.
 Talk with your health care team before using any hair-growth creams or lotions.
 Talk with your health care team about taking the B vitamin biotin.

Thrombocytopenia: ↓ platelet count

Platelet: 150,000- 400,000 → Platelets are the cells that form blood clots that stop bleeding.

Risk for bleeding → low plt ↓ 50.000 = risk for major bleeding
When chemotherapy affects bone marrow, the body’s ability to produce platelets, the body’s chief
defense against bleeding, is diminished. 
Monitor/ Symptoms:
 bruising easily
 tiny red/purple spots, or petechiae, under the skin
 gum bleeds
 nose bleeds → keep head up and apply firm pressure to nostril/bridge of nose
o if continues to bleed, ice bag over bridge of nose/nape of neck
 a lot of or long-lasting bleeding from a small cut or injection site
 blood in the urine, which may look pink, red or brown
 black tarry bloody stool
 vomiting blood or coffee grounds
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 vaginal bleeding that is different from and lasts longer than the normal menstrual period
 constant headache, blurred vision or change in level of consciousness
Avoid:
 Blowing nose forcefully, pat dry if needed
 Do not bend down w/head lower than waist
 Prevent constipation ; do not strain → drink plenty of fluids, stool softner
 Do not use suppository, enema of rectal thermometer
 Do not use blades → use electric shaver
 No tweezing eyebrows
 No tattoos or body piecing
 No aspirin
 Avoid alcohol based mouthwash = dry gums = bleeding
 Avoid hard bristle tooth brush → use soft brush
 Avoid invasive procedures such as dental work, pedicure, manicure: consult HCP
 AVOID IM infection
 If subcutaneous injection is not avoidable → use a small gauge needle, direct pressure 5-10
minutes after injection, ice pack
Monitor:
 plt count, coagulation studies, H & H → together provide info on potential/risk for bleeding
 Be prepared to administer plts if counts < 30,000
Medication:
Thrombopoietic medication:
 Orprelvekin/Neunega) =stimulate platelet production.
 The first dose is most often given 6 to 24 hours after you get chemo and is given until your
platelet count reaches the right level.
 Do not give for at least 2 days before your next chemo.
 Subcutaneous injection
 Same time
SE: fluid retention, peripheral edema, mouth sores, upset stomach/diarrhea

NEUTROPENIA/IMMUNOSUPPRESSION: ↓ WBC (NEUTROPILS)

Neutrophils are a type of white blood cell that helps your body fight infection. Neutropenia occurs when
the number of the neutrophils in your bloodstream is lower than normal, putting you at risk for illness or
infection
Causes of neutropenia
 Due to bone marrow suppression by cytoxic medications
 The most significant adverse effect chemotherapy
These factors related to cancer and cancer treatment can cause a low level of neutrophils:
 Some types of chemotherapy
 Cancers that affect the bone marrow directly, such as leukemia, lymphoma, and multiple
myeloma
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 Cancer that has spread

 Radiation therapy to several parts of the body or to bones in the pelvis, legs, chest, or abdomen

Nursing considerations:
 Monitor temperature, WBC & Absolute neutrophil count (ANC)
 FEVER > 100 F →Report to provider immediately
 Monitor skin/ mucous membranes for infection breakdown, fissures and abscess
 Cultures should obtained prior to antimicrobial therapy
 Absolute neutrophil count (ANC)
o Range 1.5-8.0 or 1500-8000
o If below 0.5 or 500, must place on neutropenic precautions.
o LOW= BAD → Place on Neutropenic precautions.
Neutropenic precaution:
 Client remain in room unless diagnostic procedure therapy as needed.
Place mask on client when transporting.
 Protect client form possible source of infection (plants, changed in water
equipment daily)
 frequent handwashing for everyone ; restrict ill visitors
 Avoid invasive procedure that can cause break in tissue (rectal
temperature, injections, indwelling catheters) unless necessary
 Keep dedicated equipment in room (BPs machine, thermometers, and stethoscope).
Medication
 Administer colony-stimulating factors:
 Filgrastim /Neupogen: → stimulate WBC production.
SE: BONE PAIN, n/v, major R/F= SEPSIS
T: Throat mouth
R: rash
O: oxygen hunger
U: urinary pain
B: bowels/diarrhea
L: Loss appetite
E: extremity changes

Client Education:
 Avoid crowds while undergoing chemotherapy.
 Take temperature daily. (report fever >100.4)
 Avoid food sources that can contain bacteria (fresh fruits, veggies,
undercooked meats, fish, eggs, pepper, & paprika)
 Avoid yard work, gardening or changing litter box
 Avoid fluids that have been sitting at room temperature longer than 1 hr.
 Wash all dishes in HOT, soapy water or dishwasher.
 Wash toothbrush daily in dishwasher or rinse in bleach solution.
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 Always washes glasses or cups after one use.

 Do not share personal hygiene with others.
 Report fever > 100 F, or other manifestations of bacterial or viral immediately to provider

ANEMIA:
Hgb: F: 11-15 HCT: 33- 45→ part of the red cell that carries the oxygen
Hgb: M: 13-17 HCT: 39-51 →

Normally, your kidneys produce a hormone called erythropoietin that stimulates the bone marrow to
make red blood cells. One of the effects of cancer can be to slow down the kidneys’ ability to make this
hormone. With less erythropoietin being made, the bone marrow does not get the stimulus it needs to
make a normal number of new red blood cells.
Nursing Actions (Anemia)
Monitor:
 Fatigue or tiredness
 Trouble breathing
 Rapid heartbeat
 Dizziness, light-headedness, inability to concentrate, or headache
 Chest pain
 Difficulty staying warm
 Loss of sex drive
 Pale skin/pallor
 Schedule activities with rest periods & using energy saving measures (Ex: sitting during showers
& ADLs, )
 Take short naps (no more than an hour at a time) during the day
 Get eight hours of sleep every night.
 Take a walk or get some other exercise every day. Some studies show that exercise helps with
tiredness during cancer treatment.
 Eat a healthy diet and drink plenty of fluids. Talk with a member of your healthcare team about
whether it would be helpful for you to eat foods that are high in protein (for example, meat,
eggs, peanut butter) or high in iron (for example, leafy green vegetables, red meat, cooked
beans).
 Keep a journal of your symptoms
MEDICATIONS:
 ERYTROPOIETIC medications→ Epoetin alfa (EPOGEN)
 Antiemetic’s medications →ferrous sulfate (feosol)
 Monitor hgb values to determine response to medications.
 Be prepared to administer blood if prescribed
Table 15-19
Oncologic Emergencies → p r i m a r i l y c a u s e d b y t u m o r o b s t r u c ti o n o f a n o r g a n o r
blood vessel

Description
Obstructive Emergencies
Superior Vena Cava Syndrome (SVCS)
• Results from obstruction of
superior vena cava by tumors or
thrombosis.
• Common causes are lung cancer,
non-Hodgkin's lymphoma, and
metastatic breast cancer.
• Presence of central venous catheter
and previous mediastinal radiation
increase risk of development.
Spinal Cord Compression
• Neurologic emergency caused by
cancer in epidural space of spinal
cord.
• Common causes are breast, lung,
prostate, GI, and renal cancers and
melanomas.
• Lymphomas can also invade
epidural space.
Third Space Syndrome 
• Shifting of fluid from vascular space
to interstitial space.
• Occurs secondary to extensive
surgical procedures,
immunotherapy, or septic shock.
Metabolic Emergencies
Manifestations
• Facial edema, periorbital edema.
• Distention of veins of head, neck,
and chest (Fig. 15-18).
• Headache, seizures.
• Mediastinal mass on chest x-ray.
• Intense, localized, and persistent
back pain accompanied by vertebral
tenderness.
• Motor weakness, sensory
paresthesia and loss.
• Autonomic dysfunction (e.g., change
in bowel or bladder function).
• Signs of hypovolemia: hypotension,
tachycardia, low central venous
pressure, decreased urine output.
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Management
• Considered a serious medical problem.
• Radiation therapy to site of
obstruction.
• Chemotherapy for tumors more
sensitive to this therapy.
• Radiation therapy and corticosteroids.
• Surgical decompressive laminectomy.
• Activity limitations and pain
management.
• Fluid, electrolyte, and plasma protein
replacement.
• During recovery hypervolemia can
occur, resulting in hypertension,
elevated central venous pressure,
weight gain, and shortness of breath.

Description
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
• Tumor cells can produce abnormal
or sustained production of
antidiuretic hormone (ADH).
• Many chemotherapy agents may
also contribute to ectopic ADH
production or potentiate ADH
effects.
Hypercalcemia
• Occurs in metastatic disease of
bone or multiple myeloma, or
when a parathyroid hormone–like
substance is secreted by cancer
cells.
• Immobility and dehydration can
contribute to or exacerbate
hypercalcemia.
Manifestations
• Water retention and hyponatremia
(hypotonic hyponatremia)
(see Chapter 49).
• Weight gain without edema,
weakness, anorexia, nausea,
vomiting, personality changes,
seizures, oliguria, decrease in
reflexes, and coma.
• Serum calcium in excess of 12 mg/dL
(3 mmol/L) often produces
symptoms.
• Apathy, depression, fatigue, muscle
weakness, ECG changes, polyuria
and nocturia, anorexia, nausea, and
vomiting.
• High calcium elevations can be life
threatening.
• Chronic hypercalcemia can result in
nephrocalcinosis and irreversible
renal failure.
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Management
• Treat underlying malignancy.
• Take measures to correct sodium-
water imbalance, including fluid
restriction, oral salt tablets or isotonic
(0.9%) saline administration, and IV
3% sodium chloride solution (severe
cases).
• Furosemide (Lasix) used in initial
phases.
• Monitor sodium level because
correcting SIADH rapidly may result in
seizures or death.
• Treat primary disease.
• Hydration (3 L/day) and
bisphosphonate therapy.
• Diuretics (particularly loop diuretics)
used to prevent heart failure or
edema.
• Infusion of bisphosphonate
zoledronate (Zometa) or pamidronate
(Aredia).

Description
Tumor Lysis Syndrome (TLS)
• Metabolic complication
characterized by rapid release of
intracellular components in
response to chemotherapy and
radiation therapy (less commonly).
• Massive cell destruction releases
intracellular components
(potassium, phosphate, DNA, RNA)
that are metabolized to uric acid by
liver.
Infiltrative Emergencies
Cardiac Tamponade
• Fluid accumulation in pericardium.
• Caused by constriction of
pericardium by tumor or
pericarditis secondary to radiation
therapy to the chest.
Carotid Artery Rupture
• Invasion of arterial wall by tumor or
erosion following surgery or
radiation therapy.
• Occurs most frequently in patients
with head and neck cancer.
Manifestations
• Hallmark signs: hyperuricemia,
hyperphosphatemia, hyperkalemia,
hypocalcemia.
• Weakness, muscle cramps, diarrhea,
nausea, and vomiting.
• Occurs within first 24 to 48 hr after
initiation of chemotherapy.
• May persist for about 5 to 7 days.
• Metabolic abnormalities and
concentrated uric acid (which
crystallizes in distal tubules of
kidneys) can lead to acute kidney
injury.
• Heavy feeling over chest, shortness
of breath, tachycardia, cough,
dysphagia, hiccups, hoarseness.
• Nausea, vomiting, excessive
perspiration.
• Decreased level of consciousness,
distant or muted heart sounds.
• Extreme anxiety.
• Bleeding: ranges from minor oozing
to spurting of blood in the case of a
“blowout” of artery.
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Management
• Identify patients at risk.
• Increase urine production using
hydration therapy.
• Decrease uric acid concentrations
using allopurinol.
• Use IV sodium bicarbonate to counter
effects of acidic properties that are
released.
• Decrease fluid around heart using (1)
surgery to create a pericardial window
or an (2) indwelling pericardial
catheter.
• Administer O2 therapy, IV hydration,
and vasopressor therapy.
• Administer IV fluids and blood
products.
• Surgery: ligation of carotid artery
above and below rupture site and
reduction of local tumor.
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Table 15-5: TNM Classification System

Primary Tumor (T)

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1-4 Ascending degrees of increase in tumor size and involvement

Tx Tumor cannot be measured or found

Regional Lymph Nodes (N)

N0 No evidence of disease in lymph nodes

N1-4 Ascending degrees of nodal involvement

Nx Regional lymph nodes unable to be assessed clinically

Distant Metastases (M)

M0 No evidence of distant metastases

M1-4 Ascending degrees of metastatic involvement, including distant nodes

Mx Cannot be determined

Prevention and Early Detection of Cancer

Early detection and prompt treatment are responsible for increased survival rates in patients with
cancer. Colonoscopy is important in reducing colon cancer mortality both by early detection of colon
cancers and by prevention (e.g., excision of adenomatous polyps).

Teach patients and the public about cancer prevention and early detection, including the following:
• ↓ or avoid exposure to known or suspected carcinogens and cancer-promoting agents, including
cigarette smoke, tanning beds, and sun exposure.
• Eat a balanced diet that includes vegetables and fresh fruits (whole grains, and adequate amounts of
fiber. Reduce dietary fat and preservatives, including smoked and salt-cured meats containing high
nitrite concentrations.
• Limit alcohol intake.
• Participate in regular exercise (i.e., 30 minutes or more of moderate physical activity five times
weekly).
• Maintain a healthy weight.
• Obtain adequate, consistent periods of rest (at least 6 to 8 hours per night).
• Eliminate, reduce, or change the perception of stressors and enhance the ability to effectively cope
with stressors).
• Have a regular physical examination that includes a health history. Be familiar with your own family
history and your risk factors for cancer.
• Learn and follow the American Cancer Society's recommended cancer screening guidelines for breast,
colon, cervical, and prostate cancer.
• Learn and practice self-examination (e.g., breast or testicular self-examination).
 16

• Know the seven warning signs of cancer, and inform the health care provider if they are present
(These actually detect fairly advanced disease.)
Table 15-6
Seven Warning Signs of Cancer
Change in bowel or bladder habits
A sore that does not heal
Unusual bleeding or discharge from any body orifice (opening)
Thickening or a lump in the breast or elsewhere
Indigestion or difficulty in swallowing
Obvious change in a wart or mole
Nagging cough or hoarseness
 Seek immediate medical care if you notice a change in what is normal for you and if cancer is suspected.

The goals of public education:

(1) Motivate people to recognize and modify behaviors that may negatively affect health
(2) Encourage awareness of and participation in health-promoting behaviors. When you teach about
cancer, try to minimize the fear that surrounds the diagnosis.

Prevention and Early Detection of Cancer

• Limit alcohol use.
• Get regular physical activity.
• Maintain a normal body weight.
• Obtain regular colorectal screenings.
• Avoid cigarette smoking and other tobacco use.
• Get regular mammography screening and Pap tests.
• Use sunscreen with a sun protection factor of 15 or higher.
• Practice healthy dietary habits, such as reducing fat consumption, avoiding processed meats, and
increasing fruit and vegetable consumption.
ONCOFETAL ANTIGENS:
• Tumor markers (e.g., CEA, AFP, PSA, CA-125)
 CA 15-3 → BREAST CANCER
 CA- 19-9 → PANCREATIC & Gallbladder cancer
 CA-125→ OVARIAN CANCER
 PSA → prostate cancer
 KRAS → colon cancer (Kola )
 EGRF → Lung cancer
Carcinoembryonic antigen (CEA):
Cancer cells of GI
Normal cells (fetal, gut, liver, pancreas)
@-fetoprotein (AFP) → LIVER CANCER
• Genetic markers (e.g., BRCA1, BRCA2) BRCA1 →breast: BRCA2 → OVARIAN
 17

GRIEF:
Table 9-4
Kübler-Ross Model of Grief
What Person
Stage Characteristics
May Say

Denial No, not me. It Denies the loss has taken place and may withdraw. This response may last minutes
cannot be to months.
true.

Anger Why me? May be angry at the person who inflicted the hurt (even after death) or at the world
for letting it happen. May be angry with self for letting an event (e.g., car accident)
take place, even if nothing could have stopped it.

Bargaining Yes me, but … May make bargains with God, asking, “If I do this, will you take away the loss?”

Depression Yes me, and I Feels numb, although anger and sadness may remain underneath
am sad.

Acceptance Yes me, but it Anger, sadness, and mourning have tapered off. Accepts the reality of the loss
is okay.

Grief of wheel:
1. Shock: (numbness, denial, inability to think straight).
2. Protest stage: anger, guilt, sadness, fear, and searching.
3. Disorganization stage: in which a person feels despair, apathy, anxiety, and confusion.
4. Reorganization: a person gradually returns to normal functioning, but he or she feels different.
5. New normal: the normal state is not the same as before. The challenge is to accept the new
normal. Trying to go back to the “old” normal (which is not there anymore) is what causes a
great deal of anxiety and stress.
Task of mourning:
 18

TYPES OF LOSS:
Necessary loss: Part of the cycle of life; anticipated, but can still be intensely felt
 Loss of a boyfriend
Actual loss: Any loss of a valued person or item
 Death of family, loss of limb/pet
Perceived loss: Any loss defined by a client that is not obvious to others
Maturational loss: Losses normally expected due to the developmental processing of life
 Child Going to college, kindergarten , marriage
Situational loss: Unanticipated loss caused by an external event
 Car accident

TYPES OF GRIEF
Normal grief:
 Anger, resentment, withdrawal, hopelessness/guilt, confusion, inability
to concentrate, insomnia
 Acceptance by 6 months after loss
 Somatic s/s: chest pain, Nausea, fatigue, palpitation=anxiety, sleepless
Anticipatory grief:
 “letting go” before the loss, expresses relief
Disenfranchised grief:
 Grief experienced through from loss of loved one through “suicide”
Dysfunction grief:
 Wailing at bedside, totally exaggerated, grief prolonged =depression

Communication:
• Determine what the client and family know
• Determine if there is a family spokesman
• Identify cultural and religious beliefs
– Consider personal space issues, eye contact, touch
• Obtain an interpreter
• Allow opportunity for informed choices
• Assist w/decision-making
– Problem-solving
– Avoid personal views/opinions
• Encourage expressions of feelings, concerns, fears
• Be honest
• Ask client/family about expectations
• Be a sensitive listener
• Extend touch if appropriate
• Encourage reminiscing
 19

• Seek assistance
• Acknowledge own feelings
• Realize it is acceptable to cry w/client/family during grief process

Stillborn: (2)
 Family might need time alone with baby
 Comfort in looking at, touching, & talking to the baby
 Bathe and dress baby
 Take photos
 Make and imprint of handprints &/or footprints
 Cut a lock of hair
 Read a story or sign a lullaby
 Record the measurements
 Name the baby
 Have baby christened or blessed
Help for family:
• Mixed emotions
• May desire safety and security of home or may have anger and sadness
• Supportive family members can help
– Perhaps move baby items to another room
• Be honest with children & explain what has happened
• Suggest that one family member be the spokesman in sharing the news about the birth, funeral
arrangements, and coordinating help.
Grieve:
 Share feelings
 Join a support group
 Write in a journal
 Make something for baby
 Healing will take time, and the goal is for families to accept the loss, but not forget the child.
Normal: resentment, withdraw from others, changes in sleep
INTERVENTIONS for grieving parents:
BABYS RIGHT:
 Be recognized → born & died
 Be named
 Be seen, touched, and helped by fam
 Have life ending acknowledgement
 Be put to rest w/dignity
Post-partum after loss:
At risk within 4 weeks
Antidepressants 4-6 week’s → hormone therapy
 20

Amputation: (2)
Intervention:
 Modify ADLS
 PAIN management
 Assistive devices are met
 Engage in participate
 Open ended question
 Interact w/positive statement
Terminal illness:

END OF LIFE: (9)
Table 9-6
Common Documents Used in End-of-Life Care
Document
Advance directive
Allow Natural Death (AND)
Directive to physicians (DTP)
Do not resuscitate (DNR)
Power of attorney for health
care (POAH)
Living will
Medical power of attorney
(MPOA)
21
Description Special Considerations
• Should comply with guidelines established by
state of residence
General term used to describe documents that give
instructions about future medical care and
treatments and who should make the decisions in
the event the person is unable to communicate
• In many settings may be used in conjunction
with DNR terminology to ensure
Written order acknowledging that comfort measures only patient/family wishes for advance directives
are being provided to patient. Used in many are followed (DNR/AND)
palliative care and hospice settings to indicate that
patient wants to die naturally with dignity and
comfort
• Indicates specific measures to be used or
withheld
Written document specifying the patient's wish to be
allowed to die without heroic or extraordinary
measures
• Must indicate any specific measures to be
used or withheld. Must be signed by a
Written physician's order instructing HCPs not to attempt physician to be valid
CPR. DNR order often requested by family
• May be the same as medical power of
attorney
Term used by some states to describe a document used • Indicates specific measures to be used or
for listing the person(s) to make health care withheld
decisions should a patient become unable to make
informed decisions for self
• Must identify specific treatments that a
person wants or does not want at end of life
Lay term used to describe any documents that give
instructions about future medical care and
treatments or the wish to be allowed to die without
heroic or extraordinary measures should the patient
be unable to communicate for self
• May be the same as durable power of
attorney for health care, health care proxy,
Term used by some states to describe a document used or appointment of a health care agent or
for listing the person(s) to make health care surrogate. Specifies measures to be used or
decisions should a patient become unable to make withheld
 22

Document Description Special Considerations

• Person appointed may be called a health care

agent, surrogate, attorney-in-fact, or proxy.
informed decisions for self

• Only for those whose illness may limit life to

less than 12 months
Physician Order for Life- A standardized physician order guided by the patient's • Guides current treatments. Differs from
Sustaining Treatment medical condition and based upon personal advance directive, which guides future
(POLST) or Medical Order preferences verbalized by patient or expressed in treatments
for Life-Sustaining advance directive • Physician completes form based on discussion
Treatment (MOLST) with patient or authorized representative, or
in review of advance directive. Signed by
physician, patient, or patient representative
• Printed on bright pink paper

Table 9-2: Physical Manifestations at End of Life

System Manifestations

Sensory system

Hearing • Usually last sense to disappear

Touch • Decreased sensation

• Decreased perception of pain and touch

Taste and smell • Decreased with disease progression

Sight • Blurring of vision

• Sinking and glazing of eyes
• Blink reflex absent
• Eyelids remain half-open

Cardiovascular • Increased heart rate; later slowing and weakening of pulse

system • Irregular rhythm
• Decreased BP
• Delayed absorption of drugs administered IM or subcutaneously

Respiratory system • Increased respiratory rate

• Cheyne-Stokes respiration (pattern of respiration characterized by alternating periods of
apnea and deep, rapid breathing)
• Inability to cough or clear secretions resulting in grunting, gurgling, or noisy congested
breathing (death rattle or terminal secretions)
• Irregular breathing, gradually slowing down to terminal gasps (may be described as guppy
breathing)

Urinary system • Gradual decrease in urine output

• Incontinence of urine
• Inability to urinate

Gastrointestinal • Slowing or cessation of GI function (may be enhanced by pain-relieving drugs)

system • Accumulation of gas
 23

System Manifestations

• Distention and nausea

• Loss of sphincter control, producing incontinence
• Bowel movement before imminent death or at time of death

Musculoskeletal • Gradual loss of ability to move

system • Sagging of jaw resulting from loss of facial muscle tone
• Difficulty speaking
• Swallowing becoming more difficult
• Difficulty maintaining body posture and alignment
• Loss of gag reflex
• Jerking seen in patients on high doses of opioids

Integumentary • Mottling on hands, feet, arms, and legs

system • Cold, clammy skin
• Cyanosis of nose, nail beds, knees
• “Waxlike” skin when very near death

Table 9-3

Psychosocial Manifestations at End of Life

• Altered decision making
• Anxiety about unfinished business
• Decreased socialization
• Fear of loneliness
• Fear of meaninglessness of one's life
• Fear of pain
• Helplessness
• Life review
• Peacefulness
• Restlessness
• Saying goodbyes
• Unusual communication
• Vision-like experiences
• Withdrawal

Box 37-8 Potter

Physical Changes Hours or Days before Death
• Increased periods of sleeping/unresponsiveness
• Coolness and color changes in extremities, nose, fingers (cyanosis, pallor, mottling)
• Bowel or bladder incontinence
• Decreased urine output; dark-colored urine
• Restlessness, confusion, or disorientation
• Decreased intake of food or fluids; inability to swallow
• Congestion/increased pulmonary secretions; noisy respirations (death rattle)
• Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern)

• Decreased muscle tone, relaxed jaw muscles, sagging mouth
• Weakness and fatigue
Table 9-8
Nursing Management
Characteristic
Pain
• Pain may be a major symptom associated with terminal
illness and the one most feared.
• Pain can be acute or chronic.
• Bone pain can be caused by metastases, fractures, arthritis,
immobility.
• Physical and emotional stressors can aggravate pain.
Delirium
• A state characterized by confusion, disorientation,
restlessness, clouding of consciousness, incoherence, fear,
anxiety, excitement, and often hallucinations
• May be misidentified as depression, psychosis, anger, or
anxiety
• Use of opioids or corticosteroids as well as their withdrawal
may cause delirium.
• Underlying disease process may contribute to delirium.
• Generally considered a reversible process
Anxiety/Restlessness
• May occur as death approaches and cerebral metabolism
slows
• May occur with tachypnea, dyspnea, sweating
24
Nursing Management
• Assess pain thoroughly and regularly to determine the quality,
intensity, location, and contributing and alleviating factors.
• Minimize possible irritants such as skin irritations from wetness,
heat or cold, and pressure.
• Administer medications around the clock in a timely manner and on
a regular basis to provide constant relief rather than waiting until
the pain is unbearable and then trying to relieve it.
• Provide complementary and alternative therapies such as guided
imagery, massage, and relaxation techniques as needed
• Evaluate effectiveness of pain relief measures frequently to ensure
that the patient is on a correct, adequate drug regimen.
• Do not delay or deny pain relief measures to a terminally ill patient.
• Perform a thorough assessment for reversible causes of delirium,
including pain, constipation, and urinary retention.
• Provide a room that is quiet, well lit, and familiar to reduce the
effects of delirium.
• Reorient the dying person to person, place, and time with each
encounter.
• Administer ordered benzodiazepines and sedatives as needed.
• Stay physically close to frightened patient. Reassure in a calm, soft
voice with touch and slow strokes of the skin.
• Provide family with emotional support and encouragement in their
efforts to cope with the behaviors associated with delirium.
• Assess for previous anxiety disorder.
• Assess for spiritual distress and/or concerns related to death as
causes of restlessness and agitation.
• Assess for urinary retention and stool impaction.
• Do not restrain.
• Use soothing music; slow, soft touch and voice.
• Limit the number of persons at the bedside.
 25

Characteristic Nursing Management

Dysphagia

• May occur because of extreme weakness and changes in
level of consciousness
• Difficulty swallowing
• Aspiration of liquids and/or solids
• Drooling/inability to swallow secretions
• Identify the least invasive alternative routes of administration for
drugs needed for symptom management.
• Suction orally as needed.
• Modify diet as tolerated/desired (soft, pureed, chopped meats).
• Hand feed small meals.
• Head elevated for meals and at least 30 minutes after
• If necessary use alternative (rectal, buccal, transdermal) medication
routes.
• Discontinue nonessential medications.
• Discuss risk of aspiration.

Weakness and Fatigue

• Expected at the end of life • Assess the patient's tolerance for activities.
• Metabolic demands related to disease process contribute to • Time nursing interventions to conserve energy.
weakness and fatigue. • Help the patient identify and complete valued or desired activities.
• Provide support as needed to maintain positions in bed or chair.
• Provide frequent rest periods.

Dehydration

• May occur during the last days of life
• Hunger and thirst are rare in the last days of life.
• As the end of life approaches, patients tend to take in less
food and fluid.
• Assess mucous membranes frequently for dryness, which can lead
to discomfort.
• Maintain complete, regular oral care to provide for comfort and
hydration of mucous membranes.
• Encourage consumption of ice chips and sips of fluids or use moist
cloths to provide moisture to the mouth.
• Use moist cloths and swabs for unconscious patients to avoid
aspiration.
• Apply lubricant to the lips and oral mucous membranes as needed.
• Do not force the patient to eat or drink.
• Teach family that hunger and thirst are rare in the last days of life.
• Reassure family that cessation of food and fluid intake is a natural
part of the process of dying.

Dyspnea

• Subjective symptom • Assess respiratory status regularly.

• Accompanied by fear of suffocation and anxiety
• Underlying disease process can exacerbate dyspnea.
• Coughing and expectorating secretions become difficult.
• Elevate the head and/or position patient on side to improve chest
expansion.
• Use a fan or air conditioner to facilitate movement of cool air.
• Teach and encourage the use of pursed-lip breathing.
• Administer supplemental oxygen as ordered.
• Suction PRN to remove accumulation of mucus from the airways.

Characteristic
Myoclonus
• Mild to severe jerking or twitching sometimes associated
with use of high dose of opioids.
• Patient may complain of involuntary twitching of
extremities.
Skin Breakdown
• Skin integrity is difficult to maintain at the end of life.
• Immobility, urinary and bowel incontinence, dry skin,
nutritional deficits, anemia, friction, and shearing forces
lead to a high risk for skin breakdown.
• Disease and other processes may impair skin integrity.
• As death approaches, circulation to the extremities decreases
and they become cool, mottled, and cyanotic.
Bowel Patterns
• Constipation can be caused by immobility, use of opioid
medications, depression, lack of fiber in the diet, and
dehydration.
• Diarrhea may occur as muscles relax or from a fecal
impaction related to the use of opioids and immobility.
Urinary Incontinence
• May result from disease progression or changes in the level
of consciousness.
• As death becomes imminent, the perineal muscles relax.
26
Nursing Management
Suction cautiously in the terminal phase.
• Administer expectorant as ordered.
• Assess for initial onset, duration, and any discomfort or distress
experienced by patient.
• If myoclonus is distressing or becoming more severe, discuss
possible drug therapy modifications with the HCP.
• Changes in opioid medication may alleviate or decrease myoclonus.
• Assess skin for signs of breakdown.
• Implement protocols to prevent skin breakdown by controlling
drainage and odor and keeping the skin and any wound areas
clean.
• Perform wound assessments as needed.
• Follow appropriate nursing management protocol for dressing
wounds.
• Follow appropriate nursing management protocol for a patient who
is immobile, but consider realistic outcomes of skin integrity vs.
maintenance of comfort.
• Follow appropriate nursing management to prevent skin irritations
and breakdown from urinary and bowel incontinence.
• Use blankets to cover for warmth. Never apply heat.
• Prevent the effects of shearing forces.
• Assess bowel function.
• Assess for and remove fecal impactions.
• Encourage movement and physical activities as tolerated.
• Encourage fiber in the diet if appropriate.
• Encourage fluids if appropriate.
• Use suppositories, stool softeners, laxatives, or enemas if ordered.
• Assess for confusion, agitation, restlessness and pain, which may
be signs of constipation.
• Assess urinary function.
• Use absorbent pads for urinary incontinence.
• Follow appropriate nursing protocol for the consideration and use
of indwelling or external catheters.
• Follow appropriate nursing management to prevent skin irritations
 27

Characteristic Nursing Management

and breakdown from urinary incontinence.

Anorexia, Nausea, and Vomiting

• May be caused by complications of disease process
• Drugs contribute to nausea.
• Constipation, impaction, and bowel obstruction can cause
anorexia, nausea, and vomiting.
• Assess the patient for complaints of nausea or vomiting.
• Assess possible contributing causes of nausea or vomiting.
• Have family provide the patient's favorite foods.
• Discuss modifications to the drug regimen with the HCP.
• Provide antiemetics before meals if ordered.
• Offer and provide frequent meals with small portions of favorite
foods.
• Offer culturally appropriate foods.
• Provide frequent mouth care, especially after vomiting.
• Ensure uninterrupted mealtimes.
• If ordered, administer medications (e.g., megestrol, corticosteroids)
to increase appetite.
• Teach family that appetite naturally decreases at end of life.

Candidiasis

• White, cottage-cheese–like oral plaques • If ordered, administer oral antifungal nystatin.
• Fungal overgrowth in the mouth due to chemotherapy and/or • Clean dentures and other dental appliances to prevent reinfection.
immunosuppression • Provide oral hygiene and use soft toothbrush.

Box 37-10 (POTTER)

Cultural Aspects of Care

Care of the Body after Death

 One's culture greatly influences which behaviors and rituals are expected at the time of death.
 Institutional guidelines and end-of-life care procedure from all cultures provide standards:
compassion, maintaining privacy and dignity, and respect for patients' and family members' cultural
beliefs and practices.
 Allow time for patients and their families to make private and public preparations and complete
unfinished communication.
 Understanding the uniqueness of cultural expectations at the end of life helps a nurse know which
questions to ask.

BOX 37-10 POTTER

 28

Implications for Patient-Centered Care

African-American: Care of the body after death depends on the African-American's country of origin and degree of
American acculturation. The presence of large extended family groups, including the church family, is common at time
of death. The mourning period is relatively short, with a memorial service and a public viewing of the body or a wake
before burial. Organ donation and autopsy are allowed.
Chinese: Death is regarded as a negative life event, and there is no concept of an afterlife. The dead are treated with the
same respect as the living and may be buried with food and other artifacts. Members of an extended family usually stay
with the deceased for up to 8 hours after death. The oldest son or daughter bathes the body under direction of an older
relative or a temple priest. They often believe the body should remain intact; thus organ donation and autopsy are
uncommon
Hispanic or Latino: Honoring family values and roles is essential in providing care and making decisions at the end of
life. People in Hispanic and Mexican-American cultures often use special objects such as amulets or rosary beads,
alternative healing practices (folk medicine), and prayer. Grief is expressed openly. Religious and spiritual rituals
(predominantly Catholic) are essential at the end of life. Death is often believed to be the will of God

Native American: Native Americans encompass diverse tribal groups with differing practices, traditions, and
ceremonies. Traditional Navajos do not touch the body after death. Care of the body in the large Navajo tribe includes
cleansing the body, painting the deceased's face, dressing in clothing, and attaching an eagle feather to symbolize a
return home. Mourners also have a ritual cleansing of their bodies. The dead are buried on the deceased's homeland (

Islamic: The deceased's body is ritualistically washed, wrapped, cried over, prayed for, and buried as soon as possible
after death. The eyes and mouth are closed, and the face of the deceased is turned toward Mecca. Muslims of the same
gender prepare the body for burial. Bodies are buried, not cremated. Autopsies interfere with a quick burial; make
autopsy requests with sensitivity and only if necessary. The proximity of loved ones after death is important since it is
believed that the soul stays with the body until it is buried. Organ donation is permissible by some Qur'an
interpretations
Buddhist: Buddhists believe in an afterlife in which humans manifest in different forms. Death is preferred at home, and
a person's state at the time of death is important. Individuals usually minimize emotional expressions and maintain a
peaceful, compassionate atmosphere. Male family members prepare the body. Buddhists recommend not touching the
body after death to give the deceased a smoother transition to the afterlife. People often say prayers while touching and
standing at the head of the deceased. The body is not left alone after death. Family and friends pay respects after death
and before cremation of the body
Hindu: The body is placed on the floor with the head facing north. People of the same gender handle the body after death.
There are no general prohibitions against autopsy. Bodies are cremated after death to purify by fire Jewish: If the
family practices Orthodox Judaism, determine if members from the Jewish Burial Society are coming to the facility
before preparing the body. A family member often stays with the body until burial. Usually the burial occurs within 24
hours but not on the Sabbath. Some but not all types of Judaism avoid cremation, autopsy, and embalming

LEGAL/ETHICAL ISSUES:

 Organ/tissue donations
 Advance directives
 Resuscitation
 Mechanical ventilation
 Feeding tube placement

Persistent vegetative state (PVS): (1)

A persistent vegetative state (PVS) is a disorder of consciousness in which
patients with severe brain damage are in a state of partial arousal rather
than true awareness. After four weeks in a vegetative state (VS), the
patient is classified as in a persistent vegetative state
Amyotrophic Lateral Sclerosis: (ALS) → Chronic
disease ending in death
 29

 Amyotrophic lateral sclerosis (ALS) is a rare progressive neuromuscular disorder characterized by

loss of motor neurons.
 known as Lou Gehrig's disease 
 The typical onset: 55 and 75 years of age.
 ALS is more common in men than women by a ratio of 2: 1.
 In ALS, motor neurons in the brainstem and spinal cord gradually degenerate for unknown reasons.
Dead motor neurons cannot produce or transport signals to muscles. Consequently, electrical and
chemical messages originating in the brain do not reach the muscles to activate them.
 Progressive muscle weakness, a classic sign of ALS:
Symptoms:
 Weaknesses vary: → tripping, dropping things, abnormal fatigue of the extremities, slurred
speech, and muscle cramps and twitches.
 Muscle wasting and fasciculation= denervation of the muscles and lack of stimulation and use.
Other symptoms include:
 Pain, sleep disorders, spasticity and hyperreflexia, drooling, emotional lability, constipation, and
esophageal reflux.
 ALS does not affect a patient's intelligence, but affected people may experience depression and
have alterations in decision making and memory.
 Death often results from respiratory tract infection secondary to compromised respiratory
function.
Nursing interventions:
(1) Facilitating communication
(2) Reducing risk of aspiration
(3) Facilitating early identification of respiratory insufficiency,
(4) Decreasing pain secondary to muscle weakness
(5) Decreasing risk of injury related to falls
(6) Providing diversional activities such as reading and companionship.
 Support the patient's cognitive and emotional functions. Help the patient and family manage the
disease process, including grieving related to the loss of motor function and ultimately death
 Discuss advance directives and artificial methods of ventilation with the patient and caregiver.

Pancreatic Cancer/Hospice palliative care)(7)

Pancreatic Cancer
 65 and 80 years of age.
 The signs and symptoms of pancreatic cancer are often similar to those of chronic pancreatitis.
 The prognosis of a patient with cancer of the pancreas is poor. The majority of patients die within 5 to 12
months of the initial diagnosis, and the 5-year survival rate is less than 5%.
33

Etiology and Pathophysiology

The cause unknown
Risk factors:
 30

 Chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic
cancer, high-fat diet, and exposure to chemicals such as benzidine.
 African Americans have a higher incidence of pancreatic cancer than whites.
 The most firmly established environmental risk factor is cigarette smoking
Clinical Manifestations
 Abdominal pain (dull, aching) Pain is frequently located in the upper abdomen to back,
occurs at night.
 Anorexia, rapid and progressive weight loss, nausea → Weight loss is due to poor digestion
and absorption caused by lack of digestive enzymes from the pancreas.
 jaundice ↔ pruritus

 Diagnostic Studies

 Abdominal ultrasound or endoscopic ultrasound (EUS), spiral CT scan, ERCP, MRI, and
 Tumor markers are used both for establishing the diagnosis of pancreatic
adenocarcinoma and for monitoring the response to treatment.
 Cancer-associated antigen 19-9 (CA 19-9) is ↑
 CA 19-9 can also be ↑ in gallbladder cancer or in benign conditions such as acute and
chronic pancreatitis, hepatitis, and biliary obstruction.

Interprofessional Care
 Surgery provides the most effective treatment
 Neoadjuvant chemotherapy → whipple
 Radiation therapy alone has little effect on survival but may be effective for pain relief. External
radiation is typically used, but implantation of internal radiation seeds into the tumor

Nursing Management:
 Comfort measures to relieve pain.
 Psychologic support is essential, especially during times of anxiety or depression.
 Adequate nutrition
 Frequent and supplemental feedings may be necessary.
 Include measures to stimulate the appetite as much as possible and to manage anorexia, nausea,
and vomiting.
 Radiation therapy: observe for adverse reactions such as anorexia, nausea, vomiting, and skin
irritation.
 The prognosis for a patient with pancreatic cancer is poor.
 A significant component of the nursing care is helping the patient and caregiver cope with the
diagnosis and prognosis. 

Palliative/Hospice Care
Goals:
 Provide comfort/support care
 Improve quality of remaining life
 Ensure death w/dignity
 Emotional support for family
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Palliative care: comfort/improve quality of care.

Principles of palliative care
 Affirms life and regards dying as a normal process.
 Neither hastens nor postpones death.
 Provides relief from pain and other distressing symptoms.
 Integrates the psychological and spiritual aspects of care.
 Offers a support system to help patients live as actively as possible until death.

Hospice care:
 Two Physician determines a person has 6 months or less to live
 Patient must agree in writing that only hospice care/not curative care used to treat terminal
illness.
 Can withdraw at any time
 Symptom management
 Advance care planning
 Spiritual care
 Family support
 Palliative, not curative care
 Quality, not quantity of life
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Table 9-2

Physical Manifestations at End of Life

System Manifestations

Sensory system

• Usually last sense to disappear

Hearing

• Decreased sensation
• Decreased perception of pain and touch
Touch

• Decreased with disease progression

Taste and smell

• Blurring of vision
• Sinking and glazing of eyes
Sight • Blink reflex absent
• Eyelids remain half-open

• Increased heart rate; later slowing and weakening of pulse

• Irregular rhythm
Cardiovascular system • Decreased BP
• Delayed absorption of drugs administered IM or subcutaneously

• Increased respiratory rate

• Cheyne-Stokes respiration (pattern of respiration characterized by alternating periods of apnea and deep,
Respiratory system rapid breathing)
• Inability to cough or clear secretions resulting in grunting, gurgling, or noisy congested breathing (death rattle
or terminal secretions)
• Irregular breathing, gradually slowing down to terminal gasps (may be described as guppy breathing)

• Gradual decrease in urine output

• Incontinence of urine
Urinary system • Inability to urinate

• Slowing or cessation of GI function (may be enhanced by pain-relieving drugs)

• Accumulation of gas
Gastrointestinal • Distention and nausea
system • Loss of sphincter control, producing incontinence
• Bowel movement before imminent death or at time of death

• Gradual loss of ability to move

• Sagging of jaw resulting from loss of facial muscle tone
Musculoskeletal • Difficulty speaking
 33

System Manifestations

• Swallowing becoming more difficult

• Difficulty maintaining body posture and alignment
system • Loss of gag reflex
• Jerking seen in patients on high doses of opioids

• Mottling on hands, feet, arms, and legs

• Cold, clammy skin
Integumentary • Cyanosis of nose, nail beds, knees
system • “Waxlike” skin when very near death

Psychosocial Manifestations at End of Life

A variety of feelings and emotions can affect the dying patient and family at the end of life Most patients
and families struggle with a terminal diagnosis and the realization that there is no cure. The patient and
family may feel overwhelmed, fearful, powerless, and fatigued. The family's response depends in part on
the type and length of the illness and their relationship with the person .

Table 9-3

P s y c h o s o c i a l M a n i f e s t a ti o n s a t E n d o f L i f e
• Altered decision making
• Anxiety about unfinished business
• Decreased socialization
• Fear of loneliness
• Fear of meaninglessness of one's life
• Fear of pain
• Helplessness
• Life review
• Peacefulness
• Restlessness
• Saying goodbyes
• Unusual communication
• Vision-like experiences
• Withdrawal
 34

Table 9-7

Nursing Management
Psychosocial Care at End of Life

Characteristic Nursing Management

Withdrawal

Patient near death may seem withdrawn from the physical environment, Converse as though the patient were alert, using a
maintaining the ability to hear but unable to respond. soft voice and gentle touch.

Unusual Communication

This may indicate that an unresolved issue is preventing the dying person from Encourage the family to talk with and reassure the
letting go. Patient may become restless and agitated or perform repetitive dying person.
tasks (may also indicate terminal delirium).

Vision-Like Experiences

Patient may talk to persons who are not there or see places and objects not visible. Affirm the dying person's experience as a part of
Vision-like experiences assist the dying person in coming to terms with transition from this life.
meaning in life and transition from it.

Saying Goodbyes

Encourage the dying person and family to verbalize

their feelings of sadness, loss, forgiveness and
It is important for the patient and family to acknowledge their sadness, mutually to touch, hug, cry.
forgive one another, and say goodbye. Allow the patient and family privacy to express their
feelings and comfort one another.
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Characteristic Nursing Management

Spiritual Needs

Assess spiritual needs. Allow patient to express his

or her spiritual needs.
Patient or family may request spiritual support, such as the presence of a chaplain. Encourage visit by appropriate spiritual care service
provider, chaplain, or family member.

Anxiety and Depression

 Anxiety is an uneasy feeling whose cause is not easily identified. Anxiety r/t fear
 Encouragement, support, and teaching decrease some of the anxiety and depression.
 Management: Relaxation strategies such as relaxation breathing, muscle relaxation, music, and imagery may be useful
Anger: (normal response to grief) → angry with the dying loved one who is leaving them
Hopelessness and Powerlessness → common in EOL
 Encourage realistic hope within the limits of the situation.
 Allow the patient and family to deal with what is within their control, and help them to recognize what is beyond
their control.
 When possible, support the patient's involvement in decision making about care to foster a sense of control and
autonomy.
FEAR:
Fear of pain
 Pain-relieving drugs available
 Assure the patient and family that drugs will be given promptly when needed and that side effects of drugs can and
will be managed.
 Reassessment of pain after medications Fear of shortness of breath. Respiratory distress and dyspnea are common
near the end of life. The sensation of air hunger =anxiety for the patient and family. Current therapies include opioids,
bronchodilators, and oxygen, depending on the cause of the dyspnea.
 Anxiety-reducing agents (e.g., anxiolytics) may help produce relaxation.
Fear of loneliness and abandonment
 Dying pt does not want to be alone
 Afraid to be abandon by family who are unable to cope

 Hold hands, touching & listening, provide companionship= sense of security

Fear of meaninglessness.
 Fear of meaninglessness leads people to review their lives.
 They review their intentions during life, examining actions and expressing regrets about what might have been. Life
review helps patients recognize the value of their lives.
 Assist patients and their families in identifying the positive qualities of the patient's life. →
Photo albums or collections of important mementos
 Sharing thoughts and feelings may enhance spirituality and provide comfort
 Respect and accept the practices and rituals associated with the patient's life review → nonjudgmental