Other psychological problems encountered in people with cancer

Acute confusion or delirium is an acute brain syndrome, which may be transient and reversible. Key features are a clouding of consciousness and difficulty registering or making sense of new information. Nursing management includes managing confused thoughts by keeping communication clear, brief, and to the point, encouraging correct orientation, responding to distress, listening to the patient’s concerns, and ensuring the safety of the patient. Psychoses are disorders of thought, feeling, and perception that lead to difficulties relating to self, other people, and the world at large. They are rarely encountered in the cancer care setting, but they are distressing and difficult to manage when they are. It is important to engage the patient and maintain a safe environment. Incidents of violence and aggression are relatively uncommon, but distressing. It is important to identify the causes, e.g. frustration, fear, or confusion, and to respond to the person, but set limits and ensure safety. Alcohol misuse is associated with many health problems. Nurses should recognize the effects of hazardous drinking and alcohol dependence, and advise the patient on sources of support.

Nausea and vomiting

Nausea and vomiting are common and distressing symptoms of cancer and its treatments. Treatment-related nausea and vomiting are covered in depth, including pre-treatment assessment, the emetogenic level of chemotherapy drugs, and pharmacological management of chemotherapy-induced nausea and vomiting. An evidence-based treatment algorithm is described, covering the wide range of possible anti-emetics. Non-pharmacological options are also described. There is also a section on anticipatory nausea and vomiting. Nausea and vomiting in advanced cancer are covered separately. The multifactorial nature of this is discussed, with a focus on different anti-emetic regimes, as well as nursing management, including detailed assessment and ongoing nutritional and psychological support.

Cancer-related breathlessness

This chapter addresses the link between cancer and breathlessness by first considering dyspnoea caused directly by malignancy (such as airway obstruction), dyspnoea indirectly caused by malignancy (e.g. pulmonary embolus), and dyspnoea caused by treatment (e.g. radiation pneumonitis). Reference is made to the complex nature of breathlessness in this setting, with clear links to physiological and psychological factors. Methodologies for diagnosing and assessing breathlessness are considered, before discussing the management and treatment of this distressing symptom. Treatment strategies are divided into non-pharmacological, such as positioning and relaxation techniques and modifications, and pharmacological interventions such as use of low-dose opiates.

Altered bowel function

This chapter explores the three most common bowel-related issues that cancer patients often face: diarrhoea, constipation, and bowel obstruction. Cancer-related causes of diarrhoea are discussed, including new cancer drug therapies. Assessment and management of diarrhoea are explored in detail, with a focus on reversible causes and pharmacological and non-pharmacological management. Constipation is explored in similar detail. Management includes dietary advice, use of laxatives, and non-pharmacological measures. Bowel obstruction is discussed, focusing on early identification of symptoms and a look at both surgical and medical management options, including management of associated symptoms.

Thrombosis

This chapter covers the aetiology, signs and symptoms, diagnosis, and treatment of venous thromboembolism (VTE). Common risk factors are described, including certain cancers such as pancreatic and lung cancers, metastatic disease, various cancer treatments, and central venous catheters. Treatment of VTE is discussed, including low-molecular-weight heparin and warfarin. New oral anticoagulants are briefly mentioned, and there is an overview of nursing care for patients with VTE.

Assessment

Assessment is one of the most complex nursing activities. It involves interpersonal and communication skills and decision-making skills. The purpose of assessment can be related to the diagnosis of specific conditions; however, assessment is often focused on the assessment of needs or health-related goals. The context and timing of assessment are important. Assessment as a process involves both non-verbal observation and verbal exchange of information, or conversation. Holistic needs assessment and care planning are an important aspect of care, particularly as patients rebuild their lives after treatment. In assessment, it is necessary to achieve a balance between objective evaluation of the patient’s problems and their subjective experience of illness or symptoms. Among the many assessment tools available, Patient-Reported Outcome Measures (PROMs) measure outcomes of treatment or care, as they are reported by the patients themselves, and may assess health needs, monitor patient progress, or evaluate services. Quality of life (QoL) is a key element of assessment. It is a complex, multifactoral concept in the context of cancer and involves the individual’s appraisal of their position in life, relative to their expectations. It includes physical (symptoms such as fatigue, pain, and side effects of treatment), functional (activities of living, including eating, sleeping, and washing), emotional (positive and negative emotional reactions to cancer), social (social support, family relationships, and sexuality), and spiritual (sense of meaning and purpose in life, faith) well-being.

Lung cancer

This chapter covers the management of non-small cell lung cancer, small cell lung cancer, and mesothelioma. It covers the epidemiology and aetiology of each specific cancer. Common presenting signs and symptoms are described, as well as the normal investigative pathway. Management of the different stages of non-small cell and small cell lung cancer are covered, including surgery, chemotherapy, and radiotherapy, and for non-small cell lung cancer the targeted therapies. The section on mesothelioma looks at the aetiology, in particular the occupational and environmental aspect, including issues surrounding compensation and notification. Management of the disease includes surgery, chemotherapy, and radiotherapy. Nursing management issues that are covered include supporting patients with poor-prognosis disease and the complex psychosocial issues of this diagnosis.

Patient information and involvement

User involvement in cancer services operates at two levels: providing information and involving patients and carers in decision-making about their own care, and involving patients and carers in decisions about the development and management of cancer services. Information can be provided to patients verbally, in written material, and through patient-held records, and they can also have access to information via the Internet. Most people want to take an active role in making decisions about their care and treatment; however, this varies from person to person. Being fully informed is important to more people than being fully involved in the decision-making process itself. Issues of consent and competence are very important when involving patients, and nurses need to take account of these and also the condition of the patient, when involving them in the decision-making process. Involving cancer service users in evaluating and managing health care has the benefits of improving services and public understanding, and improving health. It can take the form of providing information and seeking feedback on services, consulting on developments to services, and participation in planning, managing, or evaluating services. These can be achieved through questionnaires and surveys, focus groups, membership of committees, or employing service users as consultants to services. For user involvement to be effective, it should be meaningful, the language should be inclusive, and minority perspectives should be represented.

Skin and mucosal alterations

This chapter covers the most common effects that cancer and its treatment can have on the skin and mucosa. Alopecia is discussed, including the main causes, nursing support, and the role of scalp cooling for prevention; the section on oral mucositis and oesophagitis looks at causes and risk factors, including chemotherapy, radiotherapy, and targeted therapies. Prevention is explored, with a focus on recent guidelines from the United Kingdom. Treatment focuses on management of associated symptoms, such as pain and bleeding, and nutritional support. Oral care in advanced cancer offers further focus on nursing support for patients with xerostomia, candidiasis, and hypersalivation. The section on malignant wounds highlights the need for sensitive, psychologically focused care. Wound management covers guidance on managing pain, exudates, bleeding, and odour. Common wound products are also described. The final section looks at lymphoedema management, common causes, presentation, and associated problems such as mobility, altered body image, fatigue, and pain. Management focuses on complete/complex decongestive therapy.

Pain management

Pain is described as being whatever the experiencing person says it is, and their perception of pain is determined by their mood and morale and the meaning of the pain for them. Cancer pain is common, and prevalence is related to the stage of the illness: 59% in patients undergoing treatment, and 64% in those with advanced disease. Pain is multi-causal and multidimensional, and a holistic, interdisciplinary approach to assessment is necessary, encompassing physical, psychological, social, and spiritual aspects of pain (together are ‘total pain’). A narrative approach to pain assessment is helpful, keeping the focus on the patient and their experience. Pain assessment tools can also be used to identify where pain is and how much it hurts. These include: pain body map, visual analogue scales (VAS), verbal rating scales (VRS), numerical rating scales (NRS), and Brief Pain Inventory (BPI). Classifications of pain include acute and chronic pain, nociceptive pain caused by the stimulation of nerve endings, and neuropathic pain caused by nerve dysfunction or compression. Analgesic drugs may be given according to the World Health Organization's pain relief ladder: step 1, non-opioid analgesics such as paracetamol and non-steroidal anti-inflammatory drugs; step 2, mild opioids like codeine with or without non-opioid analgesics; and step 3, strong opioids like morphine with or without non-opioid analgesics. Non-pharmacological interventions for pain management include transcutaneous electrical nerve stimulation (TENS), massage, distraction, relaxation, breathing exercises, comfort measures, and presence of the nurse. Effective communication at all stages of management is essential.