Patient Assessment

Nurses are expected to be expert in assessing a patient's physical and emotional status, past health history, health practices, and both the patient's and the family's knowledge of the disease and its treatment. The oncology nurse reviews the treatment plan with the oncologist, is aware of expected outcomes and possible complications, and independently assesses the patient's general physical and emotional status. It is essential that a detailed nursing history and physical examination be completed. An oncology nurse is expected to be aware of the results and general implications of all relevant laboratory, pathology, and imaging studies. Assessment of the patient's understanding of the disease and proposed treatment is fundamental in allaying anxiety and formulating a care plan. Obtaining this information will help avoid misunderstanding and confused expectations. Thorough patient preparation improves compliance with treatment programs and may impact treatment outcomes as well.

A nursing care plan is developed in response to the particular needs identified from the assessment.¹⁴ At a minimum, this plan promotes (1) the patient's understanding of therapy goals, treatment schedules, and possible side effects of therapy; (2) physical and psychological preparation for therapy; (3) physical and psychological comfort; and (4) compliance.

Patient Education

The nurse often has a better opportunity than any other member of the healthcare team to develop the required rapport for effective educational efforts with patients and their families. Patient and family education starts before therapy and continues during and after therapy. Continual reinforcement throughout the treatment course helps to ensure success. Appropriate written and visual teaching aids may be used, as well as referrals to other professionals or community programs, such as cancer support groups. Such education includes structured and unstructured experiences to assist patients with coping with their diagnosis, long-term adjustments, and symptoms; to gain information about prevention, diagnosis and care; and to develop skills, knowledge, and attitudes to maintain or regain health status. This planned education uses a combination of methods that best meet the needs, capabilities, and learning style of the patient.³³ The ONS has enhanced this definition by recommending the following patient education outcome criteria³⁴: The patient and/or family should be able to (1) describe the state of the disease and therapy at a level consistent with the patient's educational and emotional status; (2) participate in the decision-making process pertaining to the plan of care and life activities; (3) identify appropriate community resources that provide information and services; (4) describe appropriate actions for highly predictable problems, oncologic emergencies, and major side effects of the disease and/or therapy; and (5) describe the schedule when ongoing therapy is predicted.

The change to outpatient administration of chemotherapy has increased the necessity for accurate and thorough patient and family education. This requires nurses to understand the possible side effects of each antineoplastic agent and the self-care activities for reducing their severity. Describing the side effects or problems that patients might experience from the regimen as a whole is more effective than focusing on each separate drug. Patients often express more concern about the occurrence and management of side effects than the mechanism of action of particular agents. Reiteration of important points will assist in achieving the desired outcome. Identifying a time sequence in which side effects generally occur may allay patient anxiety and will assist nurses in selecting the appropriate interventions. This may help to distinguish side effects of chemotherapy from other possible causes of similar symptoms. Patient education is facilitated when side effects are classified as immediate, early, delayed, and late.

There are a variety of teaching tools and methods available, the choice of which is based on individual patient needs and abilities. Printed, visual, and audiovisual educational materials are used in conjunction with discussion and continued reinforcement. With the increased development of the Internet, more and more cancer patients and family members are accessing the World Wide Web to gain information about cancer. Chat groups are serving as a source of information as well as support. This method of communication will continue to be an increasing source of knowledge for consumers.

Patients should be encouraged to keep personal, written, daily diaries that record treatment dates, symptoms, test dates, and questions. A personal diary provides additional written documentation of the onset of specific phenomena and accurate dates of therapy, in case the patient's medical record is not available.

Coordination of Care

The oncology nurse plays a vital role in coordinating the multiple and complex technologies now commonly employed in cancer diagnosis and treatment. This coordination encompasses direct patient care; documentation in the medical record; participation in therapy; symptom management; organization of referrals to other healthcare providers; both patient and family education; as well as counseling throughout diagnosis, therapy, and follow up. The nurse should serve as the patient's first line of communication. Ideally, the patient and family should feel free to contact the oncology nurse by phone during the entire treatment program. Many patients travel long distances, so the importance of communication by telephone must be emphasized. It allows continuous patient communication, early recognition of emergencies, and regular emotional support.

Camp-Sorrell³⁵ noted that most patient problems can be managed without the patient being seen in the office or emergency room. However, it is important for the nurse to gather sufficient information to determine patient management. Many institutions have developed guidelines for triaging phone calls and problems. These guidelines provide basic steps that are helpful in identifying patient problems over the phone before consulting with the physician and relaying specific instructions for follow-up care.

Modern cancer care is performed at multiple sites by a variety of personnel at a pace that is accelerated by a cost-conscious staff. Communication between personnel at different facilities may be suboptimal, and the communication and coordination that the oncology nurse can provide represents an invaluable service to patients who may be confused and frightened.

Direct Patient Care

The majority of ONS members provide direct patient care involving chemotherapy. National certification for chemotherapy currently does not exist. Each institution should have written policies for chemotherapy certification, administration of antineoplastic drugs (all routes), safe drug handling and disposal, management of untoward reactions, such as allergic reactions, and methods for documentation. The ONS currently offers a chemotherapy trainers course. These trainers may then offer chemotherapy training courses in the community to oncology nurses based on ONS guidelines and curriculum.

An important responsibility of nurses involved in the delivery of chemotherapy is to ensure that the correct dose and drug are administered by the correct route to the right patient. Complex regimens of potentially lethal drugs are being employed in a variety of settings. A survey of ONS members to determine extent and type of medication errors noted that 63% of the respondents reported evidence of medication errors occurring in their patient care settings. These errors included errors in dosing, incorrect drugs administered to patients or drugs administered by an incorrect route, and errors in administration and preparation.³⁶ A report from the Institute of Medicine noted that more people die annually from medication errors than from workplace injuries. A national agenda with state and local implications for reducing medical errors and improving patient safety has been set forth. Recommendations are devoted to a safer healthcare system.³⁷ In 2001, the ONS published its position statement on “Prevention and Reporting of Medication Errors,” which provides recommendations for practice, policy, systems, education, and research for the delivery of safe care.³⁸ Individual institutional guidelines should be developed to minimize the risk of chemotherapy errors.^{36, 39–42} These guidelines should include a reporting system for errors and a systematic way to review current practice to provide changes to prevent repetition of errors.

Symptom Management

Oncology nurses are challenged on a daily basis to deal with the numerous symptoms patients with cancer and their families encounter as a result of their cancer or its treatment. Nurses triage patient problems and assist in the evaluation of symptoms and initiation of interventions. For example, subjective and objective data, including information about the last chemotherapy treatment and knowledge of the patient's history, guide the nurse in determining the patient's disposition and treatment. Much progress has been made in managing the side effects of chemotherapy, and nurses have contributed significantly to this success. For example, nausea and vomiting are two of the most common symptoms associated with chemotherapy. Control of these symptoms has been a nursing research priority. Multiple studies have helped to define nausea and vomiting and to develop tools to measure occurrence, distress, and individual experiences associated with these symptoms.^43–45 This information assists in the treatment of nausea and vomiting and evaluation of the effectiveness of prescribed treatments.

Increases in healthcare costs and decreases in financial resources have challenged professionals involved in the administration of chemotherapy to evaluate the cost-effectiveness of medical and nursing treatments. Oncology nurses have assisted in the development of guidelines for the use of antiemetics particularly the 5-hydroxytryptamine–receptor antagonists.⁴⁶ These guidelines outline the optimal use and safe delivery of antiemetic drugs and have proved to be an effective means of cost containment.

Fatigue is the most distressing side effect reported by patients and is a cancer-related symptom that nurses have played a major role in managing. Nurse researchers have contributed significantly to the definition, incidence, measurement, and management of fatigue.^47–53 The ONS has played a major role in cancer fatigue management through several activities. In 1994, the organization sponsored a state-of-the-knowledge conference on cancer-related fatigue. The published report of this conference provides a list of practice and research guidelines.⁵³ In conjunction with the pharmaceutical corporation OrthoBiotech, the ONS coordinated the FIRE (Fatigue Initiative on Research and Education) project to increase the awareness of this problem. The FIRE program included funds for nursing research, professional education, and public education. The FIRE project has served as a model for subsequent programs within the ONS. The first National Cancer Fatigue Awareness Day was held in 1998. Nurses continue to address this underreported, underdiagnosed, and undertreated cancer-related symptom.

Supportive Care

Oncology nurses are closely involved with numerous supportive care issues encountered by cancer patients and their families. This chapter does not allow a detailed discussion of the numerous areas of supportive and palliative care, but two areas deserve special mention, that is, the involvement of nurses in pain management and in survivorship.

Because nurses spend more time with patients experiencing pain than does any other health professional, it is of utmost importance that the nurse be knowledgeable about pain assessment and both pharmacologic and nonpharmacologic management of pain, in order to provide good pain control as well as patient and family education.^{54, 55} However, as with other healthcare professions, barriers to providing effective pain control exist within nursing as well. The major problems are misconceptions and fears about addiction, drug tolerance, sedation, and respiratory depression; lack of knowledge about pain assessment and analgesics; and undertreatment with analgesics.⁵⁶ This is understandable when one considers the minimal time that is devoted to pain control in traditional undergraduate nursing curricula. Fortunately, these problems are now being addressed, and the education programs and resources available have improved considerably. State cancer pain initiatives, guidelines, and organizational position statements have been excellent efforts toward improving pain management. The ONS developed a position paper on cancer pain that delineated the scope of practice for nurses with different levels of expertise.⁵⁷ Even the Joint Commission for Accreditation for Healthcare Organizations has recognized the problem of inadequate pain management and changed their standards of care to emphasize appropriate management.⁵⁸

Nursing care should be planned to promote patient comfort, provide patients and their families with information related to pain control, provide information about and assistance with behavioral and physical interventions, prevent and alleviate side effects of pharmacologic therapies, and promote patient compliance with therapy and required follow up. The nurse should explain the rationale for interventions and provide time for patient and family questions. Patient education should include the names of the pharmacologic agents, dosage schedules, side effects, interventions to alleviate nausea and vomiting, such as antiemetics, and interventions to alleviate constipation. The nurse should monitor the effectiveness and side effects of pharmacologic interventions, respiratory status, and bowel functioning, as well as mental and cognitive functioning. The patient and family must know how to contact medical personnel in case of an emergency and should feel free to do so.