Nursing Support of the Child with Cancer

Marilyn J. Hockenberry

Nancy E. Kline

Cheryl Rodgers

Pediatric oncology nurses are essential contributors to the successful diagnosis, treatment, and cure of children with cancer. As a member of the multidisciplinary care team, the nurse works with physicians, social workers, child life specialists, schoolteachers, psychologists, chaplains, and other specialists to provide comprehensive care for the child and family. Innovative technologies require that nurses caring for children with cancer become experts in critical care management as well as in the provision of psychological support to the child and family. The expert oncology nurse often functions as the coordinator of patient care, facilitating communication among team members.

Advances in pediatric oncology can be attributed to multidisciplinary care, with nursing serving in key roles that have directly impacted the curability of this disease.¹ Pediatric oncology nursing roles are diverse and allow for opportunities in direct patient care, education, management, and research. Advanced practice nurses (nurse practitioners and clinical nurse specialists) have made significant contributions toward providing continuity of care for children with cancer. Children are cared for by advanced practice nurses in various patient care settings, including the hospital, outpatient setting, and home environment.

DIRECT PATIENT CARE NURSING ROLES

Nurses caring for the child with cancer in the hospital setting must keep pace with the complex advances in treatment as well as with advanced technology. The trend in pediatric oncology continues with more therapies being administered in the clinical setting, with inpatient settings used for the management of acute life-threatening complications and administration of chemotherapy regimens that cannot be given in the ambulatory setting.² Nurses with highly specialized skills staff the pediatric oncology inpatient care settings.

The nurse working with children in the tertiary care setting recognizes acute as well as long-term side effects caused by the disease and the treatment. Expert nursing care requires the ability to assess the child’s condition on the basis of extensive knowledge of childhood cancer, to develop a plan of care in collaboration with other health care professionals, to provide direct nursing care for the child, and to evaluate the child’s condition on the basis of specific nursing outcomes.² Nurses caring for children with cancer must competently manage symptoms of common side effects of treatment such as nausea and vomiting, pain, mucositis, fatigue, and anorexia. Pediatric oncology nurses are essential for providing education and support to families with a child newly diagnosed with cancer. Crisis intervention and the ability to provide emotional support are important aspects of the role. The nurse serves as a child advocate, ensuring proper preparation prior to invasive procedures and treatment. Because many patients receive frequent admissions for treatment, nurses develop long-term relationships, providing continuity of care for these families.

The nurse working in the outpatient clinical setting is often the direct link between the community and the cancer treatment center. Pediatricians who follow cases of children with cancer in community settings may communicate directly with the nursing staff regarding specific side effects or laboratory findings. Outpatient clinic nurses frequently provide education regarding administration of chemotherapy in the pediatrician’s office. Extensive knowledge of the side effects of treatment allows the nurse to provide families with an understanding of what may occur at home. Information regarding specific restrictions and changes in activities for the child is communicated with the family.

Children are now receiving in the outpatient clinical setting chemotherapy that could previously be administered only in a hospital.³ The use of moderate sedation before invasive procedures is a common practice in childhood cancer centers. Outpatient clinic nurses have extensive knowledge regarding assessment and management of children receiving complicated chemotherapy regimens and sedation. As a consequence of intensive chemotherapy regimens, blood product support is frequently necessary and is administered in the outpatient setting by nurses who are knowledgeable regarding possible reactions and who expertly manage side effects related to blood product transfusion.

Families who have children with cancer return to the outpatient setting frequently for treatment and follow-up. The nurse becomes a major support to the child and family throughout treatment. Once therapy is completed, families continue to use the nurse as a major resource for their questions and concerns. A pediatric oncology nurse is described as a source of information, reassurance, and comfort. The “expert” pediatric oncology nurse is one who has confidence in his or her knowledge, is able to provide high-quality patient and family care, and has opportunities for professional growth.⁴

ADVANCED PRACTICE ROLES

One of the most significant contributions of nursing has been the development of advanced practice roles. Advanced clinical practice in pediatric oncology nursing requires preparation at the master’s degree level. Graduate programs are designed to prepare advanced practice nurses to think independently, to function autonomously, and to participate actively within an interdisciplinary team.⁵ An extensive knowledge base in physiology, pharmacology, child health assessment, growth and development, health promotion, disease prevention, and management of common problems of childhood is essential. Once a foundation of knowledge regarding well-child care is established, graduate nursing programs should provide opportunities for experiences in the care of the child with cancer. Didactic content in the pathophysiology, diagnosis, and management of the various types of childhood cancer is essential; yet, general pediatric graduate programs often do not include these topics in the curriculum.⁵ Nurses seeking to specialize in pediatric oncology should pursue opportunities to care for children with cancer during graduate nursing study.

Many advanced practice nurses who join comprehensive childhood cancer centers have limited knowledge of the diagnosis, treatment, and management of cancer. Cancer centers must consider developing innovative educational opportunities that provide the knowledge necessary to pursue advanced practice roles. Short-term fellowship programs that allow for clinical participation
under the supervision of experienced nurses may become an important investment as nurses’ functions become more independent in the future.

Nurse Practitioners

Since the conception of the advanced practice role, nurse practitioners have demonstrated the ability to provide appropriate, cost-effective care for a range of health services, including primary care, management of chronic illness, and treatment of episodic health problems. Positions for nurse practitioners have been created in critical care areas and bone marrow transplant units, as physicians and health care administrators have recognized the quality and cost-effectiveness of the role.

Nurse practitioners serve as the coordinators of care among hospital, clinic, and community settings. The nurse practitioner must understand the assessment and management of children with cancer. Proficient in performing physical assessments and diagnostic procedures such as bone marrow aspiration and lumbar punctures and in diagnosing common pediatric illnesses, the nurse practitioner role has evolved as a vital role in the pediatric oncology specialty.

Clinical Nurse Specialists

The clinical nurse specialist complements the role of the nurse practitioner by providing continuity between the clinic and the hospital. Whereas the nurse practitioner directly cares for a selected population of patients, the clinical nurse specialist often serves as a coordinator of care for all children who are hospitalized. Clinical nurse specialists use their expertise by helping other team members to coordinate care, usually during the patient’s hospitalization. Communication between staff nurses and the clinical nurse specialist is key in providing information from the health care team managing the child’s care. The clinical nurse specialist is instrumental in implementing organized teaching programs for parents and children. Both the clinical nurse specialist and the nurse practitioner serve as resources for other nurses.

Administrators

Nurses in administrative roles face the challenge of implementing cost-effective, high-quality care to increasingly ill patients who have complex health care needs. These nurses must have an extensive background in nursing as well as in business. Managed care is changing health care, and nurses in administration will be instrumental in coordinating care in accordance with specific health care plans in the future. Administrative nurses must support the specialization of oncology nursing while meeting the demands of changing health care systems. A major aim is to direct efforts toward recruitment and retention of professionals who are skilled pediatric oncology nurses who will deliver high-quality care to these children and their families.

RESEARCH ROLES

Nurses with diverse educational backgrounds and experience are involved in research roles. Educational preparation influences the type of research role nurses pursue. Baccalaureate-level nurses typically participate in research by evaluating its applicability for nursing practice. They assist in the identification of research problems and are involved in research implementation by serving as data collectors and identifying subjects for study.

Numerous cancer centers also use baccalaureate-prepared research nurses as coordinators of clinical trials. The research nurse ensures that the study is implemented according to protocol and that data collection is accurate. Phase I clinical trials are excellent examples of studies coordinated by research nurses; the research nurse implements labor-intensive regimens according to protocol and closely monitors side effects and toxicity data. The Nursing Discipline within the Children’s Oncology Group provides opportunities for nursing to make significant contributions to clinical trials and fosters growth of nurse researchers by pairing PhD-prepared nurse scientists with master’s degree nurses to work on specific research studies.⁶ The pediatric oncology nurse with a master’s degree has the expertise to identify practical problems of clinical relevance and to facilitate using evidence to improve nursing care. Pediatric oncology nurses have paved the way in demonstrating the importance of using evidence to improve the care they provide.⁷ Examples of the impact nurses have had on patient care include implementing symptom management interventions, promoting professional collaboration in care, establishing support groups for children and adolescents, understanding the impact of having a child with cancer on the parent, and developing strategies for educating children and families on the type of cancer and treatment.⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³

The nurse in advanced practice enhances the value of research among other nurses by participating in collaborative research endeavors.

Doctoral-prepared nurses are increasing in number and serve as nursing research directors at numerous institutions. They promote interest in research and are instrumental in implementing funded nursing research projects.

NURSING STANDARDS OF CARE

The image of pediatric oncology nursing is reflected in the standards of care practiced daily by nurses. The outcome standards of pediatric oncology nursing practice, established by the Association of Pediatric Hematology Oncology Nurses, reflect the comprehensive involvement of nursing in the care of children with cancer.¹⁴ These standards assist in identifying the future focus of pediatric oncology nursing care and include providing expert clinical care through assessment, diagnosis, outcomes identification, planning, and implementation. The pediatric oncology nurse serves as a coordinator of patient care and an educator for health care teaching and health promotion. Patient and family education, psychosocial support, and growth and development assessment also are major aspects of the clinical nursing role.

PROVIDING EXPERT CLINICAL NURSING CARE

Expert nurses are able to assess the child’s condition using extensive knowledge of childhood cancer, to develop a plan of care in collaboration with other health care professionals, to provide direct nursing care, and to evaluate the child’s condition based on specific nursing outcomes.² Pediatric oncology nurses play a major role in managing disease-related and treatment-related side effects, coordinating care for central venous lines, administering chemotherapy, and preparing the child for invasive procedures. As more children are treated in the outpatient or home environment, nurses have become the coordinators of care in these settings.

Managing Side Effects

Children with cancer commonly experience side effects during their treatment that can continue well beyond the completion of treatment. These distressing symptoms occur frequently owing to the disease, aggressive therapy regimens, and medical procedures.¹⁵^,¹⁶^,¹⁷^,¹⁸^,¹⁹ Multiple symptoms frequently occur, as reported by 131 pediatric patients receiving chemotherapy for a variety of malignant diseases.¹⁹ Patients experienced a mean of 11.6 symptoms during chemotherapy treatment, with lack of energy, hair loss, pain, nausea, and feeling drowsy as the most commonly reported
symptoms. This finding is further illustrated by 509 pediatric oncology nurses who participated in a national survey evaluating nurses’ management of patient symptoms.²⁰ The average number of symptoms experienced was six, with pain being the most commonly reported symptom. Pain was also identified by these nurses as the most effectively treated symptom compared to fatigue, which was perceived as the symptom least effectively managed by nurses.²⁰ Woodgate and Degner¹⁵ described the presence of cancer symptoms as a series of transition periods reflecting the dynamic nature of the childhood cancer experience. Pediatric oncology patients and their family members expected to experience suffering as part of the cancer treatment and felt that unrelieved or uncontrolled symptoms were necessary for cure.¹⁷ Kestler and LoBiondo-Wood¹⁸ completed a recent review of the published research literature on symptom experiences of children and adolescents with cancer. The most frequent symptoms found in the literature review included pain, fatigue, nausea, and vomiting. Several gaps were noted in symptom research and include the need for longitudinal and qualitative study designs, inclusion of preschool-aged children, development of conceptual models, and creation of assessment instruments exclusively for use with children and adolescents.

Myelosuppression and Consequent Infection

Chemotherapy agents and radiation therapy cause myelosuppression. In addition, certain malignancies that metastasize to the bone marrow (e.g., leukemia, lymphoma, neuroblastoma, sarcomas) cause a decrease in the number of normal blood cell precursors. When the myelosuppressive effect is severe enough, the child becomes predisposed to infection, anemia, or bleeding, depending on which blood cell line is affected.

Infection resulting from neutropenia may be life-threatening (see Chapter 40). The bone marrow cannot produce an adequate number of neutrophils to protect against infection after cytotoxic chemotherapy is administered, or during long courses of radiotherapy. A patient with an absolute neutrophil count of less than 500 mm³ is considered neutropenic. Children who have prolonged periods of neutropenia (i.e., >7 days) are at high risk for developing infection. The neutropenic child may not demonstrate the normal signs and symptoms of infection. Fever may be the only indication that infection is present; however, medical attention and antibiotic administration should be provided promptly if the child shows any signs of infection regardless of the child’s temperature.²¹

The nurse plays an important role in minimizing the risk of infection in these children. Most infections in the neutropenic child are caused by endogenous flora (e.g., Staphylococcus, Escherichia coli, Streptococcus), and adequate protection from infection is the best defense. Hand washing before and after contact with each patient minimizes the risk of microbial transmission, and is the single most important method of preventing nosocomial infection.²¹^,²² A meta-analysis evaluating the prophylactic use of biologic response modifiers (e.g., granulocyte colony stimulating factor [G-CSF], granulocyte-macrophage colony-stimulating factor [GM-CSF]) among pediatric oncology patients found a significant decrease in the duration of neutropenia, hospitalization, and antibiotic use after cytotoxic chemotherapy.²³ Because GM-CSF activates cytokines other than neutrophils, it is used less frequently, whereas the G-CSF agents such as filgrastim and pegfilgrastrim are more commonly used and studied.²⁴

When a neutropenic child develops fever, blood cultures from the central (e.g., implanted central venous access device [CVAD]) are obtained, along with consideration of cultures of peripheral sources and other appropriate body fluids or sites (e.g., urine, stool, throat, wound, lesions, catheter exit site). Broad-spectrum intravenous (IV) antibiotics are promptly initiated. Antibiotic therapy is modified based on the culture and sensitivity of the organisms isolated.

Nursing care of the child hospitalized with fever and neutropenia is directed toward monitoring for signs of septic shock. Vital signs must be monitored frequently to identify temperature fluctuations (very low or very high), heart rate, respiratory rate, and blood pressure. Because hypotension is usually a late sign of shock in children, peripheral perfusion should be checked frequently. Delayed capillary refill and tachycardia are early signs of impending shock. Strict intake and output must be measured to monitor renal function. The child’s level of consciousness must be assessed continually for irritability, lethargy, or unresponsiveness. Temperature measurement by the rectal route and the use of suppositories and enemas must be avoided. Mouth care and perianal hygiene must be done on a regular schedule. If the child is febrile (temperature 38.3°C), blood cultures are obtained and acetaminophen is administered. The parents should be given an opportunity to ask questions during the period of acute serious illness (e.g., fever and neutropenia, septic shock), because this time is often confusing and stressful for the family.

Parents and children must be educated regarding the prevention of infection. All members of the family must practice strict hand washing to decrease the spread of pathogens among each other. The parents must know when the period of neutropenia is likely to occur following chemotherapy. If fever is suspected, they should take the child’s temperature by the oral or axillary route, but never rectally. If the child’s temperature is 38.0°C that persists for 1 hour, or 38.3°C or higher on one occasion, the parents should notify the nurse or physician immediately and should not administer acetaminophen unless instructed to do so.

Adequate nutrition is an important component in the prevention of infection. Cancer treatments often cause anorexia, nausea, and vomiting, which make adequate dietary intake difficult to achieve. Food should never be forced on the child, and should alternate feeding plans be required (e.g., gastric tube feedings, total parenteral nutrition), care must be taken to use the appropriate sterile technique to prevent infection.

Primary varicella zoster virus infection can present a potentially life-threatening danger to the immunosuppressed child (see Chapter 40). If the immunocompromised child is directly exposed to an infected person, varicella zoster immune globulin (VariZIG) (125 units/10 kg; maximum dose, 625 units) should be administered intramuscularly within 96 hours.²⁵^,²⁶ Direct exposure is defined as having an infected household contact, 1 hour or more of indoor play with an infected person, or hospital exposure through prolonged face-to-face contact with an infected health care worker or patient. Any patient who receives VariZIG should be monitored closely and started on antiviral therapy immediately for any signs or symptoms of infection.²⁶ Health care workers who have not had chickenpox should be advised to receive two doses of the varicella vaccine given 4 to 8 weeks apart and should follow their institution’s guidelines regarding any special precautions following the immunization.²⁷

After an individual has had chickenpox, varicella zoster virus persists in the dorsal root ganglia in a latent form. Immunosuppression from chemotherapy or radiation can reactivate the virus, resulting in herpes zoster (“shingles”). Some immunosuppressed patients may not manifest the typical vesicular cutaneous changes within the sensory dermatomes and may only describe sensations of pain or tingling. Treatment of patients who have zoster is similar to that of patients with primary varicella infection.²⁸

Nursing care of the child with varicella infection requires strict isolation, attention to good hygiene and hydration, fever control, and management of pruritus and pain. These children must be continually assessed for evidence of disseminated infection or secondary bacterial infection.²⁸

Pneumocystis jirovecii, formerly known as Pneumocystis carinii, generally is not pathogenic in a healthy host, but can cause a life-threatening pneumonia (Pneumocystis carinii pneumonia [PCP]) in persons who are immunosuppressed.²⁹ Fortunately, this condition is almost entirely preventable. Trimethoprim-sulfamethoxazole (TMP-SMZ), 150 mg/m² of the trimethoprim component, given by mouth, divided into two doses, two or three
consecutive days each week, is adequate prophylaxis.²⁹ For patients who are unable to take TMP-SMZ because of hypersensitivity reaction or bone marrow suppression, dapsone or atovaquone given once daily by mouth is an effective substitution.²⁹^,³⁰ Aerosolized pentamidine 300 mg/dose is another option for PCP prophylaxis and is administered once monthly.³⁰^,³¹ The patients must be old enough (usually 5 years of age or older) to cooperate with aerosolized drug administration via the Respirgard II inhaler and must come into the clinic to receive the medication. Pentamidine may also be given intravenously, but it is expensive and is associated with side effects (e.g., hypotension, hypoglycemia). Although pentamidine has been shown to prevent PCP, its administration is labor intensive, and it is certainly more costly than the medications that can be administered at home.

Respiratory syncytial virus (RSV) and cytomegalovirus (CMV) are other potentially problematic infections for children with cancer, especially patients undergoing bone marrow transplantation. All oncology patients receiving chemotherapy are considered to be at high risk for influenza-related complications and should receive antiviral treatment with oseltamivir or zanamivir within 48 hours of a suspected illness.³²

Administration of Immunizations

Live virus vaccines are contraindicated in children receiving immunosuppressive therapy because of potentially serious adverse effects.³³ Vaccine-strain poliomyelitis, measles virus, and vaccinia have been reported in immunocompromised children after administration of live virus vaccines. Immunologically normal household contacts of immunocompromised children should receive inactivated poliovirus (IPV) vaccine, because live poliovirus is transmissible following immunization with oral poliovirus vaccine (OPV).³³ Live measles, mumps, and rubella (MMR) vaccine can be administered to the siblings and household contacts of immunosuppressed children because these viruses are not transmissible after vaccination. Varicella vaccine has been given to nonimmune household contacts of children with cancer without transmission of the virus to the immune-suppressed child. Therefore, this vaccine is recommended for susceptible contacts of these children. Children who have received chemotherapy or radiation therapy should not be given live virus vaccines until at least 3 months after immunosuppressive treatments have ceased. The degree of immunosuppression and its duration may vary among patients, however. Other routine childhood immunizations, such as diphtheria-tetanus-pertussis, Haemophilus influenzae type-b conjugate, and hepatitis B, can be administered safely on a standard schedule, although immunogenicity may be reduced. Children who have Hodgkin disease and are 24 months old or older should receive pneumococcal and meningococcal vaccines because these children are at increased risk of infection from these organisms.²⁵

Bleeding and Anemia

Children with cancer are at risk of bleeding related to thrombocytopenia or coagulopathy.³⁴ Anemia may occur because of blood loss or a decrease in the production of red blood cells related to bone marrow suppression from cancer treatment or malignancy (see Chapter 39). Children who are at risk for bleeding (platelet count below 100,000 per mm³) should be placed on precautions, so the potential for bleeding can be decreased. The risk for spontaneous internal hemorrhage does not occur until the platelet count is 20,000 per mm³ or lower. Nurses should educate the family and child to avoid ibuprofen, aspirin, and aspirin-containing products. Minor pain is treated with acetaminophen after determining there is no fever. The child’s body temperature should never be taken rectally. Venipunctures and other invasive procedures (e.g., lumbar puncture and bone marrow aspiration) should be performed with caution when platelet counts are low.

The use of razors should be avoided, and a soft toothbrush should be used for dental care. Children should avoid using dental floss and not eat or chew sharp foods (e.g., tortilla chips, ice) to prevent gingival bleeding. Adolescent female patients may be given oral contraceptives or hormone therapy to suppress menses to decrease the risk of excessive bleeding. Contact sports or activities that may cause injury or bleeding (e.g., football, soccer, bicycle riding, skateboards, tree climbing) should not be permitted during periods of thrombocytopenia.

If the child experiences epistaxis, the parents should be instructed to pinch the child’s nostrils together with a gauze pad held between the thumb and index finger for at least 10 minutes. If there is persistent epistaxis, or if the patient experiences hematuria or hematochezia, the child should be evaluated at the hospital. If the child is admitted to the hospital with thrombocytopenia, nursing interventions include measures to prevent injury, inspection of body fluids for evidence of blood, monitoring of vital signs and peripheral perfusion for evidence of blood loss, and administration of platelet transfusions.

Children may become anemic from blood loss or as a consequence of chemotherapy-induced myelosuppression. Children are amazingly resilient and may tolerate low hemoglobin concentrations well, especially if the decline is gradual. Signs and symptoms of anemia include pallor, headache, dizziness, shortness of breath, fatigue, tachycardia, and heart murmur. Packed red blood cell transfusion is generally required when the hemoglobin falls below 7 g/dL.

When red blood cell transfusions are required, leukocyte-depleted or irradiated blood products are often administered. Lymphocyte reduction of packed red blood cells and platelets is used to prevent HLA-alloimmunization and refractoriness to allogeneic platelet transfusion, nonhemolytic transfusion febrile reactions, and graft-versus-host disease (GVHD).³⁵ Irradiation of cellular blood components is used to prevent posttransfusion GVHD.³⁵ The decision to administer lymphocyte-depleted or irradiated blood products depends on the child’s immunologic status and on the intensity of the chemotherapy regimen. All children who are bone marrow transplant recipients should receive leukocyte-depleted, irradiated blood products.

Transfusion of blood products may cause transfusion reactions, manifested by fever, chills, body aches, urticaria, pruritus, and, in severe cases, wheezing, tachycardia, and respiratory compromise.³⁶ If a transfusion reaction occurs, the transfusion should be discontinued and IV normal saline should be infused. Antihistamines, steroids, or acetaminophen may be administered. Limiting blood and platelet transfusions to designated donor products may be warranted if the situation is not an emergency or if the child is not a potential bone marrow transplant recipient. The use of designated donor blood products may reduce the incidence of transfusion reaction if a parent or sibling’s blood products are compatible. The institutional blood bank can provide information and instructions regarding specific designated donor programs.

Nutritional Changes

Adequate nutrition continues to be a major concern during childhood cancer treatment. Altered nutrition has been reported in 6% to 60% of all children treated for cancer.³⁷ The disease itself and the side effects of therapy (e.g., nausea, vomiting, anorexia, stomatitis, dysphagia, changes in taste) often interfere with adequate caloric intake. Conversely, the use of glucocorticoids (i.e., prednisone, dexamethasone) causes an increased appetite and an intense craving for salty foods. When these drugs are given, weight gain may be excessive, although intake of nutritious foods may be inadequate. In either case, the nurse should assess the patient’s food intake and weight at each visit. Weight should be plotted at regular intervals on a growth curve to determine changes in growth trends.

When metabolic needs exceed caloric intake, the child may benefit from a nutritional supplement given between meals. Methods to increase caloric intake include providing high-protein snacks or high-calorie ingredients in recipes. Small, frequent meals may be more appetizing if the child is suffering from nausea. If the child continues to lose weight, or drops off
the growth curve, a dietitian should be consulted. The child may require total parenteral nutrition or placement of a feeding tube to prevent malnourishment³⁷^,³⁸^,³⁹ (see Chapter 41).

Bone marrow transplant patients are a high-risk population who frequently experience gastrointestinal side effects that can result in poor nutrition.⁴⁰^,⁴¹ Researchers are exploring risk factors that can lead to earlier nutritional interventions and better nutrient support.⁴² Other research focus areas are evaluating proactive use of enteral feedings in pediatric oncology patients⁴³ and parental perception of their child’s food intake during chemotherapy.³⁷

Nausea and Vomiting

Many cancer chemotherapy agents are emetogenic, and nausea and vomiting can severely alter fluid balance in the pediatric patient (see Chapter 42). Even when chemotherapy administration is preceded by antiemetic therapy, nausea and vomiting may still occur. Some patients receiving cisplatin or carboplatin experience nausea and vomiting several days after the drugs are administered. While chemotherapy agents or IV hydration is infusing, the nurse must monitor intake and output closely and note any discrepancy that would indicate dehydration or over hydration. Patients receiving radiation therapy to the chest, abdomen, pelvis, or craniospinal axis may experience nausea, vomiting, anorexia, and diarrhea. Antiemetic or antispasmodic therapy may be indicated for these patients to provide symptomatic relief (see Chapter 42). Certain patients who suffer from anticipatory or treatment-associated nausea and vomiting may benefit from relaxation techniques or guided imagery.

TABLE 43.1 Nausea and Vomiting Assessment

Assessment Time	History
Prior to first chemotherapy course	Prior experiences with motion sickness Previous experiences with nausea and vomiting Anxiety during treatment Sensitivity to odors
With each chemotherapy course	Type and duration of chemotherapy being administered History of nausea and vomiting Anxiety If patient has received the treatment before, determine how the treatment was tolerated: what worked and what contributed to the symptoms Preferred antiemetic regimen Supporting interventions that help decrease the symptoms; does the patient use relaxation techniques, distraction, biofeedback, etc. Document the patient’s treatment preferences to control nausea and vomiting