Page 29 Complete Your CE Test Online - Click Here steps to help calculate the emesis risk of any chemotherapy regimen. This can help with choosing the best initial regimen for emesis control. (Drug interactions and other issues with nausea and vomiting treatment medications are covered in some detail in the “Drug Interactions” section.) Vomiting is easier to control with preventive regimens than nausea is. Delayed nausea is more common than acute nausea, is harder to control, and can be severely distressing to the patient. Prevention may include around-the-clock antiemetics rather than waiting for complaints of nausea or vomiting. Anticipatory nausea and vomiting typically occurs after three or four chemotherapy treatments after which the patient experienced acute or delayed N&V. It can happen in up to one-third of patients. Good control of acute and delayed N&V can prevent ANV development, but after it develops, interventions are best undertaken by a mental health professional with specific training and experience with ANV. Early identification and referral increase the possibility of success. Cognitive- behavioral therapy with progressive muscle relaxation and guided imagery, hypnosis, biofeedback, and distraction using video games have all been used; research continues on best management. Benzodiazepine drugs may also help; the NCCN recommends alprazolam, even though it is a substrate of CYP 3A (see “Drug Interactions”). Lorazepam is a benzodiazepine with less potential for drug interactions, so it might be used if any CYP 3A inhibitors or inducers are being given. All benzodiazepines can potentiate CNS depressants and may have other kinds of interactions too. Breakthrough N&V is harder to treat. After it starts, interventions may include rehydration if needed, correction of electrolyte abnormalities, or antiemetic medicines from classes not used previously. This usually means giving parenteral or rectal forms of medication because the oral route is not reliable. Olanzapine or cannabinoids (dronabinol and nabilone), for example, may be good options for breakthrough N&V. Any patient who has breakthrough N&V should be reassessed and have antiemetic regimens upgraded before the next cycle of chemotherapy begins. Nursing consideration: The effectiveness of the patient’s antiemetic regimen should be reassessed at the end of every treatment cycle. This assessment should include the number of episodes; time of onset (in relationship to doses of chemotherapy drugs and other medications); and duration of nausea, vomiting, or dry heaves. The nurse should also consider the patient’s hydration and nutritional status, weakness, weight loss, and mental status. It is important to consider possible causes for N&V beyond chemotherapy, especially if it continues for an unexpectedly long duration after chemo. It is possible that the patient has an underlying problem, such as gastrointestinal obstruction, increased intracranial pressure, or new metastases. Nursing consideration: Assess the emetogenic potential of the combination of cancer drugs in order to match it with an initial antiemetic drug regimen. Reassess effectiveness after each cycle and work with the oncologist or palliative care team if a stronger antiemetic regimen is needed, or if antiemetics need to be given for a longer time. Pain Pain is defined by the International Association for the Study of Pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Pain is one of the most common symptoms people with cancer face. It can be caused by cancer, treatment for cancer, or a combination of factors. Tumors; surgery; radiation therapy; IV chemotherapy; targeted therapy; supportive care therapies, such as bisphosphonates; and diagnostic procedures may cause pain. It is important to assess pain as to cause and chronicity; whether it is somatic, visceral, neuropathic, or mixed; and the patient’s concerns regarding and previous experience with opioids when determining the most appropriate treatments. Whether the patient has any renal or hepatic dysfunction is also important in pain management. Younger patients are more likely to have cancer pain and breakthrough pain than older patients. Patients with advanced cancer are likely to have more severe pain, and many cancer survivors have pain that continues after cancer treatment ends. Basic principles of cancer pain include the following: ● ● Cancer, treatment for cancer, or diagnostic tests may cause pain. ● ● Pain can be managed before, during, and after diagnostic and treatment procedures. ● ● Different cancer treatments may cause specific types of pain. ● ● Cancer pain may affect quality of life and ability to function even after treatment ends. ● ● Pain control can improve quality of life. ● ● Each patient with cancer-related pain needs a plan for controlling pain. Pain can be controlled in most patients with cancer, although it cannot always be completely relieved. Untreated pain can lead to emotional distress, anxiety, requests for physician-assisted suicide, unnecessary hospital admissions, and visits to emergency rooms. Pain control can greatly improve quality of life during and after cancer treatment. Pain can be managed before, during, and after diagnostic and treatment procedures. Many diagnostic and treatment procedures are painful. It helps to start pain control before the procedure begins. Sedative drugs may be used to help the patient feel calm and drowsy. Such treatments as imagery or relaxation can also help control pain and anxiety related to treatment. Knowing what will happen during the procedure and having a relative or friend stay with the patient may also help lower anxiety. Different cancer treatments may cause specific types of pain. Patients may have different types of pain, depending on the treatments they receive: ● ● Spasms, stinging, and itching caused by intravenous chemotherapy. ● ● Mucositis caused by chemotherapy, radiation, or targeted therapy. ● ● Skin pain, rash, or erythrodysesthesia syndrome (hand-foot syndrome) caused by chemotherapy (such as 5-FU, capecitabine, liposomal doxorubicin, paclitaxel) or targeted therapy (sorafenib, sunitinib). ● ● Arthralgias and myalgias caused by paclitaxel or aromatase inhibitors. ● ● Osteonecrosis of the jaw caused by bisphosphonates given for bone metastases. ● ● Pain syndromes, including mucositis, inflammation in areas receiving radiation therapy, pain flares, and radiation dermatitis. Cancer pain may affect quality of life and ability to function even after treatment ends. Pain that is severe or continues after cancer treatment ends increases the risk of anxiety and depression. Patients may be disabled by their pain, unable to work, or feel that they are losing support once their care moves from their oncology team back to their primary care team. Feelings of anxiety and depression can worsen cancer pain and make it harder to control. Each patient needs a plan to control cancer pain. Each patient’s diagnosis, cancer stage, response to pain, and personal preferences around pain relief is different. The nurse, oncologist, patient, and family can work together to help manage pain. The patient and family will need written instructions to manage pain at home, along with contingency plans for common problems, including how to contact the physician or palliative care team on the weekends or evenings. It is imperative that the cause of the pain is found early and treated quickly. Nurses will need to assess pain intermittently after starting cancer treatment. When there is new pain, and after starting any type of pain treatment. Patients are often asked to describe the pain with questions like these: ● ● When did the pain start? ● ● How long does the pain last? ● ● Where is the pain? ● ● What is the pain like (sharp, crampy, dull, throbbing, burning, radiating)? ● ● How severe is the pain on a scale of 0 to 10? ● ● Have there been changes in where or when the pain occurs?