Page 36 nursing.elitecme.com Complete Your CE Test Online - Click Here Treatment, to date, ranges from aggressive supportive care with antibiotics and antifungals to surgical management. Further chemotherapy must be withheld until complete recovery and possibly with primary prophylaxis. Patients who recover and need more chemotherapy may benefit from a right hemicolectomy before proceeding [265]. Nursing consideration: Early recognition and treatment of neutropenic enterocolitis, which often mimics appendicitis in neutropenic patients, can improve outcome [265]. Management of chemo-related diarrhea Early assessment and aggressive interventions are essential in diarrhea. In uncomplicated diarrhea, treatment is often empiric and nonspecific. Whenever possible, underlying causes such as fecal impaction should be treated. Medications such as bulk laxatives and promotility agents (e.g., metoclopramide) are discontinued if being used for opioid management. Dietary changes are commonly used to help stop or lessen the severity of diarrhea. Some recommend that patients eat foods that build stool consistency, are low in fiber, and do not stimulate or irritate the gastrointestinal tract [297]. In some cases, dietary modification for diarrhea management includes advising patients to eat small, frequent meals and avoid lactose-containing food (e.g. milk and dairy products), spicy foods, alcohol, caffeine-containing foods and beverages, certain fruit juices, gas-forming foods and beverages, high-fiber foods, and high-fat foods [126]. For mild diarrhea, the BRAT (bananas, rice, apples, toast) diet may reduce the frequency of stools. Patients with diarrhea are encouraged to increase clear liquid intake to at least three liters per day (e.g., water, sports drinks, broth, weak decaffeinated teas, caffeine-free soft drinks, clear juices, and gelatin) [164]. Pharmacologic treatment is commonly used for diarrhea. Its goals include inhibition of intestinal motility, reduction in gut secretions, and promotion of absorption. Absorbents include agents that form a gelatinous mass that makes fecal material denser. Methylcellulose and pectin are most commonly used, but there is little data to support their efficacy. These bulk-forming agents may not be tolerated in some patients because of the large volume required for therapeutic effect and the associated abdominal discomfort and bloating. Adsorbents such as kaolin, clays, and activated charcoals have been used extensively, but no data support their use. Furthermore, they may inhibit absorption of other oral antidiarrheals that may be administered [164]. Opioids bind to receptors in the gut and reduce diarrhea by reducing transit time. Loperamide is the most common opioid used, due to its availability and reduced effect on cognition, although codeine and other opioids can also be effective. Common loperamide doses begin with 4mg, followed by 2mg after each unformed stool with a maximum of about 12mg/day. Regardless of dose, loperamide may be less effective in patients with grade three or four diarrhea [63]. Mucosal prostaglandin inhibitors, also referred to as antisecretory agents, include aspirin, bismuth subsalicylate, corticosteroids, and octreotide, may help. Aspirin may be useful for radiation-induced diarrhea. Bismuth subsalicylate is believed to have direct antimicrobial effects on the bacterium Escherichia coli. This agent is contraindicated in patients who should not be taking aspirin, and large doses can produce toxic salicylate levels [164]. Corticosteroids reduce edema associated with obstruction and radiation colitis and can reduce hormonal influences of some endocrine tumors [164]. Other pharmacologic therapies for the relief of diarrhea may be specific to the underlying cause. Delayed diarrhea (>24 hours) occurs with irinotecan and can be severe. In a small study of seven patients, six patients obtained relief with oral neomycin, 1,000mg, three times daily. This relief occurred without reduction in the active metabolite of irinotecan, SN-38; thus, the poorly metabolized antibiotic did not alter efficacy of the chemotherapeutic agent [110]. In another small study of 37 patients with non-small cell lung cancer receiving irinotecan, investigators alkalized the feces through oral administration of sodium bicarbonate, water, and ursodeoxycholic acid, while speeding transit time of the drug metabolites (thought to reduce damage to the intestinal lumen by reducing stasis of the drug) through the use of magnesium oxide. The incidence of delayed diarrhea was significantly reduced in this group when compared with 32 patients receiving the same chemotherapeutic regimen without oral alkalization and controlled defecation [268]. GVHD diarrhea In addition to antidiarrheal agents and immunosuppressive medications, a specialized five-phase dietary regimen may be instituted to effectively manage the diarrhea associated with GVHD [73]. Phase-1 consists of total bowel rest until the diarrhea is reduced (NPO). Phase-2 reintroduces oral feedings consisting of beverages that are isotonic, low- residue, and lactose-free. If these beverages are well tolerated, Phase-3 may reintroduce solids containing minimal lactose, low fiber, low fat, low total acidity, and no gastric irritants. In Phase-4, dietary restrictions are progressively reduced as foods are gradually reintroduced and tolerance is established. Phase-5 includes the resumption of the patient’s regular diet, but most patients usually remain lactose intolerant [164]. Mild cognitive impairment Cognitive changes with a cancer diagnosis are very common, with patients complaining of short term memory loss, mental fogginess, difficulty concentrating, and loss of ability to multitask or perform mathematical calculations. These cognitive changes can start during and/or after cancer treatment, and some have even been observed as occurring before treatment began. Although it is often called chemo- brain, the full etiology of this problem is unclear. Studies that look at people after cancer treatment cannot account for other effects of diagnosis, treatment, or baseline differences. A multifactorial problem: Researchers are also looking at other factors that affect cognitive function. For example, surgery and anesthesia have at least a short term effect on cognition, especially in older patients, which typically resolves over a period of days to months. The stress of diagnosis and treatment, endocrine changes, nausea medications, low blood counts, depression, hormone changes, fatigue, anxiety, normal aging, and cardiovascular disease can all affect cognitive function, and some of these factors may play a role in cognitive changes before, during, and after cancer treatment [133]. Subjective complaints vs. objective measures: Subjective observations of cognitive decline do not always match objective cognitive testing. Some studies have observed that patient perceptions of cognitive impairment are often not enough to make a noticeable difference on most neurocognitive tests, although there is some evidence that patients receiving chemotherapy were using cognitive reserves during some of these tests (e.g., showing more brain activity to deal with the testing problems, which may reflect their perception of having to work harder to process problems and information). However, studies that objectively measure cognitive function have found a higher rate of cognitive impairment among people who have been treated with chemotherapy. This tends to improves over time for the majority of patients, but some differences likely persist in a few [133]. Research continues into the mild cognitive impairment related to cancer treatment, but there is no specific medical treatment for it at this time. It is important to validate patients’ symptoms as normal and suggest that they not be too hard on themselves for lapses and omissions. Nurses can help patients come up with ways to cope, such as reminder systems, keeping a written or electronic calendar and medication log, setting up and following routines, and getting support from others who are going through or have been through similar experiences [249]. Sexuality changes Cancer can affect sexual and intimate relationships of patients in a number of ways. Body image changes: chemotherapy and radiation all have different effects, some of which last months or years after treatment. Although cancer treatment teams are better at educating patients about chemotherapy and cancer treatment, sexual concerns are not usually specifically addressed. However, these concerns can be a source of distress that can negatively impact the patient’s quality of life. Unfortunately, more than 75% of health professionals wait for the