Patient Situation and Literature Review
Patients receiving chemotherapy treatment for cancer experience a great deal of extremely unpleasant and severe side effects. These include immunosuppression, anemia, thrombocytopenia, gastrointestinal symptoms, peripheral neuropathy, alopecia and fatigue (Chemotherapy side effects, n.d.). Effectively managing these symptoms increases patient quality of life despite serious and potentially terminal illness and promotes compliance with treatment in order to optimize the benefits (Perwitasari et al., 2012). Nausea and vomiting are particularly distressing symptoms among patients and nurses working in the oncology ward must be knowledgeable regarding the range of pharmacologic and nonpharmacologic techniques which can be used for control. This paper presents the case of an oncology patient and a literature review on the management of nausea which was one of her main complaints.
Patient Situation
The patient is a 61-year-old Hispanic female with a longstanding history of cigarette smoking who was diagnosed two years ago with squamous cell carcinoma of the tongue, staged as T3, N2 which has now recurred and spread to the mandible and left side of the neck. She is currently receiving her 6th cycle of fluorouracil via infusion pump with paclitaxel and cisplatinum injections. On assessment, she is alert and oriented x3 and in no acute distress. She is hypertensive with a BP of 141/74, afebrile and with normal oxygen saturation. She has lost considerable weight from 178 pounds at the start of treatment to 116 pounds at present. She has an ulcerated lesion involving the anterior tongue extending to the floor of the mouth so that her tongue has adhered to the floor of her mouth. She has an obvious lump in the left side of her neck. There are no signs of upper airway obstruction from the tumor. She has pancytopenia but still within the limits for chemotherapy. Her main complaints include severe pain reduced to moderate by analgesia with Fentanyl patch, significant fatigue, and nausea despite premedication with promethazine. She has a PEG tube in place for feeding. Based on the assessment, nausea needs to be managed better in order to prevent the exacerbation of mouth pain and promote patient comfort. Journal articles were consulted and these were located and retrieved from CINAHL, Health Source: Nursing/Academic Edition, Ovid, Proquest and Medline databases.
Literature Review
In order to appreciate the different modes of managing nausea and vomiting, it is important to understand its pathophysiology. The medulla houses the vomiting center which controls the emetic response (Middleton & Lennan, 2011). It is triggered by neurotransmitters which function following stimulation of the vagus nerve which sets off the vomiting reflex, the chemoreceptor trigger zone, the cortex of the brain and the vestibular system (Thompson, 2012). The chemoreceptor trigger zone identifies chemicals and potentially toxic substances in blood. The brain cortex can potentially stimulate nausea and vomiting through memory, sight, taste and smell. The vestibular system in the middle ear concerns balance, body movements and changes in body position which are all associated with motion sickness.
Nausea and vomiting can either be anticipatory and is experienced within 24 hours before chemotherapy is administered; acute which is observed within 24 hours after administration; or delayed which takes place beyond 24 hours post administration (Thompson, 2012). These three classifications of nausea and vomiting are mediated by different pathways. The etiology of acute nausea and vomiting is the chemotherapeutic drug itself which directly stimulates the vagus nerve (Tipton et al., 2007). Further, as the chemical components of the drug are systemically distributed, the chemoreceptor trigger zone identifies them as toxic and stimulates the vomiting center (Middleton & Lennan, 2011).
Anticipatory nausea and vomiting occurs as a conditioned response to chemotherapy, learned and reinforced by prior treatment experiences (Tipton et al., 2007). When the patient has nausea and vomiting immediately following the first treatment, he or she comes to associate the sights, sounds, smells of the treatment environment to the symptoms based on memories and through the cerebral cortex. Finally, it is not clearly known why and how delayed nausea and vomiting occurs but it is assumed that chemical residues of chemotherapeutic drugs stimulate the chemoreceptor zone (Middleton & Lennan, 2011).
In managing oncology patients undergoing chemotherapy, there is a high-level of evidence showing that a systematic assessment which includes risk factors is important in order to anticipate the severity and timing of symptoms and prevent or manage accordingly (Pamaiahgari, 2011). The capacity of the drugs the patient is receiving in inducing nausea and vomiting must be considered. Using the above patient situation, the patient is receiving fluorouracil and paclitaxel which both constitute a low risk for nausea and vomiting (Hawkins & Grunberg, 2009). However, she is also taking cisplatinum which is a high risk drug for nausea and vomiting and which is also noted to cause acute and delayed symptoms.
Other risk factors that increase likelihood are age below 50 years, being female and a prior history of morning sickness during pregnancy and motion sickness (Hawkins & Grunberg, 2009). A risk factor reducing the likelihood is excessive alcohol intake since studies show the symptoms tend to occur less in this population of patients (Middleton & Lennan, 2011). Finally, anxiety is also deemed to aggravate nausea and vomiting and plays a significant role in anticipatory and delayed symptoms (Thompson, 2012). Thus, besides addressing acute symptoms, it is imperative to also manage patient anxiety prior to chemotherapy treatment to reduce anticipated nausea and vomiting. At the same time, delayed symptoms, though these often take place post discharge and in the home, should also merit the same attention given to acute nausea and vomiting.
Pharmacologic Management
Nausea and vomiting are managed mainly though drug therapy and combination therapy has been proven to more effective than monotherapy. Particularly for acute nausea and vomiting, first-generation 5HT3 receptor antagonist drugs such as Zofran (ondansetron), intravenous or oral, work in only 20% of cases (Shwartzberg et al., 2011). This drug works by blocking the neurotransmitter serotonin’s receptor sites and preventing impulse transmission to the vomiting center. Second-generation 5HT3 receptor antagonists such as Aloxi (palonosetron) have a higher efficacy and work in both moderate and high-risk cases (Shwartzberg et al., 2011; Middleton & Lennan, 2011).
The above are general guidelines for solid-tumor malignancies. However, for leukemia and other nonsolid neoplasms, a consensus is yet to be arrived at. Further, since the emetic response is triggered through different mechanisms, a combination therapy adding Decadron (dexamethasone) and Emend (fosaprepitant dimeglumine or aprepitant in short form) to anti-5HT3 receptor drugs is recommended for maximum control (Takiuchi et al., 2006; Trigg & Higa, 2010). With appropriate use of antiemetic drugs, a 70-80% prevention rate among patients can be achieved (Pamaiahgari, 2011). However, although vomiting can be adequately controlled through drugs, nausea is still persistent in a significant number of patients and remains a major clinical issue.
Non-Pharmacologic Management
The failure of pharmacologic therapy promoted the use of complementary and alternative medicine (CAM). The National Center for Complementary and Alternative Medicine (NCCAM) defines this modality as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine” (What is complementary, 2011). An alternative health care system, such as traditional Chinese medicine (TCM), is the equivalent of conventional Western medicine among the Chinese (Snyder & Lindquist, 2006). Acupressure and acupuncture are some of the treatment components of TCM. Acupuncture is the insertion of very thin needles into acupuncture points on the skin.
A major issue with CAM is their evidence base. Their acceptance and integration into health care is quite recent and the nature of most studies done so far prevents generalization which could increase confidence in their outcomes. CAM modalities with a high level of evidence are acupressure and acupuncture which were shown to be successful in controlling acute nausea and vomiting (Molassiotis et al., 2007; Tipton et al., 2007). The region utilized is PC6 or the area two inches above the wrist on the inner forearm. Wearing loose clothing, identifying sensory triggers and avoiding them, and excluding foods and fluids that promote emesis from diet are other suggested interventions with a fair level of evidence and can be recommended (Pamaiahgari, 2011).
Many other interventions have been proposed and studied which include the use of ginger, drinking Concord grape juice, massage, aromatherapy, progressive muscle relaxation therapy, guided imagery and hypnosis (Ingersoll et al., 2010). However, the number of studies is still quite small in order to increase clinical confidence in their use. As of the present, their level of evidence has been minimal and further research is necessary. On the other hand, patients have specific responses and optimizing all options available to produce the highest level of quality of life during chemotherapy comprises quality patient care.
Other Nursing Interventions
Besides risk assessment and symptom management, patient education is also important with emphasis on prevention rather than cure (Vidall, 2011; Thompson, 2012)). Thus, compliance with prophylactic antiemetic medications must be emphasized. Nurses must also communicate exactly what the patient should expect from antiemetic therapy in light of current evidence Middleton & Lennan, 2011). Additionally, since delayed nausea and vomiting occur at home and potentially represent toxicity, patients should be taught to accurately record their symptoms and communicate the information to the physician for possible adjustment of chemotherapy schedule or dose.
In addition, drug responses noted in consecutive cycles also help predict responses for remaining cycles making nausea and vomiting management easier (Pamaiahgari, 2011). Patient education should also include discussing the differences between the classes of antiemetic drugs in terms of indications, efficacy and side effects to prevent substitution of one class with another and receiving less than optimal results (Feinberg et al., 2009; Smith, 2008). Other information needed for self-management is also warranted given that the disease is chronic and the patient spends time at home after chemotherapy administration.
In summary, guidelines are available with regard to pharmacologic treatment which is still the standard management and adherence must be ensured. CAM treatments, i.e. acupuncture and acupressure, have also been shown to effectively complement drug therapy and should be discussed with the patient. Other interventions with fair or lower levels of evidence must be considered from a risk over benefit analysis. A systematic and continuous assessment throughout the patient’s chemotherapy must be implemented which will provide information on patterns of response and facilitate optimum management. Finally, patient education is important as compliance, objective reporting of symptoms and overall self-management are essential to the success of management efforts.
References
Chemotherapy side effects sheets (n.d.). Retrieved from
http://www.cancer.gov/cancertopics/coping/chemo-side-effects
Feinberg, B.A., Gilmore, J., Haislip, S., Gondesen, T., Saleh, M.N., & Lenz, W.H. (2009).
Community Oncology, 6(2), 62-67.
Hawkins, R., & Grunberg, S. (2009). Chemotherapy-induced nausea and vomiting:
Challenges and opportunities for improved patient outcomes. Clinical Journal of
Oncology Nursing, 13(1), 54-64. Retrieved from
http://search.proquest.com/docview/222742522?accountid=12085
Ingersoll, G.L., Wasilewski, A., Haller, M., Pandya, K., Bennett, J., He, H., . . . Berry, C.
(2010). Effect of concord grape juice on chemotherapy-induced nausea and vomiting:
Results of a pilot study. Oncology Nursing Forum, 37(2), 213-21. Retrieved from
http://search.proquest.com/docview/223108452?accountid=12085
Mariano, C. (2007). Holistic nursing: Scope and standards of practice. : Jones and Bartlett
Publishers.
Middleton, J. & Lennan, E. (2011). British Journal of Nursing, 20(17), S7-S15.
Molassiotis, A., Helin, A.M., Dabbour, R., & Hummerston, S. (2007) The effects of P6
acupressure in the prophylaxis of chemotherapy-related nausea and vomiting in breast
cancer patients. Complementary Therapies in Medicine , 15(1), 3-12.
Pamaiahgari, P. (2011). Chemotherapy-induced nausea and vomiting [2011-11-11].
Adelaide, Australia, Adelaide: Joanna Briggs Institute. Retrieved from
http://search.proquest.com/docview/928971670?accountid=12085
Perwitasari, D.A., Atthobari, J., Mustofa, M., Dwiprahasto, I., Hakimi, M., Gelderblom, H.,
Kaptein, A.A. (2012). Impact of chemotherapy-induced nausea and vomiting on
quality of life in Indonesian patients with gynecologic cancer. International Journal
of Gynecological Cancer, 22(1):139-145.
Smith, C. (2008). Chemotherapy-induced nausea and vomiting: Contemporary approaches for
optimal management. ONS Connect (2008), 67-68. Retrieved from
http://search.proquest.com/docview/222740049?accountid=12085
Snyder, M. & Lindquist, R. (2006). Complementary/alternative therapies in nursing (5th ed.).
New York, NY: Springer.
Schwartzberg, L.S., Jacobs, P., Matsouka, P., Azevedo, W., & Pinto, A. (2011). The role of
second-generation 5-HT3 receptor antagonist in managing chemotherapy-induced
nausea and vomiting in hematological malignancies. Critical Reviews in
Oncology/Hematology, 83(1), 59-70.
Takiuchi, H., Kawabe, S., Goto, M., Ota, S., Kii, T., Tanaka, T., Katsu, K. (2006).
Principles of managing chemotherapy-induced nausea and vomiting. Cancer
& Chemotherapy, 33(1), 19-23.
Thompson, N. (2012). Optimizing treatment outcomes in patients at risk for chemotherapy-
induced nausea and vomiting.Clinical Journal of Oncology Nursing, 16(3), 309-13.
Retrieved from http://search.proquest.com/docview/1020694009?accountid=12085
Tipton, J. M., McDaniel, R. W., Barbour, L., Johnston, M. P., & al, e. (2007). Putting
evidence into practice: Evidence-based interventions to prevent, manage, and treat
chemotherapy-induced nausea and vomiting. Clinical Journal of Oncology
Nursing, 11(1), 69-78. Retrieved from
http://search.proquest.com/docview/222745666?accountid=12085
Trigg, M.E., & Higa, G.M. (2010). Chemotherapy-induced nausea and vomiting: Anti-emetic
trials that impacted clinical practice. Journal of Oncology Pharmacy Practice, 16(4),
233-244.
What is complementary and alternative medicine? (2011, July). Retrieved from
http://nccam.nih.gov/health/whatiscam
Vidall, C. (2011). Chemotherapy induced nausea and vomiting: A European
perspective. British Journal of Nursing 20(Supplement 10), S22–S28.
