2. EFFECTS OF CANCER ON
NUTRITIONAL STATUS AND
ITS CONSEQUENCES:
 ANEMIA:
DEFINITION—symptom of abnormally low
red blood cells (RBCs), quality of hemoglobin
(Hgb), and / or volume of packed cells (WHO)

3. Disease related
 Slow or persistent blood loss causing
decreased RBC volume
 Primary malignancies of the marrow, tumor
invasion of the marrow, or genetically
transmitted RBC deficiencies (thalassemias)
causing decreased quantity / quality of RBC
production.

4.  Impaired absorption (post-gastrectomy, celiac
disease), inadequate intake (cachexia,
alcoholism(, or decreased utilization of iron, folic
acid, vitamin K, or vitamin B1; causing decreased
maturity and function of RBCs
 Autoimmune disorders associated with
malignancy
 Conditions that lead to decreased erythropoietin
(EPO) production, decreased sensitivity to EPO,
or a reduction in erythrocyte progenitor cells,
such as acute or chronic renal disease, hemolysis

5.  Chemotherapy—destruction of rapidly dividing
normal hematopoietic cells results in decreased
production of RBC precursors and mature RBCs.
 Radio Therapy—destruction of RBC precursors
in the radiation field.
 Pharmacologic agents—inhibit RBC production
or cause decreased mineral and vitamin levels
(oral contraceptives, estrogen, phenytoin
(Dilantin), phenobarbital (Luminal).

6.  Once the diagnosis is established; underlying
cause must be identified and, if possible,
corrected.
 Supplements such as iron, vitamins, folic acid.
 RBC transfusions are indicated for the
following:
 Symptomatic anemia (dyspnea, tachycardia)
occurs, regardless of the hematocrit.
 Client is actively bleeding.
 Haemoglobin level drops below 8 g / dl

7.  History
 Physical findings
 Diagnostic tests and findings

8. Educate the client and the family regarding:-
 Purpose, dosage, side-effects, toxic effects of the
medication
 Nutrition- Counsel regarding various iron rich
diets and supplements
 Activity, frequency and rest periods can be
determined
 Sign and symptoms regarding complication like
change in mental status, increases shortness in
breath, onset of active bleeding

9.  Monitor client for complications related to
anaemia
 Assess skin for inadequate oxygenation, such
as pallor, decreased capillary refill etc
 Assess B.P in lying, sitting and standing
position for orthostatic hypotension
 Monitor occurrence of constipation or
diarrhoea related to iron supplements
 Assist in activities of daily living in case of
severe anaemia

10.  Cachexia is a complex mix of symptoms
comprising the following:
 Anaemia
 Anorexia
 Organ dysfunction
 Reduced appetite and feeling full
 Wasting of muscles
 Weakness
 Weight loss.

11. Decreased nutritional intake:
 This is probably the most important issue. It
has several causes, including the following:
 Anorexia
 dysphagia
 bowel obstruction resulting in decreased
nutritional intake
 malabsorption

12. Increased nutritional losses:
 Blood loss.
 Diarrhoea and protein loss via the intestines.
Metabolic changes:
 Abnormal metabolism mimicking insulin
resistance with increased energy
 Expenditure unrelated to the extent of disease.
 Altered carbohydrate metabolism.
 Altered lipid metabolism

13.  Poor appetite or poor eating habits:
 Psychological problems, including
depression, resulting in failure to look after
oneself
 Treatment side-effects:
-Chemotherapy may be associated with
nausea, vomiting or mucositis, thus
reducing food intake
-Radiotherapy can cause anorexia, nausea,
vomiting, diarrhoea and a dry or sore mouth

14. The main symptoms of wasting syndrome are
its defining factors, the loss of weight from
muscle and fat deterioration. Secondary
symptoms include:
 Diarrhoea or vomiting lasting for 30 days or
more
 Progressive weakness over a 30 day period
 A fever lasting for several days
 Loss of appetite or anorexia

15.  Loss of muscle bulk
 Dry and scaly skin
 Mouth to see whether there is stomatitis,
cheilosis or glossitis
 Pitting oedema

16. By collection history:
 Find out how much weight has been lost
in the previous 3 months. A loss of 10%
or more of body weight constitutes
malnutrition.
 Ask about possible reasons for poor food
intake and, if necessary, use the
assessment tool .

17.  Look at the skin to see whether it is dry
and scaly.
 Look at the mouth to see whether there is
stomatitis, cheilosis or glossitis,
indicating iron and vitamin deficiencies.
 Assess muscle bulk and muscle strength.
 Look for pitting oedema.

18.  Identification of the amount of muscle wasting
by use of BIA test or a track a patient's BMI,
body mass index, to watch for sudden,
pronounced weight loss
 Ask the dietitian about food supplements, speak
to the occupational therapist about ways to make
daily life easier, and arrange appropriate
physiotherapy.
 Steroids may stimulate the appetite but they do
not increase muscle mass.

20.  Xerostomia a subjective sensation of
dryness in the mouth characterised by a
decrease in composition and physical
properties in the quality and quantity of
saliva

21. A dry and sore mouth is most commonly due to
Candida infection, which occurs in about 10–
15% of patients with cancer at almost any stage
of the illness.
 Concurrent disease (e.g. uncontrolled diabetes).
 Drugs – anticholinergics, antihistamines,
anticonvulsants, beta-blockers, diuretics,
opioids or steroids (which predispose to candida
infection).
 Hypercalcaemia.

22.  Inadequate fluid intake causing dehydration.
 Malnutrition (e.g. anaemia, protein deficiency or
vitamin deficiency).
 Mouth breathing, either by day due to debility or
when asleep.
 Mucositis secondary to chemotherapy.
 Oral infection (e.g. candida).
 Oxygen therapy.
 Radiotherapy to the head and neck causing
diminution of salivary secretion.

23.  Artificial salivary lubricants
 Surgical interventions- salivary reservoirs
and reconstruction with a mandibular
denture
 Dental prophylaxis with before, during
and post radiation treatment

24.  Assess the proper history of the client
 Physical examination
 The patient and their family can be instructed
in the following measures.
 Artificial saliva
 Bicarbonate of soda mouthwashes
 Chilled fruit
 Moistening the mouth
 Sparkling water

25.  DEFINITION—it is the difficulty in
swallowing, pain; usually accompanied by a
sensation of material lodging in the esophagus

26.  Neurologic impairment
 Tumour infiltration and impingement of the
esophagus and mouth by tumor and/ or
treatment—related effects.
 Iatrogenic factors.
1. Psychotropic medications that impair gag
reflex and swallowing.
2. Anticholinergic drugs.
 Lifestyle-related effects

27.  Usually insidious and slowly progressive,
observe for presence of facial droop, drooling,
oral retention, choking, coughing after
swallowing, and gurgling voice quality, ability
to masticate, hold food in mouth, and propel
food to oropharynx using tongue

28.  Usually manifested as difficulty swallowing
solids progressing to difficulty in swallowing
liquids, including saliva, causing fluids and foods
to flow into the lungs, increasing the risk for
aspiration and/ or pneumonia.
 Usually associated with weight loss, anorexia,
nausea, dehydration, protein- calorie malnutrition,
cachexia, muscle wasting, and negative nitrogen
wasting.

29.  Treatment for underlying disease—nodal
radiation, laser surgery antifungal and
antibiotic medications.
 Endoscopic laser therapy
 Alternate method for feeding, which may
require short or long-term interventions

30.  Use of thickening agents (e.g., Thick-It, Nutra-
Thik, Thick’N Easy) to lessen the risk for flow
of liquids into the airway causing choking and
aspiration. .
 Medications—steroids, expectorants,
bronchodilators, pain and anxiety medications
to relieve symptoms related to dysphagia.
 Swallowing therapy and /or direct swallowing
exercise

31.  Collect the proper history of the client.
 Previous treatments for cancer.
 Presence of underlying systemic disease—
infection, cardiac, or stroke.
 Patterns of dysphagia—incidence; pattern;
alleviating, aggravating, and precipitating
factors.

32. Observe the client for:
 Observe for presence of facial droop, drooling,
oral retention, choking, coughing after
swallowing, and gurgling voice quality.
 Determine. ability to masticate, hold food in
mouth, and propel food to oropharynx using
tongue.
 Elicit client's subjective report of pain or
discomfort; weakness of lips, tongue, or jaw;
"lump in the throat."

33. Interventions to monitor complications related to
dysphagia
 Maintain daily intake and output chart
 Weigh daily or at least every other day if daily
weights upset client.
 Assess for signs and symptoms-—dehydration,
aspiration, increased / decreased secretions
 Explore the need for alternative methods for
providing nutrition.

34. Interventions to involve client / family in
care
 Determine willingness of significant
other to assist with care.
 Teach client/ family all aspects of care,
including emergency measures,
pulmonary hygiene, oral hygiene, and
appropriate time to report complications
to a member of the health care team

35. Interventions to enhance adaptation
 Provide ongoing support to client in a situation that
may potentially cause fear, anxiety and inability to
cope.
 Provide detailed written and / or audiovisual
materials.
 Initiate early referral to speech therapist and
dietitian for nutritional advice and suggestions.
 Explore patient’s awareness of and / or use of
complementary/ alternative medicine (CAM), such
as mind/ body control interventions, homeopathy,
acupuncture, and vitamins or herbal products

36.  Impaired swallowing
 Risk for aspiration
 Disturbed sensory perception: gustatory

37. DEFINITION
 A highly subjective, unobservable
phenomenon of an unpleasant sensation
experienced in the back of the throat and
the epigastrium that may or may not
culminate in vomiting. One of the most
feared side effects of cancer treatment
(Finley; 2000).

38. ETIOLOGY AND RISK FACTORS
Disease related
 Primary or metastatic tumor of the CNS
that includes the VC, or increased
intracranial pressure
 Delayed gastric emptying
 Obstruction of a portion of the GI tract.
 Food toxins, infection, or motion sickness

39. Treatment related
 Stimulation of the receptors of the labyrinth
in the inner ear.
 Obstruction, irritation, inflammation, and
delayed gastric emptying stimulating the Gl
tract through vagal visceral afferent
pathways.
 Stimulation of the VC through mucosal
injury causing release of serotonin
associated with chemotherapy

40.  Stimulation of the Vomiting center (VC)
through afferent pathways
 Side effects of medications, such as
digitalis, morphine, antibiotics, iron,
vitamins, and antineoplastic agents.
 Side effects of concentrated nutritional
supplements

41.  Younger age; increased incidence in those less
than 50 years
 Experienced by females more than males
 Increased levels of stress, emotions, and/ or
anxiety
 Noxious odors or visual stimuli.
 Conditioned (anticipatory) responses to
previous cancer treatment and / or other
stressful experiences. Occurs in 25% of
chemotherapy patients.

42. Treatment of underlying disease.
Antiemetic therapy
 Serotonin antagonists (e.g.,
ondansetron)ne receptor antagonists, such
as metoclopramide (Reglan), haloperidol
(Haldol), droperidol (lnapsine).
 Phenothiazines, such as prochlorperazine
 Corticosteroids, such as dexamethasone
 Benzodiazepines, such as lorazepam.

43.  Relaxation and distraction techniques,
including guided imagery and music therapy
 Acupressure may decrease symptom
experience and / or intensity of nausea
 Acupuncture
 Hypnosis—It is found a complete response to
anticipatory nausea and a major response to
chemotherapy—induced nausea.

44.  Foot massage—It is found that foot massage
had a significant impact on reducing feelings
of nausea.
 Deep breathing
 Exposure to fresh air and elimination of odors
 Herbal supplements—ginger (dried or fresh)
has been known to have an effect on
decreasing nausea associated with
chemotherapy (
 Aromatherapy—the use of scented candles,
essential oils, and sachets is currently being
researched

45. Assessment the client for:
 Presence of risk factors for nausea, including a
history of motion sickness or pregnancy-induced
nausea
 Presence of defining characteristics of nausea.
 Present symptoms, client’s perception of
possible correlation between occurrence of
nausea and distress; and perceived meaning of
nausea to the client and family work, role
responsibilities, and mood.

46.  Patterns of nausea—onset, frequency associated
symptoms, precipitating factors, aggravating
factors, and alleviating factors. Assess client’s
previous experiences with nausea
II. Physical examination.
 Signs of sweating, tachycardia, dizziness, pallor,
excessive salivation, and weakness.
 Laboratory reports to assess for other causes—
serum electrolytes, liver and renal function tests.
 Weight.

47. III. Psychosocial assessment.
 Explore anxiety producing events and
coping abilities.
 Attempt to identify strengths of client /
family

48.  Altered nutrition: less than body
requirement
 Risk for fluid volume deficit

49. DEFINITION
 Constipation is difficulty passing stools or a
decrease in number of stools. It may be
accompanied by gas, abdominal cramping or
pressure in the lower abdomen. Constipation
may lead to stool impaction, a severe form of
constipation where the stool will no longer
pass through the colon or rectum.

50.  Constipation is caused by a slowing of the
intestinal activity. The normal wave-like action of
the intestines, called peristalsis, serves to
continually move stools out of the body. When
peristalsis slows, the stools become hard, dry and
difficult to pass.
Constipation can have a number of causes including:
 Pain medications
 Chemotherapy drugs

51.  Decreased activity
 Poor diet
 Inadequate fluid intake
Chemotherapy drugs can cause either an increase
or decrease in peristalsis. An increase in intestinal
activity may cause stools to travel faster and be
less formed, resulting in cramping and/or
diarrhoea. A decrease in intestinal activity may
cause stool to travel slower, becoming hard and
dry and more difficult to pass, which is
constipation.

52.  Bowel obstruction
 Dehydration
 Decreased fluid intake or increased losses due to
vomiting or excessive sweating.
 Disease related to:-
- Decreased appetite and low residue intake due to
anorexia.
- Immobility

53.  Drugs
- Anticholinergics.
- Diuretics.
- Granisetron and ondansetron.
- Hyoscine, phenothiazines or tricyclic
antidepressants.
- Octreotide.
- Opioids – were they prescribed without a
laxative?

54.  Immobility and weakness
 Various conditions make it difficult to
achieve the necessary increase in
intraabdominal pressure for evacuation.
These include the following:
-decreased peristalsis associated with
immobility and general debility of cancer

55.  Other causes
-Embarrassment about sharing a toilet.
- Inability to get to the toilet unaided.
-Pain on defaecation due to local problem
such as haemorrhoids or anal fissure.

56.  A sustained change in frequency of bowel
movements from your normal. If the normally
bowel movement is once per day, a change
may be every 2nd or 3rd day.
 Hard, difficult to pass bowel movements or
passage of small, marble-like pieces of stool
without a satisfactory elimination

57.  Cramping and/or flatulence (gas).
 Bowel obstruction
 Confusion and restlessness
 Faecal incontinence
 Retention of urine.

58.  Non-pharmacological management
• Assess bowel function regularly.
• Fibre and fruit intake should be increased
if possible.
• Fluid intake should be increased if
possible.
• Mobility should be encouraged.

59.  Pharmacological management
• Always prescribe prophylactic laxatives
when starting opioids or increasing the
dose.
• Use a combination of a stimulant laxative
and a faecal softener.
• The amounts of softener and stimulant
should be adjusted to suit the individual

60.  Laxatives basically fall into the following
categories:
• bulking agents
• faecal softeners
• osmotic agents
• stimulants
• suppositories and enemas

61.  Bulking agents
 Faecal softener
 Osmotic agents
 Stimulants
 Suppositories and enemas

62.  Assess the history of the client to find out the
needs of the client and the relatives
-Presence of risk factors
-History of defining characteristics of
constipation
-Changes in usual pattern of bowel elimination
such as decreased frequency, hard stools,
abdominal cramping, increased use of
laxatives

63.  Date of last bowel movement.
 Change in factors contributing to bowel
elimination, such as activity level, fluid intake,
dietary fibre intake, and/ or laxative use.
 History of constipation and/ or chronic laxative
use.
 Anxiety regarding bowel patterns.
 Perception of incomplete evacuation following
defecation.
 Rectal pain associated with inability to defecate.

64.  Pattern of occurrence of constipation- onset;
frequency; severity associated symptoms;
precipitating, aggravating, and alleviating
factors.
 Perceived effectiveness of self- are measures
to relieve constipation.
 Perceived impact of constipation on comfort,
activities of daily living, mood.
 History of rectal fissures or abscesses.

65. Physical findings.
A. Inspection of abdomen.
 1. Symmetry.
 2. Contour.
 3. Distension.
 4. Bulges.
 5. Peristaltic waves.

66.  Auscultation of character, frequency and
presence or absence of bowel sounds in the
four quadrants of the abdomen.
 Palpation of abdomen.
 1. Masses or stool in the colon.
 2. Areas of increased resistance or
tenderness.
 Rectal examination to check for fecal
impaction, hemorrhoids, or fissures

68. DEFINITION:
 Diarrhoea refers to the passage of more than
three unformed stools in 24 hours. It is
important to check what the patient means
when they refer to ‘diarrhoea.’ Diarrhoea is
less common than constipation among cancer
patients.

69.  Osmotic Diarrhoea
 Surgery
 Secretary
 Inflammatory damage
 Infectious diarrhoea
 Chemotherapy induced
 Bone marrow transplantation–related
 Diet
 Psychological factors

71.  Antibiotics
 Faecal impaction
 Ileal resection
 Intestinal disease (Crohn’s or ulcerative
colitis)
Sulfasalazine or steroids should be used.
 Laxatives
 Malabsorption and steatorrhoea

72. Assessment:
 History
 Review of previous and current treatment of
cancer
 Review of prescription and nonpescription
medications
 Usual bowel pattern- frequency, colour, odour,
consistency of stool

73.  Recent changes in factors contributing to usual
bowel elimination patterns
1. Increased levels of stress.
2. Dietary changes that increase bowel motility
such as addiuon of tiber and roughage, fruit
juices, coffee, alcohol, fried foods, or fatty foods
3. Recent course of antibiotic therapy.
 Known food or medication intolerance or
allergies.
 Presence of flatus, cramping, abdominal pain,
urgency to defecate, recent weight loss.
 Fluid intake.

74.  National Cancer Institute Grading Criteria.
Grade 1: increase of fewer than 4 stools / day
over pretreatment.
Grade 2: increase of 4 to 6 stools / day or
nocturnal stools.
Grade 3: increase of 7 or more stools / day or
incontinence or need for parenteral support for
dehydration interfering with normal activity.
Grade 4: physiologic consequences requiring
intensive care; hemodynamic collapse

75. DEFINITION
 Hypercalcaemia is defined as a
corrected serum calcium
concentration above 2.6 mmol/litre
(10-12mg/dl). Levels above 4.0
mmol/litre will cause death in a few
days.

76. • Constipation
• Drowsiness, progressing to coma
• Muscle weakness
• Nausea and vomiting
• Polyuria
• Thirst
• Tiredness.

77. ASSESSMENT
1. Ask about the following:
 constipation
 muscle weakness
 nausea and vomiting
 polyuria
 thirst
 tiredness.

78. Assess the following:
• confusion
• dehydration, a major feature of
hypercalcaemia due to polyuria and
vomiting
• drowsiness.

79. Check the following:
• corrected serum calcium concentration
• urea and electrolytes
• ECG
• corrected calcium levels
• urea and electrolytes in order to detect
hypokalaemia and hyponatraemia

80. 4. The drugs fall into four categories
 Bisphosphonates
 Calcitonin
 Plicamycin
 Steroids

81.  Fluid electrolyte imbalance

82.  Metallic taste: It may be due to decreased
sensitivity of taste buds, decreased number of
taste buds, toxic dysfunction of taste buds,
nutritional deficiencies or poor dental hygiene.
Patient should be advised to reduce urea
content of diet; to eat white meats, eggs, dairy
products; to drink more liquids; to eat cold
food; and to have fresh fruits and vegetables

83.  DECUBITUS ULCER
DEFINITION:
‘An area of localised damage to the skin and
underlying tissue caused by pressure, shear or
friction, or a combination of these’

84.  Pathogenesis of pressure ulcers
 There are four main factors that
contribute to the development of pressure
ulcers:
• Friction
• Moisture
• Pressure
• shear.

85.  Friction
 Moisture
 Pressure
 Consider the other factors that might be
putting your patient at risk of a pressure ulcer.
These include the following:
 Anaemia
 Cachexia
 Dressings, clothing or bandages causing
abrasion

86.  Hypoproteinaemia causing interstitial oedema
 Immobility of any part due to any cause
 Immunosuppressant, which increases the risk
of infection
 Malnutrition and vitamin C or zinc deficiency,
which impair wound healing
 Neurological deficit (e.g. diabetes)
 Restraints or rails that could cause injury or
pressure
 Vascular insufficiency
 Wet skin.

87.  Decubitis ulcers can be prevention, if possible,
is the aim. There are four main areas to look
at:
• General measures
• Nutrition
• Pressure redistribution
• Skin care.

88.  DEFINITION:
A pathologic fracture occurs when a bone
breaks in an area that is weakened by another
disease process.

89. CAUSES:
 Tumors
 Primary E.G MULTIPLE MYELOMA,
PAGETS DISEASE
 secondary (metastatic) (most common)
 Benign Tumors
 Fractures more common in benign tumors (vs
malignant tumors)
 most asymptomatic prior to fracture
 Fibroxanthoma

90.  most common in children
 humerus
 femur
 bone cyst, NOF, fibrous dysplasia,
eosinophilic granuloma

91.  Bone Cyst
 aspiration and injection methylprednisolone,
bone marrow or bone graft
 curetting and bone graft (+/-) internal
fixation
 allow fracture to heal and reassess
 ORIF for femoral neck fractures

92.  Fibroxanthoma (Femur, distal tibia, humerus
Multiple in 8% of patients (associated with
neurofibromatosis):
 curetting and bone graft for impending
fractures
 immobilization and reassess after healing
for patients with fracture

93.  Fibrous Dysplasia
 curetting and bone graft (cortical
structural allograft) to prevent
deformity and fracture (+/-) internal
fixation
 expect resorption of graft and
recurrence
 pharmacologic—bisphosphonates

94.  Primary Malignant Tumors:
 Immobilization: Traction, ex fix, cast
 staging
 biopsy
 adjuvant treatment (chemotherapy)
 resection/amputation

95.  Assess the cause of the problem
 Provide adequate skin care to avoid skin
redness and ulceration
 Provide adequate foods rich in calcium and
proteins
 Provide proper immobilization of the affected
extremity
 Give psychological support

96.  Thrombophlebitis is an inflammation of a vein
(phlebitis) accompanied by an increased
tendency to form blood clots
(hypercoagulability), which leads to the
formation of a blood clot (thrombus) in the
vein. It can develop spontaneously or can be a
complication of an injury, a disease, or a
medical or surgical treatment

97.  Varicose veins
 Obesity
 Age older than 60 years (fewer complications
in this age group)
 Cigarette smoking
 Caustic materials, such as lighter fluid and
street drugs, injected intravenously

98.  Hypercoagulable states
 Risk factors for superficial
thrombophlebitis include an increased
blood clotting tendency, infection in or
near a vein, current or recent pregnancy,
varicose veins, and chemical irritation, or
other local irritation or trauma.

99.  Assessment
 History
 Physical exam
 Diagnostic Tests

100.  The goals of treatment for with superficial
thrombophlebitis are to increase comfort and
to prevent progression to DVT. Non-steroidal
anti-inflammatory drugs (NSAIDs) usually
will reverse the inflammation characteristic of
superficial thrombophlebitis and help relieve
pain. Anticoagulants (e.g., warfarin) may be
used to prevent new clot formation.

101.  Compression stockings
 Surgical intervention including clot
removal (thrombectomy), vein stripping,
or vein bypass is rarely needed in
superficial thrombophlebitis but may be
considered if anticoagulant therapy is
ineffective.

102.  DVT requires anticoagulant therapy as soon as
possible after diagnosis is confirmed. Low-
molecular-weight heparin (LMW heparin) is
used immediately to prevent thrombus
extension and often can reduce the risk of
thrombus formation and embolus migration.
 Thrombolytic therapy may be given in those
with DVT to dissolve the original clot and
prevent pulmonary embolism

103. DEFINITION:
 A pulmonary embolus is a blockage of an
artery in the lungs by fat, air, a blood clot,
or tumor cells.

104.  A pulmonary embolus is most often caused by
a blood clot in a vein, especially a vein in the
leg or in the pelvis (hip area). The most
common cause is a blood clot in one of the
deep veins of the thighs.

105.  Burns
 Cancer
 Childbirth
 Family history of blood clots
 Fractures of the hips or thigh bone
 Heart attack
 Heart surgery

106.  Long-term bed rest or staying in one
position for a long time, such as a long
plane or car ride
 Severe injury
 Stroke
 Surgery (especially orthopaedic or
neurological surgery)
 Use of birth control pills or estrogen
therapy

107.  Chest pain
 Under the breastbone or on one side
 May feel sharp or stabbing
 May also be described as a burning, aching, or
dull, heavy sensation
 May get worse with deep breathing, coughing,
eating, or bending
 One may bend over or hold your chest in
response to the pain

108.  Sudden cough, possibly coughing up
blood or bloody mucus
 Rapid breathing
 Rapid heart rate
 Shortness of breath that starts suddenly

109.  Other symptoms that may occur:
 Anxiety
 Bluish skin discoloration (cyanosis)
 Clammy skin
 Dizziness
 Leg pain, redness, and swelling
 Lightheadedness or fainting
 Low blood pressure
 Sweating
 Wheezing

110.  Hospitalization and O2 is necessary
 Thrombolytic therapy. Clot-dissolving
medications include:
-Streptokinase
-T-plasminogen activator (t-PA)
 Anticoagulation therapy.
-The most common blood thinners are heparin
and warfarin

111. DEFINITION:
 Contractures are the chronic loss of joint
motion due to structural changes in non-
bony tissue. These non-bony tissues
include muscles, ligaments, and tendons.

112.  Inherited disorders (such as muscular
dystrophy)
 Injury (including burns)
 Nerve damage
 Reduced use (for example, from
immobilization)

113.  Medication/clinical
 Check range of motion
 (ROM)—move limbs gently.
 Give diazepam if spasms
 or very spastic.
 Check ROM in the key 7 joints on both sides:
 Wrist, knee, elbow, ankle, shoulder

114.  Encourage mobilization.
 If patient is immobile, do simple range of
 motion exercises:
- Exercise limbs and joints at least twice
daily—use booklet to show caregiver how
to do ROM on each of the key 7 joints (on both
sides).

115.  Protect the joint by holding the limb above and
below it and support as much as you can.
 Bend, straighten, and move joints as far as they
normally go; be gentle and move slowly
without causing pain.
 Stretch joints by holding as before but with
firm steady pressure.
 Let the patient do it as far as they can and help
the rest of the way.
 Massage.

118. DEFINITION
 Foot Drop - also known as drop foot - is a
problem where a person has difficulty in lifting
the front part of the foot. With Foot Drop, a
patient is unable to lift the toes upwards, or
towards the shin.

119.  Drug Complications
 Nerve or Muscle Damage
 Central Nervous System Disorders

120.  Often, the only symptom a person may
experience with Foot Drop is the inability to
lift the front part of the foot.
 In typical cases - Foot Drop only affects one
foot, though it is possible for both feet to be
affected depending on the condition that is
causing it to occur

121.  The main signs that a person may be
experiencing Foot Drop are a change in gait.
Because you are unable to lift the toes, the toes
may drag along the ground when walking.
 A steppage gait is not only noticeable by the
exaggerated motion of the leg in use, but by
the sound the foot makes during the gait.

122.  Physical Therapy
 Nerve stimulation
 Use of Accessories and Devices that can help
with Foot Drop like
 Blanket Lifters
 Splints and Braces
 Foot Positioners, Stabilizers, and Elevators
 Foot Lifters

124.  Dyspepsia is a term which includes a
group of symptoms that come from a
problem in your upper gut. The gut or
'gastrointestinal tract' is the tube that
starts at the mouth, and ends at the anus.
The upper gut includes the oesophagus,
stomach, and duodenum.

125.  Gastro Esophageal reflux disease (GERD),
Chronic gastritis and Chronic peptic ulcer
 Alcoholic drinks and Spicy foods
 Chronic infections with Helicobacter pylori
bacteria
 Obesity
 Some medicines such as aspirin
 Cancer e.g. Esophageal tumor.
 Improper chewing of food
 Abnormality in pancreas or bile ducts

126.  Feeling of fullness during a meal.
 Chronic mild to severe pain.
 Chronic burning or an unpleasant
sensation of heat (heart burn).
 Other chronic signs and symptoms of
indigestion are nausea and bloating are
noted
 Belching

127. Advise clients to take the following care
 Emphasize on antacids taken as required
or pescribed: Antacids are alkali liquids
or tablets that can neutralise the stomach
acid. A dose may give quick relief.
Sucralfate and H2 receptor antagonsist,
H+ pump inhibitors anre used to control
symptoms.

128.  Advise for test for H. pylori infection
and treat if it is present.
 For dyspepsia which is likely to be
due to acid reflux - when heartburn is
a major symptom - the following
may also be worth considering
 Posture
 Bedtime

129.  Hiccups are caused by spasms of the
diaphragm leading to a sudden intake of
breath, which is cut off when the vocal
cords close quickly, causing the
characteristic sound which gives rise to
their onomatopoeic name.

130.  Diaphragmatic spasm due to
diaphragmatic irritation results in
hiccups. The diaphragmatic irritation is
often caused by gastric distension or liver
enlargement, the diaphragmatic irritation
being stimulated by involvement of two
main nerve pathways, namely the vagus
nerve and the phrenic nerve.

131.  Drugs
• Barbiturates.
• Benzodiazepines.
• Steroids
 Stimulation of the phrenic nerve
• Brain tumours, especially brainstem.
• Diaphragmatic tumour invasion.
• Mediastinal tumour.
• Meningeal infiltration by tumour deposits

132.  Stimulation of the vagus nerve
• Abdominal distension (e.g. ascites).
• Distended stomach.
• Gastro-oesophageal reflux.
• Liver tumours.
 Systemic causes
• Addison’s disease.
• Hyponatraemia.
• Kidney failure.

133. Assessment of the client:
 How long has the patient been hiccupping?
 Did the hiccup start following any recent
change in medication?
 Do the hiccups stop at night? Psychogenic
hiccups stop during sleep. Has there been any
new psychological problem?
 Has the patient had a stroke?

134. Treatment of hiccups:
 Treatment of hiccup can be unsuccessful,
and no single treatment can be
guaranteed.
 Stop any drugs that could be responsible
(e.g. steroids).

135. • Pharyngeal stimulation
• Breath-holding or rebreathing into a paper
bag. As the PCO2 rises, hiccup should
decrease, but it may restart after
resuming normal breathing.
• Dry granulated sugar to eat.
• Iced water to sip, or crushed ice to eat.

136.  Pharmacological treatments Gastric
distension
• Domperidone 10–20 mg four times daily
or
• Metoclopramide 10 mg four times daily.
 Both of these drugs are pro-kinetics and
may promote gastric emptying

137.  Smooth muscle relaxation
• Baclofen 5 mg three times daily or
• Nifedipine 5 mg as required or three times
daily.
 Suppression of the hiccup reflex
• Chlorpromazine 25 mg.

138.  Suppression of intracranial tumour CNS
irritation
• Dexamethasone, starting with 16 mg daily
or
• Phenytoin 200–300 mg at night.
 Steroids can cause hiccups, so be aware
of this when considering this treatment
option.

139. DEFINITION:
 Dysponea is one of the most common and
distressing symptoms occurring in the clients
admitted to the hospice center with advanced
cancer

140.  Primary diagnosis, that is, lung cancer.
 Secondary diagnosis, that is, pleural
effusion or metastasis to the lungs.
 Treatment for the primary disease, that is,
as anemia secondary to chemotherapy

141.  Dying clients may experience dyspnea in
the absence of hypoxia or lung disease
because of progressive muscle weakness
from cachexia, malnutrition etc.
 The role of oxygen therapy in
nonhypoxic, dyspneic cancer clients is
uncertain, but it may increase comfort
and a trial of oxygen should be used for
each client

142.  Assessment
I. Ask client about presence of feelings of
breathlessness or shortness of breath with
activities
II. Consider the use of a visual analogue
scale to measure intensity of dyspnea
III. Assess respiratory status

143.  Activity intolerance
 Impaired gas exchange

144.  DEFINITION: Narrowing of the
intestinal lumen or interference with
peristalsis.
 CAUSES:
A. Mechanical obstruction—occurs in
small intestines and accounts for 90% of
all obstructions
Extrinsic lesions
Intrinsic lesions

145. Non-mechanical obstruction
 Intra abdominal
 Extra abdominal

146.  Surgery
 Abdominal decompression
 Correction of fluid and electrolyte
imbalances
 Parenteral nutrition

147.  Assessment
 Planning and Implementation

148.  The presence of a wound that refuses to
heal is something that patients simply
cannot ignore. The discharge, bleeding,
pain and the need to have regular
dressings all act as reminders of the
advancing disease.

149. DEFINITION:
 Many cancer patients live with the knowledge
that their disease is both progressive and
incurable. For a significant minority of these
people this reality may be present in the form of a
malodorous, exuding, necrotic skin lesion, which
can be a constant physical reminder of disease
progression. These lesions are commonly known
as 'fungating wounds', the term 'fungating'
referring to a malignant process of both
ulcerating and proliferative growth.

150. A. Fungating wound may develop in the
following ways:
 As a result of a primary skin tumour such as
squamous cell carcinoma or melanoma

151.  Through direct invasion of the structures of the
skin by an underlying tumour, for example
breast cancer or haematological malignancy
such as cutaneous T-cell lymphoma.

152.  From metastatic spread of a distant
tumour. Metastasis may occur along
tissue planes, capillaries or lymph vessels

153.  Malodour
 Exudate
 Pain
 Bleeding

154.  Malodour
Debridement removes necrotic tissue and
bacteria and is the primary treatment for
malodorous fungating wounds.
Antibiotic therapy can also be effective
if this destroys the bacteria responsible
for malodour, the most common
treatment being metronidazole

155.  The use of activated charcoal dressings
can have an immediate effect on wound
malodour.
 Sugar paste and honey have recently
come back into use, mainly due to the
emergence of many antibiotic resistant
strains of bacteria, and both have
antibacterial and debriding properties.

156.  A variety of dressings have been evaluated
for the management of exudate from
fungating wounds with varying levels of
success.
 Where exudate is low, wounds should be
managed with dressings that have a low
absorbency so as not to dry out the wound,
for example hydrocolloids, semi-permeable
films and low adherent absorbent dressings.

157.  Assessment of pain is vital as this will
enable the clinician to understand the
type of pain the patient is experiencing
and determine the most appropriate
treatment
 It may also be useful to give the patient a
pre-medication before dressing changes
or a booster dose of their usual opiate is
given

158.  If pain cannot be controlled at dressing
changes then it may be worth trying a
product that requires less frequent changes
 Topical opioids are an interesting
alternative form of pain control that can be
used for painful ulcerating wounds
 Morphine and diamorphine are most
commonly used, mixed with a hydrogel
(about 1 mg of morphine to 1 g of hydrogel
for 0.08 to 0.1% mixture).

159.  Preventative measures are important to
reduce the risk of bleeding
 Oral antifibrinolytics such as tranexamic
acid may also help.
 For wounds that are actively bleeding,
there are a number of strategies available.
Sucralfate paste or an alginate may be
applied to wounds with a small amount of
bleeding.

160.  Three areas of concern in the category of
psychologic distress include depression,
anxiety and neurocognitive changes .
 Clients at the end of life may experience
anxiety related to uncertain future,
separation from loved ones, burden on
family and loss of control.

161. Assessment
 I. Recognize evidence of depression, such
as hopelessness, helplessness,
worthlessness, guilt, and sustained
suicidal ideation
 II. Assess for anxiety

162.  Anxiety.
 Risk for suicide.

163.  Many patients in palliative care settings
complain of tiredness and fatigue, and
many attribute this to poor sleep. They
may experience difficulty in getting to
sleep, difficulty in staying asleep,
wakening early, waking normally but still
feeling tired, or a combination of these

164. • Irritability
• Loss of will due to exhaustion, resulting
in inability to cope
• Lowered pain threshold, resulting in
worsening of pain which interferes with
sleep, and the lack of sleep further
reduces the pain threshold
• Tiredness and reduced activity, which
increases the risk of pressure ulcers.

165. MANAGEMENT
Assessment
 Find out why the patient is not sleeping.
Possible causes include the following:
• Breathing difficulty, especially when lying
down
• Delirium, with a disturbed body rhythm,
Depression, Fear (e.g. of dying while
asleep), Itch, Nausea and vomiting,
Nightmares

166.  Use of General and non-pharmacological
measures
 Let patients try the following simple
measures to see whether they help:
• bathing in order to relax before going to
bed
• massage or aromatherapy to aid relaxation

167. • music to aid relaxation and sleep
• progressive muscle relaxation
• warm milk or a carbohydrate snack at
bedtime.