Thirty year old Mrs. Sally Marek has presented with nausea, vomiting, drowsiness and confusion following her chemotherapeutic treatment for breast cancer. She has been admitted with dehydration due to poor consumption of food and drink. Her current health problem is Fluid Volume Deficit. The accompanying clinical features are a decreased blood pressure, fatigue over several weeks with pain and nausea giving her sleepless nights. Worrying about her son’s lonely and motherless future was probably another cause for insomnia. The pulse oximeter recorded an oxygen saturation of 96%. Her fatigue has restricted her level of activity and she could not keep up with her son; she could not also concentrate on her activities for the necessary lengths of time. Dehydration has been having its toll on her especially after her episodes of diarrhea. Having a dry mouth, cracked lips, severe oral ulcers and oral thrush, she is unable to eat or drink and has a reduced urine output. Since the last chemotherapy 2 weeks ago, she has lost 5 kg. in weight and has reflux problems where she is unable to keep food and drink down even if she consumes in small quantities. In general she is feeling “awful”. The lack of intake of food and drink has probably caused her to lose weight. Decreased urine output is probably due to her dehydration and poor fluid intake. She is worried about opting for the chemotherapy now as she has been reading information from the internet. Otto (2001) describes malignancy as the abnormal growth of cells where they do not have any or fail to fulfill the normal function of the cell. The features of unregulated cell division and growth are accompanied by uncontrolled cell functioning and abnormal motility (Otto, 2001). This excessive proliferation results in a shapeless lump which keeps on expanding as in Sally’s breast. As the new cells grow into neoplasms, they start to compete for space and essential nutrients. Neoplastic growths are referred to as benign neoplasms or malignant neoplasms (Otto 2001). Malignant neoplasms are more of the solid kinds and can kill the person having them. Chemotherapy, which involves the use of drugs for cure, control or palliation of the disease process, is the management of choice for treating Sally’s breast cancer. The disadvantages with chemotherapy are that normal cells are also harmed and side-effects are seen. Nausea and vomiting, fatigue, diarrhoea and constipation, infection and anorexia constitute the side-effects. The gastro-intestinal side effects are a reaction to the release of serotonin stimulating the chemoreceptor zone and the vomiting centre in the brain (Brown & Edwards 2005). The destruction of the cells during the treatment of chemotherapy has led to accumulation of metabolites causing the fatigue which is also a side-effect. The loss of appetite in cancer patients is a general reaction to chemotherapy (Otto, 2001). The fluid volume deficit caused the side-effects of chemotherapy. The water loss without the loss of the sodium has decreased the volume of fluid in the interstitial, intravascular or intracellular fluid leading to dehydration (Johnson, Bulechek, McCloskey, Dochterman, Mass & Moorhead 2001). Sally has fluid volume deficit caused by excessive fluid loss after her chemotherapy, the dehydration diagnosed by the features of inability to absorb food and fluids and as manifested by low blood pressure, increased pulse rate, dry mouth, cracked lips, and decreased urine output as per subjective and objective data. The goal of therapy is the management of fluid and electrolyte balance. The outcome should be a hydrated patient who can consume food and drinks without losing them through vomiting and diarrhea.
The first nursing intervention is to decrease the episodes of nausea and vomiting which are the worst side-effects of chemotherapy, by adequate administration of anti emetics (Otto, 2001). The nurse assesses the features of the nausea and vomiting including frequency and duration apart from identifying the aggravating factors. Timely administration of the anti-emetic medications should relieve the nausea. Ensuring that she has had her medications is as essential as prescribing them. It is the nurse’s duty to observe that the patient takes her medicines on time as this affects the fluid intake and thereby the fluid volume status as rehydration of the patient is extremely important for recovery (Otto, 2001). The matter should be reviewed by the doctor: if Sally has not taken the medicine or if she does not get relief for her nausea, another medication has to be given to be effective in eliminating the nauseous feeling. If she does not tolerate the oral route, intramuscular or intravenous injections may be given. Otto suggests: “The combination of antiemetic medication with different mechanisms and around the clock administration, higher doses have proved to be more effective rather than single agent dosing and as needed” (p. 663). Identification and removal of aggravating factors like visual stimuli or a source of odour prevents the triggering of the nausea and vomiting. The outome that is expected from this intervention is the promotion of comfort of the patient, her hydration and subsiding of the symptoms (Johnson et all 2001).
Maintaining adequate levels of hydration to counteract fluid volume deficit and maintain blood pressure is the second intervention. Initially assessment is made of the level of dehydration form the signs which are decreased blood pressure, weight loss, dry mouth, cracked lips, and episodes of diarrhoea. The decision on the amount and type of fluid to maintain hydration and fluid-electrolyte balance needs to be taken. Monitoring of the fluid administration by the nurse is equally important. Sally must be educated on keeping herself hydrated. A fluid balance chart must be maintained to record intake and output so that evaluation is facilitated. It is of utmost importance that the amount, frequency, and type of vomitus and any episodes of diarrhoea must be documented as well (Brown & Edwards 2005). Patient education is of significance as the patient is the best person to speak about the number of times she vomited or had loose motion. Sally must take caution to weigh herself every morning after vomiting or voiding to know her weight loss. Fluid status is indicated by daily weighing (Crisp and Taylor, 2005). Close urine output monitoring also should be a duty of the nurse. Care must be taken to keep the output between 700 mls and 1400 ml. (Brown & Edwards 2005). Sally must learn how to report differences in output and changes in her current status while also taking steps to avoid dehydration through hydration and elimination status. (Otto, 2001).
Promotion of rest and sleep is the third intervention planned for Sally. The pain of her mouth ulcers has been giving her sleepless nights. Assessment of the pain experienced by Sally is done by using the visual analogue or the verbal numerical scale or by approaching the family members (Otto 2001). Sally must be encouraged to ask for pain relievers when necessary as analgesia is effective. The effectiveness of using analgesics must be impressed upon her. Alternate therapies like oxygen therapy, heat and wheat packs can be used. Sally must contact the nurse as soon as she has pain so that she may be given some relief immediately in the hope that mood disturbances may be prevented. If these come on, sleep disturbance is the outcome and this worsens Sally’s condition. Pain management can also reduce her levels of anxiety, depression, anger and irritability (Crisp & Taylor, 2005). This promotes comfort and induces sound sleep. This pain relief also helps her to attend to her self. With lesser anxiety levels, she is able to go about her normal activities and maintain her mood when at home (Williams, Piamjariyakul, Ducey, Badura, Boltz, Olberding Wingate, Williams 2006). With this intervention, the patient outcome expected is rest and undisturbed sleep for Sally
Maintaining Sally’s skin integrity and promoting comfort is the fourth intervention. Her mouth ulcers must be inspected for the colour, vascularity, bleeding, apart from any lesions on the skin (Otto2001). Good skin is recognised by the smoothness, warmth, suppleness and turgor. Sally and her family must be educated on the skin care and the risks of potential infection from her cracked lips and low blood counts from her chemotherapy. Frequent mobilization to prevent the breaking down of pressure points and encouraging circulation is essential for preventing infection. The patient outcome aimed at is the skin integrity by the time of discharge. If there is skin impairment, Sally must report any altered sensation or pain (Ackeley & Ladwig, 2004). Sally and her family should be able to recognize any impairment.
Sally and her family would be provided with ample knowledge and understanding of the fluid management to take care of it appropriately by herself with their help at home. She would be able to prevent dehydration better and using simple interventions may even correct the dehydration as is possible. Her daily activities and her care for the son and husband may improve when her condition becomes more stable. Hopefully she will have lesser fatigue and be able to cope with her responsibilities and go back to work. Her husband may feel relieved about the sharing of work and responsibilities between them. Her son will see more of his mother.
Ackley, B.J. & Ladwig, G.B. (2004) Nursing diagnosis handbook. A guide to planning care. (6th ed.). St. Louis : Mosby.
Brown, D., & Edwards, H. (2005). Lewis’s Medical- surgical Nursing: assessment and management of clinical problems. Sydney: Mosby.
Crisp, J., & Taylor, C. (2005). Potter & Perry’s: fundamentals of nursing. ( 2nd ed.). Sydney: Elsevier.
Otto, S. E. (2001). Oncology Nursing. (4th ed.). Sydney: Mosby.
Porth, C.M. (2005). Pathophysiology : concept of altered health states. (7th ed.). Philadelphia : Lippincott
Johnson, M., Bulechek, G., McCloskey Dochterman, J., Mass, M., Moorhead, S. (2001). Nursing Diagnoses, Outcomes and Interventions: Nanda, NOC, and NIC Linkages. St Louis: Mosby.
Williams, P. D., Piamjariyakul, U., Ducey, K., Badura, J., Boltz, K. D., Olberding, K., Wingate, A., Williams, A. (2006). Cancer Treatment, Symptom Monitoring, and Self-care in Adults: Pilot Study. International Journal for Cancer, 29(5), 347 – 355.