CANCER
SYMPTOM
MANAGEMENT
FOURTH EDITION
Edited by
Connie Henke Yarbro, RN, MS, FAAN
Adjunct Clinical Associate Professor
Sinclair School of Nursing
Editor, Seminars in Oncology Nursing
University of Missouri, Columbia
Columbia, Missouri

Debra Wujcik, PhD, RN, FAAN

Director, VICC Clinical Trials Shared Resource
Associate Professor, Vanderbilt School of Nursing
Vanderbilt Ingram Cancer Center
Nashville, Tennessee

Barbara Holmes Gobel, RN, MS, AOCN®
Operations Manager, Oncology Services
Northwestern Memorial Hospital
Adjuvant Faculty, Rush University College of Nursing
Chicago, Illinois

9781284025538_FMxx_ttlpg.indd 1

Past Editors
Margaret Hansen Frogge, RN, MS
Michelle Goodman, RN, MS

4/18/13 2:17 PM


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Library of Congress Cataloging-in-Publication Data
Cancer symptom management / [edited by] Connie Henke Yarbro, Debra Wujcik, Barbara Holmes Gobel. — 4th ed.
   p. ; cm.
  Includes bibliographical references and index.
  ISBN 978-1-284-02553-8 (pbk.)
  I.  Yarbro, Connie Henke.  II.  Wujcik, Debra.  III.  Gobel, Barbara Holmes.
  [DNLM: 1. Neoplasms—nursing.  2.  Neoplasms—complications.  3.  Oncologic Nursing—methods.

  4. Patient Care Management—methods. WY 156]
 616.99’40231—dc23
2013001117
6048
Printed in the United States of America
17 16 15 14 13 10 9 8 7 6 5 4 3 2 1


Contents
Preface
Acknowledgments
The Editors
Contributors

xv
xvii
xix
xxi

Part I

The Problem of Symptom Distress

1

1

Evidence-Based Symptom Management

3


Susan S. Tavernier, PhD, RN, APRN-CNS, AOCN®

Evidence-Based Practice, 3
Evidence-Based Practice and Diffusion Theory, 5
Nursing Implications, 5

Part II

Alterations in Comfort

2

Arthralgias and Myalgias

Case Example: Distress Management, 6
Conclusion, 8
References, 8

11
13

Virginia R. Martin, MSN, RN, AOCN

®

The Problem, 13
Incidence, 13
Etiology, 15
Emerging Etiology, 17

Pathophysiology, 17
Symptom Assessment, 17
Risk Factors, 18
Self-Assessment, 18
Objective Assessment, 18
3

Degrees of Toxicity, 19
Symptom Management Strategies, 19
Therapeutic Approaches, 20
Nursing Implications, 22
Patient Self-Care, 22
References, 22
Appendix 2A: Self-Care Guide: Muscle Aches and
Joint Pain, 24

Cancer-Related Fatigue

27

Sandra A. Mitchell, PhD, CRNP, AOCN®

The Problem, 27
Incidence, 28
Etiology, 28
Pathophysiology, 29
Symptom Assessment, 29
Risk Factors, 29
Self-Assessment, 30
Objective Assessment, 30


Degrees of Toxicity, 32
Symptom Management Strategies, 33
Therapeutic Approaches, 33
Nursing Implications, 36
Patient Self-Care, 37
References, 38
Appendix 3A: Self-Care Guide: Fatigue, 42

iii


iv

Contents

4

Menopausal Symptoms

45

Sheryl Redlin Frazier, RN, MSN; Mary Egger, RN, MSN, WHNP

The Problem, 45
Incidence, 45
Etiology, 45
Pathophysiology, 47
Symptom Assessment, 47
Risk Factors, 47

Objective Assessment, 49
Symptom Management Strategies, 49
Vasomotor Symptoms, 49
Urogenital Effects and Sexual Dysfunction, 55
Osteoporosis, 56
Cardiovascular Disease, 58

Nursing Implications, 58
Patient Self-Care, 59
References, 59
Appendix 4A: Self-Care Guide: Managing the
Symptoms of Menopause: Hot Flashes and Night
Sweats, 62
Appendix 4B: Self-Care Guide: Managing the
Symptoms of Menopause: Changes in the Female
Anatomy, 64
Appendix 4C: Self-Care Guide: Osteoporosis:
Maximizing the Health of Your Bones, 66

5Pain

69

Jeannine M. Brant, PhD, APRN, AOCN®

The Problem, 69
Incidence, 71
Etiology, 71
Pathophysiology, 72
Cancer Pain Pathophysiology, 73

Symptom Assessment, 73
Risk Factors, 73
Self-Assessment and Pain History, 74
Objective Assessment, 76
Degrees of Toxicity, 77

6

Symptom Management Strategies, 77
Preventive Strategies, 77
Therapeutic Approaches, 77
Nursing Implications, 86
Patient Self-Care, 87
References, 87
Appendix 5A: Self-Care Guide: Pain, 90

Sleep Disturbances

93

Ellyn E. Matthews, PhD, RN, AOCN®, AOCNS® ; Ann M. Berger, PhD, APRN, AOCNS®, FAAN

The Problem, 93
Sleep Definition, States, and Stages, 93
Characteristics of Sleep Disturbances, 94
Sleep Disturbances and Symptom Clusters, 95
Hypersomnia and Insomnia, 95
Consequences of Impaired Sleep, 96
Incidence, 96
Etiology and Risk Factors, 97

Pathophysiology, 98
Symptom Assessment, 99
Subjective Assessment, 99
Objective Assessment, 101
Degrees of Toxicity, 101

Symptom Management Strategies, 102
Therapeutic Approaches, 102
Nursing Implications, 105
Patient Self-Care, 105
References, 107
Appendix 6A: Self-Care Guide: Managing Sleep
Disturbances, 110
Appendix 6B: Self-Care Guide: Daily Sleep
Diary, 112


Contents

Part III Alterations in Protective Mechanisms
7

113

Hypersensitivity Reactions to Antineoplastic Drugs

115

Wendy H. Vogel, MSN, FNP, AOCNP®


The Problem, 115
Incidence, 115
Etiology, 115
Pathophysiology, 117
Symptom Assessment, 120
Risk Factors, 120
Self-Assessment, 121
Objective Assessment, 121
Degrees of Toxicity, 123

Symptom Management Strategies, 124
Therapeutic Approaches, 124
Nursing Implications, 126
Patient Self-Care, 127
References, 127
Appendix 7A: Self-Care Guide: Hypersensitivity
Reaction to Antineoplastic Drugs, 129

8Infection

131

Laura J. Zitella, MS, RN, ACNP-BC, AOCN®

The Problem, 131
Incidence, 131
Etiology, 132
Pathophysiology, 133
Sources of Infection, 134
Symptom Assessment, 134

Risk Factors, 134
Self-Assessment, 134
Objective Assessment, 135
Degrees of Toxicity, 136

Symptom Management Strategies, 138
Therapeutic Approaches, 138
Nursing Implications, 148
Patient Self-Care, 149
References, 149
Appendix 8A: Self-Care Guide: Prevention of
Infection, 152
Appendix 8B: Self-Care Guide: Food Safety, 154
Appendix 8C: Self-Care Guide: Hand
Washing, 156

Part IV Alterations in Gastrointestinal Function

159

9Constipation

161

Pamela J. Haylock, PhD, RN, FAAN; Carol Curtiss, MSN, RN-BC; Robert L. Massey, PhD, RN, CNAA

The Problem, 161
Prevalence, 162
Etiology and Pathophysiology, 162
Normal Intestinal Physiology, 162

Mechanisms of Constipation, 162
Constipation in the Person with Cancer, 163
Symptom Assessment, 166
Self-Assessment, 166
Objective Assessment, 167
Degrees of Toxicity, 171

Symptom Management Strategies, 171
Therapeutic Approaches, 171
Nursing Implications, 177
Patient Self-Care, 178
References, 178
Appendix 9A: Self-Care Guide: Prevention of
Constipation, 181

v


vi

Contents

10Diarrhea

185

Paula M. Muehlbauer, RN, MSN, AOCNS ; Rachael Christine Lopez, MPH, RD, CSO
®

The Problem, 185

Incidence and Etiology, 186
Pathophysiology, 190
Symptom Assessment, 191
Risk Factors, 191
Self-Assessment, 191
Objective Assessment, 191
Symptom Management Strategies, 193
Therapeutic Approaches, 194
Nursing Implications, 202
Patient Self-Care, 203
References, 204

11

Appendix 10A: Self-Care Guide: Weekly Bowel
Pattern Diary, 206
Appendix 10B: Self-Care Guidelines: Diarrhea
from Cancer Treatment, 207
Appendix 10C: Self-Care Guide: Dietary
Guidelines to Prevent Exacerbation of
Treatment-Induced Diarrhea by Food
Group, 209
Appendix 10D: Skin Care and Incontinence
Guidelines: Taking Care of Your Skin, 211

Nausea and Vomiting

213

Janelle Tipton, MSN, RN, AOCN®


The Problem, 213
Incidence, 214
Etiology, 214
Pathophysiology, 215
Neural Structures, Transmitters, and Receptors
Involved in Emesis, 215
Symptom Assessment, 216
Risk Factors, 217
Self-Assessment, 219
Objective Assessment, 219
Degrees of Toxicity, 220
Symptom Management Strategies, 221
Therapeutic Approaches, 221
Nursing Implications, 227
12

Malignant Ascites

Consideration of Vulnerable Populations, 229
Future Research, 229
Patient Self-Care, 231
References, 231
Appendix 11A: Self-Care Guide: Nausea and
Vomiting from Chemotherapy, 234
Appendix 11B: Self-Care Guide: Nausea and
Vomiting from Radiation Therapy, 236
Appendix 11C: Self-Care Guide: Nausea and
Vomiting from Cancer or Other Causes, 238


241

Kim Slusser, RN, MSN, CHPN®

The Problem, 241
Incidence, 241
Etiology, 242
Pathophysiology, 242
Symptom Assessment, 244
Risk Factors, 244
Self-Assessment, 244
Objective Assessment, 244
Degrees of Toxicity, 246
Symptom Management Strategies, 247
Therapeutic Approaches, 247
Nursing Implications, 251

Patient Self-Care, 254
References, 254
Appendix 12A: Self-Care Guide: Malignant
Ascites Self-Assessment, 256
Appendix 12B: Self-Care Guide: Ascites, 257
Appendix 12C: Self-Care Guide: Removing
Ascites Fluid: Paracentesis, 259
Appendix 12D: Self-Care Guide: Shunt
Care, 260
Appendix 12E: Self-Care Guide: Ascites Daily
Log, 262



Contents

Part V

Alterations in Genitourinary Function

13

Bladder Disturbances

263
265

Connie Henke Yarbro, RN, MS, FAAN; Donna L. Berry, RN, PhD, AOCN® FAAN

The Problem, 265
Incidence, 265
Etiology and Pathophysiology, 266
Bladder Cancer, 267
Bladder Infection, 267
Chemotherapy-Induced Cystitis, 267
Radiation Injury, 267
Voiding Dysfunction, 267
Spinal Cord Injury, 268
Symptom Assessment, 268
Self-Assessment, 268
Objective Assessment, 268
Degrees of Toxicity, 270

Part VI Alterations in Cardiopulmonary Function

14

Symptom Management Strategies, 270
Therapeutic Approaches, 270
Nursing Implications, 275
Patient Self-Care, 275
References, 275
Appendix 13A: Self-Care Guide:
Bladder Diary, 277
Appendix 13B: Self-Care Guide:
Bladder Catheter Care, 278
Appendix 13C: Self-Care Guide: Irritative
Bladder Symptoms, 280
Appendix 13D: Self-Care Guide: Urinary
Incontinence, 282

285

Bleeding and Thrombotic Complications

287

Anna Liza Rodriguez, mha, msn, rn, ocn®

The Problem, 287
Incidence, 287
Etiology, 288
Pathophysiology, 290
Hypercoagulability of Malignancy, 290
Thrombotic Complications, 290

Symptom Assessment, 291
Risk Factors, 291
Self-Assessment, 292

Objective Assessment, 293
Degrees of Toxicity, 297
Symptom Management Strategies, 298
Preventive Strategies, 298
Therapeutic Approaches, 300
Nursing Implications, 310
Patient Self-Care, 310
References, 310
Appendix 14A: Self-Care Guide: Bleeding, 314

15Dyspnea
Margaret Joyce, PhD, ANP-BC, AOCN

317
®

The Problem, 317
Incidence, 317
Etiology, 318
Pathophysiology, 318
Symptom Assessment, 319
Self-Assessment, 319
Objective Assessment, 319
Degrees of Toxicity, 320
Symptom Management Strategies, 320
Therapeutic Approach, 320


Palliative Approach, 322
Nursing Implications, 323
Patient Self-Care, 324
References, 324
Appendix 15A: Self-Care Data Form: Weekly
Breathing Log, 326
Appendix 15B: Self-Care Guide: Shortness of
Breath (Dyspnea), 327

vii


viii

Contents

16Effusions
Diane G. Cope, phd, arnp, bc, aocnp

331
®

The Problem, 331
Pleural Effusions, 331
Incidence, 331
Etiology, 331
Pathophysiology of Pleural Effusions, 332
Normal and Abnormal Pleural Fluid
Formation, 332

Symptom Assessment of Pleural Effusions, 333
Risk Factors, 333
Self-Assessment, 333
Objective Assessment, 333
Diagnostic Evaluation, 333
Degrees of Toxicity, 334
Symptom Management Strategies for Pleural
Effusions, 335
Therapeutic Approaches, 335
Degrees of Symptom Severity, 337
Nursing Implications, 337
Patient Self-Care for Pleural Effusions, 338
Pericardial Effusions, 338
Incidence, 338
Etiology, 339

Part VII Alterations in Nutrition
17

Pathophysiology of Pericardial Effusions, 339
Normal Pericardial Fluid Formation, 339
Abnormal Pericardial Fluid Formation, 340
Symptom Assessment of Pericardial
Effusions, 340
Self-Assessment, 340
Objective Assessment, 340
Degrees of Toxicity, 341
Symptom Management Strategies for Pericardial
Effusions, 341
Therapeutic Approaches, 341

Degrees of Symptom Severity, 343
Nursing Implications, 343
Patient Self-Care for Pericardial Effusions, 344
References, 344
Appendix 16A: Self-Care Guide: Pleural Effusion
(Fluid Around the Lungs), 346
Appendix 16B: Self-Care Guide: Pericardial
Effusion (Fluid Around the Heart), 348

349

The Cancer Cachexia Syndrome

351

Regina S. Cunningham, PhD, RN, AOCN®

The Problem, 351
Incidence, 352
Etiology, 352
Pathophysiology, 353
The Effects of Cytokines, 353
Alterations in Skeletal Muscle, 353
Alterations in Glucose and Fat Metabolism, 354
Pathophysiology of Related Symptoms, 354
Symptom Assessment, 355
Risk Factors, 355
Self-Assessment, 356
Objective Assessment, 356
Degrees of Toxicity, 361

Symptom Management Strategies, 362
Therapeutic Approaches, 362
Nursing Implications, 367

Patient Self-Care, 367
References, 368
Appendix 17A: Self-Care Guide: Weekly Food
Diary, 370
Appendix 17B: Self-Care Guide:
Anorexia–Cachexia, 375
Appendix 17C: Self-Care Guide: Changes in
Taste and Smell, 378
Appendix 17D: Self-Care Guide: Tube
Feeding, 380
Appendix 17E: Self-Care Guide: Intravenous
Feeding, 383


Contents

18Dysphagia

385

Dawn Camp-Sorrell, MSN, FNP, AOCN

®

The Problem, 385
Pathophysiology, 386

Head and Neck Cancer, 386
Esophageal Stricture, 386
Post-Treatment Dysphagia, 387
Symptom Assessment, 387
Risk Factors, 387
Self-Assessment, 387
Objective Assessment, 388
Degrees of Toxicity, 390
Symptom Management Strategies, 390
Therapeutic Approaches, 390
Complications of Dysphagia, 393
Nursing Implications, 394

Patient Self-Care, 394
References, 394
Appendix 18A: Self-Care Guide: Difficulty
Swallowing: Exercises for the Tongue, 396
Appendix 18B: Self-Care Guide: Food
Suggestions for the Person with Difficulty
Swallowing, 398
Appendix 18C: Self-Care Guide: Tube
Feeding, 399
Appendix 18D: Self-Care Guide: Difficulty
Swallowing: Precautions, 402

19Mucositis

403

Debra Wujcik, PhD, RN, FAAN


The Problem, 403
Incidence, 403
Etiology, 404
Pathophysiology, 404
Symptom Assessment, 406
Risk Factors, 406
Self-Assessment, 407
Objective Assessment, 408
Degrees of Toxicity, 408

Symptom Management Strategies, 409
Therapeutic Approaches, 409
Nursing Implications, 413
Patient Self-Care, 413
References, 413
Appendix 19A: Self-Care Guide: A Healthy
Mouth, 416
Appendix 19B: Self-Care Guide: Mucositis:
A Sore Mouth, 418

20Xerostomia

421

Kerri A. Dalton, RN, MSN, OCN® ; Tracy K. Gosselin, RN, PhD, AOCN®

The Problem, 421
Incidence, 421
Etiology, 421

Pathophysiology, 422
Salivary Glands, 422
Saliva, 423
Radiation Therapy: Impact on Salivary Gland
Function, 423
Symptom Assessment, 423
Risk Factors, 423
Self-Assessment, 423

Objective Assessment, 424
Degrees of Toxicity, 425
Symptom Management Strategies, 425
Therapeutic Approaches, 426
Nursing Implications, 430
Patient Self-Care, 433
References, 433
Appendix 20A: Self-Care Guide: Dry Mouth
(Xerostomia), 435

ix


x

Contents

Part VIII Alterations in Neurological Function
21

437


Increased Intracranial Pressure

439

Margaret M. Fields, RN, MSN, ACNP-BC, AOCNP®

The Problem, 439
Incidence, 439
Etiology, 439
Pathophysiology, 440
Symptom Assessment, 442
Risk Factors, 442
Self-Assessment, 442
Objective Assessment, 442
Degrees of Toxicity, 446
22

Symptom Management Strategies, 446
Therapeutic Approaches, 446
Nursing Implications, 451
Patient Self-Care, 451
References, 452
Appendix 21A: Self-Care Guide: Increased
Pressure in the Brain, 454

Peripheral Neuropathy

457


Gail M. Wilkes, RNC, MS, AOCN®

The Problem, 457
Incidence, 458
Etiology, 458
Pathophysiology, 458
Chemotherapeutic Agents Likely to Cause
Peripheral Neuropathy, 463
Symptom Assessment, 466
Risk Factors, 466
Self-Assessment, 467

Objective Assessment, 467
Degrees of Toxicity, 472
Symptom Management Strategies, 475
Therapeutic Approaches, 475
Nursing Implications, 480
Patient Self-Care, 484
References, 485
Appendix 22A: Self-Care Guide: Peripheral
Neuropathy, 490

Part IX Anatomical and Surgical Alterations

493

23Alopecia

495


Mary Callaghan, RN, MN, AOCNS® ; Abby Cooper, RN, MSN, OCN®

The Problem, 495
Incidence, 495
Etiology, 496
Pathophysiology, 498
Symptom Assessment, 498
Risk Factors, 498
Objective Assessment, 498
Degrees of Toxicity, 499

Symptom Management Strategies, 499
Therapeutic Approaches, 499
Nursing Implications, 502
Patient Self-Care, 502
References, 502
Appendix 23A: Self-Care Guide: Cancer
Treatment-Related Hair Loss, 504


Contents

24

Altered Body Image and Sexual Health

507

Linda U. Krebs, PhD, RN, AOCN , FAAN
®


The Problem, 507
Incidence, 508
Etiology, 508
Pathophysiology, 511
Physiological Alterations in Gonadal
Function, 511
Alterations in the Sexual Response Cycle, 511
Symptom Assessment, 512
Risk Factors, 512
Self-Assessment, 512
Objective Assessment, 513
Degrees of Toxicity, 517
Symptom Management Strategies, 517
Therapeutic Approaches, 517
Complementary and Alternative Medicine, 524
Nursing Outcomes, 524

Patient Self-Care, 524
References, 525
Appendix 24A: Self-Care Guide: Suggestions
to Enhance Intimacy, Comfort, and Pleasure
After Cancer Treatment, 529
Appendix 24B: Self-Care Guide: Managing
Vaginal Dryness, 531
Appendix 24C: Self-Care Guide: Self-Injecting
Medications to Have an Erection, 533
Appendix 24D: Self-Care Guide: Preventing
Vaginal Shortening and Decreased
Elasticity, 536

Appendix 24E: Self-Care Guide: Managing Your
Penile Implant, 538

25Extravasation

541

Colleen O’Leary, MSN, RN, AOCNS ; Kimberly Catania, MSN, RN, AOCN
®

The Problem, 541
Incidence, 541
Etiology, 542
Pathophysiology, 542
Symptom Assessment, 544
Risk Factors, 544
Self-Assessment, 545
Objective Assessment, 545
Degrees of Toxicity, 546

®

Symptom Management Strategies, 546
Therapeutic Approaches, 546
Antidotes and Treatments, 548
Documentation, 550
Patient Follow-up, 551
Nursing Implications, 551
Patient Self-Care, 551
References, 551

Appendix 25A: Self-Care Guide: Extravasation, 553

26Lymphedema

555

Sheila H. Ridner, PhD, RN, FAAN

The Problem, 555
Incidence, 555
Etiology, 556
Pathophysiology, 556
Symptom Assessment, 556
Risk Factors, 556
Self-Assessment, 557
Objective Assessment, 557
Degrees of Toxicity, 558

Symptom Management Strategies, 559
Therapeutic Approaches, 559
Nursing Implications, 562
Patient Self-Care, 563
References, 563
Appendix 26A: Self-Care Guide: Swelling
(Lymphedema), 565

xi


xii


Contents

27

Ocular and Otic Complications
Colleen O’Leary, MSN, RN, AOCNS

The Problem, 569
Incidence and Etiology, 569
Pathophysiology, 571
Ocular Complications, 571
Otic Complications, 572
Symptom Assessment, 573
Risk Factors, 573
Self-Assessment, 573
Objective Assessment, 574
Degrees of Toxicity, 574
28

569

®

Symptom Management Strategies, 576
Therapeutic Approaches, 576
Nursing Implications, 578
Patient Self-Care, 578
References, 578
Appendix 27A: Self-Care Guide: Common Eye

Problems, 581
Appendix 27B: Self-Care Guide: Common
Ear/Hearing Problems, 585

Skin and Nail Bed Changes

587

Linda Morse, RN, MSN

The Problem, 587
Pathophysiology of the Skin, 587
Papulopustular Skin Rash, 588
Incidence, 588
Pathophysiology, 589
Symptom Assessment, 589
Therapeutic Approaches, 592
Hair Changes, 594
Pathophysiology, 594
Therapeutic Approaches, 595
Hand–Foot Syndrome and Hand–Foot Skin
Reaction, 595
Incidence and Etiology, 595
Pathophysiology, 595
Symptom Assessment, 595
Therapeutic Approaches, 597
Nail Toxicity, 600
Incidence and Etiology, 600
Pathophysiology, 601


Part X

Symptom Assessment, 601
Therapeutic Approaches, 601
Acute Radiation Dermatitis, 602
Incidence, 602
Pathophysiology, 602
Symptom Assessment, 602
Therapeutic Approaches, 603
Nursing Implications, 605
Patient Self-Care, 606
References, 606
Appendix 28A: Self-Care Guide: Papulopustular
Rash, 609
Appendix 28B: Self-Care Guide: Hand–Foot
Syndrome and Hand–Foot Skin Reaction, 612
Appendix 28C: Self-Care Guide: Skin Care
During Radiation Therapy, 615

Alterations in Psychosocial Function

617

29Anxiety

619

Yvonne Rucker, RN, MSN, OCN® ; Barbara Holmes Gobel, RN, MS, AOCN®

The Problem, 619

Incidence, 620
Etiology, 620
Pathophysiology, 620
Anxiety Related to the Disease, 620
Anxiety Related to Treatment, 620

Preexisting Anxiety Disorders, 620
Anxiety Related to Medical
Factors, 621
Symptom Assessment, 621
Risk Factors, 621
Self-Assessment, 621


Contents

Objective Assessment, 622
Degrees of Toxicity, 623
Symptom Management Strategies, 623
Therapeutic Approaches, 623
Nursing Implications, 629
30

Patient Self-Care, 629
References, 630
Appendix 29A: Self-Care Guide: Relaxation and
Guided Imagery, 633

Cognitive Dysfunction


637

Marlene Z. Cohen, RN, PhD, FAAN; Nicole A. Shonka, MD; Terri S. Armstrong, PhD, ANP-BC, FAANP; Jeffrey S. Wefel, PhD, ABPP

The Problem, 637
Incidence, 638
Etiology, 638
Impact on Quality of Life, 641
Pathophysiology, 641
Radiation Therapy, 642
Symptom Assessment, 643
Objective Assessment, 643
Diagnostic Evaluation, 645
Degrees of Toxicity, 645

Symptom Management Strategies, 645
Therapeutic Approaches, 647
Patient Self-Care, 649
References, 650
Appendix 30A: Self-Care Guide: Cognitive
Dysfunction, Delirium, and Dementia, 653

31Depression

655

Caryl D. Fulcher, MSN, RN, CNS-BC

The Problem, 655
Definitions of Depression, 655

Symptoms Cluster, 656
Prevalence of Depression, 657
Pathophysiology and Etiology, 657
Symptom Assessment, 657
Risk Factors, 658
Self-Assessment: The Patient’s Experience, 658
Suicide in Cancer, 658
Objective Assessment: Screening for
Depression, 660

Symptom Management Strategies, 661
Therapeutic Approaches, 661
Special Populations, 665
Nursing Implications, 666
Patient Self-Care, 666
References, 666
Appendix 31A: Self-Care Guide: Recognizing
Depression, 669
Appendix 31B: Self-Care Guide: Pleasurable
Activities, 671

32Grief

673

Cheryl Brohard, PhD, RN, AOCN®

The Problem, 673
Etiology, 673
Incidence, 673

Terminology Common to Grief, 673
Types of Grief, 674
Anticipatory Grief, 674
Preparatory Grief, 674
Complicated Grief, 675
Models and Theories of Grief, 675
Pathology, 676

Symptom Assessment, 676
Assessment by the Dimensions of Grief, 676
Duration and Ongoing Assessment, 677
Symptom Management Strategies, 678
Therapeutic Approaches, 678
Nursing Implications, 679
Patient Self-Care, 679
References, 679
Appendix 32A: Self-Care Guide:
Grief, 681

xiii


xiv

Contents

33

Spiritual Distress


683

Elizabeth Johnston Taylor, PhD, RN

The Problem, 683
Spiritual Distress Defined and Described, 683
Incidence, 684
Etiology, 684
Pathology, 685
Caveat, 685
Symptom Assessment, 685
Risk Factors, 685
Self-Assessment, 686
Objective Assessment, 686
Symptom Management Strategies, 688
Therapeutic Approaches, 688
Nursing Implications, 689

34

Patient Self-Care, 689
References, 689
Appendix 33A: Self-Care Guide: Prayer and
Meditation, 691
Appendix 33B: Self-Care Guide: Transforming
Tragedy, 694
Appendix 33C: Self-Care Guide: Leaving
a Legacy, 696

Symptoms When Death Is Imminent


699

Marie Bakitas, DNSc, APRN, AOCN®, FAAN; Margaret Firer Bishop, MS, APRN; Margaret E. Hahn, MSN, FNP, APRN, ACHPN

The Problem, 699
Delirium, 700
The Problem, 700
Pathophysiology, 702
Symptom Assessment, 702
Symptom Management Strategies, 703
Noisy Airway Secretions/Ineffective Airway
Clearance, 704
The Problem, 704
Pathophysiology, 704
Symptom Assessment, 704
Symptom Management Strategies, 705
Intractable Symptoms and Palliative
Sedation, 706
The Problem, 706
Ethical Principles Underlying the Use of Palliative
Sedation, 707

Symptom Assessment, 708
Symptom Management Strategies, 708
Care of the Patient and Family When Death Is
Imminent, 712
The Problem, 712
Symptom Assessment, 712
Symptom Management Strategies, 712

Patient and Family Self-Care, 714
Acknowledgment, 715
References, 715
Appendix 34A: Self-Care Guide: Understanding,
Managing, and Coping with Delirium as
Death Approaches, 717
Appendix 34B: Self-Care Guide: Family Care
Guide for Noisy Airway Secretions, 719
Appendix 34C: Self-Care Guide: Informed
Consent for Palliative Sedation, 720

Index721


Preface
When patients with cancer and their families are asked
what bothers them most about their treatment or disease,
they respond with examples of how the problems resulting from cancer or its treatment affect their daily activities.
These problems often make life difficult and frustrating for
the patient experiencing the problem.
The nurse assisting the patient and family needs up-todate information about the problems that can occur, options
for management of the problems, and information about
how to teach the patient and family to provide care at home.
Cancer Symptom Management, Fourth Edition provides
such information to the oncology nurse. The most common
problems experienced by patients with cancer are addressed.
Problems are identified as ‘‘symptoms’’ in this text. We recognize that some of the problems identified are not symptoms but signs or syndromes; however, rather than concern
ourselves with the semantic distinctions among these terms
we have focused on the important task of identifying the
most common problems that individuals with cancer experience, describing how the problem affects the quality of the

patient’s life and identifying what the nurse can do to help
relieve or diminish the patient’s and family’s suffering.
For the majority of individuals with cancer, their health
care has shifted from the hospital to the ambulatory care setting and the home. The challenge to health professionals is
to provide quality care and to meet the educational and care
needs of patients within the dynamic environment of the
ambulatory care setting and the home. Since family and caregivers now provide the majority of care in the home, nurses
need a wide range of tools and ideas to offer the caregivers.
Cancer Symptom Management is written by nurses and allied
professionals who are recognized for their expertise as practitioners and who understand the challenges and the impact
the symptoms have on the quality of life for a cancer patient
and their family. The authors of the chapters provide creative
approaches to evidence-based management of the most common problems experienced by cancer patients. These include
symptoms of alterations in comfort, protective mechanisms,
gastrointestinal function, genitourinary function, cardiopulmonary function, nutrition, neurological function, anatomical and surgical, and psychosocial function.

This fourth edition provides the reader with many new
updates and revisions. We have 35 new authors that have
completely rewritten the chapters or provided a comprehensive update. Four new chapters have been added to this
fourth edition.
‘‘Hypersensitivity Reactions to Antineoplastic Drugs’’
has been included to address problems related to allergic
reactions, infusion reactions, and cytokine-release reactions, and provides the nurse with approaches to managing
these reactions. The second new chapter is “Extravasation”,
which focuses on the prevention, early recognition, management, and patient education related to the extravasation
of non-irritant, irritant, and vesicant agents.
The third new chapter is ‘‘Ocular and Otic Complications.’’ Although these side effects are relatively uncommon,
advances in treatment have resulted in longer survival for
patients with cancer; thus we are seeing more adverse ocular
and otic side effects secondary to treatment.

The fourth new chapter to this edition is entitled
‘‘Symptoms When Death Is Imminent.” This chapter discusses the common cognitive, respiratory, and symptom
management strategies (including palliative sedation) at the
end-of-life stage. Family preparation for what to expect as
death approaches and the postdeath period is a major part
of the chapter.
Unique to this text are the patient self-care guides. For
each problem discussed, at least one self-care tool is provided
at the end of the chapter to assist in teaching the patient and
family how to provide care at home. Feedback from our readers, patients, and family members have been incorporated in
these updated self-care guides. They are written in a form
that patients can understand and use. The reader is encouraged to adapt these self-care guidelines to their practice.
We acknowledge the challenges and opportunities faced
by our readers and their patients who provide our purpose
for this endeavor. We hope that this text will be helpful to
both nurses and their patients and their families.
Connie Henke Yarbro
Debra Wujcik
Barbara Holmes Gobel

xv



Acknowledgments
The editors would like to pay a special tribute to
Margaret Hansen Frogge, RN, MS
Michelle Goodman, RN, MS
Margaret and Michelle served diligently as editors since the inception of this text in 1996. Their leadership and dedication
to the first three editions of Cancer Symptom Management have contributed to the continuing success of this text.


xvii



The Editors

Connie Henke Yarbro

Debra Wujcik

Barbara Holmes Gobel

xix



Contributors
Terri S. Armstrong, PhD, ANP-BC, FAANP
Professor
John S. Dunn Distinguished Professorship in
Oncology Nursing
Department of Family Health
University of Texas Health Science Center
Adjunct Professor, Department of
Neuro-Oncology
MD Anderson Cancer Center
Houston, Texas

Jeannine M. Brant, PhD, APRN, AOCN®

Oncology Clinical Nurse Specialist/Research Scientist
Billings Clinic Inpatient Cancer Care
Montana State University College of Nursing
Bozeman, Montana

Marie Bakitas, DNSc, APRN, AOCN®, FAAN
Professor, Marie L. O’Koren Endowed Chair
University of Alabama School of Nursing
Birmingham, Alabama

Mary Callaghan, RN, MN, AOCNS®
Advanced Practice Nurse, Gynecological Oncology
Northwestern Memorial Hospital
Chicago, Illinois

Ann M. Berger, PhD, APRN, AOCNS®, FAAN
Professor and Dorothy Hodges Olson Endowed
Chair in Nursing 
Clinical Nurse Specialist, Oncology
Director, Doctoral Program
University of Nebraska Medical Center
Omaha, Nebraska

Dawn Camp-Sorrell, MSN, FNP, AOCN®
Nurse Practitioner
Clinical Instructor
University of Alabama at Birmingham School of Nursing
Birmingham, Alabama

Donna L. Berry, PhD, RN, AOCN®, FAAN

Associate Professor, Department of Medicine
Harvard Medical School
Director, Phyllis F. Cantor Center for Research in
Nursing and Patient Care Services
Dana-Farber Cancer Institute
Boston, Massachusetts
Margaret Firer Bishop, MS, APRN
Department of Anesthesiology, Section of Palliative
Medicine
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire

Cheryl Brohard, PhD, RN, AOCN®
Director of Education
Houston Hospice
Houston, Texas

Kimberly Cantania, MSN, RN, CNS, AOCN®
Oncology Clinical Nurse Specialist
The Ohio State University Comprehensive
Cancer Center
Arthur G. James Cancer Hospital
Richard J. Solove Research Institute
Columbus, Ohio
Marlene Z. Cohen, RN, PhD, FAAN
Professor and Kenneth E. Morehead Endowed Chair
in Nursing
Associate Dean for Research
University of Nebraska Medical Center, College
of Nursing

Omaha, Nebraska

xxi


xxii

Contributors

Abby Cooper, RN, MSN, OCN®
Practice Manager, Oncology Services
Northwestern Memorial Hospital
Chicago, Illinois

Tracy Gosselin, RN, PhD, AOCN®
Associate Chief Nursing Officer
Duke Cancer Institute
Durham, North Carolina

Diane G. Cope, PhD, ARNP, BC, AOCNP®
Oncology Nurse Practitioner
Florida Cancer Specialists and Research Institute
Fort Myers, Florida

Margaret E. Hahn, MSN, FNP, APRN, ACHPN
Instructor in Anesthesiology
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire

Regina S. Cunningham, PhD, RN, AOCN®

Associate Chief Nursing Officer for
Cancer Services
Abramson Cancer Center
University of Pennsylvania
Philadelphia, Pennsylvania

Pamela J. Haylock, PhD, RN, FAAN
CEO, Association for Vascular Access
Medina, Texas

Carol Curtiss, MSN, RN-BC
Clinical Nurse Specialist Consultant
Curtiss Consulting
Adjunct Clinical Instructor
Tufts University School of Medicine
Boston, Massachusetts

Margaret Joyce, PhD, ANP-BC, AOCN®
Assistant Professor
University of Medicine and Dentistry of New Jersey
Newark, New Jersey
Linda U. Krebs, PhD, RN, AOCN®, FAAN
Associate Professor
University of Colorado, College of Nursing
Aurora, Colorado

Kerri A. Dalton, RN, MSN, OCN®
Clinical Nurse Specialist
Duke Cancer Institute
Durham, North Carolina


Rachael Christine Lopez, MPH, RD, CSO
Clinical Research Dietitian
National Institutes of Health
Bethesda, Maryland

Mary Egger, RN, MSN, WHNP
Instructor, Breast Center Nurse Practitioner
The Vanderbilt Breast Center
Vanderbilt University Medical Center
Nashville, Tennessee

Virginia R. Martin, MSN, RN, AOCN®
Clinical Director Ambulatory Care
Fox Chase Cancer Center
Philadelphia, Pennsylvania

Margaret M. Fields, RN, MSN, ACNP-BC, AOCNP®
Nurse Practitioner
Neruo-Oncology
MD Anderson Cancer Center
Houston, Texas

Robert L. Massey, PhD, RN, CNNA
Assistant Professor, Department of Nursing,
Director, Clinical Nursing
The University of Texas
MD Anderson Cancer Center
Houston, Texas
Ellyn E. Matthews, PhD, RN, AOCN®, AOCNS®

Associate Professor
University of Colorado College of Nursing
Aurora, Colorado

Caryl D. Fulcher, MSN, RN, CNS-BC
Clinical Nurse Specialist and Team Leader
Department of Advanced Clinical Practice
Duke University Hospital
Durham, North Carolina
Barbara Holmes Gobel, RN, MS, AOCN
Operations Manager, Oncology Services
Northwestern Memorial Hospital
Adjuvant Faculty, Rush University College of Nursing
Chicago, Illinois
®

Sandra A. Mitchell, PhD, CRNP, AOCN®
Research Scientist
National Cancer Institute, Outcomes Research Branch
Division of Cancer Control and Population
Sciences
Bethesda, Maryland


Contributors

Linda Morse, RN, MSN
Clinical Research Nurse
The Lowe Center for Thoracic Oncology
Dana-Farber Cancer Institute

Boston, Massachusetts
Paula Muehlbauer, RN, MSN, AOCNS®
Clinical Nurse Specialist
San Diego Veterans Affairs Healthcare System
San Diego State University
San Diego, California
Colleen O’Leary, MSN, RN, AOCNS®
Clinical Nurse Specialist, Head and Neck Oncology
The Ohio State University Comprehensive
Cancer Center
Arthur G. James Cancer Hospital
Richard J. Solove Research Institute
Columbus, Ohio

Susan S. Tavernier, PhD, RN, APRN-CNS, AOCN®
Post-Doctoral Fellow
University of Utah, College of Nursing
Salt Lake City, Utah
Elizabeth Johnston Taylor, PhD, RN
Associate Professor
Loma Linda University School of Nursing
Loma Linda, California
Janelle Tipton, MSN, RN, AOCN®
Oncology Clinical Nurse Specialist
University of Toledo Medical Center
Toledo, Ohio
Wendy H. Vogel, MSN, FNP, AOCNP®
Oncology Nurse Practitioner
Kingsport Hematology Oncology Associates
Kingsport, Tennessee


Sheryl Redlin Frazier, RN, MSN
Manager, Patient Care Services
The Vanderbilt Breast Center
Vanderbilt University Medical Center
Nashville, Tennessee

Jeffrey S. Wefel, PhD, ABPP
Chief ad interim, Section of Neuropsychology
Associate Professor, Department of Neuro-Oncology
MD Anderson Cancer Center
Houston, Texas

Sheila H. Ridner, PhD, RN, FAAN
Professor
Vanderbilt University School of Nursing
Nashville, Tennessee

Gail M. Wilkes, MS, APRN-BC, AOCN®
Oncology Clinical Instructor
Kilauea, Hawaii

Anna Liza Rodriguez, MHA, MSN, RN, OCN®
Director of Oncology Program
Presence Resurrection Medical Center
Chicago, Illinois
Yvonne A. Rucker, RN, MSN, OCN®
Performance Manager, Oncology Services
Northwestern Memorial Hospital
Chicago, Illinois

Nicole A. Shonka, MD
Oncologist
University of Nebraska Medical Center
Omaha, Nebraska
Kim Slusser, RN, MSN, CHPN®
Clinical Operations Director
Duke University Hospital
Durham, North Carolina

Debra Wujcik, PhD, RN, FAAN
Director, VICC Clinical Trials Shared Resource
Associate Professor, Vanderbilt School of Nursing
Vanderbilt Ingram Cancer Center
Nashville, Tennessee
Connie Henke Yarbro, RN, MS, FAAN
Adjunct Clinical Associate Professor
Sinclair School of Nursing
Editor, Seminars in Oncology Nursing
University of Missouri-Columbia
Columbia, Missouri
Laura J. Zitella, MS, RN, ACNP-BC, AOCN®
Lead Advanced Practice Provider, Inpatient Hematology/
Oncology
Nurse Practitioner
Stanford University Medical Center
San Francisco, California

xxiii