Cancer Nursing Care Plans

Cancer patients fill your assignment with overlapping problems at once: pain, nausea, neutropenia, a failing appetite, and a person trying to process a diagnosis that just changed their life. Your job is to treat the body and the head at the same time. This guide covers assessment, nursing diagnoses, goals, and the interventions you actually run at the bedside.

What is Cancer?

Cancer is not one disease. It is a group of diseases marked by uncontrolled cellular growth, where cells fail to control their own proliferation and maturation. Because it starts at the cellular level, it can arise in any tissue.

There are more than 150 types, including breast, skin, lung, colon, and prostate cancers and lymphoma. Symptoms track the tissue of origin. Treatment is some mix of chemotherapy, radiation, and surgery.

Nursing Assessment

Assess for these subjective and objective findings:

• Unexplained weight loss
• Fatigue and weakness
• Persistent pain
• Skin changes such as yellowing or darkening
• Changes in bowel or bladder habits
• Difficulty swallowing or persistent indigestion
• A changing mole or wart
• Persistent cough or hoarseness
• Unexplained bleeding or bruising
• Lumps or thickening, such as in the breast or testicles

Nursing Diagnoses

Common nursing diagnoses for cancer patients:

• Acute Pain related to tissue inflammation and treatment side effects, evidenced by reports of persistent pain, guarding, and limited mobility.
• Impaired Skin Integrity related to radiation exposure, evidenced by redness, dryness, and reported burning.
• Risk for Infection associated with immunosuppression secondary to chemotherapy.
• Imbalanced Nutrition: Less than Body Requirements related to nausea and altered taste, evidenced by weight loss, poor appetite, and food aversion.
• Fatigue related to treatment and emotional distress, evidenced by exhaustion, reduced activity, and difficulty completing daily tasks.
• Disturbed Body Image related to hair loss and surgical scars, evidenced by social withdrawal and verbalized self-consciousness.
• Anxiety related to uncertain prognosis and fear of progression, evidenced by worry, restlessness, and repeated requests for information.
• Risk for Bleeding evidenced by low platelet counts associated with chemotherapy.
• Deficient Knowledge related to unfamiliarity with treatment and symptom management, evidenced by frequent questions about side effects and home care.
• Social Isolation related to low energy and self-consciousness, evidenced by withdrawal from family and increased time alone.

Nursing Goals

Expected outcomes:

• The patient identifies and expresses feelings appropriately.
• The patient continues normal activities and plans for the future, one day at a time.
• The patient verbalizes understanding of the dying process and feels supported in grief work.
• The patient verbalizes understanding of body changes and acceptance of self.
• The patient develops coping mechanisms to deal with problems effectively.
• The patient demonstrates adaptation by setting realistic goals and participating in work, play, and relationships.
• The patient reports maximal pain relief with minimal interference with ADLs.
• The patient uses relaxation skills and diversional activities.
• The patient maintains stable weight or progressive gain toward goal, with normal labs and no signs of malnutrition.
• The patient participates in interventions to stimulate appetite and increase intake.
• The patient shows adequate fluid balance: stable vitals, moist mucous membranes, good turgor, prompt capillary refill, and adequate urine output.
• The patient reports improved energy.
• The patient performs ADLs and participates in desired activities at their ability level.
• The patient remains afebrile and heals in a timely manner.
• The patient participates in interventions to reduce infection risk.
• The patient maintains intact oral mucosa: pink, moist, and free of ulceration.
• The patient maintains usual bowel pattern.
• The patient verbalizes understanding of effects on sexuality and ways to manage them.
• The patient maintains sexual activity at the desired level.
• The patient displays an appropriate range of feelings and reduced fear, and reports anxiety at a manageable level.

Nursing Interventions and Actions

1. Providing Emotional Support and Assisting in Grieving

Cancer patients grieve. They grieve lost health, lost normalcy, and the future they had planned. That grief plays out as fear, anger, sadness, and bargaining while they also try to absorb a diagnosis and a treatment plan. Meet it head on.

Complicated Grieving related to the diagnosis and perceived loss of normalcy and future plans, evidenced by sadness, anger, and statements of hopelessness.

Assess the stage of grief the patient and significant other (SO) are in, and explain the process. Naming the grieving process normalizes what they are feeling and helps them handle it.

Review past life experiences, role changes, and coping skills. Identifies tools they already have for coping with the current situation.

Note conflict, anger, and statements of despair, guilt, or "nothing to live for." Anger and conflict are often how a patient expresses despair or spiritual distress, and can signal suicidal ideation.

Determine how the patient and SO understand and respond to death: cultural expectations, prior experience with death, beliefs about an afterlife, and faith. These shape how each person handles the possibility of dying.

Expect shock and disbelief after the diagnosis and after disfiguring procedures (colostomy, amputation). Few patients are prepared for the reality of these changes.

Provide an open, nonjudgmental environment and use active listening. Encourages honest dialogue about feelings and concerns.

Encourage the patient to verbalize, and accept sadness, anger, and rejection as normal. Knowing that deep, conflicting emotions are normal helps patients feel supported in expressing them.

Watch for mood swings, hostility, and acting out. Set limits on unsafe behavior and redirect negative thinking. Preventing destructive actions lets patients keep control and self-esteem.

Watch for debilitating depression and ask direct questions about state of mind. Cancer patients are at high risk for suicide, especially when newly diagnosed and just discharged.

Visit frequently and provide physical contact when appropriate, or frequent phone support. Arrange for a support person to stay as needed. Reduces isolation and abandonment.

Reinforce teaching about the disease and treatment. Be honest. Do not give false hope. Honest answers to direct questions about death build trust and reassure the patient that they will get accurate information.

Identify positive aspects of the situation. Remission, slow progression, and new therapies can offer realistic hope.

Help the patient and SO plan together for the future and set realistic goals. A role in problem solving restores a sense of control.

Refer to a visiting nurse, home health agency, or hospice when appropriate. Supplements the physical and emotional care family and friends can give.

2. Enhancing Body Image and Self-Esteem

Diagnosis and treatment hit confidence hard. Changes in appearance, function, and relationships pile on. Address self-esteem directly; it drives how well a patient copes with everything else.

Disturbed Body Image related to hair loss and surgical scars, evidenced by social withdrawal and verbalized self-consciousness.

Discuss how the diagnosis and treatment are affecting the patient's personal life, home, and work. Defines concerns so problem solving can start.

Review anticipated side effects, including effects on sexual activity and attractiveness (alopecia, disfiguring surgery). Tell the patient not all side effects occur and many can be minimized. Anticipatory guidance lets them prepare, such as buying a wig before radiation.

Encourage discussion of how cancer affects their roles as wage earner, parent, or homemaker. Surfacing these concerns reduces barriers to accepting treatment.

Acknowledge the difficulty and tell the patient counseling is often part of adapting. Validates their feelings and gives permission to get help.

Evaluate the support structures available to the patient and SO. Informs planning for care during and after the hospital stay.

Provide emotional support through diagnostic testing and treatment phases. Many patients need extra support during this period even if they adapt later.

Use touch when acceptable, and maintain eye contact. Affirms the person and reduces feelings of insecurity.

Refer for professional counseling as indicated. May be needed to rebuild a positive psychosocial structure when support systems are failing.

3. Managing Acute Pain

Cancer hurts. Tumors invade tissue and nerves, and surgery, radiation, and chemo add their own pain. Uncontrolled pain wrecks quality of life and feeds fatigue, so treat it aggressively and reassess often.

Acute Pain related to tissue inflammation and treatment side effects, evidenced by reports of persistent pain, guarding, and limited mobility.

Take a pain history: location, frequency, duration, and intensity on a 0-10 numeric scale, plus what relieves it. Sets the baseline for evaluating interventions. Pain lasting more than 6 months is chronic and changes therapeutic choices. Acute breakthrough pain can occur within chronic pain and needs a higher level of intervention.

Identify the timing and triggers of breakthrough pain when using around-the-clock agents (oral, IV, or patch). Pain near the end of a dosing interval signals the need for a higher dose or shorter interval. Triggered or spontaneous pain needs short half-life rescue doses.

Know the painful effects of specific therapies (surgery, radiation, chemotherapy, biotherapy) and tell the patient what to expect. Incisional pain, burning skin, low back pain, and headaches are all common, as is pain from diagnostic procedures.

Provide nonpharmacological comfort measures (massage, repositioning, backrub) and diversion (music, television). Promotes relaxation and refocuses attention.

Teach stress management and complementary therapies (relaxation, guided imagery, biofeedback, music, aromatherapy, therapeutic touch). Active participation gives a sense of control. Pain plus muscle tension increases focus on self, which raises the perceived pain level.

Provide cutaneous stimulation (heat or cold, massage). May reduce inflammation and muscle spasm. Note: heat can increase bleeding and edema after acute injury, and cold can further reduce perfusion to ischemic tissue.

Know the barriers to cancer pain management. Patients may underreport pain out of fear the disease is worse, worry about side effects, or a belief that pain is deserved. System barriers include poor assessment, fear of controlled substances and addiction, and cost.

Reassess pain relief at regular intervals and adjust the regimen. Goal: maximum control with minimum interference with ADLs.

Tell the patient and SO the expected effects and how side effects are managed. Builds realistic expectations and confidence.

Discuss adjuncts such as acupuncture and acupressure. May reduce pain without drug side effects.

Administer analgesics as indicated. See Pharmacologic Management.

4. Improving Nutritional and Fluid Volume Status

Appetite, taste, and swallowing all take a hit, and chemo and radiation add nausea, vomiting, and diarrhea. The result is poor intake, weight loss, and fluid deficits. Track intake and weight closely and intervene early.

Imbalanced Nutrition: Less than Body Requirements related to nausea and altered taste, evidenced by weight loss, poor appetite, and food aversion.

Monitor daily intake and have the patient keep a food diary. Identifies nutritional strengths and gaps.

Measure height, weight, and triceps skinfold (or other anthropometrics). Note recent weight loss and weigh daily. Measurements below standard mean stored energy (fat) is being depleted.

Assess skin and mucous membranes for pallor, delayed healing, and enlarged parotid glands. Helps identify protein-calorie malnutrition.

Monitor I&O and specific gravity, including emesis, diarrhea, and draining wounds; calculate the 24-hour balance. Continued negative balance and concentrated urine point to dehydration.

Monitor vital signs, peripheral pulses, and capillary refill. Reflect circulating volume.

Watch for bleeding (oozing from mucous membranes or puncture sites, ecchymosis, petechiae). Early detection allows prompt intervention.

Monitor labs (CBC, electrolytes, serum albumin, total lymphocyte count, serum transferrin, prealbumin). Quantifies hydration, biochemical imbalance, and malnutrition and guides dietary choices. Anticancer treatment alters these studies, so correlate with clinical status.

Hematest stools and gastric secretions. Antimetabolites inhibit renewal of GI epithelial cells, causing changes from mild erythema to ulceration with bleeding.

Encourage a high-calorie, nutrient-rich diet with supplements and frequent small meals. Metabolic needs are elevated, and supplements help maintain caloric and protein intake.

Create a pleasant dining environment and encourage shared meals. Makes mealtimes more enjoyable and may increase intake.

Encourage open communication about anorexia. It distresses the SO, who may feel rejected when the patient refuses food.

Adjust the diet around treatment: clear cool liquids, bland foods, candied ginger, dry crackers, toast, and carbonated drinks. Give liquids 1 hour before or after meals. Relief of post-therapy nausea is individual, so patients experiment. Avoiding fluids during meals prevents early fullness.

Control environmental triggers (strong odors, noise) and avoid overly sweet, fatty, or spicy foods. These trigger nausea and vomiting.

Encourage relaxation, guided imagery, and light exercise before meals. May reduce nausea and anorexia and increase intake.

Identify anticipatory nausea and vomiting and address it. Psychogenic nausea before chemo does not respond to antiemetics. Changing the treatment environment or routine may help.

Give antiemetics on a regular schedule before, during, and after antineoplastic administration. Nausea and vomiting are among the most disabling and stressful chemo side effects.

Evaluate antiemetic effectiveness. First-line agents may fail and need combination therapy.

Encourage fluid intake up to 3000 mL per day as tolerated. Maintains fluid balance and reduces the risk of hemorrhagic cystitis in patients receiving cyclophosphamide (Cytoxan).

Minimize venipunctures by combining IV starts with blood draws, and consider central venous access. Reduces hemorrhage and infection from repeated punctures.

Apply pressure to puncture sites and avoid trauma. Reduces bleeding and hematoma.

Provide IV fluids as indicated. For hydration and to dilute antineoplastic drugs, reducing nausea and nephrotoxicity.

Refer to a dietitian or nutritional support team. Builds a specific plan to address protein-calorie and micronutrient deficits.

Insert and maintain an NG or feeding tube for enteric feeding, or a central line for TPN, if indicated. With severe malnutrition (loss of 25%-30% body weight in 2 months) or NPO for 5 days with another week likely, tube feeding or TPN may be necessary.

5. Decreasing Fatigue

Cancer-related fatigue is one of the most common and disabling symptoms, driven by the disease, treatment, emotional distress, and anemia. Manage it with paced activity, rest, nutrition, and treatment of the underlying causes.

Fatigue related to treatment and emotional distress, evidenced by exhaustion, reduced activity, and difficulty completing daily tasks.

Have the patient rate fatigue on a numeric scale and note when it peaks. Informs the management plan.

Monitor the physiologic response to activity (BP, heart rate, respiratory rate). Tolerance varies with disease stage, nutrition, fluid balance, and treatment.

Plan rest periods and schedule activity for the patient's high-energy times. Involve the patient and SO in planning. Frequent rest restores energy, and timing activity to energy levels restores a sense of control.

Set realistic activity goals with the patient. Provides control and a sense of accomplishment.

Assist with self-care, keep the bed low, clear pathways, and assist with ambulation. Weakness makes ADLs hard and raises injury risk.

Encourage the patient to do what they can (self-bathing, sitting up, walking) and increase activity as able. Builds strength and stamina without overdoing it.

Assess and manage pain. Poorly controlled pain feeds fatigue.

Provide supplemental oxygen as indicated. Anemia and hypoxemia reduce oxygen for cellular uptake and worsen fatigue.

Refer to physical or occupational therapy. Programmed exercise maintains strength and muscle tone, and adaptive devices conserve energy.

6. Minimizing Infection Risk

Cancer and its treatment knock down the immune system, and the danger peaks when the white count bottoms out during chemo or after a marrow transplant. Run strict infection control: hand hygiene, isolation when indicated, and prompt cultures and antibiotics.

Risk for Infection associated with immunosuppression secondary to chemotherapy.

Monitor temperature. Fever may be masked by corticosteroids or anti-inflammatories. Catching infection early lets you start therapy promptly.

Assess all systems (skin, respiratory, genitourinary) for signs of infection continuously. Early recognition prevents progression to sepsis.

Monitor CBC with differential, granulocyte count, and platelets. Chemo, disease, and radiation suppress marrow. Tracking myelosuppression prevents infection, anemia, and hemorrhage and guides drug timing.

Obtain cultures as indicated. Identifies the organism and guides antibiotic choice.

Enforce handwashing by staff and visitors, screen and limit visitors with infections, and use reverse isolation as indicated. Protects the patient from outside sources of infection.

Emphasize personal hygiene. Limits sources of infection and secondary overgrowth.

Reposition frequently and keep linens dry and wrinkle-free. Prevents skin breakdown, a site for bacterial growth.

Balance rest and exercise. Limits fatigue while preventing stasis complications (pneumonia, pressure injury, thrombus).

Stress good oral hygiene. Stomatitis raises infection and overgrowth risk.

Limit invasive procedures and use aseptic technique. Reduces contamination and entry points for pathogens.

Administer antibiotics as indicated. For treatment or prophylaxis in immunocompromised patients. See Pharmacologic Management.

7. Maintaining Oral Mucous Membrane Integrity and Preventing Stomatitis

Chemo and radiation inflame and ulcerate the oral mucosa. Stomatitis is painful, drives down intake, and opens the door to infection. Get ahead of it with meticulous oral care.

Risk for Impaired Oral Mucous Membrane related to chemotherapy and radiation, evidenced by susceptibility to stomatitis, reported oral discomfort, and changes in mucous membrane appearance.

Assess dental health and oral hygiene periodically. Identifies prophylactic needs before chemo or radiation and gives a baseline.

Monitor for and explain signs of oral superinfection (thrush). Early recognition allows prompt treatment.

Culture suspicious oral lesions. Identifies the organism and guides drug therapy.

Have the patient inspect the oral cavity daily, noting dryness, redness, burning, voice changes, swallowing difficulty, taste changes, thick saliva, and blood-tinged emesis. Good monitoring is critical to controlling stomatitis.

Demonstrate good oral care and flag products to avoid. Alcohol- and phenol-containing products worsen dryness and irritation.

Start an oral hygiene program:

• Avoid commercial mouthwashes and lemon or glycerine swabs. Rinsing before meals can improve taste.
• Use a rinse of warm saline or dilute hydrogen peroxide or baking soda and water. Rinsing after meals and at bedtime dilutes oral acids and relieves xerostomia.
• Brush with a soft toothbrush or foam swab to protect fragile tissue. Change the toothbrush at least every 3 months.
• Floss gently or use a WaterPik cautiously, since water under pressure can injure gums or drive bacteria under the gum line.
• Keep lips moist with balm or K-Y Jelly to prevent drying and cracking.

Encourage mints, hard candy, or artificial saliva (Ora-Lube, Salivart). Stimulates secretions and keeps membranes moist, especially with dehydration and reduced saliva.

Modify the diet: avoid hot, spicy foods and acidic juices; use a straw; offer soft or blended foods, Popsicles, and ice cream as tolerated. Severe stomatitis interferes with intake and risks negative nitrogen balance and dehydration.

Encourage fluids as tolerated. Hydration keeps mucous membranes moist.

Discuss limiting smoking and alcohol. Both irritate and dry the mucosa, though you may need to compromise if they matter to the patient's emotional state.

Refer to a dentist before chemo or head and neck radiation. Prophylactic repair reduces infection risk.

Administer medications as indicated. See Pharmacologic Management.

8. Maintaining Skin Integrity

Skin takes damage from impaired immunity, treatment, and immobility. Radiation reactions and IV extravasation are the ones that surprise new nurses, so inspect skin and IV sites every shift.

Impaired Skin Integrity related to radiation exposure, evidenced by redness, dryness, and reported burning.

Inspect skin often for treatment side effects, breakdown, and delayed healing, and have the patient report open areas. Radiation can cause reddening or tanning in the field, dry or moist desquamation, ulceration, hair loss, and loss of sweat glands. Chemo can cause rashes, hyperpigmentation, pruritus, and alopecia.

Assess the IV site and vein for erythema, edema, tenderness, welts, itching, burning, blisters, ulceration, or necrosis. Phlebitis, vein flare, or extravasation requires immediate discontinuation of the antineoplastic and medical intervention.

Bathe with lukewarm water and mild soap. Cleans without irritating.

Have the patient pat skin dry and avoid vigorous rubbing or scratching. Prevents friction trauma to sensitive tissue.

Reposition frequently. Promotes circulation and prevents pressure injury.

Follow the radiation skin protocol: avoid soap, lotions, creams, powders, and deodorants on the treated area. These can interfere with radiation delivery and increase irritation. The skin stays sensitive during and after treatment.

Do not apply heat or wash off the radiation marks or tattoos. Maintenance care continues until the tissue regenerates.

Recommend soft, loose cotton clothing, and have female patients avoid bras if they create pressure over the site. Reduces friction and recall reactions.

Apply cornstarch, Aquaphor, Lubriderm, or Eucerin to the area twice daily as needed. See Pharmacologic Management.

Encourage liberal sunscreen and protective clothing. Skin breakdown signals a need to alter the chemo rate or dilution and change the IV site.

Wash skin immediately with soap and water if antineoplastic agents spill on unprotected skin (patient or caregiver). Dilutes the drug and reduces chemical burn.

Tell patients on 5-fluorouracil (5-FU) and methotrexate to avoid sun exposure, and withhold methotrexate with sunburn present. Sun worsens 5-FU burn spotting and can trigger a methotrexate "flash" reaction that intensifies the drug's effect.

Review expected dermatologic effects of chemo (rash, hyperpigmentation, peeling palms). Anticipatory guidance reduces alarm.

Tell the patient hair usually regrows after chemo but may not after radiation. Radiation effects on follicles can be permanent depending on dose. Men can be as sensitive to hair loss as women.

Apply an ice pack or warm compress per protocol. This depends on the agent: ice restricts blood flow to localize the drug, while heat disperses the drug or antidote to minimize tissue damage.

9. Normalizing Bowel Function

Cancer patients swing both ways. Opioids, low activity, dehydration, and tumor obstruction cause constipation, while chemo, radiation, and infection cause diarrhea with fluid and electrolyte loss. Track the pattern and stay ahead of it.

Constipation related to decreased activity, opioid use, and dehydration, evidenced by infrequent stools, abdominal discomfort, and reduced appetite.

Ascertain usual elimination habits. Sets the baseline for evaluating therapy.

Assess bowel sounds and record stools (frequency, consistency), especially during the first 3-5 days of Vinca alkaloid therapy. Constipation is one of the earliest signs of neurotoxicity.

Monitor I&O and weight. Diarrhea causes dehydration and electrolyte loss; inadequate intake causes constipation.

Check for impaction if there is no BM in 3 days or if distension, cramping, or headache is present. May require alternative bowel care.

Monitor serum electrolytes. Imbalances alter GI function.

Encourage fluids (2000 mL per 24 hours), increased fiber, and regular exercise. Improves stool consistency, stimulates peristalsis, and prevents diarrhea-related dehydration.

Provide small, frequent low-residue meals with adequate protein and carbohydrate (eggs, cooked cereal, bland cooked vegetables). Low-fiber foods rest the bowel when diarrhea is present.

Adjust the diet: avoid high-fat foods (butter, fried foods, nuts), high-fiber and gas-producing foods (cabbage, baked beans, chili), caffeine, and extreme temperatures. These increase GI motility and stool frequency.

Administer IV fluids as indicated. Prevents dehydration and dilutes chemo agents.

Administer antidiarrheals (loperamide, diphenoxylate/atropine, bismuth subsalicylate) as indicated. See Pharmacologic Management.

Administer stool softeners, laxatives, and enemas as indicated. Prophylaxis prevents complications in patients on Vinca alkaloids, with poor baseline bowel patterns, or with decreased motility. See Pharmacologic Management.

10. Managing Sexuality Concerns

Physical changes, fatigue, emotional distress, and treatment side effects all hit sexuality. Patients may have decreased libido, changed body image, and intimacy concerns. Raise it; most patients will not.

Disturbed Body Image related to physical changes and emotional distress, evidenced by decreased libido, altered self-perception, and concerns about intimacy.

Discuss the nature of sexuality and how it changes when threatened, and normalize seeking help. Sexuality is how people view themselves and relate to others in every area of life, so acknowledging the problem is legitimate care.

Tell the patient which treatment side effects affect sexuality. Anticipatory guidance starts the adaptation process.

Provide education and resources on sexual health, including the impact of cancer and treatment on function, common misconceptions, counseling options, and strategies to support intimacy.

Provide private time for hospitalized patients. Knock and get permission before entering. Intimacy needs continue during hospitalization and deserve an open, accepting attitude.

Refer to a sex counselor as indicated. For additional help managing the situation.

11. Reducing Fear and Anxiety and Supporting the Family

Fear and anxiety hit the patient and the whole family, and they reshape communication, roles, and relationships. Treat the family as part of the unit of care.

Anxiety related to fear of prognosis and uncertain outcomes, evidenced by expressed fear, worry, and impaired decision making.

Ineffective Coping related to a new diagnosis and changed family dynamics, evidenced by hopelessness, withdrawal, and increased family tension.

Review prior experience with cancer and what the patient understands the physician to have said. Clarifies perceptions and surfaces fears and misconceptions.

Identify the stage and degree of grief in the patient and SO. The stage dictates which interventions fit.

Note ineffective coping (poor social interaction, helplessness, giving up usual functions). Identifies problems and directs support.

Watch for denial and depression (withdrawal, anger, inappropriate remarks) and assess suicidal ideation on a 1-10 scale. Guilt, spiritual distress, and lack of cure can drive a patient to withdraw and view suicide as an option.

Encourage the patient to share thoughts and feelings. Opens a path to examine realistic fears and misconceptions.

Provide an environment where the patient can talk or stay silent without judgment. Promotes dignity and control.

Maintain frequent contact and use touch as appropriate. Conveys that the patient is not alone, building trust.

Watch the effects of isolation when required by immunosuppression or radiation implant, and limit isolation gear when possible. Sensory deprivation intensifies anxiety, fear, and alienation.

Help the patient and SO name and clarify fears to start building coping strategies. Coping skills are strained at diagnosis and through treatment, and support helps patients see that coping options exist.

Provide accurate, consistent information about diagnosis and prognosis, and do not argue with the patient's perceptions. Reduces anxiety and supports realistic decisions.

Permit expressions of anger, fear, and despair without confrontation, and normalize them. Accepting feelings lets the patient start dealing with the situation.

Explain the treatment, its purpose, and side effects, and help the patient prepare. Treatment aims to destroy malignant cells while sparing normal ones, and may include surgery (curative, preventive, palliative), chemotherapy, radiation, biotherapy, or stem cell transplant.

Explain procedures, answer questions honestly, and stay with the patient during anxiety-producing procedures. Accurate information reduces fear of the unknown.

Provide consistent caregivers when possible. Builds therapeutic relationships and continuity.

Promote a calm, quiet environment. Conserves energy and supports coping.

Encourage interaction with support systems, including local cancer support groups when family support is unavailable. Reduces isolation.

Provide reliable, consistent information and support to the SO. Improves interaction and reduces anxiety.

Include the SO in major decisions as the patient desires. Provides a support system and appropriate involvement.

Note the family makeup, including extended family, friends, and neighbors. Identifies who can help with care or provide respite.

Identify family communication and interaction patterns. Surfaces problems that could limit the family's ability to support the patient.

Assess and discuss role expectations among family members. Each person sees the situation differently, and sharing expectations builds understanding.

Assess whether the family's energy is purposeful or scattered. Guides interventions that help direct effort effectively.

Note cultural and religious beliefs. They shape reaction and adjustment to the diagnosis and outcome.

Listen for expressions of helplessness. They signal difficulty adjusting and cooperating with treatment.

Treat family members with warmth and respect, and reinforce information verbally and in writing. Builds their sense of competence in handling the situation.

Allow appropriate expressions of anger without reacting negatively. Anger is expected with a potentially fatal illness, and appropriate expression moves the family through grieving.

Acknowledge the difficulty of the situation, including the possibility of death. Communicates acceptance of what the family faces.

Identify and reinforce previously successful coping behaviors. Most people already have skills that apply here.

Stress continuous open dialogue among family members. Keeps communication clear and resolves problems.

Refer to support groups, clergy, and family therapy as indicated. For added help with the disorganization that can accompany a potentially terminal diagnosis.

12. Administering Medications and Providing Pharmacologic Support

Medications treat the cancer, control symptoms, and manage side effects. The mix depends on type and stage and includes chemotherapy, targeted therapy, immunotherapy, hormonal therapy, and supportive drugs for pain, nausea, and blood cell counts.

Opioids: codeine, morphine (MS Contin), oxycodone (OxyContin), hydrocodone (Vicodin), hydromorphone (Dilaudid), methadone (Dolophine), fentanyl (Duragesic), oxymorphone (Numorphan). Used around the clock for pain. Addiction and dependency are not a concern in this setting.

Acetaminophen (Tylenol) and NSAIDs, including aspirin and ibuprofen (Motrin, Advil). Effective for localized and generalized moderate to severe pain, with long-acting and controlled-release forms available.

Piroxicam (Feldene). Routes include oral, transmucosal, transdermal, nasal, rectal, and infusion (subcutaneous, IV, intraventricular), and may be delivered by PCA. IM use is not recommended because absorption is unreliable, painful, and inconvenient. An oral transmucosal fentanyl citrate agent is used for breakthrough pain in patients on fentanyl patches.

Indomethacin (Indocin). An adjuvant for mild to moderate pain that can be combined with opioids and other modalities.

Corticosteroids: dexamethasone (Decadron). Effective for pain from inflammatory processes (metastatic bone pain, acute spinal cord compression, neuropathic pain).

Analgesic rinses (kaolin, pectin, diphenhydramine [Benadryl], and topical lidocaine [Xylocaine]). Used for intense oral pain. Swish and spit rather than gargle, which could anesthetize the gag reflex.

Antifungal mouthwash such as nystatin (Mycostatin), and antibacterial agents. Treat or prevent secondary oral infections such as Candida, Pseudomonas, and herpes simplex.

Antinausea agents. Given before a mouth care regimen, they can prevent nausea from oral stimulation.

Opioid analgesics: hydromorphone (Dilaudid), morphine. For acute episodes of moderate to severe oral pain.

Cornstarch, Aquaphor, Lubriderm, and Eucerin (or other water-soluble moisturizing gel). Cornstarch absorbs moisture in skin folds. The moisturizers hydrate skin, relieve dryness and itching, and create a protective barrier.

Antidiarrheals:

• Loperamide (Imodium). Slows intestinal movement, allowing more water absorption and firmer stool.
• Diphenoxylate/atropine (Lomotil). Diphenoxylate reduces intestinal motility and secretion; atropine discourages abuse.
• Bismuth subsalicylate (Pepto-Bismol). Reduces stool frequency and protects the intestinal lining.

Stool softeners such as docusate sodium (Colace). Promote water absorption in the intestines, softening stool and reducing straining, which helps patients on opioids.

Laxatives such as polyethylene glycol (PEG). An osmotic laxative that draws water into the intestines for short-term relief of constipation from medications, immobility, or dietary changes.