June 12, 2000
After Hours Care
by Agnes Wong, RN, BSN, OCN
Infections and Fevers
Shortness of Breath
Nausea and Vomiting
Mucositis or Mouthsores
Receiving chemotherapy or radiation therapy for the first time can be overwhelming. Your oncology team will try to provide useful information to alleviate your fears and anxiety and to help you in caring for yourself at home. No matter how much your doctor or nurse prepares you, managing side effects from your cancer treatments can be nerve-wracking, especially when the oncology clinic is closed. Hopefully this article can provide a guideline on what to do when certain things happen.
White blood cells provide your body the immunity to fight infections. When the number of your body's white blood cells are lower, the risk for infections becomes greater. Chemotherapy and radiation therapy can both suppress the bone marrow's production of white blood cells, more specifically, your neutrophils which are your body's first line of defense.
Your doctor, nurse, or pharmacist will monitor your blood counts. After your chemotherapy treatment your doctor may prescribe a medication called Neupogen. Neupogen is a medication that helps your bone marrow produce more neutrophils.
You need to be aware on any changes with your health. If you suspect an infection or generally do not feel well, monitor your temperature. When the clinic is open, notify your oncology doctor or nurse if your temperature is 101°F (38.3°C) or higher. If the oncology clinic is closed, have someone take you to the emergency room for further evaluation. Once you arrive at the emergency room, identify yourself as a chemotherapy patient and notify the nurse or doctor that you are having a fever. During this time, do not take any medications (i.e. Tylenol, Advil, asprin, Motrin, and Vicodin) that may lower your temperature. You will only mask your fever.
Although fever is the most common sign, many cancer patients may not experience any changes in their body temperature when having an infection. Therefore, it is always good practice to take precautions and be aware of any signs of infection such as redness and swelling. Flu-like symptoms can include muscle and joint aches, headaches fatigue, nausea, slight or mild fever (less than 100°F), chills, and/or poor appetite. A kidney or bladder infection can include symptoms such as pain/burning or difficulty when urinating, reddish or bloody urine, fever and/or chills. Good handwashing before eating, after using the bathroom, and after petting animals can reduce your risks. Avoid crowds and people who have cold- or flu-like symptoms, measles, or chicken pox. Good oral hygiene can help in preventing infections in your mouth.
Shortness of breath is defined as difficulty in breathing. If you are experiencing shortness of breath, notify your doctor or nurse. If this occurs after hours or on weekends, have someone take you to the emergency room for further evaluation.
One of the causes can be anemia. Anemia is a decrease in red blood cells. One of the functions of the red blood cells is to carry oxygen throughout your body to the muscles, organs, and tissues. A simple blood test such as a complete blood count (CBC) or hemoglobin and hematocrit (H&H)levels can determine if you have anemia. If you do, a blood transfusion may be necessary. Your doctor may decide to start you on a weekly injection of Procrit. Procrit is a medication that helps your bone marrow produce more red blood cells.
Bleeding can be caused by a decrease in platelets in your blood. Some people may experience some unexpected bruising small red spots under their skin (petechiae), reddish or pinkish urine, black or bloody stools, bleeding gums or nose, vaginal bleeding, headaches or vision changes, and a change in mental status. You need to report any of these symptoms to your doctor or nurse. During after clinic hours or on weekends, if excessive bleeding occurs or if the bleeding does not stop within 10 minutes have someone take you to the emergency room for further evaluation.
Avoid any medications, which may decrease your platelets such as aspirin, coumadin, and, anti-inflammatory drugs, and sulfa drugs. If you are taking these medications, make sure that your doctor, nurse, and pharmacist are aware of it.
Avoid using dental floss or an electric toothbrush when cleaning your teeth. Instead use a soft-bristled toothbrush. No dental work should be done during your chemotherapy treatments without prior consultation with your oncologist. If you have a major dental problem, coordination of treatments is needed between your dentist and your oncologist.
Be careful around sharp objects such as knives and razors. If shaving, use an electric shaver to prevent bleeding and infections. Avoid any contact sports and activities such as football and basketball.
Nausea and vomiting is the most feared side effects of treatment among cancer patients. Fortunately, there have been recent developments of anti-nausea medications that help better control this side effect. Possible causes of nausea and vomiting can vary and can include cancer treatments, medications, certain food types, odors, and anxiety; but more commonly, it is associated with chemotherapy. These symptoms can occur within minutes to hours after chemotherapy and can resolve within 16 to 24 hours after treatment it can persist for days.
Your doctor, nurse or pharmacist will talk to you about the potential for nausea and vomiting with the chemotherapy drugs you are receiving. Prior to or during your chemotherapy treatment, they will instruct you on the drugs they give you to prevent nausea and vomiting. Such medications as Zofran, Compazine, Decadron, Ativan, or Reglan (or a combination of these drugs) can be used. It is important to take these drugs at the times the doctor, nurse or pharmacist tells you. If your nausea and/or vomiting persist when taking these drugs, notify your doctor or nurse.
If you are experiencing nausea, you want to maintain your strength. During the day, eat small, frequent, tepid (not too hot or not too cold) meals and drink more than 2 liters (8 glasses) of clear fluids. Avoid foods that are fatty, fried, spicy, acidic (sour). Avoid caffeine. Eat ``dry'' foods such as cereals, toast, and crackers. Food products with ginger (i.e. crystallized ginger, ginger tea, and ``flat'' ginger ale) may help calm your stomach. Alternative measures such as relaxation techniques (i.e. breathing exercises, imagery, and hypnosis), acupressure, acupuncture, and herbal teas can also help in reduce your nausea.
The causes of pain can vary from side effects of chemotherapy (i.e. numbness and tingling of the fingers, mouthsores, muscle aches, and stomach pains) to the disease itself. Not everyone who has cancer experiences pain but if you do, you can speak with your oncology doctor or nurse regarding medicines that can help control the pain.
For people who are experiencing chronic pain, it is important to have an effective pain management regimen. Taking your pain medication on a routine schedule may work better than taking the medication intermittently. Relaxation techniques such as meditation, breathing exercises, music therapy, and even hypnosis can help to control your pain, tension, and anxiety.
There can be some side effects from taking pain medications. One of the most common side effects is constipation. People who are taking pain medications on a regular basis should begin a bowel regimen. Taking a stool softener (Colace or docusate sodium) and a senna-derivative laxative twice a day can help prevent constipation. Avoid using any types of enemas or suppositories unless directed by your doctor or nurse. Other less common side effects include itching, slower and shallow breathing, and nausea and vomiting. If any of these symptoms occur, notify your doctor or nurse.
Constipation is defined as having a lack or infrequency of bowel movements. Inactivity, poor diet and fluid intake, certain chemotherapy drugs, pain medications, and surgery are possible causes of constipation. The symptoms can vary from bloating, abdominal fullness and/or discomforts, to nausea and vomiting.
A proper diet, adequate fluid intake, exercise, and a bowel regimen (see bowel regimen under pain section) can help prevent constipation. Eat high fiber foods such as fresh and dried fruits, vegetables, bran, wheat breads, and cereals. Drink about 8 to 12 glasses (or more) of fluids a day, especially hot liquids. And increase your activity level to stimulate your bowels to move.
If constipation continues and you have not had a bowel movement for 3 days, call your oncology doctor and/or nurse for further directions.
Diarrhea is defined as having more than 3 watery, loose stools a day. Chemotherapy, radiation therapy, dietary changes, disease, infections, and certain drugs are possible causes. Symptoms associated with diarrhea may include abdominal cramping, frequent liquid stools, and generalized weakness.
At the onset of these symptoms, Imodium or Kaopectate, an over-the-counter medication, can be taken to stop the diarrhea. Follow the instructions on the packaging. If the diarrhea does not stop or if you have more than 4 or 5 liquid stools in a 48-hour period, notify your doctor or nurse for further instructions.
When you are having diarrhea, it is important to increase your fluid intake to more than 12 glasses of clear fluids a day. Drinking clear liquids such as Gatorade or any sports drink, juices (i.e. cranberry or grape), chicken broth, and water can keep you hydrated. Rest your bowels by eating low fiber foods such as white bread, potatoes, ripe bananas, chicken, fish, cottage cheese, and eggs. Avoid any milk or milk products during this time.
Sitz baths can be comforting to the much-irritated anal area. In a bathtub or a wide deep basin place tepid or warm water about ½ or 1/3 full. Use this treatment at least twice a day for 20 minutes to promote comfort and healing.
Fatigue is the most common complaint of people who are undergoing chemotherapy and/or radiation therapy. It can occur at any time of the day, lasting from a few hours to a few days. Causes of fatigue can include uncontrolled pain, infections, poor diet, poor fluid intake, surgery, and from the disease itself. Fatigue can be harmful to a person's quality of life. It can affect your thinking and attention span, emotional well-being, and physical abilities.
There are many ways of preventing and managing fatigue. Most importantly, having adequate rest and sleep and establishing a normal sleeping pattern can be helpful. A good resting environment should be dark, well-ventilated, quiet, and comfortable. A warm bath, a hot drink, or even a massage before sleeping can help relax the body and the mind. Avoid any stimulants like caffeinated drinks, chocolate, smoking, alcohol, or exercise prior to bedtime.
A proper diet and mild exercise can help also. Eating a well-balanced and nutritious diet, taking a multi-vitamin once a day, and drinking about 8 to 12 glasses of fluids a day can help maintain your body's needs. A mild, low impact exercise such as walking, water aerobics, yoga, tai chi can help increase your body's energy level.
You need to be aware that when you feel tired, you need to take the time and rest. Do not overextend yourself. Ask for help from your friends and family. Conserving your energy and prioritizing your activities and chores can certainly help prevent fatigue.
Mouthsores are open sores or ulcers that may be dry, red, cracked, or inflamed. These sores not only can happen in your mouth but also in your throat, vagina, and rectal areas. Usually certain chemotherapy drugs, radiation therapy, and oral surgery are the causes of this problem.
Cancer patients may experience pain at the affected area, decreased appetite, dehydration, taste changes, infections, and bleeding. Good oral hygiene is the key in preventing this problem. Brush your teeth with a soft-bristled toothbrush at least twice a day. Avoid using any high-alcohol content mouthwashes. Instead use a baking soda mixture (1/2 to 1 teaspoon of baking soda in an 8-oz. glass of warm water) four times a day. Use lip balm or petroleum jelly to keep your lips moist.
At any sign of a mouthsore outbreak, call your doctor or nurse for further instructions. During this time, eat only soft and soothing foods such as ice creams, shakes, custards, and scrambled eggs. Avoid any irritating foods such as granola, tomatoes, and any citric fruits or juices.
These reactions from cancer treatments may seem minor but if left untreated, major complications can occur. If any emergencies arise when the clinic is closed, an on-call oncology doctor will be available to assist the emergency room doctors. Keep in mind that each oncology team may have different treatments for these symptoms. Always refer to your own oncology doctor or nurse for any questions or side effects.
These guidelines are taken from the practices of Kaiser Permanente Medical Center oncology clinic in San Francisco.
- Chemotherapy and You: A Guide to Self-Help During Cancer Treatment. National Institutes of Health: National Cancer Institute. 1999.
- Gates RA, Fink RM: Oncology Nursing Secrets: Questions and Answers About Caring for Patients with Cancer. Philadelphia, Hanley & Belfus, Inc. 1997.
- Miaskowski C, Buchsel P. Oncology Nursing: Assessment and Clinical Care. St. Louis, Mosby Inc. 1999.
- Yasko JM: Nursing Management of Symptoms Associated with Chemotherapy, 4th Ed. Philadelphia, Meniscus Health Care Communications, Division of Meniscus Limited. 1998.