Practical Aspects of Dealing With Cancer Therapy-Induced Nausea and Vomiting

Vivienne Pervan

T HE INITIAL practical management of the emesis associated with chemotherapy may

simply include having a kidney tray ready, standing out of range, and rubbing the patient’s back. However, because nausea and vomiting are so distressing for chemotherapy patients, both in terms of the way they feel physically and their dignity, emesis requires more than just that amount of care. Nausea and vomiting are so dis- tressing to some that they are often the reasons stated for refusing further treatment or even for not completing the course of treatment in prog- ress. To maximize the patient’s chance of cure and survival, the need to address this problem seriously has arisen.

The degree of nausea and vomiting a patient will experience when undergoing cytostatic ther- apy is related to the emetogenicity of the che- motherapeutic agent, as well as to prior experi- ence of nausea and vomiting. Symptoms may be acute, occurring within the first 24 hours of ther- apy, or delayed, occurring within 7 days of ther- apy. Anticipatory nausea and vomiting are pro- voked by the thought of further courses of che- motherapy and are triggered by sensory stimuli associated with treatment; for example, the sight of the hospital or smells associated with the hos- pital.1*2 Nausea and vomiting result in fear and anxiety in the patient, and, in addition to the effect of emesis on compliance with future ther- apy or the use of aggressive antitumor regimens3 the patient’s psychologic and physical well-being is compromised.

Several practical measures for supporting pa- tients receiving chemotherapy are available and include: counseling, dietary measures, fluid in- take, oral hygiene, avoidance of certain odors, music, relaxation and visualization therapy, breathing exercises and diversional therapy, hyp- nosis, and the use of antiemetics.

COUNSELING

Before embarking on a course of chemother- apy, the nurse should establish a good relation- ship with the patient, who is likely to be nervous and anxious about the possible side effects of treatment. The atmosphere should be calm and

relaxed, and the nurse should prepare the patient thoroughly for what lies ahead. Such counseling should be given by an empathic, competent, and knowledgeable chemotherapy nurse who is pre- pared to repeat the information already given by the doctor when consent to treatment was ob- tained. The nurse must explain any points the patient has not fully understood and assure the patient of his or her interest and support for the patient as an individual person. In addition, the nurse may also be required to counsel close family members and friends who may also require sup- port.

DIET

It is essential for the cancer patient to have a balanced diet with adequate intake of calories and protein, in order to resist the cancer and to cope with the immunosuppression and other side ef- fects associated with chemotherapy.4v5 The pa- tient likely to suffer from nausea and vomiting should be given frequent, small but nourishing meals of non-gas-forming food with reduced fat content.6 Some patients can tolerate cold food better than hot, and ice cream may be acceptable. Patients should be offered foods they particularly enjoy in order to tempt their appetites, as it is important to maintain nutritional status.4

Cancer patients receiving chemotherapy often experience taste perversion giving certain foods unpleasant, metallic, or bland tastes. These pa- tients may lose their appetite completely and should be encouraged to eat whatever food they find the least bit appetizing.’

FLUIDS

Patients should be encouraged to drink plenty of fluids in order to maintain fluid and electrolyte

From the Radiotherapy Department, Groote Schuur Hos- pital, Cape Town, South Africa.

Vivienne Pervan, RGN: Oncology Nurse, Radiotherapy Department, Groote Schuur Hospital.

Address reprint requests to Vivienne Pervan. RGN, Groote Schuur Hospital, University of Cape Town, 7925 Observatory, Cape Town, South Africa.

0 1990 by W.B. Saunders Company. 0749-2081/90/0604-1004$05.00/O

Seminars in oncology Norsing, Vol6, No 4, Suppl 1 (November), 1990: pp 3-5 3

4 VIVIENNE PERVAN

balance, which can be impaired by repeated vomiting. This will also help to reduce the toxicity of the cytostatics by flushing the chemicals through the body via the kidneys. A clear liquid diet of fruit juices, broth, tea, ginger ale and other similar drinks, will help to reduce nausea.4 Car- bonated beverages are usually easily tolerated, but any fluids are acceptable. Ice chips can be very refreshing.

ORAL HYGIENE

Many chemotherapeutic agents destroy ac- tively replicating cells within the basement membrane of the buccal mucous membrane, and up to 40% of patients with cancer experience some degree of stomatitis during chemotherapy.’ This will interfere with the patient’s comfort, nu- tritional intake, body image, and the ability to communicate with others.

Maintaining the integrity of the oral mucosa is an important nursing goal and where stomatitis occurs, restoring this integrity is important. A regular cleansing regimen will keep the oral mu- cosa moist and free of debris such as food, ne- crotic tissue, and mucus or blood. This avoids creating an environment conducive to pathogen growth.

Cleansing techniques include using a soft toothbrush, sponge-tipped applicators or oral ir- rigation. A variety of solutions are available for oral cleansing and include normal saline, hydro- gen peroxide, kaopectate, mineral oil, and lemon glycerine. Topical antibiotics or antifungals may be appropriate when infection has supervened.

AVOIDANCE OF SMELLS

Many odors can induce nausea and vomiting, and if the patient is being nursed in hospital it is important that his or her bed is positioned in the ward away from kitchens, bathrooms, sluices, and any other sources of smells and that the ward is well ventilated. When the patient’s meal is being served, the lid should be removed from the plate before it is offered, so that any odors can escape preventing possible nausea. During the admin- istration of chemotherapy, patients should be screened from the ward to protect other patients from sounds or smells of vomiting, which may trigger emesis in them. A patient being treated at home may have to prepare meals, so the kitchen

should be well ventilated and the food covered whenever possible. An extractor fan is useful.4,5

MUSIC THERAPY

Music therapy has been used effectively4 in many cancer centers, including our own. Music relaxes patients and creates a restful atmosphere. It should be slow and rhythmical, with low fre- quency tones. Orchestral music is most effec- tive-either classical, folk, pop, or jazz. It should be quiet, neither intrusive nor disruptive, and create a calm and pleasant background for the therapeutic environment.7

RELAXATION AND VISUALIZATION

Relaxation and visualization therapy has been used to good effect among patients attending our hospital for chemotherapy, particularly for gy- necological malignancies. Patients meet regularly as a group, with a therapist, who encourages them to relax either lying on mattresses or seated in comfortable chairs with their feet up. Progressive muscle relaxation, from the feet upwards or from the head downwards, is taught, and when the pa- tients are sufficiently relaxed, visualization and imagery are encouraged. Patients are asked to close their eyes and visualize a place that is es- pecially meaningful to them, and to imagine themselves to be in that place. This therapy is particularly beneficial for children because they have such vivid imaginations, but it may be nec- essary to show an adult a beautiful flower or a lovely view in order to stimulate the imagina- tion.5x7.9 Hypnosis by a person trained in its tech- niques can also be useful in helping patients to dissociate themselves from the treatment and its side effects. However, Warren’ takes the view that hypnosis should only be used if the patient has positive belief in and good expectations of this method of treatment.

BREATHING EXERCISES AND DIVERSIONAL THERAPY

Patients skeptical of the value of hypnosis may be helped by practical activities such as breathing exercises and diversional therapy. The latter can take any form, from reading to handiwork to watching videos. Encouraging groups of patients to socialize together during chemotherapy ad- ministration improves their tolerance of the drugs and enables them to support each other. Exercises

PRACTICAL MANAGEMENT OF NAUSEA AND VOMITING 5

in deep breathing can be practiced during relax- ation, such as in the planned program described by Cobb.”

THE USE OF ANTIEMETICS

Many antiemetic drugs have some activity against mild-to-moderate emetogenic stimuli, but with the exception of high-dose metoclopramide, they are generally ineffective against highly eme- togenic chemotherapy (Table l).” The drugs

Table 1. Emetogenicity of Chemotherapeutic Agents

Cisplatin

Dacarbazine

Dactinomycin

Cyclophosphamide

Lomustine

Carboplatin

Doxorubicin

Daunorubicin

Cytarabine

Procarbazine

Etoposide

Mitomycin-C

Methotrexate

5-Fluorouracil

Hydroxyurea

Sleomycin

Vinblastine

Vincristine

Chlorambucil

High likelihood of emesis

. Low likelihood of emesis

Adapted with permission.”

commonly used include dopamine antagonists such as metoclopramide, synthetic cannabinoids such as nabilone, benzodiazepines such as lora- zepam, and phenothiazines such as prochlorper- azine, which may be administered in combina- tion with corticosteroids.‘*

In a recent multicenter trial we studied the new 5-HT3 antagonist, granisetron, which was specif- ically developed as an antiemetic. The efficacy of this drug is impressive, both as prophylaxis and as treatment for the nausea and vomiting asso- ciated with cytostatic therapy. Patients experi- enced less anxiety as their nausea and vomiting were well controlled during their first treatment session, minimizing anticipatory emesis. This control of symptoms was sustained throughout subsequent cycles of treatment without significant side effects. This class of compounds may rep resent a major advance in the control of nausea and vomiting associated with cytostatic therapy.

CONCLUSION

There will always be an important place for counseling and support in the nursing care of cancer patients. However, their quality of life can certainly be improved during the administration of chemotherapy by an antiemetic agent that ef- fectively controls the distressing side effects of nausea and vomiting, thus enabling nurses to di- rect their attention to other problems that may be causing their patients distress.

REFERENCES

1. Redd WH, Hendler CS: Behavioural medicine in com- prehensive cancer treatment. J Psychsoc Oncol 1:3-17, 1983 (suppi 2)

2. Laszlo J, Lucas VS: Emesis as a critical problem in che- motherapy. N Engl J Med 306:948-949, 1981 (suppl 16)

3. Laszlo J: Anticipatory nausea and vomiting with che- motherapy. N Engl J Med 306:43 l-432, 1982 (suppl7)

4. Yasko JM, Greene P: Coping with problems related to cancer and cancer treatment. CA 37: 106-125, 1987 (suppl2)

5. Warren K: Will I be sick, nurse? Nursing Times 84:53- 54, 1988 (suppl 12)

6. Tiffany R (ed): Oncology for Nurses and Health Care Professionals (vol 2). London, UK, George Allen & Unwin, 1978, pp 63-81

7. Yasko JM: Holistic management of nausea and vomiting caused by chemotherapy. Top Clin Nuts 7:27, 1985 (suppl 1)

8. Hogan CM: Nausea and vomiting: Nursing management of symptoms associated with chemotherapy, in Yasko JM (ed): Guidelines for Cancer Care; Symptom Management. Reston, VA, Reston Publishing, 1983, pp 198-2 11

9. Cotanch PM: Relaxation training for control of nausea and vomiting in patients receiving chemotherapy. Cancer Nurs 6:277-282, 1983

10. Cobb SC: Teaching relaxation techniques to cancer patients. Cancer Nurs 7: 157-16 1, 1984

11. Clark RA, Tyson LB, Gralla RJ, et al: Antiemetic ther- any: Management of chemotherapy induced nausea and vomiting. Semin Oncol Nuts 5:53-57, 1989 (suppl 1)

12. Joss RA, Brand BC, Buser KS, Cemy T: The symp tomatic control of cytostatic drug-induced emesis. A recent history and review. Eur J Cancer 26:S3-S9, 1990 (suppl 1)