9. Immunotherapy: it has been hypothesized that clinical malignancy may occur as a result of failure of the immunological surveillance system of the body to fight off cancer cells as they develop. The goal of immunotherapy is to immunize patients against their own tumors.
   1. Nonspecific immunotherapy - encourages a host-immune response by use of an unrelated agent. Bacille Calmette-Guerin (BCG) vaccine and Corynebacterium parvutn are the two agents used for this type of immunotherapy.
   2. Specific immunotherapy - uses substances that are antigenically related to the tumor that stimulate a specific host-immune response.
   3. Side effects - malaise, chills, nausea, vomiting, diarrhea; local reaction at site of injection, such as pruritus, scabbing.
   4. Nursing care plan/implementation:
      • Goal: decrease discomfort associated with side effects of therapy.
        1. Identify measures to lessen symptoms of side effects.
        2. Know type of immunotherapy being used, adverse and desirable effects of therapy.
        3. Administer fluids, encourage rest.
        4. Administer antiemetics as ordered for nausea.
        5. Monitor for respiratory distress.
        6. Administer analgesics as ordered for pain.
      • Goal: health teaching.
        1. Comfort measures to decrease side effects of therapy.
        2. Expected and side effects of therapy.
        3. Investigational nature of therapy.
        4. Care of site of administration.
        5. Answer questions honestly.
10. Palliative care: when treatment has been ineffective in control of the disease, the nurse must plan palliative, terminal care. Cure is not possible for such patients in an advanced phase of malignancy. Symptoms increase in severity; patients and family have many special problems.
    1. General problems of terminal cancer patient:
       • Cachexia: progressive weakness, wasting, and weight loss.
       • Anemia: leukopenia, thrombocytopenia, hemorrhage.
       • Gastrointestinal disturbances: anorexia, constipation.
       • Tissue breakdown leading to decubiti, seeping wounds.
       • Urine: retention, incontinence, renal calculi, tumor obstruction of ureters.
       • Hypercalcemia occurs in 10-30% of patients.
       • Pain due to tumor growth, obstruction, vertebral compression, or secondarily to complications, e.g., decubiti, stiffened joints, stomatitis. Also neuropathy, due to prolonged use of neurotoxic chemotherapeutic agents such as vincristine.
       • Fatigue: major and debilitating problem.
    2. Nursing care plan/implementation:
       • Goal: make patient as comfortable as possible; involve nursing staff, family, support personnel, clergy, volunteers, support groups, hospice, etc.
         1. Nutrition: obtain nutritional consultation; high-calorie, high-protein diet; small, frequent meals; blenderized or strained; commercial nutritional supplements (Ensure, Vivonex, Sustacal).
         2. Prevent tissue breakdown and vascular complications: frequent turning, massage, air mattress, active and passive ROM exercises.
         3. GI tract disturbances: observe for toxic reactions to therapy, particularly vomiting and diarrhea; administer medications: antiemetics, antidiarrheal agents as ordered.
         4. Relieve pain.
            • Use supportive measures such as massage, relaxation techniques, guided imagery; and drugs for pain relief: administer codeine, fentanyl, aspirin-oxycodone HC1 (Percodan), pentazocine (Talwin), morphine, methadone, as ordered.
            • Methods of administration: oral, injected, rectal, analgesic patches, or pumps (IV or SC).
            • Monitor for side effects of narcotics: depressed respiratory status, constipation, anorexia.
       • Goal: assist patient to maintain self-esteem and identity.
         1. Encourage self-care.
         2. Spend time with patient; isolation is a great fear for the dying patient.
       • Goal: assist patient with psychological adjustment - see nursing care for grieving patients, dying patients (see Unit 6).
11. Evaluation/outcome criteria:
1. Tolerates treatment modality - complications of surgery are avoided or minimized; tolerates chemotherapy; completes radiation therapy.
2. Side effects of treatment are managed by effective nursing care and health teaching.
3. Maintains good nutritional status.
4. Uses effective coping mechanisms or seeks appropriate assistance to deal with psychosocial concerns.
5. Makes choices for follow-up care based on accurate information.
6. Finds methods to control pain and minimize discomfort.
7. Participates in decisions regarding continuation of therapy (living will, health care proxy, DNR decisions).
8. Dignity maintained until death and during dying.