CAREPLAN FOR FATIGUE

Fatigue can be confused with tiredness. Everyone gets tired. In fact, it is an expected feeling after certain activities or at the end of the day. Usually, we know why we're tired and a good night's sleep will solve the problem. Fatigue is less precise, less cause-and-effect. Fatigue is a daily lack of energy; an unusual or excessive whole-body tiredness, not relieved by sleep. It can be acute (lasting a month or less) or chronic (lasting from 1 month to 6 months or longer). Fatigue can have a profound negative impact on a person's ability to function and quality of life. Cancer-related fatigue (CRF - sometimes simply called "cancer fatigue") is one of the most common side effects of cancer and its treatments. It is often described as "paralyzing." Usually, it comes on suddenly, does not result from activity or exertion, and is not relieved by rest or sleep. It may not end - even when treatment is complete. CAUSES The exact reason for cancer fatigue is unknown, may be related to both the disease process and treatments including surgery, chemotherapy, and radiation therapy. Cancer treatments commonly associated with cancer related- fatigues are:

Chemotherapy - Any chemotherapy drug may result in fatigue. This may vary from person to person. Some people say it lasts only a couple of days. Others feel the CRF persists through and beyond completion of treatment. Drugs such as vincristine, vinblastine, and cisplatin often cause CRF. Radiation therapy - Radiation therapy can cause cumulative fatigue (fatigue that increases over time). This can occur regardless of treatment site. CRF usually lasts from 3-4 weeks after treatment stops but can continue for up to 2-3 months. Bone Marrow Transplant - This aggressive form of treatment can cause CRF that lasts up to one year. Biologic therapy - Cytokines are natural cell proteins, such as interferons and interleukins that are normally released by white blood cells in response to infection. These cytokines carry messages that regulate other elements of the immune and endocrine systems. In high amounts, these cytokines can be toxic and lead to persistent fatigue.

Other factors that may contribute to cancer-related fatigue include:

Anemia. Anemia can result from blood counts that are reduced by treatments, reducing the oxygen-carrying ability (hemoglobin) of the blood. About 7 in 10 patients experience anemia during chemotherapy. Combination therapy. Patients experiencing more than one treatment at the same time or one after the other may experience more CRF. Tumor induced "hypermetabolic" state. Tumor cells compete for nutrients, often at the expense of the normal cell's growth and metabolism. Weight loss, deceased appetite, and fatigue are common results.

Decreased nutrition from the side effects of treatments (i.e. nausea, vomiting, mouth sores, taste changes, heartburn, and diarrhea). Hypothyroidism. If the thyroid gland is under-active, metabolism may slow down so that the body does not burn food fast enough to provide adequate energy. This is a common condition in general but may happen after radiation therapy to the lymph nodes in the neck. Medications used to treat side effects such as nausea, pain, depression, anxiety, and seizures can contribute to CRF. Pain. Research shows that chronic, severe pain increases fatigue. Stress can worsen feelings of fatigue. This can include any type of stress; from dealing with the disease and the unknowns to worrying about daily accomplishments to worry about not meeting the expectations of others. Depression and fatigue often go hand in hand. It may not be clear as to which started first. Families may be confused as well. One way to sort this out is to try to understand how much of a problem is caused by the depressed feelings. Are you depressed all the time? Were you depressed before your cancer diagnosis? Are you preoccupied with feeling worthless and useless? If the answers to these questions are yes, you may need treatment for depression.

INTERVENTIONS Energy Conservation during Cancer Fatigue: Health Teachings Plan ahead and organize work:

Change storage of items to reduce trips or reaching Delegate when needed Combine motions and activities and simplify details

Schedule rest:

Balance periods of rest and work Rest before fatigue Frequent, short rests are beneficial

Pace yourself:

Moderate pace is better than rushing through activities Reduce sudden or prolonged strains Alternate sitting and standing

Practice proper body mechanics to combat cancer fatigue:

When sitting, use a chair with good support Adjust work heights - work without bending over Bend at the knees and hips, not at the back Carry several smaller loads or use a cart

Limit overhead work:

Use long handled tools Store items lower

Delegate

Limit isometric work:

Breathe evenly, do not hold your breath Wear comfortable clothes to allow for free and easy breathing

Identify effects of your environment that may cause cancerrelated fatigue:

Avoid extremes of temperature Eliminate smoke or noxious fumes Avoid long, hot showers or baths

Prioritize:

Decide what activities are important to you, and what could be delegated Use your energy on important tasks

Nutritional Intake CRF is often made worse if the patient is not eating enough or if not eating the right foods. Maintaining good nutrition can help you feel better and have more overall energy. The following are strategies to help improve nutritional intake: Basic calorie needs:

Estimated calorie needs for person with cancer is 15 calories per pound of weight if the weight has been stable. Add 500 calories per day if there is weight loss Example: A person who weighs 150 lbs. needs about 2250 calories per day to maintain weight.

Protein rebuilds and repairs damaged (and normally aging) body tissue:

Estimated protein needs are 0.5 - 0.6 grams of protein per pound of body weight. Example: A 150 lb. person needs 75-90 grams of protein per day. The best sources of protein include foods from the dairy group (8 oz. milk = 8 grams protein) and meats (meat, fish, or poultry = 7grams of protein per ounce).

Fluid Needs:

A minimum of 8 cups of fluid per day will prevent dehydration. (That is 64 ounces, 2 quarts, or 1 half-gallon). Fluids can include juice, milk, broth, milkshakes, Jello and other beverages. Of course, water is fine too. Beverages containing caffeine do NOT count. Fluid losses from excess vomiting or diarrhea will require extra fluids.

Supplemental Vitamins:

A good idea if dietary intake of sufficient nutrients is in doubt. A recommended supplement would be a multivitamin that provides at least 100% of the recommended daily allowances (RDA) for most nutrients. Vitamin supplements do not provide calories, which are essential for energy production. So vitamins cannot substitute for adequate food intake.

Role of a Dietitian in fighting cancer fatigue:

Provides suggestions to work around any eating symptoms that may be interfering with intake (i.e. early feeling of fullness, swallowing difficulty, or taste changes). Suggests ways of maximizing calories and proteins in smaller amounts of food (i.e. powdered milk, instant breakfast drinks, and other commercial supplements, or food additives).

Cancer-Related Fatigue and Exercise: Decreased physical activity, which may be the result of illness or of treatment, can lead to tiredness and lack of energy. Scientists have found that even healthy athletes forced to spend extended periods in bed or sitting in chairs develop feelings of anxiety, depression, weakness, fatigue, and nausea. Regular moderate exercise can prevent these feelings, and help a person feel energetic and stay active. Even during cancer therapy, it is often possible to continue exercise. Benefits of exercise:

Lower blood pressure Improvement in the heart's pumping ability More energetic feeling, less fatigue Increased endurance Stronger tendons, ligaments, joints, and bones Easing the pain or stiffness or arthritic joints A more positive attitude, less strain and tension Better sleeping patterns Improved appetite

Right Exercise

A good exercise plan starts slowly, allowing the body time to adjust. It is important that the patients will do something to exercise the whole body on a regular basis. Regular means every day or, at least every other day. The right kind of exercise never makes them feel sore, stiff, or exhausted. Any kind of exercise is O.K. Walking, stationary bike, or swimming (if the immune system is O.K.) is examples of types of exercise.

Wrong Exercise?

Even more dangerous than doing no exercise is exercising only occasionally and doing too much, too fast. If the patient experience soreness, stiffness, exhaustion, or feel out of breath as a result of the exercise, then they are overdoing it.

Stress management: Managing stress can play an important role in combating fatigue. following are suggestions:

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Adjust expectations. A sense of accomplishment goes a long way to reducing stress. Help others to understand and support the patient. Family and friends can be helpful if they can "put themselves in the patients shoes" and understand what fatigue means to him. Cancer support groups can be a source of support as well other people with cancer truly understand what they are going through. Relaxation techniques such as audio tapes that teach deep breathing or visualization can help reduce stress and minimize cancer fatigue. Activities that divert attention away from fatigue can also be helpful. For example, activities such as knitting, reading, or listening to music require little physical energy bur require attention. If stress seems out of control, encourage patient to talk to a health care provider.

Although CRF is a common, and often expected, side effect of cancer and its treatments, patient should feel free to mention such feelings to the people providing care. There are times when fatigue may be a clue to an underlying medical problem. Other times, there may be medical interventions to assist in controlling some of the causes of fatigue. Finally, there may be suggestions that are more specific to the situation that would help in combating the CRF. SYMPTOMS TO REPORT

Fatigue that limits the patients ability to care for themselves Increasing shortness of breath with minimal exertion Uncontrolled pain Inability to control side effects from treatments (i.e. nausea, vomiting, diarrhea, or loss of appetite). Uncontrollable anxiety or nervousness

CARE PLAN FOR Heart Rhythm Changes (Arrhythmias)

Heart Rhythm Changes (Arrhythmias) The heart pumps blood through the body continuously, in a systematic manner. Blood flows from the top, right side of the heart (the right atrium of the heart), and moves down the heart tissue into the lower chambers of the heart, called the ventricles. Heart rhythm changes, or arrhythmias, occur when there is a disruption in the heart's normal electrical system, causing it to beat irregularly. It can be diagnosed by ECG tracings. Treatment will depend upon the type of irregular heart rate, your symptoms, and the patients overall health status. A common type of arrhythmia is called atrial fibrillation, when the heart beats irregularly irregular, and fast. This means that the heart is unable to pump blood

through the body very well. Arrhythmias occur for many reasons. They can be due to:

Heart disease High blood pressure for a long time Damage to the heart muscle Chronic lung disease, or pneumonia Alcohol intake Medications Arrhythmias may be a complication of heart failure

Symptoms

Chest pain Light headedness and excessive tiredness Shortness of breath, either at rest or while performing any type of activity. This may include walking to the door, or climbing stairs. Weakness, and it might be difficult to perform usual daily activities Feeling of an irregular heart beat (palpitations)

Interventions:

Ask the patients of other taken medications (including over-thecounter, vitamins, or herbal remedies). Assess for history of diabetes, liver, kidney, or heart disease. Assess for family history of heart disease, stroke, high blood cholesterol, or high blood pressure, in a first or second-degree relative, these will pose at risk for certain problems. Smoking can cause palpitations, or an irregular heart rate. Cessation of smoking is very important; smoking can also increase the chance of developing heart vessel damage. Caffeine and alcohol can cause palpitations. Eliminate caffeine and alcohol from the patients diet, and palpitations may resolve. Encourage the patient to keep a diary of irregular heart rate or palpitations, if they are occurring regularly. Write down the foods that they have eaten, the exercise or activity they were undergoing when the rapid or irregular heartbeats occurred, and how they felt before they occurred. This diary may be valuable in determining the cause of the palpitations. Questions to ask may include: o Did the irregular heart rate or palpitations occur gradually, or did this episode come on all of a sudden? Was the patient feeling anxious? Did he perform any kind of activity, or was he resting? Make sure to exercise, under the supervision. Walking, swimming, or light aerobic activity may help to lose weight, and promote the flow of oxygen in the lungs and blood. Use relaxation techniques to decrease the amount of anxiety. If anxious, place patientf in a quiet environment, and let him close his eyes. Take slow, steady, deep breaths, and try to concentrate on things that have relaxed him in the past (such as a vacation, an area of your home, etc.). If there are ordered medication to treat this disorder, teach patient not to stop taking any medication unless healthcare provider tells to. Take the medication exactly as directed. Do not share your pills with anyone.

If missed a dose of the medication, discuss with the healthcare provider what should be done. If you experience symptoms or side effects, especially if severe, be sure to discuss them with your health care team. They can prescribe medications and/or offer other suggestions that are effective in managing such problems.

Drugs that may be prescribed There are many types of medications that may be used to treat arrhythmias. These may include:

ACE inhibitors - These drugs work by opening, or dilating, your arteries. It will lower blood pressure, and improve blood flow to kidneys, and through out body. Healthcare provider may also prescribe these medications if there is diabetes or protein in the urine, to protect the kidneys. Some examples of this medication may include: enalapril maleate (Vasotec), lisinopril (Zestril), and fosinopril sodium (Monopril) Anticoagulants - These medications prevent blood from clotting. Each of them works in a variety of ways. Depending on the overall health status, the kind of chemotherapy received, and the location of the blood clot, the healthcare provider may suggest warfarin sodium (Coumadin), or enaxoparin (Lovenox). Antianxiety medications - If symptoms are due to anxiety, healthcare provider may prescribe an Anti-anxiety medication, called an anxiolytic. These medications will help patient to relax. These may include lorazepam (Ativan), or alprazolam (Xanax). It is important to take these medications only when patient are feeling anxious. Do not operate heavy machinery, or drive an automobile while taking these. If these medications do not control symptoms, discuss this with the doctor. Aspirin - Depending on the overall health status, and the type and severity of the arrhythmia, healthcare provider may prescribe aspirin as a "blood thinner." Aspirin works by preventing platelets in the blood from forming blood clots (anti-platelet). Beta-blockers - Can be used to slow down the heart rate, and improve blood flow through your body. You may take this drug if you have been diagnosed with irregular heartbeats, or high blood pressure. Some examples of this medication may include: metoprolol (Lopressor), propranolol (Inderal ), and atenolol (Tenormin ). Calcium Channel Blockers - These medications may be given to treat chest pain, high blood pressure, or irregular heart beats. A few common drugs include verapamil HCL (Calan), and diltiazem (Dilacor XR). Digoxin - Also called digitalis, this medication works by slowing down the heart rate, and making it beat more effectively. This will pump blood through out the body better. It is also called Lanoxin . Diuretics - may be known as "water pills" as they work to prevent heart failure by making the patient to urinate out extra fluid. Patient will receive this if arrhythmias are due to fluid accumulation in the heart or lungs. Some examples of this medication may include furosemide (Lasix), and Hydrochlorthiazide. Patient may receive this medication alone or in combination with other medications. Instruct patient to not stop any of these medications abruptly, as serious side effects may occur.

SYMPTOMS TO REPORT

Fever of 100.5 F (38 C), chills, sore throat (possible signs of infection). Shortness of breath, chest pain or discomfort; swelling of your lips or throat should be evaluated immediately Feeling OF heart beat rapidly (palpitations) Any new rashes on skin, especially if there is recently changed medications Any unusual swelling in the feet and legs Weight gain of greater than 3 to 5 pounds in 1 week.

CARE PLAN FOR ARRYTHMIA AND FATIGUE

Written Project

In Partial Fulfillment of the Requirements in the Subject NCM 106 (Cellular Aberrations, Acute Biologic Crisis and Disaster Nursing)

Submitted To: Mrs. Michelle Z. Jagunap, R.N Instructor

Submitted By: Honey Lee G. Gonzaga

BSN IV-C

August 19, 2011