Assessment of Cancer Patients
Role of Radiation Therapists and General Health Assessment
Integral Role of Radiation Therapists
Radiation therapists are the only professionals within the department who see the patient every single day of their treatment course.
Because of this daily interaction, they play an essential role in the ongoing assessment of patients and the communication of potential needs to the rest of the oncology team.
General Health Assessment (Overview)
The Patient Interview: This is the first component of assessment and is typically conducted by the oncology nurse or radiation oncologist.
Data Collection: The process involves gathering data regarding the patient’s past and present health status, performing a physical examination, and established baseline laboratory information.
Self-Report Survey: This is a specific method of health assessment where individuals disclose information about various aspects of their lives. This data is critical for the radiation oncology team when designing the patient’s specific plan of care.
Categorization of Assessment
Assessment is divided into several specific domains: physical (including nutritional, pain, and blood assessments), psychosocial, cultural, and spiritual assessments, as well as special considerations for specific age groups.
Physical Assessment: Nutritional Status
The Importance of Daily Assessment
Daily physical assessment is a primary duty of the radiation therapist to ensure timely intervention if a patient's status changes.
Initial Nutritional Screening and Referral
Weight loss is frequently the first physical indicator that prompts an individual to seek medical treatment for cancer.
The oncology nurse typically performs initial screenings. Patients are referred to a dietitian or nutritionist if screening indicates a need.
Therapists monitor patients throughout treatment and make referrals to specialists when necessary.
High-Risk Areas for Nutritional Issues
Referrals are common for patients receiving treatment to the head and neck area or the pelvic area.
Patients with cancers affecting the gastrointestinal (GI) tract require particular attention.
It is essential to address nutritional challenges at the earliest stages of treatment and implement restorative measures early for these high-risk groups.
Nutritional Consequences of Cancer and Malnutrition
Nutrition is a vital component of the healing process and everyday life.
Cancer impacts nutrition by causing loss of appetite, impairing digestion, or inhibiting the processing of nutrients.
Treatment side effects can further impact the ability to eat, drink, or digest substances.
Consequences of Malnutrition:
Treatment delays.
Treatment complications.
Hospitalizations.
Lower overall treatment outcomes.
Key Nutritional Terminology
Anorexia: Defined as the inability or lack of desire to eat. It is a major cause of cancer cachexia.
Management strategies: Exercise, eating small frequent meals, drinking fluids between meals, and consuming high-calorie, high-protein foods.
Liquid supplements (e.g., Boost or Ensure) and keeping snacks nearby are encouraged.
Cachexia: A multidimensional "wasting syndrome."
Characteristics: Weight loss, muscle atrophy, fatigue, weakness, general ill health, malnutrition, and early satiety (feeling full quickly).
Prevalence: Affects one-half to two-thirds of cancer patients.
Pathology: A complex metabolic syndrome involving the loss of muscle, with or without loss of fat mass.
In children, it causes growth failure; in adults, it causes weight loss.
Stages of Cancer Cachexia
Precachexia: Earliest stage where preventive nutritional support and monitoring may be sufficient.
Cachexia: Mid-stage where nutritional supplements alone are insufficient. Pharmacologic approaches are required to address metabolic processes.
Refractory Cachexia: Advanced stage where the patient no longer responds to nutritional or medical interventions to reverse the condition. Intervention focuses purely on palliation.
Protein-Energy Malnutrition
Kwashiorkor: Produced by severe protein deficiency; primarily associated with muscle loss.
Marasmus: Calorie malnutrition characterized by the depletion of both fat and muscle; historically more associated with fat loss compared to the muscle loss seen in Kwashiorkor.
Physical Assessment: Pain Management
The Significance of Pain
Pain is one of the most feared consequences of cancer. All pain is considered real regardless of the identified cause.
Pain typically results from a combination of physiologic and psychogenic factors.
Purposes of Pain Assessment
Establishing a baseline for treatment and future intervention.
Determining the best intervention for the specific patient.
Enabling the evaluation of the effectiveness of an intervention.
The Gold Standard
The patient’s self-report is the "gold standard" for assessment.
Patients must be encouraged to view pain management as a primary part of their treatment, not secondary to anticancer therapies.
Classification of Cancer Pain
Acute Pain: New and sudden.
Causes: Diagnostic/surgical procedures, tumor growth/progression.
Emergencies: Situations like cord compression or airway obstruction require immediate radiation treatment to shrink tumors and relieve symptoms.
Chronic Pain: Pain present for 3 months or more.
Causes: Tumor invasion (bone, organs, tissues, blood, nerves) or treatment side effects (surgery, chemotherapy, radiation).
Examples: Lymphedema, radiation enteritis, radiation proctitis, and neuropathy.
The Six Dimensions of Cancer Pain Assessment
Physiologic Dimension: Determining the cause. There are three categories: pain from cancer therapy, pain from direct tumor involvement, and pain unrelated to the tumor/treatment.
Sensory Dimension: Identifying location, intensity, and quality.
Location: Asking the patient to point to or describe where the pain is.
Intensity: Translating pain into numbers or words for objective description.
Quality: Descriptors like burning, aching, throbbing, sharp, tender, stabbing, heavy, shooting, gnawing, or splitting.
Affective Dimension: Recognizing emotional responses like depression and anxiety. Anxiety often increases pain and reduces the ability to cope, yet these factors are often overlooked.
Sociocultural Dimension: Factors including ethnicity, culture, demographics, spirituality, age, gender, and race.
Behavioral Dimension: Monitoring activity levels and medication intake.
Avoidance of movement (due to pain) can lead to respiratory complications.
Therapists look for physical cues: How a patient stands, uses chair arms for support, or moves when called from the waiting room.
Cognitive Dimension: How pain influences a person's thought processes and self-view.
Functional Status and Self-Reporting
Karnofsky Performance Status Scale
Used to evaluate a patient's ability to perform activities and chores.
Score (%) | Status |
|---|---|
100 | Normal: no complaints and no evidence of disease. |
90 | Ability to carry on normal activity: minor signs or symptoms of disease. |
80 | Normal activity with effort: some signs or symptoms of disease. |
70 | Self-care: inability to carry on normal activity or do active work. |
60 | Occasional assistance required, but ability to care for most needs. |
50 | Considerable assistance and frequent medical care required. |
40 | Disability: special care and assistance required. |
30 | Severe disability: hospitalization indicated, although death not imminent. |
20 | Extreme sickness: hospitalization and active supportive treatment necessary. |
10 | Moribund status: fatal processes progressing rapidly. |
0 | Death. |
Limitations of Self-Reporting
Patients may build up a tolerance and under-report pain.
Patients may not want to be a bother or may fear further treatment.
Therapists must monitor nonverbal cues: body movement, behavior, and social interaction.
Physical Assessment: Hematologic (Blood) Status
Radiosensitivity of Blood Cells
Hematopoietic tissue (bone marrow/blood cells) is highly sensitive to radiation and chemotherapy.
Erythroblasts (stem cells) and mature lymphocytes are among the most radiosensitive cells in the human body.
Monitoring is critical when treatment fields include large volumes of bone marrow, the spine, the abdomen, or the pelvis.
Blood Assessment Key Terms
Myelosuppression: A reduction in bone marrow function causing fewer red blood cells (RBCs), white blood cells (WBCs), and platelets.
Anemia: A decrease in peripheral RBCs and hemoglobin levels.
Hemoglobin carries oxygen from the lungs to tissues and returns carbon dioxide to the lungs.
Symptoms: Pale skin, muscle weakness, fatigue.
Hematocrit: The percentage of erythrocytes in the blood; used to diagnose anemia.
Leukopenia: A decrease in WBC count, which increases infection risk. Many cancer patients also experience immunosuppression (immune system suppression).
Thrombocytopenia: A reduction in circulating platelets, impacting blood clotting.
Severe thrombocytopenia is defined as a count of or less.
This level can lead to spontaneous hemorrhage.
Psychosocial, Cultural, and Spiritual Assessment
Quality of Life (QOL)
Focuses on the quality of survival, not just its length. It is a subjective sense of well-being.
Physical factors: Loss of function, symptoms, and limited activity.
Psychological themes: Fear/anxiety, loss of personal control, uncertainty about outcomes, physician's enthusiasm for cure, and debilitating effects of treatments.
Social factors: Age, marital status, and occupation.
Response to Diagnosis
Anxiety: Response to a perceived threat characterized by arousal and uneasy feelings.
Depression: Feeling discouraged, sad, hopeless, or unmotivated.
Cultural Assessment
Values: Criteria for how to act, established in early childhood through socialization.
Beliefs: Knowledge, opinions, and faith about life and others based on values.
Customs: Conditioned behaviors or traditions passed down through families.
Cultural Competence: Essential for caring for the whole patient. Considerations include language barriers, gender preferences, family involvement, dietary differences, modesty, and attitudes toward appointments.
LGBT Population Care
Include transgender options on surveys.
Provide unisex bathrooms.
Promote sensitivity training.
Discuss sexual identity and preferred terms with the patient.
Maintain dignity via proper draping and strict confidentiality.
Spiritual Assessment
Spirituality provides meaning to life, death, and illness. It is the central philosophy guiding a person's conduct.
Spirituality vs. Religion: Spirituality is a sense of fulfillment and connection to a higher power; religion involves specific principles and rituals practiced in groups.
Four key assessment areas: Concept of God, sources of hope/strength, significance of religious practices, and the relationship between beliefs and health.
Special Cases in Assessment
Children
Evaluation includes checking for depression, withdrawal, anxiety, development, and family relationships.
Caring for children necessitates assessing the needs/concerns of primary caregivers/parents.
Adolescents
Focus on self-esteem, body image, autonomy, and social relationships.
Therapists should respect modesty, provide choices, and empathize with the need for peer interaction.
Elderly
Physical assessment focuses on functional changes (hearing, seeing, understanding).
Assessment also includes monitoring changes in economic resources, family structure, and social status.