Nausea, vomiting, and retching: complex problems in palliative care.

Patients with advanced cancer commonly experience nausea, vomiting, and/or retching (NVR) as a result of the malignant process and its treatment. Recently, increasing attention is being focused on end-of-life care, which includes relief or reduction of symptoms such as NVR. Pre-chemotherapy preparation and patient education in the palliative care setting are essential to preventing acute and delayed distress from NVR, as well as anticipatory symptoms. Careful assessment of chemotherapy-related symptoms should distinguish between the three phenomena rather than taking a global approach. Strategies for preventing anticipatory nausea, for instance, may differ significantly from those designed to reduce frequency of vomiting. Management of anticancer treatment-related NVR should incorporate both pharmacologic and nonpharmacologic approaches, whenever appropriate, with the overall goal of improving and/or maintaining the patient's quality of life.

Fatigue and quality of life outcomes of exercise during cancer treatment.

PURPOSE: Despite the recognition of fatigue as a common and distressing symptom during cancer treatment, there are few evidence-based interventions available to manage such fatigue. The purpose of this multi-institutional pilot study was to explore the effects of a home-based moderate walking exercise intervention on fatigue, physical functioning, emotional distress, and quality of life (QOL) during breast cancer treatment. DESCRIPTION OF STUDY: Fifty-two women were recruited from five university hospital outpatient departments for this pilot study with an experimental design. Subjects were randomly assigned to the walking program or to usual care during adjuvant chemotherapy or radiation therapy for breast cancer. Symptoms, physical functioning, and QOL were measured at baseline, midtreatment, and at the end of treatment. RESULTS: Women who exercised at least 90 minutes per week on 3 or more days reported significantly less fatigue and emotional distress as well as higher functional ability and QOL than women who were less active during treatment. CLINICAL IMPLICATIONS: A home-based walking exercise program is a potentially effective, low-cost, and safe intervention to manage fatigue and to improve QOL during adjuvant chemotherapy or radiation therapy for breast cancer. This health-promoting self-care activity needs further testing in large randomized clinical trials.

An instrument to measure symptom experience. Symptom occurrence and symptom distress.

This article describes the development of an instrument that measures symptom experience (symptom occurrence and symptom distress). The Adapted Symptom Distress Scale-2 (ASDS-2), adapted from the McCorkle and Young Distress Scale, is a 31-item, 5-point, self-report paper-and-pencil instrument that measures patients' perception of the occurrence and distress of 14 symptoms: nausea, vomiting, pain, eating, sleep, fatigue, bowel elimination, breathing, coughing, concentration, lacrimation, changes in body temperature, appearance, and restlessness. Use of the instrument yields a total score for symptom experience, scores for symptom occurrence, scores for symptom distress, and subscale scores for six symptom categories: gastrointestinal, fatigue/restlessness, concentration, pain/discomfort, respiratory, and appearance. Reliability and validity were determined with well adults (n = 97), medical-surgical patients (n = 82), and oncology patients (n = 175). Findings revealed a Cronbach's alpha of 0.91 for symptom experience, 0.90 for symptom occurrence, and 0.76 for symptom distress. Cronbach's alpha for the subscales ranged from 0.38 for appearance symptoms to 0.83 for gastrointestinal symptoms. Inclusion of symptoms reported by patients with cancer strengthened content validity. A contrasted groups approach was used to demonstrate construct validity.

Daily times four vinorelbine plus cisplatin in advanced non-small-cell lung cancer: a phase II trial of a novel schedule.

PURPOSE: To evaluate the efficacy of a novel multiday schedule of vinorelbine and displatin in patients with advanced NSCLC. PATIENTS AND METHODS: Thirty patients were enrolled, including 27 patients with stage IV disease, and 11 patients with performance status of 2. They received a maximum of four chemotherapy cycles with cisplatin 20 mg/m2/day and vinorelbine 15 mg/m2/day intravenously (i.v.) for four consecutive days, every three weeks, with prophylactic filgrastim. RESULTS: Sixteen patients responded (53%, 95% confidence interval (95% CI): 34%-72%), including two complete and fourteen partial confirmed responses. Median survival for all patients was 8.1 months, with actuarial one-year and two-year survival rates of 40% and 15%. Despite prophylactic filgrastim, the delivered vinorelbine dose intensity of 16.8 mg/m2/week caused febrile neutropenia in 48% of patients (16% of cycles), resulting in one treatment-related death. Common nonhematologic toxicities included delayed emesis, asthenia, and constipation. CONCLUSIONS: This multiday vinorelbine-cisplatin schedule is highly active against advanced NSCLC but results in frequent neutropenic complications. The myelotoxicity and antitumor efficacy of vinorelbine in NSCLC patients may be schedule-dependent.

The Index of Nausea, Vomiting, and Retching: a new format of the lndex of Nausea and Vomiting.

PURPOSE/OBJECTIVES: To determine the reliability of the Index of Nausea, Vomiting, and Retching (INVR), a new format of the Rhodes Index of Nausea and Vomiting Form 2 (INV-2). DESIGN AND SETTING: A parallel form study was conducted at a large, Midwestern teaching hospital and a cancer center. SAMPLE: Convenience sample of 159 subjects: 40 obstetrical, 60 oncological, 59 medical/surgical. METHODS: Two instruments, the INVR and the INV-2, were administered approximately 30-60 minutes apart. One-half of the subjects completed the INVR first, and the other half completed the INV-2 first. MAIN OUTCOME MEASURES: Equivalency measures of reliability correlation coefficients for both instruments. FINDINGS: A high rate of agreement was found in the responses between the two forms. In cases of clear disagreement, the responses to the INVR were more frequently consistent than the responses to the original form. CONCLUSIONS: INVR has tested reliability and is more user friendly for the patient and the healthcare provider. IMPLICATIONS FOR NURSING PRACTICE: Nurses have a focal role in managing symptoms. Managing nausea, vomiting, and retching requires excellent assessment skills of the patient's personal symptom experience and knowledge of pharmacology. Efficient, cost-saving assessments require accurate self-report instruments that permit patients to quantify their symptom experiences. The INVR can provide a scientific base from which to prescribe and teach patients and may improve their quality of life. Reliable and valid self-reporting instruments are essential for managing these adverse symptoms.

Phase I study of docetaxel dose escalation in combination with fixed weekly gemcitabine in patients with advanced malignancies.

PURPOSE: To determine the maximum-tolerated dose of monthly docetaxel combined with fixed-dose weekly gemcitabine and describe the dose-limiting toxicities (DLTs) of the combination. PATIENTS AND METHODS: Patients with refractory solid tumors were treated with gemcitabine days 1, 8, and 15 every 4 weeks at a fixed dose of 800 mg/m2. Two docetaxel administration schedules were studied, with the drug administered either day 1 or day 15 at doses of 45, 60, 75, and 100 mg/m2 per cycle. RESULTS: Forty patients received 132 cycles of chemotherapy. On the day-1 schedule, the maximum-tolerated docetaxel dose was the highest planned dose of 100 mg/m2 with two DLT episodes among 12 patients treated with 34 cycles at this dose level. On the day-15 schedule, delivery of the planned docetaxel doses was not feasible because of thrombocytopenia and hepatic dysfunction. Hematologic toxicities included grade 4 neutropenia in 16 patients, with three episodes of febrile neutropenia; grades 3 to 4 thrombocytopenia in nine patients; and anemia that required RBC transfusions in 10 patients. For patients treated at the highest docetaxel dose level, myelosuppression was not dose limiting and only one of 34 cycles was complicated by febrile neutropenia. The most common nonhematologic toxicities were asthenia, flu-like symptoms, and fluid retention. Antineoplastic activity was noteworthy, with partial responses in nine of 21 patients with pretreated non-small-cell lung cancer (NSCLC; 43%; 95% confidence interval, 22 to 66), in four of seven patients with breast cancer, and in one patient with esophageal adenocarcinoma. CONCLUSION: Gemcitabine 800 mg/m2 days 1,8, and 15 can be safely combined with docetaxel 100 mg/m2 day 1 of a 28-day cycle. The observed antitumor activity warrants phase II evaluation.

Hospice patients' and nurses' perceptions of self-care deficits based on symptom experience.

Although the relief and/or control of physically, emotionally, and spiritually distressing symptoms are the hallmarks of hospice care, accurate assessment of the individual's unique and often rapidly changing symptom experience is lacking. The purpose of this descriptive, correlational study was to assess and quantify hospice patients' perceptions of their symptom experiences and those of the hospice nurse assessing them. A convenience sample of 53 hospice patients (32 males, 21 females), with a mean age of 69 years, from a large midwestern home-based hospice completed the Adapted Symptom Distress Scale Form 2 (ASDS-2) at admission, and at 2 and 4 weeks after admission. The Hospice Admission Intake was completed at admission. Individual hospice nurses completed the ASDS-2 within 24 hours of their hands-on assessment, in addition to the demographic characteristics profile. Findings indicated an improvement in symptom experience, distress, and occurrence scores from admission to week 2, and in the symptom experience and distress scores from admission to week 4. Hospice nurses tended to give higher symptom experience scores than the patients gave to themselves. These findings demonstrate the importance of obtaining information about symptom experience from the patient as well as the nurse.

Establishing mechanisms to conduct multi-institutional research--fatigue in patients with cancer: an exercise intervention.

PURPOSES/OBJECTIVES: To describe the process of establishing a multi-institutional interdisciplinary team of oncology researchers and conducting a pilot study of an exercise intervention for fatigue. DATA SOURCES: Project meeting minutes and records, research team members' logs, subjects' research records, the research study proposal, and team members' individual and collective shared experiences. DATA SYNTHESIS: Site investigators established research teams at five academic medical centers. Fifty subjects were enrolled in the study and tested during their cancer treatment. Study methods, including instrumentation, were evaluated carefully and revised. CONCLUSIONS: The multi-institutional network of researchers is an effective and efficient model for testing an intervention to manage fatigue during cancer treatment. IMPLICATIONS FOR NURSING PRACTICE: Exercise is a feasible and potentially beneficial intervention to combat distressing cancer treatment-related fatigue. A pilot study is essential to determine the best methods for conducting a clinical trial and to develop the teams of researchers necessary for such a project.

Development of a preparatory sensory information videotape for women receiving chemotherapy for breast cancer.

This study describes the development and testing of a preparatory sensory information (PSI) videotape for women receiving chemotherapy for breast cancer. In telephone interviews, 40 women described the sensations they experienced before, during, and after receiving chemotherapy. Sensations described by the women were linked with procedural and temporal elements identified by certified advanced practice oncology nurses to develop a script for the PSI videotape. Women currently receiving chemotherapy or who had completed chemotherapy within the last 6 months were asked to share their experiences on videotape. After editing, a 20-minute PSI videotape was produced. Pilot testing with a group of 20 women demonstrated that the intervention helped to prepare them for the sensory experiences associated with chemotherapy and was helpful in developing anticipatory coping and self-care behaviors.

Criteria for assessment of nausea, vomiting, and retching.

PURPOSE/OBJECTIVES: To promote accurate patient assessment, effective patient teaching, and useful research design and outcomes by defining the concepts of nausea, vomiting, and retching; to review the usefulness of self-care guides in assessing the patient's symptom experience. DATA SOURCES: Journal articles, the author's clinical experiences. DATA SYNTHESIS: The concepts of nausea, vomiting, and retching may be difficult for patients to describe and for nurses to assess. Measurement and assessment methods that accurately reflect the patient's experience are critical. CONCLUSION: Management of the individual symptoms of nausea, vomiting, and retching requires expert ongoing assessment of the patient's symptom experience that extends beyond the clinic or hospital visit. Information about symptom occurrence and distress and about self-care strategies used can play a crucial role in the identification, prevention, and management of symptom experience, with the good of improving the patient's quality of life. IMPLICATIONS FOR NURSING PRACTICE: Effective management of the patient's symptom experience depends on the oncology nurse's ability to differentiate occurrence and distress of the individual symptoms and to implement current knowledge not only of chemotherapy, antiemetic drugs, and nonpharmacologic interventions but of unerring ongoing assessments that lead to cost-effective, clinically useful patient outcomes. Basic scientific knowledge for research, practice, and education necessitates reliable, valid measurement tools that differentiate the components and dimensions of the individual symptoms.

Symptom experience.

OBJECTIVE: To provide an overview of symptom experience, symptom occurrence, and symptom distress. DATA SOURCES: Published articles relating to the symptom experience, symptom occurrence, and symptom distress of patients with cancer. CONCLUSIONS: Symptom experience must include both the occurrence and distress associated with the symptom. To adequately assess symptom experience, obtaining information from patient about the occurrence and distress of the symptom experience is essential. IMPLICATIONS FOR NURSING PRACTICE: Nurses and other health care professionals can perform an essential role in the identification and management of symptom experience, thereby improving patient quality of life.

Nausea, vomiting, and retching: the management of the symptom experience.

OBJECTIVES: To examine the physiology of nausea, vomiting, and retching (NVR); the impact of NVR on the patient: current measures to control NVR; and selfcare interventions. DATA SOURCES: Research studies, abstracts, and review articles relating to NVR associated with cancer treatment as well as pharmacological and nonpharmacological interventions. CONCLUSIONS: Management of the individual symptoms of NVR require expert, ongoing assessment of the patient's symptom experience that extends beyond the clinic or hospital visit. Although a number of pharmacological antiemetic agents are currently available and additional antiemetic drugs are in phase II or II trials, nonpharmacological interventions are essential to achieve effective management. IMPLICATIONS FOR NURSING PRACTICE: Continual assessment of the individual's symptom experience is imperative. Effective management of the symptom experience depends on the oncology nurses's ability to implement current knowledge of antiemetic, and other drugs; non-pharmacological interventions; and cost-effective and clinically useful patient outcomes.

Nurses' perceptions of antiemetic effectiveness.

PURPOSES: To determine which antiemetics are being used with ondansetron (Zofran, Cerenex Pharmaceuticals, Research Triangle Park, NC) for patients receiving emetogenic chemotherapy, identify the more frequently administered antiemetic regimens, and ascertain nurses' perceptions of the effectiveness of these regimens. DESIGN: Descriptive survey. SETTING: Continental United States. SAMPLE: A random sample (N = 962) of Oncology Nursing Society members who designate themselves as practicing in the area of chemotherapy. METHODS: The Antiemetic Drug(s)/Drug Combination(s) Inventory, an open-ended questionnaire soliciting information on first- and second-line antiemetic regimens for emetogenic chemotherapy protocols, was mailed to 5,950 oncology nurses. Descriptive statistics and nondistributive analysis were used to analyze the data. FINDINGS: Ondansetron was used in 7 of 10 antiemetic regimens, which accounted for 50% of the most frequently used regimens. Nurses rated first-line antiemetic combinations as highly effective. Ondansetron alone was ranked as the seventh most effective first-line antiemetic for cisplatin protocols and fifth for noncisplatin protocols. Nurses noted limitations of ondansetron use, which included delayed nausea and vomiting and the drug's high cost. CONCLUSIONS: Study participants indicated that a variety of drugs were used in antiemetic regimens. Ondansetron use has improved the control of post-chemotherapy nausea, vomiting, and retching. IMPLICATIONS FOR NURSING PRACTICE: Antiemetics are administered regularly in the hospital and home to decrease chemotherapy-related nausea, vomiting, and retching. Managing these side-effects requires superior assessment skills and extensive knowledge of pharmacologic actions. Patient and family education on antiemetics is essential in light of increased administration of outpatient chemotherapy.

Expectation and occurrence of postchemotherapy side effects: nausea and vomiting.

Although nausea and vomiting are among the most disruptive chemotherapy side effects, little is known about patients' expectations before therapy and their experience after chemotherapy. A stratified sample of 329 subjects on nine chemotherapy regimens were asked to list their expected symptoms and level of distress. The patients listed a total of 524 responses and 28 different symptoms. This paper focuses on the symptoms of nausea and vomiting. A statistically significant relationship (P = 0.015) was found between the patients' expectations of symptom experience and their expectations of symptom distress. No significant relationship was found between the expectation of the symptom and the actual symptom experience. These findings support the need for educational interventions that provide hopeful but realistic expectations of the unknown events for patients with cancer.

Sensory perceptions of women receiving tamoxifen for breast cancer.

Tamoxifen has been used as adjuvant treatment in advanced and early-stage breast cancer for the past decade. Recently this synthetic antiestrogen drug assumed a new role of chemoprevention for women at risk of developing breast cancer. The commonly occurring side effects associated with tamoxifen administration contribute to the acceptance of this antineoplastic drug for palliation and cure. However, there are no data about the sensory effects of women receiving tamoxifen. The purpose of this study was to elicit subjects' descriptions of sensory experiences while receiving tamoxifen. These descriptions are essential for developing nursing interventions to help patients use self-care behaviors and cope with the side effects of tamoxifen. Sensory data were collected from 20 women who had been receiving tamoxifen for at least 1 month and were not receiving any other chemotherapy. Subjects provided descriptors about all senses. The senses for which subjects most frequently provided descriptors were touch, taste, and sight.

Sensory perception of patients on selected antineoplastic chemotherapy protocols.

Antineoplastic chemotherapy (ANCT) is a primary and adjuvant treatment modality for cancer. Although researchers have found that patients who are given preparatory sensory information before various health-care procedures experience less discomfort, literature describing subject's sensory experience before, during, and after ANCT is lacking. The purpose of this study was to elicit sensory responses from subjects before, during, and after one of six cycles of their initial course of treatment on one of two emetogenic ANCT protocols. These descriptions will be used to develop a preparatory sensory nursing intervention that may promote self-care and help cancer patients cope with the distress of chemotherapy. The Sensory Information Questionnaire was administered to a sample of 44 subjects who had just completed a cycle of ANCT. Subjects provided descriptors of all senses. The senses for which subjects most frequently provided descriptors were taste, touch, and smell. Descriptors varied for some sensations according to the chemotherapy drug protocols.

Comparison of prochlorperazine and lorazepam antiemetic regimens in the control of postchemotherapy symptoms.

This randomized, double-blind crossover study was undertaken to compare the antiemetic effectiveness of intravenous prochlorperazine (Compazine) and lorazepam (Ativan) in the management of postchemotherapy symptoms during two initial cycles of therapy. Each patient received at least one treatment as an outpatient. Data from the 24 patients receiving noncisplatin therapy who completed the crossover study were evaluated for antiemetic efficacy and total posttherapy symptom experience. Although results indicated no statistically significant difference between regimens in the control of posttherapy nausea and vomiting, these side effects were completely controlled in 26 of the 48 study treatment cycles. Lorazepam significantly reduced total posttherapy symptom experience by decreasing patients' experience of fatigue and pain. Findings support the value of lorazepam in antiemetic regimens and point to the need for further examination of antiemetic combinations.

Nausea, vomiting, and retching.

Although nausea, vomiting, and retching have plagued mankind since antiquity, limited attention has been given to the three symptoms as separate entities. Although knowledge of symptom occurrence is essential to practice, nurses must focus on patients' response or distress to the occurrence of symptoms. The differentiation of symptom occurrence and symptom distress of nausea, vomiting, and retching is critical to the management and self-care demands of patients and the enhancement of their quality of life. Basic research on patterns of these individual symptoms and their components promises to provide a more progressive and fruitful approach to the patient response to these symptoms.