INTRODUCTION

Chemotherapy (CHT) is one of the modalities of systemic cancer treatment performed through the administration of cytotoxic drugs, either alone or in combination, which targets cancer cells^1,2. However, CHT has nonspecific action on cells with a high proliferative capacity, that is, it acts on both cancer cells and normal cells that have rapid renewal. Thus, it causes toxicities to normal tissues that are manifested by adverse effects due to CHT^1,2.

Acute adverse effects (AE) can appear during the drug administration period and up to 24 hours after the end or they can appear later, taking months or years to manifest³. The most common AEs are nausea, vomiting, inappetence, diarrhea, constipation, weakness, fatigue, alopecia, anemia, neutropenia, among others^2,4. These AEs can generate physical, psycho-emotional, social, spiritual, and economic damages⁵.

Thus, cancer patients undergoing CHT require care aimed at preventing and controlling AEs to ensure a better quality of life and continuity of treatment^1)(2)(6. Nurses have an important role in the prevention, identification, management, and control of AEs related to CHT⁷. To guide the management of nursing care, they use the Nursing Care Systematization (NCS) as a tool.

According to Resolution 358/2009 of the Federal Council of Nursing (COFEN) of Brazil, NCS is a working methodology of Nurses, carried out through the Nursing Process, which occurs in five stages: Nursing history (anamnesis and physical examination); Nursing Diagnoses (ND); nursing care planning (expected results and actions to be taken); implementation of care and assessment of the effectiveness of actions⁸. Within the Nursing Process, diagnostic reasoning allows the construction of the nursing care and interventions plan. In the clinical practice of Nursing in Oncology, NDs will guide prophylactic and/or therapeutic actions, health education/guidance for the prevention and management of signs and symptoms of the disease, AE related to CHT, and actions regarding the individual's psychosocial and family needs⁵.

There are several studies aimed at identifying possible ND-related AEs of treatments in cancer patients^7)(9)(10. Carvalho et al⁹ carried out a study seeking to build NDs applicable to oncohematological patients, who have post-CHT AEs, based on terms identified by oncology nurses in the International Classification for Nursing Practice (ICNP®). Sousa et al¹⁰ evaluated medical records of oncohematological patients to identify possible terms in the nursing records that were comparable to NDs, according to NANDA Taxonomy II. Another study sought to identify the most frequent ND in oncohematological patients, submitted only to CHT, based on the analysis of medical records⁷. The knowledge of the priority NDs for a specific patient helps the nurses' diagnostic reasoning¹¹.

Although these studies have data regarding ND related to AEs in CHT, the results are based on retrospective AEs data that patients with a certain type of cancer presented at the end of treatment. No study has carried out a survey of possible NDs related to potential acute AEs in cancer patients who are receiving CHT associated or not with other oncological therapies.

Thus, this study aims to identify possible Nursing Diagnoses related to the acute adverse effects of chemotherapy in cancer patients.

MATERIAL AND METHOD

Study design

This is an observational, descriptive cross-sectional study with a quantitative approach, carried out at the chemotherapy outpatient clinic of a public university and large hospital, with care exclusively through the Unified Health System (SUS), located in Belo Horizonte, Minas Gerais, Brazil.

Population and sample

We selected patients by convenience sample, according to the following eligibility criteria: people aged 18 years old or older, diagnosed with malignancy, and undergoing outpatient CHT during the data collection period. We excluded patients with physical and mental incapacity to communicate, as they presented drowsiness due to the effects of medications hindering to conduct of interviews, and that physical records were unavailable for consultation. The sample consisted of 70 patients.

Data collect

Data collection was performed from October 2017 to May 2018. The study was performed in three stages. Stage 1: An interview with the patients included in the study to obtain the sociodemographic data of the sample; Stage 2: Access to the patients' medical records to obtain data regarding the clinical condition and the CHT protocol; and Stage 3: a review of the literature on possible toxicities and AEs related to the CHT protocol, and possible NDs. The authors built a semi-structured and adapted instrument, used as a guide for data collection, containing: sociodemographic data (gender, self-reported skin color, age, and civil status), clinical data (primary tumor site, disease stage, presence of metastasis, site of metastasis, and other concomitant treatments, such as surgery and/or radiotherapy), data related to CHT (protocol - monotherapy/polytherapy, CHT in use, pre-CHT medications).

We identified the possible toxicities and AEs of each patient based on the textbook, reference in oncology in Brazil, entitled “Terapêutica oncológica para enfermeiros e farmacêuticos ⁴⁾ based on the drugs that were part of the CHT protocol of each patient in the sample. Sociodemographic and clinical data were not associated with possible toxicities and were intended only to characterize the sample. Toxicities were categorized into: neurological, pulmonary, cardiovascular, gastrointestinal, hepatic, vesical/renal, reproductive, metabolic, hematological, dermatological, anaphylactic reactions, and fatigue. Subsequently, we identified the possible AEs for each toxicity related to CHT.

Finally, we elaborated the possible NDs according to the taxonomy of the North American Nursing Diagnosis Association International (NANDA-I) version 2018-2020¹¹. The possible NDs were structured according to the toxicity and AEs that could cause them and presented within each domain to which it belongs in the NANDA-I taxonomy.

Statistical analysis

We performed a quantitative and descriptive analysis of the study variables using the Statistical Package for Social Science (SPSS) software, version 19.0. Absolute (AF) and relative (RF) frequencies were calculated for sociodemographic, clinical, and possible identified toxicities, as well as measures of central tendency (mean and median) and dispersion (standard deviation, minimum and maximum) when applicable. Possible NDs have been described qualitatively and associated with potential AES.

Ethical considerations

The study is part of the project entitled “Integrative and complementary health practices: evidence for care in oncology”, which was approved with CAAE number 66568117.1.0000.5149 by the Research Ethics Committee - COEP of the Federal University of Minas Gerais and by the Hospital das Clínicas/EBSERH, according to the resolution of the National Health Council 466/2012¹². All participants signed an informed consent form (ICF).

RESULTS

The sample was composed of 58.6% of female patients, the majority declared themselves brown and 52.9% were married. The average age was 53.8 years and the highest proportion of patients was in the 40-59 age group. Table 1 shows the sociodemographic data of the study participants.

Table 1.  Sociodemographic characteristics of the sample (n = 70). Belo Horizonte - MG, Brazil, 2019. 

Note: SD= Standard Deviation

Regarding the clinical characteristics of the patients, the most prevalent primary cancer site was colon and rectum, and breast, both with a relative frequency of 30%. Stage IV was present in most (51.4%) of the sample. Metastasis was present in 55.7% of patients, 28.2% in more than one site and 33.3% had unknown sites. The lung was the organ most affected (7.6%) by metastasis.

In addition to CHT, 80% (n = 56) of the sample underwent surgery and 34.3% (n = 24) underwent radiotherapy. We should highlight that 14.3% (n = 10) of the sample underwent the three treatment modalities for cancer. Table 2 shows the clinical data related to the diagnosis of cancer and treatment of the sample.

Table 2.  Clinical characteristics of the sample (n = 70). Belo Horizonte - MG, Brazil, 2019. 

Notes: SD= Standard Deviation; CHT = Antineoplastic chemotherapy;

*Sarcomas= Kaposi's sarcoma, synovial sarcoma, soft tissue sarcoma, osteosarcoma; **Others= prostate, ovary, lung (2), cervical neuroblastoma.

*** Percentage calculated based on the total number of patients who had metastasis.

**** Percentage calculated considering the total sample n = 70;The patient may have undergone more than one therapy option.

All individuals who received CHT for cancer treatment were submitted to pre-medication (pre-CHT) protocols. In this study, the drugs most used in pre-CHT were ondansetron (94.3%), dexamethasone (81.4%), ranitidine (60.0%), folic acid (32.8%), diphenhydramine (22.8%), mannitol (15.7%), and metoclopramide (14.3%). It should be noted that the same patient used one or more pre-CHT medications.

Polychemotherapy was predominant (70%), with 32.7% undergoing the protocol known as Folfox (oxaliplatin, 5-fluorouracil (5-FU), and leucovorin). Table 3 shows information related to antineoplastic treatment protocols.

Table 3.  Distribution of study participants according to antineoplastic chemotherapy protocol and potential toxicities (n = 70). Belo Horizonte - MG, 2019. 

All participants have potential hematological toxicity (leukopenia, thrombocytopenia and/or anemia), cardiovascular (acute electrocardiographic changes such as arrhythmias, and chronic changes such as congestive heart failure); gastrointestinal (nausea, vomiting, mucositis, diarrhea, and constipation); local dermatological (phlebitis, pain, erythema and tissue necrosis due to drug extravasation) and systemic (alopecia, nail changes, urticaria, skin rash, hand-foot syndrome, hyperpigmentation, and photosensitivity) throughout the treatment, among other signs and symptoms.

Neurological damage was a frequent AE (90%), which can be mild or severe, transient or permanent, such as encephalopathy (confusion, agitation, dizziness), peripheral neuropathy (paraesthesia, muscle weakness, impotence, decreased reflexes), cranial neuropathy (ototoxicity, taste change), autonomic neuropathy (constipation, urinary changes, bladder atony), cerebellar syndromes (dysmetria, ataxia, nystagmus, vertigo), among others.

Table 4 shows the 36 possible NDs identified, categorized according to general toxicities and their possible AE.

Table 4.  Nursing diagnoses according to the adverse events induced by antineoplastic chemotherapy according to the NANDA-I taxonomy (2018-2020)¹¹. Belo Horizonte, MG, 2019. 

Note: NANDA-I = North American Nursing Diagnosis Association International;

* Nursing diagnoses that are repeated in other toxicity.

AEs have systemic repercussions, so the same AE was associated with more than one domain of the NANDA-I Taxonomy¹¹ and, consequently, generated more than one ND. Some domains and NDs have been correlated to more than one EA, which is why they appear more than once. The domain of safety/protection is the one that has more NDs (n = 12) and is related to six toxicities, and the domain of elimination and exchange is the second most present in a quantity of ND identified, with eight NDs related to four toxicities.

DISCUSSION

This study aim to identify possible NDs based on the characteristics of the CHT protocols of the patients included. There was a predominance of females (58.6%) in the sample. Similarly, data in the literature show the presence of 50% or more of the diagnosis of cancer being composed of women¹³. The most prevalent primary sites in the sample were the breast, colon, and rectum. Estimates for the 2020-2022 three-year period point to female breast cancer as the most frequent, except non-melanoma skin cancer, in all Brazilian regions, and colon and rectal cancer has an approximate risk estimate for men and women¹⁴, corroborating the predominance of women in the sample.

Regarding the age group, the largest proportion of patients was between 40-59 years old (48.6%), with an mean of 53.8 years old. Oliveira et al¹⁵ found that the average age of the first cancer diagnosis in Brazil was 51.9 years old. Data from the National Cancer Institute José Alencar Gomes da Silva (INCA) also indicate that most people with cancer are in the middle age group¹⁴. Even with screening and early cancer detection technologies, stage IV was the most prevalent (51.4%) and most (55.7%) of the sample has metastasis. Cancer staging predicts the extent and severity of cancer and is a basis for defining treatment¹. According to the Ministry of Health, 60% of cancer patients in Brazil are diagnosed at an advanced stage of the disease (III and IV)¹⁶.

In addition to CHT, 80% of people underwent surgery, 34.3% underwent radiotherapy and 14.3% underwent the three treatment modalities. Regarding the protocols, there was a predominance of polychemotherapy (70%), and the most prevalent was the Folfox protocol (n = 16; 32.7%). This protocol is widely used to treat colon and rectal cancer^4)(17)(18, which was one of the most frequent in the sample.

Regarding the possible toxicities according to the sample's CHT protocols, all participants have potential hematological, gastrointestinal, cardiovascular, and dermatological toxicity, in addition to 90% presenting potential neurological damage. Studies demonstrate that the management of AEs is still not adequate in healthcare practice, as the symptoms are not well managed or are underestimated to signs and symptoms already expected by the treatment^19,20. AEs are elements that limit the continuity of treatment and have a great impact on patients' quality of life^2,6.

Nurse assistance in CHT encompasses a series of activities, following COFEN Resolution 569/2018, which allows the applicability of NCS, acting in the planning, organization, execution, supervision, and evaluation of the care of patients undergoing cancer treatment and performance in the prevention, management, and treatment of AEs²¹.

The accuracy of the identification of the possible AEs of cancer treatments is a valuable tool for designing nursing care aimed at preventing, minimizing, and resolving AEs, even though they are considered ineviTable due to the cytotoxicity of the drug ²⁰. This is because the absence of adequate measures for the management of AEs by the service assistance team becomes a limiting element in the continuity of treatment, precisely because it impacts the quality of life of people with cancer^2,6.

The implementation of NP for cancer patients undergoing CHT allows the construction of nursing care plans based on scientific evidence and is reliable to the patient's needs, focusing on assisting in a humanized, holistic, qualified, and competent way²². In this process, ND is fundamental, as they are listed based on the nurse's clinical reasoning and from them, care will be guided in an appropriate and individualized way^11,23.

In this study, we were able to identify 36 NDs based on the AEs of the CHT. The domains with the most predominance of NDs were safety/protection, and elimination and exchange. A study performed of a university hospital in Rio de Janeiro to identify the care needs of cancer patients and to correlate these needs with the domains of the NANDA taxonomy, managed to identify the domains: nutrition; elimination and exchange; activity/rest; role relationship; coping/stress tolerance²³. These results corroborate what we found in this study.

Sousa et al¹⁰ identified 30 NDs by mapping the medical records of onco-hematological patients at a clinic in Rio de Janeiro. Comparing with the NDs found in this study, we have in common the identification of the diagnoses of Risk for infection, Risk for bleeding, Risk for impaired skin integrity, Risk for falls, Constipation, Risk for constipation, Urinary retention, Acute pain, Fatigue, Nausea, and Imbalanced nutrition, less than body needs¹⁰. Most studies that seek to identify NDs applicable in cancer patients target the sample for patients with specific types of cancer^7)(9)(10. Recent research on NDs is scarce in the literature.

Thus, the care for cancer patients is complex, as the needs may arise from psychosocial, spiritual issues, illness, CHT, and AEs caused. Therefore, the identification of NDs allows to set goals in the care process and, for this, professionals must know and be trained as to the methodology and theoretical framework that NCS and NP require in its implementation and execution^22,23.

The lack of identification of the defining characteristics of patients in CHT is a limitation of this study. However, we aim only to identify NDs. The absence of current literature on the application of NDs in oncology was also a limiting factor in this study.

CONCLUSIONS

The identification of potential NDs based on the CHT protocols allows to propose of care plans to meet the needs of cancer patients, mainly with a focus on preventing the occurrence and minimizing AEs. In this study, we identified 36 NDs according to the NANDA-I Taxonomy based on the possible EA of CHT for our sample, which had predominantly patients with breast and colon, and rectal cancer.

Therefore, due to the various impacts and vulnerabilities that the AES can cause in the individual's life, it is important that Nursing professionals recognize the potential AES and apply the NCS using the NP as their theoretical-methodological reference, with identification of NDs and care planning, to act in the prevention, monitoring, and management of the AEs of CHT. An appropriate management of AE improves the quality of life and continuity of treatment. Finally, we expect that this work will contribute to the improvement of nursing practice in Oncology and promote reflection on the applicability of NCS and NP in the care of cancer patients receiving CHT.