REPUBLIC OF CAMEROON REPUBLIQUE DU

CAMEROUN

Peace-Work-Fatherland Paix-Travail-Patrie

**************** **************

UNIVERSITY OF UNIVERSITE DE BAMENDA

BAMENDA ***********
***********

FACULTY OF HEALTH SCIENCES

DEPARTMENT OF NURSING AND MIDWIFERY

MANAGEMENT GUIDE FOR PAIN, FATIGUE, NAUSEA,

MUCOSITIS, DYSPNEA, ANOREXIA, PSYCHOLOGICAL AND
EMOTIONAL DISTRESS IN ONCOLOGY

COURSE: ONCOLOGY NURSING 4: PALIATIVE CARE AND SURVIVORSHIP

COURSE CODE: MONH6212

COURSE FACILITATOR: DR FONGANG LANDIS CHE

BY
MANE JUNIOR FRANK MBICHO; UBa25HP152

FUWEN MARY-EMMACULATE NGUM; UBa25HP167

NOELLA SAMSI; UBa25HP154

ACADEMIC YEAR 2025/2026

 TITLE

MANAGEMENT GUIDE FOR PAIN, FATIGUE, NAUSEA, MUCOSITIS, DYSPNEA,

ANOREXIA, PSYCHOLOGICAL AND EMOTIONAL DISTRESS IN ONCOLOGY

 LIST OF ABBREVIATIONS AND ACRONYMS

5-HT3: 5-Hydroxytryptamine type 3

ADLs: Activities of Daily Living
ASCO: American Society of Clinical Oncology
CACS: Cancer Anorexia-Cachexia Syndrome
CBT: Cognitive Behavioral Therapy
COX-2: Cyclo-oxygenase-2
CRF: Cancer-Related Fatigue
DT: Distress Thermometer
ESAS-r: Revised Edmonton Symptom Assessment System
ESMO: European Society for Medical Oncology
FLACC: Face, Legs, Activity, Cry, and Consolability
ISOO: International Society of Oral Oncology
MASCC: Multinational Association of Supportive Care in Cancer
NCCN: National Comprehensive Cancer Network
NK1: Neurokinin-1
NSAIDs: Nonsteroidal Anti-Inflammatory Drug(s)
OM: Oral Mucositis
P6: Pericardium 6 acupressure point
PC: Palliative Care
Q.U.E.S.T: Question, Use scales, Evaluate behavior, Sensitize parents, Take action
SpO₂: Peripheral Oxygen Saturation
SSRI: Selective Serotonin Reuptake Inhibitor
TENS: Transcutaneous Electrical Nerve Stimulation
WHO: World Health Organization
 ABSTRACT

Symptom management is the cornerstone of effective palliative care and has a significant

impact on the remaining quality of life. Any symptom that manifests can be prevented or

managed, regardless of when it occurs or to what it is related. Whether symptoms manifest at

the time of diagnosis, during treatment, or years after a cure has been established, clinicians

must remain vigilant in their understanding and approach to supporting patients suffering.

Patients frequently experience a high burden of co-occurring symptoms, with investigators

identifying between 8 and 19 symptoms experienced by more than 40% of patients during

diagnosis and treatment. This guide integrates evidence-based practices for the management of

pain, fatigue, nausea, anorexia, oral mucositis, dyspnea, and psychosocial distress. By adopting

a multimodal approach that includes pharmacological interventions, lifestyle adjustments, and

the total pain model, clinicians can address physical, emotional, spiritual, and social suffering.

Effective management requires a person-centered perspective that accounts for individual

goals, utilizes standardized assessment tools like the WHO Oral Toxicity Scale and the Distress

Thermometer, and prioritizes the treatment of nausea first to facilitate nutritional intake and

combat fatigue.
 INTRODUCTION

Cancer-related symptoms pose a substantial burden for patients living with and beyond a cancer

diagnosis. In recent years, cancer service delivery models have shifted from traditional

inpatient settings to outpatient approaches in an effort to reduce pressure on hospital systems

and improve cost-efficiency [1]. Although many patients are now receiving complex care on

an outpatient basis, data suggest that oncology outpatients have unmet symptom management

needs. Approximately one-half of adult medical oncology outpatients report moderate to severe

fatigue, and one-third report moderate to severe anxiety, depression, and pain [2]. Unmanaged

symptoms in outpatient settings contribute to negative outcomes, such as decreased quality of

life and functional ability, and inefficient health services utilization through avoidable

emergency department presentations or hospitalizations.

Symptom management refers to the strategies and interventions designed to alleviate

symptoms and improve quality of life, including pharmacologic and nonpharmacologic

approaches. Patients experience a substantial number of symptoms, particularly during periods

of diagnosis and treatment, with an average as high as 12 symptoms [3]. Specific symptoms

vary over time; pain related to surgery may resolve while new symptoms of nausea, fatigue,

sleep disturbance, and dry mouth emerge during chemotherapy or radiation [4]. Some of these

symptoms emerge as symptom clusters, which are stable groups of concurrent symptoms

related to one another [5]. Although patients routinely experience multiple symptoms, current

practice generally follows a siloed approach using single-symptom evidence-based guidelines.

Oral mucositis, for instance, affects up to 90% of head and neck cancer patients, significantly

impacting their ability to maintain hydration and nutrition [6].

To be person-centered, symptom management must take into account the wishes of the person

and the goals they want to achieve, such as maintaining functional levels or attending social

events. Clinicians must evaluate symptoms thoroughly, considering all potential causes and the
impact on the patient's quality of life. Effective communication is essential, involving the

patient and important people in their management plan using simple terms. The concept of total

pain is central to this approach, emphasizing that pain is a total, personal experience with

physical, psychological, social, and spiritual dimensions [7].

The objectives of this review are:

➢ To outline a symptom management guide for pain using the WHO analgesic ladder and the

Total Pain model.

➢ To provide a management guide for fatigue focusing on energy conservation and non-

pharmacological treatments.

➢ To establish protocols for nausea and anorexia management, emphasizing the clinical

priority of nausea control.

➢ To detail the assessment and tiered interventions for oral mucositis and dyspnea.

➢ To explore the management of psychosocial and emotional distress.

 PART ONE

SYMPTOM MANAGEMENT GUIDE FOR PAIN USING THE WHO ANALGESIC

LADDER AND THE TOTAL PAIN MODEL.

Pain symptom management guide

Symptom management, particularly pain management, is an integral part of treatment for

patients with cancer and has been linked to improved quality of life and survival. Pain is defined

as the unpleasant and emotional experience associated with actual or potential tissue damage.

Pain is always a subjective sensation. The experience varies from person to person and from

time to time. Pain is whatever the experiencing person says it is, existing whenever he/she says

it does.

• Although management differs depending on the patient, the following principles and

guidelines apply to all patients:

• Pain is common in advanced cancer and non‑malignant conditions and its

management can be difficult.

• Pain is a total, personal experience with physical, psychological, social and spiritual

dimensions. Optimal pain management will be compromised if any of these aspects

are neglected. Management requires a multidisciplinary approach.

• Pain should be assessed and quantified at every visit.

• Other causes of pain should be ruled out and addressed, and new pain or worsening

pain should prompt repeat workup.

• Mild pain should be treated with nonopioids first and then mild opioids as necessary.

More-severe pain usually requires stronger opioids.

• Severe, uncontrollable pain is a medical emergency and requires hospitalization and

intravenous (IV) pain management. Nonopioids alone will be insufficient for

inpatients hospitalized for pain crisis.

 • To maintain freedom from pain, drugs should be given on a schedule rather than on an

as-needed basis.

• A history of prior opioid use should be taken into account when treating pain with

opioids.

• Adjunctive therapy (anxiolytics) may be beneficial.

• Pain management often requires a multidisciplinary approach including pain

specialists, palliative care medicine, and psychosocial support.

Pain Assessment

Effective pain control is central to PC and improves the client-clinician relationship. Pain

assessment should always be part of the client assessment and be regarded as the fifth vital

sign. Each pain should be assessed separately and consideration should be given to pain within

the context of disease status, whether each pain is related to the disease, to the treatment, to a

secondary condition or to a concurrent disorder. Effective pain and symptom management

serves as the keystone to palliative care and decreases total pain by promoting psychological,

social and spiritual well-being.

Pain is subjective and two clients may report pain severity differently from each other. Despite

the fact that pain is specific to each person, clients can usually, accurately and reproducibly,

indicate the severity of his or her symptoms by using a pain scale. Pain scales enhance the

ability of clients to communicate the severity of their pain to health professionals and the ability

of health professionals to communicate consistently with each other. Pain scales also allow

the clinicians to assess the side effects of medications. Health professionals should carefully

conduct the initial pain assessment and clearly document their findings. This allows the

assessing health professional, and others, to compare progress in pain management against the

symptoms documented in the initial pain assessment. Many pains change with time and

frequent reassessment is necessary, especially during and after the clinical intervention. It is
common for clients to experience multiple types and/or bodily sites of pain. Each pain should

be assessed, documented, managed and reviewed.

The Total Pain Model

PC commonly uses the concept of “total pain”, as exemplified in the figure below to prompt

health professionals to consider all possible influences of the pain experience:

This multidimensional model, first introduced by Cicely Saunders, emphasizes that effective

pain management should address all facets of the human experience, rather than just alleviating

physical symptoms 11. Healthcare providers are encouraged to assess and manage not only the

physiological causes of pain but also the emotional distress, social isolation, and existential

concerns that may exacerbate a patient’s suffering12 Recent studies have reinforced the

importance of addressing total pain as part of an integrative care plan, highlighting the

interconnectedness between physical and psychological symptoms. Research indicates that

comprehensive pain management models, which include psychological support, social

connection, and spiritual care, can lead to improved patient outcomes, including better quality

of life and satisfaction with care13. Furthermore, integrating this holistic approach into routine

clinical practice may prevent the fragmentation of care that often occurs when different aspects

of pain are treated separately13.

the concept of “Total Pain” encourages healthcare providers to look beyond the physical

symptoms of pain and address the emotional, social, and spiritual factors that contribute to

suffering1. By adopting this holistic approach, healthcare professionals can provide more

compassionate, effective, and personalized care – ultimately improving the quality of life for

patients facing serious illness such as in the case of cancer

Pain Assessment in Adults

Pain levels from 0-10 can be explained verbally to the client using a scale in which 0 is no

pain and 10 is the worst possible pain imaginable. Clients are asked to rate their pain from 0

to 10. Health professionals record the client’s reported pain level to make treatment and

follow-up decisions and compare reported pain levels between client examinations

Pain Assessment in Children

Pain assessment in children often make use of the Q.U.E.S.T framework and the Wrong-

Baker faces pain rating scale

i. Q.U.E.S.T Framework

Framework Action Additional Steps

Q Question the child

U Use pain rating scales •Ask child to rate his or her pain using the Wong-

Baker FACES pain

• The child is the best person to report their pain

E Evaluate child’s . Observe the child using the Face, Legs, Activity,

behavior Cry, and CONSOL ability (FLACC) scale to

assess pain
and psychological

changes • Take cause of pain in to consideration

S Sensitize parents Ask the parent or caregiver about the child’s

previous exposure to pain, verbal pain indicators,

usual behavior or temperament

T Take action and

evaluate

the effect of this action

 ii. Wong-Baker FACES Pain Rating Scale

This pain scale is recommended for use in children who can talk (usually 3 years and older).

The Wong-Baker Faces Pain Rating Scale is a pain scale that was developed by Donna Wong

and Connie Baker. The scale shows a series of faces ranging from a happy face at 0, or "no

hurt", to a crying face at 10, which represents "hurts like the worst pain imaginable". Based on

the faces and written descriptions, the patient chooses the face that best describes their level of

pain. Record the number associated with the pain level that the child reports to make treatment

and follow-up decisions and compare reported pain level between client examinations.

Pain Management in Adults

Anything that relieves pain can enhance the quality of life. Both pharmacological and

nonpharmacological measures are essential in pain relief. Providers of palliative care should

be able to manage pain in accordance with the WHO analgesic ladder model.

Principles of Pain Management

Whenever possible, medicines for pain control should be administered in the following manner:

• by the clock

• by the mouth

• by the analgesic ladder

• by the client

WHO analgesic ladder model14

WHO Step I Analgesics – Treatment of Mild Pain

Mild pain should be treated with non-opioid analgesics such as paracetamol and nonsteroidal

anti-inflammatory drugs (NSAID). NSAID include ibuprofen, diclofenac, aspirin,

indomethacin, etc. The main indication of NSAIDs is pain of inflammatory origin especially

bone metastases. There is no concrete evidence that NSAIDS selective for cyclo-oxygenase-2

(COX-2) isoenzyme e.g. celecoxib, rofecoxib, etc. are advantageous in treating cancer pain.

However, such classes can be recommended in high-risk clients with gastrointestinal or

bleeding complications4.

WHO Step II Analgesics – Treatment of Moderate Pain

Moderate pain should be treated with step II analgesics – weak opioids. The prototype here is

codeine phosphate and others include tramadol, dihydrocodeine, hydrocodone, etc.

Traditionally, clients with moderate pain have been treated with a combination product

containing paracetamol or NSAID plus codeine, dihydrocodeine, etc. There is evidence of

synergistic and opioid dose-sparing effects from coadministration of a NSAID, but no

consistent reduction in side effects.

WHO Step III Analgesics - Treatment of Severe Pain

Severe pain should be treated with step III analgesics strong opioids. Strong opioids include

morphine, fentanyl, oxycodone, hydromorphone and buprenorphine. Morphine is an

international “gold standard” against which other opioid analgesics are measured. When used

correctly, clients do not become dependent or addicted, intolerance is uncommon and

respiratory depression does not usually occur. Oral administration of morphine is the preferred

route for both adults and children. If given parenterally, the equivalent dose is one-third of the

oral medication. Other strong opioids include -hydromorphone, oxycodone, fentanyl,

methadone etc. Strong opioids may be combined with ongoing use of step I analgesics.
Adjuvant Therapy for Pain in Adults

The principle of adjuvant therapy:

The use of adjuvants that target neuropathic pain may be particularly important because such

pain may be difficult to treat with opioids alone. Adjuvants are also useful for managing other

pains that are only partially sensitive to opioids such as bone pain, smooth or skeletal muscle

spasms or pain related to anxiety.

Use of adjuvant analgesics:

Adjuvant analgesics, or co-analgesics, are medicines that are typically used in conjunction with

other analgesics. Adjuvant analgesics can be administered alone but are typically administered

with NSAIDs or other opioids to enhance pain management. It is important to note that the use

of adjuvant analgesics with other analgesics may produce both intended and unintended effects:

• Enhance the analgesic activity of the NSAIDs or opioids

• Have independent analgesic activity for certain pain types (such as neuropathic or bone

pain)

• May counteract the side effects of NSAIDs or opioidsPain Management Children

General Principles for Opioid Use in Children

The WHO considers strong opioids as essential to the treatment of pain in

children. The use of strong opioid analgesics is recommended for the relief of moderate

to severe persisting pain in children with medical illness

✓ Dose at regular intervals so there is no gap in treatment

✓ Medicines should always be given on a regular schedule and not “as needed”,

except for rescue doses

✓ Regular doses can be complemented by rescue doses as needed to manage

breakthrough pain

✓ Use the appropriate route of administration

 ✓ Medicines should be given by the simplest, most effective, and least painful route

✓ Oral administration is preferred. Intravenous (IV) or subcutaneous, rectal or

transdermal are alternatives when oral is not feasible

✓ Intramuscular (IM) is discouraged because it is painful

✓ Adapt treatment to the individual child. Titrate to get to the correct dose

WHO Step I: Non-Opioid Treatment of Mild Pain in Children

• Paracetamol and ibuprofen are the only medicines that are recommended to manage

mild pain

• No other NSAIDs are recommended

• Infants <3 months’ old

Only paracetamol is recommended

• Children >3 months’ old

Paracetamol or ibuprofen can be used

WHO Step II: Strong Opioid Treatment of Moderate or Severe Pain in Children

• Strong opioids are the only class of medicines that are effective in the treatment of

moderate and severe pain in children. Therefore, strong opioids are an essential element in pain

management.

• Morphine is the “gold standard”

• Alternatives can be used if a child experiences intolerable side-effects

• As with adults, there is no maximum dose for opioids

• Titrate upward to find the dose that relieves pain with tolerable side-effects

• Constipation is a common side effect, and all children taking opioids should also take

a stimulant laxative and a stool softener.

Non-Pharmacological Measures (Complimentary Therapy)

Non-pharmacological pain management is the management of pain without medications. This

method utilizes ways to alter thoughts and focus concentration in clients to better manage and

reduce pain.

Methods of non-pharmacological pain management shall include:

• Education: Education of the client and family on the client’s condition and ways to

provide insight and support

• Psychosocial care: involves addressing the emotional/psychological, social-cultural,

and social-legal needs of the patient and their family. These may include but not limited to:

fear of pain/dying, sadness, diminished coping, changes in body image, helplessness,

uncertainties, role loss, feeling of abandonment, financial worries, communication breakdown

and family & future. Some of the key management approaches are: therapy/counseling,

individual counseling, family counseling, restoring family communication through family

meetings, recognition of the needs and making appropriate referral for social support, referral

for legal support, companionship, music, art, or drama therapy, recognizing and respecting the

unique cultural values and practices of the patient and family, formation of support groups and

group counseling

• Physical care: exercises, hot/cold therapy, lotion/massage therapy, acupuncture,

aromatherapy, positioning, etc.

• Spiritual care: this aims to address existential needs of patients and their families.

Such needs may include, but are not limited to: questioning life’s purpose/meaning;

relationships with God, family, friends, community; feeling punished or abandoned by God;

and existential suffering. Some of the key management approaches are: meditation and

religious counseling, allowing practice or religious rituals such as prayer, holy communion etc,

recognition of the needs and making appropriate referral to spiritual care workers.

Non-Pharmacological Pain Management in Adults

Dance therapy: Improves self-image and self-esteem Reduces stress, anxiety, and depression.

Decreases isolation, chronic pain, and body tension

Deep breathing: Easy technique to use with clients, particularly children.

Distraction: Focusing the client’s attention away from the pain

Pacing: Interrupting activities for short and frequent breaks.

Hot and cold therapy: Applying hot or cold compresses helps decrease pain.

Massage therapy: Rubbing and manipulating muscles, which increase blood circulation and

enhance relaxation.

Music therapy: Listening to music, creating music, singing, and discussing music. Providing

guided imagery with music can also be beneficial. Relieves stress, apprehension and fear.

Physical therapy: Breathing exercises, walking, washing and fetching water build strength,

maintain energy, and contribute to overall well-being.

Positioning therapy: Changing position.

Non-Pharmacological Pain Management in Children

Deep breathing: Asking child to take deep breath through the nose and blow it out through the

mouth. Counting the child’s respirations focuses child’s attention on their breathing. Asking

school-age children during a painful procedure to hold their breath, which transfers focus to

their breathing and away from the procedure.

Distraction: Reading books, blowing bubbles, and counting Stroking, patting and rocking

infants and children who are in distress.

Music therapy: Providing different forms of music therapy to children who have an intimate

understanding of music and respond well to different forms of music therapy.

 PART TWO

MANAGEMENT GUIDE FOR FATIGUE FOCUSING ON ENERGY

CONSERVATION AND NON-PHARMACOLOGICAL TREATMENTS.

Fatigue in a clinical context often termed Cancer-Related Fatigue (CRF)it is a distressing,

persistent sense of physical, emotional, or cognitive tiredness that is not proportional to recent

activity (1).

Energy Conservation Strategies

Plan: Organize the day to include scheduled rest periods before, during, and after activities.

Gather all necessary supplies for a task beforehand to avoid extra movement (2).

Pace: Maintain a slow, steady rhythm. Sitting during tasks such as dressing or meal prep, uses

25% less energy than standing (3).

Prioritize (The 3 Ps): Plan your day to include rest periods, Prioritize the most important

tasks for when you have the most energy, and Pace yourself throughout the day.(2,3)

The 10-Minute Rule: If a task takes longer than 10 minutes, try to do it sitting down (folding

laundry, prepping vegetables).( 1)

Hydration: Dehydration is a silent energy thief. Even mild dehydration can make fatigue feel

significantly heavier.(4)

Short Bursts of Activity: While it sounds counterintuitive, very light movement (like a 5-

minute walk) can sometimes "wake up" the system better than a long nap.

Nausea Management:

Nausea is often triggered by smells, textures, or even the thought of food. The key is to

minimize triggers and soothe the digestive system and utilizing antiemetic protocols,

particularly for treatment-induced symptoms (2,4).

Evidence-Based Interventions

• Physical Activity: Contrary to intuition, light-to-moderate exercise (e.g., walking,

yoga, or Tai Chi) is the first-line non-pharmacological treatment for reducing fatigue

(1).

• Cognitive Behavioral Therapy (CBT): ASCO guidelines recommend CBT and

mindfulness-based therapies to address the psychological components of exhaustion

(1).

Dietary Adjustments

Try These Avoid These

Bland foods: Toast, crackers, rice,

Strong odors: Garlic, onions, heavy perfumes.
applesauce.

Cold or room-temp foods: These have Greasy/Fried foods: These sit heavy in the

less aroma. stomach.

Clear liquids: Ginger ale, peppermint tea, Extremely sweet foods: Can trigger a "sugar

broth. crash" nausea.

Non-Food Tactics

• Ginger and Peppermint: Both are natural anti-emetics. Ginger chews or peppermint

essential oil (inhaled, not ingested) can provide quick relief.

• Acupressure: Applying firm pressure to the P6 (Neiguan) point located about three

finger-breadths up from your wrist crease, can help settle the stomach.

• Keep your head up: Stay upright for at least 30–60 minutes after eating to prevent reflux-

related nausea.

• Minimize Odors: Avoid strong cooking smells, perfumes, or tobacco smoke. Cold or

room-temperature foods often have less aroma and are better tolerated than hot meals (5).
• Pharmacological Support: In palliative settings, psychostimulants like methylphenidate

or short-term corticosteroids may be considered for rapid relief, though evidence for long-

term use remains limited (1,6).

• Antiemetic Guidelines; 5-HT3 receptor antagonists and NK1 receptor antagonists are

used for patients undergoing high-dose chemotherapy.

 PART THREE

PROTOCOLS FOR NAUSEA AND ANOREXIA MANAGEMENT, EMPHASIZING

THE CLINICAL PRIORITY OF NAUSEA CONTROL.

Anorexia (Loss of Appetite) Management

Anorexia in chronic illness often evolves into Cancer Anorexia-Cachexia Syndrome (CACS),

a complex metabolic condition requiring multidisciplinary care (6,7).

"Mechanical Eating" Strategies

Frequent, Small Meals: Aim for 6–8 small snacks per day. A large plate can be visually

overwhelming and trigger early satiety (6).

Nutrient Density: Prioritize protein and calories in every bite. Add high-calorie supplements

(protein powder, healthy oils) to shakes, soups, or yogurts.

• Liquid Nutrition: When chewing is difficult due to fatigue, high-protein shakes or

smoothies provide a more accessible energy source than solid food.

Environmental Optimization

• Social Eating: Appetite often improves in social settings or when eating in a pleasant

environment away from the "sickroom."

• Weight Monitoring: Regular weight checks can help identify the early stages of

cachexia, allowing for earlier nutritional intervention (7).

Overcoming Early Satiety

Many people with anorexia feel "full" after three bites. This is often due to delayed

gastric emptying.

• Separate Liquids and Solids: Avoid drinking large amounts of water during a meal,

which fills the stomach with non-caloric volume. Drink 30 minutes before or after.

• Texture Modification: If chewing is exhausting, pureed foods or thick soups require

less "work" to consume, reducing the energy cost of eating.

• Clinical Coordination Table

• Symptom • Primary Goal • Key Clinical Marker

• Prevent • Ability to perform Activities of

• Fatigue
Deconditioning Daily Living (ADLs).

• Urine color (should be pale yellow)

• Nausea • Maintain Hydration
and skin turgor.

• Prevent Muscle • Stability of body weight over a 7-

• Anorexia
Wasting day period.

• Strategic Note: If these three symptoms occur together, always address nausea first.

It is impossible to manage anorexia or fatigue if the act of eating or drinking triggers a

vomiting reflex. Once nausea is chemically or environmentally controlled, nutritional

intake (anorexia) can improve, which provides the fuel needed to combat fatigue.
 PART FOUR

ASSESSMENT AND TIERED INTERVENTIONS FOR ORAL MUCOSITIS AND

DYSPNEA

Pathophysiology and Impact

Oral mucositis is not merely a surface wound; it involves a complex five-phase cascade:

initiation, signaling, amplification, ulceration, and healing [15]. It affects up to 90% of head

and neck cancer patients receiving radiation and nearly all patients undergoing high-dose

chemotherapy for hematopoietic stem cell transplants [16].

In-Depth Nursing Assessment

Visual Inspection: Utilize a penlight and tongue depressor to inspect the buccal mucosa, soft

palate, and sublingual areas every 8 to 12 hours [15].

Grading: Apply the WHO Oral Toxicity Scale:

Grade 1: Soreness/erythema.

Grade 2: Erythema, ulcers, can eat solids.

Grade 3: Ulcers, requires liquid diet.

Grade 4: Alimentation not possible [17].

Functional Impact: Document the patient's ability to swallow saliva and medications, as this

dictates the shift from oral to intravenous routes.

Comprehensive Interventions

Standardized Oral Hygiene: Patients should use a non-medicated, bland mouthwash (0.9%

saline or 5% sodium bicarbonate) every 4 hours while awake. This prevents the "crusting" of

secretions and maintains a neutral pH in the oral cavity [15].

Cryotherapy Protocol: For patients receiving bolus 5-FU, instruct them to swish ice slurry

for 30 minutes, beginning 5 minutes prior to the infusion. This causes local vasoconstriction,

effectively "shielding" the basal epithelial cells from the cytotoxic agent [17].
Pharmacologic Management

Morphine Mouthwash: For localized pain, 0.2% morphine mouthwash has shown efficacy in

reducing the duration of severe pain [18].

Palifermin: In the setting of autologous stem cell transplantation, this keratinocyte growth

factor may be administered to stimulate epithelial cell proliferation [17].

Dyspnea (Shortness of Breath) Management

Clinical Presentation

Dyspnea in cancer is often multifactorial, stemming from tumor obstruction, pleural effusion,

radiation-induced pneumonitis, or chemotherapy-induced heart failure [18]. It creates a

"dyspnea-anxiety cycle" where breathlessness triggers panic, which further increases the work

of breathing.

Advanced Assessment

The ESAS-r Tool: Use the Revised Edmonton Symptom Assessment System to track

breathlessness alongside related symptoms like fatigue and anxiety [17].

Physical Indicators: Assess for the use of accessory muscles, tracheal deviation, and the

presence of a "death rattle" in end-of-life care.

Rationale: Oxygen saturation (SpO2) often correlates poorly with the subjective sensation of

breathlessness; therefore, the patient's self-report is the primary gold standard [9].

Tiered Interventions

Environmental Modification: Maintain a room temperature between 18°C and 20°C. High

humidity can often worsen the sensation of "air hunger" [8].

Airflow Stimulation (The Fan Effect): Directing a cool flow of air from a handheld fan

toward the trigeminal nerve distribution (the face) alters the afferent signaling to the brain's

sensory cortex, providing rapid, drug-free relief [19].

Breathing Retraining

Pursed-Lip Breathing: This creates back-pressure in the airways, keeping them open longer

during exhalation and improving gas exchange [20].

Opioid Titration: Low-dose morphine (2.5 mg to 5 mg orally) reduces the ventilatory

response to hypoxia and hypercapnia, effectively "quieting" the brain's respiratory center

without causing respiratory depression in opioid-naive patients [18].

 PART FIVE

MANAGEMENT OF PSYCHOSOCIAL AND EMOTIONAL DISTRESS

The Spectrum of Distress

Distress is defined as a multi-determined unpleasant experience of a psychological, social,

spiritual, or emotional nature [11]. It exists on a continuum, ranging from common feelings of

vulnerability to disabling pathological conditions such as major depression or clinical anxiety.

Nursing Screening & Triaging

Distress Thermometer (DT): A visual analog scale from 0 (no distress) to 10 (extreme

distress). A score of 4 or higher serves as the clinical "red flag" for a formal referral [11].

Problem List: Identify the "drivers" of distress, such as childcare issues, spiritual

abandonment, or fear of recurrence.

Evidence-Based Support Levels

Psychoeducation: Nurses provide foundational support by explaining what the patient can

expect from treatment. Knowledge reduces the "fear of the unknown," which is a primary driver

of anxiety [12].

Cognitive-Behavioral Techniques (CBT)

Reframing: Helping the patient move from "I cannot handle this treatment" to "This treatment

is a tool to help me manage my disease" [11].

Grounding Exercises: For acute panic, use the 5-4-3-2-1 technique (identifying 5 things you

see, 4 you can touch, etc.) to pull the patient out of an anxiety spiral and back into the present

moment.

Pharmacotherapy: For patients with persistent Grade 3 distress, Selective Serotonin Reuptake

Inhibitors (SSRIs) like Escitalopram are preferred due to their lower side-effect profile

compared to older antidepressants [12].

 SUMMARY OF MANAGEMENT PROTOCOL

A- Fatigue (Cancer-Related Fatigue)

Pharmacological Rational Non- Rational

Management pharmacological
Management
Psychostimulants These agents help Energy conservation Light exercise is the
such as counteract severe techniques (Plan, first-line
methylphenidate or exhaustion when Pace, Prioritize-the 3 intervention as it
short-term non-drug measures Ps), short scheduled prevents
corticosteroids may are insufficient, rest periods, deconditioning and
be used for rapid though evidence for hydration, and light- improves energy;
relief in palliative long-term use is to-moderate physical energy conservation
settings. limited. activity (walking, reduces unnecessary
yoga, Tai Chi). expenditure while
maintaining
function.

B- Nausea
Pharmacological Rational Non- Rational
Management pharmacological
Management
5-HT3 receptor These drugs directly Ginger/peppermint, These strategies
antagonists and NK1 block key pathways acupressure at P6 reduce sensory
receptor antagonists in the vomiting point, triggers and gastric
for chemotherapy- center and are highly bland/cold/room- irritation while
induced nausea; effective for temperature foods, supporting hydration
antiemetics per treatment-induced minimizing strong and comfort without
established nausea. odors, staying adding medication
protocols. upright after eating, burden.
and small frequent
meals.
 C- Anorexia
Pharmacological Rational Non- Rational
Management pharmacological
Management
Address underlying Controlling nausea Frequent small Small frequent
nausea first with is prerequisite nutrient-dense meals overcome
antiemetics; consider because persistent meals/snacks, liquid early satiety and
appetite stimulants vomiting reflex nutrition (high- visual overwhelm;
or corticosteroids in prevents nutritional protein shakes), nutrient-dense
selected palliative intake; metabolic separate liquids from liquids reduce
cases (not strongly changes in CACS solids, social eating, energy cost of eating
detailed in require multimodal texture modification while preventing
documents) support. (pureed foods), and muscle wasting.
weight monitoring.

D- Oral Mucositis
Pharmacological Rational Non- Rational
Management pharmacological
Management
Morphine Morphine provides Standardized oral Frequent bland
mouthwash (0.2%) localized analgesia hygiene with bland rinses maintain
for pain; Palifermin with reduced mouthwash (0.9% neutral pH, prevent
for high-risk stem systemic effects; saline or sodium crusting, and reduce
cell transplant Palifermin bicarbonate) every 4 infection risk;
patients. stimulates epithelial hours, cryotherapy cryotherapy causes
healing in specific (ice slurry) during vasoconstriction to
high-risk settings. bolus 5-FU infusion, limit drug exposure
and regular visual to oral mucosa.
inspection/grading.
 E- Dyspnea

Pharmacological Rational Non- Rational

Management pharmacological
Management
Low-dose opioids Opioids reduce the Fan directed at the Airflow on the face
(morphine 2.5-5 mg brain’s ventilatory face (trigeminal alters sensory
orally) titrated response to nerve stimulation), signaling to the brain
carefully. hypoxia/hypercapnia pursed-lip breathing, for rapid relief;
and break the cool room breathing techniques
dyspnea-anxiety environment (18- improve gas
cycle without 20°C), positioning, exchange and reduce
causing significant and calm work of breathing.
respiratory reassurance.
depression in opioid-
naïve patients.

F- Psychological & Emotional Distress

Pharmacological Rational Non- Rational

Management pharmacological
Management
Selective Serotonin SSRIs have a Distress Education reduces
Reuptake Inhibitors favorable side-effect Thermometer fear of the unknown;
such as escitalopram profile and are screening, CBT and grounding
for persistent effective for psychoeducation, interrupt anxiety
moderate-to-severe anxiety/depression Cognitive spirals and empower
distress. components of Behavioral Therapy patients with
cancer-related (CBT) techniques practical coping
distress. (reframing, skills.
grounding 5-4-3-2-1
exercise), and
mindfulness.
 G- Pain

Pharmacological Rational Non- Rational

Management pharmacological
Management
Follow WHO Ladder approach Positioning, massage, These interventions
Analgesic Ladder ensures stepwise hot/cold therapy, address the physical,
Step 1: Non-opioids escalation based on music/dance therapy, emotional, social,
(paracetamol, pain intensity; distraction, breathing and spiritual
NSAIDs); regular scheduling exercises, TENS, dimensions of
Step 2: Weak prevents pain physical therapy, “Total Pain,”
opioids (codeine, recurrence; spiritual/psychosocial enhance comfort,
tramadol); adjuvants target support reduce anxiety, and
Step 3: Strong specific pain improve overall
opioids (morphine as mechanisms opioids quality of life.
gold standard). Use may not fully cover.
adjuvants for
neuropathic or bone
pain.
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