Cancer patients with oral mucositis: challenges for nursing care1

OBJECTIVE: to analyze nursing care provided to cancer patients with oral mucositis based on the Nursing Process (NP). METHOD: this exploratory, descriptive, cross-sectional and quantitative study was conducted with 213 patients undergoing chemotherapy and/or radiotherapy in two cancer facilities: one philanthropic and one private service. RESULTS: the participants were mainly female, aged 45.8 years old on average, with up to 11 years of schooling and income of up to one times the minimum wage. Severe mucositis was related to chemotherapy associated with radiotherapy. Only 25.3% of the patients reported having received guidance from nurses during their treatment concerning self-care. The perceptions of patients regarding quality of care did not significantly differ between the private and public facilities. The basic human needs mainly affected were comfort, eating, and hygiene. Based on this finding, one NP was established listing the diagnoses, interventions and expected results to establish an ideal, though individualized, standard of nursing care to be provided to these patients. CONCLUSION: to understand oral mucositis is crucial to establish nursing care that includes prevention based on the implementation of an oral care plan.


Introduction
The experience of cancer patients overlaps with nursing care since the difficulties imposed by the disease and complications accruing from the therapy, such as oral mucositis, differentiate these patients who require specialized care.
Mucositis is a toxic inflammatory response that affects the gastrointestinal tract mucosa, a sequel of radiotherapy and/or chemotherapy or bone marrow transplantation, resulting in intense pain and impaired verbal communication and eating (1) . The occurrence of oral mucositis ranges from 40% to 76% in patients undergoing chemotherapy; 75% in individuals undergoing bone marrow transplantation; and may affect 90% of the patients undergoing radiation to the head or neck. These percentages increase when chemotherapy is associated with radiation (2) .
Instruments to measure the degree of oral mucositis lesions that impede the patient's eating (3) .
In addition to using instruments, nurses must realize that care provided to cancer patients should be planned and that following the nursing process (NP) is crucial. The NP should be theoretically supported to guide data collection, the establishment of diagnoses, the planning of interventions and assessment of results (4) . Three classifications are necessarily used by the third generation of NP: Diagnoses, Results and Interventions (5) , according to specific taxonomies such as the North American Nursing Diagnosis Association (NANDA) (6) , Nursing Interventions Classification (NIC) (7) and Nursing Outcomes Classification (NOC) (8) .
Theorists (9)(10)(11) support a concept of care in the dimension of human existence as a comprehensive, interactive and associative phenomenon that is generated between caregiver and recipients of care, aiming to generate comfort, help, promotion, and reestablishment of health, and relief of human suffering. From Heidegger's perspective, caring is a key provision to deal with the world, that is, the relationship with another individual is manifested in the relationship between the being-here and the beingin-the-world, which is revealed not only by occupation, but also by pre-occupation, guided by tolerance and patience (12) .

Results
In regard to the sociodemographic profile of the All the patients with mucositis degree 0 were undergoing chemotherapy only; 76% of those whose mucositis was classified as degree I were also undergoing chemotherapy, as well as 69.2% of those whose lesions were classified as degree II. Patients presenting more severe mucositis, degrees III or IV, were simultaneously exposed to chemotherapy and radiotherapy; 54.3% of those with lesions of degree III and 66.7% with degree IV (Figure 1).    in Piauí, Brazil. The pattern repeats in the Northeast and in Brazil in general (13) . Because women are more likely to have cancer, they are more susceptible to the adverse effects of its treatment, such as oral mucositis.
Analyzing the most affected age ranges, we observed a predominance of women between 19 and 59 years old, coinciding with adulthood. This fact has epidemiological and social importance when we verify partial or total loss, depending on the clinical condition, of the individuals' productive potential, while at an economically active age. One study (14) that applied the quality of life scale to cancer patients concluded that these individuals experienced decreased self-esteem, especially when they lose their role as providers and have to discontinue their work activities, seen as a genuine way to give vent to pulsions.
Most patients had attended up to 11 years of school; i.e., they had incomplete high school at most, and also had low incomes, not more than one times the minimum wage. Excluding the percentage of the sample composed of children, who were a minority, this information reveals failure in important determinants of heath, like education and income. Patients with higher levels of education and economic status deal better with the diagnosis of cancer and follow medical and nursing instructions and prescriptions more rigorously, such as for oral hygiene among those with oral mucositis (15) .
Additionally, it is expected that these patients have a diagnosis in the earlier stages of the disease, avoiding the occurrence of invasive carcinomas or advanced staging of oral mucositis. Low-income individuals tend to have poor oral health conditions and nutritional deficiencies (16) . The use of educational techniques in health that adopt language appropriate to a less affluent population is essential to leading these individuals to become active subjects in the process of cure. Patient education is crucial, as well as the active participation of patients in treatment.
In regard to the stratification of oral mucositis into degrees, note that patients with milder types of mucositis were treated only with chemotherapy, while chemotherapy combined with radiation was more frequent among those experiencing severe mucositis.
Chemotherapy by itself already causes severe toxicity in the gastrointestinal mucosa and, therefore, it is the treatment that is the most determinantal of lesions.
This harmful effect is strengthened when chemotherapy is associated with radiotherapy. The results are corroborated by one study (2) that shows the occurrence of oral mucositis ranging from 40% to 76% in patients undergoing chemotherapy, but reaches 90% when it is associated with radiotherapy.

Nursing Process targeted to patients with oral mucositis
Ideally, whenever providing care to a cancer patient with oral mucositis, nurses should identify the level of severity and establish a classification of risk, giving priority to preventive measures for oral mucositis. Tables 2 and 3 show that, regardless of the severity of the condition or the type of facility, the way nurses express themselves as mediating or intervening professionals, is still insufficient. This insufficiency is a fact that causes concern when we consider that the weak performance of nurses prevents the NP in oncology, which contrary to the paradigm of The NP should be supported based on a methodological framework and scientific model to systematize nurses' actions in order to achieve goals and results. The analysis of efficacy, effectiveness, and efficiency of care is essential for decision-making (5) .

Data presented in
Acknowledging the importance of nurses as key players in the implementation and systematization of care, one should determine how feasible the competencies, abilities and attitudes of nurses are toward cancer patients to establish the NP. For that, it is crucial that nurses seek support in the profession's coded literature, the NANDA (6) , NIC (7) or NOC (8) , to establish diagnoses and procedures to achieve a result that culminates in the patients' wellbeing (5) .
To establish the NP to be implemented among patients with oral mucositis, it is essential to take into account the individual's wholeness. Continuous assessment and outcomes (19) . Hence, follow-through for all the NP stages should be observed and fully implemented. History-taking of cancer patients should not only address the current disease, cancer, but also consider the individual as a whole. It should be composed of anamneses and general and specific physical assessments, taking into account the multidimensional nature of the care recipient and detecting human needs that may have been affected in order to establish nursing diagnoses (11) .
Under the domain Security/Protection, class Physical Lesion, the NANDA lists the nursing diagnosis "Impaired Oral Mucous Membrane" and related factors include radiation to head or neck and the use of anticancer agents (6) . Considering that the expected result, according to the NOC, is issues with tissue integrity of skin and mucosa and oral hygiene, both under the domain Physiological Health, class Tissue Integrity, nursing actions should be systematized to enable successful care delivery (8) .
Patients with oral mucositis experience discomfort, pain, difficulty or inability to swallow and talk, and are susceptible to secondary infections due to deficient oral hygiene (20) . Hence, many basic human needs are affected, such as comfort, eating and hygiene.
Lack of comfort is associated with the pain the condition causes. The diagnosis of this need, according to the NANDA, is under the domain Comfort, class Physical Comfort, while Acute Pain is related to the effects of cancer treatment (6) . According to the NIC (7) , Experimental studies addressing new analgesic approaches are also helpful since pain is the symptom that most strongly limits quality of life (21) . Additionally, pain heavily interferes in the quality of sleep of oncological patients, especially those with head or neck cancer (22) .
With the implementation of these interventions we expect to achieve the best prognosis for patients, which according to the NOC, is Pain Control. This outcome is Health Behavior (8) .
In regard to food deficiency, this can be diagnosed using the NANDA (6) , under the domain Nutrition and class Ingestion in "Imbalanced Nutrition: less than bodily requirements" and "Impaired Swallowing," which is related to reduced oral ingestion, nausea and vomiting, secondary to radiotherapy and chemotherapy. According to the NIC (7) , -Encourage the intake of fluids; One study (23) addressing how oral mucositis developed among 40 patient with head and/or neck cancer for 24 months after nutritional intervention with increased protein intake reports that orienting the patient in regard to the type of food to ingest during radiotherapy reduced the manifestation of severe forms of mucositis, improving the consistency of diets and decreasing the degree of mucositis and pain.
A nutritional result is expected after implementing these activities as recommended by the NOC, which is under the domain Physiological Health, class Nutrition (8) ; i.e., individuals are supposed to ingest daily nutritional requirements according to their level of activity and metabolic needs.
In regard to susceptibility to opportunistic infections accruing from inefficacious oral hygiene, the nursing diagnoses according to the NANDA are "Risk for Infection" under the domain Safety/Protection, class Infection, and "Self-care deficit: hygiene" under the domain Activity/Rest, class Self-care (6) . The first refers to the impairment of host defenses, secondary to cancer treatment, and the second refers to lack of knowledge concerning the importance of oral hygiene.
According to the NIC (7) , the following interventions are listed under the domain Basic Physiological, class Self- -Refer for dental assessment those patients with tooth decay, irregular restorations or who have dentures; -Teach how to clean dentures and educate patients to abandon them when ill fitting; -Teach how to correctly clean toothbrushes using hypochlorite; -Recommend the use of oral antiseptics specific to each patient.
A systematic review (25) conducted with 52 papers concluded that, regardless of the patient's age and type of oncological treatment, a plan for oral care including intense oral hygiene, determined better evidence both in regard to the prevention and treatment of oral mucositis.
Nurses are supposed to implement and supervise oral care, always considering it a priority to provide information to the patient and help the patient the focus of the health education process, facilitating adherence and the success of nursing interventions (23) .  (19) . In conclusion, we expect that, with the interventions presented by this study, oncological patients will receive care that addresses their unique characteristics, and is able to also strengthen their souls and not only meet their physiological needs.