Research and Theory for Nursing Practice: An International Journal, Vol. 27, No.

4, 2013

Assessment of Chemotherapy-Induced
Nausea and Vomiting in Women
With Breast Cancer: A Neuman
Systems Model Framework

Laura Bourdeanu, PhD

Department of Nursing, The Sage Colleges, New York

Vivien Dee, PhD

Azusa Pacific University, California

The importance of nursing theory and models for the development of the nursing
profession is becoming increasingly evident in literature. This article demonstrates
the use of the Betty Neuman Systems Model (NSM) to assess, as well as determine
the predictors of chemotherapy-induced nausea and vomiting (CINV) in patients
diagnosed with breast cancer receiving doxorubicin-based chemotherapy. The selec-
tion of the model for practice reflects the congruency between the level of severity of
CINV and the patient-related risk factors. In addition, the NSM was used to determine
the appropriate nursing interventions necessary to strengthen the flexible lines of
defense and the lines of resistance in addition to maintaining system stability.

Keywords: Neuman; system models; CINV; breast cancer; nursing theory

N
ursing theories and models provide coherent, systematic frameworks that
can guide and direct nursing assessment, planning, and intervention.
In addition, they can aid in generating further knowledge and distinguishing
what should form the basis of nursing practice. The benefits of having a nursing
theory include better patient care, enhanced professional status for nurses, and
guidance for research. Nursing theory in research is used to form research ques-
tions and aid in the design, analysis, and interpretation of a research study (Polit
& Beck, 2004). The purpose of this article is to summarize the conceptual basis,
values, and assumptions inherent in the Betty Neuman Systems Model (NSM) and
to illustrate the application of model to nursing practice through the examination

296 © 2013 Springer Publishing Company

http://dx.doi.org/10.1891/1541-6577.27.4.296
Chemotherapy-Induced Nausea and Vomiting in Women With Breast Cancer 297

of women with breast cancer who are experiencing chemotherapy-induced nausea

and vomiting (CINV).

THEORETICAL OVERVIEW

The NSM provides a systematic approach to evaluating the potential effect of the
client-related factors and nursing interventions as preventatives for the develop-
ment of CINV. This model is ideal for guiding nursing practice in relation to the
client with breast cancer who is experiencing CINV because it can accommodate
the complexity of the client with its open-system characteristics and consideration
of the five client variables.
The NSM is an open systems model that incorporates the four nursing
metaparadigms: person, health, environment, and nursing. This model has a
unique focus on the wellness of the client in relation to environmental stress
and reaction to stress (Neuman, 1982, 1995). In addition, Neuman’s open sys-
tems approach is constantly changing to achieve stability or to maintain the
survival of the client.

Person
According to the NSM, the client system is an open system that interacts with
both internal and external environment stressors. The client is a composite of
interrelationships among five variables that are constantly evolving: (a) physi-
ological, which refers to the bodily structure and internal functions, such as
biological composition and physical appearance; (b) psychological, including the
mental processes and interactive environmental effects, internally and externally,
such as mental status and intelligence; (c) sociocultural, that is, the combined
effects of social cultural conditions and influences such as family and culture;
(d) developmental, which refers to age-related developmental processes and
activities, such as developmental age and level of maturity; and (e) spiritual, or the
spiritual beliefs and influences such as personal meaning and religion (Neuman,
1982, 1995). These five client variables add to the complexity and individuality
of each client.
In addition to the five variables, the client structure consists of a series of
concentric circles surrounding a basic structure. The lines of resistance are a series
of concentric broken circles surrounding the basic structure and are responsible
for stabilizing and returning the client/client system to the usual wellness level.
The lines of resistance become activated when stressors invade the normal line
of defense, which functions as the standard normal state of wellness in the sys-
tem and what the client has become over time. A broken concentric circle, the
flexible line of defense, surrounds the normal line of defense and functions as a
protective mechanism for the client’s integrity. The client’s reaction to a stressor
is determined by the strength of the lines of defense or resistance (Neuman,
1982, 1995).
298 Bourdeanu and Dee

Health
In the NSM, health is defined as the condition in which all parts or subparts are
in harmony with the whole person, and occurs on a continuum, rising or falling
throughout the lifespan related to adjustment by the client/client system to environ-
mental stressors. Wellness and illness are at opposite ends of the continuum, with
continuous energy flow between the client and the environment. The severity of the
illness or degree of reaction is determined by the amount of system instability that
results from stressor invasion of the normal line of defense (Neuman, 1982, 1995).

Environment
Neuman’s concept of environment refers to any internal or external factors sur-
rounding the client with which he or she interacts at any given time. These factors
are categorized as intrapersonal, extrapersonal, and interpersonal. Intrapersonal
factors include interactions contained within the client; extrapersonal factors com-
prise all interactions occurring outside the client; and interpersonal factors arise
from interaction between two or more individuals (Neuman, 1982, 1995). In addi-
tion, the environment can be internal, external, or created. The internal environ-
ment is intrapersonal, with all interaction contained within the client, whereas
the external environment is interpersonal and extrapersonal in nature, with all
interactions occurring outside the client. The created environment is interpersonal,
extrapersonal, and intrapersonal in nature, and is subconsciously developed by
clients to protect them from reality when they are ill-prepared to handle the truth
(Neuman, 1982, 1995).
Depending on the client’s ability to handle the environmental stressors, the cli-
ent can have either a positive or a negative outcome. The severity of the effect of
the stressor on the client’s state is dependent on the five variables (physiological,
psychological, sociocultural, developmental, and spiritual) that are meant to protect
the client from instability caused by the stressors. Each variable can modify the
strength of the stressor and the extent to which the stressor has a negative effect
on the client. If the five variables cannot modify the strength of the stressor, then
the stressor will penetrate the flexible and normal lines of defense, and the client
will experience instability in the system (Neuman, 1982, 1995).

Nursing
Neuman viewed nursing as a unique profession that is concerned with keeping
the client system stable by assessing the effects of environmental stressors on the
client and assisting the client in adjusting to achieve optimal wellness through
preventions as interventions. There are three types of prevention as intervention:
primary, secondary, and tertiary. Primary prevention as intervention occurs before
any reaction to stress has occurred (Neuman, 1982, 1995). Secondary prevention as
intervention occurs when the symptom is evident (Neuman, 1982, 1995). Tertiary
prevention as intervention focuses on the return of client wellness after treatment
of symptoms (Neuman, 1982, 1995).
Chemotherapy-Induced Nausea and Vomiting in Women With Breast Cancer 299

PREVALENCE AND INCIDENCE OF CHEMOTHERAPY-

INDUCED NAUSEA AND VOMITING IN WOMEN
WITH BREAST CANCER

Breast cancer is the most common form of cancer among women, with an esti-
mated 226,870 new cases of breast cancer expected to be diagnosed in American
women during 2012, resulting in approximately 39,510 breast cancer deaths (Siegel,
Naishadham, & Jemal, 2012). Many patients with breast cancer receive chemo-
therapy after surgical resection to substantially reduce the risk of recurrence, and
combination chemotherapy with doxorubicin and cyclophosphamide is a commonly
prescribed adjuvant regimen for breast cancer (Hudis & Schmitz, 2004).
Despite advances in antiemetic therapy, up to 40% of patients receiving che-
motherapy experience CINV, and it continues to be significant and distressing side
effects (Blazer et al., 2012; Boccia, Grunberg, Franco-Gonzales, Rubenstein, & Voisin,
2013; Jones et al., 2011; Koch et al., 2013; Longo et al., 2012; Lorusso et al., 2012;
Miura et al., 2013; Navari, Gray, & Kerr, 2011; Oyama et al., 2013). The CINV can
often exacerbate negative physiological and psychological effects caused by can-
cer itself and contributes significantly to a lowered quality of life (Cohen, de Moor,
Eisenberg, Ming, & Hu, 2007; Haiderali, Menditto, Good, Teitelbaum, & Wegner,
2011; Lindley, Hirsch, & O’Neill, 1992; Martin, Rubenstein, Elting, Kim, & Osoba,
2003; Noonan, 2012; Smith, Smith, & Smith, 2012). In addition, CINV can also lead
to electrolyte, nutrition, and fluid imbalance and liver function abnormalities that
can have life-threatening consequences (Bender, McDaniel, & Murphy-Ende, 2002;
Smith et al., 2012). Most importantly, CINV may lead to the patients’ reluctance to
start chemotherapy or the patient’s withdrawal from treatment (Osoba et al., 1997;
Rhodes & McDaniel, 2001).
The main risk factor for the degree of CINV is the emetogenic potential of the
chemotherapeutic agents (Jordan, Kasper, & Schmoll, 2005). However, several
patient-related features have been identified, such as other medical disorders, depres-
sion, low alcohol intake, dysfunctional family relationships, young age, ethnicity,
and genetic makeup (Bouganim et al., 2012; Bourdeanu et al., 2012; Molassiotis,
Stamataki, & Kontopantelis, 2013; Roscoe et al., 2010; Shih, Wan, & Chan, 2009).

NSM METAPARADIGMS AND CINV: CASE EXAMPLAR

Client
Neuman’s client is a dynamic composite of interrelationships between the physi-
ological, psychological, sociocultural, spiritual, and developmental variables and
is in some state of wellness or illness (Neuman, 1982, 1995). This concept supports
how a client experiencing CINV is viewed with the client’s life experiences adding
complexity and individuality to her. The initial impact of the breast cancer diag-
nosis and subsequent treatment with chemotherapy on the client can vary, often
according to the client’s perceived outcome. Because the client’s outlook on life
and adjustment to life circumstances are based on the five variables composing the
300 Bourdeanu and Dee

TABLE 1. Client Variables

Variable Example
Physiological ethnicity, genetic factors, gastrointestinal function,
stage of breast cancer, medical comorbidities
Psychological perception of CINV, stress, decision-making patterns,
depression, anxiety, alcohol or illicit drug use
Sociocultural perceived social support, marital status or interpersonal
relationships, family relationships, insurance status,
financial resources, and the ability to obtain the proper
antiemetic regimen
Developmental age, education level
Spiritual spiritual practices, religion denomination, church
­attendance, spiritual beliefs
Note. CINV 5 chemotherapy-induced nausea and vomiting.

client’s system, a thorough assessment of these variables is warranted. Examples

of variables and stressors that could potentially affect the development of CINV or
its severity are listed in Table 1.

Health
With respect to women with CINV, health can be seen as a state of wellness that
adjusts to the changes that are associated with chemotherapy. Changes in well-
ness because of CINV can be as mild as loss of appetite without alteration in eat-
ing habits or as severe as death. Some of the changes are caused by physiological
reasons such as inability to metabolize antiemetic medications or psychological
reasons such as a previous experience with CINV that may have an impact on the
severity of the current experience with CINV. If the client developed effective cop-
ing strategies through this previous experience, then the client is able to manage
the CINV that occurs during the chemotherapy treatment and she will experience
health. Conversely, if the client cannot cope with the side effects, she will experi-
ence illness (Neuman, 1982, 1995).

Environment
While receiving chemotherapy, women with breast cancer are vulnerable to three
environmental factors (intrapersonal, interpersonal, and extrapersonal). These
stressors can impinge on the flexible line of defense, penetrate the normal line of
defense, or penetrate the basic structure (Neuman, 1982, 1995). The client maintains
varying degrees of wellness as she interacts with and adjusts to the environmental
stressors. It is essential that nurses have an accurate understanding of the client’s
environmental stressors because they are a large part of the context in which the
client with breast cancer copes with CINV. Examples of the three stressors are
listed in Table 2.
Chemotherapy-Induced Nausea and Vomiting in Women With Breast Cancer 301

TABLE 2. Client Stressors

Stressors
Intrapersonal client’s ambivalence between maintaining her role while
undergoing treatment for breast cancer, fear of the side
effects of the antiemetics along with those of chemotherapy,
attitudes, behaviors, coping patterns, response to stress,
expectations, values, and culture
Interpersonal resources; relationships of family, friends and caregivers; role
change; perceived effectiveness of the nurse/doctor–patient
interaction; perceived lack of information regarding treatment
Extrapersonal emetogenic potential of the chemotherapy, its dose and
­frequency, frequency of blood draws, financial ­difficulties,
unit/clinic noise or setup, frequency of clinic visits,
­interactions with hospital personnel, institutional policies,
employment and organizations, the person providing the
antiemetic medication teaching are unable to adapt the
information to the individual client’s situation, values and
attitudes of persons close to the client (parents, friends, etc.)
about taking ­antiemetics, information from the mass media
that the client sorts through and reinterprets

Nursing
The nursing goals designed to reduce the impact of the CINV should be mutually
derived in collaboration with the client. Measurable outcome criteria and a plan for
nursing intervention should be developed and implemented. Primary prevention
should focus on identifying clients at risk for developing CINV and providing them
with education programs with instructions on how to prevent the development of
CINV. The education plan should be personalized and combined with client education
tools so that the client has a full understanding of the plan of care once at home.
Because most chemotherapy is delivered on an outpatient basis, clients need clear
instructions regarding how to take antiemetics and when to alert the oncologist
or oncology nurse about uncontrolled CINV. Secondary prevention can take place
during treatment, when CINV can be identified and treated with additional medica-
tions or prevention education materials. Tertiary prevention is achieved by building
on the client’s strengths and conserving energy. Tertiary prevention should aim to
reeducate the client about the importance of CINV prevention.

DISCUSSION

The NSM has strong use for application to modern day nursing practice and can be
applied to clients with breast cancer experiencing CINV to attain the desired nurs-
ing outcomes. Its holistic nature readily lends itself to explaining both the diverse
chemotherapy side effects faced by the client, such as CINV, and nursing’s role in
302 Bourdeanu and Dee

assisting patients toward health. Placing the assessment of CINV within a nursing
model provides a mechanism for organizing the overall experience and examining
the relationship among the various client variables and consequences of severe CINV
developed through concept analysis. This ultimately helps identify specific predictors
of CINV that need to be included in the assessment, intervention, and evaluation. For
example, determining which of the five variables (physiological, psychological, socio-
cultural, developmental, and spiritual) contribute to the development of severe CINV
will allow nurses to determine which patients are more likely to experience severe
nausea and vomiting, provide anticipatory guidance for clients, and individualize
treatment with antinausea medications. As a result, effective primary, secondary, or
tertiary prevention as a nursing intervention can be developed such that the impact
of chemotherapy will not affect the level of instability or affect it to a lesser degree.
Further studies using the NSM are imperative to further demonstrate the suitability
of this model for the assessment of chemotherapy-induced side effects in women
with breast cancer. These studies should focus on the response of the client system
to actual or potential environmental stressors, and the use of primary, secondary,
and tertiary nursing prevention as interventions for the retention, attainment, and
maintenance of optimal client system stability.

REFERENCES
Bender, C. M., McDaniel, R. W., & Murphy-Ende, K. (2002). Chemotherapy-induced nausea
and vomiting. Clinical Journal of Oncology Nursing, 6, 94–102.
Blazer, M., Phillips, G., Reardon, J., Efries, D., Smith, Y., Weatherby, L., . . . Bekaii-Saab, T. (2012).
Antiemetic control with palonosetron in patients with gastrointestinal cancer receiving a
fluoropyrimidine-based regimen in addition to either irinotecan or oxaliplatin: A retrospec-
tive study [Clinical Trial]. Oncology, 83(3), 135–140. http://dx.doi.org/10.1159/000339145
Boccia, R., Grunberg, S., Franco-Gonzales, E., Rubenstein, E., & Voisin, D. (2013). Efficacy
of oral palonosetron compared to intravenous palonosetron for the prevention of
chemotherapy-induced nausea and vomiting associated with moderately emetogenic
chemotherapy: A phase 3 trial. Supportive Care in Cancer, 21(5), 1453–1460. http://dx.doi
.org/10.1007/s00520-012-1691-5
Bouganim, N., Dranitsaris, G., Hopkins, S., Vandermeer, L., Godbout, L., Dent, S., . . . Clemons,
M. (2012). Prospective validation of risk prediction indexes for acute and delayed che-
motherapy-induced nausea and vomiting. Current Oncology, 19(6), e414–e421. http://
dx.doi.org/10.3747/co.19.1074
Bourdeanu, L., Frankel, P., Yu, W., Hendrix, G., Pal, S., Badr, L., . . . Luu, T. (2012). Chemotherapy-
induced nausea and vomiting in Asian women with breast cancer receiving anthracycline-
based adjuvant chemotherapy. The Journal of Support Oncology, 10(4), 149–154. http://
dx.doi.org/10.1016/j.suponc.2011.10.007
Cohen, L., de Moor, C. A., Eisenberg, P., Ming, E. E., & Hu, H. (2007). Chemotherapy-induced
nausea and vomiting—Incidence and impact on patient quality of life at community
oncology setting. Supportive Care in Cancer, 15, 497–503.
Haiderali, A., Menditto, L., Good, M., Teitelbaum, A., & Wegner, J. (2011). Impact on daily
functioning and indirect/direct costs associated with chemotherapy-induced nausea and
vomiting (CINV) in a U.S. population [Multicenter Study Research Support, Non-U.S. Gov’t].
Supportive Care in Cancer, 19(6), 843–851. http://dx.doi.org/10.1007/s00520-010-0915-9
Chemotherapy-Induced Nausea and Vomiting in Women With Breast Cancer 303

Hudis, C. A., & Schmitz, N. (2004). Dose-dense chemotherapy in breast cancer and lymphoma.
Seminars in Oncology, 31, 19–26.
Jones, J. M., Qin, R., Bardia, A., Linquist, B., Wolf, S., & Loprinzi, C. L. (2011). Antiemetics for
chemotherapy-induced nausea and vomiting occurring despite prophylactic antiemetic
therapy [Research Support, N.I.H., Extramural]. Journal of Palliative Medicine, 14(7), 810–814.
http://dx.doi.org/10.1089/jpm.2011.0058
Jordan, K., Kasper, C., & Schmoll, H. J. (2005). Chemotherapy-induced nausea and vomiting:
Current and new standards in the antiemetic prophylaxis and treatement. European
Journal of Cancer, 41, 199–205.
Koch, S., Wein, A., Siebler, J., Boxberger, F., Neurath, M. F., Harich, H. D., . . . Dorje, F. (2013).
Antiemetic prophylaxis and frequency of chemotherapy-induced nausea and vomiting
in palliative first-line treatment of colorectal cancer patients: The Northern Bavarian
IVOPAK I Project. Supportive Care in Cancer, 21(9), 2395–2402. http://dx.doi.org/10.1007/
s00520-013-1801-z
Lindley, C. M., Hirsch, J. D., & O’Neill, C. V. (1992). Quality of life consequences of chemo-
therapy- induced emesis. Quality of Life Research, 1, 331–340.
Longo, F., Mansueto, G., Lapadula, V., Stumbo, L., Del Bene, G., Adua, D., . . . Quadrini, S.
(2012). Combination of aprepitant, palonosetron and dexamethasone as antiemetic pro-
phylaxis in lung cancer patients receiving multiple cycles of cisplatin-based chemotherapy.
International Journal of Clinical Practice, 66(8), 753–757. http://dx.doi.org/10.1111/j.1742-
1241.2012.02969.x
Lorusso, V., Giampaglia, M., Petrucelli, L., Saracino, V., Perrone, T., & Gnoni, A. (2012).
Antiemetic efficacy of single-dose palonosetron and dexamethasone in patients receiv-
ing multiple cycles of multiple day-based chemotherapy [Clinical Trial]. Supportive Care
in Cancer, 20(12), 3241–3246. http://dx.doi.org/10.1007/s00520-012-1469-9
Martin, C. G., Rubenstein, E. B., Elting, L. S., Kim, Y. J., & Osoba, D. (2003). Measuring
­chemotherapy-induced nuasea and emesis. Cancer, 98, 645–655.
Miura, S., Watanabe, S., Sato, K., Makino, M., Kobayashi, O., Miyao, H., . . . Yoshizawa,
H. (2013). The efficacy of triplet antiemetic therapy with 0.75 mg of palonosetron for
chemotherapy-induced nausea and vomiting in lung cancer patients receiving highly
emetogenic chemotherapy. Supportive Care in Cancer, 21, 2575–2581. http://dx.doi
.org/10.1007/s00520-013-1835-2
Molassiotis, A., Stamataki, Z., & Kontopantelis, E. (2013). Development and preliminary
validation of a risk prediction model for chemotherapy-related nausea and vomiting.
Supportive Care in Cancer, 21, 2759–2767. http://dx.doi.org/10.1007/s00520-013-1843-2
Navari, R. M., Gray, S. E., & Kerr, A. C. (2011). Olanzapine versus aprepitant for the prevention
of chemotherapy-induced nausea and vomiting: A randomized phase III trial [Clinical
Trial, Phase III Comparative Study Randomized Controlled Trial]. The Journal of Support
Oncology, 9(5), 188–195. http://dx.doi.org/10.1016/j.suponc.2011.05.002
Neuman, B. (1982). The Neuman systems model. Norwalk, CT: Appleton-Century-Crofts.
Neuman, B. (Ed.). (1995). The Neuman systems model. Norwalk, CT: Appleton & Lange.
Noonan, K. (2012). Effective prevention and management of chemotherapy-induced nausea
and vomiting. Value-Based Cancer Care, S12–S14.
Osoba, D., Zee, B., Warr, D., Latrelle, J., Kaizer, L., & Pater, J. (1997). Effect of post chemotherapy
nausea and vomiting on health-related quality of life. Supportive Care in Cancer, 5, 307–313.
Oyama, K., Fushida, S., Kaji, M., Takeda, T., Kinami, S., Hirono, Y., . . . Ohta, T. (2013). Aprepitant
plus granisetron and dexamethasone for prevention of chemotherapy-induced nausea
and vomiting in patients with gastric cancer treated with S-1 plus cisplatin. Journal of
Gastroenterology. Advance online publication. http://dx.doi.org/10.1007/s00535-012-0746-1
Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods (7th ed.). Philadelphia,
PA: Lippincott Williams & Wilkins.
304 Bourdeanu and Dee

Rhodes, V. A., & McDaniel, R. W. (2001). Nausea, vomiting, and retching: Complex problems
of palliative care. CA: A Cancer Journal for Clinicians, 51, 232–248.
Roscoe, J. A., Morrow, G. R., Colagiuri, B., Heckler, C. E., Pudlo, B. D., Colman, L., . . . Jacobs,
A. (2010). Insight in the prediction of chemotherapy-induced nausea [Research Support,
N.I.H., Extramural]. Supportive Care in Cancer, 18(7), 869–876. http://dx.doi.org/10.1007/
s00520-009-0723-2
Shih, V., Wan, H. S., & Chan, A. (2009). Clinical predictors of chemotherapy-induced nausea and
vomiting in breast cancer patients receiving adjuvant doxorubicin and cyclophosphamide.
The Annals of Pharmacotherapy, 43(3), 444–452. http://dx.doi.org/10.1345/aph.1L437
Siegel, R., Naishadham, D., & Jemal, A. (2012). Cancer statistics, 2012 [Comparative Study].
CA: Cancer Journal for Clinicians, 62(1), 10–29. http://dx.doi.org/10.3322/caac.20138
Smith, H. S., Smith, J. M., & Smith, A. R. (2012). An overview of nausea/vomiting in pallia-
tive medicine. Annals of Palliative Medicine, 1(2). http://dx.doi.org/10.3978/j.issn.2224-
5820.2012.07.06

Correspondence regarding this article should be directed to Laura Bourdeanu, PhD, Department
of Nursing, The Sage Colleges, 65 1st Street, Troy, NY 12180. E-mail: lbourdeanu@yahoo.com
Reproduced with permission of the copyright owner. Further reproduction prohibited without
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