NCM 112- RLE

Care of Clients with Problems in Oxygenation, Fluid and

Electrolytes, Infectious, Inflammatory & Immunologic Response,
Cellular Aberrations, Acute & Chronic
PREPARED BY:

ANNE MARGARET C. BOTOR, RN

Chemotherapy
 Learning
Objectives
 Learning Objectives
1. Discuss cancer and its treatment modalities
2. Define chemotherapy
3. Enumerate the purposes of chemotherapy
4. Discuss the functions of the oncology multidisciplinary team
5. Describe the types of chemotherapeutic agents
6. Discuss the possible side effects of chemotherapy and its nursing
considerations
Brief Background on
Cancer
 Cancer
A disease caused when cells divide
uncontrollably and spread into surrounding tissues.
 Cancer: Causes
Cancer arises from the transformation of
normal cells into tumor cells in a multi-stage process
that generally progresses from a pre-cancerous
lesion to a malignant tumor. These changes are the
result of the interaction between a person's genetic
factors and three categories of external agents,
including:

1. Physical carcinogens- Radiation, asbestos

2. Chemical carcinogens- Cigar, alcohol
3. Biological carcinogens- EBV, steroid hormone
 Oncology
A branch of medicine that deals with the
prevention, diagnosis, and treatment of cancer.
 Oncology Multidisciplinary Team
1. Medical oncologist
2. Surgical oncologist
3. Radiation oncologist
4. Oncology nurse
5. Oncology social worker
6. Patient navigator
7. Psychiatrist
8. Dietitian
9. Home health aide
10. Pharmacist
11. Clergy
Cancer Treatment
Modalities
 Local Therapy
a. Surgery
 Local Therapy
b. Radiotherapy
 Systemic Therapy
a. Hormonal therapy
b. Immunotherapy
c. Biological therapy
d. Chemotherapy
Chemotherapy
 Chemotherapy
Chemotherapy is an aggressive form of
chemical drug therapy meant to destroy rapidly
growing cells in the body.
Chemotherapy is a systemic treatment and is
often used in combination with other therapies, such
as surgery, radiation, or hormone therapy. The use of
combination therapy depends on:
1. The stage and type of cancer
2. Overall health
3. Previous cancer treatments
4. Location of the cancer cells
5. Personal treatment preferences
 Types of Chemotherapy Treatment
1. Neoadjuvant Chemotherapy- Delivered before
surgery with the goal of shrinking a tumor or stopping
the spread of cancer to make surgery less invasive
and more effective.
2. Adjuvant Chemotherapy- Administered after
surgery to kill any remaining cancer cells with the
goal of reducing the chances of recurrence.
3. Palliative Chemotherapy- Treatment designed
for terminal cancer patients to prolong survival and
ease symptoms but not cure disease.
 Goal of Chemotherapy
The aim of chemotherapy is to do the maximum
damage to cancer cells while causing the minimum
damage to healthy tissue.
 Chemotherapy Uses

1. Lower the total number of cancer cells in the body

2. Reduce the likelihood of cancer spreading
3. Shrink tumor size
4. Reduce current symptoms
5. After surgery or remission, to remove any remaining
cancer cells and delay or prevent a recurrence
6. To slow disease progression and reduce symptoms
in the later stages, even if a cure is unlikely
Chemotherapeutic
Agents
Chemotherapy agents act on different phases of the cell cycle.
 Alkylating agents
Chemotherapy Uses Side Effects Example

Alkylating agents- Most Multiple Leukemia Chlorambucil

common category of Myeloma Intestinal Cyclophosphami
drugs used in Sarcoma damage de
chemotherapy. It can be Hodgkin’s Patchy hair loss Thiotepa
used for most types of Disease Anemia Busulfan
cancers but are Lung Cancer Pancytopenia
generally best at Breast Cancer Cessation of
treating slow-growing Ovarian Cancer menstruation
cancers. It damages the Impaired sperm
DNA of cancer cells and production
prevent them from
dividing.
 Anti- metabolites
Chemotherapy Uses Side Effects Example
Anti-metabolites- Breast Cancer Nausea Azacitidine
Replaces structures in Leukemia Vomiting Clofarabine
the DNA of cancer cells Ovarian Cancer Ulcers Floxuridine
and alter the function of Gastrointestinal Loss of appetite
enzymes within the cell. Cancer Liver damage
Kidney failure
Frequent
sickness
Hair loss
Fatigue
Fever
Low white
blood cell count
Pancreatitis
 Anti- tumor Antibiotics
Chemotherapy Uses Side Effects Example
Anti-tumor Lung Cancer Heart Doxorubicin
antibiotics- Works by Colorectal damage Bleomycin
uncoiling strands of Cancer Low blood Mitoxantrone
DNA inside cancer Ovarian counts
cells and preventing Cancer Mouth sores
them from Prostate Fatigue
replicating. Cancer Less appetite
 Topoisomerase Inhibitors
Chemotherapy Uses Side Effects Example
Topoisomerase Leukemia Diarrhea Irinotecan
inhibitors- blocks cancer Pancreatic Nausea Topotecan
cells from dividing and Cancer Anemia Teniposide
spreading by interfering Ovarian Cancer Neutropenia
with enzymes called Gastrointestinal Thrombocytope
topoisomerases. Cancer nia
Topoisomerase inhibitors Lung Cancer
can be divided into
topoisomerase I and
topoisomerase II
depending on which
enzyme they affect.
 Anti-microtubule agents
Chemotherapy Uses Side Effects Example
Mitotic inhibitors/ Breast Nerve Cabazitaxel
Anti- microtubule Cancer Damage Docetaxel
agents- Prevents Lung Cancer Vomiting Vinorelbine
cancer cells from Myeloma Constipation
replicating by Lymphoma Lack of
inhibiting enzymes Leukemia appetite
the cells need to Abdominal
make certain pain
proteins. Weakness
Back Pain
 Chemotherapy Routes
1. Oral- most convenient
2. Intravenous- commonly used
3. Intramuscular
4. Subcutaneous
5. Intrathecal
6. Intraperitoneal
7. Intra-arterial
8. Topical
Oral Chemotherapy
Guidelines and Considerations
 Oral Chemotherapy Guidelines
General Safety Guidelines
1. Keep cancer drugs in original packaging until used or placed
within the daily pill box.
2. Do not mix chemotherapy medications with other
medications in the pill box. They should always remain
separate from other medications.
3. Perform hand hygiene before and after handling all
medications.
4. Do not let the medication come in contact with household
surfaces. If they do, clean the surface thoroughly to remove
all traces of the drug.
5. Store medications in a cool, dry place, away from excess
heat or sunlight exposure.
 Oral Chemotherapy Guidelines
Safe Medication Disposal
1. Never discard cancer medications in household
trash, place down the drain, or flush down the toilet.
2. Ask the provider or pharmacist where to return
unused and left-over medication.
3. Empty pill bottles may be put in household trash. Do
not recycle the bottles.
4. Never reuse cancer medication pill bottles.
 Oral Chemotherapy Guidelines
Exposure to household contacts
1. When possible, the patient should handle their medication
themselves.
2. If anyone other than the patient comes in contact with
cancer pills, wash the affected area with soap and water
immediately. If rash/skin changes occur, the patient should
contact their provider.
3. Caregivers should transfer the medication into a cup or
spoon when handling the medication. If picking up the
medication with their hand is unavoidable, wear disposable
gloves to prevent any unnecessary exposure.
4. If there is any contact with bodily fluids, household trash
should be double-bagged.
 Oral Chemotherapy Guidelines
Exposure to household contacts
5. A small amount of medication may be present the patient’s
urine, stool, vomit, or blood.
a. Caregivers should wear disposable gloves when
handling body fluids.
b. Items soiled with body fluids should be kept in plastic
bags until washed.
c. These items should be washed separately from other
laundry in hot water.
d. Pregnant women should not come in contact with
medications or body fluids.
e. Low-pressure toilets should be double-flushed after
each use by patients on oral cancer medications.
 Oral Chemotherapy Guidelines
Exposure to household contacts
i. The toilet lid should always be closed prior to
flushing the toilet.
ii. If any fluids splash from the toilet, the surface
should be wiped down with disinfectant cleaner
(wearing gloves).
iii. Take precautions to ensure pets do not drink
from the toilet.
6. Gloves should never be re-used. Discard gloves in
household trash after one use.
IV Chemotherapy
Guidelines and Considerations
 IV Chemotherapy Guidelines
Pre- Administration
1. Patient assessment, confirm allergies, and evaluate any
preexisting symptoms.
2. Verify signed consent for treatment was obtained and
signed by provider and patient.
3. Monitor laboratory values and verify laboratory values
within acceptable range for dosing.
4. Take measures to prevent medication errors:
a. Perform independent double-check of original orders
with a second chemotherapy-certified RN.
b. Double check for accuracy of treatment regimen,
chemotherapy agent, dose, calculations of body surface
area, schedule, and route of administration.
 IV Chemotherapy Guidelines
Pre- Administration
5. Recalculate chemotherapy doses independently for
accuracy.
6. Verify appropriate pre-medication and pre-hydration
orders.
7. Ensure patient education completed and address
outstanding patient questions.
 IV Chemotherapy Guidelines
Administration
1. Dual nurse verification and sign off at the bedside:
a. Compare original order to dispensed drug label at the
bedside with another chemotherapy-certified RN and
verify patient identity.
2. Safe handling of hazardous medications; reduce exposure
to self and others.
3. Intravenous line management: insertion, evaluation, and
assessment.
a. Check patency of IV site for brisk blood return
immediately prior to connecting hazardous agent to the
patient and as indicated during infusion.
b. Continuous monitoring for infiltration, phlebitis,
extravasation, or infection.
 IV Chemotherapy Guidelines
Administration
4. Continuous patient monitoring for acute/adverse drug
effects and allergic reactions.
5. Prompt recognition and management of hypersensitivity
reactions.
6. Safe handling and management of chemotherapy spills.
 IV Chemotherapy Guidelines
Post- Administration
1. Flush IV line, ensure brisk blood return prior to removing
peripheral IV device, flush/maintain vascular access device
according to institution policy.
2. Safe handling and disposal of hazardous waste according to
institution policy.
3. Document in medical record the medications given, patient
education, and patient response, including any adverse
events.
4. Ensure patient has appropriate discharge instructions, anti-
nausea medications, and education, and emergency contact
information of physician’s office in event of emergency.
Chemotherapy
Side Effects
 Side Effects
Generalized 1. Fatigue during chemotherapy is different
Fatigue, lack of energy from everyday fatigue. Symptoms may
include feeling worn out, drained, or an
overall lack of energy that does not go
away with rest or sleep.
2. The patient should focus on sleep hygiene.
Take short naps as needed, but do not nap
for longer than one hour. Long naps make
it harder to sleep at night.
3. Cluster activities and take frequent
periods of rest.
4. Consume a well-balanced diet with foods
rich in protein, iron, and vitamins and stay
adequately hydrated at all times.
5. Engage in light exercise as tolerated
throughout the week.
 Side Effects
Hematopoietic Neutropenia:
Bone marrow suppression 1. Abnormally low levels of white blood cells
(neutrophils).
2. Absolute neutrophil count (ANC) of 1,500/mm3 or less.
3. High risk for infection when ANC < 500/mm3.
4. The immune system is suppressed, increasing
susceptibility to infection, which can rapidly progress to
bloodstream infection.
5. Fever is most the common sign of infection in
neutropenic patient.
6. Highest risk for infection is seven to ten days after the
last chemotherapy treatment, which is the point where
the white blood cells are at their lowest (chemotherapy
nadir).
7. The nurse should educate the patient to avoid sick
contacts.
8. The best way to prevent infection is routine hand
hygiene.
9. Wear a mask when out in the community.
10. May require an injection to stimulate white blood cell
production.
 Side Effects
Hematopoietic Febrile neutropenia:
Bone marrow suppression 1. Fever in the setting of neutropenia is a
medical emergency that can lead to life-
threatening sepsis. It requires prompt
evaluation, work up, and initiation of empiric
antibiotics.
2. The nurse should encourage patients to
immediately report symptoms of fever ≥
100.4, cough, chest pain, shortness of breath,
dysuria.
3. Implement food preparation, cooking, and
storage precautions:
a. Wash fruits/vegetables well to remove
germs/pesticides.
b. Avoid eating raw or undercooked food as they
may have bacteria that can cause infection.
c. Refrigerate all leftover foods.
 Side Effects
Hematopoietic Thrombocytopenia:
Bone marrow suppression 1. Low platelet count (blood clotting factors), risk for
bleeding.
2. Risk of bleeding when platelet count < 50,000/mm3.
3. High risk when platelet count < 20,000/mm3.
4. Critical risk when platelet count < 10,000/mm3.
5. May require platelet transfusion when count is <
20,000mm/m3
6. Patients should monitor for signs of bleeding or
easy bruising.
7. Use a soft toothbrush, avoid flossing, no contact
sports or activities that increase risk for injury, and
blow nose gently.
8. Any falls with head trauma must be evaluated by
clinician due to risk for hemorrhage in the brain.
9. Avoid blood thinners: aspirin, non-steroidal anti-
inflammatory drugs (NSAIDs).
10. Do not use any rectal suppositories and avoid
dental work.
 Side Effects
Integumentary 1. Not all chemotherapy agents cause hair loss; usually
Alopecia, dermatitis/skin rash, begins about 7-15 days after the first dose.
folliculitis, urticaria, pruritis, nail 2. Patients should be told to avoid harsh shampoos or
changes, hyperpigmentation, soaps on bare scalp as these can cause irritation and
radiation recall folliculitis.
3. Wash and clean any lacerations with warm water and
soap, cover the area with a clean bandage.
4. Inform doctor or nurse if wound has any signs of
infection (redness, swelling, warmth, exudate).
5. Use mild, moisturizing soap and lotion frequently to
reduce skin dryness, itching and irritation.
6. Avoid showering/bathing with hot water, gently pat skin
dry.
7. Nail changes may occur: disruption of nailbed, nails may
become discolored or ridged.
8. Avoid nail salons due to risk for nail infection.
9. Skin darkening may occur and is usually not harmful
and does not require intervention.
10. Photosensitivity: educate regarding proper precautions
in the sun to avoid sunburn.
11. Radiation recall can occur; usually managed with topical
steroids and by discontinuing the offending agent
 Side Effects
Gastrointestinal 1. The nurse should educate the patient to take anti-nausea
Nausea, vomiting, diarrhea, constipation, medications and steroids as prescribed.
anorexia, mucositis/stomatitis, 2. If eating is difficult, eat small, frequent high-calorie meals and
dysgeusia, dry mouth, dyspepsia drinks throughout the day instead of three large meals.
3. Add high-protein shakes and supplements.
4. Avoid foods that are spicy, greasy or have strong odors.
5. Stay adequately hydrated at all times.
6. Add electrolyte sport drinks for oral rehydration and to prevent
dehydration due to diarrhea.
7. Report foul-smelling, continuous, liquid stools, as this may indicate
a GI infection such as C. difficile.
8. Take loperamide (Imodium) for diarrhea (if approved by provider).
9. For constipation, patients should increase dietary fiber and add stool
softener, such as Docusate Sodium (Colace) or laxative, such as
Senna (Senokot) as needed.
10. Eat with plastic utensils to help reduce any metallic taste in the
mouth.
11. Avoid alcohol-based mouthwashes due to their drying effects.
12. To preserve the integrity of oral mucosa, patients should rinse
mouth with salt water (normal saline solution) often, especially
before and after meals to keep mouth clean.
13. Patients can prepare homemade mouth rinse by mixing 1 cup of
warm water with 1⁄2 teaspoon of salt or baking soda. Swish the rinse
mouth for at least 30 seconds and spit out.
14. For painful mouth sores, patients should be given special oral rinses
(Magic Mouthwash) which contain topical analgesics to relieve pain
 Side Effects
Neurologic 1. It is important for the nurse to encourage all
Peripheral neuropathy, patients to report any symptoms in this category in
central neurotoxicity, order to ensure proper assessment and
ototoxicity management.
2. Painful neuropathy may require intervention with
medication and/or referral to neurologist.
3. Progressive neuropathy may require interruption
or discontinuation of offending chemotherapy
agent.
4. The patient should take measures to prevent falls:
Wear closed toe footwear with rubber soles, non-
slip mats in bathroom, remove tripping hazards in
home; consider use of cane or other mobility
devices to steady oneself when walking.
5. Take caution not to cut or burn oneself when
preparing and cooking food, or when handling hot
water/coffee.
6. Make sure the water temperature is not too hot
while washing dishes or bathing.
 Side Effects
Cardiovascular 1. The nurse should educate all patients to
Weakening of heart immediately report any symptoms of
muscle, heart failure, shortness of breath, leg swelling, chest
venous fibrosis, pain, chest tightness, or finger swelling.
peripheral edema 2. Mild leg swelling induced by
chemotherapy can be managed with
elevating legs above heart level and
reducing dietary sodium/salt intake.
3. Assess for signs and symptoms of heart
failure or irregular apical or radial pulses.
4. Some cardiotoxic chemotherapy agents
require evaluation of baseline cardiac
studies.
 Side Effects
Vascular 1. Nurses should reassure patients that
Phlebitis, Vein Sclerosis, discoloration and erythema at the
Infiltration, Extravasation intravenous site is common. Mild discomfort
can be managed by applying warm packs to
the affected site for 15 minutes, 4 times
daily.
2. Veins may at times become permanently
damaged and scarred due to chemotherapy.
3. Advise patients to immediately report pain,
burning, swelling, or other abnormal
sensation at the IV site.
4. Serious complications include
chemotherapy infiltration and
extravasation.
5. Prompt recognition and intervention are
critical.
 Side Effects
Pulmonary 1. Patients at risk for pulmonary complications
Pulmonary fibrosis, of chemotherapy include those over age 60,
pneumonitis, pulmonary former and current smokers, those receiving
edema or having had pulmonary radiation, or those
with any pre-existing lung disease.
2. Certain chemotherapy agents have a high
risk for pulmonary toxicity, and pulmonary
function tests must be performed prior to
each treatment, and cumulative dosing must
be monitored.
3. The nurse should encourage the patient to
immediately report any shortness of breath,
fever, productive cough with pink/red mucus,
difficulty taking a deep breath, feeling easily
winded, or feeling like you are ‘under water’.
 Side Effects
Reproductive/Sexuality 1. For patients of childbearing age: the nurse should
Infertility, loss of libido, ensure that discussions regarding fertility
impotence, erectile dysfunction, preservation (egg harvesting or sperm banking) occur
amenorrhea, induced premature prior to starting treatment.
ovarian failure or early 2. The nurse should make referrals to fertility clinics and
menopause specialists as indicated.
3. Patients should be told to engage in safe sex practices,
such as use of a barrier method (i.e. condom) to avoid
exposure to partners during intercourse and prevent
pregnancy while on chemotherapy. Chemotherapy can
induce significant harm to the fetus.
4. Patients should speak openly with their partner about
sexual problems and fears.
5. Females: avoid douching, as well as using soaps,
bubble bath and creams that can irritate the vulva and
vagina.
6. Water-based moisturizers may be used for vaginal
dryness.
7. Wear cotton underwear, as cotton releases sweat and
moisture to reduce the chance of infection.
 Side Effects
Psychiatric 1. Symptoms of anxiety and depression are
Anxiety, depression, anger, common in patients with complex disease
fear, grief/loss, body image progresses such as cancer.
distortion 2. Active listening and empathy are critical skills
for oncology nurses.
3. The nurse should assess patient needs and
connect to and coordinate referrals to
psychosocial services as appropriate:
psychiatrist/psychologist, therapist, or social
workers.
4. The patient should consider complementary and
alternative medicine modalities to reduce anxiety
(i.e. imagery, relaxation, reiki therapy).
5. The patient should also consider joining a support
group.
6. Antidepressants and anxiolytics may be offered.
7. Light physical exercise can help improve mood
through endorphin release.
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