Lippincott Manual of Nursing Practice, 8 th Ed Chemotherapy mikEL rlh mantong

CHEMOTHERAPY FOR CANCER

 Definition
A. Chemotherapy is the use of antineoplastic drugs to promote tumor cell destruction by interfering with cellular function and reproduction. It
includes the use of various chemotherapeutic agents and hormones.
 Principles of Chemotherapy Administration
A. The intent of chemotherapy is to destroy as many tumor cells as possible with minimal effect on healthy cells.
B. Cancer cells depend on the same mechanisms for cell division that are found in normal cells. Damage to those mechanisms leads to cell death.
C. Chemotherapy is utilized in different clinical settings:
1. As induction chemotherapy for advanced disease
a. This is given as the primary treatment for patients who present with advanced cancer for which no alternative treatment exists.
b. As an adjunct to local methods of treatment.
c. Adjuvant chemotherapy is the use of systemic treatment after the primary tumor has been controlled by surgery and/or radiation
therapy. Currently, adjuvant chemotherapy is considered standard treatment for early-stage breast and colorectal cancer. There is also
evidence to support the use of chemotherapy after surgical resection of anaplastic astrocytomas
2. To palliate symptoms of metastatic disease and or prolong survival.
D. Chemotherapeutic agents can be effective on one of the four phases of the cell cycle or during any phase of the cell cycle. The cell cycle is divided
into four stages:
1. G1 (gap one) phase: RNA and protein synthesis (enzymes for DNA synthesis are manufactured)
2. S (synthesis) phase: During a long time period the DNA component doubles for the chromosomes in preparation for cell division.
3. G2 (gap two) phase: This is a short time period; protein and RNA synthesis occurs, and the mitotic spindle apparatus is formed.
4. M (mitosis) phase: In an extremely short time period, the cell actually divides into two identical daughter cells.
5. Cells not active in the cell cycle are designated as resting (G0). Cells in this phase are, for the most part, refractory to chemotherapy.
E. Therapeutic strategies:
1. Adjuvant therapy is given to patients who have no evidence of residual disease but who are at high risk for relapse. The justifications for
adjuvant chemotherapy are the high recurrence rate after surgery for apparently localized tumors, the inability to identify cured patients at
the time of surgery, and the failure of therapy to cure these patients after recurrence of disease.
2. Neoadjuvant therapy is the administration of several courses of chemotherapy before definitive surgical intervention (eg, large breast
masses). The goal of therapy is to decrease the amount of tissue that needs to be removed as well as to attempt to maximize cure potential.
3. High dose/intensive therapy is the administration of high doses of chemotherapy, usually in association with growth factor support or
before bone marrow transplant/stem cell rescue.
4. Preoperative chemotherapy is administered prior to surgery in an attempt to downstage the primary tumor so that less invasive surgery
can be performed. For example, patients with large breast tumors can preserve the breast and undergo lumpectomy instead of mastectomy.
5. Dose intensification has received increasing emphasis in recent years as a strategy for overcoming resistance to chemotherapy. Malignant
cells may be resistant to certain drugs from the start of therapy (natural resistance) or become resistant after therapy has begun (acquired
resistance). Dose intensification suggests that chemotherapy should be given in the highest tolerated dose over the briefest interval, with the
growth factor support. This is being tested in certain malignancies and remains unproved.
F. Routes of administration:
1. Oral -capsule, tablet, or liquid
2. I.V. push (bolus) or infusion over a specified time period
3. Intramuscular
4. Intrathecal/ intraventricular given by injection via an Ommaya reservoir or by lumbar puncture
5. Intra-arterial
6. Intracavitary such as peritoneal cavity
7. Intravesical into uterus or bladder
8. Topical
G. Dosage is based on surface area (mg/m2) in both adults and children.
H. Most chemotherapeutic agents have dose-limiting toxicities that require nursing interventions (see Table 8-4, pages 142 to 147). Chemotherapy
predictably affects normal, rapidly growing cells (eg, bone marrow, GI tract lining, hair follicles). It is imperative that these toxicities be recognized
early on by the nurse.
 Safety Measures in Handling Chemotherapy
A. Personal Safety to Minimize Exposure via Inhalation
1. Chemotherapeutic agents should be prepared in a class II biologic safety cabinet (vertical laminar flow hood).
2. Vent vials with filter needle to equalize the internal pressure or use negative-pressure techniques.
3. Wrap gauze or alcohol pads around the neck of ampules when opening to decrease droplet contamination.
4. Wrap gauze or alcohol pads around injection sites when removing syringes or needles from I.V. injection ports.
5. Do not dispose of materials by clipping needles or removing needles from syringes.
6. Use puncture- and leak-proof containers for non-capped, non-clipped needles.
B. Personal Safety to Minimize Exposure via Skin Contact
1. Wear nitrile examination gloves at all times when preparing or working with chemotherapeutic agents.
2. Wash hands before putting on and after removing gloves.
3. Change gloves after each use, tear, puncture, or medication spill or after every 60 minutes of wear.
4. Wear a long-sleeve, nonabsorbent gown with elastic at the wrists and back closure.
5. Eye and face shields should be worn if splashes are likely to occur.
6. Use syringes and I.V. tubing with Luer locks (which have a locking device to hold needle firmly in place).
7. Label all syringes and I.V. tubing containing chemotherapeutic agents as hazardous material.
8. Place an absorbent pad directly under the injection site to absorb any accidental spillage.
9. If any contact with the skin occurs, immediately wash the area thoroughly with soap and water.
10. If contact is made with the eye, immediately flush the eye with water and seek medical attention.
Lippincott Manual of Nursing Practice, 8 th Ed Chemotherapy mikEL rlh mantong
11. Spill kits should be available in all areas where chemotherapy is stored, prepared, and administered.
C. Personal Safety to Minimize Exposure via Ingestion
1. Do not eat, drink, chew gum, or smoke while preparing or handling chemotherapy.
2. Keep all food and drink away from preparation area.
3. Wash hands before and after handling chemotherapy.
4. Avoid hand-to-mouth or hand-to-eye contact while handling chemotherapeutic agents or body fluids of the person receiving
chemotherapy.
D. Safe Disposal of Antineoplastic Agents, Body Fluids, and Excreta
1. Discard gloves and gown into a leak-proof container, which should be marked as contaminated or hazardous waste.
2. Use puncture- and leak-proof containers for needles and other sharp or breakable objects.
3. Linens contaminated with chemotherapy or excreta from patients who have received chemotherapy within 48 hours should be contained
in specially marked hazardous waste bags.
4. Wear non-sterile nitrile gloves for disposing of body excreta and handling soiled linens within 48 hours of chemotherapy administration.
5. In the home, wear gloves when handling bed linens or clothing contaminated with chemotherapy or patient excreta within 48 hours of
chemotherapy administration. Place linens in a separate, washable pillow case. Wash separately in hot water and regular detergent.
 Adverse Effects of Chemotherapy
1. Adverse effects of chemotherapy are graded on a scale of 0 to 4, with 0 being normal and 4 indicating life-threatening. Scoring of adverse
effects will determine if a delay in therapy is necessary, dose modification is necessary, or cessation of therapy must occur.
B. Alopecia
1. Most chemotherapeutic agents cause some degree of alopecia. This is dependent on the drug dose, half-life of drug, and duration of
therapy.
2. Usually begins 2 weeks after administration of chemotherapy. Regrowth takes about 3 to 5 months.
3. The use of scalp hypothermia and tourniquets is highly controversial.
C. Anorexia
1. Chemotherapy changes the reproduction of taste buds.
2. Absent or altered taste can lead to a decreased food intake.
3. Concurrent renal or hepatic disease can increase anorexia.
D. Fatigue
1. The cause of fatigue is generally unknown but can be related to anemia, weight loss, altered sleep patterns, and coping.
E. Nausea and Vomiting
1. Caused by the stimulation of the vagus nerve by serotonin released by cells in the upper GI tract.
2. Incidence depends upon the particular chemotherapeutic agent and dosage.
3. Patterns of nausea and vomiting:
a. Anticipatory conditioned response from repeated association between therapy and vomiting.
b. Acute occurs 0 to 24 hours after chemotherapy administration.
c. Delayed can occur 1 to 4 days after chemotherapy administration.
F. Mucositis
1. Caused by the destruction of the oral mucosa, causing an inflammatory response.
2. Initially presents as a burning sensation with no changes in the mucosa and progresses to significant breakdown, erythema, and pain of
the oral mucosa.
3. Consistent oral hygiene is important to avoid infection.
G. Anemia
1. Caused by suppression of the stem cell or interference with cell proliferation pathways.
2. May require red blood cell transfusion or injection of erythropoietin or darbepoetin.
H. Neutropenia
1. Defined as an absolute neutrophil count (ANC) of 1,500/mm 3 or less.
2. Risk of infection is greatest with an ANC less than 500/mm 3.
3. Caused by suppression of the stem cell.
4. Usually occurs 7 to 14 days after administration of chemotherapy.
5. Can be prolonged.
6. Patients should be taught to avoid infection through proper hand washing, avoiding those with illness, proper hygiene.
7. Patients need to be monitored and treated promptly for fever or other signs of infection.
I. Thrombocytopenia
1. Caused by suppression of megakaryocytes.
2. Incidence depends on the agent being used.
3. Risk of bleeding is present when platelet count falls below 50,000/mm 3.
4. Risk is high when count falls below 20,000/mm3.
5. Risk is critical when count falls below 10,000/mm3.
6. Patient should be taught to avoid injury, eg, no razors, avoid vaginal douches and rectal suppositories, and avoid dental floss during the
period of thrombocytopenia.
7. May require platelet transfusions if count drops below 20,000/mm 3.
J. Hypersensitivity Reactions
1. Nearly all of the available chemotherapeutic agents can produce hypersensitivity reactions (HSRs) in at least an occasional patient, and
some cause reactions in 5% or more of patients receiving the drug. There are several agents (L-asparaginase, paclitaxel, docetaxel, teniposide,
and doxil) for which HSRs are frequent enough to be a major form of treatment-limiting toxicity.
2. The mechanism is unknown for most of the chemotherapeutic agents in use.
3. Signs and symptoms include hives, pruritus, back pain, shortness of breath, hypotension, and anaphylaxis.
4. All unexpected drug reactions should be reported to the manufacturer.
Lippincott Manual of Nursing Practice, 8 th Ed Chemotherapy mikEL rlh mantong
 Nursing Assessment
A. Integumentary System
1. Inspect for pain, swelling with inflammation or phlebitis, necrosis, or ulceration.
2. Inspect for skin rash, characteristics, whether pruritus, general or local.
3. Assess areas of erythema and associated tenderness or pruritus. Instruct patient to avoid irritation to skin, sun exposure, or irritating
soaps.
4. Assess changes in skin pigmentation.
5. Note reports of photosensitivity, tearing of the eyes.
6. Assess condition of gums, teeth, buccal mucosa, and tongue.
a. Determine whether any taste changes have occurred.
b. Check for evidence of stomatitis, erythematous areas, ulceration, infection, or pain on swallowing.
c. Determine whether the patient has any complaints of pain or burning of the oral mucosa or on swallowing.
B. GI System
1. Assess for frequency, timing of onset, duration, and severity of nausea and vomiting episodes before and after chemotherapy.
a. Usually occurs from 1 to 24 hours after chemotherapy but may be delayed. Anticipatory vomiting may occur after first course of
therapy. Can be initiated by various cues, including thoughts, smell, or even sight of the medical personnel.
2. Observe for alterations in hydration, electrolyte balance.
3. Assess for diarrhea or constipation.
a. Ascertain any changes in bowel patterns.
b. Discuss the consistency of stools.
c. Consider the frequency and duration of diarrhea (the number of stools each day for the number of days).
d. Evaluate dietary changes or use of medications such as opioids or 5-HT3 blockers that have had an impact on diarrhea or constipation.
4. Assess for anorexia.
a. Discuss taste changes and changes in food preferences.
b. Ask about daily food intake and normal eating patterns.
5. Assess for jaundice, right upper quadrant abdominal pain, changes in the stool or urine, and elevated liver function tests that indicate
hepatotoxicity.
6. Monitor liver function tests and total bilirubin.
C. Hematopoietic System
1. Assess for neutropenia ANC less than 500/mm3.
a. Assess for any signs of infection (pulmonary, integumentary, central nervous system, GI, and urinary).
b. Auscultate lungs for adventitious breath sounds.
c. Assess for productive cough or shortness of breath.
d. Assess for urinary frequency, urgency, pain, or odor.
e. Monitor for elevation of temperature above 101° F, chills.
2. Assess for thrombocytopenia platelet count less than 50,000/mm 3 (mild risk of bleeding); less than 20,000/mm3 (high risk of bleeding).
a. Assess skin and oral mucous membranes for petechiae, bruises on extremities.
b. Assess for signs of bleeding (including nose, urinary, rectal, or hemoptysis).
c. Assess for blood in stools, urine, or emesis.
d. Assess for signs and symptoms of intracranial bleeding if platelet count is less than 20,000/mm 3; monitor for changes in level of
responsiveness, vital signs, and pupillary reaction.
3. Assess for anemia.
a. Assess skin color, turgor, and capillary refill.
b. Ascertain whether patient has experienced dyspnea on exertion, fatigue, weakness, palpitations, or vertigo. Advise rest periods as
needed.
D. Respiratory and Cardiovascular Systems
1. Assess lung sounds.
2. Assess for pulmonary fibrosis, evidenced by a dry, nonproductive cough with increasing dyspnea. Patients at risk include those over age
60, smokers, those receiving or having had pulmonary radiation, those receiving cumulative dose of bleomycin (Blenoxane), or those with any
preexisting lung disease.
3. Assess for signs and symptoms of heart failure or irregular apical or radial pulses.
4. Verify baseline cardiac studies (eg, electrocardiogram, multiple-gated acquisition scan/ejection fraction) before administering doxorubicin
(Adriamycin) or high-dose cyclophosphamide (Cytoxan).
E. Neuromuscular System
1. Determine whether patient is having difficulty with fine motor activities, such as zipping pants, tying shoes, or buttoning a shirt.
2. Determine the presence of paresthesia (tingling, numbness) of fingers or toes.
3. Evaluate deep tendon reflexes.
4. Evaluate patient for weakness, ataxia, or slapping gait.
5. Determine impact on activities of daily living and discuss changes.
6. Discuss symptoms of urinary retention or constipation.
7. Assess for ringing in ears or decreased hearing acuity.
F. Genitourinary System
1. Monitor urine output.
2. Assess for urinary frequency, urgency, or hesitancy.
3. Evaluate changes in odor, color, or clarity of urine sample.
4. Assess for hematuria, oliguria, or anuria.
5. Monitor BUN and creatinine.
 Nursing Diagnoses
Lippincott Manual of Nursing Practice, 8 th Ed Chemotherapy mikEL rlh mantong
A. Risk for Infection related to neutropenia
B. Risk for Injury related to bleeding from thrombocytopenia
C. Fatigue related to anemia
D. Imbalanced Nutrition: Less Than Body Requirements related to adverse effects of therapy
E. Ineffective protection and risk for hypersensitivity reaction related to chemotherapy
F. Impaired Oral Mucous Membranes related to stomatitis
G. Disturbed Body Image related to alopecia and weight loss
 Nursing Interventions
A. Preventing Infection
 Monitor vital signs every 4 hours; report occurrence of fever greater than 101 ° F (38.3 ° C) and chills.
 Provide patient education.
o Instruct patient to report signs and symptoms of infection:
 Fever greater than 101 ° F and/or chills
 Mouth lesions, swelling, or redness
 Redness, pain, or tenderness at rectum
 Change in bowel habits
 Areas of redness, swelling, induration, or pain on skin surface
 Pain or burning when urinating or odor from urine
 Cough or shortness of breath
o Reinforce good personal hygiene habits (routine bathing [preferably a shower], clean hair, nails, and mouth care).
o Avoid contact with people who have a transmissible illness.
o Encourage deep breathing and coughing to decrease pulmonary stasis.
 Avoid performing invasive procedures rectal temperatures, enemas, or insertion of indwelling urinary catheters.
 Monitor white blood cell count (WBC) and differential.
 Be aware that hematologic nadirs (lowest level) generally occur within 7 to 14 days after drug administration. Length of myelosuppression depends
on specific drug. Institution of further therapy usually depends on an adequate WBC and ANC.
 Calculate ANC to determine the number of neutrophils capable of fighting an infection by:
Interpretation: 105 of the 700 WBCs are neutrophils and capable of fighting an infection (indicates severe neutropenia).
 Administer prophylactic antibiotics as prescribed (if WBC is less than 500).
 Administer growth factors as prescribed. Neupogen 5 mcg/kg S.C. starting 24 hours after chemotherapy for 10 days for neutropenia prophylaxis or
Neulasta 6 mg S.C. for one dose 24 hours after chemotherapy. Should also be administered with subsequent courses of chemotherapy to hasten
neutrophil maturity.
B. Preventing Bleeding
 Avoid invasive procedures when platelet count is less than 50,000/mm 3, including I.M. injections, suppositories, enemas, and insertion of indwelling
urinary catheters.
 Apply pressure on injection sites for 5 minutes.
 Monitor platelet count; administer platelets as prescribed.
 Monitor and test all urine, stools, and emesis for blood.
 Provide patient education.
o Instruct patient to avoid straight-edge razors, nail clippers, vaginal or rectal suppositories.
o Avoid intercourse when platelet count is less than 50,000/mm 3.
o Encourage patient to blow nose gently.
o Avoid dental work or other invasive procedures while thrombocytopenic.
o Avoid the use of NSAIDs, aspirin, and aspirin-containing products.
C. Minimizing Fatigue
 Monitor blood counts (hemoglobin and hematocrit).
 Administer blood products as prescribed.
 Administer growth factors as prescribed. Erythropoetin 150 U/kg S.C. 3 × per week.
 Provide patient education and counseling
o Information about fatigue
o Reassurance that treatment-related fatigue does not mean your cancer is worse
o Why fatigue and shortness of breath may occur
o Suggestions for ways to cope with fatigue
 Energy conservation
 Caution the patient about physical overexertion; encourage rest frequently and warn patient to expect a tired feeling
 Plan frequent rest periods between daily activities; take naps that do not interrupt nighttime sleep
 Set priorities and delegate tasks to others
o Stress management
o Explain that blood transfusions, if given, are a part of therapy and not necessarily an indication of a setback
o Observe skin color
o Monitor nutritional status
D. Promoting Nutrition
 Administer antiemetics before chemotherapy and on a routine schedule (not as needed).
Lippincott Manual of Nursing Practice, 8 th Ed Chemotherapy mikEL rlh mantong
 Be aware that certain antiemetic combinations are more effective than single agents.
o A 5-HT3 inhibitor, such as ondansetron (Zofran), granisetron (Kytril), dolasetron (Anzemet), in combination with dexamethasone
(Decadron)
o Corticosteroids in combination with metoclopramide (Reglan)
 For highly emetogenic chemotherapy regimens:
o Premedicate with a 5-HT3 inhibitor and dexamethasone.
o Include an as-needed antiemetic such as metoclopramide, prochlorperazine (Compazine), dexamethasone, or lorazepam (Ativan).
 For moderately emetogenic regimens:
o Premedicate with either prochlorperazine or dexamethasone with metoclopramide plus diphenhydramine (Benadryl).
o Include an as-needed antiemetic, such as prochlorperazine or lorazepam.
o Failures may receive a 5-HT3 inhibitor.
 For low emetogenic regimens consider oral prochlorperazine.
 Extrapyramidal reactions occur frequently in patients under age 30 and over age 65. Treat dystonic reactions with diphenhydramine; treat
restlessness with lorazepam.
 If delayed nausea and vomiting begin 8 hours after acute prophylactic antiemetic therapy and continue for 24 to 36 hours, administer agents such
as metoclopramide with dexamethasone plus diphenhydramine, prochlorperazine, or lorazepam.
 Consider alternative measures for relief of anticipatory nausea, such as relaxation therapy, imagery, and distraction.
 Encourage small, frequent meals appealing to patient preferences.
 Encourage patient to eat a diet high in calories and proteins. Provide a high-protein supplement as needed.
 Discourage smoking and alcoholic beverages, which may irritate mucous membranes.
 Encourage fluid intake to prevent constipation.
 Monitor intake and output, including emesis.
 Consult dietitian about patient's food preferences, intolerances, and individual dietary interventions.
 Recognize that the patient may have alterations in taste perception, such as a keener taste of bitterness and loss of ability to detect sweet tastes.
E. Minimizing Stomatitis
 Report signs of infection erythematous areas, white patches, ulcers.
 Encourage good oral hygiene.
o Soft nylon bristled toothbrush, brush 2 to 3 times daily, rinse frequently
o Floss once daily
 Encourage the use of oral agents to promote cleansing, debridement, and comfort. Mouthwashes with more than 25% alcohol should be avoided.
 Assess the need for antifungal, antibacterial, or antiviral therapy (each infection has a different appearance).
 Administer local oral therapy such as combinations with viscous lidocaine (Xylocaine) for symptomatic control and maintenance of calorie intake.
F. Preventing and Managing Hypersensitivity Reactions
 Be alert for signs of allergic reactions such as pruritus, urticaria, and difficulty breathing, as well as back pain. Situation may worsen suddenly to
hypotension and anaphylaxis.
 Stop the medication or infusion immediately, notify the health care provider, and monitor the patient closely. Treatment is supportive and
dependent on type of reaction and its severity.
o Do not administer the agent again if there was a severe reaction resulting in significant hypotension.
o Premedicate the patient with antihistamine or corticosteroid as directed if there is a history of moderate reaction.
G. Strengthening Coping for Altered Body Image
 Reassure patient that hair will usually grow back; however, it may grow back a different texture or different color.
 Suggest wearing a turban, wig, or headscarf, preferably purchased before hair loss occurs. Many insurance companies will pay for a wig with a
prescription.
 Encourage patient to stay on therapeutic program.
 Be honest with the patient.
 Patient Education and Health Maintenance
 Make sure that patient uses good hygiene, knows symptoms of infection to report, and avoids crowds and people with infection while neutropenic.
 Advise patient to avoid using a razor blade to shave, contact sports, manipulation of sharp articles, use of hard bristle toothbrush, and passage of
hard stool to prevent bleeding while thrombocytopenic.
 Advise women to report symptoms of vaginal infection due to opportunistic fungal or viral infection.
 Encourage patient participation in plan for chemotherapy and to set realistic goals for work and activities.
 Assure patient that changes in menses, libido, and sexual function are usually temporary during therapy.
 Evaluation: Expected Outcomes
 Afebrile, no signs of infection
 No bruising or bleeding noted; stool and urine heme test negative
 Denies shortness of breath or severe fatigue
 Tolerates small, frequent meals following antiemetic
 No oral lesions or pain on swallowing
 No urticaria, shortness of breath, or change in vital signs
 Wears turban, expresses feelings about body image