Bachelor of Nursing with Honours in General Health Care

NURS N212F Nursing Therapeutics (General Health Care) II

Nursing management of clients suffering from carcinoma
and/or receiving palliative care

Learning Outcomes
Upon successful completion of the topic, students should be able to:
1. describe the characteristics and causes, cell cycle, apoptosis and metastasis, diagnostic
evaluation, classification and staging of cancer;
2. describe the principle of management of anti-cancer therapies and the related nursing
measures;
3. describe the nursing care for cancer clients and their families; and
4. describe the basic pharmacological concepts and clinical drug therapy modalities in
daily nursing practice and the related nursing considerations for cancer clients.

Neoplasms
Definition
 The terms cancer, neoplasm and tumor are often used interchangeably though they are not.
o Tumor: a lump, mass, or swelling
o Neoplasm: an abnormal mass of tissue that serves no useful purpose and may cause
harm to the host organism. A neoplasm can be either benign or malignant
 Benign neoplasm: a harmless growth that does not spread or invade other
tissues
 Malignant neoplasm: a harmful mass capable of invasion of other tissues and
metastasis to distant organs
o Cancer: refer to malignant neoplasms. It can be considered as a chronic disease that
requires ongoing management, rather than a terminal illness

Benign neoplasms vs malignant neoplasms

Characteristics Benign neoplasms Malignant neoplasms

Mode of growth  Local  Invasive

Borders  Well-differentiated  Poorly differentiated

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 Effect of neoplasm  Not harmful to host  Harmful to host
 Pushes other tissues out of  Invades and destroy
the way surrounding tissues

Speed of growth  Slow  Rapidly

Capsule  Encapsulated  No capsule

Prognosis  Good  Depends on cell type and

the time of diagnosis
 Tumor generally removed
surgically

Recurrence  Does not recur  May recur

 Benign neoplasms
o Since they are usually encapsulated, benign neoplasms are often easily removed and
tend not to recur
 Malignant neoplasms (Cancer)
o Malignant cells from the primary tumor may travel through the blood or lymph to
invade other tissues and organs and form a secondary tumor called metastasis
o Malignant neoplasms can recur after surgical removal of the primary and secondary
tumors and appear in other regions

Cancer classifications
 Cancer are classified by
o The type of cell that resembles the tumor (histology)
o The tissue presumed to be the origin of the tumor (location)
 Examples of general categories

Type of cancer Tissue of origin Example

Adenocarcinoma Glandular tissue Bronchioloalveolar

adenocarcinoma

Blastoma Embryonic tissue of organs Retinoblastoma

Carcinoma Epithelial tissue Colorectal carcinoma

Leukemia Hematopoietic B-cell prolymphocytic

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 (blood-forming) cells leukemia

Lymphoma Lymphatic tissue Follicular lymphoma

Sarcoma Connective or supportive Osteosarcoma

tissue

Germ cell tumor Totipotent cells Testicular cancer

Characteristics of cancer cells

 Uncontrollable growth
o Grow without receiving “go” signals
o Fail to respond to “stop” signals
o Infinite number of cell division
o Fail to induce apoptosis - the process in which the body uses to get rid of unneeded
cells
 Angiogenesis
o Formation of blood vessels to promote survival of cancer cells
 Evade immune destruction
o Normal immune system: detect and destroy cancer cells
o Distinguish themselves as normal cells and become invisible to the immune system
 Invasive
o Invade adjacent tissues
o Travel to distant organs

Pathophysiology and etiology

 The transformation of a normal cell to a malignant cell is called carcinogenesis.
 Carcinogenesis happens when gene mutations cause errors in cell division.
 Process of carcinogenesis involves four stages:
o Initiation
 A carcinogen cause a genetic change or irreversibly damages the DNA in a
normal cell
 The cell is then more vulnerable to other genetic changes
 This may lay the foundation for malignant transformation

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  If the process ends here, and the cancerous cell did not grow and replicate,
cancer will not happen
o Promotion
 The initiated cell is exposed to an agent that enhances its growth into a larger
mass
 During this stage, further exposure to the carcinogen increases the likelihood
of subsequent mutation resulting in malignant transformation
o Transformation
 The normal cell is transformed into a cell with malignant potential
 The cell displays altered appearance, function and growth rate.
 The genetically damaged tumor cells are inefficient and compete vigorously
with normal cells for oxygen and nutrients.
o Progression
 A series of changes that leads to the characteristics of an undifferentiated cell.
 Uncontrollable growth of malignant tumor eventually interferes with the
function of vital organs which result in detectable and symptomatic diseases.
 It is estimated that nearly one billion malignant cells are needed to produce a 1
cm mass (about the size of a pea).
 Carcinogenesis related factors
o Chemical agents
 Examples: polycyclic hydrocarbons and arsenic
o Physical agents
 High energy radiation may damage DNA and cause cancer.
 Ionizing radiation
 Ultraviolet radiation
o Drugs and hormones
 Examples: Heroin, Cocaine, Estrogen-containing contraceptive pills
o Infection and inflammation
 Examples: Herpes simplex virus types I & II (HSV-1, HSV-2), Hepatitis B
virus (HBV), Human papillomavirus (HPV)

Grading
 The measure of its degree of differentiation which reflects how closely it resembles the
normal tissue from which it arose.
o High grade (poorly differentiated)
 Behave more aggressively, grow faster and metastasize easily.
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 o Low grade (well-differentiated)
 Resemble benign tissue so closely that it is difficult to determine whether it is
a cancer cell.

Staging
 The tumor is classified and staged based on its local, regional and distant extent.
 One common method of staging is the TNM system and it is unique for each type and
location of cancer.
 The classifications are:
o Tumor (size and location)
o Node (lymph node involvement)
o Metastasis (distant spread)

Stage Manifestations

Tumor T0 No evidence of primary tumor.

Tis Carcinoma in situ.

T1, T2, T3, T4 Increasing size and extent of the tumor.

Tx Primary tumor cannot be assessed.

Nodes N0 No nearby lymph nodes involvement

N1, N2, N3 Increasing number of lymph nodes

involvement

Nx Nearby lymph nodes are unable to be

assessed

Metastasis M0 Absence of distant metastasis

M1 Presence of distant metastasis

Mx Metastasis cannot be assessed

Cancer prevention
 Primary Prevention
o The aim is to eliminate / minimize exposure to the cause of cancer. The major
preventive measures include:
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  Lifestyle modification
 Healthy diet
 Avoid sugar drinks, salty foods, preserved foods
 Eat more of a variety vegetables, fruits, whole grains and
pulses such as beans
 Limit consumption of red meat and avoid processed meats
 Stop smoking
 Smoking increases the risk of lung, oral cavity, pharynx,
larynx, oesophagus, pancreas, urinary bladder, renal, pelvis,
nasal cavities, nasal sinuses, stomach, liver, kidney and uterine
cervix cancers.
 Limit alcohol intake
 Limit to no more than 2 drinks for men and 1 for women a day
(one drink roughly equals to 280ml of beer or 125ml of table
wine).
 Weight control
 A healthy Body Mass Index (BMI) for Asian men and women
is 18.5 - 22.9.
 Physical activity
 Being moderately active: 30 minutes a day
 For maximum health benefits: 60 minutes or more of moderate
activity each day OR 30 minutes or more of vigorous activity
daily
 Decrease exposure
 Solar radiation
 Avoid sun exposure and cover exposed skin with sunscreen
with a skin protection factor of 15 or above.
 Occupational carcinogens
 Asbestos
 Indoor air pollution
 Tobacco smoke
 Cooking fumes
 Environmental pollution
 Motor vehicle exhaust emissions
 Burning of fossil in power generation
 Chemoprevention
 Aspirin: doses of at least 75 mg daily can decrease the risk of
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 colorectal cancer.
 Tamoxifen can reduce the risk of breast cancer in women who are at
high risk by nearly 50%.
 Vitamin D may play a role in reducing the risk of breast cancer.
 Vaccination
 Cancer vaccines are medicines that belong to biological response
modifiers, which work by stimulating or restoring the immune
system’s ability to fight infections and disease. There are two broad
types of cancer vaccines:
 Prophylactic vaccine: prevent cancer from developing in
healthy people
 HPV vaccine for cervical cancer
 Hepatitis B vaccine to prevent hepatitis B infection
which will leading to liver cancer
 Therapeutic vaccine: to treat an existing cancer by
strengthening the body’s natural defenses against the cancer
 BCG live attenuated vaccine for treating early stage
of bladder cancer
 Sipuleucel-T vaccine can treat prostate cancer

 Secondary Prevention
o Secondary prevention of cancer (screening) involves the use of tests to detect a cancer
before the appearance of signs or symptoms.
o A positive result indicates increased risk for the presence of cancer.
o For a screening tool or test to be effective, it must be reliable, sensitive, and specific.
 Reliability
 One that consistently yields the same results when repeated.
 Sensitivity
 The test’s ability to detect present disease. If a test is highly sensitive,
it usually is positive when cancer is present (true-positive).
 Specificity
 The test’s ability to be negative in the absence of disease actually is
present
o General techniques
 Non-invasive techniques
 Ultrasound
 MRI
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  PET scan
 CT scan
 X-ray
 Invasive techniques
 Fine needle aspiration (FNA)
 Core needle biopsy
o Examples of screening tests for early detection

Cancer site Population Test or procedure

Colorectal Individuals aged - Annual Faecal Occult Blood Test (FOBT)

50-75 - Flexible Sigmoidoscopy (FS) every 5years
- Annual FOBT plus FS every 5 years
- Colonoscopy every 10 years

Breast Women age 40 or - Breast self-examination (BSE)

above
- Clinical breast examination (CBE)
- Mammography

Cervical Women aged 25 - Pap test

or above and ever - HPV DNA test
had sex

o Genetic test
 Approximately 5-10% of cancer is inherited.
 Genetic testing is defined as analyze DNA to identify a genetic alteration that
may indicate an increased risk for developing a specific disease.

Management
 Management of cancer varies, depending on different factors such as type of tumor, status of
patient, and patient wishes.
 Major goals of treatment:
o Cure
 Complete removal of cancer
 Goal: no evidence of cancer for 5-10 years
o Control
 Stop recurrence / metastasis of cancer
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  Goal: control the growth / spread of cancer; prolong life
o Palliation
 Provision of care / therapy for symptom relief
 Goal: provide comfort; enhance quality of life; relieve suffering
 Common treatment modalities
o Surgery, radiation therapy, chemotherapy, biological therapy, target therapy and
hormonal therapy.
 Treatment strategies
o Single therapy
o Combination therapy
 Neoadjuvant therapy
 Before primary therapy
 Adjuvant therapy
 After primary therapy
 Surgery
o Goals of surgery
 Prevention
 Removal non-vital benign or precancerous tissue
 Example: removal of precancerous polyps
 Diagnosis
 Obtain tissue necessary for the diagnosis of cancer
 Example: tissue biopsy
 Treatment
 Removal the entire tumor while maintaining functions and appearance
 Example: surgery for early stage of cancer
 Palliation
 Symptom control and relieve distress.
 Examples: neurosurgical procedures for pain control; surgery to
relieve GI or urinary obstructions.
 Adjuvant / supportive therapy
 Surgical procedures performed in addition to other treatment
modalities.
 Example: implant a vascular access device, feeding tube, tracheotomy.
 Reconstructive / rehabilitative therapy

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  To repair anatomic defects
 To improve function
 For cosmetic purpose after radical surgery
 Goal: minimize deformity and improve QOL
 Examples: Breast reconstruction - an integral part of breast cancer

o Surgical risks specific to patients with cancer

 Malnutrition
 The risk of malnutrition is common among patients with cancer due to
decreased food intake and increased energy output after treatment.
 It places patients at greater risk for complications such as anemia,
infection, pneumonia, poor wound healing, and death.
 To avoid significant weight loss, it is important to manage
preoperative and postoperative nutrition aggressively. For some
patients, nutritional supplements may need to be used.
 Blood disorders
 Blood disorders including anemia, thrombocytopenia, and leukopenia
are common to patients with Cancer.
 It may be caused by the presence of the tumor or by prior cancer
treatment.
 It can be life-threatening and must be monitored through laboratory
studies both preoperatively and postoperatively.
 Thromboembolism
 It is a risk factor associated with many cancers and results from
immobility during the postoperative period.
 High risk: Patients undergoing pelvic surgery
 Early postoperative mobility is essential for patients with cancer
undergoing surgical procedures.
 Late surgical effects
 Some surgical effects can occur within a few months after surgery
depending on the area treated and type of surgery
 Examples
 Urinary tract dysfunction
 Patient is unable to control urinary function (common
with pelvic, prostate, or bladder surgeries)
 Lymphedema
 Swelling of a limb on the operative side with associated
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 pain and risk of infection (common in patients
following mastectomy and lymph node removal)
 Sexual alterations
 Pelvic surgeries may damage critical nerve pathways
leading to pain during intercourse, erectile dysfunction,
or alteration in body image.

 Radiation Therapy
o Medical use of ionizing radiation generally for treatment of cancer with malignant
tumors.
o Goals of radiation therapy:
 To deliver a precisely measured dose of radiation to a defined tumor volume
with minimal damage to surrounding healthy tissue.
 Cure or shrink early stage cancer
 Stop cancer from recurring in another body part
 Treat symptoms caused by advanced cancer

o Principles of radiation therapy

 The radiation therapy is to give a total dose of treatment within the
therapeutic ratio.
 The therapeutic ratio is the point at which enough radiation is given to
kill cancer cells but insufficient to cause permanent damage to
normal tissue.
 The total dose of radiation is divided into small daily doses, known
as fractionation, with treatment breaks on weekends. The principles
behind fractionation strategies are called the four Rs.
 Repair
 Cancer cells are less able to repair DNA damage.
 Normal cells can repair DNA damage within 24 hours.
With successive doses, cancer cells cannot.
 Repopulation
 Regrowth of cancer cells is less efficient than normal cells.
 Cancer cells cannot repopulate as efficient as normal
cells do. Fractionation is important as it gives enough
time for normal cells to repopulate, but not enough time
for cancer cells to do so.
 Redistribution
 Cells are more sensitive to radiation during some phases of the
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 cell cycle than others.
 Interruptions in the cell cycle cause redistribution of
cancer cells, meaning more cancer cells are pushed into
division and, therefore, become more sensitive to
treatment.
 Reoxygenation
 The presence of oxygen enhances the effect of ionizing
radiation. As tumor layers are broken down by
fractionation, core cells become better oxygenated,
making them more susceptible to radiation.
 To conclude
 Fractionated RT spares normal tissues because of repair and
repopulation but increases tumor damage because of
reoxygenation and redistribution.

o Types of radiation therapy

 External-beam radiation therapy (Teletherapy)
 Most widely used
 Treatment delivered from a source outside of the body
 Administered by linear accelerators (high energy X-ray / gamma ray
machines)
 Prescribed in centiGray (cGy) or rads (1cGy=1 rad)
 Internal radiation therapy
 Sealed sources (Brachytherapy)
 Involvement of specially prepared radioisotopes directly into
or near the tumor
 Advantages
 Ability to deliver a high dose of radiation to a small
area
 Two main types
 Interstitial radiation
 The radiation is directly placed into /
next to the tumor using seeds, pellets,
wires
 Intracavitary radiation
 A container of radioactive material is
placed in a cavity of the body

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  Therapeutic Nuclear medicine
 Unsealed sources (Radiopharmaceutical therapy)
 Treating patients with drugs that contain radioactive material.
 Can be administered intravenously, orally, or by
instillation directly into a body cavity.
 Example: Iodine 131 – treatment of thyroid cancer

o Side effects of radiation therapy

 Radiation does not only kill or slow the growth of cancer cells, it can also
affect nearby healthy cells. Damage to healthy cells can result in various
side effects. The side effects depend on the part of the body that is treated.
 Treatment area and possible side effects of RT:

Treatment area Possible side effects

Brain - Fatigue - Skin changes

(radiodermatitis)
- Hair loss
(alopecia) - Headache
- Nausea and vomiting - Blurry vision
- Somnolence

Breast - Fatigue - Swelling (Edema)

- Hair loss - Tenderness
(alopecia)
- Skin changes
(radiodermatitis)

Head and neck - Fatigue - Taste changes

(Dysgeusia)
- Hair loss (alopecia)
- Throat changes, such as
- Mouth changes
trouble swallowing
(Stomatitis)
(odynophagia)
- Skin changes
- Less active thyroid
(radiodermatitis)
gland
- Xerostomia

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 Pelvis - Diarrhea
- Fatigue
- Hair loss (alopecia)
- Nausea and vomiting
- Sexual problems
- Fertility problems
- Skin changes
(radiodermatitis)
- Urinary and bladder
- changes

Stomach and - Diarrhea - Skin changes

(radiodermatitis)

 The healthy cells that are damaged by radiation can be recovered within a
few months after treatment is over. However, some patients may have side
effects that do not improve.
 Some patients may experience side effects months or years after radiation
therapy is over. These are known as late effects.
 Maybe permanent and site specific
 High dose per fraction result in more severe late effect
 E.g. fibrosis, vaginal stenosis, lymphedema, fatigue, cataracts and
secondary cancers.

Nursing care of patients receiving radiation therapy

 Nursing assessment
o Assess skin and mucous membranes for adverse effects of radiation.
o Assess gastrointestinal, respiratory, and renal function for signs of adverse
effects.
o Assess patient's understanding of treatment and emotional status.
 Nursing interventions
o Maintaining optimal skin care
 Inform the patient that some skin reaction can be expected, but that it
varies from patient to patient. Examples include dry erythema, dry
desquamation, wet desquamation, epilation, and tanning.
 Do not apply lotions, ointments or cosmetics to the site of radiation
unless prescribed.
 Discourage vigorous rubbing, friction, or scratching because this can
destroy skin cells. Apply ointments as instructed by health professionals.
 Avoid wearing tight-fitting clothing over the treatment field; prevent
irritation by not using rough fabric such as wool and corduroy.
 Take precautions against exposing the radiation field to sunlight and
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 extremes in temperature.
 Do not apply adhesive or other tape to the skin.
 Avoid shaving the skin in the treatment field.
 Use lukewarm water only and mild soap when bathing.
o Maintaining adequate nutrition
 Adequate nutrition is needed to promote healing, allows patient to
recover faster, keep up the energy, and lower risk of infection.
 To prevent malnutrition, nurses should identify those who are likely to be
at most nutritional risk and provide nutritional advice and refer dietitian.
 Nausea and vomiting are serious side effects that affect nutrition. Educate
patients on handling nausea and vomiting.
o Minimize side-effects/ symptom management
 Mouth care
 Common side effects: dry mouth, cavities, loss of taste, sore mouth
and gums, infections, jaw stiffness and jaw bone changes
 To prevent complications, mouth care is very important.
 Pain control
 Pain is a frequently occurring phenomenon in cancer patients who
undergo radiation therapy.
 This symptom is usually caused by treatment side effects (e.g. skin
reactions, mucositis).
o Medication management
 Medications may be prescribed by doctor to control side effects such as
nausea or diarrhea.
o Provide emotional support
 Provide information of what to expect during treatment.
 Show empathy.
 Encourage patient to get involved with support group and meeting other
people with cancer.
 Radiation safety and protection
o Radiation therapy is a common treatment for cancer but excessive exposure can
cause serious harm.
o Goal:
 Limit the amount of radiation exposure to “As Low As Reasonably
Achievable” (ALARA)
o There are 3 principles:
 Shielding
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  Use protective barriers between source and worker whenever
possible
 Lead shielding
 Time
 Minimize time spent near the source
 Plan the work sequence well
 Radiation workers are required to carry radiation monitoring
badge during work by law
 Distance
 Maximize distance from the source
 E.g. use of long-handled handling tools when administering
I131
o Radiation protection measures:
 Oral administration – unsealed sources
 Radioactive level in the body will gradually decrease as a result of
decay and excretion by patient
 Patient must be nursed in designated rooms until radioactivity has
decayed to a safe level
 Ensure all hospital staff and visitors are aware of radiation safety
precautions and relevant warning signs. Wear a radiation badge.
 Use gloves for handling patient’s body secretions
 Care after administration (E.g. I131)
 Radiation caution sign on door of single room
 Patient stays in single room and is encouraged to care for self
 Use disposable items such as eating utensils, cups and plates
 Non-disposable items such as equipment and lines should not
be removed from patient’s room until checked for radioactivity
 Soiled items should be placed in a plastic bag, sealed and left
in patient’s room until checked for radioactivity
 Encourage fluid intake
 Stool, urine and emesis are usually discarded in toilet in
patient’s room. Instruct patient to flush 2 or 3 times after each
use
 To deal safely and efficiently with any radioactive spillage
 Wear gloves when handling urinals, bedpans and
emesis basins
 Wash hands thoroughly with soap and water after
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 removing gloves
 Patient education and care
 Isolation is temporary and nursing staff will stay in room for
essential care only
 Instruct patient and family on procedure and visiting
restrictions
 No children and women who are or may be pregnant
 Limit time spent close to the patient as less as possible
 Instruct patient to handle I131 oral preparation with care
 Encourage large amount of fluid intake
 Double flush of toilet after each use
 To deal safely and efficiently with any radioactive spillage of
contaminated body fluids
 If skin becomes contaminated, wash with soap and
water
 If clothing becomes contaminated, check level of
activity before leaving the room
 NPO before administration as instructed to prevent vomiting
 Advice on discharge
 Ensure patient’s radioactivity level is safe before discharge
 Instruct patient on diet modification and medication
 Alert patient on possible side effect
 Avoid intimate or person contact (esp. with pregnant women
and children) and keep distance from infants.
 Educate patient/family that patient body fluids (urine,
perspiration, saliva, blood and faeces) are temporarily
radioactive, handling body fluids by others should be avoided,
to utilize universal precautions and good handwashing when
handling is necessary
 Reinforce good handwashing by patient after urinating or
defecating
 Double flush toilet after use

Chemotherapy
 A systemic therapy to prevent cancer cells from multiplying, invading adjacent tissues
or developing metastases.
 There are two terms that can tell more about the use of chemical drugs to treat cancer:
“antineoplastic”, that is to fight with the tumor and “cytotoxic”, that is to ingest
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 materials toxic to cancer cells.
 Types of chemotherapy administration
o Primary therapy
 The only treatment of the disease
o Adjuvant chemotherapy
 Administer after primary treatment to reduce the chance of recurrence
o Neoadjuvant chemotherapy
 Administer before another treatment to shrink tumor before removal or
likelihood of micrometastasis
o Palliative chemotherapy
 For symptom control and enhancement of quality of life (QoL)
 Routes of administration
o Oral
o Intravenous (IV)
o Intramuscular (IM) and subcutaneous (SC)
o Intrathecal
 Administer into the central nervous system (CNS) via the cerebrospinal
fluid by means of a lumbar puncture
 Commonly used in leukemia and lymphoma
o Intra-arterial
 Administer directly into an artery supplying an organ
 Example: hepatic artery to treat hepatic tumor
o Intracavitary
 Direct instillation of drugs into a body cavity.
 Examples: intrapleural, intraperitoneal, intravesicular, intracervical

Safety measures in handling chemotherapy drugs

 Environment
o Establish a designated hazardous drug handling area
o Use of containment devices
o Protective measures
o Personal Protective Equipment
 Gloves
 Wear gloves that are powder-free and have been tested for use with
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 hazardous drugs. Double gloves are recommended for all
handling.
 Gowns
 Wear disposable, long sleeves, tight cuffs, and back closure gown.
The inner glove should be worn under the gown cuff and the outer
glove should extend over the gown to protect the skin.
 Respirators
 Wear approved respirator mask when there is a risk of aerosol
exposure such as when administering chemotherapy or cleaning
a spill. Surgical masks do not provide adequate protection.
 Eye and face protection
 Wear a face shield and/or mask that provides splash protection
whenever there is a possibility of splashing.
 Wear PPE at the following situations:
 Preparation or mixing of chemotherapy, spiking/priming IV tubing,
administering the drug, and when handling body fluids or
chemotherapy spills.

 Storage and labeling

o Store in a location that permit appropriate temperature
o Place a label to indicate the content of the drug
o Standardize instructions regarding storage of hazardous drugs
 Transportation
o Hazardous drugs should be transported in a sealed leakproof container
o The end of the syringe should be luer-lock
o Never transport with needles in place
o A “hazardous” label should be placed on the container
o Educate transporters on hazardous risk, safety precautions and knowledge of
spill kit use

 Drug spill
o A hazardous drug spill kit should be available wherever hazardous drugs are
stored, transported, prepared or administered.
o In the event of drug spill:
 post sign to warn others
 wear personal protective measures (gloves, gown, face shield, respirator)
 contain spill with plastic-backed absorbent pad
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  pick up glass fragments by using scoop. Place glass in a puncture-proof
container
 place puncture-proof container inside a bag and seal. Double-bag all
material and label outmost bag as hazardous waste
 remove PPE and place in disposable waste bag and seal
 place all items in a puncture-proof container

 Waste and disposal

o Use universal precautions when handle the blood, emesis, excreta of patients
receiving chemotherapy and within 48 hours after treatment
o Discard gloves and gown into a leak-proof container, which should be marked as
contaminated or hazardous waste.
o Flush the toilet with the lid down
o Linens contaminated with chemotherapy or excreta from patients who have
received chemotherapy within 48 hours should be contained in specially
marked hazardous waste bags.
o At 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.
o Discard all disposable items in an appropriately labeled hazardous waste container

Adverse effects of chemotherapy

 Alopecia
o Most chemotherapeutic agents cause some degree of alopecia.
o Usually begins 2 weeks after chemotherapy
 Anorexia
o Chemotherapy changes the reproduction of taste buds.
o Absent or altered taste can lead to a decreased appetite
 Diarrhea
o Common, may occur days to weeks after treatment
o If left untreated, severe dehydration and electrolyte imbalances may result
 Nausea and vomiting
 Mucositis
o Caused by the destruction of the oral mucosa, causing an inflammatory
response.

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 o Initially presents as a burning sensation with no changes in the mucosa and
progresses to significant breakdown, erythema, and pain of the oral mucosa.
o Keep mouth moist, maintain oral hygiene and avoid irritating foods.
 Fatigue
 Neutropenia
 Anemia
 Thrombocytopenia
 Hypersensitivity Reactions

Nursing diagnoses
 Imbalanced Nutrition: Less Than Body Requirements
 Risk for Infection
 Risk for Injury
 Fatigue
 Impaired Oral Mucous Membranes
 Disturbed Body Image

Nursing care for patients who are receiving chemotherapy

 Promote nutrition
o Prevent nausea and vomiting is the goal. Administer antiemetics before
chemotherapy and on a routine schedule (not as needed).
o Be aware that anti-emetic combinations are more effective than single agents.
o Consider alternative measures for relief of anticipatory nausea, such as
relaxation therapy, imagery, and distraction.
o Encourage small, frequent meals appealing to patient preferences, but
including high calories and proteins. Provide a high-protein supplement as
needed.
o Discourage smoking and alcoholic beverages, which may irritate mucous
membranes.
o Encourage fluid intake to prevent constipation.
o Monitor intake and output, including emesis.
o Consult dietitian about patient’s food preferences, intolerances, and individual
dietary interventions.
o 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

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 Minimize fatigue
o Monitor nutritional status
o Monitor blood counts (Hb and Hct).
 Administer blood products as prescribed.
 Administer growth factors as prescribed, such as erythropoietin
o Provide patient education
 Information about fatigue.
 Reassurance that treatment-related fatigue does not mean the cancer is
worse.
 Explain that blood transfusions, if given, are a part of therapy and not
necessarily an indication of a setback.
 Suggest ways to cope with fatigue
 Encourage aerobic and strength-training exercise. Balance activity and
rest.
 Plan frequent rest periods between daily activities; take naps that do
not interrupt nighttime sleep.
 Set priorities and delegate tasks to others
 Suggest ways for effective stress management (e.g. music therapy,
meditation, relaxation therapy).
 Strengthens coping for altered body image
o Reassure patient that hair will grow back; however, it may grow back a
different texture or different color.
o Suggest wearing a turban, wig, or headscarf, preferably purchased before hair loss
occurs.
o Encourage patient to stay on therapeutic program
 Management of extravasation
o If an extravasation is suspected, stop the infusion of the chemotherapy.
o Disconnect the IV tubing and attempt to aspirate all residual chemotherapy in the
IV catheter using a small syringe.
o Remove the IV catheter.
o Assess the site and apply warm or cold packs as indicated
o Notify doctor
o Apply local care or antidote as indicated
o Apply sterile dressing
o Documentation
 Management of neutropenia
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 o Physical preparation for reverse isolation for patients with neutropenia
 Single room with toilet and washing facilities (essential furniture only,
doors should be closed all the time)
 ‘strict protective isolation’ sign posted on the door
 Not to share equipment with other patients (e.g. stethoscope, tympanic
thermometer, sphygmomanometer, oximeter etc).
 All personnel and nurses should wear masks before entering the room
 All staff should wash hands before entering the room and put on clean
cotton gowns before access to the patient
 Disposable paper hand towels and antiseptic hand cleanser should be
available inside the room
 The number of visitors and visiting time should be limited and they must
be free from infection e.g. no respiratory symptoms
o Prevention of infection
 Strict protective isolation
 Start Antibiotics treatment as early as possible
 Monitor WBC and differential count daily
 Teach the patient/family the purpose and importance of neutropenic
precautions e.g. proper handwashing
 Monitor vital signs, promptly inform doctor when the patient is fever
 Observe for respiratory symptoms (e.g. breathing sounds, RR, presence of
cough, sputum or dyspnea)
 Assess neurological status as changes of CNS status are often impending
sepsis
 Assess genitor-urinary function e.g. dysuria, cloudy urine and hematuria
 Assess for skin breakdown, lesions or rashes
 Use strict aseptic techniques for all invasive procedures
 Inspect IV isite of s/s of phlebitis
Biological therapy
 Any substance that is able to alter the immune system with a stimulatory /
suppressive effect. It is also named as ‘biologic response modifier’,
‘immunotherapy’.
 The goal is to produce anti-tumor effects through the action of natural host defense
mechanisms. It alters the immune system with either stimulatory or suppressive effects.
 Include immunotherapy, targeted therapy and hormonal therapy
o Immunotherapy
 Cytokines
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  Cytokines are soluble proteins produced by lymphocytes and
monocytes that have regulatory actions on other cells in the
immune system.
 Examples: interferons
 Antibody therapy
 Monoclonal antibodies work on cancer cells in the
same way natural antibodies work, by identifying and binding to
the target cells. They then alert other cells in the
immune system to the presence of the cancer cells.
 Promotes targeting cells through antibody-antigen response
o Targeted therapy
 Definition
 Uses drugs to identify and attack specific cancer cells.
 Focus on pathways & proteins involved in the signaling process.
 Inhibit the signaling processes for the tumor to growth, invasion and
metastasis
 Benefits of targeted therapy
 More effective
 Less treatment-related side effects
 Improved QoL
 Types of targeted therapy
 Monoclonal antibodies (e.g., cetuximab)
 Intracellular signal transduction inhibitors (e.g. Gefitinib)
 Angiogenesis inhibitors (e.g. Sunitinib)
 Side effects of targeted therapy
 Allergic/ hypersensitivity reaction
 Acne-like rash
 Bleeding
 Hypertension
 Erythema
o Hormonal therapy
 Therapy that blocks the activity of the hormone in the targeting cell
 Drug therapy directed against hormone receptors on cancer cells.
 Drugs that change the ability of hormone-dependent cancers to
continue to divide.
o Often used together with surgery and or radiation therapy and/or chemotherapy
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 o Commonly used in the treatment of breast, prostate, endometrial and ovarian
cancers.
o Types of hormonal therapy
 Antiestrogens (e.g. Tamoxifen to treat breast cancer)
 Antiandrogens (e.g. Eulexin to treat prostate cancer)
 Adrenocorticorsteriods

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