Pharmacology

STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR

Session 6

LESSON TITLE: ANTINEOPLASTIC/ ANTI-CANCER DRUGS Materials:

LEARNING OUTCOMES: Notebook, Pharmacology book, Drug handbook
pens & paper
At the end of the lesson, the nursing student can:

1. Describe the nature of cancer and changes the body

undergoes when cancer occurs; References:
2. Differentiate cell- cycle specific and cell-cycle non- Kee, Joyce LeFever, Hayes, Evelyn R. &
specific drugs; McCuistion E. Pharmacoloy A Nursing
3. Identify nursing interventions and client education Process Approach 6th edition.. Singapore:
guidelines for administering chemotherapy; Elsevier Saunders Company.
4. Enumerate ways the nurse can avoid absorption of
chemotherapeutic agents; and,
5. Develop a drug study guide . (therapeutic action,
indication, contraindication, most common adverse
reaction And nursing responsibility ) of antineoplastic
drugs.

LESSON REVIEW/ PREVIEW OR HOOK ACTIVITY (5 minutes)

EVERYBODY WRITES .
What are changes the body undergoes when cancer occurs?

MAIN LESSON (50 minutes)

CANCER
Cancer: is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the
body.

Types of Cancer
• Carcinoma is a cancer that starts in the skin or the tissues that line other organs. These are most commonly
diagnosed cancers
• Sarcoma is a cancer of connective tissues such as bones, muscles, cartilage, and blood vessels.
• Leukemia is a cancer of bone marrow, which creates blood cells.
• Lymphoma and myeloma are cancers of the immune system.
• Melanoma are cancers that arise in the cells that make the pigment in the skin

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 ANTINEOPLASTIC AGENTS

• comprise one aspect of chemotherapy. These drugs act on and kill altered human cells. While their action is
intended to target abnormal cells, normal cells are also affected. These drugs can work by affecting cell survival or
by boosting the immune system in its efforts to combat the abnormal cells.

Neoplasm Cancer—Mechanisms of Growth

a. Anaplasia : Cancerous cells lose cellular differentiation and organization and are unable to function normally
b. Autonomy : Cancerous cells grow without the usual homeostatic restrictions that regulate cell growth and control. This
allows the cells to form a tumor
c. Metastasis: Cancer cells travel from the place of origin to develop new tumors in other areas of the body
d. Angiogenesis : Abnormal cells release enzymes to generate blood vessels and supply oxygen and nutrients to the
cells, generating growth. Cancerous cells rob the host cells of energy and nutrients and block normal lymph

The Body’s Immune System Response to Cancerous Cells

• Can damage or destroy some neoplastic cells
• T cells recognize the abnormal cells and destroy them
• Antibodies form in response to parts of the abnormal cell protein
• Interferons and tissue necrosis factor (TNF) play a role in the body’s attempt to eliminate the abnormal cells

Possible Causes of Cancer

• Genetic predisposition
• Viral infection
• Constant irritation and cell turnover
• Stress
• Lifestyle factors
• Environmental factors

Classifications of Tumors
• Solid tumors
▪ May originate in any body organ
▪ Carcinomas (originate in epithelial cells)
▪ Sarcomas (originate in the mesenchyma)
• Hematologic malignancies
▪ Leukemias and lymphomas that occur in the blood-forming organs

Medical management of cancer includes the use of chemotherapy. First used in the early 1950s, there are now more than
80 effective drugs available.
Chemotherapy is method of choice when there is suspected or confirmed spread of malignant cells.

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Goal of Cancer Treatment
• To destroy cancer cells using the following methods:
o Surgical removal
o Stimulation of the immune system to destroy them
o Radiation therapy to destroy them
o Drug therapy to kill them during various phases of the cell cycle

Mechanism of Action
• Functions at cellular level by interrupting cell life—modifies or interferes with DNA synthesis.
• Chemotherapeutic agents eradicate cells, both normal and malignant, that are in the process of cell
reproduction.

Drug Classification
Drugs classified by group into those that act on a certain phase of cell reproduction (cell cycle specific) or those that do
not reproduce (cell cycle nonspecific).

A. Cell cycle–specific agents: antimetabolites and mitotic inhibitors.

• Act on the cell during a particular phase of reproduction.
• Most effective in tumors where a large number of cells are dividing.
• Divided doses produce greater cytotoxic effects (not all cells will be in the same phase at the same time).
• Antimetabolites.
a. Specific for the S phase—replaces building blocks of DNA so cell can’t divide.
b. Examples of antimetabolites: Trexall (methotrexate), Purinethol (6-mercaptopurine), Adrucil (5-fluorouracil),
Vidaza (azacitidine), Cytosar-U (cytarabine), Hydrea (hydroxyurea).
• Plant alkaloids.
a. Specific for the M phase—prevent cell division by destroying the mitotic spindle.
b. Examples of mitotic inhibitors: plant alkaloids—Oncovin (vincristine), Eldisine (vindesine), Velban (vinblastine),
Vumon (teniposide).

B. Cell cycle–nonspecific drugs: alkylating agents, antitumor antibiotics, and nitrosoureas.

• Act on cells during any phase of reproduction— some drugs will attack cells in the resting phase (not actively
dividing).
• Agents are dose dependent—the more drug given, the more cells destroyed.
• These drugs are more toxic to normal tissue because they are less selective.
• Alkylating agents
a. These drugs prevent cell division by damaging the DNA “ladder” structure and are effective in all phases of the
cell cycle.
b. Included in almost all chemotherapy regimens.
c. Examples of alkylating agents: Cytoxan (cyclophosphamide), Myleran (busulfan), Alkeran (melphalan [L-PAM]),
Thioplex (thiotepa), Platinol (cisplatin).
• Antitumor antibiotics.
a. These drugs attack DNA (they act like alkylating drugs) by slipping between the DNA strands and preventing
replication.
b. Examples of antitumor antibiotics: Adriamycin (doxorubicin), Cosmegen (dactinomycin).
• Nitrosoureas.
a. Alkylating agents that are stronger and have a greater ability to attack cells in the resting phase of cell growth.
b. These drugs can cross the blood–brain barrier.
c. Examples of nitrosoureas: Zanosar (streptozocin), semustine (methyl-CCNU), Gliadel (carmustine or BCNU),
azacitidine (chlorozotocin or DCNU).

C. Other miscellaneous agents (such as Matulane [procarbazine]) are used in the chemotherapy group, but their exact
mechanism of action is unknown.

D. Hormonal agents (estrogens, androgen, progestins) work in all cycles and are used in therapy to affect the hormonal
environment (Decadron [dexamethasone], DES, Halotestin [fluoxymesterone], Nolvadex [tamoxifen], Deltasone
[prednisone]).
• Affect the growth of hormone-dependent tumors.
• Steroids interfere with the synthesis of protein and alter cell metabolism (lymphomas and leukemias).

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 • Antihormones (Nolvadex and Evista [Raloxifene]) block tumor growth by depriving the tumor of the necessary
hormones.

E. Combination chemotherapy.
• Most often administered in combination, which enhances the response rate: for example, Adriamycin,
Blenoxane (bleomycin), Velban, and dacarbazine (ABVD) used for Hodgkin’s lymphoma.
• Studies at Stanford University now suggest ABVD and a fifth or sixth chemotherapy drug be combined with
Deltasone (for its antiinflammatory effect) for 3 months for Hodgkin’s disease.
• Cancer cells divide erratically on different schedules; thus drugs that are effective alone and have different
mechanisms of action can combine to destroy even more cells.
• Drugs used in combination for synergistic activity.
• Guidelines for drug administration are carefully planned and referred to as protocols or regimens.
a. Package inserts are based on single-agent therapy, so it is important to adhere to the ordered protocol.
b. Dosages of drugs are based on height and weight calculated as body surface area.

F. Other chemotherapeutic agents that do not fall into specific categories.

• Elspar (asparaginase)—an enzyme used to treat lymphocytic leukemia; Eulexin (flutamide)—antiandrogen used
to treat prostate cancer; and Taxol (paclitaxel)—used to treat ovarian, breast, and cell lung cancers.
• Chemotherapeutic drugs cause myelosuppression; nursing interventions include blood counts and instituting
precautions if blood count falls below normal, and assess for infection.

Goals of Treatment
A. The major goal is to cure the malignancy.
• Chemotherapy, as primary mode of treatment, may include curing certain malignancies such as acute
lymphocytic leukemia, Hodgkin’s disease, lymphosarcomas, Wilms’ tumor.
• Cure may also occur in combination with other modes of treatment, radiation, or surgery.
B. Control may be the goal when cure is not realistic; the aim is to extend survival and improve the quality of life.
C. Palliation may be the goal when neither cure nor control may be achieved; this goal is directed toward client
comfort.

Chemotherapeutic Administration
A. Chemotherapeutic agents are administered through a variety of routes.
• Oral route—used frequently. Safety precautions must be observed.
• Intramuscular and subcutaneous used infrequently, as drugs are not vesicants.
• Intravenous is the most common route—provides for better absorption.
a. Potential complications: infection, phlebitis.
b. Prevention of complications: Use smallest gauge needle possible; maintain aseptic technique; monitor
intravenous (IV) site frequently; change IV fluid every 4 hours.
• Central venous catheter infusion—used for continuous or intermittent infusions.
a. Potential complications: infection, catheter clotting, sepsis, malposition of needle.
b. Prevention of complications: Maintain aseptic technique and monitor site daily; flush catheter daily and
between each use with heparin solution; assess client for signs of sepsis.
• Venous access devices (VADs)—used for prolonged infusions.
a. Potential complications: infection and infiltration from malposition.
b. Assess site frequently and assess for systemic infection.
• Intra-arterial route—delivers agents directly to tumor in high concentrations while decreasing drug’s systemic
toxic effect.
a. Potential complications: infection or bleeding at catheter site, catheter clotting,or pump malfunction.
b. Change dressing site daily and assess for signs of infection; irrigate catheter with heparin solution and avoid
kinks in tubing.
• Intraperitoneal—used for ovarian and colon cancer. High concentration of agents delivered to peritoneal cavity
via catheter, then drained.
• Other less frequently used routes are intrapleural, intrathecal, and ventricular reservoir.
B. Factors for deciding dosage and timing of drugs.
• Dosage calculated on body surface area and kilograms of body weight.
• Time lapse between doses to allow recovery of normal cells.
• Side effects of each drug and when they are
likely to occur.
• Liver and kidney function, as most antineoplastics are metabolized in one of these organs.

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Chemotherapy Safety Guidelines
A. Antineoplastic drugs are potentially hazardous to personnel and may have teratogenic and/or carcinogenic effects.
B. Safety guidelines have been issued by the Occupational Safety and Health Administration (OSHA).
• Obtain special training for drug administration.
• Use two pairs of powder-free, dispensable chemotherapy gloves, and a disposable, closed, long-sleeved gown
with outer pair of gloves covering gown cuff whenever there is risk of exposure to hazardous drugs.
• Provide syringes and IV sets with Luer lock fittings for preparing and administering hazardous drugs. Also
provide containers for their disposal.
• Use a closed-system drug-transfer device and needleless system to protect nursing personnel during drug
administration.
• Label all prepared drugs appropriately.
• Double-bag chemotherapy drugs once prepared, before transport.
• Have equipment ready to clean up any accidental spill (spill kit).
• Dispose of all materials in marked containers labeled hazardous waste.
• Dispose of all needles and syringes intact.
• Follow facility’s policies and procedures when preparing to administer chemotherapy.
• Double-check chemotherapy orders with another oncology nurse.
• Read material safety data sheets (MSDS) prior to administration.
• Use personal protective equipment (PPE).
• Wash your hands both before you put on and after you take off gloves.
• After infusion is complete, promptly dispose of any equipment that contained the drug in a puncture-proof
container that is clearly marked.
• Chemotherapy agents may be excreted in body fluids; these may be contaminated for 48 hours after the last
drug dose. Wear PPE when handling such excreta, and wash your hands after removing gloves.
• Check facility’s policies about handling linen that’s been contaminated with chemotherapy.
• If a chemotherapy drug comes into contact with your skin or a client’s skin, thoroughly wash the affected area
with soap and water, but don’t abrade the skin with a scrub brush.
• If the drug gets in your eyes, flush with copious amounts of water for at least 15 minutes while holding back
your eyelids. Then get evaluated by employee health or the emergency department (ED).
C. When infusing vesicant drugs, monitor IV carefully—at first sign of extravasation, remove IV and implement Rx
protocol.

Side Effects and Nursing Management

A. Side effects occur primarily due to the mechanism of action of potent drugs on normal cells.
• Normal cells most affected are bone marrow cells, epithelial cells of the gastrointestinal (GI) tract and hair
follicles, and cells of the gonads.
• Since other normal cells are not actively reproducing (except with tissue injury and repair), they are not
severely affected.
• Time of most severe depression of cells (termed nadir) is different for each type of cell.
B. Skin and mucosa, protective linings of the body, are damaged.
• Mucositis (cells of the mucosa are affected)—may extend from oral cavity and stomach through GI tract.
a. Symptoms may be nausea, vomiting, anorexia, fluid and electrolyte imbalance, dietary insufficiency, and
stomatitis.
b. Assess for erythema, tenderness, and ulceration.
• Clients at high risk are those with dental caries, those with gum disease, smokers, and those who drink
alcohol.
• Nursing interventions include good oral hygiene with soft toothbrush, mouthwashes (viscous Xylocaine
[lidocaine]), avoiding foods that are hot, sharp, spicy, or acidic—diet should be soft, bland, tepid.
C. Alopecia, or hair loss, caused by damage to rapidly dividing cells of the hair follicles.
• Hair loss begins 2–3 weeks after chemotherapy and continues through the cycles of chemotherapy; regrowth
occurs following the course of therapy.
• Nursing interventions include scalp hypothermia (ice cap) and scalp tourniquet; both reduce the amount of
drug reaching the hair follicle and may prevent hair loss.
D. Nausea, vomiting, and anorexia are common in clients receiving chemotherapy.
• Antiemetic regimens (Reglan [metoclopramide], Zofran [ondansetron]) may counteract these symptoms.
• Nursing interventions include supporting changes in food preferences, additional or less seasoning, small and
more frequent high-calorie, high-protein meals.
• Offer high-calorie and protein supplements.

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E. Elimination disturbance occurs when the client does not eat well, is not exercising, or has mucositis.
• Diarrhea is related to toxicity of the drugs on the mucosal lining and can quickly cause fluid volume deficit; diet
bland and low residue.
• Constipation may be related to the drugs (especially Velban and Oncovin) that affect nerve endings in the GI
tract.
a. Add more fiber and liquid to diet (3000 mL/day).
b. Avoid milk and dairy products.
c. Include low-residue foods and foods high in potassium.
d. Stool softeners are ordered to minimize constipation; may add vegetable laxative.
F. Elevated uric acid and crystal urate stone formation may occur.
G. Hematological disruptions: Damage to normal cells in the bone marrow can be life-threatening and is, therefore, the
most dangerous side effect.
• White blood cells (WBCs) and platelets have a shorter life span than red blood cells so they are more
susceptible to damage.
• White blood cell suppression—leukopenia (less than 5000/mm3 when normal white blood cell count is 5000–
10,000/mm3).
a. Granulocytes are the most suppressed, which places client at risk for bacterial infection.
b. Common sites of infection are the lung, urinary tract, skin, and blood.
c. Implementation includes meticulous aseptic technique for IV therapy as well as hand hygiene; avoid
exposure to infected persons.
d. Assess for fever, chills, and sore throat.
e. Teach signs and symptoms of infection to the cancer client with instructions to report symptoms to the
doctor or nurse.
f. Medications may be given to stimulate the production of WBCs, e.g., Neupogen (filgrastim).
• Platelet suppression to below normal (less than 150,000 mm3) is called thrombocytopenia.
a. A number less than 50,000/mm3 makes the client susceptible to bleeding gums and/or nose, easy bruising,
heavier menstrual flow, etc.
b. Teach client precautions: soft toothbrush, avoidance of douches and enemas, care with trimming nails,
avoiding venipunctures when possible, and avoidance of any activity that might increase intracranial pressure
(ICP).
• Red blood cell suppression—anemia is not usually a severe toxicity.
H. All hormonal agents cause fluid retention: Monitor weight gain, intake and output (I&O), edema, and administer
diuretics as ordered.

Nursing Considerations

Nursing Assessment
These are the important things the nurse should include in conducting assessment, history taking, and examination:
• Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal impairment, bone
marrow suppression, pregnancy and lactation, etc.) to prevent any untoward complications.

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 • Perform a thorough physical assessment (other medications taken, orientation and reflexes, vital signs, bowel
sounds, etc.) to establish baseline data before drug therapy begins, to determine effectiveness of therapy, and
to evaluate for occurrence of any adverse effects associated with drug therapy.
• Monitor result of laboratory tests such as CBC with differential to identify possible bone marrow suppression
and toxic drug effects and establish appropriate dosing for the drug; and liver and renal function tests to
determine need for possible dose adjustment and identify toxic drug effects.

Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of these drugs for therapy:
• Acute pain related to GI, CNS, and skin effects of the drug
• Disturbed body image related to alopecia, skin effects, and impaired fertility
• Anxiety related to diagnosis
• Risk for infection related to bone marrow suppression

Implementation
These are vital nursing interventions done in patients who are taking alkylating agents:
• Arrange for blood tests before, periodically during, and for at least 3 weeks after therapy to monitor bone
marrow function to aid in determining the need for a change in dose or discontinuation of the drug.
• Administer medication according to scheduled protocol and in combination with other drugs as indicated to
improve effectiveness.
• Ensure that patient is well hydrated to decrease risk of renal toxicity.
• Protect the patient from infection; limit invasive procedures when bone marrow suppression limits the patient’s
immune/inflammatory responses.
• Provide small, frequent meals, frequent mouth care, and dietary consultation as appropriate to maintain
nutrition when GI effects are severe.
• Arrange for proper head covering at extremes of temperature if alopecia occurs; a wig, scarf, or hat is
important for maintaining body temperature.
• Plan for rest periods because fatigue and weakness are common effects of the drug.

Evaluation
Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:
• Monitor patient response to therapy (alleviation of cancer being treated, palliation of signs and symptoms of
cancer).
• Monitor for adverse effects (bone marrow suppression, GI toxicity, neurotoxicity, and alopecia, renal or hepatic
dysfunction).
• Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse
effects to watch for.
• Monitor patient compliance to drug therapy.

CHECK FOR UNDERSTANDING (30 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct rationalization. Superimpositions or erasures in you answer/ratio is not
allowed. You are given 25 minutes for this activity:

Multiple Choice

1. Chemotherapy dosing is usually based on the total body surface. What should the nurse do before administering
chemotherapy?
a. Get the body mass index (BMI).
b. Ask the client about intake and output.
c. Weigh and measure the height of the patient on the day of administration.
d. Ask the client for the height and weight.
ANSWER: C
RATIO: Weigh and measure the height of the patient on the day of administration should the nurse do before administering
chemotherapy.

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2. The nurse is caring for of a client who is receiving a chemotherapy. Which of the following would be expected as a result
of the massive cell destruction that occurred from the chemotherapy?
a. Leukopenia.
b. Anemia.
c. Thrombocytopenia.
d. Hyperuricemia.
ANSWER: D
RATIO: Hyperuricemia would be expected as a result of the massive cell destruction that occurred from the chemotherapy.

3. Mitomycin (Mutamycin) is prescribed to a client with colorectal cancer. All of which are the routes of administration,
except?
a. Oral
b. Intravenous
c. Intravesical
d. Intraarterial
ANSWER: A
RATIO: Except oral route, is not a route of administration of Mitomycin.

4. The client with a testicular cancer is being treated with Etoposide (Etopophos). Which of the following side effect is
specifically associated with this medication?
a. Chest pain
b. Edema
c. Alopecia
d. Orthostatic hypotension
ANSWER: D
RATIO: Orthostatic hypotension side effect is specifically associated with Etoposide.

5. The clinic nurse provides instructions to a client receiving an antineoplastic medication. When implementing the plan,
the nurse tells the client to?
a. To drink beverages containing alcohol in moderate amount during the evening.
b. To avoid hot foods and high fiber rich foods.
c. To take acetylsalicylic acid as needed for headache.
d. To consult with health care providers before receiving immunization.
ANSWER: D
RATIO: The nurse tells the client to consult with health care providers before receiving immunization. _

6. The nurse is providing teachings to a client receiving cyclophosphamide (Cytoxan). The nurse tells the client to which
of the following?
a. Eat foods rich in potassium.
b. Increase fluid intake to 2-3 liters per day.
c. Take the medication with food.
d. Eat foods rich in purine.
ANSWER: B
RATIO: The nurse tells the client to increase fluid intake to 2-3 liters per day.

7. The nurse is monitoring a patient receiving an Iv infusion of an antineoplastic medication. During the infusion, the patient
complains of pain and redness at the insertion site. The nurse should take which actions? Select all that apply.
a. Reinsert the IV at a distal part of the same vein.
b. Increase the flow rate of the medication.
c. Notify the physician.

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d. Apply a heat or ice compress to the site.
e. Administer an antidote as prescribed.
ANSWER: C, D, E
RATIO: The nurse should take the action, notify the physician, apply a heat or ice compress to the site, and administer an
antidote as prescribed.

8. The nurse is caring for a client receiving chemotherapy when an anaphylactic reaction occurs from the medication. The
nurse should take which actions? Select all that apply.
a. Stop the medication.
b. Remove the IV line.
c. Administer Oxygen.
d. Administer epinephrine.
e. Positioned the client in a reverse Trendelenburg position.
ANSWER: A, C, D
RATIO: The nurse should take these actions: stop the medication, administer oxygen, and administer epinephrine.

9. The nurse is caring for a client who is receiving Fluorouracil (Adrucil). Which of the following symptoms would
necessitate the nurse to immediate discontinuation of the medication?
a. Palmar-plantar erythrodysesthesia.
b. Ataxia.
c. Constipation.
d. Insomnia.
ANSWER: B
RATIO: Ataxia symptom would necessitate the nurse to immediate discontinuation of the medication.

10. Nausea and vomiting are frequent adverse effects associated with antineoplastic therapy. What should the nurse advise
clients experiencing these unpleasant adverse effects?
a. Increase intake of dry or high-fiber foods, and foods that have a rough texture.
b. Consider relaxation techniques because these symptoms should improve over time.
c. Use antacids to relieve the irritation to the stomach, which should stop the nausea.
d. Try to maintain hydration and nutrition, which are very important during treatment.
ANSWER: D
RATIO: Try to maintain nutrition and hydration, which are very important during treatment should the nurse advise clients
experiencing these unpleasant adverse effects.

GUIDED / RATIONALIZATION ACTIVITY (15 minutes)

Your instructor will now rationalize the answers to you and to your classmates. Pay attention. You can now ask questions
and debate among yourselves for (ten) 10 minutes. Write the correct answer and correct/additional ratio in the space
provided.

1. ANSWER:
RATIO:

2. ANSWER:
RATIO:

3. ANSWER:
RATIO:

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4. ANSWER:
RATIO:

5. ANSWER:
RATIO:

6. ANSWER:
RATIO:

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10. ANSWER:
RATIO:_

LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

I CARE WHY? (5 minutes)

In three sentences explain relevancy of the concept to your life or how you might use it. State ways on how to prevent
cancer.

For next session, review Anti- Inflammatory Drugs, Vaccines & Sera

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