San Lorenzo College of Ormoc, Inc.

Brgy. San Pablo, Ormoc City

COLLEGE OF NURSING

RELATED LEARNING
EXPERIENCE
NCM 118
PERAPARING
CHEMOTHERAPEUTIC DRUGS
Reporters:

Bernal, Verna Mae

Cala, Vanessa Mae
Cu, Ma. Trisha Tanya
Palmitos, Peter
Payot, Bianca Romelle Stephanie
Rufin, Joymae
Villarta, Sheren
After 8 hours of classroom discussion and demonstration, the Level IV students will be
able to:

1. Define the following terms:

1.1 Chemotherapy- the use of medications to kill tumor cells by interfering with cellular
functions and reproduction .
1.2 Radiation - is the transfer of heat to another object of lower temperature situated at
a distance.

1.3 Metastasis - spread of cancer cells from the primary tumor to distant site.

1.4 Proliferation - the growth or production of cells by multiplication of parts.

1.5 Benign- not cancerous, benign tumors may grow but are unable to spread to other
organs or body part.

1.6 Malignant- having cells or processes that are characteristics of cancer.

1.7 Neoplasm- an abnormal mass of tissue ,the growth of which exceeds and is
uncoordinated with that of normal tissue and persist in the same excessive manner
after cessation of the stimulus which evoked the change.

2. Review the anatomy and physiology of the normal cell cycle

The cell cycle can be thought of as the life cycle of a cell. In other words, it is the
series of growth and development steps a cell undergoes between its “birth”—formation
by the division of a mother cell—and reproduction—division to make two new daughter
cells. In eukaryotic cells, or cells with a nucleus, the stages of the cell cycle are divided
into two major phases: interphase and the mitotic phase.
 During interphase, the cell grows and makes a copy of its DNA.
 During the mitotic phase, the cell separates its DNA into two sets and divides its
cytoplasm, forming two new cells.

Interphase has three sub phases:

  G1 phase – it is also called the first gap phase, the cell grows physically larger,
copies organelles, and makes the molecular building blocks it will need in later
steps.
 S phase - the cell synthesizes a complete copy of the DNA in its nucleus. It also
duplicates a microtubule-organizing structure called the centrosome. The
centrosomes help separate DNA during M phase.
 G2 phase – the second gap phase. The cell grows more, makes proteins and
organelles, and begins to reorganize its contents in preparation for mitosis. G 2
phase ends when mitosis begins.

In the mitotic phase or mitosis, the nuclear DNA of the cell condenses into visible
chromosomes and is pulled apart by the mitotic spindle, a specialized structure made
out of microtubules. Mitosis takes place in four stages: prophase (sometimes divided
into early prophase and prometaphase), metaphase, anaphase, and telophase.
3. State the purpose of chemotherapy
 to keep cancer from spreading
 to slow the cancer growth enough to make surgery to remove the cancer
possible
 to destroy or shrink down the cancer cells
 to reduce the chances of the cancer coming back

4. Discuss the different types of chemotherapy

 Intravenous (IV) chemotherapy - Many drugs require injection directly into a

vein. This is called intravenous or IV chemotherapy. Treatment takes a few
minutes to a few hours. Some IV drugs work better if you get them over a few
days or weeks. You take them through a small pump you wear or carry. This is
called continuous infusion chemotherapy.

 Oral chemotherapy - Oral chemotherapy is taken by mouth. This can be as a

pill, capsule, or liquid. Oral treatments for cancer are now more common. Some
of these drugs are given daily, and others are given less often.
  Injected chemotherapy - This receiving chemotherapy as a shot. The shot may
be given in a muscle or injected under the skin. These shots may be made in the
arm, leg, or abdomen.

 Intra-arterial or IA chemotherapy - An artery is a blood vessel that carries

blood from your heart to another part of your body. Sometimes chemotherapy is
injected into an artery that goes directly to the cancer.

 Chemotherapy into the peritoneum or abdomen – medications are directly

placed in the abdomen. This type of treatment works for cancers involving the
peritoneum. The peritoneum covers the surface of the inside of the abdomen and
surrounds the intestines, liver, and stomach. Ovarian cancer is one type of
cancer that frequently spreads to the peritoneum.

 Topical chemotherapy - Some types of chemotherapy come as a cream that is

put on the skin.

5. identify the indications and contraindications of chemotherapy

INDICATIONS OF CHEMOTHERAPY:
 Control
 Cure
 Palliation (benefit > side effects)

CURATIVE CHEMOTHERAPY
Adjuvant chemotherapy Neoadjuvant chemotherapy
 To treat micro metastatic event  organ preserving treatments: alone
 No evidence of cancer or with radiotherapy
 to decrease the extent of surgery
Aim: decrease relapse rate; increase
survival

PALLIATIVE CHEMOTHERAPY
Aims:
 Palliation (benefit > side effects
 Increase survival

Indications:
 metastatic colon cancer
 metastatic lung cancer
 metastatic breast cancer
CONTRAINDICATIONS OF CHEMOTHERAPY
 when facilities are inadequate to evaluate response, to monitor and manage toxic
reaction
 patients who are not likely to survive even if tumor shrinkage could not be
accomplished
 patients who are not likely to survive enough to obtain benefits
 patients who are asymptomatic with slow growing, incurable tumors, in which
case chemotherapy should be postponed until symptoms require palliation

6. differentiate the different classifications of chemotherapeutic agents

1. Alkylating agents - are most effective when a cancer cell is its resting phase
and not actively dividing

2. Antimetabolites – are drugs that have chemical structures similar to those of

various natural metabolites that are necessary for the growth and division of
rapidly growing neoplastic cells and normal cells. They inhibit DNA production in
cells that depend on certain natural metabolites to produce their DNA.

3. Antineoplastic antibiotics – these drugs tend to be more toxic to cells that are
multiplying rapidly and are more useful in the treatment of certain cancers.
Although selective to bacterial cells, they are also toxic to human cells.

4. Mitotic inhibitors - are drugs that kill cells as the process of mitosis begins.
These cell cycle-specific agents inhibit DNA synthesis.

5. Hormones and Hormone Modulators – are receptor site specific or hormone

specific to block the stimulation of growing cancer cells that are sensitive to the
presence of a particular hormone.

6. Cancer Cell-Specific Agents – these drugs would not have devastating effects
on healthy cells in the body and would be more effective against particular
cancer cells

7. Miscellaneous Antineoplastics- these drugs are used for treating a wide

variety of cancers. Many other agents thar do not fit into one of the previously
discussed classifications that are used as antineoplastics to cause cell death

8. Topoisomerase inhibitors - act by weakening the structure of a cancer cell that

is necessary for it to divide.

9. Antineoplastic Adjunctive Therapy – antineoplastic agents used in conjunction

with another treatment modality
SOURCE: Focus on Nursing Pharmacology 7th ed. By Amy Karch;
Hinkle, J., Cheever, K. “Brunner and Suddarth’s Textbook of Medical-Surgical Nursing”,
14th edition

7. explain the guidelines in preparation and administration of chemotherapeutic

drugs

 Only properly trained personnel should handle cytotoxic drugs

 Personnel preparing the drugs should wear PPE
 Review the chemotherapy drugs prescription which should have
 name of anti-neoplastic agent
 dosage
 route of administration
 date and time that each agent to be administered
  Determine the method of preparation, any calculations, fluids, diluents or other
supplies needed prior to getting under the bio-safety hood or CACI
 When preparing chemotherapy, be sure to use good aseptic technique at all
times
 Use the appropriate closed system transfer device. It is safer and will make the
preparation easier.
 Pre-medications and pre-hydrations should always be prepared first
 Syringes and and IV bottles containing cytotoxic agents should be labeled and
dated

Safety in Handling Chemotherapy for Health Care Providers

 When preparing compounding, reconstituting) chemotherapy fer administration,
use the following safety equipment to prevent exposure through inhalation, direct
contact, and ingestion:
 Class or biological safety cabinet (BSC)
 Closed system transfer devices . Puncture and leak-proof containers, IV bags
 Needleless systems (.e., IV tubing and syringes)

 If BSC is not available when preparing chemotherapy for administration, use the
following safety equipment to minimize exposure:
 Surgical N-95 respirator to provide respiratory and splash protection
 Eye and face protection (both face shield and goggles) working at or above
eye level or cleaning a spill

 When preparing or administering chemotherapy or handling Iinens and other

materials contaminated with chemotherapy or blood and body fluids of patients
receiving chemotherapy. wear the following for personal protection:
 Double layer of powder-free gloves specifically designated for
chemotherapy handling (the inner glove is worn under the gown cuff and
the outer glove is worn over the cuff)
 Long sleeve, disposable gowns (without seams or closures that can allow
drug to pass through) made of polyethylene coated polypropylene or other
laminate materials
 Linens contaminated with chemotherapy or blood and body fluids of patients
receiving chemotherapy should be placed in the following:
 Closed-system, puncture- and leak-proof containers labeled “hazardous:
chemotherapy contaminated linens”.
 Above referenced container maintained in the infusion center soiled utility
room for outpatient settings
 Above referenced container maintained in the patient room and/or soiled
utility room for inpatient settings
 Chemotherapy preparation equipment (.e., syringes, tubing. empty vials, etc.),
gowns, and gloves should be disposed of in: • Closed-system, puncture- and
leak-proof containers labeled "hazardous: chemotherapy contaminated waste"
 Wash hands with soap and water after removing gloves used to prepare or
administer chemotherapy or clean contaminated linens and other materials.
  Spill kits with the appropriate gowns, gloves, disposable absorbent materials for
cleansing large areas, and hazard sign should be kept in all areas where
chemotherapy is prepared and given.
 Implement a quality improvement program addressing safe chemotherapy
handling that includes the following:
 Standard operating policies and procedures for:
 Chemotherapy handling, preparation, and disposal
 Handling and disposal of chemotherapy spills
 Handling and disposal of blood and body fluids and contaminated
materials of patients receiving chemotherapy
 Conduct competency-based education, training, and performance
evaluations regarding chemotherapy safety procedures at orientation
and at subsequent regular intervals.
 Medical monitoring program to identify indicators of exposure
 Root cause analysis for all chemotherapy spills and exposure incidents

Source: Hinkle, J., Cheever, K. “Brunner and Suddarth’s Textbook of Medical-Surgical

Nursing”, 14th edition

8. discuss the nursing roles and responsibilities in the management of common

side effects of chemotherapy
 System Nursing Intervention
General

- Fatigue - Encourage patient to take plenty

of rest
- Eat a regular balanced diet that
includes protein.
- Avoid doing tasks that requires
strength
- Light exercises.

- Pain - Assess for pain – source, type and

intensity

Hematopoietic System

- Myelosuppression (leukopenia, - Assess for fever which may

anemia and thrombocytopenia) indicate for infection.
- Frequent monitoring of blood cell
count as ordered.
- Advise patient to avoid patients
who are symptomatically sick.
Wear mask and encourage
frequent hand hygiene.
- Iron rich foods to increase
production of hemoglobin.
- Monitor patient for bruises,
wounds and bleeding
- Avoid Aspirin and NSAIDs

Gastrointestinal System

- Nausea and Vomiting - Patient teaching: Nausea and

vomiting is a common side effect
of chemotherapy brought by
antineoplastic medications.
- Relaxation Technique and Guided
Imagery

- Constipation or Diarrhea - Eat smaller meals more often

instead of 3 larger meals each day
- Electrolyte replenishment to
prevent dehydration from vomiting
and diarrhea
- For constipation, increase fiber
 rich food
- Stomatitis (inflammation of the
mouth) - Use soft bristle toothbrush.
- Avoid spicy food.
- Advise the client to eat a bland
diet
- Instruct patient to consume cool
food and fluids – can minimize
discomfort
- Consult physician if stomatitis
persist
Integumentary

- Alopecia - Patient Teaching: Alopecia is a

common side effect of
chemotherapy brought by
antineoplastic medications.
- Establish a good patient support
system.

- Use mild, moisturizing soap and

- Skin Lesions lotion frequently to reduce skin
dryness, itching and irritation.
- Avoid showering/bathing with hot
water, gently pat your skin dry.
- Educate patient regarding proper
precautions in the sun to avoid
sunburn.

Renal System

- Urinary Frequency - Encourage adequate hydration.

- Cystitis, hematuria
- Cleanse perineal area and keep
dry
- Limit other fluids like coffee – can
cause bladder irritation and cause
increased frequency
- Report any blood in urine or any
painful urination, flank pain, pelvic
pressure, reduced urine output or
dark-colored urine and report to
attending physician immediately.

Cardiopulmonary System
- Encourage patient to immediately
 - Alveolar damage, bronchospasm, report any shortness of breath,
pneumonitis, pulmonary fibrosis fever, productive cough with
pink/red mucus and/or difficulty of
breathing
- Monitor vital signs, especially
oxygen saturation.
- Maintain good positioning by
elevating the head of the bed
- Pursed lip breathing
Reproductive System
- Patient Teaching: Inform patient
- Infertility who has a partner about changes
- Loss of Libido in reproductive function resulting
from chemotherapy
- Patient Teaching: Instruct patient
to avoid getting pregnant since
chemotherapy drugs are
teratogenic. – may advise the use
of birth controls.
Neurologic System

- Peripheral Neuropathy (altered - Encourage patient to report

sensation in the hands and feet) symptoms of neuropathy.
- Assist patient in ambulation with
the use of assistive devices.
- Patient Teaching: teach patient
and significant other about safety
precautions
- Encourage passive and active
ROM exercises
- Encourage patient to verbalize
pain – in order to give proper
medications
9. explain the possible complications of chemotherapy

POSSIBLE COMPLICATIONS OF CHEMOTHERAPY

A. Hypersensitivity Reactions
- HSRs are a subgroup of adverse drug reactions that are unexpected and associated
with mild or
progressively worsening signs and symptoms, such as rash, urticaria, fever,
hypotension, cardiac instability, dyspnea, wheezing, throat tightness, and syncope.
- Immediate HSRs appear within 1 hour of an infusion, while delayed HSRs may occur
hours afterward.
Although patients may or may not react to the first infusion of a chemotherapy agent,
repeated exposure increases the likelihood of a reaction.

B. Toxicity
- Toxicity associated with chemotherapy can be acute or chronic. Cells with rapid
growth rates (e.g., epithelium, bone marrow, hair follicles, sperm) are very susceptible
to damage, and the effects may manifest in virtually any body system.

C. EFFECTS ON THE SYSTEMS

 Gastrointestinal system
- The most common side effects of chemotherapy are nausea and vomiting, which may
persist for 24 to 48 hours; delayed nausea and vomiting may occur up to 1 week after
administration. The experience of chemotherapy induced nausea and vomiting (CINV)
may affect quality of life, psychological status, nutrition, fluid and electrolyte status,
functional ability, compliance with treatment, and utilization of health care resources
 Hematopoietic System
- Many chemotherapy agents cause some degree of myelosuppression (depression of
bone marrow function), resulting in decreased WBCs (leukopenia), granulocytes
(neutropenia), red blood cells (RBCs) (anemia), and platelets (thrombocytopenia) and
increased risk of infection and bleeding. Depression of these cells is the usual reason
for limiting the dose of the chemotherapy.
 Renal System
- Some chemotherapy agents damage the kidneys because they impair water secretion,
leading to syndrome of inappropriate secretion of antidiuretic hormone (SIADH),
decrease renal perfusion, precipitate end products after cell lysis, and cause interstitial
nephritis (Comerford, 2015). Cisplatin
(Platinol), methotrexate, and mitomycin (Mutamycin) are particularly toxic to the
kidneys.
 Cardiopulmonary System
- Several agents are associated with cardiac toxicity. Anthracyclines (e.g., daunorubicin,
doxorubicin) are known to cause irreversible cumulative cardiac toxicities, especially
when total dosage reaches 300 mg/m2 and 550 mg/m2, respectively (Comerford,
2015).
- Bleomycin (Blenoxane), carmustine (BCNU), busulfan (Busulfex, Myleran), mitomycin,
and paclitaxel/docetaxel, among other agents, have toxic effects on lung function, such
as alveolar damage, bronchospasm, pneumonitis, and pulmonary fibrosis.
- Capillary leak syndrome with resultant pulmonary edema is an effect of cytarabine
(DepoCyt, Tarabine, Ara-C), mitomycin C, cyclophosphamide, and carmustine. Subtle
onset of dyspnea and cough may progress rapidly to acute respiratory distress and
subsequent respiratory failure.
 Reproductive System
- Testicular and ovarian function can be affected by chemotherapeutic agents, resulting
in possible sterility. Women may develop problems with ovulation or early menopause,
whereas men may develop temporary or permanent azoospermia (absence of
spermatozoa).
 Neurologic System
- Chemotherapy-induced neurotoxicity, a potentially dose limiting toxicity, can affect the
central nervous system, peripheral nervous system, and/or the cranial nerves.
Neurotoxicity characterized by
metabolic encephalopathy can occur with ifosfamide, high-dose methotrexate, and
cytarabine.
 Cognitive Impairment
- Many patients with cancer experience difficulty with remembering dates, multitasking,
managing numbers and finances, organization, face or object recognition, inability to
follow directions, feeling easily distracted, and motor and behavioral changes. Although
not completely understood, these
are viewed as symptoms of cognitive impairment, defined as a decline in the
information-handling processes of attention and concentration, executive function,
information processing speed, language, visual-spatial skill, psychomotor ability,
learning, and memory.

 Fatigue
- Cancer-related fatigue has been defined as an unusual, persistent, and subjective
sense of tiredness that is not proportional to recent activity and interferes with usual
functioning (NCCN, 2015f). Fatigue is a distressing side effect for most patients that
greatly affects quality of life, during treatment and for months after treatment.

Med-Surge book page 1047-1052 (pdf version)

10. enumerate the safety precautions of internal radiation therapy

 Wash your laundry separately from the rest of the household, including towels
and sheets.
 Sit down when using the toilet to avoid splashing of body waste.
 Flush the toilet twice after each use, and wash your hands well after using the
toilet.
 Use separate utensils and towels.
 Drink extra fluids to flush the radioactive material out of your body.
 No kissing or sexual contact (often for at least a week).
 Keep a distance away from others in your household. For example, you might
be told to keep one arm’s length, or maybe six feet, between yourself and
others for a specific length of time. You might also be told to sleep in a separate
 bed in a separate room for a specific number of nights. This depends on the
type of treatment you receive.
 Avoid contact with infants, children, and women who are pregnant for a specific
amount of time.
 Avoid contact with pets for a specific amount of time.
 Avoid public transportation for a specific amount of time.
 Plan to stay home from work, school, and other activities for a specific amount
of time.

From: https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/
radiation/safety.html#:~:text=Avoid%20contact%20with%20infants%2C%20children,a
%20specific%20amount%20of%20time.

11. list down the materials needed for the procedure

Safety equipment to prevent exposure through inhalation, direct contact, and ingestion:

- Class II or Class III Biological Safety Cabinet (BSC)

- Closed system Transfer Devices

- Puncture and leak-proof containers

- IV Bags

- Needleless systems (IV tubing and syringes)

- Surgical N-95 respirator

- Face Shield or Goggles

- Powder free latex gloves

 - Disposable gowns

Book Source:
- Hinkle, J., Cheever, K. “Brunner and Suddarth’s Textbook of Medical-Surgical
Nursing”, 14th edition, Volume 1, page 349

12. Enumerate the nursing responsibilities before, during and after the procedure

Before:
- Verify the doctor’s order
- Verify signed consent.
- Assess patient for allergies, taken medications, and evaluate any preexisting
symptoms.
- Monitor laboratory values
- Prepare the materials needed
- Secure antineoplastic agents – dose, route of administration, and date and time
that each agent to be administered
- Verify the patient’s identity
- Explain the procedure to the patient
- Provide privacy
During:
- Perform Hand hygiene
- Wear protective equipment (the inner glove is worn under the gown cuff and the
outer glove is worn over the cuff)
- Check the order at the bedside with another certified RN
- Reverify patient’s identity
- Ensure a closed-system, puncture and leak-proof containers is placed nearby
After:
- Dispose of all equipment used in chemotherapy preparation and administration in
designated container
 - Monitor client for symptoms of anaphylactic reaction (e.g. itching, shortness of
breath)
- Provide patient teaching for discharge instructions
- Document in medical record the medications given, patient education, and
patient response, including any adverse events.

Book Source:
- Hinkle, J., Cheever, K. “Brunner and Suddarth’s Textbook of Medical-Surgical
Nursing”, 14th edition, Volume 1, page 349
Internet:
https://www.youtube.com/watch?v=t-uL7OIKEfc

Nursing Considerations during Chemotherapy:

1. Family, caregivers or others are adequately informed about the treatment and
administration process.
2. Education and information should be based on the patient’s reading level and literacy
and level of understanding of information provided.
3. Patient education and consent processes have been completed and documented
according to local institute requirements.
4. The planned treatment is verified with the patient and understood by them.
5. All medications are stored appropriately prior to administration.
6. Independent verification of the medication order (including chemotherapy, targeted
therapy and supportive medication) according to the protocol, the patient’s treatment
plan, patient laboratory parameters and other individual parameters.
7. The therapy and associated treatments are administered to the patient in a safe and
timely manner.
8. Any immediate and longer-term effects are appropriately managed.
9. All professional and legal responsibilities with respect to administration of
medications are met.

Home Instructions for Patients Receiving Chemotherapy:

 Know what changes to expect with chemo.

 Be ready for hair loss.
 Protect your skin from the sun when you're outside.
 Don't smoke or use any form of tobacco.
 Advice to do medical handwashing for at least 20 seconds, and as often as
possible.
 Brush your teeth with a soft-bristle toothbrush after every meal and at bedtime.
- Use a toothpaste with fluoride.
- If the patient is wearing dentures, he/she may be told to wear them only
when eating. Ask the healthcare provider.
 - Clean dentures twice a day. Soak them in antimicrobial solution when
not being worn. Rinse mouth after each meal.
 Exercise.
 Drink plenty of fluids.
 Try to eat a variety of foods for a well-balanced diet.
- be sure to cook all foods
- eat small meals many times a day to keep your strength up
- focus on high-protein foods
- eat foods that are soft. They're less likely to cause stomach irritation
 Keep your skin moisturized.
 - Use lip balm to keep your lips from drying and cracking
 - Sugarless gum and hard candy can help ease dryness.
 Stay away from people who are sick with an communicable illnesses.
 - stay away from places with big crowds
 Close the lid and flush twice after using the toilet for the first 3 days after
treatment.
 Don't get pregnant during chemotherapy.

13. demonstrate beginning skills in preparing chemotherapeutic drugs