9. chemotherapy pp

8/4/2019 9. Chemotherapy PP

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WHAT IS CANCER?

Large group of malignant diseases with

some or all of the ff characteristics:

a. Abnormal cell proliferationb. Lack of controlled growth and division

c. Ability to metastasize


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WHAT IS CANCER?

A few diseases that result from faulty or

abnormal genetic expression caused bychanges that have occurred in the DNA.


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WHAT IS CANCER?

The uncontrolled growth of

cells due to damage to DNA

(mutations) and, ocassionally

due to an inherited

propensity to develop tumors.


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Chemotherapy

A systemic intervention used in the treatment

of certain disease conditions

In modern-day use, refers primarily to the use

of cytotoxic agents to treat CANCER.

CHEMOTHERAPEUTIC AGENTS- Used only

when disease prognosis shows that patient

would benefit from the treatment


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The Cell Cycle


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Broadly, most chemotherapeutic drugs work byimpairing mitosis (cell division), effectivelytargeting fast-dividing cells.

In cancer, cells rapidly divide and does not enterthe resting phase because they areunresponsive to growth-inhibitory signals.

Only a percentage of the cancer cells are killedwith each course of chemotherapy. Therefore,repeated dosesor cycles of chemotherapymust be done.


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SITES OF ACTION OF CYTOTOXIC AGENTSSITES OF ACTION OF CYTOTOXIC AGENTS

Antibiotics

Antimetabolites

S

(2-6h)G 2

(2-32h)

M

(0.5-2h)

Alkylating agents

G1

(2-h)

G0

Vinca alkaloids

Mitotic inhibitors

Taxoids


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GOALS

CURE

CONTROL

PALLIATION


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Chemotherapymay be used as

1.) Adjuvanttherapy

2.) Neoadjuvant therapy

3.) Chemoprevention

4.) Myeloablation


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Classification of Chemotherapy Drugs

CYCLE-SPECIFIC

Antimetabolites interfere with nucleic acid synthesis

Attack during S phase of cell cycle

Cytatabine, floxuridine, fluorouracil, hydroxyurea,methotrexate, thioguanine

Enzymes Useful only for leukemias

Asparaginase Plant Alkaloids

Cycle-specific to M Phase

Prevent mitotic spindle formation

Vinblastine, vincristine


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CYCLE-NONSPECIFIC

Alkylating Agents

Disrupt deoxyribonucleic acid (DNA)

Carboplatin, Cisplatin, Cyclophosphamide,Ifosfamide, Thiotepa

Antibiotics

Bind with DNA to inhibit synthesis of DNAand RNA

Bleomycin, doxorubicin, idarubicin,mitomycin, mitoxantrone



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CYTOPROTECTIVE AGENTS

Protect normal tissue by binding with

metabolites of other cytotoxic drugs

Dexrazoxane

Mesna

FOLIC ACID ANALOGS

Antidote for methotrexate toxicity

Leucovorin



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HORMONE AND HORMONE INHIBITORS

Interfere with binding of normal hormones to

receptor proteins

Manipulate hormone levels

After hormone environment

Usually palliative,not curative

Androgens, Antiandrogens, Antiestrogens, Estrogens,

Gonadotropin, Progestins


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Other AntiCancer Agents

NovelAgents

Monoclonal Antibody

Trastuzumab (Herceptin)

Rituximab (Mabthera)

Cetuximab (Erbitux)

Tyrosine Kinase Inhibitor

Imatinib (Glivec)

EGFR Inhibitors Erlotinib (Tarceva)

Gefitinib (Iressa)

VEGF Inhibitors

Bevacizumab (Avastin)


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BIOLOGICAL THERAPY

Consists mostly of the administration ofbiologicalresponse modifiers

Also includes the use ofimmunotherapy

Biological response modifiers Alter the bodys response to therapy May cause direct cytotoxicity

Immunotherapy Uses drugs to enhance the bodys ability to destroy

cancer cells Seeks to evoke effective immune response to human

tumors by altering the way cells grow, mature, andrespond to cancer cells

May include the administration ofmonoclonal antibodies

and immunomodulatory cytokines


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Immunotherapy

Monoclonal antibodies

Specifically target tumor cells

More recent form of biotherapy that manipulates

the bodys natural resources instead ofintroducing toxic substances that arent selective

and cant differentiate between normal and

abnormal processes or cells

Recognizes only a single unique antigen

Rituximab (Rituxan)

Trastuzumab (Herceptin)


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Immunotherapy

Immunomodulary cytokines

Intracellular messenger proteins (proteins

that deliver messages within cells)

Colony-stimulating factors

Erythropoietin (Epogen), Granulocyte colony-

stimulating factor (Neupogen), Granulocyte-

macrophage CSF (Leukine)

Interferon Interleukins

Tumor Necrosis factor


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Routes of Administration

Oral Route Subcutaneous and

Intramuscular

IV administration

IV push

IV piggy back (largevolume)

Direct Introduction

Intrathecal

Intrapleural

Intraperitoneal

Chemoembolization

Ommaya reservoir
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Safehandling Chemotherapeutic Agents

Chemotherapeutic Drugs are hazardous

drugs.

a hazardous drug is defined as an agent that

presents a danger to healthcare personnel due

to its inherent toxicity.

They are carcinogenic

They are genotoxic

They are teratogenic

There is evidence of toxicity at low doses


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PREPARING CHEMOTHERAPEUTIC DRUGS

GATHERING THE EQUIPMENT

Before preparing chemotherapeutic drugs, be sure togather all the necessary equipment, including:

Patients medication order or record Prescribed drugs

Appropriate diluent (if necessary)

Medication labels

Long-sleeped gown Chemotherapy gloves

Face shield or goggles and face mask

20G needles

Hydrophobic filter or dispensing pin


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GATHERING THE EQUIPMENT(continuation) Syringes with luer-lock fittings and needles of

various sizes

IV tubing with luer-lock fittings

70% alcohol

Sterile gauze pads

Plastic bags with hazardous drug labels

Sharps disposal container Hazardous waste container

Chemotherapy spill kit


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ORGANIZING DRUG PREPARATION AREAS

Prepare chemotherapeutic drugs in well-ventilated

workspace

Perform all drug admixing or compounding within a ClassII Biological Safety Cabinet or a vertical laminar airflow

hood with a HEPA filter, which is vented to the outside

If a Class II Biological Safety Cabinet isnt available, it is

recommended to use a special respirator

Have close access to a sink, alcohol pads, and gauze pads

as well as Chemotherapy hazardous waste containers,

sharps containers, and chemotherapy spill kits


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ORGANIZING DRUG PREPARATION AREAS(cont.)

Make sure that all hazardous waste containersare made of punctureproof, shatterproof,leakproof plastic

Make sure that yellow biohazard labels areavailable for labeling all chemotherapy-contaminated IV bags, tubings, filters, andsyringes

Make sure that red sharps containers areavailable for disposal of all contaminated sharpssuch as needles.


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WEAR PROTECTIVE CLOTHING

Essential protective clothing includes a cuffed gown,

gloves, and a face shield or goggles and a face mask

Gowns should be disposable, water-resistant, andlint-free with long sleeves, knitted cuffs, and a

closed front

Gloves should be disposable, powder-free, and

made of thick latex or thick nonlatex material

Double gloving is an option when the gloves arent

of the best quality


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SAFETY MEASURES

GENERAL MEASURES

At the local level, most health care facilities

require nurses and pharmacists involved in

the preparation and delivery of

chemotherapeutic drugs and care of the

patient with cancer.

Take care to protect staff, patients and the

environment from unnecessary exposure to

chemotherapeutic drugs


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SAFETY MEASURES

Make sure your facilitys protocols for

spills are available in all areas where

chemotherapeutic drugs are handled,

including patient-care areas

Refrain from eating, drinking, smoking or

applying cosmetics in the drug-preparation

area.


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SAFETY MEASURES

ACCIDENTAL EXPOSURE If a chemotherapeutic drug comes in contact

with your skin, wash the area thoroughly withsoap and water to prevent drug absorptioninto the skin

If the drug comes in contact with your eye,immediately flush the eye with water orisotonic eyewash for at least 5 minutes, whileholding the eyelid open

After an accidental exposure, notify yoursupervisor immediately


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SAFETY MEASURES

WASTE DISPOSAL Place all contaminated needles in the sharps container;

dont recap needles

Use only syringes and IV sets that have a luer-lock fitting

Label all chemotherapeutic drugs with a yellowbiohazard label

Transport the prepared chemotherapeutic drugs in asealable plastic bag thats prominently labeled with ayellow chemotherapy biohazard label

Dont leave the drug-preparation area while wearing theprotective gear you wore during drug preparation


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SAFETY MEASURES

HANDLING A CHEMOTHERAPY SPILL

Put on protective garments, if you

arent already wearing them

Isolate the area and contain the

spill with absorbent materials from

a chemotherapy spill kit

Use the disposable dustpan and

scraper to collect broken glass or

desiccant absorbing powder


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SAFETY MEASURES

HANDLING A CHEMOTHERAPY SPILL(contn)

Carefully place the dustpan, scraper

and collected spill in a leakproof,

punctureproof, chemotherapy-designatedhazardous waste container

Prevent aerosolization of the drug at alltimes

Clean the spill area with a detergent orbleach solution


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ADMINISTERING CHEMOTHERAPEUTIC DRUGS

Gathering the equipment Prescribed drugs

IV access supplies

Sterile PNSS IV syringes and tubings with luer

lock

Leakproof chemical waste

container Chemotherapy gloves

Chemotherapy spill kit

Extravasation kit


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ADMINISTERING CHEMOTHERAPEUTIC

DRUGS

Preventing Infiltration

Use a low-pressure infusion pump to

administer vesicants through a peripheral

vein, to decrease the risk of extravasation

Use a central venous catheter for continuous

vesicant infusions


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DRUGS

Guidelines in giving vesicants

Use a distal vein that allows successive

proximal venipunctures

Avoid using the hand, antecubital space,

damaged areas, or areas with compromised

circulation

Dont probe or fish for veins

Place a transparent dressing over the site


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DRUGS

Guidelines in giving vesicants (contn)

Start the push delivery or the infusionwith normal saline solution

Inspect the site for swelling and erythema Tell the patient to report burning,

stinging, pain, pruritus, or temperaturechanges near the site

After drug administration, flush the linewith 20mL of NSS


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DRUGS

Concluding Treatment Dispose of all used needles and

contaminated sharps in the orange sharpscontainer

Dispose of PPEs in yellowchemotherapeutic waste container

Dispose of unused medications,

considered hazardous waste, according toyour facilitys policy


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ADMINISTERING CHEMOTHERAPEUTIC DRUGS

Concluding treatment (cont)

Wash hands thoroughly

Document the ff.

sequence in which the drugs were administered

site accessed, the gauge and length of the catheter,and the number of attempts

name, dose, and route of the administered drugs

Type and volume of the IV solutions and adversereactions and nursing interventions

According to facility policy, wear protectiveclothing when handling body fluids from the

patient for 48 hours after


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MANAGING COMPLICATIONS OF

CHEMOTHERAPY

ALOPECIA

Hair loss that occurs as chemotherapeutic drugs

destroy the rapidly growing cells of hair follicles

May be minimal or severe

Occurs 2-3 weeks after treatment begins

Almost always temporary

Signs and Symptoms Hair loss that may include eyebrows, lashes and body

hair
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Nursing Interventions Minimize shock and distress by warning the patient of this

possibility Discuss with the patient why it occurs Describe to the patient how much hair loss to expect

Emphasize to the patient the need for appropriate headprotection against sunburn Inform the patient that new hair may be a different texture or

color

Give the patient sufficient time to decide whether to order awig

Inform the patient that his scalp will become sore at times dueto follicles swelling

Prevention measures For patients with long hair, suggest cutting hair shorter before

treatment because washing and brushing cause more hair loss


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ANEMIA Occurs as chemo drugs destroy healthy cells and

cancer cells

RBCs are destroyed and cant be replaced by the

bone marrowSigns and symptoms

Dizziness, fatigue, pallor, and shortness of breathafter minimal exertion

Low hemoglobin level and hematocrit May develop slowly over several courses of

treatment


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Nursing Interventions Monitor hemoglobin level, hematocrit, RBC count;

report dropping values

Be prepared to administer a blood transfusion or

erythropoietinPrevention Measures

Instruct the patient to take frequent rests, increasehis intake of iron-rich foods, and take a

multivitamin with iron as prescribed If the patient has been prescribed a drug such as

epoetin, make sure he understands how to takethe drug and what adverse effects he should watchfor and report


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DIARRHEA Occurs because the rapidly dividing cells of the intestinal

mucosa are killed Complications include weight loss, F&E imbalance, and

malnutrition

Signs and symptoms An increase in the volume of stool compared with the

patients normal bowel habitsNursing Interventions Assess frequency, color, and consistency of stool

Encourage fluids, give IV fluids and potassium supplementsas orderedPrevention measures Use dietary adjustments and antidiarrheal meds Provide good perianal skin care


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EXTRAVASATION The inadvertent leakage of a vesicant solution into

the surrounding tissueSigns and Symptoms

Initial signs and symptoms may resemble those ofinfiltration blanching, pain, swelling Symptoms possibly progressing to blisters; to skin,

muscle, tissue and fat necrosis; and to tissuesloughing

Blood return is an INCONCLUSIVE test and shouldntbe used to determine if IV catheter is correctlyseated in the peripheral vein. To assess peripheralIV placement, flush the vein with NSS and observesite for swelling.


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Extravasation of Doxorubicin


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Nursing Interventions Stop the infusion Check your facilitys policy to determine if the IV

catheter is to be removed or left in place to infusecorticosteroids or a specific antidote.

Notify the physician Instill the appropriate antidote according to facility

policy. Usually, youll give the antidote forextravasation either by instilling it through theexisting IV catheter or by using a 1 mL syringe toinject small amounts subcutaneously in a circlearound the extravasated area

After the antidote has been given, remove the IVcatheter


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Preventive measures

Verify IV line patency and placement

by flushing with normal saline soln

Remember, When in doubt, take it

out!

Use a transparent, semi-permeable

dressing for inspection of site.


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INFILTRATION The inadvertent leakage of a nonvesicant solution

or medication into the surrounding tissue Infusion-site related

Signs and symptoms Blanching Change in IV flow rate Numbness and tingling in swollen area due to

nerve compression injury leading to compartmentsyndrome

Swelling around IV site (the swollen area will becool to touch)


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Nursing Interventions

Remove the IV catheter

Insert a new IV catheter in a differentlocation

Prevention Measures

Check for infiltration before, during, andafter the infusion by flushing the vein with

normal saline solution


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LEUKOPENIA Reduced leukocytes or WBCs Occurs as WBCs and cancer cells are destroyed

by chemo drugs

Signs and Symptoms Susceptibility to Infections NeutropeniaNursing Interventions

Watch for the nadir, the point of lowest bloodcell count Be prepared to administer colony-stimulating

factors Institute neutropenic precautions


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Teach the patient and caregiver about: Good hygiene practices

Signs and symptoms of infection

The importance of checking the patients temperature

regularly How to prepare low-microbe diet

How to care for vascular access devices

Instruct the patient to avoid

Crowds People with colds or respiratory infections

Fresh fruit

Fresh flowers

plants


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NAUSEA and VOMITING

Can appear in 3 different patterns

Anticipatory

Acute

Delayed


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ANTICIPATORY NAUSEA and VOMITING

Signs and Symptoms

Nausea and vomiting thats a learned response from priornausea and vomiting after a dose of chemotherapy

High anxiety levels (acts as a trigger)Nursing Interventions

Posttreatment control of nausea and vomiting may preventfuture anticipatory episodes

Prevention measures

Pretreat the patient with lorazepam (Ativan) at least 1 hrbefore arriving for treatment

Patients with overwhelming anxiety may need IV lorazepambefore chemo is administered


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ACUTE NAUSEA and VOMITING

Signs and symptoms

Nausea and vomiting occurring within the first 24hours of treatment


Treat the patient with acute nausea and vomitingwith antiemetic drugs Dexamethasone

Granisetron

Lorazepam

Metoclopramide

Ondansetron


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DELAYED NAUSEA and VOMITINGSigns and Symtoms Nausea or vomiting starting or continuing beyond

24 hours after chemo has begun

Nursing Interventions The administration of serotonin antagoninsts,

corticosteroids, various antihistamines,benzodiapines, and and metoclopramide is usuallyeffective in treating patients

Prevention Measures Administer antiemetic before chemo begins Some patients with delayed nause and vomiting are

treated with an antiemetic for 3 days or longer


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STOMATITIS Inflammation of the lining of the oral mucosa

Can spread into the esophagus and pharynx

Signs and Symptoms Painful mouth ulcers that range from mild to

severe appearing 3 to 7 days after certainchemotherapeutic drugs are given


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Nursing Interventiosn

Instruct the patient to perform meticulous oralhygiene

Administer topical anesthetic mixtures as

appropriate If pain is severe, opioid analgesics may be

prescribed until the ulcers heal

Prevention Measures

Instruct the patient to suck on ice chips whilereceiving certain drugs that cause stomatitis; thisdecreases the blood supply to the mouth, thusdecreasing ulcer formation


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THROMBOCYTOPENIA

Reduced blood platelet count

Signs and Symptoms

Bleeding gums

Coffee-ground emesis Hematuria

Hypermenorrhea

Increased bruising

Petechiae

Tarry stools

Nursing interventions

Monitor patients platelet count

Avoid unnecessary IM injections or venipuncture


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If an IM injection or venipuncture is necessary,apply pressure for at least 5 minutes; apply apressure to the site.

Instruct the patient to

Avoid cuts and bruises Shave with an electric razor

Avoid blowing his nose

Stay away from irritants that would trigger sneezing

Avoid using rectal thermometers Instruct the patient to report sudden headaches

(which could indicate potentially fatal intracranialbleeding)


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VEIN FLARE Occurs during infusion of an irritant into the vein

Signs and Symptoms

Bright redness possibly appearing in the vein along withblotches or hives on the affected arm

Burning pain or aching along the vein as well as up throughthe arm


If the reaction is severe, injection of an IV steroid may berequired

If the patient complains of pain or burning during theinfusion: Increase the dilution of the infused medication

Decrease the infusion rate

h d ff

9. chemotherapy pp

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