association of pediatric hematology/oncology nurses - fourth … · 2019. 11. 22. · nurses who...
TRANSCRIPT
EditorRuth Anne Herring
Section EditorsJoan O’Hanlon Curry
Joy HesselgraveColleen Nixon
Mary Lynn Rae
Association of Pediatric Hematology/Oncology Nurses
THE PEDIATRIC
Chemotherapyand Biotherapy
CURRICULUMFourth Edition
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THE PEDIATRIC
Chemotherapyand Biotherapy
CURRICULUMFourth Edition
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APHON Chemotherapy and Biotherapy Provider Program
CommitteeMichael Hans, Chair
Michelle A. Gillard, Vice ChairDyane W. Bunnell, Board Liaison
Ellen Olson, Education Provider Unit ChairKristin M. Belderson
Gina DoviRuth Anne Herring
Julie IsbellKerri Kramer
Colleen M. NixonMegan Ploog
Mary Lynn RaeAnne Marie Sterk
EditorRuth Anne Herring
Section EditorsJoan O’Hanlon Curry
Joy HesselgraveColleen Nixon
Mary Lynn Rae
THE PEDIATRIC
Chemotherapyand Biotherapy
CURRICULUMFourth Edition
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iv The Pediatric Chemotherapy and Biotherapy Curriculum: Fourth Edition
STAFFDave Bergeson, PhD CAE, Executive Director
Nicole Wallace, Senior Operations Manager
Jennifer Schap, Education Manager
Barbara Hofmaier, Senior Managing Editor
Sonya Jones, Senior Design Manager
Copyright © 2019 Association of Pediatric Hematology/Oncology Nurses
All rights reserved. No part of this book, except for brief quotations in critical articles and reviews, may be used or reproduced in any manner whatsoever without written permission.
Printed in the United States of America
Association of Pediatric Hematology/Oncology Nurses
8735 W. Higgins Road, Suite 300
Chicago, IL 60631-2738
ISBN 978-0-9905255-3-0
Note: As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The authors, editors, and publisher have done everything possible to make this book accurate, up-to-date, and in accord with standards accepted at the time of publication. The recommendations contained herein reflect APHON’s judgment regarding the state of general knowledge and practice in the field as of the date of publication. Any practice described in this book should be applied by the healthcare practitioner in accordance with professional standards of care pertaining to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information on dosing and contraindications before administering any drug. Caution is especially urged when new or infrequently ordered drugs or treatments are being used. Figures and tables in the book are used as examples only. They are not meant to cover all medical situations, nor do they represent endorsement of any particular institution by APHON. Any mention of specific products and opinions related to those products do not indicate or imply endorsement by APHON. The authors, editors, and publisher are not responsible for errors or omissions in the book or for the consequences of applying material in the book, and they make no warranty, expressed or implied, regarding the book’s contents.
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For Nancy E. KlineThis fourth edition of The Pediatric Chemotherapy and Biotherapy Curriculum
is dedicated to you.
You were our source of inspiration and motivation as we took on this project.
We hope we have made you proud, as we continue the work you began in educating the nurses who care for our pediatric hematology/oncology patients.
Your legacy and mentorship continue with each nurse who participates in the curriculum.
You will always be at the heart of this program.
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vii
Contents
List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Preface and Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Editors and Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
Chapter 1. Introduction and Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Standards for Practice and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Chapter 2. Overview of Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Robyn A. Blacken, BSN RN CPHON® BMTCN®; Joan O’Hanlon Curry, MS RN CPNP CPON®; Pamela Dockx, BSN RN CPON®; Erin Friedman, BSN RN CPHON®; Michael Hans, MS BSN RN-BC CPON®; Colleen Nixon, MSN RN CPHON®; Lissa Pocze, MSN RN CPNP CPON®; Maritza Salazar-Abshire, MEd MSN RN CPON®; Pat Wills-Bagnato, MSN RN CPNP CPHON®
History of Cancer Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Cancer Cell Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Hematopoiesis and Immune Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Diagnostic Assessment and Staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Pharmacodynamics, Pharmacokinetics, and Pharmacogenetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Modalities of Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Evaluation of Response to Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Differences Between Pediatric and Adult Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Chapter 3. Principles of Clinical Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39Elizabeth A. Gilger, MSN RN APRN-BC CPON®; Danielle Marcello, MSN RN-BC
Ethical Foundations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Cancer Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Legal Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Chapter 4. Chemotherapy: Principles and Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55Kristin M. Belderson, DNP RN-BC CPON®; Margie Kjellin, MSN RN NE-BC CPHON®; Lissa Pocze, MSN RN CPNP CPON®; Mary Lynn Rae, MSN RN CPHON®
Principles of Cancer Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Chapter 5. Biotherapy: Principles and Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91Jill A. Anderson, MSN RN PCNS; Ruth Anne Herring, MSN RN CPNP-AC/PC CPHON®; Maritza Salazar-Abshire, MEd MSN RN CPON®
Interaction Between the Immune System and Cancer Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Biotherapy Versus Chemotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Immunotherapy Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Targeted Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Gene Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Side Effects and Toxicities of Biotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Safe Handling of Biotherapy Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Summary of Biotherapy Agents in Pediatric Cancer Treatment Regimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Chapter 6. Safe Handling of Hazardous Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149Susanne B. Conley, MSN RN AOCNS CPON®; Mary Lynn Rae, MSN RN CPHON®; reviewed by Seth Eisenberg, RN OCN BMTCN®
Occupational Exposure Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Exposure Prevention Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Spill Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Safe Handling in the Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
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Chapter 7. Administration of Chemotherapy and Biotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .161Colleen Nixon, MSN RN CPHON®; Mary Lynn Rae, MSN RN CPHON®
Preadministration Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Chemotherapy and Biotherapy Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Patient Monitoring During Chemotherapy and Biotherapy Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Developmental Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Chapter 8. Toxicity and Symptom Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .199Michelle A. Gillard, MSN RN CPHON®; Ruth Anne Herring, MSN RN CPNP-AC/PC CPHON®; Joy Hesselgrave, MSN RN CHPPN CPON®
Hematopoietic System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Coagulation System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Nervous System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Auditory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Ophthalmologic System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Endocrine System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Pulmonary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Cardiac System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Gastrointestinal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Renal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Integumentary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Chapter 9. Psychosocial Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287Mary C. Hooke, PhD APRN PCNS FAAN CPON®
Quality of Life for Patients and Their Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
Adolescents and Young Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Chapter 10. Late Effects of Chemotherapy and Biotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295Elaine Pottenger, MS RN CPNP PMHS
Late Effects of Radiation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
Late Effects of Chemotherapy by System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .301Appendix A. Examples of Chemotherapy Administration Competency Checklists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Appendix B. Example of a Chemotherapy Preadministration Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
Appendix C. Example of a Chemotherapy Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Appendix D. Example of Patient Education Materials: Giving a Subcutaneous Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Appendix E. Family Education Sheet on Inserting an Insuflon Catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Appendix F. Common Terminology Criteria for Adverse Events (CTCAE), Version 5.0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .317SAMPLE
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List of Tables
Table 2.1. Blood Cell Types: Function, Growth Factor, Normal Value, and Life Span. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Table 2.2. Lines of Defense by the Body’s Immune Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Table 2.3. Immunoglobulins and Their Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Table 2.4. Signs and Symptoms of Childhood Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Table 2.5. Studies for the Diagnosis and Staging of Various Childhood Malignancies . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Table 2.6. Examples of Genetic Changes in Pediatric Oncology and Their Clinical Implications . . . . . . . . . . . . . . . . 22
Table 2.7. Staging Systems and Risk Stratifications Used in Pediatric Oncology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Table 2.8. Physiologic Differences in Children That May Influence Drug Disposition. . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Table 2.9. Gene Polymorphisms and Their Significance in Chemotherapy or Biotherapy. . . . . . . . . . . . . . . . . . . . . . . . . 27
Table 2.10. Indications for Surgery in Pediatric Oncology Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Table 2.11. Side Effects of Radiation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Table 2.12. Tumor Differentiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Table 2.13. Performance Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Table 3.1. Ethical and Scientific Principles in Clinical Trial Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Table 3.2. Federal Guidelines for Cancer Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Table 3.3. Criteria for APHON Standards of Professional Performance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Table 3.4. The Four Topics Method: A Case-Based Approach to Ethical Decision Making . . . . . . . . . . . . . . . . . . . . . . . . 45
Table 3.5. Phases of Clinical Trials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Table 3.6. Regulatory Agencies for Cancer Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Table 3.7. Basic Required Elements of Informed Consent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Table 4.1. Cell-Cycle-Specific Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Table 4.2. Cell-Cycle-Nonspecific Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Table 4.3. Chemotherapeutic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Table 4.4. Supportive Care Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Table 5.1. Comparison of Chemotherapy and Biotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Table 5.2. Immunotherapy in Pediatric Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Table 5.3. Differences Between Targeted Therapies: Monoclonal Antibodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 Versus Small Molecule Inhibitors
Table 5.4. Targeted Therapies in Pediatric Oncology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100
Table 5.5. Nomenclature of Monoclonal Antibodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Table 5.6. Biotherapy Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Table 6.1. Hierarchy of Hazard Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Table 6.2. Appropriate Personal Protective Equipment According to Administration Route . . . . . . . . . . . . . . . . . . 154
Table 6.3. Use of Personal Protective Equipment According to Type of Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Table 6.4. Summary of Cleaning Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Table 6.5. Common Contents of a Chemotherapy Spill Kit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
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Table 7.1. Terminology Related to Central Lines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Table 7.2. Examples of Types of Central Venous Catheters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Table 7.3. Administration of Intravenous Vesicant Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180
Table 7.4. Nursing Assessment of Extravasation and Other Reactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Table 7.5. Extravasation Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Table 7.6. Comparison of Acute Infusion Reactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Table 7.7. National Cancer Institute Grading Criteria for Allergic and Anaphylactic . . . . . . . . . . . . . . . . . . . . . . . 189 Reactions and Cytokine Release Syndrome
Table 7.8. Developmental Considerations in Chemotherapy Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Table 8.1. Format for Teaching About Blood Counts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200
Table 8.2. Summary of C17 Council Guideline and Recommendations for Primary . . . . . . . . . . . . . . . . . . . . . . . . . . . . .208 Antifungal Prophylaxis for Pediatric Hematology/Oncology Patients (not including HSCT patients)
Table 8.3. Cranial Nerves and Nursing Assessment and Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209
Table 8.4. Modified (Balis) Pediatric Scale for Peripheral Neuropathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Table 8.5. Neurotoxicities Associated with Chemotherapy and Biotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Table 8.6. Ocular Toxicities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Table 8.7. Assessing Diabetes Insipidus and SIADH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Table 8.8. Common Pulmonary Side Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Table 8.9. Pulmonary Function Testing: A Primer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Table 8.10. Comparison of Symptoms of Pulmonary Toxicities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .226
Table 8.11. Transfusion-Related Pulmonary Side Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .230
Table 8.12. QTc Intervals (in milliseconds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Table 8.13. Common Cardiac Toxicities Related to Chemotherapy and Biotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Table 8.14. Normal and Abnormal Values for Echocardiogram and Multigated Analysis . . . . . . . . . . . . . . . . . . . . . .236
Table 8.15. Suggested Anthracycline Monitoring Intervals During Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .236
Table 8.16. Converting to Anthracycline Equivalent Dosages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .236
Table 8.17. Agents That Cause Hypotension or Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Table 8.18. Emetogenic Potential of Agents and Antiemetic Regimens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240
Table 8.19. Common Antiemetic Medications, Dosing, and Side Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .244
Table 8.20. Medications Frequently Used for Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248
Table 8.21. Types of Drug-Induced Liver Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Table 8.22. Criteria for Sinusoidal Obstruction Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Table 8.23. Chemotherapy and Targeted Agents Associated with Kidney Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .259
Table 8.24. Oral Care Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .268
Table 8.25. Potential Skin Reactions Associated with Chemotherapy and Biotherapy . . . . . . . . . . . . . . . . . . . . . . . . . 273
Table 10.1. Common Late Effects of Chemotherapy for Childhood Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .296
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List of Figures
Figure 2.1. Milestones in Oncology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Figure 2.2. Milestones in the History of Biotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Figure 2.3. Development of the Pediatric Oncology Specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Figure 2.4. The Cell Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure 2.5. Mitosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 2.6. Cell-Cycle Checkpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 2.7. Hematopoietic Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 2.8. Cells of the Innate and Adaptive Immune Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 2.9. Adaptive Immune Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 3.1. Medication Order Verification System Checkpoints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Figure 4.1. The Dividing Cancer Cell. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Figure 4.2. Alkylating Agents’ Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Figure 4.3. Tubulin Inhibitors Mechanism of Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Figure 4.4. Gompertzian Model of Tumor Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
Figure 4.5. Dose Intensity: Interval Compression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Figure 5.1. The Tumor Microenvironment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Figure 5.2. Cancer Immunoediting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Figure 5.3. Cytokine Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Figure 5.4. Immune Checkpoint Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Figure 5.5. The Process of Creating Chimeric Antigen Receptor (CAR) T Cells. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Figure 5.6. Signal Transduction Pathway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Figure 5.7. Types of Therapeutic Monoclonal Antibodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Figure 5.8. Overview of Hybridoma Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Figure 5.9. BiTE Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Figure 5.10. Example of an Important Signal Transduction Pathway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Figure 5.11. Angiogenesis Inhibition by Bevacizumab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106
Figure 6.1. Hierarchy of Hazard Controls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Figure 7.1. Mosteller Formula for Calculation of Body Surface Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Figure 7.2. Therapy Delivery Map (Also Known as the Roadmap) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166
Figure 7.3. Subcutaneous Injection Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Figure 7.4. Intramuscular Injection Sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Figure 7.5. Positioning a Patient for Lumbar Puncture: Side Lying. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Figure 7.6. Holding a Patient for Lumbar Puncture: Side Lying and Sitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Figure 7.7. Algorithm for Central Venous Catheter Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Figure 7.8. Algorithm for Managing Venous Port Malfunctions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Figure 7.9. Algorithm for Managing Central Venous Catheter Malfunctions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
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Figure 7.10. Circle Prime Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Figure 7.11. Algorithm for Management of Extravasation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Figure 7.12. Algorithm for Management of Allergic Reactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Figure 7.13. Continuum of Education in Pediatric Oncology for Newly Diagnosed . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Patients and Their Families
Figure 7.14. Parental Processing of Information After a Child’s Cancer Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Figure 8.1. Pathophysiology of Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .238
Figure 8.2. Acupressure Point P6 for Nausea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Figure 8.3. Pediatric Nausea Assessment Tool (PeNAT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Figure 8.4. Modified Bristol Stool Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .250
Figure 8.5. Potential Sites of Chemotherapy-Associated Nephrotoxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .258
Figure 8.6. Symptoms of Tumor Lysis Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .262
Figure 8.7. Tumor Lysis Syndrome Cascade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .263
Figure 8.8. Five-Stage Model of Pathophysiology of Mucositis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .266
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Preface and AcknowledgmentsThe world of pediatric hematology and oncology has changed so much in the 8 years since the third edition of APHON’s Pediatric Chemotherapy and Biotherapy Curriculum was published:
• We have seen an explosion of immunotherapy and targeted therapies.
• Our understanding of how tumors interact with the immune system has greatly improved.
• We are able to identify genetic mutations and polymorphisms that have an impact on treatment choices.
• The U.S. Pharmacopeia (USP General Chapter <800> Hazardous Drugs—Handling in Healthcare Settings) has mandated important changes in how we administer chemotherapy.
• The National Cancer Institute released version 5.0 of its Common Terminology Criteria for Adverse Events.
• The federal government has established new requirements for what must be included in informed consent.
• The Children’s Oncology Group has set forth recommendations that will standardize the education of newly diagnosed patients and their families.
• We use new concepts and terminology to define treatment and disease response, including risk-based therapy, minimal resid-ual disease, and Deauville scores for positron emission tomography (PET) scans.
• Survival rates for our patients with childhood cancer have never been higher.
These exciting advances motivated the significant updating of virtually every chapter and lecture in APHON’s Pediatric Che-motherapy and Biotherapy Curriculum, as the editors and authors sought to provide nurses with the most current resources and information available, so that they can safely and knowledgeably administer chemotherapy and biotherapy to children, adoles-cents, and young adults with cancer. Built on the foundation of the previous editions, the fourth edition of The Pediatric Che-motherapy and Biotherapy Curriculum offers a wealth of updated information for the nurse who administers chemotherapy and biotherapy. Changes include enhanced explanations of foundational concepts, expanded information about biotherapy and bio-therapy agents, updated guidelines for the safe handling of hazardous drugs, additions to information on toxicities, more tables and figures, and the addition of algorithms and tools that you can use in your workplace.
The editors of the fourth edition and all the contributors have conscientiously worked to incorporate all these changes into a practical and useful nursing resource that is evidence based and user friendly.
This project has truly been the work of an amazing “village” of people, and many, many thanks are due to those who have worked to bring this curriculum to you:
• the editors who ensured that we carried the vision of Nancy Kline, lead editor of the first three editions of this curriculum, into this edition
• the contributors who shared their time and expertise so that we are better prepared to administer these agents to our patients
• the APHON leadership team for their ongoing support of this project
• our colleagues in the Children’s Oncology Group for their expertise and collaboration
• the APHON staff, who coordinated countless conference calls; organized the myriad of files, figures, and charts in our online workspace; and otherwise kept up with the thousands of details involved in this project
• the APHON publishing team, who faced the daunting tasks of meeting deadlines, tracking down elusive sources, and meld-ing nurse-speak with American Psychological Association style and format
• the more than 500 Pediatric Chemotherapy and Biotherapy Provider Program instructors who give their time and resources to teach this curriculum so diligently again and again
• and finally, the more than 12,000 APHON members and other nurses who have taken APHON’s provider course and achieved Pediatric Chemotherapy and Biotherapy Provider status in order to provide the very best care for the children, ado-lescents, and families whom we serve.
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xiv The Pediatric Chemotherapy and Biotherapy Curriculum: Fourth Edition
Editors and Contributors
EditorRuth Anne Herring, MSN RN CPNP-AC/PC CPHON®
Pediatric Nurse Practitioner
Children’s Health–Dallas
Fort Worth, TX
Section EditorsJoan O’Hanlon Curry, MS RN CPNP CPON®
Administrative Director, Pediatric Clinical Services
Child and Adolescent Center and Children’s Cancer Hospital
University of Texas MD Anderson Cancer Center
Houston, TX
Joy Hesselgrave, MSN RN CHPPN CPON®
Assistant Clinical Director, Palliative Care
Texas Children’s Hospital
Houston, TX
Colleen Nixon, MSN RN CPHON®
Hematology/Oncology Clinical Educator
Boston Children’s Hospital
Boston, MA
Mary Lynn Rae, MSN RN CPHON®
Nursing Professional Development Practitioner/Clinical Educator: Hematology/Oncology/Stem Cell Transplantation
Ann and Robert H. Lurie Children’s Hospital of Chicago
Chicago, IL
ContributorsJill A. Anderson, MSN RN PCNS
Advanced Practice Registered Nurse
Children’s Mercy Hospitals and Clinics
Kansas City, MO
Kristin M. Belderson, DNP RN-BC CPON®
Professional Development Specialist
Children’s Hospital Colorado
Aurora, CO
Robyn Blacken, BSN RN CPHON® BMTCN®
Hematopoietic Stem Cell Transplant Program Nurse
Boston Children’s Hospital
Boston, MA
Susanne B. Conley, MSN RN AOCNS CPON®
Clinical Specialist
Dana-Farber Cancer Institute
Boston, MA
Joan O’Hanlon Curry, MS RN CPNP CPON®
Administrative Director, Pediatric Clinical Services
Child and Adolescent Center and Children’s Cancer Hospital
University of Texas MD Anderson Cancer Center
Houston, TX
Pamela Dockx, BSN RN CPON®
Staff Nurse III, Inpatient Oncology
Children’s Hospital Boston
Boston, MA
Erin Friedman, BSN RN CPHON®
Clinical Education Specialist
University of Minnesota
Minneapolis, MN
Elizabeth A. Gilger, MSN RN APRN-BC CPON®
Pediatric Nurse Practitioner
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH
Michelle A. Gillard, MSN RN CPHON®
Phoenix Children’s Hospital
Phoenix, AZ
Michael Hans, MS BSN RN-BC CPON®
Nursing Staff Development Educator
St. Jude Children’s Research Hospital
Memphis, TN
Ruth Anne Herring, MSN RN CPNP-AC/PC CPHON®
Pediatric Nurse Practitioner
Children’s Health–Dallas
Fort Worth, TX
Joy Hesselgrave, MSN RN CHPPN CPON®
Assistant Clinical Director, Palliative Care
Texas Children’s Hospital
Houston, TX
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Mary C. Hooke, PhD APRN PCNS FAAN CPON®
Associate Professor
University of Minnesota School of Nursing
Minneapolis, MN
Margie Kjellin, MSN RN NE-BC CPHON®
Director of Inpatient Nursing
St. Jude Children’s Research Hospital
Memphis, TN
Danielle Marcello, MSN RN-BC
Nurse Manager
Goryeb Children’s Hospital
Morristown, NJ
Colleen Nixon, MSN RN CPHON®
Hematology/Oncology Clinical Educator
Boston Children’s Hospital
Boston, MA
Lissa Pocze, MSN RN CPNP CPON®
Randall Children’s Hospital at Legacy Emanuel
Portland, OR
Elaine Pottenger, MS RN CPNP PMHS
Pediatric Nurse Practitioner
Memorial Sloan Kettering Cancer Center
New York, NY
Mary Lynn Rae, MSN RN CPHON®
Nursing Professional Development Practitioner/Clinical Educator: Hematology/Oncology/Stem Cell Transplantation
Ann and Robert H. Lurie Children’s Hospital of Chicago
Chicago, IL
Maritza Salazar-Abshire, MEd MSN RN CPON®
Senior Nursing Instructor
University of Texas MD Anderson Cancer Center
Houston, TX
Patricia Wills-Bagnato, MSN RN CPNP CPHON®
Assistant Professor, Baylor College of Medicine
Texas Children’s Cancer and Hematology Centers
Associate Director–Clinical Division, Advanced Practice Providers
Houston, TX
ConsultantsCaroline Anderson, MSN RN CPHON®
Clinical Practice and Advanced Education Specialist
Cook Children’s Medical Center
Fort Worth, TX
Seth Eisenberg, RN OCN BMTCN®
Professional Practice Coordinator, Infusion Services
Seattle Cancer Care Alliance
Seattle, WA
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Chapter 1
Introduction and Standards
IntroductionThe Association of Pediatric Hematology/Oncology Nurses (APHON) is dedicated to promoting excellence in the care of children, adolescents, and young adults with cancer and other hematologic disorders and their families. APHON activities aimed at improving the quality of nursing care for this population include defining practice standards, devel-oping premier publications, and offering state-of-the-art conferences.
Safe and consistent administration of chemotherapy and biotherapy is a fundamental component of the care pro-vided by pediatric oncology nurses. To promote consistency in the practice of chemotherapy and biotherapy adminis-tration, APHON developed the Pediatric Chemotherapy and Biotherapy Provider Program. This program has been created to provide nurses with the theoretical knowledge base and key principles needed to safely and competently administer chemotherapy and biotherapy to children, adolescents, and young adults.
The objectives of the Pediatric Chemotherapy and Biother-apy Provider Program are
1. to establish education and practice standards for the administration of chemotherapy and biotherapy to children, adolescents, and young adults
2. to promote consistent practices in the administration, safe handling, and monitoring of side effects of chemotherapy and biotherapy to pediatric and adolescent and young adult (AYA) oncology patients.
THE PEDIATRIC CHEMOTHERAPY AND BIOTHERAPY PROVIDER PROGRAMThe Pediatric Chemotherapy and Biotherapy Provider Pro-gram has three components: a curriculum, a provider course, and an instructor course.
The Pediatric Chemotherapy and Biotherapy CurriculumThe Pediatric Chemotherapy and Biotherapy Curriculum is a comprehensive program of study that provides the spe-cific knowledge needed by registered nurses to safely care for children, adolescents, and young adults receiving
chemotherapy and biotherapy. Relevant content includes cancer cell characteristics; pharmacokinetics; classification of antineoplastic agents and their side effects; safe handling of these agents; administration issues related to specific agents and the pediatric and AYA population; and assessing, man-aging, and teaching the patient and family about the side effects of chemotherapy and biotherapy. This curriculum is the foundation for the Provider Program.
The Pediatric Chemotherapy and Biotherapy Provider CourseThe Pediatric Chemotherapy and Biotherapy Provider Course is a didactic course designed to provide pediatric hematol-ogy, oncology, and stem cell transplant nurses with a stan-dardized, evidence-based framework of essential information and resources to help them increase their knowledge, con-fidence, and competence to safely and ethically care for children, adolescents, and young adults who are receiving chemotherapy and biotherapy. After course attendance and successful completion of an online exam, participants will be issued a pediatric and AYA chemotherapy and biotherapy provider card. The provider card is issued by APHON and is initially valid for 2 years. Subsequent renewals are valid for 3 years. The provider card indicates that the nurse has the knowledge required to administer chemotherapy and bio-therapy. A provider card is not a certification. Possession of a provider card does not ensure clinical competence. APHON recommends that clinical competence be validated at the institutional level annually. See Appendix A for examples of chemotherapy administration competency checklists.
The Pediatric Chemotherapy and Biotherapy Instructor CourseThe Pediatric Chemotherapy and Biotherapy Instructor Course is a 1-day course focusing on the review of adult education principles, demonstration of effective teaching strategies, discussion of course administrative requirements, and in-depth review of the provider course teaching mate-rials. The instructor candidate who successfully completes the instructor course will receive an instructor card issued by APHON, stipulating that he or she has met the requirements to teach the Pediatric Chemotherapy and Biotherapy Pro-vider Course. Instructor qualifications are reviewed annually
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2 The Pediatric Chemotherapy and Biotherapy Curriculum: Fourth Edition
by APHON, and instructors are required to meet specific requirements in order to maintain active instructor status.
Standards for Practice and EducationIn conjunction with the Chemotherapy and Biotherapy Pro-vider Program, APHON has established practice and educa-tion standards for the administration of chemotherapy and biotherapy to children, adolescents, and young adults with cancer.
STANDARD FOR PRACTICEChemotherapy and biotherapy for children, adolescents, and young adults should be administered by registered nurses who have completed the APHON Pediatric Chemotherapy and Biotherapy Provider Course and a clinical practicum.
STANDARD FOR EDUCATIONSafe and consistent administration of chemotherapy and bio-therapy to children, adolescents, and young adults requires specific knowledge and specialized skills.
The Pediatric Chemotherapy and Biotherapy Provider Course covers the specific knowledge required through a didactic course and an online exam. A pediatric chemother-apy and biotherapy provider is a registered nurse who has successfully completed the APHON Pediatric Chemother-apy and Biotherapy Provider Course and has passed the exam with a score of 80% or higher. In addition to the didac-tic course, APHON recommends a clinical practicum by the nurse’s employer to validate the clinical skills used in the administration of chemotherapy and biotherapy.
Pediatric chemotherapy and biotherapy provider status must initially be renewed after 2 years. Subsequent renewals
are required at 3-year intervals. Renewal is obtained by suc-cessfully completing a review module and an online exam. Annual education specific to the administration of chemo-therapy and biotherapy and skill validation by employers are recommended.
A pediatric chemotherapy and biotherapy instructor is a registered nurse and APHON member who has successfully completed both the Pediatric Chemotherapy and Biotherapy Provider Course and the Pediatric Chemotherapy and Bio-therapy Instructor Course.
Requirements for a pediatric chemotherapy and biotherapy instructor include
• 2 years of clinical experience
• current national APHON membership
• current certification as a certified pediatric oncology nurse(CPON®) or certified pediatric hematology/oncology nurse(CPHON®)
• bachelor’s or graduate degree (preferred).
To maintain instructor status, the instructor must
• conduct a minimum of one provider course per year
• maintain an average score of 2.5 or higher on courseevaluations
• comply with APHON Pediatric Chemotherapy and Bio-therapy Provider Program policies and procedures
• maintain national APHON membership
• maintain current APHON Pediatric Chemotherapy andBiotherapy Provider and Instructor cards
• maintain CPON® or CPHON® certification.
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