The process of learning about chemotherapy is indeed a challenge. The e this clients need in order to survive their disease and its treatment and hopefully to go on with their lives with as few physical and emotional scars as possible.
Nursing Care of PatientsUndergoing Chemotherapy Nelia B. Perez RN, MSN
• Nursing management of the patient receiving chemotherapy requires knowledge about the treatment , skill in assessment, technical expertise, ability and reward in meeting this is to be able to provide the care desired to support the client physically and emotionally.
• Nursing care begins with a thorough understanding of the patients condition; goal of therapy , drug dose, route, schedule, administration principles; and potential side effects.
• Additional nursing management includes monitoring responses to the therapy, reassessing and documenting signs and symptoms, and communicating pertinent information to other members of the health care team.
Chemotherapy is the use ofcytotoxic drugs in the treatment of cancer. It is one of the fourmodalities- surgery, radiationtherapy, chemotherapy andbiotherapy- that provide cure,control, or palliation.Chemotherapy is systemic asopposed to localized therapysuch as surgery & radiationtherapy.
ROLE OF A NURSEPrior to chemotherapy administration1 Review- The chemotherapy drugsprescription which should have-Name of anti-neoplastic agent.-Dosage-Route of administration-Date and time that each agent to beadministered.2. Accurately identify the client3.Medications to be administered inconjunction with the chemotherapy e.gantiemetics, sedatives etc.
4.. Assess the clients condition including - Most recent report of blood countsincluding hemoglobin ,hematocrit, whiteblood cells and platelets. -Presence of any complicating conditionwhich could contraindicate chemotherapeuticagent administration i.e. infection, severestomatitis , decreased deep tendon reflexes,or bleeding .-Physical status-Level of anxiety-Psychological status.
5. Prepare for potential complicationsReview the policy and havemedication and supplies available forimmediate intervention the event ofextravasation.Review the procedure and havemedication available for possibleanaphylaxis
6.Assure accurate preparation of theagent -Accuracy of dosage calculation -Expiry date of the drug to bechecked -Procedure for correctreconstitution and -Recommended procedures for administration7.Assess patients understanding of thechemotherapeutic agents andadministration procedures.
II. Calculation of drug dosageIt is calculated based on body surface area.III. Drug reconstitution/Preparation-Pharmacy staff should reconstitute all drugspre-prime the intravenous tubing under aclass II biologic safety cabinet(BSC). Incertain conditions nurses may be required toreconstitute medications. When preparingand reconstituting safe handling guidelinesto be followed.
-All chemotherapeutic drug should beprepared according to package insert inclass II BSC.-Aseptic technique should be followed.-Personal protective equipmentincludes disposable surgical gloves,long sleeves gown and elastic or knitcuffs.-Protective eye goggles if no BSC-To minimize exposure-Wash hands before and after drughandling.-Limit access to drug preparation area
-Keep labeled drug spill kit nearpreparation area.-Apply gloves before drug handling.-Open drug vials/ ampoules away frombody.-Place absorbent pad on work surface.-Wrap alcohol wipe around neck ofampoule before opening.-Cover tip of needle with sterilize gaugewhen expelling air from syringe.-Label all chemotherapeutic drugs. Clean up any spill immediately
IV. Drug administration 1. Route- i)Oral - Emphasize the importance of complianceby the patient with prescribed schedule.Drugs withemetic potential should be taken with meals.Assure that chemotherapeutic agents are stored asdirected by the manufacturer(refrigerate, avoidexposure to direct light,etc). ii) Intramuscular and subcutaenous –Chemotherapeutic agents that can be administeredI/M or subcutaneously are few in number. Non-vesicants like L-asperaginase, bleomycin,cyclophosphamide, methotraxate. Cyta arabine,andsome hormonal agents are given I/M & /Orsubcutaneously.
-Use the smallest gauge needlepossible for the viscosity of themedication. -Change the needle afterwithdrawing the agent from a vial orampoule.-Select a site with adequate muscleand/or SC tissue.
• iii) Intravenous – It is the most common method of administration of cancer chemotherapy. May be given through central venous catheters or peripheral access. Absorption is more reliable. This route is required for administration of vesicants and it also reduces the need of repeated injection. Because the I/V provides direct access to the circulatory system, the potential for infection and life threatening sepsis is a serious complication of I/V chemotherapy.
The following guidelines to be kept in mind:-Inspect the solution, container and tubing forsigns of contamination including particles,discoloration, cloudiness, and cracks or tears inbottle or bag-Aseptic technique to be followed-Prepare medicines according to manufacturer’sdirections-Select a suitable vein-Large veins on the forearm are the preferred site.-Use distal veins first, and choose a vein aboveareas of flexion.-For non-vesicant drugs, use the distal veins ofthe hands (metacarpal veins): then the veins ofthe forearms(basilic and cephalic veins)
-For vesicants, use only the veins of theforearms. Avoid using the metacarpal andradial areas. -Avoid the antecubital fossa and thewrist because an extravasation in these areascan destroy nerves and tendons, resulting inloss of function.-Peripheral sites should be changed dailybefore administration of vesicants-Avoid the use of small lumen veins toprevent damage due to friction and thedecreased ability to dilute acidic drugs andsolutions. Select the shortest catheter withthe smallest gauge appropriate for the typeand duration of the infusion (21g to 25g for I/Vmedications and 19 g for blood products).
-Avoid a vein which has been used forvenous access within the past 24 hrs toprevent leakage from a prior puncturesite.Prevent trauma and infection at theinsertion site. -Apply a small amount of iodinebased antiseptic ointment over theinsertion site & cover the area withsterile gauze.Intravenous Chemotherapy Via CentralVein Infusion (Hickman Catheter)
A Hickman catheter is a flexiblepolymeric silicon rubber catheter whichis threaded through the cephalic veinand into the superior vena cava orthrough the venacava and into the rightatrium of the heart. Placement in a largevein permits the use of a catheter largeenough for infusion of chemotherapy,hyper osmolar fluids for nutritionpurposes, blood products and otherneeded intravenous fluids.
The silicon rubber material of catheteris chemically inert to preventdecomposition and it is anti-thrombogenicA felt cuff near the exit site anchors thecatheter on the patient’s chest and actsas an anatomic barrier to prevent entryof infection causing agents.It is either single lumen or double-lumen.IV) Intra-arterialV)Intra-peritoneal
VI)Intrathecal- Infusion of medication can begiven through an Ommaya reservoir, implantable pump and /or usually through lumbar puncture. a)Wear protective equipment (gloves, gownand eyewear). b)Inform the patient that chemotherapeuticdrugs are harmful to normal cells and thatprotective measures used by personnel minimizetheir exposure to these drugs. c)Administer drugs in a safe and unhurried environment.
d)Place a plastic backed absorbent padunder the tubing during administration tocatch any leakage. Do not dispose of any supplies orunused drugs in patient care areas.V. DocumentationRecord-chemotherapeutic drugs, dose, route ,andtime-Premedications, postmedications,prehydration and other infusions and suppliesused for chemotherapy regimen.-Any complaints by the patient of discomfortand symptoms experienced before, during,and after chemotherapeutic infusion.
VI. Disposal of supplies and unused drugs a)Do not clip or recap needles or break syringes. b)Place all supplies used intact in a leak proof ,puncture proof, appropriatelabeled container. c)Place all unused drugs in containers ina leak proof, puncture proof, appropriatelylabeled container. d)Dispose of containers filled with chemotherapeutic supplies andunused drugs in accordance withregulations of hazardous wastes.
VII. Management ofchemotherapeutic spillsChemotherapy spills should becleaned up immediately byproperly protected personneltrained in the appropriateprocedure. A spill should beidentified with a warning sign sothat other person will not becontaminated.
Supplies RequiredChemotherapy spill kit containsRespirator mask for air borne powderspillsPlastic safety glasses or gogglesHeavy duty rubber glovesAbsorbent pads to contain liquid spillsAbsorbent towels for clean up after spillsSmall scoop to collect glass fragmentsTwo large waste disposal bags
Protective disposable gownContainers of detergent solution and clear tapwater for post spill clean up.Puncture proof and leak proof containerapproved for chemotherapy waste disposalApproved, specially labeled, imperviouslaundry bag.Spill on hard surfaceRestrict area of spillObtain drug spill kitPut on protective gown, gloves, gogglesOpen waste disposal bagsPlace absorbent pads gently on the spill; becareful not to touch spill.
Spill on hard surfaceRestrict area of spillObtain drug spill kitPut on protective gown, gloves,gogglesOpen waste disposal bagsPlace absorbent pads gently on thespill; be careful not to touch spill.
Place absorbent pad in waste bagCleanse surface with absorbenttowels using detergent solution andwipe clean with clean tap water.Place all contaminated materials inthe bag.Wash hands thoroughly with soapand water.
Spill on personnel or patientRestrict area of spillObtain drug spill kitImmediately remove contaminatedprotective garments or linenWash affected skin area with soap andwaterIf eye exposure-immediately flood theaffected eye with water for at least 5 mts;obtain medical attention promptlyNotify the physician if drug spills onpatient.Documentation- Document the spill.
VIII. Staff EducationAll personnel involved in the care shouldreceive an orientation to chemo. Drugsincluding their known risk , relevanttechniques and procedures for handling,the proper use of protective equipmentand materials, spill procedures, andmedical policies covering personnelhandling chemo. agents.Personnel handling blood, vomitus, orexcreta from patients who have receivedchemotherapy should wear disposablegloves and gowns to be appropriatelydiscarded after use.
IX. Extravasation managementExtravasation is the accidental infiltrationof vesicant or irritant chemotherapeuticdrugs from the vein into the surroundingtissues at the I/V site. A vesicant is anagent that can produce a blister and /ortissue destruction. An irritant is an agentthat is capable of producing venous painat the site of and along the vein with orwithout an inflammatory reaction. Injuriesthat may occur as a result ofextravasation include sloughing oftissue , infection, pain ,and loss ofmobility of an extremity.
1.Prevention of extravasationNursing responsibilities for the preventionof extravasation include the followingKnowledge of drug s with vesicantpotentialSkill in drug administrationIdentification of risk factors e.g. multiplevene puncturesAnticipation of extravasation andknowledge of management protocolNew venepuncture site daily if peripheralaccess is used
Central venous access for 24 hrs vesicantsinfusionAdministration of drug in a quiet, unhurriedenvironmentTesting vein patency without usingchemotherapeutic agentsProviding adequate drug dilutionCareful observation of access site andextremity throughout the procedureEnsuring blood return from I/V site before,during, and after vesicant drug infusion.Educating patients regarding symptoms ofdrug infiltration , e.g. pain, burning, stingingsensation at I/V site.
2.Extravasation management atperipheral site-According to agencypolicy and approved antidote should bereadily available.The following procedure should beinitiated-Stop the drugLeave the needle or catheter in placeAspirate any residual drug and blood inthe I/V tubing, needle or catheter, andsuspected infiltration siteInstill the I/V antidoteRemove the needle
If unable to aspirate the residual drug from the IVtubing , remove needle or catheterInject the antidote sub-cutaneously clockwise into theinfiltrated site using 25 gauge needle; change theneedle with each new injectionAvoid applying pressure to the suspected infiltrationsiteApply topical ointment if orderedCover lightly with an occlusive sterile dressingApply cold or warm compresses as indicatedElevate the extremityObserve regularly for pain, erythema, induration,and necrosisDocumentation of extravasation management. All nursing personnel should be alert and preparedfor the possible complication of anaphylaxis.
X. Nursing Management of commonside effects of Chemotherapeuticdrugs..Nausea & Vomiting –Nausea is the conscious recognition ofthe subconscious excitation of an area ofthe medulla closely associated with orpart of the vomiting center. Nausea maycause the desire to vomit & it oftenprecedes or accompanies vomiting.
Avoid eating/drinking for 1-2 hrs prior toand after chemotherapy administrationEat frequent, small meals. Avoid greasy& fatty foods and very sweet foods &candies.Avoid unpleasant sights, odors & testesFollow a clear liquid dietIf vomiting is severe inform thephysician.Consider diversionary activities
Sip liquids slowly or suck ice cubesand avoid drinking a large volumeof water if vomiting is presentAdminister antiemetics to prevent orminimize nausea. Patient mayrequire routine antiemetics for 3-5days following some protocols.Monitor fluid and electrolyte status.Provide frequent, systemic mouthcare.
.Bone marrow Depression – This canlead to-Anaemia-Bleeding due to thrombocytopenia-Infection due to leukopeniaNursing ActionsAdminister packed RBC according to thephysician orders.Monitor hematocrit and haemoglobinespecially during drug nadirMaintain the integrity of the skin
Avoid activities with the greatest potential forphysical injuryUse an electric razor when shavingAvoid the use of tourniquetsEat a soft, bland diet, avoid foods that arethermally, mechanically and chemicallyirritating.Maintain the integrity of the mucousmembranes of G I tractPromote hydrate to avoid constipationAvoid enemas, harsh laxatives & the use ofrectal thermometers.Take steroids with an antacid or milk.
Avoid sources of infectionMaintain good personal hygiene.Prevent trauma to skin & mucousmembranesReport s/s of infection to physicianMonitor countsAvoid invasive procedures, no ……Raise the arm while pressure isapplied after removal of a needle orcatheter
.AlopeciaExplain hair loss is temporary, and hair willgrow when drug is stopped.Use a mild, protein based shampoo, hairconditioner every 4-7 daysMinimize the use of an electric dyer.Avoid excessive brushing and combing of theair. Combing with a wide –tooth comb ispreferred.Select wig, cap, scarf or turban before hairloss occurs.Keep head covered in summer to preventsunburn and in winter to prevent heat loss.
Fatigue - Assess for possible causeschronic pain, stress, depression and in-sufficient rest or nutritional intake. -Conserve energy & rest whentired-Plan for gradual accommodation ofactivities.-Monitor dietary & fluid intake daily.Drink 3000 ml of fluid daily, unlesscontra-indicated, in order to avoid theaccumulation of cellular waste products.
AnorexiaFreshen up before mealsAvoid drinking fluids with meals to preventfeeling of fullnessHigh protein dietMonitor and record weight weekly. Reportweight loss
Stomatitis (Oral) – -Symptoms occur 5-7 days afterchemotherapy & persist upto 10 days -Continue brushing regularly withsoft tooth brush -Use non irritant mouthwash -Avoid irritants to the mouth -Maintain good nutritional intake, eatsoft or liquid foods high in protein
-Follow prescribed medicationschedule e.g. drug for oralcandidiasis. -Report physician if symptompersists -Increase the frequency of oralhygiene every 2 hrs-Glycerin & lemon juice should neverbe used to clear mouth or teeth as itcause the tissues to become dry&irritated.
Diarrhea- Some clients experiencediarrhea during and after treatment withchemotherapy.Nursing Action –Monitor number, frequency andconsistency of diarrhea stools.Avoid eating high roughage, greasy andspicy food alcoholic beverages, tobaccoand caffeine productsAvoid using milk productsEat low residue diet high in protein andcalories
Include food high in potassium if fatigueis present like bananas, baked potatoes.Drink 3000 ml of fluid each day.Eat small frequent meals ; eat slowlyand chew all food thoroughlyClean metal area after each bowelmovement.Administer anti-diarrheal agents asprescribed.
Depression –Assess for changes in mood andaffect.Set small goals that are achievabledailyParticipate e.g. music, reading,outingsShare feelingsReassurance
.Cystitis-Is an inflammation of the bladder,which is usually caused by aninfection. Sterile cystitis not inducedby infection. Sterile cystitis notinduced by infection, can be a sideeffect of radiation therapy or due tocyclophosphamide (endoxan)administration. The metabolites ofcyclophosphamide are excreted bythe kidneys in the urine
Nursing ActionsFluid intake at least 3000 ml dailyEmpty Bladder as soon as the urgeto void is experienced.Empty bladder at least every 2-4 hrs.Urinate at bed time to avoidprolonged exposure of the bladderwall to the effects of cytoxan whilesleeping.
Take oral cytoxan early in the morning todecrease the drug concentration in thebladder during the nightReport increasing symptoms of frequencybleeding burning on urination, pain fever andchills promptly to physicianFollowing comfort measures can be adoptedif cystitis is present-Ensure dilute urine by increasing the fluidintakeAvoid foods & beverages that may causeirritation to the bladder – alcohol, coffee,strong tea, Carbonated beverages etc.
Outpatient Chemotherapy DeliveryAggressive, complex andsophisticated cancer therapies arecurrently being in ambulatory &home care settings. This shift isprovision of services from theHospital setting is a result o cost-containment efforts, advancedtechnology, competition & increasedcompetence of nurses.
Conclusion – Chemotherapyoffers patients with cancer agreat deal of hope for a cureor a means to control cancerfor a long period of time.Hope and optimism are vitalingredients in care plan.