Lec # 4 oncology ccn


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Lec # 4 oncology ccn

  1. 1. ONCOLOGY NURSINGONCOLOGY NURSING ByBy Yasmeen RahimYasmeen Rahim
  2. 2. OBJECTIVES:OBJECTIVES: By the end of this presentation, learnersBy the end of this presentation, learners will be able to:will be able to:  Define 7 cardinal signs of cancer.Define 7 cardinal signs of cancer.  Differentiate between benign andDifferentiate between benign and malignant tumor.malignant tumor.  Discuss goals of cancer therapy.Discuss goals of cancer therapy.  Explain in detail about the surgery,Explain in detail about the surgery, radiation therapy and chemotherapyradiation therapy and chemotherapy along with there nursing interventions.along with there nursing interventions.
  3. 3. 7 WARNING SIGNS OF7 WARNING SIGNS OF CANCERCANCER  C=C= change in bowel / bladder habitschange in bowel / bladder habits  A=A= a sore throat that does not heala sore throat that does not heal  U=U= unusual bleedingunusual bleeding  T=T= thickening or lump in breastthickening or lump in breast  I=I= indigestion / difficulty in swallowingindigestion / difficulty in swallowing  O=O= obvious change in warts or molesobvious change in warts or moles  NN= nagging, cough and hoarseness= nagging, cough and hoarseness
  4. 4. Malignant tumorMalignant tumor  Rapid growthRapid growth  Invasive growthInvasive growth  PoorlyPoorly demarcateddemarcated  InvasionInvasion  MetastasisMetastasis  Life threateningLife threatening DIFFERENCE BETWEEN BENIGN AND MALIGNANT TUMORS Benign tumorBenign tumor  Slow growthSlow growth  Expansive growthExpansive growth  Well demarcatedWell demarcated  No invasionNo invasion  No metastasisNo metastasis  Rarely a life threatRarely a life threat
  5. 5. GOAL OF CANCER THERAPYGOAL OF CANCER THERAPY  Treatment goals may includeTreatment goals may include the followingthe following  CURATIVE:CURATIVE: treatment shouldtreatment should completely eradicate thecompletely eradicate the malignant disease.malignant disease.  CONTROL:CONTROL: managementmanagement should prolong patient survivalshould prolong patient survival and inhibition of cancer cellsand inhibition of cancer cells growth.growth.  PALLIATION:PALLIATION: effectiveeffective symptomatic treatment shouldsymptomatic treatment should be given to the patients.be given to the patients.
  6. 6. Cont.Cont.  Our main goal for cancer therapyOur main goal for cancer therapy is to improveis to improve ““QUALITY OFQUALITY OF LIFE”LIFE” of patients.of patients.
  7. 7. MEDICAL MANAGEMENTMEDICAL MANAGEMENT  SurgerySurgery  Radiation therapyRadiation therapy  ChemotherapyChemotherapy
  9. 9. Cont.Cont.  Nursing care of the patient undergoingNursing care of the patient undergoing surgery for cancer includes fosteringsurgery for cancer includes fostering the patient's understanding of thethe patient's understanding of the specific procedure and expectedspecific procedure and expected outcome, preparing the patientoutcome, preparing the patient physically and psychologically for thephysically and psychologically for the surgery, reducing anxiety, supportingsurgery, reducing anxiety, supporting the patient's postoperative physiologicthe patient's postoperative physiologic stability, relieving pain, preventingstability, relieving pain, preventing complications, and promotingcomplications, and promoting compliance with postoperativecompliance with postoperative instructions.instructions.
  10. 10. Cont.Cont.  Cancer patients who areCancer patients who are undergoing surgery requireundergoing surgery require general perioperative nursinggeneral perioperative nursing care.care.  When surgery is used with otherWhen surgery is used with other treatment methods liketreatment methods like chemotherapy and radiationchemotherapy and radiation therapy then postoperativetherapy then postoperative complications like infection,complications like infection, impaired wound healing, DVT,impaired wound healing, DVT, altered renal and pulmonaryaltered renal and pulmonary functions can be expected.functions can be expected.
  11. 11. Cont.Cont.  Nurse should provide educationNurse should provide education and emotional support to patientand emotional support to patient and their family by assessingand their family by assessing the needs.the needs.  Nurse should discuss their fearsNurse should discuss their fears and coping mechanisms withand coping mechanisms with them.them.  Nurse should encourage patientNurse should encourage patient and family to participate activelyand family to participate actively in decision making process.in decision making process.
  12. 12. Cont.Cont.  When patient or family ask about the results of diagnostic testing and surgical procedures then nurse’s response is guided by the information which physician has previously conveyed to the patient and family.  Nurse should frequently communicate with other health care team members to be certain that the information provided is consistent.
  13. 13. Cont.Cont.  After surgery nurse should assessAfter surgery nurse should assess patient’s response to surgery andpatient’s response to surgery and monitor patient for possiblemonitor patient for possible complications like hemorrhage, fluidcomplications like hemorrhage, fluid electrolyte imbalance,electrolyte imbalance, thrombophlebitis, homodynamicthrombophlebitis, homodynamic instability and organ dysfunction.instability and organ dysfunction.  Postoperative teachings regardingPostoperative teachings regarding self care, nutrition, wound care andself care, nutrition, wound care and medications should be addressedmedications should be addressed properly.properly.
  14. 14. Cont.Cont.  Nurses have a responsibility toNurses have a responsibility to coordinate early dischargecoordinate early discharge planning and home care, asplanning and home care, as indicated, to ensure continuity ofindicated, to ensure continuity of care.care.  Referrals must be sent toReferrals must be sent to appropriate professionals andappropriate professionals and community support services.community support services.
  15. 15. BASIC FACTORS INBASIC FACTORS IN RADIATION PROTECTIONRADIATION PROTECTION  DISTANCE:DISTANCE: greater distancegreater distance from source, less exposure tofrom source, less exposure to radiation.radiation.  TIME:TIME: try to spend less time withtry to spend less time with in close contact with patient.in close contact with patient.  SHIELDING:SHIELDING: use appropriateuse appropriate material to absorb radiationmaterial to absorb radiation energy like lead aprons, glass orenergy like lead aprons, glass or aluminum shields or rubberaluminum shields or rubber gloves.gloves.
  16. 16. TOXIC EFFECTS OFTOXIC EFFECTS OF RADIATION & NURSINGRADIATION & NURSING MANAGEMENTMANAGEMENT  MAINTAIN TISSUE INTEGRITY:MAINTAIN TISSUE INTEGRITY:  Handle skin gently.Handle skin gently.  Inspect skin for integrity and doInspect skin for integrity and do frequent reassessmentsfrequent reassessments  Do NOT rub affected areaDo NOT rub affected area  Avoid using ointments, powders orAvoid using ointments, powders or lotion.lotion.  Wash skin only with moisturizing soapWash skin only with moisturizing soap and waterand water  Protect skin from exposure to sunlight, chlorinated swimming pools, extreme temperature.
  17. 17. Cont.Cont.  ALOPECIA:ALOPECIA:  Alopecia begins within 2 weeks ofAlopecia begins within 2 weeks of therapytherapy  Regrowth within 8 weeks ofRegrowth within 8 weeks of terminationtermination  Encourage to acquire wig before hairEncourage to acquire wig before hair loss occursloss occurs  Encourage use of attractive scarvesEncourage use of attractive scarves and hatsand hats  Provide information that hair loss isProvide information that hair loss is temporary BUT anticipate change intemporary BUT anticipate change in texture and colortexture and color
  18. 18. Cont.Cont.  STOMATITIS:STOMATITIS:  Use soft-bristled toothbrushUse soft-bristled toothbrush  Gentle oral hygiene is essential toGentle oral hygiene is essential to remove debris, prevent irritation andremove debris, prevent irritation and promote healing.promote healing.  Oral rinses with saline gargles/ tapOral rinses with saline gargles/ tap waterwater  Avoid ALCOHOL-based rinsesAvoid ALCOHOL-based rinses  Frequent reassurance thatFrequent reassurance that symptoms are a result of treatmentsymptoms are a result of treatment and do not represent deterioration ofand do not represent deterioration of disease.disease.
  19. 19. Cont.Cont.  PROMOTE NUTRITION:PROMOTE NUTRITION:  Serve food in ways to make itServe food in ways to make it appealingappealing  Consider patient’s preferencesConsider patient’s preferences  Provide small frequent mealsProvide small frequent meals  Avoids giving fluids while eatingAvoids giving fluids while eating  Oral hygiene PRIOR toOral hygiene PRIOR to mealtimemealtime  Vitamin supplementsVitamin supplements
  20. 20. Cont.Cont.  RELIEVE PAIN:RELIEVE PAIN:  Mild pain- NSAIDSMild pain- NSAIDS  Moderate pain- Weak opioidsModerate pain- Weak opioids  Severe pain- MorphineSevere pain- Morphine  Administer analgesics round theAdminister analgesics round the clock with additional dose forclock with additional dose for breakthrough painbreakthrough pain
  21. 21. Cont.Cont.  DECREASE FATIGUE:DECREASE FATIGUE:  Plan daily activities to allowPlan daily activities to allow alternating rest periodsalternating rest periods  Light exercise is encouragedLight exercise is encouraged  Small frequent mealsSmall frequent meals
  22. 22. Cont.Cont.  RADIATION SICKNESS:RADIATION SICKNESS:  Bed restBed rest  Small frequent feedingsSmall frequent feedings  Increased calories, increasedIncreased calories, increased protein dietprotein diet  Adequate fluid intakeAdequate fluid intake  Administer vitamins, sedatives,Administer vitamins, sedatives, antihistamine, antiemeticsantihistamine, antiemetics  Monitor intake and outputMonitor intake and output
  23. 23. Cont.Cont.  BONE MARROW DEPRESSION:BONE MARROW DEPRESSION:  Vital signs especially temperatureVital signs especially temperature  CBC monitoringCBC monitoring  Observe signs and symptoms ofObserve signs and symptoms of infectioninfection  Good oral hygiene-prevent gumGood oral hygiene-prevent gum bleeding; use soft-bristle toothbrushbleeding; use soft-bristle toothbrush or non-sting mouthwash.or non-sting mouthwash.
  24. 24. Cont.Cont.  IMPROVE BODY IMAGE:IMPROVE BODY IMAGE:  Therapeutic communication isTherapeutic communication is essentialessential  Encourage independence inEncourage independence in self-care and decision makingself-care and decision making  Offer cosmetic material likeOffer cosmetic material like make-up and wigsmake-up and wigs
  25. 25. Cont.Cont.  ASSIST IN GRIEVINGASSIST IN GRIEVING PROCESS:PROCESS:  Some cancers are curableSome cancers are curable  Grieving can be due to loss ofGrieving can be due to loss of health, income, sexuality, andhealth, income, sexuality, and body imagebody image  Answer and clarify informationAnswer and clarify information about cancer and treatmentabout cancer and treatment optionsoptions  Identify resource peopleIdentify resource people  Refer to support groupsRefer to support groups
  26. 26. CHEMOTHERAPYCHEMOTHERAPY  Use of antineoplastic agents toUse of antineoplastic agents to cure or palliative cancer in ancure or palliative cancer in an attempt to destroying tumorattempt to destroying tumor cells by interfering with cellularcells by interfering with cellular functions.functions.  It is used primarily to treatIt is used primarily to treat systemic disease rather thansystemic disease rather than localized treatment. or as anlocalized treatment. or as an adjuvant therapyadjuvant therapy to reduce tumor size preoperatively, to destroy any remaining tumor cells postoperatively,
  27. 27. ADMINISTRATION OFADMINISTRATION OF CHEMOTHERAPEUTIC AGENTSCHEMOTHERAPEUTIC AGENTS  ROUTES:ROUTES:  TopicalTopical  OralOral  IntravenousIntravenous  IntramuscularIntramuscular  SubcutaneousSubcutaneous  ArterialArterial  IntracavitaryIntracavitary  IntrathecalIntrathecal  Dosage:Dosage:  Based on theBased on the total bodytotal body surface areasurface area  PreviousPrevious response toresponse to chemotherapychemotherapy or radiationor radiation therapytherapy  Functions ofFunctions of major organmajor organ system.system.
  28. 28. Cont.Cont.  Extravasations is a seriousExtravasations is a serious problem and has to beproblem and has to be monitored carefully whilemonitored carefully while administration ofadministration of vesicantsvesicants (agents that deposited into(agents that deposited into subcutaneous tissue and causesubcutaneous tissue and cause tissue necrosis and damage totissue necrosis and damage to underlying tendons, nerves andunderlying tendons, nerves and blood vessels).blood vessels).
  29. 29. Cont.Cont.  Indications for extravasations are asIndications for extravasations are as followfollow  Absence of blood return fromAbsence of blood return from intravenous catheter.intravenous catheter.  Resistance to blood flow ofResistance to blood flow of intravenous fluid.intravenous fluid.  Swelling, pain or redness at the site.Swelling, pain or redness at the site.  If it is suspected then medicationIf it is suspected then medication administration should beadministration should be STOP immediately, ice should be applied, ice should be applied and we have to notify physician as heand we have to notify physician as he has to aspirate the infiltratedhas to aspirate the infiltrated medication.medication.
  30. 30. TOXIC EFFECTS OFTOXIC EFFECTS OF CHEMOTHERAPEUTIC AGENTSCHEMOTHERAPEUTIC AGENTS  Gastrointestinal system:Gastrointestinal system: nausea /nausea / vomiting, stomatitis, anorexia,vomiting, stomatitis, anorexia, mucositis of GI tract, diarrhea.mucositis of GI tract, diarrhea.  Hematopoietic system:Hematopoietic system: bone marrowbone marrow depression leading to leukemiadepression leading to leukemia (WBC) , anemia (RBC) and(WBC) , anemia (RBC) and thrombocytopenia (platelets).thrombocytopenia (platelets).  Renal system:Renal system: damage to kidney,damage to kidney, hyperkalemia, hyperphosphatemia,hyperkalemia, hyperphosphatemia, hypocalcemia so have to monitorhypocalcemia so have to monitor serum electrolytes.serum electrolytes.
  31. 31. Cont.Cont.  Cardiopulmonary system:Cardiopulmonary system: irreversibleirreversible cardiac toxicities, so have to closelycardiac toxicities, so have to closely monitor ejection fraction (volume of bloodmonitor ejection fraction (volume of blood with each heart beat) and signs of heartwith each heart beat) and signs of heart failure.failure.  Reproductive system:Reproductive system: testicular andtesticular and ovarian functions are affected.ovarian functions are affected. Reproductive cell are damaged resulting iReproductive cell are damaged resulting i chromosomal abnormalities in offsprings.chromosomal abnormalities in offsprings.  Integumentary system:Integumentary system: alopecia, localalopecia, local skin irritation.skin irritation.
  32. 32. Cont.Cont.  Neurologic system:Neurologic system: neurologicneurologic damage can occur withdamage can occur with repeated doses. Peripheralrepeated doses. Peripheral neuropathies, loss of DT,neuropathies, loss of DT, hearing losshearing loss and paralytic ileusand paralytic ileus may occur.may occur.  Miscellaneous:Miscellaneous: Fatigue whichFatigue which can affect quality of life.can affect quality of life.
  33. 33. NURSING MANAGEMENT INNURSING MANAGEMENT IN CHEMOTHERAPYCHEMOTHERAPY  The goal of nursing interventions isThe goal of nursing interventions is to prevent or minimize side effectsto prevent or minimize side effects caused by cancer treatments.caused by cancer treatments.  Providing nursing care to patientsProviding nursing care to patients receiving chemotherapy presentsreceiving chemotherapy presents many challenges.many challenges.  Antineoplastic drugs have systemicAntineoplastic drugs have systemic effects on normal cells as well aseffects on normal cells as well as on malignant cells, thereforeon malignant cells, therefore chemotherapy usually affect manychemotherapy usually affect many body systems.body systems.
  34. 34. Cont.Cont.  The nurse must have knowledge ofThe nurse must have knowledge of the pharmacology of antineoplasticthe pharmacology of antineoplastic agents, proper techniques of drugagents, proper techniques of drug preparation and administration, drugpreparation and administration, drug interactions, and possible adverseinteractions, and possible adverse effects of individual agents.effects of individual agents.  The nurse must be skilled in theThe nurse must be skilled in the technique of venipuncture and thetechnique of venipuncture and the management of various types ofmanagement of various types of venous access devices and drugvenous access devices and drug administration systems.administration systems.
  35. 35. Cont.Cont.  Nurses should prepare patients andNurses should prepare patients and families to manage anticipated sidefamilies to manage anticipated side effects of chemotherapy and to reporteffects of chemotherapy and to report symptoms of potentially serious sidesymptoms of potentially serious side effects early to avoid seriouseffects early to avoid serious consequences.consequences.  An important responsibility of nursesAn important responsibility of nurses involved in the delivery of chemotherapyinvolved in the delivery of chemotherapy is to ensure that the correct dose of theis to ensure that the correct dose of the correct drug is administered by thecorrect drug is administered by the correct route to the right patient.correct route to the right patient.
  36. 36. Cont.Cont.  Nurses frequently triage patientNurses frequently triage patient problems and assist in theproblems and assist in the evaluation of symptoms andevaluation of symptoms and initiation of interventionsinitiation of interventions  Subjective and objective data,Subjective and objective data, including information about theincluding information about the last chemotherapy treatmentlast chemotherapy treatment and knowledge of the patient'sand knowledge of the patient's history, guide the nurse inhistory, guide the nurse in determining the patient'sdetermining the patient's disposition and treatment.disposition and treatment.
  37. 37. Cont.Cont.  Patient education is facilitatedPatient education is facilitated when side effects are classified aswhen side effects are classified as immediate, early, delayed, andimmediate, early, delayed, and late.late.  Immediate side effects, such asImmediate side effects, such as hypersensitivity reactions, occurhypersensitivity reactions, occur within the first 24 hours.within the first 24 hours.
  38. 38. Cont.Cont.  Diarrhea and alopecia have anDiarrhea and alopecia have an onset of days to weeks and areonset of days to weeks and are considered early side effects.considered early side effects.  Delayed effects, such asDelayed effects, such as anemia or pulmonary fibrosis,anemia or pulmonary fibrosis, occur within weeks to months,occur within weeks to months, and late effects, such as secondand late effects, such as second malignancies, may not appearmalignancies, may not appear for months or years.for months or years.
  39. 39. NURSING DIAGNOSISNURSING DIAGNOSIS  Fear/anxietyFear/anxiety  situational crisissituational crisis  Threat to/change in health/socio-Threat to/change in health/socio- economic status, role functioning,economic status, role functioning, interaction patterninteraction pattern  Threat of deathThreat of death  Separation from familySeparation from family  Grieving, anticipatoryGrieving, anticipatory  Loss of physiologic well being (loss ofLoss of physiologic well being (loss of body part, change in body functionbody part, change in body function  Perceived potential deathPerceived potential death
  40. 40. NURSING DIAGNOSISNURSING DIAGNOSIS  Situational low self-esteemSituational low self-esteem  BiophysicalBiophysical  PsychosocialPsychosocial  Acute/Chronic PainAcute/Chronic Pain  Disease processDisease process  Side-effects of therapeutic agentsSide-effects of therapeutic agents  Altered nutrition, less than bodyAltered nutrition, less than body requirementsrequirements  Hypermetabolic state, consequencesHypermetabolic state, consequences of chemo, radiation, surgery,of chemo, radiation, surgery, emotional distress, fatigue, poor painemotional distress, fatigue, poor pain controlcontrol
  41. 41. NURSING DIAGNOSISNURSING DIAGNOSIS  Risk for fluid volume deficitRisk for fluid volume deficit  FatigueFatigue  Risk for infectionRisk for infection  Risk for altered mucousRisk for altered mucous membranemembrane  Risk for skin/tissue integrityRisk for skin/tissue integrity  Risk for Constipation / diarrheaRisk for Constipation / diarrhea  Risk for Altered sexualityRisk for Altered sexuality patternspatterns
  42. 42. NURSING MANAGEMENTNURSING MANAGEMENT  Assess fluid & electrolytesAssess fluid & electrolytes  Modify risk for infection &Modify risk for infection & bleedingbleeding  Administer chemotherapyAdminister chemotherapy  Protect caregiversProtect caregivers
  43. 43. PATIENT EDUCATIONPATIENT EDUCATION • THROMBOCYTOPENIA • Use soft toothbrush to avoid bleedingUse soft toothbrush to avoid bleeding gumsgums • When shaving, use electric razorWhen shaving, use electric razor • Avoid constipation, enemas, rectal tempsAvoid constipation, enemas, rectal temps • Do not use products that contain aspirin,Do not use products that contain aspirin, NSAIDNSAID • Avoid IM or sc injectionAvoid IM or sc injection • Notify MD/RN if petechiae, bruising, frankNotify MD/RN if petechiae, bruising, frank or tarry stools, change in colour of urine –or tarry stools, change in colour of urine – frank blood, dark amber, bleeding fromfrank blood, dark amber, bleeding from any part of body such as nosebleedany part of body such as nosebleed
  44. 44. Cont. • MINIMIZE SIDE EFFECTS OF NAUSEA AND VOMITING: • Avoid offensive odorsAvoid offensive odors • Small frequent feedings rather thanSmall frequent feedings rather than 3 big meals3 big meals • Adjust oral and fluid intakeAdjust oral and fluid intake • Relaxation exercises, mindRelaxation exercises, mind diversional therapies, etc.diversional therapies, etc.
  45. 45. SPECIAL CONCERNS  BleedingBleeding  Skin problemsSkin problems  Hair lossHair loss  NutritionNutrition  PainPain  FatigueFatigue  PsychosocialPsychosocial statusstatus  Body imageBody image  StomatitisStomatitis  AnorexiaAnorexia  MalabsorptionMalabsorption  Cachexia (lossCachexia (loss of body weight,of body weight, adipose,visceradipose,viscer al proteins,andal proteins,and skeletalskeletal muscle)muscle)
  46. 46. SAFE HANDLINGSAFE HANDLING  Essential to reduce risks toEssential to reduce risks to involved personnel.involved personnel.  Cytotoxic drugs are carcinogenic,Cytotoxic drugs are carcinogenic, mutagenic and teratogenic.mutagenic and teratogenic.
  47. 47. SAFE HANDLING cont’dSAFE HANDLING cont’d Potential exposure to staff occursPotential exposure to staff occurs during:during:  Preparation of medicationPreparation of medication  Administration and changing linesAdministration and changing lines etcetc  Handling of body fluids e.g. urineHandling of body fluids e.g. urine  Handling of chemo waste productsHandling of chemo waste products e.g. lines, medication bottlese.g. lines, medication bottles  Spillage / leakage of chemotherapySpillage / leakage of chemotherapy  TransportationTransportation
  48. 48. PRIOR TO CHEMOTHERAPYPRIOR TO CHEMOTHERAPY ADMINISTRATIONADMINISTRATION 1.1.Review- The chemotherapy drugsReview- The chemotherapy drugs prescription which should haveprescription which should have -Name of anti - neoplastic agent.-Name of anti - neoplastic agent. -Dosage-Dosage -Route of administration-Route of administration -Date and time that each agent to be-Date and time that each agent to be administered.administered. 2.2. Accurately identify the clientAccurately identify the client 3.3.Medications to be administered inMedications to be administered in conjunction with the chemotherapy e.gconjunction with the chemotherapy e.g antiemetics, sedatives etc should also beantiemetics, sedatives etc should also be prepare prior.prepare prior. ROLE OF A NURSEROLE OF A NURSE
  49. 49. 4.4. Assess the clients condition includingAssess the clients condition including - Most recent report of blood counts- Most recent report of blood counts including hemoglobin ,hematocrit, whiteincluding hemoglobin ,hematocrit, white blood cells and platelets.blood cells and platelets. -Presence of any complicating condition-Presence of any complicating condition which could contraindicatewhich could contraindicate chemotherapeutic agent administration i.e.chemotherapeutic agent administration i.e. infection, extravasations, severe stomatitisinfection, extravasations, severe stomatitis , decreased deep tendon reflexes, or, decreased deep tendon reflexes, or bleeding .bleeding . -Physical status-Physical status -Level of anxiety-Level of anxiety -Psychological status.-Psychological status.
  50. 50. 5.5.Prepare for potential complicationsPrepare for potential complications 6.6.Assure accurate preparation of theAssure accurate preparation of the agentagent -Accuracy of dosage calculation-Accuracy of dosage calculation - Check expiry date of the drug.- Check expiry date of the drug. -Recommended administration route-Recommended administration route 7.7.Assess patients understanding of theAssess patients understanding of the chemotherapeutic agents andchemotherapeutic agents and administration procedures.administration procedures.
  51. 51. CALCULATION OF DRUG DOSAGECALCULATION OF DRUG DOSAGE It is calculated based on body surfaceIt is calculated based on body surface area.area. DRUG PREPARATION-DRUG PREPARATION- Pharmacy staff should reconstitute allPharmacy staff should reconstitute all drugs pre-prime the intravenous tubingdrugs pre-prime the intravenous tubing under a class II biologic safety cabinetunder a class II biologic safety cabinet (BSC) which provide personnel,(BSC) which provide personnel, environmental and product safety. Inenvironmental and product safety. In certain conditions nurses may be requiredcertain conditions nurses may be required to reconstitute medications. Whento reconstitute medications. When preparing and reconstituting safe handlingpreparing and reconstituting safe handling guidelines to be followed.guidelines to be followed.
  52. 52. -All chemotherapeutic drug should be-All chemotherapeutic drug should be prepared according class II BSC.prepared according class II BSC. -Aseptic technique should be followed.-Aseptic technique should be followed. -Personal protective equipment includes-Personal protective equipment includes disposable surgical gloves, long sleevesdisposable surgical gloves, long sleeves gown and elastic or knit cuffs.gown and elastic or knit cuffs. -Protective goggles if no BSC-Protective goggles if no BSC -Wash hands before and after drug-Wash hands before and after drug handling.handling. -Limit access to drug preparation area-Limit access to drug preparation area
  53. 53. -Keep labeled drug spill kit near-Keep labeled drug spill kit near preparation area.preparation area. -Apply gloves before drug handling.-Apply gloves before drug handling. -Open drug vials/ ampoules away from-Open drug vials/ ampoules away from body.body. -Place absorbent pad on work surface.-Place absorbent pad on work surface. -Wrap alcohol wipe around neck of-Wrap alcohol wipe around neck of ampoule before opening.ampoule before opening. -Label all chemotherapeutic drugs.-Label all chemotherapeutic drugs. - Clean up any spill immediately- Clean up any spill immediately
  54. 54. IV.IV. Drug administrationDrug administration 1. Route-1. Route- i)Oral - Emphasize the importance of compliance by thei)Oral - Emphasize the importance of compliance by the patient with prescribed schedule.Drugs with emeticpatient with prescribed schedule.Drugs with emetic potential should be taken with meals.potential should be taken with meals. Assure that chemotherapeutic agents are stored asAssure that chemotherapeutic agents are stored as directed by the manufacturer(refrigerate, avoid exposure todirected by the manufacturer(refrigerate, avoid exposure to direct light,etc).direct light,etc). ii) Intramuscular and subcutaenous – Chemotherapeuticii) Intramuscular and subcutaenous – Chemotherapeutic agents that can be administered I/M or subcutaneously areagents that can be administered I/M or subcutaneously are few in number. Non-vesicants like L- asperaginase,few in number. Non-vesicants like L- asperaginase, bleomycin, cyclophosphamide, methotraxate. Cyta arabinebleomycin, cyclophosphamide, methotraxate. Cyta arabine and some hormonal agents are given I/M & /Orand some hormonal agents are given I/M & /Or subcutaneously.subcutaneously.
  55. 55. --Use the smallest gauge needle possible for theUse the smallest gauge needle possible for the viscosity of the medication.viscosity of the medication. -Change the needle after withdrawing the-Change the needle after withdrawing the agent from a vial or ampoule.agent from a vial or ampoule. -Select a site with adequate muscle and/or SC-Select a site with adequate muscle and/or SC tissue.tissue. iii) Intravenous – It is the most common methodiii) Intravenous – It is the most common method of administration of cancer chemotherapy. Mayof administration of cancer chemotherapy. May be given through central venous catheters orbe given through central venous catheters or peripheral access. Absorption is more reliable.peripheral access. Absorption is more reliable. This route is required for administration ofThis route is required for administration of vesicants and it also reduces the need ofvesicants and it also reduces the need of repeated injection. Because the I/V providesrepeated injection. Because the I/V provides direct access to the circulatory system, thedirect access to the circulatory system, the potential for infection and life threatening sepsis ispotential for infection and life threatening sepsis is a serious complication of I/V chemotherapy.a serious complication of I/V chemotherapy.
  56. 56. The following guidelines to be kept in mind:The following guidelines to be kept in mind: -Inspect the solution, container and tubing for-Inspect the solution, container and tubing for signs of contamination including particles,signs of contamination including particles, discoloration, cloudiness, and cracks or tears indiscoloration, cloudiness, and cracks or tears in bottle or bagbottle or bag -Aseptic technique to be followed-Aseptic technique to be followed -Prepare medicines according to manufacturer’s-Prepare medicines according to manufacturer’s directionsdirections -Select a suitable vein-Select a suitable vein -Large veins on the forearm are the preferred site.-Large veins on the forearm are the preferred site. -Use distal veins first, and choose a vein above-Use distal veins first, and choose a vein above areas of flexion.areas of flexion. -For non-vesicant drugs, use the distal veins of the-For non-vesicant drugs, use the distal veins of the hands (metacarpal veins): then the veins of thehands (metacarpal veins): then the veins of the forearms(basilic and cephalic veins)forearms(basilic and cephalic veins)
  57. 57. -For vesicants, use only the veins of the forearms.-For vesicants, use only the veins of the forearms. Avoid using the metacarpal and radial areas.Avoid using the metacarpal and radial areas. -Avoid the antecubital fossa and the wrist-Avoid the antecubital fossa and the wrist because an extravasation in these areas canbecause an extravasation in these areas can destroy nerves and tendons, resulting in loss ofdestroy nerves and tendons, resulting in loss of function.function. -Peripheral sites should be changed daily before-Peripheral sites should be changed daily before administration of vesicantsadministration of vesicants -Avoid the use of small lumen veins to prevent-Avoid the use of small lumen veins to prevent damage due to friction and the decreased abilitydamage due to friction and the decreased ability to dilute acidic drugs and solutions. Select theto dilute acidic drugs and solutions. Select the shortest catheter with the smallest gaugeshortest catheter with the smallest gauge appropriate for the type and duration of theappropriate for the type and duration of the infusion (21g to 25g for I/V medications and 19 ginfusion (21g to 25g for I/V medications and 19 g for blood products).for blood products).
  58. 58. --Avoid a vein which has been used forAvoid a vein which has been used for venous access within the past 24 hrs tovenous access within the past 24 hrs to prevent leakage from a prior puncture site.prevent leakage from a prior puncture site. Prevent trauma and infection at thePrevent trauma and infection at the insertion site.insertion site. -Apply a small amount of iodine-Apply a small amount of iodine based antiseptic ointment over thebased antiseptic ointment over the insertion site & cover the area with sterileinsertion site & cover the area with sterile gauze.gauze. Intravenous Chemotherapy Via CentralIntravenous Chemotherapy Via Central Vein Infusion (Vein Infusion (Hickman CatheterHickman Catheter))
  59. 59. A Hickman catheter is a flexible polymericA Hickman catheter is a flexible polymeric silicon rubber catheter which is threadedsilicon rubber catheter which is threaded through the cephalic vein and into thethrough the cephalic vein and into the superior vena cava or through thesuperior vena cava or through the venacava and into the right atrium of thevenacava and into the right atrium of the heart. Placement in a large vein permitsheart. Placement in a large vein permits the use of a catheter large enough forthe use of a catheter large enough for infusion of chemotherapy, hyper osmolarinfusion of chemotherapy, hyper osmolar fluids for nutrition purposes, bloodfluids for nutrition purposes, blood products and other needed intravenousproducts and other needed intravenous fluids.fluids.
  60. 60. The silicon rubber material of catheter isThe silicon rubber material of catheter is chemically inert to prevent decompositionchemically inert to prevent decomposition and it is anti-thrombogenicand it is anti-thrombogenic A felt cuff near the exit site anchors theA felt cuff near the exit site anchors the catheter on the patient’s chest and acts ascatheter on the patient’s chest and acts as an anatomic barrier to prevent entry ofan anatomic barrier to prevent entry of infection causing agents.infection causing agents. It is either single lumen or double-lumen.It is either single lumen or double-lumen. IV) Intra-arterialIV) Intra-arterial VV))Intra-peritonealIntra-peritoneal
  61. 61. VIVI))Intrathecal- Infusion of medication can be givenIntrathecal- Infusion of medication can be given through an Ommaya reservoir, implantablethrough an Ommaya reservoir, implantable pump and /or usually through lumbar puncture.pump and /or usually through lumbar puncture. aa))Wear protective equipment (gloves,Wear protective equipment (gloves, gown andgown and eyewear).eyewear). bb))Inform the patient that chemotherapeuticInform the patient that chemotherapeutic drugsdrugs are harmful to normal cells and thatare harmful to normal cells and that protectiveprotective measures used by personnelmeasures used by personnel minimize their exposureminimize their exposure to these drugs.to these drugs. cc))Administer drugs in a safe and unhurriedAdminister drugs in a safe and unhurried environment.environment.
  62. 62. dd))Place a plastic backed absorbent pad underPlace a plastic backed absorbent pad under thethe tubing during administration to catch anytubing during administration to catch any leakage.leakage. Do not dispose of any supplies or unusedDo not dispose of any supplies or unused drugs indrugs in patient care areas.patient care areas. V.V. DocumentationDocumentation RecordRecord -chemotherapeutic drugs, dose, route ,and time-chemotherapeutic drugs, dose, route ,and time -Premedications, postmedications, prehydration-Premedications, postmedications, prehydration and other infusions and supplies used forand other infusions and supplies used for chemotherapy regimen.chemotherapy regimen. -Any complaints by the patient of discomfort and-Any complaints by the patient of discomfort and symptoms experienced before, during, and aftersymptoms experienced before, during, and after chemotherapeutic infusion.chemotherapeutic infusion.
  63. 63. VI.VI. Disposal of supplies and unused drugsDisposal of supplies and unused drugs aa))Do not clip or recap needles or breakDo not clip or recap needles or break syringes.syringes. bb))Place all supplies used intact in a leakPlace all supplies used intact in a leak proof ,puncture proof, appropriate labeledproof ,puncture proof, appropriate labeled container.container. cc))Place all unused drugs in containers in aPlace all unused drugs in containers in a leakleak proof, puncture proof, appropriately labeledproof, puncture proof, appropriately labeled container.container. dd))Dispose of containers filled withDispose of containers filled with chemotherapeutic supplies andchemotherapeutic supplies and unusedunused drugs indrugs in accordance withaccordance with regulations of hazardous wastes.regulations of hazardous wastes.
  64. 64. VII.VII. Management ofManagement of chemotherapeutic spillschemotherapeutic spills Chemotherapy spills should be cleanedChemotherapy spills should be cleaned up immediately by properly protectedup immediately by properly protected personnel trained in the appropriatepersonnel trained in the appropriate procedure. A spill should be identified withprocedure. A spill should be identified with a warning sign so that other person willa warning sign so that other person will not be contaminated.not be contaminated.
  65. 65. Supplies RequiredSupplies Required Chemotherapy spill kit containsChemotherapy spill kit contains Respirator mask for air borne powderRespirator mask for air borne powder spillsspills Plastic safety glasses or gogglesPlastic safety glasses or goggles Heavy duty rubber glovesHeavy duty rubber gloves Absorbent pads to contain liquid spillsAbsorbent pads to contain liquid spills Absorbent towels for clean up after spillsAbsorbent towels for clean up after spills Small scoop to collect glass fragmentsSmall scoop to collect glass fragments Two large waste disposal bagsTwo large waste disposal bags
  66. 66. Protective disposable gownProtective disposable gown Containers of detergent solution and clear tapContainers of detergent solution and clear tap water for post spill clean up.water for post spill clean up. Puncture proof and leak proof container approvedPuncture proof and leak proof container approved for chemotherapy waste disposalfor chemotherapy waste disposal Approved, specially labeled, impervious laundryApproved, specially labeled, impervious laundry bag.bag. Spill on hard surfaceSpill on hard surface Restrict area of spillRestrict area of spill Obtain drug spill kitObtain drug spill kit Put on protective gown, gloves, gogglesPut on protective gown, gloves, goggles Open waste disposal bagsOpen waste disposal bags Place absorbent pads gently on the spill; bePlace absorbent pads gently on the spill; be careful not to touch spill.careful not to touch spill.
  67. 67. Spill on hard surfaceSpill on hard surface Restrict area of spillRestrict area of spill Obtain drug spill kitObtain drug spill kit Put on protective gown, gloves, gogglesPut on protective gown, gloves, goggles Open waste disposal bagsOpen waste disposal bags Place absorbent pads gently on the spill;Place absorbent pads gently on the spill; be careful not to touch spill.be careful not to touch spill.
  68. 68. Place absorbent pad in waste bagPlace absorbent pad in waste bag Cleanse surface with absorbent towelsCleanse surface with absorbent towels using detergent solution and wipe cleanusing detergent solution and wipe clean with clean tap water.with clean tap water. Place all contaminated materials in thePlace all contaminated materials in the bag.bag. Wash hands thoroughly with soap andWash hands thoroughly with soap and water.water.
  69. 69. Spill on personnel or patientSpill on personnel or patient Restrict area of spillRestrict area of spill Obtain drug spill kitObtain drug spill kit Immediately remove contaminatedImmediately remove contaminated protective garments or linenprotective garments or linen Wash affected skin area with soap andWash affected skin area with soap and waterwater If eye exposure-immediately flood theIf eye exposure-immediately flood the affected eye with water for at least 5 mts;affected eye with water for at least 5 mts; obtain medical attention promptlyobtain medical attention promptly Notify the physician if drug spills onNotify the physician if drug spills on patient.patient. Documentation- Document the spill.Documentation- Document the spill.
  70. 70. Chemotherapy offersChemotherapy offers patients with cancer apatients with cancer a great deal of hope for agreat deal of hope for a cure or a means of controlcure or a means of control cancer for a long period ofcancer for a long period of time. Hope and optimismtime. Hope and optimism are vital ingredients in careare vital ingredients in care plan.plan.
  71. 71. END OF LIFE CAREEND OF LIFE CARE  End of LifeEnd of Life is considered to beis considered to be the period of time marked bythe period of time marked by disability or disease that isdisability or disease that is progressively worse until death.progressively worse until death.  End of Life CareEnd of Life Care is the careis the care provided to a person in theirprovided to a person in their final stages of life.final stages of life.  It is also known as hospice care,It is also known as hospice care, comfort care, supportive care,comfort care, supportive care, palliative care or simplypalliative care or simply symptom management.symptom management.
  72. 72. ONCOLOGICAL EMERGENCIESONCOLOGICAL EMERGENCIES  Hematologic emergenciesHematologic emergencies  Bone marrow dysfunctionBone marrow dysfunction  Anatomical structure disordersAnatomical structure disorders  Cardiac temponadeCardiac temponade  Carotid artery ruptureCarotid artery rupture  Obstruction of superior vena cavaObstruction of superior vena cava  Pleural effusionPleural effusion  Spinal cord compressionSpinal cord compression  Tracheobronchial obstructionTracheobronchial obstruction  Metabolic disruptionsMetabolic disruptions  Electrolyte imbalanceElectrolyte imbalance
  73. 73. NURSING DIAGNOSISNURSING DIAGNOSIS  Risk for Infection related toRisk for Infection related to impaired or deficient leukocytesimpaired or deficient leukocytes  Risk for Injury related toRisk for Injury related to thrombocytopenia and bleeding.thrombocytopenia and bleeding.  Risk for Ineffective TissueRisk for Ineffective Tissue Perfusion due to reducedPerfusion due to reduced erythrocytes, or vascularerythrocytes, or vascular disruption by tumordisruption by tumor
  74. 74. CONT.CONT.  Potential for Impaired Gas ExchangePotential for Impaired Gas Exchange due to cancer involvement of thedue to cancer involvement of the lungs or alterations in fluid statuslungs or alterations in fluid status  Potential for Impaired SensorimotorPotential for Impaired Sensorimotor Function due to spinal cordFunction due to spinal cord compressioncompression  Potential for Imbalanced FluidPotential for Imbalanced Fluid Volume due to disease or treatmentVolume due to disease or treatment  Potential for Fatigue due toPotential for Fatigue due to malignant illness or its treatmentmalignant illness or its treatment
  75. 75. CONT.CONT.  Potential for Impaired MobilityPotential for Impaired Mobility due to disease complicationsdue to disease complications  Anxiety related to fear ofAnxiety related to fear of disease or treatmentdisease or treatment  Deficient Knowledge related toDeficient Knowledge related to disease, or anticancer therapiesdisease, or anticancer therapies  Potential for Ineffective CopingPotential for Ineffective Coping related to severity of illness orrelated to severity of illness or prognosisprognosis  Potential for Role Conflict due toPotential for Role Conflict due to chronic serious illnesschronic serious illness
  76. 76. SUMMARYSUMMARY The potential benefit to theThe potential benefit to the patient of treatment as anpatient of treatment as an option must always outweighoption must always outweigh the toxic effects.the toxic effects.