Management of chemo toxicities nursing perspective Nursing ppt

1. Mathew Varghese V
MSN(RAK),FHNP (CMC Vellore),
CPEPC
Nursing officer
AIIMS Delhi
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Management of Chemo toxicities-
Nursing perspective

2. Introduction
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 Chemotherapy is an important modality in cancer
treatment.
 Chemotherapy drugs act by damaging high
proliferating cells.
 By virtue of differences in both biological and
proliferation characteristics, chemotherapy
causes a greater proportion of cell death among
neoplastic as opposed to normal cells.
 Damage to normal cells result in chemotherapy
toxicities and side effects
 It can be seen that those actively dividing tissues
such bone marrow, hair follicles and
gastrointestinal mucosa are most vulnerable.

3. Classification
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1. Hematological
2. Gastrointestinal
3. Dermatological
4. Renal
5. Pulmonary
6. Cardiac
7. Neurological
8. Hepatic
9. Gonadal
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4. 1
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Hematological
Neutropenia
Anemia
Thrombocytopenia

5. What is Neutropenia?
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 Neutropenia means low neutrophil count.
 Neutropenia is a condition ,where the patient’s
ANC is < 1500 cells/mm3.

6. What is ANC and How to calculate ANC
?
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 ANC (Absolute neutrophil count) – is the total
number of neutrophils present in the blood, which
include both mature neutrophils ( segs or segmented
cells) and bands (immature neutrophils).
 Formula
ANC = (% of mature Neutrophils + % of Bands) X Total WBC)
 Unit of ANC is cells per microliter. One microliter is
equal to one cubic millimeter of blood.
 Normal range of ANC is > 1500 cells/mm3.

7. Types of Neutropenia
Type ANC Count
Mild Neutropenia 1000-1500 cells/mm3
Moderate Neutropenia 500-999 cells/mm3
Severe Neutropenia <500 cells/mm3
Profound Neutropenia <100 cells/mm3
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8. Febrile neutropenia
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 Febrile neutropenia (FN) is defined as an oral
temperature >38.3°C (101F) or two consecutive
readings of >38.0°C(100.4F) for 2 hrs. and an absolute
neutrophil count (ANC) <500cells/mm3, or expected
to fall below 500cells/mm3 in next 48 hrs.
IDSA - Infectious Diseases Society of America

9. Interventions
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 The goal is to prevent infectious complication or
detect infection at the earliest possible stage and
promptly intervene.

10. Patient and Family Education
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 Explanation of the function of while
blood cells
 Meaning of nadir
 Instructions for temperature taking
 Signs and symptoms of infection (e.g.
fever, malaise, those related to specific
organs such as cough, urinary
frequency with or without dysuria, etc.)
 Hygiene practices emphasizing hand
washing

11. Patient and Family Education
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 Identification and assessment of high‐risk
areas for infection (chest, urinary tract, skin)
 Care of access devices (e.g. Hartman line,
urinary catheter)
 Avoidance of exposure to persons with
communicable or infectious illnesses, stay
away from crowds and animals
 Maintain nutritional status by a balanced diet
 Specific directions for access to healthcare
systems (clinic or emergency)

12. Clinical Examination
 O
 S
 C
 A
 R
Oral inspection
Skin integrity
Catheter site
Anal region inspection
Routine vital signs
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13. Anemia
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 Anemia presents with symptoms of dyspnea,
dizziness, headache and palpitation.
 40 to 50 % of patients with cancer have anemia
(Before therapy)
 Increase to 80-90% after starting therapy
 Common CT drugs causing Anemia
Cyclophosphamide
MTX
5 FU
Ifosphamide

14. Management
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 Red blood cell transfusion or human recombinant
erythropoietin are the treatment options.
 For an average adult, one unit RBC transfusion
raises the hemoglobin by 1g/dl.
 Advice transfusion if Hb < 8g/dl
 Human recombinant erythropoietin has been
shown to decrease the need for transfusion
support, and improves quality of life for patients
on chemotherapy.

15. Thrombocytopenia
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 Platelet count < 100000 cells/mm3
 Common CT drugs causing Thrombocytopenia
 Platinum Drugs
 Dacarbazine
 Daunorubicine
 Doxorubicine
 Taxanes
Delayed onset of thrombocytopenia reported with
Carmustine,Lomustine,Fludarabine,Dactinomycin
…

16. Thrombocytopenia
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 Clinical manifestations include easy bruising,
petechiae, purpura, gum bleeding and
hypermenorrhoea.
 Following guidelines are recommended:
 Avoid intramuscular injections
 Avoid trauma
 Decrease the patient’s level of activity
 Avoid drugs that alter platelet function or clotting
(e.g. aspirin and non‐steroidal anti inflammatory
drugs and anticoagulants; certain herbs)

17. Guidelines…………..
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 Pressure should be applied for at least five
minutes with a pressure bandage for all IV
injections, venipuncture, and bone marrow
procedures
 Patients should avoid blowing their noses and
sneezing. For shaving, an electric razor is
recommended
 Effective and safe oral hygiene
 Avoiding intercourse if platelet <50000
 Optimal nutrition
 Avoid high risk activity
 Maintain good skin and mucous membrane

18. 2
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Gastro
Intestinal
Nausea
and
Vomiting
Anorexia and
Taste
changes
Oral
mucositis Diarrhoea Constipatio
n.
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19. Nausea and Vomiting
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 Nausea and vomiting have been ranked the first
or second worst side effects of chemotherapy
from the patient’s point of view.
 Three patterns of nausea and vomiting
associated with chemotherapy
 Acute
Delayed
 Anticipatory

20. Nausea and Vomiting
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 Acute nausea and vomiting occurs within the
first 24 hours of therapy (usually within 1 to 2
hours) and is generally most severe during the
initial 4 to 6 hours.
 Delayed emesis occurs > 24 hours after
chemotherapy and may last from one to seven
days.
 Anticipatory emesis is the experiencing of
nausea and/or vomiting before receiving another
chemotherapy treatment. It is a conditioned or
learned response to previous effects from therapy
and associated environmental stimuli,

21. Advices to pts.
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 Advice to take
 Toast and crackers
 Light tea with ginger
 Fruits and vegetables that are soft or bland
 Clear fluids
 Ice chips
 Avoid
 Fatty and fried
 Very sweet food
 Spicy and hot
 Food with strong smell

22. Nursing Advices
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 Avoid eating in a room, that's too warm or has
cooking odors
 Drink fewer liquids with meals. Drinking liquids
can cause full, bloated feeling.
 Drink sips of fluids throughout the day except at
mealtimes
 Drink beverages cool or chilled
 If nausea is problem in morning, try to eat dry
toast or biscuit
 Avoid eating foods 1-2 hrs. prior to therapy.
 Do not drink or eat until you have the vomiting
under control
 Once you have controlled vomiting, starts with

23. Anorexia and Taste changes
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 Patient may experience metallic taste after drug
therapy, a general loss of taste for food.
 Sucking on sour candies
 Using aroma to improve appeal of food,
 Use of plastic utensils if food tastes metallic
 Chewing sugar‐free gum.
 Stay calm especially at meal time
 Do not rush your meals
 Change the time, place and surrounding of
meals

24. Anorexia and Taste changes
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 Set a colorful table
 Listen to soft music while eating
 Eat as much as you can
 Watch your favorite T.V shows while eating
 Eat whenever you are hungry
 Several small meals throughout day
 Add variety to your menu
 Try some new recipe
 Take advice of dietician

25. Oral mucositis
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 Occurs 5 to 7 days after chemotherapy
 Healing occurs 10 to 14 days after cessation of therapy
 Mucositis causes mild to severe discomfort, affects fluid
and nutritional intake, and interferes with speech.
 Avoid foods that are irritating to oral mucosa,
especially spiced, acidic, or salted foods
 Use blenderized foods if necessary.
 Avoid extremely hot or cold foods
 Take extra calories with powdered milk or dietary
supplements
 Encourage fluids. Fruit juices may be soothing to oral
mucosa and add extra calories
 If needed – take medication

26. Diarrhoea
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 The agents most commonly associated with
Diarrhoea are Capecitabine, 5‐fluorouracil
Irinotecan,Methotrexate , Topotecan.
 Drink plenty of fluids
 Eat small amounts of food throughout the day
instead of 3 meals
 ORS
 Try low fiber foods-
Yogurt,Rice,Coconut water ,Banana, Bread
Avoid too hot and cold food

27. Diarrhoea
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 Avoid coffee
 Ingestion of milk should be avoided
 Common drugs used to treat CID are
Loperamide (Imodium) & Diphenoxylate
(Lomotil)

28. Constipation
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 1/3rd of cancer patients
 It is because of poor oral intake and drugs such
as opioid drugs, antiemetic drugs
 Drink plenty of fluids
 Take a drink 1 hr. prior to usual toilet time.
 Eat high fiber diet
 Do some exercises- light walking
 Common agents used to treat are
Bisocodyl,lactulose…..

29. 3. Dermatological
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 Local and Systemic.
 Local
 Phlebitis
 Urticaria
 Pain
 Erythema
 Vein discoloration,
 Tissue necrosis secondary to extravasation of a
drug.

30. Dermatological
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 Systemic
 Dermatitis
 Nail changes
 Hyperpigmentation
 Urticaria
 Photosensitivity reactions
 Hand‐foot syndrome
 Alopecia

31. Hand Foot Syndrome
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 Also called palmar-plantar erythrodysesthesia
 Symptoms
 Redness (similar to a sunburn)
 Swelling
 A sensation of tingling or burning
 Tenderness (sensitive to touch)
 Tightness of the skin
 Blisters on the palms and soles
 Cracked, flaking, or peeling skin
 Blisters, ulcers, or sores on the skin
 Severe pain
 Difficulty walking or using the hands

32. Hand Foot Syndrome
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 Limit exposure of hands and feet to hot water
when washing dishes or bathing.
 Take cool showers or baths. Carefully pat your
skin ,dry after washing or bathing.
 Avoid exposure to sources of heat, including
saunas, sitting in the sun, or sitting in front of a
sunny window.
 Avoid activities that cause unnecessary force or
friction (rubbing) on the hands or feet during the
first six weeks of treatment, such as jogging,
aerobics, and racquet sports.
 Avoid contact with harsh chemicals used in
laundry detergents or household cleaning
products.

33. Hand Foot Syndrome
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 Gently apply skin care creams to keep your hands
moist.
 Avoid rubbing or massaging lotion into your hands
and feet; this can cause friction.
 Avoid using tools or household items that require you
to press your hand against a hard surface, such as
garden tools, knives, and screwdrivers.
 Wear loose fitting, well-ventilated (air moves through
easily) shoes and clothes.
 Try not to walk barefoot and use soft slippers and
thick socks to reduce friction in your feet.
 Consider visiting a podiatrist to remove any thick
calluses and thick nails. He or she can also
recommend products that reduce friction and
pressure on the feet.

34. Alopecia
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 Most devastating side effect of chemotherapy
 Hair is an integral part of physical appearance,
and its loss may negatively affect self‐image,
body image, coping skills, and social interactions.
 Hair loss from chemotherapy is
reversible.
 Nurses and doctors should make every effort to
provide accurate information and support to
patients at risk for hair loss.

35. Alopecia
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 Explain to patient the rationale for the occurrence
of alopecia
 Encourage the patient to express emotions
regarding the information provided
 Inform the fact that hair regrows and that
changes in color and texture may occur (e.g.
curly or gray)
 Discourage the use of dryers, hot rollers, and
curling irons, since they may facilitate increased
hair loss
 Protect the head from the sun with a hat or
sunscreen for complete or nearly complete

36. Gonadal
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 Sterilization or decreased fertility
 In men, cytotoxic drugs induce reduction in sperm
counts during chemotherapy, which can be
temporary or prolonged, depending on the nature
of the cytotoxic agent and dose.
 In women, chemotherapy can cause destruction
of oocytes, which can lead to ovarian failure and
premature menopause. The chance of having
early menopause increases as the age increases.

37. Gonadal
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 Before initiating chemotherapy, patients should be
informed of the potential risk of sterility from the
planned cytotoxic therapy and semen
cryopreservation is offered to all male patients
interested in having children after the completion
of cytotoxic therapy
 During treatment, sexual relations between
partners may continue, but reliable contraceptive
methods should be used.
 It is recommended that patients wait 6 months
after the end of therapy before attempting to
conceive.

38. References
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 Management of Side Effects from
Chemotherapy by Dr. Carol Kwok -Clinical
Oncologist, Department of Oncology, Princess
Margaret Hospital
 Chapter 36- Management of complications of
chemotherapy by Eve Gilstrap and Beth Zubal –
The Washington Manual of Oncology – Second
edition
 Nutrition during chemotherapy- Eating hints for
cancer patients by Dr.Tulika Seth, AIIMS

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