2. Outline
• Chemotherapy.
• Classification of Chemotherapeutic Agents.
• Purposes of Chemotherapy.
• Principles of Chemotherapy
• Articles for Chemotherapy Administration.
• Steps of Procedure of Administration of Chemotherapy.
• Extravasation.
• Management of Extravasation.
• Management of Chemotherapeutic Spill.
3. Learning Objectives
At the end of the class students will be able to-
• Define Chemotherapy.
• Classify Chemotherapeutic Agents.
• Enlist Purposes of Chemotherapy.
• Enlist Articles Needed for Chemotherapeutic Agents.
• Explain Steps of Procedure of Administration of Chemotherapy.
• Define Extravasation.
• Describe Management of Extravasation.
• Describe Management of Chemotherapeutic Spill.
4. Introduction
Chemotherapy is the use of antineoplastic agents in an
attempt to destroy tumor cells by interfering with cellular
functions and reproduction.
Chemotherapy is the use of drugs or medications to treat
disease, a method of cancer treatment.
The medication enters the body and circulates, in order to
destroy cancer cells. Chemotherapy can be used alone or as
part of a treatment plan that could include surgery, radiation
therapy or biotherapy.
There are several goals of using chemotherapy, i.e. cure,
control and palliation. Some types of cancer respond best to
chemotherapy medications, others react best with several
treatment options combined.
5. Cont.…..
As per the cell cycle specificity the chemotherapy drugs can be divided into two
types, i.e. the cell cycle-specific drugs and cell cycle non-specific.
The cell cycle-specific drugs destroy cells actively reproducing by means of cell
cycle.
Many of these agents are specific to certain phases of the cell cycle. Most affect
cells in the S-phase by interfering with DNA and RNA synthesis.
Others such as Vinca or plant alkaloids are specific to the M-phase where they
halt mitotic spindle formation.
The cell cycle agents usually have a prolonged effect on cells leading to cellular
damage or death.
7. Purposes of Chemotherapy
• To treat the systemic diseases
• To reduce tumor size preoperatively
• To destroy any remaining tumor cells postoperatively
• To treat some forms of leukaemia
• To kill cancer cells
8. Principles of Chemotherapy
1. The intent of chemotherapy is to destroy as many tumor cells as possible with minimal effect on
healthy cells.
2. Cancer descend on the same mechanism for cell division as normal cells. Damage to those
mechanism leads to cell death.
3. Chemotherapy is utilised in different clinical setting
Adjuvant chemotherapy is the use of systemic treatment following surgery and for
radiation therapy. Adjuvant therapy is given to patients who have no evidence of residual
disease but who are at high risk for relapse.
Neoadjuvant chemotherapy is the use of systemic treatment prior to primary surgery or
radiation. The goal is to shrink or downstage the primary tumor to improve the
effectiveness of surgery as well as control/ irradicate microscopic cancer cells. The goal of
therapy is to decrease the amount of tissue that needs to be removed as well as to
attempt to maximize cure potential.
9. CONT…
High-dose/ intensive therapy is the administration of high doses of
chemotherapy usually in association with growth factor support before
bone marrow transplant/ stem cell rescue.
Palliative chemotherapy is when a cure is not possible to control the
cancer and minimize side effects from the disease.
4. Chemotherapeutic agents can be effective on any stage of the cell cycle in which
cells are dividing the cell cycle is divided into five stages-
G0 (gap 0) - Resting phase cells are not dividing in this stage and for the most
part is refractory to chemotherapy.
G1 (gap 1) phase: Ribonucleic acid RNA and Protein synthesis in rhymes for
DNA synthesis are manufactured.
10. CONT….
S Phase during a long period the DNA component doubles for the
chromosomes in preparation for cell division
G2 Phase- this protein and RNA synthesis occurs and the mitotic
spindle apparatus is formed
Mitosis phase in an extremely short period the cell divides into two
identical daughter cells.
5. Routes of administration- Oral- capsule, tablet or liquid, Intravenous- Push
(bolus) or infusion over a specified period, Intra muscular, Intrathecal, Intra-
arterial, Intracavitary, Intravesical & Topical.
6. Dosage is based on surface area in both adults and children.
7. Most chemotherapeutic agents have dose limiting toxicities that require
nursing interventions. Chemotherapy predictably affects normal rapidly
growing cells. It is imperative that these toxicities be recognised early by the
nurse.
11.
12. Personal Protective Equipment
• Gloves- Wear gloves that are powder free such as nitric,
polyurethane and have been tested for use with
hazardous drugs avoid latex drugs due to potential latex
sensitivity. Double gloves are recommended for all
handling.
• Gown- Wear disposable lint-free ground made of low
permeability fabric. the gown should have a solid front
long sleeves, tight cuffs and back closure. The intact
gloves should be worn under the gown cuff and the
outer gloves should extend over the gown to protect the
skin gown and gloves are meant for single use only.
13. Cont.…
• Respirators- Wear a National Institute for
Occupational Health and Safety approval
respirator mask when there is a risk of aerosol
exposure such as when administering
chemotherapy for cleansing oil spill. Surgical
mask do not provide adequate protection.
• Eye and face protection- Wear eye shield and
mask that provides splash protection whenever
there is a possibility of splashing.
14. Points to Remember
User biologics safety cabinet for the preparation of all chemotherapy agents.
Wear surgical gloves when handling antineoplastic agents and the excretion of
patients who received chemotherapy.
Wear disposable long-sleeved gowns when preparing and administering
chemotherapy agents.
Use luer-lock fitting on all intravenous tubing used to deliver chemotherapy.
Dispose off all equipment used in chemotherapy preparation and
administration in appropriate leak proof puncture proof container according to
biomedical waste category 5 cytotoxic drugs.
Dispose of all chemotherapy waste as hazardous material.
15. Articles
Kidney tray
Paper bag
Personal Protective Kit (cap, mask, gown, shoe cover, goggle)
Spirit swabs in a container
Gloves
Intravenous set
Micropore for sticking
Chemotherapy drug as prescribed
Intravenous cannula
16G, 18G needles
10, 20 ml disposable syringes
16. Steps of Procedure
Preprocedural steps
Explain the procedure to the patient and take consent. Educate the patient
regarding adverse effect of chemotherapy and the strategies to manage these
effects. Instruct the patient to report any side effect of chemotherapy
Check for the following
o Physicians order including any supportive care medications including pre
medications antiemetics, hydration, growth factor or emergency
medications.
o Review patients medication history including over the counter medications
for possible interactions
Check current laboratory values complete blood count, differential platelets,
liver function test and creatinine. Drugs may be withheld in severe neutropenia,
thrombocytopenia or impaired liver or kidney function.
17. Cont.…
Check the 10 rights like right drug, route, dose, time, patient, evaluation, etc.
during drug administration
Calculate the dosage according to milligrams per kilogram mg/kg or milligrams
per metre squared and by body surface area
Be aware of agents that cause anaphylactic reaction such as asparaginase,
paclitaxel detection and docetaxel so keep the emergency resuscitation
equipment and drugs available
18. Intraprocedural steps
Insert IV check for patency of IV line
Select vein puncture site free from sclerosis thrombosis for sac formation if
possible if the patient has an established IV assess the site for erythema, pain or
tenderness
Check for a blood return by aspirating at a Y- site close to the IV catheter. Do not
pinch the catheter tubing
If doubt exist about vein patency and safety of chemotherapy administration;
discontinue the administration and treat as an extravasation if a recipient
chemotherapeutic agent has been used
Monitor for pain the patient may describe it as localised to severe burning and
radiating along with vein. Examine the site for swelling.
19. Cont.….
If extravasation is suspected, stop the infusion immediately and
follow the procedure for extravasation.
During drug administration-
Use a disposable, absorbent, plastic- backed pad under the work
area
Put on protective gown, gloves and eyewear.
Monitor the patient particularly during the first 15 minutes for signs
of hypersensitivity or anaphylaxis
Monitoring the IV site throughout the infusion
20. Postprocedural steps
• Document drug dosage and any occurrence of extravasation including estimated
amount of drug
• Observe regularly after administration for pain in duration and necrosis
• Monitor for other adverse effects of infusion
• Patient may describe sensations of pain and pressure within the vessel originating
near the vein puncture site of extending 3 to 5 inches long the vein
• Discoloration- Red streak following the line of vein called a flare reaction or
darkening of vein
• Itching, urticaria, muscle cramps or pressure in the arm caused by irritation of
surrounding subcutaneous tissue.
21. Extravasation
• Extravasation is the process by which any liquid fluid or drug accidentally leaks into
the surrounding tissues in terms of Cancer therapy. Extravasation refers to the
inadvertent infiltration of chemotherapy into the subcutaneous or subdermal
tissues surrounding the intravenous or intra-arterial administration site.
22. Management of Extravasation
• If an extravasation is suspected, stop the transfusion of the chemotherapy.
• Disconnect IV tubing and attempt to aspirate all residual chemotherapy in the IV
catheter using a syringe to prevent further infusion of chemotherapeutic agent.
• Apply warm or cold packs to area for 15 to 20 minutes 4 times a day for 24 hours.
• Cold packs for injection Dactinomycin, Idarubicin, Daunorubicin,
Mechlorethamine, Doxorubicin, Mitomycin, Epirubicin, Streptozotocin.
• Warm packs for injection Vincristine, Vinorelbine, Vinblastine.
23. Cont.…
Notify the health care provider
If an antidote is available, administer as prescribed. Gently clean the area
around the extravasation with an alcohol pad. Inject the antidote
subcutaneously in a circular pattern around the site of extravasation using
a 25-gauge needle. 1-5 injections will be needed, depending on the
volume of extravasation. Change the needle with each new injection.
Elevate affected limb if applicable for 48 hours.
Reapply warm or cold compress as indicated, depending on the
chemotherapeutic agent that has been extravasated.
24. Management of Chemotherapeutic Spill
Chemotherapy spills should be cleaned up immediately by the trained personnel. A spill
should be identified with a warning sign so that other person will not be contaminated.
A spill kit contains
Heavy duty rubber gloves
Respiratory mask for airborne powder, spills
goggles
disposable gown
Disposable scoop
26. Procedure for spill management
Alert other staff in the area of the potential hazard. Limit access to the area
while a spill kit is obtained and then place the warning sign in a prominent
position.
Don personal protective equipment in this order: mask, face shield, the safety
glasses, gloves, gown.
For a liquid spell, carefully place an absorbent pad over the spilled liquid. Absorb
as much liquid as possible into the pad.
If there is broken glass in the spill, carefully pick up the glass pieces using the
disposable scoop and place all glass in the puncture proof container.
Use the cleaning solution to wash the area of the spill thoroughly, discarding all
waste generated into the waste container.
Rinse the area well with clean water.
Document the event.
27. Special considerations
Always follow the 10 rights of drug administration.
Correct use of personal protective clothing and equipment should be instituted
to minimise exposure and health risks.
Disposable gloves should be used for dispensing hands must be washed before
and after glove application.
On disposable protective clothing as well as any disposable materials used while
handling chemotherapeutic agents should be disposed of as cytotoxic waste
according to the local waste disposal regulatory guidelines.
Information ready for necessary action in the event of accidental exposure.
Minimise the number of individuals coming in contact with the cytotoxic
medications.
28. References
1. Kaur AK, Kaur S, Kaur S, Sharma S, Singh VN, Saini KS. Clinical Nursing Procedures. 1st ed. CBS
publishers & Distributors Pvt. Ltd.; 350-354.
2. Sharma S. Lippincott Manual of Medical Surgical Nursing. Wolters Kluwers. 2016; 869- 871.
3. Nettina MS. Lippincott Manual of Nursing Practice. Wolters Kluwers. 2020; 115-120.
