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Chemotherapy• Cytotoxic drugs• Hormone; hormone antagonists• Biological response modifiers
(BRMs)
Chemotherapy: Cytotoxic Drugs
• Often given in combination to attack cells at different stages of their development
• Cell cycle phase specific• Cell cycle phase nonspecific
Cytotoxic Drugs
Cytotoxic Drugs• Side effects
– Drugs act on normal as well as malignant cells
– Can be drug specific– Common:
•Bone marrow suppression-most dangerous
•Alopecia•Nausea and Vomiting-most distressing
Cancer Therapies: Bone Marrow
Transplantation• Bone marrow transplantation
– Process of replacing diseased or damaged bone marrow with normally functioning bone marrow
• Autologous-transplantation of own bone marrow post chemotherapy
• Allogenic-transplantation of bone marrow from sibling or other relative
• Matched unrelated donor (MUD)-transplantation from unrelated donor
Bone Marrow Transplantation (BMT)
• Donated marrow transfused just like blood transfusion through IV line
• Infused marrow finds its way to the pt’s bone marrow ,where it (hopefully) starts growing and producing new cells
Bone Marrow Transplantation
Unproven Methods of Treatment
• May delay treatment with potentially effective conventional therapies
• Can be harmful• Examples
– DMSO– Laetrile– Macrobiotic diets
Symptom Management• Anxiety
– when patient appears apprehensive, helpless
– May have poor eye contact, increased pulse, respirations
– May be hostile– Offer opportunity to talk– Encourage to express feelings and
source of anxiety– Recognize need for teaching, referrals
Symptom Management• Ineffective coping
– May need help setting priorities, coping with side effects
– Strategies to help include•Teaching , support groups (local ACS for
info)•Encouraging self-care•Treating physical signs and symptoms•Emphasizing abilities•Relaxation techniques
Symptom Management• Risk for Injury
– Pneumonitis/pulmonary fibrosis-cough, deep breathe, protect from exposure
– Cardiotoxicity-Monitor for s/s heart failure– Neurotoxicity-Protect extremities that are
without sensation– Cystitis: If abd, lower back irradiated
encourage increased fluid intake and frequent voiding to prevent cystitis
Symptom Management• Risk for injury
– Thrombocytopenia: gentle handling to prevent bruising/bleeding, apply pressure for 5 min after venipuncture to minimize bleeding, soft toothbrush, electric razor. Immediately report any blood in urine, stool, sputum
Symptom Management
• Risk for injury-Anemia-Palpitations, pallor, excessive fatigue.
Treated with PRBCs and EPO. High Fe intake-Diarrhea: monitor for dehydration
-Pathological fractures• Can happen with bony metastasis: gentle
handing required
Symptom Management• Risk for injury
– Reproductive cells•Females not to become PG within 2
years of chemotherapy or while receiving RT
•Males should discuss sperm banking before receiving certain drugs
Symptom Management• Excess Fluid Volume • Ascites: fluid accumulation in the
peritoneal cavity•Diuretics may be ordered•Salt poor albumin •Paracentesis-often done at bedside
–Trocar inserted, fluid drawn off-usually only done when breathing is compromised
Paracentesis
Symptom Management• Risk for Infection
– Neutropenia (low WBC count)• Avoid crowds, close contact with others with
infectious diseases• Promptly report any s/s infection• Neutropenic precautions may be needed
– Private room– Strict hand washing– Fresh fruit, vegetables, flowers not allowed
Symptom Management• Imbalanced Nutrition: Less Than Body
Requirements– High protein, high-calorie diet– Small frequent meals– Light exercise before meals may stimulate
appetite– Respect food preferences– Plastic utensils may relieve bitter taste
of some food caused by chemo
Symptom Management• Imbalanced Nutrition
– Procarbazine (Matulane)-no tyramine-can cause hypertensive crisis
– Antiemetics/sedatives alone or in combination to help with N/V•Newer drugs are more effective•Palanosetron (Aloxi), Dolasetron
(Anzemet), Ondansetron (Zofran), Granisetron (Kytril)
Symptom Management• Imbalanced Nutrition• General guidelines:
– No fluids with meals– Decrease intake of fatty foods, sweets– Eat food at room temperature– Eat slowly, chew well– Drink clear, cool, unsweetened beverages– Avoid offensive odors– Rest after eating
Symptom Management• Impaired Oral Mucous Membranes
– Frequent gentle mouth care, artificial saliva if needed
– Increase fluid intake– Gum, hard candy– No lemon glycerin swabs– Stomatitis can be painful
Symptom Management• Constipation
– Monitor bowel habits-can be caused by lack of fiber, fluid intake, chemotherapy, opioids
– High fiber diet, stool softeners, laxatives, enemas as ordered
Symptom Management• Fatigue
– Assess need for assistance– Schedule activities to conserve
energy– Encourage to prioritize activities– Daily naps/mild exercise– Assess need to work
Symptom Management
• Disturbed Body Image– Alopecia
•Hair loss starts slowly then it comes out in clumps
•Hair begins to grow back about 4-6 mo after completion of RT, soon after completion of chemo
•Hair may grow back with different color, texture
Symptom Management• Disturbed Body Image cont.
•After large doses of RT to head, hair may not grow back
•Wigs, scarves, turbans
Symptom Management• Disturbed Body Image cont.
– Radical neck dissection– Laryngectomy– Ostomy– Mastectomy– Orchiectomy– Craniotomy
Symptom Management• Grieving vs Dysfunctional Grieving
– Changes/loss trigger grief response– Behaviors that suggest beginning
acceptance include looking at/touching affected part; talking about loss
– Support as needed
Symptom Management• Interrupted Family Processes
– Patient may be concerned with meeting responsibilities
– Families may need help in their responses to patient
– Financial concerns: SW consult for insurance, disability claims
Symptom Management• Ineffective Therapeutic Regimen
Management– Pretreatment teaching plan– Know what physician has told patient and
be ready to reinforce– For chemotherapy: description of drugs,
common side effects related precautions– Provide written information to
supplement verbal information– Compliance sometimes a problem
Symptom Management• Pain
– Pain managed with various medications tailored to each patient’s needs
– NSAIDs– Opiods
• Long acting• Short acting
– Transdermal– IV medications
Medical Emergencies• Hypercalcemia• Spinal Cord Compression• Superior Vena Cava Syndrome • DIC• Tumor Lysis Syndrome
Hypercalcemia• Risk Factors: mulitple myeloma, metastatic
bone cancer; cancer of lung, breast, kidney; prolonged immobility
• S/S: fatigue, confusion, weakness, polyuria, poor muscle tone
• If untx: renal failure, coma, arrythmia. Death• Tx: IV NS and Furosemide; drugs to promote
excretion of calcium—Plicamycin, Calcitonin, Etidronate
• Nursing care: Monitor fluid status, give drugs as ordered, I&O
Spinal Cord Compression
• Risk factors: lung, breast, prostate cancers, lymphomas
• S/S: Tumor in epidural space causes intense pain, weakness, altered sensation in arms, legs, impaired bowel or bladder function
• Tx: High dose RT, steroids, surgery to relieve pressure
• Nursing Care: Analgesics as ordered; assess for full bladder, constipation, neuro checks
Superior Vena Cava Syndrome
• Risk Factors: Breast, lung cancer, lymphoma, Kaposi’s sarcoma, metastatic testicular cancer
• S/S: Redness, edema of face/conjunctiva, distended neck/ thoracic veins, dyspnea, cough, tachypnea, tachycardia, cyanosis
increased ICP
Superior Vena Cava Syndrome
• Tx: RT, diuretics, steroids• Nursing Care: Meds as ordered,
elevate head, arms but not legs, do not bend forward, symptoms usually subside in 2-3 days
Disseminated Intravascular Coagulation
(DIC)• Risk Factors: Septicemia, transfusion
reaction, Some drugs: Methotrexate, Mercaptopurine, Vincristine, Prednisone, Aspariginase
• S/S: normal clotting exaggerated, which depletes clotting factors– Early signs: petichiae, ecchymoses,
prolonged bleeding from venipuncture
Disseminated Intravascular Coagulation
(DIC)• Late signs: signs of vascular
obstruction, tachypnea, tachycardia, GI bleeding, heart failure shock
• TX: Platelets, FFP, other blood components as needed, possibly heparin
• Nursing Care: Avoid trauma, handle gently, Monitor VS, look
for bleeding
Tumor Lysis Syndrome• Risk Factors: leukemia, lymphoma• An oncologic emergency with lysis
of malignant cells• Most commonly caused as a result
of chemotherapy or irradiation treatment-related malignant cell death
Tumor Lysis Syndrome
• May occur 24hrs -> 7 days after antineoplastic therapy initiated
• TLS develops when chemo or irradiation causes the destruction (lysis) of a large number of rapidly dividing malignant cells
Tumor Lysis Syndrome
• As malignant cells are lysed, intracellular contents bloodstream high levels of K+, phosphate with secondary hypercalcemia, and uric acid risk for renal failure and altered cardiac function
Tumor Lysis Syndrome
• Clinical manifestations: • Early signs:
– Nausea– Vomiting– Anorexia, diarrhea– Muscle weakness, cramping
tetany, paresthesias, seizures, anuria, and cardiac arrest
Advanced Cancer• Nutritional therapy
– Problems• Malnutrition• Anorexia • Altered taste sensation• Nausea/vomiting• Diarrhea• Stomatitis• Mucositis
Advanced Cancer
• Communication and psychological support– Factors which may determine how the
patient copes •Ability to cope with stressful events in the
past•Availability of significant others•Ability to express feelings and concerns
Advanced Cancer• Communication and
Psychological Support:•Age at the time of diagnosis•Extent of disease•Disruption of body image•Presence of symptoms•Past experience with cancer•Attitude associated with cancer
Nursing ProcessNursing Process
•NURSING DIAGNOSES:–Coping, compromised family –Activity intolerance, related to
malaise–Risk for infection, related to
inflammation of protective mucous membranes
–Self-care deficit
Nursing Process• Knowledge, deficient • Nutrition: less than body
requirements; imbalanced, related to anorexia
• Infection, risk for• Fluid volume, deficient risk for• Fluid volume, excess• Pain, acute; Pain, chronic
Absolute Neutrophil Count
• Neutrophil: A type of WBC, specifically a form of granulocyte filled with neutrally-staining granules, tiny sacs of enzymes that help the cell to kill and digest microorganisms it has engulfed by phagocytosis. The mature neutrophil has a segmented nucleus (it is called a seg or poly) while the immature neutrophil has band-shape nucleus (it is called a band). The neutrophil has a lifespan of about 3 days.
Absolute Neutrophil Count
• Interpretation: Normal Neutrophils are key components in the system of defense against infection. An absence or scarcity of neutrophils (a condition called neutropenia) makes a person vulnerable to infection. After chemotherapy, radiation, or a blood or marrow transplant, the ANC is usually depressed and then slowly rises, reflecting the fact that the bone marrow is recovering and new blood cells are beginning to grow and mature.
Absolute Neutrophil Count
• In practical clinical terms, a normal ANC is 1.5 or higher; a "safe" ANC is 500-1500; a low ANC is less than 500. A safe ANC means that the patient's activities do not need to be restricted (on the basis of the ANC).
Action for a Low ANC
• Reverse isolation – we need to keep the patient from getting sick! So we need to wear masks to keep the client from getting our germs.
• When transporting client, have them wear a mask to protect themselves.
Standard Precautions
• Hand washing– This is the most important and basic
preventive technique for interrupting the infectious process.
– Wash hands before patient care; after touching blood, body fluids, secretions, excretions, and contaminated items; immediately after gloves are removed; between patient contacts; and when
otherwise indicated.
Isolation Technique
• Basic Principles– Thorough hand washing should be performed
before entering and after leaving a patient’s room.
– An understanding of the patient’s specific disease process and method of transmission of the infectious microorganism helps determine the use of protective barriers.
Isolation Technique
• The patient with an infectious disease should be placed in a private or isolation room with the appropriate hand washing and toilet facilities.
• Private rooms used for isolation have negative-pressure airflow to prevent infectious particulates from flowing out of the closed environment.
Isolation Technique• Special rooms with positive-pressure
airflow are also used for highly susceptible patients such as transplant recipients. No organisms are able to enter the room.
– All articles that come into contact with the patient are contaminated and should be handled appropriately to maintain protective asepsis.
Isolation Technique• The CDC issued isolation guidelines
that contain two tiers of approach.– First Tier
• Precautions designed to care for all patients in health care facilities regardless of their diagnosis or presumed infectiousness
• STANDARD PRECAUTIONS
– Second Tier•Condenses the disease-specific and
categories approach to isolation into new transmission categories:
– Airborne, droplet, and contact precautions
OtherChemotherapy Drugs
Alkylating Agents• Mode of action: interfere with DNA
replication (of malignant cells); cell-cylce non-specific
• Examples:– Cytoxan– Platinol (Cysplatin)– Leukeran (chlorambucil)
Alkylating Agents
• Used for:– Leukemia– Breast, lymphoma, lung– Testicular, ovarian, cervical cancers– Myeloma– Head and neck cancers
Alkylating Agents• Common side effects
– Myelosuppression– Alopecia– n/v– Nephrotoxic, neurotoxic, ototoxic,
cardiotoxic– Hemorrhatic cystitis– Stomatitis
Antitumor Antibiotics
• Mode of Action: inhibit DNA and RNA synthesis of malignant cell; cell-cycle nonspecific
• Examples:– Bleomycin (Blenoxane)– Doxorubicin (Adriamycin)– Mitoxantrone (Novantrone)
Antitumor Antibiotics
• Used for:– Testicular, breast, endometrial,
cervical cancers– Hodgkin’s Lymphoma– Melanoma
Antitumor Antibiotics
• Common Side Effects:– Anaphylaxis– n/v– Skin rash, alopecia, stomatitis– Pulmonary fibrosis– Myelosuppression– Cardiotoxicity– Blue or red urine
Antimetabolites
• Mode of Action: Damage the malignant cell in the “s” phase; cell cycle specific
• Examples:– Cytarabine (Cytosar)– Fluorouracil (5-FU)– Methotrexate
Antimetabolites
• Used for:– Leukemia, lymphoma– Breast, colorectal, liver, endometrial,
esphageal, pancreatic and bladder cancer
– Pancreatic, lung cancer– Head and neck cancer
Antimetabolites
• Common Side Effects:– Myelosuppression– Neurotoxic– n/v/d, stomatitis, alopecia, oral and
GI ulcerations– Anaphylaxis– Renal damage (TLS)– Pulmonary infiltrates
Hormonal Agents
• Mode of Action: – alter hormonal environment that
promotes cancer growth– Competes with estrogen for binding
sites in breast and other tissues
• Examples:– Corticosteroids: Decadron,
Solucortef, Medrol, Prednisone
Hormonal Agents
• Examples cont.– Megestrol (Megace)– Lupron– Tamoxifen (Nolvadex)
• Used for:– Breast, prostate cancers– Many chemotherapy disease
protocols
Hormonal Agents
• Common Side Effects– Fluid and electrolyte imbalances– Weight gain, edema– Neuromuscular imbalances– Menstrual changes, hot flashes, vaginal
bleeding– Hypercalcemia– n/v, headache– Impotence, testicular atrophy, gynecomastia
Vinca Alkaloids
• Mode of Action:– Inhibit cell division of malignant cell– Cell-cycle specific
• Examples– Etoposide (VP-16)– Vinblastine (Velban)– Vincristine (Oncovin)
Vinca Alkaloids• Used for:
– Testicular– Lung / small cell ca of the lung– Lymphoma, Hodgkin’s– Lymphocytic Leukemia– Head/neck– Breast– Renal/bladder
Vinca Alkaloids• Common side effects:
– Myelosuppression– Extravasation– n/v/d/fever/phlebitis– Alopecia, stomatitis– Peripheral neuropathy; loss deep tendon
reflex– Hypotension– Constipation
Miscellaneous Antineoplastic Agents
• Asparaginase (Elspar)– Cell cycle-specific (‘g’ phase)– Used for Leukemia– S.E.: n/v, chills, h.a., abd. Pain, CNS
depression, anaphylaxis
Miscellaneous Antineoplastic Agents
• Paclitaxel (Taxol)– Mitotic Inhibitor– Used for: breast, lung, ovarian
cancers– S.E. – myelosuppression, dyspnea,
hypotension, alopecia, cardotoxicity, peripheral neuropathy, anaphylaxis
Miscellaneous Antineoplastic Agents
• Topotecan (HC) [Hycantin]– Interrupts DNA synthesis– Used for: Lung, breast, esophagus
tumors and lymphoma– S.E. – Myelosuppression, n/v/d, fever,
fatigue, alopecia, elevated liver enzymes
Misc. SlidesMisc. SlidesMisc. SlidesMisc. Slides
Neutrophilia v. Neutropenia
• Neutrophilia, an increased proportion of neutrophils in the blood, is a common finding with acute bacterial infections.
• Neutropenia, a decreased proportion of neutrophils, may be seen with viral infections and after radiotherapy and chemotherapy. Neutropenia lowers the immunologic barrier to bacterial and fungal infections.
Absolute Neutrophil Count
• Absolute neutrophil count: The real number of white blood cells (WBCs) that are neutrophils. The absolute neutrophil count is commonly called the ANC. The ANC is not measured directly. It is derived by multiplying the WBC count times the percent of neutrophils in the differential WBC count. The percent of neutrophils consists of the segmented (fully mature) neutrophils) + the bands (almost mature neutrophils). The normal range for the ANC = 1.5 to
8.0 (1,500 to 8,000/mm3).
Segmented Neutrophils
Bands Neutrophils
CBC WITH DIFFERENTIAL
Test Result Flag Units Reference Interval
White Blood Count 6 1.5 L x 10-3/mL 4.0-10.5
Red Blood Count 3.50 L x 10-6/mL 4.70-6.10
Hemoglobin 10.8 L g/dL 14.0-18.0
Hematocrit 31.1 L % 42.0-52.0
Platelets 302 x 10-3/mL 140-415
Polys/Segs 23 L % 45-76
Lymphs 68 H % 17-44
Monocytes 7 % 3-10
Eos 2 % 0-4
Basos > % 0.2