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Chemotherapy/Biotherapy Chemotherapy/Biotherapy Administration Administration (Pre, Immediate and Post)(Pre, Immediate and Post)
ObjectivesObjectivesAt the completion of this session
the participant will be able to◦Identify components of pre-treatment assessment
◦Calculate BSA and confirm chemotherapy/biotherapy dosage
◦Describe required family teaching prior to chemotherapy/biotherapy administration
ObjectivesObjectivesAt the completion of this session
the participant will be able to◦Describe safety measures to verify chemotherapy/biotherapy orders
◦List steps in preparation of chemotherapy/biotherapy
◦Identify nursing measures for different routes of administration
Pre-administration Pre-administration PreparationPreparationComponents to safe preparation
for chemotherapy/biotherapy administration:◦Individual treatment plans◦Pretreatment physiologic evaluations
◦Dosing of chemotherapy/biotherapy in children and adolescents
◦Preparation of the setting◦Family assessment and education
Individual Individual Treatment PlanTreatment Plan
Review the individual treatment plan for any required pretreatment laboratory tests, imaging studies or specialized organ evaluations. Schedule all required studies
Check the general treatment plan for any amendments and updates that may alter therapy. Clarify any discrepancies
Follow institutional policies for verifying chemotherapy/biotherapy orders
Pretreatment Physiological Pretreatment Physiological AssessmentAssessment
The following should be assessed and completed prior to starting chemotherapy/biotherapy:◦ Review the individual's experience
with previous chemotherapy/biotherapy regarding side effects or toxic effects from the medications
◦ Review with the child and family the effectiveness of supportive care with past chemotherapy/biotherapy
◦ Perform a thorough physical assessment
Pretreatment Physiological Pretreatment Physiological AssessmentAssessmentAssess that all pretreatment laboratory
and imaging studies are complete and within acceptable limits. Ascertain that results of all pretreatment studies have been evaluated
Calculate the patient’s absolute neutrophil count (ANC) prior to administering chemotherapy using the following formula:
ANC = (% segs + % bands) x total white blood count
Verify within institutions ANC parameters prior to beginning treatment
Pretreatment Physiological Pretreatment Physiological AssessmentAssessment
Begin the process of physiologic preparation for chemotherapy/biotherapy. This will include hydration and plans for control of nausea and vomiting
Obtain baseline vital signsDeliver premedications for supportive
care and schedule at appropriate intervals
Dosing of Dosing of Chemotherapy/BiotherapyChemotherapy/Biotherapy
When calculating doses in pediatrics, the actual body weight is used
Chemotherapy/biotherapy doses are generally calculated using body surface area. Accuracy of weight and height measurements is essential to correct dosing of chemotherapy/biotherapy ◦ BSA = Ht (cm) X Wt (kg) ÷ 3600, then square
root the result
Dosing of Dosing of Chemotherapy/BiotherapyChemotherapy/BiotherapyMilligram/kilogram formulas are used to
calculate chemotherapy/biotherapy doses in children weighing less than 10 kilograms or who are less than 12 months of age
Maintenance fluids are calculated using the BSA. A formula for calculating fluids is 1500ml/m2/24 hours
Toxicity from prior therapy may necessitate dose reductions. Organ dysfunction may necessitate dose reduction
Preparation of Preparation of SettingSettingThe following should be obtained
before beginning chemotherapy/biotherapy: ◦ Personal protective equipment (PPE)◦ Disposal equipment◦ Chemotherapy spill kit◦ Emergency drugs and equipment
available◦ Infusion pump
Preparation of Preparation of SettingSettingThe following should be obtained before beginning chemotherapy: ◦IV fluids and tubing◦Premedications (e.g., antiemetics)
◦Emesis basin
Family Assessment & Family Assessment & EducationEducation Accomplish the following
prior to each chemotherapy/biotherapy course:◦ Identify barriers to learning,
including primary language, anxiety and illiteracy
◦ Explore with the child and family any personal preferences they have regarding chemotherapy administration, such as the time they prefer treatment to start, any rituals the child finds helpful and supportive care
Family Assessment & Family Assessment & EducationEducation
Accomplish the following prior to each chemotherapy course (cont.):◦ Review the medications to be given.
Include the name of the medication, administration route, length of therapy and administration schedule
◦ Discuss potential side effects, when they might occur and how they may be managed
◦ Review plans for the management at home after the chemotherapy/biotherapy is complete
Principles of Principles of AdministrationAdministrationComprehensive patient assessment
Review/verification of treatment plan
Preparation Safe handling principlesPatient/family educationFollow institutional guidelines
VerificationVerificationPatient-Specific Information
◦Patient identification◦Allergies◦Current height, weight, BSA◦Pre-treatment parameters such as pertinent lab values that influence dosage
◦Pre-treatment diagnostic testing results necessary to begin chemotherapy/biotherapy cycle
VerificationVerificationChemotherapy Orders & select
Biotherapy Orders per institution◦ The chemotherapy/Biotherapy order should
include: (2 RN Check) Patient identification Patient-specific measurements (body
weight, height, and body surface area) The full generic name of the drug The drug dose, dose calculation, dose
modification calculation, route, frequency, administration guidelines such as duration of infusion and rate of administration
Required monitoring Admixture fluid type, volume and rate
PreparationPreparationPreparation for Administration◦Assure test dose and/or pre-
medications and hydration are administered
◦Protect light-sensitive drugs◦ Inspect medication prior to
administration for discoloration and particulate matter
◦ Inspect medication label for drug name, dose and expiration date
PreparationPreparationPreparation for Administration
◦Assure that the mode of administration is consistent with knowledge of vesicants and irritants and matches order, label and protocol
◦Avoid bringing medications administered by different routes to the patient’s room at the same time
◦Ensure patient/family education completed
Chemotherapy/Biotherapy Chemotherapy/Biotherapy AdministrationAdministration To ensure safe
administration:◦ Follow institutional
and OSHA guidelines for administration/disposal
◦ Administer medications in accordance with
institutional medicationand nursing practice policies
and guidelines
AdministrationAdministration To ensure safe
administration:◦ Utilize the 6 rights
of safe administration: Right patient Right medication Right dose Right route Right time Right fluid/volume
◦ Use leur lock connections and safety needles
AdministrationAdministrationOral
◦Do not handle without PPE◦Tablets should not be crushed and dissolved outside of a biological safety hood
◦If an oral dose is vomited, establish guidelines for repeating the dose with the ordering clinician
AdministrationAdministrationOral
◦ Creative measures for helping small children tolerate oral medications
◦ School-age children and adolescents, who are responsible for taking their own oral chemotherapy/biotherapy, should have their doses verified by an adult
◦ Liquids should be given in an oral type syringe to deliver an accurate dose of the entire drug and minimize spills/residue
AdministrationAdministrationIntramuscular/Subcutaneous
◦ Site selection Injection into larger muscles is
recommended Avoid injection into areas of pre-existing
tenderness and/or ecchymosis or nodules from prior injections
Volume for single injection is site-dependent
◦ Smallest gauge needle as appropriate for child’s size
◦ Ensure age-appropriate preparation and teaching are completed with the patient and family
AdministrationAdministration Intramuscular/Subcutaneous
◦ If the patient is mildly thrombocytopenic, after the injection, apply pressure directly to injection site for 5 minutes to prevent formation of a hematoma
◦ Apply topical anesthetic agent or ice to the injection site prior to the injection to minimize pain
◦ Dispose of waste in accordance with OSHA and institutional policies and guidelines
◦ Rotate the site of injection for subsequent injections
AdministrationAdministrationIntravenous (IV) access must be
established and patency verified prior to administration
IV access may be established via: ◦ Peripheral IV catheter ◦ Central venous catheter(CVC)
External catheters Broviac, Hickman, Groshong, PICC
Implanted ports Medi-Port, Port-a-CathTM
AdministrationAdministration
Peripheral IV◦ Avoid site selection distal to any recent
venipuncture ◦ A new peripheral IV site is
recommended if an already existing peripheral IV site is older than 24 hours
◦ Areas over joints or bony prominences and the antecubital fossa should be avoided
◦ During IVP vesicant administration, blood return should be verified after each 0.5cc-1cc injected
AdministrationAdministrationImplanted Central Venous
Catheters◦ Assure the selected site is stabilized
just prior to injection/infusion to avoid accidental needle punctures and/or accidental drug exposure. For long-term infusions, tape the site securely, without obstructing your view of the site, so that signs of extravasation can be promptly identified
AdministrationAdministrationCVC and continuous infusion
◦ Blood return should be verified immediately prior to beginning the infusion
◦ The CVC site should be evaluated for signs of inflammation and extravasation of a vesicant infusion every hour throughout the infusion
◦ Secure IV tubing with leur lock connections
◦ Use gauze and/or plastic backed drape beneath connections during access or de-access procedures
AdministrationAdministrationIV Administration Methods◦IV Push (IVP)◦Bolus infusion◦Continuous infusion
IV Push IV Push AdministrationAdministrationIV push therapy is infused in less than 5 minutes
Methods◦Direct push: Directly infusing chemotherapy agents into the IV access device using a syringe
◦Stop cock method: Using a 3-way stop-cock to administer chemo
Continuous IV Continuous IV InfusionInfusion
Infusions should not be interrupted unless absolutely necessary
Infusion pump should be used
Ensuring drug is infused in prescribed time◦ Some protocols allow
for increasing dose by 10%
◦ Other protocols do not allow for change of rate
◦ Check with the prescribing clinician if infusion will not finish at prescribed time
Vesicants/IrritantsVesicants/IrritantsVesicants: are a class of drugs,
that when extravasated cause severe tissue damage and may lead to necrosis (Jenkins, 1998)
Irritants: are agents that have the potential to cause phlebitis and irritate tissue if extravasated, they do not cause the degree of tissue damage and necrosis that vesicants do
Monitoring for Potential Monitoring for Potential Side EffectsSide Effects
Flare Reaction◦ A localized venous inflammatory
reaction in response to an IV agent ◦ Signs and symptoms include pain,
redness at the site and along the vein length
◦ Treatment/management: Once extravasation is ruled out, the vein should be flushed with a compatible IV fluid and resolution of the redness should follow
Monitoring for Potential Monitoring for Potential Side EffectsSide EffectsHemodynamic monitoring
◦Monitor hemodynamic status taking vital signs as indicated throughout administration
Monitoring for Potential Monitoring for Potential Side EffectsSide EffectsFluid status
◦Monitor fluid status: measure urine output and urine specific gravity as needed throughout administration
◦Monitor hydration status: oral intake, skin turgur, mucous membranes, and tears, assess the impact of nausea and vomiting on oral intake
Monitoring for Potential Monitoring for Potential Side EffectsSide Effects
Specific side effects:◦ Monitor for the
occurrence of side effects
◦ Monitor the effectiveness of the anti-emetic regimen
Monitoring for Potential Side Monitoring for Potential Side Effects – Allergic ReactionsEffects – Allergic Reactions
Allergic reactions and anaphylaxis are hypersensitivity reactions to a foreign protein that can occur immediately or within minutes to hours after exposure to the offending protein
The reaction can be localized or systemic
IgE Mediated vs Non IgE IgE Mediated vs Non IgE MediatedMediated
IgE MediatedSpecific IgE is
produced at initial exposure
Reaction occurs at subsequent exposures
Anaphylaxis◦ Allergic Reaction
Non IgE Mediated No prior
sensitization required
Reaction can occur at initial exposure
Anaphylactoid◦ Non-Allergic reaction
Chung, C 2008
Signs and Symptoms Signs and Symptoms Infusion ReactionInfusion ReactionAllergic Reaction/HypersensitivityPruitis/itchingRash/desquamation Urticaria: hives, welts, whealsRigors/chillsHeadacheArthralgia/myalgiaFatigue (asthenia, lethargy, mailaise) DizzynessSweatingNausea/VomitingCough, Dyspnea, bronchospasmHypotension/hypertensionTachycardia
Heinz-Josef Lenz, 2007
Severe Infusion ReactionSevere Infusion Reaction
Life threatening and may appear within minutes of exposure
Severe bronchospasm, laryngeal edema, respiratory distress, and/or cutaneous and gastrointestinal, leading to hypotensive crisis
Chung, C 2008
Infusion ReactionsInfusion ReactionsPrevention/ProphylaxisAcetominophenAntihistaminesCorticosteroidsH2 antagonist
ManagementAntihistaminesCorticosteroidsEpinephrineOxygenVasopressorsBronchodilators
Mild to Moderate ReactionsResume infusion at 50% reduction of infusion rate oncesymptoms are completely resolved
Chung, C 2008
Monitoring for Potential Side Monitoring for Potential Side Effects – Allergic ReactionsEffects – Allergic Reactions
Nursing interventions◦ Stop Infusion◦ Maintain airway, IV access, vital signs◦ Administer medications promptly in
the event of a reaction: acetaminophen (Tylenol) diphenhydramine (Benadryl) Steroids epinephrine (Adrenaline, Sus-phrine)
Know the actual doses of medications that would be needed specifically for an individual patient receiving a potentially anaphylactic medication
DocumentationDocumentation
Date and timeVenipuncture site (central or peripheral)Venipuncture needle type, gauge, lengthVerification of blood return, prior to,
during and after infusionDrug name, dose, route and volume in mlType and amount of IV flush solution
used Infusion duration Document per institution guidelines
DocumentationDocumentation Antiemetic, dose, time Pre-med, dose, time Hydration type and
amount Method of
administration Adverse reactions/side
effects Patient tolerance of
chemotherapy/biotherapy
Ability to tolerate fluid and food
Patient and family education
Patient and Family Patient and Family EducationEducationPrior to administration and during
administration of chemotherapy/biotherapy◦ Name of medications to be given◦ Administration route and any route-
specific step-by-step administration guidelines
◦ Expected or potential side effects and when they may occur
◦ Safe handling considerations
Patient and Family Patient and Family EducationEducationSupportive care measures should be a part of the education plan
If a patient is prescribed growth factors, side effects and detailed administration techniques should be reviewed
Patient and Family Patient and Family EducationEducationEnsure discharge teaching is
completed with the patient and family, and they have all necessary medications, equipment, supplies and disposal instructions, if the patient is to receive medications at home
Patients and family members should be aware of reportable symptoms and side effects, as well as who to contact and the telephone/pager numbers
Discharge PlanningDischarge Planning
CVC teachingHome care referralReview expected or
potential side effects they may experience at home
Chemotherapy/ biotherapy schedule (calendar)
Follow-up appointment
Patient and Family Patient and Family OutcomesOutcomes
Accurate and safe administration of chemotherapy/ biotherapy
Effective management of nausea and vomiting
Effective pain and symptom management
Effective anticipatory guidance
Demonstrate the technical skills necessary to provide care at home◦ Medication
administration, central line catheter care, etc.
Effective documentation of chemotherapy/ biotherapy administration at home