NURSING CARE OF PATIENTS RECEIVING CHEMOTHERAPY Ranjita Rajesh Lecturer People’s College of Nursing Bhopal

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NURSING CARE OF PATIENTS RECEIVING
CHEMOTHERAPYRanjita RajeshLecturerPeoples
College of Nursing Bhopal
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Chemotherapy is the use of chemicals to treat
disease. Paul Erlich, considered to be the father
of chemotherapy, coined this word to describe a
specific chemical utilized in the treatment of
parasites. Today the term chemotherapy while
technically describing drug therapy for any
disease , is most frequently used in reference to
the treatment of cancer. The simple definition of
chemotherapy, although accurate , fails to
encompass its multifaceted nature which is as
complex as the disease it attempts to treat.
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Just as the word cancer represents many
different types of malignant disease, the word
chemotherapy represents many different types of
chemotherapeutic agents. The drugs used in cancer
treatment vary in their chemical structure ,
biological side effects and toxicities. Some are
effective in treating one specific types of
cancer while others are utilized in the treatment
of wide variety of malignancies. The methods of
administration also vary according to the
chemotherapeutic and new techniques for safer and
more effective administration.
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The process of learning about chemotherapy is
indeed a challenge. Nursing management of the
patient receiving chemotherapy requires knowledge
about the treatment , skill in assessment,
technical expertise, ability and desire to
support the client physically and emotionally.
The reward in meeting this is to be able to
provide the care this clients need in order to
survive their disease and its treatment and
hopefully to go on with their lives with as few
physical and emotional scars as possible.
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Nursing care begins with a thorough understanding
of the patients condition goal of therapy , drug
dose, route, schedule, administration principles
and potential side effects. Additional nursing
management includes monitoring responses to the
therapy, reassessing and documenting signs and
symptoms, and communicating pertinent
information to other members of the health care
team.
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Chemotherapy is the use of cytotoxic drugs in the
treatment of cancer. It is one of the four
modalities- surgery, radiation therapy,
chemotherapy and biotherapy- that provide cure,
control, or palliation. Chemotherapy is systemic
as opposed to localized therapy such as surgery
radiation therapy.
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There are four ways chemotherapy may be
used1. Adjuvant therapy- A course of
chemotherapy used in conjunction with another
treatment modality.2. Neoadjuvant chemotherapy-
Administration of chemotherapy to shrink the
tumor prior to surgical removal of the
tumor.3. Primary therapy- The treatment of
patients with localized cancer for which there is
an alternative but less than completely effective
treatment.4. Induction chemotherapy- The drug
therapy is given as the primary treatment for
patients with cancer for which no alternative
treatment exists.5. Combination chemotherapy-
Administration of two or more chemotherapeutic
agents in the treatment of cancer, allowing each
medication to enhance the action of the other or
act synergistically with it. e.g. MOPP regimen
for Hodgkins disease.
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ROLE OF A NURSEPrior to chemotherapy
administration1 Review- The chemotherapy drugs
prescription which should have -Name of
anti-neoplastic agent.-Dosage-Route of
administration-Date and time that each agent to
be administered.2. Accurately identify the
client 3.Medications to be administered in
conjunction with the chemotherapy e.g
antiemetics, sedatives etc.
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4.. Assess the clients condition including -
Most recent report of blood counts including
hemoglobin ,hematocrit, white blood cells and
platelets. -Presence of any complicating
condition which could contraindicate
chemotherapeutic agent administration i.e.
infection, severe stomatitis , decreased deep
tendon reflexes, or bleeding .-Physical
status-Level of anxiety-Psychological status.
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5. Prepare for potential complicationsReview
the policy and have medication and supplies
available for immediate intervention the event
of extravasation.Review the procedure and have
medication available for possible
anaphylaxis6.Assure accurate preparation of the
agent -Accuracy of dosage calculation
-Expiry date of the drug to be checked
-Procedure for correct reconstitution and
-Recommended procedures for administration7.Asses
s patients understanding of the chemotherapeutic
agents and administration procedures.
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II. Calculation of drug dosageIt is calculated
based on body surface area.III. Drug
reconstitution/Preparation- Pharmacy staff should
reconstitute all drugs pre-prime the intravenous
tubing under a class II biologic safety
cabinet(BSC). In certain conditions nurses may be
required to reconstitute medications. When
preparing and reconstituting safe handling
guidelines to be followed.
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-All chemotherapeutic drug should be prepared
according to package insert in class II
BSC.-Aseptic technique should be
followed.-Personal protective equipment includes
disposable surgical gloves, long sleeves gown and
elastic or knit cuffs.-Protective eye goggles if
no BSC-To minimize exposure -Wash hands before
and after drug handling.-Limit access to drug
preparation area
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-Keep labeled drug spill kit near preparation
area.-Apply gloves before drug handling.-Open
drug vials/ ampoules away from body.-Place
absorbent pad on work surface.-Wrap alcohol wipe
around neck of ampoule before opening.-Cover tip
of needle with sterilize gauge when expelling air
from syringe.-Label all chemotherapeutic drugs.
Clean up any spill immediately
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IV. Drug administration 1. Route- i)Oral
- Emphasize the importance of compliance by the
patient with prescribed schedule.Drugs with
emetic potential should be taken with
meals.Assure that chemotherapeutic agents are
stored as directed by the manufacturer(refrigerate
, avoid exposure to direct light,etc). ii)
Intramuscular and subcutaenous Chemotherapeutic
agents that can be administered I/M or
subcutaneously are few in number. Non-vesicants
like L-asperaginase, bleomycin,
cyclophosphamide, methotraxate. Cyta arabine,and
some hormonal agents are given I/M /Or
subcutaneously.
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-Use the smallest gauge needle possible for the
viscosity of the medication. -Change
the needle after withdrawing the agent from a
vial or ampoule.-Select a site with adequate
muscle and/or SC tissue.iii) Intravenous It is
the most common method of administration of
cancer chemotherapy. May be given through central
venous catheters or peripheral access. Absorption
is more reliable. This route is required for
administration of vesicants and it also reduces
the need of repeated injection. Because the I/V
provides direct access to the circulatory system,
the potential for infection and life threatening
sepsis is a serious complication of I/V
chemotherapy.
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The following guidelines to be kept in
mind-Inspect the solution, container and tubing
for signs of contamination including particles,
discoloration, cloudiness, and cracks or tears in
bottle or bag-Aseptic technique to be
followed-Prepare medicines according to
manufacturers directions-Select a suitable
vein-Large veins on the forearm are the
preferred site.-Use distal veins first, and
choose a vein above areas of flexion.-For
non-vesicant drugs, use the distal veins of the
hands (metacarpal veins) then the veins of the
forearms(basilic and cephalic veins)
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-For vesicants, use only the veins of the
forearms. Avoid using the metacarpal and radial
areas. -Avoid the antecubital fossa and the
wrist because an extravasation in these areas can
destroy nerves and tendons, resulting in loss of
function. -Peripheral sites should be changed
daily before administration of vesicants-Avoid
the use of small lumen veins to prevent damage
due to friction and the decreased ability to
dilute acidic drugs and solutions. Select the
shortest catheter with the smallest gauge
appropriate for the type and duration of the
infusion (21g to 25g for I/V medications and 19 g
for blood products).
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-Avoid a vein which has been used for venous
access within the past 24 hrs to prevent leakage
from a prior puncture site. Prevent trauma and
infection at the insertion site. -Apply a
small amount of iodine based antiseptic ointment
over the insertion site cover the area with
sterile gauze.Intravenous Chemotherapy Via
Central Vein Infusion (Hickman Catheter)
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A Hickman catheter is a flexible polymeric
silicon rubber catheter which is threaded through
the cephalic vein and into the superior vena cava
or through the venacava and into the right atrium
of the heart. Placement in a large vein permits
the use of a catheter large enough for infusion
of chemotherapy, hyper osmolar fluids for
nutrition purposes, blood products and other
needed intravenous fluids.
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The silicon rubber material of catheter is
chemically inert to prevent decomposition and it
is anti-thrombogenicA felt cuff near the exit
site anchors the catheter on the patients chest
and acts as an anatomic barrier to prevent entry
of infection causing agents.It is either single
lumen or double-lumen. IV) Intra-arterialV)Intra
-peritoneal
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VI)Intrathecal- Infusion of medication can be
given through an Ommaya reservoir, implantable
pump and /or usually through lumbar
puncture. a)Wear protective equipment (gloves,
gown and eyewear). b)Inform the patient that
chemotherapeutic drugs are harmful to normal
cells and that protective measures used by
personnel minimize their exposure to these
drugs. c)Administer drugs in a safe and
unhurried environment.
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d)Place a plastic backed absorbent pad
under the tubing during administration to catch
any leakage. Do not dispose of any supplies or
unused drugs in patient care areas.
V. DocumentationRecord -chemotherapeutic
drugs, dose, route ,and time
-Premedications, postmedications, prehydration
and other infusions and supplies used for
chemotherapy regimen.-Any complaints by the
patient of discomfort and symptoms experienced
before, during, and after chemotherapeutic
infusion.
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VI. Disposal of supplies and unused drugs a)Do
not clip or recap needles or break
syringes. b)Place all supplies used intact in
a leak proof ,puncture proof, appropriate
labeled container. c)Place all unused drugs in
containers in a leak proof, puncture proof,
appropriately labeled container. d)Dispose of
containers filled with chemotherapeutic
supplies and unused drugs in accordance with
regulations of hazardous wastes.
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VII. Management of chemotherapeutic
spillsChemotherapy spills should be cleaned up
immediately by properly protected personnel
trained in the appropriate procedure. A spill
should be identified with a warning sign so that
other person will not be contaminated.
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Supplies Required Chemotherapy spill kit
containsRespirator mask for air borne powder
spillsPlastic safety glasses or gogglesHeavy
duty rubber glovesAbsorbent pads to contain
liquid spillsAbsorbent towels for clean up after
spillsSmall scoop to collect glass fragmentsTwo
large waste disposal bags
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Protective disposable gownContainers of
detergent solution and clear tap water for post
spill clean up.Puncture proof and leak proof
container approved for chemotherapy waste
disposalApproved, specially labeled, impervious
laundry bag.Spill on hard surfaceRestrict area
of spillObtain drug spill kitPut on protective
gown, gloves, gogglesOpen waste disposal
bagsPlace absorbent pads gently on the spill be
careful not to touch spill.
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Spill on hard surfaceRestrict area of
spillObtain drug spill kitPut on protective
gown, gloves, gogglesOpen waste disposal
bagsPlace absorbent pads gently on the spill be
careful not to touch spill.
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Place absorbent pad in waste bagCleanse surface
with absorbent towels using detergent solution
and wipe clean with clean tap water.Place all
contaminated materials in the bag.Wash hands
thoroughly with soap and water.
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Spill on personnel or patientRestrict area of
spillObtain drug spill kitImmediately remove
contaminated protective garments or linenWash
affected skin area with soap and waterIf eye
exposure-immediately flood the affected eye with
water for at least 5 mts obtain medical
attention promptlyNotify the physician if drug
spills on patient.Documentation- Document the
spill.
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VIII. Staff EducationAll personnel involved in
the care should receive an orientation to chemo.
Drugs including their known risk , relevant
techniques and procedures for handling, the
proper use of protective equipment and materials,
spill procedures, and medical policies covering
personnel handling chemo. agents.Personnel
handling blood, vomitus, or excreta from patients
who have received chemotherapy should wear
disposable gloves and gowns to be appropriately
discarded after use.
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IX. Extravasation managementExtravasation is
the accidental infiltration of vesicant or
irritant chemotherapeutic drugs from the vein
into the surrounding tissues at the I/V site. A
vesicant is an agent that can produce a blister
and /or tissue destruction. An irritant is an
agent that is capable of producing venous pain at
the site of and along the vein with or without an
inflammatory reaction. Injuries that may occur as
a result of extravasation include sloughing of
tissue , infection, pain ,and loss of mobility of
an extremity.
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1.Prevention of extravasationNursing
responsibilities for the prevention of
extravasation include the following Knowledge
of drug s with vesicant potentialSkill in drug
administrationIdentification of risk factors
e.g. multiple vene puncturesAnticipation of
extravasation and knowledge of management
protocolNew venepuncture site daily if
peripheral access is used
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Central venous access for 24 hrs vesicants
infusionAdministration of drug in a quiet,
unhurried environmentTesting vein patency
without using chemotherapeutic agentsProviding
adequate drug dilutionCareful observation of
access site and extremity throughout the
procedureEnsuring blood return from I/V site
before, during, and after vesicant drug
infusion.Educating patients regarding symptoms
of drug infiltration , e.g. pain, burning,
stinging sensation at I/V site.
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2.Extravasation management at peripheral
site-According to agency policy and approved
antidote should be readily available.The
following procedure should be initiated-Stop the
drugLeave the needle or catheter in
placeAspirate any residual drug and blood in the
I/V tubing, needle or catheter, and suspected
infiltration siteInstill the I/V antidoteRemove
the needle
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If unable to aspirate the residual drug from the
IV tubing , remove needle or catheterInject the
antidote sub-cutaneously clockwise into the
infiltrated site using 25 gauge needle change
the needle with each new injectionAvoid applying
pressure to the suspected infiltration siteApply
topical ointment if orderedCover lightly with an
occlusive sterile dressingApply cold or warm
compresses as indicatedElevate the
extremityObserve regularly for pain, erythema,
induration, and necrosisDocumentation of
extravasation management. All nursing personnel
should be alert and prepared for the possible
complication of anaphylaxis.
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X. Nursing Management of common side effects of
Chemotherapeutic drugs..Nausea Vomiting
Nausea is the conscious recognition of the
subconscious excitation of an area of the medulla
closely associated with or part of the vomiting
center. Nausea may cause the desire to vomit it
often precedes or accompanies vomiting.
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Avoid eating/drinking for 1-2 hrs prior to and
after chemotherapy administrationEat frequent,
small meals. Avoid greasy fatty foods and very
sweet foods candies.Avoid unpleasant sights,
odors testesFollow a clear liquid dietIf
vomiting is severe inform the physician.Consider
diversionary activities
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Sip liquids slowly or suck ice cubes and avoid
drinking a large volume of water if vomiting is
presentAdminister antiemetics to prevent or
minimize nausea. Patient may require routine
antiemetics for 3-5 days following some
protocols.Monitor fluid and electrolyte
status.Provide frequent, systemic mouth care.
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.Bone marrow Depression This can lead to
-Anaemia-Bleeding due to thrombocytopenia-Infec
tion due to leukopeniaNursing ActionsAdminister
packed RBC according to the physician
orders.Monitor hematocrit and haemoglobin
especially during drug nadir Maintain the
integrity of the skin
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Avoid activities with the greatest potential for
physical injuryUse an electric razor when
shavingAvoid the use of tourniquetsEat a soft,
bland diet, avoid foods that are thermally,
mechanically and chemically irritating.Maintain
the integrity of the mucous membranes of G I
tractPromote hydrate to avoid constipationAvoid
enemas, harsh laxatives the use of rectal
thermometers.Take steroids with an antacid or
milk.
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Avoid sources of infectionMaintain good personal
hygiene.Prevent trauma to skin mucous
membranesReport s/s of infection to
physicianMonitor countsAvoid invasive
procedures, no Raise the arm while pressure is
applied after removal of a needle or catheter
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.AlopeciaExplain hair loss is temporary, and
hair will grow when drug is stopped.Use a mild,
protein based shampoo, hair conditioner every 4-7
daysMinimize the use of an electric dyer.Avoid
excessive brushing and combing of the air.
Combing with a wide tooth comb is
preferred.Select wig, cap, scarf or turban
before hair loss occurs.Keep head covered in
summer to prevent sunburn and in winter to
prevent heat loss.
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Fatigue - Assess for possible causes chronic
pain, stress, depression and in-sufficient rest
or nutritional intake. -Conserve energy rest
when tired-Plan for gradual accommodation of
activities.-Monitor dietary fluid intake
daily. Drink 3000 ml of fluid daily, unless
contra-indicated, in order to avoid the
accumulation of cellular waste products.
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AnorexiaFreshen up before mealsAvoid drinking
fluids with meals to prevent feeling of
fullnessHigh protein dietMonitor and record
weight weekly. Report weight loss
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Stomatitis (Oral) -Symptoms occur 5-7 days
after chemotherapy persist upto 10
days -Continue brushing regularly with soft
tooth brush -Use non irritant mouthwash -Avoid
irritants to the mouth -Maintain good
nutritional intake, eat soft or liquid foods high
in protein
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-Follow prescribed medication schedule e.g. drug
for oral candidiasis. -Report physician if
symptom persists -Increase the frequency of oral
hygiene every 2 hrs-Glycerin lemon juice
should never be used to clear mouth or teeth as
it cause the tissues to become dry irritated.
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Diarrhoea - Some clients experience diarrhoea
during and after treatment with
chemotherapy.Nursing Action Monitor number,
frequency and consistency of diarrhoea
stools.Avoid eating high roughage, greasy and
spicy food alcoholic beverages, tobacco and
caffeine productsAvoid using milk productsEat
low residue diet high in protein and calories
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Include food high in potassium if fatigue is
present like bananas, baked potatoes.Drink 3000
ml of fluid each day.Eat small frequent meals
eat slowly and chew all food thoroughlyClean
metal area after each bowel movement. Administer
anti-diarrhoeal agents as prescribed.
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.Depression Assess for changes in mood and
affect.Set small goals that are achievable
dailyParticipate e.g. music, reading,
outingsShare feelingsReassurance
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.Cystitis-Is an inflammation of the bladder,
which is usually caused by an infection. Sterile
cystitis not induced by infection. Sterile
cystitis not induced by infection, can be a side
effect of radiation therapy or due to
cyclophosphamide (endoxan) administration. The
metabolites of cyclophosphamide are excreted by
the kidneys in the urine
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Nursing ActionsFluid intake at least 3000 ml
dailyEmpty Bladder as soon as the urge to void
is experienced.Empty bladder at least every 2-4
hrs.Urinate at bed time to avoid prolonged
exposure of the bladder wall to the effects of
cytoxan while sleeping.
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Take oral cytoxan early in the morning to
decrease the drug concentration in the bladder
during the nightReport increasing symptoms of
frequency bleeding burning on urination, pain
fever and chills promptly to physicianFollowing
comfort measures can be adopted if cystitis is
present-Ensure dilute urine by increasing the
fluid intakeAvoid foods beverages that may
cause irritation to the bladder alcohol,
coffee, strong tea, Carbonated beverages etc.
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Outpatient Chemotherapy DeliveryAggressive,
complex and sophisticated cancer therapies are
currently being in ambulatory home care
settings. This shift is provision of services
from the Hospital setting is a result o
cost-containment efforts, advanced technology,
competition increased competence of nurses.
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Conclusion Chemotherapy offers patients with
cancer a great deal of hope for a cure or a
means of control cancer for a long period of
time. Hope and optimism are vital ingredients in
care plan.
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