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Chemotherapy-Induced Peripheral Neuropathy (CIPN): Why the complication?

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Chemotherapy-Induced Peripheral Neuropathy (CIPN): Why the complication? By: Tiffany Marbach, RN, BSN Alverno College MSN Student Spring 2008 marbactj_at_alverno.edu – PowerPoint PPT presentation

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Title: Chemotherapy-Induced Peripheral Neuropathy (CIPN): Why the complication?


1
Chemotherapy-Induced Peripheral Neuropathy
(CIPN)Why the complication?
  • ByTiffany Marbach, RN, BSN
  • Alverno College MSN Student
  • Spring 2008
  • marbactj_at_alverno.edu

2
Navigating through this tutorial
  • To advance to the next slide, click on the
  • To review the previous slide, click on the
  • At any time during the tutorial you wish to
    review a different section of the tutorial, click
    on the cell at the top of the screen

3
Objectives
  • At the conclusion of this tutorial, the learner
    should be able to
  • Understand how the peripheral nervous system
    works, what nerves are affected by neurotoxic
    agents
  • Describe the signs and symptoms of
    Chemotherapy-Induced Peripheral Neuropathy (CIPN)
  • Identify which types of chemotherapeutic agents
    contribute/cause CIPN
  • Understand who is more at risk for developing
    this complication
  • Describe how patients can have improved health
    status and outcomes when educated about how to
    live with CIPN, as well as how to prevent it
  • Understand ways to treat CIPN once it has
    developed

4
Content of Tutorial
Incidence of CIPN
Inflammation
Pathophysiology
Stress and CIPN
Chemotherapy Agents
Signs/Symptoms of CIPN
Assessment of CIPN
Patients at risk
Genetics
Pharmacologic Treatment
Nonpharmacologic Treatment
For More Information
References
Patient Teaching
Case Study
5
Incidence of CIPN
  • Chemotherapy is prolonging life
  • Cancer is becoming a chronic, manageable disease
  • Many nurses will encounter those affected by this
    common side effect
  • Estimated to occur in 20 to nearly 100 of
    cancer patients undergoing chemotherapy (Smith,
    Beck, Cohen, 2008).

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6
What is CIPN?
  • Characterized as injury, inflammation, or
    degeneration of peripheral nerve fibers
  • Can result in loss of motor and sensory nerve
    function
  • CIPN can result when certain chemotherapeutic
    agents are used to treat cancer (Marrs Newton,
    2003)
  • These agents can be referred to as neurotoxic

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7
Why is this important for my practice?
  • Encountering more and more survivors with this
    debilitating condition
  • Limited research done in this area

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8
Why is this important for my practice?
  • Incidence increases with
  • Duration of infusion (longer infusion increased
    chance)
  • Drugs given
  • Previous exposure to neurotoxic drugs
  • Combination chemotherapies (in which more than
    one neurotoxic drug is given)
  • Co-morbidities

9
Rest and Review!
  • Why is CIPN important for all nurses to learn
    about?
  • A. It isnt only oncology nurses need to care
    about it
  • B. Cancer survival rates are increasing, so more
    nurses will have exposure to patients with this
    side effect
  • C. It is the most common chemotherapy side effect

10
  • Sorry, but that is NOT why it is important for
    all nurses to be educated about CIPN.
  • Please click on the question mark below to go
    back and try the question again!

11
  • CONGRATULATIONS!
  • That is exactly why all nurses should be educated
    on CIPN and its effects!
  • Click on the arrow below to continue with the
    tutorial.

12
Pathophysiology of CIPN
  • The Peripheral Nervous System (PNS) communicates
    signals between the central nervous system (CNS,
    composed of the brain and spinal cord) and the
    periphery of the body (Marrs Newton, 2003)
  • The peripheral nerves originate from the spinal
    cord
  • The peripheral nervous system is made of three
    divisions the sensory nerves, the motor nerves,
    and the autonomic nerves

Sheffield, Getbodysmart.com, 2008 Used with
permission
13
Sensory nerves
  • Sensory nerves are responsible for detecting
  • Pain
  • Touch
  • Temperature
  • Position
  • Vibration

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14
Motor Nerves
  • Motor nerves are responsible for
  • Voluntary movement
  • Muscle tone
  • Coordination

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15
Autonomic nerves
  • Autonomic nerves are responsible for
  • Intestinal motility
  • Blood pressure
  • Involuntary muscle movements

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16
Rest and Review!
  • Sensory nerves are responsible for detecting
  • A. Blood pressure
  • B. Balance and coordination
  • C. Intestinal Motility
  • D. Temperature and pain

17
  • Sorry,
  • but that is NOT the function of the
  • sensory nerves.
  • Please click on the question mark below to go
    back and try the question again!

18
  • CONGRATULATIONS!
  • You are correct.
  • Sensory nerves are responsible for the feelings
    of temperature, pain, touch, position, and
    vibration.
  • Click the arrow below to advance to the next
    slide.

19
Pathophysiology (continued)
  • Peripheral nerves are made up of individual
    neurons, axons, cell bodies, and dendrites,
    wrapped in a myelin sheath
  • Each nerve fiber (neuron), is made up of single
    axon
  • This axon is surrounded by Schwann cells
  • Schwann cells form myelin sheath
  • Dendrites synapse with other nerves to send a
    signal across from one nerve to the next
    (Wickham, 2007)

Click below for structure of neuron diagram!
Multiple Sclerosis Resource Centre , 2008 Used
with permission
20
Pathophysiology (continued)
  • Cell body provides nourishment and maintain the
    nerve fibers
  • Dendrites extend from the cell body and
    receive/carry stimuli to the cell body
  • Axon then carries the impulse away from the
    cell body

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21
Pathophysiology (continued)
  • Peripheral nerve fibers are classified as
    myelinated or unmyelinated
  • They are grouped to their size in diameter
    (called A, B, and C fibers)
  • A Fibers (motor and sensory fibers), are largest
    in diameter, and are myelinated (allowing for
    fast impulse conduction)

22
Pathophysiology (continued)
  • B Fibers (least common fiber), are smaller in
    diameter, and are less myelinated than A fibers
  • C Fibers (some sensory and motor, but autonomic
    fibers are most common), smallest and slowest
    conducting of the PNS
  • Damage to the large fibers (A B) or small
    fibers (C), correspond with the signs/symptoms of
    CIPN (Armstrong, Almadrones Gilbert, 2005)

23
Sensory nerves are broken down into
  • Large fiber nerves
  • Are myelinated
  • Sense position, motor control, and vibration
  • Composed of neurofilaments, which act as
    framework of axon

24
Sensory nerves are broken down into
  • Small fiber nerves
  • Are unmyelinated
  • Include nerves that sense pain and temperature
  • Speed of impulse transmission depends on if
    neuron is highly myelinated (fast transmission),
    lightly myelinated (slower transmission), or
    unmyelinated (slowest transmission) (Wickham,
    2007)

25
Rest and Review!
  • Highly myelinated nerve cells conduct impulses
  • A. Fast
  • B. Slow
  • C. Very slow

26
  • Sorry! Wrong answer. Please try again.
  • Please click on the question mark below to go
    back and try the question again!

27
  • Nice job!! The highly myelinated nerve cells are
    very fast conductors!
  • Click the arrow below to advance to the next
    slide.

28
Rest and Review!
  • The function of the dendrite portion of the nerve
    cell is to
  • A. Provide the cell with food and nourishment
  • B. Receive and carry stimuli to the cell body
  • C. Carry the impulse away from the cell body

29
  • OOPS! This is NOT the function of the dendrites
  • Please click on the question mark below to go
    back and try the question again!

30
  • Excellent answer! The dendrites are responsible
    for receiving and carrying stimuli to the cell
    body!
  • Click the arrow below to advance to the next
    slide.

31
Pathophysiology (continued)
  • Peripheral neuropathy results from damage to the
    axon, myelin sheath, or cell body
  • Pathogenesis of CIPN is not completely understood
  • It is known that different sensations arise
    depending on chemotherapeutic agent administered
    (Wickham, 2007)

Multiple Sclerosis Resource Centre , 2008 Used
with permission
32
Pathophysiology (continued)
  • Chemotherapy drugs are believed to first
  • Damage sensory axons
  • Then move on to cause degeneration and dying back
    of axons and myelin sheaths (Wickham, 2007)

National Resource Council Canada, 2005 Used with
Permission
33
Pathophysiology (continued)
  • CIPN is usually symmetrical
  • Begins in distal end of longest axons
  • Sometimes known as polyneuropathy affects many
    nerves
  • Toxins (including chemotherapy) are transported
    along the axon towards the cell body (Wickham,
    2007)

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34
The stocking/glove phenomena Moves distal to
proximal
  • CIPN usually progresses from toes to feet to
    ankles to lower legs (stocking distribution)
  • Upper extremity damage usually comes later
  • Moves from fingertips to fingers to hands (glove
    distribution) (Wickham, 2007)

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35
Rest and Review!
  • Nerve cells are damaged by chemotherapy because
  • A. They arent strong enough to handle the
    toxicity
  • B. The chemotherapy causes degeneration and dying
    back of axons and myelin sheaths
  • C. The chemotherapy doesnt affect the nerve cells

36
  • NoThats not how nerve cells are damaged
  • Please click on the question mark below to go
    back and try the question again!

37
  • Youre RIGHT! That is exactly how nerve cells
    are damaged!
  • Click the arrow below to advance to the next
    slide.

38
Rest and Review!
  • In a typical pattern of CIPN, the person
    experiences neuropathy first in the
  • A. Upper leg
  • B. Toes
  • C. Hands
  • D. Upper arm

39
  • Think again. Where does neuropathy usually show
    up first in a stocking-glove pattern?
  • Please click on the question mark below to go
    back and try the question again!

40
  • GREAT job! The neuropathies usually show up first
    in the lower extremities, and progress later
    towards the upper extremities.
  • Click the arrow below to advance to the next
    slide.

41
Nerve Growth Factor
  • Axons regenerate if toxic agent removed
  • Damage to cell bodies is not completely
    reversible
  • Nerve Growth Factor (NGF) plays role in neuron
    repair
  • NGF is usually reduced after neurotoxic
    chemotherapy
  • Animal studies show if given NGF, some neuropathy
    and neural structural changes were prevented or
    reversed
  • Exact mechanism not well understood (Wickham,
    2007)

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42
Inflammation and CIPN Whats the connection?
  • Tissue repair is part of the inflammatory process
  • It is an attempt to maintain normal body
    structure and function
  • Cell regeneration can vary depending on
    tissue/cell type
  • Three types of cells that are divided according
    to ability to undergo regeneration labile,
    stable, or permanent cells (Porth, 2005)

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43
Nerve cells Permanent/Fixed Cells
  • Labile cells regenerate and divide throughout
    life (ex Epithelial cells found on skin or in
    the mouth)
  • Stable Cells stop dividing when growth ends, but
    can regenerate when confronted with certain
    stimuli (ex liver cells)
  • Permanent/Fixed cells cannot undergo mitotic
    division, and cant regenerate (ex nerve and
    cardiac muscle cells) (Porth, 2005)

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44
Nerve cells Permanent/Fixed Cells (continued)
  • When nerve cell is damaged (for example, from a
    chemotherapy drug), it can not be replaced
  • It is replaced with scar tissue
  • This scar tissue can not function like the
    destroyed cell can (for example, cant conduct
    impulses) (Porth, 2005)

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45
Rest and Review!
  • Peripheral nerve cells are considered
  • A. Labile cells
  • B. Stable cells
  • C. Permanent or fixed cells

46
  • This is not what nerve cells are classified as
  • Please click on the question mark below to go
    back and try the question again!

47
  • Right on! Nerve cells are fixed or permanent
    cells, that can not regenerate!
  • Click the arrow below to advance to the next
    slide.

48
Stress and CIPN Whats the connection?
  • CIPN can often lead to pain symptoms
  • This pain is classified as acute or chronic pain
  • Acute pain lasts less than 6 months
  • Chronic pain lasts 6 months or longer (Porth,
    2005)

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49
Stress and CIPN Whats the connection?
(continued)
  • CIPN can be considered acute or chronic
  • This depends on length of treatment,
    co-morbidities (pre-existing conditions beside
    the CIPN), and disease state
  • This can cause physiologic, psychological,
    familial, and economic stress
  • Chronic pain can lead to loss of appetite, sleep
    disturbance, and depression (Porth, 2005)

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50
Stress and CIPN Whats the connection?
(continued)
  • Two factors determine nature of stress
  • 1. Properties of the stressor
  • 2. The condition of the person under stress
  • Severe, prolonged physical and psychological
    distress disrupts health with chronic stress
    (Porth, 2005)

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51
Stress and CIPN Whats the connection?
(continued)
  • General Adaptation System (GAS)
  • Systemic reaction to stressor that causes
    physical and psychological manifestations
  • Three stages Alarm, Resistance, and Exhaustion
    (Porth, 2005)

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52
Stress and CIPN Whats the connection?
(continued)
  • 1. Alarm Stimulation of Sympathetic Nervous
    System (SNS)
  • Results in release of catecholamines (such as
    epinephrine and norepinephrine) and cortisol,
    which
  • Increase heart rate, relaxation of bronchial
    smooth muscle, decrease insulin release, etc.
  • 2. Resistance Body selects most effective
    channel of defense

53
Stress and CIPN Whats the connection?
(continued)
  • 3. Exhaustion occurs if stressor is prolonged
  • Most common with CIPN
  • Resources of the bodys coping mechanisms are
    depleted
  • Wear and tear on systems is appearing
  • Many ailments, including CIPN, begin to show wear
    and tear on the person physiologically and
    psychologically (Porth, 2005)

54
Rest and Review!
  • The stage in of the General Adaptation System
    (GAS) most active in chronic CIPN is
  • A. Alarm stage
  • B. Exhaustion stage
  • C. Resistance stage

55
  • Wrong stage of GASTry again!
  • Please click on the question mark below to go
    back and try the question again!

56
  • Correct! The Exhaustion Stage is most active with
    chronic CIPN.
  • Click the arrow below to advance to the next
    slide.

57
Chemotherapeutic agents that induce peripheral
neuropathy
  • CIPN is a dose-limiting toxicity
  • This means that patients could have chemotherapy
    dose reduced, or even held
  • This interrupts normal chemotherapy cycle which
    could affect outcome

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58
Chemotherapeutic agents that induce peripheral
neuropathy Platinum Compounds
  • Cisplatin Carboplatin
  • Affects 57-92 of patients undergoing
    chemotherapy
  • Causes axonal swelling and loss
  • Progress from sensory, to motor, to (rare)
    autonomic symptoms
  • Can occur later in treatment course
  • 66 of patients have full recovery (if developed)
  • Causes loss of sense of position and vibration
  • Numbness/tingling (paresthesias)
  • Some patients can take two years for recovery to
    occur (Armstrong, Almadrones, Gilbert, 2005)

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59
Chemotherapeutic agents that induce peripheral
neuropathy (Platinum compounds)
  • Oxaliplatin
  • Alters neuron excitability interferes with axon
    conduction
  • Causes sensory neuropathy of large fibers
  • 80 of patients develop
  • 40 of those who develop have resolution of
    symptoms in 6-8 months
  • Can cause acute neuropathy (30-60 minutes after
    infusion)
  • Cramps/spasms in hands and feet
  • Aggravated by cold weather
  • Causes sensation of loss of breath, jaw tightness
    (Armstrong, Almadrones, Gilbert, 2005)

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60
Chemotherapeutic agents that induce peripheral
neuropathy (Taxanes)
  • Paclitaxel (Taxol) and Docetaxel (Taxotere)
  • Risk depends on dosing use with other
    neurotoxic agents
  • Taxol causes CIPN in 60 of patients
  • Taxotere causes CIPN in about 49 of patients
  • Affect small fibers, causes axonal injury, and
    demyelinization
  • Altered vibratory sense, loss of deep tendon
    reflexes, paresthesias
  • Causes progressive neurological dysfunction
    (Armstrong, Almadrones, Gilbert, 2005)

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61
Chemotherapeutic agents that induce peripheral
neuropathy (Vinca Alkaloids)
  • Vincristine, Etoposide, Vinorelbine
    Vinblastine
  • Greatest potential for CIPN is Vincristine
    Occurs in about 57 of patients
  • Degenerates the peripheral nerve fibers
  • Affects small and large fibers
  • Causes most commonly motor and sensory
    disruption can cause autonomic effects
  • Paresthesisas, then progresses to muscle
    cramping/weakness, constipation, bladder
    dysfunction, altered heart rate (Marrs Newton,
    2003)

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62
Chemotherapeutic agents that induce peripheral
neuropathy
  • Miscellaneous agents used in oncology patients
    that cause CIPN include
  • Bortezomib (used for multiple myeloma)
  • Methotrexate
  • Cytarabine
  • Procarbazine
  • Interferon
  • Thalidomide
  • Corticosteriods
  • 5-FU

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63
Rest and Review!
  • Which chemotherapy agent can cause prolonged
    recovery time with peripheral neuropathies even
    two years after discontinuation of the drug?
  • A. Cisplatin
  • B. 5-FU
  • C. Etoposide
  • D. Methotrexate

64
  • This is not correct. Time to try again!!
  • Please click on the question mark below to go
    back and try the question again!

65
  • Good job! Cisplatin can unfortunately be
    long-lasting, and take even years to resolve.
  • Click the arrow below to advance to the next
    slide.

66
Rest and Review!
  • Which chemotherapy agent can be exacerbated by
    cold weather and cold objects, causing the
    patient to have sensation of loss of breath?
  • A. Carboplatin
  • B. Taxol
  • C. Taxotere
  • D. Oxaliplatin

67
  • Wrong drug! Go back and look at the question a
    little closer
  • Please click on the question mark below to go
    back and try the question again!

68
  • Excellent! Oxaliplatin can cause cold-induced
    neuropathies!
  • Click the arrow below to advance to the next
    slide.

69
Signs and Symptoms of CIPN
  • Symptoms that patients may experience depend on
    length of infusion, dose, co-morbidities, and the
    drug being administered
  • Symptoms are divided into sensory, motor, and
    autonomic symptoms, correlating with which
    peripheral nerve is affected

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70
Signs and Symptoms of CIPN
  • Sensory Symptoms include
  • Paresthesia feeling of warmth, burning,
    tingling, cold, pinprick sensation, numbness
  • Hyperesthesia increased sensitivity to sensory
    stimulus, not painful, but can cause cramping,
    usually worse at night
  • Hypoesthesia Decreased feeling sensations
  • Dysesthesia Abnormal sensation in skin that
    feels like electric sensation, tingling,
    prickling of the skin
  • Hyporeflexia decreased deep tendon reflexes
    (Visovsky, Collins, Abbott, Aschenbrenner,
    Hart, 2007)

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71
Signs and Symptoms of CIPN
  • Diminished/absent vibration sensation
  • Diminished/absent cutaneous sensation
  • Diminished/absent sense of feeling object as
    sharp or dull
  • Overall loss of sensation
  • Pain can be burning, shooting, sharp
  • Numbness/tingling (American Cancer Society, 2008)

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72
Signs and Symptoms of CIPN
  • Motor symptoms include
  • Weakness
  • Gait disturbance
  • Balance disturbance
  • Difficulty with fine motor skills (for example,
    writing, buttoning clothing, sewing) (Visovsky
    et. al., 2007)

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73
Signs and Symptoms of CIPN
  • Autonomic symptoms include
  • Constipation
  • Urinary retention
  • Sexual dysfunction (erectile dysfunction in men)
  • Blood pressure changes (Visovsky et. al., 2007)

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74
Rest and Review!
  • Which of the following describes the decreased
    feeling sensation sometimes experienced with
    CIPN?
  • A. Paresthesia
  • B. Hyporeflexia
  • C. Hypoesthesia
  • D. Hyperesthesia

75
  • Try again! Theres a better answer
  • Please click on the question mark below to go
    back and try the question again!

76
  • Awesome! Hypoesthesia is decreased sensation!
  • Click the arrow below to advance to the next
    slide.

77
Rest and Review!
  • Which symptom is a result of autonomic nerve
    damage?
  • A. Constipation
  • B. Weakness
  • C. Numbness and tingling
  • D. Balance disturbance

78
  • Sorry, but this is not a symptom of autonomic
    nerve damage.
  • Please click on the question mark below to go
    back and try the question again!

79
  • Nice! Constipation is a common symptom of
    autonomic nerve damage!
  • Click the arrow below to advance to the next
    slide.

80
Assessment of CIPN
  • Baseline neurological assessment is key
  • Allows nurse/staff to recognize changes in
    peripheral neuropathy once treatment begins
  • Must assess all motor, sensory, and autonomic
    function not only before start of treatment, but
    during and after as well (Armstrong, Almadrones,
    Gilbert, 2005)

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81
Assessment of CIPN
  • Problems with current assessment tools
  • Limited because toxicity is determined
    subjectively by healthcare provider
  • Broad categories used for scoring symptoms
  • Patients have trouble describing symptoms
  • Not much assessment beyond presence or absence of
    CIPN is uniformly performed in most clinic
    settings (Wampler, Hamolsky, Hame, Melisko,
    Topp, 2005)

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82
Assessment of CIPN
  • Three problems with measuring neuropathy
  • 1. Patient difficulty with describing the
    uncomfortable sensations, unless they are painful
  • 2. CIPN not always been considered a pertinent
    side effectusually considered a minor problem
    that would eventually resolve
  • 3. Easy, simple, and usefully comprehensive tool
    has yet to be developed (Smith, Beck, Cohen,
    2008)
  • These problems lead to unanswered questions about
    how to improve CIPN symptoms

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83
Assessment of CIPN
  • Some assessment tools include
  • Gait watch patient ambulate, watch for signs of
    pain with ambulation or unbalance
  • Motor watch for signs of weakness and symmetry
  • Reflexes in lower extremity achilles and
    patellar reflexes
  • Reflexes in upper extremity brachioradialis and
    biceps reflex (Armstrong, Almadrones, Gilbert,
    2005)

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84
Assessment of CIPN
  • Sensory vibration sense and position in great
    toe to ankle and knee, and finger to wrist and
    elbow
  • Pinprick sensation from great toe up each leg to
    point of normal sensation pinprick from finger
    up arm to point of normal sensation
  • Autonomic assess bowel sounds, orthostatic blood
    pressures, pulse regularity (Armstrong,
    Almadrones, Gilbert, 2005)

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85
Rest and Review!
  • What is a good way to test for motor disturbance
    in a person affected with CIPN?
  • A. Vibration sensation testing
  • B. Pinprick sensation testing
  • C. Assess bowel sounds
  • D. Checking reflexes

86
  • This is not the best way to test for motor
    disturbance
  • Please click on the question mark below to go
    back and try the question again!

87
  • Good job! Testing reflexes is a great way to
    assess for motor disturbances.
  • Click the arrow below to advance to the next
    slide.

88
Assessment of CIPN
  • NCI-CTCAE (National Cancer Institute Common
    Terminology Criteria for Adverse Effects)
    assesses from Grades 1-4 of Sensory and Motor
    function
  • Grade 1 Asymptomatic
  • Grade 2 Some sensory alteration or weakness
  • Grade 3 Interfering with activities of daily
    living
  • Grade 4 life threatening and disabling
    (paralysis) (Wickham, 2007)

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89
Assessment of CIPN
  • ECOG-CTC tool (Eastern Cooperative Oncology Group
    Common Toxicity Criteria) also is used to assess
    from Grades 1-4 of Sensory and Motor function
  • Oxaliplatin-Specific Scale assesses Grades 1-4
    of specific side effects (Wickham, 2007)

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90
Assessment of CIPN
  • Total Neuropathy Score
  • Most comprehensive
  • Assesses subjective and objective aspects of
    peripheral nerve function
  • Assesses presence, characteristics, and location
    of symptoms, as well as physical findings
  • Each item scored by doctor or nurse on 0-4 scale
    (Smith, Beck, Cohen, 2008)

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91
Assessment of CIPN
  • Total Neuropathy Score
  • Scores summed to obtain total score
  • Higher scores higher the degree of neuropathy
  • Wide scoring range
  • 0no problems
  • 4severe neuropathy almost causing disability
    (Smith, Beck, Cohen, 2008)

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92
Rest and Review!
  • Which neuropathy scoring tool is considered most
    effective in regards to comprehensive scoring?
  • A. NCI-CTCAE (National Cancer Institute Common
    Terminology Criteria for Adverse Effects)
  • B. Total Neuropathy Score (TNS)
  • C. ECOG-CTC tool (Eastern Cooperative Oncology
    Group Common Toxicity Criteria)
  • D. Oxaliplatin-Specific Scale

93
  • This is not considered the most comprehensive
    CIPN screening tool
  • Please click on the question mark below to go
    back and try the question again!

94
  • YES! The Total Neuropathy Score is considered one
    of the most effective CIPN screening tools!
  • Click the arrow below to advance to the next
    slide.

95
Patients at risk for developing CIPN
  • Some conditions or co-morbidities make patients
    more prone to developing CIPN complication than
    other patients
  • The following is a list of other factors that, if
    present in a patient undergoing chemotherapy with
    a neurotoxic drug, may put them more at risk for
    developing CIPN
  • Its essential to assess for risk factors to
    determine who will need close monitoring during
    treatment!

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96
Patients at risk for developing CIPN
  • Endocrine diseases include
  • Diabetes mellitus (already can causes small fiber
    injury)
  • Hypothyroidism
  • Infectious diseases include
  • HIV/AIDS
  • Lyme disease
  • Herpes zoster
  • Hereditary diseases include
  • Charcot-Marie-Tooth syndrome (causes large fiber
    injury)
  • Freidreichs ataxia (Wickham, 2007)

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Patients at risk for developing CIPN
  • Nutritional diseases include
  • Alcoholism
  • Vitamin B12 deficiency (causes large fiber
    injury)
  • Thiamine deficiency
  • Vitamin E deficiency
  • Folate deficiency
  • Crohns disease (Wickham, 2007)

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Patients at risk for developing CIPN
  • Connective tissue diseases
  • Rheumatoid arthritis
  • Lupus
  • Metal neuropathy
  • Mercury
  • Gold
  • Thallium
  • Other
  • Amyloidosis
  • Atherosclerotic heart disease
  • Sarcoidosis
  • Biliary cirrhosis
  • Uremia
  • Vasculitis
  • Ischemic lesions (Wickham, 2007)

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Patients at risk for developing CIPN
  • Medications including
  • Colchicine
  • Isoniazid
  • Hydralazine
  • Metronidazole
  • Lithium
  • Phenytoin
  • Cimetadine
  • Amiodarone
  • Pyridoxine
  • Amitriptyline (Wickham, 2007)

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Patients at risk for developing CIPN
  • Toxic neuropathy
  • Acrylamide
  • Carbon disulfide
  • Ethylene oxide
  • Carbon monoxide
  • Glue sniffing (Wickham, 2007)

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101
Rest and Review!
  • Which vitamin deficiency may contribute to
    tendency to develop CIPN?
  • A. Vitamin C
  • B. Vitamin D
  • C. Vitamin K
  • D. Vitamin E

102
  • Not the correct Vitamin deficiency
  • Please click on the question mark below to go
    back and try the question again!

103
  • Yes! Vitamin E deficiency is thought to play a
    role in development of CIPN!
  • Click the arrow below to advance to the next
    slide.

104
Rest and Review!
  • Which disease or condition may predispose a
    patient to developing CIPN?A. Atherosclerotic
    heart disease
  • B. Pregnancy
  • C. Eczema
  • D. Depression

105
  • Try againThis condition does not predispose
    someone to developing CIPN
  • Please click on the question mark below to go
    back and try the question again!

106
  • CORRECT! Atherosclerosis can predispose a person
    to developing CIPN!
  • Click the arrow below to advance to the next
    slide.

107
Genetics and CIPN
  • Observations strongly suggest correlation between
    genetics and development of CIPN and pain
  • Not many studies done on development of
    neuropathic pain or peripheral neuropathies in
    cancer patients
  • No common genetic markers have been
    satisfactorily identified (Ossipov Porreca,
    2005)

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108
Genetics and CIPN
  • One study suggests there may be genetic component
    in patients receiving Taxol for cancer
  • ABCB1 is a protein involved in Taxol elimination
    and distribution
  • Is expressed in the blood-brain barrier
  • It is not detected in peripheral nerve cells
  • However, the cells that make up blood-nerve
    barrier express ABCB1 (Sissung, Mross, Steinberg,
    Behringer, Figg, Sparreboom, Mielke, 2006)

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109
Genetics and CIPN
  • ABCB1 may protect peripheral nervous tissue
  • It does this by taking toxic substances away from
    the nervous system, and puts it back into
    systemic circulation
  • Based on expression, it was hypothesized that
    patients with low-expressed ABCB1 gene variations
    would be more likely to experience CIPN (Sissung
    et. al., 2006)

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110
Genetics and CIPN
  • None of the patients carrying the wild allele
    for ABCB1 gene developed CIPN
  • Patients carrying different variations of the
    gene did tend to have increased risk of
    developing CIPN
  • Data suggests possible genetic predisposition to
    CIPN with regulation of the ABCB1 gene (Sissung
    et. al., 2006)

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111
Genetics and CIPN
  • More research needs to be done in the area of
    genetics and CIPNthere could be a link!
  • Limitations of the study include
  • Small sample size
  • Taxol-based therapy only was tested

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112
Rest and Review!
  • With more research in the area of genetics, there
    is a possibility that genetics may play a role in
    the development of CIPN.
  • True
  • False

113
  • Try one more time!
  • Please click on the question mark below to go
    back and try the question again!

114
  • Right answer! With more research, they may find a
    genetic component to the development of CIPN!
  • Click the arrow below to advance to the next
    slide.

115
Prevention of CIPN
  • No treatment available to clinically reverse
    CIPN!
  • As health care professionals, it is important to
    educate patients on ways to prevent CIPN
  • Ways to prevent include
  • Treating and recognizing pre-existing conditions
    that put patients at risk
  • Frequent assessment during therapy (Armstrong,
    Almadrones, Gilbert, 2005)

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116
Pharmacologic treatment of CIPN
  • Amifostine
  • Chemoprotectant
  • Detoxifies chemotherapy drugs
  • Facilitates DNA repair of cells
  • Does not interfere with chemotherapy
    effectiveness
  • In lab animals, shows sparing of nerve fibers
  • In some human trials, it seems ineffective in
    preventing or reducing Taxol-induced PN
  • Needs more research with other chemotherapy drugs
    (Visovsky et. al., 2007)

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Pharmacologic treatment of CIPN
  • Vitamin E
  • Protects against cell damage such as numbness,
    tingling, burning, and pain in periphery caused
    by Cisplatin and other chemotherapy drugs
  • Studies show those who received Vitamin E
    supplementation during and after chemotherapy
    reported less CIPN
  • Possibly a relationship between Cisplatin
    neurotoxicity and Vitamin E deficiency (Visovsky
    et. al., 2007)

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Pharmacologic treatment of CIPN
  • Calcium/Magnesium infusions
  • Oxalate, found in Oxaliplatin, binds to Calcium
    and Magnesium
  • This may deplete these essential elements and be
    responsible for the neurotoxicity of Oxaliplatin
  • Patients received 1 gram of both Magnesium and
    Calcium before and after Oxaliplatin infusion
  • 65 in infusion group had no CIPN, compared to
    37 in control (Visovsky et. al., 2007)

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119
Pharmacologic treatment of CIPN
  • Tricyclic antidepressants
  • Analgesic effect in treatment of CIPN
  • Been studied as a relief of paresthesias,
    including burning, shooting, or tingling pain
  • Anticonvulsants
  • Protect against Oxaliplatin-induced CIPN
  • Patients who were treated with Carbamazepine had
    no CIPN compared to control group (Visovsky et.
    al., 2007)

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120
Pharmacologic treatment of CIPN
  • Acetyl-L-carnitine
  • Tested in presence of preexisting Taxol or
    Cisplatin-induced CIPN
  • Very small studies have been performed, but look
    promising (Visovsky et. al., 2007)
  • Xaliproden
  • Oral neuroprotecive drug, NGF analog
  • Incidence of Grade 3-4 CIPN was 39 less in
    patients who received drug versus placebo
    (Wickham, 2007)

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Pharmacologic treatment of CIPN
  • Glutamine
  • Amino acid, may have neuroprotecive properties
  • Upregulates NGF
  • In studies, those who take it for Taxol-
    preventive CIPN showed less weakness, loss of
    vibratory sensation, and toe numbness versus
    control group (Visovsky et. al., 2007)

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Pharmacologic treatment of CIPN
  • Glutathione
  • May hamper initial accumulation of platinum
    agents in peripheral nerve cells
  • Incidence of neuropathy was greater in placebo
    than control group
  • In some studies, incidences of no CIPN were
    reported with IV infusion (Visovsky et. al.,
    2007)
  • Opioids
  • Useful for painful CIPN
  • Doses can be titrated to effective range for CIPN
    and pain (Wickham, 2007)

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123
Pharmacologic treatment of CIPN
  • Alpha Lipoic acid
  • Been studied in use with diabetic polyneuropathy
  • No studies done yet with oncology population
  • Significantly improved pain, burning,
    paresthesias, and numbness in diabetic patients
  • Capsaicin ointment
  • Used in diabetic patients
  • Decrease in neuropathies in diabetic patients
    studied (Visovsky et. al., 2007)

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124
Rest and Review!
  • What class of drugs can be used to treat pain
    associated with CIPN?
  • A. Tricyclic antidepressants
  • B. Beta blockers
  • C. ACE inhibitors
  • D. Vitamins

125
  • These do not treat pain associated with CIPN!
  • Please click on the question mark below to go
    back and try the question again!

126
  • Great! Tricyclic antidepressants show some
    analgesic pain relief in patients with CIPN!
  • Click the arrow below to advance to the next
    slide.

127
Rest and Review!
  • Which amino acid may help prevent CIPN,
    especially in patients treated with Taxol?
  • A. Asparagine
  • B. Lysine
  • C. Glutamine
  • D. Valine

128
  • Wrong amino acid. Try again!
  • Please click on the question mark below to go
    back and try the question again!

129
  • Right answer!! Glutamine shows some
    neuroprotective properties in patients with CIPN!
  • Click the arrow below to advance to the next
    slide.

130
Nonpharmacologic treatment of CIPN
  • Acupuncture
  • Shown gait improvement
  • Has shown improvement in sensation and balance
  • Patients taking pain medication for CIPN ended up
    decreasing doses
  • Assistive devices
  • Canes or orthotics
  • Help prevent injury related to CIPN pain and
    sensory/motor changes (Visovsky et. al., 2007)

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131
Nonpharmacologic treatment of CIPN
  • Activity and exercise
  • Strengthening programs may be effective in
    reversing muscle strength lost to CIPN
  • In severe CIPN, may need Occupational and/or
    Physical Therapy involvement
  • Pulsed Infrared Light Therapy (PILT)
  • Delivers infrared light to improve foot perfusion
  • Not studied in oncology population, but did show
    improvement in sensation in diabetic neuropathy
    (Visovsky et. al., 2007)

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132
Nonpharmacologic treatment of CIPN
  • Transcutaneous nerve stimulation (TENS)
  • Blocks conduction of nerve signal to brain
    through electrical impulses
  • Improvement in numbness, pain, prickling
    sensation
  • Relaxation breathing
  • Includes deep-breathing exercise, yoga,
    meditation, and guided imagery
  • Improves stress and pain related to CIPN, and
    helps with improvement in mood (Marrs Newton,
    2003)

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133
Rest and Review!
  • Which of the activity can you suggest to patients
    as a nonpharmacologic way to control CIPN
    symptoms?
  • A. Yoga
  • B. Heavy lifting
  • C. Pursed-lip breathing
  • D. Running 4 miles

134
  • This IS NOT an appropriate nonpharmacologic
    intervention
  • Please click on the question mark below to go
    back and try the question again!

135
  • Good job!! Yoga is a great thing to teach
    patients to help control neuropathy and pain.
  • Click the arrow below to advance to the next
    slide.

136
Patient Teaching
  • Teach signs/symptoms early on in treatment
  • Instruct patients to report symptoms as soon as
    they emerge
  • Teach strategies for personal safety (for
    example, relying on visual input to compensate
    loss of lower-extremity sensation, remove throw
    rugs, use bath mats, etc) (ONS, 2006)

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137
Patient Teaching
  • Use good foot/hand care
  • Teach of risk for thermal injury due to loss of
    extremity sensation by
  • Lowering water temperature in home water heater
    to avoid burns
  • Use bath thermometer
  • Inspect hands/feet daily for sores/blisters
  • Teach strategies to prevent autonomic dysfunction
    including postural hypotension, constipation,
    urinary retention by
  • Dangling legs before arising
  • Consuming high fiber diet
  • Implementing stool softener use if needed
  • Adequate fluid intake (ONS, 2006)

138
Case Study
  • You are a nurse working in a busy oncology
    outpatient clinic. You are starting a 50
    year-old African American patient named Joan on
    chemotherapy for Stage III breast cancer. She is
    in your chemotherapy chair for the first time
    today for teaching and her first chemotherapy
    dose

139
  • The oncologist is ordering four cycles of
    doxorubicin (Adriamycin), along with
    cyclophosphamide (Cytoxan). This will be given
    every three weeks for a total of 12 weeks.
  • She will then receive four cycles of paclitaxel
    (Taxol) therapy

140
  • You decide to first review Joans history with
    her. You find out she has quite a few
    co-morbidities in addition to her breast cancer,
    including insulin-dependent diabetes mellitus for
    10 years, a history of alcohol abuse, depression,
    and hypothyroidism

141
  • Which of the co-morbidities listed below does NOT
    make her more susceptible to developing CIPN?
  • Hypothyroidism
  • Depression
  • Alcohol use
  • Diabetes mellitus

142
  • OOPS! Try again, there is a better answer as to
    which disease will not predispose this patient to
    developing CIPN
  • Please click on the question mark below to go
    back and try the question again!

143
  • Great job!
  • Depression is not a co-morbidity associated with
    increased risk of developing CIPN. However, you
    should continue to watch depressive symptoms, as
    they may progress with a cancer diagnosis and
    during treatment
  • Click the arrow below to advance to the next
    slide.

144
  • Being the excellent nurse you are, you assess her
    baseline neurological functioning
  • She does not have any problems picking up objects
    off the floor, buttoning a shirt, or any feeling
    of numbness or tingling in her extremities.

145
  • What else should you assess before proceeding
    with chemotherapy?
  • Her baseline understanding of CIPN
  • Her understanding of her increased risk of
    developing CIPN due to co-morbidities
  • Her ability to understand and comprehend medical
    information presented, since she will most likely
    need more information related to CIPN
  • All of the above

146
  • There may be more answers to the question
  • Please click on the question mark below to go
    back and try the question again!

147
  • Excellent job!!
  • All of the listed statements are correct, and all
    of those factors need to be assessed prior to
    chemotherapy initiation!
  • Click the arrow below to advance to the next
    slide.

148
  • Joan does very well with her four cycles of
    Adriamycin and Cytoxan. She has now received her
    first dose of Taxol
  • She comes to the clinic and reports that she is
    feeling well and has no new concerns

149
  • Joan states that she has no problems with her
    fingers/toes and has no neuropathies. Which of
    the following statements should make you as the
    nurse assessing CIPN, investigate more?
  • I feel like I am forgetting things like names
    and faces
  • I have been dropping things around the house a
    lot more lately
  • I have been eating and drinking well
  • I have had no fevers or chills

150
  • This is not a statement that warrants further
    investigation when assessing for CIPN, but should
    be pursued further if necessary
  • Please click on the question mark below to go
    back and try the question again!

151
  • Way to go!!
  • Youre correctif the patient reports she is
    dropping objects around the house for no apparent
    reason, she may be showing signs of CIPN.
  • Click the arrow below to advance to the next
    slide.

152
  • Since Joan reports she is dropping things around
    the house, and after further investigation,
    admits her fingers and toes have become numb and
    sometimes painful, you decide to talk with the
    MD, who prescribes her to take Glutamine 10 grams
    every day for the first 5 days after
    chemotherapy, to help with her neuropathy

153
  • The patient agrees to start Glutamine, and does
    take it as directed.
  • She returns to clinic after her third cycle of
    Taxol, and reports that her hands and feet have
    now become painful and she is having difficulty
    walking
  • She is prescribed an analgesic for her pain,
    which is only minimally helpful

154
  • What other strategies and nonpharmacologic ways
    can you describe for Joan to help her with her
    neuropathies and pain?
  • Yoga
  • Light exercise
  • Training for a marathon
  • Relaxation breathing
  • A, B, D
  • A B

155
  • There may be more answers to the question
  • Please click on the question mark below to go
    back and try the question again!

156
  • Great answer!!
  • Yoga, relaxation breathing, and light exercise
    are all great ways to try to combat neuropathies
    and pain!
  • Click the arrow below to advance to the next
    slide.

157
  • Despite your best efforts, as well as the MDs
    recommendations, the patients pain improves only
    slightly. She starts to have balance problems
    and describes being very uncomfortable

158
  • What can you, as the nurse, initiate next?
  • Talk to the MD about a referral to Physical and
    Occupational therapy
  • Wait and see if the pain improves once her
    chemotherapy is completed
  • Nothingif the MD doesnt think its a problem,
    then there shouldnt be a concern
  • None of the above

159
  • Not true! There is ALWAYS something you can do to
    try and help a patient
  • Please click on the question mark below to go
    back and try the question again!

160
  • Youre right!!
  • Often times when CIPN has progressed, physical
    therapy and/or occupational therapy can help
    restore some normal functioning!
  • Click the arrow below to advance to the next
    slide.

161
  • With a referral to physical and occupational
    therapy, and a dose reduction in her final Taxol
    treatment, the patient reports better symptom
    management. She is also using a cane as needed
    to help her balance

162
  • What should you, as the nurse involved in her
    case, do now?
  • Nothingshe is improving and finished with
    chemotherapy, so she is no longer your patient
  • Call her on the phone every once in a while to
    check in with her
  • Continue to make appointments so assessment of
    CIPN can be monitored

163
  • Cant you do a little more to help this patient?
  • Please click on the question mark below to go
    back and try the question again!

164
  • Great answer! By making future appointments with
    the patient, you can continue to assess her
    progress with neuropathy
  • Click the arrow below to advance to the next
    slide.

165
For more information
  • Here are a list of websites that focus on
    peripheral neuropathy
  • CancerSymptoms.org Peripheral Neuropathy
    www.cancersymptoms.org/peripheralneuropathy/index.
    shtml
  • National Institute of Neurological Disorders and
    Stroke Peripheral Neuropathy Fact Sheet
    www.ninds.nih.gov/disorders/peripheralneuropathy/d
    etail_peripheralneuropathy.htm
  • Cancer Supportive Care Programs
    Chemotherapy-Induced Peripheral Neuropathy Fact
    Sheet www.cancersupportivecare.com/nervepain.php
  • National Coalition for Cancer Survivorship
    Neuropathy www.canceradvocacy.org/resources/esse
    ntial/effects/neuropathy.aspx
  • (Wickham, 2007)

166
References
  • American Cancer Society. (2008, Winter). Side
    effects of therapy. Cure Cancer Updates,
    Research, Education, 58-62.
  • Armstrong, T., Almadrones, L., Gilbert, M. R.
    (2005). Chemotherapy-Induced peripheral
    neuropathy. Oncology Nursing Forum, 32(2),
    305-311.
  • Marrs, J., Newton, S. (2003). Updating your
    peripheral neuropathy "know-how". Clinical
    Journal of Oncology Nursing, 7(3), 299-303.
  • Microsoft Office clip are available from
    http//office.microsoft.com/en-us/clipart/default.
    aspx
  • Multiple Sclerosis Resource Centre. (2008).
    Structure of a typical neuron Damaged Neuron
    Online images. Retrieved February 27, 2008
    from the Multiple Sclerosis Resource Centre
    website at http//www.msrc.co.uk/images/gallery/n
    erve1.jpg
  • Oestreicher, P. (2007). Five minute inservice
    Put evidence into practice to treat
    chemotherapy-induced peripheral neuropathy. ONS
    Connect, 24-25.
  • Oncology Nursing Society (ONS). (2006).
    Peripheral neuropathy What interventions are
    used to prevent or reduce the effects of
    peripheral neuropathy for people with cancer? PEP
    Card. Pittsburgh, PA.
  • Ossipov, M. H., Porreca, F. (2005). Challenges
    in the development of novel treatment strategies
    for neuropathic pain. The Journal of the American
    Society for Experimental Neurotherapeutics, 2(4),
    650-661.

167
References (continued)
  • Porth, C. M. (2005). Pathophysiology concepts of
    altered health states (7th ed.). Philadelphia
    Lippincott.
  • Sheffield, S. (2008). Getbodysmart.com (2008).
    The nervous system Anatomy and Physiology
    Online image. Retrieved March 12,2008 from
    http//getbodysmart.com/ap/nervoussystem/menu/menu
    .html.
  • Smith, E. M., Beck, S. L., Cohen, J. (2008).
    The total neuropathy score A tool for measuring
    chemotherapy-induced peripheral neuropathy.
    Oncology Nursing Forum, 35(1), 96-101.
  • Sissung, T. M., Mross, K., Steinberg, S. M.,
    Behringer, D., Figg, W. D., Sparreboom, A., et
    al. (2006). Association of ABCB1 genotypes with
    paclitaxel-mediated peripheral neuropathy and
    neutropenia. European Journal Cancer, 42(17),
    2893-2896.
  • Turner, H. (2005). Microscopic image of a nerve
    cell online image. Retrieved February 27, 2008
    from the National Research Council Canada website
    at http//www.nrc-cnrc.gc.ca/images/education/pl_
    nerve.jpg
  • Visovsky, C., Collins, M., Abbott, L.,
    Aschenbrenner, J., Hart, C. (2007). Putting
    evidence into practice Evidence-based
    interventions for chemotherapy-induced peripheral
    neuropathy. Clinical Journal of Oncology Nursing,
    11(6), 901-913.
  • Visovsky, C., Daly, B. J. (2004). Clinical
    evaluation and patterns of chemotherapy-induced
    peripheral neuropathy. Journal of the American
    Academy of Nurse Practitioners, 16(8), 353-359.
  • Wampler, M. A., Hamolsky, D., Hamel, K., Melisko,
    M., Topp, K. S. (2005). Case report Painful
    peripheral neuropathy following treatment with
    docetaxel for breast cancer. Clinical Journal of
    Oncology Nursing, 9(2), 189-193.
  • Wickham, R. (2007). Chemotherapy-induced
    peripheral neuropathy A review and implications
    for oncology nursing practice. Clinical Journal
    of Oncology Nursing, 11(3), 361-376.

168
Questions, Comments, or Suggestions?
  • Please feel free to email me with any questions,
    ideas, suggestions, or comments regarding this
    tutorial. I welcome the correspondence!
  • Email marbactj_at_alverno.edu
  • THANK YOU!
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