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