Nursing Care of Patients

Undergoing Chemotherapy

Nelia B. Perez RN, MSN

• Nursing management of the
patient receiving chemotherapy
requires knowledge about the
treatment , skill in assessment,
technical expertise, ability and
reward in meeting this is to be
able to provide the care desired
to support the client physically
and emotionally.
• 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.
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.
ROLE OF A NURSE
Prior to chemotherapy administration
1 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.
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.
5. Prepare for potential complications
Review the policy and have
medication and supplies available for
immediate intervention the event of
extravasation.
Review the procedure and have
medication available for possible
anaphylaxis
6.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
administration
7.Assess patients understanding of the
chemotherapeutic agents and
administration procedures.
II. Calculation of drug dosage

It 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.
-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
-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
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.
-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.
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 manufacturer’s
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)
-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).
-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)
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.
The silicon rubber material of catheter
is chemically inert to prevent
decomposition and it is anti-
thrombogenic
A felt cuff near the exit site anchors the
catheter on the patient’s chest and acts
as an anatomic barrier to prevent entry
of infection causing agents.
It is either single lumen or double-
lumen.
IV) Intra-arterial
V)Intra-peritoneal
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.
 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. Documentation
Record
-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.
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.
VII. Management of
chemotherapeutic spills

Chemotherapy 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.
Supplies Required
Chemotherapy spill kit contains
Respirator mask for air borne powder
spills
Plastic safety glasses or goggles
Heavy duty rubber gloves
Absorbent pads to contain liquid spills
Absorbent towels for clean up after spills
Small scoop to collect glass fragments
Two large waste disposal bags
Protective disposable gown
Containers of detergent solution and clear tap
water for post spill clean up.
Puncture proof and leak proof container
approved for chemotherapy waste disposal
Approved, specially labeled, impervious
laundry bag.
Spill on hard surface
Restrict area of spill
Obtain drug spill kit
Put on protective gown, gloves, goggles
Open waste disposal bags
Place absorbent pads gently on the spill; be
careful not to touch spill.
Spill on hard surface
Restrict area of spill
Obtain drug spill kit
Put on protective gown, gloves,
goggles
Open waste disposal bags
Place absorbent pads gently on the
spill; be careful not to touch spill.
Place absorbent pad in waste bag
Cleanse 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.
Spill on personnel or patient
Restrict area of spill
Obtain drug spill kit
Immediately remove contaminated
protective garments or linen
Wash affected skin area with soap and
water
If eye exposure-immediately flood the
affected eye with water for at least 5 mts;
obtain medical attention promptly
Notify the physician if drug spills on
patient.
Documentation- Document the spill.
VIII. Staff Education
All 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.
IX. Extravasation management
Extravasation 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.
1.Prevention of extravasation
Nursing responsibilities for the prevention
of extravasation include the following

Knowledge of drug s with vesicant

potential
Skill in drug administration
Identification of risk factors e.g. multiple
vene punctures
Anticipation of extravasation and
knowledge of management protocol
New venepuncture site daily if peripheral
access is used
Central venous access for 24 hrs vesicants
infusion
Administration of drug in a quiet, unhurried
environment
Testing vein patency without using
chemotherapeutic agents
Providing adequate drug dilution
Careful observation of access site and
extremity throughout the procedure
Ensuring 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.
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 drug
Leave the needle or catheter in place
Aspirate any residual drug and blood in
the I/V tubing, needle or catheter, and
suspected infiltration site
Instill the I/V antidote
Remove the needle
If unable to aspirate the residual drug from the IV
tubing , remove needle or catheter
Inject the antidote sub-cutaneously clockwise into the
infiltrated site using 25 gauge needle; change the
needle with each new injection
Avoid applying pressure to the suspected infiltration
site
Apply topical ointment if ordered
Cover lightly with an occlusive sterile dressing
Apply cold or warm compresses as indicated
Elevate the extremity
Observe regularly for pain, erythema, induration,
and necrosis
Documentation of extravasation management.
All nursing personnel should be alert and prepared
for the possible complication of anaphylaxis.
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.
Avoid eating/drinking for 1-2 hrs prior to
and after chemotherapy administration
Eat frequent, small meals. Avoid greasy
& fatty foods and very sweet foods &
candies.
Avoid unpleasant sights, odors & testes
Follow a clear liquid diet
If vomiting is severe inform the
physician.
Consider diversionary activities
Sip liquids slowly or suck ice cubes
and avoid drinking a large volume
of water if vomiting is present
Administer 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.
.Bone marrow Depression – This can
lead to
-Anaemia
-Bleeding due to thrombocytopenia
-Infection due to leukopenia
Nursing Actions
Administer packed RBC according to the
physician orders.
Monitor hematocrit and haemoglobin
especially during drug nadir
Maintain the integrity of the skin
Avoid activities with the greatest potential for
physical injury
Use an electric razor when shaving
Avoid the use of tourniquets
Eat a soft, bland diet, avoid foods that are
thermally, mechanically and chemically
irritating.
Maintain the integrity of the mucous
membranes of G I tract
Promote hydrate to avoid constipation
Avoid enemas, harsh laxatives & the use of
rectal thermometers.
Take steroids with an antacid or milk.
Avoid sources of infection
Maintain good personal hygiene.
Prevent trauma to skin & mucous
membranes
Report s/s of infection to physician
Monitor counts
Avoid invasive procedures, no ……
Raise the arm while pressure is
applied after removal of a needle or
catheter
.Alopecia
Explain hair loss is temporary, and hair will
grow when drug is stopped.
Use a mild, protein based shampoo, hair
conditioner every 4-7 days
Minimize 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.
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.
Anorexia
Freshen up before meals
Avoid drinking fluids with meals to prevent
feeling of fullness
High protein diet
Monitor and record weight weekly. Report
weight loss
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
-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.
Diarrhea- Some clients experience
diarrhea during and after treatment with
chemotherapy.
Nursing Action –
Monitor number, frequency and
consistency of diarrhea stools.
Avoid eating high roughage, greasy and
spicy food alcoholic beverages, tobacco
and caffeine products
Avoid using milk products
Eat low residue diet high in protein and
calories
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 thoroughly
Clean metal area after each bowel
movement.
Administer anti-diarrheal agents as
prescribed.
Depression –
Assess for changes in mood and
affect.
Set small goals that are achievable
daily
Participate e.g. music, reading,
outings
Share feelings
Reassurance
.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
Nursing Actions
Fluid intake at least 3000 ml daily
Empty 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.
Take oral cytoxan early in the morning to
decrease the drug concentration in the
bladder during the night
Report increasing symptoms of frequency
bleeding burning on urination, pain fever and
chills promptly to physician
Following comfort measures can be adopted
if cystitis is present
-Ensure dilute urine by increasing the fluid
intake
Avoid foods & beverages that may cause
irritation to the bladder – alcohol, coffee,
strong tea, Carbonated beverages etc.
Outpatient Chemotherapy Delivery
Aggressive, 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.
Conclusion – Chemotherapy
offers patients with cancer a
great deal of hope for a cure
or a means to control cancer
for a long period of time.
Hope and optimism are vital
ingredients in care plan.
 Yeeeeyyy….

Next Topic --

c’_,)