Introduction
Chemotherapy is the use of drugs to kill tumor cells. Antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions and reproduction.
Nurses have important roles in providing timely interventions, which may reduce therapy associated toxicities and maximize treatment efficacy.
Goals of Chemotherapy
- Cure: Total elimination of cancerous cells.
- Control: To extend the life of the patient when cure is not possible.
- Palliation: When cancer is at an advanced stage, it may be used to relieve symptoms caused by cancer.
Classification of Chemotherapeutic Drugs
1. According to activity on cell cycle:
- Cell-cycle phase specific drugs: These are the agents that are most active against cells that are in a specific phase of the cell cycle.
- G1 phase: Bleomycin, L-asparaginase.
- G2 phase: Etoposide, topotecan.
- Cell-cycle phase nonspecific drugs: These agents do not depend on the phase of the cell cycle to be active. It affects cells in all phases of the cell cycle.
- Alkylating agents: Busulfan, cisplatin.
- Nitrosoureas: Carmustine, lomustine.
2. According to chemical group:
- Alkylating agents: These are effective in rapidly dividing cells, e.g. busulfan, chlorambucil.
- Antimetabolite agents: By deactivating the synthesis of DNA, these agents prevent the cell from replicating, e.g. 5-fluorouracil, 6-mercaptopurine.
- Antitumor antibiotics: Agents that interface with DNA synthesis by binding prevent RNA synthesis. Thus, it slows or stops cancer cells from growing and multiplying, e.g. bleomycin, mitomycin.
- Plant alkaloids: It works by crystallizing the microtubular mitotic spindle proteins during metaphase which arrests mitosis, inhibits DNA and RNA synthesis, and causes cell death, e.g. etoposide, teniposide.
- Topoisomerase inhibitors: This interferes with the action of topoisomerase enzymes. It controls the manipulation of the structure of DNA necessary for replication, e.g. topotecan, etoposide.
Routes of Chemotherapy Administration
- Oral route: Tablets, capsules, and liquid which can be given orally or sublingually.
- Intravenous route: Doses can be given as an IV bolus lasting from a few minutes to a few hours. It may continue for few days or for weeks at a time.
- Subcutaneous route: It is commonly used for some types of biologic response modifiers and chemotherapy support drugs.
- Intraventricular/intrathecal route: This route is used when drugs need to reach the cerebrospinal fluid (CSF). This is accomplished by either a lumbar puncture or the use of an indwelling subcutaneous CSF reservoir.
- Intra-arterial route: This is given into the artery that is supplying blood to the tumor. Through external catheter and implanted pump, drugs can be given.
- Intraperitoneal route: A catheter is placed directly into the abdominal wall through surgery and medication is administered.
- Intravesicular route: In this method drugs are administered through urinary catheter into the bladder, then the catheter clamped. After predetermined time the catheter is unclamped and the fluid is drained.
- Intrapleural route: Drug is administered directly into the pleural cavity. In majority of the cases this is used for symptom relief.
Principles for Handling the Chemotherapeutic Drugs
- Protect the patient.
- Protect the environment.
- Protect yourself.
Procedure
| Nursing action | Rationale | |
| a. | Preparation of client: | |
| Obtain patient’s medical history and carry out thorough physical examination. | To understand patient’s disease condition and obtain baseline data. | |
| Standard blood tests such as complete blood count (CBC), hemogram, Antigen 125 need to be done. | Knowing certain blood levels of cancer markers before chemotherapy helps to measure how the treatment is working and will also come to know about effectiveness of treatment. | |
| Some radiologic tests such as X-ray, MRI, CT, PET, and ultrasound imaging tests may be prescribed by physician before, during, and after the chemotherapy based on diagnosis. | It helps to understand the condition of the patient before and after treatment. | |
| Podiatric evaluation should be carried out as recommended by physician. | Chemotherapy can affect nails and skin and lead to infection if any existing health concerns are not addressed before starting chemotherapy. | |
| Prepare patient emotionally and physically: From physical aspect, rest, a healthy diet, and exercise can help to ensure you begin chemotherapy treatments with the strongest, most resilient body possible. Emotionally, look for a support group where patient can go to express his/her fears and anxiety about the process. | It helps patients to feel less anxious and making sure their individual needs are met means they have a better experience and faster recovery. Sharing concerns and clarifying doubts and fears reduce the stress level of clients. | |
| Explain chemotherapy regimen and how it works. | Develops understanding of the treatment plan and effect of therapy. | |
| Explain the benefits and side effects of each recommended chemotherapy regimen. | To gain cooperation from the patient. | |
| Obtain consent from patient. | To make sure that patient is aware of the associated benefits, risks, and alternative treatments, and it also represents an agreement or process by which the individual’s right to agree or refuse to medical treatment. | |
| Check vital signs. | Helps to assess the physical status. | |
| b. | Preparation of medication: | |
| Personnel preparing the drugs should wear gloves and disposable gown with elastic cuffs. (Gloves should be changed regularly and immediately, if torn or punctured. Overtly contaminated gowns require immediate removal and replacement). | For protection against cytotoxic chemicals, microbes and viruses. | |
| Administer pre-chemotherapy medications as prescribed by physician. | To prevent nausea or an allergic reaction. | |
| In case of skin contact with any cytotoxic drugs, thoroughly wash the affected area with soap and water. | Cytotoxic drugs affect all dividing cells, including those of healthy tissue. | |
| Vials containing drugs requiring reconstitution should be vented to reduce the internal pressure with a venting device using micron hydrophobic filter or chemotherapy dispensing pin. Sterile alcohol pad should be carefully placed around the needle and vial top during withdrawal from the septum. | These steps reduce the probability of spraying and spillage. | |
| While opening the glass ampule use precaution. Use 5 u filter needle while removing the drug solution. | To avoid injury and chances of spillage. | |
| Ascertain the route through which chemotherapy drugs are administered such as peripheral IV line/oral/topical. | Helps preparation of medication for administration through specific route. Some chemotherapy drugs are too caustic to be given in a traditional IV in a peripheral vein. Different types of devices are preferable depending on the length of time patient will be receiving chemotherapy. | |
| c. | Methods of administration: | |
| PICC (peripherally inserted central catheter) line: If a patient AUSES needs a catheter in place for 1 or 2 weeks, a PICC line may be considered for chemotherapy. | In PICC lines, larger amounts of fluid can be given and also occurrence of IV line extravasation (leakage of the chemotherapy agent into tissue surrounding the access site) chances is less. | |
| Long-term IV vascular access device (VAD) catheter and port: Central venous catheter (CVC): A CVC can be considered when the patient is on chemotherapy for weeks, months, or more than a month. It must be kept dry and regularly needs heparin flushing and dressing. Implantable ventricular assist device (IVAD): Some chemotherapy medications can only be given through a port, as they are too caustic to be delivered into a peripheral vein, and also if the patient is having more than four types of infusions of chemotherapy at a time, then a port is preferred. Assess the IVAD site every day. If it is tender, red, swollen or have drainage, bring it to the attention of the physician. | If patient needs a continuous infusion of chemotherapy, peripheral infusions cannot be given due to the high risks of chemotherapy leaking into surrounding tissues and accidental dislodging; in that case, CVC would be a better choice. The IVAD is made for long-term use and can be left in place for as long as we need it. When a special needle is inserted into the reservoir, it creates “access” to patient’s bloodstream. That means it can be used to give fluids, medications, blood or blood products, or IV nutrition. Sometimes, blood samples may be taken from the IVAD. | |
| d. | Administration of chemotherapy medications: | |
| Start chemotherapy as per instructions of the physician. | If it is through IV, it can take up to several hours to finish the whole infusion process. | |
| Calculate and order the amount of medicine required. | In order to provide required dosage. | |
| Check vital signs at regular intervals. | To assess for any side effect when the patient is on therapy. | |
| Label and date syringes and IV bottles containing cytotoxic drugs as “caution: chemotherapy, dispose of properly”. All wastes are considered contaminated and should be disposed of properly. | To prevent iatrogenic disease. Cytotoxic drugs are to be disposed of according to Federal, State, and local requirements. | |
| Do not recap the needles. Place these items in a puncture-resistant container along with any contaminated bottles, vials, gloves, absorbent paper, disposable gowns, gauze, and other waste. The container should then be placed in a box labeled, “cytotoxic waste only”, sealed and disposed. | Used needles are not recapped to prevent needle stick injury.Proper disposal avoids chances of contamination with toxic materials. | |
| Wash hands between glove changes and after glove removal. | Prevents cross-infection. | |
| e. | Care after procedure: | |
| Monitor for the presence of any side effect and manage them accordingly. | Early identification helps to manage side effects effectively. | |
| Monitor the effectiveness of treatment with the help of imaging techniques, blood tests, etc. | It helps in assessing the effectiveness of the treatment. | |
| f. | Patient and family education: | |
| Explain to the patient and family regarding when and how their treatment is administered, whatever possible side effects, and how to manage side effects. | Keeps family updated on patient’s progress. | |
| Welcome family members and friends to participate and encourage in-depth discussions. Encourage questions throughout the treatment process. | Patient and relatives may be anxious for hospitalization. Discussion may help to improve the patient’s condition psychologically. |
Side Effects of Chemotherapeutic Drugs
Immediate side effects are as follows:
- Extravasation: Extravasation is the leakage of chemotherapeutic drug into the subcutaneous space, and it may cause pain, necrosis, or sloughing of tissue. Indications of extravasation could be absence of blood return from the IV catheter resistance to flow of IV fluid, swelling, pain or redness at site, and burning sensation at IV site. Immediately stop the administration of chemotherapy drug. Leave the needle in place but do not infuse fluid. Aspirate any residual drug and blood in IV tubing, needle, and infiltration site. Instill the IV antidote. Remove the needle. Cleanse the site of extravasation with alcohol. Inject the subcutaneous antidote in a clockwise fashion into the infiltrating area, using a 25-gauge needle. Apply a cold or warm pack to the extravasation site for at least 24 hours. Elevate the arm. Observe site regularly for reaction. Examples of antidotes are sodium thiosulfate and hyalouronidase.
- Nausea and vomiting: Anti-emetic drugs can be administered.
- Stomatitis and mucositis: Swishing ice chips in the mouth can provide relief. In severe cases, patients may need analgesics.
Long-term side effects are as follows:
- Fatigue.
- Alopecia.
- Cardiac toxicity.
- Pulmonary toxicity.
- Renal toxicity.
- Myelosuppression.
- Peripheral neuropathy.
- Skin changes.
Special Considerations
- Skin Care: Protect the treated area by keeping it clean and dry. Avoid harsh soaps, lotions, and sun exposure.
- Fatigue Management: Encourage rest while promoting light physical activity to maintain energy levels.
- Nutrition Support: A balanced diet rich in proteins and vitamins helps tissue recovery.
- Pain & Symptom Control: Monitor for skin irritation, nausea, and mucositis, and provide appropriate relief.
- Emotional Support: Patients may experience anxiety or depression—offering reassurance and counseling can help.
- Radiation Safety: If undergoing internal radiation, visitors may need to follow time and distance restrictions.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
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