Chemotherapy

1. Chemotherapy • Cytotoxic drugs • Hormone; hormone antagonists • Biological response modifiers (BRMs)

2. Chemotherapy: Cytotoxic Drugs • Often given in combination to attack cells at different stages of their development • Cell cycle phase specific • Cell cycle phase nonspecific

3. Cytotoxic Drugs

4. 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

5. 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

6. 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

7. Bone Marrow Transplantation

8. Unproven Methods of Treatment • May delay treatment with potentially effective conventional therapies • Can be harmful • Examples • DMSO • Laetrile • Macrobiotic diets

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Paracentesis

17. 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

18. 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

19. 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)

20. 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

21. 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

22. 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

23. Symptom Management • Fatigue • Assess need for assistance • Schedule activities to conserve energy • Encourage to prioritize activities • Daily naps/mild exercise • Assess need to work

24. 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

25. Symptom Management • Disturbed Body Image cont. • After large doses of RT to head, hair may not grow back • Wigs, scarves, turbans

26. Symptom Management • Disturbed Body Image cont. • Radical neck dissection • Laryngectomy • Ostomy • Mastectomy • Orchiectomy • Craniotomy

27. 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

28. 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

29. 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

30. Symptom Management • Pain • Pain managed with various medications tailored to each patient’s needs • NSAIDs • Opiods • Long acting • Short acting • Transdermal • IV medications

31. Medical Emergencies • Hypercalcemia • Spinal Cord Compression • Superior Vena Cava Syndrome • DIC • Tumor Lysis Syndrome

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. Tumor Lysis Syndrome • Clinical manifestations: • Early signs: • Nausea • Vomiting • Anorexia, diarrhea • Muscle weakness, cramping  tetany, paresthesias, seizures, anuria, and cardiac arrest

42. Advanced Cancer • Nutritional therapy • Problems • Malnutrition • Anorexia • Altered taste sensation • Nausea/vomiting • Diarrhea • Stomatitis • Mucositis

43. 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

44. 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

45. 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

46. 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

48. 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.

49. 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.

50. 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).