Lec # 4 oncology ccn

ONCOLOGY NURSINGONCOLOGY NURSING

ByBy

Yasmeen RahimYasmeen Rahim

OBJECTIVES:OBJECTIVES:

By the end of this presentation, learners By the end of this presentation, learners will be able to:will be able to:

Define 7 cardinal signs of cancer.Define 7 cardinal signs of cancer. Differentiate between benign and Differentiate between benign and

malignant tumor.malignant tumor. Discuss goals of cancer therapy.Discuss goals of cancer therapy. Explain in detail about the surgery, Explain in detail about the surgery,

radiation therapy and chemotherapy radiation therapy and chemotherapy along with there nursing interventions.along with there nursing interventions.

7 WARNING SIGNS OF 7 WARNING SIGNS OF CANCERCANCER C= C= change in bowel / bladder habitschange in bowel / bladder habits A= A= a sore throat that does not heala sore throat that does not heal U= U= unusual bleedingunusual bleeding T= T= thickening or lump in breastthickening or lump in breast I= I= indigestion / difficulty in swallowingindigestion / difficulty in swallowing O= O= obvious change in warts or molesobvious change in warts or moles NN= nagging, cough and hoarseness= nagging, cough and hoarseness

Malignant tumorMalignant tumor Rapid growthRapid growth Invasive growthInvasive growth Poorly Poorly

demarcateddemarcated InvasionInvasion MetastasisMetastasis Life threatening Life threatening

DIFFERENCE BETWEEN BENIGN AND

MALIGNANT TUMORS

Benign tumorBenign tumor Slow growthSlow growth Expansive growthExpansive growth Well demarcatedWell demarcated No invasionNo invasion No metastasisNo metastasis Rarely a life threatRarely a life threat

GOAL OF CANCER THERAPYGOAL OF CANCER THERAPY Treatment goals may include the Treatment goals may include the

followingfollowing CURATIVE: CURATIVE: treatment should completely treatment should completely

eradicate the malignant disease.eradicate the malignant disease. CONTROL:CONTROL: management should prolong management should prolong

patient survival and inhibition of cancer patient survival and inhibition of cancer cells growth.cells growth.

PALLIATION:PALLIATION: effective symptomatic effective symptomatic treatment should be given to the patients.treatment should be given to the patients.

Cont.Cont.

Our main goal for cancer therapy Our main goal for cancer therapy is to improve is to improve ““QUALITY OF QUALITY OF LIFE”LIFE” of patients.of patients.

MEDICAL MANAGEMENTMEDICAL MANAGEMENT

Surgery Surgery

Radiation therapyRadiation therapy

Chemotherapy Chemotherapy

NURSING MANAGEMENT IN NURSING MANAGEMENT IN CANCER SURGERYCANCER SURGERY

Cont.Cont.

Nursing care of the patient undergoing Nursing care of the patient undergoing surgery for cancer includes fostering surgery for cancer includes fostering the patient's understanding of the the patient's understanding of the specific procedure and expected specific procedure and expected outcome, preparing the patient outcome, preparing the patient physically and psychologically for the physically and psychologically for the surgery, reducing anxiety, supporting surgery, reducing anxiety, supporting the patient's postoperative physiologic the patient's postoperative physiologic stability, relieving pain, preventing stability, relieving pain, preventing complications, and promoting complications, and promoting compliance with postoperative compliance with postoperative instructions. instructions.

Cont.Cont. Cancer patients who are Cancer patients who are

undergoing surgery require general undergoing surgery require general perioperative nursing care.perioperative nursing care.

When surgery is used with other When surgery is used with other treatment methods like treatment methods like chemotherapy and radiation chemotherapy and radiation therapy then postoperative therapy then postoperative complications like infection, complications like infection, impaired wound healing, DVT, impaired wound healing, DVT, altered renal and pulmonary altered renal and pulmonary functions can be expected.functions can be expected.

Cont.Cont. Nurse should provide education Nurse should provide education

and emotional support to patient and emotional support to patient and their family by assessing the and their family by assessing the needs.needs.

Nurse should discuss their fears Nurse should discuss their fears and coping mechanisms with and coping mechanisms with them.them.

Nurse should encourage patient Nurse should encourage patient and family to participate actively and family to participate actively in decision making process.in decision making process.

Cont.Cont. When patient or family ask about

the results of diagnostic testing and surgical procedures then nurse’s response is guided by the information which physician has previously conveyed to the patient and family.

Nurse should frequently communicate with other health care team members to be certain that the information provided is consistent.

Cont.Cont.

After surgery nurse should assess After surgery nurse should assess patient’s response to surgery and patient’s response to surgery and monitor patient for possible monitor patient for possible complications like hemorrhage, fluid complications like hemorrhage, fluid electrolyte imbalance, electrolyte imbalance, thrombophlebitis, homodynamic thrombophlebitis, homodynamic instability and organ dysfunction.instability and organ dysfunction.

Postoperative teachings regarding Postoperative teachings regarding self care, nutrition, wound care and self care, nutrition, wound care and medications should be addressed medications should be addressed properly.properly.

Cont.Cont.

Nurses have a responsibility to Nurses have a responsibility to coordinate early discharge coordinate early discharge planning and home care, as planning and home care, as indicated, to ensure continuity of indicated, to ensure continuity of care. care.

Referrals must be sent to Referrals must be sent to appropriate professionals and appropriate professionals and community support services.community support services.

BASIC FACTORS IN BASIC FACTORS IN RADIATION PROTECTIONRADIATION PROTECTION

DISTANCE: DISTANCE: greater distance greater distance from source, less exposure to from source, less exposure to radiation.radiation.

TIME: TIME: try to spend less time with try to spend less time with in close contact with patient.in close contact with patient.

SHIELDING: SHIELDING: use appropriate use appropriate material to absorb radiation material to absorb radiation energy like lead aprons, glass or energy like lead aprons, glass or aluminum shields or rubber aluminum shields or rubber gloves.gloves.

TOXIC EFFECTS OF TOXIC EFFECTS OF RADIATION & NURSING RADIATION & NURSING MANAGEMENTMANAGEMENT

MAINTAIN TISSUE INTEGRITY:MAINTAIN TISSUE INTEGRITY: Handle skin gently.Handle skin gently. Inspect skin for integrity and do Inspect skin for integrity and do

frequent reassessmentsfrequent reassessments Do NOT rub affected areaDo NOT rub affected area Avoid using ointments, powders or Avoid using ointments, powders or

lotion.lotion. Wash skin only with moisturizing soap Wash skin only with moisturizing soap

and waterand water Protect skin from exposure to sunlight,

chlorinated swimming pools, extreme temperature.

Cont.Cont. ALOPECIA:ALOPECIA: Alopecia begins within 2 weeks of Alopecia begins within 2 weeks of

therapytherapy Regrowth within 8 weeks of terminationRegrowth within 8 weeks of termination Encourage to acquire wig before hair Encourage to acquire wig before hair

loss occursloss occurs Encourage use of attractive scarves and Encourage use of attractive scarves and

hatshats Provide information that hair loss is Provide information that hair loss is

temporary BUT anticipate change in temporary BUT anticipate change in texture and colortexture and color

Cont.Cont. STOMATITIS:STOMATITIS: Use soft-bristled toothbrush Use soft-bristled toothbrush Gentle oral hygiene is essential to Gentle oral hygiene is essential to

remove debris, prevent irritation and remove debris, prevent irritation and promote healing.promote healing.

Oral rinses with saline gargles/ tap Oral rinses with saline gargles/ tap waterwater

Avoid ALCOHOL-based rinsesAvoid ALCOHOL-based rinses Frequent reassurance that symptoms Frequent reassurance that symptoms

are a result of treatment and do not are a result of treatment and do not represent deterioration of disease.represent deterioration of disease.

Cont.Cont.

PROMOTE NUTRITION:PROMOTE NUTRITION: Serve food in ways to make it Serve food in ways to make it

appealingappealing Consider patient’s preferencesConsider patient’s preferences Provide small frequent mealsProvide small frequent meals Avoids giving fluids while eatingAvoids giving fluids while eating Oral hygiene PRIOR to mealtimeOral hygiene PRIOR to mealtime Vitamin supplementsVitamin supplements

Cont.Cont.

RELIEVE PAIN:RELIEVE PAIN: Mild pain- NSAIDSMild pain- NSAIDS Moderate pain- Weak opioidsModerate pain- Weak opioids Severe pain- MorphineSevere pain- Morphine Administer analgesics round the Administer analgesics round the

clock with additional dose for clock with additional dose for breakthrough painbreakthrough pain

Cont.Cont.

DECREASE FATIGUE:DECREASE FATIGUE: Plan daily activities to allow Plan daily activities to allow

alternating rest periodsalternating rest periods Light exercise is encouragedLight exercise is encouraged Small frequent mealsSmall frequent meals

Cont.Cont.

RADIATION SICKNESS:RADIATION SICKNESS: Bed restBed rest Small frequent feedingsSmall frequent feedings Increased calories, increased Increased calories, increased

protein dietprotein diet Adequate fluid intakeAdequate fluid intake Administer vitamins, sedatives, Administer vitamins, sedatives,

antihistamine, antiemeticsantihistamine, antiemetics Monitor intake and outputMonitor intake and output

Cont.Cont. BONE MARROW DEPRESSION:BONE MARROW DEPRESSION: Vital signs especially temperatureVital signs especially temperature CBC monitoringCBC monitoring Observe signs and symptoms of Observe signs and symptoms of

infectioninfection Good oral hygiene-prevent gum Good oral hygiene-prevent gum

bleeding; use soft-bristle toothbrush bleeding; use soft-bristle toothbrush or non-sting mouthwash.or non-sting mouthwash.

Cont.Cont.

IMPROVE BODY IMAGE:IMPROVE BODY IMAGE: Therapeutic communication is Therapeutic communication is

essentialessential Encourage independence in Encourage independence in

self-care and decision makingself-care and decision making Offer cosmetic material like Offer cosmetic material like

make-up and wigsmake-up and wigs

Cont.Cont. ASSIST IN GRIEVING PROCESS:ASSIST IN GRIEVING PROCESS: Some cancers are curableSome cancers are curable Grieving can be due to loss of Grieving can be due to loss of

health, income, sexuality, and body health, income, sexuality, and body imageimage

Answer and clarify information Answer and clarify information about cancer and treatment optionsabout cancer and treatment options

Identify resource peopleIdentify resource people Refer to support groupsRefer to support groups

CHEMOTHERAPYCHEMOTHERAPY

Use of antineoplastic agents to Use of antineoplastic agents to cure or palliative cancer in an cure or palliative cancer in an attempt to destroying tumor cells attempt to destroying tumor cells by interfering with cellular by interfering with cellular functions.functions.

It is used primarily to treat It is used primarily to treat systemic disease rather than systemic disease rather than localized treatment. or as an localized treatment. or as an adjuvant therapy adjuvant therapy to reduce tumor size preoperatively, to destroy any remaining tumor cells postoperatively,

ADMINISTRATION OF ADMINISTRATION OF CHEMOTHERAPEUTIC AGENTSCHEMOTHERAPEUTIC AGENTS ROUTES:ROUTES:

TopicalTopical OralOral IntravenousIntravenous IntramuscularIntramuscular SubcutaneousSubcutaneous Arterial Arterial IntracavitaryIntracavitary Intrathecal Intrathecal

Dosage:Dosage: Based on the Based on the

total body total body surface areasurface area

Previous Previous response to response to chemotherapy or chemotherapy or radiation therapyradiation therapy

Functions of Functions of major organ major organ system. system.

Cont.Cont.

Extravasations is a serious Extravasations is a serious problem and has to be problem and has to be monitored carefully while monitored carefully while administration of administration of vesicants vesicants (agents that deposited into (agents that deposited into subcutaneous tissue and cause subcutaneous tissue and cause tissue necrosis and damage to tissue necrosis and damage to underlying tendons, nerves and underlying tendons, nerves and blood vessels).blood vessels).

Cont.Cont. Indications for extravasations are as Indications for extravasations are as

followfollow Absence of blood return from Absence of blood return from

intravenous catheter.intravenous catheter. Resistance to blood flow of Resistance to blood flow of

intravenous fluid.intravenous fluid. Swelling, pain or redness at the site.Swelling, pain or redness at the site. If it is suspected then medication If it is suspected then medication

administration should be administration should be STOP immediately, ice should be applied , ice should be applied and we have to notify physician as he and we have to notify physician as he has to aspirate the infiltrated has to aspirate the infiltrated medication.medication.

TOXIC EFFECTS OF TOXIC EFFECTS OF CHEMOTHERAPEUTIC AGENTSCHEMOTHERAPEUTIC AGENTS

Gastrointestinal system:Gastrointestinal system: nausea / nausea / vomiting, stomatitis, anorexia, vomiting, stomatitis, anorexia, mucositis of GI tract, diarrhea.mucositis of GI tract, diarrhea.

Hematopoietic system: Hematopoietic system: bone marrow bone marrow depression leading to leukemia depression leading to leukemia (WBC) , anemia (RBC) and (WBC) , anemia (RBC) and thrombocytopenia (platelets). thrombocytopenia (platelets).

Renal system: Renal system: damage to kidney, damage to kidney, hyperkalemia, hyperphosphatemia, hyperkalemia, hyperphosphatemia, hypocalcemia so have to monitor hypocalcemia so have to monitor serum electrolytes.serum electrolytes.

Cont.Cont. Cardiopulmonary system: Cardiopulmonary system: irreversible irreversible

cardiac toxicities, so have to closely cardiac toxicities, so have to closely monitor ejection fraction (volume of blood monitor ejection fraction (volume of blood with each heart beat) and signs of heart with each heart beat) and signs of heart failure. failure.

Reproductive system: Reproductive system: testicular and testicular and ovarian functions are affected. ovarian functions are affected. Reproductive cell are damaged resulting in Reproductive cell are damaged resulting in chromosomal abnormalities in offsprings.chromosomal abnormalities in offsprings.

Integumentary system: Integumentary system: alopecia, local alopecia, local skin irritation.skin irritation.

Cont.Cont.

Neurologic system: Neurologic system: neurologic neurologic damage can occur with damage can occur with repeated doses. Peripheral repeated doses. Peripheral neuropathies, loss of DT, neuropathies, loss of DT, hearing losshearing loss and paralytic ileus and paralytic ileus may occur.may occur.

Miscellaneous: Miscellaneous: Fatigue which Fatigue which can affect quality of life.can affect quality of life.

NURSING MANAGEMENT IN NURSING MANAGEMENT IN CHEMOTHERAPYCHEMOTHERAPY

The goal of nursing interventions is The goal of nursing interventions is to prevent or minimize side effects to prevent or minimize side effects caused by cancer treatments. caused by cancer treatments.

Providing nursing care to patients Providing nursing care to patients receiving chemotherapy presents receiving chemotherapy presents many challenges. many challenges.

Antineoplastic drugs have systemic Antineoplastic drugs have systemic effects on normal cells as well as effects on normal cells as well as on malignant cells, therefore on malignant cells, therefore chemotherapy usually affect many chemotherapy usually affect many body systems.body systems.

Cont.Cont. The nurse must have knowledge of The nurse must have knowledge of

the pharmacology of antineoplastic the pharmacology of antineoplastic agents, proper techniques of drug agents, proper techniques of drug preparation and administration, drug preparation and administration, drug interactions, and possible adverse interactions, and possible adverse effects of individual agents. effects of individual agents.

The nurse must be skilled in the The nurse must be skilled in the technique of venipuncture and the technique of venipuncture and the management of various types of management of various types of venous access devices and drug venous access devices and drug administration systems. administration systems.

Cont.Cont.

Nurses should prepare patients and Nurses should prepare patients and families to manage anticipated side families to manage anticipated side effects of chemotherapy and to report effects of chemotherapy and to report symptoms of potentially serious side symptoms of potentially serious side effects early to avoid serious effects early to avoid serious consequences.consequences.

An important responsibility of nurses An important responsibility of nurses involved in the delivery of chemotherapy involved in the delivery of chemotherapy is to ensure that the correct dose of the is to ensure that the correct dose of the correct drug is administered by the correct drug is administered by the correct route to the right patient. correct route to the right patient.

Cont.Cont. Nurses frequently triage patient Nurses frequently triage patient

problems and assist in the problems and assist in the evaluation of symptoms and evaluation of symptoms and initiation of interventions initiation of interventions

Subjective and objective data, Subjective and objective data, including information about the last including information about the last chemotherapy treatment and chemotherapy treatment and knowledge of the patient's history, knowledge of the patient's history, guide the nurse in determining the guide the nurse in determining the patient's disposition and treatment. patient's disposition and treatment.

Cont.Cont. Patient education is facilitated Patient education is facilitated

when side effects are classified as when side effects are classified as immediate, early, delayed, and immediate, early, delayed, and late.late.

Immediate side effects, such as Immediate side effects, such as hypersensitivity reactions, occur hypersensitivity reactions, occur within the first 24 hours. within the first 24 hours.

Cont.Cont.

Diarrhea and alopecia have an Diarrhea and alopecia have an onset of days to weeks and are onset of days to weeks and are considered early side effects.considered early side effects.

Delayed effects, such as anemia Delayed effects, such as anemia or pulmonary fibrosis, occur or pulmonary fibrosis, occur within weeks to months, and late within weeks to months, and late effects, such as second effects, such as second malignancies, may not appear malignancies, may not appear for months or years. for months or years.

NURSING DIAGNOSISNURSING DIAGNOSIS Fear/anxietyFear/anxiety

situational crisissituational crisis Threat to/change in health/socio-economic Threat to/change in health/socio-economic

status, role functioning, interaction patternstatus, role functioning, interaction pattern Threat of deathThreat of death Separation from familySeparation from family

Grieving, anticipatory Grieving, anticipatory Loss of physiologic well being (loss of Loss of physiologic well being (loss of

body part, change in body functionbody part, change in body function Perceived potential death Perceived potential death

NURSING DIAGNOSISNURSING DIAGNOSIS

Situational low self-esteem Situational low self-esteem Biophysical Biophysical PsychosocialPsychosocial

Acute/Chronic PainAcute/Chronic Pain Disease processDisease process Side-effects of therapeutic agentsSide-effects of therapeutic agents

Altered nutrition, less than body requirementsAltered nutrition, less than body requirements Hypermetabolic state, consequences of Hypermetabolic state, consequences of

chemo, radiation, surgery, emotional chemo, radiation, surgery, emotional distress, fatigue, poor pain controldistress, fatigue, poor pain control

NURSING DIAGNOSISNURSING DIAGNOSIS

Risk for fluid volume deficitRisk for fluid volume deficit FatigueFatigue Risk for infectionRisk for infection Risk for altered mucous membraneRisk for altered mucous membrane Risk for skin/tissue integrityRisk for skin/tissue integrity Risk for Constipation / diarrheaRisk for Constipation / diarrhea Risk for Altered sexuality patternsRisk for Altered sexuality patterns Knowledge deficitKnowledge deficit

NURSING MANAGEMENTNURSING MANAGEMENT

Assess fluid & electrolytesAssess fluid & electrolytes Modify risk for infection & Modify risk for infection &

bleeding bleeding Administer chemotherapy Administer chemotherapy Protect caregiversProtect caregivers

PATIENT EDUCATIONPATIENT EDUCATION• THROMBOCYTOPENIA• Use soft toothbrush to avoid bleeding Use soft toothbrush to avoid bleeding

gumsgums• When shaving, use electric razorWhen shaving, use electric razor• Avoid constipation, enemas, rectal tempsAvoid constipation, enemas, rectal temps• Do not use products that contain aspirin, Do not use products that contain aspirin,

NSAIDNSAID• Avoid IM or sc injectionAvoid IM or sc injection• Notify MD/RN if petechiae, bruising, frank Notify MD/RN if petechiae, bruising, frank

or tarry stools, change in colour of urine – or tarry stools, change in colour of urine – frank blood, dark amber, bleeding from frank blood, dark amber, bleeding from any part of body such as nosebleedany part of body such as nosebleed

Cont.

• MINIMIZE SIDE EFFECTS OF NAUSEA AND VOMITING:

• Avoid offensive odorsAvoid offensive odors• Small frequent feedings rather than Small frequent feedings rather than

3 big meals3 big meals• Adjust oral and fluid intakeAdjust oral and fluid intake• Relaxation exercises, mind Relaxation exercises, mind

diversional therapies, etc.diversional therapies, etc.

SPECIAL CONCERNS

BleedingBleeding Skin problemsSkin problems Hair loss Hair loss NutritionNutrition PainPain FatigueFatigue Psychosocial Psychosocial

statusstatus Body imageBody image

StomatitisStomatitis AnorexiaAnorexia MalabsorptionMalabsorption Cachexia (loss Cachexia (loss

of body weight, of body weight, adipose,visceral adipose,visceral proteins,and proteins,and skeletal muscle)skeletal muscle)

SAFE HANDLINGSAFE HANDLING

Essential to reduce risks to Essential to reduce risks to involved personnel.involved personnel.

Cytotoxic drugs are carcinogenic, Cytotoxic drugs are carcinogenic, mutagenic and teratogenic.mutagenic and teratogenic.

SAFE HANDLING cont’dSAFE HANDLING cont’d

Potential exposure to staff occurs Potential exposure to staff occurs during:during:

Preparation of medicationPreparation of medication Administration and changing lines etcAdministration and changing lines etc Handling of body fluids e.g. urine Handling of body fluids e.g. urine Handling of chemo waste products Handling of chemo waste products

e.g. lines, medication bottlese.g. lines, medication bottles Spillage / leakage of chemotherapySpillage / leakage of chemotherapy TransportationTransportation

PRIOR TO CHEMOTHERAPY PRIOR TO CHEMOTHERAPY ADMINISTRATIONADMINISTRATION1.1.Review- The chemotherapy drugs Review- The chemotherapy drugs prescription which should have prescription which should have -Name of anti - neoplastic agent.-Name of anti - neoplastic agent.-Dosage-Dosage-Route of administration-Route of administration-Date and time that each agent to be -Date and time that each agent to be administered.administered.2.2. Accurately identify the client Accurately identify the client 3.3.Medications to be administered in Medications to be administered in conjunction with the chemotherapy e.g conjunction with the chemotherapy e.g antiemetics, sedatives etc should also be antiemetics, sedatives etc should also be prepare prior.prepare prior.

ROLE OF A NURSEROLE OF A NURSE

4.4. Assess the clients condition including Assess the clients condition including - Most recent report of blood counts - Most recent report of blood counts including hemoglobin ,hematocrit, white including hemoglobin ,hematocrit, white blood cells and platelets.blood cells and platelets. -Presence of any complicating condition -Presence of any complicating condition which could contraindicate which could contraindicate chemotherapeutic agent administration i.e. chemotherapeutic agent administration i.e. infection, extravasations, severe stomatitis infection, extravasations, severe stomatitis , decreased deep tendon reflexes, or , decreased deep tendon reflexes, or bleeding .bleeding .-Physical status-Physical status-Level of anxiety-Level of anxiety-Psychological status.-Psychological status.

5.5.Prepare for potential complicationsPrepare for potential complications6.6.Assure accurate preparation of the Assure accurate preparation of the agentagent -Accuracy of dosage calculation-Accuracy of dosage calculation - Check expiry date of the drug. - Check expiry date of the drug. -Recommended administration route-Recommended administration route7.7.Assess patients understanding of the Assess patients understanding of the chemotherapeutic agents and chemotherapeutic agents and administration procedures.administration procedures.

CALCULATION OF DRUG DOSAGECALCULATION OF DRUG DOSAGE

It is calculated based on body surface It is calculated based on body surface area.area.

DRUG PREPARATION-DRUG PREPARATION- Pharmacy staff should reconstitute all Pharmacy staff should reconstitute all drugs pre-prime the intravenous tubing drugs pre-prime the intravenous tubing under a class II biologic safety cabinet under a class II biologic safety cabinet (BSC) which provide personnel, (BSC) which provide personnel, environmental and product safety. In environmental and product safety. In certain conditions nurses may be required certain conditions nurses may be required to reconstitute medications. When to reconstitute medications. When preparing and reconstituting safe handling preparing and reconstituting safe handling guidelines to be followed.guidelines to be followed.

-All chemotherapeutic drug should be -All chemotherapeutic drug should be prepared according class II BSC.prepared according class II BSC.

-Aseptic technique should be followed.-Aseptic technique should be followed.

-Personal protective equipment includes -Personal protective equipment includes disposable surgical gloves, long sleeves disposable surgical gloves, long sleeves gown and elastic or knit cuffs.gown and elastic or knit cuffs.

-Protective goggles if no BSC -Protective goggles if no BSC

-Wash hands before and after drug -Wash hands before and after drug handling.handling.

-Limit access to drug preparation area-Limit access to drug preparation area

-Keep labeled drug spill kit near -Keep labeled drug spill kit near preparation area.preparation area.

-Apply gloves before drug handling.-Apply gloves before drug handling.

-Open drug vials/ ampoules away from -Open drug vials/ ampoules away from body.body.

-Place absorbent pad on work surface.-Place absorbent pad on work surface.

-Wrap alcohol wipe around neck of -Wrap alcohol wipe around neck of ampoule before opening.ampoule before opening.

-Label all chemotherapeutic drugs.-Label all chemotherapeutic drugs.

- Clean up any spill immediately- Clean up any spill immediately

IV.IV. Drug administrationDrug administration 1. Route- 1. Route- i)Oral - Emphasize the importance of compliance by the i)Oral - Emphasize the importance of compliance by the patient with prescribed schedule.Drugs with emetic patient with prescribed schedule.Drugs with emetic potential should be taken with meals.potential should be taken with meals.Assure that chemotherapeutic agents are stored as Assure that chemotherapeutic agents are stored as directed by the manufacturer(refrigerate, avoid exposure to directed by the manufacturer(refrigerate, avoid exposure to direct light,etc).direct light,etc).

ii) Intramuscular and subcutaenous – Chemotherapeutic ii) Intramuscular and subcutaenous – Chemotherapeutic agents that can be administered I/M or subcutaneously are agents that can be administered I/M or subcutaneously are few in number. Non-vesicants like L- asperaginase, few in number. Non-vesicants like L- asperaginase, bleomycin, cyclophosphamide, methotraxate. Cyta bleomycin, cyclophosphamide, methotraxate. Cyta arabine and some hormonal agents are given I/M & /Or arabine and some hormonal agents are given I/M & /Or subcutaneously.subcutaneously.

--Use the smallest gauge needle possible for the Use the smallest gauge needle possible for the viscosity of the medication.viscosity of the medication. -Change the needle after withdrawing the -Change the needle after withdrawing the agent from a vial or ampoule.agent from a vial or ampoule.-Select a site with adequate muscle and/or SC -Select a site with adequate muscle and/or SC tissue.tissue.iii) Intravenous – It is the most common method of iii) Intravenous – It is the most common method of administration of cancer chemotherapy. May be administration of cancer chemotherapy. May be given through central venous catheters or given through central venous catheters or peripheral access. Absorption is more reliable. peripheral access. Absorption is more reliable. This route is required for administration of This route is required for administration of vesicants and it also reduces the need of vesicants and it also reduces the need of repeated injection. Because the I/V provides repeated injection. Because the I/V provides direct access to the circulatory system, the direct access to the circulatory system, the potential for infection and life threatening sepsis is potential for infection and life threatening sepsis is a serious complication of I/V chemotherapy.a serious complication of I/V chemotherapy.

The following guidelines to be kept in mind:The following guidelines to be kept in mind:-Inspect the solution, container and tubing for -Inspect the solution, container and tubing for signs of contamination including particles, signs of contamination including particles, discoloration, cloudiness, and cracks or tears in discoloration, cloudiness, and cracks or tears in bottle or bagbottle or bag-Aseptic technique to be followed-Aseptic technique to be followed-Prepare medicines according to manufacturer’s -Prepare medicines according to manufacturer’s directionsdirections-Select a suitable vein-Select a suitable vein-Large veins on the forearm are the preferred site.-Large veins on the forearm are the preferred site.-Use distal veins first, and choose a vein above -Use distal veins first, and choose a vein above areas of flexion.areas of flexion.-For non-vesicant drugs, use the distal veins of the -For non-vesicant drugs, use the distal veins of the hands (metacarpal veins): then the veins of the hands (metacarpal veins): then the veins of the forearms(basilic and cephalic veins)forearms(basilic and cephalic veins)

-For vesicants, use only the veins of the forearms. -For vesicants, use only the veins of the forearms. Avoid using the metacarpal and radial areas.Avoid using the metacarpal and radial areas.

-Avoid the antecubital fossa and the wrist -Avoid the antecubital fossa and the wrist because an extravasation in these areas can because an extravasation in these areas can destroy nerves and tendons, resulting in loss of destroy nerves and tendons, resulting in loss of function. function. -Peripheral sites should be changed daily before -Peripheral sites should be changed daily before administration of vesicantsadministration of vesicants-Avoid the use of small lumen veins to prevent -Avoid the use of small lumen veins to prevent damage due to friction and the decreased ability damage due to friction and the decreased ability to dilute acidic drugs and solutions. Select the to dilute acidic drugs and solutions. Select the shortest catheter with the smallest gauge shortest catheter with the smallest gauge appropriate for the type and duration of the appropriate for the type and duration of the infusion (21g to 25g for I/V medications and 19 g infusion (21g to 25g for I/V medications and 19 g for blood products).for blood products).

--Avoid a vein which has been used for Avoid a vein which has been used for venous access within the past 24 hrs to venous access within the past 24 hrs to prevent leakage from a prior puncture site. prevent leakage from a prior puncture site.

Prevent trauma and infection at the Prevent trauma and infection at the insertion site.insertion site. -Apply a small amount of iodine -Apply a small amount of iodine based antiseptic ointment over the based antiseptic ointment over the insertion site & cover the area with sterile insertion site & cover the area with sterile gauze.gauze.Intravenous Chemotherapy Via Central Intravenous Chemotherapy Via Central Vein Infusion (Vein Infusion (Hickman CatheterHickman Catheter))

A Hickman catheter is a flexible polymeric A Hickman catheter is a flexible polymeric silicon rubber catheter which is threaded silicon rubber catheter which is threaded through the cephalic vein and into the through the cephalic vein and into the superior vena cava or through the superior vena cava or through the venacava and into the right atrium of the venacava and into the right atrium of the heart. Placement in a large vein permits heart. Placement in a large vein permits the use of a catheter large enough for the use of a catheter large enough for infusion of chemotherapy, hyper osmolar infusion of chemotherapy, hyper osmolar fluids for nutrition purposes, blood fluids for nutrition purposes, blood products and other needed intravenous products and other needed intravenous fluids.fluids.

The silicon rubber material of catheter is The silicon rubber material of catheter is chemically inert to prevent decomposition chemically inert to prevent decomposition and it is anti-thrombogenicand it is anti-thrombogenicA felt cuff near the exit site anchors the A felt cuff near the exit site anchors the catheter on the patient’s chest and acts as catheter on the patient’s chest and acts as an anatomic barrier to prevent entry of an anatomic barrier to prevent entry of infection causing agents.infection causing agents.

It is either single lumen or double-lumen.It is either single lumen or double-lumen. IV) Intra-arterialIV) Intra-arterialVV))Intra-peritonealIntra-peritoneal

VIVI))Intrathecal- Infusion of medication can be given Intrathecal- Infusion of medication can be given through an Ommaya reservoir, implantable through an Ommaya reservoir, implantable pump and /or usually through lumbar puncture.pump and /or usually through lumbar puncture.

aa))Wear protective equipment (gloves, Wear protective equipment (gloves, gown and gown and eyewear).eyewear).

bb))Inform the patient that chemotherapeutic Inform the patient that chemotherapeutic drugs drugs are harmful to normal cells and that are harmful to normal cells and that protective protective measures used by personnel measures used by personnel minimize their exposure minimize their exposure to these drugs.to these drugs.

cc))Administer drugs in a safe and unhurried Administer drugs in a safe and unhurried environment.environment.

dd))Place a plastic backed absorbent pad under Place a plastic backed absorbent pad under the the tubing during administration to catch any tubing during administration to catch any leakage.leakage.

Do not dispose of any supplies or unused Do not dispose of any supplies or unused drugs in drugs in patient care areas.patient care areas. V.V. DocumentationDocumentationRecord Record -chemotherapeutic drugs, dose, route ,and time -chemotherapeutic drugs, dose, route ,and time -Premedications, postmedications, prehydration -Premedications, postmedications, prehydration and other infusions and supplies used for and other infusions and supplies used for chemotherapy regimen.chemotherapy regimen.-Any complaints by the patient of discomfort and -Any complaints by the patient of discomfort and symptoms experienced before, during, and after symptoms experienced before, during, and after chemotherapeutic infusion.chemotherapeutic infusion.

VI.VI. Disposal of supplies and unused drugsDisposal of supplies and unused drugsaa))Do not clip or recap needles or break Do not clip or recap needles or break syringes.syringes.bb))Place all supplies used intact in a leak Place all supplies used intact in a leak proof ,puncture proof, appropriate labeled proof ,puncture proof, appropriate labeled

container.container.cc))Place all unused drugs in containers in a Place all unused drugs in containers in a

leak leak proof, puncture proof, appropriately labeled proof, puncture proof, appropriately labeled container.container.

dd))Dispose of containers filled with Dispose of containers filled with chemotherapeutic supplies and chemotherapeutic supplies and

unused unused drugs in drugs in accordance with accordance with regulations of hazardous wastes.regulations of hazardous wastes.

VII.VII. Management of Management of chemotherapeutic spillschemotherapeutic spills

Chemotherapy spills should be cleaned Chemotherapy spills should be cleaned up immediately by properly protected up immediately by properly protected personnel trained in the appropriate personnel trained in the appropriate procedure. A spill should be identified with procedure. A spill should be identified with a warning sign so that other person will a warning sign so that other person will not be contaminated.not be contaminated.

Supplies RequiredSupplies Required Chemotherapy spill kit containsChemotherapy spill kit containsRespirator mask for air borne powder Respirator mask for air borne powder spillsspillsPlastic safety glasses or gogglesPlastic safety glasses or gogglesHeavy duty rubber glovesHeavy duty rubber glovesAbsorbent pads to contain liquid spillsAbsorbent pads to contain liquid spillsAbsorbent towels for clean up after spillsAbsorbent towels for clean up after spillsSmall scoop to collect glass fragmentsSmall scoop to collect glass fragmentsTwo large waste disposal bagsTwo large waste disposal bags

Protective disposable gownProtective disposable gownContainers of detergent solution and clear tap Containers of detergent solution and clear tap water for post spill clean up.water for post spill clean up.Puncture proof and leak proof container approved Puncture proof and leak proof container approved for chemotherapy waste disposalfor chemotherapy waste disposalApproved, specially labeled, impervious laundry Approved, specially labeled, impervious laundry bag.bag.Spill on hard surfaceSpill on hard surfaceRestrict area of spillRestrict area of spillObtain drug spill kitObtain drug spill kitPut on protective gown, gloves, gogglesPut on protective gown, gloves, gogglesOpen waste disposal bagsOpen waste disposal bagsPlace absorbent pads gently on the spill; be Place absorbent pads gently on the spill; be careful not to touch spill.careful not to touch spill.

Spill on hard surfaceSpill on hard surfaceRestrict area of spillRestrict area of spillObtain drug spill kitObtain drug spill kitPut on protective gown, gloves, gogglesPut on protective gown, gloves, gogglesOpen waste disposal bagsOpen waste disposal bagsPlace absorbent pads gently on the spill; Place absorbent pads gently on the spill; be careful not to touch spill.be careful not to touch spill.

Place absorbent pad in waste bagPlace absorbent pad in waste bagCleanse surface with absorbent towels Cleanse surface with absorbent towels using detergent solution and wipe clean using detergent solution and wipe clean with clean tap water.with clean tap water.Place all contaminated materials in the Place all contaminated materials in the bag.bag.Wash hands thoroughly with soap and Wash hands thoroughly with soap and water.water.

Spill on personnel or patientSpill on personnel or patientRestrict area of spillRestrict area of spillObtain drug spill kitObtain drug spill kitImmediately remove contaminated Immediately remove contaminated protective garments or linenprotective garments or linenWash affected skin area with soap and Wash affected skin area with soap and waterwaterIf eye exposure-immediately flood the If eye exposure-immediately flood the affected eye with water for at least 5 mts; affected eye with water for at least 5 mts; obtain medical attention promptlyobtain medical attention promptlyNotify the physician if drug spills on Notify the physician if drug spills on patient.patient.Documentation- Document the spill.Documentation- Document the spill.

Chemotherapy offers Chemotherapy offers patients with cancer a patients with cancer a great deal of hope for a great deal of hope for a cure or a means of control cure or a means of control cancer for a long period of cancer for a long period of time. Hope and optimism time. Hope and optimism are vital ingredients in care are vital ingredients in care plan.plan.

END OF LIFE CAREEND OF LIFE CARE

End of LifeEnd of Life is considered to be is considered to be the period of time marked by the period of time marked by disability or disease that is disability or disease that is progressively worse until death. progressively worse until death.

End of Life CareEnd of Life Care is the care is the care provided to a person in their provided to a person in their final stages of life.final stages of life.

It is also known as hospice care, It is also known as hospice care, comfort care, supportive care, comfort care, supportive care, palliative care or simply palliative care or simply symptom management.symptom management.

ONCOLOGICAL EMERGENCIESONCOLOGICAL EMERGENCIES

Hematologic emergenciesHematologic emergencies Bone marrow dysfunctionBone marrow dysfunction

Anatomical structure disordersAnatomical structure disorders Cardiac temponadeCardiac temponade Carotid artery ruptureCarotid artery rupture Obstruction of superior vena cavaObstruction of superior vena cava Pleural effusionPleural effusion Spinal cord compressionSpinal cord compression Tracheobronchial obstructionTracheobronchial obstruction

Metabolic disruptionsMetabolic disruptions Electrolyte imbalance Electrolyte imbalance

NURSING DIAGNOSISNURSING DIAGNOSIS

Risk for Infection related to Risk for Infection related to impaired or deficient leukocytesimpaired or deficient leukocytes

Risk for Injury related to Risk for Injury related to thrombocytopenia and bleeding.thrombocytopenia and bleeding.

Risk for Ineffective Tissue Risk for Ineffective Tissue Perfusion due to reduced Perfusion due to reduced erythrocytes, or vascular erythrocytes, or vascular disruption by tumordisruption by tumor

CONT.CONT.

Potential for Impaired Gas Exchange Potential for Impaired Gas Exchange due to cancer involvement of the due to cancer involvement of the lungs or alterations in fluid statuslungs or alterations in fluid status

Potential for Impaired Sensorimotor Potential for Impaired Sensorimotor Function due to spinal cord Function due to spinal cord compressioncompression

Potential for Imbalanced Fluid Potential for Imbalanced Fluid Volume due to disease or treatmentVolume due to disease or treatment

Potential for Fatigue due to Potential for Fatigue due to malignant illness or its treatmentmalignant illness or its treatment

CONT.CONT. Potential for Impaired Mobility Potential for Impaired Mobility

due to disease complicationsdue to disease complications Anxiety related to fear of Anxiety related to fear of

disease or treatmentdisease or treatment Deficient Knowledge related to Deficient Knowledge related to

disease, or anticancer therapiesdisease, or anticancer therapies Potential for Ineffective Coping Potential for Ineffective Coping

related to severity of illness or related to severity of illness or prognosisprognosis

Potential for Role Conflict due to Potential for Role Conflict due to chronic serious illnesschronic serious illness

SUMMARYSUMMARY

The potential benefit to the The potential benefit to the patient of treatment as an patient of treatment as an

option must always outweigh option must always outweigh the toxic effects.the toxic effects.