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02.09 Chemotherapy Patients

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Overview

  1. Antineoplastic Chemotherapy
    1. Anti-: Against
    2. -neoplastic: abnormal cells or growth
    3. Chemo-: chemical, drug
    4. -therapy: given for therapeutic benefit
    5. Drugs given to kill cancer cells and/or stop their growth
  2. Administration of Chemo
    1. Patient Safety
    2. Staff Safety
  3. Infection Prevention
    1. Immunocompromise
    2. Central Line Associated Blood Stream Infections (CLABSIs)
  4. Patient Education
    1. Drug Specific
    2. Chemotherapy Precautions

Nursing Points

General

  1. Place in therapy
    1. Cure
      1. Single-Treatment (rare)
      2. Combined-treatment (common)
    2. Control
      1. Extend life
      2. Improve quality of life
      3. Not for cure
    3. Palliative
      1. Relieve tumor-related symptoms
      2. Improve comfort
      3. Cure or control not possible
  2. “Liquid” Tumors
    1. Lymphoma
    2. Leukemia
      1. Bone Marrow Transplant (BMT)
      2. Only cure for Leukemia
      3. Completed once achieve remission
      4. High dose chemotherapy given to wipe out bone marrow
      5. New bone marrow cells transfused
    3. Myeloma
  3. Solid Tumors
    1. Adjuvant Chemotherapy
      1. After surgery/radiation
    2. Neoadjuvant Chemotherapy
      1. Before surgery/radiation
    3. Hyperthermic intraperitoneal chemotherapy (HIPEC)
      1. “hot chemo” washing of abdomen
      2. Common for pelvic and abdominal cancers
      3. Effective in contacting microscopic cells missed with surgery
      4. Chemotherapy precautions apply
  4. Common Toxicities
    1. Cardiac
    2. Pulmonary
    3. Neurologic
    4. Gastrointestinal

Assessment

  1. Functional status – every encounter with patient
    1. Fatigue
      1. Are you experiencing fatigue?
      2. If so, how severe has it been, on average, in the past week? 0-10
      3. How does fatigue interfere with your regular activities?
    2. Rundown of symptoms
      1. Constipation/diarrhea
      2. Nausea/vomiting
      3. Mucositis
    3. Toxicities
      1. Cardiac
      2. Pulmonary
      3. Neurologic
      4. Skin/Mucous membranes
      5. GI
    4. Accurate weights at every treatment
      1. Monitor for weight loss
      2. Many drugs weight-based or BSA-based
  2. Absolute Neutrophil Count
    1. Used to determine level of myelosuppression
      1. Most common treatment-limiting factor for patients
      2. Life-threatening
      3. MD will not clear for chemo until ANC >1000
      4. Leads to delay in care
    2. Nadir
      1. Lowest point of ANC
      2. Most vulnerable state
      3. 50-75% of patients with cancer die from infection while neutropenic
    3. Febrile neutropenia
      1. Modified immune response
      2. No WBCs to sound alarm of infection
      3. Oncologic emergency
      4. Leads to sepsis, shock, MODS
    4. Prevention
      1. Pharmacologic
        1. Colony stimulating factors
        2. Give 24 hours after chemotherapy
        3. Helps to stimulate growth
      2. Infection
        1. No live vaccinations
        2. Limit exposure to pets and children
        3. Wear mask in highly populated areas
        4. Limit indwelling medical devices, tampons, rectal suppositories

Therapeutic Management

  1. Infection prevention
    1. Low WBC precautions
    2. Patient to wear mask in populated areas
    3. Staff and family wear mask while in hospital
    4. Hand washing
    5. No fresh fruit or uncooked vegetables
  2. Symptom management
    1. Nausea/vomiting
    2. Fatigue
    3. Constipation/diarrhea
    4. Mucositis
    5. Anorexia
  3. Safety
    1. Chemotherapy precautions
      1. 48 hours post-chemo
      2. Double flush toilet
      3. Caregivers wear 2 sets gloves
      4. Wash soiled linens immediately
      5. Seal diapers and sanitary napkins in 2 bags before disposing
    2. Administration
      1. Independent double check
        1. In pharmacy while preparing drug (Pharmacists)
        2. At bed/chairside immediately before administering (RNs)
      2. Special tubing/devices
      3. Monitor for reactions
    3. Extravasations
      1. Most chemo drugs are vesicants
  4. Oncologic Emergencies
    1. Febrile Neutropenia
    2. Tumor Lysis Syndrome
    3. Graft vs. Host Disease
      1. Bone Marrow Transplant
      2. Body rejects engraftment with new bone marrow cells

Nursing Concepts

  1. Cellular Regulation
    1. Cancer begins as a single abnormal cell
    2. Chemotherapy targets abnormal cells to kill, control, and regulate them
  2. Coping
    1. Isolating
    2. Socioeconomic impact
    3. Stigma
    4. Symptom management
  3. Patient Education
    1. Paramount to success
    2. Separate appointments for teaching new patients are common

Patient Education

  1. Infection prevention
    1. Important to teach when to expect nadir
    2. Foods to eat
    3. Influenza, Pneumococcal vaccinations as appropriate
    4. Wash hands
  2. Continue to see Primary Care Provider
    1. Maintain established medication regimen
    2. notify PCP and oncologist of ED and hospital stays
  3. Adherence to care plan
    1. Pre-infusion labs
      1. ANC
      2. Kidney function
      3. Determine eligibility for infusion
    2. Post-infusion medications
      1. Often for symptom management

Reference Links

Video Transcript

Hey there. It’s Meg. So in this lesson we’re going to cover just the essentials of what every nurse should know about patients undergoing antineoplastic chemotherapy. Now this is a massive topic and I could really drill down into specific drugs and what we use them for, but that would literally take days and we’ve got about 10 minutes. So instead we’re going to hit the highlights. Let’s dive in. We’re going to start with this short question. When do you think a patient with cancer becomes a survivor? This might sound like it’s going to be a complicated answer, is that when their counts get better or their scans are clean or they get their last dose of chemo. Fortunately, this is a really easy answer. A patient with cancer becomes a survivor from the moment they’re diagnosed. So when we talk about chemo, I want you to remember that this person is already a survivor. They’ve already been through a lot, and that means they deserve quality of life. They deserve the best you have to give them, and they deserve to feel a connection and the truth from you. So let’s break down antineoplastic chemotherapy. What is it? Antineoplastic means we are against abnormal

Growth of cells and then chemotherapy means chemical drug and then therapy. It’s treatment. So what are we doing when we’re doing chemotherapy? We are using chemicals and drugs to treat or stop the growth of abnormal cells. Makes sense. Let’s keep going. So let’s talk specifically about chemotherapy for patients with cancer because there are chemotherapies that we use for benign illnesses. Every cancer is different and I want you to remember that. So every care plan is going to be slightly different for every patient that you treat. We’ll talk about the role in therapy because sometimes chemo is curative and sometimes it’s merely palliative and sometimes we don’t really know exactly what impact chemo is going to have on a patient until we give it. We’ll also touch on the administration process because safety during this time frame is incredibly important. We’ll also touch on infection prevention because anywhere from 50 to 75% of deaths are infection related.

That means patients are dying from infection, not from cancer. And then finally, patient education. It is so important and I want you to think of it this way. When we give someone chemo, we wear a plastic gown, we wear booties over our shoes and we wear two pairs of extra thick gloves. We put all of that on to protect ourselves from the substance that we are injecting directly into someone else’s vein. That’s how serious chemotherapy medications are and when you think about it that way, a patient has a right to know exactly what is going into their bodies and what it’s going to do to their body and they want to know as well. They want to understand the treatment that they’re getting. 

So let’s touch first on chemos place in therapy in general, I break down tumors into two different types. We have our liquid tumors and we have our solid tumors. Our liquid tumors are going to be our blood cancers, so that’s going to be leukemia, lymphoma, myeloma. One of the really cool treatments that we do for liquid tumor patients is called a bone marrow transplant. So what we do is we give incredibly high dose chemo and what we are doing is we are wiping out the bone marrow completely. We’re wiping the plates, the slate clean so that a couple of weeks after they get their high dose chemo we transfuse new marrow or new cells and that process is actually very similar to a blood transfusion. If you didn’t know it was bone marrow cells, you might not know the other type of tumor that’s more near and dear to my heart because I’m a real solid tumor. 

Surgical oncology guru is our solid tumors. That means there are tumors that are in an actual organ think lung cancer, colon cancer, breast cancer, those sorts of things. One of the really cool chemo treatments that we do for this population is called Highpack or if you’re feeling really fancy hyperthermic intraperitoneal chemotherapy. What we do with high pecs is it’s a surgical procedure using chemotherapy. It is a hot chemo wash. The reason that we do this is tiny sometimes microscopic tumors that the surgeon can’t see with their eyes. This is very common in what we call carcinomatosis which is a diffuse spread of tiny little tumors all over the patient’s abdomen and we do this so that um, the heated chemotherapy touches the tumors directly and helps them to stop growing. Now this like a bone marrow transplant is a very intricate and serious procedure and it has a lot of side effects but for some abdominal cancers, this is our best that at treating.

All right so let’s talk about how we give chemo. Now that we know why we give chemo, we actually give chemotherapy and treat it very similar to a blood transfusion and that we need a double check by two Ahrens. We need to monitor for possible reactions and we need to make sure that we’re educating our patients. Now I chose this picture over here because this is exactly what you want to not do. We need to be wearing more PPE in this situation. Now I see that this nurse is wearing chemo rated gloves, those purple gloves but I can’t tell if he’s wearing two pairs but we know that we need two pairs of gloves. We need a nonpermeable gown. And then oftentimes we’re also going to wear booties over our shoes. Now the reason this is important is that chemo spills are treated, um, like the hazardous situations that they are.

So this is all to protect the provider, um, from continued exposure to chemotherapy over time. The other two things that we want to be cognizant of during chemotherapy administration are going to be extravasations. Extravasations are when an Ivy goes bad and instead of the chemotherapy going into a vein that goes into the patient’s tissue. Now the reason that this is dangerous is that most chemotherapies are VESA currents, which means that they are destructive to tissue chemotherapy, especially. Most of them are killing our fast-growing cells, which means that the tissue is going to heal more slowly because we’ve just wiped out all of the body’s ability to regenerate growth. Then we also have chemotherapy precautions, which we’ll talk a little bit more about in our patient educations. Um, section a patient needs to be under chemotherapy precautions for 48 hours. That means we’re very carefully handling their body fluids for two days.

All right. Now, infection prevention, like we said, um, earlier in the presentation, 50 to 75% of cancer deaths are related to infection, not cancer. Now a short while, sometimes days, sometimes about a week after a patient receives chemotherapy, they hit what is called a Nater. We measure this by doing an absolute neutrophil count, which tells us how many cells, how many neutrophils specifically are in the patient’s bloodstream. When a patient is at Nader, the patient has completely wiped out all or most of their cells. This is when the patient is most vulnerable because we’re modifying the patient’s blood counts. We’re also modifying their immune response because remember, white blood cells are a big part of that. So if we have a patient who is neutropenic and they’re showing signs of infection, it is an oncologic emergency because that patient has something festering so strongly that we are able to see an immune response where there really is no immune response. 

So if we have a patient undergoing chemotherapy with a fever, we call it febrile neutropenia, and it is an emergency. The way that we avoid these things is first, of course, we are avoiding sick contacts, we are hand-washing and that goes for the patient as well as family and staff. The other way that patients with cancer are introduced to infection is by what we call a CLABSI or a central line-associated bloodstream infection. These are becoming less common because we’re doing better at preventing them, but they are a huge quality indicator. They are life-threatening and so dangerous that it is something that is now monitored by every hospital, every nursing unit, and by the government. So if a hospital or specific unit has too many CLABSI’s in a given quarter or a fiscal year, it can actually change whether or not they get government funding. So we need to take those very seriously as well.

And it’s not uncommon for oncology patients to have central lines like the one here. This is actually called a Hickman. The two that are a little more common than these are going to be pic lines, which some of you have probably already seen in your clinical. And then we also have Metta ports which are little ports that go about right here and we access with the special needle to give chemo. All right, let’s move on. Symptom management. Now, this could be an entire lesson by itself. I’m going to hit the high points here, but know that there is so much more wonderful information out there and I’ve attached some of those links to this lesson. First, we have cancer-related fatigue. Now this affects the patient’s functional status and we need to assess it at every encounter. We take cancer-related fatigue so seriously that it’s a common limiting factor and whether or not patients continue with chemotherapy.

For example, my aunt Carol is currently undergoing Taxol carbo, which is a common chemo combination for recurrent metastatic endometrial cancer. She’s been through nine cycles and is tolerated it incredibly well physiologically. However, her fatigue and peripheral neuropathy are so profound that we are taking a break from chemotherapy because it has been detrimental to her quality of life, so fatigue is so important to assess. Next, we have gastrointestinal. Now, this is going to be our trademark, nausea and vomiting and pretty much every chemotherapy out there causes nausea and vomiting and patient’s diarrhea can also be common. The other thing that we want to pay careful attention to is going to be weight loss because many chemo is um, it’s weight-based or um, body surface area based. So we want to make sure that our patient hasn’t lost too much weight because it can alter whether or not chemotherapy is toxic to the patient.

Then skin mucositis. This is another limiting factor for some patients getting chemotherapy. Mucositis is, is severe sores in the patient’s mouth, sometimes so severe, large and painful that it prevents the patient’s ability to eat. So mucositis is something that we’re looking out for and most of our chemo patients then toxicities, there are so many more toxicities and symptoms related to chemotherapy. The ones to also keep an eye out for of course, alopecia, which is hair loss, peripheral neuropathy, and some cardiac toxicities. Many chemos can cause heart failure. So if we know a patient is undergoing chemotherapy, even if we’re not the people treating the patient with chemotherapy, we need to know whether a clinical picture of a patient with chemotherapy would look like. Okay, so now let’s touch base on patient education. Remember, this is so important and I have very deliberately chosen what I put in this lesson because these are all the things that every nurse needs to know.

Whether you’re giving chemo to patients or not. Remember even a nurse who doesn’t take care of oncology patients is going to see patients with cancer because cancer patients have heart attacks. They get in car accidents and they break limbs. So this really is stuff that you need to know no matter where you work first. Remember, we need to prevent infection in our patients, so we need to tell them how to do that. Hand-washing is so important, we can not overstate it and that includes patients, family members as well as the patients themselves. Chemotherapy precautions. Remember, 48 hours after chemotherapy, our patients need to be double flushing in the toilet. Now if for say they soiled some linens or got sick on a shirt, those things need to be washed at on high heat as soon as possible. So as not to contaminate the environment surrounding the patient. 

We also need to tell the patients when to call the provider and that is why symptom education is so important because there are some side effects that we can expect and though they’re uncomfortable, they’re not uncommon. So the patient needs to know the difference between expected side effects and unexpected side effects. So for example, doxorubicin or sometimes called Adriamycin as a super common chemo given for lots and lots of things, it turns the patient’s urine red, orange. Now imagine if you were a patient and you had orange urine and you weren’t expecting it, you would panic. So that’s why educating patients on when to call the doctor is so important. And then finally nutrition. We need to optimize before treatment begins because we want patients coming in as healthy as possible. That means we want a diet that’s high in protein, we want a diet that’s high in calories and we want a diet that’s high in fluid intake. 

We want our patients maximizing their nutrition before they come in. Okay? So as much as I could keep going on and on and on and on and on, we’re going to wrap this up with our priority nursing concepts. So first we have cellular regulation because not only does cancer change the way that cells regulate themselves, chemo does to chemo is also changing that regulation process to help kill cancer cells and hopefully restore a patient’s equilibrium. Next we have, because getting chemo is not easy. It is uncomfortable and it can limit the patient’s ability to take care for themselves, to go to work, to take care of their family. And so we can not underestimate the need for coping support in these patients. And then of course, patient education. Our patients need that education to be successful at this treatment. 

[inaudible] 

Oh right. And our key points, remember, survivorship begins at diagnosis and that continues for the rest of that patient’s life. Next, we have safety. We need to protect the staff, but we also need to protect our patients and their family members by teaching them about chemo precautions and that sort of thing. We also have infection prevention. Remember, infection is the leading cause of death in oncology patients, not cancer. And then finally, education. We need to know the basics because our patients need to know them too. 

Yeah. 

Okay. That’s it for now on chemotherapy. Whew. I just gave you a lot of info. Now go out and be your best selves today, and as always, happy nursing.

 

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