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30.01 Antineoplastics

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Overview

  1. Cancer forms from unregulated cell growth due to some mutation and failure of apoptosis (cell death)
    1. Oncogenes
    2. Tumor suppressor genes
  2. Antineoplastic medication are antiCANCER therapies
    1. Targeted therapies- act on specific proteins and genes needed for cancer growth
    2. Immunotherapy- activate or suppress our own immune system
    3. Hormone therapy- stops cancers that rely on hormones
    4. Chemotherapy- Focus of this lesson
  3. Chemotherapy targets certain areas of the cell cycle to destroy the cancer cells
    1. The cancer cells are vulnerable because they are rapidly growing = in the cell cycle often
  4. Cell cycle
    1. GI: organelles duplicate
    2. S: DNA replicates
      1. DNA strand separated and duplicated
    3. G2: prepare for M phase
    4. M: Mitosis = Duplication
      1. Prophase= centrosome duplicate, microtubules form
      2. Metaphase= chromosomes align, microtubules attach
      3. Anaphase= chromosomes separate
      4. Telophase= new cell membrane forms

Nursing Points

General

  1. Several types of chemotherapies
    1. Work in different places of the cell cycle or on DNA replication
    2. Most effective with combo therapy = more cancer destruction/fewer toxicities
  2. Routes of administration
    1. PO = Oral
    2. IV = intravenous
    3. Intraarterial- the hepatic artery
    4. Intracavity- bladder, pleural space, peritoneal
    5. IT- Intrathecal- to CNS
    6. SQ- subcutaneously
    7. Topical
  3. Hazardous medication
    1. Administration
      1. Staff safety- double glove, gown, face shield
      2. Double-check with chemo nurse
      3. Verify safety for the patient
        1. Labs
          1. Nadir- low blood counts from treatment
          2. CBC = WBC (ANC), Plts, Hgb
          3. Renal function = Cr
        2. Weight- weight-based dosing
        3. Premedications
          1. Make sure they are administered as ordered
    2.  IV administration
      1. Risk of extravasation = leaking to tissue outside vein =  tissue destruction
        1. Vesicant- destroys the tissue
        2. Irritant- irritates the tissue
        3. Know antidote!
      2.  Central line preferred for IV- Check blood return!
        1.  Ports
        2.  PICC
      3.  If peripheral IV
        1.  Smallest possible
        2.  <24 hours old
        3.  Always check blood return!
      4. Timing important- cycle cell-specific chemos

Assessment

  1. Fast-growing healthy cells are also vulnerable because they are also often in the cell cycle
    1. Bone marrow = myelosuppression = low blood counts
      1. ↓ WBC- risk of infection
      2. ↓ RBC- anemia
      3. ↓ Plt- risk of bleeding
    2. Skin/ nails/ hair- loss or change
    3. GI- constipation/ diarrhea/ mucositis = mouth sores
    4. Nerves- peripheral neuropathy
    5. Gonads- infertility
  2. Nausea
    1. Toxins activate receptors in the vomiting center of the brain
  3. Fatigue
    1. Combination of cancer and cell destruction
    2. #1 patient complaint
  4. Chemo-specific organ toxicities
    1. Renal
    2. Hepatic
    3. Cardiac
    4. Pulmonary

Therapeutic Management

  1. Fatigue
    1. Common complaint
    2. Frequent rest
    3. Try to stay awake during the day or only take short naps
  2.  Nausea and vomiting
    1. Antemetics
    2. Small, frequent meals
    3. Avoid aggravating factors
  3. Diarrhea
    1. Rule out C-diff
    2. Anti-diarrheal
  4. Myelosuppression
    1. WBC
      1. G-CSF- Growth colony-stimulating factor = ↑WBC production
    2. Plts
      1. Plts infusion if needed
      2. Bleeding precautions
    3. RBC (↓ Hgb)
      1. Blood transfusion if symptomatic or Hgb <7

Nursing Concepts

  1. Cellular regulation
    1. Disruption of normal growth and destruction
    2. Cell cycle review
  2. Patient Education
    1. Safety in the home
    2. Importance of timing of meds
    3. Neutropenic precautions
  3. Pharmacology
    1. Safety with hazardous medications

Patient Education

  1. Neutropenic precautions
    1. Risk of infection
    2. Hand hygiene
    3. Food safety
    4. Avoid animal feces
    5. Monitor temperature- Before taking any NSAIDs or Acetaminophen
  2. Chemo precautions for 48 hours
    1. Wash linen separate in hot water
    2. Flush twice with the lid closed
    3. Wear gloves to handle any bodily fluids

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Video Transcript

Okay. Hi guys. We are here today talking about antineoplastics, which is an umbrella term for several types of medications used to treat cancer, more specifically, we’re talking about chemotherapy today, but I want to mention that there are other forms of medications used to treat cancer. So we have targeted therapies, those target different genes and proteins that are beneficial to prevent cancer growth, immunotherapies, activate our own immune system or components of the immune system to fight the cancer, hormone therapies, those block hormones. And those are used for cancers that rely on these hormones to grow. And this field is huge. I mean, even hormone therapy. So there’s so much research and we’re seeing more and more of these types of medications used to treat cancer. But this lesson is mostly about chemotherapy because there’s a lot of nursing considerations with chemo. 

And just to review how cancer grows, something goes wrong. We have a mutation in a cell and for some reason, our  body is producing lots of extra onco genes, which is creating the cells or allowing the cells to proliferate and not enough tumor suppressor genes. So for some reason, these stop points that should stop the cancer from growing are not working. So we get these cells, proliferating uncontrollably, right? And chemotherapy stops that because chemotherapy works within this cell cycle to stop them from going through the cell cycle. So if you remember, one cell goes in two cells come out of this cell cycle, right? And chemotherapy targets, different phases of the cell cycle. So a big one, chemo targets is the S phase. And that’s when DNA is replicated and also the M phase. And that is when the cell goes through these four different steps and eventually ends up with the two different cells. 

And I mentioned this because it’s important to consider because we give combo therapy for chemos, and we might be giving one medication that targets the S-phase. You might be getting another medication that targets the M-phase and maybe a third medication that works throughout the cell cycle. And this combination of therapies reduces toxicities to the body and increases tumor response or tumor death, right? That’s the goal. Okay. And there’s a lot of considerations when we are giving chemo. If you decide to become an oncology nurse, you are going to review all of this in detail. I don’t want to scare you away from it. Being an oncology nurse is absolutely the best. That’s why I’m doing it, but there are a lot of safety considerations. So first of all, there’s a bunch of routes of chemo. You need to make sure you’re double checking that you have the right route at all times. 

So it can be given intrathecally, directly into the CNS. IV, orally, even topically, or subcutaneously. So we just need to double check always right, that we have the right route. Cause it can be fatal if it’s given the wrong route, it’s hazardous medication. You guys know that. So we have special yellow bins. We have special ways to dispose of things that have been contaminated with chemo and then chemo precautions. This is important for staff and for patients. We’ll talk more about the consideration for patients later, but for staff, anytime we’re giving chemo, we are double gloving, We wear gowns, we wear a face shield. So there’s a lot of considerations to protect us and the patients when we administer chemotherapy. And then always, always, always its a two chemo nurse verification. And I’ll talk about some of the things that we verify before administering chemo in another slide. But first let’s talk about, extravasation, again not wanting to scare you away, but some chemos are vesicants or irritants, and that means they can cause severe extravasation. Now that means that if the drug leaks outside of the vein, its being  given IV and escapes into the tissue and it causes severe severe tissue damage. So I’ve seen patients with massive, massive scarring after getting plastic surgery from when a chemo is leaked outside of the vein. So this is serious and the best way, obviously the best thing to do would be to prevent this from happening and to do that, we always check blood return. Always, always, always check blood return before giving these chemotherapies, whether it’s in a peripheral IV or a central line.

And I just want to mention what this picture is of here. So this is a port, a lot of our cancer patients have ports. You’ve probably seen them before, but you might not know what it looks like outside of the body. So this part here is what’s actually implanted in their skin, underneath their skin. And then when they come in, we just poke a needle into that area. And that gives us a central line access. But again, we always always double triple check that blood return before giving any IV chemotherapy.

And then we’ll talk more about the patient safety. So what I mentioned, we have two chemo nurses checking all of these things. So we check their labs. Their CBC is a big one. We’re looking at their white blood cells, their platelets and their hemoglobin on their labs, right? Because chemo is going to deplete all of those things. And if they don’t have anything to start with, it would not be safe to give them chemo. It could be fatal, right? We’re also looking at their electrolytes and their kidney function like their creatine, that sort of thing, and their weight. We always check their BMI double, triple check that, compare it to the orders. If they has lost a lot of weight, which happens a lot with cancer, right? Sometimes it’s not safe to give them the same dose they’ve been getting. So we always check their weight before we give them anything. And then a lot of times we need to give pre-medications before giving chemotherapies. Um, so you always just double check that those have been done appropriately.
Side effects are huge. 
There’s so many side effects of chemotherapy and why do those happen? It’s because chemo attacks cells in that cell cycle, right? And cancer cells are in that cell cycle frequently because they are multiplying a lot. But we also have healthy cells in that cell cycle. Often those fast growing cells are the ones that are destroyed. So we’re just going to review some of the side effects here. Myelosuppression is a big one. And that’s because those cells that are within the bone marrow are those fast growing cells. So they’re destroyed. And when that bone marrow is not functioning, that’s why we have that. Pancytopenia, that’s a fancy word, right? But it’s low white blood cells, low platelets and low red blood cells, which equals low hemoglobin. Right. Okay. And to treat that, we can give infusions of platelets and red blood cells, and we actually have injections we can give to help people increase their white blood cells. 

Okay. And then we’re going to have skin hair and nail changes. Also, those are fast growing cells, right? Everyone knows hair falls out a lot, right with chemo. We also might have nails breaking and rashes can happen. GI: the GI tract is really sensitive to these chemotherapies. So we can have nausea, vomiting, diarrhea, obviously everyone, associates, chemo with nausea and vomiting. And fortunately there’s a ton of different antiemetics that we can give to these patients, um, to, to treat this or prevent it as best we can. And then the nervous system can be involved too. A lot of times we’ll have peripheral neuropathy. And that’s when the nervous system is impacted and that causes numbness and tingling to the fingertips. And gonads: So I mentioned this because we have changes to fertility, right? Again, these are all fast growing cells. That’s why we have these side effects and there’s different ways to treat all of these, but the number one side effect, I didn’t even write it on here. Cause I want you guys to write this with me is fatigue. This is a huge one. So in addition to being fatigued because they have cancer, the chemo completely wipes themout. So we always talk to our patients about managing fatigue. And we’ll talk a little bit more about that education. We need to educate our patients about neutropenic precautions because they have low white blood cells, right? So we know how to them about hand hygiene, food, safety, checking, their temperature, that sort of thing, That chemo precaution. I mentioned earlier, in addition to protecting the staff, we also want to protect patients and their family members. So this has to do with washing their linens separately, flushing twice when they go to the bathroom, wearing gloves to handle bodily fluids and chemo precautions lasts for 48 hours after getting the chemotherapy. And then it’s so important to educate our patients about adhering to the schedule, if they want to, or they’re treating their cancer, especially for cure. It’s important that we administer these medications at the right time. So they work appropriately in this cell cycle. Right? Okay. And some concepts we talked about here, cellular ruler regulation is a big one, right? There’s some mismatch that happened. Patient education is huge, huge, huge. And then pharmacology, right? I mean, this is a big one. These meds are pretty complicated in the way that they work and they have pretty severe side effects. 

So let’s just go over some quick key points here. Antineoplastics are not just chemo. We talked about some other forms, right? And those ones are really, really, a lot of research are being put into those other forms. Chemo safety for staff and patients is so important. Chemo is targeting those fast growing cells, right? So that’s fast growing cancer cells and our own other healthy cells. Right. That’s why we get the side effects and then, neutropenic precautions are important for these patients to reduce infection. All right, guys, that’s all I have. We love you. Go out and be your best self today. And as always happy nursing.

 

 

Module 0 – Pharmacology Course Introduction
Module 3 – Disease Specific Medications

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