Cancer

7. Chemotherapy: used as single treatment or in combination with surgery and radiation, for early or advanced diseases. Used to cure, increase survival time, or decrease specific lifethreatening complications. Antineoplastic agents’ primary mode of action involves interfering with the supply and utilization of building blocks of nucleic acids, as well as interfering with intact molecules of DNA or RNA, which are needed for replication and cell growth. Bone marrow, hair follicles, and the gastrointestinal tract are three areas of the body in which cells are actively dividing; this is why most side effects are related to these areas of the body. Most often antineoplastic agents are used in combination.
   1. Types: alkylating agents, antimetabolites, antitumor antibiotics, antimiotic agents, plant alkaloids, enzymes, hormones, and biotherapy. (e.g., BCG, interferon) (see Table 10-8).
   2. Major problem: lacks specificity, thus affecting normal as well as malignant cells.
   3. Major side effects: bone marrow depression, stomatitis, nausea and vomiting, gastrointestinal ulcerations, diarrhea, and alopecia (Table 7-41).
   4. Routes of administration: oral, intramuscular, intravenous (.Hickman or Groshong catheter), subclavian lines, porta caths, peripheral, intra-arterial (may have infusion pump for continuous or intermittent flow rate), intracavity (e.g., bladder through cystoscopy). (See p. 611 for information about administration of IV chemotherapeutic agents.)
   5. Nursing care plan/implementation:
      • Goal: assist with treatment of specific side effects.
        1. Nausea and vomiting—antiemetic drugs as ordered and scheduled; small, frequent, high-calorie, high-potassium, high-protein meals; chopped or blended foods for ease in swallowing; include milk and milk products when tolerated for increased calcium; carbonated drinks; frequent mouth care; antacid therapy as ordered; rest after meals; avoid food odors during preparation of meals; pleasant environment during meals; appropriate distractions; IV therapy; nasogastric tube for control of severe nausea or as route for tube feeding if unable to take food by mouth; hyperalimentation.
        2. Diarrhea—low-residue diet; increased potassium; increased fluids; atropine SO ₄-diphenoxylate HC1 (Lomotil) or kaolin-pectin (Kaopectate) as ordered; avoid hot or cold foods/liquids.
        3. Stomatitis (painful mouth)—soft toothbrushes or sponges (toothettes); mouth care q2—q4; viscous lidocaine HC1 (Xylocaine) as ordered before meals. Oral salt and soda mouth rinses; avoid commercial mouthwashes that contain high level of alcohol, which could be very irritating to mucous membranes. Avoid hot Oil foods/liquids; include bland foods at cool temperatures; remove dentures if sores are under dentures; moisten lips with lubricant.
        4. Skin care —monitor: wounds that do not heal, infections (patient receives frequent sticks for blood tests and therapy); avoid sunlight; use sunblock, especially if receiving doxorubicin (Adriamycin).
        5. Alopecia— be gentle when combing or lightly brushing hair; use wigs, night caps, scarves; provide frequent linen changes. Advise patient to have hair cut short before treatment with drugs known to cause alopecia (bleomycin, cyclosphosphamide, dactinomycin, daunorubicin hydrochloride, doxorubicin hydrochloride, 5fluorouracil, ICRF-159, hydroxyurea, methotrexate, mitomycin, VP 16-213, vincristine). Other techniques may be used, depending on patient’s age and protocol in clinical agency.
        6. Extravasation— infiltration of chemotherapeutic agents into surrounding tissues. Document and treat according to agency protocols for administered drug.
           
           

           TABLE 7-41 Common Side Effects of Chemotherapeutic Agents

           Nausea and Vomiting Mucositis Diarrhea Skin Reactions Lung Neurological Alkylating Agents Busulfan 0 0 Hyperpigmentation 0 0 Carboplatin 0 0 0 Alopecia 0 0 Cisplatin 0 0 0 Chlorambucil 0 0 0 0 0 Cyclophosphamide + 0 0 0 0 DT1C 4- 0 0 0 0 0 Ifosfamide 0 0 Alopecia 0 Encephalopathy Mechlorethamine Alopecia, rash 0 0 Melphalan 0 0 0 0 0 0 Antimetabolites Cytosine arabinoside 0 0 0 0 Fhidarabine + 0 0 0 0 0 5-Fluorouracil 0 + Phlebitis 0 Cerebellar Hydroxyurea 0 0 0 Skin atrophy 0 0 Methotrexate 4- 4« Dermatitis 0 with leucovorin + 4- Dermatitis 0 2-Deoxycoformycin 0 0 Erythema 0 Lethargy, coma 6-Mercaptopurine 0 0 Rash 0 0 Thioguanine 0 0 0 0 2-Chlorodeoxyadenosinc + 0 0 0 0 0 Antitumor Antibiotics Bleomycin 0 0 0 Erythema 0 Dactinomycin Alopecia, rash 0 0 Daunorubicin + Alopecia, vesicant 0 0 Doxorubicin 4- Alopecia, vesicant 0 0 Idarubicin 4- Alopecia, vesicant 0 0 Mitomycin C 0 Vesicant 0 Mitoxantrone + + + Alopecia, vesicant 0 0 Nitrosoureas Carmustine (BCNU) 0 0 0 0 Lomustine (CCNU) 0 0 0 0 0 Streptozocin 0 0 0 0 0 Thiotepa + + + Alopecia, rash 0 0 Plant Alkaloids Etoposide 0 0 0 0 0 0 Vinblastine 0 Alopecia, vesicant 0 Vincristine 0 0 0 Vesicant 0 + Neuropathy Taxol + 0 0 Alopecia 0 Neuropathy

2. Goal: health teaching.
   1. Orient patient and family to purpose of proposed drug regimen and anticipated side effects.
   2. Advise that frequent checks on hematological status will be necessary (patient will receive frequent IV sticks, lab tests).
   3. Advise patient/family on increased risk for infection (avoid uncontrolled crowds and individuals with upper respiratory tract infections or childhood diseases).
   4. Monitor injection site for signs of extravasation (infiltration); site must be changed if leakage suspected, and guidelines to neutralize must be followed according to drug protocol.

6. Nursing precautions with chemotherapy:

   • Nurse should wear gloves and mask when preparing chemotherapy drugs for administration. Mixing of drug into IV bag done under laminar flow hood.
   • Drugs are toxic substances, and nurses must take every precaution to handle them with care.
   • When expelling air bubbles from syringes, care must be taken that the drugs are not sprayed into the atmosphere.
   • Contaminated needles and syringes should be disposed of intact (to prevent aerosol generation) in plastic-lined box according to environmental standards. Disposable equipment should be used whenever possible.
   • If skin becomes contaminated with a drug, wash under running water.
   • Nurses should know the half-life and excretion route of the drugs being administered and take the special precautions necessary. For example, while die drug is actively being excreted, use gloves when touching patient, stool, urine, dressings, vomitus, etc.
   • If the nurse is in the early phase of pregnancy, she should seek specific information about risks to her unborn child before caring for the patient receiving chemotherapeutic agents.

8. Radiation therapy: used in high doses to kill cancer cells, or palliatively for pain relief. Side effects of radiation therapy depend on site of therapy (side effects are variable in each individual): nausea, vomiting, stomatitis, esophagitis, dry mouth, diarrhea, depression of bone marrow, suppression of immune response, decreased life span, and sterility.
   1. External radiation: cobalt or linear accelerator machine.
      • Procedure: daily treatments, Monday through Friday, for prescribed number of times according to size and location of tumor (length of treatment schedule is usually 4-6 weeks). Patient remains alone in room during treatment. (Nurse, therapist, family members cannot stay in room with patient due to radiation exposure during treatment.) Patient instructed to lie still so exactly same area irradiated each treatment. Marks (tattoos or via permanentink markers) are made on skin to delineate area of treatment; marks must not be removed during entire treatment course.
      • Nursing care plan/implementation:
        1. Goal: prevent tissue breakdown.
           • Do not wash off site-identification marks (tattoos cannot be removed); dosage area is carefully calculated and must be exact for each treatment.
           • Assess skin daily and teach patient to do same (most radiation therapy is done on outpatient basis, so patient needs skills to manage independently).
           • Keep skin dry; cornstarch usually the only topical application allowed:
           • Contraindications:
             1. Talcum powders, due to potential radiation dosage alteration.
             2. Lotions, due to increased moistening of skin.
           • Reduce skin friction by avoiding constricting bedclothes or clothing and by using electric shaver.
           • Dress areas of skin breakdown with nonadherent dressing and paper tape.
        2. Goal: decrease side effects of therapy.
           • Provide meticulous oral hygiene.
           • If diarrhea occurs, may need IV infusions, antidiarrheal medications; monitor bowel movements, possible adhesions from surgery and radiation treatments.
           • Monitor vital signs, particularly respiratory function, and BP (sloughing of tissue puts patient at risk for hemorrhage).
           • Monitor hematological status - bone marrow depression can cause fatal toxicosis and sepsis.
           • Institute reverse isolation as necessary to prevent infections (reverse isolation usually instituted if less than 50% neutrophils).
        3. Goal: health teaching.
           • Instruct patient to avoid:
             • Strong sunlight; must wear sunblock lotion, protective clothing over radiation site.
             • Extremes in temperature to the area (hot-water bottles, ice caps).
             • Synthetic, nonporous clothes or tight constrictive clothing over area.
             • Eating 2-3 hour before treatment and 2 hour after, to decrease nausea; give small, frequent meals high in protein and carbohydrates and low in residue.
             • Strong alcohol-base mouthwash; use daily salt and soda mouthwash.
             • Fatigue, an overwhelming problem. Need to pace themselves, nap; may need someone to drive them to therapy; can continue with usual activities as tolerated.
             • Crowds and persons with upper respiratory infections or any other infections.
           • Provide appropriate birth control information for patients of childbearing age.
   2. Internal radiation: sealed (radium, iridium, cesium):
   • Used for localized masses, e.g., mouth, cervix, breast, testes. Due to exposure from radiation source, precautions must be taken while it is in place. Health care personnel and family must adhere to principles of time, distance, and shielding to decrease exposure (shortest amount of time possible, stay as far away as possible from the source of radiation, and wear protective lead apron, gloves). If source of radiation accidentally falls out, it should be picked up only with forceps. Radiation officer should be notified immediately. Patient should be notified immediately. Patient should be in private room, and bed should be in the center of the room, if possible, to protect others. Unless the walls are lead lined, radiation will penetrate them; placing the bed in center of room will decrease exposure. Once the source of radiation has been removed, there is no exposure from patient, excretions, or linens.
   • Nursing care plan/implementation:
     1. Goal: assist with cervical radium implantation (cervical radium is used here as the most common example of internal radiation source).
        • Before insertion - give douche, enema, perineal prep; insert Foley, as ordered.
        • After implantation - check position of applicator q24h.
          • Keep patient on bed rest in flat position to avoid displacing applicator (may turn to side for eating).
          • Notify physician if temperature elevates, nausea and/or vomiting occur (indicates radiation reaction or infection.
          • After removal of implant (48-144 hours) - bathe, douche, and remove catheter as ordered.
     2. Goal: health teaching.
        • Explain that nursing care will be limited to essential activities in postinsertion period.
        • Signs and symptoms of complications so patient can notify staff if something unusual happens (bleeding, radiation source falls out, fever, etc.).
   • Nursing precautions for sealed internal radiation:
     1. Never handle radium directly - if applicators should accidentally be removed, pick up applicator by strings with long-handled forceps and notify radiation officer.
     2. Linen must remain in patient’s room and not be sent to laundry until source of radiation has been accounted for and returned to its container.
     3. Time, distance, and shielding are factors that increase or decrease potential effects on personnel. Need to minimize exposure of nursing staff, patient’s family, and other health professionals. Nurses who may be pregnant should not care for patients with radiation because of possible damage to the fetus from radiation exposure. Children under 16 should not be allowed to visit while internal radiation is in use.
   3. Internal radiation: unsealed (radioisotope/ radionuclide)
      • Source of radiation is given orally or intravenously or instilled into a cavity as a liquid.
      • Nursing care plan/implementation: Goal: reduce radiation exposure of others.
      1. Isolate patient and tag room with radioactivity symbol.
      2. Rotate personnel to avoid overexposure (principles of time, distance, and shielding). Staff should use good handwashing technique. Patient should be in a room with running water. (Nurse who may be pregnant should not care for patient while radiation source still active.)
      3. Encourage family to maintain telephone contact or use intercom, to decrease exposure to others.
      4. Plan independent diversional activities.
      • Specific nursing precautions (post in chart, on patient’s door).
      1. Radioactive iodine (¹³¹I): half-life 8.1 days; excreted in urine, saliva, perspiration, vomitus, feces.
         • Wear gloves and isolation gowns when handling patient, excreta, or dressings directly.
         • Collect paper plates, eating utensils, dressings, and linen in impermeable bags; label and dispose according to agency protocol.
         • Collect excreta in shielded container and send to lab daily to monitor excretion rate and disposal.
      2. Radioactive phosphorus (³²P): half-life 14 days; injected into cavity or given IV or orally.
         • If injected into cavity, turn patient q10-15min for 2 hours to ensure distribution.
         • No radiation hazard unless leakage from instillation site or from patient’s excreta, which are collected in lead-lined containers and brought to the radioisotope laboratory for disposal. Linen is collected in container, marked radioactive, and brought to the radioisotope lab for special handling.
         • Seepage will stain linens blue; wear gloves when handling contaminated linens, dressings. Excreta disposed of as in (b).
      3. Radioactive gold (^l98Au): half-life 2.7 days; usually injected into pleural or abdominal cavity.
         • May seep from instillation site or drainage tubes in cavity; stains purple.
         • Turn patient q15min for 2 hours, as in (2)(a).
         • Same precautions regarding handling excreta as in (1)(a) and (2)(b).
      4. Precautions for nurses:
         • Use principles of time, distance, and shielding when caring for patients who are having active radiation therapy treatments.
         • Nurses who may be pregnant should not accept an assignment caring for patients who have active radiation in place.
         • Always use gloves, gowns to protect skin and clothing.
         • Wear detection badge to determine exposure to energy source.

9. Immunotherapy: it has been hypothesized that clinical malignancy may occur as a result of failure of the immunological surveillance system of the body to fight off cancer cells as they develop. The goal of immunotherapy is to immunize patients against their own tumors.
   1. Nonspecific immunotherapy - encourages a host-immune response by use of an unrelated agent. Bacille Calmette-Guerin (BCG) vaccine and Corynebacterium parvutn are the two agents used for this type of immunotherapy.
   2. Specific immunotherapy - uses substances that are antigenically related to the tumor that stimulate a specific host-immune response.
   3. Side effects - malaise, chills, nausea, vomiting, diarrhea; local reaction at site of injection, such as pruritus, scabbing.
   4. Nursing care plan/implementation:
      • Goal: decrease discomfort associated with side effects of therapy.
        1. Identify measures to lessen symptoms of side effects.
        2. Know type of immunotherapy being used, adverse and desirable effects of therapy.
        3. Administer fluids, encourage rest.
        4. Administer antiemetics as ordered for nausea.
        5. Monitor for respiratory distress.
        6. Administer analgesics as ordered for pain.
      • Goal: health teaching.
        1. Comfort measures to decrease side effects of therapy.
        2. Expected and side effects of therapy.
        3. Investigational nature of therapy.
        4. Care of site of administration.
        5. Answer questions honestly.
10. Palliative care: when treatment has been ineffective in control of the disease, the nurse must plan palliative, terminal care. Cure is not possible for such patients in an advanced phase of malignancy. Symptoms increase in severity; patients and family have many special problems.
    1. General problems of terminal cancer patient:
       • Cachexia: progressive weakness, wasting, and weight loss.
       • Anemia: leukopenia, thrombocytopenia, hemorrhage.
       • Gastrointestinal disturbances: anorexia, constipation.
       • Tissue breakdown leading to decubiti, seeping wounds.
       • Urine: retention, incontinence, renal calculi, tumor obstruction of ureters.
       • Hypercalcemia occurs in 10-30% of patients.
       • Pain due to tumor growth, obstruction, vertebral compression, or secondarily to complications, e.g., decubiti, stiffened joints, stomatitis. Also neuropathy, due to prolonged use of neurotoxic chemotherapeutic agents such as vincristine.
       • Fatigue: major and debilitating problem.
    2. Nursing care plan/implementation:
       • Goal: make patient as comfortable as possible; involve nursing staff, family, support personnel, clergy, volunteers, support groups, hospice, etc.
         1. Nutrition: obtain nutritional consultation; high-calorie, high-protein diet; small, frequent meals; blenderized or strained; commercial nutritional supplements (Ensure, Vivonex, Sustacal).
         2. Prevent tissue breakdown and vascular complications: frequent turning, massage, air mattress, active and passive ROM exercises.
         3. GI tract disturbances: observe for toxic reactions to therapy, particularly vomiting and diarrhea; administer medications: antiemetics, antidiarrheal agents as ordered.
         4. Relieve pain.
            • Use supportive measures such as massage, relaxation techniques, guided imagery; and drugs for pain relief: administer codeine, fentanyl, aspirin-oxycodone HC1 (Percodan), pentazocine (Talwin), morphine, methadone, as ordered.
            • Methods of administration: oral, injected, rectal, analgesic patches, or pumps (IV or SC).
            • Monitor for side effects of narcotics: depressed respiratory status, constipation, anorexia.
       • Goal: assist patient to maintain self-esteem and identity.
         1. Encourage self-care.
         2. Spend time with patient; isolation is a great fear for the dying patient.
       • Goal: assist patient with psychological adjustment - see nursing care for grieving patients, dying patients (see Unit 6).
11. Evaluation/outcome criteria:
1. Tolerates treatment modality - complications of surgery are avoided or minimized; tolerates chemotherapy; completes radiation therapy.
2. Side effects of treatment are managed by effective nursing care and health teaching.
3. Maintains good nutritional status.
4. Uses effective coping mechanisms or seeks appropriate assistance to deal with psychosocial concerns.
5. Makes choices for follow-up care based on accurate information.
6. Finds methods to control pain and minimize discomfort.
7. Participates in decisions regarding continuation of therapy (living will, health care proxy, DNR decisions).
8. Dignity maintained until death and during dying.