Download NURSING CARE OF PATIENTS RECEIVING CHEMOTHERAPY Maj

NURSING CARE OF PATIENTS
RECEIVING CHEMOTHERAPY
Chemotherapy
-is
the
use
of
chemicals
to
treat
disease.
-Paul Erlich, considered to be the father of
chemotherapy,
. The drugs used in cancer treatment vary in their
chemical structure , biological side effects and
toxicities.
Some are effective in treating one specific types
of cancer while others are utilized in the
treatment of wide variety of malignancies.
The methods of administration also vary
according to the chemotherapeutic and new
techniques for safer and more effective
administration.
Nursing management
- requires knowledge about the treatment
-, skill in assessment
- technical expertise,
- ability and desire to support the client physically and
emotionally.
-
Nursing care begins with..........
- thorough understanding of the patients condition; goal of therapy , drug dose, route, schedule,
administration principles;
- and potential side effect
- monitoring responses to the therapy,
- reassessing
- documenting signs and symptoms,
- communicating pertinent information to other
members of the health care team.
There are five ways
1.
Adjuvant therapy- conjunction with another treatment
.
2.
Neoadjuvant chemotherapy-y to shrink the tumor prior to
surgical removal
3.
Primary therapy- localized cancer which there is an
alternative but less than completely effective treatment.
4.
Induction chemotherapy- primary treatment which no
alternative treatment exists.
5.
Combination chemotherapy- two or more
chemotherapeutic agents, allowing each medication to enhance
the action of other.
ROLE OF A NURSE
Prior to chemotherapy administration
1 Review- The chemotherapy drugs prescription which
should have
-Name of anti-neoplastic agent.
-Dosage
-Route of administration
-Date and time that each agent to be administered.
2. Accurately identify the client
3.Medications to be administered in conjunction with
the chemotherapy e.g antiemetics, sedatives etc.
4.. Assess the clients condition including
- Most recent report of blood counts including
hemoglobin ,hematocrit, white blood cells and
platelets.
-Presence of any complicating condition
eg: infection ,bleeding
-Physical status
-Level of anxiety
-Psychological status.
5. Prepare for potential complications
.
-Review the procedure and have medication available
anaphylaxis
6.Assure accurate preparation of the agent
-dosage calculation
-Expiry date checked
- correct reconstitution
-Method of administration
7.Assess patients understanding of chemotherapeutic
agents and administration procedures.
II.
Calculation of drug dosage
- based on body surface area.
III. Drug reconstitution/Preparation
-according to hospital policy and guidelines by the
manufacturer
-Aseptic technique should be followed.
-Personal protective equipment includes
disposable surgical gloves, long sleeves gown
and elastic or knit cuffs.
-Protective eye goggles
-To minimize exposure
-Wash hands before and after drug handling.
IV. Drug administration
1. Routei)Oral - Emphasize the importance of compliance by
the patient with prescribed schedule.
V.
- Drugs with emetic potential should be taken
with meals.
IV.
ii) Intramuscular and subcutaenous –
V. -can be administered I/M or subcutaneously
are few in number.
VI.
VII.-Non-vesicants like L-asperaginase,
bleomycin, cyclophosphamide, methotraxate.
Cyta arabine,and some hormonal agents are
given I/M & or subcutaneously.
VIII.
IX.-Use the smallest gauge needle possible for the
viscosity of the medication.
iii) Intravenous
-Common method .
-May be given through central venous catheters or
peripheral access.
-Absorption is more reliable.
-This route is required for administration of vesicants
and it also reduces the need of repeated injection.
-Because the I/V provides direct access to the
circulatory system, the potential for infection and life
threatening sepsis is a serious complication of I/V
chemotherapy.
The following guidelines to be kept in mind:
-Inspect the solution, container and tubing for signs of
contamination including particles, discoloration, cloudiness,
and cracks or tears in bottle or bag
-Aseptic technique to be followed
-Prepare according to manufacturer’s directions
-Select a suitable vein
-Large veins on the forearm are the preferred site.
-Use distal veins first, and choose a vein above areas of
flexion.
-For non-vesicant drugs, use the distal veins of the hands
(metacarpal veins): then the veins of the forearms(basilic and
cephalic veins)
-For vesicants, use only the veins of the forearms.
Avoid using the metacarpal and radial areas.
-Avoid the antecubital fossa and the wrist because an
extravasation in these areas can destroy nerves and
tendons, resulting in loss of function.
-Peripheral sites should be changed daily before
administration of vesicants
-Avoid the use of small lumen veins to prevent
damage due to friction and the decreased ability to
dilute acidic drugs and solutions. Select the shortest
catheter with the smallest gauge appropriate for the
type and duration of the infusion (21g to 25g for I/V
medications and 19 g for blood products).
-Avoid a vein which has been used for venous access
within the past 24 hrs to prevent leakage from a prior
puncture site.
Prevent trauma and infection at the insertion site.
-Apply a small amount of iodine based antiseptic
ointment over the insertion site & cover the area with
sterile gauze.
Intravenous Chemotherapy Via Central Vein Infusion
(Hickman Catheter)
V.
Documentation
-chemotherapeutic drugs, dose, route ,and time
-Premedications, postmedications, prehydration and
other infusions and supplies used for chemotherapy
regimen.
-Any complaints by the patient of discomfort and
symptoms experienced before, during, and after
chemotherapeutic infusion.
VI. Disposal of supplies and unused drugs
a)Do not clip or recap needles or break
syringes.
b)Place all supplies used intact in a leak
proof ,puncture proof, appropriate labeled
container.
c)Place all unused drugs in containers in a leak
proof, puncture proof, appropriately labeled
container.
d)Dispose of containers filled with
chemotherapeutic supplies and unused drugs in
accordance with regulations of hazardous wastes.
VII. Management of chemotherapeutic spills
Chemotherapy spills should be cleaned up
immediately by properly protected personnel
trained in the appropriate procedure. A spill
should be identified with a warning sign so that
other person will not be contaminated.
Supplies Required
Chemotherapy spill kit contains
Respirator mask for air borne powder spills
Plastic safety glasses or goggles
Heavy duty rubber gloves
Absorbent pads to contain liquid spills
Absorbent towels for clean up after spills
Small scoop to collect glass fragments
Two large waste disposal bags
Protective disposable gown
Containers of detergent solution and clear tap water
for post spill clean up.
Puncture proof and leak proof container approved for
chemotherapy waste disposal
Approved, specially labeled, impervious laundry bag.
Spill on hard surface
Restrict area of spill
Obtain drug spill kit
Put on protective gown, gloves, goggles
Open waste disposal bags
Place absorbent pads gently on the spill; be careful not to
touch spill.
Place absorbent pad in waste bag
Cleanse surface with absorbent towels using detergent solution
and wipe clean with clean tap water.
Place all contaminated materials in the bag.
Wash hands thoroughly with soap and water.
Spill on personnel or patient
Restrict area of spill
Obtain drug spill kit
Immediately remove contaminated protective garments or
linen
Wash affected skin area with soap and water
If eye exposure-immediately flood the affected eye with water
for at least 5 mts; obtain medical attention promptly
Notify the physician if drug spills on patient.
Documentation- Document the spill.
VIII.
Staff Education
All personnel involved in the care should receive an
orientation to chemo. Drugs including their known risk ,
relevant techniques and procedures for handling, the proper
use of protective equipment and materials, spill procedures,
and medical policies covering personnel handling chemo.
agents.
Personnel handling blood, vomitus, or excreta from patients
who have received chemotherapy should wear disposable
gloves and gowns to be appropriately discarded after use.
IX. Extravasation management
-Etravasation is the accidental infiltration of vesicant or
irritant chemotherapeutic drugs from the vein into the
surrounding tissues at the I/V site.
-A vesicant is an agent that can produce a blister and /or
tissue destruction.
-An irritant is an agent that is capable of producing venous
pain at the site of and along the vein with or without an
inflammatory reaction.
-Injuries that may occur as a result of extravasation include
sloughing of tissue , infection, pain ,and loss of mobility of an
extremity.
1.Prevention of extravasation
-Nursing responsibilities for the prevention of extravasation
include the following
-Knowledge of drug s with vesicant potential
Skill in drug administration
-Identification of risk factors e.g. multiple vene punctures
-Anticipation of extravasation and knowledge of management
protocol
-New venepuncture site daily if peripheral access is used
-Central venous access for 24 hrs vesicants infusion
-Administration of drug in a quiet, unhurried
environment
-Testing vein patency without using chemotherapeutic
agents
-Providing adequate drug dilution
-Careful observation of access site and extremity
throughout the procedure
-Ensuring blood return from I/V site before, during,
and after vesicant drug infusion.
-Educating patients regarding symptoms of drug
infiltration , e.g. pain, burning, stinging sensation at
I/V site.
2.Extravasation management at peripheral
site
-According to hospital policy and approved antidote should be
readily available.
-The following procedure should be initiatedStop the drug
-Leave the needle or catheter in place
-Aspirate any residual drug and blood in the I/V tubing, needle
or catheter, and suspected infiltration site
-Instill the I/V antidote
-Remove the needle
If unable to aspirate the residual drug from the IV tubing ,
remove needle or catheter
Inject the antidote sub-cutaneously clockwise into the
infiltrated site using 25 gauge needle; change the needle with
each new injection
Avoid applying pressure to the suspected infiltration site
Apply topical ointment if ordered
Cover lightly with an occlusive sterile dressing
Apply cold or warm compresses as indicated
Elevate the extremity
Observe regularly for pain, erythema, induration, and
necrosis
Documentation of extravasation management.
All nursing personnel should be alert and prepared for the
possible complication of anaphylaxis.
Nursing Management of
common side effects of
Chemotherapeutic drugs.
.
Nausea & Vomiting –
Nausea may cause the desire to
vomit & it often precedes or
accompanies vomiting.
.
Avoid eating/drinking for 1-2 hrs prior to and after
chemotherapy administration
Eat frequent, small meals.
Avoid greasy & fatty foods and very sweet foods &
candies.
Avoid unpleasant sights, odors & testes
Follow a clear liquid diet
If vomiting is severe inform the physician.
Sip liquids slowly or suck ice cubes and avoid
drinking a large volume of water if vomiting is present
Administer antiemetic to prevent or minimize nausea.
Patient may require routine antiemetic for 3-5 days
following some protocols.
Monitor fluid and electrolyte status.
Provide frequent, systemic mouth care.
.Bone marrow Depression – This can lead to
-Anaemia
-Bleeding due to thrombocytopenia
-Infection due to leukopenia
Nursing Actions
Administer packed RBC according to the
doctore’s order orders.
Monitor hematocrit and hemoglobin
Maintain the integrity of the skin
injury
Use an electric razor when shaving
Avoid the use of tourniquets
Eat a soft, bland diet, avoid foods that are thermally,
mechanically and chemically irritating.
Maintain the integrity of the mucous membranes of
GI tract
Promote hydrate to avoid constipation
Avoid enemas, harsh laxatives & the use of rectal
thermometers.
Take steroids with an antacid or milk.
Avoid sources of infection
Maintain good personal hygiene.
Prevent trauma to skin & mucous membranes
Avoid invasive procedures, no ……
Alopecia
Explain hair loss is temporary, and hair will grow
when drug is stopped.
Use a mild, protein based shampoo, hair conditioner
every 4-7 days
Minimize the use of an electric dyer.
Avoid excessive brushing and combing of the air.
Combing with a wide –tooth comb is preferred.
Select wig, cap, scarf or turban before hair loss
occurs.
Keep head covered in summer to prevent
sunburn and in winter to prevent heat loss.
Fatigue –
Assess for possible causes chronic pain, stress,
depression and in-sufficient rest or nutritional intake.
-Conserve energy & rest when tired
-Plan for gradual accommodation of activities.
-Monitor dietary & fluid intake daily. Drink 3000 ml
of fluid daily, unless contra-indicated, in order to avoid
the accumulation of cellular waste products.
Anorexia
Freshen up before meals
Avoid drinking fluids with meals to prevent
feeling of fullness
High protein diet
Monitor and record weight weekly. Report weight
loss
Stomatitis (Oral) –
-Symptoms occur 5-7 days after chemotherapy &
persist upto 10 days
-Continue brushing regularly with soft tooth brush
-Use non irritant mouthwash
-Avoid irritants to the mouth
-Maintain good nutritional intake, eat soft or liquid
foods high in protein
-Follow prescribed medication schedule e.g.
drug for oral candidacies.
-Report physician if symptom persists
-Increase the frequency of oral hygiene every 2
hrs
-Glycerin & lemon juice should never be used to
clear mouth or teeth as it cause the tissues to
become dry& irritated.
Diarrhoea
- Some clients experience diarrhoea during and
after treatment with chemotherapy.
Nursing Action –
Monitor number, frequency and consistency of
diarrhoea stools.
Avoid eating greasy and spicy food alcoholic
beverages, tobacco and caffeine products
Avoid using milk products
Eat low residue diet high in protein and calories
Include food high in potassium if fatigue is
present like bananas, baked potatoes.
Drink 3000 ml of fluid each day.
Eat small frequent meals ; eat slowly and chew
all food thoroughly
Administer anti-diarrhoeal agents as prescribed.
Depression
-Assess for changes in mood and affect
- small goals that are achievable daily
Participate
e.g. music, reading, outings
Share feelings
Reassurance
Cystitis-An inflammation of the bladder,
-usually caused by an infection.
-Sterile cystitis not induced by infection, can be a side
effect of radiation therapy or due to cyclophosphamide
(endoxan) administration.
-The metabolites of cyclophosphamide are excreted
by the kidneys in the urine
Nursing Actions
-Fluid intake at least 3000 ml daily
-Empty Bladder as soon as the urge to void is
experienced.
-Empty bladder at least every 2-4 hrs.
-Urinate at bed time to avoid prolonged exposure of
the bladder wall to the effects of cytoxan while
sleeping.
Take oral cytoxan early in the morning to decrease the
drug concentration in the bladder during the night
Report symptoms of frequency bleeding burning on
urination, pain fever and chills promptly to physician
Following comfort measures can be adopted if cystitis
is present
-Ensure dilute urine by increasing the fluid intake
- Avoid foods & beverages that may cause
irritation to the bladder – alcohol, coffee, strong tea,
Carbonated beverages etc.
Outpatient Chemotherapy Delivery
Aggressive, complex and sophisticated cancer
therapies are currently being in ambulatory & home
care settings.
.
Advantages
This shift is provision of services from the
Hospital setting is a result of cost-containment
efforts, advanced technology, competition &
increased competence of nurses
Conclusion
– Chemotherapy offers patients with
cancer a great deal of hope for a cure or
a means of control cancer for a long
period of time. Hope and optimism are
vital ingredients in care plan.