NURSING CARE OF PATIENTS

RECEIVING CHEMOTHERAPY

Ranjita Rajesh
Lecturer
People’s College of Nursing
Bhopal
Chemotherapy is the use of chemicals to treat
disease. Paul Erlich, considered to be the father of
chemotherapy, coined this word to describe a specific
chemical utilized in the treatment of parasites. Today
the term ‘chemotherapy’ while technically describing
drug therapy for any disease , is most frequently used
in reference to the treatment of cancer. The simple
definition of chemotherapy, although accurate , fails to
encompass its multifaceted nature which is as complex
as the disease it attempts to treat.
Just as the word “cancer” represents many
different types of malignant disease, the word
chemotherapy represents many different types of
chemotherapeutic agents. 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.
The process of learning about chemotherapy is indeed
a challenge. Nursing management of the patient
receiving chemotherapy requires knowledge about the
treatment , skill in assessment, technical expertise,
ability and desire to support the client physically and
emotionally. The reward in meeting this is to be able
to provide the care this clients need in order to
survive their disease and its treatment and hopefully to
go on with their lives with as few physical and
emotional scars as possible.
Nursing care begins with a thorough understanding of
the patients condition; goal of therapy , drug dose,
route, schedule, administration principles; and
potential side effects. Additional nursing management
includes monitoring responses to the therapy,
reassessing and documenting signs and symptoms, and
communicating pertinent information to other
members of the health care team.
Chemotherapy is the use of cytotoxic drugs in
the treatment of cancer. It is one of the four
modalities- surgery, radiation therapy,
chemotherapy and biotherapy- that provide cure,
control, or palliation. Chemotherapy is systemic
as opposed to localized therapy such as surgery
& radiation therapy.
There are four ways chemotherapy may be used:
1. Adjuvant therapy- A course of chemotherapy used in
conjunction with another treatment modality.
2. Neoadjuvant chemotherapy- Administration of
chemotherapy to shrink the tumor prior to surgical removal of the
tumor.
3. Primary therapy- The treatment of patients with localized
cancer for which there is an alternative but less than completely
effective treatment.
4. Induction chemotherapy- The drug therapy is given as
the primary treatment for patients with cancer for which no
alternative treatment exists.
5. Combination chemotherapy- Administration of two or
more chemotherapeutic agents in the treatment of cancer,
allowing each medication to enhance the action of the other or act

synergistically with it. e.g. MOPP regimen for Hodgkin’s disease.

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 which
could contraindicate chemotherapeutic agent
administration i.e. infection, severe stomatitis ,
decreased deep tendon reflexes, or bleeding .
-Physical status
-Level of anxiety
-Psychological status.
5. Prepare for potential complications
Review the policy and have medication and supplies
available for immediate intervention the event of
extravasation.
Review the procedure and have medication available
for possible anaphylaxis
6.Assure accurate preparation of the agent
-Accuracy of dosage calculation
-Expiry date of the drug to be checked
-Procedure for correct reconstitution and
-Recommended procedures for administration
7.Assess patients understanding of the
chemotherapeutic agents and administration
procedures.
II. Calculation of drug dosage

It is calculated based on body surface area.

III. Drug reconstitution/Preparation- Pharmacy

staff should reconstitute all drugs pre-prime the
intravenous tubing under a class II biologic safety
cabinet(BSC). In certain conditions nurses may be
required to reconstitute medications. When preparing
and reconstituting safe handling guidelines to be
followed.
-All chemotherapeutic drug should be prepared
according to package insert in class II BSC.
-Aseptic technique should be followed.
-Personal protective equipment includes
disposable surgical gloves, long sleeves gown
and elastic or knit cuffs.
-Protective eye goggles if no BSC
-To minimize exposure
-Wash hands before and after drug handling.
-Limit access to drug preparation area
-Keep labeled drug spill kit near preparation
area.
-Apply gloves before drug handling.
-Open drug vials/ ampoules away from body.
-Place absorbent pad on work surface.
-Wrap alcohol wipe around neck of ampoule
before opening.
-Cover tip of needle with sterilize gauge when
expelling air from syringe.
-Label all chemotherapeutic drugs.
Clean up any spill immediately
IV. Drug administration
1. Route-
i)Oral - Emphasize the importance of compliance by the
patient with prescribed schedule.Drugs with emetic potential
should be taken with meals.
Assure that chemotherapeutic agents are stored as directed by
the manufacturer(refrigerate, avoid exposure to direct
light,etc).

ii) Intramuscular and subcutaenous – Chemotherapeutic

agents that can be administered I/M or subcutaneously are few
in number. Non-vesicants like L-asperaginase, bleomycin,
cyclophosphamide, methotraxate. Cyta arabine,and some
hormonal agents are given I/M & /Or subcutaneously.
-Use the smallest gauge needle possible for the
viscosity of the medication.
-Change the needle after withdrawing the agent
from a vial or ampoule.
-Select a site with adequate muscle and/or SC tissue.
iii) Intravenous – It is the most common method of
administration of cancer chemotherapy. 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
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 medicines 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)
A Hickman catheter is a flexible polymeric
silicon rubber catheter which is threaded through
the cephalic vein and into the superior vena cava
or through the venacava and into the right atrium
of the heart. Placement in a large vein permits
the use of a catheter large enough for infusion of
chemotherapy, hyper osmolar fluids for nutrition
purposes, blood products and other needed
intravenous fluids.
The silicon rubber material of catheter is
chemically inert to prevent decomposition and it
is anti-thrombogenic
A felt cuff near the exit site anchors the catheter
on the patient’s chest and acts as an anatomic
barrier to prevent entry of infection causing
agents.
It is either single lumen or double-lumen.
IV) Intra-arterial
V)Intra-peritoneal
VI)Intrathecal- Infusion of medication can be given
through an Ommaya reservoir, implantable pump and
/or usually through lumbar puncture.
a)Wear protective equipment (gloves, gown and
eyewear).
b)Inform the patient that chemotherapeutic drugs
are harmful to normal cells and that protective
measures used by personnel minimize their
exposure to these drugs.
c)Administer drugs in a safe and unhurried
environment.
 d)Place a plastic backed absorbent pad under the
tubing during administration to catch any leakage.
Do not dispose of any supplies or unused drugs
in patient care areas.
V. Documentation
Record
-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
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
Extravasation 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 agency policy and approved
antidote should be readily available.
The following procedure should be initiated-
Stop 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.
X. Nursing Management of common side
effects of Chemotherapeutic drugs.

.Nausea & Vomiting –

Nausea is the conscious recognition of the
subconscious excitation of an area of the
medulla closely associated with or part of the
vomiting center. 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.
Consider diversionary activities
Sip liquids slowly or suck ice cubes and avoid
drinking a large volume of water if vomiting is
present
Administer antiemetics to prevent or minimize
nausea. Patient may require routine antiemetics
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
physician orders.
Monitor hematocrit and haemoglobin especially
during drug nadir
Maintain the integrity of the skin
Avoid activities with the greatest potential for physical
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 G
I 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
Report s/s of infection to physician
Monitor counts
Avoid invasive procedures, no ……
Raise the arm while pressure is applied after
removal of a needle or catheter
.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 candidiasis.
-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 high roughage, 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
Clean metal area after each bowel movement.
Administer anti-diarrhoeal agents as prescribed.
.Depression –
Assess for changes in mood and affect.
Set small goals that are achievable daily
Participate e.g. music, reading, outings
Share feelings
Reassurance
.Cystitis-
Is an inflammation of the bladder, which is
usually caused by an infection. Sterile cystitis
not induced by 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 increasing 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. This shift is provision of
services from the Hospital setting is a result o
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.