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Chemotherapy | 마이메르시 MyMerci
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Chemotherapy

NCLEX Review Guide: Chemotherapy in Oncological Nursing

Fundamentals of Chemotherapy

Definition and Mechanism of Action

  • Chemotherapy refers to the use of cytotoxic medications designed to destroy rapidly dividing cells by interfering with cell division processes. These agents work primarily by damaging DNA, disrupting RNA synthesis, or inhibiting mitosis, thereby preventing cancer cells from multiplying and spreading.
  • Most chemotherapeutic agents are cell cycle-specific, targeting cells in particular phases of division, while others are cell cycle non-specific, affecting cells regardless of their division phase.

Key Points

  • Chemotherapy affects both cancerous and normal rapidly dividing cells (bone marrow, GI tract, hair follicles), which explains most side effects.
  • Therapeutic index refers to the balance between a drug's efficacy against cancer cells versus its toxicity to normal cells.

Classification of Chemotherapeutic Agents

  • Alkylating agents (cyclophosphamide, cisplatin): Form covalent bonds with DNA, preventing cell replication regardless of the cell cycle phase.
  • Antimetabolites (5-fluorouracil, methotrexate): Interfere with DNA and RNA production by substituting for normal cellular metabolites.
  • Antitumor antibiotics (doxorubicin, bleomycin): Intercalate between DNA base pairs, preventing RNA synthesis and causing DNA strand breakage.
  • Plant alkaloids (vincristine, paclitaxel): Disrupt microtubule function during mitosis, preventing cell division.
  • Topoisomerase inhibitors (etoposide, irinotecan): Interfere with enzymes that control the manipulation of DNA structure during replication.
  • Targeted therapy agents (trastuzumab, imatinib): Target specific molecular pathways or mutations unique to cancer cells.

Comparison of Major Chemotherapy Classes

Class Mechanism Examples Common Side Effects
Alkylating Agents DNA cross-linking Cyclophosphamide, Cisplatin Myelosuppression, nausea, alopecia, secondary malignancies
Antimetabolites False substrate incorporation 5-FU, Methotrexate Mucositis, diarrhea, myelosuppression
Plant Alkaloids Microtubule disruption Vincristine, Paclitaxel Peripheral neuropathy, constipation
Anthracyclines DNA intercalation Doxorubicin, Epirubicin Cardiotoxicity, myelosuppression, alopecia

Key Points

  • Each class of chemotherapeutic agents has unique toxicity profiles that guide monitoring requirements.
  • Combination chemotherapy regimens utilize multiple drug classes to target cancer cells at different cell cycle phases while minimizing overlapping toxicities.

Administration and Safety

Routes of Administration

  • Intravenous (IV): Most common route, may be given as bolus, intermittent infusion, or continuous infusion. Requires assessment of venous access integrity before administration.
  • Oral: Increasingly common with newer agents, requires patient education regarding compliance, handling, and absorption factors.
  • Intrathecal: Direct administration into cerebrospinal fluid for central nervous system malignancies.
  • Intraperitoneal: Direct administration into the peritoneal cavity, commonly used for ovarian cancer.
  • Intravesical: Direct administration into the bladder, used primarily for bladder cancer.
  • Subcutaneous/Intramuscular: Less common routes used for specific agents like asparaginase.

CRITICAL SAFETY ALERT: Never administer vesicant chemotherapy agents through peripheral IV lines with suspected infiltration. Extravasation of vesicants can cause severe tissue necrosis requiring surgical intervention.

Key Points

  • Verify chemotherapy orders with two licensed practitioners before administration (double-check drug, dose, route, rate, patient).
  • Central venous access devices (ports, PICC lines) are preferred for vesicant administration and long-term therapy.

Safe Handling Procedures

  1. Don appropriate personal protective equipment (PPE): chemotherapy-rated gloves, gown, face shield, and mask.
  2. Prepare chemotherapy in a biological safety cabinet or isolator using closed-system transfer devices.
  3. Transport prepared drugs in sealed, labeled containers.
  4. Administer using chemotherapy-specific administration sets with Luer-lock fittings.
  5. Dispose of all materials in designated chemotherapy waste containers.
  6. Manage spills using approved chemotherapy spill kits and protocols.
  7. Document exposure incidents according to institutional policy.

Memory Aid: ESCAPE Hazards

Excretion (body fluids contain drug for 48+ hours)
Spills require immediate containment
Contamination of surfaces is invisible
Aerosols form during preparation/administration
Pregnant staff require special precautions
Equipment must be properly disposed

Key Points

  • Chemotherapy waste is considered hazardous and must be disposed of according to regulatory requirements.
  • Body fluids from patients receiving chemotherapy should be considered contaminated for at least 48 hours after administration.

Extravasation Management

  • Extravasation refers to the leakage of chemotherapy from the vein into surrounding tissue, which can cause tissue damage ranging from mild irritation to severe necrosis requiring surgical intervention.
  • Vesicant drugs (e.g., doxorubicin, vincristine, paclitaxel) cause the most severe tissue damage, while irritants (e.g., etoposide, carboplatin) cause inflammation without tissue necrosis.
  1. Stop the infusion immediately but do not remove the IV catheter.
  2. Aspirate any residual drug from the catheter if possible.
  3. Administer the appropriate antidote through the existing IV or subcutaneously around the site as prescribed.
  4. Remove the IV catheter after antidote administration.
  5. Apply cold or warm compresses based on the specific extravasated agent.
  6. Document the event, including estimated amount extravasated, site appearance, and interventions.
  7. Photograph the site if possible and follow institutional protocol for monitoring.

ANTIDOTE GUIDE: Dexrazoxane for anthracycline extravasation; sodium thiosulfate for mechlorethamine; hyaluronidase for vinca alkaloids and taxanes. Cold compresses are contraindicated for vinca alkaloids (use warm compresses instead).

Key Points

  • Early recognition and intervention are crucial for minimizing tissue damage from extravasation.
  • Each institution should have an extravasation kit readily available in areas where chemotherapy is administered.

Side Effect Management

Myelosuppression

  • Myelosuppression is the decrease in bone marrow activity resulting in reduced production of blood cells. It is the most common dose-limiting toxicity of chemotherapy, affecting white blood cells (neutropenia), platelets (thrombocytopenia), and red blood cells (anemia).
  • Neutropenia typically occurs 7-14 days after chemotherapy administration (nadir period) and is the most significant risk factor for infection in oncology patients.

Clinical Scenario: Neutropenic Fever

A 62-year-old female receiving R-CHOP chemotherapy for diffuse large B-cell lymphoma presents to the emergency department with a temperature of 38.5°C (101.3°F). Her labs show WBC 0.8 × 10³/μL with absolute neutrophil count (ANC) of 400 cells/mm³. She has no apparent source of infection but reports fatigue and chills.

Nursing Priorities:

  1. Immediately initiate neutropenic precautions and obtain blood cultures.
  2. Administer broad-spectrum antibiotics within 1 hour of presentation (per institutional protocol).
  3. Monitor vital signs frequently for signs of sepsis.
  4. Implement protective isolation measures.

Key Points

  • Neutropenic fever (temperature ≥38.3°C or ≥38.0°C for ≥1 hour with ANC <500 cells/mm³) is a medical emergency requiring immediate antibiotic therapy.
  • Growth factors (G-CSF, GM-CSF) may be administered prophylactically or therapeutically to reduce the duration and severity of neutropenia.
  • Thrombocytopenia increases bleeding risk; implement bleeding precautions when platelets <50,000/mm³ and transfuse per protocol (typically for counts <10,000-20,000/mm³).

Gastrointestinal Toxicity

  • Nausea and vomiting may be acute (within 24 hours), delayed (>24 hours), or anticipatory (conditioned response). The emetogenic potential varies by agent, with cisplatin, dacarbazine, and high-dose cyclophosphamide being highly emetogenic.
  • Mucositis involves inflammation and ulceration of the oral and/or gastrointestinal mucosa, typically occurring 5-14 days after treatment. It can lead to pain, difficulty eating/swallowing, and increased risk of infection.
  • Diarrhea is particularly common with antimetabolites (5-FU, capecitabine), irinotecan, and targeted therapies. Severe diarrhea can lead to dehydration, electrolyte imbalances, and renal dysfunction.

Antiemetic Protocol by Emetogenic Risk

High Risk: 5-HT₃ antagonist + NK-1 receptor antagonist + dexamethasone
Moderate Risk: 5-HT₃ antagonist + dexamethasone
Low Risk: Single agent (dexamethasone or 5-HT₃ antagonist)
Minimal Risk: As needed antiemetic only

Key Points

  • Antiemetic therapy should be administered prophylactically based on the emetogenic potential of the chemotherapy regimen.
  • Oral assessment using a standardized tool (e.g., WHO Oral Mucositis Scale) should be performed regularly during chemotherapy.
  • Severe diarrhea (≥7 stools/day) requires immediate intervention with antidiarrheals, hydration, and possible dose modification of chemotherapy.

Organ-Specific Toxicities

  • Cardiotoxicity is associated primarily with anthracyclines (doxorubicin, epirubicin) and can present as acute arrhythmias or as chronic cardiomyopathy. Cumulative lifetime dose limits exist to minimize risk (e.g., doxorubicin >550 mg/m²).
  • Nephrotoxicity is most commonly associated with platinum compounds (cisplatin), methotrexate, and ifosfamide. Prevention includes aggressive hydration, urinary alkalinization (for methotrexate), and mesna (for ifosfamide).
  • Neurotoxicity manifests primarily as peripheral neuropathy with agents like vincristine, paclitaxel, and oxaliplatin. Symptoms include numbness, tingling, and pain in extremities, potentially progressing to motor dysfunction.
  • Pulmonary toxicity is associated with bleomycin, methotrexate, and busulfan, presenting as pneumonitis or fibrosis. Oxygen supplementation may exacerbate bleomycin-induced lung injury.

Monitoring Requirements for Organ Toxicities

Toxicity Agents Monitoring Prevention Strategies
Cardiotoxicity Anthracyclines, trastuzumab Baseline and periodic ECHO/MUGA, ECG, troponin Dexrazoxane, liposomal formulations, cumulative dose limits
Nephrotoxicity Cisplatin, methotrexate BUN/Cr, GFR, electrolytes, urinalysis Hydration, diuresis, avoid nephrotoxic medications
Neurotoxicity Vincristine, taxanes, oxaliplatin Neurological assessment, functional assessment Dose modifications, cryotherapy (extremities)
Hepatotoxicity Methotrexate, 6-mercaptopurine LFTs, bilirubin, albumin Dose adjustments based on liver function

Key Points

  • Baseline assessment of organ function is essential before initiating potentially toxic chemotherapy regimens.
  • Early recognition of organ toxicity allows for prompt intervention, including dose modifications or discontinuation of the offending agent.

Patient Education and Support

Self-Care Strategies

  • Instruct patients on infection prevention measures during neutropenia, including hand hygiene, avoiding crowds and sick individuals, food safety practices, and prompt reporting of fever or signs of infection.
  • Teach patients to manage fatigue through energy conservation techniques, balanced activity and rest, and maintaining adequate nutrition and hydration.
  • Provide guidance on managing alopecia, including scalp care, options for head coverings, and information about wig services and financial assistance programs.
  • Educate patients about oral care protocols to prevent or minimize mucositis, including soft toothbrushes, alcohol-free mouthwash, and regular oral assessment.

Patient Self-Monitoring: The "SAFER" Checklist

Skin changes (rash, dryness, hand-foot syndrome)
Appetite and weight changes
Fever or signs of infection
Energy levels and fatigue
Respiratory symptoms or shortness of breath

Key Points

  • Provide both verbal and written instructions for managing side effects at home, including when to contact healthcare providers.
  • Encourage patients to maintain a symptom diary to track side effects and their relationship to treatment cycles.

Commonly Confused Concepts

Clarifying Frequently Confused Chemotherapy Concepts

Concept Correct Understanding Common Misconception
Adjuvant vs. Neoadjuvant Therapy Adjuvant therapy is given after primary treatment; neoadjuvant therapy is given before primary treatment Confusing the timing and purpose of these treatment approaches
Palliative vs. Curative Intent Palliative chemotherapy aims to relieve symptoms and improve quality of life; curative intent aims to eliminate all disease Assuming palliative means end-of-life care only
Vesicant vs. Irritant Vesicants cause tissue necrosis with extravasation; irritants cause inflammation without tissue necrosis Treating all chemotherapy agents with the same extravasation protocols
Neutropenic Precautions vs. Reverse Isolation Neutropenic precautions protect patients from environmental pathogens; reverse isolation protects patients from people-transmitted infections Implementing excessive isolation measures that may not be evidence-based

COMMON PITFALL: Confusing dose calculation methods. Body Surface Area (BSA) is most commonly used for chemotherapy dosing, but some agents require adjustment based on renal function (carboplatin AUC method) or flat dosing (some targeted therapies).

Key Points

  • Understand the differences between various treatment approaches and their goals to provide accurate patient education.
  • Recognize that chemotherapy dosing errors can have serious consequences; always verify calculations and follow institutional double-check procedures.

Study Tips for NCLEX Success

  • Focus on nursing priorities rather than memorizing specific drug names and dosages, which are not typically tested on NCLEX.
  • Understand the rationale behind interventions for managing common side effects and emergencies related to chemotherapy.
  • Practice prioritizing nursing actions in scenarios involving neutropenic fever, extravasation, and severe chemotherapy-induced diarrhea.
  • Review safe handling procedures and PPE requirements for chemotherapy administration.

Priority Assessment Focus Areas

  • Assessment for infection in neutropenic patients (may present atypically without typical inflammatory signs)
  • Evaluation of IV site integrity before and during vesicant administration
  • Monitoring for early signs of organ toxicity (cardiac, renal, neurological)
  • Assessing for dehydration and electrolyte imbalances with GI toxicities

Self-Assessment Checklist

  • I can explain the mechanism of action for major chemotherapy drug classes
  • I understand the nursing management of chemotherapy extravasation
  • I can identify priority interventions for neutropenic fever
  • I know the appropriate PPE for chemotherapy handling
  • I can describe key patient education points for common side effects

Quick Knowledge Check

1. What is the first nursing action when suspecting chemotherapy extravasation?
2. Which lab value is most important to monitor for risk of infection after chemotherapy?
3. What temperature threshold constitutes neutropenic fever requiring immediate intervention?
4. Which chemotherapy class is most associated with cumulative cardiotoxicity?
5. What is the appropriate management for severe diarrhea (≥7 stools/day) after chemotherapy?

Remember that your understanding of chemotherapy principles and side effect management is critical for patient safety. Focus on mastering the nursing process for oncology patients, including assessment, planning, intervention, and evaluation. Your knowledge will directly impact patient outcomes and quality of life during cancer treatment.

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