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Alexander Abesamis

on 7 December 2010

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Risks and Nursing Implications Antineoplasitic agents are used in an
attempt to destroy tumor cells by
interfering with cellular functions
and reproduction.
Chemotherapy is used primarily to
treat systemic disease
May be combined with surgery or radiation therapy
to reduce tumor size operatively
destroy any remaining tumor cells postoperatively
treat some forms of leukemia.
Goals (cure , control, palliation) should be realistic:
Goals define medications used and aggressiveness of treatment plan Actively proliferating cells within a tumor (growth fraction) are the most sensitive to chemotherapeutic agents. Non-dividing cells capable of future proliferation are the least sensitive and consequently are potentially dangerous The non-dividing cells must be destroyed, to eradicate a cancer completely Repeated cycles of chemotherapy are used to kill more tumor cells by destroying these non-dividing cells as they begin active cell division. Chemotherapeutic agents are also classified according to various chemical groups, each with a different mechanism of action. These include :

the alkylating agents
anti-tumor antibiotics
plant alkaloids
hormonal agents
miscellaneous agents
Chemotherapeutic agents from each category
may be used together :
To enhance the tumor cell kill during therapy by creating multiple cellular lesions. For synergistic actions To prevent development of drug resistant

To administer chemotherapeutic agent(s) safely.

To promote patient/significant other’s understanding
of disease/chemotherapy and side effects associated
with chemotherapeutic agents.

To prevent/minimize complications and side effects.

To provide emotional support and decrease anxiety.
in chemotherapy: EXTRAVASATION
& TOXICITY VESICANTS are those agents that, if deposited into the subcutaneous tissue (extravasation), cause tissue necrosis and damage to underlying tendons, nerves, and blood vessels. The pH of many anti-neoplastic drugs is responsible for the
severe inflammatory reaction as well as the ability of these
drugs to bind to tissue DNA.
Sloughing and ulceration of the tissue may be so severe
that skin grafting may be necessary.
All drugs categorized as vesicants or irritants should have warning labels (“Avoid Extravasation”) affixed to
prepared doses.
Indications of extravasation during administration of Vesicant agents:

Absence of blood return from the intravenous catheter
Resistance to flow of intravenous fluid
Swelling, pain, or redness at the site PRECAUTIONS
to prevent Extravasation 1. Select a large vein away from joints or tendons

2. Establish a new IV site, rather than using a pre- existing IV.

3. Make a clean venipuncture, preferably using an appropriate gauge intravenous catheter or butterfly. Leave the needle entry site visible so that it can be watched during injection.

4. Have IV flowing freely at all times with saline or D5W. 5. Inject into the medication injection port of IV
tubing slowly enough that drip does not stop or
reverse. Watch for evidence of extravasation and
check for blood return every 2-3mL during

6. Flush thoroughly with saline or D5W.

7. Elevate limb and maintain gentle pressure over
the venipuncture site for five minutes after needle
When chemotherapy is to be given via an
implanted venous access device A 22 gauge Huber point needle is inserted directly
into the dome of the device at a 90 degree angle Blood should first be aspirated to ensure location
in the vein Infuse 25mL bolus of normal saline The medication can then be administered as an
infusion via a secondary medication set. Vesicant
infusion should be infused in no less than 10 min Following infusion of the medication, flush with at
least 25mL normal saline Thrombosis or sclerosis of veins may occur due
to the local effect of chemotherapeutic agents on
the endothelium.

These can be managed conservatively with warm
or cold compresses depending on the chemotherapy
to the area plus an analgesic for pain, if required An Extravasation Tray will contain:

dimethylsulfoxide (DMSO) 99% topical solution
hydrocortisone 1% cream
sodium thiosulfate 25% injection, 10mL vial
sterile water for injection, 10mL vial
10mL syringe (for preparing sodium thiosulfate)
25 gauge needles
3mL syringes
black indelible ink
ice pack – in freezer
sterile gauze dressing and tape
Sling Procedure for the Extravasation of a Vesicant
STOP INJECTION IMMEDIATELY DO NOT FLUSH through with IV fluid Disconnect the IV tubing from the venipuncture needle and attempt to aspirate as much drug as possible with a clean syringe Notify the attending oncologist or medical resident.
If neither is available, page the medical oncologist or medical resident on-call The use of an ANTIDOTE other than dimethylsulfoxide
(DMSO) requires a physician’s order If DMSO only and no other antidote is to be used, remove venipuncture needle For Extravasation of Daunorubicin,
Doxorubicin, Epirubicin and Mitomycin Apply DMSO 99% topical solution to an area twice
that affected by the extravasation, allow to air dry,
do not cover, repeat QID for at least 7 days Elevate the limb in which the extravasation
has occurred and apply gentle pressure over
the area.
Circle affected area with indelible ink Document interventions

If possible, arrange to have a color photo-
graph taken of the affected area within
4 hours.

Otherwise, draw a simple diagram indicating the
affected area and its size for comparison at
subsequent visits For Extravasation of Vinblastine,
Vincristine, or Vinorelbine Apply warm compress to the extravasation site for 1 hour.

Care must be taken to avoid tissue injury from excessive heat Cooling may have an adverse effect with
vinca alkaloid extravasations
and local warming is recommended For all other Extravasations Apply ice pack wrapped in a towel or cold
compresses to the extravasation site for 1 hour.

Care must be taken to avoid tissue injury
from excessive cold Apply hydrocortisone 1% cream to the affected
area and cover with sterile gauze to reduce
local inflammation Apply sling if significant swelling exists.
Elevate area to minimize edema Complete required documentation for your
hospital/centre Extravasation hazard associated with Porfimer
(Photofrin) is due to irritation caused by its local
photodynamic effects.

Area of extravasation should be protected
from light for a minimum of 30 days TOXICITY Cells with rapid growth rates are very
susceptible to damage, and various body systems
may be affected as well Gastrointestinal System.

Nausea and vomiting are the most common
side effects of chemotherapy and may persist
for up to 24 hours after its administration Serotonin blockers, such as ondansetron,
granisetron, and dolasetron

Dopaminergic blockers, such as metoclopramide

Phenothiazines, sedatives, corticosteroids, and anti-
Histamines are used in combination with serotonin
blockers with the more emetogenic chemotherapeutic
Stomatitis and anorexia are also common

Mucositis and diarrhea. (Antimetabolites
and anti-tumor antibiotics, Irinotecan )
Hematopoietic System

Myelosuppression :
Thrombocytopenia Colony-stimulating factors (granulocyte colony-stimulating factor (G-CSF) , granulocyte-macrophage colony-stimulating factor (GM-CSF), and erythropoietin (EPO), can be administered after chemotherapy Renal System Due to direct effects during excretion and the
accumulation of end products after cell lysis.

Rapid tumor cell lysis = increase uric acid excretion,Hyperkalemia , Hyperphosphatemia and Hypocalcemia Cisplatin, methotrexate, and mitomycin are nephrotoxic Cardiopulmonary System
Anti-tumor antibiotics (daunorubicin and doxorubicin) may cause irreversible cumulative cardiac toxicities, especially when total dosage reaches 550 mg/m2
Bleomycin, carmustine (BCNU), and busulfan
may have cumulative toxic effects on lung function
causing Pulmonary fibrosis with prolonged usage.
Total cumulativedoses of bleomycin are not to
exceed 400 units
Reproductive System
Possible sterility, temporary or permanent
Azoospermia may develop

Possible chromosomal abnormalities in

Banking of sperm is recommended for men
before treatments are initiated
Patients and their partners are advised to use
reliable methods of birth control while receiving
chemotherapy and not to assume that sterility
has resulted.
Neurologic System
Peripheral neuropathies, loss of deep tendon
reflexes, and paralytic ileus may occur
( taxanes and plant alkaloids, especially
vincristine) Cisplatin is also responsible for peripheral
neuropathies; hearing loss due to damage to
the acoustic nerve can also occur.

Use of aseptic technique and gentle handling
Monitor laboratory results (blood cell counts),
report untoward changes promptly
Instruction of parents / family on infection prevention

Monitor closely for extravasation and toxicity.

Report local difficulties or problems of administration promptly to the Physician IMPLEMENTING SAFEGUARDS

Urinalysis of exposed personnel

Chemotherapeutic agents are associated with secondary formation of cancers and chromosome abnormalities. Additionally, nausea, vomiting, dizziness, alopecia, and nasal
mucosal ulcerations have been reported in health care
personnel who have handled chemotherapeutic agents
Safety recommendations from the Occupational Safety and Health Administration (OSHA), Oncology Nursing Society (ONS), hospitals, and other health care agencies for the preparation and handling of antineoplastic agents follow:
Use a biologic safety cabinet for the preparation of all
chemotherapy agents,

Wear surgical gloves when handling antineoplastic agents and the excretions of patients who received chemotherapy.

Wear disposable, long-sleeved gowns when preparing and administering chemotherapy agents. Use Luer-Lok fittings on all intravenous tubing used to deliver chemotherapy.

Dispose of all equipment used in chemotherapy preparation and administration in appropriate, leak-proof, puncture proof containers CHEMOTHERAPY STANDARD OF CARE
A Registered Nurse, only with documented competency, shall administer/monitor a patient receiving chemotherapy The patient/significant other will receive education on the purpose, management, administration, and side effects of the chemotherapeutic agent, based on readiness to learn and barriers to learning.
The patient will have a baseline assessment, including vital signs and neurological findings (if applicable) performed prior to administration of the chemotherapeutic agent The physician shall be notified of any significant/abnormal lab values,
and/or vital signs prior to, during, and post administration.
The patient's IV access will be assessed for stabilized placement,
erythema, pain, and/or tenderness. Validation of patency will be
evidenced by free flowing strong blood return prior to and at
frequent intervals during administration of the
chemotherapeutic agent.
The chemotherapeutic agent will be administered in accordance
With established National Oncology Nursing Society (ONS) Standards and recommendations and policy and procedure, including safe handling and administration. An infusion pump will be utilized to administer medications to be
continuously infused within a specified time frame The patient will be encouraged to express any feelings,
concerns, fears, etc., regarding chemotherapy with a supportive
and a non-judgmental attitude maintained by the nurse The patient will be instructed to report significant sensations
(i.e. burning, stinging, anaphyloctoid reaction) during and after infusion is completed
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