Chapter 11
Oncology: Nursing management in cancer care
255
reactions is critical when caring for patients receiving chemo-
therapy because these reactions are potentially life-threatening.
Prevention is the first line of defence, and nurses need to have
a clear understanding of which agents have the potential
for precipitating hypersensitivity reactions, determining the
patient’s responses to certain agents via skin testing, and pro-
viding appropriate premedication before administering agents
with a high potential for causing hypersensitivity reactions.
Education of patients should emphasise the importance of
adhering to prescribed self-administered premedication before
presenting for the infusion and recognising and reporting
the signs and symptoms to the nurse once their infusion
has started. Early intervention can prevent progression of a
reaction to systemic anaphylaxis. Most reactions coincide with
chemotherapy agent administration, but some reactions can
be delayed or occur after several uneventful courses of therapy.
Although patients may react to the first infusion of a chemo
therapy agent, repeated exposure increases the likelihood of
extravasation but are of no benefit for taxane or oxaliplatin
(Eloxatin) extravasation. Warm compresses are recommended
for vinca alkaloid extravasation. Depending on the guidelines
for specific agents, extravasation management may include
aspiration of any infiltrated medication from the tissues and
injection of a neutralising solution into the area to reduce tissue
damage. Selection of the neutralising solution depends on the
extravasated agent (Gullatte, 2007; Sauerland et al., 2006).
Examples of neutralising solutions include sodium thiosulfate,
hyaluronidase and sodium bicarbonate. Recommendations
and guidelines for managing vesicant extravasation have been
issued by individual pharmaceutical manufacturers, pharmacies
and the Australian Oncology Nursing Society. Nurses should
be aware of these guidelines prior to administering the agents.
Prevention of extravasation is essential and relies on
vigilant nursing care. Vesicant chemotherapy should never
be administered in peripheral veins involving the hand, wrist
or elbow. Peripheral administration is permitted for short
duration infusions only, and placement of the venipuncture
site should be on the forearm area using a soft, small gauge,
plastic catheter. For any frequent, or prolonged administration
of antineoplastic vesicants, tunnelled right atrial silastic cath-
eters, implanted venous access devices, or peripherally inserted
central catheters (PICC) should be inserted to promote safety
during medication administration and reduce problems with
access to the circulatory system (Figures 11-2 and 11-3).
Indwelling or subcutaneous catheters require vigilant nursing
care. Complications associated with their use include infection
and thrombosis (Arch, 2007).
Hypersensitivity reactions
Most of the available chemotherapeutic agents have the poten-
tial to cause hypersensitivity reactions; however, the overall
incidence of hypersensitivity reactions to these agents is only
about 5%. Understanding and managing hypersensitivity
Entrance site
Subclavian vein
Superior vena cava
Dacron cuff
Exit site
Figure 11-2
Tunnelled central catheter. The tunnelled central
catheter is inserted into the subclavian vein and advanced until its
tip lies in the superior vena cava just above the right atrium. The
proximal end is then tunnelled from the entry site through the
subcutaneous tissue of the chest wall and brought out through
an exit site on the chest. The Dacron cuff anchors the catheter in
place and serves as a barrier to infection.
Self-sealing septum
Huber needle
Subcutaneous tissue
Muscle
Suture
Fluid flow
Catheter
Vein
Skin line
A
B
Figure 11-3
Implanted vascular access device.
(A)
A schematic
diagram of an implanted vascular access device used for
administering medication, fluids, blood products and nutrition.
The self-sealing septum permits repeated puncture by Huber
needles without damage or leakage.
(B)
Two Huber needles used
to enter the implanted vascular port. The 90
8
needle is used for
top-entry ports for continuous infusions.
