256
Unit 3
Applying concepts from the nursing process
chemotherapy are troublesome for some patients. To minimise
discomfort, some antiemetic medications are necessary for the
first week at home after chemotherapy. Relaxation techniques,
acupressure and imagery can also help to decrease stimuli
contributing to symptoms (Dribble et al., 2007). Altering the
patient’s diet to include small frequent meals, non-spicy foods
and comfort foods may reduce the frequency or severity of
these symptoms.
Although the epithelium that lines the oral cavity quickly
renews itself, its rapid rate of proliferation makes it suscep-
tible to the effects of chemotherapy. As a result, stomatitis
and anorexia are common. The entire gastrointestinal tract
is susceptible to mucositis (inflammation of the mucosal
lining), and diarrhoea can often result. Antimetabolites and
antitumour antibiotics are the major culprits in mucositis,
diarrhoea and other gastrointestinal symptoms.
Haematopoietic system.
Most chemotherapeutic agents
cause
myelosuppression
(depression of bone marrow func-
tion), resulting in decreased production of blood cells.
Myelosuppression decreases the number of WBCs (leucopenia),
red blood cells (anaemia), and platelets (thrombocytopenia)
and increases the risk for infection and bleeding. Depression
of these cells is the usual reason for limiting the dose of the
chemotherapeutic agents. Myelosuppression is predictable,
and patients usually reach their nadir counts (point at which
blood counts are lowest) 7 to 14 days after chemotherapy has
been administered. At this time nurses anticipate associated
toxicities, especially febrile neutropenia (fever associated with
neutrophil count less than 1.0 × 10
9
/L. Monitoring blood cell
counts frequently is essential, as is protecting the patient from
infection and injury, particularly while the blood cell counts
are depressed (Duong & Loh, 2006; Nirenberg et al., 2006).
Other agents, called colony-stimulating factors (granulo-
cyte colony-stimulating factor [G-CSF], granulocytemacro-
phage colony-stimulating factor [GM-CSF], and erythropoietin
[EPO]), can be administered after chemotherapy. G-CSF and
GM-CSF stimulate the bone marrow to produce WBCs,
especially neutrophils, at an accelerated rate, thus decreasing
the duration of neutropenia. The colony-stimulating factors
decrease the episodes of infection and the need for anti
biotics and allow for timelier cycling of chemotherapy with
less need to reduce the dosage. EPO stimulates red blood
cell production, thus decreasing the symptoms of chronic
administered anaemia. Interleukin 11 (IL-11) stimulates the
production of platelets and can be used to prevent and treat
thrombocytopenia but has had limited use because of toxici-
ties such as fatigue, oedema, arrhythmias and syncope (Burcat
& McAdams, 2007; Hurter & Bush, 2007; Nirenberg et al.,
2006).
Renal system.
Chemotherapeutic agents can damage the
kidneys because of their direct effects during excretion and the
accumulation of end products after cell lysis. Cisplatin, metho
trexate and mitomycin are particularly toxic to the kidneys.
Rapid tumour cell lysis after chemotherapy results in increased
urinary excretion of uric acid, which can cause renal damage.
In addition, intracellular contents are released into the circula-
tion, resulting in excessive levels of potassium and phosphates
(hyperkalaemia and hyperphosphataemia) and diminished
levels of calcium (hypocalcaemia). (See later discussion of
tumour lysis syndrome.)
a reaction along with other predisposing risk factors such as
pre-existing allergic reactions to food, blood products and
other medications. Emergency medication and resuscitation
equipment should be easily accessible.
The usual chemotherapy hypersensitivity reaction is cat-
egorised as a type I immediate, immunoglobulin E mediated
reaction. Type I hypersensitivity reactions may present as a
local reaction and then rapidly progress to systemic anaphylaxis,
or the initial presentation may be an acute life-threatening
anaphylaxis. Symptoms include generalised itching with local-
ised or generalised urticaria; flushing of the face, hands or feet;
chest tightness; agitation; nausea and vomiting; dyspnoea and
bronchospasm; difficulty speaking; feeling of impending doom;
and hypotension (Gobel, 2005; Wilkes & Barton-Burke,
2007). The medication should be discontinued immediately
and emergency procedures initiated. Many institutions have
developed specific protocols for responding to hypersensitiv-
ity reactions including standing orders for administration of
emergency medications (de Lemos, 2006). See Chapter 48 for
further discussion of allergic reactions.
For some chemotherapeutic agents, especially if they are
essential in the treatment plan, desensitisation procedures
may be possible, and the patient is retreated with the agent
at reduced dosages or slower infusion rates. Premedication
regimes including corticosteroids, histamine-1 and histamine-2
antagonists, and antipyretics are routinely pre-administered for
certain chemotherapy agents to prevent or minimise potential
reactions.
Doxorubicin or daunorubicin can create localised allergic
reactions referred to as flare reaction. Patients typically experi
ence a hot, flushed sensation with urticaria and pruritis. The
nurse must confirm that the reaction is indeed a flare and not
an extravasation. The infusion can be temporarily discontin-
ued and restarted at a slower infusion rate after consultation
with the doctor and IV administration of hydrocortisone.
Toxicity
Toxicity associated with chemotherapy can be acute or
chronic. Cells with rapid growth rates (e.g. epithelium, bone
marrow, hair follicles, sperm) are very susceptible to damage,
and various body systems may be affected as well.
Gastrointestinal system.
Nausea and vomiting are one of
the most common side effects of chemotherapy and may persist
for up to 24 to 48 hours after its administration. The vomiting
centres in the brain are stimulated by: (1) activation of the
receptors found in the chemoreceptor trigger zone (CTZ) of
the medulla; (2) stimulation of peripheral autonomic pathways
(gastrointestinal tract and pharynx); (3) stimulation of the
vestibular pathways (inner ear imbalances, labyrinth input);
(4) cognitive stimulation (central nervous system disease,
anticipatory nausea and vomiting); and (5) a combination of
these factors.
Medications that can decrease nausea and vomiting include
serotonin blockers, such as ondansetron and dolasetron,
which block serotonin receptors of the gastrointestinal tract
and CTZ, and dopaminergic blockers, such as metoclo
pramide (Maxalon), which block dopamine receptors of the
CTZ. Phenothiazines, sedatives, corticosteroids and histamines
are used in combination with serotonin blockers with the
more emetogenic chemotherapeutic regimes. Delayed nausea
and vomiting that occurs later than 48 to 72 hours after
