Chapter 11
Oncology: Nursing management in cancer care
257
encephalopathy can occur with ifosfamide, high-dose metho
trexate and cytarabine. With repeated doses, the taxanes and
plant alkaloids, especially vincristine, can cause peripheral
neurological damage with sensory alterations in the feet and
hands. These sensations can be described as tingling, pricking
or numbness of the extremities, burning or freezing pain, sharp,
stabbing, or electric-shock-like pain and extreme sensitivity
to touch. If unreported by patients or undetected, progressive
motor axon damage can lead to loss of deep tendon reflexes,
with muscle weakness, loss of balance and coordination, and
paralytic ileus. Although usually reversible, these side effects
may take many months to resolve. Along with the usual par-
esthesias of the hands and feet, oxaliplatin has a unique and
frightening neurotoxicity presentation that is often precipi-
tated by exposure to cold and is characterised by pharyngo
laryngeal dysaesthesia consisting of lip paraesthesia, discomfort
or tightness in the back of the throat, inability to breathe and
jaw pain. Patients receiving oxaliplatin must be instructed to
avoid drinking cold fluids or going outside with hands and feet
exposed to cold temperatures to avoid exacerbation of these
symptoms. Cisplatin may cause peripheral neuropathies and
hearing loss due to damage to the acoustic nerve (Wilkes &
Barton-Burke, 2007). The ability of cytoprotectant agents to
prevent these significant neurotoxicities, including amifostine,
is being studied (Hogle, 2007; Wilkes & Barton-Burke, 2007).
Fatigue.
Fatigue, a distressing side effect for most patients
that greatly affects quality of life, can last for months after
treatment. Assessment and nursing management of fatigue
are discussed in the ‘Nursing care of patients with cancer’ sec-
tion of this chapter. Evidence-based interventions for fatigue
management are available to provide guidelines for nurses to
effectively intervene and assist their patients (Mitchell et al.,
2007).
Nursing management in chemotherapy
The nurse has an important role in assessing and managing
many of the problems experienced by the patient undergoing
chemotherapy. These problems are often widespread, affecting
many body systems because of the systemic effects on normal
as well as malignant cells.
Assessing fluid and electrolyte status
Anorexia, nausea, vomiting, altered taste and diarrhoea put
the patient at risk for nutritional and fluid and electrolyte dis-
turbances. Changes in the mucosa of the gastrointestinal tract
may lead to irritation of the oral cavity and intestinal tract,
further threatening the patient’s nutritional status. Therefore,
it is important for the nurse to assess the patient’s nutritional
and fluid and electrolyte status frequently and to use creative
ways to encourage an adequate fluid and dietary intake.
Modifying risks for infection and bleeding
Suppression of the bone marrow and immune system is an
expected consequence of chemotherapy and frequently serves
as a guide in determining appropriate chemotherapy dosage.
However, this effect also increases the risk for anaemia,
infection and bleeding disorders. Therefore, nursing assess-
ment and care focus on identifying and modifying factors
that further increase the patient’s risk. Aseptic technique
and gentle handling are indicated to prevent infection and
trauma. Laboratory test results, particularly blood cell counts,
are monitored closely. Untoward changes in blood test results
Monitoring serum urea, serum creatinine, creatinine clear-
ance and serum electrolyte levels is essential. Adequate hydra-
tion, alkalinisation of the urine to prevent formation of uric
acid crystals, and the use of allopurinol are frequently indicated
to prevent these side effects (Duong & Loh, 2006; Gullatte,
2007). Amifostine has demonstrated an ability to minimise
renal toxicities associated with cisplatin, cyclophosphamide
and ifosfamide therapy (Hogle, 2007).
Haemorrhagic cystitis is a bladder toxicity resulting from
cyclophosphamide and ifosfamide therapy. Haematuria can
range from microscopic to frank bleeding with symptoms
ranging from transient irritative urination, dysuria, suprapu-
bic pain, to life-threatening haemorrhage. Protection of the
bladder focuses on aggressive IV hydration, frequent voiding
and diuresis. Mesna is a cytoprotectant agent that binds with
the toxic metabolites of cyclophosphamide or ifosfamide in the
kidneys to prevent haemorrhagic cystitis (Hogle, 2007; Wilkes
& Barton-Burke, 2007).
Cardiopulmonary system.
Antitumour antibiotics (dauno-
rubicin and doxorubicin) are known to cause irreversible
cumulative cardiac toxicities, especially when total dosage
reaches 550 mg/m
2
. Dexrazoxane has been utilised as a car-
dioprotectant when doxorubicin is needed in individuals
who have already received a cumulative dose of 300 mg/m
2
and continuation of therapy is deemed beneficial (Wilkes &
Barton-Burke, 2007; Hogle, 2007). Cardiac ejection fraction
(volume of blood ejected from the heart with each beat) and
signs of congestive heart failure must be monitored closely.
Bleomycin, carmustine (BiCNU), and busulfan are known for
their cumulative toxic effects on lung function. Pulmonary
fibrosis can be a long-term effect of prolonged dosage with
these agents. Therefore, the patient is monitored closely for
changes in pulmonary function, including pulmonary function
test results. Total cumulative doses of bleomycin are not to
exceed 400 units.
Capillary leak syndrome with resultant pulmonary oedema
is a toxic effect of cytarabine, mitomycin C, cyclophosphamide
and BCNU. Subtle onset of dyspnoea and cough may progress
rapidly to acute respiratory distress and subsequent respiratory
failure (Wilkes & Barton-Burke, 2007).
Reproductive system.
Testicular and ovarian function can
be affected by chemotherapeutic agents, resulting in possible
sterility. Normal ovulation, early menopause or permanent ste-
rility may result. In men, temporary or permanent azoospermia
(absence of spermatozoa) may develop. Reproductive cells
may be damaged during treatment, resulting in chromosomal
abnormalities in offspring. Banking of sperm is recommended
for men before treatments are initiated to protect against ste-
rility or any mutagenic damage to sperm.
Patients and their partners need to be informed about
potential changes in reproductive function resulting from che-
motherapy. They are advised to use reliable methods of birth
control while receiving chemotherapy and not to assume that
sterility has resulted.
Neurological system.
Chemotherapy-induced neurotoxicity
can affect the CNS, peripheral nervous system (PNS), the
cranial nerves or a combination; it is a dose-limiting toxicity.
The blood–brain barrier can protect the CNS and PNS
from the toxic effects of most water soluble chemother-
apy agents, but neurotoxicity characterised by metabolic
