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Unit 3
Applying concepts from the nursing process
cancers that initially respond to therapy recur. This is true of
haematological cancers that affect the bone marrow and solid
tumour cancers treated with lower doses of antineoplastics to
spare the bone marrow from larger, ablative doses of chemo-
therapy or radiation therapy.
Bone marrow transplantation (BMT) or haematopoietic
stem cell transplants can be used to treat malignant as well as
some non-malignant diseases. The aim of such treatment is to
replace a person’s diseased or damaged bone marrow with bone
marrow that functions adequately.
Types of bone marrow transplant
Types of BMT based on the source of donor cells include:
1. Allogeneic (from a donor other than the patient): either a
related donor (i.e. family member) or a matched unrelated
donor (Australian Bone Marrow Donor Registry,
Australian Cord Blood Registry)
2. Autologous (using the patient’s own bone marrow or
stem cells)
3. Syngeneic (from an identical twin).
Donor cells can be obtained by the traditional harvesting of
large amounts of bone marrow tissue under general anaesthesia
in the operating room. A newer method, referred to as periph-
eral blood stem cell transplant (PBSCT), uses apheresis of the
donor to collect stem cells for reinfusion. It is considered to be
a safer and more cost-effective means of collection than the
traditional harvesting of marrow.
Allogeneic BMT, used primarily for disease of the bone
marrow, depends on the availability of a human leucocyte
antigen-matched donor. This greatly limits the number of
transplants possible. An advantage to allogeneic BMT is
that the transplanted cells should not be immunologically
tolerant of the patient’s malignancy and should cause a lethal
graft-versus-disease effect to the malignant cells. The recipient
must undergo ablative doses of chemotherapy and possibly
total body irradiation to destroy all existing bone marrow and
malignant disease. The harvested donor marrow is infused
intravenously into the recipient and travels to sites in the body
where it produces bone marrow and establishes itself. This
establishment of the new bone marrow is known as engraft-
ment. Once engraftment is complete (2 to 4 weeks, sometimes
and signs of infection and bleeding must be reported promptly.
The patient and family members are instructed about measures
to prevent these problems at home and this is discussed further
in the ‘Nursing care of patients with cancer’ section of this
chapter.
Administering chemotherapy
The local effects of the chemotherapeutic agent are also of
concern. The patient is observed closely during its admini
stration because of the risk and consequences of extravasation
(particularly of vesicant agents, which may produce necrosis
if deposited in the subcutaneous tissues). Local difficulties or
problems with administration of chemotherapeutic agents are
brought to the attention of the doctor promptly so that cor-
rective measures can be taken immediately to minimise local
tissue damage (see previous discussion of extravasation).
CLINICAL REASONING CHALLENGE
Mrs Brown is a 52-year-old patient with leukaemia receiv-
ing chemotherapy for the second time. At the start of the
procedure, she watches you preparing and donning the
Personal Protection Equipment (PPE). She looks anxious
and you enquire what is wrong. She reveals that she feels
that she is exposing you to risk to your own health. How
would you respond to reassure Mrs Brown that you are safe?
Protecting carers
Nurses involved in handling chemotherapeutic agents may be
exposed to low doses of the drugs by direct contact, inhalation
and ingestion. Although not all mutagens are carcinogenic,
the mutagenic activity of cytotoxic drugs can produce perma-
nent inheritable changes in the genetic material of cells.
Although long-term studies of nurses handling chemo-
therapeutic agents have not been conducted, it is known that
chemotherapeutic agents are associated with secondary forma-
tion of cancers and chromosome abnormalities. Additionally,
nausea, vomiting, dizziness, alopecia and nasal mucosal ulcer-
ations have been reported in healthcare personnel who have
handled chemotherapeutic agents.
As there are known and potential hazards associated with
handling chemotherapeutic agents, the Australian Commission
on Safety & Quality in Health Care, Quality Health New
Zealand, WorkSafe and individual health services, have devel-
oped specific precautions for those involved in the preparation
and administration of chemotherapy (Chart 11-7).
Nurses must be familiar with their institutional policies
regarding personal protective equipment, handling and disposal
of chemotherapeutic agents and supplies, and management of
accidental spills or exposures in order to incorporate these
into care (see Chart 11-7). Emergency spill kits should be
readily available in any treatment area where chemotherapy is
prepared or administered. Precautions must also be taken when
handling any bodily fluids or excreta from the patient, as many
agents are excreted unaltered in urine and faeces. Nurses have
a responsibility to educate patients, caregivers, assistive person-
nel and housekeepers concerning these precautions.
Bone marrow transplantation
Although surgery, radiation therapy and chemotherapy have
resulted in improved survival rates for cancer patients, many
guidelines for care
Safety in administering chemotherapy
Safety recommendations from the Australian Commission on
Safety & Quality in Health Care, Quality Health New Zealand,
WorkSafe, hospitals and other healthcare agencies for the
preparation and handling of antineoplastic agents follow:
• Use a biological safety cabinet for the preparation of all
chemotherapy agents.
• Wear surgical gloves and goggles when handling
antineoplastic agents and the excretions of patients who
received chemotherapy.
• Wear disposable, long-sleeved, impermeable gowns when
preparing and administering chemotherapy agents.
• Dispose of all equipment used in chemotherapy preparation
and administration in appropriate, leak-proof, puncture-proof
containers.
• Dispose of all chemotherapy wastes as hazardous materials.
When followed, these precautions greatly minimise the risk of
exposure to chemotherapy agents.
CHART
11-7
