Textbook of Medical-Surgical Nursing 3e

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Unit 3   Applying concepts from the nursing process

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

CHART 11-7

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 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.