Principles of Administration of Chemotherapy

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Principles of Administration of Chemotherapy
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Principles of Administration

• Correct Medication - Check drug against
  Physician order. 2 RNs check med, BSA.
• Correct BSA - pts current height and weight
• Correct route - affects doseage, administration
  time, pre-medication, other considerations.

• Pre-medication - given before MOST chemo timing
  varies
• Dose - mg or unit Clarify unclear orders
• Patient - correctly identify and educate patient
  and significant others.

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Pretreatment Nursing Assessment

• Patient and family history
• Previous cancer treatment
• Medical and surgical history
• Psychosocial status and cultural issues

• Patient performance status
• Allergy history
• Accurate height and weight
• Laboratory data
• Tumor characteristics
• Chemotherapy plan
• Patient and family education

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Pretreatment Plan Review

• Review chemotherapy orders
• Check drug dose and body surface area (BSA)
• Identify treatment plan
• Check current lab values

• Confirm informed consent
• Assess patient experience and readiness
• Explain procedure to patient

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Determination of Drug DoseCalculate Body Surface
Area

• Height (cm) x Weight (kg)
• 3600

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Calculation of AUC (area under the curve)

• Creatinine clearance
• (CC) (140-age) x (weight in kilograms)
• 72 x (serum creatinine)
• AUC x (cc 25) doseage
• Multiply result x 0.85 for female

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Routes of Administration

• Oral
• Intramuscular
• Intravenous
• Central venous catheter infusion
• Venous access via implantable access device

• Topical
• Intra-arterial
• Intraperitoneal
• Intrathecal
• Intracavitary
• Ventricular reservoir

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Intravenous Route

• Smallest needle size
• Forearm preferable
• Avoid joints
• Extravasation danger
• Given push, piggy- back, continuous infusion
• Rapid blood level achieved

• NO FILTERS except Taxol (paclitaxel)
• Continuous infusion must be on a pump
• Rate of infusion checked frequently
• Never play catch up
• Flush between drugs

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Vesicant Chemotherapy

• Vesicant - TISSUE NECROSIS if extravasated
• Risk factors -- elderly, confused, poor venous
  access
• Site Forearm only if peripheral
• Fresh IV site avoid multiple sticks, mastectomy
  arm

• NEVER LEAVE peipheral vesicant chemo -- Constant
  observation!
• Blood return before and q 2 to 3 cc -- peripheral
• Infusions only by Central Venous Route
• Blood return before, after and q shift - infusion

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Signs of Infiltration

• Pain or burning at IV site
• Edema or swelling at IV site
• Loss of blood return
• Redness (erythema) at IV site on arm
• Decreased IV flow pump alarm sounds
• Need to know vesicant status of drug

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Vesicant Drugs

• Nitrogen Mustard
• Na Thiosulfate
• Adriamycin
• Daunorubicin
• Epirubicin
• Idarubicin
• Topical DMSO
• Apply ice
• Elevate Extremity

• Mitoxantrone
• Ice and elevation
• Actinomycin-D
• Ice and elevation
• Vinca Alkaloids
• Heat
• Elevation
• Hyaluronidase no longer available

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Vesicant Drugs (cont.)

• Cisplatin
• More than 20 cc extravasated
• Concentration more than 0.5 mg/ml
• If less than above amounts, irritant status
• Sodium Thiosulfate
• Heat/Cold not effective

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Irritant Drugs

• Taxanes (Taxol, Taxotere)
• Ice pack for 15 - 20 minutes QID for 24 hrs
• Elevation of limb
• Ifosfamide
• Carboplatin
• Dacarbazine (DTIC)
• Carmustine (BCNU)

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Irritants (cont.)

• Doxil (Doxorubicin liposomal)
• Bleomycin
• Apply ice if needed
• Assess site daily
• VP-16
• Heat
• Elevation

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Prevention

• Large vein in forearm 2 from wrist and 1 from
  elbow
• Smallest gauge needle you can use (23 g)
• Limit IV sticks ONE per vein
• Check blood return q 2 to 3 cc for IV push
• Check blood return q 5 min-IV piggyback
• Check blood return q shift-IV infusion
• Continuous infusion thru central line ONLY

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Treatment of Extravasation

• AT FIRST SIGN, stop chemo
• Attempt to aspirate residual drug
• Remove IV
• Notify physician
• Administer antidote (if ordered)
• Heat/Cold as appropriate
• Elevate extremity
• Document extravasation and management

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Chemotherapy Spills

• Do not touch spill with unprotected hands
• Open spill kit put on both sets of gloves
• Put on gown, goggles, and mask (if needed)
• Use spill pillows to contain spill
• Use absorbent sheets to blot up as much drug as
  possible
• Use scoop and brush to pick up any glass

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Chemotherapy Spills (cont.)

• Wash area with soap or disinfectant
• Use disposable towels discard in plastic bag
• Rinse with water dispose of towels in bag
• Remove gear into plastic bag
• Put bag and all waste into second bag label
• Wash hands

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Hematologic Parameters

• WBC - 3.0 (3,000) or higher
• ANC - Higher than 1000
• ANC WBC x (Segs Bands) x 0.01
• Platelets - Higher than 100 (100,000)
• If in doubt, check with physician

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Oral Route

• Convenient non-invasive
• Compliance problematic
• GI Absorption problematic with hypermotility
  and/or prior surgery
• Nausea and vomiting may cause patient to miss all
  or part of dose
• Insurance may not cover cost of oral meds

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IM or Subcutaneous Route

• For optimal absorption, may split into multiple
  injections
• Never used with vesicants/irritants
• Platelet count must be adequate
• Z-track to prevent chemo leakage
• Patient self-administration preferable teaching
  materials are available

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Topical

• For skin lesions only
• Chemo agents 5-FU, Mustargen
• Applied until cancer is gone (redness may remain)
• Nursing Considerations Chemo gloves, apply with
  cotton swabs, cover to avoid spread, apply ONLY
  to lesion
• Patient education very important

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Intravesicular

• Superficial cancer in hollow organs (bladder
  cancer)
• Agents used Thiotepa, Mitomycin, Doxorubicin,
  BCG (not chemo)
• Instilled into bladder via catheter foley
  clamped for period of time before infusate
  drained
• Side effects excoriation, pain in bladder,
  external genitalia hematuria

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Intra-arterial Route

• Used for liver cancer treatment
• Cannulate hepatic artery continuous infusion of
  chemo may use implanted pump
• High concentration directly to tumor bed
• High rate of complication with arterial catheters
• Chemotherapy agents 5-FU, FUDR

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Intraperitoneal Route

• Indication Colon and Ovarian
• Peritoneal space has much surface area may not
  be reached by IV chemo
• Catheters used Tenckhoff, implanted port
• Chemotherapy agents used Cisplatin, Taxol
• Advantages less systemic side effects
• Disadvantages infection, BP changes, pain,

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Intrapleural

• Seeding of pleura
• Used as sclerosing agent to stop pleural
  effusions
• Injected by physician into chest tube and clamped
  Patient changes position q15 min for 1 hour
• Chemotherapy agents used Bleomycin, Adriamycin,
  Talc slurry
• Side effects SEVERE pain

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Intrathecal Route

• Meningeal spread of cancer
• Prophylaxis in Acute Lymphocytic Leukemia
• Lumbar Puncture or Ommaya Reservoir
• Chemotherapy drugs used Ara-C, MTX Never Vinca
  Alkaloids (causes immediate death)
• Side effects minimal mild headache or nausea
• Notify physician for neck rigidity or change in
  level of consciousness

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Ommaya Reservoir
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Access Devices

• Peripheral lines
• Non-tunneled central venous catheters
• Tunneled central venous catheters
• Implanted port
• Implanted pump (Infusaid, Synchromed)
• Ommaya reservoir

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Tunneled Catheter
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Implanted Port
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Peripherally Inserted Central Catheter (PICC)
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Infusaid Pump
Synchro-Med Pump
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Troubleshooting Vascular Access

• Peripheral IV inserted within 24 hours of use
• Blood return before and after each drug
• NO BLOOD -- NO DRUG!!!
• Flush with NS before and after each drug

• Reposition patient, Valsalva
• Use clot lysing agent
• Dye study for catheter patency
• For ports use correct size Huber needle

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Treatment Phase

• Identify plan for administration
• Designate workplace
• Secure spill kit and personal protective
  equipment
• Prepare equipment
• Emergency equipment available

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Local Reactions from Chemotherapy Administration

• Extravasation leakage or infiltration of a
  vesicant chemotherapy agent into local tissue
• Vesicant any agent that has the potential to
  cause blistering or tissue necrosis
• Irritant any agent that causes a local
  inflammatory reaction but does not cause tissue
  necrosis
• Flare reaction venous inflammatory response with
  subsequent histamine release that may result in
  flare reaction incidence is usually about 3 and
  duration usually less than 45 minutes

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Local Reactions
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