Chemotherapy Reactions and Management

Urticaria, fever, hypotension, cardiac instability, dyspnea, wheezing, throat tightness, and syncope are potential immediate hypersensitivity reactions (HSRs) that may occur within an hour of chemotherapy infusion. Delayed HSRs can manifest hours after administration. Patients may or may not react to the first infusion of a chemotherapy agent, but repeated exposure increases the likelihood of a reaction.

Action Steps:
- Discontinue the medication immediately.
- Initiate emergency procedures.
- Follow standing orders for the administration of emergency medications.

Chemotherapy Toxicity

Toxicity associated with chemotherapy can be categorized as acute or chronic. One of the most common acute toxicities is chemotherapy-induced nausea and vomiting (CINV), which may persist for 24-48 hours post-administration and can also occur up to one week later.

Anticipatory Nausea and Vomiting:
- Occurs prior to chemotherapy administration.
- Triggered by stimuli such as the smell of the infusion setting, the sight of healthcare providers, or the outpatient center waiting room.

Managing Delayed Nausea and Vomiting

Administer prescribed antiemetics before and after therapy. These medications may be combined and given for the first week at home following chemotherapy.
Non-Pharmacologic Approaches:
- Relaxation techniques.
- Imagery.
- Acupressure or acupuncture to decrease stimuli contributing to symptoms.
- Encourage small, frequent meals and bland foods.
- Comfort foods may help reduce the frequency or severity of symptoms.

Stomatitis

Stomatitis is commonly associated with certain chemotherapy agents due to the rapid turnover of the epithelium lining the oral cavity. The entire gastrointestinal tract is susceptible to mucositis, which includes inflammation of the mouth, throat, and gastrointestinal tract, often accompanied by diarrhea.

Nursing Intervention:
- Apply water-soluble lip lubricant to assist in the healing of mild stomatitis.

Nursing Roles in Administering Chemotherapy

Nurses play a vital role in patient and family education, emphasizing the importance of adhering to prescribed self-administered premedication before presenting to the infusion center, recognizing and reporting signs and symptoms during infusion, and educating about signs and symptoms that may occur at home following discharge. They must closely observe the patient during the administration of the agent, particularly for extravasation.

Breast Cancer Overview

Breast cancer is the most common cancer among females, with the risk increasing with age. Approximately two-thirds of invasive breast cancers are found in women aged 55 years or older. Male breast cancer is rare compared to female breast cancer.

Types of Breast Cancer

Noninvasive Carcinoma (Carcinoma In Situ):
- Ductal Carcinoma in Situ (DCIS): Characterized by the proliferation of malignant cells inside the milk ducts without invasion into surrounding tissue; does not metastasize.
Invasive Carcinoma:
- Infiltrating Ductal Carcinoma: The most common type, arising from the duct system and invading surrounding tissues, often forming a solid irregular mass.
- Infiltrating Lobular Carcinoma: Arises from lobular epithelium, often multicentric and can be bilateral.

Causes and Risk Factors of Breast Cancer

The causes of breast cancer are multifactorial, involving hormonal, genetic, and environmental factors. Risk factors include female gender, increasing age, first full-term pregnancy after age 30, personal and family history of breast cancer, genetic mutations, obesity, exposure to ionizing radiation, history of benign proliferative breast disease, hormonal factors, nulliparity, and hormone therapy.

Protective Factors for Breast Cancer

Breastfeeding for at least one year.
Regular or moderate physical activity.
Maintaining a healthy body weight.

Prevention Strategies for High-Risk Patients

Long-Term Surveillance:
- Focuses on early detection through clinical breast examinations and mammograms starting as early as age 25.
- Yearly mammography and MRI screenings may be recommended.
Chemoprevention:
- Aims to prevent disease in postmenopausal women, with Tamoxifen as an effective agent for high-risk women.
- Nurses can provide information about benefits, risks, and possible side effects of chemoprevention medications.
Prophylactic Mastectomy:
- Can reduce the risk of breast cancer by 90% and involves total mastectomy (removal of breast tissue); it is elective, not emergent.

Clinical Manifestations of Breast Cancer

Breast cancers are typically found in the upper outer quadrant of the breast.
Lesions are usually non-tender, fixed, and hard with irregular borders.
Advanced signs may include skin dimpling, nipple retraction, and skin ulceration.

Assessment and Diagnostic Findings

Methods for detection include breast self-examination, mammography, ultrasound, biopsies, and various imaging studies.
Staging classifies cancer by the extent of disease in the body.

Surgical Management

Modified Radical Mastectomy: Involves removal of the entire breast tissue, including the nipple-areola complex and a portion of axillary lymph nodes.
Total Mastectomy: Treatment for non-invasive breast cancer (e.g., DCIS), involving removal of the breast and nipple-areola complex without axillary lymph node dissection.

Nursing Process for Patients Undergoing Surgery

Preoperative Nursing Diagnoses:
- Deficient knowledge about planned surgical treatments.
- Anxiety related to cancer diagnosis.
- Fear related to specific treatments and body image changes.
- Risk for ineffective coping related to cancer diagnosis and treatment options.
- Decisional conflict regarding treatment options.
Postoperative Nursing Diagnoses:
- Acute pain and discomfort related to surgical procedure.
- Peripheral neurovascular dysfunction related to nerve irritation in the affected arm, breast, or chest wall.
- Disturbed body image related to loss or alteration of the breast.
- Risk for ineffective coping related to cancer diagnosis and surgical treatment.
- Self-care deficit related to partial immobility of the upper extremity on the operative side.
- Risk for sexual dysfunction related to loss of body part and fear of partner’s responses.
- Deficient knowledge regarding drain management, arm exercises, and hand/arm care after axillary lymph node dissection (ALND).

Collaborative Problems and Potential Complications

Lymphedema: Chronic swelling of an extremity due to interrupted lymphatic circulation.
Hematoma: Collection of blood inside a cavity; assess the surgical site for swelling, tightness, pain, and bruising.
Seroma Formation: Collection of serous fluid under the breast incision or in the axilla; symptoms include swelling, heaviness, discomfort, and a sloshing sensation.
Infection: Signs include redness, warmth around the incision, tenderness, foul-smelling drainage, and fever.

Medical Management: Radiation Therapy

Radiation therapy is utilized to decrease the chance of local recurrence in the breast. External-beam radiation typically starts six weeks after breast conservation surgery to allow the surgical site to heal and usually begins after the completion of systemic chemotherapy.

Planning Session: Before radiation begins, a simulation session maps out the anatomic areas to be treated, identified with small permanent ink markings.
After completing radiation to the entire breast, many patients receive a "boost," a dose of radiation to the lumpectomy site where cancer cells were located.

Side Effects of Radiation Therapy

Acute Side Effects: Mild to moderate erythema, breast edema, and fatigue, typically resolving within weeks to months after treatment.
Rare Long-Term Effects:
- Pneumonitis.
- Rib fracture.
- Breast fibrosis.

Nursing Management of Radiation Therapy

Provide self-care instructions for the treated area, including:
- Use mild soap with minimal rubbing.
- Avoid perfumed soaps or deodorants.
- Apply hydrophilic lotions for dryness.
- Use non-drying, antipruritic soap if pruritus occurs.
- Avoid tight clothing and excessive temperatures.
- Minimize sun exposure to the treated area.
Follow-up care includes teaching the patient about normal post-radiation sensations and care for the treated area.

Systemic Treatments: Chemotherapy

Chemotherapy involves the use of anticancer agents, often as adjuvant therapy alongside other treatments (surgery, radiation) to delay or prevent breast cancer recurrence. Treatment is administered over a period of 3 to 6 months, with regimen decisions based on tumor characteristics, patient age, physical status, and existing comorbid conditions.

Side Effects of Adjuvant Chemotherapy

Nausea and vomiting.
Bone marrow suppression.
Taste changes.
Alopecia (hair loss).
Mucositis (inflammation of mucous membranes).
Neuropathy.
Skin changes.
Fatigue.
Weight gain of more than 10 lbs in about half of patients; cause unknown.
Temporary or permanent amenorrhea.

Systemic Treatments: Hormonal Therapy

Adjuvant hormonal therapy, with or without chemotherapy, involves medications that block estrogen production, such as aromatase inhibitors. Tamoxifen is traditionally the primary hormonal agent used for both premenopausal and postmenopausal breast cancer.

Patient Education: Managing Side Effects of Adjuvant Hormonal Therapy

Hot Flashes:
- Wear breathable, layered clothing.
- Avoid caffeine and spicy foods.
- Perform breathing exercises.
Vaginal Dryness:
- Use vaginal moisturizers for everyday dryness.
Nausea and Vomiting:
- Consume a bland diet.
- Try to take medication in the evening.
Musculoskeletal Symptoms:
- Take nonsteroidal analgesics as recommended.
- Take warm baths.
Risk of Endometrial Cancer:
- Report any irregularities.
Risk for Thromboembolic Events:
- Report any redness, swelling, or tenderness in the lower extremities, or unexplained shortness of breath.
Risk for Osteoporosis or Fractures:
- Undergo a baseline bone density scan.
- Perform regular weight-bearing exercises.
- Take calcium supplements with vitamin D.

Nursing Management of Clients with Tumor

Overview about Tumor

This section provides a comprehensive understanding of tumors, including their types, characteristics, and the nursing management involved in caring for clients with cancer.

Intended Learning Outcomes (ILOs)

Differentiate between benign and malignant tumors.
Identify factors that contribute to carcinogenesis.
List diagnostic measures for cancer evaluation.
Understand nursing roles in diagnostic tests.

Definitions and Key Concepts

Cancer: A group of disorders characterized by abnormal cell proliferation, where cells ignore growth-regulating signals in their environment.
Benign Tumors: Non-cancerous growths that may grow but do not spread to other organs or body parts.
Malignant Tumors: Tumors that exhibit characteristics of cancer and can invade surrounding tissues.
Metastasis: The process by which cancer cells spread from the primary tumor to distant sites in the body.
Carcinogens: Agents such as chemicals, physical factors, and biological agents that can cause cancer.
Neoplasia: Uncontrolled cell growth that does not adhere to physiological demands, synonymous with cancer.
Oncology: The branch of medicine that deals with the study and treatment of cancer.

Characteristics of Malignant Cells

Malignant cells differ from benign cells in several key aspects:

Rate and method of growth.
Ability to metastasize or spread to other tissues.
Destructive impact on surrounding tissues.
Potential to cause death.

Factors Implicated in Carcinogenesis

Viruses and Bacteria: Certain infections can increase cancer risk.
Physical Agents: Exposure to sunlight, radiation, chronic irritation, and inflammation.
Chemical Agents: Tobacco smoke and other carcinogenic substances.
Genetic or Familial Factors: Inherited genetic predispositions and shared environmental factors.
Lifestyle Factors: Diet (high in fats, alcohol, processed meats), obesity, and lack of physical activity.
Hormonal Agents: Hormonal imbalances, whether endogenous or exogenous, can influence cancer risk.

Detection and Prevention of Cancer

Primary Prevention

Strategies aimed at reducing cancer risk include:

Health Promotion: Immunization to prevent infections associated with cancer (e.g., HPV vaccine).
Lifestyle Changes:
- Smoking cessation.
- Reduced caloric intake.
- Low-fat diet.
- Increased physical activity.
- Maintaining normal body weight.

Secondary Prevention

Focuses on screening and early detection:

Breast Cancer: Mammography.
Cervical Cancer: Pap test, HPV DNA test.
Endometrial Cancer: Monitoring signs and symptoms during menopause.
Prostate Cancer: Digital rectal examination, prostate-specific antigen test.
Colorectal Cancer: Various tests including fecal occult blood test and colonoscopy.
Lung Cancer: Low-dose helical CT scans.

Tertiary Prevention

Involves managing and monitoring cancer survivors:

Monitoring for recurrence of primary cancer.
Preventing recurrence.
Screening for second malignancies.

The Diagnostic Evaluation

Patients suspected of having cancer undergo extensive testing to determine the presence and extent of cancer, identify possible metastasis, evaluate the function of affected and unaffected body systems, and obtain tissue and cells for analysis, including tumor staging and grading.

Review of systems.
Physical examination.
Imaging studies.
Laboratory tests (blood, urine, body fluids).
Procedures such as needle biopsy.
Pathologic analysis.
Diagnostic surgery or biopsy.

Nursing Role in Diagnostic Evaluation

Nurses play a crucial role in supporting patients during diagnostic evaluations by addressing patient fears and anxieties, explaining tests and expected sensations, encouraging patients and families to express concerns, providing emotional support throughout the evaluation process, and reinforcing information provided by physicians.

Imaging Studies and Diagnostic Procedures

Laboratory tests of blood, urine, and other body fluids are essential for diagnosis.
Procedures such as needle biopsy are performed to obtain tissue samples.
Pathologic analysis is critical for determining the nature of the disease.
Diagnostic surgery, or biopsy, is performed to obtain a tissue sample for histologic analysis of cells suspected to be malignant.

Addressing Patient Fear and Anxiety

Explain the tests to be performed to the patient.
Discuss the sensations likely to be experienced during the tests.
Clarify the patient’s role in the test procedures.
Encourage the patient and family to voice their fears about the test results.
Provide support throughout the diagnostic evaluation process.
Reinforce and clarify information conveyed by the physician.
Encourage open communication among the patient, family, and healthcare providers.

Therapeutic Modalities of Cancer

Intended Learning Outcomes (ILOs)

Discuss various cancer treatment approaches, including surgery, radiation therapy, and chemotherapy.
Identify the side effects associated with cancer treatments.
Perform nursing care to manage side effects of cancer treatment.
Understand nursing roles in administering chemotherapy.

Treatment Goals of Cancer

Cure: Complete eradication of malignant disease.
Control: Prolonged survival and containment of cancer cell growth.
Palliation: Relief of symptoms and improvement of quality of life.

Treatment options are tailored based on specific type, stage, and grade of cancer.

Common Therapeutic Modalities

Surgery
Radiation therapy
Chemotherapy
Hematopoietic stem cell transplantation (HSCT)
Hyperthermia
Targeted therapy

Diagnostic Surgery and Biopsy

Diagnostic surgery, or biopsy, is performed to obtain tissue samples for analysis. Types of biopsy include:

Excisional Biopsy: Removal of the entire tumor and surrounding tissues.
Incisional Biopsy: Removal of a wedge of tissue from the tumor for analysis.
Needle Methods: Aspirating tissue fragments through a needle (e.g., needle core biopsy).

Surgery as Primary Treatment

The goal of surgery is to remove the entire tumor or as much as feasible, including surrounding tissues and lymph nodes. Surgical approaches include:

Local Excision: Removal of a small mass and a margin of normal tissue.
Wide Excision: Removal of the primary tumor, lymph nodes, and adjacent structures.

Types of Surgery

Prophylactic Surgery: Risk reduction surgery to remove organs at increased risk of cancer (e.g., colostomy, mastectomy).
Palliative Surgery: Aimed at relieving symptoms and complications when cure is not possible.
Reconstructive Surgery: Follows curative or radical surgery to improve function or cosmetic appearance.

Radiation Therapy

Radiation therapy uses ionizing radiation to interrupt malignant cell growth and control metastasis. It may be given prophylactically or in conjunction with chemotherapy. Factors influencing radiation dosage include sensitivity of target tissues, size of the tumor, radiation tolerance of surrounding normal tissues, and proximity of critical structures to the tumor.

Side Effects of Radiation Therapy

Acute Side Effects:
- Local reactions: skin irritation, alopecia, radiation dermatitis, stomatitis, xerostomia, taste changes, and bone marrow suppression.
- Systemic effects: fatigue, malaise, and anorexia.
Chronic Side Effects: Irreversible fibrotic changes, severe late effects on lungs, heart, CNS, and bladder.

Skin Integrity Management

To prevent impaired skin integrity during radiation therapy, patients should:

Use moisturizers on the skin.
Avoid sun exposure to the treatment area.
Avoid tape or bandages on the treated skin.

Alopecia

Alopecia refers to temporary or permanent hair loss, typically beginning 2 to 3 weeks after starting chemotherapy or radiation therapy. Nurses should provide information and support for coping with changes in body image.

Protecting Caregivers

To minimize exposure to radioactive implants, principles include limiting exposure duration, maintaining a safe distance from the radiation source, and using appropriate shielding equipment.

Safety Precautions for Internal Radiation (Brachytherapy)

Provide a private room for the patient.
Post appropriate notices regarding radiation safety.
Staff must wear dosimeter badges.
Avoid assigning pregnant staff to the patient's care.
Prohibit children and pregnant visitors.
Limit visits to 30 minutes daily and maintain a 6-foot distance from the radiation source.

Chemotherapy

Chemotherapy involves the use of anti-neoplastic agents to destroy tumor cells by interfering with cellular functions. It may be combined with surgery or radiation and requires repeated doses over time. Goals include reducing tumor size preoperatively, destroying remaining tumor cells postoperatively, and treating certain forms of leukemia or lymphoma.

Special Problems Associated with Chemotherapy

Extravasation: Leakage of chemotherapy agents into surrounding tissues.
Toxicity: Adverse effects on the body.
Stomatitis: Inflammation of oral tissues.
Hypersensitivity reactions: Range from mild to severe symptoms.

Administration of Chemotherapeutic Agents

Dosage is based on factors such as patient’s total body surface area, weight, previous exposure and response to treatments, and function of major organ systems.

Extravasation Management

Extravasation is the leakage of chemotherapy agents into subcutaneous tissue, which can cause inflammation and tissue damage. To prevent extravasation:

Limit peripheral administration to short durations with soft, plastic catheters.
Use central lines for continuous infusion of vesicants.
Monitor for signs of extravasation, including absence of blood return, resistance to flow, burning, pain, swelling, and redness.

Hypersensitivity Reactions (HSRs)

HSRs can manifest as mild to severe symptoms, including rash, urticaria, fever, hypotension, cardiac instability, dyspnea, wheezing, throat tightness, and syncope. Immediate reactions occur within 1 hour of infusion, while delayed reactions may happen later. Discontinue the medication immediately and initiate emergency procedures.

Toxicity Associated with Chemotherapy

Toxicity can lead to various adverse effects, necessitating careful monitoring and management during treatment.

Chemotherapy and Breast Cancer Management Guide

Chemotherapy and Breast Cancer Management Guide